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Internalizing and Externalizing Symptoms Moderate Treatment Response to School-Based Trauma and Grief Component Therapy for Adolescents

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Abstract

Internalizing and externalizing problems commonly co-occur with adolescent post-traumatic stress and grief reactions. However, little is known about whether these co-occurring symptoms moderate adolescents’ response to sequenced components of trauma- and grief-focused interventions. Forty-four middle school students (aged 12–14) rated their self-identified Top Problem during a 17-week flexibly tailored course of Trauma and Grief Component Therapy for Adolescents (TGCTA), a group-based treatment for traumatized and bereaved youth. Baseline internalizing and externalizing symptoms were examined as potential moderators of adolescents’ response to skills-building (Module I), narrative-sharing (Modules II and III), and developmental progression (Module IV) phases of intervention. Piecewise analyses of change during the three treatment phases indicated that adolescents with more internalizing symptoms showed significantly less improvement during the skills-building phase and significantly more improvement during the narrative construction phase. Findings provide preliminary evidence that: (a) traumatized and bereaved adolescents show different trajectories of response to different TGCTA components as a function of internalizing versus externalizing baseline symptoms and (b) assessing self-nominated problems and broad-spectrum internalizing and externalizing symptoms can guide trauma- and bereavement-informed treatment planning and monitoring.

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References

  • Achenbach, T. M., & Rescorla, L. A. (2001). The manual for the ASEBA school-aged forms and profiles. Burlingame, VT: University of Vermont, Research Center for Children, Youth, and Families.

    Google Scholar 

  • Angold, A., Costello, E. J., & Messer, S. C. (1995). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research, 5, 237–249.

    Google Scholar 

  • Chorpita, B. F., & Daleiden, E. L. (2014). Structuring the collaboration of science and service in pursuit of a shared vision. Journal of Clinical Child and Adolescent Psychology, 43(2), 323–338.

    Article  PubMed  Google Scholar 

  • Chorpita, B. F., Reise, S., Grubbs, K., Krull, J. L., Weisz, J. R., Becker, K. D., et al. (2010). Evaluation of the brief problem checklist: Child and caregiver interviews to measure cliical progress. Journal of Consulting and Clinical Psychology, 78, 526–536. doi:10.1037/a0019602.

    Article  PubMed  Google Scholar 

  • Christon, L. M., McLeod, B. D., & Jensen-Doss, A. (2015). Evidence-based assessment meets evidence-based treatment: An approach to science-informed case conceptualization. Cognitive and Behavioral Practice, 22(1), 36–48.

    Article  Google Scholar 

  • Cohen, J. A., Mannarino, A. P., & Iyengar, S. (2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: A randomized controlled trial. Archives of Pediatric and Adolescent Medicine, 165, 16–21.

    Google Scholar 

  • Cole-Detke, H., & Kobak, R. (1996). Attachment processes in eating disorder and depression. Journal of Consulting and Clinical Psychology, 64, 282–290.

    Article  PubMed  Google Scholar 

  • Davies, D. R., Burlingame, G. M., & Layne, C. M. (2006). Integrating small-group process principles into trauma-focused group psychotherapy: What should a group trauma therapist know?. In L. A. Schein, H. I. Spitz, G. M. Burlingame, P. R. Muskin, L. A. Schein, H. I. Spitz, ... P. R. Muskin (Eds.) , Psychological effects of catastrophic disasters: Group approaches to treatment (pp. 385–423). New York, NY: Haworth Press.

  • Dodge, K. A. (1986). A social information processing model of social competence in children. In M. Perlmutter (Ed.), Minnesota symposium on child psychology: Vol. 18. Cognitive perspectives on children’s social and behavioral development (pp. 77–125). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

    Google Scholar 

  • Dyregrov, A. (2004). Educational consequences of loss and trauma. Educational & Child Psychology, 21, 77–84.

    Google Scholar 

  • Goenjian, A. K., Walling, D., Steinberg, A. M., Roussos, A., Goenjian, H. A., & Pynoos, R. S. (2009). Depression and PTSD symptoms among bereaved adolescents 6 1/2 years after the 1988 Spitak earthquake. Journal of Affective Disorders, 112(1–3), 81–84.

    Article  PubMed  Google Scholar 

  • Goodman, R., Meltzer, H., & Bailey, V. (1998). The strengths and difficulties questionnaire: A pilot study on the validity of the self-report version. European Child and Adolescent Psychiatry, 7, 125–130.

    Article  PubMed  Google Scholar 

  • Grant, K. E., McCormick, A., Poindexter, L., Simpkins, T., Janda, C. M., Thomas, K. J., et al. (2005). Exposure to violence and parenting as mediators between poverty and psychological symptoms in urban African American adolescents. Journal of Adolescence, 28(4), 507–521. doi:10.1016/j.adolescence.2004.12.001.

