Scholastic impairments among traumatized adolescents

Experiential Avoidance, Post-Traumatic Stress Symptoms, and Academic Impairment

The ways in which Posttraumatic Stress Disorder (PTSD) symptoms lead to impairments in functioning, including academic performance, are not well understood. The present study sought to examine the role of a common maladaptive coping strategy, experiential avoidance, as a moderator of the relationship between posttraumatic stress symptoms (PTSS) and academic achievement. Participants (N = 326) were undergraduate students enrolled in introductory psychology courses at a large university in the Midwestern United States who reported at least one event potentially meeting Criterion A for PTSD. The prospective association of PTSS with current and subsequent semester GPAs, and with experiential avoidance as the moderator, were examined. The interaction between PTSS and experiential avoidance significantly predicted both current semester GPA and subsequent semester GPA, with stronger associations between PTSS and GPA being observed at higher levels of experiential avoidance. These results were not fully explained by control variables of high school performance, standardized test scores, and general negative affect. This study found that experiential avoidance significantly moderates the relationship between PTSS and academic performance. These results suggest that interventions that target PTSS and/or experiential avoidance may increase GPA. Limitations and future directions are discussed.

The Incidence of Posttraumatic Stress Symptoms in Children

OBJECTIVE

To determine the incidence of posttraumatic stress disorder (PTSD) symptoms and risk factors for their development in children and adolescents undergoing orthopaedic surgery for trauma.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Children (8 to 18), undergoing surgery for orthopaedic trauma.

INTERVENTION

Upper and lower extremity surgery for orthopaedic trauma.

MAIN OUTCOME MEASUREMENTS

PTSD symptoms at postoperative follow-up as determined by the Child PTSD Symptom Scale (CPSS).

RESULTS

A total of 176 children with an average age at surgery of 13 years (8 to 18.8 years) participated in the study. Twenty-six subjects had high levels of PTSD symptoms (15%; 95% CI = 10.0 to 21.1%). Univariable and multivariable analyses determined that female sex (OR 2.63, 95% CI = 1.06 to 6.67, P = 0.04), older age at surgery (OR 1.25, 95% CI = 1.04 to 1.51, P = 0.02), and undergoing a previous surgery (OR 2.86, 95% CI = 1.06 to 7.73, P = 0.04) were all associated with increased PTSD risk.

CONCLUSIONS

Children and adolescents experience a high level of PTSD symptoms (15%) after surgery for orthopaedic trauma. Clinicians should be aware of PTSD symptoms in children and adolescents after surgery for orthopaedic injuries and use comprehensive screening to facilitate timely intervention and treatment.

LEVEL OF EVIDENCE

II.

Tap Water Consumption Is Associated with Schoolchildren’s Cognitive Deficits in Afghanistan

Environmental influence on intelligence quotient (IQ) is poorly understood in developing countries. We conducted the first cross-sectional investigation to assess the role of socio-economic and environmental factors on schoolchildren’s IQ in Jalalabad, Afghanistan. A representative sample of 245 schoolchildren aged 7–15 was randomly selected in five schools. Children’s records included: non-verbal IQ TONI-1 scale, body mass index, socio-economic status, and further environmental indicators (water supply, proximity to a heavy-traffic road, use of surma traditional cosmetics). The mean age of the children was 11.7 years old (±2.0 years), and 70.2% and 29.8% were male and female, respectively. The children’s mean IQ was 83.8 (±12.6). In total, 37 (14.9%) of the children were overweight, 78 (31.5%) were living below the USD 1.25 poverty line, 133 (53.6%) used tap water supply, 76 (30.6%) used surma, and 166 (66.9%) were exposed to heavy road traffic. The children’s IQ was significantly and independently lowered by tap water use (−3.9; 95% CI [−7.1; −0.6]) and by aging (−1.4; 95% CI [−2.2; −0.6]), as revealed in multivariate analysis, independently of gender, socio-economic status, exposure to heavy road traffic, overweight status, and surma use. Lower IQ among older children is possibly attributed to chronic stress experienced by adolescents due to living conditions in Afghanistan. While using tap water prevents fecal peril, it may expose children to toxic elements such as lead which is known to lower their intellectual development.

Posttraumatic stress disorder symptom severity and functional impairment in the education domain

To comprehensively understand and treat Posttraumatic Stress Disorder (PTSD), we need to accurately assess how PTSD symptoms affect people's daily functioning (e.g., in work, study, and relationships). However, the predominant use of self-report functional impairment measures-which are not validated against observable behavior-limits our understanding of this issue. To address this gap, we examined the relationship between posttraumatic stress (PTS) symptoms (including symptom clusters) and subjective and objective measures of functional impairment in the education domain. University students completed online self-report measures of educational impairment, PTS symptoms, intelligence and childhood trauma. We accessed participants' average grades at the end of the semester in which they participated. After controlling for IQ and childhood trauma, increased PTS symptoms were associated with both higher subjective educational impairment and lower Grade Point Average; this relationship was strongest for subjective global ratings of educational impairment, compared to educational impairment assessed according to specific examples. Our results suggest conceptual overlap between symptoms and impairment, and point to the benefit of using both objective and subjective modes of assessing impairment.

