Posttraumatic stress disorders in children and adolescents

Post-traumatic stress disorder and associated factors among high school students who experienced war in Woldia town

Background

The experience of war in recent time is very common around the world, and the impact is profound on the mental health of the victims, especially among the young population. The most implicated mental health problem is post-traumatic stress disorder, which comes after an exposure to trauma as a severe and long-term result of the traumatic event. Studies in developed countries revealed this finding, but there is insufficient information in developing countries, where much of war and conflict exist and young population live including Ethiopia. Therefore, this study aims to assess the prevalence and associated factors of post-traumatic stress disorder among high school students who experienced war.

Objective

We assessed the prevalence and factors associated with post-traumatic stress disorder among high school students who experienced war.

Methods

A multi-centered school base cross-sectional study was conducted from May 23 to June 08, 2022. Data were collected from high school students in Woldia town. Bivariable and multivariable logistic regression was used to identify the independent factors associated with post-traumatic stress disorder.

Results

A total of 338 of the 410 students participated in this study (94.5% response rate). The prevalence of post-traumatic stress disorder was 39.2%. In the multivariable analysis, poor social support (AOR = 3.40, 95% CI: 1.45, 7.95), depression (AOR = 3.24, 95% CI: 1.69,6.21), high level of perceived stress (AOR = 2.98, 95% CI: 1.61, 5.50), being in war fighting situation (AOR = 2.85, 95% CI: 1.40, 5.78), and witnessing the murder of family members or friends (AOR = 3.05, 95% CI: 1.47, 6.32) were factors significantly associated with post-traumatic stress disorder at a p-value <0.05.

Conclusions and recommendations

In this study, around two in five of high school students had post-traumatic stress disorder. Independent factors of PTSD were depression, high stress levels, poor social support, witnessing the murder of family members/friends, and being in war fighting situation. We recommend that the Ministry of Education and the Ministry of Health collaborate to integrate mental health services into schools. This focuses on the early detection of students at risk of PTSD, such as those with depression, high perceived stress levels, and exposure to murder or war, and provides necessary social support to prevent PTSD.

Traumatic stress, mental health, and quality of life in adolescents with esophageal atresia

INTRODUCTION

We aimed to investigate QoL in EA patients in relation to comparison groups and to clinical factors including experienced traumatic stress.

MATERIAL AND METHODS

Adolescents with EA in Norway born between 1996 and 2002 were included. Clinical assessment and patient's characteristics were collected. Quality of life (PedsQL), traumatic stress (IES-13) and mental health (SDQ-20) were compared to groups of healthy controls, children with acute lymphoblastic leukemia (ALL) and kidney transplanted children (TX).

RESULTS

68 EA adolescents participated. Total scores for PedsQL were not different from the healthy group and ALL patients, but significantly better than the TX patients. The subscale for physical performance was significantly lower than in healthy adolescents, and nine (17%) patients had scores ≤70 indicating reduced health status. Five EA adolescents (12%) had mental health scores suggesting a psychiatric disorder, and six (9%) reported high traumatic stress scores with a significant correlation to days on ventilator in the neonatal period. The strongest predictors for quality of life among EA adolescents were self-reported mental health, posttraumatic stress and GERD symptoms.

CONCLUSION

Scores for Quality of life in the EA group are good except for subscale for physical performance. Symptoms of posttraumatic stress, mental strain and gastroesophageal reflux are predictors of reduced QoL.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Matching the Symptom Profile of Adolescent Disaster Survivors with Changing Diagnostic Criteria of Posttraumatic Stress Disorder: Focus on ICD-11

BACKGROUND

Considering recent changes in the diagnostic guidelines for posttraumatic stress disorder (PTSD), it has become imperative to review their influence, especially on the symptoms related to children and adolescent victims of disasters. We intended to assess the profile of posttraumatic stress symptoms (PTSS) of adolescents following an earthquake, especially the gender differences, in relation to the changing diagnostic guidelines, particularly ICD-11.

METHODS

In a cross-sectional study, PTSS and functional impairments were evaluated in school-going adolescents in Nepal, one year after the 2015 earthquake, using the Child Posttraumatic Stress Scale (CPSS).

RESULTS

A considerable proportion of adolescent survivors of the earthquake had PTSS. Most common ones were intrusive thoughts (46.7%), avoiding thoughts, conversations and feelings about the disaster (44.2%), decreased interest in activities (40.0%), distress with reminders (35.6%), and concentration problems (35.6%). Females had a higher prevalence for all the PTSS compared with males, except for avoiding thought, conversations, feelings, and being overly careful/vigilant. Proportion of adolescents who met symptomatic criteria for PTSD diagnosis in different systems ranged from 14.7% in DSM-5 to 15.6% in ICD-11 three-factor model, and 22.2% in DSM-IV and 31.7% in ICD-10. Inclusion of the criterion of significant functional impairment changed the proportions to 10.0%, 10.3%, 12.8%, and 16.4%, respectively. In all of the diagnostic systems, higher proportions of females had possible PTSD.

