- ICH GCP
- US Clinical Trials Registry
- Klinisk utprøving NCT07498257
Tilpasning og RCT av skriftlig eksponeringsterapi for ungdom
Tilpasning av skriftlig eksponeringsterapi for ungdom med posttraumatisk stresslidelse
Skriftlig eksponeringsterapi (WET) er en mental helse-terapi i fem sesjoner for post-traumatisk stresslidelse (PTSD). Forskning viser at det virker like godt som lengre behandlinger for PTSD blant personer over 18 år, selv om det krever færre sesjoner enn andre PTSD-terapier. WET er imidlertid ikke tilpasset og formelt testet i individuell terapi med personer i alderen 12 til 18 år. Vår studie har som mål å se hvordan WET kan tilpasses for å møte behovene til personer i alderen 12 til 18 år som har opplevd traumer og for tiden har PTSD-symptomer. For å tilpasse WET til denne aldersgruppen vil vi først snakke med PTSD-eksperter og personer i alderen 12 til 18 år for å lære hvilke endringer som kan gjøre WET mer egnet for unge. Vi vil også gjennomføre WET med fem personer i alderen 12 til 18 år etter manualen slik den er skrevet for personer over 18 år for å se hva som trenger justering.
I neste del av studien vil vi rekruttere 48 ungdommer i alderen 12 til 18 år ved en pediatrisk primærklinikk som har symptomer på PTSD og randomisere dem til enten å motta den tilpassede versjonen av WET eller å motta gullstandard PTSD-behandling: Trauma-fokusert kognitiv atferdsterapi. Hvis de blir tildelt tilpasset WET, vil deltakerne delta i fem til sju ukentlige terapisessioner og fem studiebesøk (før terapi, og 6 uker, 10 uker, 20 uker og 30 uker etter start av terapi). Hvis de blir tildelt TF-CBT, vil deltakerne delta i 12 til 16 ukentlige terapisessioner og fem studiebesøk (før terapi, og 6 uker, 10 uker, 20 uker og 30 uker etter start av terapi). Hensikten med studiebesøkene over en 30-ukers periode er å bedre forstå hvem de er som person og deres nåværende psykiske helse-symptomer og diagnoser. All terapi og studiebesøk kan gjennomføres på avstand eller personlig, etter ditt ønske. Personer som er 18 år kan delta uten foresattes tillatelse; personer i alderen 12 til 17 år kan kun delta med foresattes tillatelse. Vårt mål er å finne den beste måten å tilby effektiv PTSD-behandling for unge som kan leveres i virkelige pediatriske primærhelsetjenester, slik at til slutt flere kan få den hjelpen de trenger etter traumatiske opplevelser.
Studieoversikt
Status
Intervensjon / Behandling
Studietype
Registrering (Antatt)
Fase
- Ikke aktuelt
Kontakter og plasseringer
Studiesteder
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South Carolina
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Charleston, South Carolina, Forente stater, 29425
- Medical University of South Carolina National Crime Victims Research and Treatment Center
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Deltakelseskriterier
Kvalifikasjonskriterier
Alder som er kvalifisert for studier
- Barn
- Voksen
Tar imot friske frivillige
Beskrivelse
Mål 1 (Obj. 1.1) Inklusjonskriterier for ungdom med PTSD:
- Mellom 12 og 18 år gamle. Deltakere som fyller 18 etter datoen de samtykker til å delta, kan delta, men kan ikke registreres i studien hvis de allerede er 19 år.
- Medfølgende samtykkende foresatt (unntak: 18-åringer kan gi samtykke uten medfølgende foresatt)
- Eksponering for en eller flere potensielt traumatiske hendelser på NCVTRC-klinikkens telefonskjerm.
- Evne til å forstå engelsk.
- En score på større enn eller lik 6 på Child Trauma Screen (CTS)
- Bosatt i staten Sør-Carolina.
Mål 1 (Obj. 1.1) Eksklusjonskriterier for ungdom med PTSD:
- Aktiv psykose, bipolar lidelse eller en komorbid tilstand som krever et høyere nivå av umiddelbar behandling (f.eks. anorexia nervosa, alkoholabstinens).
