Perceived Parental Support in Stepped Care Trauma-Focused
Cognitive Behavioral Therapy
Henriette Koolen Bjerketvedt
Submitted as a Cand. Psychol. Thesis at The Department of Psychology
UNIVERSITY OF OSLO
Autumn 2021
II
III Abstract
Author: Henriette Koolen Bjerketvedt
Title: Perceived Parental Support in Stepped Care Trauma-Focused Cognitive Behavioral Therapy
Supervisors: Ingeborg Skjærvø and Tine K. Jensen
Background: Social support has an established positive influence on psychological well- being, and perception of social support may be an important protective factor after exposure to a potentially traumatizing event. Parents are influential on children’s post-trauma
adjustment, and this has encouraged the development of a parent-led treatment model. There is little research on the role of perceived parental support in such parent-led treatment models.
Stepped Care Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a recently developed parent-led treatment model with promising effects.
Objective: This thesis aims to increase our understanding of the role the child’s perceived parental support may have on a child’s posttraumatic stress symptoms (PTSS), both pre- treatment and in changes throughout the Stepped Care TF-CBT treatment.
Method: A subset of data from 39 children (7-12 years old) participating in the longitudinal Norwegian Stepped Care TF-CBT feasibility study was provided by the Norwegian center for violence and traumatic stress studies. Parental support and PTSS scores from pre-, mid- and post-treatment were examined using parametric and non-parametric tests.
Results: Pre-treatment, higher levels of parental support were related to higher levels of PTSS (r(37) = .331, p = .020). After treatment parental support increased and PTSS decreased, however higher increase in parental support was correlated with a lesser decrease in PTSS (r(23) = .443, p = .021) for treatment responders. Younger children experienced a higher increase in parental support. Girls reported higher levels of parental support, but there were no significant gender differences in changes in support after treatment.
Conclusion: The Stepped Care TF-CBT treatment course came with positive changes in perceived parental support and PTSS for responders. This indicates that the parent-led trauma treatment may have a positive influence on the parental support the child experienced.
However, the relationship between parental support and PTSS appears complicated, and more research is necessary to fully understand the role parental support has for PTSS pre-, in- and after treatment.
IV
V Acknowledgements
I would like to thank my supervisors Ingeborg and Tine; this thesis is a lot better with your help. Thank you, Ingeborg, for putting so much time and energy into supervising me,
answering my countless questions, and guiding me so well through this. Thank you, Tine, for valuable guidance and insights, and the time you have put into this thesis. I would like to thank you both and NKVTS for letting me use this data material and get an insight into this fascinating and interesting project. I have enjoyed learning much about Stepped Care TF-CBT through this and will bring this with me into my future role as a psychologist.
Lastly, I would like to thank family and friends for good Social Support. Thanks for letters in the post, good messages, the lighting of candles, encouraging thoughts, and all photos of cats.
Thanks to my friends and fellow thesis-writers for good company, mutual patience, late-night laughs in the library and overall good Emotional and Appraisal Support.
Henriette Koolen Bjerketvedt Oslo, October 2021
VI Table of Contents
1.0 Introduction ... 1
1.1 Social Support ... 1
1.2 Mechanisms of Social Support ... 2
1.2.1 Possible Barriers to Enact on Social Support. ... 4
1.2.2 Possible Mechanisms of Social Support in Therapy ... 4
1.3 Perceived Social Support in Studies of Post-Trauma Adjustment ... 5
1.3.1 Perceived Caregiver Support in Post-Trauma Adjustment ... 6
1.3.2 Impact of Environment and Trauma Related Factors on Perceived Social Support. ... 8
1.4 Perceived Social Support in Trauma Treatment ... 8
1.4.1 Perceived Caregiver Support in Trauma Treatment ... 9
1.5 The Current Study ... 10
1.5.1 Stepped Care Trauma-Focused Cognitive Behavioral Therapy for Children ... 11
1.5.2 Change Mechanisms in Stepped Care TF-CBT ... 11
1.5.3 Aims and Research Questions ... 12
2.0 Method ... 13
2.1 Study Design ... 13
2.2 Participants ... 13
2.2.1 Children ... 13
2.2.2 Parents ... 14
2.2.3 Municipalities ... 14
2.3 Treatment ... 15
2.3.1 Therapists ... 15
2.3.2 Stepped Care Trauma-Focused Cognitive Behavioral Therapy ... 15
2.3.3 Active Treatment Phase ... 16
2.3.4 Maintenance Phase ... 17
2.3.5 Responder Criteria ... 17
2.3.6 Treatment Fidelity ... 18
2.4 Procedure ... 18
2.4.1 Recruitment ... 18
2.4.2 Data Collection ... 18
2.5 Instruments ... 19
2.5.1 The Child and Adolescent Social Support Scale (CASSS 2000) ... 19
2.5.2 Child and Adolescent Trauma screen 2.0 (CATS 2.0) ... 20
VII
2.5.3 Questionnaire with Demographic Information ... 21
2.5.4 Clinical Global Impressions – Improvement (CGI-I) ... 21
2.6 Ethics ... 22
2.7 Analyses ... 22
2.8 Evidence Before this Study and Basis for Research Questions ... 24
3.0 Results ... 25
3.1 Background Variables ... 25
3.2 Treatment Trajectories and Outcomes ... 27
3.3 Perceived Parental Support and Posttraumatic Stress Symptoms Pre-Treatment (T1) .... 27
3.4 Changes in Posttraumatic Stress Symptoms and Perceived Parental Support During the Treatment Course ... 28
3.4.1 Changes in Perceived Parental Support ... 28
3.4.2 Changes in Posttraumatic Stress Symptoms (PTSS) ... 31
3.4.3 Relationship Between Changes in Perceived Parental Support and Posttraumatic Stress Symptoms ... 32
3.5 Age, Gender and Changes in Perceived Parental Support ... 34
4.0 Discussion ... 36
4.1 The Relationship Between Perceived Parental Support and Posttraumatic Stress Symptoms Pre-Treatment (T1) ... 36
4.2 Changes in Perceived Parental Support and Posttraumatic Stress Symptoms During the Treatment Course ... 39
4.2.1 Changes in Perceived Parental Support ... 39
4.2.2 Changes in Posttraumatic Stress Symptoms ... 41
4.2.3 Relationship Between Changes in Perceived Parental Support and Posttraumatic Stress Symptoms ... 42
4.3 Age, Gender and Changes in Perceived Parental Support ... 44
4.4 Strengths and Limitations ... 45
5.0 Conclusion and Clinical Implications ... 46
5.1 Future Research ... 46
References ... 48
VIII
1 1.0 Introduction
Exposure to cruelty, war, accidents, natural disasters, or other potentially traumatizing events is a significant occurrence in our world. A screening of youth in mental health clinics in Norway found that 80% of the children had experienced at least one potentially traumatizing event, among them non-interpersonal traumas being the most common (60%) (Skar et al., 2019). A study on a nationally representative sample of 9240 Norwegian youth showed that one out of five have experienced physical violence, one in twenty have experienced severe physical violence and one out of twenty have experienced sexual assaults from an adult (Hafstad & Augusti, 2019). They further reported that children who have experienced violence once are more likely to have experienced it several times.
