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Unaccompanied minors’ experiences of narrative exposure therapy. COGNITIVE BEHAVIOUR THERAPIST 2021. [DOI: 10.1017/s1754470x21000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Despite the understanding that unaccompanied minors’ (UAM) experience high rates of post-traumatic stress, the provision of evidence-based trauma-focused therapies is low for this population. Narrative exposure therapy (NET) is an effective short-term intervention for treating post-traumatic stress disorder (PTSD) after multiple traumatic experiences, such as those experienced by UAM. Within the existing literature, there is a lack of research investigating unaccompanied minors’ experiences of NET or any trauma-focused therapy. Participants were four UAM experiencing PTSD who formed part of a pilot delivery of NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted and transcripts were analysed using interpretative phenomenological analysis (IPA). This project identified five themes that encapsulated unaccompanied minors’ experiences of receiving NET, including the process of preparing for this therapy, what it was like to receive it, and the differences they identified at the end of treatment. The significance of this taking place within a safe therapeutic relationship was explored within the context of the attachment losses experienced by UAM, and the impact this has on emotion regulation was considered. The potential of a reduction in PTSD symptoms facilitating a positive spiral in adolescence was reflected on within this paper.
Key learning aims
(1)
To understand the experience of unaccompanied asylum-seeking minors (UAM) receiving narrative exposure therapy (NET) for post-traumatic stress disorder.
(2)
To understand the key concerns and motivators for UAM when considering engaging in NET.
(3)
To understand how these experiences relate to theoretical frameworks and the existing literature relating to emotional difficulties in adolescence.
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152
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Child Traumatic Stress and the Sacred: Neurobiologically Informed Interventions for Therapists and Parents. RELIGIONS 2021. [DOI: 10.3390/rel12030163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Children experience trauma and adverse experiences at an alarming rate. The negative impact of traumatic experiences on a child’s developing brain is pervasive, adversely affecting one’s thoughts, feelings, behaviors, physiological reactions, and social relationships. Conversely, the nature, pattern, timing and duration of therapeutic experiences can change the brain in ways that support and cultivate therapeutic growth and healing. The purpose of this paper will be to review and expand on two prominent neurobiological therapeutic frameworks within the field of child trauma therapy: the Neurosequential Model of Therapeutics and Interpersonal Neurobiology. We will discuss the ways in which trauma experiences are organized in the brain and how therapeutic and parenting interventions can address the key areas of the brain that are impacted. Further, this paper will expand on these frameworks to explore how the sacred (within primarily a Judeo-Christian monotheistic religious tradition) can be integrated within the therapeutic process—specifically through the themes of safety, relational connection, and meaning-making.
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153
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Atilola O, Stevanovic D, Moreira P, Dodig-Ćurković K, Franic T, Djoric A, Davidovic N, Avicenna M, Noor IM, Monteiro AL, Ribas A, Stupar D, Deljkovic A, Nussbaum L, Thabet A, Ubalde D, Petrov P, Vostanis P, Knez R. External locus-of-control partially mediates the association between cumulative trauma exposure and posttraumatic stress symptoms among adolescents from diverse background. ANXIETY, STRESS, AND COPING 2021; 34:626-644. [PMID: 33650438 DOI: 10.1080/10615806.2021.1891224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Locus of control (LOC) is a modifiable mediator of symptoms of posttraumatic stress disorder (PTSD) among traumatized individuals and a potential target of intervention. Compared with studies involving adults, the potential mediation effect of LOC on PTSD symptoms among trauma-exposed children and adolescents is relatively under-explored. This study, therefore, assessed the mediation effects of LOC on the association between lifetime cumulative trauma and PTSD symptoms among a large cohort of adolescents from different cultural background. Cross-sectional study. LOC was determined using the Multi-Dimension Locus of Control Scale; Posttraumatic stress symptoms using the UCLA PTSD Reaction Index; and other significant negative life events using the Life Events Checklist. Among 3826 adolescents who completed the study, external LOC explained 24% of variance (R2 = .24; F2,3823 = 619.01; p < .01) in PTSD symptoms and had significant indirect effect on the relationship between self-reported cumulative traumatic event exposure and PTSD symptoms (ß = .14; 95% BC CI [.10, .20]). Moderated mediation results showed significant potentiation of the moderation effects among older adolescents; boys; and those from more affluent families. The study further strengthened the hitherto limited evidence that external LOC partially mediate the relationship between cumulative trauma exposure and PTSD symptoms among adolescents.
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Affiliation(s)
- Olayinka Atilola
- Department of Behavioural Medicine, Lagos State University College of Medicine Ikeja, Lagos, Nigeria
| | - Dejan Stevanovic
- Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | - Paulo Moreira
- University Lusíada North (Porto), CIPD; CLISSIS, Lisboa, Portugal
| | | | - Tomislav Franic
- Child and Adolescent Psychiatry, School of Medicine, University of Split, Split, Croatia
| | - Ana Djoric
- Department of psychology, Faculty of Humanities and Social Sciences, Rijeka, Croatia
| | - Nikolina Davidovic
- Child and Adolescent Psychiatry, School of Medicine, University of Split, Split, Croatia
| | - Mohamad Avicenna
- Faculty of Psychology, State Islamic University Syarif Hidayatullah, Jakarta, Indonesia
| | | | | | - Adriana Ribas
- Institute of Psychology, Federal University, Rio de Janeiro, Brazil
| | - Dusko Stupar
- Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | | | - Laura Nussbaum
- Department of Department of Neurosciences, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | | | - Dino Ubalde
- Department of Psychology, St. Dominic College of Asia, City of Bacoor, Philippines
| | - Petar Petrov
- Department of Child and Adolescent Psychiatry, University Hospital St. Marina, Varna, Bulgaria
| | - Panos Vostanis
- School of Psychology, Leicester University, Leicester, UK
| | - Rajna Knez
- Medical school, University of Rijeka, Rijeka, Croatia
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154
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Memarzia J, Walker J, Meiser-Stedman R. Psychological peritraumatic risk factors for post-traumatic stress disorder in children and adolescents: A meta-analytic review. J Affect Disord 2021; 282:1036-1047. [PMID: 33601676 DOI: 10.1016/j.jad.2021.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/03/2021] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Meta-analytic reviews concerning predictors of PTSD in children and adolescents have predominantly identified evidence relating to pre- and post-trauma risk factors; however, there is little evidence regarding peritraumatic risk factors. This paper comprised a systematic review and meta-analysis of studies exploring psychological peritraumatic risk factors for PTSD in youth. METHODS Thirty-two studies were identified. Random effects meta-analyses were undertaken, with meta-regressions to explore the moderating role of study characteristics (gender, sex, timing of assessment after trauma, study quality, design and trauma type) on the size of effect of predictive factors. RESULTS Peritraumatic subjective threat (k = 28; r = 0.37, 95% CI=0.31-0.42) yielded a medium effect size estimate, while dissociation (k = 5; r = 0.17, 95% CI=0.03-0.29) and data-driven processing (feeling muddled or confused during the trauma) (k = 2; r = 0.29, 95% CI=0.14-0.43) yielded smaller population effect size estimates for the relationship with PTSD symptoms. Perceived life threat yielded a medium sized effect (k = 12; r = 0.37, 95% CI=0.32-0.41). The relationship between subjective threat and PTSD symptoms was moderated by the percentage of female participants. Estimates of heterogeneity were high in studies assessing perceived threat and fear (I2 = 95%), but moderate and low within studies assessing dissociation and data-driven processing (I2 = 57% and 0%, respectively). LIMITATIONS Peritraumatic psychological processes were commonly assessed using single-item measures. Studies primarily concerned single-incident traumas, limiting generalisability. CONCLUSIONS Peritraumatic experiences, particularly relating to subjective threat, are important correlates of subsequent PTSD, which implicates timely assessment of these experiences in youth to inform identification of at-risk groups and implementation and design of intervention.
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Affiliation(s)
- Jessica Memarzia
- Peterborough Integrated Neurodevelopmental Service, Child and Adolescent Mental Health Service, Cambridgeshire and Peterborough Foundation NHS Trust, Winchester Place, 80 Thorpe Road, Peterborough, PE3 6AP, Canada; Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, NR4 7TJ
| | - Jack Walker
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, NR4 7TJ
| | - Richard Meiser-Stedman
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, NR4 7TJ.
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155
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Tutus D, Pfeiffer E, Plener PL, Rosner R, Bernheim D, Sachser C. The Change in Parental Symptoms and Dysfunctional Cognitions in the Course of Trauma-Focused Cognitive-Behavioral Therapy: Sustainability Until One-Year Post-Treatment. J Child Adolesc Psychopharmacol 2021; 31:129-136. [PMID: 33370208 DOI: 10.1089/cap.2020.0097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: Symptoms of distress and dysfunctional posttraumatic cognitions (PTCs) have been frequently described in parents of children and adolescents with posttraumatic stress symptoms (PTSS), especially if the parents had experienced traumatic events themselves. The inclusion of non-offending parents in trauma-focused cognitive-behavioral therapy (TF-CBT) for children and adolescents may, thus, help parents to cope with the traumatic experience of their child. The aim of this study is to investigate the effects of TF-CBT on the parents, while taking their own history of traumatic experiences into account. Methods: Parents (N = 57, 84.2% mothers) of children and adolescents who received TF-CBT completed the Posttraumatic Diagnostic Scale, the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Posttraumatic Cognitions Inventory. Treatment effects and the sustainability at 6- and 12 months post-treatment were tested via repeated-measures analysis of variance, following the intention-to-treat approach. Results:N = 19 (35.2%) of the parents evaluated their child's trauma as the worst event, 18 (33.3%) rated their own experience as their worst event, and 17 (31.5%) indicated that their own worst traumatic experience was the same type as their child's trauma. Significant improvements (p < 0.001) emerged for parental PTSS [F(2, 837) = 8.27; d = 0.30], depression [F(3, 284) = 14.73; d = 0.41], anxiety symptoms [F(3, 185) = 17.44; d = 0.64], and dysfunctional PTCs [F(2, 465) = 13.58; d = 0.46]. Sustainability of these treatment gains remained at both follow-up time points (p < 0.05). There was no interaction between the time and the reference person of the traumatic index event, reported by parents. Conclusion: These results indicate parental benefits from participation in TF-CBT delivered to their child, until 1-year post-treatment and independently from the parental trauma history. The ongoing tendency of improvement might indicate that TF-CBT furnishes children and their parents with skills to further reduce the impact of their traumatic memories. ClinicalTrials.gov NCT01516827.
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Affiliation(s)
- Dunja Tutus
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Elisa Pfeiffer
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Rita Rosner
- Department of Psychology, Catholic University of Eichstaett-Ingolstadt, Eichstätt, Germany
| | - Dorothee Bernheim
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Cedric Sachser
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
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156
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Sadeh Y, Dekel R, Brezner A, Landa J, Silberg T. Child and Family Factors Associated With Posttraumatic Stress Responses Following a Traumatic Medical Event: The Role of Medical Team Support. J Pediatr Psychol 2021; 45:1063-1073. [PMID: 32968802 DOI: 10.1093/jpepsy/jsaa070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/13/2020] [Accepted: 07/23/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study examined the contribution of pretrauma psychosocial factors (child emotional functioning, family resources, family functioning, and social support) and environmental factors (mother's posttraumatic stress symptoms [PTSSs], medical team support [MTS]) to PTSSs of injured or seriously ill children within a pediatric rehabilitation setting. It was hypothesized that psychosocial variables would be strongly associated with child's PTSS; that mother's PTSS and MTS would mediate the association between psychosocial factors and child's PTSS; that mother's report on child's PTSS would mediate the association between mother's PTSS and child's PTSS. METHODS Participants were 196 children hospitalized following an injury/illness and assessed M = 47.7 days postevent. Children completed measures of PTSS, mothers completed measures of their own PTSS, child's PTSS, and pretrauma psychosocial factors. Family's therapist completed a MTS measure. Structural equation modeling was employed to evaluate the study hypotheses. RESULTS Pretrauma family structure and resources were associated with child's self-reported PTSS; each pretrauma variable and mother's report of child's PTSS was significantly associated. Although mother's PTSS was not directly associated with child's PTSS, this relationship was mediated by mother's report of child's PTSS. MTS mediated the relationship between pretrauma social support and mother's PTSS. CONCLUSION This study further explicates the utility of a biopsychosocial framework in predicting childhood PTSS. Findings confirm the role of pretrauma factors and environmental factors at the peritrauma period in the development of PTSS following a pediatric injury/illness. Mother's PTSS and MTS may be appropriate targets for prevention and early intervention.
