Trauma in early childhood: Empirical evidence and clinical implications

Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools

Background

: It is estimated that children below 18 years constitute 50% of the refugee population worldwide, which is the highest figure in a decade. Due to conflicts like the Syrian crises, children are continuously exposed to traumatic events. Trauma exposure can cause mental health problems that may in turn increase the risk of morbidity and mortality. Tools such as questionnaires and interview guides are being used extensively, despite the fact that only a few have been tested and their validity confirmed in refugee children and youth. : Our aim was to provide a systematic review of the validated screening and measurement tools available for assessment of trauma and mental health among refugee children and youth. : We systematically searched the databases PubMed, PsycINFO and PILOTS. The search yielded 913 articles and 97 were retained for further investigation. In accordance with the PRISMA guidelines two authors performed the eligibility assessment. The full text of 23 articles was assessed and 9 met the eligibility criteria. Results : Only nine studies had validated trauma and mental health tools in refugee children and youth populations. A serious lack of validated tools for refugee children below the age of 6 was identified. : There is a lack of validated trauma and mental health tools, especially for refugees below the age of 6. Detection and treatment of mental health issues among refugee children and youth should be a priority both within the scientific community and in practice in order to reduce morbidity and mortality.

PTSD with and without dissociation in young children exposed to interpersonal trauma

BACKGROUND

A Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) was added to the DSM-5, but little is known about this symptom pattern in young children exposed to trauma. Tailoring treatment to traumatized young children requires understanding the different patterns of trauma-related symptomatology and important correlates. The current study tested the hypothesis that type and number of child traumatic events, caregiver trauma exposure, and caregiver symptomatology would predict whether traumatized young children presented with PTSD, PTSD with clinical dissociation, or non-clinical trauma symptoms.

METHODS

A multinomial regression was conducted using data collected from an ethnically and economically diverse sample of 297 trauma-exposed children between the ages of 3 and 6 and their caregivers. Based on parent-report on a well-validated measure of trauma symptoms, children were categorized into three groups: non-clinical (n = 128), PTSD only (n = 104), or PTSD with dissociation (PTSD-DISS; n = 65). Predictors included trauma exposure, parent trauma symptoms, and child sex.

RESULTS

Girls were twice more likely than boys to be in the PTSD-DISS group; sexually abused children were almost three times as likely to be in the PTSD-DISS group; and, for every unit increase in parent avoidance symptoms or number of traumatic events, the odds of being in the PTSD-DISS group increased significantly.

LIMITATIONS

Given the cross-sectional study design, conclusions cannot be drawn regarding causality. Measures were completed by a single reporter.

CONCLUSIONS

Findings suggest that subgroups of children may be especially vulnerable to comorbid PTSD and dissociation. Implications for treatment are discussed.

A Diagnosis of Denial: How Mental Health Classification Systems Have Struggled to Recognise Family Violence as a Serious Risk Factor in the Development of Mental Health Issues for Infants, Children, Adolescents and Adults

Child and adolescent mental health services (CAMHS) routinely overlook assessing for, and providing treatment to, infants and children living with family violence, despite family violence being declared endemic across the globe. As contemporary neuro-developmental research recognises the harm of being exposed to early relational trauma, key international diagnostic texts such as the DSM-5 and ICD-10 struggle to acknowledge or appreciate the relational complexities inherent in addressing family violence and its impacts during childhood. These key texts directly influence thinking, funding and research imperatives in adult services as well as CAMHS, however, they rarely reference family violence. Their emphasis is to pathologise conditions over exploring causality which may be attributable to relational violence. Consequently, CAMHS can miss important indicators of family violence, misdiagnose disorders and unwittingly, not address unacceptable risks in the child's caregiving environment. Notwithstanding urgent safety concerns, ongoing exposure to family violence significantly heightens the development of mental illness amongst children. CAMHS providers cannot and should not rely on current diagnostic manuals alone. They need to act now to see family violence as a significant and important risk factor to mental health and to treat its impacts on children before these develop into enduring neurological difficulties.

