1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Anthony R, Paine AL, Westlake M, Lowthian E, Shelton KH. Patterns of adversity and post-traumatic stress among children adopted from care. CHILD ABUSE & NEGLECT 2022; 130:104795. [PMID: 33172646 DOI: 10.1016/j.chiabu.2020.104795] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Children adopted from care are more likely to have experienced early adversity, but little is known about the impact of early adversity on later post-traumatic stress (PTS) symptoms. OBJECTIVE To investigate sub-groups of adversity in a sample of adopted children and examine the association with later PTS symptoms. PARTICIPANTS AND SETTING A study of British children adopted from care using social worker records (N = 374) and questionnaire-based longitudinal study of n = 58 children over 4-years post adoptive placement. METHODS We used latent class analysis to identify subgroups of children based on commonalities in perinatal and postnatal adversity experienced prior to adoption and examined differences in PTS symptoms at 4-years post-placement between subgroups. RESULTS Nearly one in five (19 %) children were in the clinical or borderline ranges for symptoms of PTS arousal, 14 % for PTS avoidance and 8 % for PTS intrusion. The 5-class solution fitted the data best, with one class characterized by children with a low probability of experiencing any adversity, one perinatal adversity class and three classes capturing different patterns of adversity. The multiple complex adversity class involving both perinatal and postnatal adversity had significantly higher symptoms of PTS avoidance and arousal than other sub-groups. CONCLUSIONS The prevalence and complexity of PTS symptoms among adoptive children highlights the need for effective interventions considering different profiles of early adversity.
Collapse
Affiliation(s)
- R Anthony
- Centre for Development, Evaluation, Complexity, and Implementation in Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, UK.
| | - A L Paine
- School of Psychology, Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
| | - M Westlake
- School of Psychology, Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
| | - E Lowthian
- Centre for Development, Evaluation, Complexity, and Implementation in Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, UK
| | - K H Shelton
- School of Psychology, Cardiff University, Tower Building, 70 Park Place, Cardiff CF10 3AT, UK
| |
Collapse
|
3
|
Zhang J, Meiser-Stedman R, Jones B, Smith P, Dalgleish T, Boyle A, Edwards A, Subramanyam D, Dixon C, Sinclaire-Harding L, Schweizer S, Newby J, McKinnon A. Trajectory of post-traumatic stress and depression among children and adolescents following single-incident trauma. Eur J Psychotraumatol 2022; 13:2037906. [PMID: 35251531 PMCID: PMC8890561 DOI: 10.1080/20008198.2022.2037906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Post-traumatic stress disorder and depression have high comorbidity. Understanding their relationship is of clinical and theoretical importance. A comprehensive way to understand post-trauma psychopathology is through symptom trajectories. This study aims to look at the developmental courses of PTSD and depression symptoms and their interrelationship in the initial months post-trauma in children and adolescents. METHODS Two-hundred-and-seventeen children and adolescents aged between eight and 17 exposed to single-event trauma were included in the study. Post-traumatic stress symptoms (PTSS) and depression symptoms were measured at 2 weeks, 2 months and 9 months, with further psychological variables measured at the 2-week assessment. Group-based trajectory modelling (GBTM) was applied to estimate the latent developmental clusters of the two outcomes. Logistic regression was used to identify predictors associated with high symptom groups. RESULTS The GBTM yielded a three-group model for PTSS and a three-group model for depression. PTSS trajectories showed symptoms reduced to a non-clinical level by 9 months for all participants (if they were not already in the non-clinical range): participants were observed to be resilient (42.4%) or recovered within 2 months (35.6%), while 21.9% experienced high level PTSS but recovered by 9 months post-trauma. The depression symptom trajectories predicted a chronic non-recovery group (20.1%) and two mild symptom groups (45.9%, 34.0%). Further analysis showed high synchronicity between PTSS and depression groups. Peri-event panic, negative appraisals, rumination and thought suppression at 2 weeks predicted slow recovery from PTSS. Pre-trauma wellbeing, post-trauma anxiety and negative appraisals predicted chronic depression. CONCLUSIONS Post-trauma depression was more persistent than PTSS at 9 months in the sampled population. Cognitive appraisal was the shared risk factor to high symptom groups of both PTSS and depression.
