Involving Parents in Indicated Early Intervention for Childhood PTSD Following Accidental Injury
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- Cobham, V.E., March, S., De Young, A. et al. Clin Child Fam Psychol Rev (2012) 15: 345. doi:10.1007/s10567-012-0124-9
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Accidental injuries represent the most common type of traumatic event to which a youth is likely to be exposed. While the majority of youth who experience an accidental injury will recover spontaneously, a significant proportion will go on to develop Post-Traumatic Stress Disorder (PTSD). And yet, there is little published treatment outcome research in this area. This review focuses on two key issues within the child PTSD literature—namely the role of parents in treatment and the timing of intervention. The issue of parental involvement in the treatment of child PTSD is a question that is increasingly being recognized as important. In addition, the need to find a balance between providing early intervention to at risk youth while avoiding providing treatment to those youth who will recover spontaneously has yet to be addressed. This paper outlines the rationale for and the development of a trauma-focused CBT protocol with separate parent and child programs, for use with children and adolescents experiencing PTSD following an accidental injury. The protocol is embedded within an indicated intervention framework, allowing for the early identification of youth at risk within a medical setting. Two case studies are presented in order to illustrate key issues raised in the review, implementation of the interventions, and the challenges involved.
A Brief Overview of PTSD in Children and Adolescents
Classified as an anxiety disorder, PTSD consists of three core symptom clusters—re-experiencing of a traumatic event; emotional numbing and avoidance of reminders of that event; and physiological hyperarousal. Importantly, recent research has indicated that there is no difference in terms of distress, social, and academic impairment, between children meeting full criteria (i.e., all 3 of the symptom clusters) and children demonstrating what is referred to as ‘partial PTSD’ (Carrion et al. 2002). Partial PTSD can be described by various algorithms—that is, the ‘two of three’ method, where two of the three symptom clusters are met (Carrion et al. 2002) or the PTSD-AA method, where only one re-experiencing, one avoidance, and two hyperarousal symptoms are met (Scheeringa et al. 2011). The similar levels of subsequent impairment irrespective of diagnostic classification system that utilized highlight the importance of studying children and adolescents who meet criteria for not only the full PTSD diagnosis, but also the partial diagnosis.
Youth may develop PTSD following exposure to a wide array of traumatic events. It is important to keep in mind, however, that the majority of children and youth who experience traumatic events do not go on to develop PTSD, and of recent times, the term ‘potentially traumatic events’ (PTEs) has been advocated in order to highlight this point. The trauma that results in PTSD may be of either a chronic, recurrent nature (e.g., physical or sexual abuse; neglect), or it may represent a single incident (e.g., an act of terrorism, or a motor vehicle accident; MVA). Based on American figures, by the age of 16 years, approximately 2 in 3 youth have been exposed to a significant traumatic event (Copeland et al. 2007). And yet, in this study, although trauma exposure (across a wide range of traumatic events) was common, the development of full PTSD in the sample studied was rare—0.5 %.
The question of risk factors that make some youth more likely to develop PTSD relative to others is one that has received much attention. The most recent and comprehensive meta-analysis examining risk factors for the development of PTSD in primary school aged children and adolescents were conducted by Trickey and colleagues (Trickey et al. 2012). Trickey et al., reported that, across the 64 studies reviewed, variables relating to the subjective experience of the event and post-trauma factors accounted for medium to large population effect sizes. Specifically, the factors identified in this category included: poor family functioning; low social support; perceived threat to life; psychiatric comorbidity; peri-trauma fear; social withdrawal; use of cognitive strategies such as distraction and thought suppression; and diagnosis of PTSD at an earlier assessment point following the traumatic event. Small to medium population effect sizes were noted for the following variables: female sex; low socio-economic status; pre-trauma low self-esteem; low intelligence; pre- and post-trauma life events, pre-trauma psychological problems in the youth and parent; bereavement; post-trauma parental psychological problems; trauma severity; time elapsed since the event occurred; and media exposure to the event. Small effect sizes were observed for younger age and race.
Across the different categories of trauma exposure, PTSD in youth is associated with significant impairments in both social- and academic functioning. PTSD in young people is typically chronic and debilitating (e.g., La Greca et al. 1996). In addition, youth who develop PTSD frequently develop other psychiatric disorders. Across the age range of childhood and adolescence, comorbidity is the rule rather than the exception. In pre-school aged children with PTSD, the most common comorbid problems include: Oppositional Defiant Disorder, Separation Anxiety Disorder, Attention Deficit Hyperactivity Disorder, and Major Depressive Disorder (DeYoung et al. 2012; Scheeringa and Zeanah 2008). In primary school aged children, mood disorders (most notably depression), anxiety disorders, and attention deficit hyperactivity disorder are among the most common comorbid diagnoses (e.g., Davis and Siegel 2000). In adolescents, suicidal ideation, substance dependence, anxiety disorders (particularly, Specific Phobia, Generalized Anxiety Disorder and Social Phobia), and Major Depressive Disorder (Bolton et al. 2000; Davis and Siegel 2000; Perrin et al. 2000; Reed et al. 2007) are among the most commonly reported comorbid psychological difficulties.
Finally, untreated PTSD in children and adolescents is also likely to be associated with a significant economic burden. Societal costs include increased healthcare costs, as well as loss of productivity (Ziegler et al. 2005). The importance of the high levels of comorbidity between child/adolescent PTSD and depression, other anxiety disorders, and substance dependence is especially worth noting in terms of burden. In addition, children exposed to traumatic stress have been reported to be at greater risk for developmental delays and poor impulse control (Wong 2008)—characteristics that carry a personal, familial, and societal cost.
Why are Accidental Injuries Important?
Despite the fact that chronic or repetitive types of trauma exposure (such as abuse) tend to receive more attention both in the public and in the research domains, in fact, of all the potentially traumatic events to which a youth may be exposed, accidental injuries are the most common. In Australia, each year, 2500 per 100,000 youth require a hospital admission as a result of a serious accidental injury (AIHW—Berry and Harrison 2007). Trauma exposure to accidental injuries requiring a hospital admission thus poses an unusually significant risk to children in terms of the development of PTSD (Kassam-Adams and Winston 2004; Kenardy et al. 2006; Nixon et al. 2010). As will be noted again, single incident trauma (of which accidental injuries are one example) tends to be a neglected field, with the specific trauma type of accidental injury being even more neglected. We would argue that this is especially unfortunate given that (a) accidental injuries are the most common PTE to which a child or adolescent is likely to be exposed; and (b) there appears to be much potential to improve the psychological trajectories of children and adolescents who develop PTSD following an accidental injury—arguably more potential than there is to improve the trajectories of youth exposed to other types of PTEs.
The reported prevalence of full criteria PTSD in youth who have experienced any kind of accidental injury (including MVAs, but also other accidental injuries such as burns and sporting injuries) varies between 6 and 45 % depending on variables such as the type of injury sustained. For instance, Aaron et al. (1999) reported that 22.5 % of participants met criteria for PTSD following a physical injury. Other studies have reported that up to one third of youth who experienced an MVA were experiencing PTSD 6 weeks after their accident (Mirza et al. 1998; Stallard et al. 2004), with approximately 18 % of youth still significantly affected 6 months after the accident (e.g., Bryant et al. 2004).
As noted above, comorbidity is common in youth with PTSD. In the area of accidental injury, youth have been shown to demonstrate significantly elevated rates of other emotional and behavioral problems (especially anxiety disorders), in comparison with community samples and youth admitted to hospital for non-trauma-related health reasons (Murray et al. 2007). Importantly, an association has also recently been demonstrated between the development of PTSD and youth health-related quality of life both in the short-term and the long-term (e.g., Graham-Bermann and Seng 2005; Landolt et al. 2009).