Assessment of the relationship between life events with psychosocial competence of students in selected secondary schools in Northern and Central Uganda

Introduction

As they grow, young people transit through adolescence; a particularly challenging phase. Many go through without difficulties but some experience maladaptive responses in form of conduct and adjustment problems, pubertal challenges and life stress. Published research from the developed societies demonstrates consistent associations between young people's exposure to life events, psychosocial competence (PSC) and mental health problems. However, comparable research from income-constrained societies remains scarce. The purpose of this study was to determine the prevalence of life events in secondary school students and describe the relationship between life events and PSC in the same population.

Methods

This was a cross-sectional study. Participants were 2,902 randomly selected in Central and Northern Uganda. They responded to self-administered questionnaires on socio-demographics, life events and PSC.

Results

Northern Ugandan students were more likely to be susceptible to stress-related illness associated with major life events (p = < 0.01). Among students with a high susceptibility to stress related illness, those with low scores on self-efficacy (p = < 0.001), accurate self-assessment (p = < 0.001) and self-confidence (p = < 0.001) were mostly from the North. Students from Northern Uganda had experienced more negative events. Students with higher scores on empathy, emotional awareness, accurate self- assessment and self-confidence tended to have low distress. Students that had a low susceptibility to stress related illness (AOR = 1.97; 95% CI: 1.57 – 2.48); high scores on self-efficacy (AOR 1.37; 95% CI: 1.09 – 1.74), self-confidence (AOR 1.32; 95% CI: 1.02 – 1.72), and accurate self-assessment (AOR 2.19; 95% CI: 1.70 – 2.80) were mostly from northern Uganda.

Conclusion

It is important to help students to cope with negative life events since an association exists between negative life events and PSC domains. PSC domains of empathy, emotional awareness, accurate self-assessment and self-confidence seem to be associated with lower distress levels, implying that these should be reinforced.

The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT)

BACKGROUND

Germany hosts a large number of refugees from war-affected countries. The integration of refugees, in particular young refugees from the Middle East, is one of the major current social challenges in Germany. Mental disorders, first of all post-traumatic stress disorder (PTSD) that results from war experiences, are common among young refugees and interfere with quality of life as well as functional integration. Evidence regarding effective treatment options for this population is scarce. In this trial, we aim to evaluate the pragmatic, short-term psychotherapy Narrative Exposure Therapy for Children (KIDNET) for the treatment of young refugees in Germany.

METHODS

In a rater-blinded, multi-center, randomized-controlled trial, KIDNET is compared to treatment as usual (TAU) within the general health care system. A total number of 80 young refugees who fulfill the diagnostic criteria of PTSD will be randomized to either KIDNET or TAU. Diagnostic interviews will take place at baseline before treatment as well as 6 and 12 months thereafter. They will assess exposure to traumatic events, PTSD and comorbid symptoms, as well as parameters of integration.

DISCUSSION

The results of this study should provide evidence regarding effective treatment options for young refugees in Germany, a population that has been understudied and received only limited access to mental health care so far. Next to the effects of treatment on mental health outcomes, integration parameters will be investigated. Therefore, this study should provide broad insights into treatment options for young refugees and their potential implications on successful integration.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS), ID: DRKS00017222. Registered on 15 May 2019.

The Linguistic Integration of Refugees in Italy

The creation of laws regarding the linguistic integration of migrants has contributed to the change in Italian language teaching, which has had to adapt its materials and methodology to migrants. However, the specific case of refugees has not been specifically assessed, with the exception of experimentation with the Council of Europe toolkit for refugees. This paper aimed to study the linguistic integration of adult refugees in Italy by conducting an ethnography through participant observation and semi-structured interviews between Italian language teachers and refugees. The results of this work show both the teachers’ perceptions of the refugees’ linguistic integration and the refugees’ perceptions of linguistic integration practice. The conclusions highlight the need for more hours of Italian language courses as well as lessons based on specific integration needs. Moreover, this study emphasizes that the integration practice itself implies language learning. A final consideration is made concerning the current integration situation of refugees in Italy.

Promoting Student Success: How Do We Best Support Child and Youth Survivors of Catastrophic Events?

