Telehealth Delivery of the Child and Family Traumatic Stress Intervention is Associated With Reduced Posttraumatic Stress in Children and Caregivers

Abstract

This study evaluated whether telehealth delivery of the Child and Family Traumatic Stress Intervention (CFTSI) was associated with posttraumatic stress symptom reduction for children exposed to potentially traumatic events and their caregivers. The Child and Family Traumatic Stress Intervention is a brief (5–8 session), evidence-based, trauma-focused mental health treatment developed for implementation with children and caregivers in the early phase of the trauma response. Within traditional in-person outpatient settings, CFTSI has demonstrated effectiveness in reducing posttraumatic stress symptoms and reducing or interrupting Posttraumatic Stress Disorder in trauma-exposed youth and their caregivers, including those with extensive trauma histories. For the present study, 9 agencies that provided CFTSI via telehealth in 2020 and 2021 provided data for analysis. The sample included 129 racially and ethnically diverse caregiver-child dyads who completed CFTSI via telehealth. Paired samples t-tests revealed significant reductions in child and caregiver posttraumatic stress symptoms from pre-to post-CFTSI. Effect sizes were large and consistent with or stronger than prior studies of CFTSI implemented in person. Preliminary findings also indicated high levels of caregiver satisfaction. Current findings are particularly noteworthy given the chronic trauma exposure in the sample. The Child and Family Traumatic Stress Intervention delivered via telehealth is a viable treatment option which can increase flexibility for clinicians, families, and organizations.

Keywords

trauma posttraumatic stress disorder child ptsd/trauma telehealth evidence-based treatment

Introduction

Rates of mental health difficulties among youth in the United States are alarming. Federal prevalence data prior to the COVID-19 pandemic indicated that up to 1 in 5 U.S. children experienced a mental disorder (Perou et al., 2013). National surveys revealed sharp increases in high schoolers’ feelings of hopelessness and suicidality leading up the pandemic, with higher rates for racial and sexual minority youth (CDC, 2021). The pandemic exacerbated these pre-existing difficulties, including by increasing children’s exposure to potentially traumatic experiences such as the loss of a caregiver, domestic violence, and community violence (Hillis et al., 2022; Kofman & Garfin, 2020; O’Neill et al., 2022). These burdens were also disproportionately experienced by ethnic and racial minority youth (Kidman et al., 2021; O'Neill et al., 2022).

In 2021, key stakeholders leveraged their public platforms to bring much needed attention to the crisis of youth mental illness, along with calls for innovative and multi-faceted solutions. The US Surgeon General issued an “Advisory on Protecting Youth Mental Health” summarizing the negative effects of the COVID-19 pandemic on children’s mental wellness and the mental health difficulties that were pervasive before the pandemic (Office of the Surgeon General, 2021). Similarly, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a “National Emergency in Children’s Mental Health” (American Academy of Pediatrics, 2021). Among other recommendations, these groups highlighted the need for trauma-informed services that enhance resilience in families.

Understandably, considerable attention has focused on strains in the mental health care system which contribute to excessive and clinically inappropriate boarding times in emergency departments for youth in psychiatric crisis (Ibeziako et al., 2022). Ideally, the mental health care system should be viewed as a continuum of services of varying intensity. Innovation is necessary at all levels of care, including investment in treatments that focus on early identification and intervention to reduce children and adolescents’ suffering and support a return to the path of optimal development (Colizzi et al., 2020).

Innovative approaches to addressing mental health challenges in youth should capitalize on key protective factors, including: (1) early identification of children and adolescents who are struggling, and (2) provision of social support, especially from parents/caregivers. Interventions should be demonstrated to be effective in “real-world” clinical settings and accessible to a range of families, including racial and ethnic minority youth.

The Child and Family Traumatic Stress Intervention

The Child and Family Traumatic Stress Intervention (CFTSI) is a brief (i.e., 5–8 session), evidence-based, trauma-focused mental health treatment specifically developed for implementation after a recent traumatic event or recent disclosure of abuse in a forensic setting, such as a Child Advocacy Center (Epstein et al., 2017). This brief, early treatment has demonstrated effectiveness in reducing traumatic stress symptoms and reducing or interrupting Posttraumatic Stress Disorder (PTSD) and related disorders in trauma-exposed youth aged 7 to 18 and their caregivers, including for children with extensive trauma histories prior to the most recent event that precipitated their referral for CFTSI (Hahn et al., 2016; Hahn et al., 2019; Stover et al., 2022).

The Child and Family Traumatic Stress Intervention uses a developmentally informed, family-strengthening approach and aims to help children and caregivers find words to describe their posttraumatic stress symptoms, increase parent-child communication about the child’s trauma symptoms, and enhance parental support of the child. Children and caregivers learn about trauma and common trauma reactions and provide information to inform a comprehensive assessment of their symptoms. They collaborate to develop coping strategies which reduce symptoms contributing to the greatest distress or impairment (e.g., behavioral activation for depressive withdrawal; guided visual imagery for intrusive thoughts and images).

