The nature of trauma memories in acute stress disorder in children and adolescents

Post-traumatic stress disorder symptoms following exposure to acute psychological trauma in children aged 8-16 years in South Africa: protocol for the Sinethemba longitudinal study

INTRODUCTION

Children exposed to trauma are vulnerable to developing post-traumatic stress disorder (PTSD) and other adverse mental health outcomes. In low-and middle-income countries (LMICs), children are at increased risk of exposure to severe trauma and co-occurring adversities. However, relative to high-income countries, there is limited evidence of the factors that predict good versus poor psychological recovery following trauma exposure in LMIC children, and the role of caregiver support in these high-adversity communities.

METHODS AND ANALYSIS

We will conduct a longitudinal, observational study of 250 children aged 8-16 years and their caregivers in South Africa, following child exposure to acute trauma. Dyads will be recruited from community hospitals following a potentially traumatic event, such as a motor vehicle accident or assault. Potential participants will be identified during their hospital visit, and if they agree, will subsequently be contacted by study researchers. Assessments will take place within 4 weeks of the traumatic event, with 3-month and 6-month follow-up assessments. Participants will provide a narrative description of the traumatic event and complete questionnaires designed to give information about social and psychological risk factors. Child PTSD symptoms will be the primary outcome, and wider trauma-related mental health (depression, anxiety, behavioural problems) will be secondary outcomes. Regression-based methods will be used to examine the association of psychosocial factors in the acute phase following trauma, including caregiver support and responding, with child PTSD and wider mental health outcomes.

ETHICS AND DISSEMINATION

Ethical approvals have been granted by Stellenbosch University and the University of Bath, with additional approvals to recruit via hospitals and healthcare clinics being granted by the University of Cape Town, the Department of Health and the City of Cape Town. Study findings will be disseminated via publication in journals, workshops for practitioners and policy-makers, and public engagement events.

Trauma Memory Characteristics and Neurocognitive Performance in Youth Exposed to Single-Event Trauma

Cognitive models of posttraumatic stress disorder (PTSD) highlight characteristics of trauma memories, such as disorganisation, as key mechanisms in the aetiology of the disorder. However, studies investigating trauma memory in youth have provided inconsistent findings. Research has highlighted that PTSD in youth may be accompanied by difficulties in neurocognitive functioning, potentially impacting ability to recall the trauma memory. The present study sought to investigate both trauma memory characteristics and neurocognitive functioning in youth aged 8-17 years. Youths exposed to single-event trauma, with (N = 29, Mage = 13.6, 21 female) and without (N = 40, Mage = 13.3, 21 female) a diagnosis of PTSD, completed self-report measures of trauma memory, a narrative memory task and a set of neurocognitive tests two to six months post-trauma. A group of non trauma-exposed youths (N = 36, Mage = 13.9, 27 female) were compared on narrative and neurocognitive tasks. Results indicated that trauma memories in youth with, versus without, PTSD were more sensory-laden, temporally disrupted, difficult to verbally access, and formed a more 'central' part of their identity. Greater differences were observed for self-reported memory characteristics compared to narrative characteristics. No between group differences in neurocognitive function were observed. Self-reported trauma memory characteristics highlight an important factor in the aetiology of PTSD. The observed lack of significant differences in neurocognitive ability potentially suggests that cognitive factors represent a more relevant treatment target than neurocognitive factors in single-event PTSD. Further research to understand the cognitive factors represented by self-reported trauma memory characteristics is recommended.

The Protective Effects of Parent-Child Emotion Dialogues for Preschoolers Exposed to Intimate Partner Violence

Exposure to intimate partner violence (IPV) during early childhood is associated with self-regulation difficulties. Caregivers can facilitate children's self-regulation through emotion-focused conversations about past experiences, buffering downstream effects. However, caregivers experiencing violence may avoid distressing emotions activated by such conversations. This paper explores two different models of relational stress responses, one involving indirect effects (i.e. spillover effects) and the other moderation (i.e. buffering effects). Mothers (n = 117), oversampled for violence exposure, self-reported on IPV and participated in an emotional reminiscing task with children (aged 3-5 years); narratives were coded for maternal sensitive guidance. Maternal sensitive guidance was related to children's self-regulation. Sensitive guidance did not have indirect effects in the association between IPV exposure and children's self-regulation, but did buffer the association between physical IPV and self-regulation; this pattern did not hold for psychological IPV. Results suggest sensitive guidance during reminiscing may promote self-regulation in contexts of high IPV.

A Longitudinal Investigation of the Relationship Between Trauma-Related Cognitive Processes and Internalising and Externalising Psychopathology in Young People in Out-of-Home Care

Young people in out-of-home care are at increased risk of developing a range of posttrauma mental health difficulties, including PTSD, but more commonly anxiety, depression and externalising symptoms. Cognitive models of PTSD indicate that trauma-related maladaptive appraisals, coping strategies and trauma memory qualities are key processes in the development and maintenance of PTSD, yet there has been limited investigation of the potential role of these processes in broader posttrauma psychopathology, particularly in young people who have been exposed to complex, rather than acute, trauma. We recruited 120 10-18 years olds in out-of-home care, and their caregivers, who completed assessments at two time points: baseline and 12-month follow-up. Young people completed self-report measures of trauma-related maladaptive appraisals, coping strategies and trauma-memory qualities, as well as reporting on PTSD, anxiety, depression and externalising symptoms. Carers also reported on internalising and externalising symptoms. We found that all three cognitive processes were associated with baseline self-reported internalising symptoms, with maladaptive appraisals most robustly associated with both anxiety and depression. Changes in all three processes over 12-months predicted a change in self-reported internalising and externalising symptoms, with maladaptive appraisals and coping predicting anxiety symptoms, and coping uniquely predicting depression and externalising symptoms. Effects remained after controlling for co-occurring PTSD symptoms. Findings were not replicated when using carer-reported symptoms. These findings suggest that existing cognitive models of PTSD may also usefully explain broader posttrauma depression, anxiety and externalising symptoms in young people who have experienced maltreatment and live in out-of-home care. Clinical implications are discussed.

