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

Background: To determine the cost-effectiveness of In-Home Cognitive Behavioral Therapy (IH-CBT) for low-income mothers enrolled in a home visiting program. Methods: A cost-utility analysis was conducted using results from a clinical trial of IH-CBT and standard of care for depression derived from the literature. A probabilistic, patient-level Markov model was developed to determine Quality Adjusted Life Years (QALYs). Costs were determined using the Medical Expenditure Panel Survey. A three-year time horizon and payer perspective were used. Sensitivity analyses were employed to determine robustness of the model. Results: IH-CBT was cost-effective relative to standard of care. IH-CBT was expected to be cost-effective at a three-year time horizon 99.5%, 99.7%, and 99.9% of the time for willingness-to-pay thresholds of US$25,000, US$50,000, and US$100,000, respectively. Patterns were upheld at one-year and five-year time horizons. Over the three-year time horizon, mothers receiving IH-CBT were expected to have 345.6 fewer days of depression relative to those receiving standard home visiting and treatment in the community. Conclusions: IH-CBT is a more cost-effective treatment for low-income, depressed mothers than current standards of practice. These findings add to the growing literature demonstrating the cost-effectiveness of CBT for depression, and expand it to cover new mothers. From a payer perspective, IH-CBT is a sound option for treatment of depressed, low-income mothers. Limitations include a restricted time horizon and estimating of standard of care costs.

Purpose: The purpose was to examine whether the timing of puberty, indexed by breast development and pubic hair development, was earlier for sexually abused females compared with a matched comparison group of nonabused females, controlling for key alternative confounds. Methods: A cohort of sexually abused females and matched comparisons was followed longitudinally at mean ages 11 through 20 years. Sexually abused participants (N = 84) were referred by protective services. Comparison participants (N = 89) were recruited to be comparable in terms of age, ethnicity, income level, family constellation, zip codes, and nonsexual trauma histories. Stage of puberty was indexed at each assessment by nurse and participant ratings of breast and pubic hair development using Tanner staging-the gold standard for assessing pubertal onset and development. Cumulative logit mixed models were used to estimate the association between sexual abuse status and the likelihood of transitioning from earlier to later Tanner stage categories controlling for covariates and potential confounds. Results: Sexual abuse was associated with earlier pubertal onset: 8 months earlier for breasts (odds ratio: 3.06, 95% CI: 1.11-8.49) and 12 months earlier for pubic hair (odds ratio: 3.49, 95% CI: 1.34-9.12). Alternative explanations including ethnicity, obesity, and biological father absence did not eradicate these findings. Conclusions: This study confirms an association between exposure to childhood sexual abuse and earlier pubertal onset. Results highlight the possibility that, due to this early onset, sexual abuse survivors may be at increased risk for psychosocial difficulties, menstrual and fertility problems, and even reproductive cancers due to prolonged exposure to sex hormones.

Prenatal maternal mood may inform the adverse obstetric outcomes seen in disadvantaged populations. The contribution of having a trauma history is not well studied. We examined the impact of trauma exposure and mood symptoms on obstetric outcomes in 358 women. Women with antecedent trauma were more likely to have a history of depression, odds ratio = 2.83, 95% confidence interval [1.81, 4.42], were younger at their first pregnancy, 18.86 years versus 20.10 years, and had a higher number of previous pregnancies, 2.01 versus 1.54, compared to those with no trauma exposure. Women with prenatal anxiety had significantly smaller babies than nonanxious women, 3,313.17 g, (SD = 441.58) versus 3,429.27 g, (SD = 437.82) Trauma history magnified the effects of maternal prenatal mood on birthweight; the moderating effect was limited to those who first experienced a trauma under 18 years of age. Childhood trauma exposure increased vulnerability for low birthweight delivery associated with prenatal mood disturbance. Screening pregnant women for trauma history and current mood symptoms is indicated.

