Steven Berkowitz

The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD.

OBJECTIVE This pilot study evaluated the effectiveness of a four-session, caregiver-child Intervention, the Child and Family Traumatic Stress Intervention (CFTSI), to prevent the development of chronic posttraumatic stress disorder (PTSD) provided within 30 days of exposure to a potentially traumatic event (PTE). METHOD One-hundred seventy-six 7 to 17-year-old youth were recruited through telephone screening based on report of one new distressing posttraumatic stress symptom after a PTE. Of those, 106 youth were randomly assigned to the Intervention (n = 53) or a four-session supportive Comparison condition (N = 53). Group differences in symptom severity were assessed using repeated measures with mixed effects models of intervention group, time, and the interaction of intervention and time. Logistic regression analyses were performed to assess treatment condition and any subsequent traumas experienced as predictors for full and partial PTSD diagnosis at 3-month follow-up. An exploratory chi-square analysis was performed to examine the differences in PTSD symptom criteria B, C, and D at follow-up. RESULTS At baseline, youth in both groups had similar demographics, past trauma exposures and symptom severity. At follow-up, the Intervention group demonstrated significantly fewer full and partial PTSD diagnoses than the Comparison group on a standardized diagnostic measure of PTSD. Also, there was a significant group by time interaction for Trauma Symptom Checklist for Childrens Posttraumatic Stress and Anxiety Indices as the CFTSI group had significantly lower posttraumatic and anxiety scores than the Comparison group. CONCLUSIONS The results suggest that a caregiver-youth, brief preventative early intervention for youth exposed to a PTE is a promising approach to preventing chronic PTSD.

Traumatic Childhood Events and Autism Spectrum Disorder

Traumatic childhood events are associated with a wide range of negative physical, psychological and adaptive outcomes over the life course and are one of the few identifiable causes of psychiatric illness. Children with autism spectrum disorder (ASD) may be at increased risk for both encountering traumatic events and developing traumatic sequelae; however, this topic has been understudied. This review considers the rationale for examining traumatic events and related symptomology in individuals with ASD and summarizes the limited research on this topic. A conceptual framework for understanding the interplay of ASD, trauma and traumatic sequelae is proposed and recommendations for future research presented.

Indicated and Selective Preventive Interventions

Exposure to traumatic events places children at risk for developing distressing, significant emotional reactions such as posttraumatic stress symptoms (PTSS). These reactions also affect long-term functional outcomes. Research on identified and potential risk factors for the development of significant, persistent PTSS is under way. Evidence for preventive interventions is in its infancy but progressing. Family-centered interventions comprising education about emotional reactions to traumatic events and focusing on communication between children and parents show promising results. Only morphine has shown sufficient evidence as a pharmacologic intervention in children. Additional research is necessary to support the establishment of gold-standard preventive practices.

Evaluation and Treatment of Childhood Physical Abuse and Neglect: A Review

According to 2010 CDC estimates, 1 in 5 US children have experienced maltreatment. Risk factors for child maltreatment include child characteristics such as non-compliance and diagnostic conditions that increase caregiver burden. Parent characteristic risk factors include parental mental illness and low social support. New developments in radiologic evaluation of child maltreatment will be reviewed. New findings in evidence based psychotherapies for childhood maltreatment will be discussed. A review of the role of pharmacotherapy in child maltreatment cases will also be presented. New evidence from prevention models targeting young mothers and families are also reviewed.

Lessons learned while building a trauma-informed public behavioral health system in the City of Philadelphia

Exposure to traumatic experiences among youth is a serious public health concern. A trauma-informed public behavioral health system that emphasizes core principles such as understanding trauma, promoting safety, supporting consumer autonomy, sharing power, and ensuring cultural competence, is needed to support traumatized youth and the providers who work with them. This article describes a case study of the creation and evaluation of a trauma-informed publicly funded behavioral health system for children and adolescents in the City of Philadelphia (the Philadelphia Alliance for Child Trauma Services; PACTS) using the Exploration, Preparation, Implementation, and Sustainment (EPIS) as a guiding framework. We describe our evaluation of this effort with an emphasis on implementation determinants and outcomes. Implementation determinants include inner context factors, specifically therapist knowledge and attitudes (N=114) towards evidence-based practices. Implementation outcomes include rate of PTSD diagnoses in agencies over time, number of youth receiving TF-CBT over time, and penetration (i.e., number of youth receiving TF-CBT divided by the number of youth screening positive on trauma screening). We describe lessons learned from our experiences building a trauma-informed public behavioral health system in the hopes that this case study can guide other similar efforts.