Treatment of PTSD in Youth Following a Single Incident Trauma
Silverman et al. (2008) reviewed psychological treatments for youth exposed to traumatic events using criteria for establishing empirically supported therapies developed by Chambless and Hollon (1998), Chambless et al. (1996). Consistent with the NICE (2005) guidelines, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) was the only treatment to meet the well-established criteria. More recent reviews (e.g., Kowalik et al. 2011) continue to identify TF-CBT as the treatment of choice for childhood PTSD. A brief review of TF-CBT is presented below.
Recent models of the psychological impact of trauma suggest that the way in which people remember and recount threatening events significantly effects how well they manage and adjust to those experiences (e.g., Ehlers and Clark 2000). These models propose that PTSD and other negative psychosocial outcomes are maintained by a sense of serious current threat which arises as a consequence of the following: (1) a disturbance of autobiographical memory (i.e., an individual’s “story” about what happened to them) characterized by poor elaboration and contextualization, strong associative memory, and strong perceptual priming and (2) excessively negative appraisals of the trauma event and/or its consequences (e.g., symptoms of PTSD may be interpreted negatively—“I keep having all these thoughts about the accident that I don’t want to have—I must be going crazy!”). Adaptive changes in the trauma memory are prevented by certain behavioral (e.g., avoidance of trauma-related stimuli) and cognitive (e.g., distraction) coping styles. Trauma-focused CBT then aims to challenge unhelpful appraisals and provide exposure to the trauma memory. As noted below, the importance of working with parents is also increasingly being recognized.
Importantly, of the 21 identified treatment studies that met Silverman et al.’s (2008) inclusion criteria of being randomized clinical trials (RCTs), only three involved participants had experienced a single incident trauma. This highlights the conclusion drawn by Adler-Nevo and Manassis (2005): research on the subject of treatment of pediatric PTSD following single incident trauma represents a neglected area. Of these three studies, one focused exclusively on participants who had experienced an accidental injury in the form of an MVA (Stallard et al. 2006); one focused on single incident traumas in the form of either an MVA or an incident of violence (Smith et al. 2007); while the third focused on victims of a hurricane (Chemtob et al. 2002). Of the two studies examining children who had developed PTSD following an accidental injury, the intervention (CBT) employed by Smith et al., met the criteria for possibly efficacious, while the intervention (Psychological Debriefing) employed by Stallard et al., was classified as an experimental treatment.
In the years since the publication of the meta-analysis by Silverman et al., the first RCT examining TF-CBT with pre-school aged children experiencing PTSD following either a single incident or repeated trauma exposure was published in 2011, while the first RCT examining TF-CBT for youth experiencing PTSD following a single incident trauma was published in 2012. Building on their earlier work (Scheeringa et al. 2007), Scheeringa et al. (2011) randomly assigned 64 children aged 3–6 years to either TF-CBT or a 12-week waitlist control condition. Children had a history of both single incident and repeated trauma. Children in the active intervention condition improved significantly more on PTSD symptoms compared with children in the WL condition, and these effects were lasting to the 6-month follow-up assessment.
Nixon et al. (2012) evaluated TF-CBT and compared it to a version of itself minus the exposure element with 33 youth aged 7–17 years who had developed PTSD following a single incident trauma. Although the participants were a mixture of children who had experienced either an accidental injury or a deliberate act of violence, the RCT conducted by Nixon et al. (2012) is the single study that is most directly relevant to the current research. The study was a pilot in which participants were 33 young people who met either partial or full criteria for PTSD following a single incident trauma (including MVA, assault, house fire, home invasion). Participants were randomly assigned to either an individual TF-CBT condition or an individual TF-CBT condition without exposure (referred to as CT). Parents were involved in both conditions, with the authors noting that in both conditions, although the time spent with the child versus parents within a given session was variable, overall, approximately two thirds of total therapy time was spent with the child and one third with the parents. On the basis of their findings, Nixon et al. noted that both their TF-CBT and CT conditions were successful in improving children’s PTSD symptoms. This study represents an extremely important advance. However, the number of participants was small, and it remains unclear as to exactly how parents were involved—there do no appear to have been separate sessions for parents at any point, rather it seems that parents were given separate content within their child’s session. Importantly, the different types of single incident trauma studied are quite distinct from one another in that MVAs, and house fires are typically regarded as ‘accidents’, while home invasions and assaults are regarded as acts of intentional violence. Finally, no health-related outcomes were examined.
Overall, research has demonstrated strong support for TF-CBT in the treatment of childhood PTSD. However, more research is required focusing on youth exposed to single incident traumas. This is particularly true of accidental injury-related single incident trauma. The absence of research in this field is at odds with the high incidence of exposure to accidental injuries and subsequent development of PTSD in youth. Clearly, more work is required. In addition, several important questions remain unanswered, including the importance of parental involvement in treatment and optimal timing of interventions.
Parents: Relational Patterns in PTSD
In the meta-analysis conducted by Trickey et al. (2012), poor family functioning was observed to have a medium to large population effect size, while pre- and post-trauma parental psychopathology were noted to have small to medium population effect sizes in predicting child PTSD. Clearly, these parent-related factors do not account for all or even a majority of the variance in predicting which youth develop PTSD following exposure to a PTE. And yet, they are crucially important—not least because they are among the few factors identified that can potentially be targeted for change. Across the age span that makes up childhood and adolescence, parents or caregivers and the family system occupy unique positions of reciprocal influence (whereby children and adolescents influence their parents’ behavior and vice versa). Increasingly, attention has turned to the role of parenting practices and the relationship between parent and child dyads as potential risk factors for the development of PTSD in children. In a valuable review of studies examining parental/family variables and their association with child PTSD, Scheeringa and Zeanah (2001) proposed three relational patterns (withdrawn/unavailable; overprotective/constricting; and re-enacting/frightening) that may characterize a parent–child dyad in which post-traumatic stress exists in both the parent and the child (either about the same event or different events). Although these authors were specifically referring to pre-school aged children and their care-givers with PTSD, these relational patterns are consistent with the small literature examining parenting patterns in caregivers of youth with PTSD (e.g., McFarlane 1987; Cobham and McDermott 2010; McDermott and Cobham, 2012) and also overlap considerably with the literature on anxiety-disordered children and their parents (specifically in terms of the role of overprotection). It is thus proposed that these relational patterns represent useful constructs to keep in mind when working with a child or adolescent with PTSD and their parent (regardless of whether the parent also has PTSD).
The Role of Parents in Treatment
Quite unusually in the field of child and adolescent mental health, there are some forms of trauma exposure resulting in PTSD in children (most notably, child sexual and physical abuse), where, historically, treatment has been offered to parents alone, without children being involved. In the child sexual and physical abuse literature, early research with children who have experienced childhood sexual abuse suggested that treating parents in isolation to their children may not be the best approach. Thus, Deblinger et al. (1996) compared TF-CBT delivered in three different modalities: parents only; children only; and parents + children. These three conditions were compared with a community treatment as usual sample. The results indicated that the combined parent + child intervention developed by Deblinger et al., produced superior results. Runyon et al. (2010) demonstrated a similar result, reporting that a combined parent + child CBT group intervention produced better results with children who had experienced physical abuse compared to a parent-only version of the same intervention.
In the field of single incident trauma, on the other hand, treatment has traditionally focused on the child alone. In this area, no well-conducted research exists examining the role of parents in the treatment of their children’s PTSD.
