Dissociation and Posttraumatic Symptoms in Maltreated Preschool Children

Profiles of Maltreatment in the Child Welfare System: Predicting Mental Health Outcomes and Examining Age as a Moderator

This longitudinal study explored the unique profiles of maltreatment among youth in the child welfare system and examined their relation to mental health outcomes over time. We additionally examined the moderating role of age. Participants included 316 youth in the foster care system (age range: 6-13 years). Data were collected through the Department of Children and Family Services upon youths' entry into foster care, then quarterly for the duration of care. A latent profile analysis identified five profiles of maltreatment, categorized as primary neglect (PN), neglect and physical abuse (PA), complex trauma, complex trauma with severe sexual abuse (SA), and neglect with SA. A hierarchical general linear model applied to the data revealed that all four classes predicted higher internalizing symptom trajectories compared with the PN reference class, event rate ratios (eRRs) = 1.19-1.37, but none of these associations were significantly moderated by age. Membership in the two classes categorized by complex trauma predicted higher externalizing behavior trajectories as compared to the PN reference class, eRRs = 1.11-1.13. The relation between membership in the neglect with SA class and externalizing behaviors was moderated by age, eRR = 0.83. Finally, membership in all four classes predicted higher posttraumatic stress symptoms as compared with the reference group, eRRs = 1.84-2.45, and with all associations moderated by age, eRRs = 0.51-0.53. These findings provide insight into the maltreatment experiences of youth in the child welfare system and have important implications for treatment needs.

Considerations of Dissociation, Betrayal Trauma, and Complex Trauma in the Treatment of Incest

Child sexual abuse committed by a parent (incest) is related to particularly severe physical and psychological symptoms across the life span. Incest is associated with low self-esteem, self-loathing, feelings of contamination, worthlessness, and helplessness, as well as somatization and low self-efficacy. A child's negative constructions often are attempts to derive some meaning that justifies the incest, such as, "it is because of my badness that it happens to me." Survival often involves voluntary or involuntary disconnection from self, others, and the environment, or compartmentalization of the traumatic experiences. Dissociation with survivors of child abuse, especially when the perpetrators are from within the child's caregiver system, can be accounted for by the concept of betrayal trauma. However, with few exceptions, little appears in the literature integrating dissociation, betrayal trauma, complex trauma, and incest for the purpose of treatment. Our purpose of this review to examine the relationship between trauma-related dissociation, betrayal trauma, and complex trauma, and how understanding these concepts and their relationship can inform the treatment of incest.

Injustice is Served: Injustice Mediates the Effects of Interpersonal Physical Trauma on Posttraumatic Stress Symptoms and Depression Following Traumatic Injury

Previous research has consistently found that traumas of an interpersonal nature are associated with elevated levels of posttraumatic stress symptoms (PTSS). In the current study, we examined whether feelings of injustice related to sustained physical trauma mediate the association between the interpersonal nature of a traumatic injury and two outcomes: PTSS and depressive symptoms. The sample consisted of 176 patients admitted to a Level 1 trauma center for traumatic injuries. Participants completed measures of PTSS, depressive symptoms, and injury-related injustice perception at baseline and again at 3- and 6-month postinjury follow-ups. The results revealed that, compared to noninterpersonal injuries, interpersonal injuries were related to significantly higher levels of perceived injustice, PTSS, and depressive symptoms at all three assessment points, except for PTSS at baseline, ds = 0.47-1.23. These associations remained significant after accounting for injury severity. It is important to note that higher levels of perceived injustice 3-month postinjury follow-up mediated the association between the interpersonal nature of the trauma and higher levels of PTSS and depressive symptoms at 6 months postinjury. Our results suggest injustice may be an important factor that helps explain why interpersonal traumas are associated with poorer mental health outcomes than noninterpersonal traumas. Additionally, the current study provides some of the first prospective analyses of injustice perception and trauma outcomes.

Disorganized attachment and emotion dysregulation as mediators of the association between sexual abuse and dissociation in preschoolers

BACKGROUND

Child sexual abuse (CSA) is a prevalent social problem associated with a plethora of difficulties in preschool children. Young victims are likely to show dissociation symptoms that may significantly impede their adaptation. Yet, mechanisms linking CSA with later dissociative symptoms remain unclear. The aim of the present study was to explore whether disorganized attachment and emotion dysregulation could act as mediators of the association between CSA and dissociation.