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Affiliation(s)
- Yaara Sadeh
- The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University.,Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center
| | - Rachel Dekel
- The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University
| | - Amichai Brezner
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center
| | - Jana Landa
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center.,Sackler Faculty of Medicine, Tel-Aviv University
| | - Tamar Silberg
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center.,Holland Bloorview Kids Rehabilitation Hospital.,Department of Psychology, Bar-Ilan University
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157
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Hiller RM, Halligan SL, Meiser-Stedman R, Elliott E, Rutter-Eley E, Hutt T. Coping and support-seeking in out-of-home care: a qualitative study of the views of young people in care in England. BMJ Open 2021; 11:e038461. [PMID: 33589445 PMCID: PMC7887338 DOI: 10.1136/bmjopen-2020-038461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Young people who have been removed from their family home and placed in out-of-home care have commonly experienced abuse, neglect and/or other forms of early adversity. High rates of mental health difficulties have been well documented in this group. The aim of this research was to explore the experiences of these young people within the care system, particularly in relation to support-seeking and coping with emotional needs, to better understand feasible and acceptable ways to improve outcomes for these young people. DESIGN AND STUDY SETTING This study used 1:1 semistructured qualitative interviews with young people in out-of-home care in England, to provide an in-depth understanding of their views of coping and support for their emotional needs, both in terms of support networks and experiences with mental health services. Participants were 25 young people aged 10-16 years old (56% female), and included young people living with non-biological foster carers, kinship carers and in residential group homes. RESULTS Participants described positive (eg, feeling safe) and negative (eg, feeling judged) aspects to being in care. Carers were identified as the primary source of support, with a supportive adult central to coping. Views on support and coping differed for young people who were experiencing more significant mental health difficulties, with this group largely reporting feeling unsupported and many engaging in self-harm. The minority of participants had accessed formal mental health support, and opinions on usefulness were mixed. CONCLUSIONS Results provide insight, from the perspective of care-experienced young people, about both barriers and facilitators to help-seeking, as well as avenues for improving support.
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Affiliation(s)
| | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Elizabeth Elliott
- Department of Psychology, University of Bath, Bath, UK
- School of Psychology and Clinical Language Science, University of Reading, Reading, UK
| | - Emily Rutter-Eley
- School of Psychology and Clinical Language Science, University of Reading, Reading, UK
| | - Tilly Hutt
- Department of Psychology, University of Bath, Bath, UK
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158
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Louis JP, Ortiz V, Barlas J, Lee JS, Lockwood G, Chong WF, Louis KM, Sim P. The Good Enough Parenting early intervention schema therapy based program: Participant experience. PLoS One 2021; 16:e0243508. [PMID: 33481822 PMCID: PMC7822299 DOI: 10.1371/journal.pone.0243508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 11/22/2020] [Indexed: 11/19/2022] Open
Abstract
Background and objectives Schema therapy (ST) has become a mainstream therapy for the treatment of psychopathology and has been validated through a series of large scale, international randomized control trials. Among other things, schema therapy emphasizes the meeting of core emotional needs in children by primary caregivers as these unmet needs continue to adversely affect their lives into adulthood. An early intervention parenting program has been developed to help parents meet these core emotional needs in order to prevent the development of psychopathology in the first place. The program, Good Enough Parenting, is equally focused on reducing problems and strengthening parenting practices, regardless of where the child is on the “disordered to well-being continuum”. This study aims to explore “patient experience” by users of this program. Best clinical research guidelines advocate that participants should be used as collaborators rather than pure recipients; this process should predate large scale trials. Design An exploratory qualitative study with 55 parent-participants of Good Enough Parenting was conducted. Methods One-to-one interviews were conducted with participants, using critical incident technique and guided by semi-structured interview schedule, to explore their experiences with the program. Transcripts were then analyzed using thematic analysis. Results Coding showed a high degree of inter-rater reliability (kappa value of 0.78). The themes that emerged were Cultivating Awareness of Parents’ Own Schemas, Cultivating Intentionality, Working through Developmental Issues, Responses to Challenges at Home, Performing Multiple Roles, and the Learning Process. Participants overwhelmingly reported satisfaction within these key themes. Conclusions The results support the development of the program and the choice of “participant reported outcome measures” for use in subsequent randomized controlled trials.
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Affiliation(s)
- John Philip Louis
- Persatuan Kebajikan HOPE Worldwide Kuala Lumpur, Kuala Lumpur, Malaysia
- * E-mail:
| | - Vida Ortiz
- HOPE Worldwide Singapore, Singapore, Singapore
| | | | | | - George Lockwood
- Schema Therapy Institute Midwest, Kalamazoo, Michigan, United States of America
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159
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Dixius A, Möhler E. Feasibility and Effectiveness of a New Short-Term Psychotherapy Concept for Adolescents With Emotional Dysregulation. Front Psychiatry 2021; 11:585250. [PMID: 33551862 PMCID: PMC7858646 DOI: 10.3389/fpsyt.2020.585250] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The 'Stress-Trauma-Symptoms-Regulation-Treatment' (START) is an innovative manualized short-term treatment program for stabilization and stress resilience in emotionally dysregulated adolescents, based on an approach of stress and management and emotional regulation. The current pilot trial aims to assess the feasibility and effectiveness of the START intervention program for improvement of emotion regulation. Methods: Sixty-six adolescents between the age of 13-18 years admitted to a psychiatric unit for acute emotional or behavioral dysregulation took part in the START program for 5 weeks in an open group setting with two sessions per week (70 min/session). Before treatment, we assessed a history of adverse experience with the Child and Adolescent Trauma Screen (CATS) and the Child Posttraumatic Cognitions Inventory (CPTCI). Before and after treatment, the participants completed the FEEL-KJ, a self-report screening instrument of emotional regulation and coping strategies. Results: A large proportion of this sample had experienced traumatic events based on the CATS (75%) and the CPTCI (82%). The mean FEEL-KJ score significantly decreased after the intervention (d = -0.248, p = 0.037), while no difference was observed with regard to mean level of adaptive emotion regulation strategies (d = 0.202, p = 0.207). A positive effect of the intervention was observed on three components of the adaptive FEEL-KJ scale: accepting (d = 0.289, p = 0.08), forgetting (d = 0.271, p = 0.049) and dealing with anger (d = 0.309, p = 0.034). Conclusion: START demonstrates preliminary evidence for improvement in emotional dysregulation after a 5-weeks course of treatment. Therefore, this short-term intervention can possibly be regarded as a tool to improve emotional stability in children with a high load of trauma-related psychopathology. The results are promising and warrant future studies, specifically randomized controlled trials on the effectiveness of START for strengthening resilience at-risk-populations.
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Affiliation(s)
- Andrea Dixius
- SHG Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie, Psychosomatik, Saarbruecken, Germany
| | - Eva Möhler
- Saarland University Hospital, Homburg, Germany
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160
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de Roos C, Zijlstra B, Perrin S, van der Oord S, Lucassen S, Emmelkamp P, de Jongh A. Predictors and moderators of treatment outcome for single incident paediatric PTSD: a multi-centre randomized clinical trial. Eur J Psychotraumatol 2021; 12:1968138. [PMID: 34621497 PMCID: PMC8491723 DOI: 10.1080/20008198.2021.1968138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments. OBJECTIVE To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT). METHOD Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups. RESULTS At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile. CONCLUSIONS The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.
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Affiliation(s)
- Carlijn de Roos
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Bonne Zijlstra
- Department of Child Development and Education, University of Amsterdam (UVA), Amsterdam, The Netherlands
| | - Sean Perrin
- Department of Psychology, Lund University, Lund, Sweden
| | - Saskia van der Oord
- Faculty of Psychology and Educational Sciences, Research Group Clinical Psychology, Ku Leuven, Leuven, Belgium.,Department of Developmental Psychology, University of Amsterdam (Uva), Amsterdam, The Netherlands
| | - Sacha Lucassen
- UvA Minds Academic Treatment Centre, Amsterdam, The Netherlands
| | - Paul Emmelkamp
- Department Of Clinical Psychology, University of Amsterdam (Uva), Amsterdam, The Netherlands.,Paris Institute For Advanced Studies, France
| | - Ad de Jongh
- Department Of Social Dentistry And Behavioral Sciences, Academic Centre for Dentistry Amsterdam (Acta), University of Amsterdam, Amsterdam, The Netherlands.,Institute Of Health And Society, University Of Worcester, Worcester, UK.,School Of Psychology, Queen's University, Belfast, Northern Ireland
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161
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Hiscox LV, Hiller R, Fraser A, Rabie S, Stewart J, Seedat S, Tomlinson M, Halligan SL. Sex differences in post-traumatic stress disorder in a high adversity cohort of South African adolescents: an examination of depressive symptoms, age, and trauma type as explanatory factors. Eur J Psychotraumatol 2021; 12:1978669. [PMID: 34691370 PMCID: PMC8530480 DOI: 10.1080/20008198.2021.1978669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Evidence from high-income countries (HICs) has documented a higher rate of post-traumatic stress disorder (PTSD) in females than males. However, data are limited on sex differences in PTSD from low- and middle-income countries (LMICs), despite particularly high levels of trauma experienced by LMIC youth. OBJECTIVES In a sample of adolescents from an impoverished South African community, we examined sex differences in PTSD, as well as co-occurring depression, adolescent age, and the type and extent of trauma exposure as potential contributors to female vulnerability. METHODS Participants were recruited from high schools in the Khayelitsha area of Cape Town. Self-reported trauma exposure, PTSD and depressive symptoms were measured in 797 adolescents (62% female) aged 13-17 years. Poisson regressions were used to examine Risk Ratios (RR) based on probable PTSD diagnoses, and linear regressions were applied to assess posttraumatic stress symptom (PTSS) severity. RESULTS 92% of adolescents reported trauma exposure, of whom 28% had probable PTSD. Prevalence of PTSD was higher for females than for males, even when controlling for total trauma exposure (RR = 1.71, p < .001) and co-occurring depressive symptoms (RR = 1.45, p = .005). By contrast, sex differences in depression were eliminated after controlling for co-occurring PTSS. There was little evidence of age effects on the emergence of sex differences. At lower thresholds of interpersonal trauma, females showed higher levels of PTSS compared to males, but no sex differences were found at high levels of exposure. CONCLUSION Higher PTSD rates are observed in adolescent females in a high adversity-LMIC sample suggesting sex differences are robust across international contexts. Sex differences in PTSD are unlikely to be explained by co-occurring depression and in this context sex differences in depression may be secondary to trauma and PTSD. However, exposure to significant interpersonal trauma appears to overrule any specific female vulnerability.
