Trauma exposure and posttraumatic stress disorder in a national sample of adolescents

Early-Life Stress Affects Stress-Related Prefrontal Dopamine Activity in Healthy Adults, but Not in Individuals with Psychotic Disorder

Early life stress may have a lasting impact on the developmental programming of the dopamine (DA) system implicated in psychosis. Early adversity could promote resilience by calibrating the prefrontal stress-regulatory dopaminergic neurotransmission to improve the individual's fit with the predicted stressful environment. Aberrant reactivity to such match between proximal and distal environments may, however, enhance psychosis disease risk. We explored the combined effects of childhood adversity and adult stress by exposing 12 unmedicated individuals with a diagnosis of non-affective psychotic disorder (NAPD) and 12 healthy controls (HC) to psychosocial stress during an [18F]fallypride positron emission tomography. Childhood trauma divided into early (ages 0-11 years) and late (12-18 years) was assessed retrospectively using a questionnaire. A significant group x childhood trauma interaction on the spatial extent of stress-related [18F]fallypride displacement was observed in the mPFC for early (b = -8.45, t(1,23) = -3.35, p = .004) and late childhood trauma (b = -7.86, t(1,23) = -2.48, p = .023). In healthy individuals, the spatial extent of mPFC DA activity under acute psychosocial stress was positively associated with the severity of early (b = 7.23, t(11) = 3.06, p = .016) as well as late childhood trauma (b = -7.86, t(1,23) = -2.48, p = .023). Additionally, a trend-level main effect of early childhood trauma on subjective stress response emerged within this group (b = -.7, t(11) = -2, p = .07), where higher early trauma correlated with lower subjective stress response to the task. In the NAPD group, childhood trauma was not associated with the spatial extent of the tracer displacement in mPFC (b = -1.22, t(11) = -0.67), nor was there a main effect of trauma on the subjective perception of stress within this group (b = .004, t(11) = .01, p = .99). These findings reveal a potential mechanism of neuroadaptation of prefrontal DA transmission to early life stress and suggest its role in resilience and vulnerability to psychosis.

PTSD, cyberbullying and peer violence: prevalence and correlates among adolescent emergency department patients

OBJECTIVE

Posttraumatic stress disorder (PTSD) is often underdiagnosed and undertreated among adolescents. The objective of this analysis was to describe the prevalence and correlates of symptoms consistent with PTSD among adolescents presenting to an urban emergency department (ED).

METHODS

A cross-sectional survey of adolescents aged 13-17 years presenting to the ED for any reason was conducted between August 2013 and March 2014. Validated self-report measures were used to measure mental health symptoms, violence exposure and risky behaviors. Multivariate logistic regression analysis was performed to determine adjusted differences in associations between symptoms consistent with PTSD and predicted correlates.

RESULTS

Of 353 adolescents, 23.2% reported current symptoms consistent with PTSD, 13.9% had moderate or higher depressive symptoms and 11.3% reported past-year suicidal ideation. Adolescents commonly reported physical peer violence (46.5%), cyberbullying (46.7%) and exposure to community violence (58.9%). On multivariate logistic regression, physical peer violence, cyberbullying victimization, exposure to community violence, female gender and alcohol or other drug use positively correlated with symptoms consistent with PTSD.

CONCLUSIONS

Among adolescents presenting to the ED for any reason, symptoms consistent with PTSD, depressive symptoms, physical peer violence, cyberbullying and community violence exposure are common and interrelated. Greater attention to PTSD, both disorder and symptom levels, and its cooccurring risk factors is needed.

Prefrontal-Amygdala Dysregulation to Threat in Pediatric Posttraumatic Stress Disorder

Functional abnormalities in fear circuitry are likely to underlie the pathophysiology of pediatric posttraumatic stress disorder (PTSD), but the few studies to date have yielded conflicting findings. Furthermore, network level functional connectivity and age-related disruptions in fear circuitry have not been thoroughly explored. In a cross-sectional design, 24 healthy and 24 medication-free youth with severe PTSD completed an event-related emotion-processing task during functional MRI. Youth viewed threat and neutral images, half of which were paired with a neutral male face. Group- and age-related differences in brain activation were examined in the medial prefrontal cortex (mPFC), amygdala, and hippocampus. Amygdala functional connectivity was examined using a seed-based approach. PTSD youth showed hyperactivation of the dorsal anterior cingulate cortex (dACC) to threat images. In the dorsomedial PFC (dmPFC), age positively predicted activation in healthy youth but negatively predicted activation in PTSD youth. In the amygdala functional connectivity analysis, PTSD youth showed decreased amygdala-mPFC connectivity to threat images. Furthermore, age positively predicted amygdala-vmPFC connectivity in healthy youth, but negatively predicted connectivity in PTSD youth. Finally, dmPFC activation and amygdala-mPFC connectivity were inversely related to PTSD severity. Pediatric PTSD involves abnormal functional activation and connectivity in fear circuitry. Specifically, dACC hyperactivation is consistent with abnormal promotion of fear responses, whereas reduced amygdala-mPFC connectivity suggests impaired regulation of amygdala responses to threat. Importantly, age-dependent decreases in dmPFC activation and amygdala-vmPFC connectivity may indicate abnormal developmental processes in key emotion pathways in pediatric PTSD.

