Brief report: the impact of maternal posttraumatic stress disorder symptoms and child gender on risk for persistent posttraumatic stress disorder symptoms in child trauma victims

OBJECTIVE: To longitudinally examine the impact of maternal posttraumatic stress disorder symptoms (PTSS) on child adjustment following a child's traumatic injury, focusing on child gender differences. METHODS: Forty-one child traumatic injury victims aged 8-18 years and their biological mothers were interviewed over two follow-ups (6 weeks and 7 months). Children were administered the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale for Children and Adolescents (CAPS-CA), whereas mothers completed the CAPS. RESULTS: Six weeks post trauma, maternal PTSS were significantly related to PTSS in boys but not in girls. However, at 7 months, maternal PTSS were strongly related to child PTSS in both boys and girls. Significant 6-week maternal distress-child gender interactions suggested that maternal PTSS, especially avoidance, predicted greater 7-month PTSS but that this was primarily because of a significant relationship in females. CONCLUSIONS: Maternal distress was found to negatively impact subsequent child adjustment, particularly in females. These results underscore the importance of considering family-centered interventions for child PTSD, especially in girls.     

A model of risk for perinatal posttraumatic stress symptoms

Existing research suggests that childbirth may be a significant trigger of posttraumatic stress symptoms (PTSS). The current study examined whether subjective birthing experiences and objective childbirth characteristics mediated the association between predisposing psychosocial factors measured during pregnancy (e.g., fear of childbirth, history of trauma, and social support) and PTSS during the postpartum period. Women were recruited during pregnancy from a large Midwestern hospital. Symptoms of posttraumatic stress, obsessive compulsive disorder (OCD), and depression, as well as PTSS-related risk factors, including social support, lifetime trauma exposure, fear of childbirth, subjective perceptions, and objective characteristics of childbirth, were measured during pregnancy and 4, 8, and 12 weeks postpartum. A path model revealed that subjective perceptions of childbirth mediated the association between fear of childbirth and PTSS at 4 weeks postpartum. Objective childbirth characteristics mediated the association between fear of childbirth and PTSS at 8 weeks postpartum, and there was a direct association between fear of childbirth and PTSS. Subjective perceptions of childbirth also mediated the effect of fear of childbirth on PTSS at 4 weeks postpartum when controlling for OCD symptoms. Further, the direct effect of fear of childbirth on PTSS at 8 weeks postpartum remained significant when controlling for OCD symptoms. The current study emphasizes the importance of fear of childbirth and subjective and objective birthing experiences in predicting postpartum psychopathology. Future research should examine these models in diverse and at-risk samples. Valid assessments and effective interventions for perinatal PTSS should be explored.

     

Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury

The adverse impact on recovery of posttraumatic stress disorder (PTSD) in mild traumatic brain injury (TBI) has been demonstrated in returned veterans. The study assessed this effect in children's health outcomes following TBI and extended previous work by including a full range of TBI severity, and improved assessment of PTSD within a longitudinal design. There were 205 children and adolescents (6 to 15 years of age) who experienced a TBI that were assessed at 2, 3, 6, 12, and 18 months following the TBI. Severity of TBI was classified as mild, moderate, or severe. After controlling for the impact of the severity of TBI, premorbid behavioral and emotional problems and executive function, children with TBI and PTSD did not experience as much psychosocial recovery as those without PTSD. Furthermore the level of psychosocial function was no better than that experienced by children with a severe TBI. In contrast, severe TBI was predictive of a poorer physical recovery in the first 6 months, after which recovery was equivalent across all severity levels.     

Secondary traumatization and attachment among wives of former POWs: a longitudinal study

The aim of the present study was to examine the directionality of the association between post-traumatic stress symptoms (PTSS) and attachment insecurities across time among indirect trauma survivors. Wives of former prisoners of war (ex-POWs), with and without post-traumatic stress disorder (PTSD), and comparable controls were assessed 30 (T1) and 38 (T2) years after the Yom Kippur War. As expected, wives of ex-POWs endorsed higher PTSS compared to wives of controls. Wives of ex-POWs with PTSD endorsed higher PTSS and higher attachment avoidance compared to wives of ex-POWs without PTSD and controls. There were significant associations between PTSS and attachment insecurities. Contrary to the hypothesis, the relationship between PTSS and attachment insecurities among wives of ex-POWs was unidirectional, with attachment anxiety at T1 predicting PTSS at T2, and not vice versa. Results indicate that attachment anxiety might act as a risk factor for secondary traumatic reactions.     

