Etiologic factors in the development of posttraumatic stress disorder in children and adolescents

Post-traumatic Stress Disorder in School-age Children: A Nationwide Prospective Birth Cohort Study

Traumatic childhood events are some of the few identifiable and to some extent preventable causes of psychiatric illness. Children exposed to severely stressful events may react with post-traumatic stress disorder (PTSD) and this may impact their level of function in daily life, their future development and mental health. The traumatic stress model suggests that traumatic stress in the family, community violence, and other traumas are regarded as additive environmental factors that can outweigh protective compensatory factors and thus interact with individual vulnerabilities. This study is based on prospective panel data including the whole population of children born in Denmark from 1984 to 1994, who are followed from age 7 to age 18 (N = 679,000) in the window between 2001 and 2012. Risk factors for first-time diagnose with PTSD are analyzed by the discrete time log-odd model. We found a lifetime prevalence of 2.3% PTSD in school-age children (n = 15,636). In accordance with the model, indicators of traumatic stress in the family, family disintegration, community violence, and individual vulnerabilities predicted later diagnose with PTSD. Individual neurodevelopmental disorder - especially autism (adjusted Odds Ratio (OR 7.1) and ADHD (OR 10.7) - were predicative of PTSD. The results cooperated the traumatic stress model. Some results were inconsistent with the traumatic stress model e.g., parental substance abuse were associated with less than expected PTSD in school-age children when adjusted for other risk factors. This indicates that PTSD may be underestimated in these groups. PTSD diagnoses in administrative records underestimate the prevalence, systematically. Efforts to increase PTSD screening may allow for better management.

A Longitudinal Investigation of Children's Trauma Memory Characteristics and Their Relationship with Posttraumatic Stress Disorder Symptoms

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.

Psychological peritraumatic risk factors for post-traumatic stress disorder in children and adolescents: A meta-analytic review

BACKGROUND

Meta-analytic reviews concerning predictors of PTSD in children and adolescents have predominantly identified evidence relating to pre- and post-trauma risk factors; however, there is little evidence regarding peritraumatic risk factors. This paper comprised a systematic review and meta-analysis of studies exploring psychological peritraumatic risk factors for PTSD in youth.

METHODS

Thirty-two studies were identified. Random effects meta-analyses were undertaken, with meta-regressions to explore the moderating role of study characteristics (gender, sex, timing of assessment after trauma, study quality, design and trauma type) on the size of effect of predictive factors.

RESULTS

Peritraumatic subjective threat (k = 28; r = 0.37, 95% CI=0.31-0.42) yielded a medium effect size estimate, while dissociation (k = 5; r = 0.17, 95% CI=0.03-0.29) and data-driven processing (feeling muddled or confused during the trauma) (k = 2; r = 0.29, 95% CI=0.14-0.43) yielded smaller population effect size estimates for the relationship with PTSD symptoms. Perceived life threat yielded a medium sized effect (k = 12; r = 0.37, 95% CI=0.32-0.41). The relationship between subjective threat and PTSD symptoms was moderated by the percentage of female participants. Estimates of heterogeneity were high in studies assessing perceived threat and fear (I² = 95%), but moderate and low within studies assessing dissociation and data-driven processing (I² = 57% and 0%, respectively).

LIMITATIONS

Peritraumatic psychological processes were commonly assessed using single-item measures. Studies primarily concerned single-incident traumas, limiting generalisability.

CONCLUSIONS

Peritraumatic experiences, particularly relating to subjective threat, are important correlates of subsequent PTSD, which implicates timely assessment of these experiences in youth to inform identification of at-risk groups and implementation and design of intervention.

Engagement and Leadership in Firearm-Related Violence Prevention: The Role of the Pediatric Hospitalist

Gun violence is a US public health crisis. Approximately 7000 children are hospitalized each year because of firearm-related injuries. As pediatric hospitalists, we are poised to address this crisis, whether we care directly for patients who are victims of gun violence. In this article, we aim to provide practical tools and opportunities for pediatric hospitalists to address the epidemic of gun safety and gun violence prevention, including specifics related to the inpatient setting. We provide a framework to act within 4 domains: clinical care, advocacy, education and research.

Mental health problems among children and adolescents experiencing two major earthquakes in remote mountainous regions: A longitudinal study

OBJECTIVE

Millions of children were exposed to major earthquake in China, with serious psychological and developmental consequences. To obtain accurate rate of post-disaster related disorder and identify predictors may help inform post-disaster rescue and rehabilitation efforts. The present longitudinal study explored correlations of demographic and socioeconomic characteristics of juvenile survivors of the Ya'an and Wenchuan earthquakes in China with their trajectories of post-disaster related disorder.

METHODS

A total of 435 Chinese children and adolescents who survived the 2013 Ya'an earthquake were recruited from six primary, secondary and high schools in Baoxing County. All survivors were assessed at 12months after the disaster, when a trained psychiatrist assessed mental health problems in a face-to-face structured interview, and 153 survivors were followed up at 30months after the earthquake via telephone.

