However, the personality factor ‘optimism’ in itself may be an important asset when confronted with terrible things: Feelings of optimism and hope may help our recovery from a traumatic event.

In 2007, Hobfoll and colleagues wrote a seminal article on the five essential elements of immediate and mid-term mass-trauma intervention. The first four principles considered the importance of making people feel safe and comfortable, calming them when necessary, enhancing their feeling of being in control, and promoting connectedness with loved ones and support networks. The fifth principle was to promote hope. The authors described that there is strong evidence for the importance of retaining hope in recovery.

Recently, researchers published on the American prisoners of war who were held in Vietnam in the 1960s and early 1970s. These veterans had been examined for psychological functioning shortly after their return. In 2010, 37 years later, their resilience was measured, defined as an absence of psychiatric diagnoses. It turned out that optimism was the strongest predictor of mental health.

How can we facilitate a feeling of hope or optimism? Without stepping in the trap of underrating the distress and challenges that survivors experience? Taking the authors’ and various other tips together, there are a number of things we can do to help:

• Build on strengths: what goes well, and how can we amplify this? You can also ask what has worked for someone on earlier occasions; this may not only give them guidance but also remind them of earlier problem solving capacities.
• Convey the message that most people recover spontaneously and that feeling distressed shortly after an event does not mean that you’re going crazy.
• If someone exaggerates their personal responsibility (‘It’s all my fault’), reduce it with a sensitive cognitive behavioral intervention
• Decatastrophize: promote fact-based thinking instead of overly negative expectations. It is more helpful to accept a realistic difficult outcome (‘It will take months to rebuild my house’) than to envision a catastrophic outcome (‘I’ll never have a home again’)
• Facilitate interventions by the media, schools and universities and community leaders that work towards positive goals, organize cleaning and rebuilding, and help people to tell their story.

What’s your take on the role of optimism? And do you have tips to enhance it?

References:
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, & Ursano RJ (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70 (4) PMID: 18181708
Segovia, F., Moore,J.L., Linnville,S.E., Hoyt, R.E., & Hain, R.E. (2012). Optimism predicts resilience in repatriated prisoners of war: A 37-year longitudinal study Journal of Traumatic Stress, 25, 330-336 DOI: 10.1002/jts.21691

This month’s guest post is by Geert Smid. Geert is a psychiatrist with Foundation Centrum ’45, the Dutch national institute for specialized diagnosis and mental health treatment after

According to the current edition of the Diagnostic and Statistical Manual of Mental Disorders, delayed posttraumatic stress disorder (PTSD) must be diagnosed in individuals fulfilling criteria for PTSD if the onset of symptoms is at least 6 months after the trauma. The prevalence of delayed PTSD has for a long time remained unclear, and only few studies have examined factors that may explain its occurrence. The findings summarized below are based on prospective investigations in disaster survivors and unaccompanied refugee minors, as well as a comprehensive meta-analysis of prospective studies.

1. About a quarter of PTSD cases is with delayed onset. The results of our meta-analysis showed that delayed PTSD occurs in about one quarter of all PTSD cases. The risk of delayed PTSD did not decrease between 9 and 25 months after the traumatic event, and when traumatized populations were followed up for longer periods of time, more delayed PTSD cases were found. These findings suggest ongoing potential risk for some individuals.

2. During the interval between the trauma and delayed PTSD onset, some symptoms are likely to occur. Delayed PTSD occurred most often in individuals already reporting “subthreshold” symptoms after the traumatic event. These symptoms that precede the full PTSD syndrome are called “prodromal.” Prodromal symptoms may include intrusive memories and avoidance of reminders as well as feelings of depression and anxiety.

3. Delayed PTSD is associated with mental health service utilization. We found a high likelihood of mental health service utilization in participants endorsing delayed PTSD 4 years after a disaster. Two thirds of disaster survivors endorsing delayed PTSD used or continued using mental health services. This finding strongly suggests that symptom progression in delayed PTSD is clinically relevant.

4. Delayed PTSD can be explained from pre-existing, trauma-related, and posttraumatic factors. Survivors reporting total home destruction after a disaster, i.e. very severe disaster exposure, were at elevated risk of developing delayed PTSD. We also found that cognitive ability as indicated by higher education was associated with delayed PTSD after a disaster, presumably by promoting initial adaptation to the traumatic event and thus mitigating initial distress. Lack of perceived social support as well as new stressful life events several years after a disaster increased the risk of delayed disaster-related PTSD.

In unaccompanied refugee minors, increasing age emerged as a risk marker for delayed PTSD. This highlights the importance of the stressful transitions for these youths at the age of 18 years. For example, their legal status will be reviewed, and they will be uncertain regarding their future right to remain in theNetherlands. Thus, factors associated with delayed PTSD may be pre-existing, trauma-related, or related to the posttraumatic phase.

These factors may explain the occurrence of delayed PTSD in one of three ways. First, factors may increase the risk for PTSD in general. Second, factors may promote initial adaptation to the traumatic event and thus explain why symptoms are not full-blown from the start. Third, factors may precipitate PTSD onset despite initial adaptation and thus explain why symptoms increase in number or severity later on.

5. Severe traumatic event exposure may lead to stress sensitization. We found prospective evidence of stress sensitization, that is, enhanced reactivity of individuals to new stressors following extreme disaster exposure (such as total home destruction) during the first years after a disaster. Stress sensitization may explain progression of distress over time and has important practical implications. Averting foreseeable stressors and resource losses in the aftermath of severe trauma, diminishing the impact of chronic stressors as well as reducing stress sensitization may be a target for preventing and treating progression of posttraumatic distress.

Towards a better definition of delayed PTSD.

According to the latest proposal for DSM-5, PTSD “With Delayed Expression” is defined as follows: “if the diagnostic threshold is not exceeded until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).”  Compared with previous DSM editions, this definition is a clear step forward, because it explicitly allows for prodromal symptoms preceding the onset of full delayed PTSD. Thus the revised definition more realistically describes the possible delayed impact of traumatic events that may show a crescendo pattern over time. This is important, because effects of trauma or stressor exposure are likely not restricted to PTSD alone, but to be relevant to a wide range of psychopathology. For example, delayed trajectories of depression have also been found following a disaster, and stress sensitization has been implied in the development of psychosis.

Do you think stress sensitization could be involved in the development of depression?

And could the concept of stress sensitization be helpful in developing innovative treatment strategies for trauma- and stressor-related disorders?

Reference of the meta-analysis:
Smid GE, Mooren TT, van der Mast RC, Gersons BP, & Kleber RJ (2009). Delayed posttraumatic stress disorder: systematic review, meta-analysis, and meta-regression analysis of prospective studies. The Journal of Clinical Psychiatry, 70 (11), 1572-82 PMID: 19607763

The first point he makes regards the prevalence of PTSD. The wars in Afghanistan and Iraq have caused PTSD in army personnel but at a far lower rate than was expected. While the original estimations were around 30% of troops deployed to war zones, actual numbers were only a fraction of that: about 4% of the people deployed (8% in those reporting combat exposure), according to the most rigorous studies. This fits well with Bonanno’s argument about humans’ capacity to thrive in the face of adversity.

Even though the rates are lower than anticipated, PTSD is a serious problem for those affected and their families. One of the main, persistent issues regards the stigma about seeking help. How to reduce stigma is relatively under researched is my impression from the article. McNally indicates that when social cohesion is strong and leadership is excellent, people tend to have fewer worries about stigma. May be these two factors point to just one avenue to reduce stigma in the specific context of military units, but it is a hopeful start.

When it comes to treatment of veterans, there has been an enormous endeavor to train clinicians in evidence-based cognitive behavioral therapies (Prolongued Exposure, Cognitive Processing). For the dissemination, a train-the-trainer model with intensive supervision was used. It looks like this has been a highly effective way of disseminating and implementing evidence-based treatment. McNally points out that vital conditions had been met for a successful implementation: administrative support, guaranteed time for therapists to deliver the treatment optimally, and incentives/directives to secure maintenance.

Finally, it is still a difficult choice between investing in PTSD prevention (with the risk of spending money on screening people who will be resilient anyway) and PTSD treatment (which only takes place after damage is done). However, McNally mentions promising new preventative initiatives targeting high-risk groups. One is Battlemind debriefing, for platoons returning from combat duty. While the word ‘debriefing’ may have got all your alarm bells ringing, this is actually not the ‘ventilating emotions’ type of debriefing. It focuses on building confidence and coping skills. And makes me wonder whether it would be a helpful program for first responders such as fire fighters and paramedics as well.

Therefore, while reading McNally’s article, these questions/reminders came up:

• How can we find a balance between keeping people’s resilience in mind and paying enough attention to the seriousness of the problem for those struggling with PTSD?
• We should put more research effort in discovering what are effective ways to reduce stigma.
• Could we make more use of the train-the-trainer model to disseminate evidence-based practice than we do now?
• Would programs like Battlemind debriefing have elements that are helpful for first responders?

