Predicting adolescent posttraumatic stress in the aftermath of war: Differential effects of coping strategies across trauma reminder, loss reminder, and family conflict domains

Prevalence and potency of trauma reminders 8.5 years after a terrorist attack

Background: Empirical knowledge about the prevalence and potency of reminders several years post-trauma, and how experiences with reminders relate to mental health and functioning, is scarce.Objective: The aim of this study was threefold: (1) systematically describe the type and frequency of trauma reminders experienced by survivors 8.5 years after a terrorist attack; (2) explore the intensity and duration of reactions evoked by various reminders; and (3) examine whether experiences with trauma reminders are associated with psychological distress and level of functioning almost a decade post-trauma.Method: 289 survivors (51.2% females, M age = 27.7, SD = 4.6) of the 2011 massacre on Utøya island, Norway, were interviewed 8.5 years post-terror. Participants were presented with a list of ten potential trauma reminders and asked to rate how frequently they had experienced each one in the past month, and the intensity and duration of the reactions evoked. Current posttraumatic reactions were measured using the UCLA PTSD-RI and the HSCL-8. Associations between experiences with reminders, psychological distress, and functioning, were analysed by linear regressions.Results: At 8.5 years post-terror, approximately 90% of the participants had experienced trauma reminders within the past month (35.6% often or very often). Almost 30% had become distressed, afraid, sad, or experienced bodily reactions to a great or very great extent. The vast majority reported that the reactions only lasted for a few minutes or hours. Frequency of exposure to reminders, and the intensity of the reactions evoked, were significantly associated with psychological distress. Frequency of exposure to trauma reminders was negatively related to the survivors' level of functioning.Conclusions: Trauma reminders can still be a central source of psychological distress and impaired functioning among survivors almost a decade post-trauma. While everyone who is directly exposed to a terrorist attack does not need psychotherapy, most would probably benefit from psychoeducation about reminders.

Social connectedness and resilience post COVID-19 pandemic: Buffering against trauma, stress, and psychosis

The present study investigated psychosocial predictors of psychosis-risk, depression, anxiety, and stress in Croatia two years after the onset of the COVID-19 pandemic. Given the existing transgenerational war trauma and associated psychiatric consequences in Croatian population, a significant pandemic-related deterioration of mental health was expected. Recent studies suggest that after an initial increase in psychiatric disorders during the pandemic in Croatia, depression, stress, and anxiety rapidly declined. These findings highlight the role of social connectedness and resilience in the face of the global pandemic. We examined resilience and psychiatric disorder risk in 377 Croatian adults using an anonymous online mental health survey. Results indicate that there was an exacerbation of all mental ill health variables, including depression, anxiety, stress, and a doubled risk for psychosis outcome post-COVID pandemic. Stress decreased levels of resilience, however, those exposed to previous traumatic experience and greater social connectedness had higher resilience levels. These findings suggest that individual differences in underlying stress sensitization of Croatian population due to past trauma may continue to influence mental health consequences two years after COVID-19 pandemic. It is essential to promote the importance of social connectedness and resilience in preventing the development of variety of mental health disorders.

Loneliness and psychosocial predictors of psychosis-proneness during COVID-19: Preliminary findings from Croatia

The present study investigated psychosocial predictors of psychosis-risk, depression, anxiety, and stress in Croatia during the COVID-19 pandemic. Given Croatia's recent transgenerational war trauma and the relative lack of available prodromal data, this study presents a unique opportunity to examine the impact of loneliness and other psychosocial factors on psychosis-risk and mental health in this population. 404 Croatian participants completed an anonymous online survey of physical and mental health questions. 48 participants met the criteria for elevated psychosis-risk on prodromal questionnaire (PQ-16). Loneliness had a significant impact on psychosis-risk. Exposure to trauma was associated with psychosis-risk and loneliness, while domestic abuse/violence was associated only with the distress surrounding psychotic-like symptoms. COVID concern was also associated with psychosis-risk. Lastly, the associations between psychosis-risk and depression, anxiety, and stress were robust. These findings highlight the important role of loneliness in psychosis-proneness in Croatia. Depression, anxiety, and stress were also closely related to elevated psychosis-risk. Loneliness is a highly salient issue for individuals with psychosis and it is important to target loneliness within a multi-faceted psychosocial intervention for those at risk for schizophrenia.

