Children's reactions to traumatic events

The Assessment of Brain Volume Differences in Idiopathic Central Precocious Puberty Girls; Comparison of Age-Matched Girls and Normal Puberty Girls

Objective: Although there have been several studies on the neuroanatomical changes in idiopathic central precocious puberty (ICPP), the association between each brain region and ICPP has not yet been clearly elucidated. This study aimed to evaluate the difference in brain structure in ICPP compared with age-matched healthy controls and normal puberty controls, and additionally the correlation between brain volume difference and the luteinizing hormone (LH). Materials and Methods: The study enrolled fifteen girls with ICPP, as well as 15 age-matched healthy girls and 15 normal puberty girls as controls. The subjects underwent a 1.5 Tesla Avanto MR Scanner. Anatomical T1-weighted images were acquired with a T1 spin-echo sequence. The volumes of total and regional brain were compared with each of the two control groups and analyzed through the paired T-test, and the brain region related to the peak LH level was also analyzed through a simple correlation test. Results: The mean age of the ICPP group, age-matched group, and puberty group were 8.0 ± 0.9 years, 7.8 ± 0.9 years, and 11.9 ± 0.9 years, respectively. In our findings, the regional cerebral volumes in ICPP were different from age-matched controls. Compared with controls, ICPP showed a significant increase in gray matter (GM) volumes (the medial prefrontal cortex, superior parietal gyrus, supramarginal gyrus, angular gyrus, postcentral gyrus, superior occipital gyrus, cuneus, hippocampus, parahippocampal gyrus, posterior cingulate gyrus (PCgG), cerebellar cortex (Cb)) and in white matter (WM) volumes (the insular, caudate, splenium of corpus callosum (p < 0.001)). Especially, the GM volumes of the PCgG (r = 0.57, p = 0.03) and Cb (r = 0.53, p = 0.04) were correlated positively with LH concentrations stimulated by the gonadotropin-releasing hormone agonist. Compared to the normal puberty control, no significant difference in GM volume was found. Conclusions: This study showed the overall brain volumetric differences between ICPP girls and age-matched controls using voxel-based morphometric analysis, and further showed the correlation between brain volume and the sex hormone in ICPP. Through a comparison between the two groups, the cerebral development pattern of ICPP is similar to that of normal puberty, and these local differences in cerebral volume may affect social and congenital changes. These findings will be useful for understanding the neuroanatomical mechanisms on the specific morphological variations associated with ICPP.

Assessment of stress levels in girls with central precocious puberty before and during long-acting gonadotropin-releasing hormone agonist treatment: a pilot study

BACKGROUND

The objective of the study was to determine the stress levels of girls with central precocious puberty (CPP) before and during treatment with a long-acting gonadotropin-releasing hormone agonist (GnRHa).

METHODS

The Child Stress Scale (CSS) was used for 10 unrelated girls with CPP before and after the first year of GnRHa treatment. The CSS is divided into four subscales (physical, psychological, psychological with depressive component and psychophysiological reactions). Through a quantitative analysis, it is possible to classify stress into four stages: alarm, resistance, near-exhaustion and exhaustion.

RESULTS

At diagnosis, 90% of the girls showed stress levels scores at the alarm or resistance stage on at least one subscale, mostly in terms of physical and psychological reactions. The mean total stress score was significantly higher before when compared to after GnRHa treatment (43.4±15.6 vs. 28.9±9.7; p<0.05). The mean stress scores obtained in all subscales, except the one on psychophysiological reactions, were significantly higher before GnRHa treatment.

CONCLUSIONS

Higher stress levels were a common finding in girls with CPP before treatment. The significant stress level reduction after pubertal suppression reinforces the idea that sexual precocity is a stressful condition in children. The CSS might be a useful tool for psychological assessment of patients with CPP.

The Mental Health of Refugee Children

Refugee children are generally considered to be at high risk for mental health problems because of the extreme stressors they experience in the pre- and post-migration periods. This paper summarizes current knowledge on the manifestations of emotional disorder among refugee children and on the associated risk and protective factors. Special attention is given to the interaction of culture with the specific family, social and cultural context of refugee children. Intervention and preven tion services, as well as the implementation of community programs, are discussed.

