Post-traumatic stress disorder in children and adolescents: epidemiology, diagnosis and treatment options

Prevalence of post-traumatic stress disorder during the COVID-19 pandemic in children: a review and suggested solutions

Background

The outbreak of coronavirus began in China in December 2019. It became a pandemic and a public health emergency. There have been numerous reports related to post-traumatic stress disorder outbreaks in the COVID-19 crisis. After a natural disaster, children are at a higher risk for post-traumatic stress disorder. The current study is a review of the scientific literature on the effect of COVID-19 on the prevalence of symptoms of post-traumatic stress disorder in children.

We searched PubMed, Web of Science, and Scopus databases until February 02, 2022. The search strategy was based on a combination of the following keywords “child,” “COVID-19,” and “post-traumatic stress disorder.”

Results

By searching the Web of Science, Scopus, and PubMed databases, 173 articles were retrieved. After reviewing the inclusion criteria and in terms of eligibility, 10 articles met the inclusion criteria out of the remaining 46 articles. Based on the findings, 80% of the articles were cross-sectional and 20% of them were longitudinal. The articles reviewed in this study reported an increase in the prevalence of post-traumatic stress disorder in children during or after the COVID-19 pandemic.

Conclusions

In summary, the findings of this review showed that restrictions and fears of COVID-19 had negative psychological effects on children. As well, one of the most important issues that arose at the time of the tragedy was that children were suffering from post-traumatic stress disorder. Given that post-traumatic stress disorder can be treated, it is essential to choose the appropriate therapeutic intervention approach in order to better deal with the negative effects in children.

Cognitive behavioral therapy for children and adolescents with post-traumatic stress disorder: meta-analysis

BACKGROUND

Children and adolescents who experience traumatic events may develop post-traumatic stress disorder (PTSD), which is often associated with other psychiatric disorders, including depression and anxiety. Cognitive behavioral therapy (CBT) is widely used in psychotherapy to treat PTSD in children and adolescents. This meta-analysis evaluated previous studies on the effectiveness of CBT in the treatment of PTSD in children and adolescents.

METHODS

Randomized controlled trials (RCTs) published before July 25, 2021, were retrieved from seven databases. All RCTs of CBT compared to control, including conventional treatment or other treatments, in children or adolescents with PTSD. Random effect models were employed for all outcomes. Risk of bias was performed by Cochrane Collaboration's tool. The publication bias was evaluated using the Egger's regression analysis.

RESULTS

Nineteen RCTs were included in the meta-analysis. Compared with control, CBT was effective in reducing the symptoms of PTSD in children and adolescents, with a variety of scales used to measure the overall PTSD symptoms: CAPS (SMD = -0.41, 95%CI [-0.71, -0.12]), CPSS (SMD = -0.88, 95%CI [-1.42, -0.34]) and UCLA-PTSD RI (SMD = -1.70, 95%CI [-2.98, -0.42]). Furthermore, CBT also improved the comorbidities of depression (SMD = -0.43, 95%CI [-0.70, -0.17]) and anxiety (SMD = -0.29, 95%CI [-0.56, -0.03]) associated with PTSD. However, CBT was not effective in reducing avoidance symptoms (SMD = 0.38, 95%CI [-0.55, 1.31]).

CONCLUSION

CBT can reduce the severity of PTSD in children and adolescents and improve the symptoms of depression and anxiety, as evident in the treatment of PTSD victims of sexual abuse and war and in patients aged more than 7 years.

Neuroticism Predicts a Long-Term PTSD After Earthquake Trauma: The Moderating Effects of Personality

