Characterizing time in longitudinal trauma research

Dynamics of risk: Recent changes in psychological inflexibility precede subsequent changes in returning US veterans' posttraumatic stress

OBJECTIVES

As a malleable risk-factor, psychological inflexibility is implicated in the development and maintenance of posttraumatic stress symptoms (PTS). Unfortunately, limited research has addressed whether changes in psychological inflexibility are antecedent to changes in PTS severity over time, or whether such changes are mutually dependent.

METHODS

Utilizing bivariate latent difference score modeling, this longitudinal study sequenced intraindividual changes in psychological inflexibility and PTS severity within a sample of 305 returning US veterans. Veterans' self-reported psychological inflexibility and PTS severity were assessed quarterly over 1 year.

RESULTS

Results indicated that early reductions in psychological inflexibility potentiated later declines in veterans' PTS severity, accounting for veterans' prior levels of psychological inflexibility and PTS severity.

CONCLUSIONS

These findings underscore the unique role of changes in psychological inflexibility as an important mechanism of change in PTS severity and provide empirical support for an antecedent model of the role of psychological inflexibility in PTS recovery.

Developmental pathways from preschool irritability to multifinality in early adolescence: the role of diurnal cortisol

BACKGROUND

Early irritability predicts a broad spectrum of psychopathology spanning both internalizing and externalizing disorders, rather than any particular disorder or group of disorders (i.e. multifinality). Very few studies, however, have examined the developmental mechanisms by which it leads to such phenotypically diverse outcomes. We examined whether variation in the diurnal pattern of cortisol moderates developmental pathways between preschool irritability and the subsequent emergence of internalizing and externalizing symptoms 9 years later.

METHOD

When children were 3 years old, mothers were interviewed about children's irritability and completed questionnaires about their children's psychopathology. Six years later, children collected saliva samples at wake-up and bedtime on three consecutive days. Diurnal cortisol patterns were modeled as latent difference scores between evening and morning samples. When children were approximately 12 years old, mothers again completed questionnaires about their children's psychopathology.

RESULTS

Among children with higher levels of irritability at age 3, a steeper diurnal cortisol slope at age 9 predicted greater internalizing symptoms and irritability at age 12, whereas a blunted slope at age 9 predicted greater externalizing symptoms at age 12, adjusting for baseline and concurrent symptoms.

CONCLUSION

Our results suggest that variation in stress system functioning can predict and differentiate developmental trajectories of early irritability that are relatively more internalizing v. those in which externalizing symptoms dominate in pre-adolescence.

Prevalence of post-traumatic symptomatology and anxiety among residential nursing and care home workers following the first COVID-19 outbreak in Northern Italy

The current COVID-19 pandemic has been officially linked to the deaths of hundreds of thousands of people across the globe in just a few months. It is particularly lethal for the elderly in general, as well as for populations residing in long-term stay facilities. By this time, those working and caring for high-risk populations have been exposed to very intense and sudden levels of physical and psychological strain. The situation has taken a particularly tragic turn in residential nursing and care homes (NCH), which were hit hard by the pandemic. In residential NCH, neither residents nor workers tend to have immediate access to the same expertise, medication and equipment as in hospitals, which exacerbates an already tense situation. Among the mental health conditions related to exposure to potentially traumatic events, post-traumatic stress disorder and anxiety are the most prevalent and scientifically recognized. In this survey-based epidemiological study, we test the prevalence of anxiety and post-traumatic symptomatology in residential nursing and care home workers-a group of individuals that has been largely neglected but who nonetheless plays a very important and sensitive role in our society. We do this by focusing on the North of Italy, the most affected region during the first COVID-19 outbreak in Italy. Using a single-stage cluster design, our study returns an estimate for the prevalence of moderate-to-severe anxiety and/or post-traumatic symptomatology of 43% (s.e. = 3.09; 95% CI [37-49]), with an 18% (s.e. = 1.83; 95% CI [14-22]) prevalence of comorbidity among workers of Northern Italian NCH between 15 June and 25 July 2020 (i.e. 12-52 days after the end of national lockdown). Women and workers who had recently been in contact with COVID-19-positive patients/colleagues are more likely to report moderate-to-severe symptoms, with odds ratios of 2.2 and 1.7, respectively.

