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

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

OBJECTIVES

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

'My child could have died': counterfactual thoughts and psychological distress in parents of trauma survivors

Background: After exposure to a potentially traumatic event, survivors may experience thoughts about 'what could have happened', referred to as counterfactual thoughts (CFTs). CFTs have been found to have a negative impact on survivors' mental health. This is the first study to investigate whether parents of trauma survivors experience CFTs and the association with psychological distress in this group.Objective: The main aim of the present study is to investigate CFTs in parents of trauma survivors and the relationship between the frequency and vividness of CFTs and psychological distress.Method: The participants (N = 310, 191 females) were parents of the youths targeted in the terror attack on Utøya island, Norway, in 2011. Frequency and vividness of CFTs, posttraumatic stress reactions (PTSR), and symptoms of anxiety and depression were measured 8.5-9 years post-terror.Results: The majority of the parents (74%) reported having experienced CFTs at some time point since the attack. For almost one-third of the parents, CFTs were still present more than eight years after the attack. Higher frequency and vividness of CFTs were uniquely associated with higher levels of PTSR, anxiety, and depression.Conclusion: The present findings suggest that frequent and vivid CFTs may contribute to mental health problems in parents of trauma survivors and should be addressed in therapy.

Using experience sampling methodology (ESM) to improve our understanding of day-to-day intrusion frequency and related distress in survivors of trauma

BACKGROUND AND OBJECTIVES

Cognitive models of posttraumatic stress disorder (PTSD) suggest that appraisals of traumatic sequelae and subsequent distress drive the development and maintenance of PTSD. Posttraumatic research has relied heavily on macro-longitudinal designs, with weeks or months between assessments of trauma-related cognitions and symptoms. The present study uses experience sampling methodology (ESM) better understand the day-to-day experiences of trauma exposed individuals.

METHODS

One-hundred trauma exposed adults reported their posttraumatic symptoms, interpretations, and behaviours four times a day over a 10-day ESM period.

RESULTS

As anticipated, within-person fluctuations in negative appraisals of intrusions and maladaptive coping strategies (e.g., thought suppression) were significantly positively associated with intrusion frequency and related distress. In all cases, the associations for negative appraisals and maladaptive coping were stronger with intrusion related distress than intrusion frequency.

LIMITATIONS

The observed contemporaneous associations only demonstrate that variables reliably fluctuated together and cannot indicate causality.

CONCLUSIONS

The findings demonstrate that day-to-day fluctuations in trauma related perceptions and sequelae are significant and should be explored alongside broader individual differences to advance our understanding of the development, maintenance, and treatment of PTSD.

The PTSD Symptom Presentation and the Effect of Polytrauma on PTSD Symptom Clusters Among Young People Who Have Experienced Commercial Sexual Exploitation and Trafficking

Purpose

The purpose of this study was to describe the PTSD symptom presentation (including dissociative symptoms) of PTSD using the Diagnostic and Statistical Manual of Mental Disorders 5 th Edition diagnostic criteria and explore associations between the symptom severity for each of the four PTSD symptom clusters and polytrauma, defined as multiple exposures to different categories of potentially traumatic events.

Methods

This is a secondary analysis of cross-sectional program evaluation data among 95 young people (aged 11-19) at therapy initiation in a southeastern state in the U.S. We used descriptive statistics and multivariable linear regression to test study objectives.

Results

Eighty-one respondents (90.0%) experienced a potentially traumatic event in ≥ 2 trauma categories, in addition to experiencing CSE/T. Approximately two-thirds of respondents experienced clinically significant PTSD symptoms for each symptom cluster. Of the 31 young people who met full criteria for PTSD, 9 met criteria for the standard PTSD diagnosis, while 22 met criteria for the dissociative subtype of PTSD. On average, experiencing additional trauma categories was associated with substantively higher PTSD symptom cluster scores for each cluster.

Conclusions

These findings support the need for a comprehensive assessment of trauma symptoms that includes cluster-specific PTSD symptoms. They also underscore the need to assess the full breadth and chronicity of trauma experiences to guide treatment planning and delivery, targeting specific domains of trauma impact. These findings can also inform the tailoring and adaptation of evidence-based interventions and strategies to better meet the needs of young people who have experienced CSE/T.