PURPOSE OF REVIEW

School mental health services have achieved recognition for increased access to care and intervention completion rates. While best practice recommendations include connection of school mental health programming to multi-tiered systems of support that promote early identification and intervention, many schools struggle to operationalize student screening for trauma exposure, trauma symptoms, and service identification. Relatedly, progress monitoring for trauma symptoms, and the effect of trauma on school functioning in the context of catastrophic events, can also be difficult to systematically collect.

RECENT FINDINGS

Research regarding the effects of catastrophic events, such as exposure to natural disasters, terrorist attacks, war, or the journey to refugee status on children and youths school functioning, indicates salient age and gender differences among student responses. In addition, school professionals have been identified as sources of social support for students and as potential brokers to school linked intervention resources for children, youth, and their families. Based on our review, we outline recommendations for school professionals, including potential changes to school policies and procedures, and delineate future research questions.

Delayed Disaster Impacts on Academic Performance of Primary School Children

Social disruption caused by natural disasters often interrupts educational opportunities for children. However, little is known about children's learning in the following years. This study examined change in academic scores for children variably exposed to a major bushfire in Australia. Comparisons were made between children attending high, medium, and low disaster-affected primary schools 2-4 years after the disaster (n = 24,642; 9-12 years). The results showed that in reading and numeracy expected gains from Year 3 to Year 5 scores were reduced in schools with higher levels of bushfire impact. The findings highlight the extended period of academic impact and identify important opportunities for intervention in the education system to enable children to achieve their academic potential.

Society, individual, family, and school factors contributing to child mental health in war: The ecological-theory perspective

Mental health problems are common in war-affected areas, but children have different levels of vulnerability. Based on ecological theory (Bronfenbrenner, 2005), this study analyses how factors related to the child (cognitive capacity), their family (parental depression and parenting styles), and their school (teachers' practices and peer relations) mediate the association between traumatic stress (traumatic war experiences and stressful life-events) and child mental health (posttraumatic stress and psychological distress symptoms). The participants were 303 Palestinian children (51.2% girls) of 10-13 years (M = 10.94 ± 0.50) and their parents from the Gaza Strip. The children filled in questionnaires during school classes and the parents did so at their homes. The results of structural equation modeling substantiated the hypothesis that parental depression, poor parenting and low-quality peer relations mediated between traumatic stress and children's mental health problems. Contrary to the hypothesis, child-related factors did not mediate that association. To conclude, parents and peers provide important age-salient social resources for children in war conditions, and psychosocial interventions should therefore enhance their beneficial functions.

Maltreatment Related Trauma Symptoms Affect Academic Achievement through Cognitive Functioning: A Preliminary Examination in Japan

Child abuse and neglect could have some deleterious impacts on both intellectual and academic performance of school students. The aim of this study was to examine relationships among child maltreatment, trauma symptoms, cognitive functioning, and academic achievement. Data were collected from child guidance centers, where maltreated children were substantiated, assessed, evaluated, protected, and treated clinically. The selection criteria for subjects included Japanese children (1) who had a history of maltreatment; (2) whose IQs were measured using the Kaufman Assessment Battery for Children second edition (KABC-II); and (3) whose traumatic stress was evaluated using the Trauma Symptom Checklist for Children alternate version (TSCC-A). Covariance structure analysis showed the model that explains the relations of trauma symptom (measured by TSCC-A) on academic achievement (measured by KABC-II) as being intervened by cognitive functioning (measured by KABC-II).

Extreme Weather-driven Disasters and Children’s Health

Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to become more frequent and intense with climate change. Extreme weather-driven disasters (EWDDs) cause a substantial burden of childhood mortality and morbidity worldwide. We reviewed the published literature on EWDDs and their health impacts on children, and developed a conceptual model based on complex systems thinking to identify the health risks, vulnerabilities, and capacities of children in the context of EWDDs as a means of informing areas for adaptive intervention. We found that direct and indirect physical and mental impacts of EWDDs on child health are abundant and interrelate in complex ways. The literature review and modeling demonstrated the centrality of resilience at the level of the child and his or her direct environment, suggesting that mental health status may play a key role in a child’s experience of numerous other health outcomes of EWDDs. EWDDs interact with environmental and social systems and with individual children and their contexts in complex ways, the impacts of which are nonlinear and difficult to predict. Traditional perspectives on climate change-driven health impacts often overlook complex bio-psychosocial interactions, suggesting a need to work on preventive strategies to reduce vulnerability and build individual child resilience.

Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis

BACKGROUND

It is unclear how many children and adolescents develop post-traumatic stress disorder (PTSD) after trauma.

AIMS

To determine the incidence of PTSD in trauma-exposed children and adolescents as assessed with well-established diagnostic interviews and to examine potential moderators of the estimate.