Longitudinal modeling in developmental neuroimaging research: Common challenges, and solutions from developmental psychology

Hypotheses about change over time are central to informing our understanding of development. Developmental neuroscience is at critical juncture: although the majority of longitudinal imaging studies have observations with two time points, researchers are increasingly obtaining three or more observations of the same individuals. The goals of the proposed manuscript are to draw upon the long history of methodological and applied literature on longitudinal statistical models to summarize common problems and issues that arise in their use. We also provide suggestions and solutions to improve the design, analysis and interpretation of longitudinal data, and discuss the importance of matching the theory of change with the appropriate statistical model used to test the theory. Researchers should articulate a clear theory of change and to design studies to capture that change and use appropriately sensitive measures to assess that change during development. Simulated data are used to demonstrate several common analytic approaches to longitudinal analyses. We provide the code for our simulations and figures in an online supplement to aid researchers in exploring and plotting their data. We provide brief examples of best practices for reporting such models. Finally, we clarify common misunderstandings in the application and interpretation of these analytic approaches.

Homotypic and heterotypic continuity of internalizing and externalizing symptoms from ages 3 to 12: The moderating role of diurnal cortisol

Psychological symptoms that arise in early childhood can follow a multitude of patterns into adolescence, including homotypic continuity (i.e., similar symptoms over time) and heterotypic continuity (i.e., a shift in symptoms over time). However, we know very little about the factors that distinguish homotypic vs. heterotypic continuity of early internalizing and externalizing symptoms over development. In a separate line of research, diurnal cortisol has been shown to predict later internalizing and externalizing problems. In the current study, we tested whether diurnal cortisol patterns moderated the course of internalizing and externalizing symptoms from preschool to early adolescence. 554 children (54% male) and parents participated in a longitudinal study. Parents reported on their children's internalizing and externalizing symptoms at ages 3 and 12, and children collected diurnal saliva samples at age 9. Results showed that a steeper cortisol decline at age 9 combined with high internalizing or externalizing problems at age 3 predicted higher internalizing problems at age 12. A more blunted cortisol decline combined with early internalizing or externalizing problems predicted higher externalizing problems in early adolescence. These results illustrate the moderating role of stress system functioning in homotypic and heterotypic patterns of psychopathology from preschool to early adolescence.

The structure of co-occurring PTSD and depression symptoms in a cohort of Marines pre- and post-deployment

Symptoms of posttraumatic stress disorder (PTSD) and major depressive disorder are the most frequently co-occurring problems following potentially traumatic events. It is unclear whether these comorbidities represent two correlated but distinct disorders or a common post-event response. We sought to inform this question by examining the distinctiveness of PTSD and depression symptoms at four cross-sectional time points, using data from a parent prospective longitudinal study of 858 Marines evaluated before deployment and approximately 1, 5, and 8 months after returning from the Afghanistan war. We conducted a series of cross-sectional confirmatory factor analyses of PTSD and depression symptoms at each time point, using the Posttraumatic Stress Disorder Checklist IV and the Beck Depression Inventory II. Analyses indicated that across all four assessments, self-reported symptoms on the measures were best explained by distinct but correlated subclusters of symptoms within each measure. This structure was supported by the data both before and after deployment, even with increases in average PTSD symptoms after deployment. These findings suggest that despite shared method variance and some symptom overlap, self-reports of PTSD and depression symptoms across a stressful combat deployment show distinct symptom subclusters rather than a general common trauma reaction in this sample of Marines.

Optimizing trauma-informed intervention for intimate partner violence in veterans: The role of alexithymia

Recent research supports the efficacy of Strength at Home-Men's Program (SAH-M), a trauma-informed group intervention designed to reduce use of intimate partner violence (IPV) in veterans (Taft, Macdonald, Creech, Monson, & Murphy, 2016). However, change-processes facilitating the effectiveness of SAH-M have yet to be specified. Alexithymia, a deficit in the cognitive processing of emotional experience characterized by difficulty identifying and distinguishing between feelings, difficulty describing feelings, and use of an externally oriented thinking style, has been shown to predict PTSD severity and impulsive aggression; however, no studies have investigated the relationship between alexithymia and IPV. As such, the current study examined the role of improvements in alexithymia as a potential facilitator of treatment efficacy among 135 male veterans/service members, in a randomized control trial SAH-M. After an initial assessment including measures of IPV and alexithymia, participants were randomized to an Enhanced Treatment as Usual (ETAU) condition or SAH-M. Participants were assessed three and six months after baseline. Results demonstrated a statistically significant association between alexithymia and use of psychological IPV at baseline. Moreover, participants in the SAH-M condition self-reported significantly greater reductions in alexithymia over time relative to ETAU participants. Findings suggest that a trauma-informed intervention may optimize outcomes, helping men who use IPV both limit their use of violence and improve deficits in emotion processing.