RESULTS

The 12-month assessment indicated a post-traumatic stress disorder (PTSD) prevalence of 43.9% as well as depression (20.9%) or the criteria for both PTSD and depression (18.2%) and the other disorder (0.9%). The 30-month assessment indicated that 15.7% of subjects met the criteria for PTSD, 21.6% met the criteria for depression. No subjects met the criteria for other affective or anxiety disorders. Significant predictors of PTSD and depression were death in the family, previous earthquake experience, a poor parent-child relationship and economic pressure or poverty.

LIMITATIONS

Clinical interview face to face is quite different from via telephone and the attrition rate in the longitudinal cohort is high, which would directly affect our results of the assessment.

CONCLUSIONS

PTSD and depression may be as prevalent and persistent in disaster victims in China as elsewhere, and high co-comorbidities remain poorly understood. Although many adolescents recover over time, some exhibit chronic, delayed-onset PTSD and depression, especially those with poor relationships with their parents or those living in precarious economic conditions. Family-based therapy may be needed to support child and adolescent trauma survivors in order to prevent mental illness.

Ego Defense Mechanisms and Types of Object Relations in Adults With ADHD

OBJECTIVE

This research evaluates the personality structure of adults with ADHD from a psychodynamic perspective. The hypothesis was that possible structural characteristics in personality could be correlated with this syndrome.

METHOD

Assessment tools for ego functions (Bell Object Relations and Reality Testing Inventory [BORRTI-Form O], Defense Style Questionnaire ( DSQ-40)) were applied to a sample of 90 adults with ADHD, recruited in a specialized clinic.

RESULTS

Among the ADHD sample, 84.4% of the participants were identified as having object relations pathologies. Pathological elevations were observed mainly in the Alienation, Egocentricity, and Insecure Attachment subscales. Statistically, significant differences were found especially in the use of immature and neurotic defense mechanisms, compared with normative data.

CONCLUSION

The findings indicate that adults with ADHD make more use of immature and neurotic defense mechanisms, and presented pathological internalized object relations that are typical of an archaic and poorly structured egoic structure.

Psychological therapies for children and adolescents exposed to trauma

BACKGROUND

Children and adolescents who have experienced trauma are at high risk of developing post-traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents.

OBJECTIVES

To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random-effects model. We analysed data as short-term (up to and including one month after therapy), medium-term (one month to one year after therapy) and long-term (one year or longer).

MAIN RESULTS

Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life-threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas.Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive-behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children.The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) -0.42, 95% CI -0.61 to -0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term.CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD -0.24, 95% CI -0.42 to -0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate.We did not identify any studies that compared pharmacological therapies with psychological therapies.

AUTHORS' CONCLUSIONS

The meta-analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High-quality studies should be conducted to compare these therapies.

Research Review: Changes in the prevalence and symptom severity of child post-traumatic stress disorder in the year following trauma - a meta-analytic study

BACKGROUND

Understanding the natural course of child and adolescent posttraumatic stress disorder (PTSD) has significant implications for the identification of, and intervention for, at-risk youth. We used a meta-analytic approach to examine longitudinal changes in youth PTSD prevalence and symptoms over the first 12 months posttrauma.

METHODS

We conducted a systematic review to identify longitudinal studies of PTSD in young people (5-18 years old), excluding treatment trials. The search yielded 27 peer-reviewed studies and one unpublished dataset for analysis of pooled prevalence estimates, relative prevalence reduction and standardised mean symptom change. Key moderators were also explored, including age, proportion of boys in the sample, initial prevalence of PTSD and PTSD measurement type.

RESULTS

Analyses demonstrated moderate declines in PTSD prevalence and symptom severity over the first 3-6 months posttrauma. From 1 to 6 months posttrauma, the prevalence of PTSD reduced by approximately 50%. Symptoms also showed moderate decline, particularly across the first 3 months posttrauma. There was little evidence of further change in prevalence or symptom severity after 6 months, suggesting that it is unlikely a child would lose a PTSD diagnosis without intervention beyond this point.

CONCLUSIONS

The current findings provide key information about the likelihood of posttrauma recovery in the absence of intervention and have important implications for our understanding of child and adolescent PTSD. Results are discussed with reference to the timing of PTSD screening and the potential role of early interventions. Findings particularly highlight the importance of future research to develop our understanding of what factors prevent the action of normal recovery from the 'acute' posttrauma period.

Exposure to Chronic Community Violence

In many African American communities, violence and poverty are often part of daily living. As a result, children are at risk for difficulties in all aspect of their lives, particularly their emotional well-being. This study explored the relationship between exposure to chronic community violence and the development of complex post-traumatic stress disorder (C-PTSD), a constellation of symptoms that occur as a result of repeated exposure to traumas, in the context of specific African American cultural beliefs and values that are used as coping mechanisms. It was anticipated that the coping mechanisms would act as stress moderators, or buffers, to the development of symptoms of C-PTSD. Participants in the study included 71 African American children between the ages of 9 and 11 years who lived in a high-crime, high-poverty community in Houston, Texas. The results indicated that formal kinship and spirituality, along with high levels of combined supports, demonstrated buffering effects on exposure to violence.

