ArticlePDF Available

Cue-Centered Treatment for Youth Exposed to Interpersonal Violence: A Randomized Controlled Trial

Authors:

Abstract and Figures

This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13 schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4 discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility, adherence, and efficacy in treating youth with a history of interpersonal violence. Traditional and Simplified Chinese Abstracts by AsianSTSS 標題 : 一個隨機對照試驗:經歷人際暴力青少年的提示為本治療。 撮要 : 史丹福提示為本治療在長期經歷暴力的青少年能否減少創傷後壓力、抑鬱和焦慮,本研究提出初步證據支持其可行性和功效。從13間學校中招募65名8至17歲的青少年,隨機分配到提示為本治療和等候對照組別,並在4個特定日子進行評核。自我報告評核包括:青少年的創傷後壓力症(PTSD) 、焦慮和抑鬱症狀,亦有照顧者焦慮和抑鬱自我報告評分,和照顧者對兒童PTSD的報告。治療師評估參與者在治療面見的綜合症狀改善程度。等級綫性模型分析指出:對比等候對照組別,提示為本治療組別有更大PTSD症狀減退(包括照顧者和兒童報告),和更少照顧者焦慮。混合廣泛和不同理論的創傷介入治療(即提示為本治療)對治療有人際暴力經歷的青少年有著相當的可行性遵守度和效力。 标题 : 一个随机对照试验:经历人际暴力青少年的提示为本治疗。 撮要 : 史丹福提示为本治疗在长期经历暴力的青少年能否减少创伤后压力、抑郁和焦虑,本研究提出初步证据支持其可行性和功效。从13间学校中招募65名8至17岁的青少年,随机分配到提示为本治疗和等候对照组别,并在4个特定日子进行评估。自我报告评估包括:青少年的创伤后压力症(PTSD) 、焦虑和抑郁症状,亦有照顾者焦虑和抑郁自我报告评分,和照顾者对儿童PTSD的报告。治疗师评估参与者在治疗面见的综合症状改善程度。等级线性模型分析指出:对比等候对照组别,提示为本治疗组别有更大PTSD症状减退(包括照顾者和儿童报告),和更少照顾者焦虑。混合广泛和不同理论的创伤介入治疗(即提示为本治疗)对治疗有人际暴力经历的青少年有着相当的可行性遵守度和效果。
Content may be subject to copyright.
Journal of Traumatic Stress
December 2013, 26, 654–662
Cue-Centered Treatment for Youth Exposed to Interpersonal
Violence: A Randomized Controlled Trial
Victor G. Carrion,1Hilit Kletter,1Carl F. Weems,2Rebecca Rialon Berry,1and John P. Rettger1
1Stanford Early Life Stress Program, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine,
Stanford, California, USA
2Department of Psychology, University of New Orleans, New Orleans, Louisiana, USA
This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic
stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13
schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4
discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression.
Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated
participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the
waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as
caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility,
adherence, and efficacy in treating youth with a history of interpersonal violence.
Within the United States, exposure to violence represents a
significant problem, with prevalence rates ranging from 50.0%
to 96.0% for urban youth (Stein,Jaycox, Kataoka, Rhodes, &
Vestal, 2003). These rates remain constant across time (Cohen,
Deblinger,Mannarino,& Steer, 2004). Although prevalence
rates for posttraumatic stress disorder (PTSD) vary greatly in
youth exposed to violence, these rates are higher than for other
forms of trauma (Kearney, Wechsler, Kaur,& Lemos-Miller,
2010). In a sample of inner-city youth exposed to interpersonal
violence, rates were as high as 57.5% for PTSD and 42.5%
for subthreshold symptoms (Kletter, Weems, & Carrion, 2009).
Violence exposure is associated with increased anxiety, depres-
sion, aggression, and delinquency (Margolin & Gordis, 2000).
Exposure to violence has also been associated with poorer aca-
demic performance, which may be mediated by such factors as
disruptive behaviors and impairment in memory and concentra-
This research was supported by the Lucile Packard Foundation for Children’s
Health and the Evans Foundation grants to Dr. Carrion. The authors would
like to acknowledge the Early Life Stress Program staff: Laura Strom, Melissa
Hirt, Dina Frid, and Tara Hasan. We would also like to thank all the school
staff, children, and families who participated.
Correspondence concerning this article should be addressed to Victor G.
Carrion, Division of Child and Adolescent Psychiatry and Child Develop-
ment, Stanford University, Stanford, CA 94305–5719. E-mail: vcarrion@
stanford.edu
Copyright C2013 International Society for Traumatic Stress Studies. View
this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21870
tion (De Bellis, 2001). These cognitive problems may be related
to brain alterations in children who experience interpersonal vi-
olence (Carrion,Weems, Richert, Hoffman, & Reiss, 2010; De
Bellis et al., 1999). Thus, there is a compelling need for early
intervention and treatment development of youth exposed to
violence.
Recognition of the significance of youth violence exposure
has led to the development of interventions designed specifi-
cally for children and adolescents at risk for PTSD. The most
well validated of these treatments is trauma-focused cognitive–
behavioral therapy (TF-CBT; Cohen & Mannarino, 2008). Nu-
merous randomized controlled trials have demonstrated the ef-
ficacy of TF-CBT in alleviating PTSD, depression, and other
emotional and behavioral difficulties in traumatized children
(Cohen, Mannarino, & Knudsen, 2005; Scheeringa, Weems,
Cohen, Amaya-Jackson, & Guthrie, 2011). Although devel-
oped for the treatment of sexual trauma, TF-CBT has recently
proved superior to child-centered therapy in reducing PTSD
symptoms among youth exposed to intimate partner violence
(Cohen, Mannarino, & Iyengar, 2011). Multimodality trauma
treatment, a group cognitive–behavioral intervention has been
proven effective in both community mental health and school
settings (Amaya-Jackson et al., 2003). Child-parent psychother-
apy is a treatment for young children combining play with other
modalities to restore attachment and regulate traumatic stress
(Lieberman, Van Horn, & Gosh Ippen, 2011). Other treatments
that have shown promise for reducing posttraumatic stress
symptoms in trauma-exposed youth include eye-movement de-
sensitization and reprocessing and systems therapy (Chaffin
654
Cue-Centered Treatment 655
et al., 2004; Chemtob, Nakashima, & Carlson, 2002; Ellis et al.,
2012).
There is a growing interest in school-based interventions for
children exposed to violence (Wolmer, Laor, & Yazgan, 2003).
School-based approaches are more accessible, affordable, and
nonstigmatizing (Jaycox, Stein, & Amaya-Jackson, 2009). A
randomized controlled trial of a standardized 10-session CBT
school-based group intervention (cognitive behavioral interven-
tion for trauma in schools [CBITS]) was successful in reducing
PTSD symptoms and depression in children exposed to violence
(Stein et al., 2003). Furthermore, a universal classroom-based
program was successful in reducing PTSD symptoms, somatic
complaints, and anxiety in war-exposed children (Berger, Pat-
Horenczyk, & Gelkopf, 2007). In addition, studies have demon-
strated the effectiveness of teacher-delivered interventions in
reducing PTSD and enhancing adaptive coping and resiliency
in youth exposed to war and terror (Wolmer, Hamiel, & Laor,
2011).