"My Bad Experiences Are Not the Only Things Shaping Me Anymore": Thematic Analysis of Youth Trauma Narratives

The purpose of this study was to better understand how youth with poly-trauma histories appraise and make meaning of their traumatic experiences within the trauma narrative and processing components of Trauma-focused Cognitive Behavioral Therapy (TF-CBT), and to explore the results of the meaning-making process. Thematic analysis was employed to explore the trauma narratives of youth (N = 16) ages 8 - 16 that were created during TF-CBT. Participants experienced a mean of 5.38 types of trauma that predominantly included various forms of child maltreatment. With regard to how youth appraise and interpret their traumatic experiences, four themes emerged, including I Am Not Safe, which denotes a lack of physical and psychological safety; It's My Fault, which symbolizes misattributions of responsibility; I Am Changed, which captures alterations in systems of meaning; and Why Did This Happen to Me?, which denotes the struggle to comprehend why the traumatic events occurred and their significance. With regard to the products of the meaning-making process, three themes emerged, including Now I Know, which denotes reappraisals; I Am Safe/r, which signifies increases in perceptions of safety, and I Can Do It, which includes the participant's perceptions of growth. Results from this study provide a deeper understanding of youth's experiences during these components of treatment, and illuminate the meaning-making process. Findings can help guide clinical-decision making, and highlight the importance of explicitly attending to specific components of the meaning-making process during trauma narration and processing.

Improving the mental health and mental health support available to adolescents with social care-experience via low-intensity life story work: a realist review protocol

INTRODUCTION

Adolescents are the fastest growing group entering social care and are most at risk of mental ill-health. Life Story Work (LSW) is an existing transdiagnostic intervention thought to improve the well-being and mental health of children and adolescents under the care of a local authority by assisting the processing of trauma. Yet LSW is poorly evidenced, lacks standardisation and focuses on younger children. LSW is also high-intensity, relying on specialist input over several months. Adolescent-focused low-intensity-LSW is a promising alternative. However, there is poor evidence on how LSW, let alone low-intensity-LSW should be delivered to adolescents. We aim to identify why, how, in what contexts, for whom and to what extent low-intensity-LSW interventions can be delivered to adolescents with care-experience.

METHODS AND ANALYSIS

Undertaking a realist review, we will: (1) develop an initial programme theory (PrT) of adolescent-focused low-intensity-LSW by consulting with two key expert panels (care-experienced and professional stakeholders), and by searching the literature to identify existing relevant theories; (2) undertake a comprehensive literature search to identify secondary data to develop and refine our emerging PrT. Searches will be run between 12/2021-06/2022 in databases including MEDLINE, PsycINFO, ASSIA and relevant sources of grey literature; (3) select, extract and organise data; (4) synthesise evidence using a realist logic of analysis and undertake further iterative data searching and consultation with our expert panels; (5) write up and share the refined PrT with our expert panels for their final comments. From this process guidance will be developed to help improve the delivery of LSW to support the mental health needs of adolescents with care-experience.

ETHICS AND DISSEMINATION

Ethical approval is not required. Dissemination will include input from expert panels. We will develop academic, practice and youth focused outputs targeting adolescents, their carers, social, healthcare, and educational professionals, academics, and policymakers.

PROSPERO REGISTRATION NUMBER

CRD42021279816.

Gender Differences in the Correlations between Childhood Trauma, Schizotypy and Negative Emotions in Non-Clinical Individuals

Early life trauma has a negative impact on the developing brain, and this can lead to a wide range of mental illnesses later in life. Childhood trauma is associated with increased psychotic symptoms and negative emotions such as depressive, anxiety, and stress symptoms in adulthood. Childhood trauma has also been shown to influence sub-clinical ‘schizotypy’ characteristics of psychosis in the general population. As it has been reported that mental health outcomes after early life trauma exposure are influenced by gender, the current study aimed to investigate the gender differences in the relationship between childhood trauma, schizotypy and negative emotions. Sixty-one non-clinical participants (33 men and 28 women) aged between 18 and 45 completed self-report questionnaires to measure early life trauma, schizotypy and negative emotions. Despite similar levels of childhood trauma in men and women, early life trauma in women was associated with increased schizotypy personality characteristics (Cognitive Disorganisation) and increased depression, anxiety and stress later in life, but no correlations were observed in men. Our findings suggest that the sociocultural and biological processes affected by early life adversities may differ between the genders. Women may be more vulnerable to the influence of childhood trauma, which may be associated with increased psychopathology later in life.

A Longitudinal Investigation of Children's Trauma Memory Characteristics and Their Relationship with Posttraumatic Stress Disorder Symptoms

While trauma memory characteristics are considered a core predictor of adult PTSD, the literature on child PTSD is limited and inconsistent. We investigated whether children's trauma memory characteristics predict their posttraumatic stress symptoms (PTSS) at 1 month and 6 months post-trauma. We recruited 126 6-13 year olds who experienced a single-incident trauma that led to attendance at an emergency department. We assessed trauma memory disorganisation and sensory-emotional qualities through both narrative recall and self-report questionnaire, and PTSS at 1-month post-trauma and at 6-month follow-up. We found that, after controlling for age, children's self-reported trauma memory characteristics were positively associated with their concurrent PTSS, and longitudinally predicted symptoms 6-months later. However, observable trauma memory characteristics coded from children's narratives were not related to PTSS at any time. This suggests that children's perceptions of their trauma memories are a more reliable predictor of the development and maintenance of PTSS than the nature of their trauma narrative, which has important implications for clinical practice.