What’s your take on it?

McNally’s paper:
McNally, R. (2012). Are We Winning the War Against Posttraumatic Stress Disorder? Science, 336 (6083), 872-874 DOI: 10.1126/science.1222069

This guest post is by

Five key considerations for working with young traumatized children:

1. Young children are a high risk group for exposure to traumatic events

Infants, toddlers, and preschoolers are particularly vulnerable to trauma exposure due to their stage of development.  Young children interact with their environment before they become aware of potential dangers and threat, are strongly reliant on adults to keep them safe and have limited skills to protect themselves. As a result, young children typically fall within the highest risk category for exposure to sexual and physical abuse, unintentional injury and witnessing domestic violence.  Other potentially traumatic events for young children include natural disasters, war, terrorism, painful medical procedures and witnessing a threat to their parent/caregiver.

It is important to be aware that what a young child perceives to be threatening may be different to adults.  Additionally, young children are at risk of making false assumptions or drawing the wrong conclusions which can compound the negative impact of the trauma (e.g. “The burn happened because I was bad”).  Further, due to their limited verbal skills, it may not always be obvious that a young child has experienced a traumatic event.

2. Young children can develop posttraumatic stress disorder (PTSD)

There is a common misconception that young children (< 6 years) are not affected by trauma. Due to their limited developmental capacities there has been scepticism about the ability to diagnose PTSD or other anxiety and mood disorders during early childhood. However, there is now a strong empirical data base that indicates that young children do indeed develop PTSD. Young children also present with many of the same PTSD symptoms as older children, adolescents and adults (i.e. reexperiencing, avoidance and hyperarousal). However, due to unique developmental differences, trauma symptoms can manifest differently in this age group.  In response to concerns raised about the appropriateness of the DSM-IV PTSD criteria for preschool children, the DSM-V Task Force have proposed an age-related subtype of PTSD for preschool children.

3. Comorbidity with PTSD is common

Recent research has reported that there is a high rate of comorbidity with PTSD during early childhood. Separation anxiety disorder and oppositional defiant disorder are the most common disorders that follow or emerge concurrently with the onset of PTSD. It also appears that new onset non-PTSD disorders that develop following a traumatic event usually occur in the presence of posttraumatic stress symptoms.

Parents are typically poor reporters of child internalizing difficulties and this is particularly the case for parents of pre-verbal or barely verbal children. There is therefore the risk that the common and more easily observable disruptive trauma-related symptoms (e.g. tantrums, irritability, aggression, poor concentration) are mistaken for the “terrible twos” or misdiagnosed and mistreated as a behavioral disorder (e.g. ADHD or ODD). Accurate diagnosis, formulation and treatment planning will be greatly improved by good history-taking about exposure to potentially traumatic events, the timing of symptom onset and knowledge that PTSD may be the underlying basis of new disorders following trauma exposure.

4. PTSD during early childhood can follow a chronic and debilitating course

Thankfully, most young children are resilient or only experience transient distress following exposure to a traumatic event. However, studies with injured preschool children have shown that approximately 10% are at risk of a chronic PTSD symptom trajectory. Further, a 2-year longitudinal study has demonstrated that PTSD symptoms did not remit over time or from community treatment in preschool children with mixed traumatic experiences.

These findings are particularly concerning given that young children’s neurophysiological systems are still in the process of rapid development. Additionally, trauma during childhood has been associated with permanent structural and functional brain impairment as well as the onset of psychiatric disorders, health risk behaviors and physical health conditions in adulthood. Thus trauma that occurs during early childhood may have even greater ramifications for developmental trajectories than traumas that occur at a later stage of development. Early intervention is therefore essential!

5. The impact of trauma should be considered within the context of the parent-child relationship

It is widely recognized that the quality of the parent-child attachment, parental mental health and parenting behaviors are crucial factors that influence a child’s adjustment following trauma. For young children, the parent-child relationship is particularly important as they need a sensitive and emotionally available caregiver to cope with strong emotions during times of distress. Additionally, young children often look to their parents to determine how to interpret or respond to an event and may therefore model their parent’s fear responses and maladaptive coping responses. Parents can also influence their child’s recovery from trauma by accommodating avoidance behaviors or allowing their child to be repeatedly exposed to trauma reminders. Interventions that target child distress, parent distress and the parent-child relationship are likely to be beneficial in reducing the subsequent development of parent and child posttraumatic stress reactions.

Useful websites:

• Tulane Institute of Infant and Early Childhood Mental Health: Measures & Manuals
• US National Child Traumatic Stress Network
• Zero to Three: US National Center for Infants, Toddlers, and Families

References:

Young, A., Kenardy, J., & Cobham, V. (2011). Trauma in Early Childhood: A Neglected Population Clinical Child and Family Psychology Review, 14 (3), 231-250 DOI: 10.1007/s10567-011-0094-3
De Young, A., Kenardy, J., & Cobham, V. (2011). Diagnosis of Posttraumatic Stress Disorder in Preschool Children Journal of Clinical Child & Adolescent Psychology, 40 (3), 375-384 DOI: 10.1080/15374416.2011.563474
De Young, A., Kenardy, J., Cobham, V., & Kimble, R. (2012). Prevalence, comorbidity and course of trauma reactions in young burn-injured children Journal of Child Psychology and Psychiatry, 53 (1), 56-63 DOI: 10.1111/j.1469-7610.2011.02431.x

In preparation for the chat, I wanted to share some more information on one of the papers Julia referred to. Glenn Saxe and colleagues conducted a trial with an innovative treatment approach that integrates and tailors different services (psychotherapy, psychopharmacology, home- and community based care, and advocacy) for children and their families. It’s called Trauma Systems Therapy. The authors wanted to conduct a proper randomized controlled trial to compare the effects of TST with the effects of treatment as usual. However, this is what happened: at the 3-month follow-up

• 90% of the children in the TST group were still enrolled, while
• 90% of the children in the control group had dropped out.

Both shocking and fascinating…

The paper on the trial is open-access and worth a read. For now, I thought it would be valuable to share the authors’ key practitioner messages:

1. Premature treatment dropout is a significant problem in child mental health treatment in general and in trauma treatment specifically.
2. Treatment dropout is especially problematic in community care settings (vs. research settings) and with marginalized populations, such as urban and ethnic minority children and adolescents and their families.
3. Improved engagement and retention in trauma-treatment can be attained by a combination of a) forming a treatment alliance with the family; b) troubleshooting practical barriers to treatment engagement; and c) psychoeducation about the nature of traumatic stress and the family’s involvement with treatment.
4. An exclusive and strategic focus on treatment engagement and retention at the outset of service delivery can lead to better outcomes.

I’m very interested in your views on what helps to make PTSD treatment for children and adolescents a success:

• Do you know best practices in engagement and retention in treatment?
• What kind of research should we do to better understand dropout and how we can make sure that clients complete the therapy that would help them feel better?

This guest post is written by Julia Diehle, who is in the final year of her PhD project (supervised by dr. Lindauer and prof. Boer at the Academic Medical Center in Amsterdam). Her research project concerns a randomized controlled trial of Trauma-Focused Cognitive Behavior Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) in children with PTSD.

Treatment dropout will be the topic of next week’s #traumaresearch Twitter chat on Thursday 26 April (9pm Melbourne, 13u Amsterdam; see your local time & how to join). Julia will join us as a special guest, I hope to see many of you there! Now over to Julia: 

We do not like to talk about it but treatment dropouts and “no-shows” are a big problem in trauma therapy. Actually not in trauma therapy alone, but in outpatient settings in general. About 50% of adult patients drop out of outpatient therapy¹ and the number of children dropping out of treatment seems to be even higher. Miller and colleagues² found that more than 60% of children did not complete 8 sessions of therapy and that about 17% of the children did not even return after the intake session.

It is all about long-term vs. short-term gains

Trauma-therapy is no fun and treatment gains are achieved on the long term rather than on the short term. This may play a crucial role especially in children and adolescents, who are more present-oriented than adults, who are more future-oriented. Unlike younger children, adolescents (12 years or older) carry part of the responsibility for showing up for, and completing therapy. Parents have less influence on an adolescent than on a child younger than 12. Therefore the therapist needs to convince the adolescent of the usefulness of the therapy. However, on the short term it is more convenient for the adolescent to avoid the problems resulting from a traumatic experience than confronting them. Hence he or she might stop showing up for treatment appointments and drop out of treatment.

One would expect that treatment non-completers score higher on avoidance symptoms than treatment completers. However, treatment outcome studies almost never report on these differences. Moreover, avoidance symptoms can be very difficult to capture: If you ask an adolescent, who is an “avoidance expert”, whether he or she tries not to think about the event, this adolescent may answer: ‘I do not have to because I do not think about it.’ – And you won’t score it as an avoidance symptom.