In a randomized controlled trial (RCT), youth receiving CFTSI in traditional outpatient settings were 65% less likely than those in a supportive control condition to meet full criteria for PTSD 3 months after treatment, and 73% less likely to meet criteria for partial PTSD (Berkowitz et al., 2011). Significant decreases in children’s posttraumatic stress symptoms following participation in CFTSI compared to symptoms reported at baseline have been documented using chart review and open trial research paradigms (Hahn et al., 2016, 2019). Participation in CFTSI has also been associated with significant decreases in posttraumatic stress symptoms for caregivers (Hahn et al., 2019). These caregiver findings are particularly noteworthy because prior work has demonstrated that caregiver symptoms are a key risk factor for the development of child posttraumatic stress symptoms following upsetting experiences (Morris et al., 2012). Finally, a recent naturalistic treatment study of CFTSI implementation in 13 community-based clinical settings across the U.S. revealed a significant reduction in child-reported posttraumatic stress symptoms from pre-to post-CFTSI (Stover et al., 2022). Youth symptom recovery was not associated with child age, ethnicity, race, prior trauma history, level of caregiver distress, referral trauma type, or other factors, indicating that CFTSI participation was associated with significant symptom improvement for a wide range of youth who were treated in real-world office settings. CFTSI has been widely disseminated in Child Advocacy Centers and community mental health agencies both nationally and internationally (Hahn et al., 2019; Marans, in press; Stover et al., 2022).

Telehealth Delivery of Youth Mental Health Treatments

The COVID-19 pandemic necessitated a rapid shift in outpatient mental health treatment delivery from predominately in-person, office settings to predominately telehealth services (McBain et al., 2023). Telehealth incorporates the use of videoconferencing software for the delivery of medical care, including mental health services. Prior to the pandemic, some efforts had been undertaken to evaluate youth mental health treatments when delivered via telehealth in order to increase access (e.g., in rural settings) and reduce barriers to treatment (Gloff et al., 2015). Telehealth interventions for traumatized youth and families, more specifically, have generally been evaluated in small samples, with a focus on treatment outcomes and more limited information about patient and other stakeholder satisfaction with telehealth services. In a small (N = 15), pilot study of telehealth delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), a longer-term, evidence-based, trauma-focused treatment, Stewart and colleagues found clinically significant reductions in child- and caregiver-reported child posttraumatic stress symptoms post-treatment (Stewart, Orengo-Aguayo, Cohen, Mannarino, & de Arellano, 2017). These findings were replicated in a subsequent community based, open pilot trial of TF-CBT delivered via telehealth (N = 70) (Stewart et al., 2020). Two multiple case studies examining culturally tailored TF-CBT delivered via telehealth for African-American and Hispanic children who experienced barriers to accessing traditional outpatient treatment also revealed significant reductions in posttraumatic stress and related symptoms (Stewart, Orengo-Aguayo, Gilmore, & de Arellano, 2017; Stewart et al., 2021). It should be noted that, in both case studies, patients received iPads or other technology which ensured access to treatment, which may not be generalizable to “real-world” telehealth settings without grant funding. Limited available research suggests that patients were highly satisfied with trauma-focused treatments delivered via telehealth (Villalobos et al., 2023). Telehealth delivery of CFTSI and patient satisfaction with CFTSI have not been previously evaluated.

The Present Study

In the present study, we evaluated whether CFTSI delivered via telehealth in real-world clinical settings was associated with child and caregiver posttraumatic stress symptom reduction following youth’s recent experience or disclosure of a potentially traumatic event. Because CFTSI aims to increase communication between children and caregivers regarding children’s posttraumatic stress symptoms, we also examined whether participation in CFTSI via telehealth was associated with a reduction in the discrepancy between child and caregiver reports of symptoms for the child. Finally, we examined caregiver satisfaction with CFTSI when delivered via telehealth. We hypothesized that participating in CFTSI via telehealth would be associated with statistically significant and clinically meaningful symptom reduction for children and caregivers and significant decreases in the discrepancy between child and caregiver reports of symptoms for the child. We also hypothesized that caregivers would report moderate to high levels of satisfaction with CFTSI when delivered via telehealth.

Method

Procedure

Nine agencies that provided CFTSI via telehealth in 2020 and 2021 in the U.S. provided data for this study. As part of their CFTSI implementation, CFTSI clinicians collected and submitted clinical and continuous quality improvement data using a centralized CFTSI data system (REDCap). As part of this open trial, data were provided for 129 caregiver-child dyads who completed CFTSI via telehealth. Caregivers provided information about child and family demographics (e.g., child race, ethnicity, maternal education), as well as characteristics of the referral incident (e.g., trauma type, type of exposure child experienced, relationship of alleged perpetrator to child). The Institutional Review Board at Yale University reviewed and approved all procedures involved with the study. Sites that provided data for the study had entered into a data use agreement with the primary institution.