Brief report: post-traumatic stress during emerging adulthood in survivors of pediatric cancer

OBJECTIVE: To examine post-traumatic stress symptoms (PTSS) and disorder (PTSD) among survivors of childhood cancer and comparison peers during the transition to emerging adulthood. METHOD: From elementary and middle school, we prospectively followed a cohort of 56 cancer survivors, 60 comparison peers, and their parents. Assessments were completed after the youth's 18th birthday using questionnaires and a semi-structured psychiatric interview. Healthcare providers rated treatment severity and late effects. RESULTS: Survivors and comparison peers did not differ on rates of PTSS or PTSD, but comparison peers reported more dissociative experiences than survivors. Late effects were associated with a greater number of past PTSS. Of the 16 cancer survivors who reported a traumatic event, five (31%) were cancer-related. CONCLUSIONS: Levels of PTSS were similar for survivors and comparison peers. Research with other potentially traumatic diseases or treatments (e.g., amputations, brain tumors) is needed. The role of methodology and contextual factors in the assessment of PTSS/PTSD is discussed.     

Nonlinear relations between post-traumatic stress symptoms and electrocortical reactivity during emotional face processing in combat-exposed veterans

Combat-related post-traumatic stress symptoms (PTSS) are prevalent among recently deployed veterans, making identification of biomarkers of PTSS in this population a public health priority. Given the link between threat processing neurobiology and PTSS, the threat-related late positive potential (LPP), an ERP reflective of attentional processing sensitive to emotion and its regulation, may have utility as a cost-effective biomarker. Existing PTSS/threat-related LPP findings are mixed, possibly due to variability in PTSS across samples, but this has never been explicitly tested. To address this gap, LPP amplitudes to angry, fearful, and happy emotional face stimuli were recorded among 81 combat-exposed veterans at a VA hospital. A quadratic relationship between self-reported PTSS and LPP amplitude modulation by angry faces emerged such that greater PTSS was related to a decreased LPP response to angry faces among veterans with subthreshold PTSD and an enhanced LPP response to angry faces among veterans with probable PTSD. These results suggest that prior mixed findings may be due to variability in PTSS severity. In addition, exploratory moderation analysis revealed that PTSS was positively associated with late LPP modulation for veterans reporting low cognitive reappraisal use and negatively associated with late LPP modulation for veterans reporting high cognitive reappraisal use. All results were specific to the 1,000–3,000 ms LPP time window. Thus, the functional nature of LPP modulation by direct threat cues may depend upon PTSS severity and/or related variables (e.g., cognitive reappraisal utilization).     

What predicts post‐traumatic stress following spinal cord injury/

Objectives . Spinal cord injury (SCI) is a severe, traumatic event and recently research into the role of post‐traumatic stress disorder (PTSD) subsequent to the injury has become of increasing interest. This study has been conducted in order to investigate potential risk factors for the development of post‐traumatic stress disorder symptoms in those with SCI. Design . This cross‐sectional study used multiple regression analysis to look for associations between post‐traumatic stress symptom severity, SCI‐related factors and previously identified risk factors for PTSD such as dysfunctional cognitions, demographic factors and personality predispositions (neuroticism, alexithymia). Method . A total of 102 participants with SCI completed measures of post‐traumatic stress severity, acceptance of injury, post‐traumatic cognitions, social support, neuroticism and alexithymia. In addition, information about type, level and cause of the SCI was assessed. Results . High levels of post‐traumatic stress symptoms were found. Potential risk factors for the development of PTSD were negative cognitions of self and neuroticism. Variables that added to the variance explained by the models included time since injury and difficulty identifying feelings. Acceptance of injury was mediated by negative cognitions of the self and neuroticism. Conclusions . The study highlights the need for services to be aware of the psychological difficulties experienced by this client group. An important finding is that the acceptance of the injury is mediated by negative cognitions of the self which need to be identified as potential risk factors in order to prevent the development of post‐traumatic symptoms in this population.     

