PTSD in children and adolescents: toward an empirically based algorithma

Repetitive transcranial magnetic stimulation for post-traumatic stress disorder in adults

BACKGROUND

The estimated lifetime prevalence of post-traumatic stress disorder (PTSD) in adults worldwide has been estimated at 3.9%. PTSD appears to contribute to alterations in neuronal network connectivity patterns. Current pharmacological and psychotherapeutic treatments for PTSD are associated with inadequate symptom improvement and high dropout rates. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive therapy involving induction of electrical currents in cortical brain tissue, may be an important treatment option for PTSD to improve remission rates and for people who cannot tolerate existing treatments.

OBJECTIVES

To assess the effects of repetitive transcranial magnetic stimulation (rTMS) on post-traumatic stress disorder (PTSD) in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers. We checked reference lists of relevant articles. The most recent search was January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the efficacy and safety of rTMS versus sham rTMS for PTSD in adults from any treatment setting, including veterans. Eligible trials employed at least five rTMS treatment sessions with both active and sham conditions. We included trials with combination interventions, where a pharmacological agent or psychotherapy was combined with rTMS for both intervention and control groups. We included studies meeting the above criteria regardless of whether they reported any of our outcomes of interest.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in accordance with Cochrane standards. Primary outcomes were PTSD severity immediately after treatment and serious adverse events during active treatment. Secondary outcomes were PTSD remission, PTSD response, PTSD severity at two follow-up time points after treatment, dropouts, and depression and anxiety severity immediately after treatment.

MAIN RESULTS

We included 13 RCTs in the review (12 published; 1 unpublished dissertation), with 577 participants. Eight studies included stand-alone rTMS treatment, four combined rTMS with an evidence-based psychotherapeutic treatment, and one investigated rTMS as an adjunctive to treatment-as-usual. Five studies were conducted in the USA, and some predominantly included white, male veterans. Active rTMS probably makes little to no difference to PTSD severity immediately following treatment (standardized mean difference (SMD) -0.14, 95% confidence interval (CI) -0.54 to 0.27; 3 studies, 99 participants; moderate-certainty evidence). We downgraded the certainty of evidence by one level for imprecision (sample size insufficient to detect a difference of medium effect size). We deemed one study as having a low risk of bias and the remaining two as having 'some concerns' for risk of bias. A sensitivity analysis of change-from-baseline scores enabled inclusion of a greater number of studies (6 studies, 252 participants). This analysis yielded a similar outcome to our main analysis but also indicated significant heterogeneity in efficacy across studies, including two studies with a high risk of bias. Reported rates of serious adverse events were low, with seven reported (active rTMS: 6; sham rTMS: 1). The evidence is very uncertain about the effect of active rTMS on serious adverse events (odds ratio (OR) 5.26, 95% CI 0.26 to 107.81; 5 studies, 251 participants; very low-certainty evidence [Active rTMS: 23/1000, sham rTMS: 4/1000]). We downgraded the evidence by one level for risk of bias and two levels for imprecision. We rated four of five studies as having a high risk of bias, and the fifth as 'some concerns' for bias. We were unable to assess PTSD remission immediately after treatment as none of the included studies reported this outcome.

AUTHORS' CONCLUSIONS

Based on moderate-certainty evidence, our review suggests that active rTMS probably makes little to no difference to PTSD severity immediately following treatment compared to sham stimulation. However, significant heterogeneity in efficacy was detected when we included a larger number of studies in sensitivity analysis. We observed considerable variety in participant and protocol characteristics across studies included in this review. For example, studies tended to be weighted towards inclusion of either male veterans or female civilians. Studies varied greatly in terms of the proportion of the sample with comorbid depression. Study protocols differed in treatment design and stimulation parameters (e.g. session number/duration, treatment course length, stimulation intensity/frequency, location of stimulation). These differences may affect efficacy, particularly when considering interactions with participant factors. Reported rates of serious adverse events were very low (< 1%) across active and sham conditions. It is uncertain whether rTMS increases the risk of serious adverse event occurrence, as our certainty of evidence was very low. Studies frequently lacked clear definitions for serious adverse events, as well as detail on tracking/assessment of data and information on the safety population. Increased reporting on these elements would likely aid the advancement of both research and clinical recommendations of rTMS for PTSD. Currently, there is insufficient evidence to meta-analyze PTSD remission, PTSD treatment response, and PTSD severity at different periods post-treatment. Further research into these outcomes could inform the clinical use of rTMS. Additionally, the relatively large contribution of data from trials that focused on white male veterans may limit the generalizability of our conclusions. This could be addressed by prioritizing recruitment of more diverse participant samples.

Effect of Interactive Media-Based Music and Art Therapies on Reduction in PTSD Symptoms in Children and Adult Victims of Abduction

The aim of this study was to examine the impact of music and art therapies in reducing symptoms of PTSD among children and adults with abduction experiences in Nigeria. The study was a quasi-experiment with a pre-test, post-test and follow-up assessment design. The participants were divided into control (n = 107), music therapy (n = 108) and art therapy (n = 108) groups. The result of the ANCOVA analysis revealed no significant interactive effect of family happiness on the relationship between the interventions and reduction in PTSD symptoms, F(1,295)0.037 p = 0.848). However, there was a significant main effect of the treatment condition and PTSD scores of the participants at Times 1, 2, and 3, respectively F(1,295). 1640.756, p = 0.001). The degree of the relationship was assessed using partial eta squared, which yielded (ηp2= 0.848). It was also found that music therapy was more effective in reducing PTSD symptoms in children, while art therapy was more effective in reducing PTSD in adults. The result of this study could be useful for psychologists and mental health experts who may be interested in designing and implementing interventions targeting children and adults with PTSD symptoms. The result also has implications for control mastery theory by showing that music and art therapies could be useful in helping adults and children gain control of their minds after exposure to traumatic events.

A biomarker of brain arousal mediates the intergenerational link between maternal and child post-traumatic stress disorder

This study examined whether there is a biological basis in the child's resting brain activity for the intergenerational link between maternal interpersonal violence-related posttraumatic stress disorder (IPV-PTSD) and child subclinical symptoms. We used high-density EEG recordings to investigate the resting brain activity in a sample of 57 children, 34 from mothers with IPV-PTSD, and 23 from mothers without PTSD. These children were part of a prospective, longitudinal study focusing on the offspring of mothers with and without IPV-PTSD, reporting how the severity of a mother's IPV-PTSD can impact her child's emotional regulation and risk for developing mental illness. However, we had not yet looked into potential EEG biomarkers during resting state that might mediate and/or moderate effects of maternal IPV-PTSD severity on child mental health, and in particular the risk for PTSD. The alpha band spectral power as well as the aperiodic exponent of the power spectrum (PLE; power-law exponent) were examined as mediators of maternal IPV-PTSD and child PTSD. While there was no difference in alpha spectral power between the two groups, PLE was significantly reduced in children of mothers with IPV-PTSD compared to control children, indicating cortical hyper-arousal. Interestingly, child PLE was negatively correlated with the severity of maternal IPV-PTSD, suggesting an intergenerational interaction. This interpretation was reinforced by a negative correlation between child PLE and child PTSD symptoms. Finally, causal analyses using structural equation modelling indicated that child PLE mediated the relationship between maternal PTSD severity and child PTSD. Our observations suggest that maternal IPV-PTSD has an intergenerational impact on the child neurobehavioral development through a correlated abnormal marker of brain arousal (i.e. child PLE). These findings are potentially relevant to psychotherapy research and to the development of more effective psycho-neurobehavioral therapies (i.e. neurofeedback) among affected individuals.