Abnormal functional architecture of amygdala-centered networks in adolescent posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a prevalent, debilitating, and difficult to treat psychiatric disorder. Very little is known of how PTSD affects neuroplasticity in the developing adolescent brain. Whereas multiple lines of research implicate amygdala-centered network dysfunction in the pathophysiology of adult PTSD, no study has yet examined the functional architecture of amygdala subregional networks in adolescent PTSD. Using intrinsic functional connectivity analysis, we investigated functional connectivity of the basolateral (BLA) and centromedial (CMA) amygdala in 19 sexually abused adolescents with PTSD relative to 23 matched controls. Additionally, we examined whether altered amygdala subregional connectivity coincides with abnormal grey matter volume of the amygdaloid complex. Our analysis revealed abnormal amygdalar connectivity and morphology in adolescent PTSD patients. More specifically, PTSD patients showed diminished right BLA connectivity with a cluster including dorsal and ventral portions of the anterior cingulate and medial prefrontal cortices (p < 0.05, corrected). In contrast, PTSD patients showed increased left CMA connectivity with a cluster including the orbitofrontal and subcallosal cortices (p < 0.05, corrected). Critically, these connectivity changes coincided with diminished grey matter volume within BLA and CMA subnuclei (p < 0.05, corrected), with CMA connectivity shifts additionally relating to more severe symptoms of PTSD. These findings provide unique insights into how perturbations in major amygdalar circuits could hamper fear regulation and drive excessive acquisition and expression of fear in PTSD. As such, they represent an important step toward characterizing the neurocircuitry of adolescent PTSD, thereby informing the development of reliable biomarkers and potential therapeutic targets.

Polyvictimization: Latent profiles and mental health outcomes in a clinical sample of adolescents

OBJECTIVE

Exposure to multiple traumatic events (polyvictimization) is a reliable predictor of deleterious health outcomes and risk behaviors in adolescence. The current study extends the literature on the prevalence and consequences of adolescent trauma exposure by (a) empirically identifying and characterizing trauma exposure profiles in a large, ethnically diverse, multi-site, clinical sample of adolescents, and (b) evaluating relations among identified profiles with demographic characteristics and clinical correlates.

METHOD

Data from the National Child Traumatic Stress Network Core Data Set were used to identify and characterize victimization profiles using latent class analysis in a sample of 3,485 adolescents (ages 13-18, 63% female, 35.7% White, 23.2% Black/African American, 35.0% Hispanic/Latino). Multiple measures of psychological distress and risk behaviors were evaluated as covariates of trauma exposure classes.

RESULTS

Five trauma exposure classes, or profiles, were identified. Four classes-representing approximately half the sample-were characterized by polyvictimization. Polyvictimization classes were differentiated on number of trauma types, whether emotional abuse occurred, and whether emotional abuse occurred over single or multiple developmental epochs. Unique relations with demographic characteristics and mental health outcomes were observed.

DISCUSSION

Results suggest polyvictimization is not a unidimensional phenomenon but a diverse set of trauma exposure experiences with unique correlates among youth. Further research on prevention of polyvictimization and mechanisms linking chronic trauma exposure, gender, and ethnicity to negative outcomes is warranted.

Developmental Timing of Trauma Exposure Relative to Puberty and the Nature of Psychopathology Among Adolescent Girls

OBJECTIVE

Increased neuroplasticity and neural development during puberty provide a context for which stress and trauma can have dramatic and long-lasting effects on psychological systems; therefore, this study was designed to determine whether exposure to potentially traumatic events during puberty uniquely predicts adolescent girls' psychopathology. Because neural substrates associated with different forms of psychopathology seemingly develop at different rates, the possibility that the developmental timing of trauma relative to puberty predicts the nature of psychopathology (posttraumatic stress disorder [PTSD], depressive, and anxiety disorders) was examined.

METHOD

A subset of 2,899 adolescent girls from the National Comorbidity Survey Replication-Adolescent Supplement who completed the study 2+ years postmenarche was selected. Past-year psychiatric disorders and reports of age of trauma exposure were assessed using the Composite International Diagnostic Interview. Developmental stages were defined as the 2 years after the year of menarche ("postpuberty"), 3 years before and year of menarche ("puberty"), 2 to 6 years before the puberty period ("grade school"), and 4 to 5 years after birth ("infancy-preschool").

RESULTS

Compared to other developmental periods, trauma during puberty conferred significantly more risk (50.47% of model R(2)) for girls' past-year anxiety disorder diagnoses (primarily social phobia), whereas trauma during the grade school period conferred significantly more risk (47.24% of model R(2)) for past-year depressive disorder diagnoses. Recency of trauma best predicted past-year PTSD diagnoses.

