Dissociative symptoms over a year in a sample of sexually abused children

Investigating the dissociative subtype of post-traumatic stress disorder in single- and multi-event trauma-exposed youth: Prevalence, course, prognosis, severity and functional impairment

OBJECTIVES

This study aimed, following both single- and multi-event trauma, to ascertain prevalence and course of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in youth; how well early PTSD-DS predicts later PTSD; and whether dissociation accounts for unique variance in post-traumatic stress symptoms (PTSS) and functional impairment over and above the effect of other post-trauma cognitive processing factors and PTSS respectively.

DESIGN AND METHODS

This study is a secondary analysis of data from the Acute Stress Programme for Children and Teenagers study (n = 234) and the Coping in Care After Trauma study (n = 110) in which children had experienced single- and multi-event trauma respectively.

RESULTS

PTSD-DS diagnosis was common in children with PTSD regardless of trauma experienced (>39.0%). PTSD-DS showed a similar trajectory of natural recovery to PTSD, and it was similarly predictive of later PTSD following single-event trauma. Finally, dissociation was a significant factor in PTSS and functional impairment.

CONCLUSIONS

These results should be viewed in the context of several limitations including narrow sample of participants which reduces the generalizability of results, concerns around children's ability to conceptualize challenging concepts such as dissociation and the use of self-report measures to form diagnostic groups. The PTSD-DS diagnosis may offer clinical utility to the extant PTSD diagnosis in children and adolescents, as dissociation has been shown to be a contributory factor in the maintenance of both PTSS and functional impairment. Further research is required to inform further editions of the DSM and other diagnostic systems.

Treatment Issues While Addressing Child Sexual Abuse: A Review

Child sexual abuse is a traumatic life event that has social, psychological, political and cultural dimensions which is observed in many societies. Sexual abused children are at risk of developing behavioral, emotional, cognitive and physical health problems throughout their lives, and are especially vulnerable when their current condition is combined with other risk factors, such as poverty. In the relevant literature, it is reported that these children have a greater risk of having psychological problems and require treatment. There is evidence that psychotherapeutic treatments have beneficial effects, including ensuring the physical and emotional safety of victims, helping to relieve trauma symptoms, improving quality and functioning of life, and preventing recurrence of abuse. In this review, some of the most common treatment issues for sexual abused children are presented. The appropriateness of the treatment issues and proposed interventions addressed may vary for each victim. These treatment issues and interventions are designed not only to remedy any harm that may have occurred, but also to minimize the negative consequences of experiences of child abuse and prevent future recurrence of maltreatment.

Psychometric Properties of the Parent-Report Version of the UCLA PTSD Reaction Index for DSM-5

The UCLA PTSD Reaction Index for DSM-5 (RI-5) is a developmentally appropriate and well recognized screening tool for the assessment of Post-Traumatic Stress Disorder (PTSD) in children and adolescents. The children/adolescent self-report version of the RI-5 has been thoroughly studied in very recent years, showing adequate psychometric properties. Despite such results, the utility of the parent/caregiver-report version, which also integrates the RI-5 system, remains to be explored. As such, the present study aimed to test the general psychometric properties of the parent/caregiver-report version of RI-5, based on a sample of 457 children and adolescents, aged between 7 and 17 years, exposed to at least one potentially traumatic experience, and their respective primary caregivers. The RI-5 total score and categories revealed good internal consistency reliability. The total number of traumas reported emerged as a significant predictor of the RI-5 total score. The RI-5 total score proved to be significantly correlated with more internalizing and externalizing problems, but correlation coefficients were below .70, serving as an indicator of discriminant validity. The four-factor structure of the RI-5 was supported through confirmatory factor analysis. In conclusion, the present study provided preliminary evidence supporting the utility of the parent/caregiver-report version of the RI-5 for research purposes and for clinical assessment and treatment, anchored on a multiple informant perspective of child psychopathology.