Cognitive Coping Reduces Posttraumatic Stress Symptoms, Especially in the Context of Self-Blame

Following a traumatic event, coping strategies may affect the natural course of posttraumatic stress symptoms (PTSS). In particular, cognitive coping strategies (how one thinks about stressors) may reduce PTSS by increasing individuals' perceived control over events, appraising them as less threatening, particularly for individuals who experience self-blame after trauma. Individuals who experience a traumatic event (n =344) completed assessments at baseline (T1), one month (T2), and two months (T3). We tested whether T1 cognitive coping strategies (positive reinterpretation, acceptance, religious coping) predicted reduced T3 PTSS and whether this reduction was mediated by increased perceived control at T2. We tested whether this effect was particularly strong for individuals experiencing self-blame. Positive reinterpretation predicted decreases in, religious coping predicted increases in, and acceptance had no direct effect on PTSS. Overall, acceptance showed the greatest potential for reducing PTSS through increased perceived control over one's life. In a fully moderated mediation model, positive reinterpretation significantly interacted and acceptance marginally interacted with self-blame to predict increased perceived control and, subsequently, decreased T3 PTSS. Specifically, acceptance and positive reinterpretation were most helpful for those with higher levels of self-blame. Religious coping interacted with self-blame to predict decreased perceived control and subsequent increased PTSS. For trauma survivors experiencing self-blame, cognitive coping strategies that utilize compassionate self-talk, such as positive reinterpretation and acceptance, may be particularly helpful at increasing perceived control after trauma, while religious coping may have deleterious effects.

Spray Freeze-Drying for inhalation application: Process and Formulation Variables

High porous particles with specific aerodynamic properties were processed by the spray freeze-drying (SFD) method. Comprehensive knowledge about all aspects of the SFD method is required for particle engineering of various pharmaceutical products with good flow properties. In this review, different types of the SFD method, the most frequently employed excipients, properties of particles prepared by this method, and most recent approaches concerning SFD are summarized. Generally, this technique can prepare spherical-shaped particles with a highly porous interior structure, responsible for the very low density of powders. Increasing the solubility of spray freeze-dried formulations achieves the desired efficacy. Also, due to the high efficiency of SFD, by determining the different features of this method and optimizing the process by model-based studies, desirable results for various inhaled products can be achieved and significant progress can be made in the field of pulmonary drug delivery.

Connection between the COVID-19 pandemic, war trauma reminders, perceived stress, loneliness, and PTSD in Bosnia and Herzegovina

In order to gain a better understanding of what happens during the COVID-19 pandemic to those who were previously traumatized, this study investigated perceived stress and severity of PTSD symptoms during the COVID-19 pandemic in people who experienced the 1992-1995 war in Bosnia and Herzegovina. It was also examined how reminders of past trauma and loneliness instigated by the COVID-19 crisis relate to current stress and PTSD symptoms. The sample consisted of 123 participants (74.8% women). Participants responded to assessments of sociodemographic characteristics, exposure to COVID-related information, concerns over disease, severity of exposure to war, frequency and intensity of war trauma reminders, loneliness, stress, and severity of PTSD symptoms. Data was collected as part of the COVIDiSTRESS Global Survey. Results showed that in a population previously exposed to the effects of war, severity of PTSD symptoms was positively related to perceived stress, and loneliness during the pandemic significantly mediated this relationship. Intensity of exposure to war trauma reminders was associated with higher levels of PTSD symptom severity. Higher severity of PTSD symptoms was related to forced displacement during the war. Moreover, higher stress was related to increased concerns over disease. To conclude, those exposed to war may be more affected by the global COVID-19 pandemic and preventive measures that accompany it, while loneliness mediates the effects of PTSD and perceived stress in this population.