Exposure to potentially traumatizing events brings a risk for developing posttraumatic stress disorder (PTSD) (Perrin et al., 2014). Additionally, children who have experienced trauma have a higher risk for having mental and physical health problems, higher absence from school, severe problems with sleep and a worse subjective experience of quality of life (Hafstad & Augusti, 2019). Childhood trauma also brings health consequences in a long-term perspective. Exposure to traumatizing events in childhood is associated with adverse brain development (De Bellis et al., 1999), and it increases interpersonal problems and high-risk behavior throughout adulthood (Dye, 2018). Trauma exposure brings a higher risk for dropping out of high school (Diette et al., 2017), and a higher risk for substance abuse and incarceration (Dye, 2018). It brings an overall higher risk for mental and physical health problems in adulthood (Dye, 2018; Jaffee, 2017; Maschi et al., 2013). This brings both long- term suffering for the individual as well as increased societal costs.
Less is known about possible protective factors for children after exposure to potentially traumatizing events, and this thesis aims to increase our understanding of the role caregiver social support may have on children receiving treatment for posttraumatic stress symptoms (PTSS).
1.1 Social Support
The American Psychological Association defines social support as “the provision of assistance or comfort to others, typically to help them cope with biological, psychological, and social stressors.” (American Psychological Association, n.d.). Perceived social support is an established influential factor on youth’s mental health after exposure to potentially
traumatic events (Charuvastra & Cloitre, 2008; Thoits, 2011). A systematic review of social
2 support research suggests that perceived low social support after exposure to a potentially traumatizing event is a risk-factor for the development of PTSS in youth (Trickey et al., 2012), and another study found that high levels of perceived social support was a protective factor associated with less PTSS (Dyb et al., 2014).
There are a number of different conceptualizations of social support in the literature that are important to keep in mind when interpreting findings on the role of social support. It is of relevance to distinguish between perceived social support and the received social support, and the quantity description and the evaluation of the quality of the support (Tardy 1985). When comparing perceived social support and size of support network, perceived social support is more strongly related to health consequences and PTSD (Charuvastra & Cloitre, 2008; Thoits, 2011). The distinction between perceived- and received social support is relevant in caregiver support as well, illustrated by Zajac et al. (2015) who found that maternal and child
perspectives of caregiver support were different. A further notable conceptual distinction is between positive and negative aspects of social support (i.e. blame and felt acceptance).
Research indicates that these are separate constructs (Charuvastra & Cloitre, 2008; Thoresen et al., 2014). A comprehensive literary review suggests that a protective effect of high social support and an increased risk of with low-social support / negative social reactions may occur simultaneously after exposure to potentially traumatizing events (Charuvastra & Cloitre, 2008). This thesis focuses on positive aspects of social support.
1.2 Mechanisms of Social Support
Thoits identifies perceived social support as a mechanism in the relationship between social ties and mental health (Thoits, 2011). In her theory she describes two relational sources of support and two categories of support (Thoits, 2011). The two relational sources of support Thoits distinguishes between are support from significant others and similar others.
Significant others are from the individual’s close network, such as family members and close friends, and are people that they view as important and are emotionally tied too. Similar others are from larger and more formal groups, such as classmates or religious groups, and are individuals with similar traumatic experiences as the person.
The two categories of support are active coping assistance and emotional sustenance. Active coping assistance consists of active acts intended to lessen the situations demands or the persons emotional reactions to the demands. This can be by providing instrumental support through resources such as money or time, appraisal support through evaluative feedback or
3 informational support through kind and sufficient information and advice on problem-focused or emotional focused coping strategies. Emotional sustenance does not directly alter the situational demands nor the person’s emotional reactions to it but are demonstrations of caring that indirectly alter the individual state of well-being. This can be by providing emotional support such as love, understanding, empathy, trust, tolerance of expressed emotions and feeling mattering and belonging.
Thoits theorizes that the types of support described above have different effects on the receiver of the support depending on who provides it. Active coping assistance can, as mentioned above, be instrumental, informational and appraisal support. Instrumental support (such as help with practical tasks or resources), is often given by significant others, and can directly lessen the demands on the distressed person. Informational and appraisal support may be less effective from significant others, as they are often themselves upset and experientially dissimilar to the distressed person. This may cause the information provided to seem generic, too focused on recovery and the advice may seem naïve and unrealistic. This may increase distress by causing a sense of alienation or resistance. In contrast, Thoits’ explains that others with similar experiences may better closely tailor advice, information and coping
encouragement to the individual and enhance the individual’s sense of control in engaging with active coping efforts. Overall Thoits’ summarizes that active coping mechanisms as instrumental support from significant others and as informational and appraisal support from similar others are the most beneficial for buffering distress for the supported person (Thoits, 2011).
Thoits explains different mechanisms in emotional sustenance from significant and similar others. From significant others emotional sustenance positively influences the individual’s health by strengthening the feeling of mattering and belonging among close and caring others, as well as give sustenance to their feeling of self-worth. Emotional sustenance from
significant others often looks like explicit concern, simply being present for the distressed person and expression of distress for the persons experience. From similar others emotional sustenance offers experience-based empathy, understanding and tolerance of expressions of distress. The validation and tolerance of expressions directly reduces distress and strengthens the feeling of self-worth. Receiving emotional sustenance through emotional support from both significant others and similar others help buffer distress (Thoits, 2011).
4 In this study, the focus is on social support from a parent, which is a significant other. In some cases this parent has experienced the same traumatic experiences as the child, for instance violence from the child’s other caregiver. The categorical divisions of Thoits are thus not so clear-cut and may overlap.
1.2.1 Possible Barriers to Enact on Social Support.
A factor that influences the interaction between social support and post-trauma adjustment is the differentiation between perception of- and enactment on social support (Tardy 1985).
Someone could have potential support available but for different reasons not accept or make use of this support. Barriers to enact on social support is a separate construct from perceived social support (Thoresen et al., 2014). One study on survivors after the Utøya shooting, identified the following five social support barriers that kept the youth from talking with their available social support systems about the trauma: “They are tired of hearing about it”, “They have enough dealing with their own problems”, “They would think I'm too caught up with it”,
“I do not want to overburden my friends” and “Those who weren't at Utøya Island, wouldn't understand me”. These barriers were prevalent and reported by both genders, but more so among females. The barriers were found to be associated with PTSS and psychological distress, where higher levels of barriers coincided with higher levels of distress. In their research, perceived social support did not have a clear association with mental health after adjustment for barriers (Thoresen et al., 2014).
1.2.2 Possible Mechanisms of Social Support in Therapy
Social support in trauma treatment may interact with changes in symptoms. For instance, symptom reduction during treatment may lead youth to view others as more supportive or to enact on offered support. A reduction in symptoms may also make the youth seem more approachable by others, and increase the support given by people in their environment. The effect may also be opposite, where increased perceived social support may cause a relief in symptoms.
