Trauma-informed care for unaccompanied children: Lessons learned for practice and policy development

INTRODUCTION

The number of unaccompanied children (UC) arriving in the United States has increased significantly in recent years. UC often encounter traumatic events in their home country, during their migration journey, and upon resettlement. This article describes a congressionally-funded initiative to provide trauma-informed mental health services to UC and children separated from their parents upon arrival in the United States. It also identifies facilitators and barriers to working with UC and offers lessons learned to help inform future practice and policy development aimed at assisting this vulnerable population.

METHOD

Data were derived from qualitative interviews and a survey administered to grantees.

RESULTS

In total, grantees served 1,195 youth and families across 11 states, including UC, asylees, and new immigrants during the period of December 2018 through September 2019. Youth and families served spoke 16 languages and originated from diverse nations. Services provided included direct services to youth and families; training for providers and community members; partnerships and collaborations; and resource/product development or adaptations.

DISCUSSION

Lessons learned and recommendations derived from this initiative can assist others interested in promoting trauma-informed practice and policies for migrant children and their families. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Identification of Novel, Replicable Genetic Risk Loci for Suicidal Thoughts and Behaviors Among US Military Veterans

Importance

Suicide is a leading cause of death; however, the molecular genetic basis of suicidal thoughts and behaviors (SITB) remains unknown.

Objective

To identify novel, replicable genomic risk loci for SITB.

Design, Setting, and Participants

This genome-wide association study included 633 778 US military veterans with and without SITB, as identified through electronic health records. GWAS was performed separately by ancestry, controlling for sex, age, and genetic substructure. Cross-ancestry risk loci were identified through meta-analysis. Study enrollment began in 2011 and is ongoing. Data were analyzed from November 2021 to August 2022.

Main Outcome and Measures

SITB.

Results

A total of 633 778 US military veterans were included in the analysis (57 152 [9%] female; 121 118 [19.1%] African ancestry, 8285 [1.3%] Asian ancestry, 452 767 [71.4%] European ancestry, and 51 608 [8.1%] Hispanic ancestry), including 121 211 individuals with SITB (19.1%). Meta-analysis identified more than 200 GWS (P < 5 × 10-8) cross-ancestry risk single-nucleotide variants for SITB concentrated in 7 regions on chromosomes 2, 6, 9, 11, 14, 16, and 18. Top single-nucleotide variants were largely intronic in nature; 5 were independently replicated in ISGC, including rs6557168 in ESR1, rs12808482 in DRD2, rs77641763 in EXD3, rs10671545 in DCC, and rs36006172 in TRAF3. Associations for FBXL19 and AC018880.2 were not replicated. Gene-based analyses implicated 24 additional GWS cross-ancestry risk genes, including FURIN, TSNARE1, and the NCAM1-TTC12-ANKK1-DRD2 gene cluster. Cross-ancestry enrichment analyses revealed significant enrichment for expression in brain and pituitary tissue, synapse and ubiquitination processes, amphetamine addiction, parathyroid hormone synthesis, axon guidance, and dopaminergic pathways. Seven other unique European ancestry-specific GWS loci were identified, 2 of which (POM121L2 and METTL15/LINC02758) were replicated. Two additional GWS ancestry-specific loci were identified within the African ancestry (PET112/GATB) and Hispanic ancestry (intergenic locus on chromosome 4) subsets, both of which were replicated. No GWS loci were identified within the Asian ancestry subset; however, significant enrichment was observed for axon guidance, cyclic adenosine monophosphate signaling, focal adhesion, glutamatergic synapse, and oxytocin signaling pathways across all ancestries. Within the European ancestry subset, genetic correlations (r > 0.75) were observed between the SITB phenotype and a suicide attempt-only phenotype, depression, and posttraumatic stress disorder. Additionally, polygenic risk score analyses revealed that the Million Veteran Program polygenic risk score had nominally significant main effects in 2 independent samples of veterans of European and African ancestry.

Conclusions and Relevance

The findings of this analysis may advance understanding of the molecular genetic basis of SITB and provide evidence for ESR1, DRD2, TRAF3, and DCC as cross-ancestry candidate risk genes. More work is needed to replicate these findings and to determine if and how these genes might impact clinical care.

The role of trauma, social support, and demography on veteran resilience

BACKGROUND

Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure. In line with a novel conceptualization of resilience as being dynamic over lifespan, determined by interacting biological and environmental factors, we examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans with and without PTSD diagnoses.

METHODS

We performed regression modelling to study the relationship between resilience (measured with Connor Davidson Resilience Scale; CD-RISC), posttraumatic stress disorder (PTSD) severity (Davidson Trauma Scale; DTS), social support (Medical Outcome Study Social Support Survey; MOSSS), combat exposure (Combat Exposure Scale; CES), childhood trauma (Trauma Life Events Questionnaire; TLEQ), and demographic factors. CD-RISC was positively correlated with years of education and negatively correlated with DTS, CES and TLEQ scores.

RESULTS

We found an interaction between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale). Specifically, high resilience predicted lower PTSD symptom severity than low resilience, this relationship was amplified with increasing levels of combat exposure. Structural equation modelling (SEM) identified an optimal latent variable that represents resilience and relationships between latent variables for resilience, trauma, and illness. We derived a resilience latent variable composed of age, education level, MOSSS and race.

CONCLUSIONS

Our results support a conceptualization of resilience as a multifactorial determinant that coexists with PTSD, a state rather than trait variable, and can be quantified by biological and behavioural metrics.

HIGHLIGHTS

• Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure.• We examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans.• We found an interaction effect between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale).

