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Efendi GY, Temeltürk RD, Çakmak IB, Dinçer M. Surviving the Immediate Aftermath of a Disaster: A Preliminary Investigation of Adolescents' Acute Stress Reactions and Mental Health Needs after the 2023 Turkey Earthquakes. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1485. [PMID: 37761446 PMCID: PMC10527644 DOI: 10.3390/children10091485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
Abstract
On 6 February, southeastern Turkey and parts of Syria were struck by two powerful earthquakes, one measuring a magnitude of 7.8 and the other, nine hours later, at a magnitude of 7.5. These earthquakes have been recorded as some of the deadliest natural disasters worldwide since the 2010 Haiti earthquake, impacting around 14 million people in Turkey. For trauma survivors, the stressors associated with an event can lead to the development of acute stress disorder (ASD) or other psychiatric disorders. Trauma experiences during adolescence can impact development and affect adolescents differently than adults. Although ASD in adults has been addressed in several studies, there is much less information available about how younger populations respond to acute stress. The aim of our study was to assess the occurrence of ASD among individuals seeking help at the Şanlıurfa Mehmet Akif İnan Research and Training Hospital Child and Adolescent Outpatient Clinic following the 2023 Turkey Earthquakes and the factors associated with acute stress reactions. A child and adolescent psychiatry specialist conducted psychiatric interviews with the adolescents, and the individuals were also asked to complete 'The National Stressful Events Survey Acute Stress Disorder Short Scale' (NSESSS) to evaluate acute stress symptoms. ASD diagnoses were established according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Results showed that 81.6% of the participants (n = 49) were diagnosed with ASD, and drug treatment was initiated in 61.7% of the cases (n = 37). It was determined that ASD rates did not differ according to gender, and patients without physical injury had higher acute stress symptom scores (p > 0.05). According to the logistic regression models, paternal educational levels and adolescents' own requests for psychiatric assistance were predictors of acute stress disorder (OR 10.1, β = 2.31, p = 0.006 and OR 16.9, 95 β = 2.83, p = 0.001, respectively). Our findings revealed striking results in demonstrating the need for careful evaluation of adolescents without physical injury in terms of acute stress disorder and the need to pay close attention to the psychiatric complaints of adolescents willing to seek mental health assistance. Moreover, our study suggests that the proportion of adolescents experiencing acute stress symptoms after earthquakes might be higher than previously reported. Estimation of the incidence rate and symptoms of psychiatric distress in the short-term period following a disaster is important for establishing disaster epidemiology and implementing efficient relief efforts in the early stages. The outcomes of this study have the potential to yield novel insights into the realms of disaster mental health and emergency response policies, as well as their pragmatic implementations.
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Affiliation(s)
- Gökçe Yağmur Efendi
- Department of Child and Adolescent Psychiatry, Şanlıurfa Mehmet Akif İnan Training and Research Hospital, Şanlıurfa 63500, Türkiye;
| | - Rahime Duygu Temeltürk
- Department of Child and Adolescent Psychiatry, Ankara University, Ankara 06590, Türkiye;
| | | | - Mustafa Dinçer
- Department of Child and Adolescent Psychiatry, Şanlıurfa Mehmet Akif İnan Training and Research Hospital, Şanlıurfa 63500, Türkiye;
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May C, Miller PE, Naqvi M, Rademacher E, Klajn J, Hedequist D, Shore BJ. The Incidence of Posttraumatic Stress Symptoms in Children. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202308000-00007. [PMID: 37579777 PMCID: PMC10424889 DOI: 10.5435/jaaosglobal-d-22-00245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 04/17/2023] [Accepted: 06/30/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE To determine the incidence of posttraumatic stress disorder (PTSD) symptoms and risk factors for their development in children and adolescents undergoing orthopaedic surgery for trauma. DESIGN Prospective cohort study. SETTING Level-1 trauma center. PATIENTS Children (8 to 18), undergoing surgery for orthopaedic trauma. INTERVENTION Upper and lower extremity surgery for orthopaedic trauma. MAIN OUTCOME MEASUREMENTS PTSD symptoms at postoperative follow-up as determined by the Child PTSD Symptom Scale (CPSS). RESULTS A total of 176 children with an average age at surgery of 13 years (8 to 18.8 years) participated in the study. Twenty-six subjects had high levels of PTSD symptoms (15%; 95% CI = 10.0 to 21.1%). Univariable and multivariable analyses determined that female sex (OR 2.63, 95% CI = 1.06 to 6.67, P = 0.04), older age at surgery (OR 1.25, 95% CI = 1.04 to 1.51, P = 0.02), and undergoing a previous surgery (OR 2.86, 95% CI = 1.06 to 7.73, P = 0.04) were all associated with increased PTSD risk. CONCLUSIONS Children and adolescents experience a high level of PTSD symptoms (15%) after surgery for orthopaedic trauma. Clinicians should be aware of PTSD symptoms in children and adolescents after surgery for orthopaedic injuries and use comprehensive screening to facilitate timely intervention and treatment. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Collin May
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Patricia E. Miller
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Manahill Naqvi
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Emily Rademacher
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Justyna Klajn
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Daniel Hedequist
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Benjamin J. Shore
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
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Reppucci ML, Tong S, Simon SL, Nolan MM, Jujare S, Moulton SL, Kaar JL. Factors associated with new mental health diagnoses and resource utilization among pediatric patients following trauma admission. J Pediatr Surg 2023; 58:118-124. [PMID: 36273919 DOI: 10.1016/j.jpedsurg.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Injured children are at risk for a variety of physical and emotional sequelae that may impair their ability to return to prior function. The effect of traumatic injury on mental health in children is not well characterized or understood. We sought to determine factors associated with new mental health diagnoses and/or mental health resource utilization following admission to a Level 1 pediatric trauma center for traumatic injury. METHODS A retrospective chart review of patients admitted for accidental trauma between 2016 and 2019 was performed. Demographic data, injury characteristics, new mental health diagnoses and/or mental health resource utilization following hospitalization were extracted. Patients with prior mental health diagnosis, psychotropic prescription(s), or resource utilization were excluded from this cohort. A multivariable logistic regression model was used to examine predictors of new mental health diagnoses and/or resource utilization. RESULTS The prevalence of new mental health diagnoses or resources utilization was 9.5% (363/3828). The most common diagnoses were anxiety disorders and nonbipolar depression. The most common psychotropic medication prescribed was antidepressants. Patients with new mental illness were older (odds ratio [OR] 1.1 [95% CI: 1.06, 1.12]), more likely to sustain burn injuries (OR 6.3 [4.2, 9.5]), have non-sports related injuries (OR 3.5 [2.1, 6.0]), and be pedestrian struck (OR 2.7 [1.5, 4.8]). They additionally were more likely to sustain head, neck, and spine injuries (OR 3.8 [2.9, 5.1], 2.4 [1.1, 5.5], and 2.1 [1.3, 3.3], respectively). CONCLUSIONS There are a variety of demographic and injury specific factors associated with new mental health diagnoses and/or resource utilization in children following admission for trauma. Knowledge of these risk factors may ensure patients are allocated adequate resources to promote timely access to appropriate mental health services after hospitalization. TYPE OF STUDY Retrospective comparative study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Marina L Reppucci
