1. Neural Correlates of Symptom Reduction During TF-CBT JOSH CISLER, PHD BRAIN IMAGING RESEARCH CENTER PSYCHIATRIC RESEARCH INSTITUTE UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

2. Overview Discuss a recent collaborative study between AR BEST and BIRC to understand treatment response to TF-CBT ◦Participants were local Arkansan adolescent girls with PTSD related to assault ◦Many of the participants were even referred to us by AR BEST clinicians Purpose of the study What the study involved Results and some preliminary conclusions

3. What is TF-CBT? Trauma-focused cognitive behavioral therapy – structured psychological therapy targeting the following domains: ◦Psychoeducation and Parenting ◦Relaxation ◦Affect Modulation ◦Cognitive Coping Skills ◦Trauma Narrative / Cognitive Processing ◦In vivo exposure ◦Conjoint parent-child sessions ◦Enhancing future safety Typically delivered in 12-16 sessions Strong evidence base for traumatized children with PTSD, anxiety, depression, or externalizing behaviors related to trauma exposure

4. Purpose of the Study TF-CBT is our gold-standard treatment for youth with traumatic stress-related symptoms Nonetheless, 100% symptom reduction does not always occur

5. From Cohen et al. 2011 – randomized controlled trial of TF-CBT in a community setting On average, children after TF-CBT still demonstrated significant PTSD symptoms

6. Purpose of the Study TF-CBT is our gold-standard treatment for youth with traumatic stress-related symptoms Nonetheless, 100% symptom reduction does not always occur Our overall goal is to understand how to improve the consistency of response to TF-CBT ◦1) Can we identify pre-treatment markers of who will response best? ◦2) can we identify the mechanisms through which TF-CBT works so that we can learn how to enhance it?

7. Study Overview Recruited adolescent girls, aged 11-17, with PTSD related to physical or sexual assault Provided 12 sessions of manualized TF-CBT ◦Thanks to Drs. Karin Vanderzee, Joy Pemberton, and Ben Sigel!!!! ◦Followed standard PRACTICE modules Assessed clinical symptoms before and after treatment Assessed brain function before and after treatment ◦Functional magnetic resonance imaging (fMRI) ◦Measure brain activity while the adolescent performs a cognitive task

8. Enrollment Flow

9. Fearful expressionNeutral expression Emotion Processing Task

10. Participant gets an instruction: ‘notice your feeling’ or ‘think positive’ Then they see either a negative image or a neutral image Cognitive re-appraisal task

11. Participant gets an instruction: ‘notice your feeling’ or ‘think positive’ “the building wasn’t safe so they are taking it down to build a safer one”

12. Variable Mean/frequenc y (SD) Age13.87 (1.77) Verbal IQ95.26 (15.00) Ethnicity 39% Caucasian 52% African American 9% Biracial 0% Hispanic Total number of types of assaults 5.65 (3.98) Direct Physical Assault96% Sexual Assault87% Witnessed Violence91% Psychotropic Medication SSRI - 39% Antipsychotic – 17% SARI – 4% Alpha blocker – 4% Pre-Treatment Post- Treatment Current PTSD100%35% # comorbid diagnoses2.74 (2.22)1.00 (1.62) Current Anxiety Disorder65%17% Current Depressive Disorder 52%13% Current Bipolar Disorder4%0% Current Alcohol Use (past year) 8%4% Current Substance Use (past year) 12%17% Current Conduct/ODD26%21% UCLA PTSD Index36.04 (17.87)18.30 (16.62) SMFQ12.22 (8.25)4.61 (6.55)

15. Who is likely to be a good responder to TF-CBT? Can we identify markers that let us predict who will and will not have good responses to TF-CBT?

17. Who is likely to be a good responder to TF-CBT? Can we identify markers that let us predict who will and will not have good responses to TF-CBT? ◦Using data from the emotion processing task ◦Does pre-treatment brain activity to emotional images predict symptom reduction?

21. Who is likely to be a good responder to TF-CBT? Adolescent girls who differentiate danger from safety signals seem to be more likely to respond better to TF-CBT

22. What are the mechanisms of TF- CBT? Through what intermediate mechanisms does TF-CBT produce symptom change?

23. Penicillin Fever reduction

24. Penicillin Fever reduction Infection reduction

25. TF-CBT PTSD symptom reduction

26. TF-CBT PTSD symptom reduction ??????

28. TF-CBT PTSD symptom reduction Emotion Regulation

31. What are the mechanisms of TF- CBT? TF-CBT may improve the adolescent’s ability to regulate emotions, which results in PTSD symptom reductions Better emotion regulation may be due to specific brain changes: ◦Suppression of amygdala-insula functional connectivity ◦Heightened amygdala-dACC functional connectivity appears to be detrimental

32. Overall Discussion There is significant variability in PTSD symptom reduction during TF-CBT ◦Partly related to initial symptom severity ◦Partly related to how well the adolescent initially discriminates danger from safety ◦Partly related to how well TF-CBT helps the child learn to regulate emotions ◦Which is partly related to specific changes in brain function during emotion regulation

33. Overall Discussion There is significant variability in PTSD symptom reduction during TF-CBT ◦Partly related to initial symptom severity ◦Partly related to how well the adolescent initially discriminates danger from safety ◦Partly related to how well TF-CBT helps the child learn to regulate emotions ◦Which is partly related to specific changes in brain function during emotion regulation

34. Limitations Small sample (N=25) Only girls Only 12 sessions ◦Allows comparability across adolescents, but real-world TF-CBT can be more flexible Long-term follow-up?

35. We are recruiting for more research studies!!! Further investigations of how early life trauma changes brain function and increases risk for ◦Drug use disorders ◦PTSD ◦Risk for revictimization ◦Problems with intimacy and trust

36. We recruiting for more research studies!!! Adolescent girls age 11-17 With or without histories of physical or sexual assault With or without histories of drug use No internal metal (no braces) Adolescent and caregiver earn monetary compensation Contact Jennifer Payne: 501-526-8497