Collapse
Affiliation(s)
- Joyce Zhang
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
| | | | - Bobby Jones
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Patrick Smith
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, UK
| | - Adrian Boyle
- Emergency Department, Addenbrooke’s Hospital, Cambridge, UK
| | - Andrea Edwards
- Emergency Department, Addenbrooke’s Hospital, Cambridge, UK
| | | | - Clare Dixon
- Sussex Partnership NHS Foundation Trust, Worthing, UK
| | | | - Susanne Schweizer
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Jill Newby
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Anna McKinnon
- Cambridgeshire and Peterborough NHS Foundation Trust, UK
| |
Collapse
|
4
|
Yang X, Xu Y, Tan R, Zhou X. Event centrality and post-traumatic stress symptoms among college students during the COVID-19 pandemic: the roles of attention to negative information, catastrophizing, and rumination. Eur J Psychotraumatol 2022; 13:2078563. [PMID: 35695844 PMCID: PMC9176333 DOI: 10.1080/20008198.2022.2078563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has affected college students' mental health and caused post-traumatic stress symptoms (PTSS). Event centrality is thought to play a key role in the development of PTSS, but it is not yet clear by what mechanism. Theoretically, event centrality may affect the retrieval of traumatic memories and further prompt post-traumatic cognitions to understand events, and so may in turn be associated with PTSS in college students. However, few empirical studies have examined the mediating role of post-traumatic cognitions in the relationship between event centrality and PTSS, especially among college students during the COVID-19 pandemic. OBJECTIVES The objective of this study was to examine the mediating roles of post-traumatic cognitive factors (e.g. attention to negative information, catastrophizing, and rumination) in the relationship between event centrality and PTSS among college students during the COVID-19 pandemic. METHODS We recruited 1153 college students who completed the pandemic experiences scale, the centrality of event scale, the attention to positive and negative information scale, the cognitive emotion regulation questionnaire, and the PTSD Checklist for DSM-5 during the COVID-19 pandemic in May 2020. RESULTS In this sample of college students, event centrality directly predicted PTSS, and PTSS was also indirectly predicted by event centrality through attention to negative information, catastrophizing, and rumination. CONCLUSIONS These findings support the existing literature on the relationship between event centrality, proposed cognitive variables, and PTSS, and shed light on the mechanisms underlying PTSS. Our findings also highlight the importance and applicability of targeted cognitive interventions for PTSS in college students during the COVID-19 pandemic. HIGHLIGHTS The COVID-19 pandemic has caused post-traumatic stress symptoms among college students.Event centrality is a risk factor of post-traumatic stress symptoms among college students during the COVID-19 pandemic.Attention to negative information, catastrophizing and rumination mediate the relationship between event centrality and post-traumatic stress symptoms.
Collapse
Affiliation(s)
- Xima Yang
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, People's Republic of China
| | - Yongyong Xu
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, People's Republic of China
| | - Ruyue Tan
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao Zhou
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, People's Republic of China
| |
Collapse
|
5
|
McGuire R, Hiller RM, Ehlers A, Fearon P, Meiser-Stedman R, Leuteritz S, Halligan SL. A Longitudinal Investigation of Children's Trauma Memory Characteristics and Their Relationship with Posttraumatic Stress Disorder Symptoms. Res Child Adolesc Psychopathol 2021; 49:807-816. [PMID: 33534094 PMCID: PMC8096753 DOI: 10.1007/s10802-021-00773-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/31/2022]
Abstract
While trauma memory characteristics are considered a core predictor of adult PTSD, the literature on child PTSD is limited and inconsistent. We investigated whether children's trauma memory characteristics predict their posttraumatic stress symptoms (PTSS) at 1 month and 6 months post-trauma. We recruited 126 6-13 year olds who experienced a single-incident trauma that led to attendance at an emergency department. We assessed trauma memory disorganisation and sensory-emotional qualities through both narrative recall and self-report questionnaire, and PTSS at 1-month post-trauma and at 6-month follow-up. We found that, after controlling for age, children's self-reported trauma memory characteristics were positively associated with their concurrent PTSS, and longitudinally predicted symptoms 6-months later. However, observable trauma memory characteristics coded from children's narratives were not related to PTSS at any time. This suggests that children's perceptions of their trauma memories are a more reliable predictor of the development and maintenance of PTSS than the nature of their trauma narrative, which has important implications for clinical practice.