METHODS

A sample of 424 preschool children (274 CSA victims, 150 comparison group children; 3.5-6 years old) and their parents were recruited. Parents reported on children's emotion dysregulation at initial assessment while attachment representations were assessed through children's narratives using the Attachment Story Completion Task (Bretherton et al., 1990) coded with the Q-Sort (Miljkovitch et al., 2004). Parents reported on children's dissociative symptoms one year later.

RESULTS

Mediation analysis showed that disorganized attachment and emotion dysregulation mediated the association between CSA and dissociation. CSA was linked to greater disorganization scores that were associated with higher scores of emotion dysregulation. Emotion dysregulation was in turn associated with increased severity of dissociation symptoms in preschool children one year later.

LIMITATIONS

Given that attachment and emotion dysregulation were both assessed at T1, the temporal sequencing of mediators remains to be validated in a longitudinal design.

CONCLUSIONS

Findings highlight the relevance of fostering healthy parent-child relationships, as well as the development of optimal emotion regulation skills in young CSA victims to prevent the emergence of dissociation symptoms in this vulnerable population.

The Associations Of Maternal Emotion Dysregulation And Early Child Dissociative Behaviors

Although dissociation is believed to develop in early childhood, there is little research prospectively examining childhood dissociation or parental contributions related to its development. The current study sought to examine parent factors prospectively related to changes in dissociation symptoms in childhood. The current study sampled 68 mother-child dyads at two time points, when children were 3-4 and then 5-6 years, in which mothers with emotion dysregulation were oversampled. Maternal emotion dysregulation was assessed at both time points. Maternal dissociation was assessed only at time two. Child dissociation was assessed at each time point using a modified subscale of the Child Behavioral Checklist. Results showed moderate stability in childhood dissociation across time points. Further, maternal emotion dysregulation and dissociation were both significantly correlated with children's dissociation. Accounting for several covariates, time one maternal emotion dysregulation was prospectively associated with preschoolers' dissociative behaviors at 5-6 years old. The present work suggests that symptoms of dissociation can be observed early in childhood and that maternal factors play an early role in the development of dissociation in children.

PTSD with and without dissociation in young children exposed to interpersonal trauma

BACKGROUND

A Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) was added to the DSM-5, but little is known about this symptom pattern in young children exposed to trauma. Tailoring treatment to traumatized young children requires understanding the different patterns of trauma-related symptomatology and important correlates. The current study tested the hypothesis that type and number of child traumatic events, caregiver trauma exposure, and caregiver symptomatology would predict whether traumatized young children presented with PTSD, PTSD with clinical dissociation, or non-clinical trauma symptoms.

METHODS

A multinomial regression was conducted using data collected from an ethnically and economically diverse sample of 297 trauma-exposed children between the ages of 3 and 6 and their caregivers. Based on parent-report on a well-validated measure of trauma symptoms, children were categorized into three groups: non-clinical (n = 128), PTSD only (n = 104), or PTSD with dissociation (PTSD-DISS; n = 65). Predictors included trauma exposure, parent trauma symptoms, and child sex.

RESULTS

Girls were twice more likely than boys to be in the PTSD-DISS group; sexually abused children were almost three times as likely to be in the PTSD-DISS group; and, for every unit increase in parent avoidance symptoms or number of traumatic events, the odds of being in the PTSD-DISS group increased significantly.

LIMITATIONS

Given the cross-sectional study design, conclusions cannot be drawn regarding causality. Measures were completed by a single reporter.

CONCLUSIONS

Findings suggest that subgroups of children may be especially vulnerable to comorbid PTSD and dissociation. Implications for treatment are discussed.

[The diagnostic relevance of CBCL and YSR in diagnosing PTSD in adolescence]

BACKGROUND

The present study sought to examine the symptomatology of children and adolescents with a history of trauma experience of using the German versions of Child Behavior Checklist (CBCL) and Youth Self Report (YSR). We pursue the question to what extent symptoms differ among adolescents with and without posttraumatic stress disorder (PTSD). A further objective is comparing self-assessment of the children and adolescents with the rating of their parents or caregivers.

METHODS

Overall N = 41 patients, aged 11-18 years, and one caregiver of each patient were surveyed. All patients were referred to the forensic ambulance of the University Clinic of Child and Adolescent Psychiatry in consequence of acute burden or violent trauma.

RESULTS

Concerning the two global Scales ("Internalizing" and "Externalizing" symptoms), adolescents with PTSD reported significantly more problems than adolescents without PTSD diagnosis. Further, results on Externalizing Scale showed a systematic higher problem estimation of children and adolescents when compared to their parents.

