Dersleri yüzünden oldukça stresli bir ruh haline sikiş hikayeleri bürünüp özel matematik dersinden önce rahatlayabilmek için amatör pornolar kendisini yatak odasına kapatan genç adam telefonundan porno resimleri açtığı porno filmini keyifle seyir ederek yatağını mobil porno okşar ruh dinlendirici olduğunu iddia ettikleri özel sex resim bir masaj salonunda çalışan genç masör hem sağlık hem de huzur sikiş için gelip masaj yaptıracak olan kadını gördüğünde porn nutku tutulur tüm gün boyu seksi lezbiyenleri sikiş dikizleyerek onları en savunmasız anlarında fotoğraflayan azılı erkek lavaboya geçerek fotoğraflara bakıp koca yarağını keyifle okşamaya başlar


Are Complex Multimodal Interventions the Best Treatments for Mental Health Disorders in Children and Youth?
ISSN: 2375-4494
Journal of Child and Adolescent Behavior
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on Medical, Pharma, Engineering, Science, Technology and Business
  • Research Article   
  • J Child Adolesc Behav 2016, Vol 4(4): 305
  • DOI: 10.4172/2375-4494.1000305

Are Complex Multimodal Interventions the Best Treatments for Mental Health Disorders in Children and Youth?

Peter H Silverstone1*, Victoria YM Suen2, Chandra K Ashton1, Deena M Hamza1, Erin K Martin1 and Katherine Rittenbach1,2
1Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
2Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
*Corresponding Author: Peter H Silverstone, Department of Psychiatry, Adjunct Professor, Faculty of Business, University of Alberta, 1E7.17 Mackenzie Centre, 8114 -112 Street, Edmonton, Alberta, Canada, Tel: +1-780-407-6576, Fax: +1-780-407-6672, Email:

Received: 20-Jun-2016 / Accepted Date: 11-Jul-2016 / Published Date: 18-Jul-2016 DOI: 10.4172/2375-4494.1000305


There is a pressing need for effective interventions to treat mental health disorders in children and youth. There is evidence for increasing incidence rates across a wide range of conditions, and these can lead to very significant long-term impacts. They include depression, anxiety, abuse of drugs and alcohol, and the impacts of a variety of traumas. Recently we have carried out a number of studies in which complex and multimodal interventions were either introduced and then studied, or were on-going but hadn’t previously been rigorously tested for efficacy. Here we present a review based upon some of these multimodal programs which examined outcomes in: (1) a schoolbased program to reduce depression and suicidal thinking in youth aged 11-17 years old in which all students were screened on an electronic tablet using standard scales for depression and suicidal thinking followed by the option of an internet-based cognitive behavioural program; (2) a screening, brief intervention and referral to treatment (SBIRT) program to help youth aged 11-17 years old who had significant drug and/or alcohol abuse in which initial screening for drug and alcohol use was followed by the options of an internet-based cognitive behavioural program and referral to child and adolescent specialists; and (3) outcomes following trauma experienced by children aged 5-12 years old in two separate programs in which a complex intervention was used involving 2-3 hours of weekly interventions for both the child and a primary care-giver. The depression, suicidal thinking, and drug and alcohol results were from a large school-based program involving over 6,200 youth termed the Empowering a Multimodal Pathway Towards Healthy Youth (EMPATHY) program, for which 15-month outcomes are recently available. The other two programs treated child victims of trauma. These were firstly in an intensive 8-12 month outpatient intervention program with 50 children aged 5-11 years old who developed an attachment disorder following trauma, given in a dyad model involving their primary caregiver. Secondly, in a 12-month program for 40 children aged 8-12 years old who were victims of childhood sexual abuse, which included intermittent residential treatment. The details of the programs varied greatly, but all involved multimodal methods of treatment. In terms of outcomes, all of these programs found significant longer-term improvements in multiple areas. In conclusion, our findings from this review suggest that future research and clinical programs should consider multimodal approaches for the treatment of mental health disorders in children and youth, and future research should directly compare such programs to individual therapeutic approaches.

Keywords: Mental health; Trauma; Post-Traumatic stress disorder (PTSD); Child sexual abuse (CSA); Abandonment; Depression; Anxiety; Suicidal thinking; Drug abuse; Alcohol abuse


Many mental health disorders are first evident during childhood, and it appears that the frequency of several mental disorders may be increasing in children and youth [1,2]. Approximately 10% of youth have depression [3,4], while suicide rates are also high in this age group [5,6]. It is likely that each year between 4-7% of youth will make at least one attempt at suicide [7,8]. It is also recognized that many adults who subsequently have drug and alcohol abuse developed this during their youth, and may also have other prior mental health issues [9,10]. Additionally, abuse experienced or witnessed by youth (including physical, emotional, and sexual abuse) also frequently leads to negative longer-term psychiatric outcomes [11-13] or disruptive behaviours [14]. For all these reasons early treatment of mental health disorders in children and youth is important to decrease their longterm risks and improve outcomes [15-18].

To address this issue there have been a wide range of potential interventions proposed for the treatment of children and youth who have depression, anxiety, trauma-associated disorders, or drug and alcohol abuse. These interventions come from many different modalities, including psychotherapy [19], particularly cognitive behavioural therapy (CBT) [20], pharmacotherapy alone or in combinations with psychotherapy [21,22], psychosocial interventions [14,23], and family-based interventions [24-26]. In addition to these single modality of approaches, so-called “Multisystemic Therapy” has also been found to be effective over many years in children and youth to treat externalizing disorders such as violent offending and substance abuse, or where there is physical parental abuse or neglect [27].

Nonetheless, even in areas in which many research studies have taken place the best approach to treatment remains highly uncertain. Thus, a recent Cochrane review concluded that CBT “is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or treatment as usual or medication at follow-up, is limited and inconclusive” [28]. It is therefore clear that despite the multitude of treatment approaches, no single therapeutic intervention is likely to be successful for all children or youth, and there remains a lack of clarity about whether outcomes are better with single interventions or combined approaches.

This is important to recognize, since much of the current research literature focuses on the utility of single interventions. It is quite conceivable that better clinical outcomes could be achieved from combinations of therapy. To help illustrate such clinical possibilities, in the present review we examine three areas of recent research we have been involved in which have examined longer-term clinical outcomes (12-months) following complex multimodal interventions in children and youth. We focus on three clinical areas linked to these: (1) outcomes in youth aged 11-18 for depression and suicidal thinking; (2) outcomes in youth aged 11-18 for drug and alcohol use; and (3) outcomes following trauma experienced by children aged 5-12 in two separate programs. Details on the specific programs and their results are either published, or have been submitted for publication, and therefore only brief summaries are given here.

Depression and suicidal thinking

As noted previously, depression and suicide rates are significant in childhood and youth [1-8]. It is also clear that those who have previously harmed themselves, and/or who have depression, have a higher risk for subsequently completing suicide [29-31]. It is therefore critical to effectively address this issue, but it remains unclear if approaches specifically targeting a so-called “high-risk” group are more effective than interventions given to the whole population (so-called “universal” interventions). Recent reviews have, generally, been supportive of a variety of both high-risk and universal interventions reducing youth suicide rates [22-43], although care is required since some approaches can be problematic or ineffective [44,45]. It is likely that schools may be the most appropriate setting in which to screen and intervene with youth [46,47], which can include increasing resiliency [47-49]. Universal prevention on its own is only partially effective [50-52]. Another approach is to identify a sub-group of “highrisk” individuals and intervening in this sub-group with CBT-based interventions [53-60], although this doesn’t help the significant number of children and youth whose depressive symptoms are below the threshold for intervention [61,62].