Collapse
Affiliation(s)
- Rosie McGuire
- Department of Psychology, University of Bath, Bath, UK.
| | | | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Pasco Fearon
- Department of Clinical, Educational and Health Psychology, UCL, London, UK
| | | | | | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK. .,Department of Psychiatry, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
6
|
Hiller RM, Meiser-Stedman R, Elliott E, Banting R, Halligan SL. A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care. J Child Psychol Psychiatry 2021; 62:48-57. [PMID: 32196661 DOI: 10.1111/jcpp.13232] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Young people in out-of-home care are substantially more likely to meet criteria for PTSD than their peers, while their early maltreatment exposure may also place them at greater risk of developing the newly proposed complex PTSD. Yet, there remains limited empirical evidence for the mechanisms that might drive either PTSD or complex features in this group, and ongoing debate about the suitability of existing cognitive behavioural models and their related NICE-recommended treatments. In a prospective study of young people in out-of-home care, we sought to identify demographic and cognitive processes that may contribute to the maintenance of both PTSD symptom and complex features. METHODS We assessed 120 10- to 18-year-olds in out-of-home care and their primary carer at two assessments: an initial assessment and 12-month follow-up. Participants completed questionnaires on trauma history, PTSD symptoms and complex features, while young people only also self-reported on trauma-related (a) maladaptive appraisals, (b) memory quality and (c) coping. Social workers reported on maltreatment severity. RESULTS Young people's maltreatment severity was not a robust predictor of either PTSD symptoms or complex features. All three cognitive processes were moderately-to-strongly correlated with baseline and 12-month PTSD symptoms and complex features, with maladaptive appraisals the most robust unique driver of both, even when controlling for initial PTSD symptom severity. CONCLUSIONS Existing cognitive models of PTSD are applicable in this more complex sample of young people. The model was also found to be applicable to the additional features of complex PTSD, with the same processes driving both outcomes at both time points. Clinical implications are discussed.
Collapse
Affiliation(s)
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Rosie Banting
- Department of Psychology, University of Bath, Bath, UK
| | - 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
| |
Collapse
|
7
|
de Haan A, Landolt MA, Fried EI, Kleinke K, Alisic E, Bryant R, Salmon K, Chen SH, Liu ST, Dalgleish T, McKinnon A, Alberici A, Claxton J, Diehle J, Lindauer R, de Roos C, Halligan SL, Hiller R, Kristensen CH, Lobo BO, Volkmann NM, Marsac M, Barakat L, Kassam-Adams N, Nixon RD, Hogan S, Punamäki RL, Palosaari E, Schilpzand E, Conroy R, Smith P, Yule W, Meiser-Stedman R. Dysfunctional posttraumatic cognitions, posttraumatic stress and depression in children and adolescents exposed to trauma: a network analysis. J Child Psychol Psychiatry 2020; 61:77-87. [PMID: 31701532 PMCID: PMC7116234 DOI: 10.1111/jcpp.13101] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The latest version of the International Classification of Diseases (ICD-11) proposes a posttraumatic stress disorder (PTSD) diagnosis reduced to its core symptoms within the symptom clusters re-experiencing, avoidance and hyperarousal. Since children and adolescents often show a variety of internalizing and externalizing symptoms in the aftermath of traumatic events, the question arises whether such a conceptualization of the PTSD diagnosis is supported in children and adolescents. Furthermore, although dysfunctional posttraumatic cognitions (PTCs) appear to play an important role in the development and persistence of PTSD in children and adolescents, their function within diagnostic frameworks requires clarification. METHODS We compiled a large international data set of 2,313 children and adolescents aged 6 to 18 years exposed to trauma and calculated a network model including dysfunctional PTCs, PTSD core symptoms and depression symptoms. Central items and relations between constructs were investigated. RESULTS The PTSD re-experiencing symptoms strong or overwhelming emotions and strong physical sensations and the depression symptom difficulty concentrating emerged as most central. Items from the same construct were more strongly connected with each other than with items from the other constructs. Dysfunctional PTCs were not more strongly connected to core PTSD symptoms than to depression symptoms. CONCLUSIONS Our findings provide support that a PTSD diagnosis reduced to its core symptoms could help to disentangle PTSD, depression and dysfunctional PTCs. Using longitudinal data and complementing between-subject with within-subject analyses might provide further insight into the relationship between dysfunctional PTCs, PTSD and depression.