Associations between the Trauma Memory Quality Questionnaire and posttraumatic stress symptoms in youth: A systematic review and meta-analysis

Cognitive models of posttraumatic stress disorder (PTSD) propose that trauma memory characteristics are implicated in the etiology of the disorder. Empirical support for cognitive models in youth is necessary to ensure psychological interventions are based on appropriate theory. This meta-analysis was conducted to quantitatively investigate the strength of the associations between self-reported trauma memory characteristics (e.g., sensory and temporal features), measured using the Trauma Memory Quality Questionnaire (TMQQ), and posttraumatic stress symptoms (PTSS) in children and adolescents. PsycINFO, MEDLINE, CINAHL, PTSDPubs, and ProQuest Dissertations and Theses Global were searched for relevant literature. In total, 11 studies (N = 1,270 participants) met the inclusion criteria for the random-effects meta-analysis. A large effect size was observed for the association between trauma memory characteristics and PTSS, r = .51, 95% CI [.44, .58], and was maintained in subgroup analyses of the prospective association between trauma memory characteristics and later PTSS (k = 5, n = 6 28), r = .51, 95% CI [.42, .59]. A slightly larger effect size was observed in subgroup analyses of the cross-sectional association between trauma memory characteristics and concurrent PTSS (k = 11, N = 1,270), r = .62, 95% CI [.53, .70]. Sensitivity analyses on study quality, TMQQ alteration, chronic trauma exposure, geographical location, and PTSS measure supported the robustness of these results. These findings provide empirical support for the role of trauma memory characteristics in PTSS, congruent with cognitive models, suggesting this theoretical framework is appropriate for youth populations. Limitations and recommendations for future research are discussed.

Breaking up with my idol: A qualitative study of the psychological adaptation process of renouncing fanship

Introduction

This study aimed to explore the psychological adaptation process of renouncing fanship due to para-loveshock in the context of fandom culture.

Methods

We adopted netnography to explore social media platforms used by fans in China (Weibo, WeChat, and Douban) as research fields for 3 years.

Results

(1) The process of "breaking up with" or renouncing an idol can be divided into three phases: the resistance phase with acute stress, the negotiation phase with bargaining, and the recovery phase with attachment reconstruction. In the resistance phase, fans displayed acute stress responses due to loveshock in psychological, physical, and behavioral aspects. In the negotiation phase, fans faced four barriers to renouncement: cognitive dissonance, emotional attachment, behavioral dependence, and social threat. They bargained within the three types of cognitive framework before deciding to "leave" or "re-follow" their idol. In the recovery phase, fans adopted two types of strategies to promote recovery: healing the past and facing the future. Healing the past involved public outcry, sharing their breakup plans, cognitive reconstruction, and seeking closure to the fan role. Facing the future involved switching environments, seeking new interests, and inhibiting the re-intrusion of trauma cues. (2) Internal factors affecting the psychological adaptation process of renouncement include the level of initiative, attribution styles, experience, attachment status and core belief systems, and alternative lifestyles; external factors include social support, peer pressure from the fan community, life stressors, and types and impact of traumatic events. (3) Based on the two dimensions of orientation and commitment, fans were classified into four types: short-term rational, short-term passionate, bounded loyal, and unconditionally loyal, corresponding to non-traumatic, stressful, accumulated, and traumatic breakup processes, respectively. (4) The post-renouncement growth of fans mainly manifested in the development of mental modes, coping skills toward trauma, emotional adaptation experience, and behavior patterns.

Implications

This investigation of the recovery process from para-loveshock after renouncement of fanship can provide theoretical and practical insights into the development of psychological resilience for fans, reduction of the psychological distress and negative outcomes, and public governance on social media platform and cyber pop culture industry.

Negative Posttraumatic Cognitions in 4- to 8-year-old Children following Maltreatment

PURPOSE

Research has shown that children and adolescents suffering from posttraumatic stress often have negative posttraumatic cognitions such as negative appraisals of the trauma sequel that increase mental health problems. However, little is known about posttraumatic cognitions in young children. The aim of this study was to investigate negative posttraumatic cognitions in 4- to 8-year-old children following maltreatment. We also examined their association with child age and well-being as well as caregiver psychopathology.

