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

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

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

Supporting the emotional needs of young people in care: a qualitative study of foster carer perspectives

Young people who have been removed from their family home and placed in care have often experienced maltreatment and there is well-developed evidence of poor psychological outcomes. Once in care, foster carers often become the adult who provides day-to-day support, yet we know little about how they provide this support or the challenges to and facilitators of promoting better quality carer-child relationships. The aim of this study was to understand how carers support the emotional needs of the young people in their care and their views on barriers and opportunities for support. Participants were 21 UK foster carers, recruited from a local authority in England. They were predominantly female (86%), aged 42-65 years old and ranged from those who were relatively new to the profession (<12 months' experience) to those with over 30 years of experience as a carer. We ran three qualitative focus groups to gather in-depth information about their views on supporting their foster children's emotional well-being. Participants also completed short questionnaires about their training experiences and sense of competence. Only half of the sample strongly endorsed feeling competent in managing the emotional needs of their foster children. While all had completed extensive training, especially on attachment, diagnosis-specific training for mental health problems (eg, trauma-related distress, depression) was less common. Thematic analysis showed consistent themes around the significant barriers carers faced navigating social care and mental health systems, and mixed views around the best way to support young people, particularly those with complex mental health needs and in relation to reminders of their early experiences. Findings have important implications for practice and policy around carer training and support, as well as for how services support the mental health needs of young people in care

Development and validation of the child post-traumatic cognitions inventory (CPTCI)

Background: Negative trauma-related cognitions have been found to be a significant factor in the maintenance of post-traumatic stress disorder (PTSD) in adults. Initial studies of such appraisals in trauma-exposed children and adolescents suggest that this is an important line of research in youth, yet empirically validated measures for use with younger populations are lacking. A measure of negative trauma-related cognitions for use with children and adolescents, the Child Post-Traumatic Cognitions Inventory (CPTCI), is presented. The measure was devised as an age-appropriate version of the adult Post-Traumatic Cognitions Inventory (Foa et al., 1999). Methods: The CPTCI was developed and validated within a large (n = 570) sample, comprising community and trauma-exposed samples of children and adolescents aged 6-18 years. Results: Principal components analysis suggested a two-component structure. These components were labelled 'permanent and disturbing change' and 'fragile person in a scary world', and were each found to possess good internal consistency, test-retest reliability, convergent validity, and discriminative validity. The reliability and validity of these sub-scales was present regardless of whether the measure was completed in the acute phase or several months after a trauma. Scores on these sub-scales did not vary with age. Conclusions: The CPTCI is a reliable and valid measure that is not specific to the type of trauma exposure, and shows considerable promise as a research and clinical tool. The structure of this measure suggests that appraisals concerning the more abstract consequences of a trauma, as well as physical threat and vulnerability, are pertinent factors in trauma-exposed children and adolescents, even prepubescent children

Thought control strategies and rumination in youth with acute stress disorder and posttraumatic stress disorder following single-event trauma

Objective: Certain thought control strategies for managing the intrusive symptoms of posttraumatic stress disorder (PTSD) are thought to play a key role in its onset and maintenance. Whereas measures exist for the empirical assessment of such thought control strategies in adults, relatively few studies have explored how children and adolescents manage posttraumatic intrusive phenomena. Methods: In a prospective longitudinal study of 10-16-year-olds with PTSD, who were survivors of road traffic collisions and assaults, a variety of thought control strategies were assessed in the acute phase. These included strategies thought to be protective (reappraisal, social support) as well as maladaptive (distraction, punishment, worry). Ruminative responses to the trauma were assessed at the follow-up assessment. Results: Posttraumatic stress symptoms (PTSS) at each assessment were associated with the use of punishment and reappraisal, whereas social support and rumination were associated with PTSS symptoms at follow-up. Distraction was unrelated to PTSS at any time point. Rumination accounted for variance in PTSS symptoms at follow-up, even when accounting for baseline PTSS, and was found to mediate the relationships between reappraisal and punishment at baseline and PTSS at the follow-up assessment. Conclusions: The present study found no evidence to support advocating any particular thought control strategy for managing the intrusive symptoms of PTSD in youth in the acute posttrauma phase, and raised concerns over the use of reappraisal coping strategies. The study underscores the importance of ruminative responses in the onset and maintenance of PTSD in trauma-exposed youth