CONCLUSION

Supporting rodent models, puberty may be a sensitive period for the impact of trauma on girls' development of an anxiety disorder. Trauma prepuberty or postpuberty distinctly predicts depression or PTSD, suggesting differential etiological processes.

Childhood Exposure to Violence and Chronic Physical Conditions in a National Sample of US Adolescents

OBJECTIVES

Exposure to violence is associated with chronic physical conditions in adults. Although violence exposure is common among youths, it is unknown whether violence is associated with chronic physical conditions in childhood and adolescence. We examined the associations of violence exposure with chronic physical conditions in a population-representative sample of US adolescents and determined whether associations were explained by co-occurring mental disorders.

METHODS

Data were drawn from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A), a national cross-sectional survey of 6,483 adolescents (ages 13-17). Lifetime exposure to violence; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mood, anxiety, and substance disorders; and self-reported arthritis, frequent headaches, back or neck problems, other chronic pain, asthma, and allergies were assessed.

RESULTS

One in 4 (24.99%) adolescents reported exposure to violence. Violence exposure was associated with elevated odds of back/neck pain, headaches, chronic pain, allergies, and asthma (odds ratio [OR], 1.5-2.1; 95% confidence interval [CI], 1.1-3.5) after adjustment for sociodemographics, socioeconomic status, and lifetime mental disorders. Regarding new onsets, violence exposure was associated with greater hazard for subsequent first-onset only of back/neck pain (hazard ratio, 1.9; 95% CI, 1.2-3.0) and headaches (hazard ratio, 1.4; 95% CI, 1.1-1.8), and these associations were explained by early-onset mental disorders.

CONCLUSIONS

Childhood violence exposure is associated with chronic physical conditions that emerge early in the life course, although associations are stronger for prevalent than incident conditions. Violence exposure predicts incident pain conditions only, and these associations are explained by mental disorders that begin after violence exposure. Interventions and policies aimed at preventing violence and detecting and treating early-onset mental disorders have the potential to reduce morbidity, mortality, and health disparities beginning early in development.

Child Maltreatment, Trauma, and Physical Health Outcomes: The Role of Abuse Type and Placement Moves on Health Conditions and Service Use for Youth in Foster Care

OBJECTIVE

The purpose of the study was to investigate the relations between abuse types, non-maltreatment-related trauma, and health service utilization in a sample of youth in foster care with and without chronic medical conditions.

METHOD

A total of 213 youth, aged 8-21 years, provided self-report of general trauma and abuse exposure. Medicaid claims for each child were collected from official state databases.

RESULTS

Exposure to sexual abuse, neglect, or general trauma but not exposure to physical abuse or psychological abuse increased the rates of medical visits, while only general trauma increased medical hospitalizations. 

CONCLUSIONS

Trauma types are not equally predictive of health care utilization for youth with chronic health conditions.

Adolescent Substance Use Following a Deadly U.S. Tornado Outbreak: A Population-Based Study of 2,000 Families

Despite conceptual links between disaster exposure and substance use, few studies have examined prevalence and risk factors for adolescent substance use and abuse in large, population-based samples affected by a recent natural disaster. We addressed this gap using a novel address-based sampling methodology to interview adolescents and parents who were affected by the 4th deadliest tornado outbreak in U.S.

HISTORY

Postdisaster interviews were conducted with 2,000 adolescent-parent dyads living within a 5-mile radius of the spring 2011 U.S. tornadoes. In addition to descriptive analyses to estimate prevalence, hierarchical linear and logistic regression analyses were used to examine a range of protective and risk factors for substance use and abuse. Approximately 3% reported substance abuse since the tornado. Greater number of prior traumatic events and older age emerged as consistent risk factors across tobacco and alcohol use and substance abuse since the tornado. Tornado incident characteristics, namely, greater loss of services and resources after the tornado and posttraumatic stress disorder since the tornado, were associated with greater alcohol consumption. Service loss increased risk for binge drinking, whereas, for substance abuse, posttraumatic stress disorder increased risk and parent presence during the tornado decreased risk. Greater family tornado exposure was associated with a greater number of cigarettes smoked in female but not male teen participants. Both trauma and non-trauma-related factors are relevant to postdisaster substance abuse among adolescents. Future research should examine the role of broader ecological systems in heightening or curtailing substance use risk for adolescents following disaster exposure.

Lower structural integrity of the uncinate fasciculus is associated with a history of child maltreatment and future psychological vulnerability to stress

The experience of child maltreatment is a significant risk factor for the development of later internalizing disorders such as depression and anxiety. This risk is particularly heightened after exposure to additional, more contemporaneous stress. While behavioral evidence exists for such "stress sensitization," little is known about the mechanisms mediating such relationships, particularly within the brain. Here we report that the experience of child maltreatment independent of recent life stress, gender, and age is associated with reduced structural integrity of the uncinate fasciculus, a major white matter pathway between the amygdala and ventromedial prefrontal cortex, in young adults. We further demonstrate that individuals with lower uncinate fasciculus integrity at baseline who subsequently experience stressful life events report higher levels of internalizing symptomatology at follow-up. Our findings suggest a novel neurobiological mechanism linking child maltreatment with later internalizing symptoms, specifically altered structural connectivity within the brain's threat-detection and emotion-regulation circuitry.