There are also potential factors in therapy that are connected to both social support and post trauma adjustment, and could explain a relationship between support and trauma symptoms.
Birkeland et al. (2020) suggests that changes in maladaptive cognitions (i.e. nobody can be trusted”) through therapy may change the perception of social support as well. Furthermore, Charuvastra & Cloitre (2008) suggested emotional and behavioral avoidance could be a
5 mediating factor between perceived support and symptoms, where lack of support has been associated with higher rates of avoidance and emotional detachment after childhood
mistreatment (Charuvastra & Cloitre, 2008). Following this claim, higher levels of support may enable more trauma processing. Also, a study on posttraumatic growth in youth found that social support mediated the relationship between deliberate rumination and posttraumatic growth (Xu et al., 2019), which supports the idea that positive social support may enable trauma-processing.
In sum the pathways of social support and adjustment in treatment are unclear.
1.3 Perceived Social Support in Studies of Post-Trauma Adjustment
There are several findings based on general social support, where caregiver support and support from a broader network are both included. Dyb et al. (2014) interviewed 325 youth victims of the Utøya shooting in Norway, 5-6 months after the attack. They found that higher levels of perceived social support after the attack was highly and significantly associated with lower PTSS. Similarly, Vernberg (1996) found that for elementary school children (n=568) exposed to a hurricane, perceived social support contributed significantly to the variance in PTSS. They found that social support was one of four factors that together explained 60% of the variance, and that low perceived social support was related to higher levels of PTSS (Vernberg et al., 1996).
Furthermore, perceived general social support was found to be positively associated with posttraumatic growth in 443 Chinese middle school students who experienced a tornado (Xu et al., 2019). They found social support to have a mediating role in the relationship between deliberate rumination and posttraumatic growth. They theorized, as mentioned above, that social support enables changes in cognitions and appraisals through deliberate rumination, and thereby contributing to posttraumatic growth through positive change in self-awareness, interpersonal experiences and life values.
There may be some gender differences in the role of general social support, although findings related to gender vary. Some findings indicate that girls generally report higher levels of social support than boys (Llabre & Hadi, 1997; Vernberg et al., 1996), while others find no gender difference (Dyb et al., 2014). One paper found social support to be a protective factor only for girls, and not for boys (Llabre & Hadi, 1997). Thoresen et al. (2014) found that gender was not associated with mental health in their study after adjustment for social support
6 barriers. Additionally, caregiver support is found to have a more central role for children, while adolescence may put more weight on support from friends (Rosenthal et al., 2003). This indicates that the protective effect of support may come from different supporters among children of different ages.
1.3.1 Perceived Caregiver Support in Post-Trauma Adjustment
Family support is a strong protective factor in post trauma-adjustment (Hill et al., 1996;
Kliewer et al., 2004). Additionally, disruption in the family social support network is a significant risk-factor for the child’s adjustment after exposure to trauma (Laor et al., 2001;
Pine & Cohen, 2002). This suggests that specifically support from family members is important.
Caregiver support and reactions are particularly important in post-trauma adjustment (Gries et al., 2000; Kliewer et al. 2004). For instance, high caregiver support was significantly and strongly related to low depression and healthy emotional functioning (Gries er al.,2000). This association was found after disclosure of child sexual abuse among children between 6 and 18 years old. They researched four categories of support: feeling believed, instrumental support, action towards perpetrator and emotional support. Caregivers’ supportive reactions were more influential on the child’s post-trauma adjustment than the reaction from other significant people in their lives. For children in foster-care their foster-parents’ supportive reactions were influential, while their non-offending birth parents’ support or lack of support did not have a significant impact on functioning (Gries et al., 2000). Similarly, Kliewer et al. (2004) found that caregiver emotional support (felt acceptance) was the strongest protective factor for children who had been exposed to a potentially traumatizing event.
One study found that maternal support was related to post-trauma adjustment both short-term and longitudinally (Zajac et al., 2015). They included both maternal and child perspectives of the maternal support and both perspectives on the child’s symptomatology. This was
measured after child sexual abuse disclosure and at 9-months follow up. In this article maternal support consisted of positive and negative aspects of social support, such as emotional support and blame/doubt. They found these separate aspects of support to be differently related to symptoms. The child’s perspective of maternal emotional support was related to lower levels of anger and depression. The children’s ratings of the support were only significantly associated with self-reported outcome variables. The mother’s rating of the support coincided more with the maternal rating of the child’s adjustment (Zajac et al., 2015).
7 Similarly, Rosenthal et al. (2003) found emotional support specifically to be related to post- trauma adjustment, such as better self-esteem and more sexual-anxiety one year after child sexual abuse.
Higher caregiver social support is associated with less distress, depression, higher self-worth, resilience, and adaptive appraisals of abuse among victims of sexual assault (Esparza, 1993;
Gries et al., 2000; Johnson & Kenkel, 1991; Morrison & Clavenna-Valleroy, 1998; Rosenthal et al., 2003; Spaccarelli & Kim, 1995; Tremblay et al., 1999). Lack of caregiver social support after sexual assault is associated with more distress, depression, self-blame, and negative appraisals of abuse (Gries et al., 2000; Johnson & Kenkel, 1991; Morrison & Clavenna- Valleroy, 1998; Spaccarelli & Fuchs, 1997).
There are however findings that do not support an association between caregiver support and post-trauma adjustment. One comprehensive meta-analysis found few and weak associations between non-offending caregiver support and child adjustment after disclosure of sexual assault(Bolen & Gergely, 2014). Notably, the 29 cited articles measured support from different perspectives. Thirteen articles measured the child’s perspective of social support, of which 9 articles did find caregiver support to be significantly associated with part of
adjustment after child sexual abuse. Of the three that did not find a connection between child post-trauma adjustment and maternal support, two measured only a maternal report of the trauma adjustment (Leifer et al., 2001; Leifer et al., 2003).
Two studies did not find any association between perceived caregiver support and overall PTSS (Reyes, 2008, Zajac et al., 2015). One study on 61 children between 7 and 16 years old, all victims of sexual abuse, found that perceived caregiver support did not account for a significant amount of variance with the children’s self-reported levels of PTSS overall, depression, or anger. They only found a relationship between higher levels of caregiver support and lower scores on the subscale of disassociation (Reyes, 2008). Similarly, Zajac et al. (2015) found association between maternal support and aspects of trauma adjustment, as mentioned above, but did not find and relationship between positive aspects of maternal support and PTSS specifically (Zajac et al., 2015). That there are studies that find unclear or no relationship between PTSS and caregiver support may seem oppositional from findings of the protective effect of social support post-trauma adjustment. This does however align with findings that do report the same protective effect. While perceived caregiver support is found to be higher than support from classmates, close friends and teachers, Vernberg et al. (1996)
8 found that the protective effect of social support was only found regarding caregiver support when it was seen together with other sources of support. Caregiver support alone showed no individual relations to levels of PTSS.
