A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents

Latent classes of DSM-5 acute stress disorder symptoms in children after single-incident trauma: findings from an international data archive

Background: After a potentially traumatic event (PTE), children often show symptoms of acute stress disorder (ASD), which may evolve into posttraumatic stress (PTS) disorder. A growing body of literature has employed latent class analysis (LCA) to disentangle the complex structure underlying PTS symptomatology, distinguishing between homogeneous subgroups based on PTS presentations. So far, little is known about subgroups or classes of ASD reactions in trauma-exposed children. Objective: Our study aimed to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership (gender, age, cultural background, parental education, trauma type, and trauma history). Method: A sample of 2287 children and adolescents (5-18 years) was derived from the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive, an international archive including studies from the USA, UK, Australia, and Switzerland. LCA was used to determine distinct subgroups based on ASD symptoms. Predictors of class membership were examined using a three-step approach. Results: Our LCA yielded a three-class solution: low (42%), intermediate (43%) and high (15%) ASD symptom severity that differed in terms of impairment and number of endorsed ASD symptoms. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be of female gender, be younger of age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). Conclusions: These findings provide new information on children at risk for ASD after single-incident trauma, based on a unique set of international data. Classifying children based on latent symptom profiles helps to identify target groups for prevention and intervention after exposure to a PTE.

Alternative Models of DSM-5 Posttraumatic Stress Disorder in Portuguese Adolescents Exposed to Trauma and Childhood Adversity

The factor structure of DSM-5 posttraumatic stress disorder (PTSD) has been extensively debated, with evidence supporting the recently proposed seven-factor hybrid model. However, few studies examining PTSD symptom structure have assessed the implications of these proposed models on diagnostic criteria and PTSD prevalence. In the present study, we examined seven alternative DSM-5 PTSD models within a confirmatory factor analysis (CFA), using the Child PTSD Symptom Scale-Self-Report for DSM-5 (CPSS-5). Additionally, we generated prevalence rates for each of the seven models by using a symptom-based diagnostic algorithm and assessed whether substance abuse, depression, anxiety symptoms, and daily functioning were differentially associated with PTSD depending on the model used to derive the diagnosis. Participants were 317 adolescents aged 13-17 years (M = 15.93, SD = 1.23) who had experienced a DSM-5 Criterion A trauma and/or childhood adversity. The CFA results showed good fit indices for all models, with the seven-factor hybrid model presenting the best fit. The rates of PTSD diagnosis varied according to each model. The four-factor DSM-5 model presented the highest rate (30.6%), and the seven-factor hybrid model presented the lowest rate (17.4%). Similar to the CFA analysis, the inclusion criteria for the diagnosis based on the hybrid model also presented the strongest associations with daily functional impairment, odds ratio (OR) = 1.48, 95% CI [1.25, 1.75]; and adverse childhood experiences, OR = 1.46, 95% CI [1.16, 1.82]. Research and clinical implications of these results are discussed, and suggestions for future investigation are presented.

Long-term mental health in unaccompanied refugee minors: pre- and post-flight predictors

Unaccompanied refugee minors are a particularly vulnerable group. The aim of this study is to increase our knowledge about possible pathways to well-being and integration for unaccompanied refugee minors as they strive to establish new lives in a host county. The present study followed a group of youth who fled to Norway without their caregivers at three time points; 6 months (n = 95; M age = 13.8, 80% boys), 2 years (n = 78; M age = 16.5, 83% boys), and 5 years (n = 47; M age 20.0, 83% boys) after arrival. Linear mixed effects models were used to assess whether age, gender, and trauma exposure prior to arrival were associated with levels and changes in symptoms of posttraumatic stress (PTS), depression, anxiety, and externalizing symptoms over time. Regression analyses were conducted to examine whether daily hassles, perceived social support, and new trauma experiences predict PTS, internalization, externalization, and somatization. The mean levels of depression had decreased significantly at 5 years, but mean levels of anxiety, PTS, and externalizing symptoms did not. Females and severely trauma exposed had higher levels of symptoms. Higher age was associated with less change in symptoms of depression and posttraumatic stress over time. Five years after arrival, many still experienced clinical levels of mental health problems, and level of daily hassles was an important predictor. Support may be needed not only at arrival to handle mental health problems in general and posttraumatic stress in particular, but also after resettlement. Help to manage daily hassles may be especially important to ensure well-being and integration.

Bioecological Implications of Narrative Exposure Therapy in Low-Resource Settings: Individual, Family, Community, and Socio-Political Contexts

Traumatic stress can have detrimental effects on individuals, families, and communities. Narrative Exposure Therapy (NET) is an evidence-based intervention for decreasing individuals' posttraumatic stress disorder (PTSD) symptoms and has been tested in some of the most challenging contexts, such as in post-conflict refugee camps. Although the focus of NET is on reducing individual PTSD symptoms, the impact of NET can be seen beyond the individual level. The purpose of this manuscript was to examine some of the ecological implications of using NET with trauma-affected populations in low-resource settings. We highlight select implications of NET that extend beyond the individual to systemic effects at the family, community, and sociopolitical levels using several case examples. Finally, we outline limitations and future directions for improving the delivery of NET in settings with limited resources.

Posttraumatic Stress Disorder Among Low-Income Adolescents Experiencing Family-Neighborhood Income Disparities

Certain neighborhood factors may increase the risk of exposure to trauma, therefore increasing the risk of posttraumatic stress disorder (PTSD). Other aspects of neighborhoods can be protective, such as neighborhood-based social relationships, which provide social support that buffers the risk of developing PTSD. The strength of these social relationships may not be as dependent on neighborhood conditions as much as they are contingent on socioeconomic similarities between neighborhood residents. Using a nationally representative sample of hospital emergency department admissions in the United States (N = 13,669,251), this study hypothesized that an interaction between family-level income and neighborhood-level income would be associated with adolescent PTSD. The results show that female adolescents who resided in the highest income areas were 1.39 times more likely, 95% CI [1.09, 1.77], to be diagnosed with PTSD than those who lived in the lowest income areas. This association was not statistically significant for male adolescents. Additionally, low-income female youth were nearly one-third more likely than their non-low-income counterparts to be diagnosed, odds ratio (OR) = 1.29, 95% CI [1.12, 1.48], whereas low-income male youth were nearly twice as likely than their non-low-income counterparts to be diagnosed, OR = 1.95, 95% CI [1.62, 2.34]. Furthermore, there was an interaction among both male and female adolescents such that lower-income adolescents living in higher-income areas had higher odds of a PTSD diagnosis compared to their higher-income peers in areas that were in the same median household income quartile.

Profiles of Adjustment in Pediatric Cancer Survivors and Their Prediction by Earlier Psychosocial Factors

Objective

To examine individual differences in pediatric cancer survivors' psychosocial adjustment and test the psychosocial predictors, assessed 2-3 years earlier, of those differences.