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Suhong Tong
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Stacey L Simon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Margo M Nolan
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Swati Jujare
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Steven L Moulton
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jill L Kaar
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, Colorado, United States; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
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Yildiz Mİ, Başterzi AD, Yildirim EA, Yüksel Ş, Aker AT, Semerci B, Çakiroğlu S, Yazgan Y, Sercan M, Erim BR, Küçükparlak İ, Yildirim MH. Preventive and Therapeutic Mental Health Care after the Earthquake- Expert Opinion from the Psychiatric Association of Turkey. TURK PSIKIYATRI DERGISI = TURKISH JOURNAL OF PSYCHIATRY 2023; 34:39-49. [PMID: 36970961 PMCID: PMC10552168 DOI: 10.5080/u27305] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Two major earthquakes hit Turkey at the Kahramanmaraş region on February 6th 2023. The earthquakes affected almost 15 million individuals, resulting in more than forty thousand deaths, thousands of wounded and the destruction of ancient cities of humankind. Immediately after the earthquakes, the Psychiatric Association of Turkey organized an educational event to address the needs for a guidance on how to approach a trauma of such a big scale. The experts in this educational event summarized their presentations and prepared this review to guide the mental health professionals serving victims of this disaster. The review summarizes the early symptoms of trauma, and puts a framework on the principles of psychological first aid, the approach at the initial stages of the disaster, principles of planning, triage, and psychosocial support systems and the proper use of medications. The text covers the evaluation of the impact of trauma, aligning psychiatric practice with psychosocial interventions, the improvement of counseling skills and methods to better understand the mind during the acute post trauma phase. A set of presentations highlight the challenges in child psychiatry, brings a systematic overview to the earthquake and discuss the symptomatology, first aid and intervention principles in children and adolescents. Last, the forensic psychiatric perspective is presented, followed by a piece on the essentials of delivering bad news and the review is concluded with the emphasis on burnout, a syndrome to avoid particularly for field professionals, and possible preventive measures. Keywords: Disaster, trauma, psychosocial support, psychological first aid, acute stress disorder, post traumatic stress disorder.
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Broadbent E, Miller JR, Cheung A, Rollins EM, Novilla LKB, Downing MS, Crandall A. Concurrent Childhood Experiences Impact Underage Substance Use. CHILD MALTREATMENT 2022; 27:605-614. [PMID: 33896222 DOI: 10.1177/10775595211012480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Adverse and advantageous childhood experiences (ACEs and counter-ACEs) during adolescence are understudied. This study examined how childhood experiences affect youth tobacco/alcohol use. Participants included 489 U.S. adolescents (baseline 10-13 years; 51% female) from the first five waves of the Flourishing Families Project. Results of the cross-lagged model showed ACEs were predictive of early tobacco use only. Counter-ACEs in wave two and wave three predicted, respectively, decreased tobacco and decreased alcohol use in the following wave. Counter-ACEs were also correlated with reduced alcohol and tobacco use in later waves. These findings indicate the salience of counter-ACEs over ACEs in persistent and late adolescent substance use, though ACEs may be important to consider to prevent very early initiation of tobacco.
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Affiliation(s)
- Eliza Broadbent
- Department of Public Health, 6756Brigham Young University, Provo, UT, USA
| | - Jacob Read Miller
- Department of Public Health, 6756Brigham Young University, Provo, UT, USA
| | - Aaron Cheung
- Department of Public Health, 6756Brigham Young University, Provo, UT, USA
| | | | | | | | - AliceAnn Crandall
- Department of Public Health, 6756Brigham Young University, Provo, UT, USA
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Schauss E, Hawes K, Roberts S, Clayton JM, Li C, Littlejohn A, Bartelli D, Williams R. Examining the incidence of acute stress in pediatric trauma patients. Trauma Surg Acute Care Open 2022; 7:e000946. [PMID: 36072965 PMCID: PMC9389088 DOI: 10.1136/tsaco-2022-000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Pediatric patients can be significantly impacted emotionally by exposure to acute trauma which may negatively impact long-term functioning and lead to an increase in overall distress. This study reports on the incidence of acute stress disorder among pediatric trauma patients in a hospital setting in the southeastern region of the USA. Methods Pediatric patient mental health assessments were conducted using the Childhood Stress Disorders Checklist- Short Form (CSDC-SF) as part of a new integrated behavioral health standard of care within the Trauma Services Division of a level 1 pediatric hospital. Mental health consultations occurred at bedside on inpatient hospital admission into trauma services, or at the outpatient hospital clinic after discharge for injuries treated in the emergency department. Results Associations among type of trauma, child age, and sex were explored in a sample of 617 children (58.9% male) aged 2–18 years (Mage=10.27). The sample was primarily ethnic minorities (56.1% black/African-American, 5% Hispanic/Latinx). Fifteen per cent or more of trauma reports were for burns (26%), motor vehicle accident (22.7%), and recreational sports or leisure activity-related injury (17.5%). Sixty-four per cent of children scored ≥1 on the CSDC-SF, indicating symptoms consistent with acute stress disorder. Higher scores were associated with female sex, age, and injury type. Level of evidence Level IV study provides evidence of the link between traumatic injury and mental health symptoms in a pediatric population. Findings highlight the critical need for mental health screening and provision of integrated mental health counseling services at time of acute pediatric trauma.