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Affiliation(s)
- Lucy V Hiscox
- Department of Psychology, University of Bath, Bath, UK
| | - Rachel Hiller
- Department of Psychology, University of Bath, Bath, UK
| | - Abigail Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephan Rabie
- Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jackie Stewart
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Soraya Seedat
- Medical Research Council (MRC) Unit on Anxiety and Stress Disorders, Department of Psychiatry, Stellenbosch University, Tygerberg, Western Cape, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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162
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Wiseman H, Hamilton-Giachritsis C, Hiller RM. The Relevance of Cognitive Behavioral Models of Post-Traumatic Stress Following Child Maltreatment: A Systematic Review. TRAUMA, VIOLENCE & ABUSE 2021; 22:191-206. [PMID: 30909822 DOI: 10.1177/1524838019827894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
While it is known that young people exposed to maltreatment or abuse are at elevated risk of developing post-traumatic stress disorder (PTSD), much of our current knowledge of mechanisms that link trauma to childhood PTSD is based on single-incident, often noninterpersonal, trauma. Theoretical models highlight psychological processes of appraisals, memory, and coping as important for the development of PTSD. The aim of this review was to synthesize the literature on the role of these key psychological processes in relation to PTSD in maltreated children and teens. Studies were included if they (1) identified a sample of maltreated individuals, ≤18 years old; (2) measured (a) trauma memory, (b) appraisals, or (c) post-trauma cognitive or behavioral responses; and (3) measured PTSD symptoms. The systematic search of three electronic databases (American Psychological Association PsychNet, PubMed, and Published International Literature on Traumatic Stress) resulted in the inclusion of 36 papers, which described 31 studies and 33 unique samples. The review found cognitive behavioral models of PTSD appeared appropriate for understanding outcomes following maltreatment, but further research is needed on all processes, particularly trauma memory. Overall, there remain significant gaps in our knowledge of how psychological processes link maltreatment to PTSD. There is limited evidence concerning how maltreatment-related characteristics (e.g., chronicity, duration, and type of abuse) influence psychological processes and in turn affect outcomes. This review recommends further research in this area and suggests that, at the very least, comprehensive assessment should be conducted with all young people reporting maltreatment to identify appraisals and coping strategies that will potentially impact on their ongoing adjustment.
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Affiliation(s)
- Hannah Wiseman
- Department of Psychology, 1555University of Bath, Bath, United Kingdom
| | | | - Rachel M Hiller
- Department of Psychology, 1555University of Bath, Bath, United Kingdom
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163
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Wang S, Shi X, Chen X, Zhu Y, Chen H, Fan F. Earthquake Exposure and PTSD Symptoms Among Disaster-Exposed Adolescents: A Moderated Mediation Model of Sleep Problems and Resilience. Front Psychiatry 2021; 12:577328. [PMID: 33927648 PMCID: PMC8076540 DOI: 10.3389/fpsyt.2021.577328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 03/19/2021] [Indexed: 11/13/2022] Open
Abstract
Considerable studies have explored the potential mechanisms between trauma exposure and PTSD, but little is known about the role of sleep problems and resilience in this relationship. To address this research gap, the present study examined whether sleep problems mediated the relationship between earthquake exposure and PTSD symptoms, and whether this mediating process was moderated by resilience. A sample of 1,342 adolescents (M age = 15.54 years, SD = 1.26) completed questionnaires regarding earthquake exposure, sleep problems, resilience, and PTSD symptoms 12 months after a devastating earthquake in China. After controlling for demographic variables, earthquake exposure was significantly, and positively associated with PTSD symptoms, and sleep problems partially mediated this relationship. Tests of moderated mediation further revealed that resilience moderated the relationship between earthquake exposure and PTSD symptoms as well as sleep problems and PTSD symptoms. Specifically, the relationship between earthquake exposure and PTSD symptoms was only significant for adolescents with a lower level of resilience; meanwhile, the positive relationship between sleep problems and PTSD symptoms was stronger among low-resilient adolescents. Therefore, sleep-targeted and resilience-based interventions may be effective in alleviating PTSD symptoms resulted from the earthquake.
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Affiliation(s)
- Shuo Wang
- College of Education, Hebei University, Baoding, China
| | - Xuliang Shi
- College of Education, Hebei University, Baoding, China
| | - Xiaoyan Chen
- School of Psychology, South China Normal University, Guangzhou, China
| | - Ya Zhu
- Center for Mental Health Education and Counseling, Guangdong University of Science and Technology, Dongguan, China
| | - Huilin Chen
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Fang Fan
- School of Psychology, South China Normal University, Guangzhou, China
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164
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Hoeboer C, de Roos C, van Son GE, Spinhoven P, Elzinga B. The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents. CHILD ABUSE & NEGLECT 2021; 111:104775. [PMID: 33158585 DOI: 10.1016/j.chiabu.2020.104775] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/07/2020] [Accepted: 10/08/2020] [Indexed: 05/23/2023]
Abstract
BACKGROUND Maltreatment by a primary caregiver is an important risk factor for the development of PTSD symptoms. Whereas meta-analyses indicate that parental emotional abuse is one of the most common forms of maltreatment, the impact of emotional abuse on PTSD symptoms and treatment effectiveness is still unclear, especially in children. OBJECTIVE We aimed to investigate the impact of parental emotional abuse on PTSD symptom severity and effectiveness of trauma treatment in children and adolescents. METHOD In an outpatient sample (N = 287, mean age = 15.5 years), emotional abuse, index traumatic event, and PTSD symptoms were assessed at baseline. Thereafter, patients received evidence-based treatment for trauma-related symptoms embedded in a broader (systemic) treatment package. In a subsample (n = 130, mean age = 15.3 years) PTSD symptoms were assessed again 6 and 12 months after baseline. RESULTS Emotional abuse (rather than any other type of maltreatment) was associated with more severe PTSD symptoms in all symptom clusters. This was independent of whether emotional abuse was reported as index traumatic event or not. Moreover, PTSD symptoms were significantly reduced 6 months after the start of trauma-focused treatment, and emotional abuse was associated with more severe PTSD symptoms over the course of treatment. CONCLUSIONS These findings underline the detrimental nature of emotional maltreatment in the context of PTSD symptomatology and treatment effectiveness. This calls for routine assessment of parental emotional abuse in the diagnostic phase, even when this is not the reason of referral.
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Affiliation(s)
- Chris Hoeboer
- Leiden University, Institute of Psychology, Section Clinical Psychology, Leiden, the Netherlands; Parnassiagroep, PsyQ The Hague, the Netherlands.
| | - Carlijn de Roos
- Amsterdam University Medical Centre, Department of Child and Adolescent Psychiatry, Amsterdam, the Netherlands.
| | | | - Philip Spinhoven
- Leiden University, Institute of Psychology, Section Clinical Psychology, Leiden, the Netherlands; Leiden University Medical Center, Department of Psychiatry, the Netherlands.
| | - Bernet Elzinga
- Leiden University, Institute of Psychology, Section Clinical Psychology, Leiden, the Netherlands.
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165
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Schiff M, Pat-Horenczyk R, Ziv Y, Brom D. Multiple Traumas, Maternal Depression, Mother-Child Relationship, Social Support, and Young Children's Behavioral Problems. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:892-914. [PMID: 29294915 DOI: 10.1177/0886260517725738] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This study examined whether maternal depression, mother-child relationships, and maternal perceived social support mediate the associations between child's exposure to multiple traumatic events and behavioral problems. We recruited a representative sample of 904 Israeli (Jewish and Arab) mothers and their 2- to 6-year-old children. Data collection was conducted through structured face-to-face interviews with the mothers between July and November 2011. All measures were completed by the mothers. We used the child's and mother's exposure to political violence questionnaires, Child Behavior Checklist (CBCL), a short version of the Parental Acceptance-Rejection Questionnaire (PARQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Medical Outcomes Study (MOS) Social Support Survey. The research study model was tested using path analysis. The model showed a very good fit to the data, suggesting that maternal rejection, maternal depression, and social support play an important role in child's behavioral problems in the context of multiple traumatic events. Higher levels of maternal rejection were significantly associated with greater children behavior problems. Maternal rejection mediated the associations between maternal depressive symptoms and child's behavioral problems. Maternal perceived social support mediated the associations between child's exposure to multiple traumatic events and child's behavioral problems; child's exposure to multiple traumatic events was associated with lower levels of maternal perceived social support. In turn, lower levels of perceived social support were associated with higher levels of behavioral problems. In conclusion, in accordance with the "social stress framework," social support has a mediation role in the association between exposure to traumatic events and child's behavioral problems. Thus, enhancing social support to mothers to young children in the context of multiple traumatic events is essential for children resiliency.
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166
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Hiller RM, Meiser-Stedman R, Elliott E, Banting R, Halligan SL. A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care. J Child Psychol Psychiatry 2021; 62:48-57. [PMID: 32196661 DOI: 10.1111/jcpp.13232] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Young people in out-of-home care are substantially more likely to meet criteria for PTSD than their peers, while their early maltreatment exposure may also place them at greater risk of developing the newly proposed complex PTSD. Yet, there remains limited empirical evidence for the mechanisms that might drive either PTSD or complex features in this group, and ongoing debate about the suitability of existing cognitive behavioural models and their related NICE-recommended treatments. In a prospective study of young people in out-of-home care, we sought to identify demographic and cognitive processes that may contribute to the maintenance of both PTSD symptom and complex features. METHODS We assessed 120 10- to 18-year-olds in out-of-home care and their primary carer at two assessments: an initial assessment and 12-month follow-up. Participants completed questionnaires on trauma history, PTSD symptoms and complex features, while young people only also self-reported on trauma-related (a) maladaptive appraisals, (b) memory quality and (c) coping. Social workers reported on maltreatment severity. RESULTS Young people's maltreatment severity was not a robust predictor of either PTSD symptoms or complex features. All three cognitive processes were moderately-to-strongly correlated with baseline and 12-month PTSD symptoms and complex features, with maladaptive appraisals the most robust unique driver of both, even when controlling for initial PTSD symptom severity. CONCLUSIONS Existing cognitive models of PTSD are applicable in this more complex sample of young people. The model was also found to be applicable to the additional features of complex PTSD, with the same processes driving both outcomes at both time points. Clinical implications are discussed.
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Affiliation(s)
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Rosie Banting
- Department of Psychology, University of Bath, Bath, UK
| | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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167
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Walker JR, Teague B, Memarzia J, Meiser-Stedman R. Acute stress disorder in children and adolescents: A systematic review and meta-analysis of prevalence following exposure to a traumatic event. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2020. [DOI: 10.1016/j.jadr.2020.100041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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168
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Zhang H, Shi Y, Jing P, Zhan P, Fang Y, Wang F. Posttraumatic stress disorder symptoms in healthcare workers after the peak of the COVID-19 outbreak: A survey of a large tertiary care hospital in Wuhan. Psychiatry Res 2020; 294:113541. [PMID: 33128999 PMCID: PMC7585629 DOI: 10.1016/j.psychres.2020.113541] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/22/2020] [Indexed: 02/08/2023]
Abstract
This study examined the prevalence of posttraumatic stress disorder (PTSD) symptoms and assessed mental illness via an online survey among healthcare workers (HCWs) at the Central Hospital of Wuhan after the peak of the COVID-19 outbreak. PTSD symptoms were measured using the PTSD Checklist Civilian Version (PCL-C), with a cutoff score of 50. Among the 642 HCWs, the prevalence of probable PTSD was 20.87%. Additionally, 88.88%, 82.09%, 100%, and 95.52% of HCWs with probable PTSD reported varying degrees of anxiety, depression, somatic symptoms, and insomnia, respectively. HCWs with probable PTSD scored higher on the Hospital Anxiety and Depression Scale (HADS), Patient Health questionnaire-15 (PHQ-15), and Insomnia Severity Index (ISI) than non-PTSD HCWs (all p < 0.05). Multivariate regression analysis revealed that HCWs with negative COVID-19 tests (OR, 0.35; 95% CI, 0.21-0.58; p < 0.00), those with high Social Support Self-Rating Scale (SSRS) scores (OR, 0.30; 95% CI, 0.17-0.52; p < 0.00), and HCWs whose family members tested negative (OR, 0.64; 95% CI, 0.42-0.96; p = 0.03) were less likely to have probable PTSD. This study found a high prevalence of probable PTSD and severe mental illness among local HCWs. Our finding emphasizes the need to provide mental health support for HCWs.