Background: The heartache from the devastating 8.0 magnitude Wenchuan earthquake, which killed nearly 90,000 people in western China, is still felt despite the large-scale recovery and reconstruction of the affected areas. This study investigated the relationships of earthquake-trauma exposures and personality with posttraumatic stress disorder (PTSD), to identify the long-term consequences of the Wenchuan earthquake on the survivors and the risk factors related to chronic PTSD. We hope the findings can contribute to developing new health care prevention and interventions for the survivors. Methods: We collected a sample of 490 people over 3 years after the Wenchuan earthquake, using questionnaires about demographic information and the traumatic experience in earthquake, the Impact of Event Scale-Revised (IES-R), and the Eysenck Personality Questionnaires (EPQ), to find the consequences of the Wenchuan earthquake on the survivors and the potential factors related to the long-term morbidity of PTSD. Result: Traumatic experiences, such as witnessing someone being seriously injured, having your house seriously damaged, and having close relatives severely injured, were associated with developing PTSD. Personality measured by EPQ was also closely related to PTSD. Regression analyses indicated that a potential linear model characterized the relationship between PTSD, neuroticism and psychoticism, yet extraversion/introversion were not significant factors. In the multivariate logistic regression, neuroticism (a continuous variable measured by EPQ) was of more significance in predicting the morbidity of long-term PTSD, compared with other variables [odds ratio (OR) = 1.113, 95% confidence interval (CI) = 1.081-1.146, Wald Value = 50.467, P < 0.001]. The final path diagram built a model indicated the moderating role of personality in the relationship between traumatic experiences and PTSD (CMIN/DF = 2.324, P < 0.001; CFI = 0.879 < 0.8; RMSEA = 0.05 < 0.08). Conclusion: This study demonstrated the role of personality traits and subjective exposure experiences regarding the vulnerability associated with PTSD after earthquake. Among all personality traits, neuroticism is considered a vulnerability factor of PTSD, and other personality traits also moderate the effects of traumatic experiences associated with PTSD. These findings might be useful for psychologists to develop intervention strategies for people suffered natural disasters, and to help individuals with PTSD to heal fully.

Comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder in children and adolescents: study protocol for a systematic review and network meta-analysis

INTRODUCTION

Post-traumatic stress disorder (PTSD) is common among children and adolescents who are exposed to trauma, and it is often associated with significant negative impacts on their psychosocial functioning and quality of life. Many types of psychotherapies have been found to be effective for PTSD in children and adolescents. However, due to the lack of direct comparisons between different psychotherapies, the hierarchy of treatment efficacy is still unclear. Therefore, we plan to conduct a systematic review and network meta-analysis to evaluate the efficacy and acceptability of various types of psychotherapies for PTSD in children and adolescents.

METHODS AND ANALYSIS

A systematic search will be conducted among eight electronic databases, including PubMed, Cochrane, Embase, Web of Science, PsycINFO, Cumulative Index of Nursing and Allied Health, Published International Literature on Traumatic Stress (PILOTS) and ProQuest Dissertations, from inception to October 2017. Randomised controlled trials, regardless of language, publication year and publication type, comparing any psychotherapies for PTSD to any control condition or alternative treatment in children and adolescents (18 years old or less) diagnosed with full or subclinical PTSD will be included. Study duration and the number of treatment sessions will not be limited. The primary outcome will be PTSD symptom severity at post-treatment as measured by a rating scale reported by the child, parent or a clinician. The secondary outcomes will include: (1) efficacy at follow-up; (2) acceptability (all-cause discontinuation); (3) anxiety symptom severity; (4) depressive symptom severity and (5) quality of life and functional improvement. Bayesian network meta-analyses for all relative outcome measures will be performed. We will conduct subgroup and sensitivity network meta-analyses to determine whether the findings are affected by study characteristics. The quality of the evidence contributing to network estimates of the primary outcome will be evaluated by the Grading of Recommendations, Assessment, Development and Evaluations framework.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. The results will be published in a peer-reviewed journal, which will be disseminated electronically and in print. This network meta-analysis may be updated to inform and guide the clinical management of PTSD in children and adolescents.

PROSPERO REGISTRATION NUMBER

CRD42016051786.

A treatment development study of a cognitive and mindfulness-based therapy for adolescents with co-occurring post-traumatic stress and substance use disorder

OBJECTIVE

Substance use is common among adolescents with post-traumatic stress disorder (PTSD). We aimed to develop and study an integrated treatment for adolescents with co-occurring disorders.

DESIGN

This is a therapy development and open pilot trial study of a manualized therapy for adolescents with post-traumatic stress, depression, and substance use that uses a combination of cognitive therapy (CT) and mindfulness.

METHODS

Descriptive statistics and paired sample t-tests were calculated to assess for changes in PTSD symptoms, depression, and substance use frequency from baseline to end of treatment using standardized measures and validated by urine drug screens. We also examined for safety, predictors of clinical outcomes, and treatment retention.