Clinical Tools to Facilitate Treatment of Childhood Traumatic Grief

Cohen and Mannarino (2004) define childhood traumatic grief (CTG) as “a condition in which trauma symptoms impinge on children's ability to negotiate the normal grieving process” (p. 819). Brown and Goodman (2005) add further clarification, “According to our current understanding of CTG and normal grief, thoughts and images of a traumatic nature are so terrifying, horrific, and anxiety provoking that they cause the child to avoid and shut out these thoughts and images that would be comforting reminders of the person who died. In contrast, a child who does not have intrusive reminders, or who did not experience the death as traumatic, is able to access the person in memory in a manner that is positive and beneficial to integrating the death in his or her total life experience” (pp. 255, 257). The distressing and intrusive images, reminders, and thoughts of the traumatic circumstances of the death, along with the physiological hyperarousal associated with such re-experiencing, prevent the child from proceeding in a healthy way with the grieving process. In addition, while such children are ordinarily excluded from studies of empirically validated treatment studies because of severity and co-morbidity of their conditions, clinicians often see youngsters where traumatic death has been superimposed on a history of multiple losses and in some cases socio-cultural trauma and/or major psychiatric disorders in the child or family. The projective drawing and storytelling strategies and the evocative technique described in this article are intended to offer clinicians additional tools to deal with such seriously impacted youth so that the trauma work can be approached in the relative safety of symbolism and metaphor prior to directly confronting the trauma events.

Child Rape: Extending the Therapeutic Intervention to Include the Mother-Child Dyad

In this his paper the authors describe therapeutic interventions with survivors of child rape and sexual abuse at Alexandra Clinic in Gauteng. Cases presenting at this community clinic are described, in the context of the startling increase in crimes against children and particularly sexual offences. The literature pertaining to the effects of trauma on children, important mediating factors in the child's experience and existing interventions with child trauma survivors are then reviewed. Attention is focused on studies taking into account the impact of the trauma on the child's familial environment. A description of the general intervention approach employed is followed by a deeper exploration of two core issues which characterised this approach — the identification of both mother and child as clients and the use of the mother-child relationship as a central focus for therapeutic intervention. It is suggested that these strategies enable greater access to the experience of the younger child in particular, address the effects of secondary traumatisation upon care-takers and ensure that the gains of therapy are extended to the child's larger social network.

The Effect of Exposure during an Ongoing Climate of Violence on Children's Self-Perceptions, as Reflected in Drawings

Many children in South Africa are subjected to continually high levels of stress and political violence. Children who are exposed to violent stressors may be at increased risk for the development of stress-related effects and emotional difficulties. Current research on the effects of political violence on children thus far has yielded inconclusive results. Some researchers find severe effects, while others interpret their findings to indicate that the majority of children are resilient. In this study, the Draw-A-Person test and drawings of the street or area where the children lived were used to examine possible levels of stress and emotional difficulties, as well as coping styles and defence mechanisms, in a sample of one hundred and fifteen eight- to twelve-year-old children from Gauteng, South Africa during the 1993 pre-election period. Christiansen's checklist of behaviour difficulties was also administered to the teachers of the children, in order to gain information on the children's overt behaviour. Comparison of the Draw-A-Person Tests showed that violence appeared to be a pertinent stressor. Black South African children from particularly high violence areas showed more distress on their drawings than white suburban children, with the girl's distress levels appearing higher than the boys'. However, on drawings obtained from children distributed in areas across Gauteng, boys appeared more vulnerable than girls. Use of different coping styles and defence mechanisms appeared to influence the effect of stress on the children. Social support and denial appeared to assist coping, while feelings of helplessness and internalisation of anger appeared detrimental.

Understanding the impact of political violence in childhood: a theoretical review using a social identity approach

The present paper reviews the literature that has assessed the psychological impact of political violence on children. Concern for those growing up in situations of political violence has resulted in two areas of research within psychology: the first considers children as victims of conflict and considers the mental health consequences of political violence. The second considers children as protagonists or aggressors in conflict and considers related moral and attitudinal consequences of exposure to political violence. These two literatures are most often considered separately. Here the two strands of research are brought together using a social identity framework, allowing apparently divergent findings to be integrated into a more coherent understanding of the totality of consequences for children and young people growing up in situations of armed conflict.