Method

Pediatric cancer survivors (n = 209, aged 8-17 years at baseline) and their parents were followed for 4 years. They provided reports of survivors' psychosocial adjustment at 3 years post-baseline, and latent profile analysis (LPA) was used to identify subgroups of survivors who differed on those reports. Multinomial logistic regression was used to predict group membership from self- and parent-reported psychosocial factors at baseline (child adjustment, disposition, and parental functioning) and at 1 year post-baseline (child social relations).

Results

The LPA revealed a 3-class model as the best fit: a "Resilient" group (65%), characterized by good psychosocial adjustment; a "Self-Reported At-Risk" group (23%), characterized by subclinical elevations in self-reported internalizing and attention problems; and a "Parent-Reported At-Risk" group (12%), characterized by subclinical elevations in parent-reported internalizing, externalizing, and attention problems and in self-reported attention problems. Several psychosocial predictors, including child posttraumatic stress, affectivity, and connectedness to school, as well as parental distress and overprotection, differentiated the Resilient group from the other groups, in expected directions.

Conclusions

The majority of pediatric cancer survivors exhibit enduring resilience. The protective factors identified for them-including positive affectivity and strong connectedness to school-may inform targeted prevention strategies for the minority of survivors who are at risk for maladjustment.

Symptoms of posttraumatic stress disorder among targets of school bullying

BACKGROUND

The aim of this study was to investigate whether bullying among students is associated with symptoms of posttraumatic stress disorder (PTSD), and whether associations are comparable to other traumatic events leading to PTSD.

METHODS

Data were collected from 219 German children and adolescents: 150 students from grade six to ten and 69 patients from an outpatient clinic for PTSD as a comparison group. Symptoms of PTSD were assessed using the Children's Revised Impact of Event Scale (CRIES) and the Posttraumatic Symptom Scale (PTSS-10). A 2 × 5 factorial analysis of variance (ANOVA) with the factors gender (male, female) and group (control, conflict, moderate bullying, severe bullying, traumatized) was used to test for significant differences in reported PTSD symptoms.

RESULTS

Results showed that 69 (46.0%) students from the school sample had experienced bullying, 43 (28.7%) in a moderate and 26 (17.3%) in a severe way. About 50% of the severe bullying group reached the critical cut-off point for suspected PTSD. While the scores for symptoms of PTSD were significantly higher in bullied versus non-bullied students, no significant differences were found between patients from the PTSD clinic and students who experienced severe bullying.

CONCLUSIONS

Our findings suggest that bullying at school is highly associated with symptoms of PTSD. Thus, prevention of bullying in school may reduce traumatic experiences and consequent PTSD development.

A Longitudinal Examination of Heart-Rate and Heart Rate Variability as Risk Markers for Child Posttraumatic Stress Symptoms in an Acute Injury Sample

Heart rate (HR) alterations in the immediate aftermath of trauma-exposure have been proposed to be potentially useful markers for child and adolescent posttraumatic stress disorder (PTSD). However, it is not yet clear if this holds true for measures taken more distal to the trauma, and no studies have investigated the predictive validity of more sensitive HR variability (HRV) indices. We recruited 76 parent-child pairs (child age 6 to 13 years) after the child experienced a traumatic event leading to presentation at a hospital emergency department. At 1-month post trauma (T1), HR recordings were obtained at rest, and while children verbally recounted their traumatic experience, both alone and together with a parent. Child post-traumatic stress symptoms (PTSS) were assessed concurrently (T1), and at 3 (T2) and 6-month (T3) follow-ups. We found that for T1, elevated mean HR during trauma narratives, but not at baseline, was positively associated with PTSS, with some evidence that HRV-indices were negatively cross-sectionally associated with PTSS. Furthermore, T1 HR indices predicted PTSS at T2 and partially at T3, although these effects did not hold when T1 PTSS were added to the model. Findings suggest that, consistent with the adult literature, HR indices in children may be a concurrent marker of higher PTSS and may be predictive of longer term distress. The findings encourage further investigations that track child HR and HRV in relation to PTSS over time after trauma, in order to examine how biological profiles evolve in those with persistent symptoms.

Longitudinal Associations Between Dysfunctional Maltreatment-Related Cognitions and Psychopathology in Children and Adolescents

Dysfunctional posttraumatic cognitions seem to play an important role in adjustment after traumatic experiences. However, little research has been done on maltreated children and adolescents. Furthermore, possible causal associations between cognitions, posttraumatic stress symptoms, and internalizing and externalizing problems have rarely been investigated. In the current study, 263 maltreated children and adolescents (8-17 years of age) were assessed at baseline and again at time points 6 and either 12 or 18 months later. Cross-lagged panel analyses were used to gain a better understanding of the course of and associations among dysfunctional maltreatment-related cognitions, posttraumatic stress symptoms, and internalizing and externalizing problems. Ratings of all variables significantly decreased over time. Moderate to strong autoregressive paths emerged for all variables, denoting stability. Furthermore, the variables showed moderate to high correlations at every assessment. Posttraumatic stress symptoms moderately predicted dysfunctional maltreatment-related cognitions as well as internalizing and externalizing problems 6 months after baseline. Cross-lagged paths from the cognitions as well as from internalizing and externalizing problems to all other variables were not significant. Age, gender, and maltreatment characteristics did not play a relevant role in these cross-lagged associations when they were included as covariates. Our results underline the cognitive scar model, in which preceding posttraumatic stress symptoms adversely impact cognitions. Posttraumatic stress symptoms appear to be an important target for treatment as their reduction may help decrease internalizing and externalizing problems as well.

Long-Term Impact of Parental Post-Traumatic Stress Disorder Symptoms on Mental Health of Their Offspring After the Great East Japan Earthquake

Longitudinal studies of the long-term psychological impact of the Great East Japan Earthquake (GEJE) on parents and their children have been limited. The current study aimed to monitor parents' post-traumatic stress disorder (PTSD) symptoms and behavioral problems among their children over time and to analyze their long-term associations among the survivors of the GEJE. We used data from the GEJE Follow-up for Children study, which recruited 4- to 6-year-old children and those children's parents immediately after the GEJE in March 2011, with ongoing follow-up. Children's total, internalizing, and externalizing behavioral problems were assessed using the Child Behavior Checklist (CBCL), and parental probable PTSD was assessed using the Impact of Event Scale-R (IES-R), in 2012 (baseline) and 2014 (follow-up). Parental PTSD symptoms and children's behavioral problems declined slightly over time, and both showed a significant correlation between the surveys (r = 0.55-0.77, P < 0.001). The association between parental PTSD symptoms and children's behavioral problems was investigated using multivariate logistic regression analysis adjusting for baseline children's behavioral problems and other potential confounders. Cross-sectionally, while no significant association was detected in 2012, all types of children's behavioral problems exhibited significant positive associations with parental PTSD symptoms in multiple logistic regression analysis adjusted odds ratio (AOR) = 3.03, 3.30, and 5.34 for total, internalizing, and externalizing behavior problems, respectively. Maternal educational attainment level (higher than high school education) showed a significant negative association with children's total and externalizing behavioral problems (AOR = 0.30 and 0.13, respectively) in 2014. Longitudinally, parental PTSD symptoms in 2012 showed a significant association with children's internalizing behavioral problems in 2014 after adjusting for children's behavioral problems in 2012 and parental PTSD symptoms in 2014 (AOR = 4.62). These results suggest that the effect of the GEJE on parental PTSD symptoms and children's behavioral problems was long-term, lasting for at least 3 years. These possibilities should be carefully considered in mental health support for parents and their offspring in areas affected by the GEJE.