The Accuracy of Traumatic Memories in Posttraumatic Stress Disorder: A Review

ABSTRACT

This review sought to investigate the accuracy of traumatic memories in persons with a diagnosis of posttraumatic stress disorder (PTSD). PubMed, PsycINFO, and Embase were searched for articles, and 11 studies were included. Three different methods of studying memory accuracy were identified in the included articles: coherence, change in recollection of trauma over time, and remembering details of trauma. Three studies found a deficiency in the accuracy of traumatic memory. Despite some inconsistencies, most of the studies concluded that the memory of trauma is as accurate in people with as in those without PTSD. The only recurring difference identified across studies was in recollection of trauma over time. The findings are of importance both clinically and for the legal system.

Changes in Traumatic Memories and Posttraumatic Cognitions Associate with PTSD Symptom Improvement in Treatment of Multiply Traumatized Children and Adolescents

Refinement, targeting, and better dissemination of trauma-focused therapies requires understanding their underlying mechanisms of change. Research on such mechanisms among multiply traumatized children and adolescents is scarce. We examined the role of improvements in problematic qualities of traumatic memories and maladaptive posttraumatic cognitions in PTSD symptom reduction, in a randomized, pragmatic trial of narrative exposure therapy vs. treatment as usual with 40 participants 9-17 years old (48% female, 75% refugee background) repeatedly exposed to war or family violence related trauma. Posttraumatic cognitions, quality of traumatic memories and PTSD symptoms were assessed by self-report before and after treatment. Improvements in both quality of traumatic memories (r _MI = .36) and posttraumatic cognitions (r _MI = .46) correlated with symptom reduction. However, improvement during treatment was only significant for quality of traumatic memories (F _MI(11,333.56) = 4.77), not for posttraumatic cognitions. We detected no difference in effects of narrative exposure therapy and treatment as usual on cognitions or memories. We tentatively suggest problematic, overly sensory and incoherent quality of traumatic memories may be a useful target in the treatment of PTSD symptoms among multiply traumatized children and adolescents. Changing maladaptive posttraumatic cognitions, though important, may be challenging among those with severe, repeated trauma.

Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations

Psychological interventions can alleviate posttraumatic stress symptoms (PTSS). However, further development of treatment approaches calls for understanding the mechanisms of change through which diverse interventions affect PTSS. We systematically searched the literature for controlled studies of mechanisms of change in psychological interventions for PTSS. We aimed to detect all empirically studied mechanisms and evaluate the level of evidence for their role in the alleviation of PTSS. We identified 34 studies, of which nine were among children. We found evidence for improvements in maladaptive posttraumatic cognitions as a general mechanism of change involved in diverse interventions, among both adults and children. We also found some preliminary evidence for increases in mindfulness as a mechanism of change in mindfulness- and spiritually-oriented interventions among adults. We found scant, mixed empirical evidence for other mechanisms of change. Notably, studies on changes in traumatic memories as a mechanism of change were lacking, despite clinical emphasis on their importance. A major limitation across reviewed studies was that most could not establish temporal order of changes in mechanisms and PTSS. Including thorough analyses of mechanisms of change beyond cognitions in all future trials and improving the reporting of findings would aid the development and implementation of even more effective interventions.

Differential Effects of Poor Recall and Memory Disjointedness on Trauma Symptoms

Clinical theories of posttraumatic stress disorder (PTSD) suggest that trauma memories are disorganized. In the present study, we examined how trauma-film exposure affects two aspects of memory disorganization, poor memory recall and memory disjointedness, and their relationship to PTSD-like symptoms. In Session 1, 90 healthy participants were exposed to a trauma (n = 60) or a neutral film (n = 30). Cognitive processing styles, memory characteristics, and intrusive memories of the film were assessed. The trauma-film group reported greater memory disjointedness of the worst moments of the film but better memory recall of the film than the neutral-film group. In the trauma-film group, cognitive processing and memory disjointedness were related to intrusive memories and PTSD-like symptoms in the week after film exposure. Memory disjointedness but not poor memory recall mediated the relationship between cognitive processing and intrusions. The findings suggest that different aspects of memory disorganization need to be distinguished to explain PTSD symptoms.

A core role for cognitive processes in the acute onset and maintenance of post-traumatic stress in children and adolescents

BACKGROUND

Post-traumatic stress disorder (PTSD) is a common reaction to trauma in children and adolescents. While a significant minority of trauma-exposed youth go on to have persistent PTSD, many youths who initially have a severe traumatic stress response undergo natural recovery. The present study investigated the role of cognitive processes in shaping the early reactions of child and adolescents to traumatic stressors, and the transition to persistent clinically significant post-traumatic stress symptoms (PTSS).

METHODS

A prospective longitudinal study of youth aged 8-17 years who had attended a hospital emergency department following single trauma was undertaken, with assessments performed at 2-4 weeks (N = 226) and 2 months (N = 208) post-trauma. Acute stress disorder and PTSD were assessed using a structured interview, while PTSS, depression severity and peritraumatic and post-traumatic cognitive processes were assessed using self-report questionnaires. On the basis of their PTSS scores at each assessment, participants were categorised as being on a resilient, recovery or persistent trajectory.

RESULTS

PTSS decreased between the two assessments. Cognitive processes at the 2- to 4-week assessment accounted for the most variance in PTSS at both the initial and follow-up assessment. The onset of post-traumatic stress was associated particularly with peritraumatic subjective threat, data-driven processing and pain. Its maintenance was associated with greater peritraumatic dissociation and panic, and post-traumatic persistent dissociation, trauma memory quality, rumination and negative appraisals. Efforts to deliberately process the trauma were more common in youth who experienced the onset of clinically significant PTSS. Regression modelling indicated that the predictive effect of baseline negative appraisals remained when also accounting for baseline PTSS and depression.

