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Abstract

Objectives:

Exposure to traumatic events is common among children in the United States and many go on to develop trauma-related psychological symptoms without access to adequate outpatient mental health care. Integrating mental health interventions within primary care settings represent a promising strategy to increase access, but there is not currently an appropriate trauma-focused intervention for children in these settings. This study aimed to assess the feasibility and acceptability of an intervention newly adapted utilizing the ADAPT Framework: The Primary Care Intervention for PTSD-Youth.

Methods:

Semi-structured qualitative interviews were conducted with expert mental health providers who specialize in pediatric PTSD (N = 15), including those with experience in integrated primary care, to obtain feedback on PCIP-Y acceptability, feasibility, and recommendations for improvement. Interviews were analyzed using consensual content analysis to identify themes related to intervention usability, acceptability, and feasibility of implementation.

Results:

Three primary themes emerged: intervention acceptability, intervention feasibility, and intervention adaptations and recommendations. Providers generally viewed the intervention as appropriate, acceptable, and feasible to implement in primary care settings.

Conclusion:

Findings provide preliminary evidence that The Primary Care Intervention for PTSD-Youth is a feasible, acceptable, and promising intervention for targeting trauma-related symptoms among children in primary care settings. Future research should evaluate the intervention’s efficacy and effectiveness in clinical practice.

Keywords

trauma pediatric mental health qualitative integrated care

Introduction

The majority of children in the United States are exposed to at least 1 traumatic event, such as a natural disaster, serious accident, or child abuse, by the time they turn 16 years old.^1,2 Exposure to trauma has a range of consequences, including cognitive, emotional, and behavioral impairment.^3-7 Some children who are exposed to trauma go on to develop Post Traumatic Stress Disorder (PTSD), a psychological condition characterized by significant, persistent, and distressing changes in emotions, thoughts, and physiological reactivity following exposure to the event. Children with trauma related symptoms, including PTSD, may require efficacious mental health treatment to alleviate their symptoms. Fortunately, there are a range of evidence based psychological interventions for trauma-related symptoms among children. However, most children who experience trauma and go on to develop psychological symptoms will never access outpatient mental health treatment.^8-13 In particular, minoritized children and those from low-income families face significant barriers to accessing specialized outpatient mental health care.^7,14-16

In recent years, pediatric primary care has emerged as a promising setting for the identification and treatment of psychiatric disorders among children, partially due to the fact that children frequently attend at least 1 primary care visit per year.¹⁷ Brief psychological interventions delivered in primary care settings have been shown to efficaciously decrease depressive and anxiety symptoms, as well as increase connections to outpatient mental health treatment.^18-20 Specifically, integrated interventions hold promise in reaching children who otherwise “fall through the cracks” of accessing specialized outpatient mental health treatment. However, there has been limited research on developing and evaluating treatments to target the sequelae of trauma exposure in pediatric primary care. Recently, a novel intervention called “The Primary Care Intervention for PTSD” (PCIP) has been shown to be an efficacious, acceptable, and effective treatment for reducing trauma-related symptoms among adolescents in primary care settings.^20,21

PCIP is a low intensity, brief, and flexible intervention for adolescents and young adults aged 12 to 22 designed to be delivered in pediatric primary care.^20,21 The intervention includes 3 individual sessions, completed weekly or up to monthly, focusing on (a) psychoeducation on the effects and impacts of trauma related symptoms, including PTSD, (b) breathing retraining and relaxation skills to reduce somatic symptoms, and (c) identifying and utilizing positive coping strategies to reduce stress and comorbid anxiety and depression symptoms. The intervention manual and materials include an overview of the intervention, hypothesized mechanisms of change, modular session-by-session scripts and guides, psychoeducation handouts for patients, and activities and homework tracking worksheets for completion between session visits. Additional information regarding the development and evaluation of PCIP can be found in Ng et al²⁰ and Srivastava et al.²¹