Mental health problems among children one-year after Sichuan earthquake in China: a follow-up study

Background

On May 12, 2008, a destructive earthquake registering 8.0 on the Richter scale struck Sichuan Province, southwest China. Beichuan County was the epicenter which was one of the areas nearly completely destroyed by the earthquake. In Beichuan, about 15000 people died and 3000 people were missing. Specially, the earthquake took 1587 students' and 214 teachers' lives from the elementary and middle schools there. The main purpose of the study was to provide a better understanding of mental health problems and associated risk factors among children after earthquake.

Method

Three hundred and thirty grades 3–5 children completed the questionnaire of disaster –related experience and the Trauma Symptom Checklist for Children-Alternate Version (TSCC-A). The first survey was carried out six months after the earthquake, and the second one was carried out six months later. The measurements and methodology applied in the two sessions were identical.

Results

The prevalence rates of the problems at two time-points were 23.3% and 22.7% for anxiety, 14.5% and 16.1% for depression, and 11.2% and 13.4% for PTSD, respectively. Among demographic variables, no significant age difference existed, while it was found that 6 months after the earthquake, symptoms of anxiety, depression and PTSD were significantly more common among students in grades 4 and 5 than those in grade 3, Initial exposure to death, bereavement and extreme fear were significant predictive factors for the occurrence of anxiety, depression and PTSD.

Conclusions

Findings of this study suggest that posttraumatic mental health problems after natural disaster in children may have reached epidemic proportions and remain high for a long period. Psychologist and social workers should pay more attention to children who experienced more traumatic stresses and provide appropriate mental health interventions. Implications and limitations of these findings were discussed.

Fingertip replantation at or beyond the nail base in children

Although success of digital replantations in children has been reported by many authors, the very distal fingertip replantation remains technically demanding. The aim of this article is to review our experience with fingertip replantations at or distal to the nail base in pediatric patients and evaluate the clinical outcomes. From October 2000 to May 2007, 12 pediatric fingertips amputated at or distal to the nail base were replanted. Only one artery was anastomosed for revascularization with or without nerve repair; vein drainage was provided by the controlled bleeding technique. Eleven of the 12 replants (91%) survived; one replant of crushed digit failed. An average of 26 month (range, 6 to 36 months) follow-up revealed excellent restoration of finger motion and appearance. The regained static 2-point discrimination (S2PD) sensation was from 3.2 to 5.0 mm (mean, 4.2 mm). Both the parents and the children were satisfied with the final results. In conclusion, fingertip replantation in children allows good functional and esthetical recovery and should be attempted if technically feasible.

Exposure to potentially traumatic life events in children with special needs

A series of studies of potentially-traumatic life-events (PTLE) in children and youth with special needs (CSN) was conducted after parents of 102 CSN from interdisciplinary pediatric clinics listed PTLE at significantly higher rates on the Pediatric Emotional Distress Scale (PEDS) compared to parents 58 students with no diagnoses. Subsequent studies replicated this disparity in 213 5-15 year-olds sampled through school-distributed parent PTLE checklists instead of PEDS. Results from school samples suggested significantly more PTLE in CSN, t (211) = -3.39, p < .001. In both studies some of PTLE reported significantly more in CSN were potentially related to the special needs of the child (e.g., hospitalizations, school problems) but others were not (e.g., traumatic events such as vehicular accidents and disasters). Children exposed to more PTLE were rated as having significantly more behavior problems across measures. Suggested cost-effective screening for PTLE may enable clinicians to enhance differential diagnosis, medical management, and psychosocial interventions for CSN by taking into account PTLE and symptoms related to recent disruptive events.

Parenting support and PTSD in children of a war zone

BACKGROUND

The protective role of parenting factors on the mental well-being of children exposed to war trauma remains an under-researched area.

AIM

To establish the relationship between perceived positive parenting support and post-traumatic stress disorder (PTSD) symptoms in children exposed to war trauma.

METHODS

A random sample of 412 children aged 12-16 years was selected from the Gaza Strip and was assessed using the Gaza Traumatic Events Checklist (GTEC), the SCID (DSM-IV) and the Perceived Parenting Support Scale (PPSS).