1.3.2 Impact of Environment and Trauma Related Factors on Perceived Social Support.
Type of trauma influences the role of social support. One study reported that higher exposure to violence lessens the protective effect of high perceived social support (Kliewer et al., 2004), suggesting there to be an upper limit to the protective effect of support. Additionally, the level of social support given by the community vary with type of trauma, where
collectively shared or heroic traumas generate more social support than unshared traumas associated with stigma. For instance, childhood maltreatment has been associated with low social support (Punamäki et al., 2005). These are relevant aspects to consider because if a child receives little community support because of stigma, the caregiver support is a bigger percentage of the child’s overall support. It is also possible that stigma in the caregiver’s appraisal of the trauma can influence their support to their child. Additionally, whether the trauma has an interpersonal element may influence their perspective of social support, as support itself is an interpersonal concept (Charuvastra & Cloitre, 2008).
The protective effect of caregiver support on trauma adjustment may also interact with the child’s environment. One study found a difference in the protective effect of social support depending on the levels of violence in the child’s area of living. They found that the
protective effect of caregiver support was stronger for children in high-violence areas, while it had no protective effect on child witnesses to violence in low-violence areas (Hill et al., 1996).
In sum these studies illustrate how nuanced the effect of perceived social support may be, and how there is a gap in knowledge of how these influential factors interact and how this
influences the effect of perceived caregiver support on different aspects of post-trauma adjustment.
1.4 Perceived Social Support in Trauma Treatment
The relevance of general social support in therapy after exposure to potentially traumatizing events has been documented across several countries (Betancourt et al., 2014; Birkeland et al., 2020; Kane et al., 2016; Schultz & Weisæth, 2015). However, the number of studies
examining the role of social support in youth trauma treatment is marginal compared to adult
9 studies. Nonetheless, during the course of therapy, a co-occurrence of a decrease in PTSS and an increase in perceived social support is reported in different types of youth trauma treatment (Birkeland et al., 2020; Im et al., 2018; Salloum & Overstreet, 2012). In one study, perceived social support from family predicted lower levels of PTSS 10 months post trauma-
intervention, for 118 youth who had experienced hurricane Katrina and received Trauma- Focused Cognitive Behavioral Therapy (TF-CBT) or a trauma-focused group therapy (Jaycox et al., 2010). Higher levels of PTSS pre-treatment are observed with low levels of perceived general social support pre-treatment for youth that had experienced multiple trauma and who received TF-CBT (Birkeland et al., 2020). However, high level of perceived social support pre-treatment was not associated with steeper reduction in PTSS throughout treatment. In this study the authors also found that overall perceived social support remained stable during an 18 month follow up despite differences in the steepness of the increase through therapy (Birkeland et al., 2020).
1.4.1 Perceived Caregiver Support in Trauma Treatment
The established importance of a primary caregiver’s role in a child’s life makes them an influential factor in a child’s post-trauma adjustment and possibly also in therapy. The caregiver’s level of emotional support, perception of the trauma and emotional reactions influences the child’s trauma adjustment and mental health (Brown et al., 2020; Cinamon et al., 2021; Gries et al., 2000). In treatment the caregiver can potentially help their children challenge their negative cognitions, try to minimize their own and their child’s avoidance of trauma reminders and attempt to help regulate their child’s emotions (Cohen et al., 2017). A child’s caregiver is often a source of safety, which is important when exposure to potentially traumatizing events may provoke feeling of unsafety. Other factors such as caregivers’
physical closeness, psychopathology, emotional and cognitive reactions, avoidance and appraisals influence a child’s PTSS development (Brown et al., 2020; Charuvastra & Cloitre, 2008; Cinamon et al., 2021; Holt et al., 2014). These factors may influence whether the child perceives their caregivers as supportive and may further influence the caregiver’s involvement and support in therapy.
There are studies showing the importance of perceived support specifically from the caregiver in youth trauma therapy. Adolescents with high perceived caregiver support had a higher self- esteem, and a decrease of depressive symptoms throughout treatment, while perceived low support from the caregiver was associated with an increase in depressive symptoms
10 throughout treatment(Morrison & Clavenna-Valleroy, 1998). Additionally, higher perceived caregiver support in therapy is associated with lower levels of dropout (Ormhaug & Jensen, 2018). Perceived social support from the caregiver was shown to be a significant factor for the completion of the trauma narrative (DiCesare, 2016), and clinicians observed that caregiver support during this phase of the treatment predicted lower internalizing symptoms in follow- up measures (Yasinski et al., 2016).
As mentioned earlier, while there is support for the relationship between perceived caregiver support and different aspects of post-trauma adjustment, there is limited data on the
relationship between perceived caregiver support in therapy and specifically PTSS. Studies regarding the influence of social support on PTSS in therapy specifically have more findings for social support broadly (Birkeland et al., 2020; Salloum & Overstreet, 2012), than social support from caregivers specifically.
A possible perspective of the relationship between perceived caregiver support and trauma adjustment in therapy for children is regarding the role of a participating caregiver. Both caregiver participation and higher caregiver processing in therapy has been associated with more support given to their child and an increase in caregivers parental abilities (Cohen et al., 2004; Yasinski et al., 2016). Caregiver participation in trauma therapy has further positive benefits, such as less child depression and externalizing symptoms and less drop-out
(Deblinger et al., 1996; Holt et al., 2014; Ormhaug & Jensen, 2018). Additionally, treatment for the child also brought a decrease in depressive symptoms in mothers (Holt et al., 2014).
Overall parental participation and processing may influence both PTSS and increase the caregiver’s abilities to actively be present and supportive for their child. There are treatments where caregiver involvement is even higher, and the caregivers are the ones delivering the treatment (Thirlwall et al., 2013). Less is known about the role of social support in these parent-led treatments.
1.5 The Current Study
Despite evidence of social support having a protective effect on psychological health after exposure to trauma (Charuvastra & Cloitre, 2008; Thoits, 2011), there is little research on the role of caregiver support on PTSS specifically, and particularly when it comes to parent-led treatment models. This thesis focuses on a child’s perceived social support from their caregiver pre-treatment and after receiving a parent-led trauma treatment called - Stepped
11 Care Trauma-Focused Cognitive Behavioral Therapy (Stepped Care TF-CBT). Perceived parent support overall, emotional support, instrumental support, informational support and appraisal support will be explored.
1.5.1 Stepped Care Trauma-Focused Cognitive Behavioral Therapy for Children
The data comes from a feasibility trial testing the relatively new parent-led treatment program for children exposed to potentially traumatizing events, Stepped Care TF-CBT (Salloum, Scheeringa, et al., 2014). The treatment was developed with the goal of lowering barriers for treatment such as travel expenses, time, work demands, availability of childcare and
caregivers wishing to solve the problem on their own (Salloum, Scheeringa, et al., 2014).
Stepped Care consists of a parent-led treatment as Step One, and standard therapist-led TF- CBT as Step Two. Step One consists of scheduled caregiver-child sessions at home with therapeutical components such as trauma narrative, exposure and guidance from a therapist.