CONCLUSION

Adolescent females had a higher prevalence for most of the PTSS and at the diagnostic level. It appears that for adolescents, diagnosis of PTSD in ICD-11 has become more robust with a focus on core symptoms and having a functional impairment criterion.

Nightmares in Treatment-Seeking Youth: the Role of Cumulative Trauma Exposure

Although nightmares are frequently endorsed symptoms in children who have experienced trauma, limited research has been conducted on how nightmares vary with different forms of trauma exposure. Our goal was to assess the relationship between nightmares, trauma exposure, and symptoms of Posttraumatic Stress Disorder (PTSD) in youth. A total of 4440 trauma exposed treatment-seeking youth (ages 7 to 18) were administered the UCLA PTSD Reaction Index. Different trauma types, total traumas experienced, and PTSD symptoms were analyzed with correlations and a logistic regression in relation to nightmare frequency. Overall, 33.1% of participants reported experiencing clinically-significant nightmares. 79.1% of the sample experienced more than one trauma type, with an average of 3.06 trauma types endorsed. A binary logistic regression demonstrated the odds of reporting clinically-significant nightmares increased by 1.3 times for every additional type of trauma experienced. Lastly, nightmares were positively correlated with all PTSD criterion. The current study provides prevalence rates of trauma exposure and nightmares in a large, statewide sample of treatment-seeking youth. Each new trauma type experienced resulted in a greater likelihood of endorsing clinically-significant nightmares. This study provides useful information related to assessing and addressing nightmares in youth who have experienced trauma.

Efficacy of Psychological Intervention for Children with Concurrent Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are common conditions following motor vehicle accidents (MVAs). Mild TBI and PTSD not only share similar features but may also coexist and interact. Nonetheless, research on psychotherapeutic interventions for PTSD in patients with a history of mTBI, particularly regarding pediatric populations, is limited. The present study compared the efficacy of the prolonged exposure treatment protocol for children and adolescents (PE-A) with PTSD and mTBI (n = 16) versus PTSD alone (n = 21); treatment commenced at least 3 months following an MVA. Emotional status and cognitive functioning were assessed pre- and postintervention using questionnaires and standardized neuropsychological tests. Participants from both groups benefitted from the intervention, as reflected in their emotional status via increased ratings of well-being and decreased ratings of PTSD, anxiety, depression, and postconcussive symptoms, η² = .21-.50. Ratings of cognitive function also improved for cognitive flexibility, η² = .30; executive function in everyday life, η² = .27; and attention and inhibition, η² = .16. Parental PTSD was the strongest predictor of improvement after intervention, sr² = .35. Thus, it appears that PE-A is an effective intervention for children with MVA-related PTSD regardless of its comorbidity with mTBI.

Posttrauma psychosocial effects in children: A systematic review of measurement scales

PROBLEM

Worldwide, the psychopathological effects of catastrophes such as earthquake, hurricane and war are causing traumas in an enormous number of children. Identification and assessment of the impact on children of catastrophic events is essential to their healing and continued well-being.

METHODS

To identify the relevant tools Google Scholar, SID, PsycInfo, Medlib, MedLine, and PubMed databases were searched using the relevant Mesh terms and their equivalents including ("anxiety" or "fear" or "depression" or "psychosocial distress" or "prolonged grief" or "trauma general effect") AND ("tool and measures") OR ("cognition" and "parents") AND "scale and measures") from inception to March 2019.

FINDINGS

Sixty-four measures were identified to be applied for measuring traumas' psychosocial effects on children. Anxiety and depression, posttraumatic stress disorder (PTSD), sexual abuse, trauma general effect and stress were among the important emanated tools to the assessment of posttrauma psychosocial predicaments in children.

CONCLUSION

Few measures are identified to measure post trauma fear, prolonged grief and psychosocial distress in young children. However; a suitable scale for assessment of parents' cognition about general effects of traumas and parents' cognition about effects of trauma on children is less emphasized in current literature.

On Becoming Trauma-Informed: Role of the Adverse Childhood Experiences Survey in Tertiary Child and Adolescent Mental Health Services and the Association with Standard Measures of Impairment and Severity

CONTEXT

There is a movement toward trauma-informed, trauma-focused psychiatric treatment.

OBJECTIVE

To examine Adverse Childhood Experiences (ACE) survey items by sex and by total scores by sex vs clinical measures of impairment to examine the clinical utility of the ACE survey as an index of trauma in a child and adolescent mental health care setting.

DESIGN

Descriptive, polychoric factor analysis and regression analyses were employed to analyze cross-sectional ACE surveys (N = 2833) and registration-linked data using past admissions (N = 10,400) collected from November 2016 to March 2017 related to clinical data (28 independent variables), taking into account multicollinearity.