Examination of the dynamic interplay between posttraumatic stress symptoms and alcohol misuse among combat-exposed Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans

BACKGROUND

Although alcohol misuse co-occurs with PTSD symptoms at a strikingly high rate (i.e., nearly 52% of men and 28% of women with PTSD also meet diagnostic criteria for an Alcohol Use Disorder), the functional associations between these symptom types remain unclear.

METHODS

The current study sought to clarify the nature of posttraumatic stress-alcohol misuse relations by employing a prospective longitudinal methodology-the latent difference score approach-to examine dynamic change in posttraumatic stress symptoms and alcohol misuse among 478 combat-exposed Veterans completing a longitudinal survey of post-deployment mental and physical health. This study builds on the existing literature, as most prior research has been limited to cross-sectional studies and has not explored prospective relations between specific PTSD symptom clusters and alcohol misuse.

RESULTS

Consistent with the self-medication model, results indicated that PTSD symptoms demonstrate a prospective and proximal association with alcohol misuse during the assessment period; however, alcohol misuse did not appear to be a unique contributor to overall PTSD symptom exacerbation over time. Examination of individual PTSD symptom clusters revealed that more severe symptoms of intrusion and numbing, but not avoidance and hyperarousal, predicted greater alcohol misuse at subsequent time intervals.

LIMITATIONS

The constructs examined within this investigation relied on self-report data; diagnostic criteria for PTSD and/or Alcohol Use Disorders were not assessed. Future work may benefit from replicating these findings in clinical populations formally diagnosed with PTSD via clinician-administered structured interviews.

CONCLUSIONS

Findings underscore the importance of addressing PTSD symptoms in the context of alcohol treatment to facilitate improved drinking outcomes.

Social Causation Versus Social Erosion: Comparisons of Causal Models for Relations Between Support and PTSD Symptoms

Social support is a robust correlate of posttraumatic stress disorder (PTSD) symptoms and of general psychological distress (Ozer, Best, Lipsey, & Weiss, 2003). The nature of the causal relationship between support and PTSD remains the subject of debate, with 2 models, social erosion and social causation, often used to explain findings. Despite extensive research using these models, no studies of which we are aware have included tests of both models within the same series of analyses, across more than 2 time points, in veterans. These competing models were tested in a sample of National Guard soldiers (N = 521) who completed measures of perceived social support and the PTSD Checklist-Military version (Weathers, Litz, Herman, Huska, & Keane, 1993) at 3 months, 15 months, and 27 months following a combat deployment to Iraq. Analyses were run separately for overall PTSD symptoms and the PTSD components of intrusion, trauma-avoidance, dysphoria, and hyperarousal. Both the social erosion (βs ranging from -.10 to -.19) and social causation (βs ranging from -.08 to -.13) hypotheses were supported. Results suggested PTSD-specific symptom dimensions may both erode and be influenced by social support, whereas general psychological distress erodes social support. Implications for clinical intervention and research are discussed.

PTSD symptom presentation across the deployment cycle

BACKGROUND

Symptom-level variation in posttraumatic stress disorder (PTSD) has not yet been examined in the early post-deployment phase, but may be meaningful etiologically, prognostically, and clinically.

METHODS

Using latent class analysis (LCA), we examined PTSD symptom heterogeneity in a cohort of participants from the Marine Resiliency Study (MRS), a longitudinal study of combat Marines deployed to Iraq and Afghanistan (N=892). Typologies of PTSD symptom presentation were examined at one month pre-deployment and again one, five, and eight months post-deployment.