Implementing Trauma-Informed Care-Settings, Definitions, Interventions, Measures, and Implementation across Settings: A Scoping Review

Traumatic experiences can have long-lasting negative effects on individuals, organizations, and societies. If trauma is not addressed, it can create unsafe cultures with constant arousal, untrusting relationships, and the use of coercive measures. Trauma-informed care (TIC) can play a central role in mitigating these negative consequences, but it is unknown how and in which way(s) TIC should be implemented. Our objective was to conduct a scoping review that systematically explored and mapped research conducted in this area and to identify existing knowledge about the implementation of TIC. The search was conducted on the CINAHL, Cochrane, Embase, ERIC, Medline, PsycINFO, and Web of Science databases, and more than 3000 empirical papers, published between 2000 and 2022, were identified. Following further screening, we included 157 papers in our review, which were mainly from the USA, Australia, New Zealand, and Canada, focusing on study settings, methodologies, and definitions of TIC, as well as the types of interventions and measures used. This review shows that TIC is a complex and multifaceted framework, with no overarching structure or clear theoretical underpinnings that can guide practical implementations. TIC has been defined and adapted in varied ways across different settings and populations, making it difficult to synthesize knowledge. A higher level of agreement on how to operationalize and implement TIC in international research could be important in order to better examine its impact and broaden the approach.

[Posttraumatic stress disorder in children and adolescents: results of a cross-sectional study on the effects of the newly formulated PTSD and CPTSD diagnoses in the ICD-11]

BACKGROUND

ICD-11 presents narrowed criteria for posttraumatic stress disorder (PTSD) and introduces complex PTSD (CPTSD) with additional difficulties in self-organization (DSO). These changes can have significant effects on the frequency of the diagnosis. The aim of this study was to investigate which ICD-11 symptom clusters cause children and adolescents to miss the diagnosis and whether caregivers are more likely to attribute changes in DSO to developmental level or to the traumatic event, and how these attributions are in turn related to symptom severity.

METHODS

N = 88 German-speaking children and adolescents (age: 7-17 years) after traumatic events and N = 79 caregivers participated between September 2019 and November 2020 in a survey on PTSD symptom severity (CATS-2) and attribution of DSO symptoms (caregiver questionnaire).

RESULTS

The ICD-11 criteria (CATS‑2 and a developmentally adapted version) showed lower frequency rates for PTSD as compared to DSM‑5 and ICD-10. The ICD-11 clusters re-experiencing and hyperarousal were met the least often. Changes in DSO symptoms were predominantly rated as event-related. This attribution was associated with higher PTSD and DSO symptom severity in caregiver reports. The age-related attribution was associated with higher DSO-symptom severity, but not PTSD symptom severity in caregiver reports.

DISCUSSION

In the context of the diagnostic process and the revision of diagnostic instruments for ICD-11 (C)PTSD, development-specific symptoms should be taken into account. The trauma-related differentiation of DSO symptom changes as compared to development-related fluctuations is challenging and therefore requires several sources of information.

Post-traumatic stress disorder in a national sample of preadolescent children 9 to 10 years old: Prevalence, correlates, clinical sequelae, and treatment utilization

Although posttraumatic stress disorder (PTSD) has been well characterized in adults, its epidemiology in children is unclear. The current study provides the first population-based examination of the prevalence of PTSD, sociodemographic and psychiatric correlates, clinical sequelae, and associations with psychiatric treatment in preadolescents 9-10 years old in the United States. Data from the Adolescent Brain and Cognitive Development (ABCD) Study (release 5.0) was analyzed. Participants (unweighted n = 11,875) were recruited from 21 sites across the United States. Current and lifetime PTSD prevalence were estimated, as was treatment use among children with PTSD. Sociodemographic, psychiatric correlates and sequelae of PTSD were analyzed using logistic regression, as was the association between PTSD and psychiatric treatment. After the application of propensity weights, lifetime prevalence of PTSD was 2.17%. Sexual minority status, being multiracial, having unmarried parents, and family economic insecurity were associated with greater odds of PTSD. Among psychiatric disorders, separation anxiety was most strongly associated with PTSD, although general comorbid psychopathology was associated with greater odds of PTSD. Prior history of PTSD predicted a new onset of other psychiatric disorders after PTSD remission. Nearly one in three children with lifetime PTSD did not receive psychiatric treatment, despite negative long-term outcomes of PTSD and significant psychiatric comorbidity. Even among preadolescents who experience full remission of PTSD, a significant risk for future psychiatric illness remains. Further, the current findings underscore the need for improved efforts to reduce unmet treatment needs among those with PTSD at this age.

Children Fleeing War-Exploring the Mental Health of Refugee Children Arriving in Israel after the Ukraine 2022 Conflict

BACKGROUND

In February 2022, Ukraine suffered a devastating assault by Russia, leading to destruction, casualties, and mass displacement. Among those displaced were over 1.5 million children. Forced displacement exposes children to a heightened risk of mental health issues.

OBJECTIVE

This study investigated the prevalence of Post-traumatic stress disorder (PTSD) and other mental health issues among child refugees shortly after their displacement from Ukraine to Israel. It aimed to identify factors influencing PTSD development and explore their associations.

METHODS

The study included 59 child refugees who had arrived in Israel after fleeing the war in Ukraine. Parents completed self-report questionnaires to assess their children's mental health.

RESULTS

Only three children met the DSM diagnostic criteria for PTSD, with higher scores in the negative cognition and re-experiencing clusters. Over half of the children exhibited general mental health problems, with approximately 40 % showing internalizing problems, and 30 % showing externalizing problems. The study also found a significant comorbidity between PTSD symptoms and internalizing problems. Additionally, internalizing problems emerged as the sole significant predictor of PTSD levels when considering factors such as age, gender, economic status, parents' work status, internalizing problems, and externalizing problems.

CONCLUSIONS

Child refugees frequently experience psychological distress, even if they do not meet the formal diagnostic criteria for PTSD. They often exhibit other distress symptoms, primarily internalizing problems, which can be challenging to detect. A deeper understanding of the challenges faced by refugee children can inform the development of targeted assistance programs and the recruitment and training of personnel in host countries.

Post-traumatic stress disorder in a national sample of preadolescent children: Prevalence, correlates, clinical sequelae, and treatment utilization

Although posttraumatic stress disorder (PTSD) has been well characterized in adults, its epidemiology in children is unclear. The current study provides the first population-based examination of the prevalence of PTSD, sociodemographic and psychiatric correlates, clinical sequelae, and associations with psychiatric treatment in preadolescents in the United States. Data from the Adolescent Brain and Cognitive Development (ABCD) Study (release 5.0) was analyzed. Participants (unweighted n = 11, 875) were recruited from 21 sites across the United States. Current and lifetime PTSD prevalence were estimated, as was treatment use among children with PTSD. Sociodemographic, psychiatric correlates and sequelae of PTSD were analyzed using logistic regression, as was the association between PTSD and psychiatric treatment. Lifetime prevalence of PTSD was 2.17%. Sexual minority status, being multiracial, having unmarried parents, and family economic insecurity were associated with greater odds of PTSD. Among psychiatric disorders, separation anxiety was most strongly associated with PTSD, although general comorbid psychopathology was associated with greater odds of PTSD. Prior history of PTSD predicted new onset of other psychiatric disorders after PTSD remission. Nearly one in three children with lifetime PTSD did not receive psychiatric treatment, despite negative long-term outcomes of PTSD and significant psychiatric comorbidity. Even among preadolescents who experience full remission of PTSD, significant risk for future psychiatric illness remains. Further, the current findings underscore the need for improved efforts to reduce unmet treatment needs among those with PTSD at this age.