- Aktiv selvmordsrisiko med tanker, plan og intensjon.
- Aktiv, pågående vold, mishandling eller andre pågående traumatiske hendelser som indikerer umiddelbare sikkerhetsbekymringer.
- Barn i fosterhjem, slektsomsorg eller med aktive DSS-etterforskninger.
- Historie med gjennomgripende utviklingshemming eller intellektuell funksjonshemming.
- Annen medisinsk eller psykiatrisk tilstand som svekker deltakerens evne til å delta trygt.
- Manglende evne eller vilje hos foresatt til å samtykke for at ungdommen skal delta (unntak: 18-åringer kan gi samtykke uten medfølgende foresatt).
Mål 1 (Obj. 1.1) Inklusjonskriterier for PTSD-behandlingsleverandører:
- Mastergrad eller høyere i psykologi eller relatert disiplin (f.eks. sosialt arbeid; veiledning).
- Nåværende leverandør av traumefokusert behandling til ungdom med PTSD i poliklinisk setting i minst ett år.
- Evne til å forstå engelsk.
- Samtykke til å delta i et engangsstudiebesøk.
Mål 1 (Obj 1.1) Inklusjonskriterier for psykisk helseleverandører i pediatrisk primærhelsetjeneste:
- Mastergrad eller høyere i psykologi eller relatert disiplin (f.eks. sosialt arbeid; veiledning).
- Nåværende status som psykisk helsekliniker plassert i en integrert pediatrisk primærhelsetjeneste.
- Evne til å forstå engelsk.
- Samtykke til å delta i et engangsstudiebesøk.
Det er ingen eksklusjonskriterier for Mål 1-leverandører.
Mål 1 (Obj 1.2 teatertesting) og Mål 2 (RCT) Inklusjonskriterier for ungdom med PTSD:
- Ungdom mellom 12 og 18 år gamle. Deltakere som fyller 18 etter datoen de samtykker til å delta, kan delta, men kan ikke registreres i studien hvis de allerede er 19 år.
- Medfølgende samtykkende foresatt (unntak: 18-åringer kan gi samtykke uten medfølgende foresatt)
- Godkjenning av en eller flere eksponeringer for tidligere potensielt traumatiske hendelser. Traumatiske hendelser må ha skjedd for over en måned siden, i henhold til DSM-5-kriterier.
- Evne til å forstå engelsk.
- En score på større enn eller lik 21 på Child and Adolescent Trauma Screen (CATS).
- Bosatt i staten Sør-Carolina.
Mål 1 (Obj 1.2 teatertesting) og Mål 2 (RCT) Eksklusjonskriterier for ungdom med PTSD:
- Aktiv psykose, bipolar lidelse eller en komorbid tilstand som krever et høyere nivå av umiddelbar behandling (f.eks. anorexia nervosa, alkoholabstinens).
- Aktiv selvmordsrisiko med tanker, plan og intensjon.
- Aktiv, pågående vold, mishandling eller andre pågående traumatiske hendelser som indikerer umiddelbare sikkerhetsbekymringer.
- Barn i fosterhjem, slektsomsorg eller med aktive DSS-etterforskninger.
- Historie med gjennomgripende utviklingshemming eller intellektuell funksjonshemming.
- Annen medisinsk eller psykiatrisk tilstand som svekker deltakerens evne til å delta trygt.
- Manglende evne eller vilje hos foresatt til å samtykke for at ungdommen skal delta (unntak: 18-åringer kan gi samtykke uten medfølgende foresatt).
- Manglende minne om den traumatiske hendelsen(e).
- Personer på psykofarmaka må ha stabilisert seg på medikamentet i minst to uker før studiestartdato.
Rekruttering vil ikke inkludere spesielle grupper som fanger, gravide kvinner eller institusjonaliserte personer.
Studieplan
Hvordan er studiet utformet?
Designdetaljer
- Primært formål: Behandling
- Tildeling: Randomisert
- Intervensjonsmodell: Parallell tildeling
- Masking: Dobbelt
Våpen og intervensjoner
Deltakergruppe / Arm |
Intervensjon / Behandling |
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Eksperimentell: Eksperimentgruppe (Skriftlig eksponeringsterapi)
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Written Exposure Therapy (WET) is an evidence-based treatment (EBT) for PTSD among adults that involves five 45-60 minute sessions.