More recently, it has been suggested that a more effective method to address youth depression and suicide is to combine both universal programs with screening for high-risk youth, followed by targeted interventions [5,42,43,63], although studies utilizing such multimodal methods have not all been successful [64,65].

Summary of complex intervention

We worked with a school district in Alberta, Canada to design a new program to be received by all youth in their district during designated “health” classroom time. The aim of the program was to reduce depression and suicidal thinking in their students. This program was called Empowering a Multimodal Pathway Towards Healthy Youth (EMPATHY) [66]. It consisted of several components including:

• The use of individuals experienced in youth care who interacted with students in multiple different areas (including during designated free-time), who were termed “Resiliency Coaches”. One individual was present at every school.

• The use of an established resiliency CBT program (OVK) [67-70], targeted initially at only 2 Grades (for budgetary and other logistical reasons). OVK is an updated version of the Penn Resiliency Program [71-74]. These were given to those in Grades 6, 7, and 8 (ages 11-13).

• A 5-day integrated CBT training program was provided for the 5 Resiliency Coaches hired for this program, which included the study rationale, OVK, and the CBT internet-based programs.

• The use of electronic tablets with a specifically developed software “app” that was given within the classroom setting on a single occasion for rapid and consistent data collection during screening. This was done by the Resiliency Coaches and/or the classroom teacher.

• Rapid feedback being given to schools regarding students considered at higher risk of suicide, sometimes within 1-2 hours, as an output from this “app”.

• All students who had significant suicidal thoughts had a 1- hour interview either the same day or the following working day (for this reason little screening was carried out on Fridays), and their family was contacted immediately afterwards.

• The use of an established internet-based CBT program for the 10% of those identified by this process as being considered at greatest risk from suicide, depression, or other factors. These programs were administered in a “guided” manner by the Resiliency Coaches.

• Dedicated training on diagnosis and treatment approaches for community physicians and mental health staff working in primary care, including specific information on CBT and other treatment approaches for youth.

• Awareness of the program in the community through communication with students, parents/guardians, and the use of various types of media including print and television.

• A city-wide approach involving all public schools that catered to students in Grades 6-12 (i.e. students aged 11-17 years old).

Statistical analysis

The primary statistical method was a paired design, in which each student who completed both baseline ratings and follow-up ratings was their own control. As the data showed evidence of non-normality, a non-parametric test was carried out to compare the differences between the mean scores at baseline and 12-week follow-up. This involved Wilcoxon signed-rank test (paired), unless otherwise specified, which is a non-parametric statistical test for testing hypotheses on medians. Statistical analysis was carried out on an “intention to treat” basis utilizing R, version 3.1.0 (R Foundation for Statistical Computing, Vienna, Austria) and Stata/IC 13.1 for Windows (StataCorp, College Station, Texas, USA). Correlations were calculated using IBM SPSS Statistics 20.0 (Chicago, Illinois, USA).

The study was designed to determine potential changes in depression scale scores and in suicidality. From previous studies, it was determined that there may be a 5% decrease in both these scores. To detect a statistically significant reduction of this size would require a sample size of 65 students in a 1-sided sample size calculation completed using the G Power calculator, version 3.1, with =0.05. Given our sample size of 3,500 students, of which we estimated a minimum of 4% (i.e. 140 students) would be depressed with a similar number being suicidal, this study was adequately powered.

Outcome summary from complex intervention

The longer-term outcomes have recently been analyzed for data collected during the time period February 2014-June 2015 (Silverstone PH, personal communication). During this there were 4 time-points at which students were assessed, at Baseline, 3-months, 7-months, and 15-months. A total of 6,227 students were assessed at least once, while 1,884 completed assessment at all 4 time points. It was therefore possible to examine both cross-sectional data (by comparing each group), and longitudinal analysis (by examining those who completed all assessments and therefore acted as their own controls). At each time point the number of students assessed varied, being n=3,244 at Baseline, n=3,229 at 3-months, n=4,860 at 7-months, and n=4,497 at the final 15-months assessment. There were highly significant decreases in suicidality rates in every group at each follow-up period, with the percentage of the total school population who were actively suicidal decreasing from 4.4% at baseline (n=143 of 3,244) to 2.8% at 15-months (n=125 of 4,497). There were also highly significant decreases in scores on a measure of depression, the 9-item patient health questionnaire (PHQ-9) [75], adapted for adolescents (PHQ-A) which has been well validated in youth [76-78]. For the cross-sectional analysis there were also highly significant reductions in depression scores and in suicidal thinking. Although not primary objectives, improvements were also seen in anxiety, self-esteem, and quality-oflife, and anecdotal reports also suggested a marked decrease in rates of bullying (Silverstone PH, personal communication).

Given the multitude of different aspects of the program, as well as items not captured formally (such as the number of informal interactions between the Resiliency Coaches and students over a prolonged period) it is not possible to determine what specific factors were involved in these highly positive outcomes.

Drug and alcohol abuse

The rate of substance misuse appears to be increasing with those aged between the ages of 15 - 24 showing the highest rates of substance misuse [79,80]. Abuse of drugs or alcohol in youth increases the risk of developmental delays and in areas of cognition, motivation, and impulse control [80,81]. While there have been several interventions proposed to reduce substance misuse in adolescents [82-84], one suggested approach for youth is to utilize a combination of universal Screening, Brief Intervention for those at high risk, and Referral to Treatment when needs are identified (SBIRT) [85-87]. While used in adults quite widely, SBIRT may also be an effective approach in both schools and primary care sites, possibly used with CBT [88]. SBIRT in youth has potential public health benefits since early identification and treatment of individuals engaging in high-risk substance use may prevent subsequent substance use problems [85-88]. Several key issues arise when considering appropriate methods to utilize SBIRT most effectively including the choice of screening tools, the nature of any brief interventions, and the best methods for subsequent referral to treatment. Current evidence suggests that there are no clear differences in outcomes between programs for alcohol abuse [89].

Summary of complex intervention

The intervention was based on the EMPATHY study [66], and screening was carried out in the same manner (and at the same time) for depression and suicidal thinking. Again, data was collected electronically. However, the initial data on drug and alcohol use, previously reported [66] was subsequently transformed to allow extraction of items from the CRAFFT assessment scale (Hamza D, personal communication), named after the focus of each of the 6 questions (Car, Relax, Alone, Forget, Friends, and Trouble) [90,91]. The CRAFFT is a 6-item screening tool that can assess lifetime and current substance misuse, and is specifically designed for youth populations [90,91]. The questions are answered dichotomously (yes/ no), and each positive answer is scored as one (1) point, with a maximum score of 6. Individuals who score ≥2 are likely to be at risk of developing a substance use disorder. It should be noted that the CRAFFT has been widely used in adolescent populations [92-95], but that the questions relate to activities over the previous 12 months, and so to determine any changes, longer-term follow-up is required. In addition to screening using CRAFFT, a brief intervention was offered, namely an on-line CBT program guided by the Resiliency Coaches. If this was not effective referral to either primary care, or specialist psychiatric care, was offered. This program therefore met all criteria for SBIRT.

Statistical analysis

To test the equality of medians from two independent groups, we used a Wilcoxon rank-sum test to test hypotheses on the differences between median scores. Statistical significance was =0.05. The statistical method was a paired design, in which each student who completed both baseline ratings and follow-up ratings was their own control. A statistical power analysis was from the previous program, which determined that the study was adequately powered. Although we collected data at Baseline, 3-months, 7-months, and 15-months, because the CRAFFT questions ask about use “during the past 12- months”, the statistical comparisons were between Baseline ratings and those at 15-months.

