(PS4-D90) Comorbid Externalizing Disorders and Suicidality as Predictors Related to Targeting Traumatic Stress Among Youth with Posttraumatic Stress Disorder

Youth in community mental health settings experience a disproportionate amount of trauma, and a subset of these youth carry a diagnosis of posttraumatic stress disorder (PTSD). PTSD is a complex mental health problem that can negatively affect cognitive, emotional, behavioral, and physiological development. There is growing research supporting the use of trauma-focused treatments as effective and efficacious means of decreasing child and adolescent PTSD symptoms (e.g., Cohen & Mannarino, 2015; Foa et al., 2013). However, research conducted in community mental health systems has shown that most youth with elevated traumatic stress scores do not receive trauma-focused treatment (Starace, 2012). In fact, treatment foci and interventions in community mental health settings do not appear to vary greatly between youth with and without a PTSD diagnosis (Borntrager et al., 2013). Little to no research to date has examined what client factors might predict decision-making regarding whether or not to target trauma during therapy in community mental health. Among the many potential explanations, two possible reasons why a community therapist may choose not to target traumatic stress for a youth with PTSD are 1) the presence of a comorbid externalizing disorder and 2) suicidality, as both of these might appear to be more immediately impairing. Indeed, some research suggests that community therapists tend to prioritize externalizing concerns above internalizing for youth (Milette-Winfree & Mueller, 2018), and adult PTSD research recommends not targeting trauma with clients presenting a high risk of suicide (Bryan, 2016).

Clinical data will be analyzed from approximately 560 youth with a PTSD diagnosis  who received in-home services from Hawaiʻi’s state mental health system between July 1, 2006 and June 30, 2017. Multiple logistic regression analyses will be used to examine whether and to what extent the presence of one or more comorbid externalizing diagnoses and/or treatment targeting suicidality are associated with a lower likelihood of therapist targeting traumatic stress. Level 1 will consist of youth variables (e.g., age at treatment onset, diagnoses, functional impairment at treatment onset). Level 2 will consist of therapist variables (e.g., licensure). Possible covariates will be investigated (e.g., gender, length of treatment).

Considering estimates of the proportion of children and adolescents who have experienced one or more traumatic events vary from 25% of youth in the general population to 90% of youth receiving services through community mental health care (Saunders & Adams, 2014), results from this study might illuminate specific therapy decision-making processes that occur for particularly disadvantaged youth, who are distinctly at-risk of developing complex mental health and behavioral concerns following crises and disasters. Such research in community mental health care could help to improve the implementation of cognitive behavioral therapies for such youth. Further possibilities and implications for effective treatment will be discussed.