Is the social system of the patient the key?

With younger children it does not only take commitment of the child, but also of the parent to attend therapy. This commitment may be at risk if a child first gets worse during treatment before getting better. A parent might support the avoidance of the child when the child gets worse at the start and not take him or her to therapy anymore. Again you have to deal with short-term versus long-term gains. Furthermore the parent might be traumatized as well and you might have to deal with both, the avoidance of the parent, and of the child. Other barriers may arise from lack of time or resources. One example is the parent who has to leave work early to take the child to therapy. With younger children it is therefore necessary to convince the parent of the importance of trauma-therapy.

Saxe, Ellis, Fogler and Navalta (2012)³ investigated the effects of a Trauma Systems Therapy (TST) for youth on treatment dropout. The results were promising: The drop-out rate was only 10% in the TST group at the assessment after 3 months, while the dropout rate for the care as usual group was 90%. The authors argue that in TST, the involvement of the child’s social environment and treatment engagement approaches play a crucial role, which results in low dropout rates. The sample size of this study was very small with 10 children in the treatment and 10 children in the control condition. However, research on treatment drop-outs and no-shows is very scarce, especially in children.

Effective treatment also means keeping the patient in treatment

We try to make our treatments more effective and efficient, and for children who stay in treatment this is of great value. However we may want to think more about those children who drop out of treatment and how we can help them group to stay in treatment. This might cost more time and resources in the short term. But again it is all about the long-term consequences and the time and resources that we gain by treating a child today rather than in 5 years when the problems have become much worse. Approaches that involve the social system of the child/adolescent and the identification of barriers for treatment engagement may be a solution. Some children/adolescents (and their parents) also might need more time to get used to therapy and to understand the value of the treatment.

References:
¹Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24 (2), 190-195 DOI: 10.1037//0735-7028.24.2.190
²Miller, L., Southam-Gerow, M., & Allin, R. (2008). Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency Child & Youth Care Forum, 37 (4), 153-170 DOI: 10.1007/s10566-008-9058-2
³Saxe, G., Heidi Ellis, B., Fogler, J., & Navalta, C. (2012). Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout Child and Adolescent Mental Health, 17 (1), 58-61 DOI: 10.1111/j.1475-3588.2011.00626.x

Which papers have made you really enthusiastic? Which articles have changed your thinking? Which publications do you re-read regularly?

We’ll have a #traumaresearch chat about these questions on Wed 28/Thurs 29 March (your local time). But an hour is short, not everyone is able to join, and it may be nice to start a little thread that informs the chat and remains available afterwards (it’s also possible that I’m just a little too curious to wait another week ). So please leave a comment with your favorite(s).

It doesn’t matter whether a paper is high-impact / often cited or not. The only thing that counts is that you are a fan. And if you have time, please tell us why you like it.

To start off (let’s aim for the 20 most inpirational papers): one of my favorites is the review by Salmon & Bryant on the influence of developmental factors on posttraumatic stress. I read it in the early stages of my PhD research and keep getting back to it because it’s so rich (and quite unique) in explaining how children process information, depend on parents’ coping behavior, and understand emotions in the context of trauma:

Salmon, K., & Bryant, R. (2002). Posttraumatic stress disorder in children: The influence of developmental factors Clinical Psychology Review, 22 (2), 163-188 DOI: 10.1016/S0272-7358(01)00086-1

This Thursday the live #traumaresearch chat on Twitter (10am Amsterdam; 8pm Melbourne) will be about posttraumatic growth. We’ll discuss the recent literature review by Meyerson et al.

Feel free to join us for the full hour or part of it, as an active participant or just by reading the comments. If you would like to participate but have no Twitter experience yet: have a look at this Twitter for Trauma Researchers video, it will explain you how to get started.

What is posttraumatic growth? In short, it is ”Positive change experienced as a result of the struggle with trauma”. Or, in non-academic terms, “What doesn’t kill you makes you stronger” (Nietsche). Examples are feeling more connected to friends and family, having a clearer view of life priorities, or simply enjoying ‘the little things’ more.

As with many things in trauma research, there is quite an amount of work done with adults but far less knowledge on the experience of children and adolescents. Meyerson and colleagues summarize the findings of all articles and dissertations they could identify: 25 studies.

The literature covers a lot of ground and the small number of studies come up with many contradictory results. For example, one study found that posttraumatic stress symptoms (struggling with trauma) predicted later posttraumatic growth in child survivors of Hurricane Katrina but not vice versa. It indicates that children would indeed ‘need’ to experience these difficulties in order to feel personal growth (not suggesting that we would want any trauma to happen of course).

However, another paper by the same authors found that growth also predicted posttraumatic stress. And a third one showed that most growth was experienced with moderate (but not low or high) levels of stress. That suggests that children need some amount of struggle to be able to grow, but not an overwhelming quantity.

To generate some discussion topics for Thursday’s Twitter chat, I have summarized the main study findings in a table. That is, the number of studies that found a connection between growth and other characteristics of the young people.

The methodologist in me wants to warn you though: simple counting of studies may give very different results from a proper meta-analysis. Consider 7 ‘positive’ studies having an N of 10 or a very biased sample, while the 1 ‘negative’ study had an N of 1000 randomly sampled participants… So it’s really to provoke thoughts and make you look up this review to learn more:

What do you find intriguing about posttraumatic growth? What should we absolutely study? Any ideas about clinical implications?

Reference:
Meyerson, D., Grant, K., Carter, J., & Kilmer, R. (2011). Posttraumatic growth among children and adolescents: A systematic review Clinical Psychology Review, 31 (6), 949-964 DOI: 10.1016/j.cpr.2011.06.003

This guest post is by Odilia Laceulle. Odilia is finishing her PhD project at the Interdisciplinary Center for Psychiatric Epidemiology (UMC Groningen, with Prof. Ormel). She focuses on the influence of stressful life events on temperament and stress-reactivity during adolescence using data from the large cohort study TRAILS (TRacking Adolescents’ Individual Lifes Survey).

It is no surprise that many children and adolescents we see in clinical practice need help after being exposed to severe stress. However, not all children who are exposed to stress seek clinical help; some are able to cope with severe stress without therapy. But what defines the impact of severe stressors and who can cope with traumatic events and who cannot? And are all children at equal risk of getting exposed to these events, or can we distinguish factors that predict the likelihood of becoming a victim? 

Is epidemiological research of value?

Epidemiological research, the study of the distribution and patterns of mental and physical health and their causes or influences in a population, may help us to answer these questions. Nonetheless, epidemiological studies on stress and trauma tend to struggle with one major methodological limitation: when looking at severe stress, researchers are likely to end up with only a very small percentage of traumatised children. The statistical power to detect associations between precursors of trauma and the occurrence of the events, or between the events and subsequent mental health problems, is small. The question that consequently rises is whether this implies that epidemiology is the wrong way to study stress and trauma or at least inferior to on-spot studies focusing on clinical samples? I would say no. 

Insight in resilience

First, even though significant associations can be difficult to detect (because they are only valid for subgroups of a sample), findings can be meaningful. Whereas most children and adolescents exposed to severe stress will experience consequences in one way or another, we can detect those fortunate kids who are all right. More importantly, an epidemiological approach can help us to gain insight in factors that make these children resilient, whether these are relatively flexible (and therefore a potential subject for intervention research) or more irreversible (i.e., genetic factors). For example, in a study using data from the longitudinal cohort study TRAILS, we studied how children differed in their sensitivity to childhood stress, dependent on their genotypes¹. Results showed that certain genotypes could be distinguished that made children more sensitive to stress, whereas other genotypes made children being less affected by exposure. 

Learning from milder stressful events

Secondly, in epidemiological studies, and in the absence of focus groups, we often have the opportunity to define our own construct of stressful events or trauma. We can make inclusion criteria more strict or loosen them somewhat, depending on the research questions. Using a broader interpretation of trauma and including somewhat milder stressful events, more children will be ‘affected’. Consequently, we cannot only study inter-individual differences in the consequences of stress, but also study topics as stress sensitisation and cumulative effects. 

Or should we be more sceptical?

Sceptics might say that only really traumatic events (i.e., abuse), and not the milder stressful events, have serious and enduring consequences for children’s and adolescents’ development and well-being. Perhaps they are right. However, it seems that even relatively mild stressful events can result in surprising deviations from normative development. For example, we studied the association between both mild (end of a friendship, being thrown out of the parental home etc.) and more severe (i.e., loss of a parent) stressful events and personality development – a precursor of many aspects of mental health². Whereas adolescents’ normative personality development seems to be mainly in the direction of maturation (e.g., lower fear, shyness, more effortful control), adolescents exposed to stressful events showed less maturation or even the reverse of maturation of their personality. Moreover, for all personality traits under study, a cumulative effect (linear trend) was found consistently; the more stressful events adolescents experienced, the stronger their personality change deviated from normative development.