Outcome summary from complex intervention

The CRAFFT scores at Baseline (n=3,224), 3-months (n=3,229), 7- months (n=4,860), and 15-months (4,497) over two school years were available, as were CRAFFT scores in the 1,884 students who completed all 4 assessments (Hamza D, personal communication). The results found that rates for substance abuse increased with age. They also found that this complex SBIRT program led to a highly significant reduction in the total percentage of students who scored ≥ 2, from 14% to 7%, at the 15-month follow-up. This occurred in all Grades from 6-12 (ages 11-17) (Hamza D, personal communication). For example reductions in Grade 12 (mean age 17.3) were from 31% of the student population who scored ≥2 at Baseline to 20% for the group assessed at 15-months, while reductions in Grade 11 were from 24% at Baseline to 15% at 15-months. Interestingly, there was also a significant reduction in comorbidity with both depression and anxiety over time.

Trauma Experienced by Children

Attachment issues

During healthy childhood development, caregivers foster fundamental attachment needs leading to positive developmental outcomes, including self-esteem, social competence, and the ability to maintain relationships. All of these factors may be linked to the quality of the attachment relationship with a primary caregiver, while poor interactions may be associated with deficits in executive function, attachment, and a decreased ability to self-regulate [96-98]. It is possible that poor attachment may be one of the mechanisms leading to longer-term mental health problems [98-101]. These challenges are often compounded by problems with self-regulation, self-concept, and anxiety [102,103].

Despite growing awareness of the impact of early attachment related deficits on child neurodevelopment and mental wellbeing there are relatively few studies that have determined the most effective treatment approaches for children who develop attachment related disorders as a result of early trauma. Documented approaches with older children have included psychodynamic psychotherapy [103] and CBT [104]. Interventions with both a caregiver and a young child together, in a socalled “dyad” approach have also been suggested [105,106]. In order to address this issue, a program was developed by CASA (Child, Adolescent, and Family Mental Health) a provider of mental health services for children and families, and youth. This program, termed the Trauma and Attachment Group (TAG) Program, was designed to address developmental trauma [107-109], and is based, in part, on a trauma-informed three-stage treatment model which aims to integrate developmental, biological, psychodynamic and interpersonal theoretical perspectives [109,110]. TAG was designed to help children in middle childhood diagnosed with attachment disorders following complex developmental trauma and aims primarily to promote healing through the development and strengthening of caregiver-child attachment relationships. We recently reported in more detail on some of the outcomes from this program [111].

Summary of complex intervention for attachment issues

CASA offers a TAG program for the caregiver/child dyad for children aged 5-11, which is split into two separate sections (TAG I and II), each of which lasts 4 months and has the capacity to treat a maximum of 10 caregiver/youth dyads, during the 9-12 month course of treatment. The actual course of treatment (2 x 4 month sessions) is always the same, but if a cohort starts in January then the actual program is longer as there is a 3-month summer break. This is in contrast to those who start in September where there is only a 2-week break at the end of the calendar year. The treatment is intensive, and involves several members of the experienced multi-disciplinary team, which meets to review progress every two weeks, and includes a psychiatrist, a psychiatric nurse, a clinical support worker, psychologists, social workers, and a part-time occupational therapist. Because the program is carried out at a teaching facility, others may be involved in the program for educational purposes. In addition to group involvement, the team makes weekly support calls to families, schools, and family community-care teams where necessary. Treatment dyads (i.e. the child and their primary non-offending caregiver) meet once a week for 2-2.5 hours with separate group sessions for caregivers, children, and inclusive caregiver-child dyad sessions. Initially, the caregiver’s group is designed to increase awareness of the neurological, emotional, and behavioural effects of trauma, encourage the development of therapeutic parenting skills that promote attachment, and facilitate the development of environmental conditions for attachment to take place in the home. Secondly, there is a concurrent group play therapy experience for the children which includes therapeutic free play with staff support and guidance; physical activity to promote self-regulation; visualization; experimentation with sensory strategies; verbal processing of weekly strengths and challenges; activities related to interpersonal boundaries, emotional identification and expression, life history, and current family relationships; therapeutic stories related to trauma and attachment needs, and community snack. Finally there is a guided caregiver-child dyadic interaction.

Emotional regulation is connected to receiving consistent and attuned responses (involved in reflective functioning) from the primary caregiver. Reflective functioning on behalf of the caregiver is believed to be an integral part in the development of a child’s safety and comfort in the attachment relationship [112]. In an attempt to help develop this attunement in caregivers, TAG I begins with caregiver education on the neurological, emotional, and behavioural effects of developmental trauma, through the Neurosequential Model of Therapeutics [113,114]. This is a developmentally-driven neurobiological model, where, for example, caregivers discuss the potential impacts of trauma on brain functioning, including controls over regulation, arousal, and attention, before trying to move on to higher-level functions, such as decision-making and problem solving.

During caregiver/child dyad time, group activities for clinical stabilization include role-playing, body feeling map drawings, and safe place visualizations. Children are supported to increase their selfregulation skills both through reflection on their feelings and thoughts, and through connection with their caregiver. Caregiver-child attachment is further encouraged outside of group meeting times through dyadic activities such as “kit time”, where caregivers and children set aside time every day to do activities together that mimic early attachment behaviours (i.e. providing one-to-one attention and connections through games that encourage increased eye contact and/or increases in the amount of physical touching between the caregiver and child).

Once clinical stabilization has been achieved, the TAG facilitation team then supports the family to increase the child’s environmental safety. This is achieved, in part, through the development of family connections to school or community supports, and includes the need to help the child begin to generalize feelings of safety gained within the relationship with their caregiver, to others in the child’s social world.

Once completed, the treatment dyad progresses to the next stage, TAG II. This is a 15-week group for the children and their parents/ caregivers which focuses on trauma resolution using an attachment model. There are 3 parts to the group: (1) grounding the body orientation using movement exercises and dyad activities, and anxiety reduction using visualization, (2) sand-tray therapy, and (3) storytelling and closure. The TAG II treatment component seeks to support Trauma Resolution (stage two of van der Kolk’s treatment model) [110,111], through encouraging the child’s recollection of their early traumatic experiences in a safe environment. The caregiver learns to become a witness to the youth’s “trauma story” in a mindful, nonjudgmental, and supportive manner [115,116]. Children are supported to integrate past trauma into a narrative that also includes present experiences and respond to their present environment without viewing it through the lens of their trauma. Children begin to tell their story through drawing, collages, and sand-tray work. They also participate in regulatory activities, (i.e. learning to “be present” in their own bodies), practice mindfulness-based stress reduction [116], and are guided through relaxation exercises. During this part of the process, children are also encouraged to reframe their early attachment experiences to help them understand that the current caregiver is not the one responsible for their early developmental trauma. Caregivers are supported with regard to increasing their capacity to make sense of their own and their child's mental states, which is believed to play a critical role in helping children to self-regulate and establish healthy and meaningful relationships [112]. This reframing for both children and caregivers aims to re-build models of healthy attachment and reinforce safety and stability. The final goal of TAG II treatment is to address Reconnection and Generalization to the Community [109,110], which involves the successful transfer of treatment gains across environments.

Statistical analysis

The statistical method was a paired Student’s t-test, in which each student who completed both baseline ratings and follow-up ratings was their own control, to examine the differences between baseline and follow-up scores. Statistical significance was =0.05. This was carried out with IBM SPSS Statistics Version 22 to analyze the results, utilizing two tailed t-tests to determine statistical significance.