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Affiliation(s)
- Eraina Schauss
- The BRAIN Center, The University of Memphis, Memphis, Tennessee, USA
| | - Kiersten Hawes
- The BRAIN Center, The University of Memphis, Memphis, Tennessee, USA
| | - Sydnie Roberts
- The BRAIN Center, The University of Memphis, Memphis, Tennessee, USA
| | - Joseph Mitchell Clayton
- College of Medicine, The University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee, USA
| | - Chi Li
- The BRAIN Center, The University of Memphis, Memphis, Tennessee, USA
| | | | - Debra Bartelli
- The BRAIN Center, The University of Memphis, Memphis, Tennessee, USA
| | - Regan Williams
- College of Medicine, The University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee, USA
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Hitchcock C, Goodall B, Wright IM, Boyle A, Johnston D, Dunning D, Gillard J, Griffiths K, Humphrey A, McKinnon A, Panesar IK, Werner-Seidler A, Watson P, Smith P, Meiser-Stedman R, Dalgleish T. The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds. J Child Psychol Psychiatry 2022; 63:58-67. [PMID: 34128219 DOI: 10.1111/jcpp.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC. METHOD Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC. RESULTS In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures. CONCLUSIONS The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.
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Affiliation(s)
- Caitlin Hitchcock
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Benjamin Goodall
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Isobel M Wright
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Adrian Boyle
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - David Johnston
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Darren Dunning
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Julia Gillard
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Kirsty Griffiths
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Ayla Humphrey
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Anna McKinnon
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Macquarie University, Sydney, NSW, Australia
| | - Inderpal K Panesar
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Aliza Werner-Seidler
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Peter Watson
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Patrick Smith
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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Screening of Acute Traumatic Stress Disorder and Posttraumatic Stress Disorder in Pediatric Trauma Patients: A Pilot Study. J Trauma Nurs 2021; 28:235-242. [PMID: 34210943 DOI: 10.1097/jtn.0000000000000591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children who experience traumatic physical injuries are at risk of developing acute stress disorder and posttraumatic stress disorder (PTSD). Early identification and treatment of these high-risk children can lead to improved mental health outcomes in this population. OBJECTIVE This study assesses the feasibility of a study protocol that compares 3 screening tools for identifying patients at a high risk of later development of acute stress disorder or PTSD among pediatric trauma patients. METHODS This pilot study compared 3 questionnaires used as screening tools for predictors of later development of PTSD in a convenience sample of pediatric trauma patients aged 7-17 years. Patients were randomized to one of 3 screening tools. Families were contacted at 30, 60, and 90-120 days postinjury to complete the Child Report of Post-Traumatic Symptoms questionnaire. The sensitivity and negative predictive value of the screening tools were compared for the diagnosis of PTSD defined using the Child Report of Post-Traumatic Symptoms questionnaire. RESULTS Of the 263 patients identified for possible enrollment, 52 patients met full inclusion criteria and agreed to participate. Only 29 (55.7%) patients completed at least one follow-up questionnaire. The prevalence of acute stress disorder and PTSD in our population was 41% (95% CI [24, 61]) and 31% (95% CI [15, 51]), respectively. CONCLUSIONS In this pilot study, we sought to determine the utility of the 3 commonly used screening instruments for measuring traumatic stress symptoms in pediatric trauma patients to predict the diagnosis of acute stress disorder or PTSD. Limitations include the use of the Child Report of Post-Traumatic Symptoms screening tool as the gold standard for calculating test characteristics and lack of 24/7 enrollment capabilities. As such, a significant portion of patients were discharged prior to our teams' engagement for enrollment.
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Walker JR, Teague B, Memarzia J, Meiser-Stedman R. Acute stress disorder in children and adolescents: A systematic review and meta-analysis of prevalence following exposure to a traumatic event. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2020. [DOI: 10.1016/j.jadr.2020.100041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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McKinnon A, Scheeringa MS, Meiser-Stedman R, Watson P, De Young A, Dalgleish T. The Dimensionality of Proposed DSM-5 PTSD Symptoms in Trauma-Exposed Young Children. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2020; 47:1799-1809. [PMID: 31172404 PMCID: PMC6805819 DOI: 10.1007/s10802-019-00561-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
A subtype of the posttraumatic stress disorder diagnosis for children 6 years and younger (PTSD-6Y) was introduced in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). This study utilized confirmatory factor analytic techniques to evaluate the proposed DSM-5 PTSD-6Y factor structure and criterion and convergent validity against competing models. Data for N = 284 (3–6 years) trauma-exposed young children living in New Orleans were recruited following a range of traumas, including medical emergencies, exposure to Hurricane Katrina and repeated exposure to domestic violence. The model was compared to DSM-IV, a 4-factor ‘dysphoria’ model that groups symptoms also associated with anxiety and depression, and alternate 1- and 2- factor models. Convergent validity was established against the Child Behavior Checklist (CBCL). Criterion related validity was established by comparing each model to a categorical rating of impairment. The Dysphoria and PTSD-6Y models offered the better accounts of symptom structure, although neither satisfied minimum requirements for a good fitting model. These two models also only showed small levels of convergence with CBCL dimensions. The 1-factor model offered the most compelling balance of sensitivity and specificity, with the 2-factor model and the Dysphoria model following closely behind. These CFA results do not support the symptom clusters proposed within the DSM-5 for PTSD-6Y. Although a 4-factor Dysphoria model offers a better overall account of clustering patterns (relative to alternate models), alongside acceptable sensitivity and specificity for detecting clinical impairment, it also falls short of being an adequate model in this younger age group.