CONCLUSIONS

The present findings reveal a divergence between child and parent ratings on clinically relevant behavioral problems. Symptoms experienced by the children and youth are often not being recognized by parents. Therefore, it is essential to include the perceptions of the parents at the beginning of diagnostic assessment and counteract possible parental misunderstanding.

Risk and resilience trajectories in war-exposed children across the first decade of life

BACKGROUND

Although the effects of early-onset trauma on susceptibility to psychopathology are well-acknowledged, no study to date has followed risk and resilience trajectories in war-exposed young children over lengthy periods and charted predictors of individual pathways.

METHOD

In this prospective longitudinal study, we followed 232 children, including 148 exposed to repeated wartime trauma and 84 controls, at three time points: early childhood (1.5-5 years), middle childhood (5-8 years), and late childhood (9-11 years). Children were diagnosed at each time point and four trajectories defined: children exhibiting no pathology at any time point, those displaying early pathology that later remitted, those showing initial resilience followed by late pathology, and children presenting chronic pathology across the entire first decade. Maternal behavioral containment during trauma evocation and child social engagement during free play were observed in early childhood and maternal emotional distress self-reported across time.

RESULTS

War-exposed children showed significantly higher rates of psychopathology, with 81% exhibiting pathology at some point during childhood. In middle childhood, exposed children displayed more posttraumatic stress disorders (PTSD), anxiety disorders, and attention-deficit/hyperactivity disorders (ADHD), and in late childhood more PTSD, conduct/oppositional defiant disorders, and ADHD. War-exposed children had more comorbid psychopathologies and number of comorbidities increased with age. Notably, war-exposure increased prevalence of chronic pathology by 24-fold. Maternal factors, including mother's uncontained style and emotional distress, increased risk for early and chronic psychopathology, whereas reduced child social engagement augmented risk for late pathology.

CONCLUSIONS

Early-onset chronic stress does not heal naturally, and its effects appear to exacerbate over time, with trauma-exposed children presenting a more comorbid, chronic, and externalizing profile as they grow older. Our findings demonstrate that responses to trauma are dynamic and variable and pinpoint age-specific effects of maternal and child factors on risk and resilience trajectories. Results highlight the importance of conducting long-term follow-up studies and constructing individually tailored early interventions following trauma exposure.

Failure to differentiate between threat-related and positive emotion cues in healthy adults with childhood interpersonal or adult trauma

Enhanced threat-related processing is associated with both elevated anxiety and childhood exposure to trauma. Given the paucity of evidence regarding the effects of childhood and adult trauma exposure on subsequent psychophysiological processes in the absence of psychopathology, we investigated the relative impacts of childhood interpersonal and non-interpersonal trauma, as well as adult trauma exposure on neural processing of threat in healthy adults. We measured peak amplitudes of the N170 face-sensitive visual ERP component response to non-conscious and conscious Angry (threat) versus Happy (non-threat, positive) and Neutral (non-threat baseline) faces at temporo-occipital sites (right-T6; left-T5) in 489 psychiatrically asymptomatic adults (aged 18-70 years, 54% women, 94% right-handed). N170 peak amplitude differences between Angry vs Happy or Neutral faces were calculated and subjected to hierarchical multiple regression analysis, with trauma types (childhood interpersonal, childhood non-interpersonal and adult trauma) entered as predictors of interest. After controlling for sociodemographic and health factors, N170 peak amplitudes for non-conscious Angry vs Happy faces were inversely associated with childhood interpersonal trauma at T6 and adult trauma exposure at T5. Post-hoc repeated measures ANOVA indicated that unlike adults without trauma exposure, trauma-exposed adults failed to show significantly reduced N170 responses to Happy relative to Angry faces during non-conscious processing. This suggests that childhood interpersonal and adult trauma exposure are associated with a failure to differentiate between non-threat or positive and threat-related emotion cues. This is consistent with generalised hypervigilance seen in PTSD, and suggests trauma exposure is associated with a generalized heightened responsivity to non-conscious non-threat or positive as well as threat-related emotion cues in psychiatrically healthy adults.

Emotion Regulation in Sexually Abused Preschoolers

Emotion regulation is closely related to mental health in children and adults. Low emotion regulation competencies have been found in school-aged sexually abused girls. The aim of the present study was to investigate emotion regulation competencies in sexually abused preschool girls and boys using a multi-informant approach. Emotion regulation was assessed in 62 sexually abused and 65 non-abused preschoolers using the Emotion Regulation Checklist and the MacArthur Story Stem Battery. Both parents and educators reported lower emotion regulation competencies in sexually abused preschoolers, especially boys, than in non-abused children. The narrative task completed by the children also revealed lower emotion regulation competencies in sexually abused boys. These findings could have an important impact on intervention programs offered to these at-risk children.

