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Davis RS, Halligan SL, Meiser-Stedman R, Elliott E, Ward G, Hiller RM. A Longitudinal Investigation of the Relationship Between Trauma-Related Cognitive Processes and Internalising and Externalising Psychopathology in Young People in Out-of-Home Care. Res Child Adolesc Psychopathol 2023; 51:485-496. [PMID: 36525227 PMCID: PMC10017561 DOI: 10.1007/s10802-022-01005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2022] [Indexed: 12/23/2022]
Abstract
Young people in out-of-home care are at increased risk of developing a range of posttrauma mental health difficulties, including PTSD, but more commonly anxiety, depression and externalising symptoms. Cognitive models of PTSD indicate that trauma-related maladaptive appraisals, coping strategies and trauma memory qualities are key processes in the development and maintenance of PTSD, yet there has been limited investigation of the potential role of these processes in broader posttrauma psychopathology, particularly in young people who have been exposed to complex, rather than acute, trauma. We recruited 120 10-18 years olds in out-of-home care, and their caregivers, who completed assessments at two time points: baseline and 12-month follow-up. Young people completed self-report measures of trauma-related maladaptive appraisals, coping strategies and trauma-memory qualities, as well as reporting on PTSD, anxiety, depression and externalising symptoms. Carers also reported on internalising and externalising symptoms. We found that all three cognitive processes were associated with baseline self-reported internalising symptoms, with maladaptive appraisals most robustly associated with both anxiety and depression. Changes in all three processes over 12-months predicted a change in self-reported internalising and externalising symptoms, with maladaptive appraisals and coping predicting anxiety symptoms, and coping uniquely predicting depression and externalising symptoms. Effects remained after controlling for co-occurring PTSD symptoms. Findings were not replicated when using carer-reported symptoms. These findings suggest that existing cognitive models of PTSD may also usefully explain broader posttrauma depression, anxiety and externalising symptoms in young people who have experienced maltreatment and live in out-of-home care. Clinical implications are discussed.
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Affiliation(s)
| | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Richard Meiser-Stedman
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
| | | | - Georgina Ward
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Rachel M Hiller
- Department of Psychology, University of Bath, Bath, UK. .,Division of Psychology and Language Sciences, University College London, London, UK. .,Anna Freud National Centre for Children and Families, London, UK.
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Childhood adversity and co-occurring post-traumatic stress and externalizing symptoms among a predominantly low-income, African American sample of early adolescents. Dev Psychopathol 2023; 35:383-395. [PMID: 34924089 PMCID: PMC9207160 DOI: 10.1017/s0954579421001383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Although there is strong evidence supporting the association between childhood adversity and symptomatology during adolescence, the extent to which adolescents present with distinct patterns of co-occurring post-traumatic stress (PTS) and externalizing symptoms remains unclear. Additionally, prior research suggests that experiencing nonviolent, negative life events may be more salient risk factors for developing some forms of psychopathology than exposure to violence. The current study used latent profile analysis to identify subgroups of early adolescents with distinct patterns of PTS, physical aggression, delinquency, and substance use, and examined subgroup differences in exposure to three forms of violent and nonviolent childhood adversity. Participants were a predominantly low-income, African American sample of 2,722 urban middle school students (M age = 12.9, 51% female). We identified four symptom profiles: low symptoms (83%), some externalizing (8%), high PTS (6%), and co-occurring PTS and externalizing symptoms (3%). A higher frequency of witnessing violence was associated with increased odds of membership in subgroups with externalizing symptoms, whereas a higher frequency of nonviolent, negative life events was associated with increased odds of membership in subgroups with PTS symptoms. Interventions aimed to address childhood adversity may be most effective when modules addressing both PTS and externalizing symptoms are incorporated.