RESULTS

Thirty-seven adolescents participated in the study; 62% were study completers as defined by retention for at least 6 weeks of treatment. There were significant improvements in PTSD and depression symptoms from baseline to end of treatment, reflecting medium effect sizes, and which was associated with changes in trauma-associated cognitions. There was a reduction in cannabis use, which was the most commonly used substance.

CONCLUSIONS

Preliminary results suggest feasibility, safety, and potential clinical effectiveness of an integrated therapy for adolescents with PTSD, depression, and substance use. Retention was comparable to other therapy clinical trial studies of adolescents despite the high risk for poor treatment retention and poor clinical outcomes among adolescents with PTSD and co-occurring disorders. We discuss the rationale for continued research of this mindfulness-based CT for adolescents with co-occurring disorders.

PRACTITIONER POINTS

Adolescents with co-occurring PTSD and substance use achieved meaningful improvement in PTSD and depression symptom severity after receiving a CT and mindfulness dual diagnosis approach. An integrated manualized therapy for dual diagnosis shows promise for reducing cannabis use in adolescents with PTSD. Changes in trauma-related cognitions have the potential to improve PTSD and depression symptoms in adolescents with substance use problems.

Psychological therapies for children and adolescents exposed to trauma

BACKGROUND

Children and adolescents who have experienced trauma are at high risk of developing post-traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents.

OBJECTIVES

To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random-effects model. We analysed data as short-term (up to and including one month after therapy), medium-term (one month to one year after therapy) and long-term (one year or longer).

MAIN RESULTS

Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life-threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas.Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive-behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children.The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) -0.42, 95% CI -0.61 to -0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term.CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD -0.24, 95% CI -0.42 to -0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate.We did not identify any studies that compared pharmacological therapies with psychological therapies.

AUTHORS' CONCLUSIONS

The meta-analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High-quality studies should be conducted to compare these therapies.

The expression of personality among adolescents exposed to community interpersonal violence

The high level of crime in South Africa affects many adolescents. Experience of community interpersonal violence affects the social, emotional, and cognitive functioning of adolescents and could have an impact on their personality development. The aim of the study was to explore possible differences in the expression of personality between adolescents exposed to community interpersonal violence and those not exposed to such violence. The sample comprised 183 Grade 12 learners from a secondary school in a middle-class community in Gauteng. Participants were divided into two groups: adolescents who reported exposure to community interpersonal violence ( n = 93) and those who did not report exposure to such violence ( n = 90). Both groups completed the 16 Personality Factor and Posttraumatic Diagnostic Scales. Differences between the groups were explored using a one-way between-groups multivariate analysis of variance and t-tests for independent groups. Results indicated statistically significant differences between the two groups on Factor G (rule consciousness), Factor I (emotional sensitivity), and Factor Q4 (anxiety). Adolescents exposed to interpersonal violence reported higher levels of posttraumatic stress disorder symptoms than the control group. The group that experienced posttraumatic stress disorder symptoms differed more in terms of personality functioning (Factors I and Q4). Violence-exposed adolescents experienced more emotional volatility, difficulty to regulate emotions, anxiety, and sensitivity to environmental stressors than those not exposed to such violence. Although causality cannot be assumed, it is possible that exposure to community interpersonal violence, which could result in posttraumatic stress disorder symptoms, has implications for the personality development of adolescents. Interventions for adolescents exposed to interpersonal violence are recommended to prevent the development of posttraumatic stress disorder symptoms.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents (Review)

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team. We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy. Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group. The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified. No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others. The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses. More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Practice parameter on disaster preparedness

This Practice Parameter identifies best approaches to the assessment and management of children and adolescents across all phases of a disaster. Delivered within a disaster system of care, many interventions are appropriate for implementation in the weeks and months after a disaster. These include psychological first aid, family outreach, psychoeducation, social support, screening, and anxiety reduction techniques. The clinician should assess and monitor risk and protective factors across all phases of a disaster. Schools are a natural site for conducting assessments and delivering services to children. Multimodal approaches using social support, psychoeducation, and cognitive behavioral techniques have the strongest evidence base. Psychopharmacologic interventions are not generally used but may be necessary as an adjunct to other interventions for children with severe reactions or coexisting psychiatric conditions.