Measures

Child Posttraumatic Stress Symptoms

The Child PTSD Symptom Scale for DSM-5 (Youth and Caregiver report; CPSS-5) (Foa et al., 2018). The CPSS-5 is a modified version of the Child PTSD Symptom Scale (CPSS) (Foa et al., 2001) for DSM-5. The CPSS-5 is a valid and reliable instrument used to assess PTSD diagnosis and severity in children. It contains 27 items which are administered as a semi-structured interview, including 20 items assessing DSM-5 PTSD symptoms and 7 items assessing functional impairment during daily life. The 20 posttraumatic stress symptoms are rated on a 5-point Likert scale assessing frequency of symptoms from zero (Not at all) to 4 (6 or more times a week). Seven additional items rate functional impairment in a yes/no format. Prior work has demonstrated very good internal consistency (Cronbach’s alpha = .92) and test-retest reliability (r = .93) (Foa et al., 2018). A cut-off score of 31 is associated with a probable PTSD diagnosis in children.

Child and Family Traumatic Stress Intervention providers interviewed youth and caregivers separately using the CPSS-5 prior to CFTSI and immediately following CFTSI. For the current study, the 20 symptom items were summed to create a total posttraumatic stress symptom severity score.

Caregiver Posttraumatic Stress Symptoms

Posttraumatic Checklist-Civilian version (PCL-C) (Weathers et al., 1993). The PCL-C is a widely used measure of adult posttraumatic stress symptoms. This measure contains 17 items which were administered as a semi-structured interview by CFTSI clinicians during Session 1. Caregivers rated how much they had been bothered by these 17 symptoms since the referral incident on a 5-point Likert scale (1 = Not at all; 5 = Extremely). A total symptom score was generated by summing all items. The PCL-C is commonly used and displays good convergent validity with self-report measures and diagnostic interviews assessing PTSD in adults (Wilkins et al., 2011).

Caregiver Satisfaction

Caregiver satisfaction with CFTSI implemented via telehealth was assessed with a previously developed, unpublished survey designed to assess caregiver satisfaction with CFTSI. The satisfaction survey was administered via interview by phone or video following the family’s completion of CFTSI. Surveys were not conducted by the CFTSI provider in order to avoid social desirability effects. Caregivers were informed that their individual responses would not be seen by their CFTSI clinician and that aggregated caregiver responses would be used to inform quality improvement efforts. Sixteen items assessed whether caregivers felt they received key elements of CFTSI and the helpfulness of these elements. Sample items include, “Did CFTSI help you be better able to assist your child after his/her upsetting experience(s)?” If caregivers responded “yes”, they were asked to rate on a 4-point Likert scale how helpful they found that element of CFTSI (0 = Not helpful; 3 = Very Helpful).

Youth and Caregiver Trauma history

Children’s history of exposure to potentially traumatic experiences was assessed using the 23-item Child Trauma History Questionnaire (CTHQ). The original version of the CTHQ was developed for the original CFTSI randomized trial and adapted with permission for use as part of the ongoing CFTSI treatment (Berkowitz & Stover, 2005; Epstein & Hahn, 2013). The CTHQ is administered via separate clinical interviews with youth and caregivers. The CTHQ assesses youth exposure to a wide range of potentially traumatic event types including physical abuse, sexual abuse, neglect, community violence, domestic violence, medical trauma, and natural disasters. A total score was calculated assessing the number of trauma types experienced in the child’s lifetime according to the child, with a possible range of 0–23.

Caregivers’ history of exposure to potentially traumatic experiences was assessed using the 23-item Adult Trauma History Questionnaire (ATHQ) which was administered via clinical interview with caregivers. The ATHQ assesses adult exposure to a wide range of potentially traumatic event types including physical abuse, sexual abuse, neglect, community violence, domestic violence, medical trauma, and natural disasters. A total score was calculated assessing the number of trauma types experienced in the adult’s lifetime according to the adult, with a possible range of 0–23. The ATHQ was adapted from the CTHQ and used with permission as part of the ongoing CFTSI treatment.

Adaptations for CFTSI Delivered via Telehealth

As part of the standardized approach to training in CFTSI, clinicians participated in an in-person, 16-hour training held over two days with a CFTSI developer and/or master trainer. In response to increased, urgent demand for mental health services during the pandemic, CFTSI co-developers also created a 16-hour virtual CFTSI training, held via zoom over 3 days. After virtual or in-person training, clinicians participated in 6 months of bi-weekly consultation calls via zoom with a master consultant. Clinicians were required to satisfactorily complete a minimum of 3 CFTSI cases during the consultation period and present at least 2 cases to their CFTSI consultation call group.

Several additional strategies were employed to support CFTSI clinicians as they shifted to implementing CFTSI via telehealth in the context of the pandemic. These supports were made available to all CFTSI-trained clinicians. A webinar was developed by CFTSI co-developers, master consultants, and senior clinicians. Topics included: managing understandable CFTSI clinician anxiety during the pandemic, setting up telehealth sessions for success by approximating the family’s experience of “coming into the office”, utilizing technology to support clinical goals (e.g., screen sharing of visual aids and Likert rating scales; using virtual whiteboards; providing video clips to reinforce coping skill instruction), managing patient distractions and increasing engagement, and ensuring patient safety. In addition, we created and disseminated electronic, fillable versions of the measures that are implemented during CFTSI sessions as clinical tools to replace paper measures. Though not specific to telehealth administration, these measures were made available in other languages (e.g., Spanish) using an intensive translation and back translation approach.

