Preschooler witnesses of marital violence: Predictors and mediators of child behavior problems

The promise of compassion-based therapy as a novel intervention for adolescent PTSD

In this review, we summarize current evidence for compassion-based approaches for PTSD and the potential for their application to the adolescent PTSD population. Exposure to traumatic events is common in adolescence and PTSD remains a public health crisis. Accessibility, willingness, and engagement are significant barriers to established treatments for PTSD, with attrition rates as high as 50 %. Compassion-based therapies provide potential solutions to treatment obstacles by providing a non-threatening, transdiagnostic option unburdened by aspects of current trauma treatment which may be associated with treatment resistance (e.g., exposure, trauma narrative, induction of fear). Compassion-based approaches are intuitive for trauma treatment, as compassion activates the self-soothing system, thereby disarming the fear system and promoting affect regulation. Compassion-based treatments demonstrate reductions across a substantial range of PTSD symptoms in adults, however, in adolescents extant literature is sparse, with cross-sectional studies suggesting self-compassion is inversely associated with trauma-related psychopathology. Understanding the impact of compassion-based approaches on adolescent PTSD is warranted as the adolescent developmental period may be a particularly opportune time for this approach. Evaluation of the impact of compassion-based treatment on adolescent PTSD in clinical populations via randomized-controlled studies and comparison of its relative efficacy to current evidence-based practices is warranted.

Leveraging the developmental neuroscience of caregiving to promote resilience among youth exposed to adversity

Early adversity is a major risk factor for the emergence of psychopathology across development. Identifying mechanisms that support resilience, or favorable mental health outcomes despite exposure to adversity, is critical for informing clinical intervention and guiding policy to promote youth mental health. Here we propose that caregivers play a central role in fostering resilience among children exposed to adversity via caregiving influences on children's corticolimbic circuitry and emotional functioning. We first delineate the numerous ways that caregivers support youth emotional learning and regulation and describe how early attachment lays the foundation for optimal caregiver support of youth emotional functioning in a developmental stage-specific manner. Second, we outline neural mechanisms by which caregivers foster resilience-namely, by modulating offspring corticolimbic circuitry to support emotion regulation and buffer stress reactivity. Next, we highlight the importance of developmental timing and sensitive periods in understanding caregiving-related mechanisms of resilience. Finally, we discuss clinical implications of this line of research and how findings can be translated to guide policy that promotes the well-being of youth and families.

Intergenerational effects of maternal PTSD: Roles of parenting stress and child sex

OBJECTIVES

Parental posttraumatic stress disorder (PTSD) increases children's risk for emotional and behavioral problems. We examined parenting stress and parenting behavior quality as mediators of the relation between maternal PTSD and problematic child behaviors in a sample at high risk for trauma exposure. We also examined whether child sex moderated this association.

METHOD

Participants were 141 African American mother-child dyads (children aged 8-12). Mothers reported PTSD severity, parenting stress, and child behavior (externalizing, internalizing, and emotional self-control). Parenting behavior quality (accounting for factors including parental warmth and engagement) was assessed from an observational parent-child interaction task.

RESULTS

Parenting stress, but not observed parenting behavior quality, mediated the relation between maternal PTSD severity and child behaviors. Child sex moderated this association, such that the effect was stronger for girls.

CONCLUSIONS

Maternal PTSD may be associated with negative child behavior outcomes, and this relation appears to be mediated by increased parenting stress. Stress-reducing interventions for parents with PTSD could improve child outcomes, especially for girls. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Posttraumatic Stress Symptoms and Correlates in Women and Children From Backgrounds of Domestic Violence

Ongoing research has continued to inform our understanding of the effects of living with domestic violence on both women and children. The majority of this research, however, has tended to focus on each population separately, with only a relatively few studies to date assessing the relationship between maternal and child emotional functioning, particularly for symptoms of posttraumatic stress (PTSS). This study was designed to investigate trauma symptomatology in mother-child dyads from backgrounds of domestic violence, where the children are able to self-report on their own symptoms. In addition, the study examined anxiety and depression as important correlates of PTSD in children. Participants were recruited by staff at two metropolitan Domestic Violence Services and interviewed by the first author using standardised PTSD scales and trauma inventories. Results found no significant relationship between trauma symptoms in the mother and those in her child. With respect to children who met the criteria for a diagnosis of posttraumatic stress disorder (PTSD), they were more likely to have higher levels of anxiety and depression when compared to children who did not meet PTSD criteria. Results suggest that the emotional responses of older children may tend to reflect their own experiences rather than being a reflection of maternal distress as seems more likely with younger children. Implications of these findings include the importance of independent assessments of older children, and that older children may profit from early therapeutic interventions in their own right.

Household Chaos Moderates Indirect Pathways Involving Domestic Violence, Parenting Practices, and Behavior Problems among Preschool Children

PURPOSE

This study examined the moderating role of household chaos in indirect pathways involving domestic violence (DV), parenting practices (punitive discipline and responsive), and preschool children's internalizing and externalizing symptoms. We hypothesized that high levels of household chaos would amplify links between domestic violence and parenting difficulties, and that parenting difficulties would in turn predict child behavior problems.

METHOD

Participants in this multimethod (survey, semi-structured interview, child protection records) study included 274 preschool children (M _age = 50.86 months) and their primary caregivers who were assessed in the home at two time-points spaced 6 months apart. Child welfare documentation of moderate-severe maltreatment within the last 6 months was present for 52% of children, 44% were in households characterized by DV, and most families qualified for public assistance. Hypotheses were tested using path analysis with manifest variables within a structural equation modeling framework.

RESULTS

All models provided excellent fit to the data. DV was associated with punitive discipline practices only when household chaos was high. Punitive discipline practices in turn predicted greater child externalizing symptoms 6 months later. Follow-up analyses revealed that the moderating role of chaos was specific to DV, rather than general to other forms of adversity (child maltreatment, lifetime contextual stressors, traumatic events). This interaction between DV and chaos was salient even when controlling for exposure to other adversities and demographic covariates.