Maternal History of Child Sexual Abuse and Maladaptive Outcomes in Sexually Abused Children: The Role of Maternal Mental Health

The effects of child sexual abuse (CSA) have been found to surpass generations as maternal history of CSA is associated with increased difficulties in sexually abused children. However, little is known about the mechanisms underlying this association. The present study aimed to test maternal mental health symptoms including psychological distress, post-traumatic stress disorder (PTSD) symptoms, and dissociation as mediators of the relationship between maternal CSA and children's internalizing, externalizing, and dissociation symptoms in a large sample of sexually abused children. A total of 997 sexually abused children aged 3-14 years old and their mothers were recruited at five specialized intervention centers offering services to sexually abused children and their families. The children were divided into two groups depending on their mothers' self-reported history of CSA. Mothers completed a series of questionnaires assessing their mental health and children's functioning. Maternal history of CSA was associated with increased maternal psychological distress, PTSD symptoms, and dissociation following children's disclosure of CSA. In turn, maternal psychological distress and maternal dissociation were associated with increased child internalizing, externalizing, and dissociation symptoms. Maternal PTSD symptoms were associated with child internalizing symptoms. Maternal mental health difficulties mediated the association between maternal CSA and sexually abused children's maladaptive outcomes. Clinicians should assess for possible history of CSA in mothers of sexually abused children and determine how best to support them to cope with the aftermaths of their child's disclosure and with their own traumatic past.

The intersection of intimate partner violence and childhood sexual abuse in mother-child dyads

BACKGROUND

Child sexual abuse (CSA) and intimate partner violence (IPV) have been associated with negative consequences for adult victims and their children including a risk of revictimization and intergenerational continuity.

OBJECTIVES

The aim of this study was to document correlates of intergenerational cumulative trauma profiles in mother-child dyads.

PARTICIPANTS AND SETTING

A sample of 997 sexually abused children (mean age = 7.61 years; 79.1% girls) and their mothers was recruited.

METHODS

Latent Class Analysis (LCA) was used to identify classes of cumulative trauma among dyads. Classes were compared on validated measures of psychological functioning for both members of the dyads.

RESULTS

Four distinct classes emerged: CSA Only (43.3%), Intergenerational CSA with Psychological IPV (14.2%), Physical and Psychological IPV with Low Child Exposure (24.0%) and Intergenerational Polyvictimization (18.5%). Comparisons generally revealed lower distress in CSA Only dyads, and higher levels of psychological difficulties in the two most victimized groups. However, the dose-response pattern was not as clear as expected, as the two most victimized groups did not differ in terms of psychological functioning.

CONCLUSIONS

This study shows that higher levels of intergenerational cumulative trauma are associated with increased psychological symptoms in mothers and more dissociation in their sexually abused children. Interventions should be adapted to the specific needs of families to prevent lasting intergenerational difficulties in trauma exposed individuals.

Disorganized attachment and emotion dysregulation as mediators of the association between sexual abuse and dissociation in preschoolers

BACKGROUND

Child sexual abuse (CSA) is a prevalent social problem associated with a plethora of difficulties in preschool children. Young victims are likely to show dissociation symptoms that may significantly impede their adaptation. Yet, mechanisms linking CSA with later dissociative symptoms remain unclear. The aim of the present study was to explore whether disorganized attachment and emotion dysregulation could act as mediators of the association between CSA and dissociation.

METHODS

A sample of 424 preschool children (274 CSA victims, 150 comparison group children; 3.5-6 years old) and their parents were recruited. Parents reported on children's emotion dysregulation at initial assessment while attachment representations were assessed through children's narratives using the Attachment Story Completion Task (Bretherton et al., 1990) coded with the Q-Sort (Miljkovitch et al., 2004). Parents reported on children's dissociative symptoms one year later.

RESULTS

Mediation analysis showed that disorganized attachment and emotion dysregulation mediated the association between CSA and dissociation. CSA was linked to greater disorganization scores that were associated with higher scores of emotion dysregulation. Emotion dysregulation was in turn associated with increased severity of dissociation symptoms in preschool children one year later.

LIMITATIONS

Given that attachment and emotion dysregulation were both assessed at T1, the temporal sequencing of mediators remains to be validated in a longitudinal design.

CONCLUSIONS

Findings highlight the relevance of fostering healthy parent-child relationships, as well as the development of optimal emotion regulation skills in young CSA victims to prevent the emergence of dissociation symptoms in this vulnerable population.