RESULTS

Heterogeneity in PTSD symptom presentation was evident at each assessment point, and the degree of symptom heterogeneity (i.e., the number of classes identified) differed by time point. Symptom patterns stabilized over time from notable symptom fluctuations during the early post-deployment period to high, medium, and low symptom severity by eight months post-deployment. Hypervigilance and exaggerated startle were frequently endorsed by participants in the initial month post-deployment. Flashbacks, amnesia, and foreshortened future were infrequently endorsed. Greater combat exposure, lifespan trauma, and avoidant coping generally predicted worse outcomes.

LIMITATIONS

Data were self-report and may have limited generalizability due to our lack of women and inclusion of only combat Marines. Attrition and re-ranging of data resulted in significant missing data and affected the representativeness of the sample.

CONCLUSIONS

Symptom-level variability is highest in the month following deployment and then stabilizes over time. Should post-deployment assessments occur too soon, they may capture common and transient early post-deployment reactions, particularly anxious arousal.

Using video feedback as a tool in training parent coaches: promising results from a single-subject design

The Attachment and Biobehavioral Catch-up (ABC) parenting program focuses on three intervention targets: increasing parental nurturance, increasing parental synchrony, and decreasing parental frightening behavior. Parent coaches are expected to comment "in the moment" when behaviors relevant to these three targets are observed in sessions. Making in the moment comments is a challenging aspect of intervention, and parent coaches have struggled with their fidelity to this critical intervention component. Thus, we developed a system for coding the frequency and quality of comments from video-recorded session clips on a statement-by-statement level. To help parent coaches refine and maintain their skills in making such comments, they are taught to code segments of their own video-recorded sessions, with the expectation that gains would be seen in comments after learning to code. In this paper, we describe the fidelity coding system and present initial results from a year-long, single-subject design examining the effects of video feedback coding for a parent coach who was learning the intervention. We observed an increase in frequency of in the moment comments during the period of video feedback coding, consistent with a training effect.

Examining change in cortisol patterns during the 10-week transition to a new child-care setting

The transition to out-of-home child care brings a number of challenges for children, including complex peer interactions and extended separations from parents. Children often show a midmorning to afternoon rise in cortisol on child-care days, compared to the typical diurnal decline seen at home. Changes in cortisol were examined in a wide age range of children (N = 168; 1.2 months to 8 years, M = 3.27 years) during the 10-week transition to a new child-care setting. Structural equation modeling using latent change scores showed that children experienced an increase in the cortisol rise at child care across the 10-week transition. Furthermore, child age moderated the difference between home- and child-care cortisol patterns. Findings are placed in a developmental context, and potential implications and future directions are discussed.

What can multiwave studies teach us about disaster research: an analysis of low-income Hurricane Katrina survivors

Previous research on natural disasters has been limited by a lack of predisaster data and statistical analyses that do not adequately predict change in psychological symptoms. In the current study, we addressed these limitations through analysis of 3 waves of data from a longitudinal investigation of 313 low-income, African American mothers who were exposed to Hurricane Katrina. Although postdisaster cross-sectional estimates of the impact of traumatic stress exposure and postdisaster social support on postdisaster psychological distress were somewhat inflated, the general trends persisted when controlling for predisaster data (B = 0.88 and -0.33, vs. B = 0.81 and -0.27, respectively). Hierarchical linear modeling of the 3 waves of data revealed that lower predisaster social support was associated with higher psychological distress at the time of the disaster (β = -.16), and that higher traumatic stress exposure was associated with greater increases in psychological distress after the storm (β = .86). Based on the results, we suggest that the impact of traumatic stress on psychological trajectories cannot be accounted for solely by preexisting risk, and recommend more complex research designs to further illuminate the complex, dynamic relationships between psychological distress, traumatic stress exposure, and social support.

Young children's full-day patterns of cortisol production on child care days

OBJECTIVE

To examine toddlers' full-day patterns of cortisol production on child care days and non-child care days, with a particular focus on whether the mid-afternoon elevations at child care persist into the evening or decrease to typical levels observed on non-child care days.

DESIGN

A prospective observational study.

SETTING

Four child care centers in a suburban, mid-Atlantic area.

PARTICIPANTS

Forty-two children aged 16 to 24 months attending full-day child care.

MAIN EXPOSURE

Full-day child care.

OUTCOME MEASURE

Salivary cortisol samples obtained at wake-up, mid-morning, mid-afternoon, and bedtime for children on 2 child care days and 2 non-child care days.

