Child and Caregiver Concordance of Potentially Traumatic Events Experienced by Orphaned and Abandoned Children

Who Reports What? A Comparison of Child and Caregivers´ Reports of Child Trauma Exposure and Associations to Post-Traumatic Stress Symptoms and Functional Impairment in Child and Adolescent Mental Health Clinics

Identifying trauma-related symptoms is important for treatment planning at child and adolescent mental health services (CAMHS), and routine trauma screening may be a first step to ensure appropriate treatment. Studies with community samples have found modest agreement between children’s and caregivers´ report of exposure to potentially traumatizing events (PTEs). However, studies from clinical populations are scarce and the evidence base for screening recommendations is insufficient. The current study explores child and caregiver agreement on the child’s exposure to PTEs and its relationship with the child’s post-traumatic stress symptoms (PTSS) and functional impairment. The sample consist of 6653 caregiver-child dyads referred to Norwegian CAMHS between 2012–2017. The children were 6 to 18 years of age (M = 12.03, SD = 3.14) and 47% were boys and 45% were girls (8% missing). Children reported significantly more exposure to accidents or illness, community violence, and sexual abuse than their caregiver, but there were no differences for reports of domestic violence. Kappa results were fair to moderate, with the highest agreement rate for reports of sexual abuse, followed by domestic violence, community violence, and lowest agreement for accidents or illnesses. There were higher agreement rates among caregivers and older children, and caregivers and girls. In general, the child had higher PTSS and functional impairment scores when child exposure to PTEs were reported by both the caregiver and the child. Both children and caregivers should be included in trauma screening procedures at CAMHS to collect a more complete picture of the child’s experiences and treatment needs.

Caregiver Self-Reports and Reporting of Their Preschoolers' Trauma Exposure: Discordance Across Assessment Methods

Nearly half of preschool-aged children from low-income families in the United States have been exposed to potentially traumatic events (PTEs), yet few are identified or receive trauma-focused mental health care. Given the critical need to accurately and efficiently identify PTE-exposed individuals, the current study examined discordant caregiver self-reporting of PTE exposure and caregiver reporting of child PTE exposure across two assessment methods: checklist and interview. Research has demonstrated significant cross-method discrepancies among adults reporting stressful life experiences, but examinations of caregiver reporting for their young children have not been conducted. Further, given their possible impact on reporting patterns, caregiver and child characteristics were examined in relation to discordant caregiver reporting by trauma type. Participants were 64 low-income, racially and ethnically diverse caregivers and their preschool-aged children from a Northeastern US city. Caregivers reported self and child PTE exposure via checklist and semi-structured interview. Cross-method discordance for caregiver and child exposure by trauma type ranged from 10.9% to 46.9% (Cohen's kappa =.06-.70). Caregiver race and education were associated with discordant reporting, as were caregiver and child psychopathology. Lower levels of caregiver psychopathology were associated with discordant caregiver reporting of their own exposure, whereas higher levels were associated with discordant caregiver reporting of child exposure. Discordant caregiver reporting of PTE exposure varies by assessment format and trauma type and is differentially related to caregiver demographics and caregiver and child psychopathology. Associations between assessment methods, individual characteristics, and reporting should be considered when assessing PTE exposure to support service engagement and targeted treatment.

Potentially traumatic experiences and sexual health among orphaned and separated adolescents in five low- and middle-income countries

Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced “any” PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.

Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study

BACKGROUND

Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings.

METHODS

The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site.

RESULTS

Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]).

CONCLUSION

Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.

Gender (in) differences in prevalence and incidence of traumatic experiences among orphaned and separated children living in five low- and middle-income countries

BACKGROUND

Approximately 153 million children worldwide are orphaned and vulnerable to potentially traumatic events (PTEs). Gender differences in PTEs in low- and middle-income countries (LMIC) are not well-understood, although support services and prevention programs often primarily involve girls.

METHODS

The Positive Outcomes for Orphans study used a two-stage, cluster-randomized sampling design to identify 2837 orphaned and separated children (OSC) in five LMIC in sub-Saharan Africa and Asia. We examined self-reported prevalence and incidence of several PTE types, including physical and sexual abuse, among 2235 children who were ≥10 years at baseline or follow-up, with a focus on gender comparisons.

RESULTS

Lifetime prevalence by age 13 of any PTE other than loss of a parent was similar in both boys [91.7% (95% confidence interval (CI) (85.0-95.5)] and girls [90.3% CI (84.2-94.1)] in institutional-based care, and boys [92.0% (CI 89.0-94.2)] and girls [92.9% CI (89.8-95.1)] in family-based care; annual incidence was similarly comparable between institution dwelling boys [23.6% CI (19.1, -29.3)] and girls [23.6% CI (18.6, -30.0)], as well as between family-dwelling boys [30.7% CI (28.0, -33.6)] and girls [29.3% CI (26.8,-32.0)]. Physical and sexual abuse had the highest overall annual incidence of any trauma type for institution-based OSC [12.9% CI (9.6-17.4)] and family-based OSC [19.4% CI (14.5-26.1)], although estimates in each setting were no different between genders.

CONCLUSION

Prevalence and annual incidence of PTEs were high among OSC in general, but gender-specific estimates were comparable. Although support services and prevention programs are essential for female OSC, programs for male OSC are equally important.