CONCLUSIONS

Results point to multiple potential targets of intervention that may ultimately buffer children from the risk posed by experiencing DV in the home.

Family social support buffers the intergenerational association of maternal adverse childhood experiences and preschoolers' externalizing behavior

Despite previous work demonstrating that an accumulation of maternal adverse childhood experiences (ACEs) is associated with negative health outcomes across generations, few studies have investigated protective factors beyond the parent-child dyad in the intergenerational transmission of adversity. The current study extends previous findings by examining maternal family social support as a culturally relevant buffer in the association between mothers' ACEs and her children's behavior problems in early childhood. Participants included 121 African American mothers and their preschool-aged children experiencing high sociodemographic risk. Mothers completed questionnaires on ACEs, perceived family social support, children's violence exposure and behavior problems as well as relevant demographics. Maternal family social support moderated the relation between maternal ACEs and children's externalizing behaviors (b = -.14, p < .01), such that children of mothers who reported high ACEs and also moderate to high family social support did not show elevated externalizing behaviors; this pattern was not observed for internalizing behaviors (b = -.06, p = .06). Additionally, the intergenerational buffering effects of family social support were observed above and beyond mothers' psychopathology and children's exposure to violence. These results have implications for culturally relevant prevention and intervention efforts supporting African American mothers with young children that reflect resiliency in the face of disparities across generations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Post-Traumatic Stress, Mother's Emotion Regulation, and Parenting in Survivors of Intimate Partner Violence

Post-traumatic stress symptoms (PTSS) are high among female survivors of intimate partner violence (IPV), and children of parents experiencing PTSS are at heightened risk for a wide range of emotional and behavioral problems. Parenting has significant influence on child adjustment, and although links have been found between parental psychopathology and maladaptive parenting, little is known about the factors that may explain this relation. The current study examines mother's emotion regulation (ER) as a factor influencing the relation between mother PTSS and parenting around children's emotions in a study sample of sixty-four female survivors of IPV and their 6- to 12-year-old children. Mothers reported on their own PTSS and their parenting. Respiratory sinus arrhythmia (RSA) was used as a psychophysiological index of mother's ER. Experiential components of mother's ER was also measured by observer coding of the Meta-Emotion Interview, a structured assessment that asks parents about their attitudes toward and experiences with emotions, including their regulation of emotions. Mother's RSA reactivity moderated the relation between PTSS and negative parenting. There was also a significant indirect relation between mothers' PTSS symptom severity and supportive parenting reactions through mothers' self-report of ER. Results suggest that mother's ER abilities represent factors that significantly affect associations between maternal PTSS and parent's emotion socialization practices. Implications for assessment and intervention with families exposed to the stress of IPV are discussed.

Chronic trauma impairs the neural basis of empathy in mothers: Relations to parenting and children's empathic abilities

Early life stress carries long-term negative consequences for children's well-being and maturation of the social brain. Here, we utilize a unique cohort to test its effects on mothers' social brain, targeting mothers' neural empathic response in relation to caregiving and child empathic abilities. Mother-child dyads living in a zone of repeated war-related trauma were followed from early childhood and mother-child behavioral synchrony was repeatedly observed. At pre-adolescence(11-13 years) children's empathic abilities were assessed and mothers(N = 88, N = 44 war-exposed) underwent magnetoencephalography(MEG) while exposed to vicarious pain. All mothers showed alpha suppression in sensorimotor regions, indicating automatic response to others' pain. However, trauma-exposed mothers did not exhibit gamma oscillations in viceromotor cortex, a neural marker of mature empathy which utilizes interoceptive mechanisms for higher-order understanding and does not emerge before adulthood. Mother-child synchrony across the first decade predicted mothers' viceromotor gamma, and both synchrony and maternal viceromotor gamma mediated the relations between war-exposure and child empathic abilities, possibly charting a cross-generational pathway from mothers' mature neural empathy to children's empathic capacities. Our findings are first to probe the maternal social brain in adolescence in relation to parenting and underscore the need for targeted interventions to mothers raising children in contexts of chronic stress.

Predictors of Intrusive Sexual Behaviors in Preschool-Aged Children

Intrusive sexual behaviors (ISBs) are a specific type of problematic sexual behavior characterized by the invasive nature of the acts (e.g., touching others' private parts, attempting intercourse; Friedrich, 1997). The limited amount of research on ISBs has focused on sexual abuse history as the primary predictor. However, Friedrich, Davies, Feher, and Wright (2003) found that ISBs in children up to age 12 were related to four broad conceptual factors: (a) exposure to sexual content, (b) exposure to violent behavior, (c) family adversity, and (d) child vulnerabilities. The current study sought to replicate Friedrich's study using a clinical sample of 217 preschool-aged children (ages two to six). Results supported variables from within the child vulnerabilities construct (externalizing behaviors, β_EXT = 0.032, p = 0.001), post-traumatic stress disorder (PTSD) criteria met (β_PTSD = 0.177, p = 0.02), and an inverse relationship with age (β_AGE = -0.206, p = 0.024). These results highlight the importance of considering childhood behavioral patterns and reactivity to traumatic events as correlates of ISBs in young children.

Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale

This pilot study examined the psychometric properties of the Benevolent Childhood Experiences (BCEs) scale, a new instrument designed to assess positive early life experiences in adults with histories of childhood maltreatment and other adversities. A counterpart to the Adverse Childhood Experiences (ACEs) questionnaire, the BCEs was developed to be multiculturally-sensitive and applicable regardless of socioeconomic position, urban-rural background, or immigration status. Higher levels of BCEs were hypothesized to predict lower levels of psychopathology and stress beyond the effects of ACES in a sample of ethnically diverse, low-income pregnant women. BCEs were also expected to show adequate internal validity across racial/ethnic groups and test-retest stability from the prenatal to the postnatal period. Participants were 101 pregnant women (M=29.10years, SD=6.56, range=18-44; 37% Latina, 22% African-American, 20% White, 21% biracial/multiracial/other; 37% foreign-born, 26% Spanish-speaking) who completed the BCEs and ACEs scales; assessments of prenatal depression and post-traumatic stress disorder (PTSD) symptoms, perceived stress, and exposure to stressful life events (SLEs) during pregnancy; and demographic information. Higher levels of BCEs predicted less PTSD symptoms and SLEs, above and beyond ACEs. The BCEs showed excellent test-retest reliability, and mean levels were comparable across racial/ethnic and Spanish-English groups of women. Person-oriented analyses also showed that higher levels of BCEs offset the effects of ACEs on prenatal stress and psychopathology. The BCEs scale indexes promising promotive factors associated with lower trauma-related symptomatology and stress exposure during pregnancy and illuminates how favorable childhood experiences may counteract long-term effects of childhood adversity.

PTSD with and without dissociation in young children exposed to interpersonal trauma

BACKGROUND

A Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) was added to the DSM-5, but little is known about this symptom pattern in young children exposed to trauma. Tailoring treatment to traumatized young children requires understanding the different patterns of trauma-related symptomatology and important correlates. The current study tested the hypothesis that type and number of child traumatic events, caregiver trauma exposure, and caregiver symptomatology would predict whether traumatized young children presented with PTSD, PTSD with clinical dissociation, or non-clinical trauma symptoms.

METHODS

A multinomial regression was conducted using data collected from an ethnically and economically diverse sample of 297 trauma-exposed children between the ages of 3 and 6 and their caregivers. Based on parent-report on a well-validated measure of trauma symptoms, children were categorized into three groups: non-clinical (n = 128), PTSD only (n = 104), or PTSD with dissociation (PTSD-DISS; n = 65). Predictors included trauma exposure, parent trauma symptoms, and child sex.

RESULTS

Girls were twice more likely than boys to be in the PTSD-DISS group; sexually abused children were almost three times as likely to be in the PTSD-DISS group; and, for every unit increase in parent avoidance symptoms or number of traumatic events, the odds of being in the PTSD-DISS group increased significantly.

LIMITATIONS

Given the cross-sectional study design, conclusions cannot be drawn regarding causality. Measures were completed by a single reporter.

CONCLUSIONS

Findings suggest that subgroups of children may be especially vulnerable to comorbid PTSD and dissociation. Implications for treatment are discussed.

Political violence and mental health of Bedouin children in the West Bank, Palestine: a cross-sectional study

The Bedouin population is among the most vulnerable in Palestine, subject to forced relocation and lacking basic necessities, including water and electricity. To our knowledge, there are no studies on the mental health of Palestinian Bedouin children. A cross-sectional household survey was conducted examining exposures to traumatic events and mental health among 455 refugee children between the ages of 5-16 years old, and randomly selected from 18 Bedouin communities throughout the West Bank, including East Jerusalem. Mental health status was measured using the Strength and Difficulties Questionnaire. Based on reports by mothers, teachers and children, 44% of the participants in the study had a probable psychiatric disorder. Exposure to traumatic events, fair/poor maternal self-rated mental health, and younger age were positively associated with child mental health problems. The findings highlight the importance of maternal mental health as a contributing factor affecting children's vulnerability. Bedouin mothers and their children need immediate psychosocial intervention, as well as the protection of their basic human rights.

Young Children Exposed to Intimate Partner Violence Describe their Abused Parent: A Qualitative Study

The negative impact of intimate partner violence (IPV) begins early in the child's relationship with a caregiver. Children's relationships with, and internal working models of, abused parents have rarely been documented. The aim of this study was to collect and interpret young children's accounts of their abused parent. Interviews were conducted with 17 children aged 4 to 12 years who had witnessed IPV. Thematic analysis identified three main themes and seven sub-themes: "Coherent accounts of the parent" (sub-themes of "general benevolence", "provision of support, protection, and nurture", and "parental distress"); "Deficient accounts of the parent" ("vague accounts" and "disorganized narrations"); and "The parent as a trauma trigger" ("avoidance" and "breakthrough of intrusive memories and thoughts"). The results indicate these children may hold integrated, deficient, or blocked internal representations of an abused parent, and they illustrate the benefit of including young children as informants in research.

Maternal PTSD and Children's Adjustment: Parenting Stress and Emotional Availability as Proposed Mediators

OBJECTIVES

Maternal posttraumatic stress disorder (PTSD) is a risk factor for negative child adjustment, but it is unclear whether this association is direct (e.g., a mother's PTSD symptoms are observed, learned, and internalized by children which results in behavioral and emotional problems) or indirect, through parent-child relationship difficulties or parenting stress. We hypothesized that parenting stress and maternal emotional availability would exhibit indirect effects on relationships between maternal PTSD and children's functioning.

METHOD

Participants were 52 trauma-exposed mothers and their children (aged 7-12 years). Mothers completed measures of PTSD and parenting stress and reported on their children's functioning. Emotional availability was assessed through observer-rated mother-child interactions.

RESULTS

Emotional availability was not related to PTSD or child outcomes. Parenting stress had a substantial indirect effect on the relationships between maternal PTSD and child emotion regulation, internalizing, and externalizing behaviors.

CONCLUSIONS

Results highlight the need to target parenting stress in interventions with trauma-exposed families.

Children's Exposure to Violence: The Underlying Effect of Posttraumatic Stress Symptoms on Behavior Problems

In this study we investigated whether witnessing violence and violence victimization were associated with children's internalizing and externalizing behavior problems and examined the mediating role of posttraumatic stress (PTS) symptoms in these relationships. Secondary data analysis was conducted using 3 waves of data from the National Survey of Child and Adolescent Well-Being. Path analyses were conducted to test direct and indirect effects of violence exposure on behavior problems, using 2,064 children (ages 8-15 years) reported to Child Protective Services for maltreatment. Being a victim of violence in the home was directly associated with more internalizing (β = .06, p = .007) and externalizing behavior problems (β = .07, p = .002), whereas witnessing violence was not directly related to either internalizing (β = .04, p = .056) or externalizing behavior problems (β = .03, p = .130). PTS symptoms mediated the effects of witnessing violence and violence victimization on internalizing behavior problems (β = .02, p = .002). Our findings suggest that PTS symptoms may be a mechanism underlying the association between violence exposure and internalizing behavior problems (R(2) = .23), underscoring the potential importance of assessing PTS symptoms and providing targeted trauma-focused interventions for children exposed to violence at home.