The children who need further treatment after Step One are stepped up. For children who are considered to have responded sufficiently well go on to a maintenance phase of Step One with regular child-caregiver sessions. Stepped Care TF-CBT is a therapy with basis in treatment components from the evidence-based Trauma-Focused Cognitive Behavioral Therapy (Cohen et al., 2017). A Stepped Care TF-CBT pilot study and efficacy trial show promising effects of this parent-led treatment, and that the method is well-liked by the families (Salloum, Robst, et al., 2014; Salloum et al., 2016). However, there is little research on the role caregiver support has in the treatment. Therefor this thesis will focus on perceived parent support in the parent- led Step One of Stepped Care TF-CBT.
1.5.2 Change Mechanisms in Stepped Care TF-CBT
The theoretical foundation of the focus on exposure in Stepped Care TF-CBT is based on Foa and Kozak’s (1986) theory of emotional processing of the trauma as an important change mechanism. In Stepped Care TF-CBT the exercises that enable trauma processing through trauma narrative and in vivo exposure to trauma reminders is a central element.
Foa and Kozak’s theory of emotional processing understands trauma responses as an overgeneralization and maladaptive firing of a person’s fear structure related to the trauma.
This fear structure consists of hypersensitivity to trauma reminders and the sense of danger and meaning the child connects to the trauma reminders. They view emotional processing of the trauma as a main change mechanism (Foa & Kozak, 1986), and emotional activation in therapy is a necessary basis for emotional processing, especially activation of fear (Foa &
12 Kozak, 1986; Greenberg, 2015). To enable emotional processing as a change mechanism in therapy the fear-structure must be activated, and new correcting information of safety must be presented to ensure that the fear structure changes to become more adaptive. To ensure that new corrective information may increase feelings of safety throughout Stepped Care TF-CBT the focus is to first ensures that the children get tools that help regulate activation and then a gradual increase of exposure.
Exposure to fear-activating activities between therapy sessions is an arena where fear- activation and corrective experiences help build a more adaptive fear-structure. Habituation and fear reduction throughout treatment is also an indicator for emotional processing (Foa &
Kozak, 1986). There are findings that fear activation and fear-habituation in therapy are related to a decrease in PTSS in adults (Foa et al., 1995; Jaycox et al., 1998). Research is lacking for children.
1.5.3 Aims and Research Questions
The aim of this thesis is to better understand the role of perceived parental support on posttraumatic stress symptoms in a parent-led trauma-treatment for children.
The following questions are explored:
1) What is the relationship between perceived parental support and posttraumatic stress symptoms pre-treatment? The hypothesis is that perceived parental support will correlate negatively with PTSS pre-treatment.
2) Does the child’s perceived parental support change during treatment? If so, what is the relationship between changes in child perceived parent support and changes in PTSS? The hypothesis is that perceived parental support will increase throughout Stepped Care TF-CBT and that there will be a correlation between increase in caregiver support and a decrease in posttraumatic stress symptoms after treatment.
3) What is the relationship between age and gender and perceived social support? Based on the lack of consistent findings I do not have a pre-defined hypothesis, and I will both pre-treatment perceived parental support and changes after treatment.
13 2.0 Method
2.1 Study Design
The dataset is part of an ongoing multicenter, feasibility study led by the Norwegian center for violence and traumatic stress studies (NKVTS). The project has an exploratory
longitudinal research design for investigating a Stepped Care TF-CBT intervention for trauma-exposed children in primary-care mental health services in Norway. The overall project recruited 19 municipalities and 46 therapists. This thesis used data collected from child-parent dyads recruited between May 2019 and January 2021, where treatment was concluded by May 2021. This subset included data from 10 municipalities and 17 therapists.
All data was collected by the researchers at NKVTS, while datafile preparation, coding and analyses of the data for this thesis was done by the author.
2.2 Participants
In the period from May 2019 to January 2021, altogether 184 child-parent dyads were screened for participation in the Stepped Care TF-CBT treatment. Of these, 128 did not meet the criteria for participation due to not meeting the symptom criteria (n=112), need for an interpreter (n=2), other exclusion criteria (n=15) or unknown/missing reason (n=12). There were 56 child-parent dyads that met the criteria, of these 9 declined the treatment, 4 wanted the treatment but were unable to participate for different reasons, and 43 child-parent dyads signed consent and began the treatment. Valid baseline assessments were available for 39 children, leaving this as the final sample size included in analyses. The participants of this study include the children receiving the treatment, the parents participating in the treatment, the municipalities offering the treatment and the therapists guiding the parents and children in the Stepped Care TF-CBT treatment.
2.2.1 Children
To be included in the treatment, the children must fit within the following inclusion criteria.
They must be between 7 and 12 years of age. They must have at least one experience of a potentially traumatizing event, according to the DSM-5 A-criterion for PTSD (American Psychiatric Association, 2013). This event must have happened when the child was 3 years or older. The event must have taken place at least one month before recruitment. They must be experiencing a minimum of 5 symptoms of posttraumatic stress, where one of the symptoms is re-experiencing and one is avoidance. These symptoms must all be rated a minimum of 2 (a score of 2 means the symptom is experienced “often”) on the 0-3 intensity-scale on the Child and Adolescent Trauma Screen 2.0 (Sachser et al., 2017). Additionally, the child must live in
14 a safe environment, a person that caused the child’s traumatic experience cannot live with the child. The children themselves must confirm to feeling safe in their home and with their parent, in a conversation where the child is alone with the therapist without the parent present.
The exclusion criteria for the child for receiving Stepped Care TF-CBT include the following points. If there was suspicion of either suicidality, psychosis, autism spectrum disorders, intellectual disabilities or any other conditions that deter work with the Stepping Together workbook used in the treatment. Additionally, if the children were receiving psychotropic medication they were only included in the study if the effects were stabilized at a minimum of 4 weeks. For stimulants or benzodiazepines this period was only 2 weeks. If the child received another trauma treatment at the same time, they were excluded from the study.
2.2.2 Parents
The recruitment criteria were open for caregivers with varied relationships to the child (i.e., parents, other family, foster parents), but all participating caregivers were parents. Therefor the focus in this thesis findings will be on parents specifically and not caregivers overall.
Exclusion criterion regarding the parents were as follows; if the parents have had a substance use disorder within the past 3 months, if there was suspicion of a high suicide risk or if the parent had any other condition that would limit their ability to lead the treatment sessions with the child. This included if the parent’s comprehension of the Norwegian language was
insufficient to properly understand the workbook and follow the necessary instructions.
Additionally, a parent that was the offender or cause of the trauma exposure could not lead the treatment or live in the same household as the child.
2.2.3 Municipalities
The recruitment of different municipalities ensures a greater representability across different settings in Norway. To increase generalizability the municipalities chosen varied greatly in size, population density and geography; this was also true for the 10 municipalities included in the subsample used in this thesis. The criteria for the municipalities participation were that they belong to health sectors that offers standard TF-CBT, and that they had at minimum of two therapists employed in their primary-care mental health services for children that were eligible for receiving Stepped Care TF-CBT training.
15 2.3 Treatment
2.3.1 Therapists
The inclusion criteria for therapists training and participation were that they were employed in the primary-care health services within the municipality, that they worked with children within the ages of 7 to 12 years, and that they were a licensed clinical psychologist or psychiatrist. Therapists of other professions were considered if they had relevant training or experience. All therapist participation was voluntary.
