Towards a cognitive-behavioral model of PTSD in children and adolescents

Posttraumatic stress disorder in children and adolescents has been studied only for the past 15-20 years and is the subject of a burgeoning corpus of research. Much research has focused on examining whether children and adolescents have the same responses to trauma as those experienced by adults. Many of the research tools used to investigate children's responses are taken from measures designed for use with adults, and these measures have proven to be useful. However, it has not been established that children's responses to traumatic events are related to the same underlying processes as are adults' responses. The possible application of 2 recent cognitive models of PTSD in adults to understanding PTSD in children and adolescents is discussed in this paper, within the context of what is already known about children's reaction to trauma and existing theoretical accounts of childhood PTSD. Particular attention is paid toward the nature of children's memories of traumatic events and how these memories relate to the reexperiencing symptoms of PTSD, and cognitive processes that may play a role in the maintenance of PTSD. It is proposed that the adoption of a more specific cognitive-behavioral framework in the study of this disorder may be beneficial and lead to better treatment outcomes

The Children's Revised Impact of Event Scale (CRIES):Validity as a screening instrument for PTSD

The Children's Revised Impact of Event Scale (CRIES) is a brief child-friendly measure designed to screen children at risk for Posttraumatic Stress Disorder (PTSD). It has good face and construct validity, a stable factor structure, correlates well with other indices of distress, and has been used to screen very large samples of at-risk-children following a wide range of traumatic events. However, few studies have examined the scale's validity against a structured diagnostic interview based on the DSM-IV criteria for PTSD. In the present study, the CRIES and the PTSD section of the Anxiety Disorders Interview Schedule-Child and Parent Version (ADIS-CP) were administered to a sample of children and adolescents (n=63) recruited from hospital accident and emergency rooms and the validity of the CRIES as a screening tool evaluated. Cutoff scores were chosen from this sample with a low base-rate of PTSD (11.1%) to maximize sensitivity and minimize the likelihood that children with a diagnosis of PTSD would fail to be identified. Cutoff scores were then cross-validated in a sample of 52 clinically referred children who had a high base-rate of PTSD (67.3%). A cutoff score of 30 on the CRIES-13 and a cutoff score of 17 on the CRIES-8 maximized sensitivity and specificity, minimized the rate of false negatives, and correctly classified 75-83% of the children in the two samples. The CRIES-8 (which lacks any arousal items) worked as efficiently as the CRIES-13 (which includes arousal items) in correctly classifying children with and without PTSD. Results are discussed in light of the current literature and of the need for further development of effective screens for children at-risk of developing PTSD

Towards a cognitive-behavioral model of PTSD in children and adolescents

Abstract Post-traumatic stress disorder in children and adolescents has been studied only for the past 15 to 20 years and is the subject of a burgeoning corpus of research. Much research has focused on examining whether children and adolescents have the same responses to trauma as those experienced by adults. Many of the research tools used to investigate children's responses are taken from measures designed for use with adults, and these measures have proven to be useful. However, it has not been established that children's responses to traumatic events are related to the same underlying processes as adults' responses. The possible application of two recent cognitive models of PTSD in adults to understanding PTSD in children and adolescents is discussed in this article, within the context of what is already known about children's reaction to trauma and existing theoretical accounts of childhood PTSD. Particular attention is paid towards the nature of children's memories of traumatic events and how these memories relate to the re-experiencing symptoms of PTSD, and cognitive processes that may play a role in the maintenance of PTSD. It is proposed that the adoption of a more specific cognitive-behavioral framework in the study of this disorder may be beneficial and lead to better treatment outcomes

The nature of trauma memories in acute stress disorder in children and adolescents

Background: There is increasing theoretical, clinical and research evidence for the role of trauma memory in the aetiology of acute pathological stress responses in adults. However, research into the phenomenology of trauma memories in young people is currently scarce. Methods: This study compared the nature of trauma narratives to narratives of unpleasant non-traumatic events in young people (aged 8-17) who sought emergency medical attention following an assault or road traffic accident. Data were collected within 2-4 weeks of the index event. Symptom severity was assessed by child self-report and face-to-face diagnostic interviews. Comparisons of narrative indices were made between those children with acute stress disorder (ASD) and those without ASD. Results: Among participants (n = 50), those with ASD (38%) had significantly elevated levels of disorganisation in their trauma narrative, compared both to trauma-exposed controls and to their unpleasant comparative narrative. This effect was not accounted for by age. Regardless of ASD diagnostic status, trauma narratives had significantly higher sensory content and significantly lower positive emotion content compared to the unpleasant comparative narrative. These effects were not significant when age was included as a covariate. Acute symptom severity was significantly predicted by the level of disorganisation in the trauma narrative and the child's cognitive appraisals of the event. Conclusions: These data provide the first empirical evidence that disorganisation is not only directly linked to symptom severity, but also specific to the trauma memory. In addition, it provides support for the adaptation of adult cognitive models to acute pathological stress reactions in children and adolescents