Military Life Stressors, Family Communication and Satisfaction: Associations with Children's Psychosocial Outcomes

Families experience multiple stressors as a result of military service. The purpose of this study was to examine facets of military life and family factors that may impact child psychosocial and mental health functioning. Using baseline data from the Millennium Cohort Family Study, this study examined family demographics and composition (age, number of children), military life stressors (injury, family, and deployment stressors), family communication and satisfaction as assessed by the Family Adaptability and Cohesion Evaluation Scale-IV, parental social functioning assessed via the Short Form Health Survey-36, and child mental health and behavioral functioning (parental reports of clinician-diagnosed mental health conditions such as depression) and an adapted version of the Strengths and Difficulties Questionnaire. Injury- and family-related military stressors were significant indicators of heightened risk for child mental health conditions, whereas greater levels of parental social functioning and family satisfaction were associated with lower risk of child mental health conditions. Differential associations were found in child functioning when military-related variables (e.g., service component), sociodemographic, and family composition factors (number and age of the children in the home) were examined. These findings underscore the importance of examining the "whole child" within the broader ecological and military family context to understand factors associated with children's mental and behavioral health. The results from the present study highlight the complex relationships that may be at play, which, in turn, have considerable implications for the development of policies to support children and families encountering multiple stressors related to a parent's military service.

Psychosocial Risk Factors and Other Than Honorable Military Discharge: Providing Healthcare to Previously Ineligible Veterans

INTRODUCTION

In response to a strong focus on suicide prevention for all veterans, the Department of Veterans Affairs (VA) recently revised policy to provide emergency mental healthcare for veterans who received Other Than Honorable (OTH) discharges from the military. This current study takes a preliminary step toward identifying demographic, historic, military, clinical, and social characteristics of veterans with OTH discharges.

MATERIALS AND METHODS

N = 1,172 Iraq/Afghanistan-era veterans were evaluated between 2005 and 2016 in the multi-site VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC) Study of Post-Deployment Mental Health (PDMH Study).

RESULTS

Veterans with OTH discharges constituted 2.7% of our sample, approximating the estimated rate in the overall U.S. veteran population. Compared to veterans discharged under honorable conditions, veterans with OTH discharges were more likely to be younger and have greater odds of reporting family history of drug abuse and depression. Further, veterans with OTH discharges reported a lower level of social support and were more likely to be single, endorse more sleep problems, score higher on measures of drug misuse, have a history of incarceration, and meet diagnostic criteria for major depressive disorder. A subsequent matching analysis provided further evidence of the association between OTH discharge and two risk factors: drug misuse and incarceration.

CONCLUSION

These findings elucidate potential factors associated with veterans with OTH discharges, particularly substance abuse and criminal justice involvement. Results also indicate higher incidence of risk factors that often accompany suicidal ideation and should be a highlighted component of healthcare delivery to this vulnerable cohort of veterans.

Association of military life experiences and health indicators among military spouses

Background

The health and well-being of military spouses directly contribute to a robust military force by enabling the spouse to better support the active duty member’s career. In order to understand the overall health and well-being of military spouses, we assessed health indicators among military spouses using the Healthy People 2020 framework and examined associations of these health indicators with military experiences and psychosocial factors.

Methods

Using data from the Millennium Cohort Family Study, a U.S. Department of Defense-sponsored survey of 9872 spouses of service members with 2–5 years of military service, we examined attainment of Healthy People 2020 goals for spouses and service members, including healthy weight, exercise, sleep, and alcohol and tobacco use. Multivariable logistic regression models assessed associations of spouse health indicators with stressful military life experiences and social support, adjusting for demographics and military descriptors. The spousal survey was administered nationwide in 2011.

Results

The majority of military spouses met each health goal assessed. However, less than half met the healthy weight and the strength training goals. Reporting greater perceived family support from the military was associated with better behavioral health outcomes, while having no one to turn to for support was associated with poorer outcomes. Using the Healthy People 2020 objectives as a framework for identifying key health behaviors and benchmarks, this study identified factors, including military-specific experiences, that may contribute to physical health behaviors and outcomes among military spouses. With respect to demographic characteristics, the findings are consistent with other literature that women are more likely to refrain from risky substance use and that greater education is associated with better overall health outcomes.

Conclusions

Findings suggest that enhanced social and military support and tailored programming for military spouses may improve health outcomes and contribute to the well-being of military couples. Such programming could also bolster force readiness and retention.

Trauma-informed measurement-based care for children: Implementation in diverse treatment settings

Ongoing and comprehensive assessment is a critical part of the implementation of evidence-based care; yet, most providers fail to routinely incorporate measurement into their clinical practice. Few studies have focused on the complex application of routine assessment or measurement-based care (MBC) with children. This pilot examined the acceptability, appropriateness, adoptability, and feasibility of an MBC effort, the Clinical Improvement through Measurement Initiative (CIMI), across several child-serving settings (e.g., community mental health center, residential treatment facility). CIMI includes a comprehensive mental health assessment protocol and combines a mobile technology platform with implementation support. Survey and focus group information, assessing implementation constructs and outcomes, was collected from 44 clinicians and staff. Overall, participants agreed that the implementation process and technology were acceptable, appropriate, and feasible for use in child mental health and that CIMI can be used to guide case conceptualization, facilitate treatment planning, and monitor outcomes. Strategies that supported the implementation process were identified as were recommendations to enhance adoption. Significant differences were observed by Community versus Specialized settings with respect to feasibility and appropriateness, likely because of factors associated with inner setting (climate, compatibility), outer setting (patient needs), and the phase of implementation achieved by sites. Implications and recommendations for tailoring MBC implementation by characteristics related to setting are discussed. MBC across child service settings are discussed in the context of implementation frameworks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Benefits of Treatment Completion Over Premature Termination: Findings from the National Child Traumatic Stress Network