WET is non-inferior to gold-standard EBTs for PTSD among adults, including Cognitive Processing Therapy and Prolonged Exposure.
Each session involves 30-minutes writing following focused prompts that include recalling details of the traumatic event as well as related cognitions and emotions.
Session one also includes providing psychoeducation about posttraumatic stress disorder and the rationale for exposure.
Between sessions, the therapist reads the writing and prepares feedback.
The intervention will be delivered during five, consecutive weekly 45-60-minute sessions to participants assigned to the experimental WET condition.
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Aktiv komparator: Sammenligningsbetingelse (Traumefokusert kognitiv atferdsterapi)
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Traumafokusert kognitiv atferdsterapi (TF-CBT) er den gyldne standarden for EBT for ungdom med PTSD og består av tre faser: sikkerhet og stabilisering, gradvis eksponering og konsolidering/integrasjon. Sikkerhets- og stabiliseringsfasen inkluderer psykoedukasjon, foreldrekompetanseopplæring og bygging av mestringsevner.
Gradvis eksponeringsfase innebærer å hjelpe unge med å beskrive en detaljert fortelling om det traumatiske hendelsen(e) og lage en in vivo-hierarki av traumerelaterte fryktede, men objektivt trygge, stimuli å møte på en gradvis måte.
I den siste konsoliderings-/integrasjonsfasen finner en felles omsorgsgiver-barn-sesjon sted der barnet deler sin trauma-fortelling med en omsorgsgiver, og ungdom lærer ferdigheter og får opplæring for å forbedre fremtidig sikkerhet.
Ungdom som randomiseres til TF-CBT vil motta 12-16 påfølgende 60-minutters ukentlige sesjoner i henhold til manualen.
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Hva måler studien?
Primære resultatmål
Resultatmål |
Tiltaksbeskrivelse |
Tidsramme |
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Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Adolescents Only)
Tidsramme: Baseline through study completion, an average of 6 months.
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The Kiddie Schedule for Affective Disorders and Schizophrenia, which is a psychometrically strong tool to assess diagnoses for a wide variety of mental health conditions among adolescents, will be used to assess Posttraumatic Stress Disorder (PTSD) symptoms present and diagnostic criteria over the course of the longitudinal period.
Higher scores indicate greater likelihood of meeting diagnostic criteria for PTSD.
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Baseline through study completion, an average of 6 months.
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Child and Adolescent Trauma Screen 2.0 - Caregiver and Child Report
Tidsramme: Baseline through study completion, an average of 6 months.
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The Child and Adolescent Trauma Screen (CATS) youth and caregiver reports (ages 7-17) assess exposure to 15 different types of potentially traumatic events followed by 20-items assessing PTSD symptoms.
It is a widely used psychometrically validated tool and will be used to assess the adolescent's trauma exposure history and PTSD symptoms per self and caregiver report.
Total scores on this measure range from 0 to 60; scores of 21 or higher indicate elevated symptoms of posttraumatic stress disorder (PTSD).
Higher scores indicate greater PTSD symptom severity.
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Baseline through study completion, an average of 6 months.
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Cognitive Emotion Regulation Questionnaire-Adolescent Version
Tidsramme: Baseline through study completion, an average of 6 months.
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The Cognitive Emotion Regulation Questionnaire - Adolescent Version is a 36 item psychometrically strong measure of cognitive and emotion regulation strategies and has been used widely with trauma-exposed adolescents.
The rumination subscale of the CERQ will be used to examine changes in ruminative thinking, a proposed mechanism of WET's action to be tested in the study, over the course of treatment.
Total scores on this measure range from 36 to 180.
Several subscales are included on this measure: Self-blame, Other-blame, Rumination, Catastrophizing, Putting into perspective, Positive refocusing, Positive reappraisal, Acceptance, and Planning.
Higher scores indicate higher levels of experiencing each symptom area measured (e.g., higher scores on the self blame subscale indicate greater self-blame; higher scales on the positive re-focusing indicate greater ability to positively refocus).
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Baseline through study completion, an average of 6 months.