METHODS

The study includes N = 112 caregiver-child dyads with children's mean age of M = 6.2 (SD = 1.1) years. Children had experienced physical abuse, emotional abuse, neglect, sexual victimization, and/or domestic violence prior to participation. Posttraumatic cognitions were assessed using a short child interview including four items adapted from the Child Posttraumatic Cognitions Inventory (CPTCI; Meiser-Stedman et al in Journal of Child Psychology and Psychiatry, 50(4), 432-440, 2009).

RESULTS

Completion of the interview about posttraumatic cognitions was independent from child's age. Higher levels of negative posttraumatic cognitions were significantly associated with a higher cumulative maltreatment score (r = .35) and higher scores of posttraumatic stress symptoms (r = .39). There was no significant correlation with parent variables.

CONCLUSION

These findings indicate that posttraumatic cognitions might be an important diagnostic and treatment target for 4- to 8-year-old children.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-022-00455-4.

Posttraumatic Cognitions and Posttraumatic Stress Symptoms Among Young People Who Have Experienced Commercial Sexual Exploitation and Trafficking

OBJECTIVES

The impact of posttraumatic cognitions on the development and maintenance of posttraumatic stress symptoms (PTSS) is understudied among children and adolescents who have experienced commercial sexual exploitation/trafficking (CSE/T). The objectives of this study were to (1) explore posttraumatic cognitions among help-seeking young people aged 11-19 who have experienced CSE/T; (2) determine whether experiencing direct violence, witnessing violence, polyvictimization (ie, multiple exposures to different categories of potentially traumatic events), or demographic characteristics differentially affect whether these young people meet clinical criteria for posttraumatic cognitions using established cutoffs; and (3) explore associations between posttraumatic cognitions and PTSS among young people who have experienced CSE/T.

METHODS

This study is a secondary analysis of a baseline cross-sectional survey of 110 young people with substantiated CSE/T experiences who started trauma-focused cognitive behavioral therapy (mean [SD] age = 15.8 [1.5]) from August 1, 2013, through March 31, 2020, in a southeastern US state. We used descriptive statistics, adjusted modified Poisson regression, and adjusted linear regression to test study objectives.

RESULTS

Fifty-seven of 110 (51.8%) young people aged 11-19 met clinical criteria for posttraumatic cognitions. Increased age and a greater number of trauma categories experienced were significantly associated with meeting clinical criteria for posttraumatic cognitions. On average, higher posttraumatic cognition scores were associated with higher PTSS scores, controlling for demographic characteristics (β = 0.95; 95% CI, 0.64-1.26).

CONCLUSIONS

These findings underscore the importance of assessing comprehensive trauma history and PTSS of young people who have experienced CSE/T, with added usefulness of measuring cognitive appraisals to inform a therapeutic treatment plan. Measuring cognitive appraisals that may influence PTSS and therapeutic success can ensure an effective public health response for this population.

Lifetime adversity interacts with peritraumatic data-driven processing to predict intrusive memories

BACKGROUND AND OBJECTIVES

Although most trauma survivors experience some intrusive recollections of the traumatic event, only few subsequently develop posttraumatic stress disorder (PTSD). A well-established proximal risk-factor predictive of post-trauma psychopathology is peritraumatic cognitive processing. Another, more distal risk-factor is pre-trauma lifetime adversity. The present experimental analogue study tested the hypothesis that pre-trauma lifetime adversity interacts with peritraumatic perceptual (i.e., data-driven) processing to predict intrusive memory development.

METHODS

Fifty-three young adult women (non-clinical sample) indicated how much data-driven and conceptual processing they had engaged in while watching aversive film-clips (i.e., analogue trauma). On the subsequent three days, they reported intrusions of those clips. Moderation analyses tested for an interaction effect between lifetime adversity and data-driven processing in predicting intrusion load (number of intrusions weighted for their overall distress).