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Affiliation(s)
- Hongyi Zhang
- Department of Pediatric Surgery, Tongji Hospital, Wuhan 430030, China; Tongji Medical College and Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yuqin Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Medical College, Wuhan University of Science and Technology, Wuhan 430030, China
| | - Ping Jing
- Department of Neurology, The Central Hospital of Wuhan, Wuhan 430030, China; Tongji Medical College and Huazhong University of Science and Technology, Wuhan 430030, China
| | - Peiyan Zhan
- Department of Neurology, The Central Hospital of Wuhan, Wuhan 430030, China; Tongji Medical College and Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yue Fang
- Department of Neurology, The Central Hospital of Wuhan, Wuhan 430030, China; Tongji Medical College and Huazhong University of Science and Technology, Wuhan 430030, China
| | - Fang Wang
- Department of Neurology, The Central Hospital of Wuhan, Wuhan 430030, China; Tongji Medical College and Huazhong University of Science and Technology, Wuhan 430030, China.
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169
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Dyadic Profiles of Posttraumatic Stress Symptoms in Mothers and Children Experiencing Intimate Partner Violence. Child Psychiatry Hum Dev 2020; 51:943-955. [PMID: 32114669 DOI: 10.1007/s10578-020-00973-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Children who witness intimate partner violence (IPV) develop posttraumatic stress disorder at alarmingly high rates. Research suggests that caregivers' symptoms of posttraumatic stress (PTSS) often co-occur alongside children's PTSS, a phenomenon termed "relational posttraumatic stress." The goal of this study is to use dyad-centered analyses to examine heterogeneity in relational PTSS presentations in mother-child dyads, and to determine factors differentiating relational PTSS profiles. Data were drawn from a sample of 231 IPV-exposed, ethno-racially diverse mother-child dyads, with children ranging from ages 4 to 12. The results of a latent profile analysis indicated that a two-profile model was the best fit with the data. Both profiles indicated similar levels of PTSS across the dyad; however, they differed in overall symptom severity. Parenting and IPV severity significantly predicted profile membership; however, age did not. Results suggest that similarities in PTSS presentation should be expected in mother-child dyads, at least in families who experience IPV.
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170
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Stensland SØ, Thoresen S, Jensen T, Wentzel-Larsen T, Dyb G. Early Pain and Other Somatic Symptoms Predict Posttraumatic Stress Reactions in Survivors of Terrorist Attacks: The Longitudinal Utøya Cohort Study. J Trauma Stress 2020; 33:1060-1070. [PMID: 32662140 DOI: 10.1002/jts.22562] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/10/2020] [Accepted: 03/24/2020] [Indexed: 11/10/2022]
Abstract
Survivors of traumatic events commonly suffer from long-term pain and related somatic symptomatology. To test the predominant hypothesis that survivors' pain comprises sequela of persistent posttraumatic stress symptoms (PTSS), we assessed the sequential order of symptom development among young survivors of a terrorist attack. All 490 survivors of the 2011 Utøya (Norway) attacks were invited to the longitudinal Utøya cohort study; 355 (72.4%) participated. The mean survivor age was 19.3 years (SD = 4.6) and 169 were female (47.6%). Somatic symptoms, including headache, other pain and fatigue, and PTSS, were measured 4-5 months (T1), 14-16 months (T2), and 32-33 months (T3) after the attack. Longitudinal associations between somatic symptoms and PTSS were assessed in cross-lagged structural equation model (SEM) analyses, which were adjusted for known confounders. Higher pain levels and other somatic symptoms at T1 consistently predicted PTSS at T2 in SEM analyses, r = .473, p < .001. Beyond this early-to-intermediate posttraumatic phase, somatic symptoms did not significantly predict PTSS: T2-T3, r = .024, p = .831; T1-T3, r = -.074, p = .586. PTSS did not significantly predict later somatic symptomatology at T1-T2, r = .093, p = .455; T2-T3, r = .272, p = .234; or T1-T3, r = -.279, p = .077. The findings indicate that survivors' early pain and related somatic symptoms strongly and consistently predict later psychopathology. After severe psychological trauma, early interventions may need to address individuals' pain to hinder chronification.
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Affiliation(s)
- Synne Øien Stensland
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway.,Research and Communication Unit for Musculoskeletal Health (FORMI), Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Siri Thoresen
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Tine Jensen
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway.,Department of Psychology, Faculty of Social Sciences, University of Oslo, Norway
| | - Tore Wentzel-Larsen
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway.,Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Grete Dyb
- Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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171
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Worthington MA, Mandavia A, Richardson-Vejlgaard R. Prospective prediction of PTSD diagnosis in a nationally representative sample using machine learning. BMC Psychiatry 2020; 20:532. [PMID: 33172436 PMCID: PMC7653804 DOI: 10.1186/s12888-020-02933-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent research has identified a number of pre-traumatic, peri-traumatic and post-traumatic psychological and ecological factors that put an individual at increased risk for developing PTSD following a life-threatening event. While these factors have been found to be associated with PTSD in univariate analyses, the complex interactions of these risk factors and how they contribute to individual trajectories of the illness are not yet well understood. In this study, we examine the impact of prior trauma, psychopathology, sociodemographic characteristics, community and environmental information, on PTSD onset in a nationally representative sample of adults in the United States, using machine learning methods to establish the relative contributions of each variable. METHODS Individual risk factors identified in Waves 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were combined with community-level data for the years concurrent to the NESARC Wave 1 (n = 43,093) and 2 (n = 34,653) surveys. Machine learning feature selection and classification analyses were used at the national level to create models using individual- and community-level variables that would best predict the new onset of PTSD at Wave 2. RESULTS Our classification algorithms yielded 89.7 to 95.6% accuracy for predicting new onset of PTSD at Wave 2. A prior diagnosis of DSM-IV-TR Borderline Personality Disorder, Major Depressive Disorder or Anxiety Disorder conferred the greatest relative influence in new diagnosis of PTSD. Distal risk factors such as prior psychiatric diagnosis accounted for significantly greater relative risk than proximal factors (such as adverse event exposure). CONCLUSIONS Our findings show that a machine learning classification approach can successfully integrate large numbers of known risk factors for PTSD into stronger models that account for high-dimensional interactions and collinearity between variables. We discuss the implications of these findings as pertaining to the targeted mobilization emergency mental health resources. These findings also inform the creation of a more comprehensive risk assessment profile to the likelihood of developing PTSD following an extremely adverse event.
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Affiliation(s)
| | - Amar Mandavia
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, USA
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172
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Cusinato M, Iannattone S, Spoto A, Poli M, Moretti C, Gatta M, Miscioscia M. Stress, Resilience, and Well-Being in Italian Children and Their Parents during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8297. [PMID: 33182661 PMCID: PMC7696524 DOI: 10.3390/ijerph17228297] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
The novel coronavirus (COVID-19) outbreak has forced parents and children to adopt significant changes in their daily routine, which has been a big challenge for families, with important implications for family stress. In this study, we aimed to analyze the potential risk and protective factors for parents' and children's well-being during a potentially traumatic event such as the COVID-19 quarantine. Specifically, we investigated parents' and children's well-being, parental stress, and children's resilience. The study involved 463 Italian parents of children aged 5-17. All participants completed an online survey consisting of the Psychological General Well Being Index (PGWB) to assess parental well-being, the Strengths and Difficulties Questionnaire (SDQ) to measure children's well-being, the Parent Stress Scale (PSS) to investigate parental stress, and the Child and Youth Resilience Measure (CYRM-R) to measure children's resilience. The results show that confinement measures and changes in daily routine negatively affect parents' psychological dimensions, thus exposing children to a significant risk for their well-being. Our results also detect some risk factors for psychological maladjustments, such as parental stress, lower levels of resilience in children, changes in working conditions, and parental psychological, physical, or genetic problems. In this study, we attempted to identify the personal and contextual variables involved in the psychological adjustment to the COVID-19 quarantine to identify families at risk for maladjustment and pave the way for ad hoc intervention programs intended to support them. Our data show promising results for the early detection of the determinants of families' psychological health. It is important to focus attention on the needs of families and children-including their mental health-to mitigate the health and economic implications of the COVID-19 pandemic.
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Affiliation(s)
- Maria Cusinato
- Pediatric Diabetes Unit, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy; (M.C.); (C.M.)
| | - Sara Iannattone
- Child and Adolescent Neuropsychiatry Unit, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy; (S.I.); (M.G.)
- Department of General Psychology, University of Padua, 35131 Padua, Italy;
| | - Andrea Spoto
- Department of General Psychology, University of Padua, 35131 Padua, Italy;
| | - Mikael Poli
- Department of Developmental Psychology and Socialization, University of Padova, 35131 Padua, Italy;
| | - Carlo Moretti
- Pediatric Diabetes Unit, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy; (M.C.); (C.M.)
| | - Michela Gatta
- Child and Adolescent Neuropsychiatry Unit, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy; (S.I.); (M.G.)
| | - Marina Miscioscia
- Child and Adolescent Neuropsychiatry Unit, Department of Women’s and Children’s Health, Padua University Hospital, 35128 Padua, Italy; (S.I.); (M.G.)
- Department of Developmental Psychology and Socialization, University of Padova, 35131 Padua, Italy;
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173
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Zerach G, Elklit A. Polyvictimization and Psychological Distress in Early Adolescence: A Mediation Model of Defense Mechanisms and Coping Styles. JOURNAL OF INTERPERSONAL VIOLENCE 2020; 35:4732-4756. [PMID: 29294815 DOI: 10.1177/0886260517716944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In the current study, we aim to examine the link between exposure to multiple traumatic events (polyvictimization), posttraumatic stress disorder (PTSD) symptoms (PTSS), and psychiatric symptomatology in early adolescence. Furthermore, we aim to explore the mediating roles of defense styles and coping styles in the associations between polyvictimization, PTSS, and psychiatric symptomatology. Data from a Danish national representative sample of 390 eighth-grade students with a mean age of 13.95 (SD = 0.37) years were used. Participants responded to validated self-report questionnaires in 2001. The dimensions of immature defense styles and emotional and avoidance coping mediated the positive associations between polyvictimization, PTSS, and psychiatric symptomatology. Serial multiple mediation indicated that the sum of exposure to traumatic events was significantly associated with more immature defense styles, associated with both high levels emotional and avoidance coping, which, in turn, were associated with high levels of PTSS and psychiatric symptomatology. Polyvictimization is related to adverse outcomes in early adolescence. Both immature defense styles and emotional and avoidance coping styles should be considered as risk factors for the development of psychological distress following exposure to multiple traumas.
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Affiliation(s)
| | - Ask Elklit
- University of Southern Denmark, Odense, Denmark
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174
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Bountress KE, Gilmore AK, Metzger IW, Aggen SH, Tomko RL, Danielson CK, Williamson V, Vladmirov V, Ruggiero K, Amstadter AB. Impact of disaster exposure severity: Cascading effects across parental distress, adolescent PTSD symptoms, as well as parent-child conflict and communication. Soc Sci Med 2020; 264:113293. [PMID: 32858492 PMCID: PMC7689632 DOI: 10.1016/j.socscimed.2020.113293] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/16/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE Natural disasters are common and have potentially deleterious impacts on individuals, as well as on the relationships among family members (Adams et al., 2015; Paul, 2015). Additionally, caregiver-, offspring-, and family-level outcomes are often correlated following disaster. OBJECTIVE Thus, longitudinal work is needed to clarify the prospective associations among such constructs following severe disasters. METHOD The current study included 1,271 adolescents and investigated whether disaster exposure impacted adolescent posttraumatic stress disorder (PTSD) symptoms, parent distress, and family parent-child conflict and communication, as well as whether/how these factors influenced one another over time. This study used a dynamic cascade model and included adolescents (ages 12-17) and caregivers present for tornadoes in Missouri and Alabama in 2011. These participants were part of a larger study involving a web-based intervention. RESULTS Over and above covariates (i.e., adolescent age, gender, race, treatment, prior trauma, adolescent alcohol use and depressive symptoms, and household income), families who experienced greater severity of disaster exposure had adolescents who reported more baseline PTSD symptoms and caregivers who reported more distress at baseline. CONCLUSIONS Providing tangible resources (e.g., housing, food, transportation, essential possessions) to families post-disaster may reduce parent distress and adolescent PTSD symptoms. Additionally, reducing adolescent PTSD symptoms may prospectively improve relationships between parents and adolescents.