Outcome summary from complex intervention for attachment issues

The primary measure used to determine if changes occurred following participation in TAG was the Attachment sub-scale of the Parenting Relationship Questionnaire (PRQ) [117]. Preliminary findings demonstrated statistically significant improvements in attachment, communication, discipline practices, involvement, and relational frustration [111]. Additionally, there were statistically significant improvements in the ability of caregivers to recognize and understand both their own and their child’s feelings about the parentchild relationship, and a trend indicating a reduction in symptoms typical of post-traumatic stress disorder (PTSD). Longer-term and more detailed findings have recently been analyzed (Ashton C, personal communication) and these further support preliminary findings. There is also an extensive qualitative analysis (Ashton C, personal communication) which demonstrates that some of the clinical benefits may be due to the multiple non-specific interactions that occurred both in groups and during individual time. These included the recognition that other parents were experiencing similar challenges, or the benefits of improved relational interactions between the dyad from the caregiver being “forced” to spend time playing with their child. The provision of psycho-education on the effects of trauma has also been suggested to improve outcomes.

Victims of childhood sexual abuse

Child sexual abuse (CSA) is frequent [118,119], with as many as 1- in-6 girls and 1-in-12 boys experiencing sexual abuse that has involved bodily contact [120], and it is currently uncertain if these rates are changing [121,122], particularly given the increase in use of internet pornography [123,124]. The impact of CSA is very significant, with a substantially greater risk for a range of future medical, psychological, behavioural, and sexual disorders [11-13,125]. It is possible that these long-term issues may reflect physiological changes [126-129]. For these reasons, preventing CSA is of great importance [130,131].

In adults who have experienced CSA long-term problems can include an increased risk of suicide attempts, and multiple other psychological, behavioural, sleep, and sexual issues [132-135]. Some of these outcomes are linked to inappropriate feelings of shame that these victims frequently feel [136-138]. Perhaps the most important of these psychological issues is the development of post-traumatic stress disorder (PTSD), since these symptoms are closely linked to poorer longer-term outcomes [139,140]. This occurs in approximately 40% of CSA survivors [140,141]. It is possible that these changes are mediated via neurobiological or cognitive developmental changes that occur following CSA [142-145].

Treating CSA victims has, more recently, utilized trauma-focused cognitive behavioural therapy (TF-CBT), which can be effective for many children in reducing the number who have PTSD symptoms after treatment [146,147]. TF-CBT consists of skills-building components, a trauma narrative during which children describe and cognitively process their personal trauma experiences, treatment closure including conjoint caregiver–child sessions and safety planning, and its benefits have been shown to be continued over extended periods in children who have been victims of CSA [147]. In more limited research studies there have been findings suggesting that other treatment modalities may also have some efficacy, including eye movement desensitization and reprocessing (EMDR), animal-assisted therapy, art-therapy, and play therapy [148-151]. However, questions remain about possible benefits of combinations of therapeutic approaches, as well as the most effective therapy for different ages or types of CSA [144], as well as the length of treatment and possible standardization of treatment components [152,153]. Access issues for children and youth who have experienced CSA also occur [154]. Finally, recent evidence suggests that brief intensive interventions are effective for PTSD [155,156].

For these reason a novel program was introduced by a charitable organization to help victims of CSA. This involved the use of multiple therapies, all of which had some evidence of efficacy, but was given in shorter more intensive interventions over a 12-month period [157,158]. The program was implemented in 2014 at a purposedesigned “camp-like” residential facility called the “Be Brave Ranch” (BBR).

Summary of complex intervention

The program involves a 4-week initial stay at BBR, where intensive therapeutic interventions are employed for 8 - 10 hours from Monday to Friday. Weekends are dedicated to a variety of community-based recreational activities [158-161]. Children return to the BBR for further interventions, followed by additional reassessment at 13-weeks, 26-weeks, and 52-weeks. Assessments of progress take place before starting at the BBR (“Baseline”) at the end of the initial 4-week stay (“Assessment #2”), at the end of the 13-week stay (“Assessment #3”), at the end of the 26-week stay (“Assessment #4”), and at the end of the final 52-week visit (“Assessment #5”).

Central to the program is the daily TF-CBT group, which comprises 100 hours of group therapy across 12 months, focusing on: (1) developing self-regulation skills; (2) supportive discussions about the child’s CSA experience; (3) processing the child’s trauma narrative; and (4) conjoint caregiver–child sessions, as well as safety planning to facilitate appropriate closure [160]. During each of their visits to BBR, children repeat the sharing of their trauma narrative, an approach consistent previous findings that repeated exposure to the trauma was more efficacious than supportive therapy alone [161]. Treatment fidelity is ensured through the use of a detailed program guide as well as daily clinical consultations and weekly team meetings.

In conjunction with TF-CBT, the multimodal program at BBR includes multiple other interventions including daily cardiovascular exercise, yoga, music, art, EMDR, individual counselling, and interactions with animals, most of which have some level of evidence supporting efficacy in the treatment of CSA [146].

Statistical analysis

The statistical method was a paired Student’s t-test, in which each student who completed both baseline ratings and subsequent followup ratings was their own control. This was used to examine the differences between baseline and all subsequent follow-up scores. Statistical significance was =0.05. This was carried out with IBM SPSS Statistics Version 22 to analyze the results, utilizing two tailed t-tests to determine statistical significance.

Outcome summary from complex intervention

Over the short-term this program has been found to decrease symptoms of PTSD as well as depression and anxiety [159]. The initial longer-term findings for the first group of 40 CSA victims has recently been published [158], and demonstrated highly statistically significant reductions in Child Posttraumatic Stress Disorder Symptom Scale (CPSS) scores, which decreased from a mean score at baseline of 20.8 ± 1.4 to a mean of 12.5 ± 2.3 at 52-weeks. There was also a marked reduction in the percentage of children whose scores were above threshold for the diagnosis of PTSD, decreasing from 73% at baseline to 29% at 52-weeks. It should be noted that while much of the reduction in mean CPSS scores occurred in the first 4-weeks, the percentage reduction in those who met criteria for PTSD continued over time.


This review has examined the potential effectiveness of 3 different multimodal interventions in three different clinical areas. These were selected as models we have been involved with, and are very familiar regarding the outcomes. This is not intended to be a conclusive review of the literature, but rather to utilize these approaches to clarify that complex multimodal treatment approaches can lead to positive outcomes. This is important since much of the current research literature focuses on the utility of single interventions, though it remains uncertain if this is the most effective treatment approach for children and youth who have mental health problems.

In the three areas we have reviewed it is also clear that each of three study programs are quite different from each other, in terms of techniques, therapeutic approaches used, population served, and numbers involved. Despite these obvious and considerable differences, each of them shows that clinical treatment approaches that utilize a variety of components can be highly effective clinically at creating change, and merit considering them together despite these differences. This review potentially illustrates that multimodal approaches may have benefits compared to standard single approaches. One possible reason for this, which is poorly explored in the literature, is the potential cumulative benefits of different interventions. This is widely recognized in other areas of human behaviour, where repetition or reinforcement in utilizing a variety of methods can alter both thinking and behaviours across a vast range of activities. One clear example is cigarette smoking cessation, where combinations of approaches seem to be more effective [161] and can include pharmacotherapy [160], nicotine replacement [161], health promotion [162], and using technological methods for reinforcement [163].