The Associations Of Maternal Emotion Dysregulation And Early Child Dissociative Behaviors

Although dissociation is believed to develop in early childhood, there is little research prospectively examining childhood dissociation or parental contributions related to its development. The current study sought to examine parent factors prospectively related to changes in dissociation symptoms in childhood. The current study sampled 68 mother-child dyads at two time points, when children were 3-4 and then 5-6 years, in which mothers with emotion dysregulation were oversampled. Maternal emotion dysregulation was assessed at both time points. Maternal dissociation was assessed only at time two. Child dissociation was assessed at each time point using a modified subscale of the Child Behavioral Checklist. Results showed moderate stability in childhood dissociation across time points. Further, maternal emotion dysregulation and dissociation were both significantly correlated with children's dissociation. Accounting for several covariates, time one maternal emotion dysregulation was prospectively associated with preschoolers' dissociative behaviors at 5-6 years old. The present work suggests that symptoms of dissociation can be observed early in childhood and that maternal factors play an early role in the development of dissociation in children.

Parents' descriptions of young children's dissociative reactions after trauma

There is limited research on the phenomenology of how young children who have been exposed to trauma express the intrusive symptom of dissociative reactions. The current qualitative study utilized interviews from a semi-structured diagnostic clinical interview with 74 caregivers of young children (ages 3 to 7) who were exposed to trauma to identify parents' descriptions of their children's dissociative reactions during a clinical interview. Based on results from the interview, 45.9% of the children had dissociative reactions (8.5% had flashbacks and 41.9% had dissociative episodes). Interviews were transcribed to identify themes of dissociative reactions in young children. Common themes to flashbacks and dissociative episodes included being triggered, being psychologically in their own world (e.g., spaced out and shut down), and displaying visible signs (e.g., crying and screaming). For flashbacks, caregivers reported that it seemed as if the child was re-experiencing the trauma (e.g., yelling specific words and having body responses). For dissociative episodes, caregivers noted that the child not only seemed psychologically somewhere else (e.g., distant and not there) but also would be physically positioned somewhere else (e.g., sitting and not responding). Caregivers also expressed their own reactions to the child's dissociative episode due to not understanding what was occurring, and trying to interrupt the occurrences (e.g., calling out to the child). Themes, descriptions, and phrases to describe dissociative reactions in young children after trauma can be used to help parents and professionals more accurately identify occurrences of dissociative reactions.

Cumulative childhood trauma, emotion regulation, dissociation, and behavior problems in school-aged sexual abuse victims

BACKGROUND

Child sexual abuse is associated with a plethora of devastating repercussions. A significant number of sexually abused children are likely to experience other forms of maltreatment that can seriously affect their emotion regulation abilities and impede on their development. The aim of the study was to test emotion regulation and dissociation as mediators in the association between cumulative childhood trauma and internalized and externalized behavior problems in child victims of sexual abuse.

METHODS

Participants were 309 sexually abused children (203 girls and 106 boys; Mean age = 9.07) and their non-offending parent. Medical and clinical files were coded for cumulative childhood trauma. At initial evaluation (T1), parents completed measures assessing children's emotion regulation abilities and dissociation. At Time 2 (T2), parents completed a measure assessing children's behavior problems. Mediation analyses were conducted with emotion regulation and dissociation as sequential mediators using Mplus software.

RESULTS

Findings revealed that cumulative childhood trauma affects both internalized and externalized behavior problems through three mediation paths: emotion regulation alone, dissociation alone, and through a path combining emotion regulation and dissociation.

LIMITATIONS

Both emotion regulation and dissociation were assessed at T1 and thus the temporal sequencing of mediators remains to be ascertained through a longitudinal design. All measures were completed by the parents.

CONCLUSIONS

Clinicians should routinely screen for other childhood trauma in vulnerable clienteles. In order to tackle behavior problems, clinical interventions for sexually abused youth need to address emotion regulation competencies and dissociation.