Objective: To evaluate potential differences in therapeutic outcomes between youths who completed a full course of treatment as planned compared to youths who terminated treatment prematurely. Method: Using longitudinal data from the National Child Traumatic Stress Network (NCTSN) Core Data Set, the present study examined demographic characteristics, trauma history, scores on standardized measures, and ratings of functional impairment and behavior problems in a large clinical sample of children and adolescents exposed to trauma who received treatment at NCTSN centers across the United States. Baseline and follow-up data were used to compare treatment completers (n= 3,108) and noncompleters (n = 4,029). Results: Both treatment completers and noncompleters received benefits from treatment by NCTSN mental health providers in that both groups showed significant decreases in mean scores from baseline to follow-up on all standardized measures. However, compared to noncompleters, treatment completers showed three types of significantly greater benefit at follow-up. These included: (a) greater rates of decline (i.e., steeper slopes) on all outcome measures; (b) greater reductions in the odds of falling within the clinical range on standardized measures; and (c) greater reductions in the odds of exhibiting functional impairment and behavior problems at follow-up. In contrast, compared to treatment completers, noncompleters reported significantly higher rates of lifetime exposure to community violence, psychological maltreatment, physical abuse, neglect, sexual abuse, and sexual assault. Conclusion: These findings underscore the value of incorporating engagement and retention strategies in treatments for traumatized youths to maximize therapeutic benefit and raise the standard of care.

Association of Childhood Trauma Exposure With Adult Psychiatric Disorders and Functional Outcomes

IMPORTANCE

Being exposed to trauma is a common childhood experience associated with symptoms and impairments in childhood.

OBJECTIVE

To assess the association between cumulative childhood trauma exposure and adult psychiatric and functional outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, population-based cohort study of 1420 participants. A community representative sample of participants was assessed with structured Child and Adolescent Psychiatric Assessment interviews up to 8 times in childhood (ages 9-16 years; 6674 observations; 1993-2000) for lifetime trauma exposure as defined by the Diagnostic and Statistical Manual of Mental Disorders. Participants were followed up 4 times in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) with the structured Young Adult Psychiatric Assessment Interview for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood. Analysis was completed in 2018.

EXPOSURE

Participants were assessed with the structured Child and Adolescent Psychiatric Assessment interview (parent and self-report) up to 8 times in childhood for lifetime trauma exposure (ages 9-16 years; 6674 observations; 1993-2000).

MAIN OUTCOMES AND MEASURES

Participants were assessed up to 4 times with the structured Young Adult Psychiatric Assessment interview (self-report) in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood.

RESULTS

Among the 1420 study participants, 630 (49.0%) were female and 983 (89.4%) were white. By age 16 years, 30.9% of children (n = 451) were exposed to 1 traumatic event, 22.5% (n = 289) were exposed to 2 such events, and 14.8% (n = 267) were exposed to 3 or more. Cumulative childhood trauma exposure to age 16 years was associated with higher rates of adult psychiatric disorders (odds ratio for any disorder, 1.2; 95% CI, 1.0-1.4) and poorer functional outcomes, including key outcomes that indicate a significantly disrupted transition to adulthood (eg, failure to hold a job and social isolation). Childhood trauma exposure continued to be associated with higher rates of adult psychiatric and functional outcomes after adjusting for a broad range of childhood risk factors, including psychiatric functioning and family adversities and hardships (adjusted odds ratio for any disorder, 1.3; 95% CI, 1.0-1.5).

CONCLUSIONS AND RELEVANCE

Cumulative childhood trauma exposure was associated with poor adult outcomes even after accounting for many of the childhood and family factors associated with both trauma exposure and poor adult outcomes. Childhood trauma exposures are common, but often preventable, thus providing a clear target for child-focused public health efforts to ameliorate long-term morbidity.

Prevalence of psychiatric morbidity in United States military spouses: The Millennium Cohort Family Study

BACKGROUND

Approximately half of US service members are married, equating to 1.1 million military spouses, yet the prevalence of psychiatric morbidity among military spouses remains understudied. We assessed the prevalence and correlates of eight mental health conditions in spouses of service members with 2-5 years of service.

METHOD

We employed baseline data from the Millennium Cohort Family Study, a 21-year longitudinal survey following 9,872 military-affiliated married couples representing all US service branches and active duty, Reserve, and National Guard components. Couples were surveyed between 2011 and 2013, a period of high military operational activity associated with Operation Iraqi Freedom and Operation Enduring Freedom. Primary outcomes included depression, anxiety, posttraumatic stress disorder (PTSD), panic, alcohol misuse, insomnia, somatization, and binge eating, all assessed with validated self-report questionnaires.

RESULTS

A total of 35.90% of military spouses met criteria for at least one psychiatric condition. The most commonly endorsed conditions were moderate-to-severe somatization symptoms (17.63%) and moderate-to-severe insomnia (15.65%). PTSD, anxiety, depression, panic, alcohol misuse, and binge eating were endorsed by 9.20%, 6.65%, 6.05%, 7.07%, 8.16%, and 5.23% of spouses, respectively. Having a partner who deployed with combat resulted in higher prevalence of anxiety, insomnia, and somatization. Spouses had lower prevalence of PTSD, alcohol misuse, and insomnia but higher rates of panic and binge eating than service members. Both members of a couple rarely endorsed having the same psychiatric problem.

CONCLUSIONS

One third of junior military spouses screened positive for one or more psychiatric conditions, underscoring the need for high-quality prevention and treatment services.

Brain Structural Covariance Network Topology in Remitted Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a prevalent, chronic disorder with high psychiatric morbidity; however, a substantial portion of affected individuals experience remission after onset. Alterations in brain network topology derived from cortical thickness correlations are associated with PTSD, but the effects of remitted symptoms on network topology remain essentially unexplored. In this cross-sectional study, US military veterans (N = 317) were partitioned into three diagnostic groups, current PTSD (CURR-PTSD, N = 101), remitted PTSD with lifetime but no current PTSD (REMIT-PTSD, N = 35), and trauma-exposed controls (CONTROL, n = 181). Cortical thickness was assessed for 148 cortical regions (nodes) and suprathreshold interregional partial correlations across subjects constituted connections (edges) in each group. Four centrality measures were compared with characterize between-group differences. The REMIT-PTSD and CONTROL groups showed greater centrality in left frontal pole than the CURR-PTSD group. The REMIT-PTSD group showed greater centrality in right subcallosal gyrus than the other two groups. Both REMIT-PTSD and CURR-PTSD groups showed greater centrality in right superior frontal sulcus than CONTROL group. The centrality in right subcallosal gyrus, left frontal pole, and right superior frontal sulcus may play a role in remission, current symptoms, and PTSD history, respectively. The network centrality changes in critical brain regions and structural networks are associated with remitted PTSD, which typically coincides with enhanced functional behaviors, better emotion regulation, and improved cognitive processing. These brain regions and associated networks may be candidates for developing novel therapies for PTSD. Longitudinal work is needed to characterize vulnerability to chronic PTSD, and resilience to unremitting PTSD.