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Affiliation(s)
- Kaitlin E Bountress
- Virginia Institute for Psychiatry and Behavioral Genetics, Virginia Commonwealth University, United States.
| | - Amanda K Gilmore
- Mark Chaffin Center for Healthy Development and Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, United States
| | - Isha W Metzger
- University of Georgia, Department of Psychology, United States
| | - Steven H Aggen
- Virginia Institute for Psychiatry and Behavioral Genetics, Virginia Commonwealth University, United States
| | - Rachel L Tomko
- Addiction Sciences Division, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, United States
| | - Carla Kmett Danielson
- National Crime Victim Research & Treatment Center (NCVC), Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, United States
| | - Vernell Williamson
- Virginia Institute for Psychiatry and Behavioral Genetics, Virginia Commonwealth University, United States
| | - Vladimir Vladmirov
- Virginia Institute for Psychiatry and Behavioral Genetics, Virginia Commonwealth University, United States
| | - Kenneth Ruggiero
- College of Nursing, Medical University of South Carolina, United States
| | - Ananda B Amstadter
- Virginia Institute for Psychiatry and Behavioral Genetics, Virginia Commonwealth University, United States
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175
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Danzi BA, La Greca AM. Treating Children and Adolescents with Posttraumatic Stress Disorder: Moderators of Treatment Response. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2020; 50:510-516. [DOI: 10.1080/15374416.2020.1823849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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176
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Abstract
OBJECTIVES After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury. METHODS Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review. RESULTS Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS. CONCLUSIONS Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.
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177
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Does pre-event lack of emotional support increase the risk of post-event PTSD, anxiety, depression symptoms and lack of support? A comparative population-based study among victims of threat and violence. J Anxiety Disord 2020; 75:102269. [PMID: 32795919 DOI: 10.1016/j.janxdis.2020.102269] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/08/2023]
Abstract
Our knowledge about the effects of perceived emotional support on PTSD, anxiety and depressive symptoms after serious threat and violence is primarily based on post-event studies. Very little is known about the extent to which (1) victims lacking pre-event emotional support are more at risk of post-event symptoms and lack of post-event support than victims with pre-event emotional support, and (2) victims with pre-event emotional support and victims lacking emotional support are more at risk of post-event anxiety and depressive symptoms than nonvictims with similar pre-event support levels. For this purpose, we conducted a 2-wave prospective study (VICTIMS) using the Dutch population-based longitudinal LISS panel. Multivariate logistic regression analyses were conducted, controlling for pre-event demographics, symptoms, and physical, work-related and financial problems. As hypothesized, victims (Nvictims total = 187) lacking pre-event support more often had high post-event PTSD, anxiety and depressive symptoms than victims with pre-event support. No significant differences were found between victims and nonvictims with pre-event emotional support (Nnonvictims total = 2,828, not exposed to any event). Since victims and nonvictims with pre-event support did not differ in post-event symptoms and support, the findings offer strong evidence for the buffering hypothesis of emotional support.
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178
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Guo J, Yang Y, Jiang X, Guo M, Li X, Huang P, Liu Z. Differential promoter methylation and G-712A polymorphism of brain-derived neurotrophic factor in post-traumatic stress disorder patients of Li and Han populations in Hainan province. Gene 2020; 769:145192. [PMID: 33007373 DOI: 10.1016/j.gene.2020.145192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 12/15/2022]
Abstract
This study aimed to explore the correlations of promoter methylation and single-nucleotide polymorphism (SNP) of brain-derived neurotrophic factor (BDNF) with post-traumatic stress disorder (PTSD) in Li and Han nationalities in Hainan province. Depression- and anxiety-related questionnaires were performed for PTSD-related information collection and analysis, with 164 PTSD patients and 141 healthy controls included. Serum BDNF level was measured and the methylation of BDNF promoter was evaluated. The BDNF SNP genotyping was performed, after which the risk genotypes for PTSD were detected and analyzed using logistic regression analysis. Our study found that the PTSD incidence was different in Li and Han nationalities. Serum BDNF level in PTSD patients in Li nationality was obviously lower than that in patients in Han nationality, while the methylation of BDNF promoter was higher in patients in Li nationality. The G-712A rather than rs6265 genotypes presented significant difference between PTSD patients and healthy controls. Meanwhile, the patients in Li nationality with AG genotype at G-712A inclined to depression, and patients with GG genotype had a greater degree of PTSD. G-712A and promoter methylation of BDNF were independent risk factors for PTSD. Our study demonstrated that the differences of PTSD patients between Li and Han nationalities were attributed by SNP G-712A genotypes and promoter methylation of BDNF.
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Affiliation(s)
- Juncheng Guo
- Department of Hepatobiliary Surgery, Central South University Xiangya School of Medical Affiliated Haikou Hospital, Haikou 570208, Hainan, PR China
| | - Yijun Yang
- Department of Hepatobiliary Surgery, Central South University Xiangya School of Medical Affiliated Haikou Hospital, Haikou 570208, Hainan, PR China
| | - Xiangling Jiang
- Psychological Research Center, Hainan General Hospital, Haikou 570311, Hainan, PR China
| | - Min Guo
- Psychological Research Center, Hainan General Hospital, Haikou 570311, Hainan, PR China.
| | - Xiang Li
- The Third People's Hospital of Hubei Province, Wuhan 430032, Hubei, PR China
| | - Ping Huang
- University of South China, Hengyang 421001, Hunan, PR China
| | - Zhuo Liu
- Psychological Research Center, Hainan General Hospital, Haikou 570311, Hainan, PR China
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179
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Li Y, Lv Q, Li B, Luo D, Sun X, Xu J. The role of trauma experiences, personality traits, and genotype in maintaining posttraumatic stress disorder symptoms among child survivors of the Wenchuan earthquake. BMC Psychiatry 2020; 20:439. [PMID: 32894097 PMCID: PMC7487586 DOI: 10.1186/s12888-020-02844-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/30/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is the most prevalent type of psychiatric disorder among children after an earthquake. This study investigated the role of trauma experiences, personality traits, and genotype in the maintenance of PTSD symptoms. METHODS In a previous large-scale epidemiological investigation 1 year after the Wenchuan earthquake, 215 children with PTSD symptoms were selected at random with their blood samples collected. All of them were followed up, and their PTSD symptoms were assessed 3 years later. The adolescent version of the UCLA PTSD Reaction Index, the earthquake exposure scale, and the Junior Eysenck Personality Questionnaire were used to determine PTSD symptoms, trauma experiences, and personality traits, respectively. We sequenced candidate genes involved in the regulation of long-term potentiation via NMDA-type receptors to identify the related SNP variations. RESULTS Being trapped for a longer period of time, feeling one's own or a family member's life to be in danger, losing a close family member or friend, extraversion, neuroticism, TrkB, G72 and CNTF were found to be associated with the maintenance of PTSD symptoms. CONCLUSIONS Experiences, personality traits, and genotype influenced the maintenance of PTSD in child survivors who were considered to be followed up without medicine. This result could help to identify potential targets for treatment and promote the rational allocation of medical resources.
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Affiliation(s)
- Yuwei Li
- grid.13291.380000 0001 0807 1581Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuyue Lv
- grid.13291.380000 0001 0807 1581Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Li
- grid.13291.380000 0001 0807 1581Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Luo
- grid.13291.380000 0001 0807 1581Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xueli Sun
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Jiajun Xu
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China.
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180
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Li Y, Duan W, Chen Z. Latent profiles of the comorbidity of the symptoms for posttraumatic stress disorder and generalized anxiety disorder among children and adolescents who are susceptible to COVID-19. CHILDREN AND YOUTH SERVICES REVIEW 2020; 116:105235. [PMID: 32834272 PMCID: PMC7342099 DOI: 10.1016/j.childyouth.2020.105235] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 05/16/2023]
Abstract
The present study aims to examine the comorbidity patterns of the symptoms (intrusion and avoidance) for posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) and the role of perceived threat and courtesy stigma in distinguishing specific patterns of the symptoms for PTSD and GAD among children and adolescents who are susceptible to coronavirus disease 2019 (COVID-19) in Hubei, China. A total of 1172 (683 female and 489 male) children and adolescents aged 8-18 years were involved in completing the measurements of PTSD, GAD, perceived threat of COVID-19, and COVID-19-related courtesy stigma. The Latent Profile Analysis identified the three profiles of the symptoms for PTSD and GAD which were labeled as Moderate PTSD, Mild Comorbidity, and Severe Comorbidity. The scores of the symptoms for PTSD, GAD, perceived threat, and stigma were different among the three profiles. The risk factors (i.e., perceived threat and stigma) that are related to comorbidity patterns were examined through a three-step method. The possibility of entry into the Severe Comorbidity Profile increased with increasing perceived threat and stigma. The mental health care interventions for children and adolescents who are susceptible to COVID-19 can be developed to reduce perceived threat and stigma.
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Affiliation(s)
- Yumei Li
- Department of Social & Behavioural Sciences, City University of Hong Kong, China
| | - Wenjie Duan
- Social and Public Administration School, East China University of Science and Technology, China
| | - Zheng Chen
- Institute of Education, Wuhan University, China
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181
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Birkeland MS, Holt T, Ormhaug SM, Jensen TK. Perceived social support and posttraumatic stress symptoms in children and youth in therapy: A parallel process latent growth curve model. Behav Res Ther 2020; 132:103655. [PMID: 32590214 DOI: 10.1016/j.brat.2020.103655] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/08/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
Many studies show that perceived social support protects against the development of posttraumatic stress symptoms (PTSS) in the aftermath of trauma, but less is known about support in relation to PTSS in trauma therapy. This study examined associations between perceived social support and PTSS in children and adolescents during trauma therapy. Parallel process latent growth curve modeling was used to examine trajectories of perceived social support and PTSS over five measurement waves in a sample of 156 patients, aged between 10 and 18 years (M age = 15.1, SD = 2.2, 79.5% girls), randomized to receive trauma-focused cognitive behavior therapy (TF-CBT) or therapy-as-usual (TAU). Across all participants there was an average decline in PTSS and increase of perceived social support from pre-therapy to 18 months after therapy. Most of the change occurred during therapy and was maintained after therapy. Higher levels of PTSS prior to therapy were associated with lower levels of perceived social support prior to therapy, and a decrease in PTSS was associated with increase in perceived social support. This co-development may have been directed by a third underlying factor or short-term temporal effects. Studies investigating within-person associations over shorter time intervals will benefit our understanding of possible temporal effects.
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Affiliation(s)
| | - Tonje Holt
- Division of Mental & Physical Health, Norwegian Institute of Public Health, Norway
| | - Silje M Ormhaug
- Norwegian Centre for Violence and Traumatic Stress Studies, Norway
| | - Tine K Jensen
- Norwegian Centre for Violence and Traumatic Stress Studies, Norway; Department of Psychology, University of Oslo, Norway
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182
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Pfeiffer E, Ormhaug SM, Tutus D, Holt T, Rosner R, Wentzel Larsen T, Jensen TK. Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents. Eur J Psychotraumatol 2020; 11:1776048. [PMID: 33029318 PMCID: PMC7473296 DOI: 10.1080/20008198.2020.1776048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND There is a broad evidence-base for the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in treating children and adolescents with posttraumatic stress disorder (PTSD). The effect of therapist characteristics on patient symptoms has been neglected in psychotraumatology research and necessitates further investigation. OBJECTIVE This study aims to investigate the impact of therapist characteristics (gender, clinical experience and theoretical background) on posttraumatic stress symptoms (PTSS) in a heterogeneous and international sample of traumatized children and adolescents. METHOD Data from two RCTs on the effectiveness of TF-CBT in Norway and Germany were included, comprising N = 52 therapists (78.8% female) and N = 153 patients (72.3% female). All therapists underwent thorough training and continuous supervision in TF-CBT. The Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) assessed pre- and post-treatment served as the outcome variable in a linear mixed-effects model with therapists' theoretical background, prior clinical experience and gender as independent variables, adjusted for patient gender, measurement time and country. The possibility of an interaction between therapist and patient gender was investigated subsequently. RESULTS None of the therapist characteristics were significantly related to PTSS. There was no indication of an interaction between patient and therapist gender (p =.878). CONCLUSION The lack of evidence for a relationship of therapists' theoretical orientation and clinical experience with outcome suggests that a wider dissemination of TF-CBT may be warranted. More studies with larger therapist and patient sample sizes and including only community practice are needed.