Efficacy of a Crisis Intervention in Improving Mother-Child Interaction and Children's Play Functioning

OBJECTIVE

We examined the efficacy of a crisis-based intervention in improving mother-child interaction and children's play functioning for families who had experienced domestic violence.

METHOD

Using a pretest-posttest two-group control study design, we assigned the intervention group (n=20 mother-child dyads) to the Family Intervention for Improving Occupational Performance (FI-OP) program and the control group (n=17 dyads) to a playroom program. Both programs consisted of eight 30-min sessions. We videotaped dyads during free play and used standardized tools to assess interactions, play skills, and playfulness.

RESULTS

After the intervention, mother-child interaction was significantly better in the FI-OP group than in the playroom group. The children in the FI-OP group also demonstrated significantly greater improvement in play skills, but not in playfulness.

CONCLUSION

FI-OP is a promising program for improving aspects of mother-child interaction and children's play functioning among survivors of domestic violence.

Gender differences in caregiver-child relationship mediation of the association between violence exposure severity and adolescent behavior problems

The main objectives of this study were to investigate (1) the relationship between mild, moderate, and severe violence exposure in the home and behavior problems in adolescents; (2) the caregiver-child relationship as a potential mediator in this relationship; and (3) gender differences. A series of path analyses were conducted using a sample drawn from the National Survey of Child and Adolescent Well-Being (NCSAW-I) of 848 adolescents (ages 11-15) who had been reported to Child Protective Services for maltreatment and who remained in their homes. Exposure to violence and the caregiver-child relationship were reported by adolescents. Both caregiver ratings and adolescent self-reports were used to assess adolescents' behavior problems. Path analysis indicated that exposure to mild and severe violence was directly associated with higher levels of child-reported behavior problems. However, exposure to violence was not directly associated with caregiver ratings of adolescent behavior problems. The caregiver-child relationship mediated the relationship between mild and moderate violence on both caregiver and child-reported adolescent behavior problems. Gender differences also emerged; for girls, the caregiver-child relationship mediated the effects of mild and moderate violence, whereas for boys, it mediated the effects of severe violence on behavior problems. Study findings suggest caregiver-child relationships as a critical underlying mechanism in the association between violence exposure and adolescent behavior problems, highlighting the importance of adding the caregiver-child relationship factor to intervention efforts.

Interparental Violence and the Mediating Role of Parental Availability in Children's Trauma Related Symptoms

This cross-sectional study examined the hypothesis that parental psychopathology in Interparental Violence (IPV) families crosses over to children, because parental psychopathology spills over to parental functioning. In a high-risk sample of IPV exposed families, we tested whether parental psychopathology spills over to parental availability, which, in turn, shows a crossover effect to children's trauma-related symptoms. The study population consisted of 78 IPV exposed children (4-12 years), and their 65 custodial parents referred to outpatient Children's Trauma Centers in the Netherlands for intervention. Consistent with our hypotheses, parental psychopathology was negatively related to parental availability, suggesting a spillover effect. Although parental psychopathology was not associated with children's trauma-related symptoms directly, we found evidence for the predicted indirect, crossover effects. We found an indirect crossover effect from parental psychopathology to children's trauma-related anxiety, depression, and anger, through the spillover effect of parental availability. Clinical implications for treatment and study limitations are discussed.

Caregiver insightfulness and young children's violence exposure: testing a relational model of risk and resilience

This study employed a relational post-traumatic stress frame to explore the co-contribution of young children's exposure to violence and caregiver insightfulness on child behavioral outcomes in a high-risk, non-referred sample of caregivers and preschoolers (n = 64; mean age 3.83 years, SD = .77). Caregiver insightfulness did not have a main effect on child outcomes but did moderate the relation between violence exposure and child behavior across all observed outcomes. Violence-exposed children with non-insightful caregivers demonstrated higher caregiver-rated internalizing and externalizing behaviors and observer-rated negative affect than all other groups. Among children not exposed to violence, insightfulness was not related to children's behavior problems or negative affect, suggesting violence-specific processes. Though cross-sectional, results suggest that the effects of violence and caregiver insightfulness on child outcomes are contingent on one another and that caregiver insightfulness may play a protective role in contexts of violence.

Playfulness and Interaction: An Exploratory Study of Past and Current Exposure to Domestic Violence

Violence against women affects mother-child interactions, which may in turn affect their children's playfulness. We examined the effect of a history of violence against mothers on mother-child interactions and children's playfulness. This cross-sectional pilot study consisted of 36 mother-child dyads residing in family crisis shelters due to serious violence from an intimate partner. One subgroup had experienced violence during childhood, another had posttraumatic stress disorder (PTSD). Instruments included Posttraumatic Diagnostic Scale, Test of Playfulness, and Coding Interactive Behavior System. Mann-Whitney test and Spearman's rank correlation coefficients were calculated. Results indicated that children of mothers without PTSD were more playful than children of mothers with PTSD. Mothers who had not reported of childhood exposure to violence and who did not have PTSD had better interactions with more playful children.

Trauma-focused cognitive behaviour therapy versus treatment as usual for post traumatic stress disorder (PTSD) in young children aged 3 to 8 years: study protocol for a randomised controlled trial

BACKGROUND

Following horrific or life-threatening events approximately 10 to 15% of young children develop post traumatic stress disorder (PTSD). The symptoms of this disorder are distressing - nightmares, flashbacks, anger outbursts and disturbed play. These symptoms cause major disruption to a child's functioning and, if left untreated, can persist for many years. As yet, there are no established empirically-validated treatments for PTSD in young children. Trauma-focused cognitive behaviour therapy (TF-CBT) is a psychological intervention that is effective in treating the disorder in older children (8 to 12 years), adolescents and adults. This study examines TF-CBT adapted for children aged between 3 and 8 years.