Screening for post-traumatic stress symptoms in looked after children

Purpose: Many children who are looked after by the state have experienced adverse and traumatic life circumstances prior to being removed from their biological parents. Previous research has highlighted that many of them experience barriers to accessing psychological therapies. The purpose of this paper is to investigate the feasibility of assessing post-traumatic stress disorder (PTSD)-like symptoms using a screening tool, and through this to determine the prevalence of PTSD-like symptoms in looked after children presenting with emotional and/or behavioural problems.   Design/methodology/approach: The Child Revised Impact of Events Scale (CRIES-8) was identified as a suitable screening tool for PTSD-like symptoms. This measure was piloted for three months, and the prevalence of PTSD-like symptoms amongst respondents ( n=27) was recorded.   Findings: Prevalence of PTSD-like symptoms was found to be high 75 per cent amongst respondents. The psychometric properties of the CRIES-8 were similar to those found in a previous study assessing PTSD following a single-incident trauma. Health care professionals reported finding the CRIES-8 to be a clinically useful measure.   Originality/value: Prevalence of PTSD-like symptoms may be high amongst looked after children, and the CRIES-8 appears to have good psychometric properties when used with this population. It is likely that this highly treatable condition is under-detected: thus, recommendations are made for clinical practice and further research

Parents’ and teachers’ knowledge of trauma and Post-Traumatic Stress Disorder in children and adolescents and their agreement towards screening

Background: Trauma exposure is common in children and adolescents. Parents and other key adults, such as teachers, are necessary to facilitate help-seeking behavior, which involves recognizing trauma and adverse reactions and awareness of accessing treatments. Where screening measures in schools are used to detect post-traumatic stress disorder (PTSD), the attitudes of parents and teachers towards screening need to be considered. Objective: To examine whether parents and teachers can accurately detect trauma events, symptoms and effective treatments. In addition, to assess how supportive parents and teachers are towards PTSD screening in schools. Method: A total of 439 parents and 279 teachers completed online questionnaires assessing PTSD knowledge across three domains: traumatic events, PTSD symptoms and evidence-based treatments. Responses of acceptability of using PTSD screening tools in schools were elicited. Results: Teachers and parents were accurate in recognizing trauma events and PTSD symptoms. However, understanding was inclusive, with events not considered traumatic and non-PTSD diagnostic criteria being endorsed. Trauma-Focussed Cognitive-Behavioral Therapy was recognized as an effective treatment for PTSD, but Eye-Movement Desensitization and Reprocessing was not. Treatments not recommended by health guidelines were frequently endorsed. The majority of participants were supportive of PTSD screening in schools, but a minority were not. Conclusions: Parents and teachers are able to recognize trauma events and symptoms of PTSD, although this tends to be overly inclusive. Schools could be targeted to promote understanding trauma among parents and teachers. Agreement with screening is encouraging and further research is warranted to understand barriers and facilitators

Psychological peritraumatic risk factors for post-traumatic stress disorder in children and adolescents: A meta-analytic review

Background Meta-analytic reviews concerning predictors of PTSD in children and adolescents have predominantly identified evidence relating to pre- and post-trauma risk factors; however, there is little evidence regarding peritraumatic risk factors. This paper comprised a systematic review and meta-analysis of studies exploring psychological peritraumatic risk factors for PTSD in youth. Methods Thirty-two studies were identified. Random effects meta-analyses were undertaken, with meta-regressions to explore the moderating role of study characteristics (gender, sex, timing of assessment after trauma, study quality, design and trauma type) on the size of effect of predictive factors. Results Peritraumatic subjective threat (k = 28; r = 0.37, 95% CI=0.31–0.42) yielded a medium effect size estimate, while dissociation (k = 5; r = 0.17, 95% CI=0.03–0.29) and data-driven processing (feeling muddled or confused during the trauma) (k = 2; r = 0.29, 95% CI=0.14–0.43) yielded smaller population effect size estimates for the relationship with PTSD symptoms. Perceived life threat yielded a medium sized effect (k = 12; r = 0.37, 95% CI=0.32–0.41). The relationship between subjective threat and PTSD symptoms was moderated by the percentage of female participants. Estimates of heterogeneity were high in studies assessing perceived threat and fear (I2 = 95%), but moderate and low within studies assessing dissociation and data-driven processing (I2 = 57% and 0%, respectively). Limitations Peritraumatic psychological processes were commonly assessed using single-item measures. Studies primarily concerned single-incident traumas, limiting generalisability. Conclusions Peritraumatic experiences, particularly relating to subjective threat, are important correlates of subsequent PTSD, which implicates timely assessment of these experiences in youth to inform identification of at-risk groups and implementation and design of intervention