RESULTS

Palestinian children were exposed to different types of war-traumatic events. The number of exposed traumatic events was independently associated with the severity of post-traumatic symptoms scores or the diagnosis of PTSD, while perceived parenting support was found to act as a protective factor in this association.

CONCLUSIONS

Interventions in war zones need to ensure the minimal possible disruption to communities and family units, and to involve parents in preventive or treatment programmes for children exposed to trauma.

Ecological predictors of traumatic stress symptoms in caucasian and ethnic minority children exposed to intimate partner violence

Traumatic stress symptoms were assessed for 218 children ages 5 to 13 following exposure to intimate partner violence: 33% of Caucasian and 17% of minority children were diagnosed with posttraumatic stress disorder. A risk and protective factors model was used to predict traumatic stress symptoms. For Caucasian children, the best predictors were mothers' mental health and low self-esteem. For minority children, the amount of violence, mothers' low self-esteem, and low income predicted traumatic stress. Social support to the mother, inclusive of friends, relatives, and religion, was a protective element. Implications for assessment and intervention are discussed in light of each group's experiences.

Assessing road rage victimization and perpetration in the Ontario adult population: the impact of illicit drug use and psychiatric distress

BACKGROUND

To investigate the association among illicit drug use, psychiatric distress and road rage victimization and offending. Particular attention is given to the most serious forms of road rage behaviour.

METHODS

The data are based on the 2002 CAMH Monitor and include a sample of 2,421 Ontario adults aged 18 and older. Logistic regression analyses were conducted with illicit drug use and psychiatric distress (GHQ) and demographic factors as independent variables.

RESULTS

Past-year road rage victimization was reported by 42% of the sample and 31% reported any type of road rage offending. Approximately 5% were classified as respondents with serious road rage involvement. The logistic regression analyses revealed significant relationships between illicit drug use and road rage outcomes. Cannabis use was significantly associated with general road rage victimization and offending, while stimulant use substantially increased the likelihood of victimization and membership in the serious road rage classification. Psychiatric distress significantly increased the odds of both road rage victimization and serious road rage involvement.

CONCLUSION

These data reveal different indicators of road rage offending, victimization and serious involvement. Further work is needed to clarify the mechanisms associated with the relationship among stimulant use, psychiatric distress and serious road rage involvement.

Posttraumatic syndromes in children and adolescents after road traffic accidents--a prospective cohort study

BACKGROUND

The impact of road traffic accidents (RTAs) on the physical health of children is well recognized, but their psychological consequences have only recently become a topic of research. While other traumatic experiences in childhood are well studied, this kind of trauma has been poorly investigated to date.

SAMPLING AND METHODS

A prospective cohort study was conducted of 8- to 18-year-old children and adolescents who were involved in RTAs in a large urban area during a 6-month period. The children and adolescents were interviewed within 1 week after the accident and, again, 3 months later. In total, 72 children and adolescents took part in the study. Symptoms of posttraumatic stress, depression and anxiety were assessed by a structured clinical interview and standardized questionnaires.

RESULTS

One week after the accident, 11% of the children met the diagnostic criteria for posttraumatic stress disorder (PTSD) according to ICD-10 and a further 13% met the criteria for 'subsyndromal PTSD'. Complex syndromes consisting of subsyndromal posttraumatic stress, (separation) anxiety and depression were common among those children. Isolated cases of anxiety and depression symptoms were also observed but rarely reached an impairing level. Three months after the accident, 25% of the children reported persistence of the PTSD symptoms (measured by the Impact of Event Scale - Revised). The strongest predictor of the extent of posttraumatic stress after 3 months was proven to be the initial level of PTSD symptoms. This predictor alone accounted for 38% of its variance.

CONCLUSIONS

Our results provide evidence that even after 'everyday' RTAs, psychological consequences are common. Special attention should be paid to the common occurrence of subsyndromal psychological disturbances and more complex syndromes. The results further indicate the limitations of the PTSD concept in the assessment of posttraumatic disturbances in childhood and adolescence.