CONCLUSIONS

Cognitive processes play an important role in the onset and maintenance of PTSS in children and adolescents exposed to trauma. Trauma-related appraisals play a particular role when considering whether youth make the transition from clinically significant acute PTSS to persistent PTSS.

Relationship between posttraumatic stress symptoms, caregiving response, and parent mental health in youth exposed to single incident trauma

BACKGROUND

Family factors may alter the risk of developing posttraumatic stress disorder (PTSD) or depression in young people after a traumatic event, but it is not clear which modifiable family variables can be addressed in psychological therapies. This study examined the relationships between family factors (Expressed Emotion [EE] and family accommodation) and psychopathology (posttraumatic stress symptoms; PTSS) in young people following a single incident trauma. Potential mediators of these relationships were also investigated.

METHOD

Sixty-six parent-child dyads (aged 8-17 years) were assessed within one month of attending an Emergency Department. Self-reported PTSS and perceived EE were assessed in young people. Parents' own PTSS, mood symptoms, EE, and accommodating behaviours were also assessed.

RESULTS

Cross-sectional analyses revealed that young person-perceived EE, parent-reported emotional over involvement (EOI) and accommodation behaviours significantly predicted higher PTSS in young people. The stress experienced as a consequence of EE mediated the relationship between young person-perceived EOI and PTSS in young people. Parental PTSS and anxiety were positively correlated with EOI and accommodation. Parental PTSS was not significantly associated with symptoms in young people.

CONCLUSIONS

The results support the hypothesis that EE and accommodation are positively associated with PTSS in young people in the month following a potentially traumatic event. Understanding the child in the context of their family environment and relationships offers an important framework for making sense of and facilitating adaptive adjustment following a traumatic event.

Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents

Important advances in understanding traumatic stress reactions in children and young people have been made in recent years. The aim of this review was to synthesise selected recent research findings, with a focus on their relevance to clinical practice. We therefore address: findings on the epidemiology of trauma exposure and Posttraumatic Stress Disorder (PTSD); recent changes to diagnostic classification; implications for screening and assessment of traumatic stress reactions; and treatment outcome studies including interventions for acute and chronic PTSD, dissemination of effective treatments into community settings, and early interventions. We conclude with recommendations for clinical practice and suggestions for future areas of research.

Centrality of Event and Mental Health Outcomes in Child and Adolescent Natural Disaster Survivors

The experience of trauma could be considered a central event in one's life, such that it could be a core component of one's identity and life story. Indeed, trauma memories are well-remembered, vivid, intense, and easily accessible (Berntsen & Rubin, 2006). The present study investigated the mediating role of sensory-based trauma memory quality in the relationship between centrality of event and mental health outcomes among child and adolescent survivors of a natural disaster (N = 225) in its immediate aftermath. Results of mediation analyses revealed that centrality of trauma event is related to symptoms of acute stress disorder and depression through sensory-based trauma memory quality (indirect effect 95% C.I. [.06, .11] and [.04, .10], respectively). These findings support the contention that centrality of event is associated to heightened accessibility and vividness of sensory-based trauma memory quality, which in turn is related to an increase in trauma-related symptoms in the immediate aftermath of a natural disaster, where the reminders of trauma are particularly salient in the survivors' environment and daily activities.

A Longitudinal Examination of the Relationship between Trauma-Related Cognitive Factors and Internalising and Externalising Psychopathology in Physically Injured Children

Cognitive models of posttraumatic stress disorder (PTSD) highlight maladaptive posttrauma appraisals, trauma memory qualities, and coping strategies, such as rumination or thought suppression, as key processes that maintain PTSD symptoms. Anxiety, depression and externalising symptoms can also present in children in the aftermath of trauma, yet there has been little empirical investigation of the potential relevance of posttrauma cognitive processes for such difficulties. Here, we examined whether: a) acute maladaptive cognitive processes (specifically, maladaptive appraisals, memory qualities, and cognitive coping) were associated with symptoms of PTSD, internalising, and externalising at 1-month posttrauma (T1); and b) changes in these cognitive processes predicted symptom change at a follow-up assessment 6 months later (T2). We recruited 132 6–13 year old children and their parents from emergency departments following the child’s experience of an acute trauma. Children self-reported on their maladaptive appraisals, trauma-memory and cognitive coping strategies, along with symptoms of PTSD, anxiety and depression. Parents also rated children’s internalising and externalising symptoms. We found each cognitive process to be robustly associated with PTSD and non-PTSD internalising symptoms at T1, and change in each predicted change in symptoms to T2. Maladaptive appraisals and cognitive coping were unique predictors of children’s posttrauma internalising. Effects were partially retained even controlling for co-occurring PTSD symptoms. There was less evidence that trauma-specific cognitive processes were associated with externalising symptoms. Findings suggest aspects of cognitive models of PTSD are applicable to broader posttrauma psychopathology, and have implications for how we understand and target children’s posttrauma psychological adjustment.

Adolescents' trajectory through peer loss after a road traffic accident

This mixed method study investigated the short- and long-term effects of peer loss on eight adolescents after a fatal school bus accident. Phenomenological analysis of their retrospective narratives revealed three patterns (living in despair, collecting my pieces, remembering, and moving on). Quantitative findings indicate progressive decrease in post-traumatic stress symptoms severity across time; increase in positive changes in perceptions of self, others, and life between 18 and 34 months; and stable continuing bond with the deceased peers.