Pediatric cancer, posttraumatic stress and fear-related neural circuitry

This review examines the neurobiological effects of pediatric cancer-related posttraumatic stress symptoms (PTSS). We first consider studies on prevalence and predictors of childhood cancer-related PTSS and compare these studies to those in typically developing (i.e., noncancer) populations. Then, we briefly introduce the brain regions implicated in PTSS and review neuroimaging studies examining the neural correlates of PTSS in noncancer populations. Next, we present a framework and recommendations for future research. In particular, concurrent evaluation of PTSS and neuroimaging, as well as sociodemographic, medical, family factors, and other life events, are needed to uncover mechanisms leading to cancer-related PTSS. We review findings from neuroimaging studies on childhood cancer and one recent study on cancer-related PTSS as a starting point in this line of research.

Perceived consequences of hazing exposure during the first year of college: Associations with childhood victimization

Objective: This study investigates the association between histories of childhood victimization and perceived consequences of college hazing. Participants: First-year college students at four US universities (N = 120). Method: Participants completed Web-based surveys asking about childhood victimization (eg, child maltreatment), peer victimization, and perceived consequences of hazing during college. Results: Results indicated that college students with childhood victimization histories perceived hazing to be negative. In particular, physical dating violence and a greater total number of childhood victimization exposures were related to a higher number of perceived negative consequences. Conclusion: Past victimization exposures confer risk on college students who experience hazing, in that these students are more likely to perceive negative consequences of hazing. Hazing-related policies and outreach efforts should consider these potential negative consequences, and counselors should be aware of the link between past victimization and how hazing might be experienced.

Examination of Child Placement, Emotional, Behavioral and Attachment Problems Among Children with Caregiver-Perpetrated Trauma Histories

Caregiver-perpetrated trauma (CPT) is associated with adverse consequences for youth, including out-of-home placement. Although promotion of kinship care placement has recently increased, effects on youth remain unclear. Psychosocial functioning of 1107 CPT-exposed youth ages 2 to 18 was compared across placement types using generalized mixed models. Youth remaining at home had increased Somatization symptoms compared to kinship (OR = .25, CI = 0.07-.88) and foster care (OR = .32, CI = 0.11-.98) youth. Both out-of-home placement types had higher odds of Attachment Problems (OR = 3.61, CI = 2.22-5.87 and 4.41, CI = 2.71-7.18 respectively). PTSD symptoms varied, youth in kinship care had increased self-reported re-experiencing symptoms (OR = 2.66, CI = 1.04-6.8), while youth in foster care had elevated clinician-rated PTSD (OR = 2.07, CI = 1.1.3-3.80). Given the limited differences between kinship and foster care, studies should continue to delineate the impact of child placement type to inform child welfare policy.

Child and family traumatic stress intervention (CFTSI) reduces parental posttraumatic stress symptoms: A multi-site meta-analysis (MSMA)

BACKGROUND

Following traumatization, caregiver support is a crucial factor contributing to children's successful management of posttraumatic reactions and their recovery. Caregivers who have been traumatically impacted themselves, however, may be compromised in this posttraumatic caregiving role. Although there are a number of evidence-based child trauma treatments that are effective in reducing children's trauma symptoms, the impact of child treatment on participating caregiver's posttraumatic symptoms (PTS) has received less attention.

OBJECTIVE

Explore PTS reduction caregivers experience through participation in their child's evidence-based trauma-focused mental health treatment.

PARTICIPANTS AND SETTING

640 Child-Caregiver dyads referred for the Child and Family Traumatic Stress Intervention (CFTSI) following formal disclosure of abuse in a Child Advocacy Center (CAC).

METHODS

Data were collected from 10 community treatment sites trained in CFTSI. A multi-site meta-analytic approach was used to evaluate pooled and site-specific therapeutic effect sizes for caregivers and children.

RESULTS

CFTSI was associated with significant changes (Hedge's g = 1.17, Child-rated; g = 0.66, caregiver-rated) in children's PTS and with clinically meaningful improvements in PTS for 62% of participating caregivers who had started CFTSI with clinical levels of PTS as measured by the Post Traumatic Checklist-Civilian Version (PCL-C). The overall mean PCL-C change (9.31, SD = 12.9) in paired, pre-post PCL-C scores is close to a clinically meaningful change of 10 or higher. There was a robust moderate pooled effect size (g = 0.70, N = 640, p < 0.0001).

CONCLUSION

The value of a reduction in caregiver PTS as a secondary outcome of children's trauma-focused treatment is discussed.

Attachment and social support mediate associations between Polyvictimization and psychological distress in early adolescence

The current study assesses associations between multiple experience of traumatic events (polyvictimization), PTSD symptoms (PTSS) and psychiatric symptoms in early adolescence, and explores the mediating roles of attachment orientations and perceived social support in the associations between polyvictimization, PTSS and psychiatric symptoms. In 2001, a representative national sample of 390 Danish eighth-graders (M = 13.95, SD = .37) completed validated self-report questionnaires. Polyvictimization was related to higher PTSS and psychiatric symptoms. Importantly, polyvictimization was significantly linked to high attachment anxiety, which was linked with low perceived social support, which in turn was linked with high PTSS levels and psychiatric symptoms. Polyvictimization might have dire consequences in early adolescence. An individual's high attachment anxiety might be connected with lack of perceived social support, which should be seen as a possible psychological distress mechanism subsequent to exposure to a number of potentially traumatic events.

Posttraumatic stress and health-related quality of life in parents of children with cardiac rhythm devices

PURPOSE

Studies have shown a high prevalence of post-traumatic stress disorders (PTSD) among parents of children with life-threatening diseases. However, it is yet unknown whether parents of children with cardiac rhythm device develop posttraumatic stress symptoms or even PTSD.