Making Trauma Less Traumatic: Implementing Inpatient Pediatric Screening of Acute Stress Symptoms

OBJECTIVES

Pediatric patients hospitalized for physical injury and trauma are at increased risk of developing acute stress disorder. Routine identification and referral for treatment of patients with psychological sequelae of traumatic injury were added to the accreditation requirements of the American College of Surgeons for pediatric trauma centers in 2022. We aimed to use quality improvement methodology with iterative interventions to increase psychological screening consults for admitted pediatric trauma patients to 80% in 6 months.

METHODS

We planned a quality improvement intervention to increase identification of posttraumatic psychological symptoms in pediatric trauma patients. We created a Making Trauma Less Traumatic consultation service with a dedicated therapist to provide screening, treatment, and referral. Key interventions included education of key stakeholders and iterative improvements in consultation workflow. Our primary measure was frequency of eligible pediatric trauma patients who had consultation requests for posttrauma therapy during admission. We additionally monitored percent of patients with positive symptom screens and lost to follow-up.

RESULTS

From September 2020 through November 2021, consults for eligible pediatric trauma patients improved from a baseline of 4.1% to a weekly mean of 100%. Of those screened, 32.7% had at least 1 symptom of acute stress. No families declined screening or therapy, though 29.5% were lost to intended follow-up.

CONCLUSIONS

We present a successful model of implementing routine psychological screening of pediatric trauma patients utilizing a dedicated consultation service. A high number of admitted patients screened positive for symptoms during hospitalization. Families were accepting of the intervention though follow-up was challenging.

Anger and aggression in children aged 6-12 in lockdowns during the COVID-19 pandemic in Turkey

Objective: This study investigated the relationship between parents’ emotional states and the anger and aggression levels of their children between the ages of 6-12 who were in social isolation during the coronavirus disease 2019 (COVID-19) pandemic in Turkey. Materials and Methods: The study adopted a cross-sectional and descriptive design. The sample consisted of 261 parents. Data were collected online during lockdowns between May and September 2020 due to the COVID-19 pandemic. Results: More than half of the participants reported that they were unhappy (53.2%), sad (63.2%), and worried about the future due to the COVID-19 pandemic (70.8%). Less than a quarter of the participants were angry (17.6%). Children living in districts had significantly higher verbal aggression scores than those living in city centers (p

Associations between parent posttraumatic stress symptoms (PTSS) and later child PTSS: Results from an international data archive

The extant literature indicates that parent and child posttraumatic stress symptoms (PTSS) are associated. However, the magnitude of this association at different time points and in the context of covariates has been difficult to quantify due to the methodological limitations of past studies, including small sample sizes. Using data from the Prospective studies of Acute Child Trauma and Recovery Data Archive, we harmonized participant-level parent and child data from 16 studies (N = 1,775 parent-child dyads) that included prospective assessment of PTSS during both the acute and later posttrauma periods (i.e., 1-30 days and 3-12 months after exposure to a potentially traumatic event, respectively). Parent and child PTSS demonstrated small-to-moderate cross-sectional, ρs = .22-.27, 95% CI [.16, .32], and longitudinal associations, ρ = .30, CI [.23, .36]. Analyses using actor-partner interdependence models revealed that parent PTSS during the acute trauma period predicted later child PTSS. Regression analyses demonstrated that parent gender did not moderate the association between parent and child PTSS. The findings suggest that parent PTSS during the acute and later posttrauma periods may be one of a constellation of risk factors and indicators for child PTSS.

Rediscovering latent trauma: An adopted adult's perspective

Though studies showing a causal relationship between adoption and trauma are scarce, there is enough cross-disciplinary research to suggest such a connection. Likewise, there are many adult adopted persons, like myself, who see their adoption narratives as traumatic in one way or another. Mental health outcomes for adopted people also indicate adoption might be a source of and not just a preventative measure against trauma. In this paper, I utilize an autoethnographic approach to highlight the relationship between infant adoption and what I refer to as "latent traumatic memories." Recounting several major life events that led to traumatic upheavals in my understanding of my own identity as an adopted person, I then relate my story to current research on trauma experienced very early in life and how it is remembered implicitly in the body. My account, I argue, highlights the need to further research adopted people's evolving views about their adoption and how and to what extent certain events in adulthood precipitate the rediscovery of latent trauma.

Systematic Review and Meta-analysis: Prevalence of Posttraumatic Stress Disorder in Trauma-Exposed Preschool-Aged Children

OBJECTIVE

Trauma exposure is common in preschool-aged children. Understanding the psychological impact of such exposure and the prevalence of posttraumatic stress disorder (PTSD) in this population is important for provision of appropriate and timely intervention. This pre-registered (PROSPERO: CRD41019133984) systematic review and meta-analysis examined the prevalence of PTSD in trauma-exposed preschool-aged children.

METHOD

Literature searches were conducted of PubMed (Medline), PsycINFO and PILOTS, alongside reference lists of relevant reviews. Studies were selected if they comprised trauma-exposed samples with a mean age of less than 6.5 years, and PTSD was assessed using standardized interviews at least 1-month post trauma. Information on sample characteristics, trauma exposure, PTSD measurement, and diagnostic criteria were extracted. For studies that applied more than one PTSD diagnostic algorithm, the most age-appropriate criteria were used to estimate pooled prevalence estimate across studies. A random-effects model was used for meta-analysis.

RESULTS

Eighteen studies were included (N = 1941). The pooled PTSD prevalence was 21.5% (95% CI = 13.8%-30.4%) when using the most developmentally appropriate diagnostic algorithm that was available. When focusing on the subset of studies that reported both standard adult criteria and age-appropriate criteria (k = 12), a pooled estimate of 4.9% (95% CI = 2.5%-8.0%) was obtained for standard adult criteria (DSM-IV), and 19.9% (95% CI = 12.1%-29.0%) was obtained for age-appropriate criteria (PTSD-AA). Prevalence was 3-fold higher following interpersonal and repeated trauma exposure, compared to non-interpersonal or single-event trauma, respectively. Higher prevalence was found when age-appropriate diagnostic tools were used. There was significant heterogeneity across studies and a lack of studies conducted in low-income countries and applying age-appropriate diagnostic algorithms.

CONCLUSION

Preschool-aged children are vulnerable to developing PTSD following trauma exposure. Younger children show prevalence trends similar to those of older youths and adults following different types of trauma. Age-appropriate diagnostic criteria are essential to ensure that appropriate identification and early support are provided.

From mothers to children and back: Bidirectional processes in the cross-generational transmission of anxiety from early childhood to early adolescence

BACKGROUND

Maternal psychopathology and caregiving behavior are linked with child anxiety and these associations may be particularly salient when families face mass trauma together and members influence each other's symptomatology and resilience. Despite the well-known mother-to-child effects, less research addressed the longitudinal bidirectional effects of maternal and child's anxiety symptoms on each other.

