Q4 | 2020 Research Round Up

Alisic and colleagues (2020) discuss in this commentary how clinical practice guidelines for the treatment of traumatic stress can become more inclusive and equitable for children and young people. After reviewing international trauma treatment guidelines, the authors identify two areas for possible improvement: (1) increasing the representation of children’s cultural background and (2) creating opportunities for children’s voices to be heard. The authors highlight that current international guidelines offer little information on how to tailor treatment to young people’s cultural needs. Furthermore, the authors underscore that there is limited diversity across all the stages of the guideline development process (including the evidence-base itself). The narrow focus on high-income western countries and white populations poses a serious barrier to identifying and addressing ethnic and cultural issues. The authors also report that young people were not consulted and included in the development of clinical practice guidelines. Finally, they identify concrete steps to address these issues: setting up committees for the consultation and co-creation of clinical guidelines with young people and their families; involving experts from different fields (e.g. anthropology, sociology); and identifying existing culturally-relevant research and culturally-competent treatment adaptations. In sum, the authors argue that promoting research and developing treatment guidelines “with, by and for” under-represented groups should take high priority to move the fields towards greater inclusivity and equity.

Alisic, E., Roth, J., Cobham, V., Conroy, R., De Young, A., Hafstad, G., Hecker, T., Hiller, R., Kassam-Adams, N., Lai, B., Landolt, M., Marsac, M., Seedat, S. and Trickey, D., (2020). Working towards inclusive and equitable trauma treatment guidelines: a child-centered reflection. European Journal of Psychotraumatology, 11(1), p.1833657. doi: 10.1080/20008198.2020.1833657 

Childhood abuse and neglect is associated with an increased risk of developing PTSD. The evidence-base for psychological interventions for PTSD in children and adolescents is well-established. Yet, there is an ongoing debate about the suitability and appropriateness of the existing therapeutic approaches for the treatment of young people who have been exposed to more complex traumatic experiences, such as maltreatment. The Bennett and colleagues (2020) review builds on Leenarts et al (2013) to provide an update on the evidence-base of psychological interventions for maltreatment-related PTSD. Twenty studies were selected. Ten were from the US, five from Europe, two from Africa, two from Asia and one from South America. Nine studies reported a majority of participants who self-identified as White or Caucasian, three reported majority of participants who identified as Black, one reported majority Hispanic and one majority Latino or White/Latino. Six studies did not describe the ethnicity of the sample. The authors report that trauma-focused cognitive behavioural therapy (TF-CBT, a manualised family-focused treatment developed by Cohen, Mannarino and Deblinger) remains the best supported psychological intervention for young people following childhood maltreatment. New studies suggest that improvement in symptoms is maintained up to 1-year after treatment ends. Also, initial evidence suggests the suitability of this therapeutic approach in lower-middle income countries. Other cognitive behavioural based interventions were identified as promising, including prolonged exposure (PE). The evidence for other therapies remains limited. In sum, current evidence suggests that TF-CBT may be an effective therapeutic approach for maltreatment-related child PTSD. The effectiveness of other therapeutic modalities remains largely unexplored.

Bennett, R. S., Denne, M., McGuire, R., & Hiller, R. M. (2020). A systematic review of controlled-trials for PTSD in maltreated children and adolescents. Child maltreatment, Advance online publication. https://doi.org/10.1177/1077559520961176

Trauma-focused cognitive-behavioural therapy (TF-CBT) is a manualised family-focused treatment protocol for traumatised young people (and their non-offending caregivers) developed by Cohen, Mannarino and Deblinger. TF-CBT has a robust evidence-base, with more than 20 trials showing its effectiveness. Yet, to date, TF-CBT has not been systematically implemented nor evaluated in any Latin American country. Stewart and colleagues (2020), in this study, trained providers in TF-CBT and evaluated its feasibility and effectiveness in El Salvador, one of the countries with the highest rates of violence and homicides in the world. Fifteen Salvadoran psychologists were trained in TF-CBT. They then provided treatment to 121 Salvadoran young people in the community. The result of this study indicate that it was (1) feasible to train local providers in TF-CBT, (2) treatment completion rate was high (86%), and (3) young people experienced a large and clinically meaningful reduction in trauma-symptoms at the end of treatment. In sum, this study provides preliminary evidence for the implementation and effectiveness of evidence-based trauma-focused treatment for young people in Central America.