The therapists underwent a two-day training in trauma understanding and standard TF-CBT treatment from certified TF-CBT consultants from NKVTS. Additionally, they had to complete a 10-hour web course in TF-CBT. Furthermore, they were instructed in Stepped Care TF-CBT from Dr. Alison Salloum in an additional two-day training. Monthly video consultations with Dr. Alison Salloum and weekly telephone/video guidance by psychologists at NKVTS continued throughout the project period.
2.3.2 Stepped Care Trauma-Focused Cognitive Behavioral Therapy
This study explores Stepped Care TF-CBT which is an intervention developed by Dr. Alison Salloum (Salloum, Scheeringa, et al., 2014). The intervention is based upon the TF-CBT principals of psychoeducation, parenting skills, stress-management techniques, affective expression and modulation, developing a narrative of trauma, cognitive processing and in vivo (real life) exposure of trauma triggers (Cohen et al., 2017). Stepped Care TF-CBT was developed for children between 3-12 years who are victims of trauma, with one workbook for ages 3 to 6, and another for ages 7 to 12. The latter workbook, called Stepping together, is the workbook used in this study and was translated into Norwegian by NKVTS.
The therapy was developed with a goal of lowering waitlists, being a cost-effective trauma treatment and overcoming barriers for treatment such as logistical barriers as time, work demands and childcare. Including parents in treatment addresses the major barrier of parents wishing to solve the problem on their own (Salloum, Scheeringa, et al., 2014). The parent’s active role in the treatment allows parents to make the treatment individually and culturally relevant (Salloum, Scheeringa, et al., 2014). Stepped Care introduces a Step One treatment level in primary-care, which in Norway is the low-threshold municipal mental health services that require no referral. The children who need continued treatment are referred up to Step Two, which is treatment in-clinic with a psychologist at the Child and Adolescent Mental Health Services (CAMHS/BUP). If a child is referred to Step Two CAMHS/BUP take over
16 treatment responsibility and do evaluation and further treatment. Recommended treatment at Step Two is standard, therapist-led TF-CBT.
Step One includes an active treatment phase with frequent therapist contact, and a
maintenance phase for treatment responders that includes two occasions of therapist contact.
Additionally, the parents get access to a web-based component that provides psychoeducation.
Normally the Step One treatment phase lasts 6-9 weeks and the maintenance phase is 6 weeks.
2.3.3 Active Treatment Phase
The active treatment phase consists of 11 scheduled at-home sessions between the parent and the child, as well as 3 meetings at the therapist’s office with the child, parent and the therapist present. Additionally, there is weekly parental guidance over phone calls. Due to the covid-19 pandemic, individual adjustments were made. Some therapist-meetings were done digitally, others face to face.
During the at-home sessions the child and parent work through the Stepping Together workbook in a quiet area at a set time. The workbook has separate tasks and worksheets for each session, with a guided description for the parent delivering the treatment. The book consists of tasks focusing on building coping skills such as identifying difficult emotions, coping with negative cognitions and feelings, and regular practice of relaxations skills. These elements and developing a trauma narrative are the focus in the first 4 sessions. The next 4 at- home meetings focus on gradual exposure to trauma reminders, with a focus on decreasing fear reactions and increasing feelings of safety over time. The final three sessions focus on the last steps of exposure, discussing a relapse plan and reviewing the completed book.
Throughout the sessions there is a focus on praise and cooperation between the parent and child.
Additionally, there is a separate part of the workbook for the parent. This includes
psychoeducation on PTSD and tasks for the parent that focuses on social support, parental guilt, parentings techniques, parenting challenges and motivation to complete the treatment with the child.
The 3 meetings in the therapist’s office are before the start of the at-home sessions, after completing two weeks and after a subsequent two weeks. The first meeting after screening includes explaining the treatment and PTSS, introducing the workbook, showing the first
17 activity the child and parent are going to do together, and showing the relaxation exercises. It also includes a section with the parent alone with the therapist to plan the first two weeks, and to focus on motivation. The two remaining meetings includes going through the parts of the workbook that have been completed so far, and separate conversation with the child and the parent. The therapist and parent plan the exposure to trauma reminders together at the second meeting, and work on motivation in both meetings.
After the completion of the workbook, a fourth meeting with the therapist happens to assess progress and responder status. This includes an evaluation of child’s needs and symptoms to decide if the child should be stepped up to additional treatment with therapist-led TF-CBT in CAMSH/BUP. If the child is considered a responder, the child-parent dyad enters the
maintenance phase.
2.3.4 Maintenance Phase
This phase consists of weekly scheduled sessions between the child and parent with a focus on the relaxation exercises and positive child-parent activities. The child and parent do the relaxation exercises together three times a week and use tools from the treatment phase to communicate about emotions. The therapist makes one phone call to the parent in the middle of the maintenance phase to check-in and see how they are doing. After the maintenance phase the child’s symptoms are evaluated again to assess whether the responder-criteria are maintained. If they are the treatment is concluded with a celebration and diploma. If the child is a non-responder, they are stepped up to Step Two.
2.3.5 Responder Criteria
Whether a child needs to be stepped up is considered by the therapists throughout the treatment, and the therapist can step the child up to Step Two any time in the treatment progress if they deem it necessary. At screening (T0), after the active treatment phase (T2) and after the maintenance phase (T3) there are set assessments of whether the child needs are best met with stepping up to Step Two.
The child is considered a responder to Step One if the child reports fewer than five posttraumatic stress symptoms with an intensity of 2 “often” (on a scale from 0 to 3) according to CATS 2.0. Additionally, the therapist must rate the child’s clinical global impressions improvement (CGI-I) to be improved, much improved or very much
improved/symptom free. When responder criteria are met, the therapist does an individual
18 evaluation of whether the child should be stepped up, or if the child can progress to
maintenance phase or finish the treatment.
2.3.6 Treatment Fidelity
To ensure treatment fidelity, all therapist sessions were recorded. These recordings were used by NKVTS psychologists to listen to each therapists’ first three cases in their entirety. The psychologist then scored these recordings on fidelity to the method (a checklist of 22 fidelity items, where at least 20 (90%) of the fidelity items had to be completed) and gave the
therapists feedback. After the three first cases, the consultants would listen to one session from each case.
2.4 Procedure 2.4.1 Recruitment
The children were most often directed to the municipal primary-care mental health services by the health contact at their school, or because the parents directly contacted the municipal health services. After screening for symptoms and inclusion/exclusion criteria they were offered the Stepped Care TF-CBT treatment. Parental consent from parents was obtained.
2.4.2 Data Collection
All data collected from children, parents and therapists, and audio recordings from the therapist sessions were encrypted and sent electronically to safe storage in the service for sensitive data (TSD).
The data was collected on four different occasions. These occasions were Screening (T0), before the first treatment session (T1), after finishing the treatment phase (T2, 6-9 weeks after T1), and after the maintenance phase (T3, 6 weeks after T2). Between screening (T0) data and pre-treatment (T1) data there was a maximum of 4 weeks. If the time in between lasts longer than 4 weeks, the screening was repeated before treatment start. In the analysis in this thesis, both the screening and T1 will be our baseline scores, and therefore referred to as pre-
treatment “T1”.