Given this, while it is clearly speculative, it is possible that the effectiveness of complex multimodal therapies may indicate that utilizing different approaches allows such reinforcements to occur more frequently. Another potential benefit is that all of these programs offer an intensive period of interaction, and certainly there is evidence linking this to positive clinical outcomes in adults. Linked to this is the possible role of repeated interactions with different groups and therapists, since in all these complex interactions there were interactions with many different individuals. It is therefore conceivable that such a large group of interactions may allow children to identify different therapists or support systems which suit them individually, whereas being limited to a single individual or methodology may not allow this. Despite such speculation, at this time it does appear that complex multimodal treatment programs appear to offer significant clinical benefits across a wide range of indications. Future research could therefore usefully compare best practice single interventions (such as CBT) against more complex interactions. This should be done in the same group of children and youth with the same conditions, ideally where they would be randomized to either group. Without such studies it is not possible to identify the potential best clinical approaches.


  1. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, et al. (2013) Mental health surveillance among children--United States, 2005-2011. MMWR Suppl 62: 1-35.
  2. Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, et al. (2003) Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry 60: 709-717.
  3. Nardi B, Francesconi G, Catena-Dell'osso M, Bellantuono C (2013) Adolescent depression: clinical features and therapeutic strategies. Eur Rev Med Pharmacol Sci 17: 1546-1551.
  4. Bor W, Dean AJ, Najman J, Hayatbakhsh R (2014) Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Aust N Z J Psychiatry 48: 606-616.
  5. Hawton K, Saunders KE, O'Connor RC (2012) Self-harm and suicide in adolescents. Lancet 379: 2373-2382.
  6. Clifford AC, Doran CM, Tsey K (2013) A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health 13: 463.
  7. Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, et al. (2012) Youth risk behavior surveillance - United States, 2011. MMWR Surveill Summ 61: 1-162.
  8. Carli V, Hoven CW, Wasserman C, Chiesa F, Guffanti G, et al. (2014) A newly identified group of adolescents at "invisible" risk for psychopathology and suicidal behavior: findings from the SEYLE study. World Psychiatry 13: 78-86.
  9. Guerrini I, Quadri G, Thomson AD (2014) Genetic and environmental interplay in risky drinking in adolescents: a literature review. Alcohol Alcohol 49: 138-142.
  10. Conway KP, Swendsen J, Husky MM, He JP, Merikangas KR (2016) Association of lifetime mental disorders and subsequent alcohol and illicit drug use: results from the national comorbidity survey-adolescent supplement. J Am Acad Child Adolesc Psychiat 55: 280-288.
  11. Mulvihill D (2005) The health impact of childhood trauma: an interdisciplinary review, 1997-2003. Issues Compr Pediatr Nurs 28: 115-136.
  12. Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, et al. (2010) Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc 85: 618-629.
  13. Flynn AB, Fothergill KE, Wilcox HC, Coleclough E, Horwitz R, et al. (2015) Primary Care Interventions to Prevent or Treat Traumatic Stress in Childhood: A Systematic Review. Acad Pediatr 15: 480-492.
  14. Epstein RA, Fonnesbeck C, Potter S, Rizzone KH, McPheeters M (2015) Psychosocial Interventions for Child Disruptive Behaviors: A Meta-analysis. Pediatrics 136: 947-960.
  15. Davidson LL, Grigorenko EL, Boivin MJ, Rapa E, Stein A, et al. (2015) A focus on adolescence to reduce neurological, mental health and substance-use disability. Nature 527: S161-166.
  16. Lawrence D, Hafekost J, Johnson SE, Saw S, Buckingham WJ, et al. (2015) Key findings from the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Aust N Z J Psychiat Dec.
  17. Shoemaker EZ, Tully LM, Niendam TA, Peterson BS (2015) The Next Big Thing in Child and Adolescent Psychiatry: Interventions to Prevent and Intervene Early in Psychiatric Illnesses. Psychiatr Clin North Am 38: 475-494.
  18. Fernandes V, Osório FL (2015) Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis. Eur Psychiat 30: 756-764.
  19. Forti-Buratti MA, Saikia R, Wilkinson EL, Ramchandani PG (2016) Psychological treatments for depression in pre-adolescent children (12 years and younger): systematic review and meta-analysis of randomised controlled trials. Eur Child Adolesc Psychiat Mar 11.
  20. Stallard P, Skryabina E, Taylor G, Anderson R, Ukoumunne OC, et al. (2015) A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years. Southampton (UK): NIHR Journals Library; 2015 Nov.
  21. Thoma N, Pilecki B, McKay D (2015) Contemporary Cognitive Behavior Therapy: A Review of Theory, History, and Evidence. Psychodyn Psychiatry 43: 423-461.
  22. Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR (2015) Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep 17: 52.
  23. Wu MS, Hamblin RJ, Storch EA (2015) Evidence-Based Psychological Treatments of Pediatric Mental Disorders. Adv Pediatr 62: 165-184.
  24. Hernandez L, Rodriguez AM, Spirito A (2015) Brief Family-Based Intervention for Substance Abusing Adolescents. Child Adolesc Psychiatr Clin N Am 24: 585-599.
  25. Young AS, Fristad MA (2015) Family-Based Interventions for Childhood Mood Disorders. Child Adolesc Psychiatr Clin N Am 24: 517-534.
  26. Kato N, Yanagawa T, Fujiwara T, Morawska A (2015) Prevalence of Children's Mental Health Problems and the Effectiveness of Population-Level Family Interventions. J Epidemiol 25: 507-516.
  27. Zajac K, Randall J, Swenson CC (2015) Multisystemic Therapy for Externalizing Youth. Child Adolesc Psychiatr Clin N Am 24: 601-616.
  28. James AC, James G, Cowdrey FA, Soler A, Choke A (2015) Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev Feb 18: CD004690.
  29. Friedmann H, Kohn R (2008) Mortality, or probability of death, from a suicidal act in the United States. Suicide Life Threat Behav 38: 287-301.
  30. Spirito A, Esposito-Smythers C (2006) Attempted and completed suicide in adolescence. Annu Rev Clin Psychol 2: 237-266.
  31. Beghi M, Rosenbaum JF (2010) Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. Curr Opin Psychiatry 23: 349-355.
  32. Pirkis J, Too LS, Spittal MJ, Krysinska K, Robinson J, et al. (2015) Interventions to reduce suicides at suicide hotspots: a systematic review and meta-analysis. Lancet Psychiatry 2: 994-1001.
  33. Di Napoli WA, Della Rosa A (2015) Suicide and attempted suicide: epidemiological surveillance as a crucial means of a local suicide prevention project in Trento's Province. Psychiatr Danub 27: S279-284.
  34. Calear AL, Christensen H, Freeman A, Fenton K, Busby Grant J, et al. (2016) A systematic review of psychosocial suicide prevention interventions for youth. Eur Child Adolesc Psychiatry 25: 467-482.
  35. Wilcox HC, Wyman PA (2016) Suicide Prevention Strategies for Improving Population Health. Child Adolesc Psychiatr Clin N Am 25: 219-233.
  36. Strunk CM, King KA, Vidourek RA, Sorter MT (2014) Effectiveness of the surviving the teens suicide prevention and depression awareness program: an impact evaluation utilizing a comparison group. Health Educ Behav 41: 605-613.
