Feasibility of a trauma-focused internet- and mobile-based intervention for youth with posttraumatic stress symptoms

Figures & data

Figure 1. Study flow.

Note. CATS = Child and Adolescent Trauma Screen, Sachser et al., 2022, CUDIT-R = Cannabis Use Disorder Identification Test-Revised, Adamson et al., 2010, IMI = Internet-and mobile-based intervention. PTSD = Posttraumatic Stress Disorder, PTSS = Posttraumatic Stress Symptoms.

Table 1. Overview of the session content of the IMI.

Thematic unit	Session content
Safety and coping skills (sessions 1–3)	Clarification of treatment motives and goals, Psychoeducation on trauma, PTSD, and trauma-focused interventions.
	Psychoeducation on arousal, developing an individual arousal scale, getting to know and practicing of relaxation skills encompassing self-soothing techniques and distress tolerance skills.
	Psychoeducation on the function of emotions, getting to know and practicing of affective regulation skills (i.e. acceptance-based emotion regulation).
Processing of the traumatic event (sessions 4–6)	Imaginal exposure of the traumatic event by drafting a first version of a trauma narrative from the perspective of a neutral observer.
	Imaginal exposure of the traumatic event by writing a trauma narrative from a first-person perspective.
	Imaginal exposure of the traumatic event by writing a further trauma narrative from a first person perspective focusing on feelings and thoughts.
Consolidation and integration (sessions 7–9)	Psychoeducation on maladaptive trauma-related thoughts, getting to know and practicing cognitive techniques for restructuring maladaptive thoughts and developing new helpful thoughts.
	Relapse prevention, Evaluation of predefined goals, psychoeducation on posttraumatic growth.
	Refreshment of skills, redefining individual goals.

Table 2. Sociodemographic data at baseline.

Characteristics	Total sample (N = 32)
PTSS (CATS), M (SD)	31.63 (7.64)
PTSD diagnosis (CAPS-CA-5, clinician-rated), n (%)	21 (66)
CAPS-CA-5, total score (SD)	31.5 (7.89)
Dissociative symptoms, n (%)	8 (25)
Potentially traumatic events (most distressing) M (SD)	2 (2.56)
Gender n (%)
Female	28 (87)
Male	3 (9)
Diverse	1 (3)
Age M (SD)	19 (1.7)
Minor n (%)	4 (13)
Self-reported mental disorder n (%)
Lifetime diagnosis of any mental disorder	18 (56)
Depression	11 (34)
PTSD	7 (22)
Borderline personality disorder	3 (9)
Anxiety disorder	2 (6)
Attention deficit hyperactivity disorder	1 (3)
Bulimia nervosa	1 (3)
Personality disorder (not defined)	1 (3)
Alcohol consumption disorder	1 (3)
Previous treatment (for any mental disorder) n (%)	16 (50)
Physical disease n (%)	6 (19)
Current medical treatment n (%)	9 (28)
Reasons for participating in IMI study n (%)
Preference for self-help	20 (62)
IMI seems appealing	14 (44)
Prolonged waiting times for face-to-face therapy	13 (41)
No psychotherapy facility located	9 (28)
Worries about not being taken seriously	6 (19)
Concerns about disclosing personal matters to strangers	5 (16)
Lack of knowledge of services available	5 (16)
Timing or travel constraints	4 (13)
No other treatment identified	4 (13)
Financial concerns	3 (9)
Problems not deemed severe enough for psychotherapy	3 (9)
Unavailable psychotherapy services in the residential region	2 (6)
No psychotherapy due to fear of stigmatization	2 (6)
Confidence in self-help	2 (6)
Other reasons	1 (3)
Recruitment source n (%)
Relatives	9 (28)
Instagram	8 (25)
Friends	6 (19)
Counselling centre	6 (19)
Insurance company	4 (13)

Notes. M = mean. PTSD = Posttraumatic Stress Disorder. PTSS = Posttraumatic Stress Symptoms measured with CATS (Child and Adolescent Trauma Screen, Sachser et al., 2022). CAPS-CA-5 = Clinician Administered PTSD Scale for DSM 5 – Child and Adolescent Version (Pynoos et al., 2015). SD = standard deviation. T1 =  Baseline, self-rated online assessment before IMI access.

*15-item screen for exposure to potentially traumatic events defined as distressing and disturbing events in the Child and Adolescent Trauma Screen.

Figure 2. Completion rates of IMI sessions in % (n = 32).

Note. Session numbers 1–3 deal with safety and coping skills. Sessions 4–6 deal with trauma processing. Session 7–9 deal with consolidation/integration of the traumatic event(s), with session 9 being a booster-session.

