Lisa Amaya-Jackson

Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events.

The article reviews the current status (1993–2007) of psychosocial treatments for children and adolescents who have been exposed to traumatic events. Twenty-one treatment studies are evaluated using criteria from Nathan and Gorman (2002) along a continuum of methodological rigor ranging from Type 1 to Type 6. All studies were, at a minimum, robust or fairly rigorous. The treatments in each of these 21 studies also are classified using criteria from Chambless et al. (1996), and Chambless and Hollon (1998). Trauma-Focused Cognitive-Behavioral Therapy met the well-established criteria; School-Based Group Cognitive-Behavioral Treatment met the criteria for probably efficacious. All the other treatments were classified as either possibly efficacious or experimental. Meta-analytic results for four outcomes (i.e., posttraumatic stress, depressive symptoms, anxiety symptoms, and externalizing behavior problems) across all treatments compared to waitlist control and active control conditions combined reveal that, on average, treatments had positive, though modest, effects for all four outcomes. We also cover investigative work on predictors, moderators, and mediators of treatment outcome, as well as the clinical representativeness and generalizability of the studies. The article concludes with a discussion of practice guidelines and future research directions.

Cognitive‐Behavioral Psychotherapy for Children and Adolescents With Posttraumatic Stress Disorder After a Single‐Incident Stressor

OBJECTIVE To test the efficacy of a group-administered cognitive-behavioral psychotherapy (CBT) protocol for pediatric posttraumatic stress disorder (PTSD) after a single-incident stressor. METHOD After a school-wide selection-to-treatment procedure conducted in two elementary and two junior high schools, children and adolescents with DSM-IV PTSD by structured interview were entered into an 18-week, group-administered CBT protocol using a single case across time and setting experimental design. Assessments of PTSD, anxiety, depression, trait anger, locus of control, and disruptive behavior were conducted at baseline, posttreatment, and at 6-month follow-up. RESULTS Experimental control across time (staggered start date) and setting (school and age) was demonstrated. Fourteen of 17 subjects completed treatment. Of these, 8 (57%) no longer met DSM-IV criteria for PTSD immediately after treatment; 12 (86%) of 14 were free of PTSD at 6-month follow-up. On intent-to-treat analyses, treatment produced a robust beneficial effect posttreatment on the Clinician-Administered PTSD Scale-Child and Adolescent Version, with additional improvement accruing at follow-up (p < .001). Improvements of a similar magnitude were seen for depression (p < .001), anxiety (p < .001), and anger (p < .005). Locus of control remained external from pre- to posttreatment but became strongly internal at follow-up (p < .001). CONCLUSION More clinical trials are required to confirm that CBT is a safe, acceptable, and effective treatment for PTSD in children and adolescents.

Adverse Behavioral and Emotional Outcomes from Child Abuse and Witnessed Violence

This article examines mental health outcomes of children who have witnessed violence in their social environment and/or have been physically abused. Participants (n = 167) come from a longitudinal study on child maltreatment. Outcomes—including depression, anger, and anxiety—are measured by the Child Behavior Checklist and the Trauma Symptom Checklist for Children. The authors used adjusted multivariate analyses to test the statistical significance of associations. The majority of children were female (57%) and non-White (64%). One third had been physically victimized; 46% had witnessed moderate-high levels of violence. Results confirm that children are negatively affected by victimization and violence they witness in their homes and neighborhoods. Victimization was a significant predictor of child aggression and depression; witnessed violence was found to be a significant predictor of aggression, depression, anger, and anxiety. Implications will be discussed.

Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: a randomized clinical trial

BACKGROUND The evidence base for trauma-focused cognitive behavioral therapy (TF-CBT) to treat posttraumatic stress disorder (PTSD) in youth is compelling, but the number of controlled trials in very young children is few and limited to sexual abuse victims. These considerations plus theoretical limitations have led to doubts about the feasibility of TF-CBT techniques in very young children. This study examined the efficacy and feasibility of TF-CBT for treating PTSD in three- through six-year-old children exposed to heterogeneous types of traumas. METHODS Procedures and feasibilities of the protocol were refined in Phase 1 with 11 children. Then 64 children were randomly assigned in Phase 2 to either 12-session manualized TF-CBT or 12-weeks wait list. RESULTS In the randomized design the intervention group improved significantly more on symptoms of PTSD, but not on depression, separation anxiety, oppositional defiant, or attention deficit/hyperactivity disorders. After the waiting period, all participants were offered treatment. Effect sizes were large for PTSD, depression, separation anxiety, and oppositional defiant disorders, but not attention-deficit/hyperactivity disorder. At six-month follow-up, the effect size increased for PTSD, while remaining fairly constant for the comorbid disorders. The frequencies with which children were able to understand and complete specific techniques documented the feasibility of TF-CBT across this age span. The majority were minority race (Black/African-American) and without a biological father in the home, in contrast to most prior efficacy studies. CONCLUSIONS These preliminary findings suggest that TF-CBT is feasible and more effective than a wait list condition for PTSD symptoms, and the effect appears lasting. There may also be benefits for reducing symptoms of several comorbid disorders. Multiple factors may explain the unusually high attrition, and future studies ought to oversample on these demographics to better understand this understudied population.

Functional Impairment and Utilization of Services Associated With Posttraumatic Stress in the Community

This study describes social functioning and service utilization patterns associated with posttraumatic stress symptoms relative to nonpsychiatric controls and depressive disorder controls in a cross-sectional epidemiological survey. Data from 49 cases and 147 controls who participated in the North Carolina component of the Epidemiologic Catchment Area study were examined. Results indicate that symptoms of posttraumatic stress were associated with impairment along several domains of functioning: social, financial, physical, and psychological. Individuals with posttraumatic stress were found to have more socioeconomic disadvantages and impaired functioning. Despite this, individuals with posttraumatic stress are receiving relatively few mental health services. Further research assessing service use, treatment, and functional outcomes are indicated.