Although PCIP displays promising effectiveness among adolescent samples,^20,21 the level of complexity within the intervention and associated materials makes it inappropriate for use with younger children. School-aged children (eg, those 6-11), although more independent than children in early childhood, are less developmentally advanced than adolescents and, therefore, require additional scaffolding to benefit from psychological interventions. For example, although older youth can readily participate in individual therapy, school-aged children require caregiver involvement in therapy to provide support in skill acquisition, participation, and generalization of learning outside of therapy sessions.^22,23 Additionally, research has called for increased attention to developmental differences in the adaptation and implementation of psychological intervention. Indeed, school-aged children presenting with trauma-related symptoms have meaningfully different clinical presentations from adolescents.^24,25 Given these developmental considerations and the significant challenges school-aged children face in obtaining appropriate outpatient trauma-focused mental health care, our research team adapted PCIP to be suitable for delivery to this younger age group. The goal of the present study was to assess expert mental healthcare provider attitudes regarding initial feasibility and acceptability of the content in the adapted intervention: The Primary Care Intervention for PTSD-Youth (PCIP-Y).

Methods

The Primary Care Intervention for PTSD-Youth (PCIP-Y)

The adaptation of PCIP to be appropriate for delivery to youth ages 6 to 11 was co-led by a clinical psychology graduate student and clinical psychology postdoctoral fellow, under the supervision of an assistant professor in clinical psychology. The adaptation team had specialized clinical training in child mental health, child development, integrated primary care, and trauma-focused interventions. The adaptation was guided by the principles of the ADAPT guidance, a widely utilized set of guidelines for the efficacious adaptation of a range of health interventions to new settings or populations.²⁶ Guidance provided by ADAPT states that utilizing an existing intervention in a new context may be more efficient than creating a completely new intervention, but that the efficaciousness of an intervention may not be immediately transferable to a new context. Therefore, ADAPT guidance recommends that clinical researchers first assess the rational for a new intervention, then plan and undertake intervention adaptation, followed by planning and completing adapted intervention piloting and evaluation.²⁶ Supplemental Figure S1 provides additional information regarding how the ADAPT guidance were implemented in the present study.

Therefore, the team first evaluated the original PCIP manual to identify intervention elements that were and were not developmentally appropriate for the new age group. For example, the original intervention included significant education regarding cognitive coping strategies that were deemed to be too complex for younger children to grasp in the context of a brief intervention. Then, the team conducted a literature review to identify key coping skills that had the strongest research evidence in targeting each PTSD symptom cluster (avoidance, hyperarousal, negative alterations in mood/cognitions, and re-experiencing) among school-aged youth in service of identifying which skills from the original PCIP should be retained, and simplified, for the new population. Literature review also informed developmental adaptations, including identifying effective intervention strategies for children, as compared to adolescents, to promote recovery following exposure to traumatic events. Afterwards, the intervention team collaboratively drafted the new intervention manual for PCIP-Y.

The adapted PCIP-Y is a 4-session intervention that can be flexibly delivered in 30- to 50-min sessions within an integrated primary care setting. Sessions may be delivered between 1 week and 1 month apart. The first session focuses on introducing the intervention, symptom assessment, psychoeducation, and breathing retraining. Based on information gathered in the first session, the provider decides which 2 PTSD symptom clusters are most impairing for the child (re-experiencing, hyperarousal, negative thoughts/mood, and/or avoidance). Like the original PCIP, the PCIP-Y manual is modularized with 1 session for each possible symptom cluster, such that the provider has freedom to tailor the use of specific sessions to each patient. Each symptom cluster session includes homework review, breathing retraining, and targeted psychoeducation and coping skills training to correspond with each symptom cluster. The last session of PCIP-Y is delivered to caregivers only and focuses on caregiving skills to decrease child behavioral disturbance in the context of trauma-related symptoms as well as facilitation of connection to further psychological treatment for the patient, if necessary. PCIP-Y additionally differed from the original intervention in several ways. First, PCIP-Y requires caregiver involvement at each therapy session. Second, intervention handouts have become more simplified and child friendly (see Figure 1). Third, the manual includes substantive scripted guidelines to guide providers in strategies to present intervention content in a developmentally appropriate manner. Supplemental Figure S2 includes a visual representation of the modules in the intervention.