Psychological Sequelae of Failed Scalp Replantation

Published reports of avulsed scalp replant attempts have been promising. Numerous case reports and published series have demonstrated a greater than 90 percent replantation success rate. However, there exists a paucity of articles on the management of patients following failed scalp replantation attempts. The authors recognize numerous stressors that affect these patients, including the inciting traumatic event, hospitalizations, multiple surgical interventions, postsurgical therapies, and disfigurement caused by non-hair-bearing scalp. Thus, as part of the medical management for scalp replant patients, one must address the psychological factors surrounding the medical management. Over the past 25 years, the authors have experienced four cases of scalp replant failures, each posing an opportunity to examine the postoperative course of these patients. Symptoms ranging from mild anxiety to depressive symptoms have been observed in all of these patients. In fact, patient symptoms often satisfied the criteria for major depressive disorder or posttraumatic stress disorder. The authors recognize the importance of informing patients and their families of the immediate and potential long-term complications following an unsuccessful scalp replant attempt. The authors advise that all patients be provided immediate psychiatric evaluation and, if necessary, counseling and medication therapy, regardless of scalp replantation outcome.

The psychosocial aspects of children exposed to war: practice and policy initiatives

The atrocities of war have detrimental effects on the development and mental health of children that have been documented since World War II. To date, a considerable amount of knowledge about various aspects of this problem has been accumulated, including the ways in which trauma impacts child mental health and development, as well as intervention techniques, and prevention methods. Considering the large populations of civilians that experience the trauma of war, it is timely to review existing literature, summarize approaches for helping war-affected children, and suggest future directions for research and policy.

Coping and resilience of children of a mentally ill parent

This paper examines the needs and stress reactions of children of mentally ill parents, as well as coping and resilience. The study is based on the interviews of six 9-11 years old children and narratives of seventeen female grown up children of mentally ill parents. The younger and older children of the mentally ill parents had not been informed about their parent's illness. The illness of the parent aroused a variety of emotions in them. The children used both practical problem solving and emotional coping mechanisms. Informal social support was available to them but seldom from the public services. It is recommended that professionals in mental health and child welfare services clarify their roles when working with mentally ill parents. The best interest of the child and the parenting they need should be carefully assessed. Open care measures should be offered to families early enough to prevent serious child welfare and mental problems.

Psychiatric distress among road rage victims and perpetrators

OBJECTIVE

To investigate the relation between psychiatric distress and road rage, paying particular attention to the potential link between psychiatric illness and frequent involvement in serious forms of road rage.

METHOD

This study reports data on road rage involvement, demographic characteristics, and mental health for a representative sample of 2610 adults in Ontario. The mental health indicator was the 12-item General Health Questionnaire.

RESULTS

A cluster analysis revealed 5 distinct groups of people affected by road rage. The most serious offenders (referred to hereafter as the hard core road rage group), representing 5.5% of those affected, exhibited frequent involvement in the most severe forms of road rage and were the most likely (27.5%) to report psychiatric distress.

CONCLUSIONS

Road rage, particularly experiences of victimization, is related to psychiatric distress. Evidence of psychiatric distress was highest among hard core road rage perpetrators, individuals noted for frequent involvement in serious aggressive and violent conduct. Further research is needed on violence and road rage and its link to mental health.

Parent-child discrepancy in reporting children's post-traumatic stress reactions after a traffic accident

This study examines possible parent-child discrepancies in the reporting of post-traumatic stress reactions in children after a traffic accident. Sixteen children exposed to the same traffic accident were interviewed about post-traumatic stress reactions at 5 weeks and at 6 months after the event, utilizing the Child Posttraumatic Stress Reaction Index (CPTS-RI). Independently, the parents' reported their child's degree of post-traumatic stress reactions on the CPTS-RI: Parent questionnaire, at the same two times. Clinicians also assessed the children's level of general functioning on the Children's Global Assessment Scale. The children reported significantly more post-traumatic stress reactions than observed by their parents 4 weeks after the accident. The parent-child discrepancy was more pronounced among younger children. The level of children's self-reported post-traumatic stress reactions decreased significantly from the first to the second assessment. At the second assessment, 6 months after the accident, there was no significant parent-child discrepancy observed. The children showed a normal level of functioning despite their post-traumatic stress reactions. The reported parent-child discrepancy indicates that information about children's post-traumatic stress reactions after an accident is best obtained directly from the children.

Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes

Grief and dissociation after traumatic exposures are among the most important predictors of posttraumatic stress disorder (PTSD). This article introduces the Traumatic Dissociation and Grief Scale (TDGS), a 23-item measure easily administered. The TDGS, the Child PTSD-Reaction Index (CPTSD-RI), and a questionnaire concerning risk factors related to the event (losses, injury, and witnessing death and injuries) were administered to school-aged children who had been directly exposed to the 1999 earthquakes in Turkey and to a nonexposed control group. Factor analysis of the TDGS yielded four factors: perceptual distortions, body-self distortions, irritability, and guilt and anhedonia. A moderate positive correlation was noted between the TDGS and the CPTSD-RI. Different sets of risk factors were associated with the different scale factors. The results suggest that the assessment of psychopathology in children following a disaster requires the complementary evaluation of symptoms of posttrauma, dissociation, and grief.

Post-traumatic stress in children following motor vehicle accidents

BACKGROUND

This study examined children's experiences following a motor vehicle accident (MVA).

METHODS

Approximately 9 months following the accident, children (n=50) and their parents (n=50) participated in extensive interviews about the accident and in comprehensive, structured diagnostic interviews concerning overall psychological functioning. Additional assessments included post-traumatic stress questionnaires, archival police report records, and emergency treatment medical records.

RESULTS

Of the 50 children, 7 children (14%) met criteria for PTSD diagnosis, and an additional 5 children met criteria for specific phobia (10%) related to the automobile accident on the structured diagnostic interview (DICA-R-C; total of 24%). Degree of physical injury predicted more PTSD symptoms, and previous accident experiences predicted fewer symptoms, before and after controlling for other variables. Holding degree of physical injury and age constant revealed that social support predicted fewer PTSD symptoms.

CONCLUSIONS

Findings suggest the possible inoculating role of previous accidents and the importance of social support following MVA injury.

Healing traumatized children: creating illustrated storybooks in family therapy

In this article we describe the therapeutic practice of creating illustrated storybooks in family therapy with traumatized children. Illustrated stories offer a predictable structure to sessions and facilitate engagement and participation of children in therapy. The therapeutic emphasis of storybooks can be adjusted to take into account a child's life story, verbal capacity, level of anxiety, and traumatic hyperarousal. The creation of storybooks is an active process that embraces important aspects of trauma-specific interventions, including expression of trauma-related feelings; clarification of erroneous beliefs about the self, others, or the traumatic event; and externalization of traumatic stimuli into artwork, allowing for exposure and habituation of the arousal response. A focus on visual images together with narrative takes advantage of children's developmental capacities and spontaneous pleasure in the creation of art, thus minimizing anxiety and enhancing feelings of mastery, competence, and hope. The creation of storybooks is compatible with family interventions that foster a safe family context, strengthen attachment relationships, insure appropriate structure and boundaries, and enhance parenting capacity as well as those interactions that facilitate understanding and dialogue between family members.

Psychological impact of traumatic injuries: what the surgeon can do

In their treatment of accident and assault victims, plastic surgeons have unique opportunities to identify and refer patients with posttraumatic stress symptoms. This article describes brief assessments that surgeons or their clinic staff can use to evaluate traumatically injured adults and children for trauma-related psychological symptoms. An immediate postinjury evaluation (within 10 days of the trauma) consists of 11 questions to determine the presence of the following risk factors for posttrauma maladjustment: panic during or immediately after the trauma, reexperiencing symptoms, avoidance, sleep disturbance, injury from an assault, previous trauma and psychiatric history, and blaming someone else for the injury. The seven follow-up interview questions assess reexperiencing symptoms, avoidance, trauma-related phobias, depression, irritability, and increased substance use, all of which, if present, suggest psychological impairment. Questions recommended for the evaluation of younger children assess changes in play and recreational activity, sleep disturbance, night terror, aggression, irritability, avoidance, emergence of new fears, and loss of recently acquired developmental skills. The assessments require less than 2 minutes and are easily integrated into the hospital or clinic examinations of these patients.

Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up

The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12-month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3-month and 6-month evaluations, but 44 percent of the children continued to report symptoms at 12-month follow-up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re-injury, mood disorders, body-image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons.