METHODS

This cross-sectional investigation is part of a comprehensive single-center study of long-term medical and psychosocial outcomes in pediatric patients with pacemaker (PM) and implantable cardioverter defibrillator (ICD). 69 patients (78%) were included in the study, with the participation of 69 mothers and 57 fathers. Parents completed the Posttraumatic Diagnostic Scale and Medical Outcomes Study Short Form-36 item questionnaire. Child's medical data was collected retrospectively from patients' hospital records.

RESULTS

At assessment, the patients (39% females) were on average 11.2 years old. The predominant device type was PM in 56 cases (81%). The mean time since device implantation was 6.3 years (SD = 4.3). Full heart-disease related PTSD was diagnosed in one mother and no father, while partial heart-disease-related PTSD was diagnosed in 3 mothers (4%) and 2 fathers (4%). Parental HRQoL-especially regarding the mental health dimension-was affected in both parents. In both parents, total PTSD symptom severity scores were a significant predictor for mental health summary scores after controlling for child age at implantation, presence of other non-cardiac disease in the child, parental age, and presence of own chronic disease.

CONCLUSIONS

Special attention should be given to parental PTSD symptoms in the clinical follow-up of PM and ICD patients as some parents might probably benefit from psychological support.

Relationship between posttraumatic stress symptoms, caregiving response, and parent mental health in youth exposed to single incident trauma

BACKGROUND

Family factors may alter the risk of developing posttraumatic stress disorder (PTSD) or depression in young people after a traumatic event, but it is not clear which modifiable family variables can be addressed in psychological therapies. This study examined the relationships between family factors (Expressed Emotion [EE] and family accommodation) and psychopathology (posttraumatic stress symptoms; PTSS) in young people following a single incident trauma. Potential mediators of these relationships were also investigated.

METHOD

Sixty-six parent-child dyads (aged 8-17 years) were assessed within one month of attending an Emergency Department. Self-reported PTSS and perceived EE were assessed in young people. Parents' own PTSS, mood symptoms, EE, and accommodating behaviours were also assessed.

RESULTS

Cross-sectional analyses revealed that young person-perceived EE, parent-reported emotional over involvement (EOI) and accommodation behaviours significantly predicted higher PTSS in young people. The stress experienced as a consequence of EE mediated the relationship between young person-perceived EOI and PTSS in young people. Parental PTSS and anxiety were positively correlated with EOI and accommodation. Parental PTSS was not significantly associated with symptoms in young people.

CONCLUSIONS

The results support the hypothesis that EE and accommodation are positively associated with PTSS in young people in the month following a potentially traumatic event. Understanding the child in the context of their family environment and relationships offers an important framework for making sense of and facilitating adaptive adjustment following a traumatic event.

Reported Levels of Upset in Youth After Routine Trauma Screening at Mental Health Clinics

Importance

Clinical guidelines recommend routine screening for trauma at youth mental health clinics. However, many clinicians are concerned that screening may be upsetting both for youths who have been exposed to trauma and for those who have not.

Objectives

To investigate levels of upset following routine trauma screening and whether type of trauma and symptoms of posttraumatic stress were associated with level of upset.

Design, Setting, and Participants

Survey study in which data from routine screening for trauma exposure and trauma-related symptoms were collected from January 1, 2015, to December 31, 2017. Nearly half (n = 40) of all youth mental health clinics in Norway submitted survey data. Participants included youths aged 6 to 18 years referred to treatment.

Main Outcomes and Measures

The trauma screening inventory, Child & Adolescent Trauma Screening Questionnaire, was administered. Self-reported levels of upset after initial screening were scored on a scale ranging from 1 (not upsetting) to 7 (very upsetting).

Results

Among 10 157 youths aged 6 to 18 years (mean [SD] age, 13.0 [3.1] years; 5320 [55.0%] female), surveyed, 8021 (79.1%) reported exposure to at least 1 potentially traumatizing event and a mean (SD) of 2.44 (2.27) different types of events (range, 0-15). Only 453 participants (4.5%) reported high levels of upset, while 2757 participants (27.2%) reported moderate levels of upset and 6942 participants (68.4%) reported no or low levels of upset. Youths who had been exposed to any type of traumatic event reported significantly higher levels of upset compared with those reporting no trauma exposure, and a higher number of reported traumatic events was associated with a higher level of upset (point estimate, 0.23; 95% CI, 0.22-0.24; P < .001). Among participants who reported trauma, exposure to sexual abuse (point estimate, 0.87; 95% CI, 0.77-0.95; P < .001) and higher levels of posttraumatic stress symptoms (point estimate, 0.05; 95% CI, 0.04-0.05; P < .001) were associated with higher levels of upset.

Conclusions and Relevance

A high level of trauma exposure was found among youths referred to youth mental health clinics, but trauma screening was well tolerated, with most participants reporting no or low levels of upset. These findings can be used to support therapists and health care leaders in implementing routine trauma screening to better identify youths who are in need of trauma-focused treatment.

Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents

Important advances in understanding traumatic stress reactions in children and young people have been made in recent years. The aim of this review was to synthesise selected recent research findings, with a focus on their relevance to clinical practice. We therefore address: findings on the epidemiology of trauma exposure and Posttraumatic Stress Disorder (PTSD); recent changes to diagnostic classification; implications for screening and assessment of traumatic stress reactions; and treatment outcome studies including interventions for acute and chronic PTSD, dissemination of effective treatments into community settings, and early interventions. We conclude with recommendations for clinical practice and suggestions for future areas of research.

Post-traumatic stress disorder and its risk factors in bereaved Tibetan adolescents 3 years after the 2010 Yushu earthquake, a cross-sectional study in China

OBJECTIVES

This study examined the incidence of symptomatological post-traumatic stress disorder (PTSD) in bereaved Tibetan adolescents 3 years after the 2010 Yushu earthquake, then to identify possible and relational risk factors of PTSD by a cross-sectional study.

METHODS

A total of 867 bereaved Tibetan adolescents seriously impacted by the 2010 earthquake were investigated. Symptomatological PTSD was evaluated by the PTSD Checklist-Civilian Version. And coping styles were evaluated by the Coping Styles Scale. Exposure of trauma to the 2010 Yushu earthquake was evaluated by a checklist about earthquake containing sociodemographic variables.

RESULTS

3 years after the Yushu earthquake, 24.4% of the bereaved Tibetan adolescents had symptomatological PTSD. The results also indicated that coping styles and disaster-related experiences after the 2010 earthquake were connected with PTSD among survivors. When the 2010 earthquake struck, those having symptomatological PTSD were more probably to be buried/injured/amputated, and to witness burial/injury/death, and to have property damage. An individual who adopted positive coping skill was probably to have less symptomatological PTSD.

CONCLUSIONS

The results showed that the existence of PTSD in bereaved Tibetan adolescents in the Yushu earthquake was very prevailing after 3 years. Effective psychological rescue work should be carried out, especially targeting bereaved Tibetan adolescents with more severe PTSD.