Figure 1.

Example PCIP-Y handout: breathing retraining.

Provider Interviews

In line with Step 3 of the ADAPT process,²⁶ we went on to seek expert feedback on the acceptability and feasibility of the material in PCIP-Y from mental health providers who specialize in treating PTSD among school-aged children, particularly in integrated care settings (including integrated primary care). Feedback was gathered through individual semi-structured qualitative interviews.

Mental health providers who specialized in working with the youth aged 6 to 11 were recruited to participate in semi-structured qualitative interviews to inform additional developmental considerations and adaptations for delivering PCIP-Y, a brief trauma intervention in integrated primary care settings. Participants were recruited through social media platforms, word of mouth, professional connections, and emails to professional organization listservs, and completed an online screening survey through Qualtrics (Qualtrics, Utah 2020) assessing eligibility for further interview participation. Of the 36 partial responses and 39 providers who completed the screening survey, 15 were eligible for and completed qualitative interviews (age range: 25-39, M = 31.93, SD = 4.085). Eligible participants had or were in the process of obtaining a doctoral or masters level degree in a field that would lead to licensure as a mental healthcare provider and a minimum of 2 years’ experience or specialization in providing mental health services to youth aged 6 to 11 who experienced trauma. Participants completed informed consent for research participation prior to enrollment. Table 1 outlines participant demographic characteristics. Participants were majority cisgender women (n = 13, 86.7%), straight (n = 13, 86.7%), White (n = 10, 66.7%), and non-Hispanic (n = 11, 73.3%).

Table 1.

Participant Demographic Characteristics.

Size (n)	15
Age	M (SD)
	31.93 (4.085)
Years of experience	6.73 (3.390)
Gender	n (%)
Man	1 (6.7)
Woman	13 (86.7)
Non-binary	1 (6.7)
Race
Asian	1 (6.7)
White	11 (73.3)
Multiracial	2 (13.3)
Prefer Not to Choose	1 (6.7)
Ethnicity
Hispanic Latino	4 (26.7)
Non-Hispanic Latino	11 (73.3)
Sexuality
Bisexual	1 (6.7)
Straight	13 (86.7)
Queer	1 (6.7)
Highest degree
Bachelors	1 (6.7)
Masters	7 (46.7)
PhD	7 (46.7)
Licensure
Licensed	8 (53.3)
Pursuing licensure	7 (46.7)

Semi-structured individual qualitative interviews were conducted via zoom and took between 1 and 2 h. Given prior qualitative research focusing on informing the initial development of PCIP,^20,21 current individual interviews exclusively focused on obtaining feedback on the perceived effectiveness, appropriateness, and acceptability of the adapted manual and intervention materials (eg, handouts). Interviewers shared the PCIP-Y manual with participants, summarized each session in PCIP-Y, and asked questions to elicit interviewee feedback and suggested additional adaptations. Participants did not have prior experience with or exposure to PCIP-Y ahead of study participation. An additional focus of interviews was gaining participant recommendations regarding the level and extent of involvement of parents or caregivers in each session. Specific questions targeted each symptom cluster, and brief explanations of each session of the adapted intervention were followed by questions such as, “What do you think of session 1?,” “ What additional information would you want to gather in session 1?”, and “How, or would you, involve the child or parent more or less in session 1?” The complete interview guide can be found in the online Supplemental Materials accompanying this article (Supplemental Figure S3).