The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents

Objective: Increasingly, children are being diagnosed with psychiatric disorders, including preschool-age children. These diagnoses in young children raise questions pertaining to 1) how diagnostic algorithms for individual disorders should be modified for young age groups, 2) how psychopathology is best detected at an early stage, and 3) how to make use of multiple informants. The authors examined these issues in a prospective longitudinal assessment of preschool- and elementary school-age children who were exposed to a traumatic event. Method: Participants were 114 children (age range: 2-10 years) who had experienced a motor vehicle accident. Parents and older children (age range: 7-10 years) completed structured interviews 2-4 weeks (initial assessment) and 6 months (6-month follow-up) after the traumatic event. A recently proposed alternative symptom algorithm for diagnosing posttraumatic stress disorder (PTSD) was utilized and compared with the standard DSM-IV algorithms for diagnosing PTSD and acute stress disorder. Results: At the 2- to 4-week assessment, 11.5% of the children met conditions for a diagnosis of PTSD based on the alternative algorithm criteria per parent report, and 13.9% met criteria for this diagnosis at the 6-month follow-up. These percentages were much higher than those for DSM-IV diagnoses of acute stress disorder and PTSD. Among 7- to 10-year-old subjects, the use of combined parent- and child-reported symptoms to derive a diagnosis resulted in an increased number of children in this age group who were identified with psychiatric illness relative to the use of parent report alone. Agreement between parent and child on symptoms for 1) a diagnosis of PTSD based on the alternative algorithm criteria and 2) diagnoses of DSM-IV acute stress disorder and PTSD in this age group was poor. Among 2- to 6-year-old subjects, the alternative algorithm PTSD diagnosis per parent report was a more sensitive predictor of later onset psychopathology relative to a diagnosis of DSM-IV acute stress disorder or PTSD per parent report. However, among 7- to 10-year-old subjects, a combined symptom report (from both parent and child) was optimal in predicting posttraumatic psychopathology. Conclusions: These findings support the use of the proposed alternative algorithm for assessing PTSD in young children and suggest that the diagnosis of PTSD based on the alternative algorithm criteria is stable from the acute phase onward. When both parent- and child-reported symptoms are utilized for the assessment of PTSD among 7- to 10-year-old children, the alternative algorithm and DSM-IV criteria have broad comparable validity. However, in the absence of child-reported symptoms, the alternative algorithm criteria per parent report appears to be an optimal diagnostic measure of PTSD among children in this age group, relative to the standard DSM-IV algorithm for diagnosing the disorder

The role of the family in child and adolescent posttraumatic stress following attendance at an emergency department

Objective: To evaluate the role of family factors in posttraumatic stress symptomatology (PTSS) in children and adolescents who have attended an emergency department following assaults or motor vehicle accident. Methods: Children and their parents completed self-report questionnaires and semistructured interviews relating to their psychopathology and cognitive styles at 2-4 weeks and 6 months after trauma. Results: Parental depression was correlated with child PTSS at each assessment point. Less consistent findings were observed for family functioning. Parental endorsement of worry was a correlate of child PTSS at each assessment and a mediator between parental depression and child PTSS. Conclusions: A role for family factors, in particular parental depression and parental endorsement of worry, in the development of child PTSS is supported. Weaknesses of the study are discussed, and suggestions for future research are given

Acute stress disorder and posttraumatic stress disorder in children and adolescents involved in assaults or motor vehicle accidents