METHODS

Mothers and children exposed to chronic war-related trauma from Sderot, Israel, and comparison group were followed at three time-points; Early childhood (T1:N = 232, M_Age  = 2.76 years), late childhood (T3:N = 176, M_Age  = 9.3 years), and early adolescence (T4:N = 110, M_Age  = 11.66 years). At each time-point maternal and child's anxiety symptoms were evaluated via questionnaires and maternal sensitivity was coded from videotaped observations of parent-child interactions. Bidirectional associations were examined using traditional cross-lagged panel model (CLPM) and CLPM with random intercepts (RI-CLPM).

RESULTS

Trauma-exposed mothers and children exhibited more anxiety symptoms and lower maternal sensitivity. Cross-lagged panel models revealed cross-time bidirectional associations between maternal anxiety and child anxiety from early to late childhood. Child anxiety at each time-point predicted maternal anxiety and maternal sensitivity at the next stage; however, maternal sensitivity did not show longitudinal associations with child anxiety, highlighting children's role in shaping caregiving.

CONCLUSIONS

Findings demonstrate bidirectional cross-generational influences of mother and child on each other's anxiety in contexts of trauma and pinpoint early childhood as a sensitive period for such mutual influences. Children's increased anxiety following trauma appears to be further exacerbated via its impact on increasing maternal anxiety and compromising sensitive caregiving, underscoring the potential benefits of parental and mother-child interventions for trauma-exposed populations.

What's in a name? Comparing alternative conceptualizations of posttraumatic stress disorder among preadolescent children following the Boston Marathon bombing and manhunt

BACKGROUND AND OBJECTIVES

New diagnostic criteria for posttraumatic stress disorder (PTSD) were introduced by DSM-5 and ICD-11. It remains unclear how well these new definitions of PTSD capture the posttrauma responses of children, particularly when using parent report. This study compared different conceptual models of PTSD in children following the Boston Marathon bombing and manhunt.

DESIGN AND METHODS

Parents/caretakers (N = 254) reported on PTSD symptoms of their children (ages 4-11) following the Boston Marathon bombing and manhunt. Algorithms compared criteria from ICD-11, DSM-IV, and DSM-5 (specifically the "Preschool" criteria).

RESULTS

DSM-5 Preschool criteria identified twice as many children as ICD-11, and over four times as many as DSM-IV. DSM-5 Preschool criteria identified all cases detected by ICD-11 and DSM-IV. Across models, all identified cases had greater trauma exposure than non-identified children. DSM-5 Preschool and ICD-11 (but not DSM-IV) cases had greater clinical decline than non-identified children. The Avoidance cluster showed the most variability in identifying cases.

CONCLUSIONS

Newer models of PTSD are likely to identify more children than DSM-IV, mostly related to changes in the Avoidance criteria. The DSM-5 Preschool definition is the most inclusive model. ICD-11 may provide a balance between inclusivity and stringency in detecting childhood PTSD.

Systematic Review on the Application of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Preschool-Aged Children

Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most widely studied and disseminated treatments for posttraumatic stress disorder (PTSD) and other comorbid conditions, and has been identified as a "level one" or "well-established" intervention for school-aged children and adolescents. The present systematic review examined the literature on the application of TF-CBT within a preschool-aged population (i.e., children ages three to six), as well as the developmental literature that could increase the efficacy of TF-CBT for preschool-aged children. Information on the use of TF-CBT with preschool-aged children was extracted from randomized controlled trials, case studies, meta-analyses, and other forms of empirical evidence, as part of the evidence-based practice in psychology framework. In comparison to research with school-aged children and adolescents, fewer studies have directly assessed the efficacy of TF-CBT for preschool-aged children who have been exposed to trauma. Given the few studies published to date and difference in treatment protocols for TF-CBT used with preschool-age children, TF-CBT appears to meet criteria as a "level two" or "probably efficacious" intervention for preschool-aged children specifically. According to the available literature, language and cognitive abilities, family context, culture, and clinician expertise are considered as potential variables to address when contemplating the use of TF-CBT for preschool-aged children with symptoms of post-traumatic stress.

The Dimensionality of Proposed DSM-5 PTSD Symptoms in Trauma-Exposed Young Children

A subtype of the posttraumatic stress disorder diagnosis for children 6 years and younger (PTSD-6Y) was introduced in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). This study utilized confirmatory factor analytic techniques to evaluate the proposed DSM-5 PTSD-6Y factor structure and criterion and convergent validity against competing models. Data for N = 284 (3–6 years) trauma-exposed young children living in New Orleans were recruited following a range of traumas, including medical emergencies, exposure to Hurricane Katrina and repeated exposure to domestic violence. The model was compared to DSM-IV, a 4-factor ‘dysphoria’ model that groups symptoms also associated with anxiety and depression, and alternate 1- and 2- factor models. Convergent validity was established against the Child Behavior Checklist (CBCL). Criterion related validity was established by comparing each model to a categorical rating of impairment. The Dysphoria and PTSD-6Y models offered the better accounts of symptom structure, although neither satisfied minimum requirements for a good fitting model. These two models also only showed small levels of convergence with CBCL dimensions. The 1-factor model offered the most compelling balance of sensitivity and specificity, with the 2-factor model and the Dysphoria model following closely behind. These CFA results do not support the symptom clusters proposed within the DSM-5 for PTSD-6Y. Although a 4-factor Dysphoria model offers a better overall account of clustering patterns (relative to alternate models), alongside acceptable sensitivity and specificity for detecting clinical impairment, it also falls short of being an adequate model in this younger age group.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use

OBJECTIVES

After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

METHODS

Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

RESULTS

Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

CONCLUSIONS

Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

Adverse caregiving in early life: The trauma and deprivation distinction in young children

Knowledge and understanding about the impact of cumulative adverse experiences on the health and wellbeing of children, adolescents, and adults has rapidly expanded over the past 30 years. Despite the invaluable attention and support this proliferation has drawn to the importance of early childhood experiences, we believe that it is time to move beyond broad indices of risk and toward more specific and individualized understanding of how risk exposures are linked to clinical outcomes in young children. Within infant and early childhood mental health, there is a need for greater specificity in linking adverse caregiving experiences in early life to psychopathology in children. We highlight a framework distinguishing experiences of trauma from experiences of deprivation and use the examples of posttraumatic stress disorder and reactive attachment disorder to demonstrate how greater specificity in our understanding of early adverse caregiving can lead to more accurate and targeted diagnosis and treatment for young children. Both researchers and clinicians benefit from an approach to gain a greater appreciation of the links between specific types of experiences and outcomes in the children that we serve.

Supporting migrants and refugees with posttraumatic stress disorder: development, pilot implementation, and pilot evaluation of a continuing interprofessional education for healthcare providers

BACKGROUND

Refugees and migrants face an increased risk of developing posttraumatic stress disorder (PTSD). Adequate care can be insufficient due to language barriers, cultural differences, and knowledge deficits of health service providers. Therefore, professional associations requested that healthcare providers to be educated to provide culturally sensitive care. An evidence-based educational intervention in the form of a continuing interprofessional education (CIPE) for healthcare providers on the topic of PTSD in migrants and refugees was developed, pilot-implemented, and evaluated according to the first two levels of the Kirkpatrick evaluation model (reaction and learning).

METHODS

The development of a curriculum for the CIPE intervention was based on a narrative literature review. Its content was validated by experts (N = 17) in an online survey and analyzed using both the Content Validity Index and a thematic analysis. The evaluation of the CIPE intervention was performed by conducting a pilot study with a quasi-experimental single group, using a pre-posttest design. In total, there were 39 participants distributed among three pilot courses. We collected and analyzed data on satisfaction, knowledge, and feasibility.