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.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy.Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group.The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified.No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others.The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses.More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Childhood trauma and psychiatric disorders as correlates of school dropout in a national sample of young adults

The effect of childhood trauma, psychiatric diagnoses, and mental health services on school dropout among U.S.-born and immigrant youth is examined using data from the Collaborative Psychiatric Epidemiology Surveys, a nationally representative probability sample of African Americans, Afro-Caribbeans, Asians, Latinos, and non-Latino Whites, including 2,532 young adults, aged 21-29. The dropout prevalence rate was 16% overall, with variation by childhood trauma, childhood psychiatric diagnosis, race/ethnicity, and nativity. Childhood substance and conduct disorders mediated the relation between trauma and school dropout. Likelihood of dropout was decreased for Asians, and increased for African Americans and Latinos, compared to non-Latino Whites as a function of psychiatric disorders and trauma. Timing of U.S. immigration during adolescence increased risk of dropout.

Risk factors for posttraumatic stress reactions among Chinese students following exposure to a snowstorm disaster

Background

It is important to understand which factors increase the risk of posttraumatic stress disorder (PTSD) in adolescents. Previous studies have shown that the most important risk factors for PTSD include the type, severity, and duration of exposure to the traumatic events.

Methods

A cross-sectional survey was used to investigate the psychological symptoms associated with the aftermath of a snowstorm disaster in the Hunan province of China in January 2008. Students living in Hunan were surveyed at a three-month follow-up after the disaster. The questionnaire battery included the Impact of Event Scale-Revised (IES-R, trauma and symptoms associated with PTSD), the Chinese version of the Life Orientation Test-Revised (LOT-R, optimism and pessimism), the Chinese version of the Eysenck Personality Questionnaire (EPQ, neuroticism and extraversion), the Chinese Trait Coping Style Questionnaire (TCSQ, positive and negative coping styles), and a range of questions addressing social demographic characteristics and factors relating to the snowstorm. The survey was administered in school, and 968 students completed and returned the questionnaires.

Results

The results showed that 14.5% of the students had a total IES-R score ≥20. Students with greater school-to-home distances showed higher levels of posttraumatic stress symptoms than students who lived shorter distances from school. Students with emotional support from their teachers reported higher levels of posttraumatic stress symptoms (21.20%) than students without a teacher's emotional support (11.07%). The IES-R total and subscale scores correlated with all variables except extraversion. The binary logistic regression analysis results showed that the teacher's emotional support [odds ratio (OR) = 1.72, 95% confidence interval (CI) = 1.13-2.62], school-to-home distance (OR = 1.01, 95% CI = 1.00-1.01), negative coping (OR = 1.05; 95% CI = 1.02-1.08), and neuroticism (OR = 1.04, 95% CI = 1.02-1.06) were risk factors that predicted PTSD frequency and severity (percentage correct = 85.5%).

Conclusions

The risk factors that significantly impacted the onset of posttraumatic stress reactions in students living in Hunan, China following a snowstorm disaster were the school-to-home distance, negative coping, neuroticism, and teacher's emotional support.

Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review

BACKGROUND

Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD.

METHODS

Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites.

RESULTS

The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT.

CONCLUSION

There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.

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.

The Role of Family Processes in Childhood Traumatic Stress Reactions for Youths Living in Urban Poverty

This article reports findings from a cross-sectional study exploring relationships between trauma exposure, childhood traumatic stress, and family functioning. Data were collected from a sample of 100 mostly African American, 6- to 9-year-old children and their caregivers who were living in low-income, urban neighborhoods and analyzed using hierarchical multiple regressions. The children experienced high levels of exposure and traumatic stress symptoms. Trauma exposure was correlated with reexperiencing, avoidance, and arousal and also with externalizing behavior problems. Reexperiencing and avoidance symptoms were related to lower ratings of the value of family routines reported by caregivers. Higher ratings of family structure, including both organization and support, were related to fewer internalizing and externalizing behavior problems.