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Affiliation(s)
- Anna McKinnon
- Centre for Emotional Health, Department of Psychology, Macquarie University, North Ryde, New South Wales, 2109, Australia.
| | - Michael S Scheeringa
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, 1440 Canal St., MS 8448, New Orleans, 70112, USA
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Elizabeth Fry Building, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Peter Watson
- Medical Research Council Cognition and Brain Sciences Unit, 15 Chaucer Rd, Cambridge, CB2 7EF, UK
| | - Alexandra De Young
- Centre for Children's Burns & Trauma Research, Centre for Children's Health Research, University of Queensland, Level 7, 62 Graham Street, South Brisbane, Queensland, 4101, Australia
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, 15 Chaucer Rd, Cambridge, CB2 7EF, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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Kassam-Adams N, Kenardy JA, Delahanty DL, Marsac ML, Meiser-Stedman R, Nixon RDV, Landolt MA, Palmieri PA. Development of an international data repository and research resource: the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive. Eur J Psychotraumatol 2020; 11:1729025. [PMID: 32284820 PMCID: PMC7144287 DOI: 10.1080/20008198.2020.1729025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Studies that identify children after acute trauma and prospectively track risk/protective factors and trauma responses over time are resource-intensive; small sample sizes often limit power and generalizability. The Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive was created to facilitate more robust integrative cross-study data analyses. Objectives: To (a) describe creation of this research resource, including harmonization of key variables; (b) describe key study- and participant-level variables; and (c) examine retention to follow-up across studies. Methods: For the first 30 studies in the Archive, we described study-level (design factors, retention rates) and participant-level (demographic, event, traumatic stress) variables. We used Chi square or ANOVA to examine study- and participant-level variables potentially associated with retention. Results: These 30 prospective studies (N per study = 50 to 568; overall N = 5499) conducted by 15 research teams in 5 countries enrolled children exposed to injury (46%), disaster (24%), violence (13%), traffic accidents (10%), or other acute events. Participants were school-age or adolescent (97%), 60% were male, and approximately half were of minority ethnicity. Using harmonized data from 22 measures, 24% reported significant traumatic stress ≥1 month post-event. Other commonly assessed outcomes included depression (19 studies), internalizing/externalizing symptoms (19), and parent mental health (19). Studies involved 2 to 5 research assessments; 80% of participants were retained for ≥2 assessments. At the study level, greater retention was associated with more planned assessments. At the participant level, adolescents, minority youth, and those of lower socioeconomic status had lower retention rates. Conclusion: This project demonstrates the feasibility and value of bringing together traumatic stress research data and making it available for re-use. As an ongoing research resource, the Archive can promote 'FAIR' data practices and facilitate integrated analyses to advance understanding of child traumatic stress.
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Affiliation(s)
- Nancy Kassam-Adams
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Justin A Kenardy
- Department of Psychology, University of Queensland, Brisbane, Australia
| | | | - Meghan L Marsac
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Markus A Landolt
- Child and Adolescent Health Psychology, University of Zurich, Zurich, Switzerland
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12
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Lenferink LIM, Egberts MR, Kullberg ML, Meentken MG, Zimmermann S, L Mertens Y, A T Schuurmans A, Sadeh Y, Kassam-Adams N, Krause-Utz A. Latent classes of DSM-5 acute stress disorder symptoms in children after single-incident trauma: findings from an international data archive. Eur J Psychotraumatol 2020; 11:1717156. [PMID: 32128042 PMCID: PMC7034476 DOI: 10.1080/20008198.2020.1717156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022] Open
Abstract
Background: After a potentially traumatic event (PTE), children often show symptoms of acute stress disorder (ASD), which may evolve into posttraumatic stress (PTS) disorder. A growing body of literature has employed latent class analysis (LCA) to disentangle the complex structure underlying PTS symptomatology, distinguishing between homogeneous subgroups based on PTS presentations. So far, little is known about subgroups or classes of ASD reactions in trauma-exposed children. Objective: Our study aimed to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership (gender, age, cultural background, parental education, trauma type, and trauma history). Method: A sample of 2287 children and adolescents (5-18 years) was derived from the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive, an international archive including studies from the USA, UK, Australia, and Switzerland. LCA was used to determine distinct subgroups based on ASD symptoms. Predictors of class membership were examined using a three-step approach. Results: Our LCA yielded a three-class solution: low (42%), intermediate (43%) and high (15%) ASD symptom severity that differed in terms of impairment and number of endorsed ASD symptoms. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be of female gender, be younger of age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). Conclusions: These findings provide new information on children at risk for ASD after single-incident trauma, based on a unique set of international data. Classifying children based on latent symptom profiles helps to identify target groups for prevention and intervention after exposure to a PTE.
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Affiliation(s)
- Lonneke I M Lenferink
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
| | - Marthe R Egberts
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
| | | | - Maya G Meentken
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sarah Zimmermann
- Department of Developmental Psychology and Clinical Psychology across the Lifespan, University of Siegen, Siegen, Germany
| | - Yoki L Mertens
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Angela A T Schuurmans
- Calm Kids, Center for Child Psychology and Game Therapy, Duiven, The Netherlands.,Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Yaara Sadeh
- The Edmond and Lily Safra Children's Hospital, The Sheba Medical Center, Ramat Gan, Israel.,The Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan, Israel
| | - Nancy Kassam-Adams
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Annegret Krause-Utz
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands.,Leiden Institute for Brain and Cognition, Leiden, The Netherlands
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13
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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.
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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
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14
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Relationship between posttraumatic stress symptoms, caregiving response, and parent mental health in youth exposed to single incident trauma. J Affect Disord 2019; 251:15-22. [PMID: 30889475 DOI: 10.1016/j.jad.2019.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/24/2019] [Accepted: 03/03/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Family factors may alter the risk of developing posttraumatic stress disorder (PTSD) or depression in young people after a traumatic event, but it is not clear which modifiable family variables can be addressed in psychological therapies. This study examined the relationships between family factors (Expressed Emotion [EE] and family accommodation) and psychopathology (posttraumatic stress symptoms; PTSS) in young people following a single incident trauma. Potential mediators of these relationships were also investigated. METHOD Sixty-six parent-child dyads (aged 8-17 years) were assessed within one month of attending an Emergency Department. Self-reported PTSS and perceived EE were assessed in young people. Parents' own PTSS, mood symptoms, EE, and accommodating behaviours were also assessed. RESULTS Cross-sectional analyses revealed that young person-perceived EE, parent-reported emotional over involvement (EOI) and accommodation behaviours significantly predicted higher PTSS in young people. The stress experienced as a consequence of EE mediated the relationship between young person-perceived EOI and PTSS in young people. Parental PTSS and anxiety were positively correlated with EOI and accommodation. Parental PTSS was not significantly associated with symptoms in young people. CONCLUSIONS The results support the hypothesis that EE and accommodation are positively associated with PTSS in young people in the month following a potentially traumatic event. Understanding the child in the context of their family environment and relationships offers an important framework for making sense of and facilitating adaptive adjustment following a traumatic event.