Results

Sample

Study participants included 129 caregiver-child dyads who completed CFTSI via telehealth following a recent potentially traumatic experience or recent disclosure of past physical or sexual abuse in the context of a formal forensic interview at a Child Advocacy Center. Families were eligible for inclusion if the child was between 7 and 18 years old, the child and/or caregiver reported at least one child trauma symptom on the pre-CFTSI CPSS-5, and there was a caregiver available to participate in CFTSI who did not intentionally harm the child.

Participating youth were 75.2% female, 21.7% male, and 1.6% non-binary or gender non-conforming. The majority identified as Hispanic (54.3%). In terms of racial background, 20.2% of youth identified as black, 13.2% white, 12.4% multi-racial, 2.3% Asian, 1.6% American Indian/Alaska Native, 1.6% Native Hawaiian or other Pacific Islander, and the remainder were from another racial group or preferred not to say. Eleven percent of youth received special education services at school. The majority lived with a single parent (53.5%). Eight percent had been removed from their primary caregiver at some point during childhood.

In terms of the recent event which brought the child for CFTSI treatment, the majority of participants was referred for sexual abuse (61.2%), 17.1% for domestic violence, 13.2% for physical abuse, 1.6% for assault, and the remaining for “other” trauma types. Most youth were directly victimized (69.8%) with an additional 5.4% identified as both victims and witnesses of the referral incident. The majority of alleged perpetrators of recent traumatic events were in a caregiving role with the child (52.7%) and the majority lived in the home with the child (51.9%).

The vast majority of participating caregivers were biological mothers (81.4%), 8.5% were fathers, and the rest were other important adults in the child’s life (e.g., grandmother, step-mother, extended family member, foster/adoptive mother). Maternal education status varied widely, with 14% having less than a high school degree, 14.7% having a high school degree, 7% having a college degree, and 4.7% having a master’s degree. Additional information about participant demographics and index events is provided in Tables 1 and 2.

Table 1.

Demographic Information (N = 129).

Variable	Frequency (Percent)
Child gender
Female	97 (75.2%)
Male	28 (21.7%)
Other	2 (1.6%)
Unknown	2 (1.6%)
Child ethnicity
Hispanic	70 (54.3%)
Non-Hispanic	47 (36.4%)
Unknown	12 (9.3%)
Child race
Other	37 (28.7%)
Black/African-American	26 (20.2%)
Unknown	26 (20.2%)
White	17 (13.2%)
Multiracial	16 (12.4%)
Asian	3 (2.3%)
Native Hawaiian/Other Pacific Islander	2 (1.6%)
American Indian/Alaska Native	2 (1.6%)
Participating caregiver
Birth mother	105 (81.4%)
Birth father	11 (8.5%)
Aunt	4 (3.1%)
Grandmother	3 (2.3%)
Step-mother	1 (.8%)
Cousin	1 (.8%)
Kinship foster mother	1 (.8%)
Adoptive mother	1 (.8%)
Out of home placement?
No	111 (86.0%)
Yes	10 (7.8%)
Unknown	8 (6.2%)
Child receiving special education services?
No	102 (79.1%)
Yes	14 (10.9%)
Unknown	13 (10.1%)
Custody arrangement
Single parent	69 (53.5%)
Both parents/shared custody	51 (39.5%)
Other	8 (6.2%)
Welfare agency	1 (.8%)
Birth mother education level
Unknown	64 (49.6%)
High school diploma (or equivalent)	19 (14.7%)
Less than high school	18 (14%)
Bachelor’s degree	9 (7.0%)
Some college (no degree)	8 (6.2%)
Master’s degree	6 (4.7%)
Associate’s degree	5 (3.9%)

Table 2.

Characteristics of the Referral Incident (N = 129).

Variable	Frequency (Percent)
Referral incident trauma type
Sexual abuse	79 (61.2%)
Domestic violence	22 (17.1%)
Physical abuse	17 (13.2%)
Other	7 (5.4%)
Assault	2 (1.6%)
Unknown	2 (1.6%)
Child type of exposure to index trauma
Victim	90 (69.8%)
Witness	29 (22.5%)
Both	7 (5.4%)
Unknown	3 (2.3%)
Alleged perpetrator in caregiving role?
Yes	68 (52.7%)
No	53 (41.1%)
Unknown	8 (6.2%)
Alleged perpetrator living in the home?
Yes	67 (51.9%)
No	58 (45%)
Unknown	4 (3.1%)

Child Posttraumatic Stress Symptom Reduction Following CFTSI as Reported by Child and Caregiver

Average pre- and post- child and caregiver posttraumatic stress symptoms are presented in Table 3. Youth participants reported experiencing approximately 6 trauma types in their lifetime (M = 5.66, SD = 4.00). At screening, 49 children (i.e., 38%) reported posttraumatic stress symptoms associated with probable PTSD diagnosis (i.e., at or above a total score of 31).

Table 3.

Means and Standard Deviations for Child and Caregiver Posttraumatic Stress Symptoms Before and After CFTSI (N = 129).