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Hicks TA, Zaur AJ, Keeley JW, Amstadter AB. The association between recreational cannabis use and posttraumatic stress disorder: A systematic review and methodological critique of the literature. Drug Alcohol Depend 2022; 240:109623. [PMID: 36162309 PMCID: PMC9665003 DOI: 10.1016/j.drugalcdep.2022.109623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Given recent changes in the legal status of cannabis, the risks and benefits associated with its use have become an important public health topic. A growing body of research has demonstrated that posttraumatic stress disorder (PTSD) and recreational cannabis use (RCU) frequently co-occur, yet findings are inconsistent (e.g., direction of effect) and methodological variability makes comparison across studies difficult. METHODS We conducted a comprehensive systematic review of all studies (N = 45) published before May 2020 regarding etiologic models of co-occurring RCU and PTSD, as well as provided a methodological critique to inform suggestions for future research initiatives. RESULTS Findings indicate that a majority of studies (n = 37) demonstrated a significant association between RCU and PTSD. Findings provide evidence for the self-medication and high-risk models posited to explain co-occurring RCU and PTSD despite variability in assessment of RCU, which includes commonly used non-standardized self-report questions. CONCLUSION The association between RCU and PTSD is likely bidirectional. Results inform clinicians and researchers working in the mental health and cannabis use fields how the variability in findings on the association between RCU and PTSD may be attributable, in part, to methodological issues that permeate the extant literature pertaining to RCU and PTSD.
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Affiliation(s)
- Terrell A Hicks
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, USA; Department of Psychology, Virginia Commonwealth University, USA.
| | - Angela J Zaur
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, USA
| | - Jared W Keeley
- Department of Psychology, Virginia Commonwealth University, USA
| | - Ananda B Amstadter
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, USA; Department of Psychology, Virginia Commonwealth University, USA; Department of Human and Molecular Genetics, Virginia Commonwealth University, USA
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Rates of Dual Diagnosis in Child and Adolescent Psychiatric Inpatients: A Scoping Review. J Addict Med 2021; 16:101-109. [PMID: 33534276 DOI: 10.1097/adm.0000000000000818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Child and adolescent psychiatric (CAP) inpatient admissions have increased since 2009 and the clinical profile of these patients has become more complex. Unrecognized dual diagnosis, that is, comorbid substance use or substance use disorder (SUD) may contribute to this problem, but the prevalence of dual diagnosis in this population is inadequately understood. The goal of this scoping review was to summarize the range and content of research on this topic. METHODS MEDLINE, EMBASE, and PsychINFO databases were systematically searched for studies published from 2008 to 2019 containing information on rates of comorbid substance use or SUD in CAP inpatients. RESULTS A total of 23,326 abstracts were located. After removing duplicates, screening abstracts and full-text papers, and extracting data with full-text reviews, fourteen studies meeting our criteria remained. Rates of substance use or SUD ranged from 0.9% to 54.8%, differing on the basis of: (1) type of outcome; (2) type of data source; and (3) whether samples had a specific diagnostic focus or not. Rates of any type of SUD were reported in approximately 25% of samples from administrative databases, in 17.7% to 38.5% of chart reviews, and in 55% of studies with data from clinical research examinations. The highest rates of substance-specific substance use or SUD were for alcohol, cannabis, and nicotine. CONCLUSIONS We located 14 studies, but methodologic heterogeneity precluded quantitative calculation of a single estimate for the prevalence of dual diagnosis. However, most of the rates suggest that this is an important problem in CAP inpatients, meriting further research. We suggest ways to improve future studies.
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Fokas K, Robinson CSH, Witkiewitz K, McCrady BS, Yeater EA. The Indirect Relationship Between Interpersonal Trauma History and Alcohol Use via Negative Cognitions in a Multisite Alcohol Treatment Sample. ALCOHOLISM TREATMENT QUARTERLY 2020; 38:290-305. [PMID: 33012968 DOI: 10.1080/07347324.2019.1669513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although interpersonal trauma history (ITH) is frequently associated with alcohol use disorder (AUD), little is known about specific psychological constructs that may indirectly link these phenomena. This study hypothesized that one such construct may be negative cognitive schemas that often emerge in the aftermath of trauma. Secondary latent variable modeling was conducted using the Project MATCH sample of adults receiving treatment for AUD (N = 1726; 24.3% women; 38.63% ITH). The negative cognitions latent variable provided an excellent fit to the data and showed evidence of strong measurement invariance. As hypothesized, negative cognitions mediated the inverse association between ITH at baseline and percent days abstinent from alcohol 12 weeks later. Findings suggest that negative cognitions may be a specific underlying mechanism and potential treatment target for individuals with ITH and AUD.