Qualitative Analysis

Interviews were de-identified and transcribed by a team of research assistants. Transcribed interviews were qualitatively analyzed using Nvivo software. Consensual Content analysis of interview data²⁷ was conducted to identify potential developmental adaptations of intervention materials, acceptability and utility of handouts for youth, and in-session adaptation considerations when providing services to young children and their caregivers with particular focus on parental involvement in sessions. An initial codebook was developed and iteratively adapted as codes were applied and new codes and themes emerged during analysis. Two researchers collaboratively coded all transcripts while iteratively adapting the codebook; applied codes were analyzed for additional themes in feedback to guide further intervention adaptation.

Results

A consensual content analysis, taking an iterative deductive and inductive approach, was conducted to examine providers’ reactions to the intervention including its usability, acceptability, and feasibility of implementation. The analysis yielded 3 main themes: Intervention Acceptability, Intervention Feasibility, and Intervention Adaptations and Recommendations. Overall providers were highly receptive to the intervention noting its brevity, overall framework, and individual session structure. Providers thought that the embedded nature of the intervention into primary care settings was a strength and would start to address certain access barriers to care for youth and families.

I mean I think investing in, like, mental health care in the primary care setting is so important in terms of, like, decreasing stigma and increasing access to care. So, I think that sounds great to like, be able to have somebody go to a PCP visit, get their medical workup, and then also, you know, get really concrete skills to help with PTSD symptoms, that sounds great (#10003)

Theme 1: Acceptability

There was an overall positive consensus on the acceptability of the intervention (n = 14). Specifically, providers thought the brief nature of the intervention was a strength and that because of this, it would be more useful and acceptable to both the providers implementing the intervention and the families and youth receiving the intervention. One provider stated:

I think if I had access to an intervention that was very brief and I knew how to implement it well, I think that would be, one, good for the client and good for my own growth as a clinician (#10001).

Providers also liked that the framework of the intervention is a stepped care model. A key factor increasing acceptability was that the end of PCIP-Y specifically included the clinician facilitating referral at the end of treatment to additional care if desired by the family and determined by clinical judgement. The specific structure of the individual sessions was also acceptable to providers who felt it made the intervention more usable.

Yeah, I think it’s great. I think it provides a number of tangible skills, it has the option to connect them to longer term care, it’s very feasible, and I think could definitely be impactful. (#10003).

However, providers noted that PCIP-Y may not be universally beneficial or effective for all youth and families. In particular, they noted that this intervention may not be the best fit for youth with complex trauma histories, ongoing trauma exposure, or more severe symptoms of PTSD.

I guess it sounds really good for like a single incident trauma maybe. I’m not sure I guess it would be, and it always is more complicated when you are working with you know a child involved in a child welfare system or something where we wouldn’t be quite sure if they would be safe when they went home. But for something like a burn or a motor vehicle accident or sexual abuse by a non-offending caregiver, it sounds like it would be really helpful. (#10004).

Overall the providers felt the intervention was highly acceptable to both providers and youth specifically due to its brief nature, integrated setting, structured sessions and overall stepped care model.

Theme 2: Feasibility

Overall, all participants agreed that PCIP-Y was a feasible psychological intervention to deliver in primary care settings. Participants expressed that the structure of the intervention increased feasibility of delivery. They noted that a particular strength of the structure was that it was both compact, being just 4 sessions, and that each session had a concrete focus on increasing coping skills. One participant, in particular, noted that focusing on skill acquisition, rather than trauma re-processing, increased intervention feasibility:

So, that’s something else that makes me feel really positively about your team’s approach, is this overlap in terms of being very practical around dealing on what’s happening right now on coping skills and making sure people feel supported rather than delving into trauma narrative and these other things that are not as practical and necessary or succinct in a two to four session format. (#10006).

However, several participants reported some concern related to the amount of material included in the manual (n = 4). Participants expressed specific concerns related to the feasibility of families both learning a range of new skills in session and then being asked to implement these skills at home:

The only thing that comes to mind is this one also seems like it could potentially be trying to do too many things. Especially because it’s gonna be asking parents to implement a number of things at home. (#10002).