The Prevalence of PTSD Symptoms and Depressive Symptoms and Related Predictors in Children and Adolescents 3 Years After the Ya'an Earthquake

The objectives of this study were to investigate the prevalence of post-traumatic stress disorder (PTSD) symptoms and depressive symptoms in teenage survivors three years after the Ya'an earthquake to assess the differences between left-behind (LBC) and non-left-behind (non-LBC) children, and to explore predictors for PTSD symptoms and depressive symptoms. The participants were assessed using children's revised impact of event scale (CRIES) and short mood and feelings questionnaire (SMFQ), after which t tests, Chi square tests, and a multivariate logistic regression were conducted to examine the differences in the LBC and identify the associated predictors. It was found that the PTSD and depressive symptom prevalences were 13.10% and 20.75%, with the LBC having a significantly higher prevalence than the non-LBC. The PTSD and depression symptoms tended to be highly comorbid (r = .52, p < .001). Being female, being aged less than 15, having siblings, being an LBC, and having higher exposure were found to be associated with PTSD and depressive symptoms.

Parental Experiences of Supporting Children with Clinically Significant Post-Traumatic Distress: a Qualitative Study of Families Accessing Psychological Services

The aim of this study was to investigate the experiences of parents in providing support to their child following trauma exposure in cases where children are experiencing clinically significant levels of post-traumatic distress. Qualitative interviews were conducted with parents whose child was exposed to a trauma and referred for psychological treatment. Parents reported considerable anxiety in coping with their child's post-traumatic distress. Avoidance of trauma-related discussions was encouraged due to concerns that non-avoidant approaches may worsen children's post-trauma difficulties. Nonetheless, parents were often sensitive to their child's distress and offered reassurance and other forms of support. Many barriers existed to accessing psychological treatment, and perceptions of inadequate guidance from therapists on supporting child adjustment contributed to parental distress. The results illustrate the strategies used by parents in supporting their child post-trauma and may assist mental health professionals in providing acceptable guidance to parents following child trauma.

The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales

BACKGROUND

Despite the emphasis placed on childhood trauma in psychiatry, comparatively little is known about the epidemiology of trauma and trauma-related psychopathology in young people. We therefore aimed to evaluate the prevalence, clinical features, and risk factors associated with trauma exposure and post-traumatic stress disorder (PTSD) in young people.

METHODS

We carried out a comprehensive epidemiological study based on participants from the Environmental Risk Longitudinal Twin Study, a population-representative birth-cohort of 2232 children born in England and Wales in 1994-95. At the follow-up home visit at age 18 years, participants were assessed with structured interviews for trauma exposure, PTSD, other psychopathology, risk events, functional impairment, and service use. Risk factors for PTSD were measured prospectively over four previous assessments between age 5 and 12 years. The key outcomes were the prevalence, clinical features, and risk factors associated with trauma exposure and PTSD. We also derived and tested the internal validity of a PTSD risk calculator.

FINDINGS

We found that 642 (31·1%) of 2064 participants reported trauma exposure and 160 (7·8%) of 2063 experienced PTSD by age 18 years. Trauma-exposed participants had high rates of psychopathology (187 [29·2%] of 641 for major depressive episode, 146 [22·9%] of 638 for conduct disorder, and 102 [15·9%] of 641 for alcohol dependence), risk events (160 [25·0%] of 641 for self-harm, 53 [8·3%] of 640 for suicide attempt, and 42 [6·6%] of 640 for violent offence), and functional impairment. Participants with lifetime PTSD had even higher rates of psychopathology (87 [54·7%] of 159 for major depressive episode, 43 [27·0%] of 159 for conduct disorder, and 41 [25·6%] of 160 for alcohol dependence), risk events (78 [48·8%] of 160 for self-harm, 32 [20·1%] of 159 for suicide attempt, and 19 [11·9%] of 159 for violent offence), and functional impairment. However, only 33 (20·6%) of 160 participants with PTSD received help from mental health professionals. The PTSD risk calculator had an internally validated area under the receiver operating characteristic curve of 0·74, indicating adequate discrimination of trauma-exposed participants with and without PTSD, and internally validated calibration-in-the-large of -0·10 and calibration slope of 0·90, indicating adequate calibration.

INTERPRETATION

Trauma exposure and PTSD are associated with complex psychiatric presentations, high risk, and significant impairment in young people. Improved screening, reduced barriers to care provision, and comprehensive clinical assessment are needed to ensure that trauma-exposed young people and those with PTSD receive appropriate treatment.

FUNDING

The Medical Research Council, the National Institute of Child Health and Development, the Jacobs Foundation, the Nuffield Foundation, the National Society for Prevention of Cruelty to Children, the Economic and Social Research Council, the National Institute for Health Research, MQ, and Canadian Institutes for Advanced Research.

Extending poly-victimization theory: Differential effects of adolescents' experiences of victimization on substance use disorder diagnoses upon treatment entry

BACKGROUND

Although victimization is a known contributor to the development of substance use disorders, no research has simultaneously examined how characteristics of victimization experienced over time, such as the type of abuse, the presence of poly-victimization, closeness to perpetrator(s), life threat or fear, and negative social reactions to disclosing victimization, cluster into profiles that predict substance use disorders.

OBJECTIVE

The aim of the current study is to assess how profiles of victimization and trauma characteristics are associated with substance use disorders and assess potential gender differences.

PARTICIPANTS AND SETTING

Participants were 20,092 adolescents entering substance use treatment.

METHODS

We used latent class and multi-group latent class analysis to extract classes of victimization and associated characteristics. Emergent classes were used to predicted substance use disorder status at treatment intake.

RESULTS

Five classes were extracted: poly-victimization + high harmful trauma characteristics, sexual abuse + negative social reaction and perceived life threat, emotional abuse + trusted perpetrator, physical abuse and low all. Similar classes were found for the multi-group model. In both the overall and female-specific models, the poly-victimization + high harmful trauma characteristics class was more severe than all other classes in terms of opioid use disorder, tobacco use disorder, and dual diagnosis. Other class differences were found across gender.

CONCLUSIONS

Adolescents entering treatment can be distinguished by their profiles of victimization experiences and associated characteristics, and these profiles evidence different associations with substance use disorder diagnoses. Results point to a need for more nuanced assessment of victimization experiences and gender-specific interventions.