When the earth stops shaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology

OBJECTIVE

To examine risk and protective processes for posttraumatic stress reactions and negative sequelae following the Northridge earthquake (EQ) among youths diagnosed for pre-EQ psychopathology.

METHOD

Symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety, and social impairment were evaluated using telephone interviews among 66 children participating in a family-genetic study of childhood-onset depression at the time of the EQ.

RESULTS

Significant predictors of PTSD symptoms 1 year after the EQ included perceived stress and resource loss associated with the EQ, a pre-EQ anxiety disorder, and more frequent use of cognitive and avoidance coping strategies. PTSD symptoms were associated with high rates of concurrent general anxiety symptoms, depressive symptoms, and social adjustment problems with friends. The only significant correlation between sibling scores was on measures of sibling reports of objective exposure.

CONCLUSIONS

Preexisting anxiety disorders represent a risk factor for postdisaster PTSD reactions. Postdisaster services need to attend to the needs of these youths as well as those of youths experiencing high levels of subjective stress, resource loss, and/or high exposure. That children within families show significant variation in postdisaster reactions underscores the need for attention to individual child characteristics and unshared environmental attributes.

Comparing perceived self-efficacy among adolescent Bosnian and Croatian refugees with and without posttraumatic stress disorder

To examine the relationship between posttraumatic stress disorder (PTSD) and perceived self-efficacy (PSE), 98 Bosnian and Croatian refugees, ages 13-18, completed Bandura's Children's Multidimensional Scales of Perceived Self-Efficacy, which measure self-predicted social functioning in 9 areas. Through interviews, participants were categorized according to DSM-IV criteria as traumatized PTSD-positive, traumatized PTSD-negative, and nontraumatized. ANCOVAs showed PTSD-positive participants exhibit higher PSE than nontraumatized participants in 5 of 9 areas. No significant differences among 3 female groups were observed; however, nontraumatized boys demonstrated lower PSE than the 2 traumatized groups in 7 of 9 areas. Thus, PTSD did not have a negative impact on PSE in this cultural context. Furthermore, surviving traumatic experience and preserving social support networks may be protective factors for maintaining high levels of PSE.

Prospective study of post-traumatic stress disorder in children involved in road traffic accidents

OBJECTIVE

To determine the prevalence of severe psychological trauma --that is, post-traumatic stress disorder--in children involved in everyday road traffic accidents.

DESIGN

12 month prospective study.

SETTING

Accident and emergency department, Royal United Hospital, Bath.

SUBJECTS

119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries.

MAIN OUTCOME MEASURE

Presence of appreciable psychological distress; fulfillment of diagnostic criteria for post-traumatic stress disorder.

RESULTS

Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment.

CONCLUSIONS

One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.

Symptomatology and adaptive functioning for children exposed to normative stressors, dog attack, and parental violence

OBJECTIVE

To examine and identify predictors of posttraumatic symptomatology and adaptive functioning of children exposed to single and repetitive adverse events that varied in severity.

METHOD

A sample of 86 patients and their children, aged 4 to 9 years, were interviewed after three types of adverse experiences; repetitive exposure to parental violence, a dog attack, or a milder stressor. The PTSD Reaction Index, Child Dissociative Checklist, and Child Behavior Checklist were used.

RESULTS

Trauma symptoms were greater for the first two groups, younger children, and girls. Gender effects were most evident in the dog attack group and depended on type of symptoms and informant. Supportiveness in the parenting relationship aided prediction of both trauma symptoms and adjustment.

CONCLUSIONS

Children appear to experience elevated posttraumatic stress disorder symptomatology after both single and repetitive adverse events that are potentially life-threatening. A positive parental relationship is associated with fewer symptoms and better adaptive functioning. The mechanisms through which this support interacts with behavioral and physiological systems to facilitate better regulation await further research.

Posttraumatic stress symptoms and medical procedures in children

OBJECTIVE

To focus on posttraumatic stress symptoms after childhood diseases such as cancer, organ transplantation, and severe burns.

METHODS

Differential diagnoses, risk factors, and treatment aspects (psychological and pharmacological) are discussed.

RESULTS

The concept of adjustment problems in chronic or severe illnesses is widely used in pediatrics. Many aspects of severe childhood diseases are traumatic, as defined by the DSM-IV: severe illnesses are life-threatening, medical procedures threaten the child's physical integrity, and disorganized behaviour periods are common.