Extreme Weather-driven Disasters and Children’s Health

Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to become more frequent and intense with climate change. Extreme weather-driven disasters (EWDDs) cause a substantial burden of childhood mortality and morbidity worldwide. We reviewed the published literature on EWDDs and their health impacts on children, and developed a conceptual model based on complex systems thinking to identify the health risks, vulnerabilities, and capacities of children in the context of EWDDs as a means of informing areas for adaptive intervention. We found that direct and indirect physical and mental impacts of EWDDs on child health are abundant and interrelate in complex ways. The literature review and modeling demonstrated the centrality of resilience at the level of the child and his or her direct environment, suggesting that mental health status may play a key role in a child’s experience of numerous other health outcomes of EWDDs. EWDDs interact with environmental and social systems and with individual children and their contexts in complex ways, the impacts of which are nonlinear and difficult to predict. Traditional perspectives on climate change-driven health impacts often overlook complex bio-psychosocial interactions, suggesting a need to work on preventive strategies to reduce vulnerability and build individual child resilience.

The effects of the Omagh bomb on adolescent mental health: a school-based study

BACKGROUND

The main objective of this study was to assess psychiatric morbidity among adolescents following the Omagh car bombing in Northern Ireland in 1998.

METHODS

Data was collected within schools from adolescents aged between 14 and 18 years via a self-completion booklet comprised of established predictors of PTSD; type of exposure, initial emotional response, long-term adverse physical problems, predictors derived from Ehlers and Clark's (2000) cognitive model, a PTSD symptoms measure (PDS) and the General Health Questionnaire (GHQ).

RESULTS

Those with more direct physical exposure were significantly more likely to meet caseness on the GHQ and the PDS. The combined pre and peri trauma risk factors highlighted in previous meta-analyses accounted for 20% of the variance in PDS scores but the amount of variance accounted for increased to 56% when the variables highlighted in Ehlers and Clark's cognitive model for PTSD were added.

CONCLUSIONS

High rates of chronic PTSD were observed in adolescents exposed to the bombing. Whilst increased exposure was associated with increased psychiatric morbidity, the best predictors of PTSD were specific aspects of the trauma ('seeing someone you think is dying'), what you are thinking during the event ('think you are going to die') and the cognitive mechanisms employed after the trauma. As these variables are in principle amenable to treatment the results have implications for teams planning treatment interventions after future traumas.

Prevalence of psychiatric symptoms in children and adolescents one year after the 2009 L'Aquila earthquake

BACKGROUND

In 2009, an earthquake devastated the Abruzzo region in Italy. Despite the occurrence of several disasters in this country, no study on mental health of Italian children has ever been conducted in complex emergencies. Objective of the study was to assess the prevalence of psychiatric symptoms among children in the affected area 12 to 17 months after the event.

METHODS

A community sample of 1839 3-14 years children was identified from the general population assigned to 37 paediatricians of the National Health System, including children living in the earthquake epicentre, the surrounding earthquake zone, and the adjacent non-affected areas. Psychiatric symptoms were assessed with the Child Behavior Checklist (CBCL) and the Youth Self Report (YSR), completed by 452 children aged 11-14 years. The association between symptoms and sociodemographic, health, family, and earthquake-related factors was examined.

RESULTS

The prevalence of CBCL-defined cases was 14.9% in the epicentre, 13.0% in the remainder earthquake zone, 13.9% in the unaffected area (p = .876). No differences among areas were found when comparing the YSR results. Prevalence of CBCL-defined post-traumatic stress (PTS) cases was 8.4% in the epicentre, 4.0% in the remainder earthquake zone, 2.2% in the unaffected area (p = .002). PTS and anxiety were significantly more frequent in the epicentre than in other areas only in the 6-10 year-old children group (respectively p = .009 and p = .014). In multivariate logistic analyses, factors associated with PTS were living in the epicentre (OR = 3.6) and child or maternal history of mental health care prior to the earthquake (respectively OR = 7.1 and OR = 4.5).

CONCLUSIONS

Children living in the epicentre, particularly those 6-10 years old, had the highest prevalence of CBCL-defined cases, and of PTS and anxiety symptoms one year after the earthquake. No signs of increased psychopathology were detected in younger (3-5 years) or older children (11-14 years). Family and health related factors showed stronger association with psychiatric outcomes than earthquake-related factors. The identification of populations at higher risk of developing psychiatric symptoms has implications for public health interventions in complex emergencies.

Trauma Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of Childhood Sexual Abuse

This study examined the relationship between the characteristics of childhood sexual abuse (CSA) and the severity of consequent posttraumatic stress disorder (PTSD), depression, suicidal ideation, and substance use in a sample of 83 female adolescents aged 13-18 years seeking treatment for PTSD. Nearly two-thirds of the sample (60.7%, n = 51) reported the perpetrator of the CSA was a relative. A large portion (40.5%, n = 34) of the sample reported being victimized once, while almost a quarter of the sample reported chronic victimization (23.8%, n = 20). PTSD and depression scores were in the clinical range, whereas reported levels of suicidal ideation and substance use were low. The frequency of victimizations was associated with suicidal ideation. Contrary to expectation, CSA characteristics including trauma type, perpetrator relationship, and duration of abuse were unrelated to PTSD severity, depressive symptoms, or substance abuse.