RESULTS

Distinct ACE items emerged for males, females, and those with self-identified sex and for ACE total scores in regression analysis. In hierarchical regression analysis, the final models consisting of standard clinical measures and demographic and system variables (eg, repeated admissions) were associated with substantial ACE total score variance for females (44%) and males (38%). Inadequate sample size foreclosed on developing a reduced multivariable model for the self-identified sex group.

CONCLUSION

The ACE scores relate to independent clinical measures and system and demographic variables. There are implications for clinical practice. For example, a child presenting with anxiety and a high ACE score likely requires treatment that is different from a child presenting with anxiety and an ACE score of zero. The ACE survey score is an important index of presenting clinical status that guides patient care planning and intervention in the progress toward a trauma-focused system of care.

Gender Differences in Prevalence of Somatoform Disorders in Patients Visiting Primary Care Centers

The aim of this study was to examine the gender differences in the prevalence of somatoform disorders among a sample of Qatari patients who were visiting primary health care centers and to investigate the severity of diagnostic categories and the most frequent somatic symptoms in these patients. The first stage of the study was conducted with the help of general practitioners, using the somatic symptom module of the Patient Health Questionnaire 12-item General Health Questionnaire. Overall, 2320 subjects were approached, and a total of 1689 patients, of whom 892 were men and 797 were women, agreed to participate in the study. The prevalence rate of somatoform disorders among the total screened sample was 23.9%. The prevalence rate was slightly higher in Qatari women (24.2%) than in Qatari men (23.7%). Housewives (43.5%) and men in administrative posts (37.9%) reported higher somatic symptoms compared to other professions. Prolonged depressive reaction was significantly higher in women compared to men ( P = .003). There was a significant gender difference in certain psychiatric diagnostic categories such as depressive episode, recurrent depressive disorder, dysthymia, and brief depressive reaction. Backache was the most common reported symptom in men, whereas headache was more common in women. The present study revealed that the prevalence of somatoform disorders in Qatar is as high as the overall prevalence reported in prior studies done in other primary care settings. The prevalence of somatoform disorders was slightly higher in Qatari women than in men.

Gender Differences in Neurocognitive Performance Among Children With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are frequent sequelae after motor vehicle accidents (MVAs). These two pathologies often have overlapping neurocognitive deficits across several domains, such as attention, memory, and executive functions. The present study was an effort to examine the contribution of gender to these overlapping symptoms. To this end, psychodiagnostic and neuropsychological data were collected on 61 children and adolescents 3 months following MVA. All participants were diagnosed with PTSD, and about half (n = 33) also received a diagnosis of mTBI. Analyses of variance revealed significant interactions between gender and mTBI (ηp2=.15), such that girls with mTBIs preformed significantly worse than noninjured girls on measures of executive functions (Cohen's d = 3.88) and sustained attention (Cohen's d = 3.24). Boys, on the other hand, did not differ significantly on any of those measures, irrespective of TBI injury status. Similarly, comparisons to the normative population revealed that, whereas boys showed impaired neurocognitive performances regardless of TBI status, impaired performances in girls were limited to those cases in which the girls were comorbid for PTSD and mTBI. It appears then that whereas PTSD alone might explain boys' reduced neurocognitive performance, among girls the comorbidity of PTSD and mTBI is required to account for performance deficits.

Abnormal functional architecture of amygdala-centered networks in adolescent posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a prevalent, debilitating, and difficult to treat psychiatric disorder. Very little is known of how PTSD affects neuroplasticity in the developing adolescent brain. Whereas multiple lines of research implicate amygdala-centered network dysfunction in the pathophysiology of adult PTSD, no study has yet examined the functional architecture of amygdala subregional networks in adolescent PTSD. Using intrinsic functional connectivity analysis, we investigated functional connectivity of the basolateral (BLA) and centromedial (CMA) amygdala in 19 sexually abused adolescents with PTSD relative to 23 matched controls. Additionally, we examined whether altered amygdala subregional connectivity coincides with abnormal grey matter volume of the amygdaloid complex. Our analysis revealed abnormal amygdalar connectivity and morphology in adolescent PTSD patients. More specifically, PTSD patients showed diminished right BLA connectivity with a cluster including dorsal and ventral portions of the anterior cingulate and medial prefrontal cortices (p < 0.05, corrected). In contrast, PTSD patients showed increased left CMA connectivity with a cluster including the orbitofrontal and subcallosal cortices (p < 0.05, corrected). Critically, these connectivity changes coincided with diminished grey matter volume within BLA and CMA subnuclei (p < 0.05, corrected), with CMA connectivity shifts additionally relating to more severe symptoms of PTSD. These findings provide unique insights into how perturbations in major amygdalar circuits could hamper fear regulation and drive excessive acquisition and expression of fear in PTSD. As such, they represent an important step toward characterizing the neurocircuitry of adolescent PTSD, thereby informing the development of reliable biomarkers and potential therapeutic targets.