Table 3. Means and Standard Deviations for participant responses to the IMI for all time points in the study completer sample

Variable/time point	Pre (T1) (n = 32)	Mid (T2) (n = 23)	Post (T3) (n = 22)	Follow-Up (T4) (n = 19)
Posttraumatic stress symptoms (CATS), M, SD	31.63 (7.64)	27.17 (8.59)	22.59 (10.59)	21.63 (11.21)
PTSD severity (CAPS-CA-5), total score, SD	31.47 (7.89)	–	21.14 (11.82)	–
Depressive symptoms (PHQ-9*), M, SD	12.66 (4.11)	11.91 (4.79)	8.73 (5.21)	8.68 (4.55)
Anxiety symptoms (GAD-7), M, SD	10.78 (4.41)	10.78 (3.91)	8.27 (4.93)	7.37 (4.23)
Health-related quality of life (KIDSCREEN), M, SD	28.50 (4.93)	29.83 (6.11)	32.64 (6.58)	33.84 (6.44)
Posttraumatic cognitions (CPTCI-SF), M, SD	25.97 (5.6)	–	23.82 (7.51)	–

Note. CAPS-CA-5 = Clinician Administered PTSD Scale for DSM 5 – Child and Adolescent Version (Pynoos et al., 2015).

CATS = Child and Adolescent Trauma Screen (Sachser et al., 2022). CPTCI-SF = Posttraumatic Cognitions Inventory Short Form (McKinnon et al., 2016). GAD-7 = Generalized Anxiety Disorder Assessment (Spitzer et al., 2006). KIDSCREEN = Health-Related Quality of Life Questionnaire for Children and Young People (Ravens-Sieberer et al., 2010). M = Mean. PHQ-9 = Patient Health Questionnaire (Kroenke et al., 2001). SD = Standard Deviation. T1 = Baseline before IMI access. T2 = after completion of the third session or 3 weeks after IMI access. T3 = after completion of the eight core sessions, or 8 weeks after IMI access. T4 = 6 months after IMI access.

Table 4. Participant responses from Pre (T1) to Post-Treatment (T3), Pre-Treatment (T1) to Follow-Up (T4), and Post-Treatment (T3) to Follow-Up (T4) in a per-protocol analysis with study completer data.

Variable	M (SD)*	M (SD)*	n	t(df)	p	d	95%CI
	Pre (T1)	Mid (T2)
Posttraumatic stress symptoms (CATS)	30.39 (7.38)	27.17 (8.59)	23	2.27 (22)	0.033	0.46	0.04–0.87
Depressive symptoms (PHQ-9*)	11.83 (3.94)	11.91 (4.79)	23	−0.01 (22)	0.913	−0.02	−0.42–0.37
Anxiety symptoms (GAD-7)	9.70 (4.18)	10.65 (3.92)	23	−1.53 (22)	0.139	−0.31	−0.71–0.10
Health-related quality of life (KIDSCREEN)	29.04 (4.93)	29.83 (6.10)	23	−0.80 (22)	0.434	−0.16	−0.56–0.24
	Pre (T1)	Post (T3)
Posttraumatic stress symptoms (CATS)	31.05 (8.45)	22.59 (10.59)	22	4.27 (21)	<.001	0.88	0.39–1.35
PTSD severity (CAPS-CA-5)	31.14 (7.69)	21.14 (11.82)	22	4.52 (21)	<.001	0.93	0.43–1.41
Depressive symptoms (PHQ-9*)	12.23 (4.67)	8.73 (5.21)	22	3.48 (21)	0.002	0.71	.25–1.16
Anxiety symptoms (GAD-7)	10 (4.71)	8.27 (4.94)	22	1.61 (21)	0.123	0.33	−.09–.74
Health-related quality of life (KIDSCREEN)	29.18 (5.07)	32.64 (6.58)	22	−2.26 (21)	0.034	−0.47	−.89– –.03
Posttraumatic cognitions (CPTCI-SF)	25.95 (6.29)	23.82 (7.51)	22	2.07 (21)	0.052	0.42	0–.84
	Pre (T1)	Follow-Up (T4)
Posttraumatic stress symptoms (CATS)	30.53 (7.98)	21.63 (11.21)	19	3.83 (18)	0.001	0.84	0.32–1.34
Depressive symptoms (PHQ-9*)	11.37 (3.89)	8.68 (4.55)	19	2.34 (18)	0.031	0.51	.05–.97
Anxiety symptoms (GAD-7)	9.84 (4.68)	7.37 (4.23)	19	2.44 (18)	0.025	0.54	.06–0.99
Health-related quality of life (KIDSCREEN)	29.63 (4.90)	33.84 (6.44)	19	−2.85 (18)	0.011	−0.63	−1.09– –.15
	Post (T3)	Follow-Up (T4)
Posttraumatic stress symptoms (CATS)	20.18 (9.29)	19.47 (9.7)	17	.52 (16)	0.612	0.12	−.34–.57
Depressive symptoms (PHQ-9*)	6.94 (3.29)	8.06 (4.38)	17	−1.42 (16)	0.174	−0.33	−.79–.14
Anxiety symptoms (GAD-7)	6.67 (3.99)	6.67 (4.01)	17	0 (16)	1	0	−.45–.45
Health-related quality of life (KIDSCREEN)	33.82 (6.43)	34.35 (6.52)	17	−.35 (16)	0.734	−0.08	−.53–.37