The Parent Trauma Response Questionnaire (PTRQ): development and preliminary validation

Background: Following a child's experience of trauma, parental response is thought to play an important role in either facilitating or hindering their psychological adjustment. However, the ability to investigate the role of parenting responses in the post-trauma period has been hampered by a lack of valid and reliable measures. Objectives: The aim of this study was to design, and provide a preliminary validation of, the Parent Trauma Response Questionnaire (PTRQ), a self-report measure of parental appraisals and support for children's coping, in the aftermath of child trauma. Methods: We administered an initial set of 78 items to 365 parents whose children, aged 2-19 years, had experienced a traumatic event. We conducted principal axis factoring and then assessed the validity of the reduced measure against a standardized general measure of parental overprotection and via the measure's association with child post-trauma mental health. Results: Factor analysis generated three factors assessing parental maladaptive appraisals: (i) permanent change/damage, (ii) preoccupation with child's vulnerability, and (iii) self-blame. In addition, five factors were identified that assess parental support for child coping: (i) behavioural avoidance, (ii) cognitive avoidance, (iii) overprotection, (iv) maintaining pre-trauma routines, and (v) approach coping. Good validity was evidenced against the measure of parental overprotection and child post-traumatic stress symptoms. Good test-retest reliability of the measure was also demonstrated. Conclusions: The PTRQ is a valid and reliable self-report assessment of parenting cognitions and coping in the aftermath of child trauma.

The Childhood to Prison Pipeline: Early Childhood Trauma as Reported by a Prison Population

This study explored the degree and type of childhood trauma experienced before the age of 18 years reported by prison inmates. The Adverse Childhood Experiences (ACE) instrument was administered to 328 incarcerated and/or recently released individuals. Participants included women, males convicted of sex offenses, and males convicted of low-risk crimes. The majority of respondents reported levels of childhood trauma substantially above that reported in the general population. Women and males convicted of sex offenses reported the highest degree of trauma. The discussion addresses how rehabilitation counselors can collaborate with others in the counseling profession for earlier identification of individuals who may be experiencing or have experienced childhood trauma and promote better trauma-informed transition services to postsecondary education and employment and reduce levels of incarceration.

Comparing Children's Memories for Negative Versus Positive Events in the Context of Posttraumatic Stress Symptoms

How well children remember negative events is not fully understood. Previous research has failed to simultaneously test memory and perceptions of memory for both negative and positive events. Children (n = 38, 7-17 years) recruited from a hospital following accidental injury were tested for their memory of an injury-producing accident (negative event) and a positive event (unexpectedly receiving a $50 gift voucher). Objective accuracy of memory, memory quality characteristics (e.g., how coherently the event was recalled), children's judgments of their memory (meta-cognitive), and posttraumatic stress (PTS) symptoms were assessed 2 months post-injury. Children's memories for their experiences were verified using witness/parent reports. Memory quality characteristics of children's free recollection were coded with a previously used standardized system. Overall, children showed high levels of accuracy for both events, with little degradation over time. High PTS children showed little evidence of deficits in coherence or organization in their narratives relative to low PTS children. Although in some instances high PTS children judged their memory quality to be poor compared to low PTS children, this depended on how this was assessed (e.g., self-report questionnaire vs. coded narratives). In terms of limitations, it is unclear whether the findings will generalize for memories of repeated events. Witness verification of the accident details itself could be prone to error. In conclusion, the findings are broadly supportive of the proposal made by theorists who argue that trauma memories are recalled no less accurately than other distinctive memories. The role of meta-cognitive elements of children's memory and reporting in PTS is less clear.

The Importance of Memory Specificity and Memory Coherence for the Self: Linking Two Characteristics of Autobiographical Memory

Autobiographical memory forms a network of memories about personal experiences that defines and supports well-being and effective functioning of the self in various ways. During the last three decades, there have been two characteristics of autobiographical memory that have received special interest regarding their role in psychological well-being and psychopathology, namely memory specificity and memory coherence. Memory specificity refers to the extent to which retrieved autobiographical memories are specific (i.e., memories about a particular experience that happened on a particular day). Difficulty retrieving specific memories interferes with effective functioning of the self and is related to depression and post-traumatic stress disorder. Memory coherence refers to the narrative expression of the overall structure of autobiographical memories. It has likewise been related to psychological well-being and the occurrence of psychopathology. Research on memory specificity and memory coherence has developed as two largely independent research domains, even though they show much overlap. This raises some important theoretical questions. How do these two characteristics of autobiographical memory relate to each other, both theoretically and empirically? Additionally, how can the integration of these two facilitate our understanding of the importance of autobiographical memory for the self? In this article, we give a critical overview of memory specificity and memory coherence and their relation to the self. We link both features of autobiographical memory by describing some important similarities and by formulating hypotheses about how they might relate to each other. By situating both memory specificity and memory coherence within Conway and Pleydell-Pearce’s Self-Memory System, we make a first attempt at a theoretical integration. Finally, we suggest some new and exciting research possibilities and explain how both research fields could benefit from integration in future research.

Dysfunctional posttraumatic cognitions as a mediator of symptom reduction in Trauma-Focused Cognitive Behavioral Therapy with children and adolescents: Results of a randomized controlled trial

OBJECTIVE

To investigate whether the change in dysfunctional posttraumatic cognitions (PTC) during Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a mediator of posttraumatic stress symptom (PTSS) reduction in a sample of children and adolescents.

METHOD

A bootstrap mediation analysis was performed to investigate the indirect effect of dysfunctional PTC on treatment outcome in a recently completed RCT study with children and adolescents (n = 123; 7-17 years old) that investigated the effectiveness of TF-CBT.

RESULTS

The mediation model revealed that changes in dysfunctional PTC mediated the relationship between the group (TF-CBT vs. waitlist) and PTSS at the end of treatment.

