Tag: mental health

Title: More than the loss of a parent: Potentially traumatic events among orphaned and abandoned children

Authors: Kathryn Whetten, Jan Ostermann, Rachel Whetten, Karen O’Donnell, Nathan Thielman, and The Positive Outcomes for Orphans Research Team

Date: March 25, 2011

Abstract: This study examines rates of potentially traumatic events and associated anxiety and emotional/behavioral difficulties among 1,258 orphaned and abandoned children in 5 low- and middle-income countries. The study quantifies the types of events the children experienced and demonstrates that anxiety and emotional/behavioral difficulties increase with additional exposure. As policies for orphaned and abandoned children are being implemented, this study helps policy makers and care providers recognize that (a) children and caregivers are willing to report experiences of potentially traumatic events, (b) those who report such events are at higher risk for experiencing additional events, (c) resulting symptomatology indicates a need for appropriate mental health services, and (d) boys are as vulnerable as girls, indicating an equal need for protection.

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Title: Posttraumatic stress in AIDS-orphaned children exposed to high levels of trauma: the protective role of perceived social support

Authors: Lucie Cluver, Dylan S Fincham, Soroya Seedat

Date: 2009

Abstract: Poor urban children in South Africa are exposed to multiple community traumas, but AIDS-orphaned children are at particular risk for posttraumatic stress. This study examined the hypothesis that social support may moderate the relationship between trauma exposure and posttraumatic stress for this group. Four hundred twenty-five AIDS-orphaned children were interviewed using standardized measures of psychopathology. Compared to participants with low perceived social support, those with high perceived social support demonstrated significantly lower levels of PTSD symptoms after both low and high levels of trauma exposure. This suggests that strong perception of social support from carers, school staff, and friends may lessen deleterious effects of exposure to trauma, and could be a focus of intervention efforts to improve psychological outcomes for AIDS-orphaned children.

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Title: Persisting mental health problems among AIDS-orphaned children in South Africa

Authors: Lucie Cluver, Mark Orkin, Frances Gardner, Mark E Boyes

Date: 2011



By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS. Cross-sectional studies show psychological problems for AIDS-orphaned children, but until now no longitudinal study has explored enduring psychological effects of AIDS-orphanhood in low-income countries.


A 4-year longitudinal follow-up of AIDS-orphaned children with control groups of other-orphans and non-orphans. 1021 children (M = 13.4 years, 50% female, 98% isiXhosa-speaking) were interviewed in 2005 and followed up in 2009 with 71% retention (49% female, M = 16.9 years), in poor urban South African settlements. Children were interviewed using sociodemographic questionnaires and well-validated standardised scales for assessing depression, anxiety, and post-traumatic stress. Data were analysed using mixed-design ANOVA and backward-stepping regression.


AIDS-orphaned children showed higher depression, anxiety, and post-traumatic stress disorder (PTSD) scores in both 2005 and 2009 when compared with other-orphans and non-orphans. Backward-stepping regression, controlling for baseline mental health, and sociodemographic cofactors such as age, gender, and type of bereavement, revealed that being AIDS-orphaned in 2005 was associated with depression, anxiety, and PTSD scores in 2009. This was not the case for other-orphaned or non-orphaned children. Age interacted with orphan status, such that there was a steep rise in psychological distress in the AIDS-orphaned group, but no rise with age amongst other-orphans and non-orphans.


Negative mental health outcomes amongst AIDS-orphaned children are maintained and worsen over a 4-year period. It is important that psychosocial support programmes are sustained, and focus on youth as well as young children.



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Title: Effects of stigma on the mental health of adolescents orphaned by AIDS

Authors: Lucie Cluver, Frances Gardner, Don Operario

Date: 2008



By 2010, an estimated 18.4 million children in Sub-Saharan Africa will be orphaned by AIDS. Research in South Africa shows that AIDS orphanhood is independently associated with heightened levels of psychological problems. This study is the first to explore the mediating effects of stigma and other factors operating on a community level, on associations between AIDS orphanhood and mental health. We assessed the associations of four risk factors that can potentially be addressed at a community level (bullying, stigma, community violence, and lack of positive activities) with psychological problems and orphanhood status.


One thousand twenty-five participants aged 10-19 were recruited from deprived urban settlements in South Africa. The sample included adolescents orphaned by AIDS (n = 425), adolescents orphaned by non-AIDS causes (n = 241), and nonorphaned adolescents (n = 278). Participants were interviewed using standardized psychological measures of depression, anxiety, posttraumatic stress, peer problems, delinquency, and conduct problems. Information on risk factors and demographic characteristics were also assessed.