An additional concern related to feasibility was that it may be difficult to engage both children and caregivers in each psychotherapy session. Participants had different ideas about what would be the most beneficial levels of parental and child involvement, and that flexibility in involvement may be the most useful and improve feasibility. When asked about what they may want to change 1 participant succinctly noted that:

Making sure parent and child, when appropriate, get their separate times, get sort of their chance to share their perspective. (#10007).

Theme 3: Recommendations

Participants offered several recommendations to improve PCIP-Y. Most notably, participants stated that integrating increased flexibility in the method of intervention delivery would significantly increase the feasibility and acceptability of PCIP-Y. Participants recommended specific allowances for flexibility in level of caregiver involvement. One participant stated that this type of flexibility may be particularly critical in pediatric primary care settings, where there are often limitations in physical space to deliver clinical interventions:

With some settings that would be challenging, just for like the child to have a place to be and be supervised. . . it may be important for different settings to have like a, what if they have to be in the same room for some like logistical reason and how that would be handled, even if like ideally they’re not. (#10002)

Participants also recommended increased flexibility with regard to intervention duration. Participants stated that, based on a patient’s clinical presentation and available resources, it would be beneficial for clinicians to be able to either increase or decrease the number of sessions in PCIP-Y. For example, 1 participant recommended adding additional therapy sessions for patients who had experienced complex trauma:

I could imagine maybe, if there’s flexibility in a setting. . . adding in an extra session or two for families who really need that extra support or are very symptomatic or have really complex childhood trauma. I could see that being helpful. (#10006)

An additional recommendation from participants was to simplify intervention materials, including handouts and worksheets. Participants stated that some materials could be edited for brevity to aid in reading comprehension:

I think that the handout for the caregiver is a lot of words. And so, I’m just thinking of some of the families that may not, you know, want to read so much, or, you know, education levels may impact their ability to understand the writing, so I like the option of kid friendly version, cause that could also be very helpful for the caregivers. (#10012)

Discussion

The focus of the present study was on evaluating a developmental adaptation of The Primary Care Intervention for PTSD (PCIP), a brief low intensity intervention for trauma related symptoms for adolescents in primary care settings, for children ages 6 to 11 (PCIP-Y). Following intervention adaptation, we conducted a series of interviews with expert clinicians in child mental health to obtain feedback on PCIP-Y acceptability, feasibility, and recommendations for improvement. Qualitative analysis revealed that PCIP-Y is an acceptable and feasible intervention to target trauma-related symptoms among school-aged children in primary care settings.

Overall, participants responded positively to PCIP-Y. Participants reported that the brevity of the intervention made it appealing for delivery within primary care settings. This finding is consistent with previous research stating that successful implementation of mental health treatment within primary care is contingent on interventions being brief and focused on skill acquisition.²⁴ A strength of PCIP-Y is its positioning as a stepped care model, such that children receiving the intervention in primary care settings may be connected to additional mental health services if warranted as part of the manualized treatment. In prior research, stepped care models have been shown to increase mental health service uptake for populations who typically encounter significant barriers to care.^28-30 Since PCIP-Y may be delivered to any child exhibiting trauma-related symptoms and intervention utilization with each patient is dependent on clinical judgement, it is reasonable to expect that PCIP-Y may be a sufficient stand alone intervention for some children presenting with trauma-related symptoms. However, the PCIP-Y as it is may not be acceptable for all children with trauma-related symptoms. Consistent with the stepped care model, some participants identified that PCIP-Y may not be enough to effectively treat trauma-related symptoms among all children, for example those presenting with complex trauma. It is likely that, for these children, PCIP-Y would function best as an initial intervention prior to connecting the child to long-term trauma-focused treatment.