[Supporting a teenager confronted with a traumatic experience]

Everyone reacts differently to a traumatic event. There is a risk of underestimating a teenager's traumatic experience by considering only the usual post-traumatic stress diagnosis criteria. However, when the trauma has not been able to be sufficiently developed, the adolescent's suffering is revealed through their behaviour. The therapeutic support of the youngster and their family enables them to reposition the traumatic event within the continuity of their history and to relaunch a thought process, often frozen by the traumatic experience.

A latent class analysis of trauma based on a nationally representative sample of US adolescents

PURPOSE

Traumatic events in adolescence rarely occur in isolation. Multiple traumatic experiences are prevalent, diverse and a well-established risk factor for mental health disorders. The aim of this study was to explore and explain the heterogeneity in trauma profiles in a nationally representative sample of US adolescents.

METHOD

Using latent class analysis, data on 10,123 adolescents aged between 13 and 18 from the National Comorbidity Survey Adolescent Supplement were examined. In addition, the relationships between the emergent classes and demographic and clinical variables were explored.

RESULTS

A four-class solution was the best fit of adolescent trauma patterns, with classes labelled as low risk, sexual assault risk, non-sexual risk and high risk. When compared to the low risk class, those in the other classes were significantly more likely not to live with either biological parent, display symptoms indicative of mood and anxiety disorders, and to have higher rates of disorder comorbidity.

CONCLUSIONS

This provides evidence of four distinct groups of adolescents who have experienced a variety of traumas. Evidence demonstrates the increased risk of adolescents with a history of trauma meeting the diagnostic criteria for not only individual disorders but also comorbidity across disorder categories.

Children's disaster reactions: the influence of exposure and personal characteristics

This paper reviews children's reactions to disasters and the personal and situational factors that influence their reactions. Posttraumatic stress disorder (PTSD) and posttraumatic stress reactions are the most commonly studied outcomes, though other conditions also occur including anxiety, depression, behavior problems, and substance use. More recently, traumatic grief and posttraumatic growth have been explored. New research has delineated trajectories of children's posttraumatic stress reactions and offered insight into the long-term consequences of their disaster experiences. Risk factors for adverse outcomes include pre-disaster vulnerabilities, perception of threat, and loss and life disruptions post-disaster. Areas in need of additional research include studies on the timing and course of depression and anxiety post-event and their interactions with other disorders, disaster-related functional and cognitive impairment, positive outcomes, and coping.

Ein Schritt nach vorne?

In diesem Artikel wird die Berücksichtigung der Entwicklungsperspektive bei den trauma- und belastungsbezogenen Störungen im DSM-5 und im Entwurf der ICD-11 erläutert. Es wird diskutiert, inwiefern die allgemeinen Kriterien der vorgeschlagenen Diagnosen auf Kinder und Jugendliche zutreffen. Darüber hinaus werden altersspezifische Erscheinungsformen dargestellt und erörtert. Die Einführung eines altersspezifischen Subtyps für Kinder bis zu sechs Jahren im DSM-5 und der Vorschlag einer neuen Diagnose, der Komplexen Posttraumatischen Belastungsstörung (KPTBS), in der ICD-11 könnten sich als wichtige Schritte in Richtung einer stärkeren Berücksichtigung der Entwicklungsperspektive bei der Diagnosestellung erweisen. Es besteht jedoch weiterhin Forschungsbedarf, um mehr Klarheit über altersspezifische Unterschiede bei den trauma- und belastungsbezogenen Störungen zu schaffen und um die Wechselwirkungen zwischen diesen Störungsbildern zu verstehen. Schließlich treten belastende Erfahrungen, Traumatisierungen, Trauerfälle und emotionale Vernachlässigung im Kindesalter sehr häufig zusammen auf.

Aggressive and violent behaviors in the school environment among a nationally representative sample of adolescent youth

BACKGROUND

The purpose of this study was to describe the prevalence of aggressive and violent behaviors in the context of the school environment in a nationally representative sample of adolescent youth and to illustrate these patterns during 2001-2011.

METHODS

We analyzed data from 84,734 participants via the Youth Risk Behavior Surveillance System (YRBSS). Frequencies were visualized using heatmaps. One-way analyses of variance and corresponding post hoc tests helped to identify if differences in prevalence fluctuated significantly across all years.

RESULTS

Rates of youth feeling unsafe in their school environment, bringing weapons to school, and engaging in physical fighting on school property continue to persist. Findings illustrated that Hispanic youth and youth classified as "other" have emerged as particularly high-risk demographic subgroups over the past decade. Peer victimization and sexual victimization continue to affect girls disproportionately.