Jaycox et al. (2010) suggest that structured interventions such
as TF-CBT have adequate treatment effects, but that in real-
world settings these effects may be diminished compared to
modified CBT interventions such as CBITS that specifically
include elements targeting ease of implementation and adher-
ence. The availability of interventions such as TF-CBT and
CBITS has had a significant impact on the successful treatment
of traumatized children. The development of new modalities,
however, continues to be necessary because not all children
respond to available treatments. In particular, children who ex-
perience traumatization within a context of ongoing adversity
may derive limited benefit from processing an isolated trau-
matic event. More efforts need to be developed to empower
this group of children through knowledge (insight) into their
condition. The emphasis on multiple or recurring traumas, the
gained insight into the connection between history, feelings,
and behaviors, the acknowledgment that parents may not be
available for treatment in all sessions are a few of the charac-
teristics that the Stanford cue-centered treatment shares with
CBITS; however, unlike CBITS, cue-centered treatment em-
phasizes individual treatment rather than group prevention. Al-
though group intervention is a cost-effective approach, many
youth may not respond to group interventions or may need
an individual focus to their own cues, history, feelings, and
behaviors.
Cue-centered treatment was developed in recognition of the
growing need for a manualized treatment aiming to increase
youth insight into how an individual’s history of exposure
to trauma may relate to current emotional experiences and
how these in turn may be linked to maladaptive behaviors.
Although authors have called for the inclusion of insight
oriented techniques for the treatment of traumatized youth
(Osofsky, 2003) and have implemented them in broadbased
community intervention models (Osofsky et al., 2007), ran-
domized trials have yet to show that their inclusion (within
CBT protocols) is feasible and linked to reductions in PTSD
symptoms. The cue-centered treatment protocol helps (a) in-
corporate evidence-based treatments for childhood trauma; (b)
educate the child on how to become his or her own agent
of change; (c) increase the child’s understanding of his or
her traumatic experiences and symptoms, as well as effective
methods to counteract them; and (d) increase the child’s in-
sight into the relationship between trauma history, current emo-
tions, and behavioral responses to unconscious trauma-mimetic
cues.
Cue-centered treatment incorporates several unique compo-
nents that render it a distinguishable intervention for trauma-
exposed youth. First, through the use of a life timeline, cue-
centered treatment aims to address the impact of their allostatic
load, examining the direct influence of circumscribed traumatic
events as well as other daily or life stressors. Second, several
cue-centered treatment sessions focus on teaching youth and
caregivers about the conditioning process that occurs through
repeated exposure to trauma, resulting in increased sensitiv-
ity of fear and anxiety networks. As the child identifies cues
associated with this conditioning and develops more adaptive
responses to the cues, the child develops self-efficacy. Third,
through the use of insight-oriented strategies and visual icons
linking history, emotions, and behaviors, the child is challenged
to avoid compartmentalization of these constructs while cur-
rent behaviors are placed in an empathic context. Finally, in
addition to utilizing behavioral, cognitive, and emotional ap-
proaches to develop new responses, cue-centered treatment in-
cludes a physiological approach (how the child feels physically)
recognizing that many children who experience trauma are
sensitive to their interoceptive cues (e.g., increased heart rate,
sweating).
The purpose of the current study was to examine the effi-
cacy of cue-centered treatment as a short-term, manual-based
intervention for youth with interpersonal violence exposure un-
dergoing concurrent and chronic environmental adversity. We
hypothesized that cue-centered treatment would demonstrate
feasibility and efficacy in reducing symptoms of PTSD and
that these symptoms would steadily decrease from session to
session. Rates of comorbidity in individuals with PTSD are
as high as 80.0% for mood and anxiety disorders (Pfeffer-
baum, 1997). Therefore, we chose to also evaluate anxiety
and depression in youth, and it was hypothesized that cue-
centered treatment would result in a reduction in both. Addi-
tionally, based on the work of Silverman and colleagues, we
reasoned that as youth symptoms improved, caregivers’ symp-
toms might also benefit from reduced stress associated with
a symptomatic child (Silverman, Kurtines, Jaccard, & Pina,
2009).
Method
Participants
Youth were considered appropriate for the study if they were
between 8–17 years old, had a history of exposure to violence,
a nonabusing caretaker willing to participate in the study, and
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
656 Carrion et al.
Figure 1. CONSORT flow diagram of enrollment.
no current exposure to perpetrators of violence. Youth were
excluded from the study if they had significant medical illness,
documentation of a diagnosis of autism or schizophrenia, his-
tory of mental retardation or an intelligence quotient (IQ) less
than 70, substance dependency, and lack of proficiency in En-
glish. A diagnosis of PTSD or minimum symptom level was
not required for participation as treatment was also intended
to be preventive for those youth currently not exhibiting sig-
nificant symptoms. Sixty-nine youth met inclusion criteria and
were scheduled for a diagnostic evaluation during which they
and their caregiver completed assessment measures and signed
assent and consent forms approved by an institutional review
board. Of these 69, four participants failed to show for the intake
evaluation.
The final sample consisted of 65 youth who were ran-
domly assigned by the study coordinator to either the Stan-
ford cue-centered treatment manual-based treatment (n=38)
or a waitlist (n=27) and to one of two therapists using
a computer-generated number series. Twenty-four individuals
(13 assigned to cue-centered treatment, 11 to waitlist) did not
complete treatment (see reasons in Figure 1) and were included
in the intent-to-treat analysis (see below). Forty-one youths
completed all phases of the treatment. Nonsignificant differ-
ences were found between treatment completers and noncom-
Table 1
Participant Characteristics
CCT intervention Waitlist control Total
Demographics (n)(n)(n)
Gender
Female 16 10 26
Male 22 17 39
Ethnicity
African American 16 17 33
Hispanic/Latino 15 11 26
Mixed ethnicity 4 1 5
Pacific Islander 1 0 1
Note. CCT =cue-centered treatment.
pleters with regard to age, gender, ethnicity, and pretreatment
scores across measures. A flowchart of participation is shown in
Figure 1.
Demographic data for youth who completed the study are
depicted in Table 1. Mean age was 11.56 years (range =8–
17 years). There were slightly more boys (60.0%, n=39) than
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Cue-Centered Treatment 657
girls (40.0%, n=26). Two participants (3.1%) were taking
psychotropic medication.
Measures
Youth self-report inventories. The UCLA PTSD Reaction
Index for DSM-IV-Child Version (UCLA PTSD-RI) is a 48-
item semistructured interview evaluating children’s exposure
to 26 types of traumatic events and PTSD diagnostic criteria
according to the Diagnostic and Statistical Manual of Mental
Disorders (4th ed., DSM-IV; American Psychiatric Associa-
tion, 1994; Pynoos, Rodriguez, Steinberg, Stuber, & Frederick,
1998). It shows good internal consistency (α=.90) and test-
retest reliability (r=.84; Roussos et al., 2005). Youth provided
PTSD-RI ratings following every treatment session. The PTSD-
RI has been used in several treatment outcome studies includ-
ing the evaluation of symptom changes per session (Taylor &
Weems, 2011).
The revised Children’s Manifest Anxiety Scale (RCMAS;
Reynolds & Richmond, 1985) consists of 37 yes or no items
that assess the level and nature of anxiety. The RCMAS has
been shown to have good internal consistency (α=.87), test-
retest reliability (r=.68), and concurrent validity (e.g., r=
.85).
The Children’s Depression Inventory is a 27-item self-report
measure of youth depression symptoms (Kovacs, 1992). The
Children’s Depression Inventory has adequate internal consis-
tency (α=.71 to .89), test-retest reliability, and concurrent
validity (e.g., r=.55; Kovacs, 1992).
The Violence Exposure Scale for Children-Revised is a 21-
item, cartoon-based interview of community violence exposure.
Responses are measured on a thermometer type rating scale
ranging from never to lots of times. Internal consistency for the
Violence Exposure Scale for Children-Revised ranges from .80
to .86 (Shahinfar, Fox, & Leavitt, 2000).
Caregiver inventories. The UCLA PTSD Reaction Index
for DSM-IV-Parent Version (UCLA PTSD-RI) was completed
by caretakers at each of the four assessment points.