RESULTS

Increased data-driven processing predicted intrusion load primarily in individuals reporting more than three lifetime adversities, explaining 55% of variance. No such relationship was found for conceptual processing.

LIMITATIONS

Present analogue findings have yet to be replicated in a clinical population. Moreover, the conceptual processing scale was restricted by low internal consistency.

CONCLUSION

Present findings support the idea that intrusions are the result of poorly elaborated and primarily perceptually-formed memory traces; however, this was primarily the case in vulnerable individuals reporting several lifetime adversities. Results replicate the importance of peritraumatic processing in intrusion development but additionally point to a moderating effect of lifetime adversity.

Trajectory of post-traumatic stress and depression among children and adolescents following single-incident trauma

OBJECTIVE

Post-traumatic stress disorder and depression have high comorbidity. Understanding their relationship is of clinical and theoretical importance. A comprehensive way to understand post-trauma psychopathology is through symptom trajectories. This study aims to look at the developmental courses of PTSD and depression symptoms and their interrelationship in the initial months post-trauma in children and adolescents.

METHODS

Two-hundred-and-seventeen children and adolescents aged between eight and 17 exposed to single-event trauma were included in the study. Post-traumatic stress symptoms (PTSS) and depression symptoms were measured at 2 weeks, 2 months and 9 months, with further psychological variables measured at the 2-week assessment. Group-based trajectory modelling (GBTM) was applied to estimate the latent developmental clusters of the two outcomes. Logistic regression was used to identify predictors associated with high symptom groups.

RESULTS

The GBTM yielded a three-group model for PTSS and a three-group model for depression. PTSS trajectories showed symptoms reduced to a non-clinical level by 9 months for all participants (if they were not already in the non-clinical range): participants were observed to be resilient (42.4%) or recovered within 2 months (35.6%), while 21.9% experienced high level PTSS but recovered by 9 months post-trauma. The depression symptom trajectories predicted a chronic non-recovery group (20.1%) and two mild symptom groups (45.9%, 34.0%). Further analysis showed high synchronicity between PTSS and depression groups. Peri-event panic, negative appraisals, rumination and thought suppression at 2 weeks predicted slow recovery from PTSS. Pre-trauma wellbeing, post-trauma anxiety and negative appraisals predicted chronic depression.

CONCLUSIONS

Post-trauma depression was more persistent than PTSS at 9 months in the sampled population. Cognitive appraisal was the shared risk factor to high symptom groups of both PTSS and depression.

Four perspectives on traumatized youths' therapeutic alliance: Correspondence and outcome predictions

OBJECTIVE

Does the rater-perspective of youths' therapeutic alliance matter? To answer this, we evaluated the relationships between four perspectives of youths' alliance, then, we examined whether each perspective and potential discordance between the perspectives predicted outcomes.

METHOD

Participants were 65 youth (M age = 15.11, SD = 2.14; 76.9% girls) undergoing trauma-focused cognitive behavioral therapy (TF-CBT) and their therapists (n = 24). Youths' alliance was rated by youth, therapists and parents using the Therapeutic Alliance Scale for Children-revised and by observers using the Therapy Process Observational Coding System-Alliance scale. Posttraumatic stress symptoms (PTSS) were assessed with the Child PTSD Symptom Scale (CPSS) and the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA).

RESULTS

The alliance ratings by youth-parent, parent-therapist, and therapist-observer significantly correlated. Only a higher youth-rated alliance significantly predicted fewer PTSS. Furthermore, a higher therapist-rated than youth-rated alliance significantly predicted higher scores on CPSS and CAPS-CA, and a higher parent-rated than youth-rated alliance predicted significantly higher CPSS score.

CONCLUSION

Therapists should explicitly check in with youth clients about the alliance; because only youths' evaluation of their alliance predicted the outcome and an overestimation of their alliance by therapists and parents predicted more PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

The correlation between social support and post-traumatic stress disorder in children and adolescents: A meta-analysis

BACKGROUND

Risk factors exploring the link between trauma and Post-traumatic stress disorder (PTSD) have been extensively explored in adults, however, less is known about child and adolescent populations.