Violent Victimization and Perpetration: Joint and Distinctive Implications for Adolescent Development

To date few reports have provided direct comparison of psychosocial vulnerability and resources among youth with victimization and perpetration histories. Within a racially diverse, high-risk adolescent sample (n = 849), this study undertakes MANCOVA tests on a multidimensional set of risk and protective factors contrasting youth with histories of 1) neither violent victimization nor perpetration, 2) victimization only , 3) both perpetration only, and 4) both victimization and perpetration. All three violence-affected groups reported elevated risk and diminished protection, with perpetrating victims demonstrating the greatest psychosocial impairment. Detailed contrasts among the youth group profiles provide insights regarding overlapping and distinct developmental etiologies and implications for preventive and remedial intervention.

Psychological impact of disasters on children: review of assessment and interventions

BACKGROUND

There is a wide range of mental and behavioral sequel in children following disasters, which can last long. This review discusses the nature and extent of the psychiatric problems, their management options and process to organize the psychological interventions for affected children.

DATA SOURCES

Literatures were searched through PubMed with the words "children, disaster, psychiatry, and mental health" and relevant cross references were included in the review.

RESULTS

Proportions of children having posttraumatic symptoms or syndromal diagnoses vary in different studies depending on various factors like nature and severity of disaster, diagnostic criteria used, cultural issues regarding meaning of trauma, support available, etc. Common psychiatric manifestations among children include acute stress reactions, adjustment disorder, depression, panic disorder, post-traumatic stress disorder, anxiety disorders specific to childhood and psychotic disorders. Comorbidities and sub-clinical syndromes are also common. Most of the post-disaster mental health interventions can be provided in the community by the local disaster workers. Supportive counselling, cognitive behavior therapy, brief trauma/grief-focused psychotherapy, and play therapy are the commonly utilized methods of psychological intervention, which can be given in groups. Information about the efficacy of medications is still emerging, while many are being used and found useful.

CONCLUSIONS

Following disaster, systematic screening for psychological problems in children is suggested. An integrated approach using psycho-socio-educational and clinical interventions is expected to be effective.

The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review

Children and adolescents in the U.S. and worldwide are commonly exposed to traumatic events, yet practitioners treating these young people to reduce subsequent psychological harm may not be aware of-or use-interventions based on the best available evidence. This systematic review evaluated interventions commonly used to reduce psychological harm among children and adolescents exposed to traumatic events. Guide to Community Preventive Services (Community Guide) criteria were used to assess study design and execution. Meta-analyses were conducted, stratifying by traumatic exposures. Evaluated interventions were conducted in high-income economies, published up to March 2007. Subjects in studies were <or=21 years of age, exposed to individual/mass, intentional/unintentional, or manmade/natural traumatic events. The seven evaluated interventions were individual cognitive-behavioral therapy, group cognitive behavioral therapy, play therapy, art therapy, psychodynamic therapy, and pharmacologic therapy for symptomatic children and adolescents, and psychological debriefing, regardless of symptoms. The main outcome measures were indices of depressive disorders, anxiety and posttraumatic stress disorder, internalizing and externalizing disorders, and suicidal behavior. Strong evidence (according to Community Guide rules) showed that individual and group cognitive-behavioral therapy can decrease psychological harm among symptomatic children and adolescents exposed to trauma. Evidence was insufficient to determine the effectiveness of play therapy, art therapy, pharmacologic therapy, psychodynamic therapy, or psychological debriefing in reducing psychological harm. Personnel treating children and adolescents exposed to traumatic events should use interventions for which evidence of effectiveness is available, such as individual and group cognitive-behavior therapy. Interventions should be adapted for use in diverse populations and settings. Research should be pursued on the effectiveness of interventions for which evidence is currently insufficient.

Applying EMDR on children with PTSD

OBJECTIVE

To find out child-adjusted protocol for eye movement desensitization and reprocessing (EMDR).

METHOD

Child-adjusted modification were made in the original adult-based protocol, and within-session measurements, when EMDR was used in a randomized controlled trial (RCT) on thirty-three 6-16-year-old children with post-traumatic stress disorder (PTSD).

RESULTS

EMDR was applicable after certain modifications adjusted to the age and developmental level of the child. The average treatment effect size was largest on re-experiencing, and smallest on hyperarousal scale. The age of the child yielded no significant effects on the dependent variables in the study.

CONCLUSIONS

A child-adjusted protocol for EMDR is suggested after being applied in a RCT for PTSD among traumatized and psychosocially exposed children.