The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective

Major trauma remains a significant cause of mortality and morbidity in young people and adolescents throughout the western world. Both the physical and psychological consequences of trauma are well documented and it is shown that peri-traumatic factors play a large part in the emotional recovery of children involved in trauma. Indeed, parental anxiety levels may play one of the biggest roles. There are no publically available guidelines on pre-hospital accompaniment, and where research has been done on parental presence it often focuses primarily on the parents or staff, rather than the child themselves. Whilst acknowledging the impact on parents and staff, the importance of the emotional wellbeing of the child should be reinforced, to reduce the likelihood of developing symptoms in keeping with post-traumatic stress disorder. This non-systematic literature review, aims to examine the impact of parental accompaniment to hospital, following paediatric trauma, and to help pre-hospital clinicians decide whether accompaniment would be of benefit to their patient population. The lack of published data does not enable a formal recommendation of parental accompaniment in the helicopter to be mandated, though it should be the preference in land based conveyance. Future research is needed into the emotional recovery of children after trauma, as well as the experiences of patient, parent and staff during conveyance.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents (Review)

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team. We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy. Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group. The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified. No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others. The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses. More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

A school based study of psychological disturbance in children following the Omagh bomb

OBJECTIVE

To assess the extent and nature of psychiatric morbidity among children (aged 8 to 13 years) 15 months after a car bomb explosion in the town of Omagh, Northern Ireland.

METHOD

A survey was conducted of 1945 school children attending 13 schools in the Omagh district. Questionnaires included demographic details, measures of exposure, the Horowitz Impact of Events Scale, the Birleson Self-Rating Depression Scale, and the Spence Children's Anxiety Scale.

RESULTS

Children directly exposed to the bomb reported higher levels of probable PTSD (70%), and psychological distress than those not exposed. Direct exposure was more closely associated with an increase in PTSD symptoms than in general psychiatric distress. Significant predictors of increased IES scores included being male, witnessing people injured and reporting a perceived life threat but when co-morbid anxiety and depression are included as potential predictors anxiety remains the only significant predictor of PTSD scores.

CONCLUSIONS

School-based studies are a potentially valuable means of screening and assessing for PTSD in children after large-scale tragedies. Assessment should consider type of exposure, perceived life threat and other co-morbid anxiety as risk factors for PTSD.

Translational reciprocity: bridging the gap between preclinical studies and clinical treatment of stress effects on the adolescent brain

The genetic, biological, and environmental backgrounds of an organism fundamentally influence the balance between risk and resilience to stress. Sex, age, and environment transact with responses to trauma in ways that can mitigate or exacerbate the likelihood that post-traumatic stress disorder will develop. Translational approaches to modeling affective disorders in animals will ultimately provide novel treatments and a better understanding of the neurobiological underpinnings behind these debilitating disorders. The extant literature on trauma/stress has focused predominately on limbic and cortical structures that innervate the hypothalamic-pituitary-adrenal axis and influence glucocorticoid-mediated negative feedback. It is through these neuroendocrine pathways that a self-perpetuating fear memory can propagate the long-term effects of early life trauma. Recent work incorporating translational approaches has provided novel pathways that can be influenced by early life stress, such as the glucocorticoid receptor chaperones, including FKBP51. Animal models of stress have differing effects on behavior and endocrine pathways; however, complete models replicating clinical characteristics of risk and resilience have not been rigorously studied. This review discusses a four-factor model that considers the importance of studying both risk and resilience in understanding the developmental response to trauma/stress. Consideration of the multifactorial nature of clinical populations in the design of preclinical models and the application of preclinical findings to clinical treatment approaches comprise the core of translational reciprocity, which is discussed in the context of the four-factor model.

Offspring psychological and biological correlates of parental posttraumatic stress: review of the literature and research agenda

Millions of individuals with posttraumatic stress disorder (PTSD) are parents. A burgeoning literature suggests that offspring of parents with this condition may be at increased risk for psychological problems. The current paper provides an integrative and comprehensive review of the diverse research literature examining the sequelae of parental posttraumatic stress among offspring. Over 100 studies that evaluated psychological and/or biological variables among children of parents with PTSD are reviewed. Findings suggest parental symptoms of posttraumatic stress are uniquely related to an array of offspring outcomes, including internalizing-type problems, general behavioral problems, and altered hypothalamic-pituitary-adrenal axis functioning. Although very little work has directly evaluated mechanisms of transmission, there is increasing support for genetic and epigenetic effects as well as parenting behaviors. These and other mechanisms are discussed; drawing upon findings from other literatures to consider how parental PTSD may impart psychobiological vulnerability upon offspring. We conclude with a detailed discussion of the methodological strengths and challenges of the extant research, along with a recommended agenda for future research in this important area of study.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy.Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group.The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified.No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others.The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses.More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Reducing the Risk of Posttraumatic Stress Disorder in Children Following Natural Disasters