METHODS

The current meta-analysis aimed to systematically evaluate and summarise the child focused literature to estimate the strength of the relationship between social support and PTSD symptoms following traumatic events.

RESULTS

Fifty primary studies reporting an effect size for the relationship between total social support scale or a source of social support with PTSD were included. A small effect size was found for the relationship between social support and PTSD (r = -0.12, 95% CI -0.16 to -0.07, k = 41), with large heterogeneity (I² = 90.3%). The effect sizes between peer support (r = -0.18, 95% CI -0.10 to -0.25, k = 12), family support (r = -0.16, 95% CI -0.09 to -0.24, k = 13) and teacher support (r = -0.20, 95% CI -0.15 to -0.24, k = 5) and PTSD were also small. Moderator analyses indicated that studies reporting on participants exposed to abuse (r = -0.25) and correlations based on univariate data (r = -0.14) had higher correlations and medium heterogeneity. The main effect size was robust to publication bias and study quality.

LIMITATIONS

The cross-sectional design of the studies limits the findings and future research using prospective and longitudinal design would help to explain the relationship between social support and PTSD further.

CONCLUSIONS

The current review suggests that social support may only play a small role in protecting against PTSD and future research may benefit from exploring the link between post-trauma cognitions and social support.

DECRYPT trial: study protocol for a phase II randomised controlled trial of cognitive therapy for post-traumatic stress disorder (PTSD) in youth exposed to multiple traumatic stressors

BACKGROUND

Post-traumatic stress disorder (PTSD) is a distressing and disabling condition that affects significant numbers of children and adolescents. Youth exposed to multiple traumas (eg, abuse, domestic violence) are at particular risk of developing PTSD. Cognitive therapy for PTSD (CT-PTSD), derived from adult work, is a theoretically informed, disorder-specific form of trauma-focused cognitive-behavioural therapy. While efficacious for child and adolescent single-event trauma samples, its effectiveness in routine settings with more complex, multiple trauma-exposed youth has not been established. The Delivery of Cognitive Therapy for Young People after Trauma randomised controlled trial (RCT) examines the effectiveness of CT-PTSD for treating PTSD following multiple trauma exposure in children and young people in comparison with treatment as usual (TAU).

METHODS/DESIGN

This protocol describes a two-arm, patient-level, single blind, superiority RCT comparing CT-PTSD (n=60) with TAU (n=60) in children and young people aged 8-17 years with a diagnosis of PTSD following multiple trauma exposure. The primary outcome is PTSD severity assessed using the Children's Revised Impact of Event Scale (8-item version) at post-treatment (ie, approximately 5 months post-randomisation). Secondary outcomes include structured interview assessment for PTSD, complex PTSD symptoms, depression and anxiety, overall functioning and parent-rated mental health. Mid-treatment and 11-month and 29-month post-randomisation assessments will also be completed. Process-outcome evaluation will consider which mechanisms underpin or moderate recovery. Qualitative interviews with the young people, their families and their therapists will be undertaken. Cost-effectiveness of CT-PTSD relative to TAU will be also be assessed.

ETHICS AND DISSEMINATION

This trial protocol has been approved by a UK Health Research Authority Research Ethics Committee (East of England-Cambridge South, 16/EE/0233). Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations and clinical workshops.

TRIAL REGISTRATION

ISRCTN12077707. Registered 24 October 2016 (http://www.isrctn.com/ISRCTN12077707). Trial recruitment commenced on 1 February 2017. It is anticipated that recruitment will continue until June 2021, with 11-month assessments being concluded in May 2022.