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Acceptability of Intervention Measure (Youth and Caregivers)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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The Acceptability of Intervention Measure is a 4-item measure used to assess patient perceptions of new interventions, including whether they believe the new treatment is agreeable, palatable, or satisfactory on a five-point Likert scale.
This measure will be administered to adolescents and their caregivers to gauge acceptability of the experimental intervention for meeting the needs of the adolescent population.
Scores are averaged; total scores on this measure range from 1 to 5. Higher scores indicate greater acceptability of the intervention (either Written Exposure Therapy or Trauma-focused Cognitive Behavior Therapy).
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6 weeks post-baseline and through study completion, an average of 6 months.
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Feasibility of Intervention Measure (Youth and Caregivers)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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The Feasibility of Intervention Measure is a 4-item measure to assess perceptions of whether an intervention will be able to be successfully implemented within a given agency or setting to a certain population of interest.
This measure will be administered to adolescents and caregivers to gauge perceptions of feasibility of WET for delivery with adolescents.
Scores are averaged; total scores on this measure range from 1 to 5. Higher scores indicate greater perceived feasibility of the intervention (either Written Exposure Therapy or Trauma-focused Cognitive Behavior Therapy).
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6 weeks post-baseline and through study completion, an average of 6 months.
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Intervention Appropriateness Measure (Youth and Caregivers)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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The Intervention Appropriateness Measure is a 4-item measure to assess perceptions of whether an intervention is perceived as appropriate for addressing the needs/symptoms of a population.
This measure will be administered to adolescents and caregivers to gauge perceptions of the appropriateness of WET delivered to 12 to 18 year olds.
Scores are averaged; total scores on this measure range from 1 to 5. Higher scores indicate greater perceived feasibility of the intervention (either Written Exposure Therapy or Trauma-focused Cognitive Behavior Therapy).
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6 weeks post-baseline and through study completion, an average of 6 months.
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Semi-Structured Interview (Adolescents Only)
Tidsramme: 6 week follow up (WET condition only)
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Questions will include probes about how to enhance the intervention to elicit impressions of the un-adapted content (e.g., written prompt wording, relevance of psychoeducational content, helpfulness), areas in need of adaptation, gaps missing in the manual, and recommendations for adaptations (e.g., wording alterations, content adaptations).
Interviews will also inquire about barriers and facilitators to traditional trauma-focused treatment and whether WET meets or does not meet priorities and needs of adolescents with PTSD and their caregivers.
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6 week follow up (WET condition only)
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Sekundære resultatmål
Resultatmål |
Tiltaksbeskrivelse |
Tidsramme |
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Revised Children's Anxiety and Depression Scale - Caregiver and Child Report
Tidsramme: Baseline through study completion, an average of 6 months.
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Revised Children's Anxiety and Depression Scale caregiver and child surveys are 25-item scales assessing for depression and anxiety symptoms among youth.
The full subscales from the RCADS-47 for social phobia and obsessive compulsive disorder symptoms will also be administered to youth.
The RCADS-25 is psychometrically strong scales for use with adolescents and caregivers and therefore will be used to assess participant self-reported symptoms of depression and anxiety.
Scores range from 0 to 75 and raw scores are converted to T scores in relation to normed data based on same aged peers.
Higher scores on this measure indicate greater levels of depression and anxiety.
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Baseline through study completion, an average of 6 months.
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The Kiddie Schedule for Affective Disorders and Schizophrenia (Select Screeners and Full Modules: Schizophrenia, Mania, Eating Disorder, Suicidal Ideation; Adolescents Only)
Tidsramme: Baseline through study completion, an average of 6 months.
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The Kiddie Schedule for Affective Disorders and Schizophrenia, which is a psychometrically strong tool to assess diagnoses for a wide variety of mental health conditions among adolescents.
Screeners and, full modules when indicated following screens, will be used to facilitate accurate screening and diagnosis of comorbidities to identify whether participants meet inclusion or exclusion criteria at baseline (i.e., active psychosis, active suicidal plan and intent, anorexia nervosa, severe substance use withdrawal symptoms, active psychosis).
This interview has several subscales that allow for a diagnostic interview to assess common psychiatric conditions among youth and does not have a standardized range of scores.