CONCLUSION

This concept, which remains insufficiently investigated, is a promising area of investigation for prospective and prevention studies.

Mental and physical health effects of intimate partner violence on women and children

The battering of female partners and the concomitant emotional abuse that is almost always part of the coercive control have significant mental and physical health consequences for the women who experience this type of violence. Children who live in households fraught with the conflict, violence, and unpredictable danger of domestic violence often witness the battering of their mothers and may also be victims of child abuse themselves. This article highlights current knowledge regarding the mental and physical health effects of intimate partner violence on women and their children, and discusses needed directions for screening, intervention, research, and changes in the health care system.

Refugee children in Sweden: post-traumatic stress disorder in Iranian preschool children exposed to organized violence

Fifty preschool children from 47 Iranian families living as refugees in Sweden were assessed individually, simultaneously with parental interviews focusing on exposure to organized violence and post-traumatic stress symptomatology in the children. Information given by the children increased the prevalence of a Post-Traumatic Stress Disorder (PTSD) diagnosis (DSM-III-R) from 2% to 21% in the 42 children with traumatic exposure through war and political persecution. The amount of traumatic exposure was strongly related to the prevalence of PTSD. The stability of prevalence was high in a follow-up 2 and 1/2 years later; 23% of the children with traumatic exposure still met the full criteria of PTSD according to DSM-III-R.

Talking with children about death and dying

This paper outlines the development of childrens' understanding about the concept of death, and describes common grief reactions. Using this framework, the principle elements of talking with children on such a sensitive topic are discussed. A variety of potential clinical interventions at individual, family and group levels are proposed.

The impact of the peace treaty on psychological well-being: a follow-up study of Palestinian children

This research examined the impact of the Israeli-Palestinian peace treaty and Palestinian children's perception of it on their self-esteem and neuroticism. We also studied the relative importance of earlier exposure to traumatic experiences and psychosocial resources indicated by the children's creativity, intelligence and political activity in influencing their psychological well-being after the peace treaty. The sample used was a follow-up group of 64 Palestinian children of 11-12 years of age, living in the Gaza Strip. The results showed that the level of neuroticism was significantly lower after the peace treaty than before. The children's earlier exposure to traumatic experiences was still significantly related to high neuroticism and low self-esteem after the peace treaty. Acceptance of the treaty and participating in the subsequent festivities mitigated the negative impact of the traumatic experiences on their well-being. Increased neuroticism and decreased self-esteem were found only among children who refused to accept the peace treaty and did not participate in the festivities. Creativity and Intifada activity promoted their post-peace treaty well-being, in terms of psychosocial resources. The more creative the children were, the more their neurotic symptoms decreased because of the treaty and the higher self-esteem they had after it. The more active the children were during the Intifada, the more their self-esteem increased because of the treaty.

Is it possible to assess the impact of abuse on children with pervasive developmental disorders?

Although it is now recognized that children may exhibit widespread symptoms of stress following exposure to abuse or neglect, the impact of traumatic experiences on children with pervasive developmental disorders has received little attention. The present paper describes a strategy devised to assess the long-term effects of abuse on a group of children who had attended a specialist autistic school where physical and emotional mistreatment of pupils was well documented. Because most of the children had very limited communication skills, the evidence relied heavily on retrospective parental reports. Despite the problems inherent in using such data it was possible to derive reliable measures that could be used to test hypotheses about predicted patterns of behavioral change, based on work with other children who have been abused. In most cases, too, parental reports could be corroborated by information from other sources. Consistent patterns in both the nature and timing of behavioral disturbances were found, which seemed to relate specifically to the period of abuse at the school.

Post-traumatic stress symptoms in children and parents following a school-based fatality

In 1991 the roof blew off a Swindon Primary School. One child was killed. Two years later 19 of her classmates were interviewed. The parent who collected the child from school that day was also interviewed. Recalled levels of post-traumatic stress syndrome (PTSD) symptoms were assessed in both parent and child in the month following the incident. The children's symptom levels at 2 years were also assessed. Parents and children recalled significant post-traumatic stress reactions at 1 month. The level of symptoms in parents did not correlate with that of their own children.