Posttraumatische Kognitionen als Mediator zwischen auslösendem Ereignis und posttraumatischen Belastungssymptomen in Kindheit und Jugend

Zusammenfassung. Theoretischer Hintergrund: Dysfunktionale posttraumatische Kognitionen über das Selbst und die Welt als Folge traumatischer Erfahrungen können die Entwicklung einer posttraumatischen Belastungsstörung begünstigen. Fragestellung: Diese Studie untersucht das Wirkgeflecht zwischen der Art des traumatischen Ereignisses (interpersonell/akzidentiell), posttraumatischen Kognitionen und posttraumatischen Belastungssymptomen in Kindheit und Jugend. Methode: Erhoben wurden Daten von N = 48 Jugendlichen (9 – 17 Jahren) mittels Selbstbericht. Ergebnisse: Die Mediationsanalyse zeigte, dass posttraumatische Kognitionen als signifikanter Mediator für interpersonelle im Vergleich zu akzidentiellen Erfahrungen wirkten. Diskussion: Die Ergebnisse zeigen, dass mit interpersonellen Traumata konfrontierte Kinder und Jugendliche in besonderem Maße Erschütterungen des Selbst- und Weltbildes ausgesetzt sind. Die Erkenntnisse betonen die Bedeutung kognitiver Elemente in der Traumatherapie mit Kindern und Jugendlichen.

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.

Changes in the Network Structure of Post-traumatic Stress Disorder Symptoms Among Earthquake Exposed Adolescents in China: A 2-Year Longitudinal Study

Despite considerable studies focused on the symptoms of posttraumatic stress disorder (PTSD), little is understood about how symptoms of PTSD naturalistically change over time. Using network analyses approaches, the current study aimed to understand the nature of the association between PTSD symptoms at different time points among adolescents who experienced an earthquake. This study enrolled 900 youth survivors who completed 3 assessments with the Child PTSD Symptom Scale at 1 year, 1.5 years, and 2 years after the Wenchuan earthquake. A graphical Gaussian model (GGM) was used to investigate how symptom networks changed across these time points and to identify the symptoms that were the most central within the network. Results from GGM indicated that different symptoms were observed to have highest centrality at different time points. Feeling distant or cut off from others, avoid thoughts and feelings about the trauma, and feeling irritable or having angry outbursts appeared as the node with highest centrality at 1 year (T1), 1.5 years (T2), and 2 years (T3) post-earthquake, respectively.

Predictors and moderators of treatment outcome for single incident paediatric PTSD: a multi-centre randomized clinical trial

BACKGROUND

With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments.

OBJECTIVE

To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT).

METHOD

Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups.

RESULTS

At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile.

CONCLUSIONS

The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.

A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care

BACKGROUND

Young people in out-of-home care are substantially more likely to meet criteria for PTSD than their peers, while their early maltreatment exposure may also place them at greater risk of developing the newly proposed complex PTSD. Yet, there remains limited empirical evidence for the mechanisms that might drive either PTSD or complex features in this group, and ongoing debate about the suitability of existing cognitive behavioural models and their related NICE-recommended treatments. In a prospective study of young people in out-of-home care, we sought to identify demographic and cognitive processes that may contribute to the maintenance of both PTSD symptom and complex features.

METHODS

We assessed 120 10- to 18-year-olds in out-of-home care and their primary carer at two assessments: an initial assessment and 12-month follow-up. Participants completed questionnaires on trauma history, PTSD symptoms and complex features, while young people only also self-reported on trauma-related (a) maladaptive appraisals, (b) memory quality and (c) coping. Social workers reported on maltreatment severity.

RESULTS

Young people's maltreatment severity was not a robust predictor of either PTSD symptoms or complex features. All three cognitive processes were moderately-to-strongly correlated with baseline and 12-month PTSD symptoms and complex features, with maladaptive appraisals the most robust unique driver of both, even when controlling for initial PTSD symptom severity.

CONCLUSIONS

Existing cognitive models of PTSD are applicable in this more complex sample of young people. The model was also found to be applicable to the additional features of complex PTSD, with the same processes driving both outcomes at both time points. Clinical implications are discussed.