The data was collected electronically before the meetings with the therapists. The parent left the room with an iPad to fill out their questionnaire, while the child remained with the therapist. The child was informed that their responses on perceived parental support would not be shared with their parent. When the child filled out their questionnaire, the therapist remained nearby to assist if the child had questions. The questions about trauma symptoms
19 (CATS 2.0) and about clinical global impressions scale (CGI) were asked by the therapist to the child face-to-face, in an interview style meeting. The therapists logged these data
electronically after the meeting.
2.5 Instruments
2.5.1 The Child and Adolescent Social Support Scale (CASSS 2000)
The children’s perception of parental support was measured with the Child and Adolescence Social Support Scale 2000 (CASSS 2000) (Malecki & Demary, 2002) at pre-treatment (T1), after the treatment phase (T2) and after the maintenance phase (T3). The scale consists of 12 questions where child reports on a scale from 1-6 where 1 is “never”, 2 is “almost never”, 3 is
“some of the time”, 4 is “most of the time”, 5 is “almost always” and 6 is “always”. CASSS gives one total score for perceived parent support and 4 scores for different modules. These modules are emotional support, instrumental support, informational support and appraisal support.
Emotional support is the child’s perception of love, understanding, empathy, and trust in their relationship with their parent. This module includes three statements for the child to rate, which is “my parents show they are proud of me”, “my parents understand me” and “my parents listen to me when I need to talk”. Instrumental support involves the child’s perception of receiving resources, both physical and the parent’s time. This module consists of three statements, which are “my parents help me practice my activities”, “my parents take time to help me decide things” and “my parents get me many of the things I need”. Informational support is about the child’s perception of parent’s advice and information, which consists of the following three statements; “my parents make suggestions when do not know what to do”,
“my parents give me good advice” and “my parents help me solve problems by giving me information”. Appraisal support is the child’s perception of kind evaluative feedback and consists of the three statements that are “my parents tell me I did a good job when I do something well”, “my parents nicely tell me when I make mistakes” and “my parents reward me when I’ve done something well” (Malecki & Demary, 2002).
The perceived parental support scale of CASSS has a good reliability of .88-.96 Cronbach’s alpha (Malecki & Demary, 2002). The scores are calculated with a minimum of 10 answers, where the missing data is replaced by the mean of the answered questions. The scores are summed, with a total score range from 12 to 72 and module score ranges from 3 to 18. The
20 perceived parental support mean score found among a non-clinical population of 353
American children was male/female: 52.63/51.83 (Malecki & Demary, 2002).
The measure is validated for children between 8 and 11 years old (Malecki & Demary, 2002), and translated to Norwegian by NKVTS. The translation was done in collaboration with the developers and was translated back to English after the first translation to ensure the validity of the translation.
2.5.2 Child and Adolescent Trauma screen 2.0 (CATS 2.0)
The child and adolescent trauma screen (2.0) is an updated version of CATS 1.0 and is currently under validation and only used in research projects. The CATS 1.0 (Sachser et al., 2017) is a much-used trauma screen, and has been validated in Norway. It showed good convergent and construct validity, as well as a factor structure that aligns with DSM-V PTSD (Nilsson et al., 2021). In an international validation study on CATS 1.0 the self-report proved good to excellent reliability with Cronbach’s alpha ranging between .88 and .94 (Sachser et al., 2017). The 2.0 updated version has two parts. Part 1 assesses any potentially traumatizing events the child has been exposed to. The list includes 14 different types of events related to exposure to- or witnessing violence in different settings, severe bullying, sexual assault, natural disasters and frightening medicinal procedures. The list also includes the opportunity to select a 15th option which is “other” and specify the event, if they have experienced something that is not on the list. Part 1 is filled out during screening (T0), after active
treatment phase (T2) and after the maintenance phase (T3). The child is asked in an interview with the therapist without the parent present.
Part 2 of CATS 2.0. measures posttraumatic stress symptoms. The assessment is based upon DSM-5 and ICD-11 PTSD symptom criterion (American Psychiatric Association, 2013;
World Health Organization, 2019). CATS 2.0 measures PTSS and complex PTSD with 20 questions. These questions capture scores on the four main categories of symptoms: re- experience, avoidance, negative changes in cognitions and emotions, and
reactivity/hyperarousal. There are five questions regarding re-experiencing, that asks
questions regarding disturbing or frightening thoughts or memories of the trauma and dreams or visual flashbacks to the event. There are two questions about avoidance, including thought- avoidance and avoidance of physical trauma reminders. There are seven questions about negative changes in cognitions and emotions, including questions about guilt, memory loss, appraisal of the trauma and negative cognitions about others and the world. There are six
21 questions regarding reactivity/hyperarousal, that touch upon doing dangerous of unsafe thing, being easily frightened and problems with concentration and sleep.
The child chooses between the answers 0-3, where 0 is “never”, 1 is “sometimes”, 2 is “often”
and 3 is “almost all the time”. CATS 2.0 gives a total score for trauma symptoms with a range of possible scores from 0 to 60. If the child has an overall score that is 21 or above the child most likely fills the criteria for a PTSD diagnosis. If the child scores 15 or higher, with at least one symptom in each category the child should be offered a trauma focused treatment. In this thesis the child must rate the symptom a 2 or above for the symptom to count in the
assessment of the responder criteria.
2.5.3 Questionnaire with Demographic Information
The parents filled out a questionnaire at pre-treatment (T1) where they were asked about different demographic factors. The questionnaire included questions about their own and their child’s age and gender, and their areas of birth (with the options of answering Norway, Asia with Turkey, North America/Oceania, Western Europe, Eastern Europe, South/central America, Africa). They were also asked about their role in regard to their child, where the answer options were: father, mother, foster-father, foster-mother, other family, other. They were asked about whether the child had siblings, and the child’s living-conditions, with the response options of: living together with both parents, living mostly with mother, living mostly with father, spending equal amounts of time with mother and with father, in foster- care or other.
The questionnaire also asked about annual household income, asking the parent to choose between the options of 200 000 NOK or less, 500 000 NOK or less, 1 000 000 NOK or less or more than 1 000 000 NOK. The questionnaire askes about highest level of the parents’
education with options of no education, primary education, high-school, vocational training, 4 years or less of university or more than 4 years at university. Parents current work status was asked, with answer options either normally in fulltime work, normally in part time work, student, seeking work or receiving financial support/other.