CONCLUSIONS

Though some variation within demographic subgroups exists, rates of aggressive and violent behaviors in the context of the school environment continue to persist. Implications for the coordinated prevention of aggressive and violent behaviors among adolescent youth are discussed and recommendations for school-based prevention efforts are identified.

Associations between motor vehicle crashes and mental health problems: data from the National Survey of Adolescents-Replication

Motor vehicle crashes (MVCs) are a leading cause of physical injuries and mortality among children and adolescents in the United States. The purpose of this study was to examine associations between having an MVC and mental health outcomes, including posttraumatic stress disorder (PTSD), depression, and drug and alcohol misuse in a nationally representative sample of adolescents. A sample of 3,604 adolescents, aged 12-17 years, was assessed as part of the 2005 National Survey of Adolescents-Replication (NSA-R) study. Data were weighted according to the 2005 U.S. Census estimates. Within this sample, 10.2% of adolescents reported having at least 1 serious MVC. The prevalence of current PTSD and depression among adolescents having an MVC was 7.4% and 11.2%, respectively. Analyses revealed that an MVC among adolescents aged 15 years and younger was independently associated with depression (OR = 2.17) and alcohol abuse (OR = 2.36) after adjusting for other risk factors, including a history of interpersonal violence. Among adolescents aged 16 years and older, an MVC was associated only with alcohol abuse (OR = 2.08). This study was the first attempt to explore adverse mental health outcomes associated with MVCs beyond traumatic stress symptoms among adolescents in a nationally representative sample.

Predictors of delayed disclosure of rape in female adolescents and young adults

BACKGROUND

Delayed disclosure of rape has been associated with impaired mental health; it is, therefore, important to understand which factors are associated with disclosure latency. The purpose of this study was to compare various demographics, post-rape characteristics, and psychological functioning of early and delayed disclosers (i.e., more than 1-week post-rape) among rape victims, and to determine predictors for delayed disclosure.

METHODS

Data were collected using a structured interview and validated questionnaires in a sample of 323 help-seeking female adolescents and young adults (12-25 years), who were victimized by rape, but had no reported prior chronic child sexual abuse.

RESULTS

In 59% of the cases, disclosure occurred within 1 week. Delayed disclosers were less likely to use medical services and to report to the police than early disclosers. No significant differences were found between delayed and early disclosers in psychological functioning and time to seek professional help. The combination of age category 12-17 years [odds ratio (OR) 2.05, confidence intervals (CI) 1.13-3.73], penetration (OR 2.36, CI 1.25-4.46), and closeness to assailant (OR 2.64, CI 1.52-4.60) contributed significantly to the prediction of delayed disclosure.

CONCLUSION

The results point to the need of targeted interventions that specifically encourage rape victims to disclose early, thereby increasing options for access to health and police services.

Factor structure of the Parent Emotional Reaction Questionnaire: analysis and validation

BACKGROUND

Although many children experience violence and abuse each year, there is a lack of instruments measuring parents' emotional reactions to these events. One instrument, the Parent Emotional Reaction Questionnaire (PERQ), allows researchers and clinicians to survey a broad spectrum of parents' feelings directly related to their children's traumatic experiences. The objectives of this study were: (1) to examine the factor structure and the internal consistency of the PERQ; (2) to evaluate the discriminant validity of the instrument; and (3) to measure whether potential subscales are sensitive to change.

METHOD

A Norwegian sample of 120 primary caregivers of a clinical sample of 120 traumatized children and youths (M age=14.7, SD=2.2; 79.8% girls) were asked to report their emotional reactions to their child's self-reported worst trauma. Exploratory factor analysis was used to explore the underlying factor structure of the data.

RESULTS

The analysis of the PERQ showed a three-factor structure, conceptualized as PERQdistress, PERQshame, and PERQguilt. The internal consistencies of all three subscales were satisfactory. The correlations between the PERQ subscales and two other parental measurements revealed small to moderate effect sizes, supporting the discriminant validity of the PERQ subscales. The differences in sum scores of the PERQ subscales before and after a therapeutic intervention suggest that all of the subscales were sensitive to change.

CONCLUSIONS

Study findings support the validity of conceptualizing the PERQ as three separate subscales that capture clinically meaningful features of parents' feelings after their children have experienced trauma. However, the subscales need to be further evaluated using a larger sample size and a confirmatory factor analytic approach.