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15
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Smith P, Dalgleish T, Meiser‐Stedman R. Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents. J Child Psychol Psychiatry 2019; 60:500-515. [PMID: 30350312 PMCID: PMC6711754 DOI: 10.1111/jcpp.12983] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Abstract
Important advances in understanding traumatic stress reactions in children and young people have been made in recent years. The aim of this review was to synthesise selected recent research findings, with a focus on their relevance to clinical practice. We therefore address: findings on the epidemiology of trauma exposure and Posttraumatic Stress Disorder (PTSD); recent changes to diagnostic classification; implications for screening and assessment of traumatic stress reactions; and treatment outcome studies including interventions for acute and chronic PTSD, dissemination of effective treatments into community settings, and early interventions. We conclude with recommendations for clinical practice and suggestions for future areas of research.
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Affiliation(s)
- Patrick Smith
- Department of PsychologyInstitute of Psychiatry Psychology & NeuroscienceKing's College LondonLondonUK
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences UnitUniversity of CambridgeCambridgeUK
- Cambridgeshire and Peterborough NHS Foundation TrustCambridgeUK
| | - Richard Meiser‐Stedman
- Department of Clinical Psychology, Norwich Medical SchoolUniversity of East AngliaNorwichUK
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16
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Colom-Lapetina J, Li AJ, Pelegrina-Perez TC, Shansky RM. Behavioral Diversity Across Classic Rodent Models Is Sex-Dependent. Front Behav Neurosci 2019; 13:45. [PMID: 30894806 PMCID: PMC6414415 DOI: 10.3389/fnbeh.2019.00045] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/19/2019] [Indexed: 11/27/2022] Open
Abstract
Symptoms of trauma and stressor related disorders such as post-traumatic stress disorder (PTSD) often develop well after the traumatic experience has occurred, and so identifying early predictors of risk or resilience is important for the implementation of interventional therapies. For example, passive coping strategies such as tonic immobility and peritraumatic dissociation during the trauma itself are risk factors for the developments of PTSD, especially in women. However, discrete, sex-specific coping responses that predict later outcomes in animal models have not been rigorously defined. Recently, we identified an active, escape-like response exhibited primarily by a subset of female rats in a classic auditory fear conditioning task (“darting”). Here, we asked whether darting during conditioning predicted active responding in a single forced swim (SFS) session to study the potential for darting to reflect a trait-like behavioral strategy that translated across stress models. Male and female Sprague-Dawley (SD) rats were tested in auditory fear conditioning acquisition and memory tests to identify Darters, and then a 15-min SFS 2 weeks later. We observed a significant effect of sex in conditioned freezing behavior, with males exhibiting greater freezing than females across conditioning and testing trials in comparison to females. However, females demonstrated higher velocities in response to shock presentations, and were more likely to exhibit darting behavior in response to the conditioned stimulus (CS). In SFS measures, females engaged in active behaviors such as climbing, head shaking, and diving in greater proportions than males, while males spent more time immobile throughout testing. Despite females exhibiting a more diverse behavioral repertoire in both tests, Darters did not differ from Non-darters in any SFS measure. These results suggest that the propensity to dart does not reflect a simple hyperactivity, and that despite conceptual overlap across the two tests (inescapable stress exposure and the ability to measure active vs. passive coping), the behavioral strategies engaged by an individual animal in each are likely driven by discrete mechanisms. We discuss potential challenges in interpretation of standard behavioral outcomes in classic models across the sexes, and consider the potential need for novel models that better tap into motivational states in females.
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Affiliation(s)
- José Colom-Lapetina
- Department of Psychology, Northeastern University, Boston, MA, United States
| | - Anna J Li
- Department of Psychology, Northeastern University, Boston, MA, United States
| | | | - Rebecca M Shansky
- Department of Psychology, Northeastern University, Boston, MA, United States
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17
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Qi W, Ratanatharathorn A, Gevonden M, Bryant R, Delahanty D, Matsuoka Y, Olff M, deRoon-Cassini T, Schnyder U, Seedat S, Laska E, Kessler RC, Koenen K, Shalev A. Application of data pooling to longitudinal studies of early post-traumatic stress disorder (PTSD): the International Consortium to Predict PTSD (ICPP) project. Eur J Psychotraumatol 2018; 9:1476442. [PMID: 29938009 PMCID: PMC6008580 DOI: 10.1080/20008198.2018.1476442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Understanding the development of post-traumatic stress disorder (PTSD) is a precondition for efficient risk assessment and prevention planning. Studies to date have been site and sample specific. Towards developing generalizable models of PTSD development and prediction, the International Consortium to Predict PTSD (ICPP) compiled data from 13 longitudinal, acute-care based PTSD studies performed in six different countries. Objective: The objectives of this study were to describe the ICPP's approach to data pooling and harmonization, and present cross-study descriptive results informing the longitudinal course of PTSD after acute trauma. Methods: Item-level data from 13 longitudinal studies of adult civilian trauma survivors were collected. Constructs (e.g. PTSD, depression), measures (questions or scales), and time variables (days from trauma) were identified and harmonized, and those with inconsistent coding (e.g. education, lifetime trauma exposure) were recoded. Administered in 11 studies, the Clinician Administered PTSD Scale (CAPS) emerged as the main measure of PTSD diagnosis and severity. Results: The pooled data set included 6254 subjects (39.9% female). Studies' average retention rate was 87.0% (range 49.1-93.5%). Participants' baseline assessments took place within 2 months of trauma exposure. Follow-up durations ranged from 188 to 1110 days. Reflecting studies' inclusion criteria, the prevalence of baseline PTSD differed significantly between studies (range 3.1-61.6%), and similar differences were observed in subsequent assessments (4.3-38.2% and 3.8-27.0% for second and third assessments, respectively). Conclusion: Pooling data from independently collected studies requires careful curation of individual data sets for extracting and optimizing informative commonalities. However, it is an important step towards developing robust and generalizable prediction models for PTSD and can exceed findings of single studies. The large differences in prevalence of PTSD longitudinally cautions against using any individual study to infer trauma outcome. The multiplicity of instruments used in individual studies emphasizes the need for common data elements in future studies.