METHODS/DESIGN

This protocol describes a two-arm exploratory randomised controlled trial comparing TF-CBT to treatment as usual (TAU) in children aged 3 to 8 years with a principal diagnosis of PTSD following a single-event discrete trauma. Using a half-crossover design, 44 participants will be randomly allocated to receive the intervention or to receive TAU. Those allocated to TAU will be offered TF-CBT at the end of the 'treatment' period (approximately 12 weeks) if still indicated. The primary outcome is PTSD diagnosis according to DSM-5 criteria for children 6 years and younger at post-treatment. Secondary outcomes include effects on co-morbid diagnoses and changes in emotion and trauma symptoms at each of the follow-up points (post-treatment, 3-months, 12-months). Additionally, broader efficacy will be considered with regard to treatment feasibility, acceptability and service utilisation. The key targets of the intervention are trauma memory, the interpretation of the meaning of the event, and the management of symptoms.

DISCUSSION

This is the first European trial to examine the efficacy of TF-CBT in alleviating PTSD in very young children. As well as providing much-needed data on the utility of the intervention, this exploratory trial will also allow us to gather important information about the feasibility of delivering the treatment in UK National Health Service (NHS) settings, and its acceptability to the children and their families. This study will highlight aspects of the intervention that need improvement or modification in preparation for a full-scale evaluation in a larger sample.

TRIAL REGISTRATION

ISRCTN35018680 , registered on 18 November 2013.

Association between parents' PTSD severity and children's psychological distress: a meta-analysis

The authors conducted a meta-analysis of studies on the correlation between parents' PTSD symptom severity and children's psychological status. An extensive search of the literature yielded 550 studies that were screened for inclusion criteria (i.e., parent assessed for PTSD, child assessed for distress or behavioral problems, associations between parent PTSD and child status examined). Sixty-two studies were further reviewed, resulting in a final sample of 42 studies. Results yielded a moderate overall effect size r = .35. The authors compared effect sizes for studies where only the parent was exposed to a potentially traumatic event to studies where both parents and children were exposed. A series of moderators related to sample characteristics (sex of parent, type of traumatic event) and study methods (self-report vs. diagnostic interview, type of child assessment administered) were also evaluated. The only significant moderator was type of trauma; the effect size was larger for studies with parent-child dyads who were both exposed to interpersonal trauma (r = .46) than for combat veterans and their children (r = .27) and civilian parent-child dyads who were both exposed to war (r = .25). Results support the importance of considering the family context of trauma survivors and highlight areas for future research.

Maternal childhood abuse, intimate partner violence, and child psychopathology: the mediator role of mothers' mental health

This study examined the mediator role of mothers' mental health in the relationship among maternal childhood abuse (CA), intimate partner violence (IPV), and offspring's psychopathology, and explored whether mediational pathways were moderated by children's sex. Participants were 327 Spanish outpatient children, 8 to 17 years old, and their mothers. Mothers' global psychological distress and depressive symptoms mediated the associations between mothers' violence history and children's externalizing problems. However, only depressive symptoms fully mediated these relationships. Children's sex did not have a moderating role in adjusted paths. Mothers' depressive symptoms are an important mechanism by which maternal violence experiences could affect externalizing problems in Spanish children.

Contribution of family violence to the intergenerational transmission of externalizing behavior

Research finds that early antisocial behavior is a risk for later intimate partner violence (IPV) perpetration and victimization, and that children's exposure to their parents' IPV is a risk for subsequent behavior problems. This study tests whether intimate violence (IPV) between partners contributes independently to the intergenerational transmission of antisocial behavior, using the Children in the Community Study, a representative sample (N = 821) followed for over 25 years in 6 assessments. The present study includes a subsample of parents (N = 678) and their offspring (N = 396). We test the role of three mechanisms by which IPV may influence child antisocial behavior-parental psychopathology, parenting practices, and child self-regulation. Results suggest that IPV independently increased the risk for offspring externalizing problems, net of the effects of parental history of antisocial behavior and family violence. IPV also increased the risk for parental post traumatic stress disorder (PTSD) and alcohol use disorder 2 years later, but not for major depressive disorder. Alcohol use disorder independently increased the risk for offspring externalizing behavior, but IPV continued to predict offspring externalizing net of parental alcohol use. Parenting, particularly low satisfaction with the child, was significantly associated with both IPV and externalizing behavior, but did not mediate the effects of IPV on externalizing. IPV predicted higher levels of emotional expressivity, aggression and hostile reactivity, and depressive mood in offspring. Implications for future research and prevention are discussed.

Toward greater specificity in identifying associations among interparental aggression, child emotional reactivity to conflict, and child problems

This study examined specific forms of emotional reactivity to conflict and temperamental emotionality as explanatory mechanisms in pathways among interparental aggression and child psychological problems. Participants of the multimethod, longitudinal study included 201 two-year-old children and their mothers who had experienced elevated violence in the home. Consistent with emotional security theory, autoregressive structural equation model analyses indicated that children's fearful reactivity to conflict was the only consistent mediator in the associations among interparental aggression and their internalizing and externalizing symptoms 1year later. Pathways remained significant across maternal and observer ratings of children's symptoms and with the inclusion of other predictors and mediators, including children's sad and angry forms of reactivity to conflict, temperamental emotionality, gender, and socioeconomic status.