Variable	Screening/Session 1 Mean (SD)	Post-CFTSI Mean (SD)
Child CPSS-5^a	24.48 (16.24)	7.73 (9.20)
Caregiver CPSS-5^b	19.20 (13.78)	6.84 (8.48)
PCL^c	31.31 (11.31)	24.05 (8.64)
Discrepancy (child CPSS-5 and caregiver CPSS-5)^d	13.06 (11.19)	3.41 (4.84)

^at = 13.64, p < .001.

^bt = 10.66, p < .001.

^ct = 8.55, p < .001.

^dt = 9.92, p < .001.

Following CFTSI, there was a significant decrease in child-reported CPSS-5 scores in the sample as a whole (t = 13.64, p < .001) (see Figure 1). The mean decrease was 16.75 points and the effect size was considered large (Cohen’s d = 1.20) (See Figure 1). When considering only children who began with symptom levels associated with probable PTSD diagnosis, the pattern of findings was the same, including statistically significant decreases in symptoms (t = 18.50, p < .001) and a large effect size (Cohen’s d = 2.64). Following CFTSI, only 4 children in the sample as a whole (3.1%) reported symptom levels associated with probable PTSD diagnosis.

A similar pattern of findings emerged with caregiver ratings of children’s posttraumatic stress symptoms. Caregiver rated CPSS-5 scores also decreased significantly from pre-to post- (t = 10.66, p < .001), with a mean decrease of 12.36 points and a large effect size (Cohen’s d = .94) (See Figure 1).

CFTSI and Discrepancy in Child and Caregiver Ratings of Child Posttraumatic Stress Symptoms

Consistent with prior CFTSI evaluation studies, children reported significantly higher levels of their own trauma reactions at baseline than their caregivers (t = 3.66, p < .001). Mean pre- and post-discrepancies are presented in Table 3. The mean discrepancy at screening was considerable (M = 13.06 points, SD = 11.19). At post, the mean discrepancy was 3.41 (SD = 4.84). This decrease was statistically significant (t = 9.92, p < .001) and the effect size was large (Cohen’s d = .87) (See Figure 2). Taken together, these findings indicate that youth and caregivers rated youth’s trauma symptoms with greater concurrence following participation in CFTSI.

Caregiver Posttraumatic Stress Symptom Reduction following CFTSI

Mean session 1 and post-CFTSI PCL scores are presented in Table 3. Caregivers reported experiencing approximately 8 trauma types in their lifetime (M = 7.83, SD = 3.49). Caregiver PCL scores decreased significantly from Session 1 to post- (t = 8.55, p < .001). The mean decrease was 7.26 points and the effect size was considered large (Cohen’s d = .82) (See Figure 1).

Caregiver Satisfaction With CFTSI Delivered via Telehealth

Caregiver satisfaction data were available for a smaller subset of the total sample (N = 54), which is due either to difficulties reaching caregivers to complete this additional, “optional” assessment and/or the lack of availability of staff other than the CFTSI provider to conduct the survey. Therefore, the following results should be considered preliminary. Satisfaction survey data indicate that caregivers were satisfied with CFTSI delivered via telehealth. Ninety-eight percent of caregivers reported that CFTSI delivered via telehealth was helpful overall to them and their child. Ninety-six percent reported that CFTSI delivered via telehealth helped them be able to assist their child after their upsetting experience, and 94.4% agreed that if they had a friend dealing with a similar situation, they would suggest trying CFTSI.

Discussion

This study provides evidence that CFTSI delivered via telehealth in “real-world” clinical settings during the initial phases of the COVID-19 pandemic was associated with significant improvements in child posttraumatic stress symptoms in a highly traumatized, racially and ethnically diverse sample. Significant improvements were seen in both child and caregiver reports of children’s posttraumatic stress symptoms following CFTSI, including for children who began with very high levels of trauma symptoms associated with probable PTSD diagnosis. Current findings add to the existing literature documenting that participation in CFTSI is associated with reduced posttraumatic stress symptoms for children and suggest that CFTSI delivery via telehealth is similarly associated with symptomatic improvement. Mean decreases in posttraumatic stress symptoms and associated effect sizes were consistent with or stronger than those documented in prior studies of CFTSI delivered in traditional in-person settings (Stover et al., 2022).

The Child and Family Traumatic Stress Intervention’s brevity and effectiveness can increase early identification and intervention for trauma-exposed youth and decrease the need for longer-term care. As a result, CFTSI has the potential not only to improve the lives of children and families, but also to help alleviate long waitlists for overburdened child mental health agencies. In this way, in addition to reducing post-traumatic suffering, CFTSI can help increase access to care and allow behavioral health programs to serve more children and families. In the current study, only 3.1% of youth reported posttraumatic stress symptoms associated with probable PTSD diagnosis following CFTSI and only 20.9% of youth were referred by their provider for additional trauma-focused treatment. These findings are especially notable given the brevity of CFTSI (i.e., 5–8 sessions) and the high rates of prior trauma exposure for youth in this study (i.e., approximately 6 different trauma types).

The current study also adds to prior research documenting that CFTSI participation is associated with posttraumatic stress symptom reduction for caregivers, as well. These findings are important because caregiver symptoms are a key predictor of children’s symptoms following a potentially traumatic experience. Therefore, interventions that support both children and caregivers’ recovery following exposure to potentially traumatic experiences are essential for the child’s recovery.