A significant number of children suffer long-term psychological disturbance following exposure to a natural disaster. Evidence suggests that a dose-response relationship exists, so that children and adolescents who experience the most intense or extensive exposure to the risk factors for posttraumatic stress disorder (PTSD) are likely to develop the most serious and persistent symptoms. Risk factors include gender, age, personality, extent of exposure to the natural disaster, amount of damage to property and infrastructure, witnessing the death or injury of others or perceiving a threat to one's own life. Knowing these factors enables various strategies to be put in place to decrease the risk of psychological disturbance following traumatic events. Reestablishing a sense of safety, security and normality is important in the aftermath of a natural disaster, and promoting social connectedness, positive family functioning and effective coping mechanisms can make children more resilient in the face of catastrophic events. This paper examines the risk and protective factors associated with the development of PTSD, and considers how schools can use this knowledge to contribute to the recovery effort and reduce the prevalence of PTSD among pupils in the wake of a natural disaster.

Posttraumatic stress disorder in adolescents after Typhoon Morakot-associated mudslides

The aims of this study were to examine prevalence rate of post-traumatic stress disorder (PTSD), its associated factors and co-occurring psychological problems in a group of displaced adolescents 3 months following Typhoon Morakot in Taiwan. The relationship of trauma dimension and PTSD was also explored. A total of 271 adolescents who had been evacuated from their homes participated in this school-based survey. Adolescents were interviewed using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Subjects themselves completed the following questionnaires: an inventory of exposure experiences to Typhoon Morakot, the Chinese version of Impact of Events Scale-Revised, the Center for Epidemiological Studies Depression Scale, and the Family APGAR Index. Teachers completed the Teacher's Report Form in the Achenbach system of Empirically Bases Assessment. Results revealed that the prevalence of PTSD related to Typhoon Morakot was 25.8%. Adolescents who were female, had PTSD related to previous traumatic events before Typhoon Morakot, had more exposure experiences, were physically injured, or had family member in same household died or seriously injured were more likely to have the diagnoses of PTSD. Meanwhile, adolescents with PTSD had more severe depression, internalizing, externalizing, social, thought, and attention problems than those without PTSD. Our findings indicate that specialized trauma services are needed for these youngsters to lessen prolonged vulnerabilities.

Assessing the factor structure of posttraumatic stress disorder symptoms in war-exposed youths with and without Criterion A2 endorsement

Posttraumatic stress disorder's (PTSD) tripartite factor structure proposed by the DSM-IV is rarely empirically supported. Other four-factor models (King et al., 1998; Simms et al., 2002) have proven to better account for PTSD's latent structure; however, results regarding model superiority are conflicting. The current study assessed whether endorsement of PTSD's Criterion A2 would impact on the factorial invariance of the King et al. (1998) model. Participants were 1572 war-exposed Bosnian secondary students who were assessed two years following the 1992-1995 Bosnian conflict. The sample was grouped by those endorsing both parts of the DSM-IV Criterion A (A2 Group) and those endorsing only A1 (Non-A2 Group). The factorial invariance of the King et al. (1998) model was not supported between the A2 vs. Non-A2 Groups; rather, the groups significantly differed on all model parameters. The impact of removing A2 on the factor structure of King et al. (1998) PTSD model is discussed in light of the proposed removal of Criterion A2 for the DSM-V.

Psychological impact of disasters on children: review of assessment and interventions

BACKGROUND

There is a wide range of mental and behavioral sequel in children following disasters, which can last long. This review discusses the nature and extent of the psychiatric problems, their management options and process to organize the psychological interventions for affected children.

DATA SOURCES

Literatures were searched through PubMed with the words "children, disaster, psychiatry, and mental health" and relevant cross references were included in the review.

RESULTS

Proportions of children having posttraumatic symptoms or syndromal diagnoses vary in different studies depending on various factors like nature and severity of disaster, diagnostic criteria used, cultural issues regarding meaning of trauma, support available, etc. Common psychiatric manifestations among children include acute stress reactions, adjustment disorder, depression, panic disorder, post-traumatic stress disorder, anxiety disorders specific to childhood and psychotic disorders. Comorbidities and sub-clinical syndromes are also common. Most of the post-disaster mental health interventions can be provided in the community by the local disaster workers. Supportive counselling, cognitive behavior therapy, brief trauma/grief-focused psychotherapy, and play therapy are the commonly utilized methods of psychological intervention, which can be given in groups. Information about the efficacy of medications is still emerging, while many are being used and found useful.

CONCLUSIONS

Following disaster, systematic screening for psychological problems in children is suggested. An integrated approach using psycho-socio-educational and clinical interventions is expected to be effective.