Given this lack, it is worth looking briefly at the related field of child anxiety disorders, where the question of parental involvement in treatment has received considerable attention of recent years. As Rapee (2012) notes in his recent review, the issue of whether there is any additional benefit in involving parents in the treatment of anxiety-disordered children is a ‘vexed’ one, with Khanna and Kendall (2009) commenting that ‘even child-focused programs involve parents to some degree’. A number of meta-analyses and reviews would seem to indicate that programs in which parents are actively involved in treatment produce no greater gains than programs targeting the anxious children alone (In-Albon and Schneider 2006; James et al. 2006). However, their very meticulous review of the literature led Cresswell and Cartwright-Hatton (2007) to conclude that involving parents in treatment does provide an additional benefit, although the effects may be small. Importantly, the meta-analyses to date have not considered the different ages of the children in different studies, and whether this variable makes a difference to the utility of incorporating parents. Admittedly, as has been noted by other authors, few studies that feature in the meta-analyses and reviews referred to have either a large enough age range or sufficient power to detect an age effect (Cresswell and Cartwright-Hatton 2007; Rapee 2009). From a clinical, intuitive perspective, two things are often assumed: (1) there are many advantages to actively involving parents in therapy; and (2) this is particularly true for younger children, as opposed to adolescents (e.g., Rapee 2012). In relation to the first assumption, Siqueland and Diamond (1998) provided an elegant rationale for parental involvement in treatment that is as relevant for parents for children with PTSD as it is for parents of anxiety-disordered children: “parents can help their child practice the skills taught them in [session] … and generalize learning to other contexts … [as] maintenance of gains … will depend on the child’s continuing ability to use these coping skills on new challenges and opportunities. Second, parents’ beliefs and attitudes about their child’s abilities, their own abilities to cope, and the safety of the world may impede progress. Third, changes in the child may threaten parents by destabilizing familiar, though uncomfortable, family dynamics” (p. 82). Based on our own work (e.g., Cobham 2012; Cobham et al. 2010), we would add that active involvement in treatment also provides parents with the opportunity to learn strategies that they are able to apply in their own lives and to reflect upon the ways in which they are parenting their anxious children and whether or not these current strategies are effective. Increasingly, researchers in the field of child anxiety disorders are noting that parental involvement in a child’s treatment occurs on a continuum, with many different levels of intensity available—and that there may be specific characteristics about individual cases that make active parental involvement more or less likely to be beneficial (e.g., parental anxiety; Cobham et al. 1998). In keeping with this attitudinal shift, attention is moving toward an attempt to understand the factors (within a child, within a family) that make parental involvement more or less important.
Returning to the role of parents in the treatment of their children’s PTSD, a final point worth making is that, although efficacious treatments for PTSD in youth exist, only a minority of children with PTSD engage in or are retained in ‘trauma treatment’ (e.g., McKay et al. 2005). The issue of how to increase attendance and adherence at child therapy is one that is beginning to receive some long overdue attention (Nock and Kazdin 2005). Of the small number of controlled studies which have evaluated methods for achieving these goals, one of the strategies noted to be successful is providing greater attention to parent issues during the course of treatment (e.g., Prinz and Miller 1994). Most recently, Saxe et al. (2012) reported that forming a treatment alliance with the family and providing psychoeducation are potentially critical strategies in improving engagement and retention in trauma treatment.
To sum up the ‘vexed’ question of parents’ involvement in the treatment of their children’s PTSD, the evaluation of a condition that deliberately and systematically includes parents in treatment is in keeping with the most recent practice parameters for treating youth with PTSD (American Academy of Child and Adolescent Psychiatry 2010). Increasingly, it is being acknowledged that parental reactions, psychopathology and coping strategies all have the potential to play an important role in the development and maintenance of children’s PTSD (e.g., Keppel-Benson et al. 2002; Le Brocque et al. 2010; Meiser-Stedman et al. 2006). To date, very few treatment studies in this area have included a parental treatment component, with those that have, concluding that a combined parent and child trauma-focused CBT condition results in the best outcomes for children. Although the recent pilot studies conducted by Smith et al. (2007) and Nixon et al., (2012) did include some degree of parental involvement, this was not quantified and did not appear to be administered in a standardized fashion. Based on the literature from the related field of child anxiety disorders, it may be concluded that parental involvement appears to confer some additional benefit, though the effect may be small in size. From the limited evidence available, it is clear that an important direction for future research centers around the question of whether involving parents in treatment significantly enhances child-focused TF-CBT.
The Timing and Context of Treatment
One of the most controversial issues in the treatment of PTSD (regardless of whether the client group is children, adolescents or adults) is timing. The reason for this is straightforward—as noted, although many (perhaps most) people experience some distress and stress in the immediate aftermath of a PTE, the overwhelming majority do not develop PTSD and recover from their distress without requiring professional help. As McNally et al. (2003) note in their seminal paper, “the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery” (p. 45). Psychological debriefing has been particularly controversial as the most widely used method of crisis intervention. As McNally et al., note, although most survivors describe the experience of psychological debriefing as helpful, there is no robust evidence that debriefing decreases the incidence of PTSD, and indeed, a growing body of evidence indicating that it may actually interfere with individuals’ natural recovery from trauma (e.g., Bisson et al. 1997). McNally et al., are clear in differentiating between ‘crisis interventions’ (delivered in the immediate aftermath of a PTE) and ‘psychotherapy’ that is administered weeks or months after the PTE. In reviewing the adult literature on CBT interventions administered 1 to 3 months after a trauma, McNally et al., noted that these interventions show encouraging results for individuals with PTSD and that “relative to no treatment, CBT promotes recovery from trauma” (p. 72).
The present study attempts to examine the issue of timing with an even greater degree of precision. As noted previously, a crucial gap in this literature is the absence of studies that seek to provide early, indicated intervention to, at risk, youth through using a stepped screening and assessment process. Traditionally, RCTs have represented the gold standard in answering the question of how large a reduction in risk occurs among those experiencing a psychological disorder, and tertiary interventions will always have a role in the treatment of PTSD. However, increasingly in the adult literature, attention is turning toward the many benefits of early intervention, screen and treat approaches, and a stepped care model (e.g., Roberts et al. 2009; Zatzick et al. 2004). Recently, Zatzick et al. (2009) compared the effect size, reach indices and population-level reductions in PTSD incidence in an adult sample who participated in either a CBT trial or a stepped collaborative care (CC) trial. Collaborative care is defined by Zatzick et al. (2004) as “a disease management strategy that uses multifaceted interventions…with the aim of integrating mental health interventions into general medical care” (p. 499). The CBT trial demonstrated a larger effect size (50 % PTSD prevention) compared to the CC trial (7 % prevention); but a significantly reduced reach (27/10,000) compared to (1762/10,000) in the CC trial. Modeling of the reach data indicated that dissemination of the stepped collaborative care model used would produce a 9.5 times greater reduction in the incidence of PTSD compared to the CBT approach. When it comes to PTSD related to traumatic injuries, increasing reach can be achieved via routine screening in a medical setting. As demonstrated by the work of Zatzick and colleagues, the ability to increase our reach has a direct impact on the potential for disease reduction. As such, the importance of early, targeted intervention approaches cannot be overemphasized.
The cases reported here represent, to the best of our knowledge, the first reported cases in which accidental injury-related PTSD in youth is treated using TF-CBT and an early intervention approach (in the form of a stepped screening and assessment model embedded within a medical setting).
The following provides an overview of two TF-CBT interventions developed by three of the authors for the treatment of PTSD specifically following a non-intentional injury. A context, in terms of the study design, is also briefly provided. This is followed with two case studies to illustrate challenges in the implementation of each program with young people and the positive outcomes associated with the interventions. The cases have been selected with a view to highlighting key issues and controversies covered in the preceding review.