RESULTS

The curriculum for a half-day course, consisting of 8 modules, showed almost excellent content validity (S-CVI = 0.92). In the pilot-implementation phase, participants were "very satisfied" with the pilot courses and a positive effect on their knowledge was detected. No correlation between satisfaction and knowledge gain was found.

CONCLUSIONS

The CIPE intervention can be considered feasible and seems promising in its effects on satisfaction and knowledge. The insights gained in this study can be used to adapt and optimize the educational intervention, whereby the feedback from course attendees is particularly useful. Future studies need to further examine the effects in larger samples and more robust study designs.

Pretreatment cortisol predicts trauma-focused psychotherapy response in youth with (partial) posttraumatic stress disorder

BACKGROUND

Despite availability of effective trauma-focused psychotherapies, treatment non-response in youth with (partial) posttraumatic stress disorder remains substantial. Studies in adult PTSD have suggested that cortisol is associated with treatment outcome. Furthermore, cortisol prior to treatment could be used to predict treatment success. However, there is a lack of comparable studies in youth with (partial) PTSD. The objective of the current study was therefore to test whether cortisol prior to treatment would differ between treatment responders and non-responders and would positively predict the extent of clinical improvement in youth with (partial) PTSD.

METHODS

Youth aged 8-18 with PTSD (79.2%) or partial PTSD (20.8%) were treated with 8 sessions of either trauma-focused cognitive behavioral therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR). Prior to treatment initiation, salivary cortisol was measured in treatment responders (n = 23) and treatment non-responders (n = 30) at 10 and 1 min before and 10, 20 and 30 min after personalized trauma script driven imagery (SDI). The cortisol stress response (>1.5 nmol/L increase from baseline) and basal cortisol secretion was assessed during the SDI procedure. We hypothesized that treatment responders would display higher cortisol levels caused by increased cortisol reactivity prior to trauma-focused psychotherapy relative to psychotherapy non-responders and higher cortisol levels would positively predict the extent of clinical improvement.

RESULTS

Script driven imagery did not induce a cortisol stress response in all but two participants. Prior to treatment responders showed significantly higher basal cortisol secretion during SDI compared to treatment non-responders. This effect remained significant after controlling for gender. Higher pre-treatment basal cortisol secretion further positively predicted the extent of clinical improvement during trauma-focused psychotherapy.

CONCLUSION

Because SDI failed to provoke a cortisol stress response in our sample, the question if cortisol reactivity differs between treatment responders and non-responders remains inconclusive. However, our results do suggest that higher pretreatment basal cortisol secretion forms a potential indicator of prospective trauma-focused psychotherapy response in youth with (partial) PTSD. Although, the amount of uniquely explained variance in clinical improvement by pre-treatment cortisol secretion is limited and still renders insufficient basis for clinical applicability, these findings do suggest directions for future studies to delineate the mechanisms of treatment success in youth with (partial) PTSD.

Mental Sleep Activity and Disturbing Dreams in the Lifespan

Sleep significantly changes across the lifespan, and several studies underline its crucial role in cognitive functioning. Similarly, mental activity during sleep tends to covary with age. This review aims to analyze the characteristics of dreaming and disturbing dreams at different age brackets. On the one hand, dreams may be considered an expression of brain maturation and cognitive development, showing relations with memory and visuo-spatial abilities. Some investigations reveal that specific electrophysiological patterns, such as frontal theta oscillations, underlie dreams during sleep, as well as episodic memories in the waking state, both in young and older adults. On the other hand, considering the role of dreaming in emotional processing and regulation, the available literature suggests that mental sleep activity could have a beneficial role when stressful events occur at different age ranges. We highlight that nightmares and bad dreams might represent an attempt to cope the adverse events, and the degrees of cognitive-brain maturation could impact on these mechanisms across the lifespan. Future investigations are necessary to clarify these relations. Clinical protocols could be designed to improve cognitive functioning and emotional regulation by modifying the dream contents or the ability to recall/non-recall them.

Validation of the Diagnostic Infant and Preschool Assessment in a Danish, trauma-exposed sample of young children

Background:

There exist only few developmentally sensitive assessment instruments for identifying posttraumatic stress disorder (PTSD) and other potentially comorbid affective and behavioral symptomatology in preschool children. Consequently, young children who exhibit post-trauma symptomatology risk not being identified and not receiving the appropriate treatment. One of the few instruments that exist is the Diagnostic Infant and Preschool Assessment (DIPA).

Objective:

To examine internal reliability and convergent validity of the Danish version of the DIPA, a semi-structured interview of caregivers about their child’s mental health.

Method:

In total, 62 caregivers of trauma-exposed children aged 1-6 years were interviewed with the DIPA and completed the Strengths and Difficulties Questionnaire (SDQ).

Results:

The children had experienced between one and eight traumas (Mdn = 3). Based on the DIPA, 48.4% of the children exhibited PTSD. The DIPA showed good to excellent internal consistency for the disorders of major depressive disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, separation anxiety disorder and overall internal consistency of PTSD and reactive attachment disorder. Internal consistency was lower for each symptom cluster of PTSD and the overall consistency of sleep disorder with Cronbach’s alpha ranging between 0.54 and 0.69. Correlations between continuous scores of eight disorders of the DIPA and SDQ scales provided support for convergent validity of the DIPA.

Conclusion:

The study provides preliminary evidence to support the Danish version of DIPA as a valid measure of symptoms of young children exposed to psychological trauma. As a standardized assessment tool, the DIPA can aid in early and structured assessment of young children exposed to trauma and can help guide treatment for those in need.

The importance of the DSM-5 posttraumatic stress disorder symptoms of cognitions and mood in traumatized children and adolescents: two network approaches

BACKGROUND

The aim of this study is to provide a better understanding of the central symptoms of DSM-5 posttraumatic stress disorder (PTSD) in children and adolescents from the perspective of the child and its caregiver. Identifying core symptoms of PTSD can help clinicians to understand what may be relevant targets for treatment. PTSD may present itself differently in children and adolescents compared to adults, and no study so far has investigated the DSM-5 PTSD conceptualization using network analysis.

METHODS

The network structure of DSM-5 PTSD was investigated in a clinical sample of n = 475 self-reports of children and adolescents and n = 424 caregiver-reports using (a) regularized partial correlation models and (b) a Bayesian approach computing directed acyclic graphs (DAGs).

RESULTS

(a) The 20 DSM-5 PTSD symptoms were positively connected within the self-report and the caregiver-report sample. The most central symptoms were negative trauma-related cognitions and persistent negative emotional state for the self-report and negative trauma-related cognitions, intrusive thoughts or memories and exaggerated startle response for the caregiver-report. (b) Similarly, symptoms in the negative alterations in cognitions and mood cluster (NACM) have emerged as key drivers of other symptoms in traumatized children and adolescents.

CONCLUSIONS

As the symptoms in the DSM-5 NACM cluster were central in our regularized partial correlation networks and also appeared to be the driving forces in the DAGs, these might represent important symptoms within PTSD symptomatology and may offer key targets in PTSD treatment for children and adolescents.

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.

Development of a Brief Screen for Symptoms of Posttraumatic Stress Disorder in Young Children: The Young Child PTSD Screen

OBJECTIVE

The ability to reliably detect posttraumatic stress disorder (PTSD) symptoms that require treatment in young children through screening efforts is a critical step toward providing appropriate treatment. The developmental differences in this age group compared to older youths pose challenges for accurate detection. A brief age-appropriate screen has not yet been quantitatively validated. This study aimed to address that gap by creating a rapid and brief screen based on empirical data that focused on sensitivity and face validity for children aged 3 to 6 years.