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

Objective To examine posttraumatic stress symptoms (PTSS) inparents of children with cancer as a function of time sincediagnosis, treatment status, and relapse history, and as comparedto parents of healthy children. Method Participants includedparents of 199 children with cancer, comprising a cross-sectionalsample of diagnoses and treatment phases, ranging from currentlyon therapy to long-term survivors, and 108 parents of healthychildren obtained via acquaintance control methods. Parentscompleted a standardized self-report measure of PTSS. ResultsWithin the cancer group, parental report of PTSS differed asa function of treatment status and time since diagnosis. Parentsof children on active treatment endorsed similar levels of PTSSas control parents, whereas parents of children off treatmentreported significantly lower levels of PTSS than did controls.Similarly, parents of long-term survivors reported significantlylower levels of PTSS than did controls, while parents of recentlydiagnosed children did not differ from controls on PTSS. Incontrast, parents of children who had suffered a relapse reportedsignificantly higher levels of PTSS, and were much more likelyto be identified as a posttraumatic stress disorder (PTSD) case.Conclusions As a group, parents of children with cancer didnot demonstrate any evidence of increased PTSS relative to parentsof healthy children. Time since diagnosis, child treatment status,and relapse history are significant determinants of parent PTSS.Only parents of children who experienced a relapse appear tobe at increased risk of PTSD. The current results appear discrepantfrom the existing literature, and possible explanations forthese discrepancies are examined.     

A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents

Post-traumatic stress disorder (PTSD) is a complex and chronic disorder that causes substantial distress and interferes with social and educational functioning. Consequently, identifying the risk factors that make a child more likely to experience traumatic distress is of academic, clinical and social importance. This meta-analysis estimated the population effect sizes of 25 potential risk factors for PTSD in children and adolescents aged 6-18 years across 64 studies (N=32,238). Medium to large effect sizes were shown for many factors relating to subjective experience of the event and post-trauma variables (low social support, peri-trauma fear, perceived life threat, social withdrawal, comorbid psychological problem, poor family functioning, distraction, PTSD at time 1, and thought suppression); whereas pre-trauma variables and more objective measures of the assumed severity of the event generated small to medium effect sizes. This indicates that subjective peri-trauma factors and post-event factors are likely to have a major role in determining whether a child develops PTSD following exposure to a traumatic event. Such factors could potentially be assessed following a potentially traumatic event in order to screen for those most vulnerable to developing PTSD and target treatment efforts accordingly. The findings support the cognitive model of PTSD as a way of understanding its development and guiding interventions to reduce symptoms.     

Peritraumatic dissociation as a mediator of peritraumatic distress and PTSD: a retrospective, cross-sectional study

The objective of the present article was to examine the mediational significance of peritraumatic dissociation in the relationship between peritraumatic distress and posttraumatic stress disorder (PTSD). A total of 71 individuals with spinal cord injuries completed interviews and questionnaires measuring PTSD symptomatology, peritraumatic dissociation, and peritraumatic distress. Peritraumatic dissociation was found to partially mediate the relationship between peritraumatic distress and PTSD symptomatology. These findings provide support for the hypothesis that peritraumatic distress and peritraumatic dissociation significantly impact PTSD severity. The findings also support the hypothesis that peritraumatic dissociation is provoked by peritraumatic distress. The results further indicate that although peritraumatic dissociation seems to be a significant risk factor for PTSD, it is not necessary for the development of PTSD; the presence of peritraumatic distress may be sufficient. These findings highlight the importance of investigating peritraumatic reactions after a traumatic event in order to identify individuals at risk for developing PTSD. Such a practice may help prevent the development of chronic conditions.     

Do assault-related variables predict response to cognitive behavioral treatment for PTSD?

This study examined the hypothesis that variables such as history of prior trauma, assault severity, and type of assault, previously found to be associated with natural recovery, would also predict treatment outcome. Trauma-related variables were examined as predictors of posttreatment posttraumatic stress disorder (PTSD) severity in a sample of 73 female assault victims with chronic PTSD who completed treatment in a comparative outcome study (E. B. Foa et al., 1999). Results indicated that after controlling for initial severity of PTSD symptoms, the experience of trauma in childhood and sustaining physical injury during the adult assault were predictive of greater PTSD severity following treatment.     