  37. Daniel SS, Goldston DB (2009) Interventions for suicidal youth: a review of the literature and developmental considerations. Suicide Life Threat Behav 39: 252-268.
  38. Burns J, Dudley M, Hazell P, Patton G (2005) Clinical management of deliberate self-harm in young people: the need for evidence-based approaches to reduce repetition. Aust N Z J Psychiatry 39: 121-128.
  39. Gould MS, Greenberg T, Velting DM, Shaffer D (2003) Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42: 386-405.
  40. Robinson J, Hetrick SE, Martin C (2011) Preventing suicide in young people: systematic review. Aust N Z J Psychiatry 45: 3-26.
  41. Steele MM, Doey T (2007) Suicidal behaviour in children and adolescents. Part 2: treatment and prevention. Can J Psychiatry 52: 35S-45S.
  42. Weare K, Nind M (2011) Mental health promotion and problem prevention in schools: what does the evidence say? Health Promot Int 26: i29-69.
  43. Robinson J, Pirkis J (2014) Research priorities in suicide prevention: an examination of Australian-based research 2007-11. Aust Health Rev 38: 18-24.
  44. Wei Y, Kutcher S, LeBlanc JC (2015) Hot Idea or Hot Air: A Systematic Review of Evidence for Two Widely Marketed Youth Suicide Prevention Programs and Recommendations for Implementation. J Can Acad Child Adolesc Psychiat 24: 5-16.
  45. Saunders K, Brand F, Lascelles K, Hawton K (2014) The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm patients. Emerg Med J 31: 796-798.
  46. Calear AL, Christensen H (2010) Systematic review of school-based prevention and early intervention programs for depression. J Adolesc 33: 429-438.
  47. Bond L, Butler H, Thomas L, Carlin J, Glover S, et al. (2007) Social and school connectedness in early seconda school as predictors of late teenage substance use, mental health, and academic outcomes. J Adolesc Health 40: e9-18.
  48. Durlak JA, Weissberg RP, Dymnicki AB, Taylor RD, Schellinger KB (2011) The impact of enhancing students' social and emotional learning: a meta-analysis of school-based universal interventions. Child Dev 82: 405-432.
  49. Brière FN, Rohde P, Shaw H, Stice E (2014) Moderators of two indicated cognitive-behavioral depression prevention approaches for adolescents in a school-based effectiveness trial. Behav Res Ther 53: 55-62.
  50. Spence SH, Shortt AL (2007) Research Review: Can we justify the widespread dissemination of universal, school-based interventions for the prevention of depression among children and adolescents? J Child Psychol Psychiat 48: 526-542.
  51. Merry SN, Hetrick SE, Cox GR, Brudevold-Iversen T, Bir JJ, et al. (2011) Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database Syst Rev: CD003380.
  52. van Zoonen K, Buntrock C, Ebert DD, Smit F, Reynolds CF, et al. (2014) Preventing the onset of major depressive disorder: a meta-analytic review of psychological interventions. Int J Epidemiol 43: 318-329.
  53. Wiefferink CH, Peters L, Hoekstra F, Dam GT, Buijs GJ, et al. (2006) Clustering of health-related behaviors and their determinants: possible consequences for school health interventions. Prev Sci 7: 127-149.
  54. Wei Y, Kutcher S (2012) International school mental health: global approaches, global challenges, and global opportunities. Child Adolesc Psychiatr Clin N Am 21: 11-27.
  55. Chung T, Colby SM, Barnett NP, Rohsenow DJ, Spirito A, et al. (2000) Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses. J Stud Alcohol 61: 579-587.
  56. Dever BV, Kamphaus RW, Dowdy E, Raines TC, Distefano C (2013) Surveillance of middle and high school mental health risk by student self-report screener. West J Emerg Med 14: 384-390.
  57. O'Leary-Barrett M, Topper L, Al-Khudhairy N, Pihl RO, Castellanos-Ryan N, et al. (2013) Two-year impact of personality-targeted, teacher-delivered interventions on youth internalizing and externalizing problems: a cluster-randomized trial. J Am Acad Child Adolesc Psychiat 52: 911-920.
  58. Balázs J, Miklósi M, Keresztény A, Hoven CW, Carli V, et al. (2013) Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk. J Child Psychol Psychiat 54: 670-677.
  59. Bertha EA, Balázs J (2013) Subthreshold depression in adolescence: a systematic review. Eur Child Adolesc Psychiatry 22: 589-603.
  60. Teesson M, Newton NC, Slade T, Chapman C, Allsop S, Hides L, et al. (2014) The CLIMATE schools combined study: a cluster randomised controlled trial of a universal Internet-based prevention program for youth substance misuse, depression and anxiety. BMC Psychiat 14: 32.
  61. Sheffield JK, Spence SH, Rapee RM, Kowalenko N, Wignall A, et al. (2006) Evaluation of universal, indicated, and combined cognitive-behavioral approaches to the prevention of depression among adolescents. J Consult Clin Psychol 74: 66-79.
  62. Sawyer MG, Pfeiffer S, Spence SH, Bond L, Graetz B, et al. (2010) School-based prevention of depression: a randomised controlled study of the beyondblue schools research initiative. J Child Psychol Psychiat 51: 199-209.
  63. Silverstone PH, Bercov M, Suen VY, Allen A, Cribben I, et al. (2015) Initial Findings from a Novel School-Based Program, EMPATHY, Which May Help Reduce Depression and Suicidality in Youth. PLoS One 10: e0125527.
  64. Tak YR, Van Zundert RM, Kuijpers RC, Van Vlokhoven BS, Rensink HF, et al. (2012) A randomized controlled trial testing the effectiveness of a universal school-based depression prevention program 'Op Volle Kracht' in the Netherlands. BMC Public Health 12: 21.
  65. Wijnhoven LA, Creemers DH, Vermulst AA, Scholte RH, Engels RC, et al. (2014) Randomized controlled trial testing the effectiveness of a depression prevention program ('Op Volle Kracht') among adolescent girls with elevated depressive symptoms. J Abn Child Psych 42: 217-228.
  66. Kindt KCM, van Zundert RMP, Engels RC (2012) Evaluation of a Dutch school-based depression prevention program for youths in high risk neighborhoods: study protocol of a two-armed randomized controlled trial. BMC Public Health 12: 212-218.
  67. Kindt KCM, Kleinjan M, Janssens JMAM, Scholte RHJ (2014) Evaluation of a School-Based Depression Prevention Program among Adolescents from Low-Income Areas: A Randomized Controlled Effectiveness Trial. Int J Environ Res Public Health 11: 5273-5293.
  68. Jaycox LH, Reivich KJ, Gillham J, Seligman ME (1994) Prevention of depressive symptoms in school children. Behav Res Ther 32: 801-816.
  69.  Gillham JE, Reivich KJ (1999) Prevention of depressive symptoms in school children: A research update. Psychol Sci 10: 461-462.
  70. Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatté AJ, et al. (2007) School-based prevention of depressive symptoms: A randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program. J Consult Clin Psychol 75: 9-19.
  71. Gillham JE, Reivich KJ, Brunwasser SM, Freres DR, Chajon ND, et al. (2012) Evaluation of a group cognitive-behavioral depression prevention program for young adolescents: a randomized effectiveness trial. J Clin Child Adolesc Psychol 41: 621-639.
  72. Spitzer RL, Kroenke K, Williams JB (1999) Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 282: 1737-1744.
  73. Ganguly S, Samanta M, Roy P, Chatterjee S, Kaplan DW, et al. (2013) Patient health questionnaire-9 as an effective tool for screening of depression among Indian adolescents. J Adolesc Health 52: 546-551.
  74. Richardson LP, McCauley E, McCarty CA, Grossman DC, Myaing M, et al. (2012) Predictors of persistence after a positive depression screen among adolescents. Pediatrics 130: e1541-1548.