The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of US Afghanistan and Iraq era veterans

The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US military Afghanistan/Iraq-era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re-contact participants for follow-up studies. The overwhelming majority (94%) of participants consented to be re-contacted for future studies, and our recently completed feasibility study indicates that 73-83% of these participants could be reached successfully for enrollment into longitudinal follow-up investigations. Longitudinal concurrent cohort follow-up studies will be conducted (5-10+ years post-baseline) to examine predictors of illness chronicity, resilience, recovery, functional outcome, and other variables, and will include neuroimaging, genetic/epigenetic, serum biomarker, and neurocognitive studies, among others. To date, the PDMH study has generated more than 35 publications from the baseline data and the repository has been leveraged in over 20 publications from follow-up studies drawing from this cohort. Limitations that may affect data collection for a longitudinal follow-up study are also presented.

Mental Health Among Military Personnel and Veterans

This commentary describes the prevalence of mental health problems affecting military service members and veterans in North Carolina and the rest of the nation, with a special emphasis on those who served in the recent wars in Iraq and Afghanistan. Approximately 1.9 million of these veterans have become eligible for Veterans Affairs health care since 2002, and an estimated 1.16 million veterans have registered for this care.

Drug use and childhood-, military- and post-military trauma exposure among women and men veterans

BACKGROUND

The current study was undertaken to examine whether posttraumatic stress symptoms (PTSS) and depressive symptoms mediated the association between trauma exposure (combat-related trauma and non-combat traumas occurring before, during, and after military service), and drug abuse symptoms use among male and female veterans.

METHODS

Participants were 2304 (1851 male, 453 female) veterans who took part in a multi-site research study conducted through the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center (VISN 6 MIRECC). Path analytic models were used to determine the association between problematic past-year drug use and combat-related and non-combat trauma experienced before, during, or after the military and whether current post-traumatic stress symptoms or depressive symptoms mediated these associations.

RESULTS

For both male and female veterans, depressive symptoms significantly mediated the effects of pre- and post-military trauma on drug abuse symptoms.

CONCLUSION

Mental health providers who work with trauma-exposed Iraq and Afghanistan era veterans should assess for drug use, depressive symptoms, and life-span trauma (i.e., not only combat-related traumas) as part of a thorough trauma-based assessment for both men and women.

Establishing a methodology to examine the effects of war-zone PTSD on the family: the family foundations study

Military deployment may adversely affect not only returning veterans, but their families, as well. As a result, researchers have increasingly focused on identifying risk and protective factors for successful family adaptation to war-zone deployment, re-integration of the returning veteran, and the longer-term psychosocial consequences of deployment experienced by some veterans and families. Post-traumatic stress disorder (PTSD) among returning veterans may pose particular challenges to military and military veteran families; however, questions remain regarding the impact of the course of veteran PTSD and other potential moderating factors on family adaptation to military deployment. The Family Foundations Study builds upon an established longitudinal cohort of Army soldiers (i.e. the Neurocognition Deployment Health Study) to help address remaining knowledge gaps. This report describes the conceptual framework and key gaps in knowledge that guided the study design, methodological challenges and special considerations in conducting military family research, and how these gaps, challenges, and special considerations are addressed by the study.

The Millennium Cohort Family Study: a prospective evaluation of the health and well-being of military service members and their families

The need to understand the impact of war on military families has never been greater than during the past decade, with more than three million military spouses and children affected by deployments to Operations Iraqi Freedom and Enduring Freedom. Understanding the impact of the recent conflicts on families is a national priority, however, most studies have examined spouses and children individually, rather than concurrently as families. The Department of Defense (DoD) has recently initiated the largest study of military families in US military history (the Millennium Cohort Family Study), which includes dyads of military service members and their spouses (n > 10,000). This study includes US military families across the globe with planned follow-up for 21+ years to evaluate the impact of military experiences on families, including both during and after military service time. This review provides a comprehensive description of this landmark study including details on the research objectives, methodology, survey instrument, ancillary data sets, and analytic plans. The Millennium Cohort Family Study offers a unique opportunity to define the challenges that military families experience, and to advance the understanding of protective and vulnerability factors for designing training and treatment programs that will benefit military families today and into the future.

The impact of social support on psychological distress for U.S. Afghanistan/Iraq era veterans with PTSD and other psychiatric diagnoses

This study aimed to examine the degree to which posttraumatic stress disorder (PTSD) affects the relationship between social support and psychological distress for U.S. Afghanistan/Iraq era veterans with and without co-occurring psychiatric disorders. Veterans (N=1825) were administered self-report questionnaires and a structured diagnostic interview as part of a multi-site study of post-deployment mental health through the Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Main and interaction effects models assessed the association between psychological distress and social support for three comparisons conditions (Controls vs. PTSD-only, non-PTSD, and PTSD plus co-morbid diagnoses). Having PTSD was a critical factor in attenuating the strength of this association, more so than other diagnoses. Furthermore, those with PTSD plus co-morbid diagnoses did not demonstrate significantly larger attenuation in that association compared to the PTSD-only group, indicating that psychiatric comorbidity may be less important in considering the role of social support in PTSD. By understanding this relationship, new avenues for engaging and enhancing treatment outcomes related to social support for veterans of this cohort may be identified. Additional longitudinal research could help evaluate the effect of PTSD symptom clusters, social support type, and trauma exposure type on these relationships.