Emotion regulation as a mediator of the relation between sexual abuse and behavior problems in preschoolers

Maltreated children show poor emotion regulation competencies compared to non-maltreated children. Emotion regulation has been found to mediate the association between maltreatment and behavior problems in children. The aim of the present study was to examine the relationships among child sexual abuse (CSA), emotion regulation (ER), and internalized and externalized behavior problems in preschoolers using conditional process analyses. ER competencies were assessed in 127 children aged 41-79 months (62 abused, 65 non-abused) by their parents (N=124) and early childhood educators (N=88) using the Emotion Regulation Checklist (Shields & Cicchetti, 1995, 1997). Behavior problems were evaluated by parents using the Child Behavior Checklist (Achenbach & Rescorla, 2000, 2001). ER was found to completely mediate the relation between CSA and internalized behavior problems and partially mediate the relation between CSA and externalized behavior problems. Parents' and educators' evaluations of ER were also found to differ as a function of child gender. The discussion focuses on the relationships among CSA, ER, behavior problems, and child gender. The clinical implications of these findings are also examined. Promoting the optimal development of ER could prevent the emergence and exacerbation of behavior problems in these at-risk children and, in turn, foster resilience.

Symptoms of Dissociation in a High-Risk Sample of Young Children Exposed to Interpersonal Trauma: Prevalence, Correlates, and Contributors

Children who have experienced interpersonal trauma are at an increased risk of developing dissociation; however, little is known about the prevalence or correlates of dissociation in young children. The current study examined symptoms of dissociation in 140 children (mean age = 51.17 months, range = 36-72 months, SD = 10.31 months; 50.0% male; 45.7% Hispanic) who experienced trauma (e.g., witnessing domestic violence, experiencing abuse). Child dissociation and exposure to traumatic events were assessed using a clinician-administered interview with the biological mother (mean age = 32.02 years, SD = 6.13; 49.3% Hispanic; 25.5% married or cohabitating). Mothers completed measures of maternal dissociation, depression/anxiety, and child behavior problems. At least subclinical dissociation was present for 24.3% of children. Robust regression with least trimmed squares estimation showed that greater maternal dissociation was related to greater child dissociation, adjusting for child internalizing symptoms, number of traumas, and maternal depression/anxiety, B = 0.09, χ(2) = 10.47, p < .001, R(2) Δ = .04. Children who experienced direct victimization did not exhibit a significantly higher level of dissociation compared to children who experienced other traumas, F(1, 138) = 3.76, p = .054, η(2) = .03. These findings highlight the need to assess dissociation in traumatized young children.

Trauma experience in children and adolescents: an assessment of the effects of trauma type and role of interpersonal proximity

The psychiatric sequelae associated with childhood experience(s) of trauma is complex and distinguishable from that of adult trauma exposure. Categories of impairment associated with experiences of early trauma include internalizing and externalizing emotional and behavioral problems, posttraumatic stress symptomatology, and dissociation. The present study assessed the relationship between the type of trauma experience (i.e., non-interpersonal or interpersonal) and the manifestation of a wide range of psychiatric symptomatology using prospective longitudinal data from a community sample of ethnically diverse children and adolescents (N=1676; ages 4-18). The study also examined the relationship between different types of trauma experiences (e.g., direct, vicarious, interpersonal) and levels of various symptom domains (e.g., anxiety, posttraumatic stress, conduct problems). A number of factors relevant to the relationship between early trauma experience and subsequent impairment including temperament, socioeconomic status, sex, and age were included in the analyses. Results indicated that interpersonal traumas involving significant interpersonal proximity were associated with externalizing problems (i.e., oppositional defiant and conduct problems). Direct trauma experiences and emotionality were positively associated with almost all symptom domains. Implications for the relationship between trauma and developmental psychopathology are discussed.

Modeling Patterns of Negative Life Events and Mental Health in Faroese Adolescents

OBJECTIVES

The objective of this study was to identify naturally occurring typologies of Faroese adolescents on the basis of their exposure to traumatic and negative life events. It was hypothesized that underlying typologies of trauma and negative life events would be uncovered. Furthermore, it was hypothesized that males would be overrepresented in classes characterized by the endorsement of a wide range of trauma and negative life events. On the basis of prior research, it was also hypothesized that females had endorsed more traumas of a sexual nature and that males had endorsed more traumas of a violent nature. Finally, post-traumatic stress, negative affectivity, and somatization were examined in the different typologies.