Risikofaktoren der Posttraumatischen Belastungsstörung nach Trauma-Typ-I bei Kindern und Jugendlichen

Es wird ein Überblick zu Risikofaktoren einer Posttraumatischen Belastungsstörung (PTB) nach einem einmaligen traumatischen Ereignis in Kindheit und Jugend gegeben. Dazu wurde eine umfangreiche Literaturrecherche durchgeführt, als deren Ergebnis 55 Einzelstudien identifiziert werden konnten. Die berücksichtigten Studien sollten sowohl eine quantitative Erfassung der posttraumatischen Symptomatik als auch der Prädiktoren beinhalten. Prädiktoren wurden in prä-, peri- und posttraumatische Faktoren eingeteilt, wobei sich die folgenden als besonders vielversprechend herausstellten: Prätraumatische psychische Morbidität, Stressorschwere, Lebensgefahr, Ressourcenverlust und peritraumatische emotionale Reaktion, sowie eine Akute Belastungsstörung bzw. PTB nach dem Ereignis, Komorbidität, weitere kritische Lebensereignisse und mangelnde soziale Unterstützung.

Post-Traumatic Stress Disorder in Turkish Child and Adolescent Survivors Three Years after the Marmara Earthquake

The study investigated the emergence of post-traumatic stress disorder (PTSD) symptoms in child and adolescent survivors in Turkey three years after the 1999 Marmara Earthquake, with consideration of the severity of exposure and the survivors' gender and age. A representative sample of 293 young earthquake survivors (152 female and 141 male between the ages of 8 and 15) participated in the study. Participants' scores on the Post-Traumatic Stress Disorder Reaction Index for Children indicated that 31.4% reported moderate, 24.2% reported severe, and 3.8% reported very severe traumatic stress reactions. Analysis of the Revised Impact of Events Scale for Children scores revealed that 56% reported severe PTSD symptoms. While severity of exposure and gender were significantly associated with severity of PTSD symptoms, age was not related to PTSD symptoms. The results indicated a high need for addressing the mental health problems of the child and adolescent trauma survivors in Turkey.

Attachment style, home-leaving age and behavioral problems among residential care children

In a prospective study, the attachment style, home-leaving age, length of time in residential care, and behavioral problems among Israeli residential care children (N = 68), were studied. Data analyses showed that children removed from their homes at a later age suffered from higher levels of anxiety, depression and social problems compared to children taken from their homes at the age of 7 or less. It was also found that a prolonged stay (over 2 years) in residential care was related to higher levels of anxiety and depression. An interaction effect of a child's attachment style and home-leaving age was found in the child's level of aggressive behavior.

Posttraumatic stress symptoms in the pediatric intensive care unit

PURPOSE

Children who experience acute injury or illness severe enough to result in a pediatric intensive care unit (PICU) stay are at risk for posttraumatic stress symptoms, as are their parents. A distinction is made between injury-related traumatic events, illness-related traumatic events, and treatment-related traumatic events, all of which contribute to this risk.

CONCLUSIONS

This paper reviews what the PICU experience is like for children and their parents, the emerging literature on posttraumatic stress symptoms in PICU patients and their parents, and current knowledge regarding risk and resiliency factors for these children.

PRACTICE IMPLICATIONS

Children hospitalized in the PICU should be monitored for posttraumatic stress disorder during and after their stay. Risk and resiliency factors are a focus for practice and for future research.

Post-traumatic stress disorder in children and adolescents one year after a super-cyclone in Orissa, India: exploring cross-cultural validity and vulnerability factors

BACKGROUND

It has been asserted that psychological responses to disasters in children and adolescents vary widely across cultures, but this has rarely been investigated. The objectives of the study were to clinically evaluate the construct of traumatic stress symptoms and disorder in children and adolescents after a super-cyclone in Orissa, India; to find out the prevalence at one year; compare the effect in high and low exposure areas and study the factors associated with it.

METHODS

Clinical examination of children and adolescents (n = 447) was done, supplemented by a symptoms checklist based on International Classification of Mental and Behavioural Disorders, Diagnostic Criteria for Research and a semi-structured questionnaire for disaster related experiences.

RESULTS

A majority of children had post-traumatic symptoms. Post-traumatic stress disorder (PTSD) was present in 30.6% (95% confidence interval: 26.4 to 34.9), and an additional 13.6% had sub-syndromal PTSD. Parents or teachers reported mental health concerns in 7.2% subjects, who were a minor proportion (12.8%) of subjects with any syndromal diagnosis (n = 196). Significantly more (43.7%) children in high exposure areas had PTSD than that (11.2%) in low exposure areas (p < 0.001). Depression was significantly associated with PTSD. Binary logistic regression analysis indicated that high exposure, lower educational level and middle socioeconomic status significantly predicted the outcome of PTSD. Extreme fear and perceived threat to life during the disaster, death in family, damage to home, or staying in shelters were not significantly associated with PTSD.

CONCLUSION

Following natural disaster PTSD is a valid clinical construct in children and adolescents in Indian set up; and though highly prevalent it may be missed without clinical screening. Its manifestation and associated factors resembled those in other cultures.