The influence of perceived stress on the onset of arthritis in women: findings from the Australian Longitudinal Study on women's health

BACKGROUND

Psychosocial factors are considered as risk factors for some chronic diseases. A paucity of research exists surrounding the role of perceived stress in arthritis onset.

PURPOSE

Perceived stress as a risk factor for arthritis development was explored in an ageing cohort of Australian women.

METHODS

This study focused on 12,202 women from the 1946-1951 cohort who completed the Australian Longitudinal Study on Women's Health surveys in 2001, 2004 and 2007. Longitudinal associations were modelled, with and without a time lag.

RESULTS

Findings from the multivariate time lag modelling, excluding women with persistent joint pain, revealed that perceived stress predicted the onset of arthritis, with women experiencing minimal and moderate/high stress levels having a 1.7 and 2.4 times greater odds of developing arthritis 3 years later, respectively (p's < 0.001).

CONCLUSION

Chronically perceiving life as stressful is detrimental to future health. The findings provide support for perceived stress to be considered alongside other modifiable risk factors.

Psychological impact of esophageal atresia: review of the research and clinical evidence

Esophageal atresia (EA) occurs in one out of 2500 to 4500 live births. As the vast majority of infants are now surviving neonatal corrective surgery, the focus has shifted from mortality to morbidity associated with EA. However, little is known about its psychological morbidity. This paper synthesizes research and clinical evidence to highlight the psychological sequelae of EA, including its impact on parents' psychological functioning and its effects on child development from infancy to adulthood. Whether it is discovered at birth or prenatally, EA is a psychologically traumatic event, and parents are at risk for developing traumatic stress reactions following diagnosis. Neonatal surgery and intensive care, risk of complications, associated anomalies, and genetic etiologies multiply risk for parents' acute and post-traumatic stress disorders (PTSD). Parental PTSD has a negative impact on infant and child development through its effects on parenting skills and parent-child interactions. EA children are also at risk for PTSD because of invasive and stressful procedures they undergo during the neonatal period. Consequences of EA can have an important long-term impact on children's psychological and social development. The scant studies pertaining to cognitive functioning suggest that EA does not affect mental development during infancy, but may be associated with deficits as children reach school age. Long-term sequelae are unclear because psychological functioning in adults has not yet been adequately examined. Research and clinical evidence of psychological morbidity associated with EA has implications for clinical practice. Psychological support for parents must begin during the neonatal period and should continue as an integral component of long-term follow up for both children and parents. Support is best provided within the context of a multidisciplinary treatment team that follows patients from birth through childhood and adolescence. Psychological follow up should continue into adulthood, as patients grow up and transition from pediatric to adult health-care settings.

Child maltreatment: the neurobiological aspects of posttraumatic stress disorder

Childhood trauma due to physical abuse, neglect, or sexual abuse is a serious problem in the United States. Trauma can result in disruption or injury to the developing brain and lead to neurodevelopmental deficits that affect a child's functioning and can result in lifelong problems. Research has provided insight into how early childhood maltreatment affects brain development. This article examines the research on trauma, its effects on the brain, and evidence-based interventions. An overview of normal brain functioning and posttraumatic stress disorder is presented. Implications for social work practice with children who have experienced child maltreatment are discussed.

Posttraumatic stress disorder in children and adolescents: a review of psychopharmacological treatment

PTSD in children and adolescents differs from the adult disease. Therapeutic approaches involve both psychotherapy and psychopharmacotherapy.

OBJECTIVES

The current paper aims at reviewing studies on psychopharmacological treatment of childhood and adolescent PTSD. Additionally, developmental frameworks for PTSD diagnosis and research along with an experimental model of quenching and kindling in the context of stress exposure are presented. We conducted an extensive literature search of reviews on psychopharmacotherapy as well as studies on psychopharmacological treatment for PTSD among children and adolescents. We used the database PubMed and focused on the time period of the last 10 years up to January 2009. Pertinent earlier papers were also included.There are a limited number of studies specifically assessing the psychopharmacological treatment of PTSD in children and adolescents. The vast majority of them lack verification in RCTs. Only the use of imipramine, divalproex sodium and sertraline were already evaluated in RCTs. Future studies should take into account developmental approaches to the diagnosis and treatment of PTSD in children and adolescents. In this context, different underlying neurobiological patterns, which are reflected in distinct clinical symptomatology, require a precise investigation and a symptom-orientated psychopharmacological approach.

Posttraumatic stress disorder in the pediatric trauma patient

Recent research has uncovered the prevalence of posttraumatic stress disorder (PTSD) after traumatic experiences in the pediatric population at an alarming rate. This review discusses new challenges in identifying children at risk for the development of PTSD, as well as understanding the unique aspects of this disorder found in the pediatric population. In addition to the characterization of pediatric PTSD, this review addresses current screening tools and treatment strategies used in childhood stress disorders.