The relationship of internalizing problems with emotional intelligence and social skills in secondary education students: gender differences

Internalizing problems (depression, anxiety, social anxiety, somatic complaints, post-traumatic symptoms, and obsession-compulsion) are very important in adolescents’ development. These problems can be related with people who lack social skills and poorly handle their emotions. This study assessed 1358 secondary education students (12–17 years) to analyze the relationship linking internalizing problems, emotional intelligence, and social skills. The results showed not only how these constructs were related, but how students’ internalizing problems varied according to their emotional intelligence and social skills. They also indicated that two in every three males, and just over one in every two females, obtained high scores for internalizing problems. The model showed a good fit: χ²(85) = 201.161 p < 0.001; χ²/gl = 2.367; CFI = 0.919; NFI = 0.869; TLI = 0.900; RMSEA = 0.075, IC 95% (0.062–0.089). Finally, gender influenced the way that internalizing problems, emotional intelligence, and social skills were related, and an inverse relation appeared to link internalizing problems, emotional intelligence (r = − .77), and social skills (r = − .52) for females, while this relationship was poorer for males. By way of conclusion, we state that internalizing problems are related with emotional intelligence and social skills in secondary education students, but this relationship differs according to gender.

How to Do a Systematic Review: A Best Practice Guide for Conducting and Reporting Narrative Reviews, Meta-Analyses, and Meta-Syntheses

Systematic reviews are characterized by a methodical and replicable methodology and presentation. They involve a comprehensive search to locate all relevant published and unpublished work on a subject; a systematic integration of search results; and a critique of the extent, nature, and quality of evidence in relation to a particular research question. The best reviews synthesize studies to draw broad theoretical conclusions about what a literature means, linking theory to evidence and evidence to theory. This guide describes how to plan, conduct, organize, and present a systematic review of quantitative (meta-analysis) or qualitative (narrative review, meta-synthesis) information. We outline core standards and principles and describe commonly encountered problems. Although this guide targets psychological scientists, its high level of abstraction makes it potentially relevant to any subject area or discipline. We argue that systematic reviews are a key methodology for clarifying whether and how research findings replicate and for explaining possible inconsistencies, and we call for researchers to conduct systematic reviews to help elucidate whether there is a replication crisis.

Psychopathology and Quality of Life in Traumatized or Victimized Underage Individuals as Factors for Forensic Multilevel Assessment-A Pilot Investigation

Background: Psychological sequels to criminal violence can be long lasting and severe. They are in many countries not sufficiently considered in court cases as an important circumstance that could be used to assess the severity of the crime, also guiding redress, compensation, and rehabilitation of the victim, and-in children-child custody considerations. So far, the focus of forensic assessment has often been limited to diagnostic categories, especially "posttraumatic stress disorder" (PTSD), a diagnosis that presently is subjected to rapidly changing definitions both in and between diagnostic systems. Other indicators such as quality of life (QoL) might be of equal importance as compared to clinical or research diagnostic categories to understand and evaluate the impact of a crime and the amount of help needed and, in the legal context, redress to be asked. Symptoms might differ depending on the crime encountered. Objective and Methods: QoL and general symptom patterns including a PTSD diagnosis were assessed in a group of 10- to 17-year-old minors with (n = 33) and without (n = 49) PTSD diagnosis who all had experienced sexual abuse, physical abuse, death of a parent, or their parents' divorce, using standardized diagnostic instruments. Results: PTSD patients reported a significantly lower QoL than non-PTSD controls. Reported symptom patterns with potential impact on life, such as intrusive thoughts, differed between the victims of different crime types, with the highest rates of both intrusive symptoms and combined symptom profile in victims of sexual abuse. Data indicate that the changes between older and present criteria and between DSM and recently published ICD 11 might help identify different groups and symptom profiles. Conclusion: Specific trauma-related symptom profiles integrating the type of crime encountered and its individual impact on QoL may help improve future forensic assessment and guide compensation and rehabilitation plans. Carefully designed studies are now needed to further explore the use and forensic usability of complex indicators and the impact of violence in different forensic settings.

A mixed-methods investigation of parent-child posttrauma discussion and the effects of encouraging engagement

Recent developments in the child trauma field include preventative interventions that focus on augmenting parental support. However, we have limited knowledge of how parents experience trauma conversations with children. We examined how parents and children experienced both spontaneous trauma conversations and a structured task in which they generated a joint trauma narrative, following the child's experience of an acute trauma. Parent and child ratings of distress during the structured narrative were low for all 127 families that took part, with child ratings of distress being lower overall than parent ratings. Task-related distress was positively associated with parent and child PTSD symptoms. Thematic analysis of semi-structured interviews conducted with a subset of twenty parents identified both facilitators of (e.g. open and honest relationship with child) and barriers to (e.g. parent/child avoidance of discussion) spontaneous trauma-related conversations with their child. Additionally, parents described the structured trauma narrative task as an opportunity to start the conversation with their child, to understand their child's feelings, and for the child to process the trauma. However, the task was also uncomfortable or upsetting for some parents/children, and resulted in parents becoming more overprotective. The findings can inform development of low-dose interventions that encourage families to engage in trauma-related conversations following child experiences of trauma.

The relationship between maladaptive appraisals and posttraumatic stress disorder: a meta-analysis

Cognitive models of post-traumatic stress disorder (PTSD) suggest maladaptive appraisals play a central role in the aetiology of this disorder. The current meta-analysis sought to provide a comprehensive, quantitative examination of the relationship between maladaptive appraisals and PTSD. One-hundred and 35 studies met study inclusion criteria and were subject to random effects meta-analysis. A large effect size was found for the relationship between appraisals and PTSD (r = 0.53, 95% CI = 0.51-0.56, k = 147), albeit with significant heterogeneity. In studies using only the Posttraumatic Cognitions Inventory or Child Post-traumatic Cognitions Inventory, the effect size remained large (r = 0.56; k = 104). In adults, appraisals about the self had a large effect size (r = 0.61), appraisals about the world had a medium effect size (r = 0.46) and self-blame appraisals had a small effect size (r = 0.28). In child/adolescent studies, large effect sizes were found for both 'fragile person in a scary world' and 'permanent and disturbing change' appraisals (r = 0.54 and r = 0.60, respectively). The effect size remained large in prospective longitudinal studies up to one year after trauma. There was no moderation effect for civilian vs military populations, questionnaire vs interview measures of PTSD, single vs multiple trauma exposure, or intentional vs unintentional trauma. The main effect size estimate was robust to sensitivity analyses concerning statistics used, study quality and outliers. These findings are consistent with the strong role for maladaptive appraisals in the aetiology of PTSD proposed by cognitive models. In particular, the role of self-appraisals in adults was highlighted. Avenues for future research include more studies in child, multiple trauma and military populations and longer-term follow up studies.

