Evidence in Action

A quarterly research brief from the Center on Trauma and Children

Volume 1, Issue 3
July 2013 

The Center on Trauma and Children (CTAC) is dedicated to the enhancement of the health and well-being of children and their families through research, service and dissemination of information about child abuse and trauma.

Visit our website:
www.uky.edu/CTAC

 

  

 

 

 

 

Factors Affecting the Completion of Trauma-Focused Treatments: What Can Make a Difference?

 

The following is a study conducted by the Center on Trauma and Children and recently published in Traumatology, 19(1), 28-40 by Ginny Sprang, Carlton D. Craig, James J. Clark, Keren Vergon, Michele Staton-Tindall, Judy Cohen, and Robin Gurwitch.

 

Why is Treatment Dropout an Issue in the Trauma Field?

 

Premature treatment dropout is a significant problem in the field of child psychotherapy, with 48% to 62% no show rates for initial appointments (Harrison et al., 2004; McKay, McCadam, & Gonzales, 1998).  High treatment attrition may indicate that the prescribed intervention is ineffective at addressing the needs of the target population, and those who drop out early may fail to realize any or only limited symptom relief. Although trauma treatment for children may involve additional, significant problems associated with engagement and completion, most of what we know about treatment completion comes from the general psychotherapy literature. To address this gap in the literature, this study investigates the impacts of child and family characteristics, problem type, and trauma type on treatment dropout in traumatized children receiving trauma-informed evidence-based practices.

 

What are the Basic Components of the Study?

 

This study uses de-identified data generated by the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS) collected between spring 2004 and fall 2010 with 1,842 (66.8%) completing treatment and 917 (33.2%) dropping out of treatment. Measurements included Trauma History Profile, Child Behavior Checklist, Trauma Symptom Checklist for Children-Alternate, UCLA Posttraumatic Stress Disorder-Reaction Index, end of treatment status, demographic variables, clinician evaluation, and Trauma History. The children in the sample ranged in age from birth to 20.9 years with a mean of 11.45 (SD=4.34) years.  The majority were female (55.9%) and White (53%) with African-American children making up 34.2% of the sample. Close to one-third (31.9%) of the sample was of Hispanic ethnicity. 10% of the sample reported not being born in the United States, and nearly one fifth of the sample (18.4%) did not list English as their primary language. In addition nearly one fifth of the sample (19.9%) was in state custody or placed in out-of-home care with a relative. More than half of the sample (57.8%) received public assistance. 

 

What Significant Findings Did Researchers Report?

 

The study used sequential logistic regression analyses to assess prediction of the probability of a given subject having dropped out of treatment. Several factors that significantly predicted dropout were identified. Children of another race were 57.5% more likely to drop out of treatment than were Caucasian children. A bivariate analysis of the "other" race category showed that African American children were significantly more likely to drop out of treatment than were other racial groups. Children in state custody were 34.3% less likely to drop out of treatment than were children with their biological caregivers. For the trauma exposure variables, only the "other trauma" category was significant and these children were 45.3% less likely to drop out of treatment. Children who were diagnosed with MDD (Major Depressive Disorder) or suspected of having MDD were 2.08 and 1.72 times more likely, respectively, to drop out of treatment than children who were not depressed. Children who were diagnosed with PTSD were 1.57 times more likely to drop out of treatment than those who were not diagnosed with PTSD. Children with ODD (Oppositional Defiant Disorder) and suspected of having ODD were 1.67 and 1.89 times more likely, respectively, to drop out of treatment than those not diagnosed with the disorder. Conversely, children diagnosed with GAD (Generalized Anxiety Disorder) and suspected of having the disorder were 26.6% and 46.1% less likely, respectively, to drop out of treatment than those not diagnosed with GAD. ADHD and Conduct Disorder diagnoses were not reliable predictors of dropout.

   

How Do We Improve Retention Rates in Trauma Treatment?

  • Including dropout management services such as trackers, incentives, and outreach staff that specifically target those most at risk for drop-out such as African American children, those with high levels of trauma-related avoidance, and those in the care of their biological parents.
  • Targeted services that specifically acknowledge the cultural practices and behaviors of a population (i.e. therapist matching) can be effective at engaging families that may otherwise view the therapeutic experience as foreign, threatening or dismissive.
  • Approaches that address specific symptoms that interfere with treatment engagement such as trauma-related avoidance should be specifically integrated early into treatment episodes to decrease barriers to attendance.
  • The inclusion of motivational interviewing, along with parent training, has been found to be effective in increasing treatment retention among clients from child welfare populations (Chaffin et al., 2009).

 

Why focus on treatment completion?

 

The capacity of any evidence-based approach to include or integrate dropout prevention strategies may ultimately speak to its feasibility and utility in real-world treatment settings. Preventing the premature termination from a trauma treatment should be considered as fundamental to effective service delivery as ensuring the clinical fidelity to the essential elements of that treatment.

 

 

The authors would like to acknowledge the 56 sites within the NCTSN that have contributed data to the Core Data Set as well as the children and families who have contributed to our growing understanding of child traumatic stress.

 

This article was developed (in part) under Grant Number 3U79SM054284-10S/SM-11-011 from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, and U.S. Department of Health and Human Services.