The Roles of Between-Session Habituation and Distress Tolerance in Two Exposure-Based Trauma-Focused Treatments in Children with Posttraumatic Stress

Patterns of association among key processes in child trauma-focused treatments for posttraumatic stress are not well understood. There is evidence of between-session habituation and distress tolerance as mechanism of exposure-based therapy with adults with posttraumatic stress disorder, but limited research exists among children.

This study examined patterns of association during treatment for between-session habituation and distress tolerance in a parent-led/therapist-assisted treatment, Stepping Together for Children after Trauma (Stepping Together-CT) versus Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) with children (ages 4–12).

Measures included child/parent self-reports of subjective distress, distress tolerance, and heart rate and skin conductance level to a trauma reminder, collected three times during treatment and primary measures of posttraumatic stress symptoms and impairment collected at post-treatment (Stepping Together-CT: n = 43; TF-CBT: n = 71). We used linear mixed-effect models with repeated measures, mediation, moderated mediation, and linear regression to estimate effects.

In Stepping Together-CT, parent-reported child distress and child distress change rates followed a concave pattern. In TF-CBT, parent-reported distress change rate was convex and child distress did not significantly change. In both conditions, child distress tolerance change rate increased over time and heart rate reactivity decreased prior to increasing over time, but not skin conductance level reactivity. Change in parent perception of child peak distress during trauma retelling in Stepping Together-CT was associated with later change in trauma symptom improvement.

Parent perception of child distress during trauma processing may play a role in symptom reduction, with implications for parent-led trauma treatments.