METHOD

A systematic literature search identified 72 peer-reviewed articles on 43 independent samples (n = 3563). Samples consisting only of participants seeking or receiving mental health treatment were excluded. Main analyses involved pooled incidence estimates and meta-analyses of variance.

RESULTS

The overall rate of PTSD was 15.9% (95% CI 11.5-21.5), which varied according to the type of trauma and gender. Least at risk were boys exposed to non-interpersonal trauma (8.4%, 95% CI 4.7-14.5), whereas girls exposed to interpersonal trauma showed the highest rate (32.9%, 95% CI 19.8-49.3). No significant difference was found for the choice of assessment interview or the informant of the assessment.

CONCLUSIONS

Research conducted with the best available assessment instruments shows that a significant minority of children and adolescents develop PTSD after trauma exposure, with those exposed to interpersonal trauma and girls at particular risk. The estimates provide a benchmark for DSM-5 and ICD-11.

Narrative exposure therapy for immigrant children traumatized by war: study protocol for a randomized controlled trial of effectiveness and mechanisms of change

BACKGROUND

Millions of children worldwide suffer from posttraumatic stress disorder (PTSD) symptoms and other mental health problems due to repeated exposure to war or organized violence. Forms of cognitive-behavioral therapy (CBT) are the most commonly used treatment for PTSD and appear to be effective for children as well, but little is known about the mechanisms of change through which they achieve their effectiveness. Here we present the study protocol of a randomized controlled trial (RCT) studying the effectiveness and mechanisms of change of Narrative Exposure Therapy (NET), a CBT-based, manualized, short-term intervention for PTSD symptoms resulting from repeated traumatization, in immigrant children traumatized by war.

METHODS/DESIGN

We are conducting a multicentre, pragmatic RCT in a usual care setting. Up to 80 9-17-year-old immigrant children who have experienced war and suffer from PTSD symptoms will be randomized into intervention (NET) and control (treatment as usual, TAU) groups of equal sizes. The effectiveness of NET treatment will be compared to both a waiting list and the parallel TAU positive control group, on the primary outcomes of PTSD and depressive symptoms, psychological distress, resilience, and level of cognitive performance. The effects of the intervention on traumatic memories and posttraumatic cognitions will be studied as potential mechanisms of change mediating overall treatment effectiveness. The possible moderating effects of peritraumatic dissociation, level of cognitive performance, and gender on treatment effectiveness will also be considered. We hypothesize that NET will be more effective than a waitlist condition or TAU in reducing PTSD and other symptoms and improving resilience, and that these effects will be mediated by changes in traumatic memories and posttraumatic cognitions.

DISCUSSION

The results of this trial will provide evidence for the effectiveness of NET in treating trauma-related symptoms in immigrant children affected by war. The trial will also generate insights into the complex relationships between PTSD, memory functions, posttraumatic cognitions and cognitive performance in children, and help guide the future development and implementation of therapeutic interventions for PTSD in children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02425280 . Registered 15 April 2015.

Topical Review: Families Coping With Child Trauma: A Naturalistic Observation Methodology

OBJECTIVE

To introduce a novel, naturalistic observational methodology (the Electronically Activated Recorder; EAR) as an opportunity to better understand the central role of the family environment in children's recovery from trauma.

METHODS

Discussion of current research methods and a systematic literature review of EAR studies on health and well-being.

RESULTS

Surveys, experience sampling, and the EAR method each provide different opportunities and challenges for studying family interactions. We identified 17 articles describing relevant EAR studies. These investigated questions of emotional well-being, communicative behaviors, and interpersonal relationships, predominantly in adults. 5 articles reported innovative research in children, triangulating EAR-observed behavioral data (e.g., on child conflict at home) with neuroendocrine assay, sociodemographic information, and parent report. Finally, we discussed psychometric, practical, and ethical considerations for conducting EAR research with children and families.

CONCLUSIONS

Naturalistic observation methods such as the EAR have potential for pediatric psychology studies regarding trauma and the family environment.

The parent ratings of traumatized children with or without PTSD

Two clinical and 2 structured clinical interviews were used to identify children with posttraumatic stress disorder (PTSD), traumatized children without PTSD, and nontraumatized controls. Parents evaluated child conduct by marking the Conners' Parent Rating Scale-48 (CPRS-48; Conners, 1989). Data analysis indicated that the CPRS-48 Total scores and the Anxiety and Psychosomatic subscales scores of the PTSD group significantly exceeded the scores of the comparison groups. Children with PTSD and traumatized children without PTSD did not significantly differ on the Hyperactivity Index. The Hyperactivity Index scores of traumatized children without PTSD and nontraumatized controls were not significantly different. Nonsignificant differences were observed between groups on the CPRS-48 Impulsivity-Hyperactivity, Conduct Problems, and Learning subscales. Overall, PTSD was marked by higher internalizing scores and trauma exposure without PTSD was not associated with increased psychological morbidity.

