Child and family traumatic stress intervention (CFTSI) reduces parental posttraumatic stress symptoms: A multi-site meta-analysis (MSMA)

Abstract

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.

Introduction

In the aftermath of traumatic experiences, family social support is a significant factor contributing to children's success in managing posttraumatic reactions, as well as in the reduction of children's posttraumatic stress (PTS) symptom levels (Cox, Kenardy, & Hendrikz, 2008; Hill, Levermore, Twaite, & Jones, 1996; Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012). Moreover, it is widely recognized that primary caregivers can play a critical role in helping children reconcile aversive experiences and develop emotional self-regulation (National Academies of Sciences & Medicine, 2016; Petersen, Joseph, & Feit, 2014). However, due to their trauma histories, or to their involvement in (or reactions to) events which impact their children, caregivers may themselves be traumatically impacted. The extent to which caregivers are suffering from their traumatic reactions may, in turn, influence their ability to serve effectively in a caregiving role at a time when a child is particularly vulnerable following traumatization (Knott & Fabre, 2014).

Parents with their own trauma histories are more likely to have negative views of themselves as caregivers (Sherman, Gress Smith, Straits-Troster, Larsen, & Gewirtz, 2016) and to report more problems in their relationships with, and perceptions of, their children (Creech & Misca, 2017; van Ee, Kleber, & Jongmans, 2015). A longitudinal study of intrafamilial sexual abuse found that mothers of sexually abused females who were themselves sexually abused reported the most unstable and harsh childhoods, the most current psychological distress, the least emotional support from family, and the least supportive parenting (Trickett, Noll, & Putnam, 2011). Furthermore, caregivers with PTS symptoms are more likely to endorse the use of harsh and aggressive parenting practices, including both moderate (e.g., pushing) and severe (e.g., hitting with a fist) physical aggression with their children (Leen-Feldner, Feldner, Bunaciu, & Blumenthal, 2011). Hyperaroused, hypervigilant, avoidant, or over-indulgent responses by traumatized caregivers toward traumatized children can potentiate a child's acute physiological responses and predict persistent posttraumatic symptomatology (Nugent, Ostrowski, Christopher, & Delahanty, 2007). A meta-analytic review of the literature examining the role of parenting behaviors in childhood posttraumatic distress found that negative parenting (hostility, overprotection) was significantly associated with child PTSS, accounting for 5.3% of the variance in childhood PTSS (Mean ES 0.23, p < 0.0001)(Williamson et al., 2017).

Children of parents with PTSD are at greater risk for poorer social adjustment, as well as heightened levels of anxiety and depression (Cicchetti and Toth, 2009, Ostrowski et al., 2011); they also have been found to have greater levels of emotional and behavioral problems (Kreaiori, Klari, Petrov, & Mihi, 2016; Selimbasic, Sinanovic, Avdibegovic, Brkic, & Hamidovic, 2017). Further, recent studies document the relationship between parental and child PTSD symptoms, demonstrating significant correlations between parent PTSD and child PTSD symptoms (Hagan et al., 2017; Morris, Gabert-Quillen, & Delahanty, 2012; Wise & Delahanty, 2017), as well as increased risk for child abuse and PTSD among those children whose parents have PTSD (Cross et al., 2018). Although the deleterious effects of parental PTSD on children's functioning are now well-established, the process or processes by which these changes are mediated continues to be an important area of research.

The trauma treatment field now includes several child treatment models with strong evidence supporting their effectiveness in reducing children's posttraumatic symptoms. Several of these evidence-based models protocolize the involvement of a parent or supportive caregiver in treatment including Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Child Parent Psychotherapy (CPP) and the Child and Family Traumatic Stress Intervention (CFTSI) (Cohen, Mannarino, & Deblinger, 2017; Epstein, Hahn, Berkowitz, & Marans, 2017; Lieberman, Van Horn, & Ippen, 2005). Accordingly, given parents’ critical role in their children's recovery and the impact that parental trauma symptoms have on children, the effect of child trauma treatment models on participating caregivers is an important area of investigation. In a randomized controlled comparison of TF-CBT (N = 71) to treatment as usual (TAU) (N = 64), investigators found that parents’ emotional reactions and depressive symptoms decreased significantly from pre- to post-therapy, but they found no significant differences between the two treatment conditions with respect to depressive scores at the end of treatment (t (132) = 1.69, p = .094) (Holt, Jensen, & Wentzel-Larsen, 2014). Moreover, a second RCT comparing TF-CBT (N = 40) to a waitlist condition (N = 40) found a significant time effect F(1, 82) = 2.55, p = 0.02, without a time-group interaction F(1, 82) = 1.09, p = 0.30, suggesting a similar reduction in parental depressive symptoms in the TF-CBT and waitlist groups. Across both conditions, most of the parents remained unchanged (74%), some of them improved (20%), and a few worsened (6%) (Tutus, Keller, Sachser, Pfeiffer, & Goldbeck, 2017). In an open treatment study of 199 parents who participated in Child Parent Psychotherapy (CPP), latent difference score analysis showed that PTSS decreased significantly by more than 0.5 SD for parents and children (Hagan et al., 2017). In the present study, we explored the benefits that caregivers derived concerning their own traumatic stress symptom reduction from participating in a brief evidence-based child trauma treatment model by utilizing a multi-site meta-analytic approach to evaluate the pooled and site-specific therapeutic effect sizes in data collected by 10 Child Advocacy Centers (CACs).