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Affiliation(s)
- Kathryn Fokas
- University of New Mexico, Department of Psychology, Center on Alcoholism, Substance Abuse, and Addictions
| | - Charles S H Robinson
- University of Florida, Department of Clinical and Health Psychology, Center for Pain Research and Behavioral Health
| | - Katie Witkiewitz
- University of New Mexico, Department of Psychology, Center on Alcoholism, Substance Abuse, and Addictions
| | - Barbara S McCrady
- University of New Mexico, Department of Psychology, Center on Alcoholism, Substance Abuse, and Addictions
| | - Elizabeth A Yeater
- University of New Mexico, Department of Psychology, Center on Alcoholism, Substance Abuse, and Addictions
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Allwood MA. Developmental and Measurement Implications of Using the UCLA PTSD Reaction Index with College Students. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2020; 13:45-53. [PMID: 32318227 PMCID: PMC7163894 DOI: 10.1007/s40653-019-0249-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Studies measuring Posttraumatic Stress Disorder (PTSD) symptoms from childhood into adulthood have been hampered by use of different measures across different developmental stages. Use of one measure across age groups would reduce measurement error and strengthen our understanding of the developmental progression of trauma. Thus, this study examined whether the UCLA PTSD Reaction-Index (PTSD-Index), which was developed for use with children and adolescents (aged 7 to 18), could be used with young adults. The utility of the measure was examined among three age groups of college students (17-18, 19-20, and 21-25). Sex differences and race/ethnicity differences were also examined. Findings indicate that the PTSD-Index is internally consistent and reliable when used with college students. Furthermore, the factor structure for the measure is similar for adolescents and for emerging adults. In sum, the PTSD-Index appears to be an appropriate screener for PTSD symptoms among young adults. The findings are relevant for both the DSM-IV and DSM-5 screening measures, and the findings have both research and clinical implications. The findings are particularly important for longitudinal studies that are challenged with addressing developmental progression of PTSD symptoms among participants, while also addressing changes in the PTSD nosology.
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Affiliation(s)
- Maureen A. Allwood
- Department of Psychology, John Jay College of Criminal Justice, City University of New York, 524 West 59th Street, New York, NY 10019 USA
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Cole J, Sprang G, Silman M. Interpersonal Trauma Exposure, Trauma Symptoms, and Severity of Substance Use Disorder among Youth Entering Outpatient Substance Abuse Treatment. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2019; 12:341-349. [PMID: 32318204 PMCID: PMC7163824 DOI: 10.1007/s40653-018-0239-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A substantial body of literature has found associations between interpersonal victimization, trauma symptoms, and substance use disorders (SUD) among adolescents. Secondary data analysis was conducted on structured interview data collected by treatment providers as 172 adolescents (ages 12-19) entered outpatient substance abuse treatment. Results indicate high prevalence rates of interpersonal trauma exposure: 71.5% self-reported trauma exposure, specifically direct physical abuse or assault, sexual abuse or assault, and/or witnessing intimate partner violence of a parent. Severity of SUD, as measured by number of DSM-5 criteria endorsed, was not only associated with the number of types of criterion A events for Posttraumatic Stress Disorder but also more self-reported internalizing problems. There was no significant relationship between the severity of SUD and the severity of trauma symptoms at treatment intake, gender, or attention problems. Ongoing assessment of possible trauma symptoms is recommended throughout substance abuse treatment with youth who have reported trauma exposure, as well as continued screening of trauma exposure.