An Indicated Early Intervention Framework Comparing Child and Family-Focused Interventions: The Study Design
The manualized interventions described here are currently being evaluated in a National Health and Medical Research Council (NHMRC) funded, multi-site RCT evaluating the efficacy of TF-CBT in youth (7–16 years) experiencing PTSD following an accidental injury. The design of this study is unique in the literature; in that, participants are identified and screened for PTSD within 2 weeks of their accident but are not admitted to the trial unless they continue to screen positive and fulfill diagnostic criteria for PTSD approximately 6 weeks following their accident. The study was designed in this way with a view to finding the balance between early intervention (before a youth’s PTSD and associated problems becomes entrenched) and avoiding the provision of treatment to youth who will spontaneously recover from a ‘premature’ diagnosis of PTSD. The assessment and intervention timeframes clearly place the interventions in McNally et al.,’s (2003) ‘psychotherapy’ category, as opposed to ‘immediate emotional first aid’. Participants are recruited through major Australian Children’s Hospitals. Following a positive screen on the Child Trauma Screening Questionnaire (CTSQ; Kenardy et al. 2006) and a diagnosis of either full or partial PTSD on the Clinician Administered PTSD Scale for Children (CAPS-CA; Nader et al. 1994), participants are randomly assigned to one of three conditions: child-focused TF-CBT, family-focused TF-CBT or waitlist control. Full details of the study methodology and rationale for treatment conditions are available, see Kenardy et al. (2010).
The interventions consist of 2 integrated but distinct programs—one for parents (“My child and the accident: A story with a good ending”; Cobham et al. 2007a) and one for youth (“Me and the accident: A story with a good ending”; Cobham et al. 2007b). Each program consists of a workbook which is given to parents/youth and a therapist manual. In both treatment conditions, participants are seen individually. All sessions in both treatment conditions are of approximately 1.5 h in duration. Both programs constitute TF-CBT and have been strongly influenced by the Ehlers and Clark (2000) model of emotional trauma.
Providing psychoeducation about PTSD (with a view to helping parents to understand how PTSD develops and is maintained), as well as explaining the rationale for the youth program (with particular emphasis on the need for youth to retell their story about the accident);
Teaching parents about core concepts from the youth program (for instance, “The Scientific Approach” and “Intruder Thoughts”) in order that parents have a sound understanding of key concepts to be taught to their children—and are thus able to encourage their children to generalize the use of these concepts and strategies;
Normalizing the ways in which families can change (e.g., becoming more protective, seeing the world as a more dangerous place) when ‘something bad happens to a family member’, and encouraging parents to think about any changes that may have occurred in their own parenting behaviors or within the family system more generally; and
Strategies for helping parents to manage their children’s traumatic stress more effectively (e.g., re-establishing routines), and problem-solving.
Children whose parents receive this program are aware that their parents are attending their own sessions. However, the extent to which they are aware of the content of the parent sessions is a matter left to the parent–child dyad to determine.
Psychoeducation about the role of thoughts, behaviors (avoidance), and physical reactions in anxiety (and in PTSD in particular);
Stories—why these are important, how they might be unnecessarily frightening, and how they can change;
Danger and ‘nowness’—children’s perceptions of current danger or threat and to what extent they feel that the traumatic event is happening again now (as opposed to in the past) when they retell their accident story;
“Hot spot thoughts” and the Scientific Approach to gathering evidence both for and against distressing and anxiety-provoking thoughts;
“Intruder thoughts” and how to manage these;
Behavioral experiments; and
A plan for the future—“You’re not just a survivor, you’re an expert” (relapse prevention and developing a Tip Sheet to help other youth experiencing traumatic stress following an accidental injury).
Children tell their story of the accident for the first time in the second session. In this session, therapists use standardized prompts to elicit as much information from the child about what happened; and what they were thinking, feeling and doing before, during and after the accident. In this session, therapists are essentially prompting children in order to obtain as full an account of their story as possible. In contrast, in each subsequent session (sessions 3–6), therapists are active participants in the story-telling. They make use of the Scientific Approach as well as standardized questions (e.g., “But what actually happened?”) to help children challenge their unhelpful appraisals. After each telling of the story, children rate the scariness and nowness of their story. In session 6 (entitled, “I’m so over it”), children review and record changes from session to session in these scores, after telling their story for a final time. At the booster session 4 weeks later, children receive a copy of their final version of their accident story.
Regardless of their condition, the structure and communication processes involved in the youth program are identical. Thus, each session, both parents and the youth are invited into the therapy room and each family member is asked for their perspective on how the previous week has been. The therapist then provides the parent(s) with a brief overview of the session content to be covered. The parent(s) then leave the room. At the end of each session, parents are asked to return to the therapy room, and their child provides them with a summary of what was covered in the session, as well as homework tasks to be completed.
Case Illustrations and Method
The case studies are presented to highlight some of the key issues discussed in the earlier review, the promising outcomes achieved through the implementation of the two different programs, and the challenges involved in using this type of trauma-focused intervention with children and adolescents.
The following measures were used to determine post-traumatic stress caseness, severity, and associated variables of interest prior to and following intervention. All have strong and well-documented psychometric profiles and are discussed in depth in the description of the research protocol (Kenardy et al. 2010).
Measures of child symptoms included the Child Trauma Screening Questionnaire (CTSQ; Kenardy et al. 2006), the Child PTSD Symptom Scale (CPSS; Foa et al. 2001), the Spence Child Anxiety Scale (SCAS; Spence 1998), the Child Depression Inventory—Short Version (CDI-S; Kovacs 1983), and the Child Behavior Checklist (CBCL; Achenbach and Rescorla 2003). Child diagnostic status was determined using the Clinician Administered PTSD Scale for Children (CAPS-CA; Nader et al. 1994).
Measures of parent symptoms included the Depression Anxiety and Stress Scale (DASS; Lovibond and Lovibond 1995), the State-Trait Anxiety Inventory (STAI; Spielberger et al. 1970), and the Post-traumatic Stress Diagnostic Scale (PDS; Foa 1992).
Child Quality of life was measured by the Pediatric Quality of Life Inventory, Child and Parent Versions (PedsQL; Varni et al. 1999).
Satisfaction with the intervention was assessed using a 7-item questionnaire completed by parents and children. Parents and children rated on a 5-point scale, from 1 (no satisfaction) to 5 (very much) how satisfied they were with various aspects of the intervention. An average satisfaction score was calculated for parents and children.
Changes in PTSD diagnostic status and severity of PTSD were assessed using the CAPS-CA. The reliable change index (RCI; Jacobson and Traux 1991) was calculated to determine whether the magnitude of the change on symptom questionnaires was statistically reliable. The RCI could only be calculated for measures for which test–retest reliability data were available. For measures where the RCI could not be calculated (PedsQL and DASS), qualitative interpretations were made.
Case Study 1: Method
Description of Accident and Injury
Abby was an 8-year-old Caucasian girl who lives with both of her biological parents, older brother, and sister. The family endorsed belonging to the highest socio-economic group listed on the demographic questionnaire (combined income >A$120,000). Abby was admitted to hospital for treatment of a burn injury to her abdomen, pelvic, and genital area. The burn injuries were sustained when Abby knocked over a hot noodle cup, which she had been holding in her lap. Her mother (Samantha) was sleeping at the time and her older sister (11 years old) provided the immediate response to Abby’s accident, taking her to the shower and running cold water over her burns. Samantha reported experiencing high levels of distress when she became aware of what had happened.