Reciprocity of exposure and psychological problems

These are not the only findings highlighting the importance of relatively mild stress in children’s psychological development. Using data from a British epidemiological study, we studied associations between stress exposure and psychological problems³. As expected, exposure to stress predicted the development of psychological problems. But in addition to that, we found that the association between stress and problems was reciprocal. That is, being exposed to stress did not only predict later problems, but was also predicted by psychological problems prior to the event. This suggests that children may not be at equal risk of getting exposed to stressful events.

Questions that remain

What we do not know yet, is whether the established associations are short term, long lasting or irreversible. And what about the implications? Even if we can find factors that account for high resilience in traumatized -but healthy- kids, can we translate this relatively fundamental research to intervention? Of course, these are just some of the questions that remain. Nonetheless, I would argue that epidemiological studies are a valuable way to study the gray area between a stress-free, uncomplicated, youth and severe trauma. It can help us reaching and studying those that might need help but do not ask for it, as well as the resilient kids who just do not need help.

References:

1. Nederhof, E., Bouma, E., Riese, H., Laceulle, O., Ormel, J., & Oldehinkel, A. (2010). Evidence for plasticity genotypes in a gene-gene-environment interaction: the TRAILS study Genes, Brain and Behavior, 9 (8), 968-973 DOI: 10.1111/j.1601-183X.2010.00637.x
2. Laceulle, O., Nederhof, E., Karreman, A., Ormel, J., & Aken, M. (2011). Stressful Events and Temperament Change during Early and Middle Adolescence: The TRAILS Study European Journal of Personality DOI: 10.1002/per.832
3. Laceulle, O.M., O’Donnell, K., Glover, V., O’Connor, G.O., Ormel, J., van Aken, M.A.G., & Nederhof, E., (submitted). Stressful events and psychological difficulties: testing alternative candidates for sensitivity.

Here is a video with simple instructions and tailored tips for those interested in mental health and/or trauma research, including how to join tomorrow’s journal club:

It covers how to:

1. Create a Twitter account
2. Fill out your profile and send your first tweet
3. Find trauma & PTSD experts to follow
4. Use hashtags, with examples specific for research and mental health
5. Join the #traumaresearch journal club via Twitter or Tweet chat

Let me know if any questions come up, I’m more than happy to help (@EvaAlisic).

The #traumaresearch Journal Club

The first #traumaresearch journal club will take place Februari 23rd, 10pm GMT (which corresponds to 5pm New York, 23u Amsterdam, Friday 24th 9am Melbourne). We will discuss a recent systematic review on the effects of cognitive behavioral therapy for children with PTSD and topics of interest for future chats. Students, academics, clinicians, all are welcome.

The second one will be March 15th, 9am GMT (4am New York - for really early, or late, birds! -, 10am Amsterdam, 8pm Melbourne). Vote in the sidebar for the paper we should discuss!

Cognitive Behavioral Therapy (CBT) is probably the most used, or at least most recommended, treatment for children with Posttraumatic Stress Disorder (PTSD). As I am quite fond of systematic reviews and meta-analyses, the new meta-analysis on the efficacy of trauma focused CBT by Kowalik and colleagues quickly grabbed my attention. Although (and because?) I have a few critical questions regarding the publication, I think it merits attention from researchers and clinicians.

What is CBT?

CBT is a psychological treatment that addresses ‘associations between stimuli and conditioned fear responses, the influence of environmental factors on symptom expression, and cognitive and affective regulation.’ Cohen and colleagues, who have developed trauma focused CBT, use the PRACTICE acronym to describe its elements. It requires a little bit of fantasy (two P’s!) and it seems to have changed slightly over the years but it gives a succinct overview:

Parental treatment component, including parenting skills
Psychoeducation
Relaxation and stress management skills
Affective expression and modulation skills
Cognitive coping skills
Trauma narrative and cognitive processing of the child’s traumatic experiences
In vivo desensitization to trauma reminders
Conjoint child-parent sessions
Enhancing safety and future development

Selective set of studies?

The purpose of the review by Kowalik et al. was to calculate an estimate of the overall efficacy* of CBT in the treatment of PTSD in children. Randomized controlled trials were selected if they compared CBT to an active control group (e.g., supportive unstructured psychotherapy, nondirective supportive treatment, and child-centered therapy). The authors used somewhat particular search terms: PTSD OR posttraumatic stress disorder OR sexual abuse. The latter was a surprise; why include sexual abuse explicitly but not violence, disaster, road traffic accident, traumatic bereavement, etc? It would be interesting to see whether those terms would result in additional studies and potentially different effect sizes.

CBCL as an outcome measure

The only outcome measure utilized with some consistency across studies turned out to be the Child Behavior Checklist (CBCL). The CBCL is a general scale for behavior problems in children, including composite scores for internalizing problems, externalizing problems, and total competency (i.a. social challenges, participation and school problems). It is not specific for PTSD. Moreover, there is some evidence that it isn’t a valid measure for PTSD. However, it does provide a general indication of child well-being and can be used as a relevant outcome measure.

Results

Eight trials satisfied the selection criteria. Of interest is that five of these were by Cohen et al. or Deblinger et al., the developers of the trauma focused CBT protocol.

The results: The total CBCL, internalizing and externalizing scores showed statistically significant differences between CBT and active control groups, in favor of CBT. There was no significant difference between the groups with regard to competency.

Evidence of efficacy of CBT?

The fail-safe N (i.e. the number of studies needed to overturn a significant effect) was 4 studies for total problems and internalizing scores and 0 for externalizing problems. Although the authors argue that this provides strong evidence that CBT is effective, I am not completely sure. Is it enough for such a conclusion? In favor of the authors’ argument is the fact that the comparisons were with active treatment, not with a waitlist-control. On the other hand, the authors do not mention that all of the eight studies are on sexual abuse victims only. Instead, the title of the review implies it covers PTSD in general. In my view, they should have described this limitation.

CBT seems to better address internalizing symptoms such as anxiety and depression than it does externalizing symptoms such as aggression and/or rule-breaking behaviors according to the review. That does make sense, knowing that PTSD is predominantly an internalizing disorder. The authors suggest that a next step would be to deconstruct components of CBT. One very recent example has just been published online. Salloum and colleagues compared two conditions within a trauma and grief intervention for children: a focus on building coping skills only, or building coping skills + a trauma narrative (the C and T from PRACTICE respectively). Their findings suggest that the trauma narrative is not a necessity for symptom reduction, unless children have high levels of symptoms.

In general, the evidence of the effectiveness of CBT for children with PTSD is quite convincing and extending quickly (see e.g. Cohen et al. 2009). This review adds knowledge with regard to CBCL outcomes in trials that compared CBT to active treatment after sexual abuse.

What’s your view on the paper? And what should be studied next?

Leave a comment or join the #traumaresearch chat!

Kowalik, J., Weller, J., Venter, J., & Drachman, D. (2011). Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: A review and meta-analysis Journal of Behavior Therapy and Experimental Psychiatry, 42 (3), 405-413 DOI: 10.1016/j.jbtep.2011.02.002

* The authors seem to use efficacy and effectiveness interchangeably. Efficacy usually refers to the effects under experimental conditions, while effectiveness refers to the effects in real-life (less-controlled) conditions.

This is a guest post by Dr. Meghan Marsac. Meghan is a behavioral researcher and the Director of Training at the Center for Injury Research & Prevention at The Children’s Hospital of Philadelphia. Meghan has recently led the development of Coping Coach, a web-based video game for children experiencing acute traumatic stress, and The Cellie Coping Kit, a toolkit for children with chronic diseases and their families.    

As a field, we have made significant progress in developing models and identifying key risk factors associated with the development of post-traumatic stress disorder (PTSD) in children who experience  acute medical traumatic events (see these key publications). Additionally, we have given much attention to the evaluation of preventive interventions. For example, our team has recently evaluated After The Injury, a web-based intervention for parents of injured children.

However, a standard process for the development of preventive interventions is less clear, and therefore this post provides you with some starting points. Below is a list of tips to consider and questions to ask when beginning to develop a new preventive intervention:

1. Identify the problem and purpose of the intervention

• What is the problem that needs addressed? 
• What specific behaviors are the focus of the intervention?

2. Link intervention goals to past research and theory

• What are the current techniques or theories in the field that can be integrated into or adapted for the intervention?

3. Select the target population and determine the level of the intervention

• Who will complete the intervention?
• What cultural factors should be considered?
• Is this a universal intervention for any child who has experienced a medical trauma or is the intervention for children at-risk for difficulties?

4. Identify potential barriers of intervention implementation

• What would get in the way of someone in the target audience being able to complete this intervention?

