Background: Every year, many children are exposed to potentially traumatizing events, such as domestic violence, sexual and physical abuse, and severe accidents. Such events put children at risk of developing mental health difficulties, and many will need therapy. To date, several treatments have been proven to improve posttraumatic stress symptoms (PTSS) and related symptoms in children. Nevertheless, there is a gap between the need for and access to therapeutic care. Caregivers want to help and are a potentially unused resource in treatment. The parent-led therapist-assisted Stepping together for children after trauma (Stepping Together-CT; aged 7-12 years) has shown promising results in helping traumatized children and may be one way to help increase access to effective trauma treatment. However, less is known about the role of the participating caregivers and the way in which they will manage the task of leading the treatment with their child.
Objective: The overall aim of this thesis was to better understand the role of the participating caregivers in the parent-led therapist-assisted Stepping Together-CT. More specifically, the aims were as follows: (1) to provide a better understanding of how caregivers experience the treatment model; (2) to increase the knowledge of which caregiver factors are related to completion and response among children receiving Stepping Together-CT; (3) to gain knowledge about potential bidirectional associations between caregiver and child symptoms during Stepping Together-CT
Method: The data in this study were obtained from children and caregivers who participated in the Norwegian stepped-care TF-CBT study with the primary objective of investigating the feasibility of the first step, Stepping Together-CT, as a low-threshold intervention in Norwegian ordinary first-line services that provide short-term treatment for children. Eighty-two child-caregiver dyads who participated in the study were included (child age: 7-12 years, mean = 9.9 years). Qualitative interviews with the caregivers were completed 1-3 weeks after they had completed or dropped out of the treatment with their child. Quantitative data from both children and caregivers were collected at three time points: pretreatment, at baseline (T1); mid-treatment, after the active treatment phase (T2); and posttreatment, after the maintenance phase (T3). Interviews about caregivers’ experience with Stepping Together-CT were analyzed using interpretative phenomenological analysis. Logistic regression analyses were used to investigate whether caregiver factors were associated with noncompletion or nonresponse. Finally, a random intercept cross-lagged panel model was used to examine potential bidirectional associations between caregiver and child symptoms during the treatment.
Results: Many caregivers described how taking part in the treatment led to a sense of parental agency and feeling empowered to help their children with trauma-related difficulties and reconnect with their children. More specifically, they described how this was facilitated by acquiring an increased understanding of their children and themselves, by gaining competence, and by making use of the therapist’s support. Most of the children and caregivers were able to complete the treatment with good results despite caregivers’ symptoms of anxiety, depression, and posttraumatic stress (PTS), as well as parenting stress and practical barriers. However, a lower level of educational achievement among caregivers was associated with noncompletion. Furthermore, higher levels of emotional reactions to their child’s trauma and greater perceived social support were associated with nonresponse. Both children’s symptoms of PTS and depression and caregivers’ symptoms of PTS and depression improved after the parent-led treatment. There were bidirectional associations between child and caregiver symptoms. Levels of caregiver emotional reactions predicted subsequent child symptoms of PTS and depression, and levels of child symptoms of PTS predicted subsequent caregiver emotional reactions. However, these results must be interpreted with caution due to the relatively small and homogenous sample, with many caregivers having a high level of education and only a few child-caregiver dyads being from a non-Nordic background.
Conclusion: The findings of this thesis imply that caregivers can manage the task of leading trauma treatment with their child. Caregivers seem to find the treatment acceptable, and the shift of therapeutic tasks appears to facilitate caregiver empowerment and improve the caregiver-child relationship. Most caregivers, including caregivers with their own mental health challenges, seem to be able to complete the treatment with good outcomes for their child. However, there may be a need to tailor the treatment for some families. Caregivers with less education may need more assistance in performing Stepping Together-CT, and treatment response may improve if caregivers’ emotional reactions to their children’s trauma are addressed. Allowing for treatment development and adaptations that account for the mutual influences between children’s and caregivers’ symptoms may further enhance treatment outcomes. Taken together, these findings contribute to an enhanced understanding of the role of caregivers in Stepping Together-CT and the way in which caregivers can contribute to child trauma treatment to alleviate PTSS in their children and at the same time improve their relationship with their child.