Many children and youths experience traumatic events each year. Although recovery is commonly reported, trauma exposure may have severe consequences on children’s mental health, development and functioning, and many children need help overcoming their symptoms. Considerable effort and progress have been achieved over the past several decades in developing effective treatments for trauma-affected youths and their families. However, we still do not fully understand how these interventions work to alleviate youths’ trauma-related symptoms and distress. The overarching aim of this dissertation is to gain a better understanding of what contributes to different change trajectories and non-response in the treatment of traumatized youths and explore the processes and mechanisms that might be central to therapeutic change.
The data were derived from two randomized controlled trials conducted in Norway and Germany investigating the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in regular outpatient clinics.
The first area of investigation involved variations in symptom change trajectories during treatment and follow-up and an examination of possible predictors associated with the treatment response. The findings demonstrated heterogeneity in the treatment response within the sample, and the participants’ trajectories (i.e., changes in posttraumatic stress symptoms (PTSS) during treatment and follow-up) could be best represented by two latent classes. Compared to the responder group (79% of the sample), the non-responder group (21% of the sample) was characterized by higher initial PTSS levels and slower improvement in PTSS over time. When examining whether gender, age, trauma type, comorbid depression, anxiety, and posttraumatic cognitions were associated with treatment response, gender was the only significant predictor with girls exhibiting a greater risk of non-response. Overall, the results indicate that TF-CBT is a helpful intervention for children and youths with a range of traumatic experiences, many of whom exhibit high levels of posttraumatic cognitions and additional comorbid symptoms.
Treatment response was also investigated in the second paper of this thesis. The aim of this study was to examine whether narrative changes during the course of treatment were associated with changes in PTSS by comparing two groups of youths with different treatment outcomes (i.e., responders versus non-responders). The results indicate that youths who receive TF-CBT develop more coherent and meaningful trauma narratives during treatment with a greater internal focus which is thought to be helpful for traumatized youths. However, the observed narrative changes were not associated with treatment response. These findings imply that narrative changes in itself may not be sufficient for reducing PTSS. Other aspects of the trauma narrative work might be more strongly related to symptom improvement than the narrative changes per see, which should be investigated in future studies.
In paper III, the direction of the influence between the changes in PTSS, posttraumatic cognitions and depressive symptoms during treatment and follow-up were examined. The results demonstrated that the changes in posttraumatic cognitions preceded the changes in PTSS and depressive symptoms, indicating that changes in posttraumatic cognitions represent an important mechanism of change in TF-CBT. Therefore, therapists should work toward strengthening and optimizing interventions and strategies that contribute to more adaptive and helpful cognitions during trauma treatment.
Collectively, the findings in this thesis may help elucidate therapy processes and change mechanisms important in the treatment of traumatized youth. However, more research is needed to identify children at risk of treatment non-response as this might be a path toward improving clinical practice and patient care for traumatized children and youths.