AIDS-orphaned adolescents reported higher levels of stigma and fewer positive activities than other groups. There were no reported differences on bullying or community violence. All community-level risk factors were associated with poorer psychological outcomes. Multivariate analyses controlling for age and gender showed that experience of stigma significantly mediated associations between AIDS orphanhood and poor psychological outcomes.


Reduction of AIDS-related stigma could potentially reduce adverse psychological outcomes among AIDS-orphaned adolescents.

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Study Title: Improving Outcomes for Youth in Foster Care: Trauma-Focused CBT

Context: Children and adolescents in foster care have significant, and often unmet, mental health needs (Leslie, Hurlburt, Landsverk, & Barth, 2004). For school-aged youth, the most common problems are disruptive behavior disorders and sequelae of trauma exposure (e.g., Posttraumatic Stress Disorder [PTSD], Depression) (Landsverk, Burns, & Stambaugh, in press). Such mental health problems, in turn, are linked to a range of negative outcomes (e.g., functioning, placement stability/permanency) (James, Landsverk, & Slymen, 2004; Landsverk, Davis, Granger, Newton, & Johnson, 1996). There is tremendous interest in the field to increase use of evidence-based treatments that target specific mental health problems and needs of youth in foster care. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) potentially provides an excellent fit. Evidence from randomized trials supports the efficacy of TF-CBT in treating PTSD, behavior problems, and other trauma sequelae (Cohen, Deblinger, Mannarino, & Steer, 2004). Although TF-CBT holds promise for youth in foster care, there are likely complexities in providing it to such youth. Findings from dismantling research indicate that caregiver involvement is crucial for maximizing treatment effects of TF-CBT (Deblinger, Lippman, & Steer, 1996). However, available evidence and our clinical experience suggest that foster parents are infrequently engaged in a proactive and ongoing manner in their foster children’s mental health treatment.

Study Aims: Therefore the primary aim of the proposed R34 is to conduct a pilot study of TF-CBT with children and adolescents in foster care, with a targeted focus on engaging foster parents in treatment. The proposed project brings together two complementary interventions-evidence-based engagement strategies (McKay, Stoewe, McCadam, & Gonzales, 1998) and TF-CBT (Cohen, Deblinger & Mannarino, 2006; Deblinger & Heflin, 1996)-in an attempt to improve treatment and outcomes for youth in foster care.

Methods: The project includes two phases: Phase 1: (a) preliminary feasibility study (N = 10) of the evidence-based engagement strategies and TF-CBT; and (b) refinement and development of a manualized engagement intervention based on feedback from foster parents and other key informants. Phase 2: pilot study (N=80) of the refined engagement strategies and TF-CBT (ECBT) compared to ‘usual practice’ TF-CBT (i.e., no specialized engagement) to assess implementation of the combined intervention and provide preliminary data on critical outcomes (e.g., PTS symptoms, behavioral problems, placement stability). Findings will be used to inform a large-scale randomized trial (i.e., R- 01) on effectiveness of ECBT to improve outcomes for youth in foster care with mental health problems. Youth in foster care have very high rates of mental health problems (Leslie, Hurlburt, Landsverk, & Barth, 2004). These include externalizing (e.g., conduct disorder, ADHD, oppositional defiant disorder) as well as internalizing (e.g., anxiety, depression, PTSD) problems. Recent research on epidemiology and treatment has suggested that this combination of symptoms is often related to youth in foster care’s extensive histories of exposure to trauma (Simms, Dubowitz, & Szilagyi, 2000) Therefore, effective treatment of the symptoms requires explicit evidence-based treatment that addresses both the underlying sequelae of trauma and the immediate behavioral manifestations. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) is an evidence- based treatment that appears promising, with specific modifications, for this group of high-risk youth (Deblinger, Lippman, & Steer, 1996).

Implications: The proposed research builds from and combines existing evidence- based strategies (Cohen, Deblinger, Mannarino, & Steer, 2004; McKay, Stoewe, McDadam, & Gonzales, 1998) to more effectively treat some of the nation’s most at-risk and vulnerable youth. Findings from this research will be used to develop and disseminate more effective treatments for youth with mental health problems in the foster care system. Such findings should help improve treatment, services, and outcomes within the entire system of care that serves youth with mental health problems (e.g., specialty mental health providers, child welfare and child protective services, juvenile justice).