Traumatic childhood experiences in the 21st century: broadening and building on the ACE studies with data from the National Child Traumatic Stress Network

The study objectives were to (a) examine the association between total number of trauma types experienced and child/adolescent behavioral problems and (b) determine whether the number of trauma types experienced predicted youth behavioral problems above and beyond demographic characteristics, using a diverse set of 20 types of trauma. Data came from the National Child Traumatic Stress Network's (NCTSN) Core Data Set (CDS), which includes youth assessed and treated for trauma across the United States. Participants who experienced at least one type of trauma were included in the sample (N = 11,028; age = 1&frac12;-18 years; 52.3% girls). Random effects models were used to account for possible intraclass correlations given treatment services were provided at different NCTSN centers. Logistic regression analyses were used to investigate associations among demographic characteristics, trauma, and emotional and behavioral problems as measured by the Child Behavior Checklist (CBCL). Significant dose-response relations were found between total number of trauma types and behavior problems for all CBCL scales, except Sleep, one of the subscales only administered to 1&frac12;- to 5-year-olds. Thus, each additional trauma type endorsed significantly increased the odds for scoring above the clinical threshold. Results provide further evidence of strong associations between diverse traumatic childhood experiences and a diverse range of behavior problems, and underscore the need for a trauma-informed public health and social welfare approach to prevention, risk reduction, and early intervention for traumatized youth.

Lifetime major depression and comorbid disorders among current-era women veterans

BACKGROUND

Most research on women veterans' mental health has focused on postraumatic stress disorder (PTSD) or reactions to military sexual trauma. Although depression is also a frequent diagnosis among women veterans, little is known about its characteristics, including comorbid conditions and patterns of disorder onset. We investigated lifetime diagnoses of major depressive disorder (MDD) and comorbid conditions in a primarily treatment-seeking research sample of male and female veterans to determine frequency of lifetime MDD, comorbid disorders and their temporal onset.

METHOD

The 1700 veterans (346 women; 1354 men) completed diagnostic interviews as participants in a research registry. Rates of and gender differences in lifetime MDD and comorbid conditions (PTSD, other anxiety disorders, substance use and eating disorders) were calculated. We assessed the percentage of cases in which MDD preceded the comorbid condition (primary onset MDD).

RESULTS

Lifetime MDD was frequent in this sample, and significantly more common in women (46.5%) than in men (36.3%). Gender differences in comorbidity were found for anxiety and eating disorders (more common in women); and for alcohol and nicotine use disorders (more common in men). However, primary onset MDD was no more common among women than among men, and was in neither case the predominant pattern of comorbid lifetime disorder onset.

LIMITATIONS

The sample is not representative of all veterans, and lifetime diagnoses were based on retrospective recall.

CONCLUSIONS

MDD usually follows the onset of other comorbid disorders among women veterans, indicating the need to assess for earlier lifetime disorders in veterans with MDD.

Alcohol use and trauma exposure among male and female veterans before, during, and after military service

BACKGROUND

The present study examined lifespan and combat-related trauma exposure as predictors of alcohol use among male and female veterans. Posttraumatic stress and depressive symptoms were examined as mediators of the effects of trauma exposure on alcohol use.

METHODS

Data were examined from 1825 (1450 male, 375 female) veterans and active duty service members who took part in a multi-site research study conducted through the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center (VISN 6 MIRECC).

RESULTS

For both men and women, depressive symptoms significantly mediated the effects of non-combat trauma exposure experienced before, during and after the military, as well as combat-exposure, on alcohol use. With posttraumatic stress symptoms, the models for men and women differed. For men, the effects of non-combat trauma exposure during and after military service, and combat exposure, on alcohol use were mediated by PTSD symptoms; however, for women, PTSD symptoms did not mediate these relationships.

CONCLUSION

Findings are discussed in the context of potential gender differences in response to trauma such as use of alcohol to cope with traumatic events.

Use of the breakthrough series collaborative to support broad and sustained use of evidence-based trauma treatment for children in community practice settings

Empirically supported treatments for posttraumatic stress reactions in children are not widely available. This observational study evaluates the feasibility and utility of adapting the Institute for Healthcare's Breakthrough Series Collaborative (BSC) to support the broad implementation and sustained use of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in community practice settings. Study findings indicated that agency staff in diverse roles viewed the BSC methodology as a valuable and practicable approach for facilitating skillful delivery of TF-CBT with fidelity. Use of TF-CBT increased over the course of the collaborative and findings from a survey conducted one year later indicated that participating agencies were able to sustain and spread the practice.

Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses

Although documentation that war inflicts psychological casualties dates back to the American Civil War and earlier, most research began after the Vietnam conflict, when studies focused on post-traumatic stress disorder (PTSD). With ongoing conflicts in Iraq and Afghanistan, there has been significant research to illuminate the epidemiology of war-related psychological casualties. Significant findings include an appreciation for the role combat plays in the development of mental disorders, including PTSD and traumatic brain injury (TBI). Recent research has endeavoured to understand and improve psychological resilience to temper potentially adverse mental health effects of military service in the theatre of combat operations. Over 2 million US service members have now deployed and returned over 3 million times to the Iraq and Afghanistan conflicts. Mental health providers in the Departments of Defense and Veterans Affairs healthcare systems have consequently observed steep increases in mental health service use among these personnel. The Departments have responded aggressively to bolster staffing levels, increase capacity, improve available services, and anticipate future needs. Scientists and clinicians continue efforts to understand the determinants, prevention, recognition, and treatment of combat-related mental disorders.

Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network

Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as complex trauma. Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs routinely screen for trauma exposure and associated symptoms beyond an initial assessment of the precipitating event. This study examines trauma histories, including complex trauma exposure (physical abuse, sexual abuse, emotional abuse, neglect, domestic violence), posttraumatic stress, and behavioral and emotional problems of 2,251 youth (age 0 to 21; M = 9.5, SD = 4.3) in foster care who were referred to a National Child Traumatic Stress Network site for treatment. High prevalence rates of complex trauma exposure were observed: 70.4% of the sample reported at least two of the traumas that constitute complex trauma; 11.7% of the sample reported all 5 types. Compared to youth with other types of trauma, those with complex trauma histories had significantly higher rates of internalizing problems, posttraumatic stress, and clinical diagnoses, and differed on some demographic variables. Implications for child welfare practice and future research are discussed.