A socio-ecological analysis of risk, protective and promotive factors for the mental health of Burundian refugee children living in refugee camps

Children and adolescents' mental health risk and resilience arise from a complex interplay of factors on several socio-ecological levels. However, little is known about the factors that shape the mental health of refugee youth living in refugee camps close to ongoing conflict. We conducted a cross-sectional study with a representative sample of 217 Burundian refugee children aged 7-15 and their mothers residing in refugee camps in Tanzania to investigate associations between risk, protective and promotive factors from various ecological levels (individual, microsystem, exosystem), and children's post-traumatic stress disorder (PTSD) symptoms, internalizing and externalizing problems, and prosocial behavior. Data were collected using structured clinical interviews and analyzed using multiple regression models. Exposure to violence across all contexts and engagement coping were risk factors for PTSD symptoms and internalizing problems, while only violence by mothers seemed to increase children's vulnerability for externalizing problems. A differential impact of violence exposures on prosocial behavior was observed. Higher-quality friendships appeared to protect youth from PTSD symptoms and externalizing problems, while they also promoted children's prosocial behavior, just as mothers' social support networks. Prevention and intervention approaches should integrate risk, protective and promotive factors for refugee youth's mental health across multiple ecological contexts and take into account context-specific and adaptive responses to war and displacement.

Review: How should child mental health services respond to the refugee crisis?

BACKGROUND

Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs.

AIMS

To review the research literature on risk and protective factors, and associated mental health interventions for refugee children.

METHODS

Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria.

RESULTS

The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation.

CONCLUSIONS

In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.

Associations Between Trauma Type, Timing, and Accumulation on Current Coping Behaviors in Adolescents: Results from a Large, Population-based Sample

The development of adolescents' coping in response to stress is critical for adaptive functioning; these coping strategies may be shaped by numerous environmental factors during childhood, including experiences such as exposure to trauma. Childhood trauma has been shown to undermine contemporaneous coping, but how does a history of exposure to trauma and the characteristics of that trauma (type, timing, and accumulation) relate to current coping among adolescents? We addressed this question using a nationally-representative sample of 9427 adolescents (ages 13-18; 48.9% female; 66% White). Adolescents reported on their lifetime exposure to 18 different traumas, including witnessing or experiencing interpersonal violence, accidents, disasters, and violent or accidental loss of loved ones, as well as their current use of coping behaviors when under stress (problem-focused, positive emotion-focused, and negative emotion-focused coping strategies). The study's results highlight that exposure to nearly all forms of trauma was unrelated to problem-focused and positive emotion-focused coping behaviors, but strongly associated with increased negative emotion-focused coping. Use of each coping style did not vary with age at first exposure to trauma, but increased with the number of lifetime traumatic events experienced. The findings suggest that the extent of prior exposure to trauma, including variations across type and timing, may be related to a particular form of coping that has been linked to increased risk for mental health problems. Study results highlight coping strategies as a potential target for prevention and treatment efforts, and indicate a need to better understand the malleability and trajectory of coping responses to stress for promoting healthy youth development.

The effect of parental loss on cognitive and affective interference in adolescent boys from a post-conflict region

Little is known about the impact of early-life stressors such as parental loss on cognitive-affective processing during adolescence, especially in regions chronically affected by war and armed conflict. Here, we tested 72 male adolescents living in Northern Uganda (ages 14-19), 52 of whom still had both of their parents and 20 participants who had experienced parental loss. Participants completed a classic color-naming Stroop task as well as an affective interference task, the opposite emotions test (OET). Adolescents with parental loss showed a decrease in performance over time, especially on the Stroop task. Critically, this decrement in performance was positively associated with reported symptoms of trauma, but only in the parental loss group. The current data suggest a difficulty in maintaining cognitive control performance in youths with experience of parental loss. The findings are discussed in relation to traumatic stress and mental health in post-conflict regions.