Participant perspectives on the PCIP-Y intervention suggest that it is feasible to deliver within integrated primary care settings. Participants identified the structured nature of the intervention manual as significantly increasing intervention feasibility, noting that PCIP-Y’s emphasis on targeted psychoeducation and coping skills rather than trauma-reprocessing was a significant strength. This result stands in contrast to primary care interventions for PTSD among adult samples, wherein evidence-based interventions do typically include a direct trauma-reprocessing component.^31,32 It is reasonable that short-term trauma-reprocessing may be more feasible in adults than younger children, as children typically require substantial support in making meaning of traumatic events given their developmental level.³³

Qualitative results also suggest potential barriers to feasibility with regard to delivering PCIP-Y. Participants reported that the scope of expected caregiver involvement within the intervention may be difficult for some families to manage. Participants primarily identified competing obligations and inter-generational trauma exposure as barriers to caregiver involvement in treatment. These challenges are consistent with barriers identified in the broader childhood trauma implementation science literature and highlight the significant difficulty of disseminating efficacious psychological care to all children with trauma-related mental health concerns. It is particularly challenging to consistently involve caregivers in their children’s psychological treatment, despite strong evidence that caregiver involvement in care improves clinical outcomes.²⁶ Implementing interventions, such as PCIP-Y, in primary care settings may in itself be an avenue to decrease stigma and practical barriers to caregiver involvement in treatment, particularly for low-income families.^34,35

Additional themes emerged regarding recommendations to improve the feasibility and acceptability of PCIP-Y. Overall, participants strongly recommended maximizing flexibility in intervention delivery to increase uptake and effectiveness of the intervention in primary care settings. Participants recommended possible adaptations that could be made at the discretion of the intervention provider, including: changing intervention length, augmenting the setting the intervention is delivered in, and tailoring intervention materials to the patient and caregiver’s developmental level. One of the hallmarks of PCIP-Y is the flexibility offered within intervention delivery, and we have adjusted the manual in response to this feedback to further highlight potential avenues wherein a clinician can tailor the intervention to meet the specific needs of each patient. Overall, this result highlights the promise of utilizing highly flexible, modularized, and manualized interventions to increase widespread dissemination of psychological care.^35,36

Findings of the present study are promising with regard to increasing the scope of mental health interventions available in primary care settings, as PCIP-Y is the first proposed intervention to target trauma-related symptoms among school-aged children in integrated care. Comprehensively integrating mental health services into primary care settings is an effective approach to significantly improving psychological outcomes among children and decreasing the mental health burden in the United States. Integrating behavioral health into primary care settings is particularly critical to increase access to mental health services for minoritized children, who face substantial barriers in accessing specialized outpatient treatment.³⁷ Notably, the results of this paper present perceptions of the acceptability and feasibility of PCIP-Y with some adjustments. It is important to test the adapted intervention and integrated feedback from interviews with providers in a real world setting to examine if PCIP-Y’s flexibility in modules and manualized procedures are appropriate in integrated care settings. However, a critical next step is to conduct a pilot hybrid effectiveness implementation randomized control trial to evaluate the real-world acceptability, feasibility, and effectiveness of PCIP-Y in treating trauma-related symptoms among school-aged children in integrated care settings. Implementation of the intervention can reveal additional adaptations to improve acceptability and feasibility of the intervention in Primary care settings.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319261434719 – Supplemental material for Feasibility and Acceptability of the Primary Care Intervention for PTSD-Youth

Supplemental material, sj-docx-1-jpc-10.1177_21501319261434719 for Feasibility and Acceptability of the Primary Care Intervention for PTSD-Youth by Gia Chodzen, Gray Bowers, Rddhi Moodliar and Lauren C. Ng in Journal of Primary Care & Community Health

Footnotes

ORCID iD

Gia Chodzen

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Mental Health under Grant 5T32MH073517-18, the John and Polly Sparks Early Career Grant for Psychologists Investigating Serious Emotional Disturbance (SED), and by the Walter Katkovsky Research Grant. Transparency and Openness Promotion guidelines were followed.

Declaration of Conflicting Interests

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

Data Availability Statement

The data that support the findings of this study are not openly available due to protect participant confidentiality and are available from the corresponding author* upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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