METHODS

A trauma-exposed group (N = 284) and a non-trauma-exposed group (N = 46), aged 3 to 6 years, were assessed using a semistructured diagnostic interview with their primary caregivers.

RESULTS

One hundred twenty combinations of items were evaluated for sensitivity, specificity, positive predictive value, negative predictive value, associations with functional impairment, and frequency of false positives. Many combinations of items performed well on these psychometrics, and the final selection of a 6-item screener was influenced by considerations of face validity so that the screen would best reflect the unique symptoms of PTSD.

CONCLUSION

The screener proposed is a promising tool that will benefit from additional research to examine its psychometric properties as a stand-alone PTSD screen. Future research ought to include test-retest reliability and replication of these findings in other samples and settings. Eventual uses of a brief screen for PTSD in young children include screening during primary care visits and large-scale screening efforts following disasters, for which cost and time need to be considered.

The Neural Basis of Empathy and Empathic Behavior in the Context of Chronic Trauma

Background: Accumulating evidence in social neuroscience suggests that mature human empathy relies on the integration of two types of processes: a lower-order process mainly tapping into automatic and sensory mechanisms and a higher-order process involving affect and cognition and modulated by top-down control. Studies have also indicated that neural measures of empathy often correlate with behavioral measures of empathy. Yet, little is known on the effects of chronic trauma on the neural and behavioral indices of empathy and the associations among them. Methods: Mothers exposed to chronic war-related trauma and nonexposed controls (N = 88, N = 41 war-exposed) underwent magnetoencephalography (MEG) while watching stimuli depicting vicarious emotional distress. Maternal empathic behavior was assessed during mother-child interaction involving a joint task. Results: Empathy-evoking vignettes elicited response in alpha rhythms in a network involving both sensorimotor and viceromotor (anterior insula) regions, suggesting integration of the sensory and affective components of empathy. Whereas exposure to chronic stress did not affect the level of neural activations in this network, it reduced maternal empathic behavior. Furthermore, trauma exposure impaired the coherence of brain and behavior; only among controls, but not among trauma-exposed mothers, the neural basis of empathy was predicted by maternal empathic behavior. Conclusions: Chronic stress takes a toll on the mother's empathic ability and indirectly impacts the neural basis of empathy by disrupting the coherence of brain and behavior.

Presence of Sleep Disturbances Among Child Trauma Survivors: Comparison of Caregiver and Child Reports

A significant body of research has been devoted to demonstrating high rates of sleep impairment, and the subsequent adverse implications of sleep difficulties, among adult trauma survivors, particularly those diagnosed with posttraumatic stress disorder (PTSD). Yet considerably less work has been focused on sleep disturbances among trauma-exposed children, especially preschoolers. Pediatric research is paramount in light of the numerous developmental and functional implications that may result from sleep impairment. Prior studies have also documented disagreement between caregiver's and children's reports of trauma-related symptoms; however, the level of concordance rates regarding sleep difficulties is unknown in this population. The present study investigated the rates of multiple types of sleep disturbances using caregiver's and children's reports as well as caregiver-child concordance rates regarding these difficulties. Three hundred and forty-two treatment-seeking children ages of 3-18 years (M = 9.68, SD = 4.00; 61.1% female, 60.4% Black) and their caregivers were included in the study. Sleep disturbances were common in this sample, and children endorsed higher levels of sleep symptoms (range 46-72%) than their caregivers (range 14-51%). Nearly half (47%) of preschool children evinced significant sleep impairment per their caregiver. Inter-rater agreement between caregiver's and children's reports for all sleep symptoms were below acceptable levels (range κ = 0.01-.13), indicating that the concordance rate for caregiver-child trauma-related sleep problems is quite low. Findings illustrate the relevance of sleep disturbances among trauma-exposed children and point to the need to assess both caregiver's and children's symptoms regarding sleep impairment.

PTSD in Children Below the Age of 6 Years

PURPOSE OF REVIEW

This review summarizes the latest evidence and developments in the validation of PTSD diagnostic criteria for children 6 years and under (PTSD<6Y), discusses the limitations of the current diagnostic criteria, and highlights areas for future research.

RECENT FINDINGS

Research has found that the DSM-5 PTSD<6Y, and a similar version in the DC:0-5, currently provides the most developmentally sensitive classification of PTSD for young children. In contrast, preliminary evidence suggests that the ICD-11 criteria might not appropriately capture PTSD in young children. The inclusion of PTSD<6Y, the first developmental subtype in the DSM-5, represents an important step towards having a diagnostic system that is developmentally sensitive and relevant across the life span. However, further validation work and research with regard to the definition of trauma and functional impairment as well as with the age-appropriate description of symptoms is needed, especially in the youngest age group (0-3 years).

Child Abuse and Neglect

Physical, sexual, and emotional abuse and various forms of neglect of children are associated with substantially increased risk for concurrent and subsequent psychopathology and are among the common problems encountered by clinicians in many clinical settings. Such cases pose additional challenges for clinicians because of the many complex family and system forces that engulf these children and their families. Assessing maltreated children generally requires more time than evaluations of children who have not experienced maltreatment. Young children, who experience the highest rates of maltreatment, present especially complex assessments because they are so dependent upon their caregiving environments. Treatment of psychopathology associated with maltreatment, which is often multimodal, requires addressing a variety of external factors that may perpetuate or exacerbate symptoms and impaired functioning. We suggest that the more clinicians understand the different cultures of the legal and child protective services systems will help them advocate more effectively for maltreated children's bests interests so that the complexity of their problems is matched by the comprehensiveness of our efforts to minimize their suffering, enhance their development, and promote their competence.

Posttraumatic Stress Disorder in Very Young Children: Diagnostic Agreement Between ICD-11 and DSM-5

The prevalence of posttraumatic stress disorder (PTSD) in very young children depends on the diagnostic criteria. Thus far, studies have investigated the International Classification of Diseases (11th rev.; ICD-11) criteria for PTSD only in samples of children older than 6 years of age. The aim of this study was to test the diagnostic agreement between the ICD-11 and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for children who are 6 years old and younger. Caregivers of children aged 3-6 years in foster care in Germany (N = 147) and parents of children aged 1-4 years who had attended a hospital in Switzerland following burn injuries (N  = 149) completed a questionnaire about children's PTSD. Rates of PTSD were calculated according to ICD-11 (considering a specific and a more general conceptualization of intrusive memories) and DSM-5 criteria and were compared using McNemar's tests and Cohen's kappa. The proportion of children who met the ICD-11 criteria was 0.6-25.8% lower than the proportion of PTSD cases according to the DSM-5 criteria. The diagnostic agreement between each ICD-11 algorithm and DSM-5 was moderate, κ = 0.52-0.66. A systematic investigation of adaptions of the ICD-11 avoidance cluster identified alternative symptom combinations leading to higher agreement with the DSM-5 requirements. Furthermore, DSM-5 had higher predictive power for functional impairment than the ICD-11 algorithms. In conclusion, the findings suggest that the ICD-11 criteria show less sensitivity in very young children, which can be explained by the more stringent avoidance cluster.

