Trauma-Focused CBT: Potential Mechanisms that Inhibit and Facilitate Change

描述（由申请人提供）：儿童虐待和人际逆境使儿童面临创伤后应激障碍（PTSD）、抑郁和自杀、药物滥用以及一系列负面心理健康结果的风险增加。最近的证据表明，童年时期的逆境会产生有害的神经生物学和社会心理影响，并将风险延伸到成年期。针对创伤的认知行为疗法（TF-CBT）在众多随机临床试验中被证明是一种有效的治疗虐待和创伤儿童的方法。TF-CBT的早期干预有可能改变与童年逆境相关的风险轨迹。拟议研究的总体目标是确定这种治疗中潜在的变化机制、变化的抑制因素和早期退出的预测因素。拟议的研究将对变化过程的复杂分析整合到正在进行的TF-CBT有效性试验中，该试验已被运送到整个特拉华州的社区精神卫生机构。75名接受TF- CBT治疗的儿童的会话将用一个观察编码系统进行编码，该系统旨在捕捉理论上重要的治疗过程。假设TF-CBT与治疗过程中的情感唤醒和创伤的认知/情绪处理的曲线模式有关，当儿童在治疗的暴露阶段形成创伤叙事时，其峰值水平出现。情感唤起的短暂增加被认为反映了创伤记忆的激活，并促进了处理。在这个叙述阶段，更多的加工被假设为PTSD症状和问题儿童行为改善的主要预测因素。治疗师的支持和照顾者在治疗中的参与被期望通过减少逃避来帮助孩子为改变做准备，逃避是后来觉醒和处理的主要抑制剂。当接触到儿童的叙述时，照顾者的回避和处理也有望预测儿童的结果。拟议的研究有可能揭示可以动员的关键过程，以提高TF-CBT的效力，降低辍学率，并在传播工作中加强治疗师培训。

DESCRIPTION (provided by applicant): Child maltreatment and interpersonal adversity put children at increased risk for posttraumatic stress disorder (PTSD), depression and suicide, substance abuse, and a host of negative mental health outcomes. Recent evidence documents that childhood adversity can have pernicious neurobiological and psychosocial effects that extend risk into adulthood. Trauma- Focused Cognitive-Behavioral Therapy (TF-CBT) has been demonstrated in numerous randomized clinical trials to be an efficacious treatment for maltreated and traumatized children. Early intervention with TF-CBT has the potential to alter the trajectory of risk associated with childhood adversity. The overall goals of the proposed research are to identify potential mechanisms of change, inhibitors of change, and predictors of early dropout in this treatment. The proposed research integrates a sophisticated analysis of the process of change into an ongoing effectiveness trial of TF-CBT that has been transported to community mental health facilities throughout the state of Delaware. Sessions from 75 children who received TF- CBT will be coded with an observational coding system designed to capture theoretically important therapeutic processes. TF-CBT is hypothesized to be associated with a curvilinear pattern of in-session affective arousal and cognitive/emotional processing of the trauma, with peak levels occurring when the child develops a trauma narrative in the exposure phase of therapy. A transient increase in affective arousal is thought to reflect activation of the trauma memories and to facilitate processing. More processing during this narrative phase is hypothesized to be the primary predictor of improvement in PTSD symptoms and problematic child behaviors. Therapist support and caregiver involvement in treatment are expected to help prepare the child for change by decreasing avoidance, a primary inhibitor of later arousal and processing. Caregiver avoidance and processing when exposed to the child's narrative are also expected to predict child outcomes. The proposed research has the potential to reveal key processes that can be mobilized to increase the potency of TF-CBT, reduce rates of dropout, and enhance therapist training as dissemination efforts are undertaken. PUBLIC HEALTH RELEVANCE: Child maltreatment and interpersonal trauma increase risk for a number of serious mental health disorders. Childhood adversity can be associated with pernicious neurobiological and psychosocial sequelae that extend risk into adulthood. Trauma- Focused Cognitive-Behavioral Therapy (TF-CBT) is an empirically-supported treatment that can alter this identifiable trajectory of risk. The goal of the proposed research is to identify key processes that inhibit and facilitate therapeutic change. Understanding how TF-CBT has its immediate and long-term effects can guide efforts to increase its potency, reduce dropout, and optimize therapy delivery.