Impact of a Terrorist Attack on the Mental Health of Directly Exposed French Adolescents: Study Protocol for the First Step of the AVAL Cohort Study

Background: Several terrorist attacks have recently taken place in France and Europe. Various studies have shown a high prevalence of Post-Traumatic Stress Disorder (PTSD) and other psychiatric disorders among the victims of these attacks. Nevertheless, research in this field is scarce and no cohort study has been conducted yet to evaluate the impact of a terrorist attack on teenagers directly exposed to this type of events. Therefore, we decided to work on the AVAL (Adolescents Victimes de l'Attentat de Londres) cohort study in order to measure the psycho-traumatic impact of this attack and to describe these adolescents' health care pathways. Material and method: The 53 students of a French high school who were directly exposed (criterion A1 of PTSD in DSM-5) to the terrorist attack perpetrated in London on March 22, 2017 constitute the target population of this monocentric cross-sectional observational study. We decided not to include the three students who were physically wounded and, therefore, didn't have the same sensorial exposition. The primary endpoint will be the prevalence of PTSD 12 to 15 months after the attack, measured by the PCL-5 (Post-traumatic stress disorder Check-List for DSM-5) global severity score: the diagnosis of PTSD will be retained when the score is > 32. We will also use an extensive battery of clinical tests to assess the prevalence of anxiety disorders, mood disorders, sleep disorders, addictions, suicide risk, and alterations in social, family, and school functioning 12 to 15 months after the attack. We will also describe these adolescents' health care pathways since the attack and collect data from the clinical evaluation performed during the initial intervention of the medico-psychological emergency cell within 10 days after the attack. Discussion: The findings of this study are intended to provide epidemiological data about the psycho-traumatic impact of a terrorist attack on the mental health of directly exposed adolescents and to describe these adolescents' health care pathways, thus contributing to improve the immediate, post-immediate, and delayed response strategies after a major psycho-traumatic event involving adolescents (and in particular after terrorist attacks), as well as the identification and psychiatric care of the young survivors requiring specialized care. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03493243. Ethics and Dissemination: The regional ethics committee (Comité de Protection des Personnes Ouest IV-Nantes) approved the study protocol (Reference 10/18_3). All participants (and their legal guardians, for minors) must sign the informed consent to participate. The protocol was presented at the French congress of psychiatry in Nantes (France) in November 2018. After study completion, the results will be published and detailed in Marion Grenon's MD thesis in psychiatry.

Altered resting-state dorsal anterior cingulate cortex functional connectivity in patients with post-traumatic stress disorder

OBJECTIVE

The brain functional alterations at regional and network levels in post-traumatic stress disorder patients are still unclear. This study explored brain functional alterations at regional and network levels in post-traumatic stress disorder patients with resting-state functional magnetic resonance imaging and evaluated the relationship between brain function and clinical indices in post-traumatic stress disorder.

METHODS

Amplitude of low-frequency fluctuation and seed-based functional connectivity analyses were conducted among typhoon survivors with ( n = 27) and without post-traumatic stress disorder ( n = 33) and healthy controls ( n = 30) to assess the spontaneous brain activity and network-level brain function. Pearson correlation analyses were performed to examine the association of brain function with clinical symptom and social support.

RESULTS

Both the post-traumatic stress disorder group and the trauma-exposed control group showed decreased amplitude of low-frequency fluctuation in the dorsal anterior cingulate cortex relative to the healthy control group. The post-traumatic stress disorder group showed increased dorsal anterior cingulate cortex functional connectivity with the right paracentral lobule and bilateral precentral gyrus/postcentral gyrus relative to both control groups. Both traumatized groups exhibited decreased dorsal anterior cingulate cortex functional connectivity with the right hippocampus and left cerebellum relative to the healthy control group. More decreased dorsal anterior cingulate cortex functional connectivity with the right hippocampus was found in the post-traumatic stress disorder group. The Checklist-Civilian Version score positively correlated with functional connectivity between the dorsal anterior cingulate cortex and the right paracentral lobule as well as between the dorsal anterior cingulate cortex and the right precentral gyrus/postcentral gyrus. The social support was associated with functional connectivity between the dorsal anterior cingulate cortex and the bilateral precentral gyrus/postcentral gyrus as well as the dorsal anterior cingulate cortex and the left middle frontal gyrus.

CONCLUSION

Trauma exposure may result in aberrant local and network-level functional connectivity in individuals with or without post-traumatic stress disorder. Altered amplitude of low-frequency fluctuation in the dorsal anterior cingulate cortex may be a predisposing risk factor for post-traumatic stress disorder development following trauma exposure. More prominent decreased dorsal anterior cingulate cortex functional connectivity with the right hippocampus might be specific in the post-traumatic stress disorder group. Improvement of social support might possibly be significant for post-traumatic stress disorder patients.

Do dysfunctional posttraumatic cognitions play a mediating role in trauma adjustment? Findings from interpersonal and accidental trauma samples of children and adolescents

Background: Trauma adjustment varies in children and adolescents. Studies on objective risk factors of posttraumatic stress symptoms (PTSS) yielded inconsistent results. Dysfunctional posttraumatic cognitions (PTCs) might play a mediating role between risk factors and posttraumatic symptomatology. Objective: To investigate the interplay of the characteristics of the trauma (e.g. trauma type), the characteristics of the individual (e.g. age, sex), and the characteristics of the social environment (e.g. parental distress, marital status) on PTSS and depression, taking the child's dysfunctional PTCs into account as a possible mediator. Method: Structural equation modelling was used to better understand trauma adjustment in two heterogeneous samples of children and adolescents: a sample of 114 participants aged 7-16 after accidental trauma and a sample of 113 participants aged 6-17 after interpersonal trauma. Results: In the accidental trauma sample, dysfunctional PTCs mediated the positive associations of younger age and lower parental educational level on child PTSS, but not on depression. In the interpersonal trauma sample, being female positively predicted child depression. Furthermore, parental dysfunctional PTCs positively predicted both child PTSS and depression. No mediation effect of child dysfunctional PTCs was found in the interpersonal trauma sample. Child dysfunctional PTCs moderately to strongly predicted child PTSS and depression in both trauma samples. Conclusions: The impact of the characteristics of the individual and the characteristics of the social environment on child PTSS and depression might depend on the type of trauma experienced. Dysfunctional PTCs mediated between the characteristics of the individual and the characteristics of the social environment and the severity of PTSS in the aftermath of accidental trauma, but not of interpersonal trauma.

A senior high school-based survey on the long-term impact of the Wenchuan earthquake on survivors' quality of life: PTSD as a mediator

Previous earthquake-related studies mostly focused on the prevalence and risk factors of post-traumatic stress disorder (PTSD), and there are only a few articles on the subsequent long-term outcomes of earthquakes. This study aimed to investigate the long-term impact of the Wenchuan earthquake on the quality of life (QOL) of surviving senior high school students 2-3 years post-disaster and to clarify whether PTSD was a mediator in the relationship of earthquake-related exposure and QOL. The study collected 1031 survivors' self-report questionnaires on socio-demographic data, earthquake-related experiences, PTSD symptoms (PCL-C), and QOL (WHOQOL-BREF). The results showed that earthquake-related exposure experiences were negatively associated with QOL scores, and the severity of PTSD symptoms was significantly and negatively related to QOL scores. Structural equation model (SEM) analysis showed that earthquake-related exposure was directly related to the severity of PTSD symptoms, while insignificantly directly related to QOL. Therefore, earthquake-related exposure was indirectly related to QOL (totally mediated by severity of PTSD symptoms). PTSD was a mediator in the relationship between earthquake-related exposure and QOL among adolescents: earthquake-related exposure affected the survivors' QOL mainly mediated by the PTSD symptoms that developed. Therefore, to improve the QOL of the survivors after an earthquake, more attention should be paid to survivors who have PTSD symptoms.