The Beck Anxiety Inventory (BAI) is a 21-item self-report
measure of common anxiety symptoms with high internal con-
sistency (α=.92 to .94) and convergent validity (r=.85to.93;
Beck, Epstein, Brown, & Steer, 1988). The Beck Depression
Inventory (BDI-II) is a 21-item self-report measure of somatic
and psychological aspects of depression The BDI-II has high
internal consistency (α=.91), test-retest reliability (α=.93),
and convergent validity (r=.93; Beck, Steer, & Brown, 1996).
A medical and developmental history form and a demographics
form were also completed by caretakers.
Therapist ratings. The Children’s Global Assessment
Scale is a numeric scale (1–100) used by mental health pro-
fessionals to rate the general functioning of children under the
age of 18. The Children’ Global Assessment Scale has adequate
reliability (α=.83 to .91) and acceptable concurrent and dis-
criminant validity (Schaffer et al., 1983). The Children’s Global
Assessment Scale has been used in a number of treatment out-
come studies (e.g., Cohen, Mannarino, Perel, & Staron, 2007).
Procedure
Recruitment began in October 2009 and ended in July 2011.
Follow-ups occurred between December 2009 and September
2011. Participants were recruited from 13 urban low-income
schools. The first author conducted workshops for approxi-
mately 50 school staff members on the symptoms and impair-
ment associated with trauma and violence exposure, and asked
them to refer students who appeared at risk for these experi-
ences. The counselor or wellness coordinator of each school
gathered all referrals and provided them to the study’s research
coordinator.
Caregivers of youth identified as at risk for trauma exposure
completed a brief telephone interview to determine whether
youth met inclusion/exclusion criteria. The telephone inter-
view consisted of providing caregivers information regarding
the study’s purpose, design, and compensation. Caregivers were
asked their child’s age, history of medical and psychiatric con-
dition, history of educational or psychological testing, history
of trauma exposure and relationship to trauma perpetrator. Ther-
apy sessions were conducted at the child’s school. Parents were
required to participate in four of the 15 sessions. Participants in
the cue-centered treatment group began treatment immediately
while treatment for the waitlist control group occurred 3 months
following initial assignment to waitlist (the time it takes to com-
plete the treatment). Youth were evaluated at preintervention,
midintervention (session 8), posttreatment, and at a 3-month
follow-up. After preintervention youth were only assessed on
symptom measures. Caregivers received a $25 grocery gift card
for the completion of assessments at each time point.
Two licensed therapists (PhD and MFT) with experience in
the treatment of childhood trauma were trained in the admin-
istration of the cue-centered treatment protocol over 3 months
by the study’s principal investigator (VGC). Therapists also
had weekly supervision on the manual, phone consultation,
and case conferences. Fidelity to the treatment protocol was as-
sessed by two independent research assistants utilizing a fidelity
form (available upon request). The raters randomly listened to
25.0% of all audiotapes and used the form to check yes or no on
whether session objectives were met. Fidelity was established
to be 91.2%.
The Stanford cue-centered treatment is a manualized pro-
tocol designed for implementation in clinic or school settings
for youth who have experienced repeated exposure to trau-
matic events and adverse circumstances. Cue-centered treat-
ment consists of 15 weekly, individual sessions, designed to
last approximately 50 minutes. Cue-centered treatment is an
integrative approach, combining elements from cognitive, be-
havioral, psychodynamic, expressive, and family therapies to
address four core domains (cognition, behavior, emotions, and
physiology). Psychoeducation is a keystone in cue-centered
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
658 Carrion et al.
treatment. The primary goal of cue-centered treatment is to
build strength and resilience by empowering the child through
knowledge regarding the relationship between their history of
trauma exposure, and current affective, cognitive, behavioral,
or physiological responses. Children and parents learn about
the significance of traumatic stress, how adaptive responses be-
come maladaptive, how to cope with rather than avoid ongoing
stress, and the importance of verbalizing their life experiences.
The treatment process involves overall competence building,
reduction of physical symptoms of anxiety, modification of
cognitive distortions, and facilitation of emotional expression.
In cue-centered treatment, youth and caregivers learn to recog-
nize and effectively manage maladaptive responses that occur
in response to traumatic reminders (cues).
Although cue-centered treatment is a structured program in
terms of specific session requirements and goals, it is also de-
signed to be flexible, and can be adapted to each child’s devel-
opmental level and therapists’ strengths. The manual contains
numerous pictorial tools intended to help youth understand dif-
ficult therapeutic concepts; such as intensity or severity. The
manual describes each session’s goals and specific objectives,
the role of the therapist in facilitating these, a breakdown of ac-
tivities and a list of materials (i.e., visual icons, questionnaires,
handouts) required during the session. A background section
describes in greater detail the session’s objectives and theoret-
ical and research underpinnings, and provides brief illustrative
case examples. The manual is available upon request to the
corresponding author.
Data Analysis
Planned sample size was calculated based on expected medium
to large effect sizes and actual sample size was a function of
participant recruitment during the project period. The main out-
come comparisons (treatment vs. waitlist) were analyzed with
hierarchical linear models (using the program HLM 7; Rau-
denbush, Bryk, Cheong, Congdon, & du Toit, 2011; see also
Bryk & Raudenbush, 1987, 1992). In the first stage of the
analysis, hierarchical linear modeling (HLM) was used to es-
timate the within-subject change (random effects, Level 1) to
test if change was linear or curvilinear in nature. The second
stage (fixed effects, Level 2) HLM was used to test if there
were differential effects of treatment condition on trends of the
within-subject slopes for each outcome. Specifically, the HLM
analyses nested pre- to postchange (Level 1) in outcomes as a
function of treatment group (immediate treatment vs. waitlist).
The linear values were squared to create the quadratic curvilin-
ear trend similar to previous research and as suggested by Bryk
and Raudenbush (1992). A significant linear slope suggests
gradual change across treatment and a significant quadratic
slope suggests strong initial gains followed by a leveling off.
Changes across individual sessions were also tested via trend
analyses of PTSD-RI scores using HLM. Again, in first stage
of the analysis, HLM was used to estimate the within-subject
change (random effects, Level 1) to test if change was linear or
curvilinear in nature. The second stage HLM was used to test if
there were any effects of age or gender on these trends (fixed ef-
fects, Level 2) on the within-subject slopes for the PTSD scores
across the sessions. Treatment maintenance was examined us-
ing a series of paired sample ttests comparing posttreatment
with follow-up.
Results
The average age of participants was 11.56 years (SD =1.90)
with no differences between cue-centered treatment (M=
11.67, SD =2.06) and waitlist (M=11.46, SD =1.66). Par-
ticipants reported an average of 5.03 (SD =1.88) total traumas
with no differences between cue-centered treatment (M=5.25,
SD =2.34) and waitlist (M=4.81, SD =1.42). Nonsignifi-
cant differences were also observed between groups in terms
of gender and ethnicity comparisons (Table 1). All participants
reported exposure to at least two traumatic events; the most
common traumas reported included separation/loss (75.0%),
witnessing violence (61.5%), homicide (51.9%), physical abuse
(25.0%), and bullying (25.0%). No significant differences were
found between the waitlist and treatment groups on amount of
violence exposure, t(59) =.801, p=.426 with both groups
reporting moderate levels of exposure, waitlist (n=23; M
=27.65, SD =14.12); treatment (n=38, M=25.00, SD
=11.48). Additionally, there were no baseline differences be-
tween groups on child and parent reports on any of the measures
(Table 2; ns varied somewhat across time and measures).