Child and adolescent mental disorders: the magnitude of the problem across the globe

OBJECTIVE

Describe objectively the global gaps in policy, data gathering capacity, and resources to develop and implement services to support child mental health.

METHODS

Report on the World health Organization (WHO) child and adolescent mental health resources Atlas project. The Atlas project utilized key informants and was supplemented by studies that focused on policy. This report also draws on current epidemiological studies to provide a context for understanding the magnitude of the clinical problem.

RESULTS

Current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from a disabling mental illness; that suicide is the third leading cause of death among adolescents; and that up to 50% of all adult mental disorders have their onset in adolescence. While epidemiological data appears relatively uniform globally, the same is not true for policy and resources for care. The gaps in resources for child mental health can be categorized as follows: economic, manpower, training, services and policy. Key findings from the Atlas project include: lack of program development in low income countries; lack of any policy in low income countries and absent specific comprehensive policy in both low and high income countries; lack of data gathering capacity including that for country-level epidemiology and services outcomes; failure to provide social services in low income countries; lack of a continuum of care; and universal barriers to access. Further, the Atlas findings underscored the need for a critical analysis of the 'burden of disease' as it relates to the context of child and adolescent mental disorders, and the importance of defining the degree of 'impairment' of specific disorders in different cultures.

CONCLUSIONS

The recent finding of substantial gaps in resources for child mental health underscores the need for enhanced data gathering, refinement of the economic argument for care, and need for innovative training approaches.

EMDR treatment for children with PTSD: results of a randomized controlled trial

The objective of the study was to examine the efficacy of EMDR treatment for children with post-traumatic stress disorder (PTSD) compared with untreated children in a waiting list control group (WLC) participating in a randomized controlled superiority trial (RCT). Thirty-three 6-16-year-old children with a DSM-IV diagnosis of PTSD were randomly assigned to eight weekly EMDR sessions or the WLC group. The Posttraumatic Stress Symptom Scale for Children (PTSS-C scale) was used in interviews with children to evaluate their symptoms and outcome. Post-treatment scores of the EMDR group were significantly lower than the WLC indicating improvement in total PTSS-C scores, PTSD-related symptom scale, and the subscales re-experiencing and avoidance among subjects in the EMDR group, while untreated children improved in PTSD-non-related symptom scale. The improvement in re-experiencing symptoms proved to be the most significant between-group difference over time. The results of the present exploratory study including a limited number of children with PTSD are encouraging and warrant further controlled studies of larger samples of children suffering from PTSD.

Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: two case reports and a pilot study in an African refugee settlement

BACKGROUND

Little data exists on the effectiveness of psychological interventions for children with posttraumatic stress disorder (PTSD) that has resulted from exposure to war or conflict-related violence, especially in non-industrialized countries. We created and evaluated the efficacy of KIDNET, a child-friendly version of Narrative Exposure Therapy (NET), as a short-term treatment for children.

METHODS

Six Somali children suffering from PTSD aged 12-17 years resident in a refugee settlement in Uganda were treated with four to six individual sessions of KIDNET by expert clinicians. Symptoms of PTSD and depression were assessed pre-treatment, post-treatment and at nine months follow-up using the CIDI Sections K and E.

RESULTS

Important symptom reduction was evident immediately after treatment and treatment outcomes were sustained at the 9-month follow-up. All patients completed therapy, reported functioning gains and could be helped to reconstruct their traumatic experiences into a narrative with the use of illustrative material.

CONCLUSIONS

NET may be safe and effective to treat children with war related PTSD in the setting of refugee settlements in developing countries.

Bringing order out of chaos: a culturally competent approach to managing the problems of refugees and victims of organized violence

The collaborative program of the Transcultural Psychosocial Organization (TPO) provides a community-oriented and culturally sensitive public health response to the psychosocial problems of refugees and victims of organized violence. This paper describes the 9-step model that TPO has developed as a blueprint for each new intervention. Beneficiaries participate in determining priorities and there is an orientation toward culturally competent training, capacity-building, and sustainability. Two cases, one related to Sudanese refugees in Uganda and the other to internally displaced persons and returnees in postwar Cambodia, show how the TPO intervention protocol is adapted to local settings. The paper provides preliminary evaluative comments on the model's performance.