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Affiliation(s)
- Wei Qi
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Andrew Ratanatharathorn
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York , USA
| | - Martin Gevonden
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Richard Bryant
- Faculty of Science, University of New South Wales School of Psychology, Kensington, Australia
| | - Douglas Delahanty
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Yutaka Matsuoka
- Division of Health Care Research, National Cancer Center, Center for Public Health Sciences, Tokyo, Japan
| | - Miranda Olff
- Department of Psychiatry, University of Amsterdam Academic Medical Center, Amsterdam-Zuidoost, The Netherlands
| | | | - Ulrich Schnyder
- Department of Psychiatry, University of Zurich School of Medicine, Zurich, Switzerland
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University School of Medicine and Health Sciences, Cape Town, South Africa
| | - Eugene Laska
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Karestan Koenen
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Arieh Shalev
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
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18
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Lai BS, Lewis R, Livings MS, La Greca AM, Esnard AM. Posttraumatic Stress Symptom Trajectories Among Children After Disaster Exposure: A Review. J Trauma Stress 2017; 30:571-582. [PMID: 29193316 PMCID: PMC5953201 DOI: 10.1002/jts.22242] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 06/30/2017] [Accepted: 07/13/2017] [Indexed: 11/06/2022]
Abstract
Natural disasters, such as hurricanes and floods, are increasing in frequency and scope. Youth exposed to disasters are at risk for developing posttraumatic stress symptoms (PTSS). However, not all youth who report initially elevated PTSS report persistent PTSS that last beyond the first three to six months postdisaster. Thus, it is crucial to understand how and why youth differ in their patterns of PTSS. This study reviewed the literature on children's postdisaster PTSS, evaluating the typical number and types of patterns for children's PTSS trajectories, as well as risk and protective factors predicting trajectory membership. This review identified eight empirical studies on youth PTSS trajectories following natural disasters; these studies included 8,306 children aged 3 to 18 years. All studies identified resilience, recovery, and chronic trajectories. Evidence for a delayed trajectory was mixed. Proportions of children falling into each trajectory varied widely across studies, but overall, resilience was the most prevalent trajectory. These findings were consistent across study factors (i.e., analytic strategy, assessment timing, and study selection criteria). Female gender, disaster exposure, negative coping, and lack of social support were significant risk factors for chronic trajectories across several studies. Future research should combine individual level participant data across studies of children's responses to disasters to better understand PTSS trajectories.
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Affiliation(s)
- Betty S. Lai
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Rayleen Lewis
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | | | | | - Ann-Margaret Esnard
- Andrew Young School of Policy Studies, Georgia State University, Atlanta, Georgia, USA
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19
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Meiser-Stedman R, McKinnon A, Dixon C, Boyle A, Smith P, Dalgleish T. Acute stress disorder and the transition to posttraumatic stress disorder in children and adolescents: Prevalence, course, prognosis, diagnostic suitability, and risk markers. Depress Anxiety 2017; 34:348-355. [PMID: 28135019 PMCID: PMC5381710 DOI: 10.1002/da.22602] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/09/2016] [Accepted: 12/24/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Early recovery from trauma exposure in youth is poorly understood. This prospective longitudinal study examined the early course of traumatic stress responses in recently trauma-exposed youth, evaluated the revised DSM-5 acute stress disorder (ASD) and PTSD diagnoses and alternative diagnoses, and identified risk factors for persistent traumatic stress. METHOD Participants were 8- to 17-year-old emergency departments attendees exposed to single incident traumas. Structured clinical interviews were undertaken at 2 (n = 226) and 9 weeks (n = 208) posttrauma. RESULTS Using the revised criteria in DSM-5, 14.2% met criteria for ASD at week 2 and 9.6% met criteria for PTSD at week 9. These prevalences were similar to the corresponding DSM-IV diagnoses (18.6% ASD at week 2; 8.7% PTSD at week 9). Using the same diagnostic criteria (DSM-IV or DSM-5) across assessments (i.e., "2-week PTSD") suggested that caseness declined in prevalence by approximately half. Overlap between DSM-IV and DSM-5 ASD and DSM-5 preschool child PTSD diagnoses was considerable. Two diagnoses were strongly predictive of corresponding week 9 diagnoses. Youth with ASD who subsequently had PTSD reported more negative alterations in cognition and mood at 2 weeks than those youth who did not develop PTSD. CONCLUSIONS Youth exposed to single-event traumas experience considerable natural recovery in the first months posttrauma. Using DSM-5 criteria, ASD may not capture all clinically significant traumatic stress in the acute phase and is only moderately sensitive for later PTSD. Future research needs to address the role and etiology of negative alterations in cognition and mood symptoms.
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Affiliation(s)
- Richard Meiser-Stedman
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge.,Department of Clinical Psychology, University of East Anglia, Norwich, UK
| | - Anna McKinnon
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge
| | - Clare Dixon
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge
| | - Adrian Boyle
- Cambridge University Hospitals NHS Foundation Trust
| | - Patrick Smith
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge.,Cambridgeshire and Peterborough NHS Foundation Trust
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20
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Peltonen K, Kangaslampi S, Saranpää J, Qouta S, Punamäki RL. Peritraumatic dissociation predicts posttraumatic stress disorder symptoms via dysfunctional trauma-related memory among war-affected children. Eur J Psychotraumatol 2017; 8:1375828. [PMID: 29209466 PMCID: PMC5706949 DOI: 10.1080/20008198.2017.1375828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 08/18/2017] [Indexed: 10/31/2022] Open
Abstract
Background: Among adults there is strong evidence about peritraumatic dissociation (PD) predicting posttraumatic stress disorder (PTSD), yet evidence among children is very limited. It has been suggested that disturbances in memory functioning might explain the association between PD and PTSD, but this has not yet been empirically tested. Objective: We aimed to test the hypotheses that greater PD would be associated with more posttraumatic stress disorder (PTSD) symptoms, and that some of this association would be mediated by disorganized and non-verbal memories about the traumatic event. Method: The sample included 197 Palestinian children (10-12-years) living in the Gaza Strip, participating in the aftermath of the 2008/9 war. Self-report questionnaires were used to measure PD (Peritraumatic Dissociative Experiences Questionnaire) three months post-war, as well as trauma-related memory (Trauma Memory Quality Questionnaire) and PTSD symptoms (Children's Revised Impact of Event Scale) six months later. Exposure to war trauma was assessed by a checklist. Structural equation modelling was used to examine direct and indirect paths from PD to posttraumatic PTSS, controlling for number of traumatic war events. Results: Structural equation modelling results showed that greater self-reported PD predicted higher levels of PTSS nine months post-war, and that a significant part, but not all, of this relationship was mediated via the quality of trauma-related memories. Conclusions: This study provided empirical evidence that, among war-affected children, greater PD during traumatic events is linked with higher levels of PTSD symptoms several months later, even when accounting for their personal exposure to war trauma. Further, the study supported the idea that the detrimental effects of dissociation during a traumatic event may be due to dysfunctional memories characterized by disorganization and lack of access to verbal and coherence. Further tests of these hypotheses with larger samples and more points of measurement are called for.