According to Samantha, Abby was kept in hospital for longer than was initially intended due to some complications as well as her mother’s lack of confidence in being able to care for her at home. While in hospital, Abby underwent two dressing changes and had an indwelling catheter inserted daily. Following discharge, Abby attended the outpatient’s clinic over a two-week period to undergo two more dressing changes and final review.
At the initial diagnostic assessment, 6 weeks following her hospital admission, Abby met criteria for full PTSD. Specifically, Abby was experiencing intrusive recollections and nightmares. She also reported extreme distress at and avoidance of exposure to cues that reminded her of the accident (e.g., the couch on which she had been sitting, a display of noodles at the supermarket, and the front seat of the car in which she had traveled to hospital). Abby also reported being unable to remember many aspects of the traumatic event. She reported difficulty concentrating on even previously enjoyable tasks, as well as persistent hypervigilance and an exaggerated startle response since the accident. In addition to these symptoms, Abby also demonstrated an increased clinginess to her mother and sister and reported that she felt guilty about the accident because this had upset her mother who was ill on the day of the accident.
Importantly, according to her own self-report, prior to treatment, Samantha actively avoided talking to her daughter about the accident (thinking this would make Abby’s distress worse), allowed Abby to avoid all accident-related stimuli, and became generally more protective about her daughter.
Relevant Background History
Abby had not previously been admitted to hospital, nor had she previously presented for psychological assistance.
Samantha had a self-reported history of child sexual abuse, and more recently, a history of migraines, anxiety, and depression. Samantha stated that she had been previously hospitalized during one depressive episode and had also previously received counseling. She also reported experiencing current symptoms of traumatic stress and general distress resulting from Abby’s burn injury (e.g., intrusive images of accident and treatment, sleep disturbance, excessive guilt).
Case Study 1: Results
Baseline assessment and diagnosis
Case Study 1: Pre- to post-treatment outcome scores and diagnostic information
4-week (following parent intervention)
SCAS total score
2 (T score = 47)
0 (T score = 39)
27 (T score = 76)a
15 (T score = 65)a, b
9 (T score = 58)
5 (T score = 51)
18 (moderate)a, b
20 (moderate)a, b
With respect to parent functioning, Samantha met criteria for a diagnosis of partial PTSD and demonstrated a moderate level of PTSD symptom severity. Furthermore, she scored in the clinical range on the STAI state and trait forms, suggesting a high level of trait and state anxiety. However, her self-report on the DASS indicated normal levels of anxiety and depression and mild levels of stress. It should be noted, however, that the DASS incorporates more of the physical elements of anxiety, whereas the STAI refers more to worrying and anxiousness generally.
Upon being accepted into the study, Abby was randomly allocated to the family-focused therapy condition.
Session and Activity Completion
Abby and Samantha attended all sessions on time, were very motivated and engaged during sessions, and completed all in-session activities. Abby was very articulate at describing her emotions and demonstrated a good understanding of session content. Abby and Samantha were also both compliant with completing the homework tasks.
Story Retelling and the Behavioral Experiment
In the parent sessions, Samantha found the story-telling task very difficult. During the first story-telling, she reported subjective units of distress (SUDs) of up to 10/10 and was tearful throughout. Key issues that arose from Samantha’s story included the distress she felt when she was first separated from Abby in the emergency department, seeing Abby in pain (e.g., “stop screaming”), and dressing changes (she was unable to stay in the room). Samantha was also particularly upset that she was unable to control her anxiety in front of her daughter and that Abby kept apologizing to her for the accident. At the next session, Samantha reported that it was the first time she had talked about the incident in that much detail, and she was feeling much calmer and less guilty after telling the story. By the end of the final session, Samantha reported that she did not feel as though she was reliving the event as much and was more positive and realistic about how she handled the situation.
In the child sessions, Abby also found the first story-telling very difficult and reported SUDS ratings of up to 10/10. She spoke in a very quiet, timid voice and became teary during the middle of the story. She required lots of prompting and reassurance to continue talking, often answered, “I don’t remember” and skipped past distressing parts of the story. Abby reported that she felt like she was getting burnt all over again and her perception of current danger was an 8/10. Following this session, Abby’s distress escalated. She reported that this was a consequence of thinking about the accident but, importantly, also of seeing her mother’s distress. During the next session, Samantha reported that Abby had increased sleep disturbance, reduced appetite, and had been more teary and clingy over the 4 days since the last session. She also reported that she had refused to look at her workbook until the day before and that it took her 3 h to do that week’s homework activity (thought diary).
However, there was a dramatic improvement when Abby told the story for a second time. Abby reported a SUDs of 8/10 at the start of the story; however, she became increasingly confident and her SUDs dropped to 0 during the story and remained there until the end. By the final story retelling in session 6, Abby spoke in a confident loud voice, provided significant detail with no prompting and described positive aspects of the experience. Abby’s danger rating also dropped to 1/10.
For the behavioral experiment task, Abby was assisted to develop and implement a graduated exposure hierarchy focusing on noodles. By the booster session, Abby was able to talk about noodles without becoming upset, no longer avoided watching advertisements for noodles on television and was able to eat dry or cold noodles.
Process Issues and Barriers
At the time of the exacerbation in Abby’s traumatic stress symptoms (following the first retelling of the story), Samantha reported that Abby’s father was expressing concerns about the treatment program. According to Samantha, he was upset at his daughter’s distress and was worried that treatment was making her worse. In order to contain the father’s anxiety, the offer made at the beginning of treatment was reiterated for him to attend sessions and/or have telephone contact with the therapist. Although this offer was declined, it appeared to have had the effect of containing the father’s anxiety, and by the end of Abby’s treatment, the father was pleased with the progress made by both his wife and daughter.
Both Abby and Samantha reported that the program helped them to overcome Abby’s difficulties. Abby’s average satisfaction rating for the child program was 4.86/5, indicating a high level of satisfaction with the program. Samantha’s average satisfaction rating for the treatment program was 5.0/5. Specifically, Samantha reported that she found it particularly useful to gain a good knowledge regarding the therapy material before her daughter started sessions, so that she could assist Abby during therapy. Telling the story for the first time was reported as the most difficult component of therapy by both Abby and Samantha; however, both agreed that it was also the most important element of the treatment program. Samantha also reported that she gained greater confidence in her parenting skills over the course of treatment, which helped her to assist Abby in her therapy tasks.
Following treatment, Abby’s results on the diagnostic interview and questionnaire indicated a significant improvement in functioning. Abby no longer met criteria for partial or full PTSD. Abby showed significant improvements in her sleep, avoidance of activities and places that reminded her of the accident and no longer experienced intrusive recollections of the accident or hospital admission. At post-treatment, Abby no longer became distressed when discussing or reminded of the accident. Overall, she reported significant improvements in her functioning following treatment.
Consistent with the information derived from the diagnostic interview, Abby showed significant improvements in PTSD symptoms on the CPSS by post-treatment (immediately following the child sessions), with her scores reducing into the nonclinical range. There was a similar reduction in overall anxiety levels as measured by the SCAS questionnaire and the Internalizing scale of the CBCL.
In terms of health-related quality of life, at post-treatment, Abby demonstrated marked improvements in physical and emotional functioning as indicated by both child and parent reports on this measure. There was an apparent reduction in school functioning by the post-treatment point. It is, however, important to note that the pre-treatment assessment was conducted while Abby was on school holidays, whereas the post-treatment assessment was conducted when she had returned to school. Based on Samantha’s report, the onset of Abby’s school functioning difficulties was following the accident, largely due to difficulties Abby had separating from her mother, concerns about what her friends thought about the accident and also because Samantha was concerned about the teachers eating noodle cups in the school playground. Across the course of therapy, Abby was able to attend school again most days for the whole day, and the teacher was reportedly happy with her progress.