Mothers' physical abusiveness in a context of violence: Effects on the mother–child relationship

The purpose of this study was to investigate the effects of mothers' physical abusiveness on the quality of the mother–child relationship, and note how it further varied by their exposure to interparental violence (IPV). The sample consisted of 232 clinic-referred children, aged 2 to 7 years, and their biological mothers. Slightly more than a quarter of the children (N = 63, 27.2%) had been physically abused by their mothers; approximately half of these children also had a history of exposure to IPV (N = 34, 54%). Investigating effects of physical abuse in the context of IPV history on mothers' and children's emotional availability, we found that physically abused children with no IPV exposure appeared less optimally emotionally available than physically abused children with an IPV exposure. However, subsequent analyses showed that although dyads with dual-violence exposure showed emotional availability levels similar those of nonabusive dyads, they were more overresponsive and overinvolving, a kind of caregiving controllingness charasteric of children with disorganized attachment styles. These findings lend some support to the notion that the effects of abuse on the parent–child relationship are influenced by the context of family violence, although the effects appear to be complex.

DSM-V diagnostic criteria for bereavement-related disorders in children and adolescents: developmental considerations

Two bereavement-related disorders are proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V): Adjustment Disorder Related to Bereavement, to be located in the main body of the text as an official diagnostic entity; and Bereavement-Related Disorder, including a Traumatic Death Specifier, to be located in the Appendix as an invitation for further research. These diagnoses currently do not include developmentally informed criteria, despite the importance of developmental processes in the ways children and adolescents grieve. In this article, we draw upon a selective review of the empirical literature and expert clinical knowledge to recommend developmentally informed modifications and specifiers of the proposed criteria for both bereavement disorders and strategies to improve future research. This article is derived from an invited report submitted to the DSM-V Posttraumatic Stress Disorder, Trauma, and Dissociative Disorders Sub-Work Group, and suggested modifications have received preliminary approval to be incorporated into the DSM-V at the time of this writing. Adoption of these proposals will have far-reaching consequences, given that DSM-V criteria will influence both critical treatment choices for bereaved youth and the next generation of research studies.

An fMRI study of the brain responses of traumatized mothers to viewing their toddlers during separation and play

This study tested whether mothers with interpersonal violence-related posttraumatic stress disorder (IPV-PTSD) vs healthy controls (HC) would show greater limbic and less frontocortical activity when viewing young children during separation compared to quiet play. Mothers of 20 children (12-42 months) participated: 11 IPV-PTSD mothers and 9 HC with no PTSD. During fMRI, mothers watched epochs of play and separation from their own and unfamiliar children. The study focused on comparison of PTSD mothers vs HC viewing children in separation vs play, and viewing own vs unfamiliar children in separation. Both groups showed distinct patterns of brain activation in response to viewing children in separation vs play. PTSD mothers showed greater limbic and less frontocortical activity (BA10) than HC. PTSD mothers also reported feeling more stressed than HC when watching own and unfamiliar children during separation. Their self-reported stress was associated with greater limbic and less frontocortical activity. Both groups also showed distinct patterns of brain activation in response to viewing their own vs unfamiliar children during separation. PTSD mothers' may not have access to frontocortical regulation of limbic response upon seeing own and unfamiliar children in separation. This converges with previously reported associations of maternal IPV-PTSD and atypical caregiving behavior following separation.

PTSD in children and adolescents: toward an empirically based algorithma

In considering potential revisions for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), describing developmental influences on symptomatic expression is a high priority. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Research conducted in the past 15 years is reviewed that pertains to expressions of posttraumatic stress disorder (PTSD) symptoms in preschool and school age children and in adolescents. This research has attempted to determine the usefulness of the DSM-IV criteria for PTSD in children and adolescents. Based on the studies of preschool children, evidence supports two sets of suggestions: first, we suggest that developmental manifestations are warranted in A-D criteria of PTSD; and second, we suggest that a developmental preschool PTSD subtype is warranted that lowers the C threshold from three to one symptom. For school-age children and young adolescents, the evidence is more limited. Nevertheless, there is also evidence suggesting that modifications in PTSD criteria A-D, including fewer Cluster C symptoms, may facilitate accurate diagnosis in this age group.

The effectiveness of parent-child interaction therapy with depressive mothers: the changing relationship as the agent of individual change

This study uses a multi-method approach to investigate the effectiveness of Parent-Child Interaction Therapy (PCIT) in reducing children's behavior problems when parents report clinical levels of depressive symptoms. Participants were 132 children, 2-7 years of age, and their biological mothers, who either reported low (N = 78) or clinical levels of depressive symptoms (N = 54). Results showed that depressive mothers were likely to report more severe child behavior problems than non-depressive mothers at the pre-treatment assessment, but that depressive mothers reported greater reductions in child behavior problems than non-depressive mothers from pre- to post-treatment. The two groups showed similar levels of observed interaction quality at the pre-treatment assessment (i.e., parent and child emotional availability and parent verbalization patterns) and similar improvements in interaction quality from pre- to post-treatment. The implications of the findings for clinical practice were discussed.

Posttraumatic stress disorder in infants and young children exposed to war-related trauma

OBJECTIVE

Although millions of the world's children are growing up amidst armed conflict, little research has described the specific symptom manifestations and relational behavior in young children exposed to wartime trauma or assessed factors that chart pathways of risk and resilience.

METHOD

Participants included 232 Israeli children 1.5 to 5 years of age, 148 living near the Gaza Strip and exposed to daily war-related trauma and 84 controls. Children's symptoms were diagnosed, maternal and child attachment-related behaviors observed during the evocation of traumatic memories, and maternal psychological symptoms and social support were self-reported.

RESULTS

PTSD was diagnosed in 37.8% of war-exposed children (n = 56). Children with PTSD exhibited multiple posttraumatic symptoms and substantial developmental regression. Symptoms observed in more than 60% of diagnosed children included nonverbal representation of trauma in play; frequent crying, night waking, and mood shifts; and social withdrawal and object focus. Mothers of children with PTSD reported the highest depression, anxiety, and posttraumatic symptoms and the lowest social support, and displayed the least sensitivity during trauma evocation. Attachment behavior of children in the Exposed-No-PTSD group was characterized by use of secure-base behavior, whereas children with PTSD showed increased behavioral avoidance. Mother's, but not child's, degree of trauma exposure and maternal PTSD correlated with child avoidance.