Maternal depression negatively impacts maternal functioning and parenting behaviors. Mothers participating in home visiting programs are at particularly elevated risk for depressive symptoms due to demographic and associated risk factors. Moreover, additional empirical evidence has demonstrated that mothers with depression do not benefit from home visiting interventions to the same extent as their peers without depression. The purpose of this study was to identify predictors of depression course in mothers participating in home visiting over the first 18 months of service. Participants were 220 low income mothers participating in a home visiting program who completed the Beck Depression Inventory-II (BDI-II) at enrollment and 9 and 18 months later. Measures of childhood maltreatment history, social support, and locus of control were also collected at enrollment. Group-based trajectory modeling revealed 3 groups labeled as minimal (63.6%), mild (30.5%), and moderate-severe (5.9%). Although a slight decrease in depressive symptoms was observed over time in the minimal and mild groups, mothers in the moderate-severe group exhibited a large increase from enrollment to 9 months that persisted through 18 months. Membership in the mild and moderate-severe groups was predicted by history of childhood maltreatment, low levels of social support, and an external locus of control. Implications of these findings for home visiting programs are discussed. (PsycINFO Database Record

We describe a multiyear pilot dissemination of a trauma-focused group treatment, Trauma and Grief Component Therapy for Adolescents, coupled with a trauma-informed staff training, Think Trauma, to six residential juvenile justice (JJ) facilities. All staff members were trained in Think Trauma. Seventy-seven youth from four facilities completed the treatment groups and 69 completed all pre- and postgroup assessment measures. The aims of this study were to determine whether trauma-focused interventions (a) could be implemented in complex JJ systems, (b) would be associated with a decrease in posttraumatic symptoms and reactions in youth, and (c) might contribute to reduced Incident Reports in facilities. A related question was whether we would receive feedback that youth who participated in the trauma and/or grief narrative components of the intervention were adversely affected. Pre- and postgroup assessments indicated significant reductions in symptoms of posttraumatic stress, depression, and anger, but not in anxiety or sexual concerns. There were significantly greater reductions in posttraumatic stress disorder (PTSD) among incarcerated youth who completed all modules of the group treatment intervention relative to incarcerated youth who received an abbreviated version. Two of the facilities tracked their Incident Reports and reported reductions. No Incident Reports or therapist feedback documented that the trauma/grief processing components of the intervention were destabilizing to the youth.

Child maltreatment impacts approximately two million children each year, with physical abuse and neglect the most common form of maltreatment. These children are at risk for mental and physical health concerns and the ability to form positive social relationships is also adversely affected. Child Adult Relationship Enhancement (CARE) is a set of skills designed to improve interactions of any adult and child or adolescent. Based on parent training programs, including the strong evidence-based treatment, Parent-Child Interaction Therapy (PCIT), CARE was initially developed to fill an important gap in mental health services for children of any age who are considered at-risk for maltreatment or other problems. CARE subsequently has been extended for use by adults who interact with children and youth outside of existing mental health therapeutic services as well as to compliment other services the child or adolescent may be receiving. Developed through discussions with Parent-Child Interaction Therapy (PCIT) therapists and requests for a training similar to PCIT for the non-mental health professional, CARE is not therapy, but is comprised of a set of skills that can support other services provided to families. Since 2006, over 2000 caregivers, mental health, child welfare, educators, and other professionals have received CARE training with a focus on children who are exposed to trauma and maltreatment. This article presents implementation successes and challenges of a trauma-informed training designed to help adults connect and enhance their relationships with children considered at-risk.

Research has suggested that parenting behaviors and other parental factors impact the long-term outcome of children’s posttraumatic stress disorder (PTSD) symptoms. In a sample of 62 children between the ages of one and six who experienced life-threatening traumas, PTSD was measured prospectively 2 years apart. Seven maternal factors were measured in a multi-method, multi-informant design. Both moderation and mediation models, with different theoretical and mechanism implications, were tested. Moderation models were not significant. Mediation models were significant when the mediator variable was maternal symptoms of PTSD or depression (measured at Time 1), self-report of maternal escape/avoidance coping (measured at Time 2), or self-report emotional sensitivity (measured at Time 2). Greater maternal emotional sensitivity was associated with greater Time 2 PTSD symptoms among children. Observational measures of emotional sensitivity as the mediator were not supported. Correlation of parents’ and children’s symptoms is a robust finding, however caution is warranted in attributing children’s PTSD symptoms to insensitive parenting.

