Frank W. Putnam’s research while affiliated with University of North Carolina at Chapel Hill and other places

Background: Following traumatization, caregiver support is a crucial factor contributing to children's successful management of posttraumatic reactions and their recovery. Caregivers who have been traumatically impacted themselves, however, may be compromised in this posttraumatic caregiving role. Although there are a number of evidence-based child trauma treatments that are effective in reducing children's trauma symptoms, the impact of child treatment on participating caregiver's posttraumatic symptoms (PTS) has received less attention. Objective: Explore PTS reduction caregivers experience through participation in their child's evidence-based trauma-focused mental health treatment. Participants and setting: 640 Child-Caregiver dyads referred for the Child and Family Traumatic Stress Intervention (CFTSI) following formal disclosure of abuse in a Child Advocacy Center (CAC). Methods: Data were collected from 10 community treatment sites trained in CFTSI. A multi-site meta-analytic approach was used to evaluate pooled and site-specific therapeutic effect sizes for caregivers and children. Results: CFTSI was associated with significant changes (Hedge's g = 1.17, Child-rated; g = 0.66, caregiver-rated) in children's PTS and with clinically meaningful improvements in PTS for 62% of participating caregivers who had started CFTSI with clinical levels of PTS as measured by the Post Traumatic Checklist-Civilian Version (PCL-C). The overall mean PCL-C change (9.31, SD = 12.9) in paired, pre-post PCL-C scores is close to a clinically meaningful change of 10 or higher. There was a robust moderate pooled effect size (g = 0.70, N = 640, p < 0.0001). Conclusion: The value of a reduction in caregiver PTS as a secondary outcome of children's trauma-focused treatment is discussed.

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self‐injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web‐based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web‐based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample |d|s = 0.44–0.90, as well as reduced NSSI. The improvements in NSSI among the most self‐injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation |d|s = 0.54–1.04 vs. |d|s = 0.24–0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs.

Childhood sexual abuse (CSA) is implicated in the etiology of eating disorders (ED) and health problems in females, but prospective evidence is limited. ED symptoms are widespread but often undertreated, potentially contributing to subsequent ED-related health problems. Using data from Trickett and colleagues’ Female Growth and Development Study, the present report investigated the prospective associations among CSA, ED symptomatology in adolescence, and ED-related health problems in adulthood. Females with substantiated CSA and demographically-matched comparisons (N = 135) were followed at mean ages 11 through 24. Symptom counts and diagnoses of anorexia nervosa (AN) and bulimia nervosa (BN) over the lifetime were assessed in adolescence. Self-reported physical health problems were assessed in adulthood. Controlling for depression, anxiety, and age, CSA participants reported more symptoms and related health problems of BN, but not AN, relative to comparisons. CSA was not associated with the likelihood of receiving a diagnosis for either ED. BN symptom count accounted for a portion of the association between CSA and increased BN-related health problems. This report provided prospective evidence for the associations between CSA and BN symptoms and BN-related health problems. These findings support the recommendations to bolster resources and expertise for trauma-informed ED screening and treatment, ED treatments for patients with subthreshold symptoms, and enhanced treatments addressing ED and health problems for sexual abuse survivors.

Depression is prevalent among mothers who participate in home visitation programs. This case study describes In-Home Cognitive Behavioral Therapy (IH-CBT), an empirically based treatment for depressed mothers that is strongly integrated with ongoing home visitation. The use of a Parenting Enhancement for Maternal Depression (PEMD) module was added to address parenting difficulties in a depressed mother. This case describes issues and challenges encountered in delivering treatment in the home with low-income, depressed mothers. Issues involving engagement, adaptation to the setting, responding to the unique needs of low-income mothers, and partnership with concurrent home visiting to optimize outcomes are considered. Long-term follow-up (18 months after the end of treatment) permits examination of sustainability of gains. Implications for treating this high-risk population are discussed.

Background: Interpersonal trauma and trauma-related disorders cost society billions of dollars each year. Because of chronic and severe trauma histories, dissociative disorder (DD) patients spend many years in the mental health system, yet there is limited knowledge about the economic burden associated with DDs. Objective: The current study sought to determine how receiving specialized treatment would relate to estimated costs of inpatient and outpatient mental health services. Method: Patients’ and individual therapists’ reports of inpatient hospitalization days and outpatient treatment sessions were converted into US dollars. DD patients and their clinicians reported on use of inpatient and outpatient services four times over 30 months as part of a larger, naturalistic, international DD treatment study. The baseline sample included 292 clinicians and 280 patients; at the 30-month follow-up, 135 clinicians and 111 patients. Missing data were replaced in analyses to maintain adequate statistical power. The substantial attrition rate (>50%) should be considered in interpreting findings. Results: Longitudinal and cross-sectional analyses of cost estimates based on patient reported inpatient hospitalization significantly decreased over time. Longitudinal cost estimates based on clinician-reported outpatient services also significantly decreased over time. Cross-sectional cost estimates based on patient and clinician reported inpatient hospitalization were significantly lower for patients in later stages of treatment compared to those struggling with safety and stabilization. Cross-sectional cost estimates based on clinician-reported outpatient services were significantly lower for patients in later stages of treatment compared to those in early stages. Conclusions: This pattern of longitudinal and cross-sectional reductions in inpatient and outpatient costs, as reported by both patients and therapists, suggests that DD treatment may be associated with reduced inpatient and outpatient costs over time. Although these preliminary results show decreased mental health care utilization and associated estimated costs, it is not clear whether it was treatment that caused these important changes.