Principal Investigator: Shannon Dorsey (University of Washington)

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Study Title: Trauma-Focused CBT: Potential Mechanisms that inhibit and facilitate change

Context: Child maltreatment and interpersonal adversity put children at increased risk for posttraumatic stress disorder (PTSD), depression and suicide, substance abuse, and a host of negative mental health outcomes. Recent evidence documents that childhood adversity can have pernicious neurobiological and psychosocial effects that extend risk into adulthood. Trauma- Focused Cognitive-Behavioral Therapy (TF-CBT) has been demonstrated in numerous randomized clinical trials to be an efficacious treatment for maltreated and traumatized children. Early intervention with TF-CBT has the potential to alter the trajectory of risk associated with childhood adversity.

Study Aims: The overall goals of the proposed research are to identify potential mechanisms of change, inhibitors of change, and predictors of early dropout in this treatment. The proposed research integrates a sophisticated analysis of the process of change into an ongoing effectiveness trial of TF-CBT that has been transported to community mental health facilities throughout the state of Delaware.

Methods: Sessions from 75 children who received TF- CBT will be coded with an observational coding system designed to capture theoretically important therapeutic processes. TF-CBT is hypothesized to be associated with a curvilinear pattern of in-session affective arousal and cognitive/emotional processing of the trauma, with peak levels occurring when the child develops a trauma narrative in the exposure phase of therapy. A transient increase in affective arousal is thought to reflect activation of the trauma memories and to facilitate processing. More processing during this narrative phase is hypothesized to be the primary predictor of improvement in PTSD symptoms and problematic child behaviors. Therapist support and caregiver involvement in treatment are expected to help prepare the child for change by decreasing avoidance, a primary inhibitor of later arousal and processing. Caregiver avoidance and processing when exposed to the child’s narrative are also expected to predict child outcomes.

Implications: The proposed research has the potential to reveal key processes that can be mobilized to increase the potency of TF-CBT, reduce rates of dropout, and enhance therapist training as dissemination efforts are undertaken.

Principal Investigator: Adele Hayes (University of Delaware)

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Study Title: Treatment of Suicidal and Self-Injurious Adolescents with Emotional Dysregulation

Study Aims: The long term aim of our research is to develop and evaluate effective treatments for adolescents at high risk for suicide that will reduce suicidal and self-injurious behaviors as well as improve functioning and the quality of life of teens and their families. The primary aim of the research proposed here is to evaluate the efficacy of dialectical behavior therapy (DBT) for adolescents by comparing it to a combined individual and group supportive therapy control condition (I/GST) chosen specifically to maximize internal validity.

Methods: Subjects will be 170 teens 13-17 years old with borderline personality traits referred to treatment due to high risk for suicide. Outcome targets include reduced frequency and severity of suicidal behaviors, especially suicide attempts, inpatient or ER treatment for suicidality, increased maintenance in and compliance with treatment, and enhanced functioning across multiple domains. DBT has an empirical track record with adults of reducing the incidence, frequency and medical risk of suicide attempts and non-suicidal self-injuries among individuals meeting criteria for borderline personality disorder (BPD). However, although DBT is widely used with suicidal adolescents, particularly those with difficulties characteristic of BPD such as poor emotion regulation and impulse control, no randomized trial of DBT with adolescents has been conducted. Thus, although non- randomized trials suggest effectiveness, without a randomized trial we simply do not know whether DBT for adolescents is efficacious or not. Given the severity of the problem and the lack of alternative treatments for high risk adolescents, addressing this question is important. The second aim of this research is to analyze mediators of reduced suicidal and self-injurious behaviors in adolescents. DBT is based on a theoretical model that suicidal behavior is a combined outcome of high stressful events and emotion dysregulation together with inadequate behavioral skills for coping with negative emotions and life events. Risk factors for adolescent suicide and intentional self-injury include most importantly family conflict but also conflict with peers, teachers, losses, legal or disciplinary problems (stressful events) combined with high negative emotions and inadequate abilities in emotion regulation. We will analyze the potential mediating effects on suicidal behaviors of decreases in family conflict, increases in parent DBT behavioral skills, reductions in emotion dysregulation and increases in DBT behavioral skills. Preliminary data on cost-effectiveness will also be collected.

Investigators: Michele Stacy Berk, Judith Cohen

Title: The Potential for Successful Family Foster Care: Conceptualizing Competency Domains for Foster Parents

The potential to foster successfully starts with developing and supporting competency in 12 domains: (1) providing a safe and secure environment; (2) providing a nurturing environment; (3) promoting educational attainment and success; (4) meeting physical and mental healthcare needs; (5) promoting social and emotional development; (6) supporting diversity and children’s cultural needs; (7) supporting permanency planning; (8) managing ambiguity and loss for the foster child and family; (9) growing as a foster parent; (10) managing the demands of fostering on personal and familial well-being; (11) supporting relationships between children and their families; and (12) working as a team member. This article describes each domain and reviews relevant research to help guide the assessment of practicing and future foster parents.

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