In relation to progress as rated by Abby in her workbook, her “scariness” rating for her accident story dropped from 10/10 to 0/10; her “nowness” rating (i.e., how much it feels like the event is occurring again now) similarly dropped from 10/10 to 0/10 by the final session. Over the course of treatment, Abby’s perception of ‘how dangerous place the world is’ dropped from 8/10 to 1/10 by the final session.
In terms of parent functioning, Samantha no longer demonstrated any PTSD symptoms as measured by the PDS. In fact, this was evident immediately following the parent component of the intervention (week 4) and maintained at post-treatment assessment. However, Samantha demonstrated a significant increase in state anxiety as measured by the STAI, as well as depression and stress, as measured by the DASS. Samantha demonstrated depression and stress in the moderate level at post-treatment and state anxiety in the clinical range. Further probing revealed that a close friend’s baby had passed away in the weeks leading up to the post-assessment and that Samantha was experiencing some stress, anxiety, and depression in relation to this event.
In terms of reliable change indices (at a criterion of p < .05 or better), as is evident in Table 1, a clinically reliable change was demonstrated for the SCAS, CPSS, CBCL Internalizing scale, and the STAI State Scale. Clinically reliable change was not evident for the STAI Trait scale, CBCL externalizing scale, or CDI, although it should be noted that CBCL Externalizing and CDI scores were not in the clinical range at pre-treatment.
Case Study 2: Pre- to post-treatment outcome scores and diagnostic information
SCAS total score
18 (T score = 100)a
9 (T score = 70)a, b
28 (T score = 73)a
29 (T score = 74)a
11 (T score = 59)
17 (T score = 65)a
Diagnostic interview data was collected and analyzed for 6- and 12-month follow-up. At both follow-up points, Abby did not meet criteria for PTSD, with total severity ratings in the normal ranges.
Case Study 2: Method
Description of Accident and Injury
Melissa was a 15-year-old Caucasian girl, living with both parents and her older sister. The family endorsed belonging to the highest socio-economic group listed on the demographic questionnaire (combined income >A$120,000). Melissa was admitted to the study following her involvement in a car accident in which she was a passenger of a car hit by an intoxicated driver. The car was in burst into flames. Melissa suffered some neck, back, and knee pains following the accident and spent four nights in hospital. Nobody else was injured in the accident.
Melissa met criteria for full PTSD at the diagnostic interview 6 weeks after her accident. Specifically, she was experiencing intrusive recollections and nightmares about the car being engulfed by flames and her friends screaming. She would become very distressed when reminded of the accident and reported that it would take her hours to calm down. Melissa was also avoiding a number of reminders of the accident. These included not seeing or speaking with her friends that were involved in the accident and taking pain killers to help erase the memory. She also had difficulty in remembering important aspects of the accident (e.g., the actual impact, calling her mother directly after) and reported a sense of foreshortened future—that that she was living on ‘borrowed time’. At the time of the initial assessment, Melissa was having difficulty falling sleeping and completing her school work and was easily angered, even punching walls on a number of occasions. When in the car, she would constantly check her seatbelt, asked the driver to slow down and was always on the lookout for other cars. Even at home, she would demonstrate extreme startle responses to the sounds of cars and found herself ducking at the sound of screeching tires on one occasion. At the beginning of therapy, Melissa was only attending approximately two mornings of school per week, with no pre-morbid school non-attendance issues.
History of Presenting Problem and Previous Assistance
Six years prior to the most recent accident, Melissa was involved as a passenger in another car accident when a car ran a stop sign and crashed into the car that Melissa was traveling in. Melissa was trapped in the car for a short period of time. Following this first accident, Melissa developed claustrophobia, reporting that she was unable to enter enclosed spaces, especially lifts, for a long time afterward. She received approximately 25–30 sessions of psychological intervention during which her claustrophobia improved.
Melissa’s mother, Amanda, reported that her first husband had committed suicide (they did not have any children together) and that this sometimes made it difficult for her to cope with Melissa’s anxieties and low mood. Amanda also reported a history of depression following a fall in 2008 for which she was still receiving medical assistance. Amanda also reported feeling impatient and frustrated with Melissa in relation to her traumatic stress and the amount of psychological input she had received since the first accident 6 years previously. Both Melissa and her mother reported a strained and often tumultuous relationship between Melissa’s father and all other members of the family.
Case Study 2: Results
Baseline assessment and diagnosis
The CAPS-CA indicated that Melissa met criteria for PTSD, falling into the extreme range. Scores on her self-report measures were consistent with the PTSD diagnosis, with Melissa falling in the clinical range on the CPSS. Melissa’s scores on the CDI and SCAS also indicated clinical levels of depression and anxiety. Parent-report scores on the CBCL indicated that Melissa was experiencing clinical levels of internalizing behaviors.
Amanda did not complete the PTSD measure unfortunately. However, her DASS-21 indicated that she was experiencing severe anxiety, moderate levels of depression, and mild symptoms of stress. She also reported high levels of trait and state anxiety on the STAI.
Upon acceptance into the study, Melissa was randomly allocated to the child-focused therapy condition.
Session and Activity Completion
Melissa completed all sessions, although her attendance was irregular—she would often cancel or not present to scheduled sessions. Therefore, there were sometimes 2 or 3 weeks between sessions. Melissa completed all in-session activities. However, despite therapist encouragement, she did not complete any homework tasks.
At the beginning of the first therapy session, Melissa disclosed recent suicidal ideation to the therapist. Therefore, a large proportion of the first session was spent preparing a safety plan with Melissa. Melissa’s mother, Amanda, was also informed, as per the study guidelines. Melissa was also followed up by telephone over the next week to ensure safety, and her depression levels and suicidal ideation were monitored throughout the course of therapy.
Story Retelling and the Behavioral Experiment
Melissa found the story-telling task to be quite difficult. During the first story-telling, Melissa reported subjective units of distress (SUDs) of 9–10 out of 10, was tearful throughout, and was unable to recall large parts of the story. Following this session, Melissa canceled three sessions in a row, claiming illness and back pain. In a phone conversation between the therapist and Amanda, possible avoidance was discussed. Amanda agreed that avoidance was the most likely explanation, and strategies for encouraging Melissa’s attendance were discussed. Following this, Melissa attended the next session where avoidance was also discussed with her, although she was adamant that her non-attendance was not due to avoidance. Melissa was able to participate in the story-telling task again, and her SUDs decreased to mostly 7 s.
In the lead up to the next session, Melissa demonstrated multiple efforts to avoid the story-telling task. This included feigning sickness so as not to attend her next session; pleading with Mom; and refusal to engage in the task once she arrived for the session. The importance of the task was reiterated and compromises were made to make the story-telling more manageable (such as keeping eyes open and using past tense). Melissa also requested that her mother sit in on the story-telling task, and this was agreed to by the therapist. However, it became apparent quite quickly that this was another attempt at avoiding the task as she appeared to intensify her distress levels upon her mother’s arrival, clinging to her mother’s arm and wailing during the task. This was markedly different from any previous story-telling attempts. It was the impression of both the therapist and Melissa’s mother that Melissa was amplifying her distress in order to be allowed to discontinue the task. Following this session, a phone call between the therapist and Melissa revealed that Melissa felt that her symptoms were increasing after exposure and this was normalized and the rationale for this part of therapy was reiterated. The following two story-telling sessions went smoothly and Melissa’s SUDs ratings decreased in the final story-telling to 4. It was noted that in the final story-telling, she was also incorporating some humor into her account and was proud of the way she had acted during the traumatic experience.