CONCLUSION

Change in dysfunctional PTC is an important mechanism mediating the reduction of PTSS in TF-CBT. Monitoring dysfunctional PTC throughout treatment might, therefore, be an important factor in optimizing treatment outcome.

Dysfunctional maltreatment-related cognitions in children and adolescents

BACKGROUND

Dysfunctional trauma-related cognitions correlate highly with chronic stress. Studies on maltreatment-related cognitions and their predictors in children and adolescents are rare.

METHODS

The study sample consisted of 231 children aged 8-17 years who had experienced maltreatment including domestic violence, emotional abuse, neglect, physical, and sexual abuse. Using multiple linear regression analysis, gender, age, index-event, multi-type maltreatment, out-of-home-care, and migration background were investigated as possible predictors of dysfunctional maltreatment-related cognitions. Additionally, the associations between dysfunctional cognitions and posttraumatic stress symptoms (PTSS) as well as further internalizing and externalizing symptoms were calculated.

RESULTS

Gender emerged as a significant predictor of dysfunctional maltreatment-related cognitions. Moreover, there was an interaction effect of gender and age, with female adolescents showing most dysfunctional cognitions. Furthermore, experiencing five different maltreatment types had an impact, leading to more dysfunctional cognitions compared to single-type maltreatment. Dysfunctional maltreatment-related cognitions correlated highly with PTSS and internalizing symptoms, and moderately with externalizing symptoms.

CONCLUSIONS

Dysfunctional maltreatment-related cognitions are associated with psychological symptoms after maltreatment and, therefore, need to be addressed in assessment and treatment. Trial registration DRKS00003979. Registered 03 July 2012.

Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms

OBJECTIVE

To understand the meaning of trauma narration, we examined changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy (TF-CBT) and explored the relationship between changes in narratives and in posttraumatic stress.

METHOD

The sample consisted of 12 non-responders and 12 maximum-responders to treatment (M = 14.3, SD = 2.35, range = 10-17; 75% girls). The youth were assessed with the Clinical-Administered PTSD-Scale for Children and Adolescents both pre- and post-treatment. Their first and last narratives were coded according to a standardized coding manual.

RESULTS

For the group as a whole there was an increase in organized thoughts and reports of internal events (e.g., descriptions of thoughts and feelings), while narrative fragmentation decreased. There were no significant narrative changes in external events (e.g., descriptions of actions and dialogues). Max-responders differed significantly from non-responders in developing more organized thoughts. We did not find a significant relationship between changes in narratives and changes in posttraumatic stress symptoms (PTSS).

CONCLUSIONS

Youth receiving TF-CBT develop narratives that contain more organized thoughts and a greater internal focus, which are both thought to be helpful for traumatized youth. However, more coherent and organized trauma narratives were not related to reductions in PTSS. Clinical or methodological significance of this article: This study suggests that trauma-focused cognitive behavioral therapy contributes to more organized and coherent trauma narratives for traumatized youth. Although, this may be important and contribute to meaning making, therapist should be aware that this may not be sufficient in reducing posttraumatic stress symptoms in youth.

Trauma memory characteristics and the development of acute stress disorder and post-traumatic stress disorder in youth

BACKGROUND & OBJECTIVES

The present study addresses gaps in knowledge regarding the association between trauma memory processes and posttraumatic stress responses in youth. Our primary goal was to explore the relative contribution of perceptions of trauma memory quality versus narrative trauma memory characteristics to explain overall adjustment.

METHODS

Children (N = 67) were interviewed within four weeks (T1) of an injury leading to hospital treatment and then again eight weeks later (T2). In each interview, the child told a trauma narrative (which were later coded), and answered the Trauma Memory Quality Questionnaire (Meiser-Stedman, Smith, Yule, & Dalgleish, 2007a), a self-report measure indexing the sensory, fragmented, and disorganised characteristics of trauma memory. They then completed measures of Acute Stress Disorder (ASD) symptoms and associated psychopathology at T1 and measures of Posttraumatic Stress (PTS) symptoms and associated psychopathology at T2.

RESULTS

Self-reported trauma memory characteristics predicted ASD symptoms cross-sectionally at T1 and PTS symptoms prospectively over time. At both time points, self-reported trauma memory characteristics accounted for all of the unique variance in symptoms initially explained by narrative characteristics. A reduction in self-report ratings, but not the hypothesised narrative features (e.g., disorganised or lexical elements of the narrative), significantly predicted a reduction in PTS symptoms over time.

LIMITATIONS

The small sample size and the absence of a within-subjects narrative control were the main limitations of the study.

CONCLUSIONS

These findings underscore the importance of self-reported trauma memory characteristics to the aetiology of PTSD.

The relationship between posttraumatic stress symptoms and narrative structure among adolescent terrorist-attack survivors

BACKGROUND

The structure of trauma narratives is considered to be related to posttraumatic stress symptomatology and thus the capacity to make a coherent narrative after stressful events is crucial for mental health.

OBJECTIVE

The aim of this study is to understand more of the relationship between narrative structure and posttraumatic stress symptoms (PTSS). More specifically, we investigated whether internal and external focus, organization, fragmentation, and length differed between two groups of adolescent survivors of a mass shooting, one group with low levels of PTSS and one group with high levels of PTSS.

METHOD

The sample comprised 30 adolescents who survived the shooting at Utøya Island in Norway in 2011. They were interviewed 4-5 months after the shooting and provided a free narrative of the event. PTSS were assessed using the UCLA Posttraumatic Stress Disorder Reaction Index (PTSD-RI).

RESULTS

We found that survivors with high levels of PTSS described more external events and fewer internal events in their narratives compared with survivors with low levels of symptoms. The analysis also showed that especially narratives containing more descriptions of dialogue and fewer organized thoughts were related to higher levels of PTSS. The groups did not differ in levels of narrative fragmentation or in length of the narratives.