Trends in serious emotional disturbance among youths exposed to Hurricane Katrina

OBJECTIVE

To examine patterns and predictors of trends in DSM-IV serious emotional disturbance (SED) among youths exposed to Hurricane Katrina.

METHOD

A probability sample of adult pre-hurricane residents of the areas affected by Katrina completed baseline and follow-up telephone surveys 18 to 27 months post-hurricane and 12 to 18 months later. Baseline adult respondents residing with children and adolescents (4-17 years of age) provided informant reports about the emotional functioning of these youths (n = 576) with the Strengths and Difficulties Questionnaire (SDQ). The surveys also assessed hurricane-related stressors and ongoing stressors experienced by respondent families.

RESULTS

SED prevalence decreased significantly across survey waves from 15.1% to 11.5%, although even the latter prevalence was considerably higher than the pre-hurricane prevalence of 4.2% estimated in the US National Health Interview Survey. Trends in hurricane-related SED were predicted by both stressors experienced in the hurricane and ongoing stressors, with SED prevalence decreasing significantly only among youths with moderate stress exposure (16.8% versus 6.5%). SED prevalence did not change significantly between waves among youths with either high stress exposure (30.0% versus 41.9%) or low stress exposure (3.5% versus 3.4%). Pre-hurricane functioning did not predict SED persistence among youths with high stress exposure, but did predict SED persistence among youth with low-moderate stress exposure.

CONCLUSIONS

The prevalence of SED among youths exposed to Hurricane Katrina remains significantly elevated several years after the storm despite meaningful decrease since baseline. Youths with high stress exposure have the highest risk of long-term hurricane-related SED and consequently represent an important target for mental health intervention.

Enhancing national capacity to conduct child and family disaster mental health research

A substantial number of children and families experience emotional difficulties in the aftermath of disasters and terrorist events. Only recently has training in disaster preparedness and response been systematically incorporated into the curricula of mental health disciplines. The goal of the Child & Family Disaster Research Training & Education Program is to enhance the nation's capacity and infrastructure needed to conduct rigorous disaster mental health research on children and families. This article describes the creation and training of 10 specialized research teams, curriculum development, implementation of the program, and progress to date as well as lessons learned and challenges to sustainability.

Building National Capacity for Child and Family Disaster Mental Health Research

Disaster mental health is a burgeoning field with numerous opportunities for professional involvement in preparedness, response, and recovery efforts. Research is essential to advance professional understanding of risk and protective factors associated with disaster outcomes; to develop an evidence base for acute, intermediate, and long-term mental health approaches to address child, adult, family, and community disaster-related needs; and to inform policy and guide national and local disaster preparedness, response, and recovery programs. To address the continued need for research in this field, we created the Child & Family Disaster Research Training & Education (DRT) program, which is focused specifically on enhancing national capacity to conduct disaster mental health research related to children, a population particularly vulnerable to disaster trauma. This paper describes the structure and organization of the DRT program, reviews the training curriculum, discusses implementation and evaluation of the program, and reviews obstacles encountered in establishing the program. Finally, key lessons learned are reviewed for the purpose of guiding replication of the DRT model to address other areas of community mental health.

Serious emotional disturbance among youths exposed to Hurricane Katrina 2 years postdisaster

OBJECTIVE

To estimate the prevalence of serious emotional disturbance (SED) among children and adolescents exposed to Hurricane Katrina along with the associations of SED with hurricane-related stressors, sociodemographics, and family factors 18 to 27 months after the hurricane.

METHOD

A probability sample of prehurricane residents of areas affected by Hurricane Katrina was administered a telephone survey. Respondents provided information on up to two of their children (n = 797) aged 4 to 17 years. The survey assessed hurricane-related stressors and lifetime history of psychopathology in respondents, screened for 12-month SED in respondents' children using the Strengths and Difficulties Questionnaire, and determined whether children's emotional and behavioral problems were attributable to Hurricane Katrina.

RESULTS

The estimated prevalence of SED was 14.9%, and 9.3% of the youths were estimated to have SED that is directly attributable to Hurricane Katrina. Stress exposure was associated strongly with SED, and 20.3% of the youths with high stress exposure had hurricane-attributable SED. Death of a loved one had the strongest association with SED among prehurricane residents of New Orleans, whereas exposure to physical adversity had the strongest association in the remainder of the sample. Among children with stress exposure, parental psychopathology and poverty were associated with SED.

CONCLUSIONS

The prevalence of SED among youths exposed to Hurricane Katrina remains high 18 to 27 months after the storm, suggesting a substantial need for mental health treatment resources in the hurricane-affected areas. The youths who were exposed to hurricane-related stressors, have a family history of psychopathology, and have lower family incomes are at greatest risk for long-term psychiatric impairment.

DSM-V PTSD diagnostic criteria for children and adolescents: a developmental perspective and recommendations

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) should ensure systematic attention to age-specific manifestations and selective modifications of the diagnostic criteria for posttraumatic stress disorder (PTSD) among children and adolescents. The authors propose developmental refinements to the conceptual framework for PTSD based on an appreciation of the different neurosignatures of danger and safety, and maturational processes that underlie symptom presentation. This includes preliminary evidence for the developmental salience of additional dimensions for PTSD (e.g., recklessness and thrill-seeking). The authors provide conservative recommendations for DSM-V diagnostic criteria that primarily highlight age-related developmental manifestations that, if included in the accompanying text, would bring a richer appreciation of developmentally linked symptom presentations.