Intrusive trauma recollections is associated with impairment of interference inhibition and psychomotor speed in PTSD

BACKGROUND

Intrusive cognitions that enter consciousness involuntarily are prominent symptoms of posttraumatic stress disorder (PTSD). The present study aimed to identify neuropsychological mechanisms involved.

METHOD

Fifty PTSD outpatients and 50 healthy controls were tested using Finger Tapping, Simple and Choice Reaction Times and Stroop Tasks, to measure motor, psychomotor speed, response selection, and interference inhibition ability respectively.

RESULTS

PTSD patients performed poorly in all tests, presumably owing to their generalized slowness of information processing and motor reaction. Psychomotor speed was a predictor of slowness and high error rate during the Stroop. Impaired inhibition, as measured by the interference index of the Stroop task, explained 9.7% of the predicated variance in frequency of re-experiencing PTSD symptoms and 23.5% of the predicated variance in augmentation of the interference response time.

CONCLUSION

Impaired interference control may be related to internal (re-experiencing) and external (sensory) stimuli that leads to cognitive deficits in PTSD patients.

A theoretical model of continuity in anxiety and links to academic achievement in disaster-exposed school children

This study tested a theoretical model of continuity in anxious emotion and its links to academic achievement in disaster-exposed youth. An urban school based sample of youths (n = 191; Grades 4–8) exposed to Hurricane Katrina were assessed at 24 months (Time 1) and then again at 30 months (Time 2) postdisaster. Academic achievement was assessed through end of the school year standardized test scores (~31 months after Katrina). The results suggest that the association of traumatic stress to academic achievement was indirect via linkages from earlier (Time 1) posttraumatic stress disorder symptoms that predicted later (Time 2) test anxiety. Time 2 test anxiety was then negatively associated with academic achievement. Age and gender invariance testing suggested strong consistency across gender and minor developmental variation in the age range examined. The model presented advances the developmental understanding of the expression of anxious emotion and its links to student achievement among disaster-exposed urban school children. The findings highlight the importance of identifying heterotypic continuity in anxiety and suggest potential applied and policy directions for disaster-exposed youth. Avenues for future theoretical refinement are also discussed.

Severe War Trauma and Post-Traumatic Stress Disorder in Adolescents with Sensory Impairments: A Cross-sectional Study

A paucity of studies of the psychological status of adolescents with sensory impairments in political conflict areas is noted. This study was set up to examine the exposure of adolescents with sensory impairments (ASIs) to severe war trauma and development of post-traumatic stress disorder (PTSD) as compared to their able-bodied peers (ABPs). It also answers the question whether their impairments have made them more resilient in facing traumatic events. A cross-sectional study of all ASIs attending special schools in three administrative districts in Lebanon (n=166) as well as a group of 166 age and sex-matched ABPs from neighboring schools was conducted. The Post Traumatic Stress Reaction Checklist for children (PTSRC) was used to assess exposure to severe trauma, PTSD and their determinants. ASIs reported a lower exposure to severe traumatic events (24.1%) as compared to their ABPs (69.9%), and risk factors for their exposure were an older age group, a fatherless family, and severe visual impairment. Prevalence rates for PTSD were similar in the two study groups (17.5% and 16.4%). Younger ASIs were at a significantly higher risk of developing PTSD. Lower exposure to trauma among ASIs points to the more sheltered life that they lead. Given the same exposure as ABPs, similar rates of PTSD are noted among the two study groups. This may indicate that having a sensory impairment may protect from PTSD due to decreased exposure to severe trauma and not due to increased resilience of subjects.

Annual Research Review: Positive adjustment to adversity--trajectories of minimal-impact resilience and emergent resilience

BACKGROUND

Research on resilience in the aftermath of potentially traumatic life events (PTE) is still evolving. For decades, researchers have documented resilience in children exposed to corrosive early environments, such as poverty or chronic maltreatment. Relatively more recently, the study of resilience has migrated to the investigation of isolated PTE in adults.

METHODS

In this article, we first consider some of the key differences in the conceptualization of resilience following chronic adversity versus resilience following single-incident traumas, and then describe some of the misunderstandings that have developed about these constructs. To organize our discussion, we introduce the terms emergent resilience and minimal-impact resilience to represent trajectories of positive adjustment in these two domains, respectively.

RESULTS

We focused in particular on minimal-impact resilience, and reviewed recent advances in statistical modeling of latent trajectories that have informed the most recent research on minimal-impact resilience in both children and adults and the variables that predict it, including demographic variables, exposure, past and current stressors, resources, personality, positive emotion, coping and appraisal, and flexibility in coping and emotion regulation.