Child Self-Report Inventories
The mean changes in child symptoms by treatment versus wait-
list are presented in Table 2. The results of the HLM analysis
of the overall within-subject PTSD-RI scores (child reported)
change curves indicated significant linear, t(98) =−4.67, p
<.001 and quadratic, t(98) =3.72, p<.001, components
for PTSD symptoms. The significant curvilinear pattern is
consistent with the larger declines from pre- to midtreatment
followed by smaller decreases from midtreatment to posttreat-
ment. Level 2 analyses on PTSD-RI scores indicated that there
was a significant effect of treatment group (wait vs. immedi-
ate treatment) on both the linear (B=−21.41, SE =9.87),
t(96) =−2.17, p=.033 and quadratic (B=4.62; SE =2.28),
t(96) =2.02, p=.046, terms suggesting larger and quicker
reductions in the immediate treatment group. Follow-up anal-
yses were consistent with this and indicated a larger (based on
η2effect size) reduction in PTSD-RI scores from pre- to post-
treatment in the intervention group (partial η2=.58), than in
the wait group (partial η2=.27). At posttreatment, individuals
who received the intervention had lower PTSD-RI scores than
those in the wait group, independent sample t(41) =3.10, p=
.004, 90% confidence interval for the mean difference [4, 19],
d=0.97.
The HLM analyses for the RCMAS and Children’s De-
pression Inventory indicated significant linear, t(90) =−3.21,
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Cue-Centered Treatment 659
Table 2
Pretreatment, Midtreatment, and Posttreatment Outcome Measures
Pretreatment Midtreatment Posttreatment
Measure MSDMSDMSDη2
Children’s Global Assessment Scale
UCLA PTSD Reaction Index-Child*
55.70 10.78 64.26 10.38 70.96 10.63 .73
Treatment 22.70 14.30 8.96 7.96 7.50 9.10 .58
Waitlist 25.80 18.90 20.86 17.83 19.20 15.50 .27
Revised Children’s Manifest Anxiety Scalea
Treatment 11.60 6.00 7.67 5.34 5.40 5.40 .46
Waitlist 12.00 6.60 8.09 7.65 8.60 7.90 .18
Children’s Depression Inventory
Treatment 11.80 7.30 7.18 6.29 6.20 7.10 .30
Waitlist 9.90 6.40 8.14 8.74 7.40 7.30 .11
UCLA PTSD Reaction Index-Parent**
Treatment 23.30 14.50 17.12 12.27 16.10 11.00 .20
Waitlist 19.20 10.80 20.15 15.15 21.70 12.40 .01
Beck Anxiety Inventory**
Treatment 12.40 11.80 9.48 9.79 9.00 7.90 .21
Waitlist 8.50 10.10 7.33 9.47 9.80 11.30 .12
Beck Depression Inventory
Treatment 13.90 10.50 12.33 9.28 9.10 9.50 .25
Waitlist 12.10 11.40 8.89 11.37 7.20 6.40 .16
PTSD =posttraumatic stress disorder.
ap=.08.
*p<.05. **p<.01.
p=.002, and quadratic, t(90) =2.29, p=.025, effects on Level
1 for the RCMAS and a linear trend for the Children’s Depres-
sion Inventory, t(93) =1.78, p=.078. On Level 2, the effect of
treatment (wait vs. no wait) on RCMAS scores approached
significance on the linear trend (B=−1.47; SE =0.83),
t(93) =−1.77, p=.079, suggesting a steeper linear reduction
in RCMAS scores in the immediate treatment group. Follow-up
analyses on the RCMAS indicated a larger (based on η2effect
size) reduction in RCMAS scores from pre- to posttreatment
in the intervention group (partial η2=.46), than in the wait
group (partial η2=.18). At posttreatment the difference be-
tween treated and wait was not statistically significant, but com-
parison suggested a medium effect size, independent sample
t(42) =1.60, p=.117, d=0.49. There was not a significant
effect of treatment on Children’s Depression Inventory scores
(B=−1.18, SE =0.87), t(93) =−1.36, p=.177.
Caregiver Report of Child PTSD Symptoms
Means are reported in Table 2; HLM analyses on the parent
reported PTSD-RI-Parent Version indicated only a significant
effect of treatment group (wait vs. no wait) on a linear trend,
(B=−4.79; SE =1.72), t(101) =−2.78, p=.006, suggesting
a steep linear reduction in PTSD symptoms in the immedi-
ate treatment group. Again follow-up indicated a much larger
(based on η2effect size) reduction in UCLA PTSD-RI-Parent
Version scores from pre- to posttreatment in the intervention
group (partial η2=.20), and little or no change in the wait
group (partial η2=.01).
Caregiver Self-Report of Anxiety and Depression
Symptoms
Means are reported in Table 2 and HLM analyses for the BAI
and BDI indicated linear trend effects on Level 1 for the BAI,
t(102) =−1.79, p=.080; however, on Level 2, there was a
significant effect of treatment group (wait vs. no wait) on BAI
scores for the linear trend (B=−3.84, SE =1.37), t(102) =
2.80, p=.006, suggesting a steep linear reduction in BAI
scores in the immediate treatment group but increases in the
wait group. Follow-up indicated a (based on η2effect size)
reduction in BAI scores from pre- to posttreatment in the in-
tervention group (partial η2=.21), and an increase in the wait
group (partial η2=.12). There was no significant effect of
treatment on the BDI (B=−1.27, SE =1.18), t(102) =−1.07,
p=.287.
Therapist Ratings of Overall Improvement
Analyses of the Children’s Global Assessment Scale combined
youth initially randomized to treatment and also the waitlist
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
660 Carrion et al.
Figure 2. Reductions in UCLA PTSD Reaction Index (PTSD-RI) scores across
treatment sessions. PTSD =posttraumatic stress disorder.
youth after they had received treatment, as has been done in
previous research (Cohen & Mannarino, 2008). Mean scores at
pre-, mid-, and post-treatment are reported in Table 2. The
results of the HLM analysis of the overall within-subject Chil-
dren’s Global Assessment Scale change indicated significant
linear (B=8.53, SE =2.53), t(83) =3.37, p<.001, but not
quadratic, t(83) =−0.37, p=.711, components for PTSD
symptoms. The significant linear pattern is consistent with
steady increases in therapist-reported functioning from pre- to
midtreatment and from mid- to posttreatment.
Symptom Changes per Session
Analyses of session-level change in PTSD symptoms also com-
bined youth initially randomized to treatment and also the wait-
list youth after they had received treatment. HLM analyses indi-
cated significant decreases on PTSD symptoms across sessions
(Figure 2; ns varied across sessions). Level 1 HLM analyses
indicated a significant linear (B=−2.84, SE =0.42), t(500) =
6.72, p<.001, and curvilinear (quadratic) change (B=0.13,
SE =0.02), t(500) =5.60, p<.001. The significant curvilinear
pattern is consistent with sharper declines early in treatment
followed by smaller decreases later in treatment with a general
leveling off near the end of treatment. The results of the Level 2
HLM analyses on the effect of age, gender, or initial assignment
to treatment versus wait indicated no significant effects of age,
gender, or initial assignment on the decrease trends.
Follow-Up Analyses
Treatment maintenance was examined using a series of paired
sample ttests comparing posttreatment symptoms with symp-
toms reported at follow-up. There were no significant differ-
ences between posttreatment and 3-month follow-up for the
PTSD-RI-Child (Mdifference =−1.05, SE =0.92), t(36) =
1.15, p=.259. Additionally, there were no significant dif-
ferences for the Children’s Depression Inventory (Mdifference =
0.50, SE =0.71), t(37) =0.70, p=.487, RCMAS (Mdifference =
0.19, SE =0.47), t(36) =0.41, p=.686, BAI (Mdifference =
2.14, SE =1.33), t(28) =1.60, p=.120, and BDI (Mdifference =
0.24, SE =1.69), t(28) =−0.14, p=.887. There was a
significant decrease on the PTSD-RI-Parent completed about
their child’s symptoms (Mdifference =5.37, SE =1.42), t(34)
=3.78, p=.001, suggesting continued improvement from the
perspective of the caregiver.