The child and family traumatic stress intervention (CFTSI) is a manualized mental health treatment that has demonstrated efficacy in reducing children's trauma symptoms and as a result, decreasing the probability of full-fledged PTSD and related disorders in children (Berkowitz, Stover, & Marans, 2011; Epstein et al., 2017; Hahn, Oransky, Epstein, Stover, & Marans, 2015; Marans, 2013; Oransky, Hahn, & Stover, 2013). CFTSI is designed to be implemented with children ages 7–18 and their non-offending caregivers during the days and weeks immediately following a potentially traumatic event or the formal disclosure of physical or sexual abuse (such as in a forensic interview); CFTSI is implemented in 5–8 sessions. CFTSI targets traumatic reactions including intrusion symptoms, avoidance, alterations in arousal and negative alterations in cognition. These may impact the child across physical, affective, cognitive and emotional domains. The goals of CFTSI include: (a) increasing caregiver understanding of the child's posttraumatic experience, as well as their own posttraumatic experience; (b) improving child and caregiver capacity to observe and recognize trauma reactions; (c) increasing caregiver support of the child by enhancing communication between the child and caregiver about the child's trauma symptoms; (d) teaching coping strategies to help the child and caregiver master traumatic reactions; and (e) improving screening and assessing the need for longer-term mental health treatment or other services.

The CFTSI protocol calls for clinicians to identify caregiver PTS symptoms through the pre- and post-intervention administration of a standardized symptom assessment. As such, assessment of caregiver's PTS symptoms serves three goals in CFTSI: (a) to help the clinician understand how the caregiver is impacted by his or her symptoms; (b) to help the caregiver gain mastery over symptoms and regain a sense of control; and (c) to inform the clinician about the possible need for a referral for a caregiver's treatment, as per the standard CFTSI protocol. In order to help the caregiver gain mastery over trauma symptoms and thus regain a greater sense of control, the clinician first helps the caregiver improve self-observing capacity about their symptoms, as well as the ability to identify trauma reminders that give rise to those symptoms. Caregivers then learn strategies to effectively manage the symptoms they have now successfully identified (e.g., establishment of structured, predictable routines; focused breathing; guided imagery; sleep hygiene, etc.).

In a randomized controlled study of CFTSI, 112 participants aged 7–17 years (mean age = 12) were referred from a child maltreatment forensic service, an urban police department, and a pediatric emergency department following exposure to a potentially traumatic event. Those who endorsed at least one new and distressing symptom of PTSD on the Posttraumatic Checklist–Civilian (PCL; (Weathers, Littz, Huska & Keane, 1994)) within 30 days of the PTE were randomized using a block design to CFTSI (N = 53) or an active 4-session comparison condition that included psychoeducational components and the teaching of coping skills (N = 53). The RCT outcome focused on the diagnosis of PTSD immediately after the intervention (N = 86) and again three months post-intervention, as measured by the UCLA PTSD Reaction Index (PTSD-RI) for DSM IV (Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998). Logistic regression, controlled for new, potentially traumatic events, examined group differences in PTSD diagnosis at three months post-treatment (N = 83). Three months following the end of treatment, the CFTSI group was significantly less likely to have PTSD (β = −1.063, p = .046), reducing the odds of a full diagnosis of PTSD by 65% and the odds of partial or full PTSD by 73% (β = –1.32, p = .008) (Berkowitz et al., 2011).

A chart review of CFTSI cases (N = 114) completed following disclosure of sexual abuse during a forensic interview in a Child Advocacy Center (CAC) examined: (a) caregiver and child agreement concerning the child's trauma history, child's PTSD and mood symptoms, and children's functional impairment while controlling for caregivers’ symptoms (Oransky et al., 2013); and (b) outcomes of treatment in a CAC setting (Hahn et al., 2015). The children in the sample, 86.8% female, ranged from 7 to 16 years of age (M = 10.72, SD = 2.69) and caregivers were predominantly mothers. We measured child PTSD symptoms using Part I, and functional impairment using Part II of the Child PTSD Symptom Scale (CPSS) (Foa, Johnson, Feeny, & Treadwell, 2001). We assessed caregiver PTSD symptoms using the PCL-C (Weathers et al., 1994). Children reported significantly higher rates of PTSD and mood symptoms as compared to caregiver rating of children's symptoms (t(110) = 4.94, p < .001). Parent–child discrepancies were positively correlated with children's greater self-reported PTSS (r = 24, p < .05). Additionally, caregiver PTSS severity was significantly and positively correlated with caregiver reports of children's PTSS (r = 55, p < .001) and depressive symptom severity (r = .36, p < .001), as well as with children's greater self-reported PTSS symptoms (r = .40, p < .001) (Oransky et al., 2013).

Child-reported CPSS symptoms were significantly lower post-intervention as compared with pre-intervention scores (t(117) = 11.07, p < 001) (Hahn et al., 2015). At baseline, we found a significant difference between child and caregiver ratings of child traumatic stress symptom severity, with children reporting higher levels of traumatic stress symptoms as compared to caregivers [t(106) = 3.55, p < .01]. We found no significant difference between child and caregiver ratings of child traumatic stress symptom severity post-intervention, indicative of an increase in concordance between caregiver and child reports of child symptoms (Hahn et al., 2015). Moreover, caregiver's baseline PTSD symptoms as assessed using the PCL-C (Weathers et al., 1994) were not associated with child's post-intervention symptom severity (Hahn et al., 2015). Consequently, this finding was contrary to some research which has found that caregiver stress at baseline is predictive of child symptom levels at the end of treatment (Eckshtain, Marchette, Schleider, Evans, & Weisz, 2018). We hypothesized that specific components of the CFTSI treatment might interrupt the process by which parental stress mediates a child's posttraumatic recovery (Epstein et al., 2017).