ASSESSING ANGELS IN THE NURSERY: A PILOT STUDY OF CHILDHOOD MEMORIES OF BENEVOLENT CAREGIVING AS PROTECTIVE INFLUENCES

This pilot study provides the first empirical test of the concept of "Angels in the Nursery" by examining whether childhood memories of benevolent caregiving experiences protect against heightened levels of psychopathology in high-risk mothers. The study hypothesized that (a) elaborated childhood memories of feeling loved by a caregiver ("angel memories") would moderate adulthood posttraumatic stress disorder (PTSD) symptoms in mothers with childhood maltreatment histories, and (b) spontaneous traumatic intrusions ("ghost memories") would mediate childhood maltreatment and adulthood PTSD symptoms. Participants were 54 mothers (M = 32.79 years, SD = 8.91; 59.2% African American, 13.0% Caucasian, 5.6% Latina, 22.2% biracial/multiracial) who completed standardized assessments of childhood maltreatment and adulthood PTSD symptoms, and a novel instrument, the Angels in the Nursery Interview ("Angels Interview," Van Horn, Lieberman, & Harris, 2008). Results showed that angel memories significantly moderated childhood maltreatment and adulthood PTSD symptoms, consistent with a protective effect. Higher levels of ghost memories during the Angels Interview were significantly associated with more extensive childhood maltreatment, but did not mediate maltreatment and PTSD symptoms. Findings indicate that the Angels Interview can identify pathogenic intrusions rooted in childhood maltreatment and protective factors to promote maternal mental health and buffer the intergenerational transmission of trauma.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Clinical Pictures and Moderating Factors

PURPOSE OF REVIEW

This paper surveys the existent theoretical and research literature regarding the needs of preschool children in the context of disasters and terrorism with the aim of understanding (a) the consequences of such events for young children and (b) the main moderating variables influencing the event-consequence association to learn how to enhance their resilience.

RECENT FINDINGS

Consequences include a variety of emotional, behavioral, and biological outcomes. Implications for refugee children are discussed. Main moderating variables were mother's sensitivity and mother's PTSD symptoms. Exposure to disasters and terrorism may have severe effects on the mental health and development among preschool children. Future research should explore the implications of different levels of exposure and the effects of moderating psychosocial and biological variables, including the parent-child triad, on the event-consequence relationship.

The protective role of maternal posttraumatic growth and cognitive trauma processing among Palestinian mothers and infants

War survivors use multiple cognitive and emotional processes to protect their mental health from the negative impacts of trauma. Because mothers and infants may be especially vulnerable to trauma in conditions of war, it is urgent to determine which cognitive and emotional processes are effective for preventing negative trauma impacts." This study examined whether mothers' high posttraumatic growth (PTG) and positive posttraumatic cognitions (PTC) protected (a) their own mental health and (b) their infants' stress regulation and sensorimotor and language development from the effects of war trauma. The participants were 511 Palestinian mothers and their infants living in the Gaza strip. The mothers were interviewed in their second trimester of pregnancy (T1) as well as when the infant was four months (T2) and twelve months (T3). Mothers reported posttraumatic growth (PTG; Tedeschi & Calhoun, 1996) at T1 and posttraumatic cognitions (PTCI; Foa et al., 1999) at T2. They also reported their exposure to traumatic war events both at T1 and T3 and described their mental health conditions (e.g., PTSD and/or depressive and dissociation symptoms) at T3. The Infant Behaviour Questionnaire (IBQ) was used to measure infants' stress regulation at T2 and sensorimotor and language development at T3. The results, based on regression analyses with interaction terms between trauma and PTG, showed that high levels of traumatic war events were not associated with high levels of PTSD, depressive, or dissociation symptoms among mothers showing high levels of PTG. This suggests that PTG may protect maternal mental health from the effects of trauma. In turn, positive maternal PTCs appeared to protect the infants' stress regulation from the effects of war trauma. The study concludes by discussing ways to develop and implement preventive interventions for mother-infant dyads in war conditions.

The Role of Environmental Factors in the Aetiology of Social Anxiety Disorder: A Review of the Theoretical and Empirical Literature

Social anxiety disorder (SAD) is characterised by a marked and persistent fear of social/performance situations, and a number of key environmental factors have been implicated in the aetiology of the disorder. Hence, the current article reviews theoretical and empirical evidence linking the development of SAD with parenting factors, traumatic life events, and aversive social experiences. Specifically, research suggests that the risk of developing SAD is increased by over-controlling, critical and cold parenting, an insecure attachment style, aversive social/peer experiences, emotional maltreatment, and to a lesser extent other forms of childhood maltreatment and adversity. Moreover, these factors may lead to posttraumatic reactions, distorted negative self-imagery, and internalised shame-based schemas that subsequently maintain SAD symptomatology. However, further research is necessary to clarify the nature, interactions, and relative contributions of these factors. It is likely that SAD develops via a complex interplay of biological and environmental factors, and that multiple aetiological pathways underlie the development of the disorder.

