OBJECTIVE
Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.


METHODS
We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: <or=14 years, 15 to 18 years, or as an adult (>or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.


RESULTS
Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.


CONCLUSIONS
The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study

This article reviews recent evidence related to public health epidemiology and intervention for traumatic stress and PTSD. Recent evidence is presented regarding incidence of traumatic stress worldwide, as well as most frequent types of traumas, indicators of the public health burden of PTSD, and prevalence, predictors, and correlates of PTSD. Public health perspectives on intervention and treatment are delineated, and innovations in both psychosocial and psychopharmacological interventions are highlighted. PTSD has been associated with substantial medical and economic burden. Recent public health preventive innovations include integrated medical/behavioral health care, acute CBT and attention interventions, modifications to CBT protocols, use of novel and augmentative psychopharmacological agents, and use of technology. Recent research regarding the scope and impact of traumatic stress, as well as prevention strategies for PTSD, have resulted in an improved understanding of its impact and more effective public health interventions.

PTSD as a Public Mental Health Priority

Importance Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low- and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population. Objectives To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors. Design, Setting, and Participants A randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis. Interventions In the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population. Main Outcomes and Measures The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured. Results A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): rural Kenya (Cohend = 1.04 [95% CI, 0.72-1.36]), urban Kenya (Cohend = 0.56 [95% CI, 0.29-0.83]), and urban Tanzania (Cohend = 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC in both rural (Cohend = 0.86 [95% CI, 0.64-1.07]) and urban (Cohend = 0.99 [95% CI, 0.75-1.23]) Kenya. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohend = 0.09 [95% CI, −0.08 to 0.26]; urban Tanzania, Cohend = 0.11 [95% CI, −0.09 to 0.31]). A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events). Conclusions and Relevance This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya. Trial Registration ClinicalTrials.gov identifier:NCT01822366

Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial

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Trauma-Focused CBT for Children and Adolescents: Treatment Applications.

Recent conceptualisations of resilience have advanced the notion that it is a dynamic and multifaceted construct. However, its adaptive components, especially those forged by adversity, have not been fully realised, and its neurobiological and psychosocial underpinnings are yet to be meaningfully integrated. In part, this is because a developmental perspective is often neglected in the formulation of resilience. In this review, we consider the findings of resilience research, with a specific emphasis on the developmental period of adolescence. To bridge the gaps in our current understanding, we propose a model of resilience that is predicated on experiencing adversity. Specifically, our model provides a sophisticated insight into the components of resilience, which, together with intrinsic features, involves facilitation of, and skill acquisition via strengthening processes we term tempering and fortification. The model also points to the potential trajectories of adversity-driven resilience and forms the basis of a framework that allows for individual variance in resilience, and the identification of both neurobiological and psychosocial targets for prevention and therapeutic interventions.

/pdf/modelling-resilience-in-adolescence-and-adversity-a-novel-399833y3p7.pdf

Modelling resilience in adolescence and adversity: a novel framework to inform research and practice

Trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established, evidence-based treatment for children who have experienced trauma, has been increasingly utilized in a group format. Group therapy formats are appealing because they can be highly effective and have the potential to reach larger numbers of clients. Moreover, TF-CBT group delivery may be particularly valuable in reducing the feelings of shame, isolation, and stigma experienced by youth and their caregivers in the aftermath of traumatic experiences. This article reviews the group TF-CBT research, discusses the therapeutic benefits of TF-CBT therapy groups, and provides clinical and logistical guidance for implementing TF-CBT in group format, including a session-by-session protocol. Future directions for research and clinical work in this area are also discussed.

Applying Trauma-Focused Cognitive–Behavioral Therapy in Group Format

Improvements in personal resiliency among youth who have completed trauma-focused cognitive behavioral therapy: a preliminary examination

Trauma-focused Cognitive Behavioural Therapy (TF-CBT) has been utilized with children of a wide age range and with diverse trauma experiences. This article will focus on the application of ...

/pdf/trauma-focused-cognitive-behavioural-therapy-for-young-2lfcz5pmfl.pdf

Trauma-focused cognitive behavioural therapy for young children: clinical considerations.

This pilot study evaluated the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training programs augmented with a systematic "PRACTICE What You Preach" (PWYP) self-care focus, which has trainees personally utilize the coping skills they teach their clients. Participants were 115 clinicians/supervisors who completed a PWYP TF-CBT training program. Pre- to post-training analyses documented significant increases in participants' competency and fidelity in implementing TF-CBT (ps < .001), significantly more frequent use of coping skills including instrumental social support (p < .01), active coping (p < .001), humor (p < .01), and restraint (p < .01), and significant decreases in secondary traumatic stress (STS; p < .001). Children's symptoms of PTSD (ps < .001) and behavior problems (p < .05) also decreased significantly. This preliminary evidence suggests that training augmented with PWYP may enhance clinicians'/supervisors' personal coping and reduce their levels of STS without compromising treatment implementation efforts and client outcomes.

/pdf/disseminating-trauma-focused-cognitive-behavioral-therapy-15syx08q1y.pdf

Disseminating Trauma-Focused Cognitive Behavioral Therapy with a Systematic Self-care Approach to Addressing Secondary Traumatic Stress: PRACTICE What You Preach

Elisabeth Pollio

Papers

Applying Trauma-Focused Cognitive–Behavioral Therapy in Group Format

Improvements in personal resiliency among youth who have completed trauma-focused cognitive behavioral therapy: a preliminary examination

Trauma-focused cognitive behavioural therapy for young children: clinical considerations.

Disseminating Trauma-Focused Cognitive Behavioral Therapy with a Systematic Self-care Approach to Addressing Secondary Traumatic Stress: PRACTICE What You Preach

Effective Therapies for Children and Non‐offending Caregivers in the Aftermath of Child Sexual Abuse or Other Traumas