The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds

BACKGROUND

The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC.

METHOD

Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC.

RESULTS

In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures.

CONCLUSIONS

The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.

Population Prevalence of the Posttraumatic Stress Disorder Subtype for Young Children in Nationwide Surveys of the British General Population and of Children in Care

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating condition that when left untreated can have severe lifelong consequences for psychological, social, and occupational functioning. Initial conceptualizations of PTSD were centered on adult presentations. However, the instantiation of developmentally appropriate PTSD in young children (PTSD-YC) criteria, tailored to preschool (6 years old and younger) children, represents an important step toward identifying more young children experiencing distress. This study explored population-level prevalence of PTSD-YC indexed via an alternative algorithm for DSM-IV PTSD (AA-PTSD).

METHOD

Representative population data were used to test whether application of AA-PTSD criteria, relative to the DSM-IV PTSD algorithm, increased identification of 5- to 6-year-old children with clinical needs in both the general population (n = 3,202) and among looked after children (ie, in Britain, foster children are called looked after children [more commonly referred to as children in care].) (n = 137), in whom the risk of mental health issues is greater.

RESULTS

Notably, no 5- to 6-year-old children in the general population sample were diagnosed with PTSD using adult-based DSM-IV criteria. In contrast, AA-PTSD prevalence was 0.4% overall, rising to 5.4% in trauma-exposed children. In looked after children, overall PTSD prevalence rose from 1.2% when applying adult-based DSM-IV criteria to 14% when using AA-PTSD criteria. Of trauma-exposed looked after children, 2.7% met criteria for DSM-IV PTSD compared with 57.0% when applying AA-PTSD criteria. In both samples, use of the alternative algorithm to index PTSD-YC criteria markedly increased identification of children experiencing functional impairment owing to symptoms.

CONCLUSION

Results demonstrate the utility of the PTSD-YC diagnosis beyond at-risk and treatment-seeking samples. Use of PTSD-YC criteria substantially improves identification of 5- to 6-year-old children burdened by PTSD at the population level.

The CEP5 Peptide Promotes Abiotic Stress Tolerance, As Revealed by Quantitative Proteomics, and Attenuates the AUX/IAA Equilibrium in Arabidopsis

Peptides derived from non-functional precursors play important roles in various developmental processes, but also in (a)biotic stress signaling. Our (phospho)proteome-wide analyses of C-TERMINALLY ENCODED PEPTIDE 5 (CEP5)-mediated changes revealed an impact on abiotic stress-related processes. Drought has a dramatic impact on plant growth, development and reproduction, and the plant hormone auxin plays a role in drought responses. Our genetic, physiological, biochemical, and pharmacological results demonstrated that CEP5-mediated signaling is relevant for osmotic and drought stress tolerance in Arabidopsis, and that CEP5 specifically counteracts auxin effects. Specifically, we found that CEP5 signaling stabilizes AUX/IAA transcriptional repressors, suggesting the existence of a novel peptide-dependent control mechanism that tunes auxin signaling. These observations align with the recently described role of AUX/IAAs in stress tolerance and provide a novel role for CEP5 in osmotic and drought stress tolerance.

Chiropractic students call for action against unsubstantiated claims

Background

The 2019 coronavirus pandemic is a current global health crisis. Many chiropractic institutions, associations, and researchers have stepped up at a time of need. However, a subset of the chiropractic profession has claimed that spinal manipulative therapy (SMT) is clinically effective in improving one’s immunity, despite the lack of supporting scientific evidence. These unsubstantiated claims contradict official public health policy reflecting poorly on the profession. The aim of this commentary is to provide our perspective on the claims regarding SMT and clinically relevant immunity enhancement, drawing attention to the damaging ramifications these claims might have on our profession’s reputation.

Main text

The World Federation of Chiropractic released a rapid review demonstrating the lack of clinically relevant evidence regarding SMT and immunity enhancement. The current claims contradicting this review carry significant potential risk to patients. Furthermore, as a result of these misleading claims, significant media attention and public critiques of the profession are being made. We believe inaction by regulatory bodies will lead to confusion among the public and other healthcare providers, unfortunately damaging the profession’s reputation. The resulting effect on the reputation of the profession is greatly concerning to us, as students.

Conclusion

It is our hope that all regulatory bodies will protect the public by taking appropriate action against chiropractors making unfounded claims contradicting public health policy. We believe it is the responsibility of all stakeholders in the chiropractic profession to ensure this is carried out and the standard of care is raised. We call on current chiropractors to ensure a viable profession exists moving forward.

North, East, South, West: mapping vascular tissues onto the Arabidopsis root

The Arabidopsis root has provided an excellent model for understanding patterning processes and cell fate specification. Vascular patterning represents an especially interesting process, as new positional information must be generated to transform an approximately radially symmetric root pole into a bisymmetric structure with a single xylem axis. This process requires both growth of the embryonic tissue alongside the subsequent patterning. Recently researchers have identified a series of transcription factors that modulate cell divisions to control vascular tissues growth. Spatial regulation in the signalling of two hormones, auxin and cytokinin, combine with other transcription factors to pattern the xylem axis. We are now witnessing the discovery of increasingly complex interactions between these hormones that can be interpreted through the use of mathematical models.