Prevalence and risk factors of domestic violence among Mongolian Women

AIMS

The purpose of this study was to investigate the prevalence and determinants of domestic violence in Mongolian women.

METHODS

The survey was administered to 5500 people in 1000 households randomly selected from two districts of Ulaanbaatar, Mongolia.

RESULTS

The response rate was 90.3% (total of 4967, and 3338 were women.). About 37.7% of respondents reported that they were affected by some type of domestic violence during the previous 6 months; 17.9% of all respondents reported physical violence, 21.9% reported emotional violence, 10% reported sexual abuse, and 6.9% reported financial violence. Major risk factors for violence against women included having only a primary education or less, low income, living in a rented house, and living with an unemployed partner who uses alcohol.

CONCLUSIONS

Domestic or intimate partner violence (IPV) is widespread in Mongolia and is usually committed in family circles, often away from public view. This study suggests that increasing employment for men may help reduce poverty and alcohol abuse and, thus, IPV.

Nursing Care of Children after a Traumatic Incident

The objective of this study was to describe the nursing interventions with children and their parents to reduce the impact of a traumatic incident. A traumatic incident can be a natural disaster, a plane or car accident, or child abuse. The author has conducted an interdisciplinary integrative review of the research literature on the health impact of childhood trauma. This research is summarized and the results are synthesized and presented in a diagram that demonstrates the strong relationships that trauma has to both short and long-term health status. The impact of post-traumatic stress disorder (PTSD) and interventions to reduce its impact are described. Predictability and continuity in nursing care grounded in both routine and personnel are important. Nurses can teach self-soothing techniques and coping skills prior to using exploratory dialogue to assist the child and the parent in reviewing the traumatic incident. Nurses can also act as advocates for unsafe situations and practices, such as corporal punishment. Assessment of children for history of trauma is indicated, especially children who exhibit signs of short-term health effects. Areas for health education and future research are also presented.

Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care

OBJECTIVE

This study investigated pediatrician-reported practices in identifying, assessing, and treating traumatic exposure and posttraumatic stress disorder (PTSD) in children.

METHOD

Focus groups guided the development of a survey that was mailed to primary care pediatricians in Massachusetts in 2005. Descriptive statistics and multivariate analyses were used to describe clinical practices and perceived barriers to care.

RESULTS

A 60% (N=597) survey response-rate was obtained. On average, pediatricians reported that less than 8% of patients had psychological problems that may be related to traumatic exposure. Only 18% of pediatricians agreed that they had adequate knowledge of childhood PTSD. About 15% of pediatricians reported frequently learning about traumatic event(s) from direct inquiry in the past year. Only 10% of pediatricians reported frequent assessment and treatment of posttraumatic stress symptoms. Most pediatricians (72%) agreed that greater collaborations with mental health providers would improve pediatric assessment of PTSD. Finally, having received PTSD-specific training and believing that pediatricians should identify and manage PTSD were each significantly associated with learning about a traumatic event from direct inquiry.

CONCLUSION(S)

Providing PTSD-specific training and changing pediatricians' attitudes about childhood PTSD may be useful first steps in improving care for children.

Own and parental war experience as a risk factor for mental health problems among adolescents with an immigrant background: results from a cross sectional study in Oslo, Norway

BACKGROUND

An increasing proportion of immigrants to Western countries in the past decade are from war affected countries. The aim of this study was to estimate the prevalence of war experience among adolescents and their parents and to investigate possible differences in internalizing and externalizing mental health problems between adolescents exposed and unexposed to own and parental war experience.

METHOD

The study is based on a cross-sectional population-based survey of all 10th grade pupils in Oslo for two consecutive years. A total of 1,758 adolescents were included, all with both parents born outside of Norway. Internalizing and externalizing mental health problems were measured by Hopkins Symptom Checklist-10 and subscales of the Strengths and Difficulties Questionnaire, respectively. Own and parental war experience is based on adolescent self-report.

RESULTS

The proportion of adolescents with own war experience was 14% with the highest prevalence in immigrants from Eastern Europe and Sub-Saharan Africa. The proportion of parental war experience was 33% with Sub-Saharan Africa being highest. Adolescents reporting own war experience had higher scores for both internalizing and externalizing mental health problems compared to immigrants without war experience, but only externalizing problems reached statistically significant differences. For parental war experience there was a statistically significant relationship between parental war experience and internalizing mental health problems. The association remained significant after adjustment for parental educational level and adolescents' own war experience.

CONCLUSION

War exposure is highly prevalent among immigrants living in Oslo, Norway, both among adolescents themselves and their parents. Among immigrants to Norway, parental war experience appears to be stronger associated with mental health problems than adolescents own exposure to war experience.