5. Before fully developing the intervention, consider evaluation

• How will the intervention objectives and goals be measured?
• What will determine whether or not the intervention is efficacious?
• How can a need for potential changes or revisions be identified?

6. Draft intervention content to match intervention goals

• What intervention activity or component teaches the knowledge or skills needed to solve the identified problem and meet the intervention goals?
• Are there effective techniques currently that can be translated and integrated into the new intervention?

7. Build an intervention prototype and complete engagement and usability testing

• Would the target audience be interested in this type of an intervention?
• What would encourage potential audience members to use this intervention?
• What would prevent them from engaging in this intervention program?
• If applicable, what should the intervention look and feel like?
• Are members of the target population able to complete intervention tasks without additional assistance?

8. Evaluate intervention and revise if indicated

• Was the intervention implemented as intended?
• Were the intervention goals achieved?
• If not, what needs changed or strengthened to be able to achieve initial goals? Or do initial goals need revised?

Meghan’s team currently has training opportunities for students!

References:

Kazak AE, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer MA, & Rourke M (2006). An integrative model of pediatric medical traumatic stress. Journal of pediatric psychology, 31 (4), 343-55 PMID: 16093522

Marsac ML, Kassam-Adams N, Hildenbrand AK, Kohser KL, & Winston FK (2011). After the injury: initial evaluation of a web-based intervention for parents of injured children. Health education research, 26 (1), 1-12 PMID: 20858769

This week I explain how to start with Twitter and I invite you for a live Tweet chat.

A few examples of interesting tweets in the past few days:

Setting up 

Setting up your Twitter account is easy. Go to www.twitter.com and within 3 minutes you’re up and running with Twitter’s straightforward instructions to sign up and to get started. Make sure your username as short as possible without losing meaning: when people ‘retweet’ (repeat) or reply to one of your tweets, they will need to include your username within the 140 characters.

When people consider following you on Twitter, they look at your profile. They don’t tend to follow empty ones. Therefore, take another 5 minutes for 4 important steps:

1. Upload a picture in your profile; either of yourself or of something that represents you. Don’t stay an egg.
2. Write a short bio (maximum 160 characters) with your main interests.
3. Write your first Tweet! And your second. And your third. Then you’re ready to be followed.
4. Let me (@EvaAlisic) know you are on Twitter; I’ll send around a tweet with your name and interests.

Who to follow?

When you follow people, you see their tweets in your feed. The easiest way to start, is to click on this Twitterlist of trauma, PTSD and recovery researchers & institutions. When you’re logged in on Twitter, you can click on ‘subscribe’ to follow the entire list, or you can click ‘follow’ on the profiles of members you are most interested in. Some examples:

• @nctsn - the US National Child Traumatic Stress Network: “Raising the standard of care and improving access to services for traumatized children, their families, and communities throughout the US.”
• @traumareport - Trauma Lab: “The Trauma and Attachment Report is a weekly online research report published out of York University in Toronto, Canada”
• @safetymd - Flaura Winston, MD: “Mother,engineer,pediatrician, researcher. Credible info to keep children & adolescents safe.”

I also follow a few people who tweet on psychology in general, for example:

The London School of Economics’ Impact blog has a number of interesting lists of tweeting academics. Chris Jarrett has made a list on the British Psychological Society’s Research Digest.

What to tweet?

Everything you want, basically. For example:

• questions you have about particular methods / theories / …
• links to your own and others’ papers
• PhD scholarships and academic positions that become available in your Department
• interesting news items
• upcoming seminars & conferences

And along the way, you’ll start to know people and interact with them.

What style? And how often?

LSE Impact blog has made a nice overview of three styles you could adopt, from very formal to very personal. Tips that I have often seen: take your time to develop your ‘voice’; have a look at what other people do and decide what you like; and experiment with different styles. Yesterday, Inger Mewburn (aka @thesiswhisperer) referred to this article on thin vs. thick tweets on her blog.

Regarding the frequency: I think checking Twitter twice a day is ideal but once a day is a good starting point. It will keep you updated and people will slowly but surely get to know you.

#tprres?

Hashtags are used on Twitter to categorize tweets so they become searchable and follow-able. A hashtag for trauma research will allow you to follow discussions, ask questions, and find interesting people in your research domain. So far, #tprres (Trauma, PTSD & Recovery Research), has been suggested. But we could also use a more straightforward one, such as #traumaresearch. Please cast your vote for the best hashtag (second poll on the page).

Tweet chat

If there is enough interest, we’ll have Tweet chats (live chats on Twitter) among trauma researchers. Would you like to participate in one in the next few weeks? Please cast your vote for the best date & time (first poll on the page).

Recently, a fourth meta-analysis on predictors of posttraumatic stress in children has been published, which makes it interesting to compare findings and methods (yes, in that order, for busy people). It gives clinicians insight in risk factors for PTSD and it shows academics what needs to be studied in the next few years.

These are the four meta-analyses I know of, published over a period of 6 years: Kahana et al. (2006), Cox et al. (2008), Alisic et al. (2011), and Trickey et al. (2012). In a nutshell, the reviews combined correlational effect sizes to see which risk factors are associated with children’s posttraumatic stress symptoms. Their methods varied, which I will summarize below, but the findings converge to a number of interesting conclusions.

For clinical practice: what we do know

Applying Cohen’s criteria for correlational effect sizes (see note below; 0 is a near zero effect, # is a small, ## a medium, and ### a large effect), these are the findings of the meta-analyses for those risk factors measured in at least 5 studies:

In general, the variables that are more psychological (‘proximal’) are more strongly associated with posttraumatic stress then those variables that are more objective/demographical (‘distal’). This has also been found for adults (Ozer et al., 2003). We don’t get very far by measuring demographics and a few characteristics of the event. As Trickey et al. conclude, we should not overestimate female gender as  a risk factor. It’s effect has quite consistently shown to be rather small. Instead, we need to measure acute stress reactions and other psychological problems such as depressive symptoms. In addition, family functioning, parental distress, and to what extent a child thought that he/she might die, seem to be (very) important.

Interestingly, age showed quite consistently not to be a very good predictor of posttraumatic stress. Does that mean that we can apply all adult literature to children now? I don’t expect that to be the case. We are looking only at the relationship between age and amount of stress symptoms as measured according to the DSM. That’s quite specific. It doesn’t tell us anything about the different combinations of symptoms that children may have, nor about symptoms that are not included in the DSM yet but tend to be child-specific (see e.g. the work of Michael Scheeringa and colleagues). Also, age may have a moderating effect or it’s relation with PTSD may be moderated by something else. For example, Trickey et al. found that younger children tended to be more vulnerable to developing posttraumatic stress after group trauma then after individual trauma.

For future research: what we don’t know yet

In my view it’s quite shocking that there isn’t a lot of empirical literature, while the question of vulnerability and causes of posttraumatic stress is of great importance. Variables that may be very important, haven’t been studied often enough to be summarized in a robust manner (I applied the 5 studies minimum here). A lack of social support is found to be one of the most important predictors of  posttraumatic stress in adults. In children, a few studies show tentative evidence that it is a key factor in children’s recovery.

Also, as Trickey et al. pointed out, there are a number of cognitive factors, which influence make sense from a theoretical point of view but which haven’t been studied in-depth in children yet. For example,  thought suppression and rumination would be of relevance for future research.

The list of what still needs to be studied is quite long. To finish with a more general note, we will gradually need to look not only at the ‘simple’ relations between risk factors and amount of stress but also at the specific processes that are underlying these relations. Parental distress and family functioning are predictive of child posttraumatic stress; what then, happens there exactly? What would we need to do to help parents and families to be more supportive of children’s recovery?

A review of the methods

A quick and dirty overview of the main differences between the four meta-analyses to finish…

________________________________________________________________________

________________________________________________________________________

My personal stance is that it is important to look at longitudinal relations between risk factors and outcomes such as PTSD. Looking at cross-sectional relationships, may induce biased thinking about causality (even with longitudinal relations, we’re not sure about causality, but at least it’s closer and allows us to speak of predictors). Take the example of measuring appraisal of life threat at the same time as level of posttraumatic stress. It may well be that appraisal of life threat causes PTSD but it may also be that children with higher stress scores are simply more prone to remembering life threat than children with lower stress scores.

Similarly, it is incredibly difficult to make choices regarding measures. Trickey et al. have required measures to be validated in the literature, Cox et al. also accepted psychometrics described in the articles themselves, while our only criterion was that the intrusion and avoidance had to be included in the measure and that the outcome measurement took place at least three months post-trauma. These differences in decision making along the way may have caused different findings.

However, when we start taking all methodological differences and related limitations too seriously into consideration, we’ll get desperate. It’s only by accumulating good primary studies, having independent groups replicating each other’s work (see Kahana et al), and synthesizing this evidence repeatedly according to the latest standards, that we’ll make progress. So, back to work tomorrow .