Posttraumatic Symptomatology in Children and Adolescents After an Industrial Fire

OBJECTIVE This investigation evaluated the extent and nature of posttraumatic symptomatology (PTS) in children and adolescents 9 months after an industrial fire at the imperial Foods chicken-processing plant in Hamlet, North Carolina, caused extensive loss of life. METHOD Using a PTS self-report measure plus self- and teacher reports of comorbid symptoms the authors surveyed 1,019 fourth- to ninth-grade students in the community where the fire occurred. RESULTS Three factors comprising PTS were identified: reexperiencing, avoidance and hyperarousal. Reexperiencing and avoidance were positively correlated; hyperarousal proved weakly correlated with reexperiencing, perhaps because exposure was largely indirect. Using a T score cutoff of 65 on the reexperiencing factor as indicative of PTS 9.7% of subjects met criteria for PTS; 11.9% met criteria for posttraumatic stress disorder (PTSD) using DSM-III-R PTSD criteria. Degree of exposure was the most powerful predictor of PTS. Race (African-American) and gender (female) posed significant risk factors for PTS. Self-reported internalizing symptoms and teacher-reported externalizing symptoms were positively predicted by intercurrent PTS, and independently of PTS, by degree of exposure. Comorbid symptoms showed interesting interactions with exposure, race, and gender. Lack of self-attributed personal efficacy predicted PTS but did not moderate the effects of race or gender on PTS risk. CONCLUSIONS This study, which used a population-based sampling strategy, strengthens and extends findings from earlier literature on pediatric PTSD in showing that (1) PTS and comorbid internalizing and externalizing symptoms rise in direct proportion to degree of exposure; (2) gender and race show variable effects on risk for PTS and comorbid symptoms; and (3) comorbid symptoms are positively correlated with PTS and may represent primary outcomes of traumatic exposure in their own right.

Understanding the Behavioral and Emotional Consequences of Child Abuse

Children who have suffered early abuse or neglect may later present with significant behavior problems including emotional instability, depression, and a tendency to be aggressive or violent with others. Troublesome behaviors may persist long after the abusive or neglectful environment has changed or the child has been in foster care placement. Neurobiological research has shown that early abuse results in an altered physiological response to stressful stimuli, a response that deleteriously affects the childs subsequent socialization. Pediatricians can assist caregivers by helping them recognize the abused or neglected childs altered responses, formulate more effective coping strategies, and mobilize available community resources.

Directly Questioning Children and Adolescents About Maltreatment A Review of Survey Measures Used

The methodological, legal, and ethical issues related to questioning children about their maltreatment experiences in research studies are complex. A review of the literature was conducted examining what studies to date have directly asked children about victimization and how study investigators dealt with the human participants issues related to subsequent disclosure. This article examines how different studies have defined and operationalized abuse in survey questions for children, reports prevalence rates when available, describes the differing methods used to collect child self-report data, and highlights how investigators have dealt with the ethical issues related to informed consent and disclosure up to this point.

Effects of Electroconvulsive Therapy in Adolescents with Severe Endogenous Depression Resistant to Pharmacotherapy

BACKGROUND This open, prospective study examined the effects of electroconvulsive therapy (ECT) in 10 adolescents with primary, endogenous, psychotic depression who were resistant to antidepressant pharmacotherapy. METHODS Change in symptom severity from baseline was assessed weekly with Hamilton Depression Rating Scale (HDRS) ratings, and outcome was measured additionally at 1 month, and again at 1 year, post-ECT. RESULTS All but 1 patient demonstrated dramatic improvement, with statistically significant decreases in mean HDRS score detected after the first week of treatment. All responders maintained the benefits of their treatment. CONCLUSIONS The results provide evidence of the clinical effectiveness of ECT in adolescents with phenomenological characteristics shown to be predictive of ECT response in adults.

Dissociation predicts later attention problems in sexually abused children

OBJECTIVE The goals of this research are to develop and test a prospective model of attention problems in sexually abused children that includes fixed variables (e.g., gender), trauma, and disclosure-related pathways. METHODS At Time 1, fixed variables, trauma variables, and stress reactions upon disclosure were assessed in 156 children aged 8-13 years. At the Time 2 follow-up (8-36 months following the initial interview), 56 of the children were assessed for attention problems. RESULTS A path analysis involving a series of hierarchically nested, ordinary least squares multiple regression analyses indicated two direct paths to attention problems including the childs relationship to the perpetrator (beta=.23) and dissociation measured immediately after disclosure (beta=.53), while controlling for concurrent externalizing behavior (beta=.43). Post-traumatic stress symptoms were only indirectly associated with attention problems via dissociation. Taken together, these pathways accounted for approximately 52% of the variance in attention problems and provided an excellent fit to the data. CONCLUSIONS Children who report dissociative symptoms upon disclosure of CSA and/or were sexually abused by someone within their family are at an increased risk of developing attention problems. PRACTICE IMPLICATIONS Findings from this study indicate that children who experienced sexual abuse at an earlier age, by someone within their family, and/or report symptoms of dissociation during disclosure are especially likely to benefit from intervention. Effective interventions should involve (1) providing emotion regulation and coping skills; and (2) helping children to process traumatic aspects of the abuse to reduce the cyclic nature of traumatic reminders leading to unmanageable stress and dissociation.