Dissociation mediates the relationship between sexual abuse and child psychological difficulties

The aim of the present study was to evaluate, using structural equation modeling, a theoretical model in which dissociation is a core process mediating the relationship between childhood sexual abuse (CSA) and internalizing, externalizing, and sexualized behaviour difficulties in children. A total of 290 children aged 2-12 participated in this study in Québec, Canada from 1998 to 2004, including 138 children with histories of CSA and 152 non-abused children. To assess child dissociative symptoms, internalizing and externalizing difficulties, as well as sexualized behaviour difficulties, the Child Dissociative Checklist, the Child Behaviour Checklist and the Child Sexualized Behaviour Inventory were completed by parents. Dissociation mediated the relationship between CSA and internalizing, externalizing, and sexualized behaviour difficulties, with the model explaining respectively 42.5%, 49.9% and 33.9% of the variance of these difficulties. Findings are consistent with a model where dissociation is a common pathway linking CSA and child psycho-sexual difficulties.

Sleep problems and dissociation in preschool victims of sexual abuse

OBJECTIVE

Child sexual abuse (CSA) is associated with a host of deleterious impacts, yet little is known about the short-term correlates in children. This study aimed to investigate the association between dissociation and sleep problems in a sample of preschool-age sexual abuse victims while controlling for potentially confounding variables, including gender, age, polytrauma, CSA characteristics, and parental distress.

METHOD

The sample consisted of 179 children (ages 3-6 years) and their non-offending parents. Parents completed questionnaires assessing their child's dissociative symptoms and sleep problems as well as their own level of psychological distress.

RESULTS

Regression analyses revealed that sleep problems were significantly associated with dissociative symptoms over and above all other control variables (children's gender and age, polytrauma, and parental distress). A longer duration of sexual abuse also predicted greater dissociative symptoms in preschool children.

CONCLUSION

Findings highlight the association between sleep problems and dissociation in preschool-age victims of CSA. Further research is needed to understand their impact on children's development to design appropriate treatment and prevention initiatives aimed at fostering resilience in young vulnerable children.

Gender as a predictor of posttraumatic stress symptoms and externalizing behavior problems in sexually abused children

Despite the proliferation of studies documenting outcomes in sexually abused victims, gender differences remain understudied. The bulk of studies have relied on retrospective samples of adults with insufficient representation of male victims to explore gender specificities. This study examined differential outcomes among boy and girl victims of sexual abuse. A predictive model of outcomes including abuse characteristics and sense of guilt as mediators was proposed. Path analysis was conducted with a sample of 447 sexually abused children (319 girls and 128 boys), aged 6-12. Being a girl was a predictor of posttraumatic stress symptoms, while being a boy was a predictor of externalizing problems. Being a boy was also associated with more severe abuse, which in turn predicted posttraumatic stress symptoms. Child's gender was not related to perpetrator's relationship to the child or sense of guilt. However, sense of guilt predicted posttraumatic stress symptoms and externalizing problems while perpetrator's relationship to the child predicted externalizing problems. Gender specificities should be further studied among sexually abused children, as boys and girls appear to manifest different outcomes. Sense of guilt should be a target in intervention for sexually abused children, as results highlight its link to heightened negative outcomes.

A longitudinal study of emotion regulation among sexually abused preschoolers

The aim of the present study was to investigate the evolution of emotion regulation competencies in sexually abused preschoolers. Children's emotion regulation abilities and their emotional lability and negativity were assessed shortly after disclosure of sexual abuse and one year later, and compared to those of non-abused children. A sample of 47 sexually abused (37 girls, 10 boys) and 74 non-abused children (54 girls, 20 boys), aged 3-7 years (M=56.83months; SD=9.55), participated in the study. Parents and daycare educators or teachers completed the Emotion Regulation Checklist (Shields & Cicchetti, 1997) and an adapted version of the History of Victimization Form (Parent & Hébert, 2006). Parents reported more emotional lability/negativity in sexually abused children, with an increase of difficulties and a larger difference between groups at follow-up assessment conducted one year later. Parents of sexually abused children, especially those of boys, also reported lower emotion regulation competencies in their child than parents from the comparison group. According to educators, victims of sexual abuse had lower emotion regulation abilities, but their lability/negativity tended to subside over time. Various hypotheses are proposed to explain the differences between sexually abused boys' and girls' emotion regulation competencies, and between the two informants. Clinical implications are also discussed. Emotion regulation seems to be an important dimension to consider in future interventions for this specific population.