_________________________________________________________________________

Notes:

For the table on findings, I have applied Cohen’s criteria, with correlational effect sizes below .10 = negligible (0), .10 = small (#), .30 = medium (##), .50 = large (###). I have conversed Kahana et al.’s findings from d to r. With regard to Trickey et al.’s analysis, I have applied Cohen’s criteria to their rhos, however, it may well be that this is an underestimation (the authors once state .30 as a large effect, and .47 once as a medium to large effect if I understood it correctly). Any suggestions for making the findings optimally comparable are very welcome.

For the table on methodology, I have made a selection of characteristics and could add according to interest/suggestions. The difference longitudinal/cross-sectional: only longitudinal studies have been selected/analyzed vs. cross-sectional studies, potentially mixed with longitudinal studies, in the analyses.

Articles:
Kahana, S., Feeny, N., Youngstrom, E., & Drotar, D. (2006). Posttraumatic Stress in Youth Experiencing Illnesses and Injuries: An Exploratory Meta-Analysis Traumatology, 12 (2), 148-161 DOI: 10.1177/1534765606294562
Cox CM, Kenardy JA, & Hendrikz JK (2008). A meta-analysis of risk factors that predict psychopathology following accidental trauma. Journal for specialists in pediatric nursing : JSPN, 13 (2), 98-110 PMID: 18366377

Alisic E, Jongmans MJ, van Wesel F, & Kleber RJ (2011). Building child trauma theory from longitudinal studies: a meta-analysis. Clinical psychology review, 31 (5), 736-47 PMID: 21501581

Trickey D, Siddaway AP, Meiser-Stedman R, Serpell L, & Field AP (2011). A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical psychology review, 32 (2), 122-138 PMID: 22245560

In 2012, the blog weekly features a summary or discussion of a recent scientific article on traumatic stress in children.

This week a summary of Hall Brown et al. (Oct 2011) on sleep in children after Hurricane Katrina.

In childhood it is normal to have some nighttime fears. Most children outgrow them. However, when fears continue to exist, they endanger sleep quality and daily functioning. One situation in which this may happen, is after traumatic exposure.

We know that adult mental health problems and sleep difficulties are related after trauma but we have only very limited data on children. Therefore, Hall Brown and colleagues studied the role of sleep problems in the maintenance of posttraumatic stress symptoms in youths who experienced Hurricane Katrina.

The study: The sample consisted of 191 children and adolescents in New Orleans who had complete data for Time 1 (24 months post-Katrina) and Time 2 (30 months post-Katrina). The children were between 8 and 15 years old, mostly African American, with boys accounting for 55% of the sample. The youths came from a neighborhood that had encountered massive damage. For example, many children reported having thought that someone might die in the hurricane, that their homes were badly damaged, that they witnessed someone else being hurt, or that they had a pet hurt or die.

The study used self-report questionnaires. The children filled out the Posttraumatic Stress Reaction Index for children (PTSD-RI, by Frederick et al., 1992) and a measure to assess the exposure to the hurricane and its aftermath (La Greca et al. 1998). Sleep disturbance and fear of sleeping alone were assessed via two  items of the Revised Child Anxiety and Depression Scales (RCADS, Chorpita et al., 2000): “Having trouble sleeping” and “I feel scared if I have to sleep on my own”. The analyses consisted of t tests and multivariate linear regression models.

What did they find? Two fifths of the sample had moderate to very severe symptoms of posttraumatic stress. An important number of children reported sleep disturbance (46% and 50% at T1 and T2 respectively), while a somewhat smaller number reported fear of sleeping alone (25% and 16%). Children with sleep disturbance or fear of sleeping alone reported more posttraumatic stress symptoms than children who did not report sleep problems. General sleep disturbance at T1 predicted posttraumatic stress at T2, also after controlling for age, gender, continued home  damage, and posttraumatic stress at T1. This was not the case for fear of sleeping alone: this item did not have predictive power left when the other variables were introduced in the model.

What to conclude? The authors suggest that sleep disturbances are common in the aftermath of childhood trauma and persist for an important number of children. Because sleep problems can result in fatigue and irritability, they may interfere with processes that otherwise contribute to recovery. The authors argue that more research is needed into strategies to reduce sleep difficulties after trauma. One avenue to address the problem may be cognitive behavioral therapy (CBT).

Limitations of the study: the authors used two one-item questions to measure sleep problems while this would ideally be a set of questions, the data were self-reported, and they did not have the chance to identify sleep problems in the sample prior to Katrina.
Brown, T., Mellman, T., Alfano, C., & Weems, C. (2011). Sleep fears, sleep disturbance, and PTSD symptoms in minority youth exposed to Hurricane Katrina Journal of Traumatic Stress, 24 (5), 575-580 DOI: 10.1002/jts.20680

To start with the tips. Things that relatives, friends, and professionals can help survivors with and inform them about, based on international expert consensus (see the article by Hobfoll et al. below, and the manual for  Psychological First Aid):

1. Promote a sense of safety. Make sure survivors feel as comfortable as possible, and reassure them that they are safe now (in Liège/Luik we can assume that this is really the case).
2. Promote calming. For survivors who are overwhelmed by emotions (e.g. a panic attack), help them to breathe slowly (with an emphasis on breathing out) and to be aware of their body (e.g., feet on the ground) and surroundings.
3. Promote a sense of self- and community efficacy. It is important for survivors to feel in control (as opposed to in the traumatic situation). Empower survivors by facilitating their own decision making. It often helps to pick up normal routines as soon as possible.
4. Promote connectedness. Social support turns out to be one of the most important predictors of recovery. Help survivors to activate their network and receive both emotional and material support (e.g., have someone cook a meal).
5. Instill hope. Most people are resilient and will recover from a traumatic event without needing professional help. Survivors who are optmisitic and feel confident about their capacitie to recover are more likely to experience a good outcome.

Regarding good websites:

• For young people: Nahetziekenhuis is a good Dutch website about recovery from traumatic injury. This one was made by Headspace after the Australian bushfires and has some good information in English.
• For adults: the Dutch tip sheets by the Institute for Psychotrauma are helpful. The US National Center for PTSD also provides a lot of information (focus on veterans but many things are relevant for civilians too).
• For parents: the information on www.kind-en-trauma.nl is made for teachers but equally relevant for parents. In English, there are tip sheets about helping preschoolers, school-age children, and adolescents after trauma, made by the U.S. National Child Traumatic Stress Network (NCTSN). Aftertheinjury from Children’s Hospital of Philadelphia is also very informative.
• For professionals: the complete Psychological First Aid manual is very comprehensive. This is the link to the full guide by the NCTSN
• For teachers: this website is made for Dutch speaking teachers who work with children after traumatic events. For a short overview in English see my earlier post on supporting children in the classroom after trauma, and see also the toolkit for educators by the NCTSN.

The article by Hobfoll and colleagues:
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, & Ursano RJ (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70 (4) PMID: 18181708

For example, physical activity may promote children’s recovery. A recent publication by Soyeon Ahn (University of Miami) and Alicia Fedewa (University of Kentucky) suggests it is a potentially important addition to therapy. The authors combined the findings of 73 studies examining the effects of physical activity on mental health outcomes, such as depression, anxiety, self-esteem, and PTSD in children.

Physical activity interventions significantly reduced mental health problems, including PTSD, and enhanced self-esteem in high-quality trials (in line with earlier research with adults). The largest effects were found for circuit or strength training, and for a combination of aerobic and resistance training exercise. The more children took part in these activities, the less mental health problems they experienced.

One could argue that being physically active would help children who are overweight, but not children who are of typical weight. It turns out that is not the case; irrespective of their weight, children profit from physical activity. Furthermore, the review shows that teachers are able to lead these interventions successfully. Thus,  schools may contribute to children’s mental health not only by talking about it, teaching children coping skills, and referring to mental health care services, but also by simply providing more physical activities.

Of course, with regard to trauma, more specific research on the effects of sports activities should be done, and it is necessary to think about possibilities for children with physical disabilities due to serious injury. But the major implication of this review is that clinicians, parents, and teachers should encourage children to be physically active.

Do you systematically discuss physical activity with children who have been exposed to trauma, and if so, what is your experience?

Reference:

Ahn, S., & Fedewa, A. (2011). A Meta-analysis of the Relationship Between Children’s Physical Activity and Mental Health Journal of Pediatric Psychology, 36 (4), 385-397 DOI: 10.1093/jpepsy/jsq107

We spoke in-depth with the parents of 25 children who had been through varied types of trauma, including serious road traffic accidents, witnessing murder, sexual assault, the loss of a sibling, and an explosion at home. The events had happened at least 6 months previously and the children were between 8 and 12 years old at the time of the interview.