COVID-19 unmasked: preschool children's negative thoughts and worries during the COVID-19 pandemic in Australia

Background: The COVID-19 pandemic and its consequences are stressful for many children and their families. Previous research with school-aged children has shown that negative thoughts and worries can predict mental health symptoms following stressful events. So far preschool children have been neglected in these investigations. Objective: The aim of this study was to explore negative thoughts and worries that preschool aged children are having during the COVID-19 pandemic. Method: As part of a larger mixed-method study, caregivers of N = 399 preschoolers aged between 3 and 5 years (M = 4.41) answered open-ended questions about their COVID-19 related thoughts and worries. Reflexive thematic analysis was used to identify relevant themes from the qualitative data. A theoretical model of child thoughts and worries was developed based on these qualitative findings and the existing empirical and theoretical literature. Results: Caregivers gave examples that indicated that preschoolers had difficulties understanding causality and overestimated the risk of COVID-19 infection. Caregivers reported that their children expressed worries about getting sick and infecting others as well as about changes in daily life becoming permanent. Caregivers observed their children's preoccupation with COVID-19 and worries in conversations, play and drawings as well as in behavioural changes - increased arousal, cautiousness, avoidance and attachment-seeking behaviour. Conclusion: Preschool children can and do express negative thoughts and worries and have also experienced threat and increased vulnerability during the COVID-19 pandemic. A theoretical model is proposed that could inform assessments, interventions and future research in the field.

Post-traumatic Stress Symptoms in Adolescents Exposed to the Earthquake in Lombok, Indonesia: Prevalence and Association With Maladaptive Trauma-Related Cognition and Resilience

Background: Natural disasters may physically and psychologically affect individuals and their surrounding community. This study determines the prevalence of post-traumatic stress (PTS) symptoms and its association with maladaptive trauma-related cognition and resilience among adolescents post-earthquake. Materials and Methods: Data were collected, in this cross-sectional study, during an intervention program post-earthquake held in a state high school located at Lombok, Indonesia. The study sample engaged students 14-19 years of age using the purposive sampling method. The questionnaires used to measure PTS symptoms, maladaptive trauma-related cognition, and resilience were Children's Revised Impact of Event Scale-13 (CRIES-13), Child Post-Traumatic Cognitions Inventory (CPTCI), and Child and Youth Resilience Measure-Revised (CYRM-R), respectively. Results: The prevalence of PTS symptoms was 69.9%. Among the respondents, 61.37% were female and 56.48% had mothers with lower educational levels. Using multiple linear regression, the final predictors of PTS symptoms were excessive reactions (e.g., wailing loudly, miserable shrieking) of proxy during earthquake (β = 3.283, p = 0.005), maladaptive trauma-related cognition (β = 0.224, p = 0.002), and resilience (β = 0.192, p < 0.001) with female gender (β = 7.350, p < 0.001) as a control variable. Through simple linear regression, victims who witnessed injury or death during the earthquake (p = 0.003), had a proxy died during the earthquake (p = 0.01), and trapped victims or those who had difficulty escaping (p = 0.01) were identified to potentially predict the occurrence of PTS symptoms, warranting further study. Conclusion: The presence of excessive proxy reactions during the earthquake, maladaptive trauma-related cognition, and resilience in adolescents exposed to a natural disaster are worth targeting and prioritizing in future post-disaster interventions.

Rumination in posttraumatic stress disorder: A systematic review

Initial models and empirical investigations of rumination in the clinical literature were predominantly in the domain of depression. However, rumination is now well-established as a transdiagnostic cognitive process, including in the context of posttraumatic stress. To clarify the current understanding of rumination in posttraumatic stress, we conducted a systematic review of the empirical literature on rumination in posttraumatic stress disorder (PTSD). Six sub-groups of studies on this topic were identified; these addressed: (i) the frequency and nature of rumination, (ii) cross-sectional relationships between rumination and PTSD symptoms, (iii) the capacity of rumination to predict PTSD longitudinally, (iv) other processes associated with rumination, (v) neurobiological correlates of rumination, and (vi) whether treating PTSD reduces rumination. This review synthesizes these domains of research and identifies key methodological limitations which limit causal inferences, and points to important areas of future research to advance knowledge on rumination in PTSD.