The Mania, schizophrenia, eating disorder, and suicide screeners and full modules when screeners are positive will be used.
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Baseline through study completion, an average of 6 months.
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Mental Health Statistics Improvement Program (MHSIP) Youth Survey (Caregiver and Youth Report)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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The Mental Health Statistics Improvement Program (MHSIP) Youth Survey is a standardized tool to assess youth and caregiver's perceptions of mental health services they received including treatment satisfaction and appropriateness of the intervention to meet one's mental health needs.
It has been used among adolescent and caregiver populations and has strong psychometric properties.
Total scores on this measure range from 25 to 125.
Higher scores indicate greater satisfaction with the intervention (either Written Exposure Therapy or Trauma-focused Cognitive Behavior Therapy).
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6 weeks post-baseline and through study completion, an average of 6 months.
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Therapeutic Alliance Scale for Children (TASC) - Revised (Caregiver and Child Report)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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The Therapeutic Alliance Scale for Children (TASC) - Revised is a 12 item measure designed to assess therapeutic alliance between therapists and patients as perceived by the patient and by their caregiver.
This will be administered during the follow up phase to assess perceptions of the therapeutic alliance.
Total scores on this measure range from 12 to 48.
Higher scores indicate greater levels of therapeutic alliance.
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6 weeks post-baseline and through study completion, an average of 6 months.
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Prolonged Grief Scale - 13 (Adolescents Only)
Tidsramme: 6 weeks post-baseline and through study completion, an average of 6 months.
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Youth who endorse traumatic loss will complete the thirteen item Prolonged Grief Scale to assess for symptoms of traumatic grief.
Total scores on this measure range from 11 to 55; scores of 30 or higher indicate elevated symptoms of prolonged grief.
Higher scores indicate higher levels of prolonged grief disorder symptoms.
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6 weeks post-baseline and through study completion, an average of 6 months.
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Rosenberg Self Esteem Scale
Tidsramme: Baseline through study completion, an average of 6 months.
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The Rosenberg Self Esteem Scale is comprised of 10 items assessing self esteem among youth.
Responses range from 0 to 30 and lower scores indicate lower levels of self esteem.
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Baseline through study completion, an average of 6 months.
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Multidimensional Scale of Perceived Social Support
Tidsramme: Baseline through study completion, an average of 6 months.
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The Multidimensional Scale of Perceived Social Support will be administered to youth and their caregivers to assess perceptions of their current social support.
This twelve item scale has a potential score range of 12 to 84; higher scores indicate higher levels of perceived social support.
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Baseline through study completion, an average of 6 months.
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Posttraumatic Stress Disorder Checklist - 8 (Caregiver Only)
Tidsramme: Baseline, 6-, 10-, 20-, 30-week follow up
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The Posttraumatic Stress Disorder (PTSD) Checklist - 8 will be used to assess caregiver symptoms of PTSD.
Total range of potential scores is from 8 to 32 and higher scores indicate greater PTSD symptomatology among caregivers.
Scores over 12 indicate likelihood of PTSD symptoms.
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Baseline, 6-, 10-, 20-, 30-week follow up
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Alabama Parenting Questionnaire (Caregivers only)
Tidsramme: Baseline through study completion, an average of 6 months.
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The Alabama Parenting Questionnaire, nine item short form, will be used to assess parenting approaches and strategies among caregivers who participate in the trial over the course of the study.
Three subscales are assessed in the measure: Positive parenting (possible score range: 6-30), inconsistent discipline (possible score range: 6-30), and poor supervision (possible score range: 9-45).
Higher scores on each subscale indicate greater levels of each of the subscale categories assessed.
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Baseline through study completion, an average of 6 months.
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Parental Self Efficacy Scale (caregivers only)
Tidsramme: Baseline through study completion, an average of 6 months.
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The Parental Self Efficacy Scale 5 item measure will be used to assess Parental Self Efficacy among caregivers who participate in the study.
Total score responses range from 5 to 25 and higher scores indicate higher levels of perceived self efficacy as a parent.
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Baseline through study completion, an average of 6 months.
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DSM-5-TR Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure (Caregiver Report)
Tidsramme: Baseline through study completion, an average of 6 months.