CONCLUSIONS

Large proportions of young children exposed to repeated wartime trauma exhibit a severe posttraumatic profile that places their future adaptation at significant risk. Although more resilient children actively seek maternal support, avoidance signals high risk. Maternal well-being, sensitive behavior, and support networks serve as resilience factors and should be the focus of interventions for families of war-exposed infants and children.

Health-related quality of life of Palestinian preschoolers in the Gaza Strip: a cross-sectional study

Background

Research on children's responses to wartime trauma has mostly addressed Post-Traumatic Stress Disorder (PTSD). However, PTSD is only one aspect of a complex set of responses. This study proposes to expand knowledge of well-being in children exposed to political violence through widening the conceptualization of well-being beyond PTSD, morbidity, and mortality by measuring health-related quality of life (HRQOL) and its facets, physical health, and psychosocial health.

Methods

In 2007, we used a cross-sectional random sample of kindergartens to examine factors associated with HRQOL, as measured by the PedsQL 4.0, in 350 preschoolers in the Gaza Strip, Palestine, where political violence and deprivation are widespread.

Results

About 65% of the mothers reported severely impaired psychosocial and emotional functioning in their children. Preschoolers had lower HRQOL than the US reference sample and samples of children in other low income countries with large effect size. HRQOL was comparable to those of US children with several chronic diseases. Factors associated with lower HRQOL were older child age, male gender, and more exposures to traumatic events. Factors associated with HRQOL subscales were for lower psychosocial health: older child age, history of food, water, and electricity deprivation during incursion, and witnessing assassination of people by rockets. For lower physical health: older child age, history of food, water, and electricity deprivation during incursion, and having heard of a killing of a friend by soldiers.

Conclusions

HRQOL, including psychosocial health and emotional functioning is often severely impaired among preschoolers in the Gaza Strip. Exposure to both violent and non-violent negative events was associated with HRQOL in preschoolers.

Trauma in early childhood: Empirical evidence and clinical implications

Children in the birth to 5 age range are disproportionately exposed to traumatic events relative to older children, but they are underrepresented in the trauma research literature as well as in the development and implementation of effective clinical treatments and in public policy initiatives to protect maltreated children. Children from ethnic minority groups and those living in poverty are particularly affected. This paper discusses the urgent need to address the needs of traumatized young children and their families through systematic research, clinical, and public policy initiatives, with specific attention to underserved groups. The paper reviews research findings on early childhood maltreatment and trauma, including the role of parental functioning, the intergenerational transmission of trauma and psychopathology, and protective contextual factors in young children's response to trauma exposure. We describe the therapeutic usefulness of a simultaneous treatment focus on current traumatic experiences and on the intergenerational transmission of relational patterns from parent to child. We conclude with a discussion of the implications of current knowledge about trauma exposure for clinical practice and public policy and with recommendations for future research.

Associations between parental posttraumatic stress disorder and both offspring internalizing problems and parental aggression within the National Comorbidity Survey-Replication

Data from the National Comorbidity Survey-Replication were used to evaluate links between parental posttraumatic stress disorder (PTSD) and elevated (1) offspring internalizing problems and (2) parental physical aggression toward children. We extended prior tests via the use of an independent nationally representative sample and by examining specific associations between these outcomes and PTSD above and beyond variance accounted for by several theoretically relevant demographic factors and PTSD-related comorbidity. As hypothesized, offspring anxiety and depression was elevated among parents with PTSD compared to those without the condition. Parents with PTSD also were more likely to endorse the use of both moderate (e.g., pushing) and severe (e.g., hitting with a fist) physical aggression with their children. These findings advance work in the area by suggesting that there is a unique relation between PTSD and these outcomes, which sets the stage for research to elucidate factors uniquely introduced by PTSD.

Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center

This paper examines the sustainability and outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as delivered by practitioners in a community-based child protection program who had received training in the model several years earlier. Formerly described as Abuse-Focused CBT, AF-CBT is an evidence-based treatment (EBT) for child physical abuse and family aggression/conflict that was included in the National Child Traumatic Stress Network's initial EBT dissemination efforts in 2002. Seven practitioners participated in a year-long learning collaborative in AF-CBT and in similar training programs for 4 other EBTs. The agency's routine data collection system was used to document the clinical and adjustment outcomes of 52 families presenting with a physically abused child who received their services between 2 and 5 years after the AF-CBT training had ended. Measures of the use of all 5 EBTs documented their frequency, internal consistency, and intercorrelations. Controlling for the unique content of the other four EBTs, the amount of AF-CBT Abuse-specific content delivered was related to improvements on standardized parent rating scales (i.e., child externalizing behavior, anger, anxiety, social competence) and both parent and clinician ratings of the child's adjustment at discharge (i.e., child more safe, less scared/sad, more appropriate with peers). The amount of AF-CBT General content was related to a few discharge ratings (better child prognosis, helpfulness to parents). These novel data provide suggestive evidence for the sustainability and clinical benefits of AF-CBT in an existing community clinic serving physically abused children and their families, and are discussed in the context of key developments in the treatment model and dissemination literature.

Posttraumatic stress among young urban children exposed to family violence and other potentially traumatic events

This study examines the relationship between the number of types of traumatic events experienced by children 3 to 6 years old, parenting stress, and children's posttraumatic stress (PTS). Parents and caregivers provided data for 154 urban children admitted into community-based mental health or developmental services. By parent and caregiver report, children experienced an average of 4.9 different types of potentially traumatic events. Nearly one quarter of the children evidenced clinically significant PTS. Posttraumatic stress was positively and significantly related to family violence and other family-related trauma exposure, nonfamily violence and trauma exposure, and parenting stress. Additionally, parenting stress partially mediated the relationship between family violence and trauma exposure and PTS. This study highlights the need for early violence and trauma exposure screening in help-seeking populations so that appropriate interventions are initiated.