Note. *Means and standard deviations represent pairwise data. CAPS-CA-5 = Clinician Administered PTSD Scale for DSM 5 – Child and Adolescent Version (Pynoos et al., 2015). CATS = Child and Adolescent Trauma Screen (Sachser et al., 2022). CPTCI-SF = Posttraumatic Cognitions Inventory Short Form (McKinnon et al., 2016). CSQ-I = Client Satisfaction Questionnaire, adapted for internet-based interventions (Boß et al., 2016). GAD-7 = Generalized Anxiety Disorder Assessment (Spitzer et al., 2006). KIDSCREEN = Health-Related Quality of Life Questionnaire for Children and Young People (Ravens-Sieberer et al., 2010). PHQ-9 = Patient Health Questionnaire (Kroenke et al., 2001). T1 = Baseline before IMI access. T2 = after completion of the third session or 3 weeks after IMI access. T3 = after completion of the eight core sessions, or 8 weeks after IMI access. T4 = 6 months after IMI access.

Table 5. Longitudinal relationship between outcomes and time (T1 to T2, T1 to T3, T1 to T4) in a multivariate model repeated measures (MMRM) analysis.

	Regression Coefficient		MMRM Model			Effect size
Variable/Outcome	βchange	SE	T	df	p	d	95%CI
Posttraumatic stress symptoms (CATS)
Mid-Intervention (T2)	−3.43	1.33	2.59	24.33	.016	−0.45	−0.8– –0.1
Post-Assessment (T3)	−7.44	1.81	4.12	23.56	<.005	−0.97	−1.46– –0.49
Follow-Up (T4)	−7.78	1.96	3.96	23.96	<.005	−1.02	−1.54– –0.5
PTSD severity (CAPS-CA-5)
Post-Assessment (T3)	−10.08	2.13	4.74	21.24	<.001	−1.31	−1.87– –0.75
Depressive symptoms (PHQ-9*)
Mid-Intervention (T2)	0.07	0.72	0.09	25.07	.927	0.02	−0.35– −0.39
Post-Assessment (T3)	−3.01	0.91	3.29	23.85	.003	−0.76	−1.23– –0.29
Follow-Up (T4)	−2.29	0.96	2.39	23.45	.025	−0.58	−1.07– –0.08
Anxiety symptoms (GAD-7)
Mid-Intervention (T2)	0.62	0.59	1.06	23.34	.302	0.15	−0.13–0.44
Post-Assessment (T3)	−1.82	0.95	1.92	25.91	.066	−0.44	−0.9–0.02
Follow-Up (T4)	−2.48	0.84	2.95	23.57	.007	−0.6	−1.02– –0.18
Health-related quality of life (KIDSCREEN)
Mid-Intervention (T2)	0.58	0.95	0.62	22.48	.544	0.11	−0.27–0.51
Post-Assessment (T3)	3.81	1.39	2.74	23.8	.011	0.77	0.19–1.35
Follow-Up (T4)	4.71	1.31	3.59	22.5	.001	0.95	0.41–1.5
Posttraumatic Cognitions (CPTCI)
Post-Assessment (T3)	−2.14	0.99	2.14	21.13	.044	−0.34	−0.6–−0.02

Note. CAPS-CA-5 = Clinician Administered PTSD Scale for DSM 5 – Child and Adolescent Version (Pynoos et al., 2015). CATS = Child and Adolescent Trauma Screen (Sachser et al., 2022). CPTCI-SF = Posttraumatic Cognitions Inventory Short Form (McKinnon et al., 2016). GAD-7 = Generalized Anxiety Disorder Assessment (Spitzer et al., 2006). KIDSCREEN = Health-Related Quality of Life Questionnaire for Children and Young People (Ravens-Sieberer et al., 2010). PHQ-9 = Patient Health Questionnaire (Kroenke et al., 2001). T1 = Baseline before IMI access. T2 = after completion of the third session or 3 weeks after IMI access. T3 = after completion of the eight core sessions, or 8 weeks after IMI access. T4 = 6 months after IMI access.

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Data availability statement

The data that support the findings of this study are available from the corresponding author, [ChS], upon request.