In-session caregiver behavior predicts symptom change in youth receiving trauma-focused cognitive behavioral therapy (TF-CBT).

Abstract

Objective Involving caregivers in trauma-focused treatments for youth has been shown to result in better outcomes, but it is not clear which in-session caregiver behaviors enhance or inhibit this effect. The current study examined the associations between caregiver behaviors during Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and youth cognitive processes and symptoms. Method Participants were a racially diverse sample of Medicaid-eligible youth (ages 7–17) and their non-offending caregivers (N= 71 pairs) who received TF-CBT through an effectiveness study in a community setting. Caregiver and youth processes were coded from audio-recorded sessions, and outcomes were measured using the Child Behavior Checklist (CBCL) and UCLA PTSD Reaction Index for DSM-IV (UPID) at 3, 6, 9, and 12 months post-intake. Results Piecewise linear growth curve modeling revealed that during the trauma narrative phase of TF-CBT, caregivers’ cognitive-emotional processing of their own and their child's trauma-related reactions predicted decreases in youth internalizing and externalizing symptoms over treatment. Caregiver support predicted lower internalizing symptoms over follow-up. In contrast, caregiver avoidance and blame of the child predicted worsening of youth internalizing and externalizing symptoms over follow-up. Caregiver avoidance early in treatment also predicted worsening of externalizing symptoms over follow-up. During the narrative phase, caregiver blame and avoidance were correlated with more child overgeneralization of trauma beliefs, and blame was also associated with less child accommodation of balanced beliefs. Conclusions The association between in-session caregiver behaviors and youth symptomatology during and after TF-CBT highlights the importance of assessing and targeting these behaviors to improve clinical outcomes.

Caregivers’ abuse stigmatization and their views of mental health treatment following child sexual abuse

“…These and other motivational strategies (e.g., Miller and Rollnick 2002; Prochaska et al, 1992) may offer opportunities to provide feedback and education about caregiver-specific reactions or perceived obstacles to engagement. This type of approach is also consistent with various models of trauma-focused interventions, such as TF-CBT (Cohen et al, 2006; Deblinger & Haflin, 1996), which emphasize education and skill-building as a critical first phase of intervention and are significantly more effective when caregivers also completes their portion of the treatment (Deblinger et al, 2006; Yasinski et al, 2016). …”

“…If caregivers who feel stigmatized are more motivated to hide, deny, or escape reminders of stigmatizing events (e.g., Ehlers & Clark 2000; Feiring et al, 1996; Ketelaar & Au, 2003; Tangney et al, 2007), they may be less receptive to information about mental health treatment. They may also be less engaged in their child’s treatment, a critical component of youth improvement in trauma-focused therapies (Deblinger et al, 2006; Yasinski et al, 2016). Just as youth with shame and self-blame for CSA may misinterpret changes in caregivers’ expectations, caregivers with similar reactions might be more prone to interpret feedback on their children’s distress or treatment recommendations as condemnations of their parenting (Deblinger & Runyon, 2005).…”

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

“…Treatment of trauma-related anxiety may be different, considering findings that parental mental health, support, emotional reaction to and unhelpful beliefs about trauma exposure moderated some important outcomes for children (Cohen & Mannarino, 1996, 2000; Nixon et al, 2012; Weems & Scheeringa, 2013). In a study employing objective, process coding of TF-CBT sessions (Yasinski et al, 2016), parental cognitive-emotional processing and emotional support predicted improvement in child internalizing symptoms, whereas parental avoidance and child blame predicted worse externalizing symptoms.…”

Identifying and addressing barriers to treatment for child sexual abuse survivors and their non-offending caregivers

“…Given the focus of CSA treatment, cultural and religious beliefs can contribute to apprehension about seeking or engaging in therapy for some youth and their families (Fraynt et al, 2014). Notably, in-session avoidance by both the child and caregiver have been found to predict child outcomes (Yasinski et al, 2016) and drop-out (Yasinski et al, 2018) in trauma-focused therapy, which suggests that avoidance may play an especially important role in treatment adherence following CSA.…”

“…Further, policy can inform training and practice guidelines for mental health clinicians. For example, children and caregivers may be avoidant of therapy for CSA and research demonstrates that in-session avoidance predicts child outcomes (Yasinski et al, 2016) and dropout (Yasinski et al, 2018). Therefore, it is pertinent that mental health professionals are competent in identifying and addressing avoidance in session in a trauma-informed manner.…”