Maternal childhood trauma, postpartum depression, and infant outcomes: Avoidant affective processing as a potential mechanism

BACKGROUND

Women who have experienced childhood trauma may be at risk for postpartum depression, increasing the likelihood of negative outcomes among their children. Predictive pathways from maternal childhood trauma to child outcomes, as mediated by postpartum depression, require investigation.

METHODS

A longitudinal sample of South African women (N=150) was followed through pregnancy and postpartum. Measures included maternal trauma history reported during pregnancy; postpartum depression through six months; and maternal-infant bonding, infant development, and infant physical growth at one year. Structural equation models tested postpartum depression as a mediator between maternal experiences of childhood trauma and children's outcomes. A subset of women (N=33) also participated in a lab-based emotional Stroop paradigm, and their responses to fearful stimuli at six weeks were explored as a potential mechanism linking maternal childhood trauma, postpartum depression, and child outcomes.

RESULTS

Women with childhood trauma experienced greater depressive symptoms through six months postpartum, which then predicted negative child outcomes at one year. Mediating effects of postpartum depression were significant, and persisted for maternal-infant bonding and infant growth after controlling for covariates and antenatal distress. Maternal avoidance of fearful stimuli emerged as a potential affective mechanism.

LIMITATIONS

Limitations included modest sample size, self-report measures, and unmeasured potential confounders.

CONCLUSIONS

Findings suggest a mediating role of postpartum depression in the intergenerational transmission of negative outcomes. Perinatal interventions that address maternal trauma histories and depression, as well as underlying affective mechanisms, may help interrupt cycles of disadvantage, particularly in high-trauma settings such as South Africa.

Traumatic Life Events and Psychopathology in a High Risk, Ethnically Diverse Sample of Young Children: A Person-Centered Approach

Studies of the association between traumatic experiences and psychopathology in early childhood have primarily focused on specific types of events (e.g., sexual abuse) or aggregated different types of events without differentiating among them. We extend this body of work by investigating patterns of traumatic event exposure in a high-risk, ethnically diverse sample of children ages 3-6 (N = 211; 51 % female) and relating these different patterns to parents' reports of child externalizing, internalizing, and post-traumatic stress symptomatology. Using latent class analysis, which divides a heterogeneous population into homogenous subpopulations, we identified three patterns of traumatic events based on parents' responses to an interview-based assessment of trauma exposure in young children: (1) severe exposure, characterized by a combination of family violence and victimization; (2) witnessing family violence without victimization; and (3) moderate exposure, characterized by an absence of family violence but a moderate probability of other events. The severe exposure class exhibited elevated internalizing and post-traumatic stress symptoms relative to the witness to violence and moderate exposure classes, controlling for average number of traumatic events. Results highlight the need for differentiation between profiles of traumatic life event exposure and the potential for person-centered methods to complement the cumulative risk perspective.

Clinical improvements in adopted children with fetal alcohol spectrum disorders through neurodevelopmentally informed clinical intervention: A pilot study

Research on early intervention for young children (infants and toddlers) with fetal alcohol spectrum disorders (FASD), particularly children with comorbid maltreatment experiences, is limited. Existing research has primarily focused on structuring environments to be responsive to the needs experienced by children with FASD rather than improving their functioning. The purpose of this study is to present outcomes from an early psychosocial intervention with 10 adopted, maltreated young children diagnosed with FASD, aged 10-53 months (M = 35 months), and their adoptive parents. The potential for early, targeted interventions to improve developmental outcomes for children with prenatal alcohol exposure was examined, as well as improving the skills of and reducing stress experienced by their adoptive parents. Based on the outcomes of a neurodevelopmentally informed assessment protocol, the 10 children whose data are presented were recommended to receive a range of regulatory, somatosensory, relational, and cognitive enrichments. As part of their treatment, children and caregivers received Child-Parent Psychotherapy (CPP), and caregivers (here, adoptive parents) also received Mindful Parenting Education (MPE). Related-samples Wilcoxon signed-rank tests indicated that scores of several measures of child developmental functioning improved from pre- to post-intervention and that parents' caregiving skills improved while their caregiving stress decreased. Reliable change analyses indicated that change observed from pre- to post-intervention was reliable. The promise of using neurodevelopmentally informed assessment strategies to sequence interventions for young children with diverse neurodevelopmental insults is discussed.