    Article  PubMed  Google Scholar 

  • Grassetti, S. N., Herres, J., Williamson, A. A., Yarger, H. A., Layne, C. M., & Kobak, R. (2015). Narrative focus predicts symptom change trajectories in group treatment for traumatized and bereaved adolescents. Journal of Clinical Child & Adolescent Psychology, X, 1–9. doi:10.1080/15374416.2014.913249.

    Google Scholar 

  • Hayes, A. M., Feldman, G. C., Beevers, C. G., Laurenceau, J. P., Cardaciotto, L., & Lewis-Smith, J. (2007). Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 75(3), 409.

    Article  PubMed  Google Scholar 

  • Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York City: Guilford Press.

    Google Scholar 

  • Jaycox, L. H., Cohen, J. A., Mannarino, A. P., & Schonlau, M. (2010). Children’s mental health care following Hurricane Katrina: A field trial of trauma-focused therapies. Journal of Traumatic Stress, 23(2), 223–231. doi:10.1002/jts.20518.

    PubMed  PubMed Central  Google Scholar 

  • Kaplow, J. B., Layne, C. M., Pynoos, R. S., Cohen, J., & Lieberman, A. (2012). DSM-V diagnostic criteria for bereavement-related disorders in children and adolescents: Developmental considerations. Psychiatry, 75, 243–266.

    Article  PubMed  Google Scholar 

  • Kaplow, J. B., Saunders, J., Angold, A., & Costello, E. J. (2010). Psychiatric symptoms in bereaved versus nonbereaved youth and young adults: A longitudinal epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1145–1154.

    PubMed  PubMed Central  Google Scholar 

  • Kerig, P., & Becker, S. P. (2010). From internalizing to externalizing: Theoretical models of the processes linking PTSD to juvenile delinquency. In S. J. Egan (Ed.), Posttraumatic stress disorder (PTSD): Causes, symptoms, and treatment (pp. 33–78). Hauppage, NY: Nova Science Publishers.

    Google Scholar 

  • Kobak, R., Zajac, K., Herres, J., & Krauthamer-Ewing, S. (2015). Attachment based treatments for adolescents: The secure cycle as a framework for assessment, treatment and evaluation. Attachment and Human Development, 17(2), 220–239.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lambert, M. J. (2010). Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice. Washington, DC: American Psychological Association.

    Book  Google Scholar 

  • Laor, N., Wolmer, L., Kora, M., Yucel, D., Spirman, S., & Yazgan, Y. (2002). Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes. Journal of Nervous and Mental Disease, 190(12), 824–832.

    Article  PubMed  Google Scholar 

  • Layne, C. M., Greeson, J. K. P., Kim, S., Ostrowski, S. A., Reading, S., Vivrette, R. L., et al. (2014). Links between trauma exposure and adolescent high-risk health behaviors: Findings from the NCTSN core data set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), S40–S49.

    Article  Google Scholar 

  • Layne, C. M., Kaplow, J. B., & Youngstrom, E. A. (2016). Applying evidence-based assessment to childhood trauma and bereavement: Concepts, principles, and practices. In M. A. Landholt, M. Cloitre, & U. Schnyder (Eds.), Evidence based treatments for trauma-related disorders in children and adolescents. Cham: Springer International Publishing AG.

    Google Scholar 

  • Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagic, B., Black, M., Savjak, N., et al. (2001). Trauma/grief focused group psychotherapy: School-based postwar intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5, 277–290.

    Article  Google Scholar 

  • Layne, C. M., Saltzman, W. R., Poppleton, L., Burlingame, G. M., Pasalic, A., Durakovic, E., et al. (2008). Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1048–1062.

    Article  PubMed  Google Scholar 

  • Lochman, J. E., & Wells, K. C. (2004). The coping power program for preadolescent aggressive boys and their parents: Outcome effects at the 1-year follow-up. Journal of Consulting and Clinical Psychology, 72, 571–578.

    Article  PubMed  Google Scholar 

  • Lyon, A. R., Ludwig, K., Romano, E., Koltracht, J., Vander Stoep, A., & McCauley, E. (2014). Using modular psychotherapy in school mental health: Provider perspectives on intervention-setting fit. Journal of Clinical Child & Adolescent Psychology, 43(6), 890–901.

    Article  Google Scholar 

  • McClatchey, R. S., & Vonk, M. E. (2005). An exploratory study of post-traumatic stress disorder symptoms among bereaved children. OMEGA-Journal of Death and Dying, 51(4), 285–300.