CONCLUSIONS

The research on minimal-impact resilience is nascent. Further research is warranted with implications for a multiple levels of analysis approach to elucidate the processes that may mitigate or modify the impact of a PTE at different developmental stages.

Comparative effectiveness of interventions for children exposed to nonrelational traumatic events

OBJECTIVES

To assess the effectiveness of interventions targeting traumatic stress among children exposed to nonrelational traumatic events (eg, accidents, natural disasters, war).

METHODS

We assessed research on psychological and pharmacological therapy as part of an Agency for Healthcare Research and Quality-commissioned comparative effectiveness review. We conducted focused searches of Medline, Cochrane Library, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, and Web of Science. Two trained reviewers independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We used qualitative rather than quantitative analysis methods because of statistical heterogeneity, insufficient numbers of similar studies, and variation in outcome reporting.

RESULTS

We found a total of 21 trials and 1 cohort study of medium or low risk of bias from our review of 6647 unduplicated abstracts. We generally did not find studies that attempted to replicate findings of effective interventions. In the short term, no pharmacotherapy intervention demonstrated efficacy, and only a few psychological treatments (each with elements of cognitive behavioral therapy) showed benefit. The body of evidence provides little insight into how interventions to treat children exposed to trauma might influence healthy long-term development.

CONCLUSIONS

Our findings serve as a call to action: Psychotherapeutic intervention may be beneficial relative to no treatment in children exposed to traumatic events. Definitive guidance, however, requires far more research on the comparative effectiveness of interventions targeting children exposed to nonrelational traumatic events.

An evaluation of posttraumatic stress disorder and parent stress in children with orthopaedic injuries

OBJECTIVES

Trauma has more than physical effects on pediatric patients and their families. The purpose of this study was to evaluate pediatric orthopaedic trauma patients and patients with isolated nonoperative upper extremity (UE) fractures for emotional/psychologic symptoms associated with posttraumatic stress disorder (PTSD) and parent stress.

METHODS

An institutional review board-approved prospective study of patients aged 8-18 years who sustained a traumatic injury or isolated UE fracture from October 2009 to May 2010 was performed. Demographic data were obtained and the Child PTSD Symptom Scale was used. The Parent Stress Index was used to evaluate the stress of the parents/guardian. For 80% power, we needed 32 per group. P value was set at <0.05.

RESULTS

A total of 76 children and their parents/guardians participated in the study. The mean age was 12.6 years (8-17 years). There were 56 males (74%) and 20 females (26%). The average time since injury was 12 months (3-89 months). The prevalence of PTSD between the high-energy trauma patients and the low-energy nonoperative UE patients was not significant. Overall, 33% of the children had PTSD. Involvement in music was significant between patients with and without PTSD (P = 0.037) and may be protective against PTSD.

CONCLUSIONS

PTSD commonly affects pediatric patients who sustain injuries as a result of a traumatic event, whether low- or high-energy mechanisms. We found no factors significantly associated with or predictive of PTSD and did not find an association of PTSD with parent stress. We need to maintain a high index of suspicion in pediatric trauma patients regardless of the energy associated with the traumatic event.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Screening for traumatic exposure and psychological distress among war-affected adolescents in post-conflict northern Uganda

BACKGROUND

The war in northern Uganda has had a debilitating effect on the mental health of children and adolescents in the population. This study measures the prevalence and considers the aetiology of psychological distress in war-affected adolescents 4 years after the end of the conflict.

METHODS

This is a cross-sectional study of 205 adolescents, aged 12-19, from a boarding primary school in Gulu, northern Uganda. A war experiences checklist was developed with the assistance of local professionals. The Impact of Event Scale-Revised (IES-R) measured post-traumatic stress symptoms. Finally, the Acholi Psychosocial Assessment Instrument (APAI) was used to measure locally described mental health constructs similar to the Western concepts of depression and anxiety.

RESULTS

Four years after the end of the war, 57% of the students were still found to have clinically significant levels of post-traumatic stress symptoms using a similar cut-off score to previous studies among the same population. Both components of traumatic exposure: (i) the number of types of traumatic event experienced; and (ii) whether the adolescent was abducted were significantly associated with psychological distress. There was a strong correlation between post-traumatic stress symptoms and internalising symptoms.

CONCLUSION

War-affected adolescents may continue to suffer from significant psychological stress in the years following the cessation of conflict. Multiple exposure to a number of different types of traumatic event may directly increase the likelihood of psychological distress especially for those exposed to the most extreme violence. The feasibility of employing a locally developed and validated screening instrument is demonstrated. Implications for future research and intervention in post-conflict areas are considered.