Exposure to violence among substance-dependent pregnant women and their children

This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Participants (N = 715) completed the Violence Exposure Questionnaire within 7 days after their admission to the program. Their rates of lifetime abuse ranged from 72.7% for physical abuse to 71.3% for emotional abuse to 44.5% for sexual abuse. Their rates of abuse remained high during their current pregnancy, ranging from 40.9% for emotional abuse to 20.0% for physical abuse to 7.1% for sexual abuse. Nearly one third of the women reported having physical fights with their current partner (lifetime), and 25% of these women reported that children were present during those physical fights. A total of 30% of the women perceived a need for counseling regarding exposure to violence for themselves and 15% perceived a need for counseling for their children. Study findings confirm previous reports of high rates of abuse and violence exposure among substance-abusing pregnant women and their strong need for counseling for psychosocial sequelae. This study affirmed the value of routine screening for violence exposure in this at-risk population as well as the need to train therapists in specific strategies for helping such women address this complex array of problems.

The health impact of childhood trauma: an interdisciplinary review, 1997-2003

Research has shown a strong relationship between childhood trauma and psychological difficulties in later life; more recent research has indicated that the long-term effects are even greater for physical illness. These long-term effects have highlighted Posttraumatic Stress Disorder (PTSD) as a possible mediator variable. The illnesses identified include, but are not limited to, eating disorders, substance abuse, phobias, multiple personality disorders, irritable bowel syndrome, rheumatoid arthritis, and autoimmune disorders. Childhood trauma is an area of interdisciplinary interest; therefore, a variety of disciplines have been carrying out research in this area. This article is an integrative review of the literature over the last five years across disciplines, including nursing, medicine, psychology, education, social services, and government agencies. The review searched for themes, common constructs, and definitions, plus gaps in the present literature that need to be addressed. Particular attention was paid to measurement tools, and the importance of post traumatic stress disorder. Databases included were Medline, Proquest, Canadian Health Network (CHN), Canadian Business and Current Affairs (CBCA) Education, Educational Resources Information Center (ERIC) Plus, Cumulative Index to Nursing & Allied Health Literature (CINAHL), American Psychological Association Database Information (PsychINFO), and Cochrance.

Posttraumatic stress symptoms in children recovering from minor orthopaedic injury and treatment

BACKGROUND

This study was designed to determine the prevalence of high levels of posttraumatic stress disorder (PTSD) symptoms among pediatric orthopaedic trauma patients recovering from injury and to see whether injury or demographic variables are associated with the presence of the symptoms.

METHODS

Four hundred pediatric orthopaedic trauma patients completed the Child PTSD Symptom Scale questionnaire. Demographic and injury variables were tested to see if any were associated with the presence of high levels of posttraumatic stress symptoms.

RESULTS

The average age of respondents was 11 years. The average time since injury was 36 days. The mean Injury Severity Score and summed Extremity Abbreviated Injury Score were 4 and 2, respectively. A total of 130 (33%) met criteria for high levels of PTSD symptoms. None of the variables tested were associated with high levels of PTSD symptoms, except one. Patients admitted to the hospital after injury were significantly more likely to develop high levels of PTSD symptoms.

CONCLUSIONS

High levels of posttraumatic stress disorder symptoms are common in the recovery period after pediatric orthopaedic trauma, even among patients with relatively minor injury. Children admitted to the hospital after injury are at higher risk for such symptoms.

Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers

BACKGROUND

Research suggests that up to 4 of 5 children experience symptoms of an acute stress response (ASR) after a motor vehicle-related injury, and approximately 25% will develop posttraumatic stress disorder (PTSD). The degree to which physicians recognize this problem has not been reported. Our objective was to evaluate current awareness and practices of a cohort of pediatric emergency care providers regarding posttraumatic stress in children.

METHODS

Participants were identified from a list of the American Academy of Pediatrics Section on Emergency Medicine and surveyed on their awareness of ASR after motor vehicle-related injury, risk factors for developing PTSD, and practices regarding emergency department (ED) interventions. Surveys from physicians not practicing clinical emergency medicine were excluded.

RESULTS

Of 322 surveys returned, 287 responses met inclusion criteria. Among these respondents, 198 (69%) were pediatric emergency medicine board certified or eligible and 260 (91%) practiced in a designated pediatric ED. Only 20 of 287 respondents (7%) believed that children were likely to develop symptoms of posttraumatic stress at levels previously described. Also in contrast to recent literature, 248 respondents (86%) felt that severity of injury was associated with future development of PTSD. Associated parental injury was identified accurately as a risk factor by 250 respondents (87%). Of interest, only 31 respondents (11%) were aware of any available tools to assess risk for PTSD. In addition, 56 of 287 respondents (20%) indicated that they would not use such tools in the ED, most commonly citing time and cost constraints. Finally, only 52 respondents (18%) reported giving any verbal guidance and only 9 (3%) provided any written instructions about posttraumatic stress to their patients and families.