    Article  Google Scholar 

  • O’Connor, M., Lasgaard, M., Shevlin, M., & Guldin, M. (2010). A confirmatory factor analysis of combined models of the harvard trauma questionnaire and the inventory of complicated grief—revised: Are we measuring complicated grief or posttraumatic stress? Journal of Anxiety Disorders, 24(7), 672–679.

    Article  PubMed  Google Scholar 

  • Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care, 11, 2–10.

    Article  Google Scholar 

  • Pynoos, R., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998). The UCLA PTSD reaction index for DSM-IV (revision 1). Los Angeles, CA: UCLA Trauma Psychiatry Program.

    Google Scholar 

  • Pynoos, R. S., Steinberg, A. M., Layne, C. M., Liang, L. J., Vivrette, R. L., Briggs, E. C., et al. (2014). Modeling constellations of trauma exposure in the national child traumatic stress network core data set. Psychological Trauma: Theory, Research, Practice, and Policy, 6((Suppl 1)), S9–S17.

    Article  Google Scholar 

  • Raudenbush, S. W., Bryk, A. S., Cheong, Y. F., Congdon, R. T., & du Toit, M. (2011). HLM 7: Hierarchical linear and nonlinear modeling. Chicago, IL: Scientific Software International.

    Google Scholar 

  • Saigh, P. A., Yasik, A. E., Obserfield, R. A., Halamandaris, P. V., & McHugh, M. (2002). An analysis of internalizing and externalizing behaviors of traumatized urban youth with and without PTSD. Journal of Abnormal Psychology, 111, 462–470. doi:10.1037//0021-843Z.111.3.462.

    Article  PubMed  Google Scholar 

  • Saltzman, W., Layne, C. M., Pynoos, R. S., Olafson, E., Kaplow, J. B., & Boat, B. (2016). Trauma and grief component therapy for adolescents: A modular approach to treating traumatized and bereaved youth. Cambridge: Cambridge University Press.

    Google Scholar 

  • Saltzman, W. R., Layne, C. M., Steinberg, A. M., & Pynoos, R. S. (2006). Trauma/grief-focused group therapy with adolescents. In L. Schein, H. Spitz, G. Burlingame, & P. Muskin (Eds.), Group approaches for the psychological effects of terrorist disasters (pp. 629–729). New York, NY: The Hawthorne Press.

    Google Scholar 

  • Saltzman, W. R., Pynoos, R. S., Layne, C. M., Steinberg, A. M., & Aisenberg, E. (2001). Trauma and grief-focused intervention for adolescents exposed to community violence: Results of a school-based screening and group treatment protocol. Group Dynamics: Theory, Research, and Practice, 5, 291–303.

    Article  Google Scholar 

  • Weist, M. D., Youngstrom, E. A., Stephan, S., Lever, N., Fowler, J., Taylor, L., et al. (2014). Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health. Journal of Clinical Child and Adolescent Psychology, 43(2), 244–255.

    Article  PubMed  Google Scholar 

  • Weisz, J. R., Chorpita, B. F., Frye, A., Ng, M. Y., Lau, N., Bearman, S. K., et al. (2011). Youth top problems: Using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. Journal of Consulting and Clinical Psychology, 79(3), 369–380. doi:10.1037/a0023307.

    Article  PubMed  Google Scholar 

  • Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., et al. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69(3), 274–282.

    Article  PubMed  Google Scholar 

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Acknowledgements

This work was supported by funds from the Delaware Division of Prevention and Behavioral Health Services (to Dr. Roger Kobak) and the Irene Darley Fund and Peter and Helen Bing (to Dr. Robert Pynoos).

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Authors and Affiliations

  1. Drexel University, 3020 Market St., Suite 510, Philadelphia, PA, 19104, USA

    Joanna Herres

  2. University of Delaware, Newark, DE, USA

    Ariel A. Williamson & Roger Kobak

  3. UCLA/Duke University National Center for Child Traumatic Stress, Los Angeles, CA, USA

    Christopher M. Layne & Robert S. Pynoos

  4. Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA

    Christopher M. Layne & Robert S. Pynoos

  5. University of Texas Health Science Center at Houston, Houston, TX, USA

    Julie B. Kaplow

  6. Advanced Studies in Education and Counseling, California State University, Long Beach, Long Beach, CA, USA

    William R. Saltzman

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  1. Joanna Herres
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  2. Ariel A. Williamson
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Correspondence to Joanna Herres.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Herres, J., Williamson, A.A., Kobak, R. et al. Internalizing and Externalizing Symptoms Moderate Treatment Response to School-Based Trauma and Grief Component Therapy for Adolescents. School Mental Health 9, 184–193 (2017). https://doi.org/10.1007/s12310-016-9204-1

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