  75. Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, et al. (2010) Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 126: 1117-1123.
  76. Patton R, Deluca P, Kaner E, Newbury-Birch D, Phillips T, et al. (2014) Alcohol screening and brief intervention for adolescents: The how, what, and where of reducing alcohol consumption and related harm among young people. Alcohol Alcoholism 49: 207-212.
  77. Carney T, Myers B (2012) Effectiveness of early interventions for substance-using adolescents: findings from a systematic review and meta-analysis. Subst Abuse Treat Prev Policy 7: 25.
  78. Curtis BL, McLellan AT, Gabellini BN (2014) Translating SBIRT to public school settings: an initial test of feasibility. J Subst Abuse Treat 46: 15-21.
  79. Hamza DM, Silverstone PH (2014) A Systematic Review of Treatment Modalities for Alcohol Use Disorder. J Subst Abuse Alcohol 2: 1023.
  80. Toumbourou JW, Stockwell T, Neighbors C, Marlatt GA, Sturge J, et al. (2007) Interventions to reduce harm associated with adolescent substance use. Lancet 369: 1391-1401.
  81. Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, et al. (2011) Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol 79: 433-440.
  82. Committee on Substance Abuse, Levy SJ, Kokotailo PK (2011) Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics 128: e1330-1340.
  83. Yuma-Guerrero PJ, Lawson KA, Velasquez MM, von Sternberg K, Maxson T, et al. (2012) Screening, brief intervention, and referral for alcohol use in adolescents: a systematic review. Pediatrics 130: 115-122.
  84. Sterling S, Valkanoff T, Hinman A, Weisner C (2012) Integrating substance use treatment into adolescent health care. Curr Psychiatry Rep 14: 453-461.
  85. Vendetti J, McRee B, Hernandez A, Karuntzos G (2013) Screening, brief intervention, and referral to treatment (SBIRT) implementation models and work flow processes: commonalities and variations. Addict Sci Clin Pract 8: 1.
  86. Hamza DM, Silverstone PH (2015) In the treatment of alcohol abuse there are no clear differences in outcomes between inpatient treatment and outpatient programs. J Addict Prevent 3: 9.
  87. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, et al. (1999) A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 153: 591-596.
  88. Knight JR, Harris SK, Sherritt L, Van Hook S, Lawrence N, et al. (2007) Prevalence of positive substance abuse screen results among adolescent primary care patients. Arch Pediatr Adolesc Med 161: 1035-1041.
  89. Pilowsky DJ, Wu LT (2013) Screening instruments for substance use and brief interventions targeting adolescents in primary care: a literature review. Addict Behav 38: 2146-2153.
  90. Harris SK, Louis-Jacques J, Knight JR (2014) Screening and brief intervention for alcohol and other abuse. Adolesc Med State Art Rev 25: 126-156.
  91. Dhalla S, Zumbo BD, Poole G (2011) A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Curr Drug Abuse Rev 4: 57-64.
  92. Whiteside U, Cronce JM, Pedersen ER, Larimer ME (2010) Brief motivational feedback for college students and adolescents: a harm reduction approach. J Clin Psychol 66: 150-163.
  93. Delima J, Vimpani G (2011) The neurobiological effects of childhood maltreatment: An often overlooked narrative related to the long-term effects of early childhood trauma? Family Matters 89: 42-52.
  94. Schore A (2005) Back to basics: Attachment, affect regulation, and the developing right brain: Linking developmental neuroscience to pediatrics. Pediatrics in Review. 26: 204-217.
  95. Anda RF, Brown DW, Felitti VJ, Bremner JD, Dube SR, et al. (2007) Adverse childhood experiences and prescribed psychotropic medications in adults. Am J Prev Med 5: 389.
  96. Anda R, Butchart A, Felitti V, Brown B (2010) Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences. Am J Prev Med 39: 93-98.
  97. Johnson SB, Riley AW, Granger DA, Riis J (2013) The science of early life toxic stress for pediatric practice and advocacy. Pediatrics 131: 319-327.
  98. Shonkoff JP, Garner AS (2012) Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129: e232-246.
  99. Knoverek AM, Briggs EC, Underwood LA, Hartman RL (2013) Clinical considerations for the treatment of latency age children in residential care. J Fam Violence 7: 653.
  100. Wöller W, Leichsenring F, Leweke F, Kruse J (2012) Psychodynamic psychotherapy for posttraumatic stress disorder related to childhood abuse--Principles for a treatment manual. Bull Menninger Clin 76: 69-93.
  101. Cohen JA, Mannarino AP, Kliethermes M, Murray LA (2012) Trauma-focused CBT for youth with complex trauma. Child Abuse Negl 36: 528-541.
  102. Cornett N, Bratton SC (2014) Examining the impact of child parent relationship therapy (CPRT) on family functioning. J Marital Fam Ther 40: 302-318.
  103. Marvin R, Cooper G, Hoffman K, Powell B (2002) The circle of security project: Attachment-based intervention with caregiver-pre-school child dyads. Attachment Hum Develop 4: 107-124.
  104. Rahim M (2014) Developmental trauma disorder: an attachment-based perspective. Clin Child Psychol Psychiatry 19: 548-560.
  105. Bremness A, Polzin W (2014) Commentary: Developmental Trauma Disorder: A Missed Opportunity in DSM V. J Can Acad Child Adolesc Psychiatry 23: 142-145.
  106. van der Kolk BA (2005) Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiat Ann 35: 401-408.
  107. van der Kolk BA, Fisler RE (1994) Childhood abuse and neglect and loss of self-regulation. Bull Menninger Clin 58: 145-168.
  108. Ashton CK, O’Brien-Langer A, Silverstone PH (2016) The CASA Trauma and Attachment Group (TAG) program for children who have attachment issues following early developmental trauma. J Can Acad Child Adolesc Psychiat, 25: 35-42.
  109. Slade A (2005) Parental reflective functioning: an introduction. Attach Hum Dev 7: 269-281.
  110. Snyder R, Shapiro S, Treleaven D (2012) Attachment theory and mindfulness. J Child Fam Stud 21: 709-717.
  111. Perry BD (2009) Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. J Loss Trauma 14: 240-255.
  112. Purvis KB, Cross DR, Dansereau DF, Parris SR (2013) Trust-based relational intervention (TBRI): A systemic approach to complex developmental trauma. Child Youth Serv 34: 360-386.
  113. Kabat-Zinn J (2011) Some reflections on the origins of MBSR, skillful means, and the trouble with maps. Contemp Buddhism 12: 281-306.
  114. Kamphaus RW, Reynolds CR (2006) Parenting relationship questionnaire. Minneapolis, MN: NCS Pearson.
  115. Finkelhor D (1994) The international epidemiology of child sexual abuse. Child Abuse Neglect 18: 409-417.
  116. Pereda N, Guilera G, Forns M, Gómez-Benito J (2009) The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl 33: 331-342.
  117. Martin EK, Silverstone PH (2013) How Much Child Sexual Abuse is "Below the Surface," and Can We Help Adults Identify it Early? Front Psychiatry 4: 58.
  118. Finkelhor D (2009) The prevention of childhood sexual abuse. Future Child 19: 169-194.
  119. Collin-Vézina D, Hélie S, Trocmé N (2010) Is child sexual abuse declining in Canada? An analysis of child welfare data. Child Abuse Negl 34: 807-812.
  120. Diamond M, Jozifkova E, Weiss P (2011) Pornography and sex crimes in the Czech Republic. Arch Sex Behav 40: 1037-1043.
  121. Livingstone S, Smith PK (2014) Annual research review: Harms experienced by child users of online and mobile technologies: the nature, prevalence and management of sexual and aggressive risks in the digital age. J Child Psychol Psychiat 55: 635-654.