CONCLUSION

Specific attributes of narrative structure proved to be related to the level of PTSS. On the basis of our results, we can recommend that practitioners focus especially on two elements of the trauma narratives, namely, the amount of external events, particularly dialogues, within the narrative and the number of organized thoughts. Participants with high levels of PTSS provided trauma narratives with low amount of organized (explanatory) thoughts accompanied by detailed descriptions of dialogues and actions, which is indicative for "here and now" quality of recall and a lack of trauma processing.

Psychometric Properties of the German Version of the Child Post-Traumatic Cognitions Inventory (CPTCI-GER)

Dysfunctional trauma-related cognitions are associated with posttraumatic stress disorder (PTSD). The psychometric properties of the German version of the Child Post-Traumatic Cognitions Inventory (CPTCI-GER) were assessed in a sample of 223 children and adolescents (7-16 years) with a history of different traumatic events. Confirmatory factor analyses supported the original two-factor structure--permanent and disturbing change (CPTCI-PC) and fragile person in a scary world (CPTCI-SW). The total scale and both subscales showed good internal consistency. Participants with PTSD had significantly more dysfunctional trauma-related cognitions than those without PTSD. Dysfunctional posttraumatic cognitions correlated significantly with posttraumatic stress symptoms (PTSS; r = .62), depression (r = .71), and anxiety (r = .67). The CPTCI-GER has good psychometric properties and may facilitate evaluation of treatments and further research on the function of trauma-related cognitions in children and adolescents. (Partial) correlations provide empirical support for the combined DSM-5 symptom cluster negative alterations in cognitions and mood.

Participant, rater, and computer measures of coherence in posttraumatic stress disorder

We examined the coherence of trauma memories in a trauma-exposed community sample of 30 adults with and 30 without posttraumatic stress disorder. The groups had similar categories of traumas and were matched on multiple factors that could affect the coherence of memories. We compared the transcribed oral trauma memories of participants with their most important and most positive memories. A comprehensive set of 28 measures of coherence including 3 ratings by the participants, 7 ratings by outside raters, and 18 computer-scored measures, provided a variety of approaches to defining and measuring coherence. A multivariate analysis of variance indicated differences in coherence among the trauma, important, and positive memories, but not between the diagnostic groups or their interaction with these memory types. Most differences were small in magnitude; in some cases, the trauma memories were more, rather than less, coherent than the control memories. Where differences existed, the results agreed with the existing literature, suggesting that factors other than the incoherence of trauma memories are most likely to be central to the maintenance of posttraumatic stress disorder and thus its treatment.

[Supporting a teenager confronted with a traumatic experience]

Everyone reacts differently to a traumatic event. There is a risk of underestimating a teenager's traumatic experience by considering only the usual post-traumatic stress diagnosis criteria. However, when the trauma has not been able to be sufficiently developed, the adolescent's suffering is revealed through their behaviour. The therapeutic support of the youngster and their family enables them to reposition the traumatic event within the continuity of their history and to relaunch a thought process, often frozen by the traumatic experience.

Psychometric properties of the Posttraumatic Cognition Inventory within a Northern Ireland adolescent sample

OBJECTIVES

This study sought to investigate the psychometric properties of the Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999, Psychol. Assess., 11, 303) among a cohort of older adolescents and to determine the relationship between post-traumatic cognitions and a variety of psychological outcomes including depression, anxiety, stress, and loneliness.

METHODS

The PTCI was investigated among a large sample (N = 785) of Northern Irish adolescents. Confirmatory factor analysis and composite reliability analysis were conducted to assess the psychometric properties of the scale.

RESULTS

The familiar three-factor solution of negative cognitions of self, negative cognitions of the world and others, and self-blame was supported; however, it was necessary to remove eight items from the original 33-item scale. The three-factor structure was subsequently demonstrated to be factorially invariant across gender and to possess satisfactory internal reliability. The three PTCI factors were found to correlate with depression, anxiety, stress, and three dimensions of loneliness.

CONCLUSION

These results provide the first piece of evidence that older adolescents cognitively respond to trauma in a similar manner to adults, that the PTCI is factorially invariant between genders, and that trauma cognitions are correlated with feelings of loneliness. The contextual dependent nature of the structure of the PTCI factors is discussed in relation to future research efforts.

PRACTITIONER POINTS

The PTCI is a valid and reliable measure of trauma-related cognitions among adolescents and works equally well for male adolescents and female adolescents. Trauma cognitions are associated with a range of mental health problems beyond post-traumatic stress disorder including depression, anxiety, stress, and various aspects of loneliness. Reductions in trauma cognitions in survivors of trauma will have wide-scale clinical benefits to patient well-being. The exact structure and make-up of items in the PTCI may well be dependent on culture, context, and the nature of the trauma. The study is limited due to the fact that the authors could not assess the severity of the trauma experienced by the adolescent sample.

Trauma and traumatic loss in pregnant adolescents: the impact of Trauma-Focused Cognitive Behavior Therapy on maternal unresolved states of mind and Posttraumatic Stress Disorder

Pregnant adolescents are a group at high risk for exposure to traumatic experiences. The present study aimed to examine if Trauma-Focused Cognitive Behavior Therapy (TF-CBT) typically applied to Posttraumatic Stress Disorder (PTSD), could also be applied to unresolved states of mind in a sample of socially at-risk pregnant adolescents. Forty-three adolescents who were in their second trimester of pregnancy and who also had positive indices of unresolved states of mind or symptoms of PTSD were randomly assigned to either the treatment as usual (parenting classes) or intervention (parenting classes + TF-CBT) group. Adolescent mother-infant dyads were then re-assessed at infant ages 6 and 12 months on a broad range of measures, including those specific to attachment, as well as to PTSD, and adolescent behavioral adjustment. Twenty-six of the 43 (60%) recruited subjects completed all components of the study protocol. Although there were no significant effects of the TF-CBT intervention on maternal attachment, infant attachment, PTSD diagnosis and adolescent behavioral adjustment, several study limitations restrict our ability to draw firm conclusions about the efficacy of TF-CBT for use in pregnant adolescents with complex trauma. The discussion offers insight and guidance for clinical work and future intervention research efforts with this vulnerable population.