Socio-economic status and co-morbidity as risk factors for trauma

Clinical experience and previous studies indicate that low socioeconomic positions are overrepresented in trauma populations. The reason for this social variation in injury risk is likely to be multifactorial. Both individual and environmental sources of explanation are plausible to contribute. We investigated the impact of the influence of socioeconomic factors and co-morbidity on the risk of becoming a trauma victim in a case-control study including 7,382 trauma patients matched in a one to five ratio with controls matched by age-, gender- and municipality from a level 1 trauma centre. Data from the trauma cohort were linked to national registries. Associations between socioeconomic factors and co-morbidity were estimated by conditional logistic regression. The trauma patients had been treated for psychiatric, substance abuse and somatic diagnoses to a higher extent than the controls. In the conditional logistic regression analysis a low level of education and income as well as co-morbidity (divided into psychiatric, substance abuse and somatic diagnoses) were all independent risk factors for trauma. Analysing patients with an injury severity score >15 separately did not alter the results, except for somatic diagnoses not being a risk factor. Recent treatment for substance abuse significantly increased the risk for trauma. Low level of education and income as well as psychiatric, substance abuse and somatic co-morbidity were all independent risk factors for trauma. Active substance abuse strongly influenced the risk for trauma and had a time dependent pattern. These insights can facilitate future implementation of injury prevention strategies tailored to specific risk groups.

Treatment Guided by an Online Course

This article describes the successful treatment of a 16-year-old female presenting with chronic posttraumatic stress disorder (PTSD) related to alleged childhood sexual abuse using trauma-focused cognitive behavioral therapy (TF-CBT). Treatment was delivered by a graduate student who learned the treatment through the completion of an online training course and was supervised by a licensed clinical psychologist. Both the student and the supervisor had extensive training and experience in the delivery of cognitive behavioral therapy (CBT) interventions for adolescents. Several challenges were encountered, most notably the reemergence of legal proceedings related to the alleged abuse during the course of treatment. Treatment implications are discussed, including the need to tailor manualized treatments for particular clients and the utility of online training courses. Overall, this case study adds to the limited literature on the treatment of chronic PTSD in adolescents and provides support for the transportability of TF-CBT to practice settings, as well as the dissemination potential of an online course.

Posttraumatic stress mediates the relationship between childhood victimization and current mental health burden in newly incarcerated adults

The purpose of this study was to evaluate the interrelationship among childhood abuse and traumatic loss, posttraumatic stress symptoms (PTSS), and Axis I psychiatric disorders other than PTSD among newly incarcerated adults, and to test a proposed model in which the severity of PTSS mediates the relationship between childhood abuse/loss and adult psychiatric disorders. Four hundred sixty-five male and female inmates participated in a structured clinical research interview. Four types of interpersonal potentially traumatic experiences (physical abuse, sexual abuse, emotional abuse, and traumatic loss) were assessed for occurrence prior to the age of 18 years old. Current psychiatric disorders and PTSS were also assessed by structured interview. Negative binomial regression was used to evaluate the association between the cumulative number of types of childhood abuse/loss experienced and number of current Axis I disorders, and to test the mediation model. Approximately half of the sample (51%) experienced 1 or more types of childhood abuse/loss, and 30% of the sample had at least one psychiatric disorder other than PTSD. For both men and women, childhood physical abuse and childhood sexual abuse were independently associated with psychiatric morbidity, and an increasing number of types of childhood trauma experienced was associated with an increase in the number of current Axis I diagnoses. However, these associations were no longer statistically significant when severity of PTSS was added to the model, providing support for the proposed mediation model. Implications for secondary prevention services for at-risk inmates are discussed.

Amygdala response to negative stimuli predicts PTSD symptom onset following a terrorist attack

OBJECTIVE

Individuals with posttraumatic stress disorder (PTSD) exhibit heightened amygdala reactivity and atypical activation patterns in the medial prefrontal cortex (mPFC) in response to negative emotional information. It is unknown whether these aspects of neural function are risk factors for PTSD or consequences of either trauma exposure or onset of the disorder. We had a unique opportunity to investigate this issue following the terrorist attacks at the 2013 Boston Marathon and the ensuing manhunt and shelter in place order. We examined associations of neural function measured prior to the attack with PTSD symptom onset related to these events.

METHODS

A sample of 15 adolescents (mean age = 16.5 years) who previously participated in a neuroimaging study completed a survey assessing posttraumatic symptoms related to the terrorist attack. We examined blood oxygen level dependent (BOLD) response to viewing and actively down-regulating emotional responses to negative stimuli in regions previously associated with PTSD, including the amygdala, hippocampus, and mPFC, as prospective predictors of posttraumatic symptom onset.

RESULTS

Increased BOLD signal to negative emotional stimuli in the left amygdala was strongly associated with posttraumatic symptoms following the attack. Reduced bilateral hippocampal activation during effortful attempts to down-regulate emotional responses to negative stimuli was also associated with greater posttraumatic symptoms. Associations of amygdala reactivity with posttraumatic symptoms were robust to controls for pre-existing depression, anxiety, and PTSD symptoms and prior exposure to violence.

CONCLUSIONS

Amygdala reactivity to negative emotional information might represent a neurobiological marker of vulnerability to traumatic stress and, potentially, a risk factor for PTSD.

Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment

During the last 30 years, there has been a substantial increase in the study of posttraumatic stress disorder (PTSD). Several high-profile traumatic events, such as the wars in Afghanistan and Iraq, and the terrorist attacks of September 11 on the World Trade Center, have led to a greater public interest in the risk and protective factors for PTSD. In this In Review paper, I discuss some of the important advances in PTSD. The paper provides a concise review of the evolution of PTSD diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, impact of PTSD in the community, an overview of the established risk factors for developing PTSD, and assessment and treatment. Throughout the paper, controversies and clinical implications are discussed.