METHODS

Latent class analyses were conducted with the use of data collected from a self-report questionnaire survey from 687 Faroese eighth graders (85% response rate). The questionnaire included a traumatic and negative life event list, the Harvard Trauma Questionnaire-Part IV, and the Trauma Symptom Checklist.

RESULTS

Three classes of adolescents were identified on the basis of their exposure to potentially traumatic and negative life events. The baseline class (81.3%) had a low probability of the endorsement of all potentially traumatic and negative life events, except threats of violence and bullying. This group had low scores for post-traumatic symptoms, negative affectivity, and somatization. Class 2 (13.7%) comprised mainly males and had the highest probability of endorsement of threats of violence, physical assault, and bullying; this group also had high scores for post-traumatic stress symptoms, negative affectivity, and somatization. Finally, Class 1 (5.0%) consisted of adolescents with a relatively high risk of exposure to all potentially traumatic events and negative life events, except threats of violence. This group had the highest scores for post-traumatic stress symptoms, negative affectivity, and somatization.

CONCLUSIONS

The present study can be said to be a concise picture of trauma exposure and its consequences among Faroese adolescents, and it is thereby a valuable tool for the national planning of preventive and interventional strategies and for empirically founded economic prioritization. These results emphasize the importance of choosing a trauma-informed strategy in various disciplines, such as pediatrics, child and adolescent psychiatry, social work, and school psychology when the aim is to provide the appropriate intervention.

Dissociative symptoms over a year in a sample of sexually abused children

This study aims to document the evolution of dissociative symptoms over time in preschoolers who disclose sexual abuse. Specifically, this study explores the frequency of dissociative symptoms as a function of child gender. A follow-up evaluation was conducted 1 year after initial disclosure among a sample of 48 sexually abused children, and their results were contrasted with those of a control group composed of 71 non abused children. Children's dissociative symptoms were evaluated by non-offending parents. Data showed that children reporting sexual abuse displayed a greater frequency of dissociative symptoms than non-sexually abused children at both evaluation times. Further analysis indicated that the evolution of dissociative symptoms in sexually abused children may be gender related. Although a decline in dissociation symptoms over time was evident for sexually abused girls at follow-up, sexually abused boys displayed greater dissociative symptoms. Results are discussed in terms of their implications for interventions for sexually abused children.

Dissociation in middle childhood among foster children with early maltreatment experiences

OBJECTIVE

This study examined levels of dissociation in school-aged foster children who had been maltreated before age 5.

METHOD

Data were collected from 118 children (age in years: M = 9.34, SD = 1.02) and their caregivers. Chi-Square and ANOVA were used to compare foster children (n = 67) to community comparison children (n = 51). Regression analyses examined predictors of dissociation for the foster children.

RESULTS

The foster children showed significantly higher levels of dissociation than the control children. Within the foster care group, number of placement transitions, female gender, and maltreatment subtype significantly predicted dissociation.

CONCLUSIONS

The foster children were more dissociative than the control children. The finding that children who had experienced all types of abuse and who had experienced physical abuse with emotional maltreatment and neglect showed the highest levels of dissociation is consistent with findings from previous research.

PRACTICE IMPLICATIONS

The findings from this study suggest that maltreated girls and children with specific maltreatment profiles are at increased risk for dissociation. Further, as number of foster placements appears to contribute to dissociation, child welfare professionals should consider this factor during placement transitions.

Dissociation in foster preschoolers: a replication and assessment study

This study replicated the Child Behavior Checklist factor structure of traumatic sequelae in maltreated children that was established by A. C. Hulette and colleagues (in press; see also A. Cholankeril et al., 2007). The factors represent dissociation and posttraumatic stress disorder symptomatology. The present study also examined the extent to which these 2 factor scores varied depending on specific maltreatment experiences. Results indicated that children who experienced both physical and sexual abuse in addition to neglect had significantly higher levels of dissociation than children who experienced (a) sexual abuse alone or with neglect, (b) physical abuse alone or with neglect, or (c) only neglect. The current study provides evidence that children who experience multiple forms of maltreatment are more likely to be dissociative, perhaps due to a greater need for a coping mechanism to manage the distress of that maltreatment.