Faculty Bibliography

Although abundant evidence exists indicating the prevalence of trauma exposure among youth in residential care, few models exist for creating trauma-informed milieu treatment. This article outlines the problem and describes the implementation of Trauma Systems Therapy (TST) in three residential centers. TST is unique in emphasizing youth emotions and behaviors as well as the role a distressed or threatening social environment may play in keeping a traumatized youth in a dysregulated state. This dual emphasis makes TST specifically appropriate to implementation in congregate care, focusing assessment and intervention strategies on both clinical treatment and the functioning of the therapeutic milieu itself. Data are reported on incidents of the use of physical restraint; numbers of disrupted foster care placements following discharge from residential treatment; and scores on psychometric measures of children's functioning and emotion regulation capacity. Knowledge gained through TST implementation in these three residential centers has important implications for developing a model of trauma-informed congregate care.

This study tracked the clinical course of 124 children receiving trauma systems therapy (TST). In addition, exploratory analyses compared hospitalization rates before and after implementation of the model and comparative cost savings were estimated. Children ages 3-20 who experienced potentially traumatic events received TST intervention. Measures of clinical course, children's psychiatric and psychosocial functioning, and social-environmental stability were taken at intake, 4-6 months, and 12-15 months. Exploratory analyses of cost savings were evaluated by comparing pre- and post-implementation hospitalization rates and lengths of stay for children under the care of the county mental health department. Emotion regulation, social-environmental stability, and child functioning/strengths improved significantly with treatment. Improvement in child functioning/strengths and in social-environmental stability significantly contributed to overall improvement in emotion regulation. Children who became stable enough to transition to office-based services during early treatment tended to stay in treatment and continued to improve. The number of children needing crisis-stabilization services at 15 months was reduced more than half for those who completed treatment. Poorer baseline emotion regulation was associated with hospitalization, and poorer social-environmental stability predicted fewer days-to-hospitalization. Exploratory analyses show that post-implementation hospitalization rates dropped 36% and average length of stay decreased by 23%, suggesting that further exploration of potential cost savings is warranted. These findings underscore the clinical importance of intervention and long-term treatment to stabilize the social environment of children and adolescents with posttraumatic stress, and emphasize the potential cost effectiveness of an intensive, community-based treatment approach at the county level

BACKGROUND:  This study aimed to obtain preliminary evidence for the extent to which a novel intervention embedded within a systems-oriented treatment model [trauma systems therapy (TST)] engages and retains traumatized children and their families in treatment. METHOD/METHODS:  Twenty youth who had prominent symptoms of posttraumatic stress were randomly assigned to receive TST or care as usual (CAU). RESULTS:  At the 3-month assessment, 90% of TST participants were still in treatment, whereas only 10% of CAU participants remained. Within-group analyses of TST participants demonstrated significant reductions in posttraumatic stress and aggression as well as a slight improvement in home safety. CONCLUSIONS:  These preliminary findings point to the need to utilize effective engagement approaches to retain traumatized children and their families in treatment.

Introduction: Trauma Systems Therapy (TST) intervention arose out of the recognition that the patient population we served, many of whom were suffering from the aftermath of traumatic stress, were not improving from the traditional approaches we were using. Method: This article summarizes the experience of developing an approach to assessment and treatment called trauma systems therapy (TST), that my colleagues and I have been evaluating and developing over the past 10 years. Results: TST is classified by the National Child Traumatic Stress Network an effective and promising intervention .This work resulted in the writing of the book, Collaborative treatment of traumatized children and teens: The trauma systems therapy approach (Saxe, Ellis, & Kaplow 2006), which is the manual for TST. This book gives details about how and why we developed trauma systems therapy, and is the guide for assessment, treatment and systems implementation using this model. Conclusions: TST makes sense in light of what we know about the neurobiological underpinnings of traumatic stress disorders as well as our understanding of difficulty with emotional regulation. TST is both an effective clinical model for treatment of traumatized children and adolescents, and also an organizational model for the integration of services among agencies that provide treatment to these children.

BACKGROUND: This study evaluated the potential benefits of a centrally acting selective serotonin reuptake inhibitor, sertraline, versus placebo for prevention of symptoms of posttraumatic stress disorder (PTSD) and depression in burned children. This is the first controlled investigation based on our review of the early use of a medication to prevent PTSD in children. METHODS: Twenty-six children aged 6-20 were assessed in a 24-week double-blind placebo-controlled design. Each child received either flexibly dosed sertraline between 25-150 mg/day or placebo. At each reassessment, information was collected in compliance with the study medication, parental assessment of the child's symptomatology and functioning, and the child's self-report of symptomatology. The protocol was approved by the Human Studies Committees of Massachusetts General Hospital and Shriners Hospitals for Children. RESULTS: The final sample was 17 subjects who received sertraline versus 9 placebo control subjects matched for age, severity of injury, and type of hospitalization. There was no significant difference in change from baseline with child-reported symptoms; however, the sertraline group demonstrated a greater decrease in parent-reported symptoms over 8 weeks (-4.1 vs. -0.5, p=0.005), over 12 weeks (-4.4 vs. -1.2, p=.008), and over 24 weeks (-4.0 vs. -0.2, p=0.017). CONCLUSIONS: Sertraline was a safe drug, and it was somewhat more effective in preventing PTSD symptoms than placebo according to parent report but not child report. Based on this study, sertraline may prevent the emergence of PTSD symptoms in children

Posttraumatic stress disorder (PTSD) is a common and disabling anxiety disorder that may occur in the aftermath of exposure to potentially traumatic life events. PTSD is moderately heritable, but few specific molecular variants accounting for this heritability have been identified. Genes regulating the hypothalamic-pituitary-adrenal (HPA) axis, such as corticotrophin-releasing hormone type 1 receptor gene (CRHR1), have been implicated in traumatic-stress related phenotypes but have yet to be studied in relation to PTSD. The present study sought to examine the relation between 9 single nucleotide polymorphisms (SNPs) in the CRHR1 gene and posttraumatic stress symptoms in a prospective study of pediatric injury patients (n=103) who were first assessed in the acute aftermath of their injury at the hospital. Results indicated that multiple SNPs were associated with acute symptoms at a univariate level, and after correction for multiple testing, rs12944712 was significantly related to acute PTSD symptoms. Longitudinal latent growth curve analyses suggest that rs12944712 is also related to both acute symptom level and trajectory of symptoms over time. The present study adds support for the role of CRHR1 in the stress response following potentially traumatic event exposure in youth. It should be noted that the sample size in this study was small, and therefore statistical power was low; following, results from this study should be considered preliminary. Although results are not definitive, the findings from this study warrant future replication studies on how variation in this gene relates to response to traumatic event exposure in youth