Title: Psychological distress amongst AIDS-orphaned children in urban South Africa
Authors: Lucie Cluver, Frances Gardner, Don Operario
Abstract: BACKGROUND: South Africa is predicted to have 2.3 million children orphaned by Acquired Immune Deficiency Syndrome (AIDS) by 2020 (Actuarial Society of South Africa, 2005). There is little knowledge about impacts of AIDS-related bereavement on children, to aid planning of services. This study aimed to investigate psychological consequences of AIDS orphanhood in urban township areas of Cape Town, South Africa, compared to control groups of children and adolescents orphaned by other causes, and non-orphans. METHOD: One thousand and twenty-five children and adolescents (aged 10-19) were interviewed using socio-demographic questionnaires and standardised scales for assessing depression, anxiety, post-traumatic stress, peer problems, delinquency and conduct problems. RESULTS: Controlling for socio-demographic factors such as age, gender, formal/informal dwelling and age at orphanhood, children orphaned by AIDS were more likely to report symptoms of depression, peer relationship problems, post-traumatic stress, delinquency and conduct problems than both children orphaned by other causes and non-orphaned children. Anxiety showed no differences. AIDS-orphaned children were more likely to report suicidal ideation. Compared to Western norms, AIDS-orphaned children showed higher levels of internalizing problems and delinquency, but lower levels of conduct problems. CONCLUSIONS: Children orphaned by AIDS may be a particularly vulnerable group in terms of emotional and, to a lesser extent, behavioural problems. Intervention programs are necessary to ameliorate the psychological sequelae of losing a parent to AIDS.
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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