RESULTS

Children showed different patterns of cortisol production on child care days compared with non-child care days (chi(2)(4) = 18.21, P = .001). Child care days were characterized by an afternoon increase in cortisol levels (unlike non-child care days) and decreases to bedtime values that were comparable with levels on non-child care days.

CONCLUSION

Results suggest that the effects of child care on children's cortisol production are time limited across the day.

The interplay of perceived social support and posttraumatic psychological distress following orofacial injury

Social support is believed to mediate psychosocial recovery in vulnerable populations after trauma. In this study, we examine the relationships between perceived social support and posttraumatic stress disorder symptoms in a cohort of 287 socio-economically disadvantaged adults with orofacial injury, using 3 waves of data collected over a period of 1 year after the injury. Using structural equation modeling process, we evaluated the cross-lagged effects between perceived social support (PSS) and posttraumatic stress disorder (PTSD) symptoms. We found that PSS had a direct influence on PTSD only when examined concurrently. After controlling the covariates, the model supports the cross-lagged effect for PTSD symptoms on PSS at T2 and T3, which suggests a reciprocal contribution between symptoms and support as time progressed. Our data suggest that, over time, high rates of PTSD symptoms are related to a diminished perception of available social support.

Sequential Temporal Dependencies in Associations Between Symptoms of Depression and Posttraumatic Stress Disorder: An Application of Bivariate Latent Difference Score Structural Equation Modeling

Depression and posttraumatic stress disorder (PTSD) are highly comorbid conditions that may arise following exposure to psychological trauma. This study examined their temporal sequencing and mutual influence using bivariate latent difference score structural equation modeling. Longitudinal data from 182 emergency room patients revealed level of depression symptom severity to be positively associated with changes in PTSD intrusion, avoidance, and hyperarousal over 3 time intervals, beginning shortly after the traumatic event. Higher scores on depression anticipated increases (or worsening) in PTSD symptom severity. The pattern of influence from PTSD symptom severity to change in depression symptom severity simply followed the general trend toward health and well-being. Results are discussed in terms of the dynamic interplay and associated mechanisms of posttrauma depression and PTSD symptom severity.

Stressful but rewarding: Norwegian personnel mobilised for the 2004 tsunami disaster

Adequate responses to disasters and emergency situations rely, among other factors, on coping abilities in disaster workers and emergency personnel. In this study, different aspects of disaster-related stressors and training/experience were investigated in Norwegian personnel (n = 581) mobilised for the 2004 tsunami disaster. The level of stress reactions, measured nine to ten months after the tsunami, was relatively low in this sample, indicating that the personnel coped well with the challenges of the disaster. The level of intrusive memories was higher in disaster-area personnel (n = 335) than in home-base personnel (n = 246). Stress reactions were significantly associated with witnessing experiences (disaster-area group) and with having to reject victims in need of help (both groups). Specific preparation for the mission was associated with a lower level of stress reactions in disaster-area personnel. Such factors may be considered in training and preparation programmes for disaster workers.

Latent difference score approach to longitudinal trauma research

In this article, the authors introduce a latent difference score (LDS) approach to analyzing longitudinal data in trauma research. The LDS approach accounts for internal sources of change in an outcome variable, including the influence of prior status on subsequent levels of that variable and the tendency for individuals to experience natural change (e.g., a natural decrease in posttraumatic stress disorder [PTSD] symptoms over time). Under traditional model assumptions, the LDSs are maximally reliable and therefore less likely to introduce biases into model testing. The authors illustrate the method using a sample of children who experienced significant burns or other injuries to examine potential influences (i.e., age of child-adolescent at time of trauma and ongoing family strains) on PTSD symptom severity over time.

Maximizing follow-up in longitudinal studies of traumatized populations

Although longitudinal research is essential in understanding the nature and course of posttraumatic mental health problems, high rates of attrition often threaten the internal validity of such studies and make results hard to interpret. C. K. Scott (2004) developed an approach to minimizing attrition in longitudinal studies that consistently yielded retention rates in excess of 90% through to 2-year follow-up. In this article, the authors discuss the interface between trauma exposure and participation in longitudinal research, before describing in detail a model to address those effects. The effectiveness of the model is examined with reference to traumatic stress in a large community sample (N = 887) with eight waves of data over 2 years.