Ecological predictors of traumatic stress symptoms in caucasian and ethnic minority children exposed to intimate partner violence

Traumatic stress symptoms were assessed for 218 children ages 5 to 13 following exposure to intimate partner violence: 33% of Caucasian and 17% of minority children were diagnosed with posttraumatic stress disorder. A risk and protective factors model was used to predict traumatic stress symptoms. For Caucasian children, the best predictors were mothers' mental health and low self-esteem. For minority children, the amount of violence, mothers' low self-esteem, and low income predicted traumatic stress. Social support to the mother, inclusive of friends, relatives, and religion, was a protective element. Implications for assessment and intervention are discussed in light of each group's experiences.

Posttraumatic stress disorder reactions among children with learning disabilities exposed to terror attacks

Posttraumatic stress disorder (PTSD) reactions were examined among adolescents exposed to terror attacks. In the first stage, 56 children with learning disabilities (LDs) were compared with 48 nonclinical controls aged 14 to 18 years. Posttraumatic stress disorder in children with LD was significantly higher than in the control group. Next, hierarchic regression predicting PTSD reactions among children with LD was performed. Results revealed that personal exposure to terror, past personal threatening life events, avoidant and anxious attachment, and the anxious attachment x threatening past events interaction contributed significantly to the explained variance of PTSD. Examination of the source of this interaction revealed that adolescents high in anxious attachment who underwent more threatening past life events were more prone to PTSD when exposed personally to terror attacks. The findings suggest that adolescents with LD have difficulties in cognitive processing of traumatic events. This group of adolescents is in double jeopardy for developing PTSD symptoms if they personally experienced threatening events in the past and are characterized by anxious attachment. The anxious attachment damages their self-regulation, intensifies their distress, and exacerbates the risk for PTSD. Hence, special attention and specific intervention are needed for youth with LD to enhance their coping strategies.

Exposure to violence and cardiovascular and neuroendocrine measures in adolescents

BACKGROUND

Exposure to violence has clear, detrimental psychological consequences, but the physiological effects are less well understood.

PURPOSE

This study examined the influence of exposure to violence on biological basal and reactivity measures in adolescents.

METHODS

There were 115 high school student participants. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), HR variability (HRV), and cortisol levels were recorded during baseline and a laboratory stressor. The Exposure to Violence interview was administered and assessed two dimensions: total observed violence and total personally experienced violence. These were then divided into component parts: lifetime frequency, proximity, and severity.

RESULTS

Greater total experienced violence was associated with increased basal SBP (r = .19, p < .05) and decreased acute stress reactivity in terms of SBP (beta = -.13, p = .05), HR (beta = -.21, p = .00), and HRV (beta = .13, p = .05). Lifetime frequency of experienced violence was associated with higher basal DBP (r = .33, p < .05), HR (r = .33, p < .05), and cortisol (r = .53, p < .00), and decreased SBP (beta = -.27, p < .05) and DBP (beta = -.31, p < .05) reactivity. Exposure to violence is associated with increased biological basal levels in adolescents, supporting allostatic-load research and decreased cardiovascular reactivity, supporting the inoculation effect.

CONCLUSIONS

The findings illustrate that being a victim of violence has more pervasive biological consequences than witnessing violence and that the accumulation of stressful experiences has the greatest effect on biological markers.

Posttraumatic Stress and Depressive Symptoms, Alcohol Use, and Recurrent Traumatic Life Events in a Representative Sample of Hospitalized Injured Adolescents and Their Parents

OBJECTIVE

Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings.

METHODS

Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms.

RESULTS

Fifty-seven percent [corrected] of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms.

CONCLUSIONS

The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.

Acute stress disorder symptoms in gunshot-injured youth

PROBLEM

The prevalence of acute stress disorder symptoms (ASDS) and other psychiatric comorbidities in youth with recent gunshot injuries.

METHODS

Children (n=20) admitted to an urban hospital ER for gunshot injuries over a 4-year period were evaluated for ASDS, co-morbid DSM-III-R diagnoses, legal and gang involvement, and psychiatric history; medically hospitalized children (n=36) similar in age, sex, race, and socioeconomic status served as a control group.

FINDINGS

Gunshot-injured youth reported a 75% rate of ASDS compared to a 14% rate in medically ill youth (OR 18.6; chi2 = p < .0001). Parent ratings of ASDS closely corresponded with youth ratings. Youth rated reexperiencing the event as the most frequent distressing symptom. Gunshot injury was associated with legal problems, gang involvement, marijuana/alcohol dependence, conduct disorder, social phobia, and agoraphobia compared to youth with medical illness.

CONCLUSIONS

Compared to youth with medical illness, gunshot-injured youth were 18.6 times (p = .0001) more likely to show symptoms of ASDS. Further research, developmentally appropriate assessment, prevention, and treatment are needed in this area.

Behavior problems in New York City's children after the September 11, 2001, terrorist attacks

Children's behavior was assessed with 3 cross-sectional random-digit-dial telephone surveys conducted 11 months before, 4 months after, and 6 months after September 11, 2001. Parents reported fewer behavior problems in children 4 months after the attacks compared with the pre-September 11 baseline. However, 6 months after the attacks, parents' reporting of behavior problems was comparable to pre-September 11 levels. In the 1st few months after a disaster, the identification of children who need mental health treatment may be complicated by a dampened behavioral response or by a decreased sensitivity of parental assessment to behavioral problems.