Post-Traumatic Stress Disorder and Risk for Incident Rheumatoid Arthritis

OBJECTIVE

To examine the association between symptoms of post-traumatic stress disorder (PTSD) and rheumatoid arthritis (RA) risk in a prospective cohort and to characterize the role of smoking in this relationship.

METHODS

A subset (n = 54,224) of the Nurses' Health Study II, a prospective cohort of female nurses, completed the Brief Trauma Questionnaire and a screen for PTSD symptoms. Participants were categorized based on trauma exposure and number of PTSD symptoms. Incident RA cases (n = 239) from 1989 to 2011 were identified. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) between PTSD symptoms and incident RA. To identify the impact of smoking, secondary and subgroup analyses were performed. In all analyses, PTSD and smoking were lagged 2 years before the development of RA.

RESULTS

Compared to no history of trauma/PTSD symptoms, the HR for ≥4 PTSD symptoms and incident RA was 1.76 (95% CI 1.16-2.67) in models adjusted for age, race, and socioeconomic status. The risk for RA increased with an increasing number of PTSD symptoms (P = 0.01). When smoking was added to the model, the HR for RA remained elevated (HR 1.60 [95% CI 1.05-2.43]). In a subgroup analysis, excluding women who smoked before PTSD onset, results were unchanged (HR 1.68 [95% CI 1.04-2.70]).

CONCLUSION

This study suggests that women with high PTSD symptomatology have an elevated risk for RA, independent of smoking, adding to emerging evidence that stress is an important determinant of physical health.

A Model for Creating a Supportive Trauma-Informed Culture for Children in Preschool Settings

The all too common exposure of young children to traumatic situations and the life-long consequences that can result underscore the need for effective, developmentally appropriate interventions that address complex trauma. This paper describes Head Start Trauma Smart (HSTS), an early education/mental health cross-systems partnership designed to work within the child's natural setting-in this case, Head Start classrooms. The goal of HSTS is to decrease the stress of chronic trauma, foster age-appropriate social and cognitive development, and create an integrated, trauma-informed culture for young children, parents, and staff. Created from a community perspective, the HSTS program emphasizes tools and skills that can be applied in everyday settings, thereby providing resources to address current and future trauma. Program evaluation findings indicate preliminary support for both the need for identification and intervention and the potential to positively impact key outcomes.

Evaluating relational repair work with infants and mothers impacted by family violence

This paper describes the delivery of a therapeutic infant/mother group work intervention program called The Peek-a-Boo ClubTM, which ran from mid-2005 until early 2012. It examines the importance of intervening early with infants and mothers impacted by family violence. The intervention used an ‘infant led’ approach to facilitate the repair of relational ruptures in the infant/mother attachment as a consequence of experiencing family violence. It provides an overview of the intervention and work undertaken to enhance the quality of the attachment between mothers and their infants. In particular, it presents the demographic data of 128 mothers and their infants who participated over a specific period (2007–2011) and then the results of a small quantitative pre- versus post-pilot evaluation of 30 groups over this same time period. Further qualitative data is also included. The challenges and complexities involved in collecting data from this ‘hard to reach’, ambivalent and vulnerable client group are discussed. The results of the evaluation indicate some limitations in the methodology, however, overall The Peek-a-Boo ClubTM program was associated with improved scores on outcome measures assessing infant, mother and infant–mother functioning. Though only a small study, it supports intervening early to assist mothers and infants impacted by family violence in order to repair relational disruption, and encourage mother’s availability to respond sensitively to their infant’s efforts in managing affect regulation. A more comprehensive, tailored and systematic evaluation of such interventions is recommended.

Does adolescent's exposure to parental intimate partner conflict and violence predict psychological distress and substance use in young adulthood? A longitudinal study

Little is known about the extent to which parental conflict and violence differentially impact on offspring mental health and substance use. Using data from a longitudinal birth cohort study this paper examines: whether offspring exposure to parental intimate partner violence (involving physical violence which may include conflicts and/or disagreements) or parental intimate partner conflict (conflicting interactions and disagreements only) are associated with offspring depression, anxiety and substance use in early adulthood (at age 21); and whether these associations are independent of maternal background, depression and anxiety and substance use. Data (n=2,126 women and children) were taken from a large-scale Australian birth-cohort study, the Mater University of Queensland Study of Pregnancy (MUSP). IPC and IPV were measured at the 14-year follow-up. Offspring mental health outcomes--depression, anxiety and substance use--were assessed at the 21-year follow-up using the Composite International Diagnostic Interview (CIDI). Offspring of women experiencing IPV at the 14-year follow-up were more likely to manifest anxiety, nicotine, alcohol and cannabis disorders by the 21-year follow-up. These associations remained after adjustment for maternal anxiety, depression, and other potential confounders. Unlike males who experience anxiety disorders after exposure to IPV, females experience depressive and alcohol use disorders. IPV predicts offspring increased levels of substance abuse and dependence in young adulthood. Gender differences suggest differential impact.