Engaging foster parents in treatment: a randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies

The goal of this study was to examine the impact of supplementing Trauma-focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006) with evidence-based engagement strategies on foster parent and foster youth engagement in treatment, given challenges engaging foster parents in treatment. A randomized controlled trial of TF-CBT standard delivery compared to TF-CBT plus evidence-based engagement strategies was conducted with 47 children and adolescents in foster care and one of their foster parents. Attendance, engagement, and clinical outcomes were assessed 1 month into treatment, end of treatment, and 3 months post-treatment. Youth and foster parents who received TF-CBT plus evidence-based engagement strategies were more likely to be retained in treatment through four sessions and were less likely to drop out of treatment prematurely. The engagement strategies did not appear to have an effect on the number of canceled or no-show sessions or on treatment satisfaction. Clinical outcomes did not differ by study condition, but exploratory analyses suggest that youth had significant improvements with treatment. Strategies that specifically target engagement may hold promise for increasing access to evidence-based treatments and for increasing likelihood of treatment completion.

Trajectories of depressive symptoms in foster youth transitioning into adulthood: the roles of emotion dysregulation and PTSD

Foster youth often experience considerable adversity both in and out of foster care, including histories of abuse and/or neglect, and further stressors within the foster system. These adverse experiences often occur at key developmental periods that can compromise emotional functioning and lead to posttraumatic symptomatology, including posttraumatic stress disorder (PTSD) and emotion dysregulation. In the face of difficult histories and ongoing mental health challenges, youth transitioning into adulthood may be particularly vulnerable to increases in depressive symptoms. We explored the trajectory of depressive symptoms in foster youth from age 17 to 19 using a piecewise linear growth model, examining the effects of PTSD and emotion dysregulation on youth's depressive symptoms over time. Results revealed depressive symptoms decreased from age 17 to 18 but increased from 18 to 19. PTSD and emotion dysregulation predicted greater baseline depressive symptoms and decreases in symptoms from age 17 to 18, whereas only PTSD predicted increases in depressive symptoms from 18 to 19. Females reported higher levels of depressive symptoms compared to males. Additionally, emotion dysregulation was a stronger predictor of depressive symptoms for females than males. Implications for service delivery for foster youth transitioning into adulthood are discussed.

Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings

BACKGROUND

Terrorist attacks have been shown to precipitate posttraumatic stress disorder (PTSD) symptomatology in children and adolescents, particularly among youths with high exposure to media coverage surrounding such events. Media exposure may be particularly likely to trigger PTSD symptoms in youths with high physiological reactivity to stress or with prior psychopathology or exposure to violence. We examined the interplay between media exposure, preattack psychopathology, autonomic nervous system (ANS) reactivity, and prior violence exposure in predicting PTSD symptom onset following the terrorist attack at the 2013 Boston Marathon.

METHODS

A community sample of 78 adolescents (mean age = 16.7 years, 65% female) completed a survey about the bombings, including media exposure to the event and PTSD symptoms. All respondents participated in a study assessing psychopathology prior to the attack, and sympathetic and parasympathetic reactivity to a laboratory-based stressor was assessed in a subset (N = 44) of this sample. We examined the associations of media exposure, ANS reactivity, preattack psychopathology, and prior violence exposure with onset of PTSD symptoms related to the bombings.

RESULTS

Media exposure, preattack psychopathology, and prior violence exposure were associated with PTSD symptoms. Moreover, media exposure interacted with sympathetic reactivity to predict PTSD symptom onset, such that adolescents with lower levels of sympathetic reactivity developed PTSD symptoms only following high exposure to media coverage of the attack.

CONCLUSIONS

We provide novel evidence that physiological reactivity prior to exposure to an unpredictable traumatic stressor predicts PTSD symptom onset. These findings have implications for identifying youths most vulnerable to PTSD following wide-scale trauma.

Victims' use of professional services in a Dutch sexual assault centre

BACKGROUND

Prior research endorsed the establishment of sexual assault centres in the Netherlands because of the potential benefit for victims' mental recovery. In 2012, the first Dutch sexual assault centre was founded at the University Medical Center Utrecht. The aim of the centre is to provide 24/7 coordinated and integrated services (i.e., medical, forensic, and psychological) in one location.

OBJECTIVE

The purpose of the present study was to describe demographic, background, and assault characteristics of victims seen at the centre within one week post-assault, and their use of post-assault services in order to improve current services.

METHOD

From January 2012 to September 2013, prospective data of 108 patients were collected. To describe the population included, frequency counts and proportions were generated for categorical variables.