Stress response symptoms in adolescent and young adult children of parents diagnosed with cancer

The aim of this study was to assess stress response symptoms in children of parents diagnosed with cancer 1-5 year prior to study entry. The impact of event scale was used to measure stress response symptoms in terms of intrusion and avoidance; the youth self-report assessed emotional and behavioural functioning; the state-trait anxiety inventory for children measured trait-anxiety. Participants included 220 adolescents (aged 11-18 years) and 64 young adults (aged 19-23 years) from 169 families. Twenty-one percent of the sons and 35% of the daughters reported clinically elevated stress response symptoms. Daughters, particularly those whose mothers were ill, reported significantly more intrusion and avoidance than did sons. Intrusion among daughters was positively related to age. Stress response symptoms in both sons and daughters were significantly associated with trait anxiety, but not with intensity of treatment or time since diagnosis. Daughters whose parents suffered from recurrent illness reported more symptoms than did daughters whose parents had a primary disease. Children (daughters in particular) with clinically elevated stress response symptoms reported significantly more problems of internalising and cognition than did their norm group peers. One-fifth of the sons and more than one-third of the daughters expressed clinically elevated stress response symptoms. These children also reported internalising and cognitive problems. Daughters appeared to be more at risk than sons.

Traumatic stress in parents of children admitted to the pediatric intensive care unit

OBJECTIVE

To measure the prevalence of parental acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) and to examine the relationship between ASD symptoms and PTSD symptoms in parents of infants and children admitted to the pediatric intensive care unit (PICU). To examine the correlation between parental perceptions of illness severity and objective measures. To assess the association among demographic, situational, and illness factors and the severity of ASD and PTSD.

DESIGN

Prospective cohort study.

SETTING

Thirty-eight bed PICU at an urban children's hospital.

PATIENTS

The parents of 272 children admitted to the PICU for >48 hrs.

INTERVENTIONS

ASD symptoms were assessed using the Acute Stress Disorder Scale during the child's admission. PTSD symptoms were assessed using the PTSD Checklist at least 2 months after discharge. The severity of illness was measured using the Pediatric Risk of Mortality (PRISM III) score.

MEASUREMENTS AND MAIN RESULTS

Of the 272 parents completing the initial assessment, 87 (32%) met symptom criteria for ASD. Of the 161 parents completing follow-up, 33 (21%) met symptom criteria for PTSD. PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU, unexpected admission, parent's degree of worry that the child might die, and the occurrence of another hospital admission or other traumatic event subsequent to the index admission. Neither ASD nor PTSD responses were associated with objective measures of a child's severity of illness (PRISM III score).

CONCLUSION

Traumatic stress symptoms are common among parents in the PICU and may persist long after discharge. There is strong support from these data for continued attention to supporting parents both during and after a child's PICU admission.

Elementary school children's responses 3 months after the September 11 terrorist attacks: a study in Washington, DC

This study examined the responses of elementary school children in Washington, DC, to the September 11 terrorist attacks. Parents (primarily mothers) of children in kindergarten through Grade 6 and children in Grades 4 to 6, including 47 matched parent-child pairs, completed questionnaires regarding exposure, stress reactions, and constructive actions taken 3 months after the attacks. Parent reports and, to an even greater extent, children's self-reports revealed high levels of negative reactions to the attacks on behalf of the children. These reactions were best understood in the context of their exposure to the attacks, primarily through television news, and the reactions of and coping assistance provided by their parents. Implications for school personnel, health care professionals, and intervention efforts are discussed.

Post-traumatic stress disorder in maltreated youth: a study of diagnostic comorbidity and child factors

The study of post-traumatic stress disorder (PTSD) in maltreated youth has received increased attention, though extensive comparisons to maltreated youth without PTSD and administrations of anxiety-based structured diagnostic interviews remain needed. We examined maltreated youth with or without PTSD using structured diagnostic interviews and standardized child self-report measures. We hypothesized that maltreated youth with PTSD, compared to their peers without PTSD, would experience significantly greater duration of abuse, diagnostic comorbidity, PTSD symptomatology, dysfunctional family environment, and avoidant coping styles. Results indicated that the group with PTSD did indeed experience significantly greater duration of abuse, diagnostic comorbidity, and PTSD symptomatology, though less so dysfunctional family environment or avoidant coping styles. The presence of a mood or anxiety disorder was highly predictive of PTSD in this sample. Results are discussed within the context of evolving etiological and maintenance models of PTSD in maltreated youth.

Structured group therapy for posttraumatic stress disorder in incarcerated male juveniles

This is the first study to evaluate the efficacy of a structured group therapy for posttraumatic stress disorder (PTSD) in incarcerated male juveniles. Ten groups of juveniles (n = 45) completed a 12-session intervention with pre- and postassessments composed of the Post Traumatic Stress Disorder Reaction Index (C. Frederick, 1985) and supplementary measures of anxiety, anger, and depression. Overall, group participants experienced significant reductions in self-reported PTSD symptoms. Supplemental analyses suggest that this treatment was most beneficial for youth with trauma related to gang and community violence.