Objective: The authors investigated acute stress disorder and later posttraumatic stress disorder (PTSD) in children and adolescents who had been involved in assaults or motor vehicle accidents. Method: They interviewed 93 patients 10-16 years old who were seen in an emergency department for having been assaulted or involved in a motor vehicle accident within 4 weeks after the assault or accident to assess acute stress disorder. At 6 months, they reinterviewed 64 (68.8%) of the patients to assess PTSD. Results: At initial interview, 18 (19.4%) of the 93 patients had acute stress disorder and 23 (24.7%) met all acute stress disorder criteria except dissociation. At 6 months, eight of the 64 patients (12.5%) had PTSD. Acute stress disorder and PTSD did not differ in prevalence between patients who had been assaulted and those who had been in accidents. Sensitivity and specificity statistics and regression modeling revealed that the diagnosis of acute stress disorder was a good predictor of later PTSD but that dissociation did not play a significant role. Conclusions: Acute stress disorder has merit as a predictor of later PTSD in children and adolescents, but dissociation has questionable utility

Maladaptive Cognitive Appraisals Mediate the Evolution of Posttraumatic Stress Reactions:A 6-Month Follow-Up of Child and Adolescent Assault and Motor Vehicle Accident Survivors

A prospective longitudinal follow-up study (n = 59) of child and adolescent survivors of physical assaults and motor vehicle accidents assessed whether cognitive processes predicted posttraumatic stress symptomatology (PTSS) at 6 months posttrauma in this age group. In particular, the study assessed whether maladaptive posttraumatic appraisals mediated the relationship between initial and later posttraumatic stress. Self-report measures of PTSS, maladaptive appraisals, and other cognitive processes, as well as structured interviews assessing for acute stress disorder and posttraumatic stress disorder (PTSD), were completed at 2-4 weeks and 6 months posttrauma. PTSS and PTSD at 6 months were associated with maladaptive appraisals and other cognitive processes but not demographic or objective trauma severity variables. Only maladaptive appraisals were found to associate with PTSS/PTSD after partialing out initial symptoms/diagnosis and to mediate between initial and later PTSS. It was argued that, on this basis, maladaptive appraisals are involved in the development and maintenance of PTSS over time, whereas other cognitive processes (e.g., subjective threat, memory processes) may have an effect only in the acute phase. The implications of this study for the treatment of PTSS in youths are discussed

Diagnostic, demographic, memory quality, and cognitive variables associated with acute stress disorder in children and adolescents

To date, no studies have investigated factors associated with acute stress disorder (ASD) in children and adolescents. Relationships between ASD and a number of demographic, trauma, cognitive, and trauma memory variables were therefore investigated in a sample (N=93) of children and adolescents involved in assaults and motor vehicle accidents. Several cognitive variables and the quality of trauma memories, but not demographic or trauma variables, were correlated with ASD and also mediated the relationship between peritraumatic threat and ASD. Finally, nosological analyses comparing ASD with indexes of posttraumatic stress disorder in the month posttrauma revealed little support for the dissociation mandate that uniquely characterizes ASD. The results are discussed with respect to assessment and treatment for the acute traumatic stress responses of children and young people

A survey of evidence-based practice, training, supervision and clinician confidence relating to post-traumatic stress disorder (PTSD) therapies in UK child and adolescent mental health professionals

Background: Post-Traumatic Stress Disorder (PTSD) in children and adolescents has received increasing recognition in recent decades. Despite development of treatments and improved dissemination efforts, research has identified a number of barriers to implementing these approaches. Objective: This study sought to understand what interventions mental health professionals working with children and adolescents utilised to treat PTSD, their training and supervision, their confidence in assessing and treating PTSD, and how these factors relate to clinicians characteristics (e.g. age, gender, professional background). Method: The study comprised an internet-delivered survey of clinicians working in child and adolescent mental health services in the UK (N = 716). Results: Many clinicians (>40%) had not received training in working with PTSD, with considerable variation between professional background. Lack of training and supervision was associated with reduced clinician confidence in treating children with PTSD (possible range 0–10; training M = 7.54, SD = 1.65, no training M = 5.49, SD = 2.29; supervision M = 7.53, SD = 1.63, no supervision M = 5.98, SD = 2.35). Evidence-based therapies for PTSD such as Trauma-Focused Cognitive-Behavioural Therapy and Eye Movement Desensitisation and Reprocessing were only endorsed modestly by clinicians (58.4% and 37.5%, respectively). Regression analyses identified that lack of training and supervision were significant barriers to the use of evidence-based interventions. Other predictors of clinician confidence and use of evidence-based interventions included profession and years of experience. Participants almost universally wanted more training in working with PTSD. Conclusions: Evidence-based treatments are not currently universally delivered by mental health professionals in the UK, with certain professions particularly lacking training and confidence with this condition. Training around trauma and PTSD may be an ongoing need to boost and maintain confidence in working with PTSD in youth