Objective: Literature on the treatment of dissociative disorders (DDs) suggests that these individuals require long-term and specialized treatment to achieve stabilization and functionality. There is considerable empirical support for specialized phasic, dissociation-focused treatment in reducing a myriad of psychological symptoms and self-harm in this population. However, until recently, there has been a paucity of longitudinal treatment research on DD patients. Method: In the present six-year follow-up study, 61 therapists who participated in the initial phase of the Treatment of Patients with Dissociative Disorders (TOP DD) study answered questionnaires about their study patient’s stressors, quality of life, global functioning, victimization, and safety. These results provided a view of patients’ progress six years since the beginning of the TOP DD study. Results: Longitudinal analyses demonstrated patients had significantly fewer stressors (Χ²(6) = 18.76, p < .01, canonical r = .48, N = 76), instances of sexual revictimization (X²(1) = 107.05, p < .001) and psychiatric hospitalizations (t(54) = 2.57, p < .05, Cohen’s d = .43), as well as higher global functioning (Χ²(2) = 59.27, p < .001, canonical r = .65, N = 111). Conclusions: These findings continue to support the initial results of the TOP DD study that, despite marked initial difficulties and functional impairment, DD patients benefit from specialized treatment.

Home visiting is an effective preventive intervention that can improve parenting outcomes for at-risk, new mothers, thereby optimizing subsequent child development. A history of maltreatment in childhood is common in mothers participating in home visiting, yet the extent to which such a history is related to parenting outcomes during home visiting is unknown. The current study evaluated whether mothers with a history of maltreatment in childhood respond less favorably to home visiting by examining the direct and indirect pathways to subsequent parenting stress, a key parenting outcome affecting child development. First-time mothers (N = 220; age range = 16–42) participating in one of two home visiting programs, Healthy Families America or Nurse Family Partnership, were evaluated at enrollment and again at 9-and 18-month post-enrollment assessments. Researchers administered measures of maternal history of maltreatment in childhood, depressive symptoms, social support, and parenting stress. Maternal history of maltreatment in childhood predicted worsening parenting stress at the 18-month assessment. Mediation modeling identified two indirect pathways, one involving social support at enrollment and one involving persistent depressive symptoms during home visiting, that explained the relation between a history of maltreatment in childhood and parenting stress at the 18-month assessment. Ways to improve the preventive effects of home visiting for mothers with a history of maltreatment in childhood through the identification of relevant intervention targets and their ideal time of administration are discussed.

Home visiting is an effective preventive intervention that can improve parenting outcomes for at-risk, new mothers, thereby optimizing subsequent child development. A history of maltreatment in childhood is common in mothers participating in home visiting, yet the extent to which such a history is related to parenting outcomes during home visiting is unknown. The current study evaluated whether mothers with a history of maltreatment in childhood respond less favorably to home visiting by examining the direct and indirect pathways to subsequent parenting stress, a key parenting outcome affecting child development. First-time mothers (N = 220; age range = 16–42) participating in one of two home visiting programs, Healthy Families America or Nurse Family Partnership, were evaluated at enrollment and again at 9-and 18-month post-enrollment assessments. Researchers administered measures of maternal history of maltreatment in childhood, depressive symptoms, social support, and parenting stress. Maternal history of maltreatment in childhood predicted worsening parenting stress at the 18-month assessment. Mediation modeling identified two indirect pathways, one involving social support at enrollment and one involving persistent depressive symptoms during home visiting, that explained the relation between a history of maltreatment in childhood and parenting stress at the 18-month assessment. Ways to improve the preventive effects of home visiting for mothers with a history of maltreatment in childhood through the identification of relevant intervention targets and their ideal time of administration are discussed.

Background: Evidence suggests that maternal interpersonal trauma can adversely affect offspring health, but little is known about potential transmission pathways. We investigated whether interpersonal trauma exposure had direct and indirect associations with offspring social-emotional development at 12-months of age in an at-risk, home visited population. Methods: A retrospective cohort study was conducted of 1172 mother-child dyads who participated in a multi-site, early childhood home visiting program. Children were born January 2007 to June 2010 and data were collected at enrolment (prenatal/birth) through 12-months of age. Multivariable path analyses were used to examine the relationship between maternal interpersonal trauma, subsequent psychosocial mediators (maternal depressive symptoms, social support, and home environment), and the outcome of child social-emotional development measured with the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE). Maternal interpersonal trauma was characterized as any previous exposure, the level of exposure, and type (e.g. abuse) of exposure. Results: The prevalence of maternal interpersonal trauma exposure was 69.1%, and exposures ranged from 1 type (19.3%) to 7 types (2.3%). Interpersonal trauma was associated with a 3.6 point (95% confidence interval 1.8, 5.4) higher ASQ:SE score among offspring and indicated greater developmental risk. An estimated 23.4% of the total effect was mediated by increased maternal depressive symptoms and lower social support. Differential effects were observed by the level and type of interpersonal trauma exposure. Conclusion: Maternal interpersonal trauma exposures can negatively impact child social-emotional development, acting in part through maternal psychosocial factors. Future research is needed to further elucidate the mechanisms of intergenerational risk.