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The DSM-5-TR Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure is a 25 item measure will be used to assess caregiver perceptions of their child mental health with regard to several domains (Depression, Anger and Irritability, Mania, Anxiety, Somatic symptoms, Inattention, Suicidal ideation/attempt, Psychosis, Sleep disturbance, Repetitive thoughts and behaviors, and Substance use).
The measure will be administered to assess caregiver perceptions of these symptoms among youth as perceived by caregivers over the course of the study as well as will be used at baseline to screen for the presence of potential comorbid symptoms that could indicate a need to further assess for potential exclusion criteria
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Baseline through study completion, an average of 6 months.
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Andre resultatmål
Resultatmål |
Tiltaksbeskrivelse |
Tidsramme |
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Accountable Health Communities Health Related Social Needs Screening Tool - Caregiver and Child Report
Tidsramme: Baseline
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Select items from the Accountable Health Communities Health Related Social Needs Screening Tool will be used to assess for factors related to social determinants of health, such as food insecurity, housing insecurity, and other basic needs.
Questions are administered to caregivers and youth to characterize the sample and to connect families to resources, as needed.
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Baseline
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Adverse Childhood Events Scale - Youth Version
Tidsramme: Baseline
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Adolescent participants will complete the Adverse Childhood Events Scale - Youth Version at baseline to assess for a wide range of adverse childhood events that are not captured on the CATS 2.0 including emotional abuse, divorce, familial incarceration, parental substance use, and neglect.
Findings will be used to inform comprehensive trauma assessment.
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Baseline
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Measure of Adolescent Relationship Harassment and Abuse - Short Form
Tidsramme: Baseline
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Adolescent participants will complete the Measure of Adolescent Relationship Harassment and Abuse - Short Form at baseline to assess for exposure to Teen Dating Violence, some of which may not otherwise be captured on the CATS 2.0.
Findings will be used to inform comprehensive trauma assessment.
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Baseline
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HARK Intimate Partner Violence Screener (Caregiver Only)
Tidsramme: Baseline
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The HARK will be used to screen for lifetime and past year Intimate Partner Violence among caregivers in the study at baseline.
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Baseline
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Trauma History Questionnaire (Caregivers Only)
Tidsramme: Baseline
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Caregivers will complete the 24 item trauma history questionnaire to assess for trauma history among caregivers who participate in the study.
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Baseline
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Samarbeidspartnere og etterforskere
Samarbeidspartnere
Publikasjoner og nyttige lenker
Generelle publikasjoner
- Sloan DM, Marx BP, Lee DJ, Resick PA. A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial. JAMA Psychiatry. 2018 Mar 1;75(3):233-239. doi: 10.1001/jamapsychiatry.2017.4249.
- Sloan DM, Marx BP, Acierno R, Messina M, Muzzy W, Gallagher MW, Litwack S, Sloan C. Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2023 Nov 1;80(11):1093-1100. doi: 10.1001/jamapsychiatry.2023.2810.
- LoSavio ST, Worley CB, Aajmain ST, Rosen CS, Wiltsey Stirman S, Sloan DM. Effectiveness of written exposure therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. Psychol Trauma. 2023 Jul;15(5):748-756. doi: 10.1037/tra0001148. Epub 2021 Oct 28.
Studierekorddatoer
Studer hoveddatoer
Studiestart (Faktiske)
Primær fullføring (Antatt)
Studiet fullført (Antatt)
Datoer for studieregistrering
Først innsendt
Først innsendt som oppfylte QC-kriteriene
Først lagt ut (Faktiske)
Oppdateringer av studieposter
Sist oppdatering lagt ut (Faktiske)
Siste oppdatering sendt inn som oppfylte QC-kriteriene
Sist bekreftet
Mer informasjon
Begreper knyttet til denne studien
Nøkkelord
Ytterligere relevante MeSH-vilkår
Andre studie-ID-numre
- Pro00149514
Plan for individuelle deltakerdata (IPD)
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IPD-planbeskrivelse
Legemiddel- og utstyrsinformasjon, studiedokumenter
Studerer et amerikansk FDA-regulert medikamentprodukt
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