Discussion
The current investigation supports the use of cue-centered
treatment to treat youth exposed to interpersonal violence in
school settings. Cue-centered treatment resulted in significant
reduction in youth posttraumatic symptoms by both parent and
child report and therapist ratings showed improvement in over-
all functioning. Furthermore, treatment gains were maintained
over time. Effect sizes were strongest for PTSD-RI symptoms
and the significant curvilinear pattern is consistent with the
larger declines from pre- to midtreatment followed by smaller
decreases from midtreatment to posttreatment. In addition, the
HLM on session-level analyses indicated that PTSD symptoms
decreased across sessions, with larger symptom reductions ob-
served earlier in treatment followed by less substantial reduc-
tions later on. The explanation for the significant symptom
reduction in the earlier phase of treatment is unclear, and the
critical role of each treatment component cannot be examined
in the current design. However, it is possible that psychoeduca-
tion and coping skills received in the initial sessions provided
youth with knowledge and hope imperative to symptom relief,
and accounted for the sharp decline in PTSD symptoms.
Cue-centered treatment was also associated with improve-
ment in youth overall functioning as rated by the therapists
on the Children’s Global Assessment Scale. As symptoms de-
creased, functioning improved across time points. Improving
function in youth with PTSD symptoms is pivotal because these
symptoms can have a deleterious effect on social, emotional,
and academic development. Although Children’s Global As-
sessment Scale scores indicate overall improvement in func-
tioning, it is possible that these changes are due to time alone.
The specificity of cue-centered treatment efficacy to PTSD,
rather than depression, was consistent for both children and
caregivers. This may reflect cue-centered treatment’s direct ap-
proach to responses to trauma-mimetic cues, and lower empha-
sis in mood-related items. Of interest, even though cue-centered
treatment does not emphasize the caregivers’ experience or re-
quires caregivers to come to every session, those caregivers in
the treatment group had a significant decrease of anxiety. A
number of explanations could account for this change, such as
psychoeducation into the child’s condition, improvement in the
child’s behavior and mood, their own participation in a number
of sessions, and feeling supported in terms of getting help for
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Cue-Centered Treatment 661
their child. Future work should research these possibilities, as
well as the anxiety specificity. Notably, these treatment gains
were maintained at follow-up evaluation for both children and
caregivers.
The results of this trial contribute to the extant literature by
demonstrating the benefits of a hybrid intervention, combining
core elements of different theoretical approaches, for reducing
psychiatric symptoms in youth exposed to chronic adversity.
The data provide support for the notion (Osofsky, 2003) that
the inclusion of insight-oriented techniques in the treatment of
traumatized youth is feasible and linked to reductions in PTSD.
Based on the results, the use of cue-centered treatment appears
feasible in school settings that provide easy access to youth,
dedicated time for sessions, and a supportive, structured envi-
ronment. The cue-centered treatment approach represents just
the second protocol to help reduce nondisaster-related PTSD in
a school setting. This study presents with a number of signif-
icant strengths relative to other trauma-focused interventions
performed in school settings, including random assignment,
inclusion of caregiver data, and clinical evaluation of child
symptoms by therapists. Though emphasis on the development
of skillful coping behaviors appears consistent across similar
treatments for youth trauma, cue-centered treatment specifi-
cally emphasizes the connection between environmental ex-
periences, traumatic responses, and trauma-mimetic cues (i.e.,
vis-a-vis a classical conditioning paradigm). The results of the
present initial feasibility trial of cue-centered treatment further
suggests that processing traumatic events and adverse experi-
ences across the lifespan, gaining self-empowerment through
knowledge, and developing competency may provide an effica-
cious approach for youth who would find it difficult to process
isolated traumatic events while experiencing ongoing adversity.
Study limitations included a relatively small sample size. The
groups were similar in pretreatment scores on most measures,
and the data suggest that while the waitlist group demonstrated
reduced symptomatology between pre- and postintervention
assessments, the reductions were larger in the group receiving
the intervention across measures. However, larger samples are
needed to produce more statistically robust conclusions for the
comorbid anxiety and depression. Follow-up could be improved
by lengthening its time and assessing recurrent trauma and
health service utilization.
Future studies should examine the utility of the Stanford cue-
centered treatment protocol in other treatment settings. Cogni-
tive and personality measures should be added to future trials
to learn which individuals will benefit most from which cue-
centered treatment components. Reduced symptomatology has
been shown to have a strong impact on academic functioning
such as grades and attendance (Stein et al., 2003), thus future
studies should incorporate both behavioral and academic out-
come measures. Comparisons are needed between cue-centered
treatment and other active psychosocial treatments to determine
specificity for different types of traumas and populations. Fi-
nally, outcome studies integrating biological markers will in-
form potential mechanisms of action, helping future treatment
development. Cue-centered treatment may provide an alterna-
tive intervention for youth who do not respond to available
treatments.
References
Amaya-Jackson, L., Reynolds, V., Murray, M. C., McCarthy, G., Nelson, A.,
Cherney, M. S., . . . March, J. S. (2003). Cognitive-behavioral treatment for
pediatric posttraumatic stress disorder: Protocol and application in school
and community settings. Cognitive and Behavioral Practice,10, 204–213.
doi:10.1016/S1077-7229(03)80032-9
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington, DC: Author.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for
measuring clinical anxiety: Psychometric properties. Journal of Consulting
and Clinical Psychology,56, 893–897. doi:10.1037//0022-006X.56.6.893
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck
Depression Inventory (2nd ed.). San Antonio, TX: Psychological Corp.
Berger, R., Pat-Horenczyk, R., & Gelkopf, M. (2007). School-based inter-
vention for prevention and treatment of elementary-students’ terror-related
distress in Israel: A quasi-randomized controlled trial. Journal of Traumatic
Stress,20, 541–551. doi:10.1002/jts.20225
Bryk, A. S., & Raudenbush, S. W. (1987). Application of hierarchical lin-
ear models to assessing change. Psychological Bulletin,101, 147–158.
doi:10.1037//0033-2909.101.1.147
Bryk, A., & Raudenbush, S. W. (1992). Hierarchical linear models for social
and behavioral research: Applications and data analysis methods.Newbury
Park, CA: Sage.
Carrion, V. G., Weems, C. F., Richert, K., Hoffman, B. C., & Reiss, A. L.
(2010). Decreased prefrontal cortical volume associated with increased bed-
time cortisol in traumatized youth. Biological Psychiatry,68, 491–493.
doi:10.1016/j.biopsych.2010.05.010
Chaffin, M., Silovsky, J. F., Funderberk, B., Valle, L. A., Brestan, E. V., Bal-
achova, T., . . . Bonner, B. L. (2004). Parent–child interaction therapy with
physically abusive parents: Efficacy for reducing future abuse reports. Jour-
nal of Consulting and Clinical Psychology,72, 500–510. doi:10.1037/0022–
006X.72.3.500
Chemtob, C. M., Nakashima, J., & Carlson, J. G. (2002). Brief treatment
for elementary school children with disaster-related posttraumatic stress
disorder: A field study. Journal of Clinical Psychology,58, 99–112.
doi:10.1002/jclp.1131
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A
multisite, randomized controlled trial for children with sexual abuse-related
PTSD symptoms. Journal of the American Academy of Child and Adolescent
Psychiatry,43, 393–402. doi:10.1097/00004583-200404000-00005
Cohen, J. A., & Mannarino, A. P. (2008). Trauma-focused cognitive be-
havioural therapy for children and parents. Child & Adolescent Mental
Health,13, 158–162. doi:10.1111/j.1475-3588.2008.00502.x
Cohen, J. A., Mannarino, A. P., & Iyengar, S. (2011). Community treat-
ment of posttraumatic stress disorder for children exposed to intimate part-
ner violence. Archives of Pediatrics & Adolescent Medicine,165, 16–21.