This study also demonstrated that CFTSI participation was associated with significant decreases in the discrepancy between children’s and caregivers’ ratings of children’s posttraumatic stress symptoms. These findings may be driven by caregivers and children communicating more about symptoms as they occurred and/or by caregivers increasing their observational capacities to identify when children were experiencing symptoms, both of which are key clinical goals in CFTSI. Identification of distress and communication about distress are important initial steps that may then prompt caregivers to provide needed support to their children, including coaching in the use of coping skills. Similarly, as caregivers’ own posttraumatic stress symptoms improve with CFTSI participation, they may be better equipped to identify their children’s needs, remain regulated, and provide emotional and instrumental support. Because caregiver-child communication was not formally assessed in this study, we were unable to examine communication as a possible mediator of intervention effects. It is possible that current discrepancy findings reflect regression to the mean. Future studies should examine whether increased caregiver-child communication is a mechanism of change in CFTSI.

Finally, this study provides preliminary evidence that CFTSI delivered via telehealth is acceptable to caregivers. Caregiver satisfaction was generally very high in surveys following CFTSI completion, though these ratings were only available for a subsection of the total sample. As telehealth interventions become increasingly common, it will be important to document not only their ability to improve symptoms and enhance functioning but also to assess patients’ experiences of receiving treatment in this modality.

Strengths and Limitations

Strengths of the current study include the racial and ethnic diversity of the sample. Further, study participants had experienced chronic trauma exposure, in addition to the index event which prompted the CFTSI referral. Finally, study findings were achieved within the broader context of significant upheaval in the mental health care system and heightened pandemic-related stress in the U.S. and across the globe (McBain et al., 2023; Vinkers et al., 2020).

Despite its strengths, this study has limitations that should be acknowledged. Because there was no comparison condition of participants who: (1) did not receive CFTSI; or (2) received CFTSI in in-person settings, this study does not provide evidence of the effectiveness of CFTSI delivered via telehealth over no treatment, another treatment, or CFTSI delivered in-person. Instead, this study provides evidence that children and caregivers who completed CFTSI via telehealth in community settings experienced significant reductions in posttraumatic stress. Although RCTs are important for establishing cause-effect relationships between an intervention and outcome, multiple limitations of RCTs have been discussed (Deaton & Cartwright, 2018; Hahn et al., 2019; Kostis & Dobrzynski, 2020). Naturalistic studies such as the current one can provide lower cost, complementary evidence regarding how empirically supported interventions are working when delivered in real-world clinical settings with diverse patient populations (Leichsenring, 2004). Future studies of CFTSI delivered via telehealth should build on current findings and incorporate comparison condition(s).

In addition, although the current sample was racially and ethnically diverse, study participants were largely female, which may limit generalizability to some extent. Prior work established that symptom reduction with CFTSI did not differ for males and females (Stover et al., 2022). Additional studies will be helpful for understanding whether CFTSI is similarly effective for gender-nonconforming youth, who are at high risk for trauma exposure and mental health difficulties (CDC, 2021).

Future Directions

Telehealth CFTSI appointments could address many treatment barriers for traumatized youth and families associated with traditional outpatient settings (e.g., lack of childcare or transportation, high costs of fuel, parking, or public transit, work or school conflicts) (Villalobos et al., 2023), including in rural settings with limited mental health resources (Gloff et al., 2015). Telehealth may be easier to access for individuals whose traumatic experiences have contributed to physical injury and/or disability. CFTSI in telehealth may also provide families and agencies with greater scheduling flexibility (e.g., virtual appointments can more easily be conducted during a caregiver’s lunch hour or during a child’s study hall), which may be associated with increased engagement (Schriger et al., 2022). Finally, some patients may simply prefer telehealth appointments over in-person appointments (Villalobos et al., 2023). Future studies, including RCTs, should evaluate whether CFTSI delivered via telehealth increases access to care, reaches more families, and/or shortens agency waitlists, compared to treatment as usual and/or compared to CFTSI delivered in traditional, office settings.

Future studies should also assess CFTSI clinician’s perceptions of telehealth delivery and use findings to enhance training and revisions of CFTSI when delivered via telehealth. In addition, it will be important to ensure that CFTSI clinicians providing treatment via telehealth receive adequate training and appropriate equipment to deliver treatment effectively (e.g., computers with webcams). Similarly, policies that provide universal broadband access will be essential to ensure that CFTSI via telehealth is accessible to youth and families who need it. Future work should also examine implementation variables, such as the percentage of clinicians who are trained to deliver CFTSI who go on to meet training requirements and provide CFTSI via telehealth to eligible families, to ensure the viability of this treatment option.

Finally, participating in CFTSI via telehealth may not be appropriate for all patient populations. Children with neurodevelopmental conditions which contribute to inattention and/or hyperactivity, individuals with language or communication disorders or visual or hearing impairments, and those with other complex clinical presentations may be better served by in-person treatment. In addition, children who do not have a private space at home to participate in telehealth CFTSI appointments may benefit less from this modality. Future work should examine whether the presence of comorbid conditions such as Attention-Deficit/Hyperactivity Disorder (ADHD) and/or household variables such as the availability of private space for conducting telehealth sessions moderate treatment response for youth receiving CFTSI via telehealth.