Even though our questions mainly regarded the child’s recovery, parents talked a lot about their own role in this recovery. In particular, they spoke about two elements of their parenting. The first concerned becoming aware of the child’s needs. Parents tried to figure out what would be normal reactions to the event and to what extent their child showed those or more severe reactions. They used various strategies, including:

• asking the child directly how he/she felt
• comparing the child’s behavior before and after the event
• deciding whether the child’s behavior was in line with his/her character
• comparing the child’s reactions with those of a sibling
• checking with other adults (e.g., the teacher) whether they saw changes in behavior or school performance

Second, parents adopted a variety of strategies to act on the needs they identified. To facilitate the child’s recovery, there was often an element of giving the child control over situations. Parents’ approach included:

• providing opportunities to talk about the event without pushing the child
• answering questions about the event at the child’s pace
• guiding confrontations with reminders (e.g., helping a child to go to school by bike again after a traffic accident)
• protecting from unnecessary harm (e.g., from sensation seeking television crews)
• hiding own distress
• searching for help (e.g., mental health care)
• taking up normal routines again
• providing fun activities / enjoyable moments

Even though we focused on positive, responsive parenting strategies here (and this sample consisted of parents of children who had recovered relatively well), parents felt that their own distress influenced how their children were doing. We have seen this in our meta-analysis as well; parents’ stress reactions predict children’s posttraumatic stress over time. Some parents told that they had tried to hide their own emotions from their children when they judged them too intense but found out that their child knew about or had picked up the tension anyway.

Parents also talked about other types of interference with their children’s recovery; when professionals (e.g., police, physicians) communicated in a very different, abrupt way with the child. Some parents explained they had tried to follow their child’s pace in talking about the event and answering questions the child had, when a professional just ‘jumped in’ giving information which upset the child. On the other hand, psychoeducation (e.g., regarding restoring normal routines) by health care professionals was regarded very favorably by parents.

What can we learn from parents’ accounts? When you see parents after their child has been exposed to a traumatic event, it may be helpful to explore to what extent they use the above strategies and what the outcomes are. It will give you an idea of how the child is doing as well as how the parents cope with it. While it’s good to be careful regarding the strategy of hiding emotions (it’s unhelpful to burden a child with intense emotions but it’s important to communicate about them so a child isn’t left in the dark about what is happening), the other strategies are in line with current knowledge. Second, it appears to be important to make sure that you are aligned with parents regarding the timing and content of information given to children about what happened exactly during the traumatic event or what is going to happen (e.g., in medical or judicial procedures). Finally, parents value receiving psychoeducation. Give them information about what normal stress reactions are, and tips to support their child (e.g., going back to school as soon as possible to restore normal routines).

What kind of parenting strategies do you often see after trauma?

Alisic, E., Boeije, H., Jongmans, M., & Kleber, R. (2011). Supporting Children After Single-Incident Trauma: Parents’ Views Clinical Pediatrics DOI: 10.1177/0009922811423309

In the last 30 years, more and more research has been published on predictors of posttraumatic stress. Mainly in adults, but also in children.

To synthesize findings in adult survivors, Brewin and colleagues (2000) combined 77 studies on risk factors for PTSD in a meta-analysis. Important to note, about one third of these studies was conducted in military samples. The authors summarized the information on 14 risk factors. The strongest and most consistent predictors were: trauma severity, lack of social support, and additional (posttrauma) life stress.

Three years later, Ozer and colleagues published a somewhat similar meta-analysis on 68 studies with adults (only 47 studies were included in both analyses; which shows again that much depends on the selection criteria one applies…). The most important predictors they found, were: perceived life threat, lack of support, peritraumatic emotions, and peritraumatic dissociation.

So while both groups of researchers found that factors closely related to the event and the person’s reaction were important, they did differ on the exact characteristics.  In addition, Brewin et al. found that demographics did not help much (no to small effects) in explaining posttraumatic stress, while Ozer et al. did not even start to analyse them. Social support, on the other hand, appears a consistently present predictor. And fortunately one we could do something about.

Regarding children, three meta-analyses have been published recently. Two of them focused on injury/illness and one included all types of traumatic exposure. The last one, conducted by our group, included a comparison of the three studies. Because our study is more recent, included more studies, and was more strict its analyses, I’ll describe our findings mainly, but having a look at the reviews by Kahana et al. and Cox et al. is certainly worthwhile. Their references are shown below.

We included 34 longitudinal studies that measured predictors within 3 months posttrauma and posttraumatic stress at 3 months or more. Just like in Brewin’s paper, we did not find large effects for demographic variables, but found support for more ‘proximal’ variables. Various forms of short-term distress in the children themselves as well as in their parents were quite strong predictors for longer-term child posttraumatic stress. Within children’s distress, their posttraumatic stress reactions at 1-3 months had the strongest effect. However, the difference with acute stress reactions (0-1 month) was very small, which did not support the current strategy of ‘watchful waiting’: the prediction did not get much better over time. Unfortunately, we could not include social support in our analyses, as the variable wasn’t studied often enough yet.

Meanwhile, a few tentative conclusions can be made. First, among the most predictive factors, there are a number on which we can intervene (I am assuming a causal effect), such as social support, posttrauma distress in children, and parental distress. Second, none of the factors explains a large part of later posttraumatic stress (the maximum was 31% of the stress reactions). We will probably need to work with combinations of factors. That wasn’t possible in a meta-analysis format yet for methodological reasons (not enough studies used the same sets of variables), but will hopefully be doable in the near future.

A final thought: it is interesting that we tend to focus on the characteristics of those people who have symptoms. We have put far less effort in understanding why someone is resilient. This is slowly changing though, and there are a number of researchers disentangling trajectories of recovery at the moment (e.g., Bonanno, Le Brocque). I think that will bring about important steps forward.

References

Brewin, C., Andrews, B., & Valentine, J. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68 (5), 748-766 DOI: 10.1037/0022-006X.68.5.748

Ozer, E., Best, S., Lipsey, T., & Weiss, D. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129 (1), 52-73 DOI: 10.1037/0033-2909.129.1.52

Kahana, S., Feeny, N., Youngstrom, E., & Drotar, D. (2006). Posttraumatic Stress in Youth Experiencing Illnesses and Injuries: An Exploratory Meta-Analysis Traumatology, 12 (2), 148-161 DOI: 10.1177/1534765606294562

Cox, C., Kenardy, J., & Hendrikz, J. (2008). A Meta-Analysis of Risk Factors That Predict Psychopathology Following Accidental Trauma Journal for Specialists in Pediatric Nursing, 13 (2), 98-110 DOI: 10.1111/j.1744-6155.2008.00141.x

Alisic, E., Jongmans, M., van Wesel, F., & Kleber, R. (2011). Building child trauma theory from longitudinal studies: A meta-analysis Clinical Psychology Review, 31 (5), 736-747 DOI: 10.1016/j.cpr.2011.03.001

So for the researchers between you, here is my suggestion. Let’s systematically include the 12 item Reactions to Research Participation Questionnaire (RRPQ-C and RRPQ-P) in our measures. It will inform you about how children experience your study, which has a number of advantages. When you are still in a pilot phase, it may help you to evaluate the informed consent and other study procedures from both a child’s and a parent’s perspective (by the way, this measure can be used with a broad range of topics, not only trauma). It can also assist you when you are evaluating a completed study. And it can help us build a good evidence base to inform Institutional Review Boards and other Ethics committees. That will help avoiding future decisions based on gut feelings about what is harmful and what not. What do you think?

The questionnaire is very easy to use and doesn’t require any specialist training. It has acceptable psychometric characteristics, and covers four domains:

1. the child’s or parent’s positive appraisals of research participation,
2. his/her negative appraisals of research participation,
3. assessment of informed consent and trust in the research team, and
4. understanding of his/her rights as a research participant.

Download the RRPQ-C and RRPQ-P here (in English). For Dutch and Flemish researchers, a Dutch version of the questionnaire is now available as well: de Vragenlijsten Onderzoeksdeelname voor Kinderen en Ouders (VOD-K en VOD-O). Download them here.

Kassam-Adams, N., & Newman, E. (2002). The reactions to research participation questionnaires for children and for parents (RRPQ-C and RRPQ-P) General Hospital Psychiatry, 24 (5), 336-342 DOI: 10.1016/S0163-8343(02)00200-1

Kassam-Adams, N., & Newman, E. (2005). Child and parent reactions to participation in clinical research General Hospital Psychiatry, 27 (1), 29-35 DOI: 10.1016/j.genhosppsych.2004.08.007

• It doesn’t hurt to ask about trauma. These clinicians were more worried about not asking about trauma.
• It is important to let children talk about their potential traumatic history in their own words and in their own time.
• Clinicians should make sure that they have the appropriate skills to engage in trauma-related conversations with children. Some of the LinkedIn members saw clinicians being afraid of discussing trauma as an important area for improvement of care.
• If you are a mental health clinician wanting to learn about discussing traumatic exposure or posttraumatic stress reactions with children and adults, the online trauma focused CBT training is a good start.
• When asked, many children and youths are remarkably open about their experiences.