Stewart, R. W., Orengo-Aguayo, R., Villalobos, B. T., Nicasio, A. V., Dueweke, A. R., Alto, M., … & de Arellano, M. A. (2020). Implementation of an Evidence-Based Psychotherapy for Trauma-Exposed Children in a Lower-Middle Income Country: the Use of Trauma-Focused Cognitive Behavioral Therapy in El Salvador. Journal of Child & Adolescent Trauma. Advance online publication. https://doi.org/10.1007/s40653-020-00327-9

In this commentary, Danese and colleagues (2020) argue that the assessment and treatment of trauma-related mental health difficulties among young people lags behind international clinical guidelines and current research. Young people with trauma-related psychopathology often go undetected. To receive the best possible care, young people must be able to promptly access effective treatment. The authors propose four ways to improve the detection of childhood trauma-related mental health difficulties: (1) to improve current understanding of the barriers to healthcare use (e.g. stigma, hopelessness, socio-economic factors); (2) increase the implementation of screening procedure in primary care or non-specialist health settings (e.g. schools); (3) develop accurate prediction models to identify those young people at greatest risk of developing trauma-related mental health difficulties; (4) improve knowledge and skills around child and adolescent mental health among primary care practitioners (e.g. GPs, nurses). The authors argue that child and adolescent mental health professionals need more specialist training and clinical capacity. This will help to improve the treatment of trauma-related mental health difficulties. In sum, this article argues that adequate screening protocols and prompt access to specialist evidence-based treatment is paramount to improve care provision for trauma-exposed young people.

Danese, A., McLaughlin, K. A., Samara, M., & Stover, C. S. (2020). Psychopathology in children exposed to trauma: detection and intervention needed to reduce downstream burden. BMJ (Clinical research ed.), 371, m3073. https://doi.org/10.1136/bmj.m3073

Parents of traumatised young people frequently develop trauma-related symptoms of their own. This, in turn, might negatively affect a young person’s symptoms and response to treatment. Trauma-focused cognitive-behavioural therapy (TF-CBT) is a well-established treatment for children and adolescents with PTSD manualised by Cohen, Mannarino and Deblinger. Unlike other trauma-focused psychological interventions, in TF-CBT non-offending carers (i.e. parents who did not perpetrate the trauma for which the child or young person is receiving treatment) play a crucial role in treatment. In this study, Tutus and colleagues (2020) investigated if symptom improvement among parents who participate in the treatment delivered for their child’s PTSD is sustained up to one year after treatment. The 57 parents who took part in this longitudinal study were primarily of German origin (80%), had a wide range of ages (29-59 years) and educational backgrounds. The authors found that parents experienced substantial improvements in depression, anxiety, trauma-related symptoms and negative post-traumatic cognitions up to one year after treatment. Interestingly, this was not affected by parental trauma history. In sum, the results of this study highlight the long-term mental health benefits for parents who participate in their child’s trauma-focused treatment.

Tutus, D., Pfeiffer, E., Plener, P. L., Rosner, R., Bernheim, D., & Sachser, C. (2020). The Change in Parental Symptoms and Dysfunctional Cognitions in the Course of Trauma-Focused Cognitive-Behavioral Therapy: Sustainability Until One-Year Post-Treatment. Journal of child and adolescent psychopharmacology, 10.1089/cap.2020.0097. Advance online publication. https://doi.org/10.1089/cap.2020.0097

Researchers hypothesise that during adolescence, young people experience a period of heightened sensitivity to the caregiving environment. As such, this developmental stage may represent a uniquely favourable period for recovery of function among individuals exposed to severe early psychosocial deprivation. In this study, Colich and colleagues (2020), investigated whether the quality of caregiving among Romanian adolescents is associated with better functioning among young people who had experienced early institutionalisations/deprivation (n=187) and community-raised peers (n=78). Three domains of functioning — reward processing, executive function and mental health — were examined at ages 8, 12, and 16. The researchers found a positive association between higher quality of adolescent caregiving and greater reward sensitivity and executive function performance at both ages 12 and 16. Moreover, higher caregiving quality was also linked with less mental health difficulties at age 16. In sum, these findings support the notion that adolescence may represent a window of opportunity for recovery — even following extreme forms of early deprivation.

Colich, N. L., Sheridan, M. A., Humphreys, K. L., Wade, M., Tibu, F., Nelson, C. A., Zeanah, C. H., Fox, N. A., & McLaughlin, K. A. (2020). Heightened sensitivity to the caregiving environment during adolescence: implications for recovery following early-life adversity. Journal of child psychology and psychiatry, and allied disciplines, 10.1111/jcpp.13347. Advance online publication. https://doi.org/10.1111/jcpp.13347

This study by Hein and colleagues (2020) examined if two dimensions of early adversity, social deprivation and violence exposure, have distinct effects on brain development. The sample of young people (n=167) recruited for this study had substantial representation of understudied youth, including Black/African-Americans (70%) and adolescents from low-income families. The authors focused their analyses on brain regions which play a central role in threat and reward processing (i.e. the amygdala and ventral striatum, respectively). There were two main findings. First, early violence exposure was linked with more sustained brain activation in response to threat-related social cues (i.e. angry faces). Second, early social deprivation was associated with decreased brain activation to socially rewarding cues (i.e. happy faces). These findings were independent of current levels of symptoms of depression and anxiety as well as current life stress. In sum, this study provides supporting evidence for theories that suggest threat and social deprivation (two dimensions of early adversity) may have overlapping but also distinct effects on brain development.