CONCLUSIONS

Findings suggest that physicians underestimate the likely development of an ASR and PTSD in the pediatric population. At present, few physicians offer written or even verbal instruction related to the development of posttraumatic symptoms. Physician education along with a systematic approach of assessment and intervention is necessary to address the gap between underrecognition of this concern and desired clinical practice.

Psychosocial treatment of children in foster care: a review

A substantial number of children in foster care exhibit psychiatric difficulties. Recent epidemiological and historical trends in foster care, clinical findings about the adjustment of children in foster care and adult outcomes are reviewed, followed by a description of current approaches to treatment and extant empirical support. Available interventions for these children can be categorized as either symptom-focused or systemic, with empirical support for specific methods ranging from scant to substantial. Even with treatment, behavioral and emotional problems often persist into adulthood resulting in poor functional outcomes. We suggest that self-regulation may be an important mediating factor in the appearance of emotional and behavioral disturbance in these children.

Clinical perspectives on neurobiological effects of psychological trauma

Physical trauma to the brain has always been known to affect brain functions and subsequent neurobiological development. Research primarily since the early 1990s has shown that psychological trauma can have detrimental effects on brain function that are not only lasting but that may alter patterns of subsequent neurodevelopment, particularly in children although developmental effects may be seen in adults as well. Childhood trauma produces a diverse range of symptoms and defining the brain's response to trauma and the factors that mediate the body's stress response systems is at the forefront of scientific investigation. This paper reviews the current evidence relating psychological trauma to anatomical and functional changes in the brain and discusses the need for accurate diagnosis and treatment to minimize such effects and to recognize their existence in developing treatment programs.

Recognizing the potential effect of stress and trauma on premature infants in the NICU: how are outcomes affected?

Extensive research of the long-term outcomes of premature infants has shown significant risk for emotional, behavioral, and psychological problems. Chronic stress and trauma have not been researched specifically in this population, however, studies of the neurobiological impact of traumatic stress on infants and children in the general population show noteworthy parallels in symptomotology. Careful consideration should be given to practitioner caregiving, parent education, future research, assessment, and interventions while being mindful of the impact that chronic stress and trauma may have on the developing brain of the premature infant.

Behavioral aspects of trauma in children and youth

Trauma is prevalent in the lives of children. It derives from many sources, and, depending on its characteristics, can produce transient or enduring and devastating consequences. Early trauma, if left untreated, can set the stage for chronic deficits in the behavioral repertoires of affected children, and thus shape personality development. Additionally, when trauma is repetitive and chronic, the developing brain may be affected in ways that impede otherwise effective intervention. Yet diagnosing traumatic stress in children requires a departure from exclusively adult-like considerations and attention must be devoted to the ongoing developmental processes. Trauma-associated clinical features in children are sharply distinct from those that are associated with adult traumatization and must be taken into account from screening and diagnosis through treatment and outcome evaluation. We suggest that a learning foundation for symptom development will best assist the identification and selection of efficacious treatments. Pediatricians should make use of validated screening procedures that effectively identify affected children to facilitate timely referral and ongoing monitoring of treatment outcomes for their patients. A representative list of such instruments can be found in Table 1. With respect to hospital-based trauma work, we suggest the following recommendations: Professionals must be alert to the presence of acute stress symptoms in any child or parent after all injury incidents. These symptoms may occur in any injured child regardless of age, gender, injury severity, mechanism of injury, or length of time since injury. Certain mechanisms of injury, (ie, pedestrian versus motor vehicle collision), place the parent at higher risk for symptomatology. All family members, including parents and siblings, must be considered at risk for acute and long-term functional abnormalities. It is important to educate patients and family members that acute stress symptoms are common after an injury incident and are likely to resolve as the patient's injuries heal. Yet despite this, before discharge from the hospital, parents must be taught to evaluate their traumatized child's behavior, as well as their own, for any evidence of posttraumatic stress disorder. Health care providers must anticipate potential strain upon family relationships and financial resources. Parent's posttraumatic stress symptoms may result in deterioration of their own ability to support their injured child. And finally, reassessment of patient and family members should occur within the first days, at 1 to 2 weeks, 6 months, and 1 year following injury to ensure proper recovery and optimization of psychosocial function.