RESULTS

The mean age was 21.3 years (SD=9.8). Most victims were female (91.7%). A large proportion of victims reported background characteristics known to increase the risk for post-traumatic stress disorder (PTSD) and revictimisation such as prior sexual abuse (32.4%), pre-existing use of mental health services (45.4%), and not living with both biological parents (61.7%). Most patients (88.9%) consulted the centre within 72 hours post-assault. The uptake of services was high: 82.4% received emergency medical care, 61.7% underwent a forensic-medical exam, 34% reported to the police, and 82.4% utilised psychological services.

CONCLUSION

To prevent revictimisation and PTSD, current psychological services could be improved with immediate trauma-focused treatments. Current forensic services may be improved with the use of standard top to toe forensic-medical examinations for both children and adults.

Outcomes of traumatic exposure

There is a great need to recognize, prevent, reduce, or treat the immediate and long-term effects of childhood trauma. Most children affected by trauma will not develop long-term posttraumatic sequelae due to their resilience, but comorbid psychopathological outcomes occur and are more common after exposure to severe traumatic events. Factors influencing posttraumatic outcomes are numerous. Young dependent children tend to be more susceptible than older children; children with pain or injury are also more susceptible. Psychopathological effects may not be evident until adulthood. Awareness of the range of adverse outcomes underscores the importance of preventive interventions, accurate assessment, diagnosis and where possible, treatment. Advocacy and public policy initiatives are essential to improving outcomes.

[Forensic psychiatric assessment of posttraumatic stress disorder]

The assessment of trauma-related disorders is becoming increasingly more important in forensic psychiatric expert opinions. The most important diagnosis in this context is posttraumatic stress disorder. The essential diagnostic criteria of this disorder are outlined. Differential diagnostic considerations are often necessary with respect to less specific symptom complexes, such as the complex posttraumatic stress disorder or diagnoses which as a rule cannot etiologically be causally associated with trauma alone, such as depression or anxiety disorders. Furthermore, the significance of symptom validity tests is critically discussed. Test results have to be considered carefully in the medicolegal context and require a thorough clinical assessment.

Rape-related symptoms in adolescents: short- and long-term outcome after cognitive behavior group therapy

BACKGROUND

Efficacy studies on treatment in adolescent victims of single rape are lacking, even though sexual victimization is most likely to occur during adolescence and despite the fact that adolescents are at risk to develop subsequent posttraumatic stress disorder.

AIM

The aim of this prospective observational study was to evaluate the short- and long-term outcomes of a nine-session cognitive behavior group therapy (STEPS), including a parallel six-session parents' group on rape-related symptomatology in female adolescents (13-18 years). STEPS includes psychoeducation, exposure in sensu as well as in vivo, cognitive restructuring, and relapse prevention.

METHODS

Fifty-five female adolescents with mental health problems due to single rape, but without prior sexual trauma, received STEPS while their parents participated in a support group. Subjects were assessed on posttraumatic stress (PTS) and comorbid symptoms using self-report questionnaires prior to and directly after treatment, and at 6 and 12 months follow-up.

RESULTS

Repeated measures analysis showed a significant and large decrease in symptoms of PTS, anxiety, depression, anger, dissociation, sexual concerns, and behavior problems directly after treatment, which maintained at 12 months follow-up. Time since trauma did not influence the results. Dropout during STEPS was 1.8%.

CONCLUSIONS

The results potentially suggest that the positive treatment outcomes at short- and long-term may be caused by STEPS. The encouraging findings need confirmation in future controlled studies on the effectiveness of STEPS because it may be possible that the treatment works especially well for more chronic symptoms, while the less chronic part of the sample showed considerable improvement on its own.

Low vagal tone magnifies the association between psychosocial stress exposure and internalizing psychopathology in adolescents

Vagal tone is a measure of cardiovascular function that facilitates adaptive responses to environmental challenge. Low vagal tone is associated with poor emotional and attentional regulation in children and has been conceptualized as a marker of sensitivity to stress. We investigated whether the associations of a wide range of psychosocial stressors with internalizing and externalizing psychopathology were magnified in adolescents with low vagal tone. Resting heart period data were collected from a diverse community sample of adolescents (ages 13-17; N = 168). Adolescents completed measures assessing internalizing and externalizing psychopathology and exposure to stressors occurring in family, peer, and community contexts. Respiratory sinus arrhythmia (RSA) was calculated from the interbeat interval time series. We estimated interactions between RSA and stress exposure in predicting internalizing and externalizing symptoms and evaluated whether interactions differed by gender. Exposure to psychosocial stressors was associated strongly with psychopathology. RSA was unrelated to internalizing or externalizing problems. Significant interactions were observed between RSA and child abuse, community violence, peer victimization, and traumatic events in predicting internalizing but not externalizing symptoms. Stressors were positively associated with internalizing symptoms in adolescents with low RSA but not in those with high RSA. Similar patterns were observed for anxiety and depression. These interactions were more consistently observed for male than female individuals. Low vagal tone is associated with internalizing psychopathology in adolescents exposed to high levels of stressors. Measurement of vagal tone in clinical settings might provide useful information about sensitivity to stress in child and adolescent clients.