Little is known regarding neuroendocrine responses in adolescent girls with posttraumatic stress disorder (PTSD) who have experienced sexual abuse. Therefore, we collected saliva samples three times daily for 3 days to assess concentrations of salivary alpha amylase (sAA) - a surrogate marker for autonomic nervous system (ANS) activity and, in particular, sympathetic activity - in sexually abused adolescent girls. Twenty-four girls (mean age: 15±1.4 years) who had experienced recent sexual abuse (i.e., sexual abuse occurred 1-6 months prior to study enrollment) and 12 healthy comparison subjects (mean age: 14.8±1.3 years) completed a structured interview and assessments to ascertain symptoms of posttraumatic stress, then collected saliva at home upon awakening, 30 minutes after waking, and at 5 p.m. on three consecutive school days. For sexually abused girls, total PTSD symptoms were associated with higher overall morning levels of sAA (r[20]=0.51, p=0.02), a finding driven by intrusive symptoms (r[20]=0.43, p<0.05) and hyperarousal symptoms (r[20]=0.58, p=0.01). There were no significant differences in diurnal sAA secretion between the sexually abused girls and healthy comparison adolescents. Overall morning concentrations of sAA in sexually abused girls are associated with overall PTSD severity as well as symptoms of hyperarousal and intrusive symptoms, possibly reflecting symptom-linked increases in ANS tone. These data raise the possibility that alterations in ANS activity are related to the pathophysiology of sexual abuse-related PTSD in adolescent girls, and may inform therapeutic interventions (e.g., antiadrenergic medications).

Child maltreatment contributes to depression in adults. Evidence indicates that such experiences are associated with poorer outcomes in treatment. Mothers in home visiting programs display high rates of depression and child maltreatment histories. In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat maternal depression in home visiting. The purpose of this study was to examine the moderating effects of child maltreatment history on depression, social functioning, and parenting in mothers participating in a clinical trial of IH-CBT. Ninety-three depressed mothers in home visiting between 2 and 10 months postpartum were randomly assigned to IH-CBT (n = 47) plus home visiting or standard home visiting (SHV; n = 46). Mothers were identified via screening and then confirmation of major depressive disorder diagnosis. Measures of child maltreatment history, depression, social functioning, and parenting were administered at pre-treatment, post-treatment, and 3-month follow-up. Results indicated high rates of maltreatment in both conditions relative to the general population. Mixed model analyses found a number of main effects in which experiences of different types of trauma were associated with poorer functioning regardless of treatment condition. Evidence of a moderating effect of maltreatment on treatment outcomes was found for physical abuse and parenting and emotional abuse and social network size. Future research should focus on increasing the effectiveness of IH-CBT with depressed mothers who have experienced child maltreatment.

Research on older children and high-resource families demonstrates that maternal improvement in depression often leads to parallel changes in parenting and child adjustment. It is unclear if this association extends to younger children and low-income mothers. This study examined if In-Home Cognitive Behavioral Therapy (IH-CBT), a treatment for depressed mothers participating in home visiting programs, contributes to improvements in parenting and child adjustment. Ninety-three depressed mothers in home visiting between 2 and 10 months postpartum were randomly assigned to IH-CBT (n = 47) plus home visiting or standard home visiting (SHV; n = 46). Mothers were identified via screening and subsequent diagnosis of major depressive disorder (MDD). Measures of depression, parenting stress, nurturing parenting, and child adjustment were administered at pre-treatment, post-treatment, and 3 months follow-up. Results indicated that there were no differences between IH-CBT and controls on parenting and child adjustment. Low levels of depression were associated with decreased parenting stress and increased nurturing parenting. Improvement in depression was related to changes in parenting in low-income mothers participating in home visiting programs. IH-CBT was not independently associated with these improvements, although to the extent that treatment facilitated improvement; there were corresponding benefits to parenting. Child adjustment was not associated with maternal depression, a finding possibly attributed to the benefits of concurrent home visiting or measurement limitations. Future research should focus on longer-term follow-up, implications of relapse, and child adjustment in later years.