Hein, T. C., Goetschius, L. G., McLoyd, V. C., Brooks-Gunn, J., McLanahan, S. S., Mitchell, C., … & Monk, C. S. (2020). Childhood violence exposure and social deprivation are linked to adolescent threat and reward neural function. Social cognitive and affective neuroscience, 15(11), 1252-1259. doi: 10.1093/scan/nsaa144

Childhood maltreatment is one of the most significant risk factors for developing mental health problems. However, there is still debate about whether different dimensions of childhood maltreatment are linked to specific mental health difficulties. In this study, Struck and colleagues (2020) investigated the prevalence of self-reported childhood maltreatment in a large sample of adults (n=1579) of Western European ancestry with and without mental health difficulties. In line with previous studies, the prevalence of childhood maltreatment of all types was higher among adults experiencing mental health difficulties. Almost 60% reported having a history of moderate to severe maltreatment of at least one type. While symptoms of depression and anxiety were most strongly linked with exposure to emotional abuse and neglect, symptoms of schizophrenia were more strongly associated with physical neglect. The researchers also found that individuals with persistent/chronic depression reported more childhood maltreatment experiences of any type than individuals with non-chronic depression. Finally, exposure to childhood maltreatment was associated with earlier onsets of symptoms among individuals with depression or bipolar disorder only. In sum, these findings suggest that different dimensions of childhood maltreatment may be more strongly associated with different types of mental health difficulties.

Struck, N., Krug, A., Yuksel, D., Stein, F., Schmitt, S., Meller, T., Brosch, K., Dannlowski, U., Nenadić, I., Kircher, T., & Brakemeier, E. L. (2020). Childhood maltreatment and adult mental disorders – the prevalence of different types of maltreatment and associations with age of onset and severity of symptoms. Psychiatry research, 293, 113398. https://doi.org/10.1016/j.psychres.2020.113398

The experience of trauma in one generation may influence subsequent generations by impacting parenting practises. Jensen and colleagues (2020) investigated the impact of lifetime trauma on parenting behaviour among 732 Rwandan caregivers living in severe poverty — many of whom had experienced war and community violence. The authors found that among carers, lifetime trauma and recent hardship were linked with higher levels of depression, anxiety, and PTSD symptoms. Heightened symptoms were in turn associated with more self-reported rejection towards their infant and toddlers. Interestingly, this association was partly explained by difficulties in emotion regulation. In sum, the findings of this study show that poor mental health and emotion dysregulation associated with trauma and stress may negatively affect parenting practices.

Jensen, S., Sezibera, V., Murray, S. M., Brennan, R. T., & Betancourt, T. S. (2020). Intergenerational impacts of trauma and hardship through parenting. Journal of child psychology and psychiatry, and allied disciplines. Advance online publication. https://doi.org/10.1111/jcpp.13359

In this study, Matthews and colleagues (2020) examined the associations between childhood victimization (e.g. maltreatment, bullying) and loneliness from mid-childhood to young adulthood. This study benefitted from a large sample of twins (n= 2232), which allowed the researchers to measure and control for the possible influence of predisposing genetic and environmental factors. The families were recruited to represent the population in England and Wales in terms of socio-economic background as well as ethnicity (10% non-white background). The results showed that the more a child was exposed to different forms of victimisation, the greater the reported loneliness in childhood (age 12). Being bullied during childhood was uniquely associated with loneliness, even after controlling for several factors, including mental health, social isolation, and genetic influences. Also, bullying during childhood continued to predict loneliness in young adulthood (age 18), even in the absence of ongoing victimization. However, this longitudinal association was explained by genetic factors. That is, only those with a genetic vulnerability seemed to continue to feel lonely over time. In adolescence, varied forms of victimization were linked with loneliness in young adults. Maltreatment and cyberbullying were the most robust predictors, even after statistically controlling for possible predisposing genetic factors. In sum, this study indicates that young people exposed to different forms of interpersonal victimisation might be at increased risk of loneliness, even after controlling for genetic factors.

Matthews, T., Caspi, A., Danese, A., Fisher, H. L., Moffitt, T. E., & Arseneault, L. (2020). A longitudinal twin study of victimization and loneliness from childhood to young adulthood. Development and psychopathology, 1–11. Advance online publication. https://doi.org/10.1017/S0954579420001005