Tag: trauma

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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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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Title: Cognitive behavioral therapy for symptoms of trauma and traumatic grief in refugee youth

Author: Laura Murray, Judith Cohen, B Heidi Ellis, Anthony Mannarino

Date: 2008

Abstract: The diverse clinical presentation of refugee children and adolescents after their traumatic experiences requires a treatment model that can mitigate a number of internalizing and externalizing symptoms. Refugee populations also require interventions that can adjust to the wide-ranging experiences likely encountered during preflight, flight, and resettlement. There is some evidence that immigration stressors or social stressors, such as discrimination, are associated with symptoms of posttraumatic stress disorder in refugee youth. Therefore refugee youth may benefit from multiple levels of services, ideally integrated. This article focuses on the mental and behavioral health component of services for refugee youth.

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Study Title: Randomized Controlled Trial of Ways to Improve OVC HIV Prevention and Well-Being (Zambia CBT)

Context: With millions of youth orphaned by AIDS in sub-Saharan Africa undergoing high levels of stress-related problems—such as interpersonal and problem-solving skills deficits, unhealthy thoughts, and maladaptive behaviors—addressing trauma and stress is a pressing need. Addressing these stressors is especially important in preventing the spread of HIV by reducing stress-induced risky sexual behaviors among orphaned and vulnerable children. Other studies have shown that cognitive behavior therapy interventions, when adapted for local environments, have been effective in addressing such stress-related problems.

Study Aims: This study will focus on comparing the effectiveness of psychosocial counseling (PC) and trauma-focused cognitive behavioral therapy (TF-CBT). The study will primarily compare the effectiveness of psychosocial counseling and trauma-focused cognitive behavioral therapy in addressing the stress-related problems among orphaned and vulnerable children (OVC). In addition, the study will examine the effectiveness of these two major types of treatment in reducing sexual risk behaviors while accounting for factors that mediate and moderate HIV risk behaviors. Finally, this study will compare the cost-effectiveness of the two treatment methods.

Methods: This study, which is being conducted in Zambia, utilizes a randomized controlled trial of psychosocial counseling and trauma-focused cognitive behavioral therapy, which has been utilized in other previous and ongoing studies. The major outcomes that this study will analyze include HIV risk behaviors, emotional and behavioral health, social support, overall well-being and mental health development of OVC. Researchers will recruit adolescents aged 13-17 who report risky sexual behavior, including recent sex without a condom. Adolescent participants and their caregivers will be assessed utilizing a computerized interviewing program that will enhance privacy and honesty of responses.

Policy Implications:

  • This study will provide necessary scientific evidence on the feasibility, effectiveness, and cost effectiveness of interventions for OVC affected by HIV/AIDS.
  • Results from this study will help inform efficient program design, policy, and effectiveness of interventions for preventing HIV among OVC living in low-resource settings.

M-Principal Investigators: Laura Murray (Johns Hopkins University) and Paul Bolton (Harvard University)

Investigators: Judith Cohen (University of Pittsburg), Shannon Dorsey (University of Washington), Kathryn Whetten (Duke University),

Contact Information: [email protected]

 

Study Title: Improving Outcomes for Orphaned Youth: Implementation of Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief

Context: Approximately 50 million orphaned and abandoned adolescents currently live in sub-Saharan Africa. Previous studies have indicated that many of these children and adolescents, who often have mental health problems associated with parental loss, have high rates of other traumatic experiences and ongoing trauma exposure. Because the gap in mental health care is large in sub-Saharan Africa, with few individuals in need of treatment receiving even minimal support, more information regarding how to best implement effective interventions, like Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for orphaned and abandoned children (OAC) is needed. Cognitive behavioral therapy approaches have been shown to be effective in low- and middle-income countries with adults and in wealthier nations with children and adolescents. More research on the effectiveness of CBT approaches effect resource-poor settings is needed. It is also critical to identify what level of provider and supervisor support is needed for maximum effectiveness and local feasibility. 

Study Aims: This research will examine the effectiveness of TF-CBT for treating unresolved grief and traumatic stress for OAC and adolescents in two East African countries, Tanzania and Kenya. The randomized trial will examine the effectiveness of TF-CBT compared to receipt of services as usual in these countries. The study involves collaboration with local organizations in Tanzania and Kenya, in which nine local counselors in each country will be trained by both a US-based TF-CBT expert and Tanzanian lay counselors who gained TF-CBT expertise in a previous feasibility study of TF-CBT for OAC, to deliver group-based TF-CBT for childhood traumatic grief to children ages 7-13. This study will evaluate the effectiveness of TF-CBT compared to existing services as usual orphan supports. The study will also examine the impact of implementation factors (e.g., intervention fidelity, lay counselor-supervisor relationship, child/guardian attendance) to study how enhanced local involvement and responsibility (i.e., Tanzanian lay counselor involvement in co-training and supervision) impacts outcomes.

Methods: This study build on previous work demonstrating that TF-CBT is a feasible and acceptable approach for OAC and adolescents by including a control group to properly examine the effectiveness of the TF-CBT approach. The 18 counselors who are trained in TF-CBT will deliver the treatment in 20 groups in each country, 10 rural and 10 urban, resulting in a total of 320 children and adolescents receiving the treatment (40 groups). TF-CBT and mental health experts will oversee the training of the lay counselors and the treatment given to the groups.

Policy Implications:

  • The study will examine the effectiveness of TF-CBT treatment for OAC and adolescents, as compared to receipt of services as usual in two East African Countries.
  • Incorporating experienced lay counselors in providing training and supervision in TF-CBT will inform future efforts to build local expertise and sustainability. This work will inform not only TF-CBT for CTG efforts but also efforts for scale up of other mental health interventions.
  • Generate important recommendations for OAC treatment and training approaches that are effective in low- and middle-resource settings.

M-Principal Investigators: Shannon Dorsey (University of Washington) and Kathryn Whetten (Duke University)

Investigators: Dafrosa Itemba (TAWREF), Kevin King (University of Washington), Rachel Manongi (KCMC), Karen O’Donnell (Duke University), Augustine Wasonga (ACE Africa)

Contact Information: [email protected]

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