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Affiliation(s)
- Elisa Pfeiffer
- Clinic for Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University Ulm, Ulm, Germany
| | - Silje Mørup Ormhaug
- Norwegian Center for Violence and Traumatic Stress Studies (NKVTS), Oslo, Norway
| | - Dunja Tutus
- Clinic for Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University Ulm, Ulm, Germany
| | - Tonje Holt
- Division of Mental & Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Rita Rosner
- Department of Psychology, Catholic University of Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Tore Wentzel Larsen
- Norwegian Center for Violence and Traumatic Stress Studies (NKVTS), Oslo, Norway.,Centre for Child and Adolescent Mental Health, Oslo, Norway
| | - Tine K Jensen
- Norwegian Center for Violence and Traumatic Stress Studies (NKVTS), Oslo, Norway.,Department of Psychology, University Oslo, Oslo, Norway
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183
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Fimiani R, Gazzillo F, Fiorenza E, Rodomonti M, Silberschatz G. Traumas and Their Consequences According to Control-Mastery Theory. Psychodyn Psychiatry 2020; 48:113-139. [PMID: 32628581 DOI: 10.1521/pdps.2020.48.2.113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The aim of this article is to introduce the reader to how control-mastery theory (CMT; Gazzillo, 2016; Silberschatz, 2005; Weiss, 1993), an integrative relational cognitive-dynamic theory of mental functioning, psychopathology, and psychotherapeutic process, understands traumas, their consequences, and their mastery. In the first part of this article, we will present an overview of the debate about the definition of trauma within the different editions of the Diagnostic and Statistical Manual of Mental Disorders. Then, we will focus on the concept of complex traumas and on their consequences on mental health. Finally, we will discuss how CMT conceptualizes traumas and their pathological consequences. We will stress in particular how, according to CMT, in order for a painful experience to become a trauma, its victim has to come to believe that s/he caused it in the attempt to pursue a healthy and adaptive goal. In order to master traumas and disprove the pathogenic beliefs developed from them, people attempt to reexperience situations similar to the traumatic ones in safer conditions while giving them happier endings.
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Affiliation(s)
- Ramona Fimiani
- Department of Dynamic and Clinical Psychology "Sapienza" University of Rome
| | - Francesco Gazzillo
- Department of Dynamic and Clinical Psychology "Sapienza" University of Rome
| | - Eleonora Fiorenza
- Department of Dynamic and Clinical Psychology "Sapienza" University of Rome
| | - Martina Rodomonti
- Department of Dynamic and Clinical Psychology "Sapienza" University of Rome
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184
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Siddaway AP. Adverse childhood experiences research: commonalities with similar, arguably identical, literatures and the need for integration. Br J Psychiatry 2020; 217:397-398. [PMID: 31663490 DOI: 10.1192/bjp.2019.191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Adverse childhood experiences (ACEs) and their impact cannot be clearly distinguished from other distressing life experiences. Much can be therefore be learned by integrating ACEs research with similar, well-established literatures. Future research needs to explain individual differences in relationships between ACEs and particular variables and locate reliable and strong risk factors for ACEs themselves.
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185
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Haag K, Fraser A, Hiller R, Seedat S, Zimmerman A, Halligan SL. The emergence of sex differences in PTSD symptoms across development: evidence from the ALSPAC cohort. Psychol Med 2020; 50:1755-1760. [PMID: 31409434 PMCID: PMC7408572 DOI: 10.1017/s0033291719001971] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/05/2019] [Accepted: 07/13/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cross-sectional evidence suggests females in late adolescence exhibit higher rates of post-traumatic stress symptoms (PTSS) than males and younger age groups. However, longitudinal evidence is limited, and underlying factors are not well understood. We investigated the emergence of sex differences in PTSS from childhood to adolescence in a large, longitudinal UK cohort, and tested whether these could be explained by overlap between PTSS and depressive symptoms, or onset of puberty. METHODS Trauma exposure and PTSS were assessed at ages 8, 10, 13 (parent-report) and 15 (self-report) years in a sub-sample of 9966 children and adolescents from the ALSPAC cohort-study. Analyses of PTSS focused on those who reported potential trauma-exposure at each time-point (ranged from n = 654 at 15 years to n = 1231 at 10 years). Age at peak-height velocity (APHV) was used as an indicator of pubertal timing. RESULTS There was no evidence of sex differences in PTSS at ages 8 and 10, but females were more likely to show PTSS at ages 13 (OR 1.54, p = 0.002) and 15 (OR 2.04, p = .001), even once symptoms related to depression were excluded. We found little evidence that the emergence of sex differences was related to pubertal timing (as indexed by APHV). CONCLUSIONS Results indicate that females show higher levels of PTSS in adolescence but not during childhood. The emergence of this sex difference does not seem to be explained by overlap with depressive symptoms, while the influence of pubertal status requires further investigation.
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Affiliation(s)
| | - Abigail Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council (MRC) Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
| | - Rachel Hiller
- Department of Psychology, University of Bath, Bath, UK
| | - Soraya Seedat
- Department of Psychiatry, Medical Research Council (MRC) Unit on Anxiety and Stress Disorders, Stellenbosch University, Tygerberg, Western Cape, South Africa
| | - Annie Zimmerman
- Department of Psychology, University of Bath, Bath, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Sarah L. Halligan
- Department of Psychology, University of Bath, Bath, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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186
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Disasters in Germany and France: An Analysis of the Emergency Events Database From a Pediatric Perspective. Disaster Med Public Health Prep 2020; 13:958-965. [PMID: 31217040 DOI: 10.1017/dmp.2019.24] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of this study was to conduct comprehensive analyses of disaster patterns for Germany and France from a pediatric perspective. METHODS An analysis of the Emergency Events Database (EM-DAT), epidemiological database with standard methods of descriptive and comparative statistics respecting the strengthening the reporting of observational studies in epidemiology (STROBE) criteria, was performed. RESULTS Between 2006 and 2016, there were 41 and 42 disasters in Germany and France claiming 259 and 4973 lives, respectively. Ages of afflicted individuals were not specified in EM-DAT. In Germany, most events were storms (37%), extreme temperatures (17%), floods (17%), and transport accidents (17%). In France, most events were storms (45%), extreme temperatures (17%), floods (19%), and transport accidents (14%). In Germany, most lives (96) were lost in transport accidents. In France, most casualties were due to the heat waves of 2006 and 2015 (1388 and 3275). Reported event types in Germany and France were similar, but heat waves struck France more significantly than Germany. CONCLUSIONS Pediatric data are not explicitly captured in EM-DAT, but reported disaster patterns suggest that exposures to heat and cold, storms, trauma, chemicals, water, and infectious agents are possible mechanisms of injury. Age-stratified disaster data are needed to enable a timely, transparent, coordinated, and sustained data-driven approach to pediatric disaster resilience.
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187
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Qi R, Luo Y, Zhang L, Weng Y, Surento W, Jahanshad N, Xu Q, Yin Y, Li L, Cao Z, Thompson PM, Lu GM. Social support modulates the association between PTSD diagnosis and medial frontal volume in Chinese adults who lost their only child. Neurobiol Stress 2020; 13:100227. [PMID: 32490056 PMCID: PMC7256056 DOI: 10.1016/j.ynstr.2020.100227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/03/2020] [Accepted: 05/02/2020] [Indexed: 11/30/2022] Open
Abstract
Losing an only child is a devastating life event that a parent can experience and may lead to post-traumatic stress disorder (PTSD). Social support could buffer against the negative influence of this trauma, but the neural mechanism underlying this alleviation effect remains poorly understood. In this study, voxel-based morphometry was conducted on brain MRI of 220 Han Chinese adults who had lost their only child. We performed multiple regression analysis to investigate the associations between social support scores – along with PTSD diagnosis, age, sex, body mass index (BMI) – and brain grey matter (GM) volumes in these bereaved parents. For all trauma-exposed adults, social support-by-diagnosis interaction was significantly associated with medial prefrontal volume (multiple comparisons corrected P ˂ 0.05), where positive correlation was found in adults with PTSD but not in those without PTSD. Besides, PTSD diagnosis was associated with decreased GM volume in medial and middle frontal gyri (P ˂ 0.001, uncorrected); older age was associated with widespread GM volume deficits; male sex was associated with lower GM volume in rolandic operculum, insular, postcentral gyrus (corrected P ˂ 0.05), and lower GM in thalamus but greater GM in parahippocampus (P ˂ 0.001, uncorrected); higher BMI was associated with GM deficits in occipital gyrus (corrected P ˂ 0.05) and precuneus (P ˂ 0.001, uncorrected). In conclusions, social support modulates the association between PTSD diagnosis and medial frontal volume, which may play an important role in the emotional disturbance in PTSD development in adults who lost their only child.
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Affiliation(s)
- Rongfeng Qi
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, China
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Marina del Rey, CA, 90292, USA
| | - Yifeng Luo
- Department of Radiology, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, 75 Tongzhenguan Road, 214200, Wuxi, China
| | - Li Zhang
- Mental Health Institute, The Second Xiangya Hospital, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, Hunan, 410011, China
| | - Yifei Weng
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, China
| | - Wesley Surento
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Marina del Rey, CA, 90292, USA
| | - Neda Jahanshad
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Marina del Rey, CA, 90292, USA
| | - Qiang Xu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, China
| | - Yan Yin
- Hangzhou Seventh People's Hospital, Mental Health Center of Zhejiang University School of Medicine, 305 Tianmushan Road, Hangzhou, Zhejiang, 310013, China
| | - Lingjiang Li
- Mental Health Institute, The Second Xiangya Hospital, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, Hunan, 410011, China
| | - Zhihong Cao
- Department of Radiology, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, 75 Tongzhenguan Road, 214200, Wuxi, China
| | - Paul M. Thompson
- Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Marina del Rey, CA, 90292, USA
- Corresponding author.
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, China
- Corresponding author. Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province, 210002, China.
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188
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Cao X, Wang L, Cao C, Fang R, Chen C, Hall BJ, Elhai JD. Depicting the associations between different forms of psychopathology in trauma-exposed adolescents. Eur Child Adolesc Psychiatry 2020; 29:827-837. [PMID: 31489500 DOI: 10.1007/s00787-019-01400-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/30/2019] [Indexed: 01/21/2023]
Abstract
Psychiatric comorbidity in traumatized youth is prevalent, but such associations between two disorders may be confounded with other comorbid conditions. Few studies have examined the unique relationships among multiple disorders. Which disorders maximally explain the relationships between others and whether such disorders differ by sex remain largely unknown. Using a construct-level network approach, this study characterized the independent associations among nine prevalent emotional and behavioral disorders/problems evaluated by the PTSD Checklist for DSM-5, the Revised Children's Anxiety and Depression Scale, and the Youth Self-Report in a sample of 1181 disaster-exposed adolescents (53.9% girls; a mean age of 14.3 ± 0.8 years). The associations were strong among the seven internalizing problems and between the two externalizing ones, but weaker between these two spectra of psychopathology. Major depressive disorder (MDD) was most strongly connected with others, maximally accounting for the associations, especially those between the two spectra. Overall and individual association strength and the connecting role of MDD were generally equivalent across sex. These findings highlight the necessity of MDD in linking comorbid forms of psychopathology in traumatized youth, and suggest MDD as a potential intervention priority in this population.
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Affiliation(s)
- Xing Cao
- Laboratory for Traumatic Stress Studies, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing, 100101, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Li Wang
- Laboratory for Traumatic Stress Studies, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing, 100101, China.