2.5.4 Clinical Global Impressions – Improvement (CGI-I)
The Clinical Global Impression – Improvement scale is answered by the therapist, the child and the parent at each therapist meeting and in addition by the parent at each phone call with the therapist, to closely monitor the child’s status and symptoms. The CGI-I is part of the Clinical Global Impressions scale, which is an assessment of the child’s current condition and
22 level of improvement (Busner & Targum, 2007). The CGI-I consists of one question, which is
“Compared to the patient’s condition at admission to the project, this patient’s condition is”, and a 1-8 rating score. The answers are 1 no symptoms, 2 very much improved, 3 much improved, 4 minimally improved, 5 no change from baseline, 6 minimally worse, 7 much worse or 8 very much worse. After active treatment phase (T2) and after maintenance phase (T3) this scale is used as part of the assessments of the child’s need to be stepped up or if child has reached responder status. This scale has been used on children undergoing Stepped Care TF-CBT previously (Salloum, Robst, et al., 2014).
2.6 Ethics
The study has been approved by the regional ethics committee south-east (REK 2018/771). It was additionally registered on clinicaltrials.gov (reference number NCT04073862). To ensure the treatment was safe for the children all therapist sessions were recorded. The NKVTS consultants review the therapists first cases and give the therapist feedback and weekly
guidance. The therapists and the NKVTS consultants confer if the child’s CGI-I score indicate that the child is getting worse to ensure proper treatment. All recordings and data gathered were sent electronically to secure storage (TSD).
The child was interviewed about the trauma experiences and trauma symptoms alone with the therapist and without the parent. This was to ensure that the child could answer without adjusting to the parent’s presence. Research has found that the majority of children generally are not upset by being assessed of trauma and symptoms, or by participation in studies (Dos Santos et al., 2016). It was also important that the child was not placed in a difficult position when asked about perceived parental support, therefore the parent was not present when the child filled out their questionnaires.
2.7 Analyses
All preparation and coding of variables were done using IBM SPSS syntax and all analyses were done in IBM SPSS 27. All relevant assumptions for statistical tests were examined.
Shapiro-Wilks’s test of normality was conducted for the PTSS variables, perceived social support overall and the separate modules of perceived social support. The threshold for statistical significance was set to 5%.
The scores and change scores for parental support and PTSS were checked for outliers, defined as values 1.5 times the interquartile range above the 3rd percentile or below the 1st percentile, as is the standard definition in IBM SPSS 27. None of the identified outliers were
23 considered extreme and there was no reason to suspect errors in registration. Still, the
relatively small sample size in this study makes the analyses sensitive to be skewed by outliers. On the other hand, removing outliers could also influence outcomes through a reduction in statistical power. For transparency, when removing outliers from analyses changed the outcomes, analyses both with and without outliers will be reported.
To explore the relationship between perceived social support and PTSS pre-treatment (T1) Pearson’s correlation analysis was conducted with the scores of CATS 2.0 and CASSS scores for total, instrumental, appraisal, informational, and emotional support at pre-treatment (T1).
To explore changes in perceived parental support during the treatment course and any relationship with changes in PTSS the following analysis were conducted. A one-way repeated measure ANOVA with a post hoc test with a bonferroni adjustment was conducted with the CATS 2.0 scores to explore the change from pre-treatment (T1) scores to after the maintenance phase (T3) scores. To explore the changes in perceived parental support scores a non-parametric analysis was chosen due to violation of the assumption of normal distribution for CASSS scores after active treatment (T2). A Friedman analysis with a Dunn’s post hoc test with a bonferroni correction was done with the CASSS scores at the three points of measure (T1, T2, T3). The same analysis was conducted with the 4 types of parental support in CASSS separately. The one-way repeated measure ANOVA and Friedman analyses were done only for the patients that completed the maintenance phase and provided T3 data (n=28).
Tests including CASSS scores from after active treatment phase (T2) had 27 participants due to missing variables for one participant.
To further explore the extent of changes in scores across the Stepped Care TF-CBT, change- variables were computed by subtracting pre-treatment (T1) scores from the scores after the active treatment (T2) and after the maintenance phase (T3) separately. This was computed for CASSS and CATS 2.0. The variables of change from pre-treatment (T1) to after active treatment phase (T2) included responders (n=27, missing=1) and non-responders (n=5). The variable of change from pre-treatment (T1) to after maintenance phase (T3) included the responder-group (n=28). The change scores were normally distributed. To explore if changes in perceived parental support and PTSS were related, a Pearson’s correlation test was
conducted with change-variables for CASSS and CATS 2.0. To further understand the significant correlations, additional Pearson’s correlation analysis was done with the relevant change-variables of the 4 types of parental support in CASSS.
24 To explore age differences in perceived parental support, a Pearson’s correlation analysis was conducted with age and CASSS scores, and also with the change-variables for CASSS. To further understand the significant correlations, additional Pearson’s correlation analysis was done with the relevant change-variables of the 4 types of parental support in CASSS. To explore gender-differences in perceived social support during the treatment course a mixed- model ANOVA was conducted with gender and CASSS scores from the responder group at pre-treatment (T1), after active treatment phase (T2) and after maintenance phase (T3).
No analyses were done to compare the outcome groups due to a lack of statistical strength by the small sample sizes in the non-responder (n=5) and drop-out (n=6) groups. Additionally, no analyses were done to explore the differences in types of trauma as this is out of the scope of this thesis.
2.8 Evidence Before this Study and Basis for Research Questions
To get a comprehensive overview of the relevant research on social support and parental support in trauma adjustment and trauma therapy for children the author did a comprehensive search on APAs international database of psychology, PsycINFO. The following search was conducted:
Search results were limited to research that included relevant terms from four categories: 1) social support, 2) relevant trauma treatment 3) youth as population and 4) trauma or relevant diagnoses. The following terms were included in the separate categories: 1) social support, parent* support, caregiver support. 2) trauma (adjacent to) therap*, Stepped Care, cognitive behavior* therap*, trauma* (adjacent to) intervention, trauma* (adjacent to) treatment, trauma-focused cognitive behavioural therapy. 3) child*, boy*, girl*, youth, adolescen*. 4) trauma*, post-traumatic stress, ptsd. This search was within title, abstract, heading word, key concepts, original title and mesh.
This gave 138 results. The foundation of this thesis introduction was made up of the relevant results from these, as well as relevant articles from the articles lists of references.
25 3.0 Results
3.1 Background Variables
Background variables and demographics for the participants are described in Table 1. All children were between the ages of 7 and 12 years old, with an overall mean age of 9.7 years.
Of the participants, 20 (51.2%) were boys and 19 (48.7%) were girls. Nearly all participants were born in Norway (95 %) and most of the children lived in the same household as both their parents (59%).
All participating parents were biological parents of the children. Both mothers and fathers participated and 76.9 % of the participating parents in this sample were mothers. The parents mean age was 41.5 years, with a range from 30 to 61 years. Among all parents, 61% have attended university.
Table 1 also contains comparisons according to treatment outcome (responder, non-responder or drop out), however these numbers should be interpreted with care due to a small sample size in the non-responder and drop-out groups. Non-responders (n=5) and dropouts (n=6) had a slightly higher age-average (10.6 years) compared to responders (n=28, 9.3 years), and a higher percentage received treatment for interpersonal trauma. Seventy-five per cent of parents for responding children had higher education (minimum 4 years of university), compared to 40% and 17% for non-responders and drop-outs respectively. Children in the drop out group were more likely to not live with both parents and were more likely to have a lower household income.