doi:10.1001/archpediatrics.2010.247
Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually
abused children: 1 year follow-up of a randomized controlled trial. Child
Abuse & Neglect,29, 135–145. doi:10.1016/j.chiabu.2004.12.005
Cohen, J. A., Mannarino, A. P., Perel, J. M., & Staron, V. (2007). A pilot ran-
domized controlled trial of combined trauma-focused CBT and sertraline
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
662 Carrion et al.
for childhood PSTD symptoms. Journal of the American Academy of Child
& Adolescent Psychiatry,46, 811–819. doi:10.1097/chi.0b013e31805-
47105
De Bellis, M. D. (2001). Developmental traumatology: The psychobiologi-
cal development of maltreated children and its implications for research,
treatment, and policy. Development and Psychopathology,13, 539–564.
doi:10.1017/S0954579401003078
De Bellis, M. D., Keshavan, M. S., Clark, D. B., Casey, B. J., Giedd, J. A., Bor-
ing, A. M., . . . Ryan, N. D. (1999). Developmental traumatology: II. Brain
development. Biological Psychiatry,45, 1271–1284. doi:10.1016/S0006-
3223(99)00045-1
Ellis, B. H., Fogler, J., Hansen, S., Forbes, P., Navalta, C. P., & Saxe, G.
(2012). Trauma systems therapy: 15-month outcomes and the importance of
effecting environmental change. Psychological Trauma: Theory, Research,
Practice, and Policy,4, 624–630. doi:10.1037/a0025192
Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. S., Langley, A. K.,
Gegenheimer, K. L. . . . Schonlau, M. (2010). Children’s mental health care
following Hurricane Katrina: A field-trial of trauma-focused psychothera-
pies. Journal of Traumatic Stress,23, 223–231. doi:10.1002/jts.20518
Jaycox, L. H., Stein, B. D., & Amaya-Jackson, L. (2009). School-based treat-
ment for children and adolescents. In E. B. Foa, T. M. Keane, M. J. Friedman,
&J.A.Cohen(Eds.),Effective treatments for PTSD: Practice guidelines
from the International Society for Traumatic Stress Studies (2nd ed., pp.
327–345). New York, NY: Guilford Press.
Kearney, C., Wechsler, A., Kaur, H., & Lemos-Miller, A. (2010). Posttraumatic
stress disorder in maltreated youth: A review of contemporary research
and thought. Clinical Child and Family Psychology Review,13, 46–76.
doi:10.1007/s10567-009-0061-4
Kletter, H., Weems, C. F., & Carrion, V. G. (2009). Guilt and posttraumatic
stress symptoms in child victims of interpersonal violence. Clinical Child
Psychology and Psychiatry,14, 71–83. doi:10.1177/1359104508100137
Kovacs, M. (1992). Manual of the Children’s Depression Inventory. Toronto,
Ontario, Canada: Multi-Heath Systems.
Lieberman, A. F., Van Horn, P. J., & Ghosh Ippen, C. (2011). Toward evidence-
based treatment: Child–parent psychotherapy with preschoolers exposed to
marital violence. Journal of the American Academy of Child and Adolescent
Psychiatry,44, 1241–8.
Margolin, G., & Gordis, E. B. (2000). The effects of family and commu-
nity violence on children. Annual Review of Psychology,51, 445–479.
doi:10.1146/annurev.psych.51.1.445
Osofsky, J. D. (2003). Psychoanalytically based treatment for trau-
matized children and families. Psychoanalytic Inquiry,23, 530–543.
doi:10.1080/07351692309349048
Osofsky, J. D., Kronenberg, M., Hammer, J. H., Lederman, J. C., Katz, L.,
Adams, S., . . . Hogan, A. (2007). The development and evaluation of the
intervention model for the Florida Infant Mental Health Pilot Program. Infant
Mental Health Journal,28, 259–280. doi:10.1002/imhj.20135
Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of
the past 10 years. Journal of the American Academy of Child & Adolescent
Psychiatry,36, 1503–1511.
Pynoos, R., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998).
UCLA PTSD Index for DSM-IV. Los Angeles, CA: University of California,
Los Angeles.
Raudenbush, S. W., Bryk, A. S., Cheong, Y. F., Congdon, R. T., & du Toit, M.
(2011). HLM 7: Hierarchical linear and nonlinear modeling. Skokie, IL:
Scientific Software International.
Reynolds, C. R., & Richmond, B. O. (1985). Factor structure and construct
validity of “What I Think and Feel: The Revised Children’s Manifest Anxiety
Scale.” Journal of Personality Assessment,43, 281–283. doi:10.1037/022-
006x.49.3.352
Roussos, A., Goenjian, A. K., Steinberg, A. M., Sotiropoulou, C., Kakaki,
M. Kabakos, C., . . . Manouras, V. (2005). Posttraumatic stress and depres-
sive reactions among children and adolescents after the 1999 earthquake
in Ano Liosia, Greece. American Journal of Psychiatry,162, 530–537.
doi:10.1176/appi.ajp.162.3.530
Schaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P.,
Bird, H., & Aluwhalia, S. (1983). A children’s global assess-
ment scale (CGAS). Archives of General Psychiatry,40, 1228–1231.
doi:10.1001/archpsyc.1983.01790100074010
Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., &
Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for post-
traumatic stress disorder in three to six year-old children: A randomized
clinical trial. Journal of Child Psychology and Psychiatry,52, 853–860.
doi:10.1111/j.1469-7610.2010.02354.x
Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000). Preschool children’s expo-
sure to violence: Relation of behavior problems to parent and child reports.
American Journal of Orthopsychiatry,1, 115–125. doi:10.1037/h0087690
Silverman, W. K., Kurtines, W. M., Jaccard, J., & Pina, A. A. (2009). Direc-
tionality of change in youth anxiety treatment involving parents: An initial
examination. Journal of Consulting and Clinical Psychology,77, 474–485.
doi:10.1037/a0015761
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., &
Fink, A. (2003). A mental health intervention for school children exposed to
violence: A randomized controlled trial. Journal of the American Medical
Association,290, 603–611. doi:10.1001/jama.290.5.603
Stein, B. D., Jaycox, L. H., Kataoka, S., Rhodes, H. J., & Vestal, K.
D. (2003). Prevalence of child and adolescent exposure to community
violence. Clinical Child and Family Psychology Review,2, 247–264.
doi:10.1023/B:CCFP.0000006292.61072.d2
Taylor, L. K., & Weems, C. F. (2011). Cognitive–behavior ther-
apy for disaster exposed youth with posttraumatic stress: Results
from a multiple-baseline examination. Behavior Therapy,42, 349–363.
doi:10.1016/j.beth.2010.09.001
Wolmer,L., Hamiel, D., & Laor, N. (2011). Preventing children’s posttraumatic
stress after disaster with teacher-based intervention: A controlled study.
Journal of the American Academy of Child & Adolescent Psychiatry,50,
340–348. doi:10.1016/j.jaac.2011.01.002
Wolmer, L., Laor, N., & Yazgan, Y. (2003). School reactivation programs after
disaster: Could teachers serve as clinical mediators? Child and Adolescent
Psychiatric Clinics of North America,12, 363–381. doi:10.1016/S1056-
4993(02)00104-9
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
... Child parent psychotherapy 86,89,93,96 Parent-child interaction therapy 87,88,90,91,94,95,97,98 Trauma-focused cognitive behavioral therapy 89,92,96,99 Dialectical behavioral therapy 90,93,97,100 Cue-centered therapy 91,94,98,101 Eye movement desensitization and reprocessing 92,95,99,102 Biofeedback and neurofeedback 93,94,96,97,100,101,103,104 Psychiatry: Psychiatrists may be a critical part of the integrated health team depending on the severity of the presenting symptoms. It is important to identify psychiatrists who (1) understand the biology and physiology of trauma, (2) recognize developmental trauma disorder, 95,98,102,105 and do not over diagnose or inadvertently misdiagnose children exposed to ACEs with other conditions, such as oppositional defiant disorder or attention deficit hyperactivity disorder, and (3) are cognizant of issues surrounding over medication and polypharmacy use especially with foster youth. ...