Can traumatic stress alter the brain? Understanding the implications of early trauma on brain development and learning

BACKGROUND

Youth who experience traumatic stress and develop post-traumatic symptoms secrete higher levels of the glucocorticoid cortisol than youth with no trauma history. Animal research suggests that excess corticosterone secretion can lead to neurotoxicity in areas of the brain rich in glucocorticoid receptors such as the hippocampus and the prefrontal cortex (PFC). These two areas of the brain are involved in memory processing and executive function, both critical functions of learning.

METHODS

In this article, we summarize findings presented at the National Summit for Stress and the Brain conducted at Johns Hopkins University's Department of Public Health in April 2011. The presentation highlighted structural and functional imaging findings in the hippocampus and PFC of youth with post-traumatic stress symptoms (PTSS).

RESULTS

Youth with PTSS have higher levels of cortisol. Prebedtime cortisol levels predict decreases in hippocampal volume longitudinally. Cortisol levels are negatively correlated with volume in the PFC. Functional imaging studies demonstrate reduced hippocampal and PFC activities on tasks of memory and executive function in youth with PTSS when compared with control subjects.

CONCLUSIONS

Effective interventions for youth with PTSS should target improved function of frontolimbic networks. Treatment outcome research using these potential markers can help develop more focused interventions that target the impaired learning of vulnerable youth experiencing traumatic stress.

Neuropsychological Effects of Posttraumatic Stress Disorder in Children and Adolescents

Posttraumatic Stress Disorder (PTSD) can affect people of all ages but the literature is lacking on children and adolescents who experience PTSD. The consequences of this disorder extend beyond the basic symptoms by which it is defined. Neuroanatomically, the brains of children with PTSD have been found to be abnormally symmetrical in several structures, resulting in abnormal functioning. Neuropsychological assessment reveals that children and adolescents with the PTSD syndrome have significant deficits in memory, attention, executive functioning, and in overall verbal intelligence that needs to be discriminated from other syndromes with similar deficits, for example, Attention Deficit Hyperactivity Disorder (ADHD). This review presents the research findings with regard to these deficits in learning and behaviour that school psychologists encounter with students who experience PTSD. Implications for the practice of school psychology and suggestions for future research are discussed.

Children's mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies

New Orleans school children participated in an assessment and field trial of two interventions 15 months after Hurricane Katrina. Children (N = 195) reported on hurricane exposure, lifetime trauma exposure, peer and parent support, posttraumatic stress disorder (PTSD), and depressive symptoms. Teachers reported on behavior. At baseline, 60.5% screened positive for PTSD symptoms and were offered a group intervention at school or individual treatment at a mental health clinic. Uptake of the mental health care was uneven across intervention groups, with 98% beginning the school intervention, compared to 37% beginning at the clinic. Both treatments led to significant symptom reduction of PTSD symptoms, but many still had elevated PTSD symptoms at posttreatment. Implications for future postdisaster mental health work are discussed.

Cognitive impairment and functioning in PTSD related to intimate partner violence

Posttraumatic stress disorder (PTSD) has been associated with neuropsychological impairments across multiple domains, but consensus regarding the cognitive profile of PTSD has not been reached. In this study of women with PTSD related to intimate partner violence (n = 55) and healthy, demographically similar comparison participants (NCs; n = 20), we attempted to control for many potential confounds in PTSD samples. All participants were assessed with a comprehensive neuropsychological battery emphasizing executive functioning, including inhibition, switching, and abstraction. NCs outperformed PTSD participants on most neuropsychological measures, but the differences were significant only on speeded tasks (with and without executive functioning components). The PTSD group's mean performance was within the average range on all neuropsychological tests. Within the PTSD group, more severe PTSD symptoms were associated with slower processing speed, and more severe dissociative symptoms were associated with poorer reasoning performance. These results suggest that women with PTSD related to intimate partner violence demonstrate slower than normal processing speed, which is associated with the severity of psychiatric symptoms. We speculate that the cognitive slowing seen in PTSD may be attributable to reduced attention due to a need to allocate resources to cope with psychological distress or unpleasant internal experiences.

Attention and memory in school-age children surviving the terrorist attack in Beslan, Russia

Little is known about the impact of terrorism on children's cognitive functioning and school learning. The primary purpose of this study was to report on cognitive functioning among school-age children 20 months after a terrorist attack against their school. Participants included 203 directly and indirectly exposed children from Beslan and 100 nonexposed children from another town of the Russian Federation. All children were tested using nonverbal neuropsychological measures of attention, memory, and visual-spatial performance. Predisaster traumatic events and terrorism-related exposure factors were evaluated. Findings revealed that overall, directly and indirectly exposed children performed significantly less well than controls in all domains. In addition, direct exposure and loss of a family member were associated with poor memory performance.