Clinical implications of traumatic stress from birth to age five

Children aged birth to five years are exposed to a disproportionately increased amount of potentially traumatic events compared to older children. This review examines the prevalence of traumatic exposure in the birth-to-five age range, the indicators and diagnostic criteria of early traumatic stress, and the contextual issues associated with the experience of early trauma. The article also selectively reviews the impact of trauma on the biological, emotional, social, and cognitive functioning of young children's development along with some promising clinical treatment and service interventions that target the parent-child relationship as a vehicle of trauma recovery. Despite extensive documentation of the negative impact of trauma on the normal development of young children, research, clinical, and policy efforts to address the psychological repercussions of early victimization remain remarkably limited. Future directions in research and clinical practice as well as implications for policy are discussed.

Domestic violence in women with serious mental illness involved with child protective services

The purpose of this study is to describe mothers with serious mental illness who have experienced domestic violence and are involved with child protective services. One hundred twenty-two files from the Department of Child and Family Services were reviewed. According to this retrospective review, the majority of the mothers and children had been exposed to domestic violence (62.6%). Mothers with the diagnoses of major depression-single episode and major depression-recurrent were most likely to have disclosed domestic violence exposure, compared to mothers with other serious mental illnesses. Our findings, and that of other cited studies, support the practice of routine assessment of domestic violence in women with serious mental illnesses, identification of safe havens for mothers and children, and access to continuing parenting support for these vulnerable family groups.

Parent--child relationship and mother's sexual assault history

Although there is clinical conjecture regarding the effects of maternal trauma on parent- child relationships, research is scarce and this area remains to be explored. In a domestic violence sample, there was significant reduction in quality of parent-child relationships when the mother had experienced sexual assault or rape during adulthood. There was no correlation between the mother's history of childhood sexual assault or rape and parent-child relationship. Survivors of sexual assault may be best served through interventions that utilize relational models. Family-based interventions may be particularly effective in addressing problems in parent-child relationships stemming from the mother's trauma history.

Effects of a conditional cash transfer program on children's behavior problems

OBJECTIVES

Governments are increasingly using conditional cash transfer programs to reduce the negative effects of poverty on children's development. These programs have demonstrated benefits for children's nutrition and physical development, but the effect of conditional cash transfers on children's behaviors has not been systematically evaluated. The objective of this study was to evaluate the effects of a conditional cash transfer on children's behavior by using a quasi-experimental design.

METHODS

In 1997, the Mexican government initiated a large-scale conditional cash transfer (Oportunidades) in 506 very poor rural communities. Oportunidades provided cash transfers that were contingent on visits to medical practitioners, consumption of nutritional supplementation, and school enrollment. In 2003, an assessment of 4- to 6-year-old children in these households was conducted, and outcomes were compared with children from 152 additional poor rural communities who had been recruited by using rigorous matching procedures. The primary outcome measure for this analysis was maternal report of behavior problems in terms of anxiety/depressive and aggressive/oppositional symptoms. Analyses reported here compared 778 children from beneficiary households who had received 3.5 to 5.0 years of exposure to the program and a comparison group of 263 children who had received no exposure to the program at the time of assessment but whose families later enrolled in the program.

RESULTS

Participation in Oportunidades was associated with a 10% decrement in aggressive/oppositional symptoms but was not associated with significant decrements in anxiety/depressive symptoms or total problem behaviors while controlling for covariates. Effects of treatment did not differ by children's gender or ethnicity.

CONCLUSIONS

Although this large-scale conditional cash transfer program for poor Mexican families did not directly address children's behavior problems, it found evidence of indirect effects on children's behavior. Results suggest that interventions that focus on investing in basic human capital needs may exert longer term ripple effects on children's development.

Young children's responses to September 11th: The New York City experience

Although the knowledge base regarding very young children's responses to trauma has been expanding, descriptions of their responses to terrorism remain sparse. Yet, their vulnerability makes this an important group to study. Recent events in the United States (9/11, Hurricane Katrina) make this question highly relevant. This study aims to provide extensive descriptions of how children 5 years or younger on September 11th who were living in close proximity to Ground Zero responded that day and in the following months. Sixty-seven New York City parents (with 104 children) participated in focus groups between November 2001 and May 2002. Focus groups also provided a foundation for an in-depth study examining young children's adaptation following 9/11 and changes in parenting behaviors after the disaster. Findings on children's behavioral and emotional reactions on 9/11 and in the 8 months after as well as their need to return to normalcy are reported. Consistent with current understanding of trauma symptoms in young children, parents reported behaviors including chronic sleep disruptions, fearful reactions, development of new fears, and increased clinginess and separation anxiety following the disaster. On the actual day, children's responses were described as ranging from calm and cooperative to difficult and panicky. Implications for working with parents and young children affected by terrorism or community-level trauma and directions for future research are discussed.

Anxiety symptoms in rural Mexican adolescents: a social-ecological analysis

BACKGROUND

We investigated the contributions of individual, family, and community-level factors for explaining anxiety symptoms among rural adolescents in Mexico.

METHOD

As part of a large-scale survey, 3,553 adolescents and their mothers from 333 poor, rural communities in seven Mexican states provided cross-sectional data on family level, socio-economic and psychosocial factors, and individual-level data on anxiety symptoms. Community standard of living indicators were also gathered.

RESULTS

Linear regressions adjusted for sampling design indicated that adolescents' anxiety symptoms were uniquely predicted by mothers' depressive symptoms, maternal perceived stress, larger family size, and lower maternal and adolescent educational attainment. Family income and community standard of living were not directly associated with adolescent symptoms. Adolescent females reported more symptoms than males, but gender did not moderate the relationship between the predictors and adolescents' symptoms.

CONCLUSIONS

We found that maternal mental health was a key factor in adolescent children's psychological wellbeing; this finding extends prior research in economically developed countries that emphasizes the importance of maternal functioning for child mental health. Family size, gender, and the educational attainment of mothers and adolescents also uniquely contributed to adolescents' anxiety symptoms in these rural Mexican communities.