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Affiliation(s)
- Jennifer Cole
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky, 333 Waller Avenue, Suite 480, Lexington, KY 40504 USA
| | - Ginny Sprang
- Department of Psychiatry, Center on Trauma and Children, University of Kentucky, Lexington, KY USA
| | - Miriam Silman
- Center on Trauma and Children, University of Kentucky, Lexington, KY USA
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Banerjee N, Ironson G, Fitch C, Boroughs MS, Safren SA, Powell A, O’Cleirigh C. The Indirect Effect of Posttraumatic Stress Disorder Symptoms on Current Alcohol Use Through Negative Cognitions in Sexual Minority Men. J Trauma Stress 2018; 31:602-612. [PMID: 30028033 PMCID: PMC6286675 DOI: 10.1002/jts.22304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 11/06/2022]
Abstract
Self-medication theory posits that some trauma survivors use alcohol to cope with posttraumatic stress disorder (PTSD) symptoms, but the role of negative posttraumatic cognitions in this relationship is not well defined. We examined associations among PTSD symptoms, posttraumatic cognitions, and alcohol intoxication frequency in 290 men who have sex with men (MSM), who reported a history of childhood sexual abuse (CSA). Using a bootstrap approach, we examined the indirect effects of PTSD symptoms on alcohol intoxication frequency through posttraumatic cognitions regarding the self, world, and self-blame. In separate regression models, higher levels of PTSD symptoms and posttraumatic cognitions were each associated with more frequent intoxication, accounting for 2.6% and 5.2% of the variance above demographics, respectively. When examined simultaneously, posttraumatic cognitions remained significantly correlated with intoxication frequency whereas PTSD symptoms did not. Men reporting elevated posttraumatic cognitions faced increased odds for current alcohol dependence, odds ratio (OR) = 2.19, 95% CI [1.13, 4.22], compared with men reporting low posttraumatic cognitions, independent of current PTSD diagnosis. A higher level of PTSD symptom severity was indirectly associated with more frequent alcohol intoxication through cognitions about the self and world; the indirect to total effect ratios were 0.74 and 0.35, respectively. Negative posttraumatic cognitions pertaining to individuals' self-perceptions and appraisals of the world as dangerous may play a role in self-medication with alcohol among MSM with a history of CSA. Interventions targeting these cognitions may offer potential for reducing alcohol misuse in this population, with possible broader implications for HIV-infection risk.
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Affiliation(s)
- Nikhil Banerjee
- Department of Psychology, University of Miami, Coral
Gables, Florida, USA
| | - Gail Ironson
- Department of Psychology, University of Miami, Coral
Gables, Florida, USA
| | - Calvin Fitch
- Department of Psychology, University of Miami, Coral
Gables, Florida, USA
| | | | - Steven A. Safren
- Department of Psychology, University of Miami, Coral
Gables, Florida, USA
| | - Alexis Powell
- Miller School of Medicine, University of Miami, Miami,
Florida, USA
| | - Conall O’Cleirigh
- Department of Psychiatry, Harvard Medical
School/Massachusetts General Hospital, Boston, Massachusetts, USA
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9
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Threlfall JM, Auslander W, Gerke D, McGinnis H, Myers Tlapek S. Mental Health and School Functioning for Girls in the Child Welfare System: the Mediating Role of Future Orientation and School Engagement. SCHOOL MENTAL HEALTH 2017; 9:194-204. [PMID: 28572859 PMCID: PMC5429384 DOI: 10.1007/s12310-017-9207-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study investigated the association between mental health problems and academic and behavioral school functioning for adolescent girls in the child welfare system and determined whether school engagement and future orientation meditated the relationship. Participants were 231 girls aged between 12 and 19 who had been involved with the child welfare system. Results indicated that 39% of girls reported depressive symptoms in the clinical range and 54% reported posttraumatic symptoms in the clinical range. The most common school functioning problems reported were failing a class (41%) and physical fights with other students (35%). Participants reported a mean number of 1.7 school functioning problems. Higher levels of depression and PTSD were significantly associated with more school functioning problems. School engagement fully mediated the relationship between depression and school functioning and between PTSD and school functioning, both models controlling for age, race, and placement stability. Future orientation was not significantly associated with school functioning problems at the bivariate level. Findings suggest that school engagement is a potentially modifiable target for interventions aiming to ameliorate the negative influence of mental health problems on school functioning for adolescent girls with histories of abuse or neglect.