Psychological aspects of traumatic injury in children and adolescents

Each year millions of children are exposed to some form of extreme traumatic stressor. These traumatic events include natural disasters (e.g., tornadoes, floods, hurricanes), motor vehicle accidents, life-threatening illnesses and associated painful medical procedures (e.g., severe burns, cancer, limb amputations), physical abuse, sexual assault, witnessing domestic or community violence, kidnapping, and sudden death of a parent. During times of war, violent and nonviolent trauma (e.g., lack of fuel and food) may have terrible effects on children's adjustment. The events of September 11, 2001 and the unceasing suicidal attacks in the Middle East underscore the importance of understanding how children and adolescents react to disasters and terrorism. The body of literature related to children and their responses to disasters and trauma is growing. Mental health professionals are increasing their understanding about what factors are associated with increased risk (vulnerability) and affect how children cope with traumatic events. Researchers recognize that children's responses to major stress are similar to adults' (reexperiencing the event, avoidance, and arousal) and that these responses are not transient. A review of the literature indicates that PTSD is the most common psychiatric disorder after traumatic experiences, including physical injuries. There is also evidence for other comorbid conditions, including mood, anxiety, sleep, conduct, learning, and attention problems. In terms of providing treatment, CBT emerges as the best validated therapeutic approach for children and adolescents who experienced trauma-related symptoms, particularly symptoms associated with anxiety or mood disorders. The best approach to the injured child requires injury and pain assessment followed by specific interventions, such as pain management, brief consultation, and crisis intervention immediately after the specific traumatic event. Family support also may be necessary to help the family through this difficult period. The main conclusion that arises from the research on resilience in development is that extraordinary resilience and recovery power of children depend on basic human protective systems operating in their favor. This finding has produced a fundamental change in the framework for understanding and helping children at high risk or already in trouble. This shift is evident in a changing conceptualization of the goals of prevention and intervention that currently address competence and problems. Strategies for fostering resilience described in this article should be tested in future controlled psychotherapy trials to verify their efficacy on children's protective factors.

Acute stress disorder in children related to violence

TOPIC

Unidentified and untreated acute stress responses in children may result in chronic posttraumatic stress disorder (PTSD), other serious psychiatric disorders, and/or developmental arrest.

PURPOSE

To review and identify gaps in current literature on acute stress disorder (ASD) in children and examine current treatments.

SOURCES

Review of the

CONCLUSIONS

More developmentally appropriate, standardized measurement instruments are needed. Future research must focus on prospective studies of children exposed to trauma in order to better understand the association between ASD and PTSD. Future studies must include children at different developmental stages.

Forensic evaluation of trauma syndromes in children

There are significant differences between a clinical evaluation and a forensic evaluation [289-291]. These differences must be kept solidly in mind in performing the evaluation. The forensic evaluator needs to assess the validity of complaints, including the possibility of malingering and the child's ability to describe symptoms accurately, the connection between the symptoms and a given incident, and the potential long-term sequelae of a trauma. The goal of the interview is not to treat, but to obtain information. Assessing the validity of complaints is perhaps the greatest challenge. This requires obtaining and reconciling data from numerous sources, including interviews with the child and parents, and information from other sources, as well as rating scales and validity testing. One must be very cautious in asking leading questions and using standardized PTSD protocols, lest they teach the parents and child about the symptoms of PTSD and thereby distort the information they provide as a result. The forensic interviewer should consider what will be needed when called to testify in court. What data will convince the jury? How might the opposing attorney challenge the assessment? What scientific studies support the findings and conclusions concerning the diagnosis, functional impairment, and validity. The precise DSM-IV-TR diagnosis is not always key in a forensic evaluation. What is essential is establishing the connection between the trauma and ensuing emotional problems. All of the symptoms the individual has as a result of the trauma become important, whether or not they contribute to fulfillment of DSM-IV-TR criteria. This contrasts with a clinical evaluation in which one needs to demonstrate the existence of a DSM-IV-TR diagnosis for reimbursement purposes. Finally, the forensic evaluator should be familiar with current practice guidelines for examination of children with PTSD. Any deviation may need to be explained in court [264,292].

The perpetrators of domestic violence

There has been little useful research in recent years into those who perpetrate domestic violence. Domestic violence is always anchored in a social context in which the aspirations of men and women are dealt with unequally. The majority of perpetrators of domestic violence are men. Perpetrators are often young, troubled, unemployed, and of low self-esteem; they have often experienced abuse (of various types) themselves. However, these factors do not justify their abusive behaviour. General practitioners and other health workers have a responsibility to broach the subject of domestic violence with both perpetrators and victims. They are in a key position to break the silence that allows it to continue. Programs for stopping domestic violence can be effective for those who are motivated to change their behaviour and see the programs through to completion.

Trauma, drugs and violence among juvenile offenders

Trauma typically occurs when one experiences a situation where life has been threatened or lost. If the trauma is not resolved, negative residual effects may result in alcohol and drug use, involvement in violent activities as well as the development of mental health problems such as posttraumatic stress disorder (PTSD). Findings from a National Institute on Drug Abuse-funded study examining the link between trauma, drug use and violence among youth are presented. Results from interviews with 414 juveniles remanded to the Office of Children and Family Services (formerly New York State Division For Youth) for assault, sexual assault, robbery or homicide, document the trauma experienced by these youth, as well as how it correlated with their drug usage and participation in violent, illegal activities. Discussion of these findings, their implications for understanding and intervening, and recommendations for future research are highlighted.