An Empirical Theory of the Development of Homicide within Individuals

There have been many attempts to explain violent behavior, identify its causes, and predict its occurrence among youth and adults. Research and theoretical constructions have dealt with such far-ranging aspects as childhood health, peer and parental interactions, neuropsychological function, school and community support, and substance use and dependency. Theories have tended to focus on one or a few of these aspects, but there is an effort by many researchers to converge on an integrated approach. By demonstrating unique risk patterns in random samples of later-homicidal abused infants, children, and youth, violent and homicidal delinquents, and homicidal adults, five studies by Zagar and colleagues provide the best current empirical evidence for a view of the development of delinquency as a process of accumulating risks. These risks begin with prenatal substance exposure and continue with abusive or neglectful parenting, academic failure, court contacts, compromised executive function and resultant poor social functioning. Analysis by sex shows that males' and females' risks are virtually identical. Various theories are evaluated with respect to these empirical risk patterns for development of violence and homicide. A proposal for the necessary elements of a successful, overarching explanatory theory is offered.

Posttraumatic stress symptoms and brain function during a response-inhibition task: an fMRI study in youth

Youth who experience interpersonal trauma and have posttraumatic stress symptoms (PTSS) can exhibit difficulties in executive function and physiological hyperarousal. Response inhibition has been identified as a core component of executive function. In this study, we investigate the functional neuroanatomical correlates of response inhibition in youth with PTSS. Thirty right-handed medication-naïve youth between the ages of 10 and 16 years underwent a 3-Tesla Functional Magnetic Resonance Imaging scan during a response-inhibition (Go/No-Go) task. Youth with PTSS (n = 16) were age and gender matched to a control group of healthy youth (n = 14). Between-groups analyses were conducted to identify brain regions of greater activation in the No/Go-Go contrasts. PTSS and control youth performed the task with similar accuracy and response times. Control subjects had greater middle frontal cortex activation when compared with PTSS subjects. PTSS subjects had greater medial frontal activation when compared with control subjects. A sub-group of youth with PTSS and a history of self-injurious behaviors demonstrated increased insula and orbitofrontal activation when compared with those PTSS youth with no self-injurious behaviors. Insula activation correlated positively with PTSS severity. Diminished middle frontal activity and enhanced medial frontal activity during response-inhibition tasks may represent underlying neurofunctional markers of PTSS.

Dissociation predicts later attention problems in sexually abused children

OBJECTIVE

The goals of this research are to develop and test a prospective model of attention problems in sexually abused children that includes fixed variables (e.g., gender), trauma, and disclosure-related pathways.

METHODS

At Time 1, fixed variables, trauma variables, and stress reactions upon disclosure were assessed in 156 children aged 8-13 years. At the Time 2 follow-up (8-36 months following the initial interview), 56 of the children were assessed for attention problems.

RESULTS

A path analysis involving a series of hierarchically nested, ordinary least squares multiple regression analyses indicated two direct paths to attention problems including the child's relationship to the perpetrator (beta=.23) and dissociation measured immediately after disclosure (beta=.53), while controlling for concurrent externalizing behavior (beta=.43). Post-traumatic stress symptoms were only indirectly associated with attention problems via dissociation. Taken together, these pathways accounted for approximately 52% of the variance in attention problems and provided an excellent fit to the data.

CONCLUSIONS

Children who report dissociative symptoms upon disclosure of CSA and/or were sexually abused by someone within their family are at an increased risk of developing attention problems.

PRACTICE IMPLICATIONS

Findings from this study indicate that children who experienced sexual abuse at an earlier age, by someone within their family, and/or report symptoms of dissociation during disclosure are especially likely to benefit from intervention. Effective interventions should involve (1) providing emotion regulation and coping skills; and (2) helping children to process traumatic aspects of the abuse to reduce the cyclic nature of traumatic reminders leading to unmanageable stress and dissociation.

Earthquake survivors' quality of life and academic achievement six years after the earthquakes in Marmara, Turkey

This study investigates the quality of life (QOL) and academic achievement of earthquake survivors six years after the earthquakes in Marmara, Turkey. Data were collected from 407 Turkish university students. Of these, 201 were earthquake survivors and 206 had not been exposed to an earthquake. The Turkish adaptation of the brief version of the World Health Organisation's QOL instrument (WHOQOL-BREF, TR) was used to measure QOL. The results reveal that the earthquake survivors' psychological and environmental domains of QOL and academic achievement were significantly lower than those of individuals not exposed to an earthquake. The results also highlight the risk factors that affect the QOL of the earthquake survivors significantly. These are their gender, their age at the time of earthquake and the continued existence of financial difficulties linked to the earthquakes.