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Affiliation(s)
- Jennifer M Threlfall
- Department of Social Policy and Social Work, University of York, Heslington, York, YO10 5DD UK
| | - Wendy Auslander
- George Warren Brown School of Social Work, Washington University in St. Louis, Campus Box 1196, St. Louis, MO 63130 USA
| | - Donald Gerke
- George Warren Brown School of Social Work, Washington University in St. Louis, Campus Box 1196, St. Louis, MO 63130 USA
| | - Hollee McGinnis
- George Warren Brown School of Social Work, Washington University in St. Louis, Campus Box 1196, St. Louis, MO 63130 USA
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Münzer A, Ganser HG, Goldbeck L. Social support, negative maltreatment-related cognitions and posttraumatic stress symptoms in children and adolescents. CHILD ABUSE & NEGLECT 2017; 63:183-191. [PMID: 27930959 DOI: 10.1016/j.chiabu.2016.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 06/06/2023]
Abstract
Social support by family, friends and significant others is known to buffer the impact of adverse life events on children's well-being and functioning, however little is known about pathways explaining this association. We investigated whether maltreatment-related cognitions mediate the association between social support and posttraumatic stress symptoms (PTSS). Furthermore, age was introduced as moderator. We assessed the history of maltreatment in 200 maltreated children and adolescents (age 8-17 years) using a semi-structured interview. Participants' perceived current social support, maltreatment-related negative cognitions related to the subjectively "worst" experience of maltreatment and PTSS during the past month were assessed using self-report questionnaires. A set of mediation analyses demonstrated, that negative maltreatment-related appraisals mediated the relation between perceived social support and PTSS. The hypothesized negative associations of social support with PTSS and dysfunctional cognitions did not differ between children (8-11;11 years) and adolescents (12-17;11 years). Thus, the protective function of social support after maltreatment can be explained by fewer negative beliefs maltreated youth have about themselves and the world. These results provide support to models of social-cognitive processing and emphasize the importance of cognitive coping in regard to episodes of maltreatment which can be shaped within social interactions with non-abusive caregivers, friends, and significant others.
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Affiliation(s)
- A Münzer
- University of Ulm, Department of Child and Adolescent Psychiatry/Psychotherapy, Steinhövelstr. 1, 89075 Ulm, Germany.
| | - H G Ganser
- University of Ulm, Department of Child and Adolescent Psychiatry/Psychotherapy, Steinhövelstr. 1, 89075 Ulm, Germany
| | - L Goldbeck
- University of Ulm, Department of Child and Adolescent Psychiatry/Psychotherapy, Steinhövelstr. 1, 89075 Ulm, Germany
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Ranney ML, Patena JV, Nugent N, Spirito A, Boyer E, Zatzick D, Cunningham R. PTSD, cyberbullying and peer violence: prevalence and correlates among adolescent emergency department patients. Gen Hosp Psychiatry 2016; 39:32-8. [PMID: 26786845 PMCID: PMC4779373 DOI: 10.1016/j.genhosppsych.2015.12.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is often underdiagnosed and undertreated among adolescents. The objective of this analysis was to describe the prevalence and correlates of symptoms consistent with PTSD among adolescents presenting to an urban emergency department (ED). METHODS A cross-sectional survey of adolescents aged 13-17 years presenting to the ED for any reason was conducted between August 2013 and March 2014. Validated self-report measures were used to measure mental health symptoms, violence exposure and risky behaviors. Multivariate logistic regression analysis was performed to determine adjusted differences in associations between symptoms consistent with PTSD and predicted correlates. RESULTS Of 353 adolescents, 23.2% reported current symptoms consistent with PTSD, 13.9% had moderate or higher depressive symptoms and 11.3% reported past-year suicidal ideation. Adolescents commonly reported physical peer violence (46.5%), cyberbullying (46.7%) and exposure to community violence (58.9%). On multivariate logistic regression, physical peer violence, cyberbullying victimization, exposure to community violence, female gender and alcohol or other drug use positively correlated with symptoms consistent with PTSD. CONCLUSIONS Among adolescents presenting to the ED for any reason, symptoms consistent with PTSD, depressive symptoms, physical peer violence, cyberbullying and community violence exposure are common and interrelated. Greater attention to PTSD, both disorder and symptom levels, and its cooccurring risk factors is needed.
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Affiliation(s)
- Megan L Ranney
- Department of Emergency Medicine, Rhode Island Hospital/Alpert Medical School, Brown University, 593 Eddy Street, Claverick 2, Providence, RI 02903, USA; Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
| | - John V Patena
- Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
| | - Nicole Nugent
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI 02903, USA.
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI 02903, USA.
| | - Edward Boyer
- Department of Emergency Medicine, University of Massachusetts Worcester, 55 Lake Avenue, North Worcester, MA 01655, USA.
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, 2815 Eastlake Avenue, Seattle, WA 98102, USA.
| | - Rebecca Cunningham
- Department of Emergency Medicine, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA; Injury Control Research Center, University of Michigan, Ann Arbor, MI 48109-2800, USA.
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