Genetic pathways to posttraumatic stress disorder and depression in children: Investigation of catechol-O-methyltransferase (COMT) Val158Met using different PTSD diagnostic models

The catechol-O-methyltransferase (COMT) Val158Met polymorphism has been linked to PTSD, although findings have been inconsistent. Recently, different diagnostic criteria for PTSD have been introduced by ICD-11 and DSM-5, including separate criteria for adults and for young children (i.e., the preschool criteria). The preschool criteria may be applicable to older children as well. This study is the first to examine COMT associations with depression and PTSD, using new diagnostic models, in school-age children (7-11 years) exposed to a natural disaster. Children (n = 115) provided saliva samples for genotyping and completed measures assessing disaster exposure, posttraumatic stress, and depressive symptoms. COMT Met allele carriers were at risk for PTSD, but only when using ICD-11 (OR = 6.99) or the preschool criteria (OR = 4.77); there was a trend for DSM-IV and no association for DSM-5 (adult criteria). However, all children agreed upon as having PTSD by both DSM-5 and ICD-11 were Met allele carriers. The genetic association between the COMT Met allele and PTSD seemed primarily driven by arousal symptoms, as a significant relationship emerged only for the PTSD arousal symptom cluster. In contrast, COMT Val allele homozygosity was associated with depression (OR = 4.34). Thus, findings suggest that opposing COMT genotypes increased vulnerability to depressive versus arousal-based clinical presentations following trauma exposure. As a result, the heterogeneity of the DSM-5 PTSD criteria and its inclusion of depressive symptoms may mask COMT associations with DSM-5 PTSD. Future research should consider how the use of different diagnostic models of PTSD may influence genetic findings.

Understanding the Impact of Natural Disasters on Psychological Outcomes in Youth from Mainland China: a Meta-Analysis of Risk and Protective Factors for Post-Traumatic Stress Disorder Symptoms

Post-traumatic Stress Disorder (PTSD) is a mental illness that causes significant distress and impairment. Studies generally indicate lower rates of PTSD post-disaster in Chinese child populations. Irrespective of population examined, findings suggest that trauma alone cannot account for the development of PTSD (Ma et al. 2011). It is important to understand what other variables may contribute to the onset of PTSD. This was the first meta-analysis conducted to investigate risk and protective factors for PTSD (as well as mediating/moderating variables) in children directly impacted by natural disasters in China. Understanding these factors can help guide disaster readiness efforts, as well as post-disaster interventions (Yule et al. 2000). Also, this study is extremely relevant given recent earthquakes in China that have devastated many.

Trauma characteristics and sleep impairment among trauma-exposed children

Trauma-related sleep difficulties are quite common and their functional and clinical importance are increasingly recognized. High rates of sleep problems have been documented among trauma-exposed adults, particularly those diagnosed with posttraumatic stress disorder (PTSD); however, research with trauma-exposed children is relatively limited. Research specifically with child samples is critical due to the numerous developmental and functional implications that may result from sleep impairment. Characteristics of the traumatic event may play a key role in understanding sleep difficulties, yet, these associations are not well understood among trauma-exposed children. The current study therefore investigated whether aspects of the traumatic event (i.e., type, nature, chronicity, age of onset, removal from home, and complex trauma) were related to higher levels of sleep disturbances among 276 treatment-seeking children ages 6-18 years (M = 10.88, SD = 3.39; 63.4% female; 62.7% Black). Sleep problems were common in this sample. Domestic and community violence exposure were associated with higher levels of select sleep difficulties, as were interpersonal trauma, chronic trauma, a trauma that began early in life, and complex trauma. Nonetheless, type of trauma and characteristics of the traumatic event were largely unrelated to sleep problems on either caregiver's or children's reports. Removal from the home was not linked with sleep impairment. Although findings signify the relevance of sleep disturbances among trauma-exposed children, trauma characteristics may have limited influence on sleep problems.

Sexual abuse in very young children: a psychological assessment in the Amsterdam Sexual Abuse Case study

Background: Child sexual abuse (CSA) is a worldwide problem affecting children of all ages and socioeconomic backgrounds. A knowledge gap exists regarding the psychological outcomes for children, boys in particular, who are abused during their early lives. Objective: To provide a descriptive psychological profile of children who experienced sexual abuse as infants or toddlers from a male daycare worker and babysitter, and to assess the psychopathological impact on their parents. Method: Parents of children involved in the Amsterdam Sexual Abuse Case (41 parents; 44 children, age range 3-11 years, 30 boys, 14 girls) completed measures on post-traumatic stress disorder (PTSD), dissociation, sexual and non-sexual behaviour problems, and attachment insecurity in their children, as well as on parental psychological well-being, 3 years after disclosure. Sexual abuse characteristics were obtained from police records. Results: We found that 3% of confirmed child victims had PTSD, 30% sexual behaviour problems, 24% internalizing problems, 27% attachment insecurity, and 18% any psychiatric disorder (including PTSD); 39% were asymptomatic. In parents, we found feelings of guilt, shame, and anger about the abuse of their child; 19% showed PTSD symptoms and 3% showed avoidant and 8% anxious attachment problems in their intimate relationship. Parental symptomatology was related to child symptomatology, except for child sexual behaviour problems. One-quarter of confirmed child victims and 45% of parents had received psychological treatment. Conclusions: Three years after disclosure, extrafamilial CSA in very young children was associated with sexual and non-sexual behaviour problems and attachment insecurity, but rarely with PTSD or dissociation. For parents it was associated with PTSD symptoms and emotional reactions. Assessments and interventions should focus on the wide spectrum of problems that follow CSA, as well as on parental psychopathology and the parent-child relationship. Future follow-up assessments in our longitudinal study should provide insights into longer-term outcomes.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence?: Evidence From Post-Genocide Rwanda

Whether children or adolescents exhibit higher levels of posttraumatic stress symptoms (PTSS) in response to violence is an unresolved research question. We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8-19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. PTSS were assessed with a symptom checklist based on DSM-IV indexed using an overall score comprising the sum of scores on all items and mean item scores of each of five distinct factors identified in a factor analysis within this sample. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal. This discordance in factorial response to violence may help explain prevailing inconsistencies in the age-PTSS association reported to date.

Children exposed to a natural disaster: psychological consequences eight years after 2004 tsunami

BACKGROUND

There is a need for studies that follow up children and adolescents for many years post disaster since earlier studies have shown that exposure during natural disasters constitutes a risk factor for poor psychological health.

AIMS

The main aim was to examine whether there was an association between severity of exposures during a natural disaster experienced in childhood or adolescence and posttraumatic stress symptoms, psychological distress, self-rated health, diagnosis of depression, anxiety or worry, thoughts about or attempted suicide, physical symptoms or daily functioning eight years later in young adulthood. A second aim was to compare psychological distress and self-rated health of exposed young adults with a matched population-based sample.

METHOD

Young adults, who experienced the 2004 tsunami as children between 10 and 15 years of age, responded to a questionnaire eight years post disaster. The results were compared to a matched population sample.

RESULTS

The results showed that the likelihood for negative psychological outcomes was higher for those who had been exposed to several types of exposures during this natural disaster.

CONCLUSIONS

The negative psychological impact on children and adolescents can still be present eight years post-disaster and seems to have association with the type of exposure; loss, physical presence and subjective experience. It is important for clinicians, who meet young adults seeking help, to be conscious about the impact as long as eight years post disaster and to be aware of possible clinical implications associated with severity of exposures.