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Affiliation(s)
- Kirsi Peltonen
- University of Tampere, Finland/Faculty of Social Sciences/Psychology, Tampere, Finland
| | - Samuli Kangaslampi
- University of Tampere, Finland/Faculty of Social Sciences/Psychology, Tampere, Finland
| | - Jenni Saranpää
- Lapua Developmental and Family Counselling, Lapua, Finland
| | - Samir Qouta
- Islamic University of Gaza, Department of Education and Psychology, Gaza
| | - Raija-Leena Punamäki
- University of Tampere, Finland/Faculty of Social Sciences/Psychology, Tampere, Finland
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21
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Kassam-Adams N, Marsac ML. Brief Practical Screeners in English and Spanish for Acute Posttraumatic Stress Symptoms in Children. J Trauma Stress 2016; 29:483-490. [PMID: 27923266 DOI: 10.1002/jts.22141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 11/10/2022]
Abstract
With millions of children experiencing acute traumatic events, validated screening tools are needed in both research and service contexts. We aimed to identify and evaluate short forms of the Acute Stress Checklist for Children in English (ASC-Kids) and Spanish (Cuestionario de Estrés Agudo-Niños [CEA-N]), using data from 4 samples (Ns of 254, 225, 176, and 80) of children with recent acute trauma. Confirmatory factor analyses of the full checklist in the largest sample guided item selection for 6-item and 3-item short forms. Across samples, both short forms (ASC-6/ASC-3 in English; CEA-6/CEA-3 in Spanish) were correlated with acute stress disorder (ASD) symptom severity on the full checklist (r = .79 to .92), and on an interview measure (r = .52 to .62). Receiver operating curve analyses for each short form detecting current ASD status showed high areas under the curve (.76 to .95). Cutoff scores identified based on Sample 1 provided acceptable sensitivity (.59 to 1.00) and specificity (.57 to .86) across samples. Children scoring above the cutoff on each screener reported greater concurrent impairment from ASD symptoms and more severe posttraumatic stress 3 months later. These very brief measures could expand clinicians' and researchers' ability to screen for acute posttraumatic stress in children.
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Affiliation(s)
- Nancy Kassam-Adams
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Division of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Meghan L Marsac
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Child and Adolescent Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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McKinnon A, Meiser-Stedman R, Watson P, Dixon C, Kassam-Adams N, Ehlers A, Winston F, Smith P, Yule W, Dalgleish T. The latent structure of Acute Stress Disorder symptoms in trauma-exposed children and adolescents. J Child Psychol Psychiatry 2016; 57:1308-1316. [PMID: 27472990 PMCID: PMC5091623 DOI: 10.1111/jcpp.12597] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The revision of Acute Stress Disorder (ASD) in the DSM-5 (DSM-5, 2013) proposes a cluster-free model of ASD symptoms in both adults and youth. Published evaluations of competing models of ASD clustering in youth have rarely been examined. METHODS We used Confirmatory Factor Analysis (combined with multigroup invariance tests) to explore the latent structure of ASD symptoms in a trauma-exposed sample of children and young people (N = 594). The DSM-5 structure was compared with the previous DSM-IV conceptualization (4-factor), and two alternative models proposed in the literature (3-factor; 5-factor). Model fit was examined using goodness-of-fit indices. We also established DSM-5 ASD prevalence rates relative to DSM-IV ASD, and the ability of these models to classify children impaired by their symptoms. RESULTS Based on both the Bayesian Information Criterion, the interfactor correlations and invariance testing, the 3-factor model best accounted for the profile of ASD symptoms. DSM-5 ASD led to slightly higher prevalence rates than DSM-IV ASD and performed similarly to DSM-IV with respect to categorising children impaired by their symptoms. Modifying the DSM-5 ASD algorithm to a 3+ or 4+ symptom requirement was the strongest predictor of impairment. CONCLUSIONS These findings suggest that a uni-factorial general-distress model is not the optimal model of capturing the latent structure of ASD symptom profiles in youth and that modifying the current DSM-5 9+ symptom algorithm could potentially lead to a more developmentally sensitive conceptualization.
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Affiliation(s)
- Anna McKinnon
- Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia.