Epidemiology of child traumatic stress

In this article, we present an update on epidemiologic research that addresses the scope and impact of children's exposure to traumatic events in daily living, as well as under special circumstances, such as natural disasters. Toward this end, we provide an overview of the findings of key selected studies that estimate the prevalence of children's exposure to trauma and associated developmental, functional, mental, and physical health problems. Over the past few years, epidemiologic research on child traumatic stress has demonstrated that children's exposure to traumatic events is more common than once thought and that children exposed to multiple traumatic events are at a substantially greater risk for a wide range of adverse mental and physical health problems than children who have not suffered cumulative traumatic experiences. These findings have important implications for the provision of mental health and medical services to children and adolescents who have experienced child traumatic stress.

The psychological risks of Vietnam: the NVVRS perspective

In recent years, controversy concerning the psychological consequences of service in the Vietnam war has rearisen. In this article, the Co-Principal Investigators of the National Vietnam Veterans Readjustment Study (NVVRS) provide a perspective on new findings reported by B. P. Dohrenwend et al. (2006) that addresses criticisms of the NVVRS PTSD (posttraumatic stress disorder) prevalence findings, and on a perspective that was provided by R. J. McNally (2006) in an accompanying commentary. They find that Dohrenwend et al.'s study, which evaluated empirically a variety of the critics' alternative explanations and found little support for any of them, represents a landmark contribution to the trauma field. However, they found that McNally's commentary misrepresented the history and context of the NVVRS, and then misinterpreted Dohrenwend et al.'s findings and their importance.

A taxometric investigation of dissociation in Vietnam veterans

There is long-standing debate about whether elevated dissociative symptoms are common in posttraumatic stress disorder (PTSD) or whether there is a distinct subtype of cases with elevated dissociation. The current investigation examined the latent structure of dissociative symptoms in a sample of 316 male, trauma-exposed Vietnam veterans, 76 of whom were diagnosed with current PTSD. Three taxometric procedures (MAMBAC, MAXEIG, and MAXCOV) were performed on three indicator sets drawn from the Dissociative Experiences Scale. Taxometric analyses consistently revealed a taxon (subtype) of highly dissociative individuals. The taxon members had significantly more severe posttraumatic symptoms and were more often diagnosed with current PTSD than were non-taxon members. Among participants with a current PTSD diagnoses, only 32% belonged to the dissociative taxon, suggesting that there is a subtype of severe PTSD with elevated dissociation.

Adverse race-related events as a risk factor for posttraumatic stress disorder in Asian American Vietnam veterans

Few studies have explored the relationship between exposure to adverse race-related events and posttraumatic stress disorder (PTSD). This study examined whether adverse race-related events can give rise to symptoms that meet the criteria for a PTSD diagnosis as specified in the DSM-IV. Three hundred Asian American Vietnam veterans were administered a Mississippi Scale and a questionnaire that assessed exposure to adverse race-related events in the military and associated PTSD symptoms. A subsample was administered the Clinician-Administered PTSD Scale. A majority of the participants (77%) reported exposure to adverse race-related events. Depending on the number of events to which they were exposed, between 13% and 36% reported symptoms consistent with meeting full criteria for PTSD. Mississippi Scale scores increased significantly as a function of frequency of exposure to adverse race-related events. These results converge with the Clinician-Administered PTSD Scale findings to demonstrate that adverse race-related events can be traumatic and associated with PTSD. These findings support the construct and convergent validity of race-related PTSD.

Families at risk: comment on Dirkzwager, Bramsen, Adèr, and van der Ploeg (2005)

New findings from a study by A. J. E. Dirkzwager, I. Bramsen, H. Adèr, and H. M. van der Ploeg (2005; see record 2005-06518-006) provide important empirical information on the adverse psychological and functional adjustment of families of former Dutch peacekeepers suffering from posttraumatic stress disorder (PTSD). In this comment the authors consider a few methodological limitations and issues for future study, including the need for intergenerational studies of the legacy of peacekeeping-related PTSD. Attention to considering the treatment needs of families of traumatized former peacekeepers is encouraged.

Psychiatric disorder, impairment, and service use in rural African American and white youth

BACKGROUND

The Caring for Children in the Community Study examined the prevalence of DSM-IV psychiatric disorders and correlates of mental health service use in rural African American and white youth.

METHODS

Four thousand five hundred youth aged 9 to 17 years from 4 North Carolina counties were randomly selected from school databases. Parents completed telephone questionnaires about their children's behavior problems. A second-stage sample of 1302 was identified for recruitment into the interview phase of the study, and 920 (70.7%) of these were successfully interviewed at home using the Child and Adolescent Psychiatric Assessment and related measures of service use.

RESULTS

Weighted back to general population estimates, 21.1% of youth had 1 or more DSM-IV psychiatric disorders in the past 3 months. Prevalence was similar in African American (20.5%) and white (21.9%) youth. The only ethnic difference was an excess of depressive disorders in white youth (4.6% vs 1.4%). Thirteen percent of participants (36.0% of those with a diagnosis) received mental health care in the past 3 months. White youth were more likely than African American youth to use specialty mental health services (6.1% vs 3.2%), but services provided by schools showed very little ethnic disparity (8.6% vs 9.2%). The effect of children's symptoms on their parents was the strongest correlate of specialty mental health care.

CONCLUSIONS

In this rural sample, African American and white youth were equally likely to have psychiatric disorders, but African Americans were less likely to use specialty mental health services. School services provided care to the largest number of youths of both ethnic groups.

Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11

CONTEXT

The terrorist attacks of September 11, 2001, represent an unprecedented exposure to trauma in the United States.

OBJECTIVES

To assess psychological symptom levels in the United States following the events of September 11 and to examine the association between postattack symptoms and a variety of indices of exposure to the events.

DESIGN

Web-based epidemiological survey of a nationally representative cross-sectional sample using the Posttraumatic Stress Disorder (PTSD) Checklist and the Brief Symptom Inventory, administered 1 to 2 months following the attacks.