Caregiver instability and early life changes among infants reported to the child welfare system

This study describes the extent of caregiver instability (defined as a new placement for 1 week or longer in a different household and/or with a new caregiver) in a nationally representative sample of infants, followed for 5-7 years. Data were drawn from the National Survey of Child and Adolescent Well-Being (NSCAW), a longitudinal study of 5,501 children investigated for child maltreatment. The analysis sample was restricted to 1,196 infants. Overall, 85.6% of children who were infants at the time of the index maltreatment experienced at least one caregiver instability event during their first 2 years of life. Caregiver instability was associated with the child having a chronic health condition and the caregiver being older than 40 years of age at baseline. The levels of instability reported in this study from infancy to school entry are extremely high. Children with more risk factors were significantly more likely to experience caregiver instability than children with fewer risk factors. The repeated loss of a young child's primary caregiver or unavailable, neglectful care can be experienced as traumatic. Some evidence-based programs that are designed to work with young maltreated children can make a substantial positive difference in the lives of vulnerable infants.

Addressing childhood trauma in a developmental context

With the anticipated publication of the DSM-5 in May 2013, much reflection and work has been done on reviewing existing psychiatric nomenclature including, but not limited to the field of traumatic exposure. Traditionally, understanding of the psychiatric and psychological effects of trauma have been developed from studies with adults and then applied to trauma-exposed children with some modifications. While this is an important step to understanding the sequelae of trauma in children and adolescents, the adverse developmental effects of traumatic exposures on the rapidly evolving neurological, physical, social and psychological capacities of children calls for a developmentally sensitive framework for understanding, assessing and treating trauma-exposed children. The importance of early attachment relationships in infancy and childhood means that severely disrupted early caregiving relationships may have far-reaching and lifelong developmental consequences and can therefore be considered traumatic. Given the high rates of violence and trauma exposure of South African children and adolescents, the need for a developmentally based understanding of the effects of trauma on child and adolescent mental health becomes even more pronounced. In this paper, we draw on theoretical perspectives to provide a practical, clinically driven approach to the management of developmental trauma.

Evidence-based treatments for traumatized children and adolescents

This article reviews recent advances in empirically supported psychotherapeutic treatments for children and adolescents experiencing trauma and provides a brief summary of available interventions, as well as a context for their use. We highlight the American Academy of Child and Adolescent Psychiatry's recent practice guidelines for trauma treatment and discuss their implications for clinicians, including the benefits of involving caregivers in treatment and the rationale for using practices that are specifically trauma-focused as first-line intervention. Finally, we discuss the status of research on the real-world implementation of these therapies and the need for further research, particularly regarding clinician knowledge and use of empirically supported practices, potential stepped-care approaches to trauma treatment, and the need to reduce attrition in child trauma research and practice.

Mismatch or cumulative stress: toward an integrated hypothesis of programming effects

This paper integrates the cumulative stress hypothesis with the mismatch hypothesis, taking into account individual differences in sensitivity to programming. According to the cumulative stress hypothesis, individuals are more likely to suffer from disease as adversity accumulates. According to the mismatch hypothesis, individuals are more likely to suffer from disease if a mismatch occurs between the early programming environment and the later adult environment. These seemingly contradicting hypotheses are integrated into a new model proposing that the cumulative stress hypothesis applies to individuals who were not or only to a small extent programmed by their early environment, while the mismatch hypothesis applies to individuals who experienced strong programming effects. Evidence for the main effects of adversity as well as evidence for the interaction between adversity in early and later life is presented from human observational studies and animal models. Next, convincing evidence for individual differences in sensitivity to programming is presented. We extensively discuss how our integrated model can be tested empirically in animal models and human studies, inviting researchers to test this model. Furthermore, this integrated model should tempt clinicians and other intervenors to interpret symptoms as possible adaptations from an evolutionary biology perspective.