For the behavioral experiment task, Melissa and her therapist developed a survey around the hot spot thoughts that she had been “out of control” and “irrational” in her immediate reaction to the driver of the car that hit the car she was traveling in. Immediately following the accident, this driver (who, according to Melissa, was clearly intoxicated) approached Melissa and her friends and began verbally abusing them. Melissa reported that she wanted to hit the other driver, but that she was able to restrain this impulse and instead, continued trying to calm her friends. Following discussion with the therapist about whose opinion counted in relation to whether her impulse to hit the other driver proved that she was indeed “irrational” and “out of control”, the survey was sent to a subset of staff members of a university Psychology department via email. The survey briefly described a de-identified case in which the facts were stated and respondents were asked to what extent they considered either the thoughts or actions of the girl in the scenario to be irrational and/or out of control. The therapist printed out the responses for Melissa, who reported that she found the survey to be extremely reassuring and validating.
Process Issues and Barriers
A number of barriers came up throughout the course of therapy. The biggest barrier was that Melissa’s symptoms became worse before they got better. For example, on the nights following the story-telling task, she experienced an increase in nightmares about the accident. This increase in symptoms exacerbated Melissa’s avoidance, thus leading to large periods of non-attendance between sessions which made the story-telling task all the more difficult when she did attend. Therefore, a lot of time was dedicated to helping Melissa understand the rationale behind the imaginal exposure task. Further, helping Melissa to problem-solve ways to make the task more manageable allowed her a feeling of control over the task and was effective in assisting her to engage in the task. Melissa was particularly motivated by the idea of being in control of her memories, rather than the memories controlling her. Once she was able to engage in the task and could see her symptoms beginning to improve, she was able to gain the confidence to continue.
Finally, despite therapist encouragement, Melissa did not complete any of her homework throughout the course of the therapy, and she lost her workbook half way through. This may have been yet another manifestation of avoidance. Because Melissa was avoiding therapy tasks between sessions, it is possible that this may have led to a feeling of ‘starting over’ at each subsequent session and led to the increase of re-experiencing symptoms following sessions.
Over the course of the therapy, both Melissa and Amanda reported marked improvement in Melissa’s participation in previously avoided activities. Significantly, this included Melissa gaining her learner driver’s license, returning to sports and spending time with her friends. Her suicidal ideation had also ceased, and by the final session, she was attending school full time. Melissa reported that she had gained an understanding of how her avoidance had maintained her symptoms and she was making a conscious effort to no longer engage in avoidant behavior.
Melissa’s average satisfaction rating for the program was 3.30/5 indicating moderate levels of satisfaction with the program. Her mother’s average satisfaction rating was slightly higher at 3.7/5. Melissa reported that the behavioral experiment, learning to use the Scientific Approach to challenging her hot spot thoughts, and learning to stop avoiding her memories of the accident were the most helpful elements of the program. As with the first case, the retelling of the accident story was identified as the most difficult part of the program.
At post-treatment, the clinical interview indicated that Melissa demonstrated a marked reduction in PTSD symptoms, falling from the extreme range at pre-treatment to the mild range at post-treatment. Although she still had some trouble sleeping and was experiencing occasional nightmares and exaggerated startle response, Melissa no longer reported any avoidance symptoms or physiological or psychological reactivity to exposure to trauma reminders. Melissa was engaging in activities that she had previously avoided, such as going out with friends, driving, going to school, and participating in sports. Melissa’s self-report questionnaires were consistent with this improvement, with KD no longer falling in the clinical range for anxiety. While the CDI-S still indicated depression in the clinical range, it should be noted that this had decreased by 3 standard deviations from pre- to post-treatment.
In relation to progress as rated by Melissa in her workbook, her “scariness” rating for her accident story dropped from 10/10 to 1/10, and her “nowness” rating (i.e., how much it feels like the event is occurring again now) for the story dropped from 8/10 to 1/10 by the final session. Over the course of treatment, Melissa’s perception of ‘how dangerous a place the world is’ dropped from 8/10 to 2/10 by the final session.
While Amanda indicated on the Overall Functioning questionnaire that Melissa had significantly improved in all areas of functioning, this was not supported by post-treatment scores on the PedsQL or the CBCL, which continued to reveal clinical levels of both internalizing and externalizing behaviors. However, Amanda’s own self-reported depression and anxiety had improved, as demonstrated by significantly reduced scores on the DASS-21 and STAI (trait subscale).
Clinically reliable change was shown for scores on the SCAS, CDI, CPSS, and the Trait subscale of the STAI at a criterion of p < .05 or better. A clinically reliable change was not found for parent reported behaviors on the CBCL or the State subscale of the STAI. Overall, however, the outcomes both for this client and her mother were positive. Melissa demonstrated a marked reduction in her PTSD symptoms, moving from the extreme range to the mild range. Functionally, Melissa made significant gains in terms of her avoidance—by post-treatment, she had returned to school, resumed her social life, and was able to travel comfortably in cars once more. Melissa’s mother also experienced some gains at post-treatment in terms of her depression, anxiety and stress, as well as her trait anxiety.
Diagnostic interview data was collected and analyzed for 6- and 12-month follow-up. At both follow-up points, Melissa did not meet criteria for PTSD, with total severity ratings in the normal ranges.
Considered together, the outcomes for the cases reported here were positive, providing preliminary support for the TB-CBT interventions described, as well as for the utility of early, indicated intervention using a stepped screening and assessment process within a medical context. It is important to re-emphasize that although the present study describes two participants and their mothers who received different treatment conditions, for many reasons (including the fact that a single case only is reported on for each condition; and the difference in ages between the participants), this paper is focused less on drawing comparisons between the two conditions and more on noting the common themes across the two cases.
In considering the results, it is important to think carefully about the two clients and how they compare with one another. The girls were identical in terms of race and socio-economic status. Clearly, their ages differed, with Abby being an 8-year-old primary school student and Melissa, a 15-year-old high-school student. Melissa also presented with a slightly larger number pre-existing risk factors for PTSD compared to Abby (including post-trauma social withdrawal, psychiatric comorbidity, pre-trauma life events, and pre-trauma psychological difficulties). If it had been measured, Melissa may also have qualified for the risk factor of poor family functioning. Both girls shared the risk factors of being female and having a parent with pre-trauma psychological problems. Abby had one risk factor that Melissa did not: post-trauma psychological difficulties in a parent (with her mother meeting criteria for partial PTSD). Although Melissa’s mother did not complete this measure, the therapist had no indication that she was experiencing any current symptoms of traumatic stress.
Both clients demonstrated marked reductions in their PTSD symptoms on both a diagnostic interview and self-report measure. Furthermore, these diagnostic improvements were maintained at 6- and 12-month follow-up. Both clients made significant functional gains, in terms of overcoming significant avoidance (e.g., of school). Reliable positive changes were also seen in both clients’ self-reported overall anxiety scores.