SETTING AND PARTICIPANTS

Sample of 2273 adults, including oversamples of the New York, NY, and Washington, DC, metropolitan areas.

MAIN OUTCOME MEASURES

Self-reports of the symptoms of PTSD and of clinically significant nonspecific psychological distress; adult reports of symptoms of distress among children living in their households.

RESULTS

The prevalence of probable PTSD was significantly higher in the New York City metropolitan area (11.2%) than in Washington, DC (2.7%), other major metropolitan areas (3.6%), and the rest of the country (4.0%). A broader measure of clinically significant psychological distress suggests that overall distress levels across the country, however, were within expected ranges for a general community sample. In multivariate models, sex, age, direct exposure to the attacks, and the amount of time spent viewing TV coverage of the attacks on September 11 and the few days afterward were associated with PTSD symptom levels; sex, the number of hours of television coverage viewed, and an index of the content of that coverage were associated with the broader distress measure. More than 60% of adults in New York City households with children reported that 1 or more children were upset by the attacks.

CONCLUSIONS

One to 2 months following the events of September 11, probable PTSD was associated with direct exposure to the terrorist attacks among adults, and the prevalence in the New York City metropolitan area was substantially higher than elsewhere in the country. However, overall distress levels in the country were within normal ranges. Further research should document the course of symptoms and recovery among adults following exposure to the events of September 11 and further specify the types and severity of distress in children.

Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial

CONTEXT

Extracts of Hypericum perforatum (St John's wort) are widely used for the treatment of depression of varying severity. Their efficacy in major depressive disorder, however, has not been conclusively demonstrated.

OBJECTIVE

To test the efficacy and safety of a well-characterized H perforatum extract (LI-160) in major depressive disorder.

DESIGN AND SETTING

Double-blind, randomized, placebo-controlled trial conducted in 12 academic and community psychiatric research clinics in the United States.

PARTICIPANTS

Adult outpatients (n = 340) recruited between December 1998 and June 2000 with major depression and a baseline total score on the Hamilton Depression Scale (HAM-D) of at least 20.

INTERVENTIONS

Patients were randomly assigned to receive H perforatum, placebo, or sertraline (as an active comparator) for 8 weeks. Based on clinical response, the daily dose of H perforatum could range from 900 to 1500 mg and that of sertraline from 50 to 100 mg. Responders at week 8 could continue blinded treatment for another 18 weeks.

MAIN OUTCOME MEASURES

Change in the HAM-D total score from baseline to 8 weeks; rates of full response, determined by the HAM-D and Clinical Global Impressions (CGI) scores.

RESULTS

On the 2 primary outcome measures, neither sertraline nor H perforatum was significantly different from placebo. The random regression parameter estimate for mean (SE) change in HAM-D total score from baseline to week 8 (with a greater decline indicating more improvement) was -9.20 (0.67) (95% confidence interval [CI], -10.51 to -7.89) for placebo vs -8.68 (0.68) (95% CI, -10.01 to -7.35) for H perforatum (P =.59) and -10.53 (0.72) (95% CI, -11.94 to -9.12) for sertraline (P =.18). Full response occurred in 31.9% of the placebo-treated patients vs 23.9% of the H perforatum-treated patients (P =.21) and 24.8% of sertraline-treated patients (P =.26). Sertraline was better than placebo on the CGI improvement scale (P =.02), which was a secondary measure in this study. Adverse-effect profiles for H perforatum and sertraline differed relative to placebo.

CONCLUSION

This study fails to support the efficacy of H perforatum in moderately severe major depression. The result may be due to low assay sensitivity of the trial, but the complete absence of trends suggestive of efficacy for H perforatum is noteworthy.

The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context

This study employed data from two Congressionally mandated efforts (the American Indian Vietnam Veterans Project and the National Vietnam Veterans Readjustment Study) to examine differential prevalence of posttraumatic stress disorder (PTSD) among 5 ethnically defined samples of male Vietnam theater veterans. Lay interviews assessed individual experiences before, during, and after the war from 1,798 male Vietnam theater veterans. Clinical reinterviews using the SCID were conducted with subsamples (N = 487). The prevalence of both 1-month and lifetime PTSD was higher for the 2 American Indian samples than for Whites. Once logistic regressions controlled for differential exposure to war-zone stress, ethnicity was no longer a significant predictor of PTSD.

The prevalence of potentially traumatic events in childhood and adolescence

This paper examines exposure to potentially traumatic events from middle childhood through adolescence, and vulnerability to such exposure. Analyses are based on the first 4 annual waves of data from a longitudinal general population study of youth in western North Carolina, involving 4,965 interviews with 1,420 children and adolescents and their parents or guardians. Participants reported on DSM extreme stressors ("high magnitude events"), other potentially traumatic events ("low magnitude events"), and background vulnerability factors. In this general population sample, one-quarter experienced at least one high magnitude event by age 16, 6% within the past 3 months. One third experienced a low magnitude event in the past 3 months. The likelihood of such exposure increased with the number of vulnerability factors.

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE

This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates.

METHODS

A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina.

RESULTS

The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for.

CONCLUSIONS

Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.

Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings

OBJECTIVE

To develop consensus-based guidelines for training in mental health and psychosocial interventions for trauma-exposed populations in the international arena.

PARTICIPANTS

The Task Force on International Trauma Training of the International Society for Traumatic Stress Studies.

EVIDENCE

The Task Force engaged in a 1-year dialogue on the practice of international training, drawing upon field experience, literature review, and consultation with key informants.

CONSENSUS PROCESS

This statement was prepared on the basis of shared dialogue, consensus decision making, and a writing process involving all Task Force members. It was then disseminated for review to more than 200 professionals of more than 60 service and academic organizations. Written and oral suggestions from over 80 persons were incorporated and revisions made on the basis of consensus.

CONCLUSIONS

The generated guidelines addresses four dimensions: (1) values, (2) contextual challenges in societies during or after conflicts, (3) core curricular elements, and (4) monitoring and evaluation. The guidelines can improve international training.