Overgeneralized Beliefs, Accommodation, and Treatment Outcome in Youth Receiving Trauma-Focused Cognitive Behavioral Therapy for Childhood Trauma

Abstract

Inhibition of fear generalization with new learning is an important process in treatments for anxiety disorders. Generalization of maladaptive cognitions related to traumatic experiences (overgeneralized beliefs) have been demonstrated to be associated with posttraumatic stress disorder (PTSD) in adult populations, whereas more balanced, accommodated beliefs are associated with symptom improvement. It is not yet clear whether: 1) overgeneralization and accommodation are associated with PTSD treatment outcome in youth, or 2) whether accommodated beliefs can interact with or inhibit cognitive overgeneralization, as has been demonstrated in research on behavior-based fear generalization. The current study examined the relationships between overgeneralized and accommodated beliefs, child age, and symptom reduction in a sample of 81 youth (age 7-17 years), who received Trauma-Focused Cognitive Behavioral Therapy. Overgeneralized and accommodated beliefs expressed during the exposure phase of treatment were coded in audio-recorded therapy sessions. Overgeneralization predicted (a) higher internalizing symptom scores at post-treatment, particularly for younger children, and less improvement over treatment, and (b) higher externalizing scores at 1 year follow-up and steeper symptom increases over this period. In contrast, accommodation was associated with (a) lower post-treatment internalizing symptoms and greater improvement over treatment, and (b) lower externalizing scores at 1 year follow-up, particularly for younger children. High levels of accommodation moderated the relationship between overgeneralization and worse symptom outcomes, except when predicting the slope of internalizing scores over treatment, and age did not moderate these effects. There were no significant predictors of child-reported PTSD-specific symptoms, although PTSD symptoms did decrease significantly over the course of treatment and maintain one year after treatment.

Constructive and Unproductive Processing of Traumatic Experiences in Trauma-Focused Cognitive-Behavioral Therapy for Youth

“…Sessions during the trauma narrative phase of TF-CBT were coded for indicators of unproductive processing (overgeneralization, rumination, avoidance) and constructive processing (decentering, accommodation of corrective information), as well as levels of negative emotion. In previous analyses of this trial (Ready et al, 2015), more overgeneralization during the narrative phase predicted less improvement in internalizing symptoms at posttreatment and a worsening of externalizing symptoms over the 12-month follow-up. In contrast, more accommodation predicted improvement in internalizing symptoms and also moderated the negative effects of overgeneralization on internalizing and externalizing symptoms.…”

In-session caregiver behavior predicts symptom change in youth receiving trauma-focused cognitive behavioral therapy (TF-CBT).

“…Twenty-one of these youth without follow-up data were included in the current study (four were not because they did not have least one caregiver session during phase 2). Ready et al (2015) reported that there were no significant differences on pre-treatment symptoms, post-treatment symptoms, or demographic factors for youth with and without complete follow-up data. The full intent-to-treat sample of 71 youth was included in HLM analyses, using Full Information Maximum Likelihood (FIML) to account for missing data.…”

“…As in the Ready et al (2015) study, a level-1 within-person equation was used to examine symptom reduction in two pieces: from pre- to post- treatment (0, 3, and 6 months) and from post-treatment through 12-month follow-up (6, 9, and 12 months). Separate models were estimated with CBCL externalizing and internalizing symptoms and UPID PTSD symptoms as the outcomes.…”

“…The primary child outcomes from this trial are reported in two previous publications (Ready et al, 2015; Webb, Hayes, Grasso, Laurenceau, & Deblinger, 2014). Webb and colleagues examined the trajectories of symptom change over the course of treatment.…”

“…Symptom improvement on internalizing and PTSD symptoms was maintained through the 12-month follow-up, but there was a significant linear increase in externalizing symptoms over this period. Ready et al (2015) then examined two hypothesized predictors of these symptom trajectories: child overgeneralization (global, exaggerated and overly abstract trauma-related beliefs about self, others, or the world that are broadly applied across time and life situations) and accommodation (more balanced views of self, others, or the world). More child overgeneralization of trauma beliefs in the narrative phase of TF-CBT predicted less change in internalizing symptoms over the course of treatment and also greater increases in externalizing symptoms over the follow-up period.…”