Next time, I will describe the instrument to systematically measure children’s reactions to questions about trauma in research: the Response to Research Participation Questionnaire for Children and Parents (RRPQ-C and RRPQ-P, available in English and Dutch)!

Three issues are of particular interest and importance I think: 1) Is it necessary to do trauma research with children while we could also do studies with adults and translate the findings? 2) How do we get an idea of whether it actually hurts to ask about trauma? and 3) What empirical evidence do we have so far?
Is it necessary to do research in children instead of adults?

Yes it is! Children are not little adults; they really have their distinctive characteristics. Salmon and Bryant (see references below) pointed out that children differ from adults in a number of ways. For example, they can’t fully grasp and convey complex emotions until about 10 years of age. In addition, their way of processing information (about the event, about other people’s reactions) is not yet fully developed, and they have less of a frame of reference than adults have, which may result in distinctive interpretations of an event. And finally, they are in a completely different situation as they depend to a large extent on their caregivers.

Another reason to do research in children, is that they run the risk to remain ‘silent consumers’. We tend to think for, and decide about them, without asking children themselves about their opinion. In my view, giving children a voice is essential. In the interview studies we did with eight to twelve year olds, they were very eager to give their view and tell about what they thought was important for future child survivors of traumatic events (some of the tips they gave: ‘to have a cuddly toy to make you laugh again’ and to ask parents and friends for help and comfort).

How do we know whether it is harmful?

We could do an experiment, asking a group of children questions about trauma while asking other children neutral questions, and then measure the difference in distress in the short and long run. But we can also integrate our quest for knowledge in ongoing research. If we measure children’s distress caused by a study that has been approved by the appropriate ethics committee, we don’t do any potential additional harm while we can systematically gather data. Nancy Kassam-Adams and Elana Newman from the US have started this endeavor a couple of years ago in a hospital setting. They studied children’s and parents’ reactions to a study on acute stress symptoms to traffic-related injury with the Reactions to Research Participation Questionnaire (the RRPQ-C for children and RRPQ-P for parents). The RRPQ is a quick 12-item measure that can easily be included in many studies. It is freely available in at least English and Dutch, I’ll describe it into more detail in a separate post.

In addition to measuring children’s reactions to trauma research, we should also measure reactions to other types of research. For example, studies on learning, on other psychology topics, and studies in medicine. This would provide us with a baseline regarding children’s reactions to research in general. Because, if we find distress reactions after trauma research, how do they compare to distress reactions after a task that had to be done under time-pressure, one that was extremely boring, or after a body examination that was quite scary?

What is the evidence so far?

Current empirical knowledge indicates that asking children about trauma does not hurt. For example, in the studies we did in classrooms and in clinical samples, we asked teachers and parents afterwards whether the children showed a change in behavior or an increase in stress symptoms. The adults did not report any worries or doubts, with the exception of one family who found out that their child needed some more help. They did not regret participation. In Kassam-Adams and Newman’s study  only 5% of the 200 children reported being upset or sad. In contrast, 77% felt good about helping others by taking part in the study.

References

Salmon, K., & Bryant, R. (2002). Posttraumatic stress disorder in children: The influence of developmental factors Clinical Psychology Review, 22 (2), 163-188 DOI: 10.1016/S0272-7358(01)00086-1

Kassam-Adams N, & Newman E (2005). Child and parent reactions to participation in clinical research. General hospital psychiatry, 27 (1), 29-35 PMID: 15694216

Alisic, E., van der Schoot, T., van Ginkel, J., & Kleber, R. (2008). Looking Beyond Posttraumatic Stress Disorder in Children The Journal of Clinical Psychiatry, 69 (9), 1455-1461 DOI: 10.4088/JCP.v69n0913

My thoughts go out to those in Norway who have been affected by the tragic events in the past days, both in Oslo and Utøya. I can’t imagine the scale of this tragedy, and wish survivors all the strength and time needed to come to terms with the experience and the loss of loved ones. When you are looking for information about helping the youngsters and their families involved, below are some links to resources.

Several important things to do at this moment are:

• to tell children that they are safe and comfort them
• to organize any practical arrangements that are necessary
• if children are still separated from their primary caregivers, to organize their reunion
• to tell them that it is normal to feel distressed after such an abnormal event
• to pick up daily routines to restore a feeling of predictability and control

Perhaps the most important thing to say is that most people who experience a traumatic event are resilient: after some initial distress, they will feel better over time and won’t need mental health care. There is still controversy regarding ‘debriefing’ after trauma (see Bisson et al. below for a description of the discussion). From the current base of evidence it looks like it is not helpful to do debriefing shortly after an event and in my view, a safe rule would be: a child (or parent) needs to feel that it is okay, but not necessary, to talk about the experience.

When you are a parent, one thing we learned in our own research at the National Psychotrauma Center for Children and Youth is that you can’t trick a child: children notice very quickly how you feel, even if you think you hide your emotions. Make sure there is no discrepancy between what a child sees and hears from you: it is okay to say that you feel anxious/angry/… If you feel that you are overwhelmed by the experience, try to find other adults to support you and your child. In general, be attentive to your own needs (as in the airplane instructions: you won’t be able to help your child if you don’t have ‘oxygen’ yourself).

What kind of distress reactions to expect in youths? Common posttraumatic stress reactions in children and adolescents include: nightmares, repetitive intrusive thoughts about what happened, feeling anxious, avoiding thoughts/feelings/people related to the event, concentration difficulties, separation anxiety (not wanting to separate from caregivers/loved ones), over-alertness, irritability, and feeling guilty. Usually, children (as well as adults) show distress in the weeks after a traumatic event, which diminishes gradually.

What is a normal trajectory of recovery? As a rule of thumb we expect to see some improvement in four weeks. If a survivor doesn’t feel better at all after four weeks, it is a good idea to check with your GP or a mental health care professional whether extra services are needed. Of course, if you worry about your child, yourself or someone else before the four weeks have passed, do give a professional a call to discuss your worries.

Resources

General: the Norwegian Center for Crisis Psychology (Senter for Krisepsykologi) has this link in Norwegian, and Atle Dyregrov also made available this pdf: REAKSJONER UTØYA

For young people: I am still looking for a good website in English or Norwegian for you (any suggestions from readers are very welcome), this one was made by Headspace after the Australian bushfires and has some good information.

For parents: these are tip sheets about helping preschoolers, school-age children, and adolescents after trauma, by the U.S. National Child Traumatic Stress Network (NCTSN). Aftertheinjury from Children’s Hospital of Philadelphia may also be very informative.

For professionals: the complete Psychological First Aid guide is very comprehensive. This is the link to the full guide by the NCTSN

Specifically for teachers: for a short overview see my earlier post on supporting children in the classroom after trauma, and see also the toolkit for educators by the NCTSN

Bisson, J., Brayne, M., Ochberg, F., & Everly, G. (2007). Early Psychosocial Intervention Following Traumatic Events American Journal of Psychiatry, 164 (7), 1016-1019 DOI: 10.1176/appi.ajp.164.7.1016 

If you think this information is helpful, please share the link.

At the National Psychotrauma Center for Children and Youth in the Netherlands, we are currently writing up some of our experiences with these youngsters. One of the most confronting issues is that children are often ‘lost’ in judicial and placement struggles, which makes it difficult to start a ‘normal’ grieving process. Some good tips about understanding and supporting children after fatal intimate partner violence can be found in the book by Harris-Hendriks, Black, and Kaplan. They notably give clear examples of how one can explain to young children what has happened or where the perpetrator is, to give them as much support as possible from the immediate aftermath.

Book When Father Kills Mother

Dutch Toolkit Child en Trauma

Teachers in primary schools feel rather uncertain about their role and skills when it comes to trauma and traumatic stress (see the Dutch news). They don’t get much training about child mental health in pre-teacher education, even though psychological well-being is a requirement for children’s learning. Now I do certainly not want to argue that teachers should learn to be therapists, but I think that they can play an important role in signaling chronic traumatic stress symptoms and referring children and parents to specialists.

To build teachers’ confidence, we made a Toolkit Child and Trauma. It consists of a website and a booklet about traumatic exposure, posttraumatic stress, classroom skills, specialized organizations, and self care. We made the toolkit in collaboration with teachers, in order to really tune in to their needs and interests. The main idea of the toolkit is that children are resilient: most of them will overcome difficulties with the support of their social environment.

The tips we elaborated on for assisting a child after a traumatic event:

1) Provide structure

2) Give room (but do not push) to process the experience

3) Do not avoid the trauma

4) Facilitate positive experiences

5) Continue to monitor symptoms and behavior

6) Support and inform the parents

7) If necessary, refer the child to mental health care