The Dutch version of the Child Posttraumatic Cognitions Inventory: validation in a clinical sample and a school sample

BACKGROUND

With the inclusion of trauma-related cognitions in the DSM-5 criteria for posttraumatic stress disorder (PTSD), the assessment of these cognitions has become essential. Therefore, valid tools for the assessment of these cognitions are warranted.

OBJECTIVE

The current study aimed at validating the Dutch version of the Child Posttraumatic Cognitions Inventory (CPTCI).

METHOD

We included children aged 8-19 years in our study and assessed the factor structure, reliability and validity of the CPTCI in a clinical sample (n=184) and a school sample (n=318).

RESULTS

Our results supported the two-factor structure of the CPTCI and showed good internal consistency for the total scale and the two subscales. We found significant positive correlations between the CPTCI and measures of PTSD, depression, and anxiety disorder. The CPTCI correlated negatively with a measure of quality of life. Furthermore, we found significantly higher scores in the clinical sample than in the school sample. For children who received treatment, we found that a decrease in CPTCI scores was accompanied by a decrease in posttraumatic stress symptoms and comorbid problems indicating that the CPTCI is able to detect treatment effects.

CONCLUSION

Overall, our results suggest that the Dutch CPTCI is a reliable and valid instrument.

How can Saudi Arabia use the Decade of Action for Road Safety to catalyse road traffic injury prevention policy and interventions?

Motor vehicle accidents are the leading cause of death in adolescents and young adults worldwide. Nearly three-quarters of road deaths occur in developing countries and men comprise a mean 80% of casualties. The rate of road traffic accidents caused by four-wheeled vehicles is the highest globally reported road traffic accidents statistic. In Saudi Arabia, the motor vehicle is the main means of transportation with one person killed and four injured every hour. Over 65% of accidents occur because of vehicles travelling at excess speed and/or drivers disobeying traffic signals. Road traffic injuries cause considerable economic losses to victims, their families, and to nations as a whole. Strategic prevention plans should be implemented soon by various sectors (health, police, transport, and education) to decrease the mortality and morbidity among adolescent and young age group. Strong and effective coordination between ministry of health and other ministries together with World Health Organization and other related organisations will be an important step towards implementing the international Decade of Action for Road Safety (2011-2020). The aim of this review article is to highlight some aspects of the health impacts of road traffic accidents.

Research Methods in Child Disaster Studies: A Review of Studies Generated by the September 11, 2001, Terrorist Attacks; the 2004 Indian Ocean Tsunami; and Hurricane Katrina

BACKGROUND

A comprehensive review of the design principles and methodological approaches that have been used to make inferences from the research on disasters in children is needed.

OBJECTIVE

To identify the methodological approaches used to study children's reactions to three recent major disasters-the September 11, 2001, attacks; the 2004 Indian Ocean Tsunami; and Hurricane Katrina.

METHODS

This review was guided by a systematic literature search.

RESULTS

A total of 165 unduplicated empirical reports were generated by the search and examined for this review. This included 83 references on September 11, 29 on the 2004 Tsunami, and 53 on Hurricane Katrina.

CONCLUSIONS

A diversity of methods has been brought to bear in understanding children's reactions to disasters. While cross-sectional studies predominate, pre-event data for some investigations emerged from archival data and data from studies examining non-disaster topics. The nature and extent of the influence of risk and protective variables beyond disaster exposure are not fully understood due, in part, to limitations in the study designs used in the extant research. Advancing an understanding of the roles of exposure and various individual, family, and social factors depends upon the extent to which measures and assessment techniques are valid and reliable, as well as on data sources and data collection designs. Comprehensive assessments that extend beyond questionnaires and checklists to include interviews and cognitive and biological measures to elucidate the negative and positive effects of disasters on children also may improve the knowledge base.

Treatment of posttraumatic stress disorder in children and adolescents

PURPOSE OF REVIEW

We review recent evidence regarding risk factors for childhood posttraumatic stress disorder (PTSD) and treatment outcome studies from 2010 to 2012 including dissemination studies, early intervention studies and studies involving preschool children.

RECENT FINDINGS

Recent large-scale epidemiological surveys confirm that PTSD occurs in a minority of children and young people exposed to trauma. Detailed follow-up studies of trauma-exposed young people have investigated factors that distinguish those who develop a chronic PTSD from those who do not, with recent studies highlighting the importance of cognitive (thoughts, beliefs and memories) and social factors. Such findings are informative in developing treatments for young people with PTSD. Recent randomized controlled trials (RCTs) confirm that trauma-focused cognitive behaviour therapy (TF-CBT) is a highly efficacious treatment for PTSD, although questions remain about effective treatment components. A small number of dissemination studies indicate that TF-CBT can be effective when delivered in school and community settings. One recent RCT shows that TF-CBT is feasible and highly beneficial for very young preschool children. Studies of early intervention show mixed findings.

SUMMARY

Various forms of theory-based TF-CBT are highly effective in the treatment of children and adolescents with PTSD. Further work is needed to replicate and extend initial promising outcomes of TF-CBT for very young children. Dissemination studies and early intervention studies show mixed findings and further work is needed.