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China.
| | - Chengqi Cao
- Laboratory for Traumatic Stress Studies, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing, 100101, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Ruojiao Fang
- Laboratory for Traumatic Stress Studies, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing, 100101, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Chen Chen
- Laboratory for Traumatic Stress Studies, CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Beijing, 100101, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Brian J Hall
- Global and Community Mental Health Research Group, Department of Psychology, Faculty of Social Sciences, University of Macau, Macau, China
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jon D Elhai
- Department of Psychology, University of Toledo, Toledo, OH, USA
- Department of Psychiatry, University of Toledo, Toledo, OH, USA
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189
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Unterhitzenberger J, Sachser C, Rosner R. Posttraumatic Stress Disorder and Childhood Traumatic Loss: A Secondary Analysis of Symptom Severity and Treatment Outcome. J Trauma Stress 2020; 33:208-217. [PMID: 32216150 DOI: 10.1002/jts.22499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 11/08/2022]
Abstract
Loss is a commonly experienced traumatic event among children. Although the experience of loss can potentially lead to posttraumatic stress symptoms (PTSS), little is known about PTSS levels after traumatic loss versus other traumatic events. We investigated data from a randomized controlled trial (RCT) on trauma-focused cognitive behavioral therapy (TF-CBT) versus a waitlist condition for children with PTSS. In a secondary analysis, we compared participants who reported traumatic loss as their index event (n = 23) to those who reported the two most frequently reported index events in the RCT: sexual abuse (SA; n = 59) and physical violence (PV; n = 55). The index event was rated according to the participants' most distressing traumatic event reported on the Clinician-Administered PTSD Scale for Children and Adolescents. Participants who experienced traumatic loss reported fewer PTSS and better general functioning than those who reported SA. A subgroup RCT (n = 19) revealed TF-CBT to be highly effective in reducing PTSS in cases of traumatic loss, d = 1.69. The effect sizes for PTSS indicated that all three trauma groups benefited from TF-CBT. In the waitlist group, PTSS symptoms improved for SA and PV, ds = 0.76 and 0.98, respectively, but not for traumatic loss, d = 0.23. These findings suggest that TF-CBT is a feasible and promising treatment for children who experience PTSS after traumatic loss. The results are limited by the post hoc quality of the analyses and lack of a measure of grief in the RCT.
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Affiliation(s)
| | - Cedric Sachser
- Clinic for Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstätt-Ingolstadt, Eichstätt, Germany
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190
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Brown A, Bennet J, Rapee RM, Hirshfeld-Becker DR, Bayer JK. Exploring the stress sensitization theory with temperamentally inhibited children: a population-based study. BMC Pediatr 2020; 20:264. [PMID: 32471371 PMCID: PMC7260781 DOI: 10.1186/s12887-020-02159-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/20/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND This study explored whether temperamentally inhibited children who experience early trauma are vulnerable to developing internalizing problems in the face of later life-stressors. METHODS A validated screen for temperamental inhibition was distributed to parents of young children attending preschools in six government regions of Melbourne, Australia. Screening identified 11% of children as inhibited (703 of 6347 screened) and eligible for a prevention study. Participants were 545 parents of inhibited preschoolers (78% uptake), of whom 84% were followed into mid childhood (age 7-10 years: wave 1, n = 446; wave 2, n = 427; wave 3, n = 426). Parents and children then completed questionnaires for child internalizing (anxious and depressive) symptoms, and parents received a diagnostic interview for child anxiety disorder. In mid-childhood parents also completed questionnaires annually to describe recent life-stressors experienced by their child, and any potentially traumatic events in the first four years of life. RESULTS Only one in 14 temperamentally inhibited children had experienced a potentially traumatic event in early childhood. In mid childhood 56% experienced recent life-stressors. Inhibited children who had early life trauma experienced slightly more anxiety disorder and symptoms in mid childhood. Those children with more recent life-stressors in mid childhood also had slightly more symptoms of anxiety and depression. In contrast to stress sensitization, inhibited children with early trauma plus recent stressors did not show especially high mid-childhood internalizing difficulties. CONCLUSIONS Early life trauma and recent life-stressors each convey a small risk for children with an inhibited temperament to develop internalizing problems. Nevertheless, early life stress may not always result in negative sensitization for children in the general population.
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Affiliation(s)
- Amy Brown
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Joanna Bennet
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Ronald M. Rapee
- Centre for Emotional Health, Macquarie University, Sydney, Australia
| | - Dina R. Hirshfeld-Becker
- Child Cognitive Behavioral Therapy Program, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Jordana K. Bayer
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
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191
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Wamser-Nanney R, Sager JC, Campbell CL. Does Maternal Support Mediate or Moderate the Relationship between Sexual Abuse Severity and Children's PTSD Symptoms? JOURNAL OF CHILD SEXUAL ABUSE 2020; 29:333-350. [PMID: 32125250 DOI: 10.1080/10538712.2020.1733160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/27/2020] [Accepted: 02/05/2020] [Indexed: 06/10/2023]
Abstract
Maternal support and abuse severity are often considered to be vital factors in predicting children's functioning following childhood sexual abuse (CSA); however, much of the prior research has examined support and abuse severity as main effects, without consideration of how these factors may interrelate to predict children's post-CSA functioning. Further, even though mediators and moderators are conceptually distinct, maternal support has been theorized to be both a mediator and a moderator of symptoms, and it is unclear if support acts as either among sexually abused children. The aim of the present study was to investigate whether caregiver-reported maternal support mediates or moderates the relationships between sexual abuse severity and children's trauma-related symptoms. The study included 235 treatment-seeking children ages 3-16 (M = 8.85, SD = 3.77) and their non-offending mothers. Contrary to expectations, caregiver-rated maternal support did not mediate nor moderate the relationship between abuse severity and children's symptoms (range r2 =.002 -.03). Caregiver-rated maternal support may play a small role in mitigating sexually abused children's trauma symptoms. Irrespective of abuse severity, children with less supportive mothers may not be at heightened risk for experiencing higher levels of trauma-related difficulties.
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Affiliation(s)
- Rachel Wamser-Nanney
- Department of Psychological Sciences, University of Missouri, St. Louis, Missouri, USA
| | - Julia C Sager
- Department of Psychological Sciences, University of Missouri, St. Louis, Missouri, USA
| | - Claudia L Campbell
- Department of Psychological Sciences, University of Missouri, St. Louis, Missouri, USA
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192
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McLaughlin KA, Colich NL, Rodman AM, Weissman DG. Mechanisms linking childhood trauma exposure and psychopathology: a transdiagnostic model of risk and resilience. BMC Med 2020; 18:96. [PMID: 32238167 PMCID: PMC7110745 DOI: 10.1186/s12916-020-01561-6] [Citation(s) in RCA: 218] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/17/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Transdiagnostic processes confer risk for multiple types of psychopathology and explain the co-occurrence of different disorders. For this reason, transdiagnostic processes provide ideal targets for early intervention and treatment. Childhood trauma exposure is associated with elevated risk for virtually all commonly occurring forms of psychopathology. We articulate a transdiagnostic model of the developmental mechanisms that explain the strong links between childhood trauma and psychopathology as well as protective factors that promote resilience against multiple forms of psychopathology. MAIN BODY We present a model of transdiagnostic mechanisms spanning three broad domains: social information processing, emotional processing, and accelerated biological aging. Changes in social information processing that prioritize threat-related information-such as heightened perceptual sensitivity to threat, misclassification of negative and neutral emotions as anger, and attention biases towards threat-related cues-have been consistently observed in children who have experienced trauma. Patterns of emotional processing common in children exposed to trauma include elevated emotional reactivity to threat-related stimuli, low emotional awareness, and difficulties with emotional learning and emotion regulation. More recently, a pattern of accelerated aging across multiple biological metrics, including pubertal development and cellular aging, has been found in trauma-exposed children. Although these changes in social information processing, emotional responding, and the pace of biological aging reflect developmental adaptations that may promote safety and provide other benefits for children raised in dangerous environments, they have been consistently associated with the emergence of multiple forms of internalizing and externalizing psychopathology and explain the link between childhood trauma exposure and transdiagnostic psychopathology. Children with higher levels of social support, particularly from caregivers, are less likely to develop psychopathology following trauma exposure. Caregiver buffering of threat-related processing may be one mechanism explaining this protective effect. CONCLUSION Childhood trauma exposure is a powerful transdiagnostic risk factor associated with elevated risk for multiple forms of psychopathology across development. Changes in threat-related social and emotional processing and accelerated biological aging serve as transdiagnostic mechanisms linking childhood trauma with psychopathology. These transdiagnostic mechanisms represent critical targets for early interventions aimed at preventing the emergence of psychopathology in children who have experienced trauma.
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Affiliation(s)
- Katie A McLaughlin
- Department of Psychology, Harvard University, 33 Kirkland Street, Cambridge, MA, 02138, USA.
| | - Natalie L Colich
- Department of Psychology, University of Washington, Box 351525, Seattle, WA, 98195, USA
| | - Alexandra M Rodman
- Department of Psychology, Harvard University, 33 Kirkland Street, Cambridge, MA, 02138, USA
| | - David G Weissman
- Department of Psychology, Harvard University, 33 Kirkland Street, Cambridge, MA, 02138, USA
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193
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Pittman LD, Cutright NL, McNeela L, Awada S, Pabis JM, Kochanova K, Shelleby E. Coping Strategies and Psychological Symptoms Among Children on St. Thomas in the Aftermath of Hurricanes Irma and Maria. J Trauma Stress 2020; 33:151-160. [PMID: 31800137 DOI: 10.1002/jts.22471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/10/2022]
Abstract
Research has shown that experiencing a hurricane can lead to internalizing, externalizing, and posttraumatic stress (PTS) symptoms in children. However, the effects of experiencing two hurricanes within a short time frame have not been examined. Moreover, there is limited research examining how children's coping is linked to their psychological functioning and no research using the empirically supported conceptualization of coping that includes primary control coping (i.e., attempts to control the stressor) and secondary control coping (i.e., attempts to adapt to the stressor). This study examined the psychological functioning of 108 children and adolescents (69.7% Black, Non-Hispanic; 56.5% female; M age = 11.59 years, SD = 2.43) in Grades 3-12 as measured 3 months after experiencing Hurricanes Irma and Maria on the island of St. Thomas. Participants completed electronic questionnaires about their demographic characteristics, hurricane exposure (i.e., perceived life-threat, life-threatening events, loss/disruption after hurricanes), coping strategies utilized, and their psychological functioning (i.e., PTS, internalizing, and externalizing symptoms). A principal component analysis of the coping items determined four coping factors: primary control, secondary control, disengagement, and negative coping. Linear regressions, including children's age and aspects of hurricane exposure, found primary control coping was positively associated with PTS symptoms, β = .18, whereas secondary control coping was negatively associated with PTS and externalizing symptoms, βs = -.17 and -.19, respectively. Negative coping, but not disengagement coping, was positively associated with all three outcomes, βs = .31-.42. These findings suggest positive ways children can cope after experiencing a hurricane, informing possible early intervention efforts.
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Affiliation(s)
- Laura D Pittman
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
| | | | - Lauren McNeela
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
| | - Samantha Awada
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
| | - Jacqueline M Pabis
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
| | - Kristina Kochanova
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
| | - Elizabeth Shelleby
- Psychology Department, Northern Illinois University, DeKalb, Illinois, USA
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194
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Liu X, Tang B, Zhao F, Xue C, Dong J, Zhang L. Post-traumatic positive and negative psychological changes experienced by child and adolescent earthquake survivors in remote rural western China: a cross-sectional study six years after the Yushu earthquake. PSYCHOL HEALTH MED 2020; 26:184-195. [PMID: 32156163 DOI: 10.1080/13548506.2020.1738020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Yushu, Qinghai province is located in remote Tibetan plateau in Western China, struck by a disastrous earthquake in 2010. The study aimed to find out the positive and negative psychological changes and related risk factors of children and adolescents who had experienced Yushu earthquake, 6 years after it occurred. Methods: A cross-sectional research was adopted in the capital of Yushu Autonomous Prefecture in August 2016. The short form of the Changes in Outlook Questionnaire (CiOQ-S) was used, which is a 10-item self-report instrument consists of two subscales. A total of 591 valid questionnaires completed by local junior students were finally included in our study. Results: The mean scores of the positive and negative psychological changes were 19.28 and 13.08, respectively. The factors associated with positive psychological changes included high level of education, male gender, and uninjured in the earthquake. The factors associated with negative psychological changes included living in a pasture instead of downtown, injured during the earthquake, and not receiving psychological counselling. Conclusions: The current analysis tries to investigate the long-term psychological effects of earthquakes among children and adolescents, which aims to improve the psychological health status for child and adolescent survivors of similar events.