  122. Maniglio R (2009) The impact of child sexual abuse on health: a systematic review of reviews. Clin Psychol Rev 29: 647-657.
  123. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, et al. (2006) The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 256: 174-186.
  124. Belsky J, de Haan M (2011) Annual Research Review: Parenting and children's brain development: the end of the beginning. J Child Psychol Psychiatry 52: 409-428.
  125. Kaffman A (2009) The silent epidemic of neurodevelopmental injuries. Biol Psychiatry 66: 624-626.
  126. Watts-English T, Fortson BL, Gibler N, Hooper SR, De Bellis MD (2006) The Psychobiology of Maltreatment in Childhood. J Social Issues 62: 717-736.
  127. Wurtele SK (2009) Preventing sexual abuse of children in the twenty-first century: preparing for challenges and opportunities. J Child Sex Abus 18: 1-18.
  128. Yancey CT, Hansen DJ, Naufel KZ (2011) Heterogeneity of individuals with a history of child sexual abuse: an examination of children presenting to treatment. J Child Sex Abus 20: 111-127.
  129. Kajeepeta S, Gelaye B, Jackson CL, Williams MA (2015) Adverse childhood experiences are associated with adult sleep disorders: a systematic review. Sleep Med 16: 320-330.
  130. Wosu AC, Gelaye B, Williams MA (2015) History of childhood sexual abuse and risk of prenatal and postpartum depression or depressive symptoms: an epidemiologic review. Arch Womens Ment Health 18: 659-671.
  131. O'Brien BS, Sher L (2013) Child sexual abuse and the pathophysiology of suicide in adolescents and adults. Int J Adolesc Med Health 25: 201-205.
  132. Kendall-Tackett KA, Williams LM, Finkelhor D (1993) Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull 113: 164-180.
  133. Pettersen KT (2013) A study of shame from sexual abuse within the context of a Norwegian incest center. J Child Sex Abus 22: 677-694.
  134. Feiring C, Simon VA, Cleland CM, Barrett EP (2013) Potential pathways from stigmatization and externalizing behavior to anger and dating aggression in sexually abused youth. J Clin Child Adolesc Psychol 42: 309-322.
  135. Schönbucher V, Maier T, Mohler-Kuo M, Schnyder U, Landolt MA (2012) Disclosure of child sexual abuse by adolescents: a qualitative in-depth study. J Interpers Violence 27: 3486-3513.
  136. Cort NA, Gamble SA, Smith PN, Chaudron LH, Lu N, et al. (2012) Predictors of treatment outcomes among depressed women with childhood sexual abuse histories. Depress Anxiety 29: 479-486.
  137. Aydin B, Akbas S, Turla A, Dundar C, Yuce M, et al. (2015) Child sexual abuse in Turkey: an analysis of 1002 cases. J Forensic Sci 60: 61-65.
  138. Gospodarevskaya E (2013) Post-traumatic stress disorder and quality of life in sexually abused Australian children. J Child Sex Abus 22: 277-296.
  139. Ehlert U (2013) Enduring psychobiological effects of childhood adversity. Psychoneuroendocrinology 38: 1850-1857.
  140. De Bellis MD, Spratt EG, Hooper SR (2011) Neurodevelopmental biology associated with childhood sexual abuse. J Child Sex Abus 20: 548-587.
  141. Enlow MB, Egeland B, Blood EA, Wright RO, Wright RJ (2012) Interpersonal trauma exposure and cognitive development in children to age 8 years: a longitudinal study. J Epidemiol Community Health 66: 1005-1010.
  142. Veltman MWM, Browne KD (2001) Three decades of child maltreatment research: implications for the school years. Trauma Violence Abuse 2: 215-239.
  143. Greenspan F, Moretzsohn AG, Silverstone PH (2013) What treatments are available for Childhood Sexual Abuse, and how do they compare? Int J Adv Psychol 2: 232-241.
  144. Mannarino AP, Cohen JA, Deblinger E, Runyon MK, et al. (2012) Trauma-focused cognitive-behavioural therapy for children sustained impact of treatment 6 and 12 months later. Child Maltreatment 17: 231-241.
  145. Scott TA, Burlingame G, Starling M, Porter C, Lilly JP (2003) Effects of individual client-centered play therapy on sexually abused children’s mood, self-concept, and social competence. Int J Ther 12: 7-30.
  146. Pifalo T (2006) Art therapy with sexually abused children and adolescents: Extended research study. Art Ther 23: 181-185.
  147. Dietz TJ, Davis D, Pennings J (2012) Evaluating animal-assisted therapy in group treatment for child sexual abuse. J Child Sex Abus 21: 665-683.
  148. Ewing CA, Macdonald PM, Taylor M, Bowers MJ (2007) Equine-facilitated learning for youths with severe emotional disorders: a quantitative and qualitative study. Child Youth Care Forum 36: 59-72.
  149. Keeshin BR, Strawn JR, Luebbe AM, Saldaña SN, Wehry AM, et al. (2014) Hospitalized youth and child abuse: a systematic examination of psychiatric morbidity and clinical severity. Child Abuse Negl 38: 76-83.
  150. Kolko DJ, Baumann BL, Caldwell N (2003) Child abuse victims' involvement in community agency treatment: service correlates, short-term outcomes, and relationship to reabuse. Child Maltreat 8: 273-287.
  151. Paul LA, Gray MJ, Elhai JD, Massad PM, Stamm BH (2006) Promotion of evidence-based practices for child traumatic stress in rural populations: identification of barriers and promising solutions. Trauma Violence Abuse 7: 260-273.
  152. Ehlers A, Hackmann A, Grey N, Wild J, Liness S, et al. (2014) A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. Am J Psychiatry 171: 294-304.
  153. Cloitre M (2014) Alternative Intensive Therapy for PTSD. Am J Psychiatry 171: 249-251.
  154. Silverstone PH, Greenspan F, Silverstone M, Sawa H, Linder J (2015) A novel, intensive, and comprehensive program to help children aged 8-12 who have been victims of child sexual abuse: The Be Brave Ranch (BBR) 1-year program. J Child Adolesc Behav 3: 1.
  155. Linder J, Silverstone PH (2016) Initial long-term findings from a multimodal treatment program for child sexual abuse victims demonstrate reduction of PTSD frequency and symptoms. J Child Adolesc Behav 4: 3.
  156. Silverstone PH, Greenspan F, Silverstone M, Sawa H, Linder J (2016) A complex multimodal 4-week residential treatment program significantly reduces PTSD symptoms in child sexual abuse victims. J Child Adolesc Behav 4: 275.
  157. Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N (2013) Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents (Review). Evid Based Child Health 8: 1004-1116.
  158. Foa EB, McLean CP, Capaldi S, Rosenfield D2 (2013) Prolonged exposure vs supportive counseling for sexual abuse-related PTSD in adolescent girls: a randomized clinical trial. JAMA 310: 2650-2657.
  159. Stead LF, Koilpillai P, Lancaster T (2015) Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev: CD009670.
  160. McDonough M (2015) Update on medicines for smoking cessation. Aust Prescr 38: 106-111.
  161. Stead LF, Perera R, Bullen C, Mant D, Lancaster T (2008) Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev Jan 23: CD000146.
  162. Golechha M (2016) Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward. Int J Prev Med 7: 7.
  163. Das S, Tonelli M, Ziedonis D (2016) Update on Smoking Cessation: E-Cigarettes, Emerging Tobacco Products Trends, and New Technology-Based Interventions. Curr Psychiatry Rep 18: 51.

Citation: Silverstone PH, Suen VYM, Ashton CK, Hamza DM, Martin EK, et al. (2016) Are Complex Multimodal Interventions the Best Treatments for Mental Health Disorders in Children and Youth?. J Child Adolesc Behav 4: 305. Doi: 10.4172/2375-4494.1000305

Copyright: © 2016 Silverstone PH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.