Briefly comparing the outcomes when considering treatment condition assignment, immediately post-treatment, there was relatively little difference between the two cases, with a few exceptions in favor of the family-focused condition. It is important, however, to consider the outcomes noted below in light of the fact that the youth in the child-focused condition had a prior history of exposure (and resulting psychological impairment) to the same type of traumatic incident (i.e., an MVA) that resulted in her inclusion in this trial. The client satisfaction ratings for the clients in the family-focused condition were notably higher than the ratings reported by the clients in the child-focused condition. In addition, the magnitude of change for youth workbook ratings concerning the scariness and nowness of their accident story, as well as their danger perceptions was greater for the child in the family-focused condition. Finally, at post-treatment, the client in the family-focused condition no longer met criteria for a diagnosis of PTSD compared to the client in the child-focused condition, who continued to meet criteria for mild PTSD, although both were diagnosis-free at follow-up. It seems that for the client in the child-focused condition, it took longer to achieve the same magnitude of change. The mothers’ perceptions of their children’s gains also differed somewhat between the conditions. Thus, the mother in the family-focused condition echoed her daughter’s perception that the child’s overall anxiety had reduced, whereas the mother in the child-focused condition rated her daughter’s internalizing symptoms as slightly worse at post-treatment. Clinically, this is consistent with the ages of the two clients—typically, parents are likely to have a better chance at being in agreement with their 8-year olds’ experience of internalizing symptoms than with their 15-year olds’ experience. It is also interesting that, on the PedsQL, both the child and mother in the family-focused condition reported greater magnitudes of change from pre- to post-treatment compared to the youth and mother in the child-focused condition. Surprisingly, the mother in the child-focused condition reported a reliable positive change in her trait anxiety. The mother in the family-focused condition actually reported reliable changes for the worse in her state anxiety, depression, and stress. However, it appears that these changes may have been related to other stressors in her own life, as opposed to her daughter’s PTSD.
More interesting and meaningful than the comparisons between the two treatment conditions are the common themes that emerged across the two cases. The first and perhaps most important of these was the role of parental involvement. To briefly reiterate, the 8-year-old client was randomly assigned to a condition where her mother completed 4 parent-only sessions followed by the 6-session child program, while the 15-year-old client was randomly assigned to a condition where her mother was invited to participate in the beginning and end of 6 child-focused sessions. While both clients demonstrated some avoidance of therapy materials, this (arguably unsurprisingly) was much more pronounced for the adolescent client in the child-focused condition than the 8-year-old client in the family-focused condition. As alluded to earlier, the therapeutic hypothesis around Melissa’s avoidance was that her avoidance of sessions was caused by the distress she experienced after telling her story. Her avoidance in turn meant that she did no out of session work and had only two consecutive weekly sessions (due to non-attendance). Melissa reported being afraid that the sessions were exacerbating her nightmares. Overall, it was the impression of the therapeutic team that Melissa experienced each therapy session after session 2 as ‘starting over’ and that she possibly would have made more gains more quickly if she had been more engaged and less avoidant. Although Melissa’s mother did not participate in any individual parent sessions, she was able to be engaged by the therapist as a vital ally around the crucial subject of avoidance. Without the active involvement of her mother in this manner, Melissa would most likely have dropped out of therapy. It is tempting to speculate that some, if not most of this avoidance, could have been overcome by having Melissa’s mother even more involved through the completion of the parent sessions. Even taking her age (15 years) and developmental stage into account, Melissa was largely compliant when her mother insisted that she attend sessions. The therapist’s engagement of Melissa’s mother was in response to Melissa’s avoidance—if it had been pre-emptive engagement through the parent sessions, it is possible that this may have had even more positive effect. However, in the end, although Melissa’s level of engagement was far from optimal, the significantly less intense form of parental involvement used in this case was sufficient. Melissa made outstanding functional gains and continued to be free of a PTSD diagnosis up to 12 months following the completion of her 6-session treatment program. Interestingly, this is in light of her mother’s pre-existing psychological difficulties, as well as the history of a maternal PTE (the suicide of her first husband), and a potentially low level of family functioning. In contrast, Abby’s mother (who also experienced pre-existing psychological difficulties in addition to meeting criteria for partial PTSD in relation to Abby’s accident) completed four individual parent sessions—at the end of which, she no longer met criteria for partial PTSD. Although there is no empirical evidence for this, there was a clear feeling that Abby (all things taken into account) required this more intense level of parental involvement to achieve the excellent outcomes she achieved.
The second common theme across the two cases was that both mothers appeared to be demonstrating a relational pattern described by Scheeringa and Zeanah (2001). Thus, following the traumatic event, Abby’s mother had become overprotective, while Melissa’s mother initially seemed to have become somewhat withdrawn and less available to her daughter. In Melissa’s case (where there was no documented maternal PTSD), this pattern was quickly changed via the therapist’s appeal for assistance in getting Melissa to sessions. In Abby’s case, the overprotection began to reduce by the end of the parent sessions and continued to reduce over the course of the child sessions.
Related to the first theme, a third common theme across the two cases was the importance of the therapist’s alliance with the family in terms of ensuring retention (Saxe et al. 2012). This has already been described for Melissa’s case, but there was also a point in Abby’s case where her continued engagement appeared uncertain. This occurred when her distress escalated and her father talked about withdrawing her from treatment. A strong family alliance was able to prevent this from occurring.
Other common themes of note emerged across the two cases. Both clients experienced an exacerbation of their symptoms following the first retelling of their accident story. Preparing clients in advance by normalizing this kind of response is a helpful means of dealing with this issue. Ensuring that parents are engaged, understand the rationale for story retelling, and feel able to discuss their concerns with the therapist are integral strategies for containing parents’ predictable distress as their child’s symptoms appear to become worse. A final common theme was the difficulty and importance of the trauma narrative. Both clients reported the story to be the most difficult component of the program (as did the mother in the family-focused condition)—but, by the same token, youth and maternal feedback on the interventions indicated that the retelling of the story, though difficult, was an essential ingredient.
Suggestions for Future Research
The two case studies described here raise rather than answer a number of interesting questions. One of the most interesting and important of these is around parent involvement. In the child anxiety literature, there has long been an argument that younger children are more likely to benefit from parental involvement in treatment compared to adolescents. In the adolescent case described here, it was the opinion of the therapeutic team that greater gains may have been seen more quickly if the family had been allocated to the family-focused condition. However, as previously noted, over time, it became clear that for this client, the intensity of the parental involvement was sufficient. Clearly, parental involvement in children and adolescents’ treatment is going to occur on a continuum, with varying and potentially individualized levels of intensity in between. The challenge then seems to be to provide no more in the way of parental involvement than is required. The question of whether there are certain client characteristics (e.g., age, nature of traumatic event, presence of parental PTSD) that ‘slide the scale’ from minimal to more in terms of the required intensity of parental involvement is a crucial issue for future research.
A second interesting and important direction for future research centers around a cost-benefit analysis of not only each of the treatments described here (but also an exploration of the different intensity levels in between) versus doing nothing or a ‘watchful waiting’ approach. The cost of untreated mental health problems in youth is notoriously under-researched, as is the cost of delivering interventions relative to the benefits they produce.
In conclusion, the current study illustrates the acceptability and feasibility (as well as the challenges) of implementing the TB-CBT interventions described within the framework of an early, indicated intervention approach. The two cases described in this paper screened at high risk on the 10-item CTSQ 2 weeks after their accident and then met full criteria for PTSD at the diagnostic assessment conducted 6 weeks post-accident. Clearly, conclusions about the efficacy of the interventions described in this paper are not possible at this stage, and we await the results of the RCT currently being conducted by our group. Importantly, questionnaire data at follow-up could only be obtained for one of the two cases and has therefore not been included here.
The paper described a state-of-the-art TF-CBT protocol that can be implemented with and without a parent component. The implementation of each of the two programs, including the challenges involved and how these were managed, was described, as were the results from the two cases. This paper has focused on a theme that was common to the success of both cases—namely the importance of parental involvement in treatment (at variable levels). The paper identified some early directions for future research and provides very preliminary support for the TF-CBT protocol described.