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

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

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

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

Child posttraumatic stress symptoms in an acute injury sample: Patterns of associations among child report, parent report, and child heart rate parameters

Parent–child agreement on measures of child posttraumatic stress disorder (PTSD) is moderate at best, and understanding of this discrepancy is limited. To address this, we conducted an item-level investigation of parent–child symptom agreement to examine the potential influence of parental posttraumatic stress symptoms (PTSS) on parents’ reports of their child's PTSS. We also examined heart rate (HR) indices as possible independent indicators of child PTSD, examining patterns of association with parent versus child report. Parent–child dyads (N = 132, child age: 6–13 years, 91.7% White) were recruited after the child's hospital admission following an acute, single-incident traumatic event. At 1-month posttrauma, questionnaires assessing children's PTSS (self- and parental reports) and parental PTSS were administered. For a subset of participants (n = 70), children's HR recordings were obtained during a trauma narrative task and analyzed. Parent and child reports of child PTSS were weakly positively correlated, r =.25. Parental PTSS were found to be stronger positive predictors of parental reports of child PTSS than the children's own symptom reports, β = 0.60 vs. β = 0.14, and were associated with higher parent-reported child PTSS relative to child reports. Finally, children's self-reported PTSS were associated with HR indices, whereas parent reports were not, βs = −.33–.30 vs. βs = −.15–.01. Taken together, children's self-reported PTSS could be a more accurate reflection of their posttrauma physiological distress than parent reports. The potential influence of parental PTSS on their perceptions of their child's symptoms warrants further consideration

Cost-effectiveness of psychological interventions for children and young people with post-traumatic stress disorder

Background: PTSD in youth may lead to long‐lasting psychological implications, educational difficulties and increased healthcare costs. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost‐effectiveness of a range of psychological interventions for children and young people with PTSD. / Methods: A decision‐analytic model was constructed to compare costs and quality‐adjusted life years (QALYs) of 10 psychological interventions and no treatment for children and young people with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta‐analysis. Other model input parameters were based on published sources, supplemented by expert opinion. / Results: Cognitive therapy for PTSD, a form of individual trauma‐focused cognitive behavioural therapy (TF‐CBT), appeared to be the most cost‐effective intervention for children and young people with PTSD (with a probability of .78 amongst the 11 evaluated options at a cost‐effectiveness threshold of £20,000/QALY), followed by narrative exposure (another form of individual TF‐CBT), play therapy, and other forms of individual TF‐CBT. After excluding cognitive therapy from the analysis, narrative exposure appeared to be the most cost‐effective option with a .40 probability of being cost‐effective amongst the remaining 10 options. EMDR, parent training and group TF‐CBT occupied middle cost‐effectiveness rankings. Family therapy and supportive counselling were less cost‐effective than other active interventions. There was limited evidence for some interventions, in particular cognitive therapy for PTSD and parent training. / Conclusions: Individual forms of TF‐CBT and, to a lesser degree, play therapy appear to be cost‐effective in the treatment of children and young people with PTSD. Family therapy and supportive counselling are unlikely to be cost‐effective relative to other interventions. There is a need for well‐conducted studies that examine the long‐term clinical and cost‐effectiveness of a range of psychological treatments for children and young people with PTSD

A longitudinal examination of the relationship between trauma-related cognitive factors and internalising and externalising psychopathology in physically injured children

Cognitive models of posttraumatic stress disorder (PTSD) highlight maladaptive posttrauma appraisals, trauma memory qualities, and coping strategies, such as rumination or thought suppression, as key processes that maintain PTSD symptoms. Anxiety, depression and externalising symptoms can also present in children in the aftermath of trauma, yet there has been little empirical investigation of the potential relevance of posttrauma cognitive processes for such difficulties. Here, we examined whether: a) acute maladaptive cognitive processes (specifically, maladaptive appraisals, memory qualities, and cognitive coping) were associated with symptoms of PTSD, internalising, and externalising at 1-month posttrauma (T1); and b) changes in these cognitive processes predicted symptom change at a follow-up assessment 6 months later (T2). We recruited 132 6–13 year old children and their parents from emergency departments following the child’s experience of an acute trauma. Children self-reported on their maladaptive appraisals, trauma-memory and cognitive coping strategies, along with symptoms of PTSD, anxiety and depression. Parents also rated children’s internalising and externalising symptoms. We found each cognitive process to be robustly associated with PTSD and non-PTSD internalising symptoms at T1, and change in each predicted change in symptoms to T2. Maladaptive appraisals and cognitive coping were unique predictors of children’s posttrauma internalising. Effects were partially retained even controlling for co-occurring PTSD symptoms. There was less evidence that trauma-specific cognitive processes were associated with externalising symptoms. Findings suggest aspects of cognitive models of PTSD are applicable to broader posttrauma psychopathology, and have implications for how we understand and target children’s posttrauma psychological adjustment

Trauma memory characteristics and the development of acute stress disorder and post-traumatic stress disorder in youth

Background & objectives: The present study addresses gaps in knowledge regarding the association between trauma memory processes and posttraumatic stress responses in youth. Our primary goal was to explore the relative contribution of perceptions of trauma memory quality versus narrative trauma memory characteristics to explain overall adjustment.  Methods: Children (N = 67) were interviewed within four weeks (T1) of an injury leading to hospital treatment and then again eight weeks later (T2). In each interview, the child told a trauma narrative (which were later coded), and answered the Trauma Memory Quality Questionnaire (Meiser-Stedman, Smith, Yule, & Dalgleish, 2007a), a self-report measure indexing the sensory, fragmented, and disorganised characteristics of trauma memory. They then completed measures of Acute Stress Disorder (ASD) symptoms and associated psychopathology at T1 and measures of Posttraumatic Stress (PTS) symptoms and associated psychopathology at T2.  Results: Self-reported trauma memory characteristics predicted ASD symptoms cross-sectionally at T1 and PTS symptoms prospectively over time. At both time points, self-reported trauma memory characteristics accounted for all of the unique variance in symptoms initially explained by narrative characteristics. A reduction in self-report ratings, but not the hypothesised narrative features (e.g., disorganised or lexical elements of the narrative), significantly predicted a reduction in PTS symptoms over time.  Limitations: The small sample size and the absence of a within-subjects narrative control were the main limitations of the study.  Conclusions: These findings underscore the importance of self-reported trauma memory characteristics to the aetiology of PTSD