Latent profiles of the comorbidity of the symptoms for posttraumatic stress disorder and generalized anxiety disorder among children and adolescents who are susceptible to COVID-19

The present study aims to examine the comorbidity patterns of the symptoms (intrusion and avoidance) for posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) and the role of perceived threat and courtesy stigma in distinguishing specific patterns of the symptoms for PTSD and GAD among children and adolescents who are susceptible to coronavirus disease 2019 (COVID-19) in Hubei, China. A total of 1172 (683 female and 489 male) children and adolescents aged 8-18 years were involved in completing the measurements of PTSD, GAD, perceived threat of COVID-19, and COVID-19-related courtesy stigma. The Latent Profile Analysis identified the three profiles of the symptoms for PTSD and GAD which were labeled as Moderate PTSD, Mild Comorbidity, and Severe Comorbidity. The scores of the symptoms for PTSD, GAD, perceived threat, and stigma were different among the three profiles. The risk factors (i.e., perceived threat and stigma) that are related to comorbidity patterns were examined through a three-step method. The possibility of entry into the Severe Comorbidity Profile increased with increasing perceived threat and stigma. The mental health care interventions for children and adolescents who are susceptible to COVID-19 can be developed to reduce perceived threat and stigma.

Perceived social support and posttraumatic stress symptoms in children and youth in therapy: A parallel process latent growth curve model

Many studies show that perceived social support protects against the development of posttraumatic stress symptoms (PTSS) in the aftermath of trauma, but less is known about support in relation to PTSS in trauma therapy. This study examined associations between perceived social support and PTSS in children and adolescents during trauma therapy. Parallel process latent growth curve modeling was used to examine trajectories of perceived social support and PTSS over five measurement waves in a sample of 156 patients, aged between 10 and 18 years (M age = 15.1, SD = 2.2, 79.5% girls), randomized to receive trauma-focused cognitive behavior therapy (TF-CBT) or therapy-as-usual (TAU). Across all participants there was an average decline in PTSS and increase of perceived social support from pre-therapy to 18 months after therapy. Most of the change occurred during therapy and was maintained after therapy. Higher levels of PTSS prior to therapy were associated with lower levels of perceived social support prior to therapy, and a decrease in PTSS was associated with increase in perceived social support. This co-development may have been directed by a third underlying factor or short-term temporal effects. Studies investigating within-person associations over shorter time intervals will benefit our understanding of possible temporal effects.

Editorial: Improving children's mental health. What does that mean, actually?

The importance of promoting child and adolescent mental health seems self-evident. However, child and adolescent psychologists and psychiatrists are not necessarily in agreement with each other about what promoting mental health means, the desirability of intervening to influence development, and whether improving mental health promotion justifies reducing young people's autonomy. If expressed and discussed openly, diverging views and opinions about these issues can be constructive and deepen insights. Philosophical discussions about the belief systems and their relation to theoretical models underlying specific research questions, methodological choices, and interpretations of findings raise awareness of the inherent subjectivity of mental health evidence and research, and stimulate 'clear thinking', arguably the most valuable implement in any scientist's toolbox.

Commentary: I thought I was going to die and the world is not safe-how to help children recover after trauma? Reflections on Meiser-Stedman et al. (2019)

Children all over the world experience exposure to trauma. Why do only some young people have significant traumatic stress symptoms in the days and weeks immediately post-trauma while others do not, and why do some youth then recover without treatment while others go on to suffer from persistent PTSD? This important question is examined in a comprehensive study by Meiser-Stedman et al., (2019). In a sample of single-event trauma exposed youth, they investigate the role cognitive processes may have in shaping early reactions and in maintaining post-traumatic stress symptoms (PTSS) over time. For the onset of PTSS, perceived threat and feeling overwhelmed and confused during the traumatic event was associated with significant PTSS. For the maintenance of PTSS, poorly elaborated, sensory-based memories, dissociation, rumination, and negative appraisals were associated with higher PTSS. The newly revised International Society for Traumatic Stress Studies' guidelines for the prevention and treatment of PTSS found no strong evidence to recommend any of the evaluated preventive or early intervention programs. This commentary highlights how understanding different trajectories for the onset and maintenance of post-traumatic stress may inform our development of prevention and early intervention strategies. Cognitive processes seem to play an important role in the development of PTSS but these may play out differently in youth exposed to single events and youth with interpersonal trauma experiences. Knowledge on memory processing, meaning making, the role of social support and maladaptive cognitions need to be implemented in systems of trauma-informed care.