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter Watson
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge, UK
| | - Clare Dixon
- Department of Psychology, University of Bath, Somerset, UK
| | - Nancy Kassam-Adams
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Flaura Winston
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick Smith
- Institute of Psychiatry, Psychology, and Neuroscience, Kings College London, London, UK
| | - William Yule
- Institute of Psychiatry, Psychology, and Neuroscience, Kings College London, London, UK
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge, UK
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23
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Marsac ML, Ciesla J, Barakat LP, Hildenbrand AK, Delahanty DL, Widaman K, Winston FK, Kassam-Adams N. The role of appraisals and coping in predicting posttraumatic stress following pediatric injury. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2016; 8:495-503. [PMID: 27065067 DOI: 10.1037/tra0000116] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Given the millions of children who experience potentially traumatic injuries each year and the need to maximize emotional and physical health outcomes following pediatric injury, the current study examined the individual and collective contributions of the malleable variables of appraisals and coping in predicting posttraumatic stress symptoms (PTSS) in children following injury. METHOD This study combined data from 3 prospective investigations of recovery from pediatric injury (N = 688) in which children ages 8-17 years were recruited shortly after an injury (within 4 weeks). At baseline (T1), children completed measures of their threat appraisals of the injury event and PTSS. Six to twelve weeks later (T2), children completed a measure of coping and PTSS. Finally, PTSS was assessed again 6 months post-injury (T3). RESULTS Structural equation modeling analyses provide evidence that appraisals and coping contribute to PTSS. Furthermore, results suggest that escape coping mediates the relationship between threat appraisals and PTSS. CONCLUSIONS Early interventions designed to prevent or reduce PTSS after pediatric injury may be more successful if they primarily target modifying escape coping behaviors. To best inform clinical practice, future research should examine factors influencing the development of children's appraisals and coping behaviors in the context of potentially traumatic events. (PsycINFO Database Record
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Affiliation(s)
- Meghan L Marsac
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia
| | | | - Lamia P Barakat
- Division of Oncology, The Children's Hospital of Philadelphia
| | - Aimee K Hildenbrand
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia
| | | | - Keith Widaman
- Department of Psychology, University of California-Davis
| | - Flaura K Winston
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia
| | - Nancy Kassam-Adams
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia
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24
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Ranney ML, Patena JV, Nugent N, Spirito A, Boyer E, Zatzick D, Cunningham R. PTSD, cyberbullying and peer violence: prevalence and correlates among adolescent emergency department patients. Gen Hosp Psychiatry 2016; 39:32-8. [PMID: 26786845 PMCID: PMC4779373 DOI: 10.1016/j.genhosppsych.2015.12.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is often underdiagnosed and undertreated among adolescents. The objective of this analysis was to describe the prevalence and correlates of symptoms consistent with PTSD among adolescents presenting to an urban emergency department (ED). METHODS A cross-sectional survey of adolescents aged 13-17 years presenting to the ED for any reason was conducted between August 2013 and March 2014. Validated self-report measures were used to measure mental health symptoms, violence exposure and risky behaviors. Multivariate logistic regression analysis was performed to determine adjusted differences in associations between symptoms consistent with PTSD and predicted correlates. RESULTS Of 353 adolescents, 23.2% reported current symptoms consistent with PTSD, 13.9% had moderate or higher depressive symptoms and 11.3% reported past-year suicidal ideation. Adolescents commonly reported physical peer violence (46.5%), cyberbullying (46.7%) and exposure to community violence (58.9%). On multivariate logistic regression, physical peer violence, cyberbullying victimization, exposure to community violence, female gender and alcohol or other drug use positively correlated with symptoms consistent with PTSD. CONCLUSIONS Among adolescents presenting to the ED for any reason, symptoms consistent with PTSD, depressive symptoms, physical peer violence, cyberbullying and community violence exposure are common and interrelated. Greater attention to PTSD, both disorder and symptom levels, and its cooccurring risk factors is needed.
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Affiliation(s)
- Megan L Ranney
- Department of Emergency Medicine, Rhode Island Hospital/Alpert Medical School, Brown University, 593 Eddy Street, Claverick 2, Providence, RI 02903, USA; Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
| | - John V Patena
- Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
| | - Nicole Nugent
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI 02903, USA.
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI 02903, USA.
| | - Edward Boyer
- Department of Emergency Medicine, University of Massachusetts Worcester, 55 Lake Avenue, North Worcester, MA 01655, USA.
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, 2815 Eastlake Avenue, Seattle, WA 98102, USA.
| | - Rebecca Cunningham
- Department of Emergency Medicine, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA; Injury Control Research Center, University of Michigan, Ann Arbor, MI 48109-2800, USA.
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25
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Pratto F. The Arbitrary, Objective, and Subjective. PSYCHOLOGICAL INQUIRY 2016. [DOI: 10.1080/1047840x.2016.1111704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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26
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Nilsson D, Nordenstam C, Green S, Wetterhall A, Lundin T, Svedin CG. Acute stress among adolescents and female rape victims measured by ASC-Kids: a pilot study. Nord J Psychiatry 2015; 69:539-45. [PMID: 25732866 DOI: 10.3109/08039488.2015.1013056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Rape is considered a stressful trauma and often with durable consequences. How the aftermath of rape is for young adolescents' girls considering acute stress is an overlooked field and remains to be studied. AIMS In this study, we wanted to investigate acute stress among adolescent victims of rape and the psychometric properties of the Acute Stress Checklist for Children (ASC-Kids). METHODS A clinical sample (n = 79) of raped girls, 13-17 years old who had turned to a special rape victim unit for treatment, answered the ASC-Kids. ASC-Kids was also given to a group of minor stressed, non-raped adolescents in the same age range (n = 154) together with the University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index (UCLA PTSD RI), and the Sense of Coherence Scale 13 (SOC-13). RESULTS The scores from the groups were compared and showed significant differences in mean values on all the diagnostic criteria of acute stress disorder. In the clinical group, 36.7% obtained full ASD criteria. ASC-Kids could discriminate well between groups. Cronbach's alpha was found to be excellent, and the correlation between the UCLA PTSD RI and ASC-Kids found to be good; both ASC-Kids and UCLA PTSD RI had a good and moderate negative correlation with SOC-13. CONCLUSION Adolescent female rape victims were shown to have a very high level of acute stress, and the ASC-Kids was found to have sound psychometrics and can be a valuable screening instrument to support clinicians in their assessments of an indication of adolescents after potentially stressful events such as rape.
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Affiliation(s)
- Doris Nilsson
- a Doris Nilsson, Department for Behavioral Sciences and Learning , Section for Psychology, Linköping University , SE-581 83 Linköping , Sweden
| | - Carin Nordenstam
- b Carin Nordenstam, National Centre for Disaster Psychiatry, Akademiska sjukhuset, Uppsala University , SE-751 85 Uppsala , Sweden
| | - Sara Green
- c Sara Green, Department for Behavioral Sciences and Learning , Section for Psychology, Linköping University , SE-581 83 Linköping , Sweden
| | - Annika Wetterhall
- d Annika Wetterhall, Department for Behavioral Sciences and Learning , Section for Psychology, Linköping University , SE-581 83 Linköping , Sweden
| | - Tom Lundin
- e Tom Lundin, National Centre for Disaster Psychiatry, Akademiska sjukhuset, Uppsala University , SE-751 85 Uppsala , Sweden
| | - Carl Göran Svedin
- f Carl Göran Svedin, Child and Adolescent Psychiatry, Department of Clinical and Experimental Medicine , Faculty of Health Sciences, Linköping University , SE-581 85 Linköping , Sweden
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