Conclusion

This study provides initial evidence that telehealth delivery of CFTSI is associated with significant improvements in youth and caregiver posttraumatic stress symptoms following exposure to a potentially traumatic experience. In addition, the discrepancy between youth and caregiver ratings of youth’s posttraumatic stress symptoms decreased after participating in CFTSI delivered via telehealth. Finally, preliminary survey data collected from a subset of the larger sample suggest that CFTSI delivered via telehealth is associated with high levels of caregiver satisfaction. The Child and Family Traumatic Stress Intervention delivered via telehealth is a viable treatment option which can increase flexibility for clinicians, families, and organizations and potentially reduce common barriers for traumatized youth and families to access care in traditional outpatient settings.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially sponsored by SAMSHA (H79SM085114).

ORCID iD

Megan C. Goslin

References

American Academy of Pediatrics . (2021). AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/

Berkowitz

Stover

(2005). Trauma history questionnaire parent and child version. Yale Child Study Center Trauma Section. Unpublished questionnaire.

Berkowitz

Stover

Marans

(2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 52(6), 676–685. https://doi.org/10.1111/j.1469-7610.2010.02321.x

CDC . (2021). Youth risk behavior survey: Data summary and trends report 2009–2019. https://www.cdc.gov/nchhstp/dear_colleague/2020/dcl-102320-YRBS-2009-2019-report.html

Colizzi

Lasalvia

Ruggeri

(2020). Prevention and early intervention in youth mental health: Is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems, 14, 23. https://doi.org/10.1186/s13033-020-00356-9

Deaton

Cartwright

(2018). Understanding and misunderstanding randomized controlled trials. Social Science & Medicine, 210, 2–21. https://doi.org/10.1016/j.socscimed.2017.12.005

Epstein

Hahn

(2013). Child trauma history questionnaire-parent and child versions. Yale Child Study Center Trauma Section. Unpublished questionnaire.

Epstein

Hahn

Berkowitz

Marans

(2017). The child and family traumatic stress intervention. In Landolt

M. A.

Cloitre

Schnyder

(Eds.), Evidence-based treatments for trauma related disorders in children and adolescents (pp. 145–166). Springer International Publishing.

Foa

E. B.

Asnaani

Zang

Capaldi

Yeh

(2018). Psychometrics of the child PTSD symptom scale for DSM-5 for trauma-exposed children and adolescents. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 47(1), 38–46. https://doi.org/10.1080/15374416.2017.1350962

10.

Foa

E. B.

Johnson

K. M.

Feeny

N. C.

Treadwell

K. R.

(2001). The child PTSD symptom scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376–384. https://doi.org/10.1207/S15374424JCCP3003_9

11.

Gloff

N. E.

LeNoue

S. R.

Novins

D. K.

Myers

(2015). Telemental health for children and adolescents. International Review of Psychiatry, 27(6), 513–524. https://doi.org/10.3109/09540261.2015.1086322

12.

Hahn

Oransky

Epstein

Smith Stover

Marans

(2016). Findings of an early intervention to address children’s traumatic stress implemented in the child advocacy center setting following sexual abuse. Journal of Child and Adolescent Trauma, 9(1), 55–66. https://doi.org/10.1007/s40653-015-0059-7

13.

Hahn

Putnam

Epstein

Marans

Putnam

(2019). Child and family traumatic stress intervention (CFTSI) reduces parental posttraumatic stress symptoms: A multi-site meta-analysis (MSMA). Child Abuse & Neglect, 92, 106–115. https://doi.org/10.1016/j.chiabu.2019.03.010

14.

Hillis

N'konzi

J. P. N.

Msemburi

Cluver

Villaveces

Flaxman

Unwin

H. J. T.

(2022). Orphanhood and caregiver loss among children based on new global excess COVID-19 death estimates. JAMA Pediatrics, 176(11), 1145–1148. https://doi.org/10.1001/jamapediatrics.2022.3157

15.

Ibeziako

Kaufman

Scheer

K. N.

Sideridis

(2022). Pediatric mental health presentations and boarding: First year of the COVID-19 pandemic. Hospital Pediatrics, 12(9), 751–760. https://doi.org/10.1542/hpeds.2022-006555

16.

Kidman

Margolis

Smith-Greenaway

Verdery

A. M.

(2021). Estimates and projections of COVID-19 and parental death in the US. JAMA Pediatrics, 175(7), 745–746. https://doi.org/10.1001/jamapediatrics.2021.0161

17.

Kofman

Y. B.

Garfin

D. R.

(2020). Home is not always a haven: The domestic violence crisis amid the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S199–S201. https://doi.org/10.1037/tra0000866

18.

Kostis

J. B.

Dobrzynski

J. M.

(2020). Limitations of randomized clinical trials. The American Journal of Cardiology, 129, 109–115. https://doi.org/10.1016/j.amjcard.2020.05.011

19.