The Role of Personality and Subjective Exposure Experiences in Posttraumatic Stress Disorder and Depression Symptoms among Children Following Wenchuan Earthquake

This study aims to investigate the role of personality traits and subjective exposure experiences in posttraumatic stress disorder and depression symptoms. In Qingchuan, 21,652 children aged 7 to 15 years were assessed using face-to-face interviews one year after the Wenchuan earthquake in China. The Junior Eysenck Personality Questionnaire, a modified earthquake exposure scale, the UCLA Posttraumatic Stress Disorder Reaction Index (adolescent), and the Adolescent Depression Inventory were used to assess personality characteristics, trauma experiences, posttraumatic stress disorder and depression symptoms, respectively. The measurement was completed with 20,749 children. After adjusting for other factors by multinomial logistic regression analysis, neuroticism, having felt unable to escape from the disaster and having been trapped for a longer time were risk factors of posttraumatic stress disorder and depression symptoms. Socialization was a protective factor of them. Having felt extreme panic or fear was a risk factor of posttraumatic stress disorder symptoms. For depression symptoms, introversion and psychoticism were risk factors, and extraversion was a protective factor. This study was conducted with the largest representative sample of child survivors of a natural, devastating disaster in a developing country. These results could be useful for planning psychological intervention strategies for children and for influencing further research.

Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

The diagnosis of mental disorder initially appears relatively straightforward: Patients present with symptoms or visible signs of illness; health professionals make diagnoses based primarily on these symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary. We provide histories and descriptions of three systems with different purposes relevant to understanding and classifying mental disorder. Two major diagnostic manuals—the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders—provide classification systems relevant to public health, clinical diagnosis, service provision, and specific research applications, the former internationally and the latter primarily for the United States. In contrast, the National Institute of Mental Health’s Research Domain Criteria provides a framework that emphasizes integration of basic behavioral and neuroscience research to deepen the understanding of mental disorder. We identify four key issues that present challenges to understanding and classifying mental disorder: etiology, including the multiple causality of mental disorder; whether the relevant phenomena are discrete categories or dimensions; thresholds, which set the boundaries between disorder and nondisorder; and comorbidity, the fact that individuals with mental illness often meet diagnostic requirements for multiple conditions. We discuss how the three systems’ approaches to these key issues correspond or diverge as a result of their different histories, purposes, and constituencies. Although the systems have varying degrees of overlap and distinguishing features, they share the goal of reducing the burden of suffering due to mental disorder.

Service usage typologies in a clinical sample of trauma-exposed adolescents: A latent class analysis

OBJECTIVE

The purpose of this study is to describe typologies of service utilization among trauma-exposed, treatment-seeking adolescents and to examine associations between trauma history, trauma-related symptoms, demographics, and service utilization.

METHOD

Latent class analysis was used to derive a service utilization typologies based on 10 service variables using a sample of 3,081 trauma-exposed adolescents ages 12 to 16 from the National Child Traumatic Stress Network Core Dataset. Services used 30 days prior to the initial assessment from 5 sectors were examined (health care, mental health, school, social services, and juvenile justice).

RESULTS

A 5-class model was selected based on statistical fit indices and substantive evaluation of classes: (a) High intensity/multisystem, 9.5%; (b) Justice-involved, 7.2%; (c) Low intensity/multisystem, 19.9%; (d) Social service and mental health, 19.9%; and (e) Low service usage/reference, 43.5%. The classes could be differentiated based on cumulative trauma, maltreatment history, PTSD, externalizing and internalizing symptoms, and age, gender, race/ethnicity and place of residence.

CONCLUSIONS

This study provides new evidence about patterns of service utilization by trauma exposed, treatment seeking adolescents. Most of these adolescents appear to be involved with at least 2 service systems prior to seeking trauma treatment. Higher cumulative exposure to multiple types of trauma was associated with greater service utilization intensity and complexity, but trauma symptomatology was not. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Psychosocial symptoms in very young children assessed for sexual abuse: A qualitative analysis from the ASAC study

Child sexual abuse (CSA) is a worldwide problem with serious consequences. No recognizable symptom pattern for suspected CSA has yet been identified in very young children. We aim to investigate psychosocial symptoms in a sample of children with confirmed or strongly suspected CSA and the interpretations given to such symptoms by independent clinical experts. Secondly we examined whether experts were able to identify confirmed victims of severe CSA. A qualitative study including inductive content analysis of medical files and focus group discussions with independent experts on the interpretation of psychosocial symptoms was conducted. We included 125 children (76 boys, 60.8%, and 49 girls, 39.2%; median age 3.3 years; age range 0-11) who were involved in the Amsterdam sexual abuse case (ASAC) and had been examined for strongly suspected CSA. We identified four themes among the psychosocial symptoms: problems concerning emotions, behavior, toilet training, and development, whether or not associated with the daycare center or the perpetrator. Clinical experts identified signs of posttraumatic stress disorder (PTSD), regression in continence skills (not otherwise explained), and problems triggered by exposure to the perpetrator or the abuse location as concerning symptoms for CSA. Less concerning symptoms were designated as worrisome if they were numerous and there was no clear explanation for these symptoms. A clear symptom pattern was lacking and about half of the confirmed severe victims of CSA did not display any psychosocial problems. Therefore, it is difficult for experts to identify confirmed CSA victims. Thus, the assessment of suspected CSA should be over time and multidisciplinary.

A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD

The World Health Organization's proposals for posttraumatic stress disorder (PTSD) in the 11th edition of the International Classification of Diseases, scheduled for release in 2018, involve a very brief set of symptoms and a distinction between two sibling disorders, PTSD and Complex PTSD. This review of studies conducted to test the validity and implications of the diagnostic proposals generally supports the proposed 3-factor structure of PTSD symptoms, the 6-factor structure of Complex PTSD symptoms, and the distinction between PTSD and Complex PTSD. Estimates derived from DSM-based items suggest the likely prevalence of ICD-11 PTSD in adults is lower than ICD-10 PTSD and lower than DSM-IV or DSM-5 PTSD, but this may change with the development of items that directly measure the ICD-11 re-experiencing requirement. Preliminary evidence suggests the prevalence of ICD-11 PTSD in community samples of children and adolescents is similar to DSM-IV and DSM-5. ICD-11 PTSD detects some individuals with significant impairment who would not receive a diagnosis under DSM-IV or DSM-5. ICD-11 CPTSD identifies a distinct group who have more often experienced multiple and sustained traumas and have greater functional impairment than those with PTSD.

Optimizing clinical thresholds for PTSD: Extending the DSM-5 preschool criteria to school-age children

Background/Objective: To examine the effect of using the DSM-5 preschool criteria to diagnose posttraumatic stress disorder (PTSD) in school-age children (ages 7-11). Method: Children exposed to Hurricane Ike (N = 327) were assessed for symptoms of PTSD and other trauma-related factors eight months post-disaster. Results: About twice as many children were identified as having PTSD using the DSM-5 preschool criteria compared to the DSM-5 adult criteria. The preschool criteria identified all children diagnosed by the adult criteria and many additional children. Although children who met both the adult and the preschool criteria reported the most functional impairment, children identified by the preschool criteria only reported greater impairment than children not diagnosed. The effect of including impairment in the diagnostic criteria was more marked for the preschool criteria than for the adult criteria. Additionally, PTSD defined by the preschool criteria was significantly associated with more PTSD risk factors than PTSD as defined by the adult criteria. Model fit was similar for both sets of criteria. Conclusions: The preschool criteria may be advantageous for screening for PTSD risk in school-age children. Further research is needed to optimize developmentally-appropriate PTSD criteria for school-age children.