Abstract: Stepped Care Versus Standard Trauma-Focused Cognitive Behavioral Therapy for Young Children (Society for Social Work and Research 20th Annual Conference - Grand Challenges for Social Work: Setting a Research Agenda for the Future)

Schedule:

Thursday, January 14, 2016: 1:30 PM

Meeting Room Level-Meeting Room 8 (Renaissance Washington, DC Downtown Hotel)

* noted as presenting author

Alison Salloum, PhD, Associate Professor, University of South Florida, Tampa, FL

Wei Wang, PhD, Associate Professor, University of South Florida, Tampa, FL

John Robst, PhD, Research Associate Professor, University of South Florida, Tampa, FL

Tanya K. Murphy, MD, Professor, University of South Florida, St. Petersburg, FL

Michael S. Scheeringa, MD, MPH, Remi Gonzalez, MD Professorship of Child Psychiatry, Vice Chair of Research, Tulane University, New Orleans, LA

Judith A. Cohen, MD, Medical Director, Allegheny General Hospital, Pittsburgh, PA, Pittsburgh, PA

Eric A. Storch, PhD, Professor, University of South Florida, St. Petersburg, FL

Background and Purpose: There are effective psychotherapies for young children after trauma, but these treatments require weekly therapist-led sessions ranging from 3 months to one year. For some families, the time commitment, costs, stigma, and transportation needed for in-office therapy meetings are treatment barriers that limit access to care. Further, some parents may not seek treatment for their child due to wanting to solve the problem independently. Newer service delivery models are needed to address treatment barriers and provide alternative treatments that are accessible, efficient, affordable, and effective. Trauma-focused cognitive behavioral therapy (TF-CBT; 3 to 6 months of weekly therapist-led treatment) is a well-established evidence-based treatment for children ages 3-18 years that is widely disseminated. TF-CBT was developed into a stepped care model (SC-TF-CBT) to address treatment barriers. SC-TFCBT consists of Step One, a parent-led therapist-assisted treatment. Non-responders receive Step Two, 9 sessions of TF-CBT. The current study addressed the next step in the development of SC-TF-CBT, comparing the effectiveness and costs of SC-TF-CBT relative to standard TF-CBT among young children ages 3-7 years.

Methods: A total of 53 young children (ages 3-7 years; M=5.04, SD=1.49) and their parent/guardian (ages 22-57 years; M=32.81, SD=8.42) were randomized (2:1) to SC-TF-CBT or TF-CBT. There were four assessment periods, all conducted by the blinded evaluator: screening/baseline, after Step One, post-treatment, and 3-month follow-up. Caregivers were provided compensation for their participation in the assessments ($25 for baseline, $50 for each remaining assessment). Standardized measures of posttraumatic stress symptoms (PTSS), severity, internalizing and externalizing behaviors, parent treatment credibility and satisfaction were collected. Therapist and patient time as well as cost characteristics were also collected. We conducted two analyses, “difference tests” (linear mixed-effects model for continuous outcomes or generalized linear mixed-effects model for non-continuous outcomes) and non-inferiority tests. Included in the model were treatment status, time, and treatment by time interaction. The presence of a non-significant interaction would suggest that the outcomes of the two conditions changed at comparable rates. Since the intent-to-treat (ITT) analysis and completers results were comparable, we reported the ITT results.

Results: Of those who participated in Step One, the response rate was 71% (22/31; ITT 22/35, 63%) and these treatment gains were maintained at the 3-month follow-up. There were comparable improvements over time in PTSS and secondary outcomes in both conditions. SC-TF-CBT was not inferior to TF-CBT on the primary outcome of PTSS, and the secondary outcome of severity and internalizing symptoms, but non-inferiority for externalizing symptoms was not supported. There were no statistical differences in comparisons of changes over time from pre- to post-treatment and pre- to 3 month follow-up for PTSD diagnostic status, treatment response or remission. Parent satisfaction was high for both conditions. Costs were 51.3% lower for children in SC-TF-CBT compared to TF-CBT.

Conclusions and Implications: Although future research is needed, preliminary evidence suggests that SC-TF-CBT is comparable to TF-CBT, and delivery costs are significantly less than standard care. SC-TF-CBT may be a viable service delivery system to address treatment barriers.