Leichsenring

(2004). Randomized controlled versus naturalistic studies: A new research agenda. Bulletin of the Menninger Clinic, 68(2), 137–151. https://doi.org/10.1521/bumc.68.2.137.35952

20.

Marans

Responding to childhood trauma: Developing and learning from collaborations beyond the consulting room the psychoanalytic quarterly. (in press).

21.

McBain

R. K.

Cantor

Pera

M. F.

Breslau

Bravata

D. M.

Whaley

C. M.

(2023). Mental health service utilization rates among commercially insured adults in the US during the first year of the COVID-19 pandemic. JAMA Health Forum, 4(1), Article e224936–e224936. https://doi.org/10.1001/jamahealthforum.2022.4936

22.

Morris

Gabert-Quillen

Delahanty

(2012). The association between parent PTSD/depression symptoms and child PTSD symptoms: A meta-analysis. Journal of Pediatric Psychology, 37(10), 1076–1088. https://doi.org/10.1093/jpepsy/jss091

23.

Office of the Surgeon General . (2021). Protecting youth mental health. The U.S. Surgeon General’s Advisory.

24.

O’Neill

K. M.

Dodington

Gawel

Borrup

Shapiro

D. S.

Gates

Becher

R. D.

(2022). The effect of the COVID-19 pandemic on community violence in Connecticut. The American Journal of Surgery, 225(4), 775–780. https://doi.org/10.1016/j.amjsurg.2022.10.004

25.

Perou

Bitsko

R. H.

Blumberg

S. J.

Pastor

Ghandour

R. M.

Gfroerer

J. C.

Hedden

S. L.

Crosby

A. E.

Visser

S. N.

Schieve

L. A.

Parks

S. E.

Hall

J. E.

Brody

Simile

C. M.

Thompson

W. W.

Baio

Avenevoli

Kogan

M. D.

Huang

L. N.

Centers for Disease Control and Prevention CDC . (2013). Mental health surveillance among children--United States, 2005-2011. MMWR Supplements, 62(2), 1–35.

26.

Schriger

S. H.

Klein

M. R.

Last

B. S.

Fernandez-Marcote

Dallard

Jones

Beidas

R. S.

(2022). Community mental health clinicians’ perspectives on telehealth during the COVID-19 pandemic: Mixed methods study. JMIR Pediatrics and Parenting, 5(1), Article e29250. https://doi.org/10.2196/29250

27.

Stewart

Orengo-Aguayo

Cohen

Mannarino

de Arellano

(2017a). A pilot study of Trauma-Focused Cognitive-Behavioral Therapy delivered via telehealth technology. Child Maltreatment, 22(4), 324–333. https://doi.org/10.1177/1077559517725403

28.

Stewart

Orengo-Aguayo

Wallace

Metzger

I. W.

Rheingold

A. A.

(2021). Leveraging technology and cultural adaptations to increase access and engagement among trauma-exposed African American youth: Exploratory study of school-based telehealth delivery of trauma-focused cognitive behavioral therapy. Journal of Interpersonal Violence, 36(15–16), 7090–7109. https://doi.org/10.1177/0886260519831380

29.

Stewart

Orengo-Aguayo

Young

Wallace

Cohen

Mannarino

de Arellano

(2020). Feasibility and effectiveness of a telehealth service delivery model for treating childhood posttraumatic stress: A community-based, open pilot trial of trauma-focused cognitive–behavioral therapy. Journal of Psychotherapy Integration, 30(2), 274–289. https://doi.org/10.1037/int0000225

30.

Stewart

Orengo-Aguayo

R. E.

Gilmore

A. K.

de Arellano

(2017b). Addressing barriers to care among hispanic youth: Telehealth delivery of trauma-focused cognitive behavioral therapy. The Behavior Therapist, 40(3), 112–118.

31.

Stover

C. S.

Hahn

Maciejewski

K. R.

Epstein

Marans

(2022). The child and family traumatic stress intervention: Factors associated with symptom reduction for children receiving treatment. Child Abuse & Neglect, 134, 105886. https://doi.org/10.1016/j.chiabu.2022.105886

32.

Villalobos

B. T.

Dueweke

A. R.

Orengo-Aguayo

Stewart

R. W.

(2023). Patient perceptions of trauma-focused telemental health services using the Telehealth Satisfaction Questionnaire (TSQ). Psychological Services, 20(1), 107–121. https://doi.org/10.1037/ser0000605

33.

Vinkers

C. H.

van Amelsvoort

Bisson

J. I.

Branchi

Cryan

J. F.

Domschke

Howes

O. D.

Manchia

Pinto

de Quervain

Schmidt

M. V.

van der Wee

N. J. A.

(2020). Stress resilience during the coronavirus pandemic. European Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology, 35, 12–16. https://doi.org/10.1016/j.euroneuro.2020.05.003

34.

Weathers

Litz

Herman

Huska

J. A.

Keane

(1993). The PTSD checklist (PCL): Reliability, validity, and diagnostic utility. Paper Presented at the Annual Convention of the International Society for Traumatic Stress Studies.

35.

Wilkins

K. C.

Lang

A. J.

Norman

S. B.

(2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28(7), 596–606. https://doi.org/10.1002/da.20837