Collapse
Affiliation(s)
- Anke de Haan
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland,Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Markus A. Landolt
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland,Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Eiko I. Fried
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | | | - Eva Alisic
- Jack Brockhoff Child Health and Wellbeing Program, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Karen Salmon
- School of Psychology, Victoria University of Wellington, Wellington, New Zealand
| | - Sue-Huei Chen
- Department of Psychology, National Taiwan University, Taipei, Taiwan
| | - Shu-Tsen Liu
- Department of Psychology, National Taiwan University, Taipei, Taiwan
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK,Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), Cambridge, UK
| | - Anna McKinnon
- Department of Psychology, Centre for Emotional Health Clinic, Macquarie University, Sydney, NSW, Australia
| | - Alice Alberici
- Sussex Partnership NHS Foundation Trust, West Sussex Child and Adolescent Mental Health Service, West Sussex, UK
| | | | - Julia Diehle
- Department of Child and Adolescent Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ramón Lindauer
- Department of Child and Adolescent Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,De Bascule, Academic Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - Carlijn de Roos
- De Bascule, Academic Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - 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
| | - Rachel Hiller
- Department of Psychology, University of Bath, Bath, UK
| | | | - Beatriz O.M. Lobo
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Nicole M. Volkmann
- Department of Human Development, Institute of Psychology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Meghan Marsac
- Kentucky Children’s Hospital, University of Kentucky, Lexington, KY, USA,Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Lamia Barakat
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Kassam-Adams
- Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Susan Hogan
- School of Psychology, Flinders University, Adelaide, SA, Australia
| | | | - Esa Palosaari
- School of Management, University of Tampere, Tampere, Finland
| | | | - Rowena Conroy
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Vic, Australia
| | - Patrick Smith
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,South London and Maudsley NHS Foundation Trust, London, UK
| | - William Yule
- Department of Psychology, King’s College London Institute of Psychiatry, London, UK
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
8
|
Cooper DK, Wieling E, Pfeiffer A. Bioecological Implications of Narrative Exposure Therapy in Low-Resource Settings: Individual, Family, Community, and Socio-Political Contexts. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF FAMILY THERAPY 2019; 40:353-367. [PMID: 34334934 PMCID: PMC8323547 DOI: 10.1002/anzf.1392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Traumatic stress can have detrimental effects on individuals, families, and communities. Narrative Exposure Therapy (NET) is an evidence-based intervention for decreasing individuals' posttraumatic stress disorder (PTSD) symptoms and has been tested in some of the most challenging contexts, such as in post-conflict refugee camps. Although the focus of NET is on reducing individual PTSD symptoms, the impact of NET can be seen beyond the individual level. The purpose of this manuscript was to examine some of the ecological implications of using NET with trauma-affected populations in low-resource settings. We highlight select implications of NET that extend beyond the individual to systemic effects at the family, community, and sociopolitical levels using several case examples. Finally, we outline limitations and future directions for improving the delivery of NET in settings with limited resources.
Collapse
Affiliation(s)
| | - Elizabeth Wieling
- Department of Human Development and Family Science, University of Georgia
| | - Anett Pfeiffer
- vivo Outpatient Clinic for Survivors of Trauma and Torture in Uganda
| |
Collapse
|