Feasibility of a trauma-informed parent-teacher cooperative training program for Syrian refugee children with autism

Although the number of Syrians affected by the civil war rises, little work has been done to address the needs of Syrian refugee children with autism spectrum disorder. This research aimed to test the feasibility and acceptability of a culturally sensitive intervention developed specifically for children with autism spectrum disorder affected by trauma. Local partners advised the program team on cultural norms. Nine parents and 11 teachers were recruited to participate in 12-week parent-teacher cooperatives in a large Turkish city. We used qualitative methods to analyze interviews with each participant after intervention completion. A total of 14 participants completed the program (70%). All interviewees were women and Syrian refugees. Local political events, transportation costs and safety, and illnesses impacted attrition and attendance. All participants were satisfied with program content, including gains in autism knowledge, behavior management skills, and social support. Program-related challenges included applying skills to nonverbal children. The majority of participants made recommendations for program improvement, including a need for services outside urban areas. Flexible program delivery methods, including online options, might better accommodate participants unable to travel due to distance, political unrest, or safety. More research is needed to rigorously test program outcomes and to evaluate efforts to train local program leaders.

Posttraumatic stress symptoms in young people with cancer and their siblings: results from a UK sample

PURPOSE

This study investigated levels of posttraumatic stress symptoms (PTSS) in children with cancer and their siblings from a British sample. It also examined aspects of the Ehlers and Clark ¹ model of posttraumatic stress disorder in the current population.

METHODS

Sixty participants (34 children with cancer and 26 siblings) aged between 8 and 18 years completed measures of PTSS, maladaptive appraisals, trauma-centered identity, perceived social support and family functioning.

RESULTS

Over a quarter of the sample scored above the clinical cutoff on the Impact of Events Scale-Revised. No differences were observed between patients and siblings with respect to levels of PTSS. Maladaptive appraisals and age were found to account for unique variance in levels of PTSS for the overall sample.

CONCLUSIONS

Rates of PTSS in the sample were relatively high. Support was found for aspects of the Ehlers and Clark ¹ model in explaining PTSS for the current population.

Society, individual, family, and school factors contributing to child mental health in war: The ecological-theory perspective

Mental health problems are common in war-affected areas, but children have different levels of vulnerability. Based on ecological theory (Bronfenbrenner, 2005), this study analyses how factors related to the child (cognitive capacity), their family (parental depression and parenting styles), and their school (teachers' practices and peer relations) mediate the association between traumatic stress (traumatic war experiences and stressful life-events) and child mental health (posttraumatic stress and psychological distress symptoms). The participants were 303 Palestinian children (51.2% girls) of 10-13 years (M = 10.94 ± 0.50) and their parents from the Gaza Strip. The children filled in questionnaires during school classes and the parents did so at their homes. The results of structural equation modeling substantiated the hypothesis that parental depression, poor parenting and low-quality peer relations mediated between traumatic stress and children's mental health problems. Contrary to the hypothesis, child-related factors did not mediate that association. To conclude, parents and peers provide important age-salient social resources for children in war conditions, and psychosocial interventions should therefore enhance their beneficial functions.

The Preliminary Development and Validation of a Trauma-Related Safety-Seeking Behavior Measure for Youth: The Child Safety Behavior Scale (CSBS)

Safety-seeking behaviors (SSBs) may be employed after exposure to a traumatic event in an effort to prevent a feared outcome. Cognitive models of posttraumatic stress disorder propose SSBs contribute to maintaining this disorder by preventing disconfirmation of maladaptive beliefs and preserving a sense of current threat. Recent research has found that SSBs impact children's posttraumatic stress symptoms (PTSS) and recovery. In this paper, we sought to develop and validate a novel 22-item Child Safety Behavior Scale (CSBS) in a school-based sample of 391 pupils (age 12-15 years) who completed a battery of questionnaires as well as 68 youths (age 8-17 years) who were recently exposed to a trauma. Of the sample, 93.1% (N = 426) completed the new questionnaire. The sample was split (n = 213), and we utilized principal components analysis alongside parallel analysis, which revealed that 13 items loaded well onto a two-factor structure. This structure was superior to a one-factor model and overall demonstrated a moderately good model of fit across indices, based upon a confirmatory factory analysis with the other half of the sample. The CSBS showed excellent internal consistency, r = .90; good test-retest reliability, r = .64; and good discriminant validity and specificity. In a multiple linear regression, SSBs, negative appraisals, and number of trauma types each accounted for unique variance in a model of PTSS. This study provides initial support for the use of the CSBS in trauma-exposed youth as a valuable tool for further research, clinical assessment, and targeted intervention.

A Longitudinal Examination of the Relationship between Trauma-Related Cognitive Factors and Internalising and Externalising Psychopathology in Physically Injured Children

Cognitive models of posttraumatic stress disorder (PTSD) highlight maladaptive posttrauma appraisals, trauma memory qualities, and coping strategies, such as rumination or thought suppression, as key processes that maintain PTSD symptoms. Anxiety, depression and externalising symptoms can also present in children in the aftermath of trauma, yet there has been little empirical investigation of the potential relevance of posttrauma cognitive processes for such difficulties. Here, we examined whether: a) acute maladaptive cognitive processes (specifically, maladaptive appraisals, memory qualities, and cognitive coping) were associated with symptoms of PTSD, internalising, and externalising at 1-month posttrauma (T1); and b) changes in these cognitive processes predicted symptom change at a follow-up assessment 6 months later (T2). We recruited 132 6–13 year old children and their parents from emergency departments following the child’s experience of an acute trauma. Children self-reported on their maladaptive appraisals, trauma-memory and cognitive coping strategies, along with symptoms of PTSD, anxiety and depression. Parents also rated children’s internalising and externalising symptoms. We found each cognitive process to be robustly associated with PTSD and non-PTSD internalising symptoms at T1, and change in each predicted change in symptoms to T2. Maladaptive appraisals and cognitive coping were unique predictors of children’s posttrauma internalising. Effects were partially retained even controlling for co-occurring PTSD symptoms. There was less evidence that trauma-specific cognitive processes were associated with externalising symptoms. Findings suggest aspects of cognitive models of PTSD are applicable to broader posttrauma psychopathology, and have implications for how we understand and target children’s posttrauma psychological adjustment.