Peritraumatic reactions in relation to trauma exposure and symptoms of posttraumatic stress in high school students

Background: Exposure to traumatic events is clearly associated with a diversity of subsequent mental health problems, with posttraumatic stress disorder (PTSD) as the most prevalent disorder. Epidemiologically, trauma exposure rates are more prevalent than PTSD, indicating that most trauma victims do not develop PTSD. More knowledge is needed to understand the development of the different posttraumatic pathways including the significance of pretraumatic, peritraumatic and posttraumatic risk factors. Objective: To study peritraumatic reactions in relation to trauma exposure and symptoms of posttraumatic stress and to enhance our understanding of peritraumatic reactions as mediators between trauma and later symptomatology. Method: The study was composed of a representative community sample of 5332 second year high school students (mean age 17.3 years) who completed the Juvenile Victimization Questionnaire (SAQ/JVQ), Trauma Symptom Checklist for Children (TSCC) and answered questions about peritraumatic reactions. Mediation effects of peritraumatic reactions on the trauma exposure relationship to symptoms was tested using the PROCESS macro for SPSS. Results: Traumatic events are common (84.1%) and are accompanied in three-quarters of the students with at least one form of peritraumatic reaction. Peritraumatic reactions, especially peritraumatic dissociative reactions, mediate the relationship between trauma exposure and symptoms, and gender moderates the effect of peritraumatic dissociation. This moderating effect was found to be larger for boys than for girls, indicating gender differences in response to trauma. Conclusions: The results indicate the need to screen for peritraumatic reactions as early as possible after a traumatic event in order to identify those at risk for PTSD.

The association between peer victimization, PTSD, and dissociation in child victims of sexual abuse

BACKGROUND

Sexually abused children present a host of psychological difficulties, including dissociation and post-traumatic stress (PTSD) symptoms. Negative repercussions associated with sexual abuse may interfere with children's ability to interact competently with their peers, and might put them at risk for peer victimization. The aims of the study were 1) to describe peer victimization experiences of sexually abused children using a multi-informant approach (self, parents, teachers), and 2) to examine if peer victimization experiences are associated with clinical levels of PTSD and dissociation after controlling for relevant variables.

METHOD

Participants were 158 children (104 girls and 54 boys; Mean age=9.10) and their non-offending parents consulting after the disclosure of sexual abuse. Children, parents, and teachers completed a measure assessing peer victimization (Self-Report Victimization Scale). Measures of trauma-related symptoms (PTSD and dissociation) were used as outcome variables.

RESULTS

More than half (60%) of sexually abused children reported being picked on, 51% reported sustaining verbal victimization and a third (35%) physical victimization by peers in the school context. Inter-informant agreement was higher between parents and teachers than between self-reports and adults' reports. Peer victimization experiences increased the odds by up to three-fold for clinical levels of dissociation and PTSD symptoms.

LIMITATIONS

Our findings are based on cross-sectional data, and therefore, causal relationships cannot be inferred. No control group was included in the study.

CONCLUSIONS

Results have significant relevance for prevention and intervention. Clinicians should include assessment of peer victimization experiences when evaluating sexually abused school-aged children. Prevention initiatives in terms of peer victimization could indirectly prevent worsening of symptoms in abused children.

Emotion Regulation in Sexually Abused Preschoolers

Emotion regulation is closely related to mental health in children and adults. Low emotion regulation competencies have been found in school-aged sexually abused girls. The aim of the present study was to investigate emotion regulation competencies in sexually abused preschool girls and boys using a multi-informant approach. Emotion regulation was assessed in 62 sexually abused and 65 non-abused preschoolers using the Emotion Regulation Checklist and the MacArthur Story Stem Battery. Both parents and educators reported lower emotion regulation competencies in sexually abused preschoolers, especially boys, than in non-abused children. The narrative task completed by the children also revealed lower emotion regulation competencies in sexually abused boys. These findings could have an important impact on intervention programs offered to these at-risk children.