... Child parent psychotherapy 86,89,93,96 Parent-child interaction therapy 87,88,90,91,94,95,97,98 Trauma-focused cognitive behavioral therapy 89,92,96,99 Dialectical behavioral therapy 90,93,97,100 Cue-centered therapy 91,94,98,101 Eye movement desensitization and reprocessing 92,95,99,102 Biofeedback and neurofeedback 93,94,96,97,100,101,103,104 Psychiatry: Psychiatrists may be a critical part of the integrated health team depending on the severity of the presenting symptoms. It is important to identify psychiatrists who (1) understand the biology and physiology of trauma, (2) recognize developmental trauma disorder, 95,98,102,105 and do not over diagnose or inadvertently misdiagnose children exposed to ACEs with other conditions, such as oppositional defiant disorder or attention deficit hyperactivity disorder, and (3) are cognizant of issues surrounding over medication and polypharmacy use especially with foster youth. ...
... 96,99,103,106 Flora Traub and René e Boynton-Jarrett 107 offer insightful recommendations to pediatric practices to improve resilience to ACEs, including: (1) train all staff in traumainformed care, (2) screen risk and protective factors, (3) employ non-physicians to help with screening, education, and care coordination, (4) create a medical home, (5) create an integrated behavioral health program, (6) offer group-based parenting support and education, (7) offer peer-based education, (8) customize health care to the needs of the family, (9) identify local resources, and (10) be aware of barriers to engagement. 97,100,104,107 In addition, the American Academy of Pediatrics offers a Trauma Guide, which includes "Trauma Toolbox for Primary Care," 108 "Helping Foster and Adoptive Families Cope With Trauma: A Guide for Pediatricians," 98,101,105,108,109 and additional resources. ...
Article
Full-text available
Background: Adverse Childhood Experiences (ACEs) are associated with behavioral, mental, and clinical outcomes in children. Tools that are easy to incorporate into pediatric practice, effectively screen for adversities, and identify children at high risk for poor outcomes are lacking. Objective: To examine the relationship between caregiver-reported child ACEs and related life events with health outcomes. Participants and setting: Participants (0-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. There were 367 participants randomized. Methods: Participants were randomized 1:1:1 to item-level (item response), aggregate-level (total number of exposures), or no screening for ACEs (control arm) with the PEdiatric ACEs and Related Life Event Screener (PEARLS). We assessed 10 ACE categories capturing abuse, neglect, and household challenges, as well as 7 additional categories. Multivariable regression models were conducted. Results: Participants reported a median of 2 (IQR 1-5) adversities with 76 % (n = 279) reporting at least one adversity; participants in the aggregate-level screening arm, on average, disclosed 1 additional adversity compared to item-level screening (p = 0.01). Higher PEARLS scores were associated with poorer perceived child general health (adjusted B = -0.94, 95 %CI: -1.26, -0.62) and Global Executive Functioning (adjusted B = 1.99, 95 %CI: 1.51, 2.46), and greater odds of stomachaches (aOR 1.14; 95 %CI: 1.04-1.25) and asthma (aOR 1.08; 95 %CI 1.00, 1.17). Associations did not differ by screening arm. Conclusion: In a high-risk pediatric population, ACEs and other childhood adversities remain an independent predictor of poor health. Increased efforts to screen and address early-life adversity are necessary.
... One intervention described by Perry and Daniels (2016) implemented both trauma-sensitive practices within the school and extracurricular clinical services. Overall, four interventions (k = 9 studies) utilised group settings with individual components, three interventions (k = 4 studies) utilised pure group settings, and one intervention (k = 1 study; Carrion et al., 2013) offered purely individual treatment (see Table 5). The implemented interventions' duration varied, with the number of sessions necessary ranging between 5 and 20. ...
Article
Full-text available
Background: Interpersonal violence against children and adolescents can affect their mental health and functioning in the long term. To reduce mental health problems in children and adolescents, school-based mental health interventions have been shown to be beneficial. A review of school-based interventions designed to mitigate posttraumatic symptoms after interpersonal violence is lacking to date. Methods: We searched for original studies published in English or German until November 2019 in 6 electronic databases. Supplementary search strategies to reduce publication bias were implemented. Peer-reviewed original studies assessing school-based interventions for children and adolescents under the age of 21 after interpersonal violence were included. Relevant data was extracted, synthesised and assessed qualitatively. The methodological quality of included studies was assessed. Results: Of 5,021 unduplicated publications, 15 studies met eligibility criteria. The included studies were almost exclusively conducted in the USA; over half utilised a randomised-controlled design. Studies mainly focussed on Posttraumatic Stress Disorder (PTSD) or depression. In all studies, implemented interventions partially or fully mitigated posttraumatic symptoms. Nine school-based interventions, five of which were based on cognitive behavioural therapy (CBT), were identified. School staff were often involved in intervention implementation besides mental health professionals. Conclusions: School-based interventions can be beneficial to reduce mental health problems in children and adolescents after interpersonal violence. Trained school staff aided by mental health professionals can implement trauma-informed practices at school. While school-based interventions may be a feasible way to provide children and adolescents with accessible mental health care, further research on school-based trauma interventions outside the USA is necessary.
... For example, treatment of maternal depression, yielded on average, medium effects on parenting quality and young children's mental health (Cuijpers et al., 2015;Gunlicks & Weissman, 2008), and treatment-related improvements in parental panic disorder have been found to result in long-term improvements in children's anxiety and depression symptoms (Schneider et al., 2013). Child and adolescent treatment for anxiety or post-traumatic stress disorder (PTSD) are similarly associated with improvements in parental anxiety (Carrion et al., 2013;Cobham et al., 1998;Escovar et al., 2019) and parental post-traumatic stress (Martin et al., 2019), respectively. In contrast, the literature on parent management training (PMT) programs that primarily target parenting behavior and show robust downstream effects on child outcomes (Eyberg et al., 2008;McCart et al., 2016;Yap et al., 2016), presents mixed results with regard to its effects on parent symptoms (Barlow et al., 2012;Colalillo & Johnston, 2016). ...
Article
Full-text available
Given the high rates of co-occurrence of psychopathology within families, it is important to identify and characterize interventions that simultaneously reduce both parent and child symptoms, and improve parenting quality. This is needed as intervention development is increasingly moving toward integrated interventions that target some combination of parent and child mental health, and parenting behavior. Even so, much remains unknown regarding which treatment components provide maximum benefit for parent symptoms, child symptoms, and parenting behavior. This systematic review identified and characterized psychotherapeutic interventions that report improvements in each of three outcomes: parent symptoms, child symptoms and parenting behavior. Fifty-six unique interventions were eligible for review, of which 25 reported improvements in all three outcomes. All 25 of these interventions directly intervened on parenting behavior, often as the sole target of the intervention. Few interventions improved all three outcomes in samples in which parents, children or both met clinical-level thresholds of psychopathology. Additional research is needed to better understand the bi-directional and transactional influences of treatment on family members, and to better inform the development of interventions for dually disordered parent-child dyads across a range of diagnostic profiles.
... To date, two RCTs have been done with CCT. The first involved sixty-five youth between the ages of 8-17 (average age 11.56) from 13 low-income, high risk schools in the San Francisco Bay Area, California [46]. The majority were minorities consisting of 33 African American, 26 Latino, 1 Pacific Islander, and 5 mixed. ...