Identifying Youth at Risk for Difficulties Following a Traumatic Event: Pre-event Factors are Associated with Acute Symptomatology

This study examined factors related to childrens acute symptoms following a potentially traumatic event (PTE) to more clearly identify domains that should be included in screenings of youth exposed to a PTE. In particular, the authors examined whether trauma category (i.e., sexual abuse/disclosure of abuse, intentionally perpetrated traumas other than sexual abuse, and unintentional traumas) was related to symptoms after controlling for other relevant factors. Participants were 112 youth presenting for clinical evaluation within a month of a PTE and their nonoffending caregivers. Using data from baseline assessments collected as part of a randomized controlled trial of a secondary prevention program, the following factors were tested in 3 hierarchical regression models: index PTE category, history of traumatic exposure, preindex event functioning, and parenting behaviors. Prior trauma exposure, preindex event functioning, and hostile parenting were uniquely related to childrens symptoms in the acute posttraumatic period after controlling for time since the event and child age, but trauma category was not. Implications for identifying and referring children at high risk for poor outcomes in the early aftermath of a PTE are discussed. An exclusive focus on the event is insufficient and more comprehensive understanding of the child and family is required.

Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement.

Child and adolescent posttraumatic stress disorder (PTSD) is associated with an increased risk for a number of deleterious mental and physical health outcomes that if untreated may persist throughout the life course. Efficacious interventions applied soon after trauma exposure have the potential to reduce or prevent the development of PTSD symptoms and their associated impact on behavior and physical health. We review extant research related to treatment-modifiable peritraumatic predictors of pediatric PTSD, which have informed an emerging field of pharmacologic secondary prevention (i.e., occurring shortly following trauma exposure) of PTSD. Challenges and opportunities for early posttrauma PTSD prevention are described. Finally, we offer new models for biologically informed integration of pharmacologic and psychosocial secondary prevention intervention strategies for children and adolescents.

Brief Report: Examining the Association of Autism and Adverse Childhood Experiences in the National Survey of Children’s Health: The Important Role of Income and Co-occurring Mental Health Conditions

Adverse childhood experiences (ACEs) are risk factors for mental and physical illness and more likely to occur for children with autism spectrum disorder (ASD). The present study aimed to clarify the contribution of poverty, intellectual disability and mental health conditions to this disparity. Data on child and family characteristics, mental health conditions and ACEs were analyzed in 67,067 youth from the 2011–2012 National Survey of Children’s Health. In an income-stratified sample, the association of ASD and ACEs was greater for lower income children and significantly diminished after controlling for child mental health conditions, but not intellectual disability. Findings suggest that the association of ACEs and ASD is moderated by family income and contingent on co-occurring mental health conditions.

Prevention of Youth Violence: A Public Health Approach

The causes of youth violence are multifactorial and include biological, individual, familial, social, and economic factors. The influence of parents, family members, and important adults can shape the beliefs of the child toward violence in a significant manner. However, the influence of school and the neighborhood also have an important role in attitudes and behaviors of children toward violence. The complexity of factors related to violence requires a comprehensive public health approach. This article focuses on evidence-based models of intervention to reduce violence while emphasizing collective impact as a guiding principle.

An Examination of Partner Violence, Polyexposure, and Mental Health Functioning in a Sample of Clinically Referred Youth.

Objective: Substantial literature has indicated that witnessing partner violence (WPV) is correlated with poor emotional, behavioral, and functional outcomes and is often associated with exposure to other potentially traumatic events. Young children are often overrepresented in the WPV group. This study fills an important gap in the literature by examining the association between WPV and other co-occurring trauma types and the association of early exposure to WPV with polyexposure, symptoms, and functional impairment. Method: Data from 8,446 youth presenting for clinical evaluation at a National Child Traumatic Stress Network Center were analyzed to examine (a) the association of WPV with polyexposure (defined as 4 or more trauma types); (b) the specific contribution of WPV in the context of polyexposure to posttraumatic stress, internalizing and externalizing symptoms, comorbid psychiatric conditions, functional impairment, and service utilization; and (c) the consequences of early exposure to WPV. Results: Youth with WPV were more likely to experience polyexposure than were youth without WPV (OR = 2.35, 95% confidence interval (CI) [2.11, 2.62]). When polyexposure was included in regression models, WPV was significantly associated with higher mean scores of functional impairment. Moreover, WPV before age 2 resulted in significantly greater risk of polyexposure than did WPV at age 7 or older (OR = 1.54, 95% CI [1.27, 1.86], for ages 7-10 and OR = 1.36, 95% CI [1.08, 1.72], for ages 11 and older). Conclusion: Early screening and intervention for WPV is needed to prevent polyexposure as well as impairments associated with both WPV and polyexposure.