A qualitative cancer screening study with childhood sexual abuse survivors: experiences, perspectives and compassionate care

OBJECTIVE

The childhood sexual abuse (CSA) survivor population is substantial and survivors have been identified as part of the population who were under-screened or never-screened for breast, cervical and colon cancer. Our objective was to learn CSA survivor perspectives on, and experiences with, breast, cervical and colon cancer screening with the intention of generating recommendations to help healthcare providers improve cancer screening participation.

DESIGN

A pragmatic constructivist qualitative study involving individual, semistructured, in-depth interviews was conducted in January 2014. Thematic analysis was used to describe CSA survivor perspectives on cancer screening and identify potential facilitators for screening.

PARTICIPANTS

A diverse purposive sample of adult female CSA survivors was recruited. The inclusion criteria were: being a CSA survivor, being in a stable living situation, where stable meant able to meet one's financial needs independently, able to maintain supportive relationships, having participated in therapy to recover from past abuse, and living in a safe environment. 12 survivors were interviewed whose ages ranged from the early 40s to mid-70s. Descriptive saturation was reached after 10 interviews.

SETTING

Interviews were conducted over the phone or Internet. CSA survivors were primarily from urban and rural Ontario, but some resided elsewhere in Canada and the USA.

RESULTS

The core concept that emerged was that compassionate care at every level of the healthcare experience could improve cancer screening participation. Main themes included: desire for holistic care; unique needs of patients with dissociative identity disorder; the patient-healthcare provider relationship; appointment interactions; the cancer screening environment; and provider assumptions about patients.

CONCLUSIONS

Compassionate care can be delivered by: building a relationship; practising respect; focusing attention on the patient; not rushing the appointment; keeping the environment positive and comfortable; maintaining patient dignity; sharing control whenever possible; explaining procedures; and using laughter to reduce power imbalance through shared humanity.

The roles of emotion dysregulation and dissociation in the association between sexual abuse and self-injury among juvenile justice-involved youth

To date, scholars have established associations among nonsuicidal self-injury and sexual abuse, posttraumatic stress symptoms, and dissociation. However, leading theoretical models of the mechanisms underlying the association between trauma and negative outcomes suggest a more parsimonious explanation in that deficits in emotion regulation may underlie these various risk factors for self-injury. This study examined whether sexual abuse was differentially associated with nonsuicidal self-injury over and above other forms of traumatic experiences and whether the association between sexual abuse and self-injury was statistically mediated by emotion dysregulation and dissociation. Participants included 525 youth (392 boys, 133 girls) recruited from the U.S. juvenile justice system who completed measures of self-reported trauma exposure, posttraumatic stress symptoms, dissociation, and emotion dysregulation. Results of a hierarchical regression demonstrated that sexual abuse predicted posttraumatic stress symptoms and self-injury over and above other forms of traumatic experiences. Results of bootstrapped mediation analyses indicated that emotion dysregulation and dissociation in combination were implicated in self-injury among youth. The results suggest that youth in the juvenile justice system who experience sexual abuse may be at risk for higher rates of posttraumatic stress symptoms and that self-injury may be particularly salient for youth who experience sexual abuse. Furthermore, the results shed light on the role that dissociation and emotion dysregulation play in the relation between sexual abuse and self-injury, suggesting that a larger framework of self-regulation may have both empirical and clinical utility in helping to understand the underlying processes at play in these associations.

Lessons learned from child sexual abuse research: prevalence, outcomes, and preventive strategies

Although child sexual abuse (CSA) is recognized as a serious violation of human well-being and of the law, no community has yet developed mechanisms that ensure that none of their youth will be sexually abused. CSA is, sadly, an international problem of great magnitude that can affect children of all ages, sexes, races, ethnicities, and socioeconomic classes. Upon invitation, this current publication aims at providing a brief overview of a few lessons we have learned from CSA scholarly research as to heighten awareness of mental health professionals on this utmost important and widespread social problem. This overview will focus on the prevalence of CSA, the associated mental health outcomes, and the preventive strategies to prevent CSA from happening in the first place.