Article
Full-text available
Purpose Few of the existing evidence-based interventions for child trauma exposure were specifically designed to address experiences and outcomes of complex developmental trauma. Stanford’s cue-centered therapy (CCT) was designed to address this gap by offering a flexible, integrative, and insight-oriented treatment approach that is grounded in principles of neuroscience, developmental trauma, client empowerment, and allostasis. This article reviews the CCT rationale, treatment components, evidence base, and training approach. Recent findings Studies demonstrate promising outcomes indicating CCT effectiveness in reducing child and caregiver posttraumatic stress, and in improving child functioning. Further research, however, is needed to identify which clients are best-suited for CCT (versus other available child trauma treatments) and to identify which components of CCT are most critical for addressing complex developmental trauma. Summary CCT advances the field of child trauma treatment by offering an intervention approach focused on addressing complex developmental trauma. Positive treatment and training outcomes indicate utility of CCT for clients and clinicians. Innovations in research and training approaches are needed to further dissemination and implementation of CCT and other related child trauma interventions for complex developmental trauma.
... Se valoró que la combinación de contenidos de información sobre neurociencia básica del estrés traumático, y ejercicios prácticos de mindfulness, podía ser efectiva para los objetivos planteados. La literatura refiere los efectos positivos y sanadores de la psicoeducación en relación al trauma disminuyendo la sintomatología (24). También, la necesidad de autocuidados en el personal más expuesto que realiza labores de apoyo psicológico. ...
Article
Full-text available
Introducción: El artículo describe un modelo de intervención temprana para la prevención de patología, y promoción de la resiliencia, tras los terremotos de la isla de Puerto Rico en enero de 2020. El 7 de enero de 2020 un terremoto de magnitud 6,4 en la escala Richter, sacudió la isla de Puerto Rico. Como consecuencia, gran parte de la población sufrió desplazamientos de sus domicilios y cierres de muchas escuelas. Todo ello sobre lo ya anteriormente vivido, como el Huracán María en 2017, aumentando así su carga de estrés alostática. Tras la ayuda inicial de los cuerpos de rescate, se detecta la necesidad de apoyo psicológico a la población y a profesionales proveedores de dicho apoyo. Métodos: Contando con una precaria infraestructura, se decide realizar una intervención con el objetivo de proporcionar información del impacto del estrés traumático en el organismo, así como ejercicios prácticos de mindfulness dirigidos a dichos profesionales. El programa integra lecciones de la Terapia de Claves Traumáticas y ejercicios del currículo Pure Power. Resultados: Se confirma, a través de un cuestionario de satisfacción, la necesidad de este tipo de programas, y se valora extrapolar el modelo a otras poblaciones de riesgo similares, en términos de evitar las consecuencias del trauma, disminuir la carga alostática, y prevenir y promocionar la salud mental. Se sugiere realizar próximas formaciones de ampliación de este programa, para confirmar su efectividad y mantenimiento en el tiempo.
Chapter
This chapter explores the distinct needs of youth who have been placed in the custody of the foster care system. The authors discuss the impact of abuse and neglect, removal from the biological family, and repeated relocation to different home and school settings upon the mental health and development of youth in foster care. The developmental impact of adverse experiences on these youth across different psychosocial development stages, mental health conditions to which this population is vulnerable, and challenges to meeting educational needs are delineated. The authors identify and discuss strategies for effective clinical intervention and advocacy that counselors may implement in school settings.
Article
Full-text available
Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well—CBT and IPT—has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.
Chapter
This chapter explores the distinct needs of youth who have been placed in the custody of the foster care system. The authors discuss the impact of abuse and neglect, removal from the biological family, and repeated relocation to different home and school settings upon the mental health and development of youth in foster care. The developmental impact of adverse experiences on these youth across different psychosocial development stages, mental health conditions to which this population is vulnerable, and challenges to meeting educational needs are delineated. The authors identify and discuss strategies for effective clinical intervention and advocacy that counselors may implement in school settings.
Article
Full-text available
Imaging methods have elucidated several neurobiological correlates of traumatic and adverse experiences in childhood. This knowledge base may foster the development of programs and policies that aim to build resilience and adaptation in children and youth facing adversity. Translation of this research requires both effective and accurate communication of the science. This review begins with a discussion of integrating the language used to describe and identify childhood adversity and their outcomes to clarify the translation of neurodevelopmental findings. An integrative term, Traumatic and Adverse Childhood Experiences (TRACEs+) is proposed, alongside a revised ACEs pyramid which emphasizes that a diversity of adverse experiences may lead to a common outcome and that a diversity of outcomes may result from a common adverse experience. This term facilitates linkages between the ACEs literature and the emerging neurodevelopmental knowledge surrounding the effect of traumatic adverse childhood experiences on youth in terms of the knowns and unknowns about neural connectivity in youth samples. How neuroscience findings may lead directly or indirectly to specific techniques or targets for intervention and the reciprocal nature of these relationships is addressed. Potential implications of the neuroscience for policy and intervention at multiple levels are illustrated using existing policy programs that may be informed by (and inform) neuroscience. The need for transdisciplinary models to continue to move the science to action closes the paper.
Article
Full-text available
This meta-analysis aimed at providing an up-to-date estimate on the efficacy of psychological interventions for pediatric PTSD and to analyze the association between treatment efficacy and study quality. We systematically searched PsycINFO, Medline and recent meta-analyses for randomized controlled trials (RCTs). RCTs were eligible if a) they included at least 10 participants per group, b) compared a psychological intervention to a control condition or another psychological intervention and c) mean age was below 19 years. Study quality was assessed independently by both authors on the basis of eight quality criteria. We explored the potential associations between study quality and effect sizes in three ways. Firstly, we compared effect-sizes of high-quality vs. lower-quality studies. Secondly, we analyzed study quality as a continuous predictor of effect sizes. And thirdly, we examined the relationship between the eight individual quality criteria and effect sizes. A total of 46 eligible RCTs were included in the meta-analysis. Psychological interventions produced a large effect size when compared to waitlist (g = 1.07, k = 23, NNT = 1.81) and a medium effect size when compared to active control conditions (g = 0.60, k = 15, NNT = 3.03) at post-treatment. Overall, study quality was moderate. Comparisons of high-quality trials (k = 16) with lower-quality trials (k = 30) produced only non-significant findings in main-analyses as well as moderator sub-analyses. Study quality as a continuous variable was also not found to be related to effect sizes in any of the main analyses, nor was any of the eight individual quality criteria. The summary of the available literature strongly suggests that psychological interventions are effective in treating PTSD in children and adolescents. No significant associations between study quality and treatment efficacy were observed.
Article
• We evaluated the Children's Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.
Article
A psychoanalytic orientation provides an important perspective for developing community-based prevention and intervention programs for traumatized children and their families. In New Orleans, the Violence Intervention Program for Children and Families is designed to reduce the risk of exposure to violence, mental health problems following exposure, interference with normal developmental progression, academic performance, family functioning, onset of behavioral and conduct disturbances, later psychopathology, and subsequent violence. The program includes an unusual focus on work with police officers as first responders to increase their sensitivity and responsiveness to traumatized children. A psychoanalytic perspective helps a therapist or interventionist understand a person's strengths and weaknesses, frustrations, and conflicts as well as those within a chaotic environment and social situation. The psychoanalytic approach allows for more effective therapeutic approaches as well as more flexible problem-solving strategies.
Article
This paper describes a multimodality trauma treatment protocol (MMTT) for children and adolescents with PTSD. Based upon empirically validated cognitive-behavioral methods of treating PTSD in adults and anxiety and aggression in children, MMTT was developed as a group intervention administered in schools to treat children and adolescents exposed to single-incident trauma resulting in PTSD. In this paper, the protocol development and outcome data are described, followed by a detailed overview of the protocol. Attention is given to clinical implications for both school and community mental health center application of the protocol.