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Affiliation(s)
- Xu Liu
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
| | - Bihan Tang
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
| | - Fangjie Zhao
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
| | - Chen Xue
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
| | - Junqiang Dong
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
| | - Lulu Zhang
- Department of Health Service, College of Health Service, Naval Medical University of the Chinese People's Liberation Army , Shanghai, PR China
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195
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Danese A, Smith P, Chitsabesan P, Dubicka B. Child and adolescent mental health amidst emergencies and disasters. Br J Psychiatry 2020; 216:159-162. [PMID: 31718718 DOI: 10.1192/bjp.2019.244] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The mental health of children and young people can be disproportionally affected and easily overlooked in the context of emergencies and disasters. Child and adolescent mental health services can contribute greatly to emergency preparedness, resilience and response and, ultimately, mitigate harmful effects on the most vulnerable members of society.
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Affiliation(s)
- Andrea Danese
- Professor of Child & Adolescent Psychiatry, Social, Genetic & Developmental Psychiatry Centre and the Department of Child & Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and Consultant Child & Adolescent Psychiatrist, National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression, South London and Maudsley NHS Foundation Trust, UK
| | - Patrick Smith
- Reader in Clinical Psychology, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and Consultant Clinical Psychologist, National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression, South London and Maudsley NHS Foundation Trust, UK
| | - Prathiba Chitsabesan
- Consultant Child & Adolescent Psychiatrist, Pennine Care NHS Foundation Trust; and Visiting Chair, Manchester Metropolitan University, UK
| | - Bernadka Dubicka
- Chair, Faculty of Child & Adolescent Psychiatry, Royal College of Psychiatrists; Consultant Child & Adolescent Psychiatrist, Pennine Care NHS Foundation Trust; and Honorary Reader, University of Manchester, UK
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196
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Brown EJ, Goodman RF, Cohen JA, Mannarino AP, Chaplin WF. An Exploratory Trial of Cognitive-Behavioral vs Client-Centered Therapies for Child-Mother Dyads Bereaved from Terrorism. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2020; 13:113-125. [PMID: 32318234 PMCID: PMC7163875 DOI: 10.1007/s40653-019-00264-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The study was an evaluation of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT; Cohen et al. 2017) with child-caregiver dyads who experienced the death of a loved one from terrorism, using a hybrid efficacy/effectiveness design in which there were no required minimum symptom levels. Forty children ages 4-17 years old whose fathers died in the line of duty on 9/11/2001 and their mothers participated in an RCT comparing TF-CBT and Client-Centered Therapy (CCT). At baseline, mothers' PTSD, depression, and prolonged grief symptoms were highly elevated, whereas children's were at normative levels. Using intent-to-treat analysis, condition-by-time interactions showed significantly greater symptom reduction for mothers receiving CBT than those receiving CCT. For the children, both treatments led to significant symptom improvements.
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Affiliation(s)
- Elissa J. Brown
- Department of Psychology, St. John’s University, Queens, NY USA
- Child HELP Partnership, St. John’s University, 152-11 Union Turnpike, Flushing, NY 11367 USA
| | - Robin F. Goodman
- Department of Psychiatry, Allegheny General Hospital, Pittsburgh, PA USA
| | - Judith A. Cohen
- Department of Psychiatry, Allegheny General Hospital, Pittsburgh, PA USA
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197
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Danese A. Annual Research Review: Rethinking childhood trauma-new research directions for measurement, study design and analytical strategies. J Child Psychol Psychiatry 2020; 61:236-250. [PMID: 31762042 DOI: 10.1111/jcpp.13160] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
Childhood trauma is a key modifiable risk factor for psychopathology. Despite significant scientific advances, traumatised children still have poorer long-term outcomes than nontraumatised children. New research paradigms are, thus, needed. To this end, the review examines three dominant assumptions about measurement, design and analytical strategies. Current research warns against using prospective and retrospective measures of childhood trauma interchangeably; against interpreting cross-sectional differences in putative mediating mechanisms between adults with or without a history of childhood trauma as evidence of longitudinal changes from pre-trauma conditions; and against directly applying explanatory models of resilience or vulnerability to psychopathology in traumatised children to forecast individual risk in unseen cases. The warnings equally apply to research on broader measures of adverse childhood experiences (ACEs). Further research examining these assumptions can generate new insights on how to prevent childhood trauma and its detrimental effects.
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Affiliation(s)
- Andrea Danese
- Social, Genetic and Developmental Psychiatry Centre, King's College London, London, UK.,Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression, South London and Maudsley NHS Foundation Trust, London, UK
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198
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Racine N, Eirich R, Dimitropoulos G, Hartwick C, Madigan S. Development of trauma symptoms following adversity in childhood: The moderating role of protective factors. CHILD ABUSE & NEGLECT 2020; 101:104375. [PMID: 32014798 DOI: 10.1016/j.chiabu.2020.104375] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 05/13/2023]
Abstract
BACKGROUND Although the buffering effect of protective factors on children's outcomes following exposure to adverse childhood experiences has been well documented, research gaps remain as to whether this buffering effect differs based on the type of adversity experienced (i.e., maltreatment versus household dysfunction). OBJECTIVE To examine whether protective factors moderate the association between cumulative adversity, as well as adversity subtypes (i.e., maltreatment and household dysfunction) and child trauma-related distress in a clinical sample referred for treatment following exposure to adversity. PARTICIPANTS AND SETTING One-hundred and seventy-six children (aged 3-18) referred to a child abuse treatment clinic and who's files were opened between January 2016 and June 2017 were included. METHODS Data were collected, extracted, and coded from clinical files using a standardized data extraction protocol. Protective factors included: using individual coping strategies, peer support, individual social skills, caregiver physical caregiving, caregiver psychological caregiving, and educational involvement. RESULTS Cumulative childhood adversity (b = .16, p = .04) positively predicted child trauma-related distress. The link between exposure to cumulative adversity and child trauma-related distress varied as a function of protective factors: there was a positive association between adversity and child trauma-related distress for children who had low levels of protective factors, but not for those with high levels of protective factors (b=-0.56, p=<.001). Similar findings were observed when data was stratified by maltreatment and household dysfunction. CONCLUSIONS Bolstering children's protective factors prior to, and during child abuse treatment, may reduce trauma-related distress following exposure to adversity.
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Affiliation(s)
- Nicole Racine
- University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada; Alberta Children's Hospital Research Institute, 3330 Hospital Dr. NW, 3B2X9, Calgary, AB, Canada
| | - Rachel Eirich
- University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
| | - Gina Dimitropoulos
- University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada; Alberta Children's Hospital Research Institute, 3330 Hospital Dr. NW, 3B2X9, Calgary, AB, Canada
| | - Cailey Hartwick
- Child Abuse Service, Alberta Children's Hospital, 3820 24 Avenue NW, T2P 2M5, Calgary, AB, Canada
| | - Sheri Madigan
- University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada; Alberta Children's Hospital Research Institute, 3330 Hospital Dr. NW, 3B2X9, Calgary, AB, Canada.
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199
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Yochman A, Pat-Horenczyk R. Sensory Modulation in Children Exposed to Continuous Traumatic Stress. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2020; 13:93-102. [PMID: 32318232 PMCID: PMC7163836 DOI: 10.1007/s40653-019-00254-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Preliminary evidence supports a possible association between post-traumatic stress disorder (PTSD) and sensory modulation disorder (SMD). Nevertheless, the research focusing on this relationship in children is notably limited. This study examined children with and without PTS symptoms, by comparing their mothers' perceptions of their responses to sensory events in daily life. Mothers of 134 non-referred children aged 5-11, exposed to continuous traumatic stress due to political violence, completed the UCLA-RI and the Short Sensory Profile questionnaires. Significant differences emerged between children with different levels of PTS symptoms in various sensory modalities. Furthermore, half of the symptomatic children had suspected clinically significant deficits in sensory processing. In addition, PTSD symptoms were significantly associated with most of the sensory processing scores. Logistic regression indicated that the overall sensory processing score was a significant predictor of group classification. The results indicate that children with PTS symptoms may be at increased risk for sensory processing deficits. Evaluation of sensory processing should be incorporated into the routine evaluation of this population in order to determine whether this is an additional factor contributing to a child's difficulties in participating in daily activities. Subsequent intervention programs should then address the multiple needs of these children.
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Affiliation(s)
- Aviva Yochman
- School of Occupational Therapy, Faculty of Medicine of Hadassah and the Hebrew University of Jerusalem , 24026, Mount Scopus, 91240 Jerusalem, Israel
| | - Ruth Pat-Horenczyk
- Paul Baerwald School of Social Work and Social Welfare, the Hebrew University of Jerusalem, Jerusalem, Israel
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200
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Ge F, Li Y, Yuan M, Zhang J, Zhang W. Identifying predictors of probable posttraumatic stress disorder in children and adolescents with earthquake exposure: A longitudinal study using a machine learning approach. J Affect Disord 2020; 264:483-493. [PMID: 31759663 DOI: 10.1016/j.jad.2019.11.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 09/30/2019] [Accepted: 11/12/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Evidence has identified risk factors associated with individuals with trauma exposure who develop posttraumatic stress disorder (PTSD). How to combine risk factors to predict probable PTSD in young survivors using machine learning is limited. The study aimed to integrated multiple measures at 2 weeks after the earthquake using machine learning for the prediction of probable PTSD at 3 months after earthquake. METHODS A total of 2099 young survivors with earthquake exposure were included. We integrated multiple domains of variables to 'train' a machine learning algorithm (XGBoost). Thirty-one combination types were implemented and evaluated. The resulting XGBoost was utilized in identifying individual participants as either probable PTSD or no PTSD. RESULTS Any combination type predicted young survivor probable PTSD, with prediction accuracies ranging between 66%-80% (p < 0.05). In particular, the combination of earthquake experience, everyday functioning, somatic symptoms and sleeping correctly predicted 683 out of 802 cases of probable PTSD, translating to a classical accuracy of 74.476% (85.156% sensitivity and 60.366% specificity) and an area under the curve of 0.80. The most relevant variables (e.g. age, sex, property loss and a sedentary lifestyle) revealed in the present study. LIMITATIONS Participants from a specific district might limit the generalizability of our results. Self-report questionnaires and non-standardized measures were used to assess symptoms. CONCLUSION Detection of probable PTSD according to self-reported measurement data is feasible, may improve operational efficiencies via enabling targeted intervention, before manifestation of symptoms.
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Affiliation(s)
- Fenfen Ge
- Mental Health Center of West China Hospital and Disaster Medicine Center, Sichuan University, Chengdu 610041 Sichuan, P. R. China.
| | - Ying Li
- Embedded System and Intelligent Computing Laboratory, University of Electronic Science and Technology of China, Chengdu 610041 Sichuan, P. R. China.
| | - Minlan Yuan
- Mental Health Center of West China Hospital, Sichuan University, Chengdu 610041 Sichuan, P. R. China.
| | - Jun Zhang
- Mental Health Center of West China Hospital and Disaster Medicine Center, Sichuan University, Chengdu 610041 Sichuan, P. R. China.
| | - Wei Zhang
- Mental Health Center of West China Hospital, Sichuan University, Chengdu 610041 Sichuan, P. R. China.
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