Translating the Cognitive Model of PTSD to the Treatment of Very Young Children: A Single Case Study of an 8-Year-Old Motor Vehicle Accident Survivor

Posttraumatic stress disorder (PTSD) is a clinical condition that occurs after a discrete traumatic event, such as an accident or assault. Research into PTSD has primarily been adult-focused; however, there is a growing body of evidence evaluating the theory and treatment of PTSD in young children. Consequently, cognitive behavior therapy (CBT) interventions for PTSD in youth have been developed that focus on 3 core components of the cognitive model-a disorganized memory of the trauma, maladaptive appraisals of the trauma and its effects (meanings), and dysfunctional coping mechanisms (management). Here, we describe the extension of this treatment approach (termed CBT-3M) to very young children (3-8 years) through the case of Dylan, an 8-year-old motor vehicle accident survivor. This serves as an illustration of the underlying theory and its successful application. Further work is intended to provide evidence of the efficacy of this treatment via an ongoing treatment trial.

Trauma-focused cognitive behaviour therapy versus treatment as usual for post traumatic stress disorder (PTSD) in young children aged 3 to 8 years: study protocol for a randomised controlled trial

BACKGROUND

Following horrific or life-threatening events approximately 10 to 15% of young children develop post traumatic stress disorder (PTSD). The symptoms of this disorder are distressing - nightmares, flashbacks, anger outbursts and disturbed play. These symptoms cause major disruption to a child's functioning and, if left untreated, can persist for many years. As yet, there are no established empirically-validated treatments for PTSD in young children. Trauma-focused cognitive behaviour therapy (TF-CBT) is a psychological intervention that is effective in treating the disorder in older children (8 to 12 years), adolescents and adults. This study examines TF-CBT adapted for children aged between 3 and 8 years.

METHODS/DESIGN

This protocol describes a two-arm exploratory randomised controlled trial comparing TF-CBT to treatment as usual (TAU) in children aged 3 to 8 years with a principal diagnosis of PTSD following a single-event discrete trauma. Using a half-crossover design, 44 participants will be randomly allocated to receive the intervention or to receive TAU. Those allocated to TAU will be offered TF-CBT at the end of the 'treatment' period (approximately 12 weeks) if still indicated. The primary outcome is PTSD diagnosis according to DSM-5 criteria for children 6 years and younger at post-treatment. Secondary outcomes include effects on co-morbid diagnoses and changes in emotion and trauma symptoms at each of the follow-up points (post-treatment, 3-months, 12-months). Additionally, broader efficacy will be considered with regard to treatment feasibility, acceptability and service utilisation. The key targets of the intervention are trauma memory, the interpretation of the meaning of the event, and the management of symptoms.

DISCUSSION

This is the first European trial to examine the efficacy of TF-CBT in alleviating PTSD in very young children. As well as providing much-needed data on the utility of the intervention, this exploratory trial will also allow us to gather important information about the feasibility of delivering the treatment in UK National Health Service (NHS) settings, and its acceptability to the children and their families. This study will highlight aspects of the intervention that need improvement or modification in preparation for a full-scale evaluation in a larger sample.

TRIAL REGISTRATION

ISRCTN35018680 , registered on 18 November 2013.

A novel function for a redox-related LEA protein (SAG21/AtLEA5) in root development and biotic stress responses

SAG21/AtLEA5 belongs to the late embryogenesis-associated (LEA) protein family. Although it has been implicated in growth and redox responses, its precise roles remain obscure. To address this problem, we characterized root and shoot development and response to biotic stress in SAG21/AtLEA5 over-expressor (OEX) and antisense (AS) lines. AS lines exhibited earlier flowering and senescence and reduced shoot biomass. Primary root length was reduced in AS lines, as was the number of laterals relative to the primary root. Root hair number was unchanged but root hair length was proportional to SAG21/AtLEA5 expression level, with longer root hairs in OEX lines and shorter root hairs in AS, relative to wild type. Growth of the fungal nectroph, Botrytis cinerea and of a virulent bacterial pathogen (Pseudomonas syringae pv. tomato) was affected by SAG21/AtLEA5 expression; however, growth of an avirulent P.syringae strain was unaffected. A SAG21/AtLEA5-YFP fusion was localized to mitochondria, raising the intriguing possibility that SAG21 interacts with proteins involved in mitochondrial ROS signalling, which in turn, impacts on root development and pathogen responses.

Prevalence of hepatitis B markers in patients and staff in a hospital for the mentally handicapped

Patients and staff at a hospital for the mentally handicapped were screened for markers of infection with hepatitis B virus. Of 436 patients, 14 (3.2%) were carriers of hepatitis B surface antigen (HBsAg), of whom four were carriers of hepatitis B e antigen (HBeAg) and were considered to be 'infectious'. One-quarter of the patients had markers of hepatitis B infection. Males were four times more likely to have markers than females; and 13 of the 14 carriers of HBsAg were male. Patients with Down's Syndrome (DS) were six times more likely to be HBsAg positive, but were not more likely to have markers of infection than other patients. Phenytoin therapy did not predispose to carriage of HBsAg. Of 439 staff members, 26 (5.9%) had markers of hepatitis B infection. It was not considered that staff were at increased risk of infection with hepatitis B virus at the hospital, and that post-exposure prophylaxis for hepatitis B should continue. It is suggested that patients with DS who are not immune to hepatitis B should be offered immunization.