Parental posttraumatic stress symptoms as a moderator of child's acute biological response and subsequent posttraumatic stress symptoms in pediatric injury patients

OBJECTIVE: To examine how parental responses following pediatric injury may influence their child's posttraumatic stress symptoms (PTSS). METHODS: Heart rate (HR) from 82 pediatric injury patients was measured during emergency medical services (EMSs) transport and following hospital admission. Twelve-hour urinary cortisol levels were assessed upon admission. Child PTSS and parental PTSS and general distress were assessed 6 weeks and 6 months after trauma. RESULTS: Six-week parental PTSS predicted 6-month child PTSS even after controlling for demographics and general parent distress (DeltaR(2) = .08, p = .03). Parental PTSS moderated the relationship between (a) child cortisol levels and 6-month child PTSS (DeltaR2 = .08, p = .03) and between (b) hospital HR and 6-month child PTSS (DeltaR2 = .09, p = .03). CONCLUSION: The present findings suggest that parental response to trauma may interact with child acute physiological responses to predict persistent child PTSS.     

Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors

OBJECTIVE: To describe rates and concordance of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in adolescent childhood cancer survivors and their mothers and fathers. METHOD: Participants were 150 adolescent survivors of childhood cancer, 146 mothers, and 103 fathers who completed the Impact of Events Scale-Revised, the Posttraumatic Stress Disorder Reaction Index, and the PTSD module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. RESULTS: PTSS are common in families of childhood cancer survivors. Parents reported more symptomatology than former patients. Mothers and fathers had relatively equal rates of current PTSD and levels of PTSS. Nearly 30% of mothers met diagnostic criteria since their child's diagnosis, with 13.7% currently experiencing PTSD. Nearly 20% of families had at least one parent with current PTSD. Ninety-nine percent of the sample had at least one family member reexperiencing symptoms. CONCLUSIONS: Both PTSD and PTSS help in understanding the experience of adolescent cancer survivors and their families. Within families of childhood cancer survivors, it is likely that some member may be experiencing treatable bothersome memories, arousal, or avoidance specific to the cancer experience.     

Quality of life after traumatic injury: a latent trajectory modeling approach

Background: It is largely unknown how quality of life (QoL) changes following accidental injuries. Equally, the mechanisms underlying such changes have not yet been identified in detail. This study of injured accident survivors aimed to: (1) detect a model of change which best explains the observed course of QoL, and (2) identify potential predictor variables. Methods: 323 injured accident survivors were interviewed within 2 weeks of the trauma, and followed up at 6 and 12 months. Latent trajectory modeling was used to analyze the fit of three potential trajectories regarding the observed course of general QoL as measured by the Questions on Life Satisfaction questionnaire. Results: The trajectory model adopting a negative square-root change fitted the observed data best, meaning that shortly after the accident, general QoL decreased strongly with diminishing negative changes occurring later on. Early and prolonged QoL impairment was largely attributable to the initial level of posttraumatic stress as measured by the Clinician-Administered PTSD Scale. To a lesser extent, depressive symptoms also predicted change in subjective QoL, while injury severity showed no direct effect; rather, its impact on QoL was mediated by initial posttraumatic stress. By contrast, reduced occupational functioning was attributable to injury severity rather than psychopathology. Conclusions: When treating injured accident survivors, clinicians should consider symptoms of posttraumatic stress and comorbid depression in order to prevent or mitigate negative changes in QoL.     

A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents

Recent years have witnessed a rapid acceleration in the recognition and documentation of posttraumatic stress disorder (PTSD) and posttraumatic stress symptomatology (PTSS) in childhood cancer survivors and their parents. However, applicability of PTSD both diagnostically and conceptually to cancer-related traumatic responses remains poorly articulated within the current literature. Following an outline of childhood cancer and PTSD, this paper critically examines the applicability of such a diagnosis to this clinical population. It then systematically reviews the current evidence base (24 studies) on PTSD and PTSS in childhood cancer survivors and their parents. Prevalence of PTSD and PTSS, as well as associated predictors, in this clinical population varies widely. Findings are considered in the light of a number of contemporary theories of PTSD. Limitations within current conceptualizations of PTSD are highlighted with respect to the nature of cancer as a traumatic event and the specific features of traumatic stress manifestations in childhood cancer survivors and their parents. Finally, a number of pertinent research areas are elucidated which are argued to warrant further investigation.     

Coping with serious accidental injury: a one-year follow-up study

BACKGROUND: The aim of this study was to analyze changes of coping strategies in severely injured accident victims over time and to compare patients with high and low posttraumatic stress disorder (PTSD) symptom levels with regard to their coping patterns and accident-related cognitions. METHODS: 106 consecutive patients with severe accidental injuries admitted to a trauma surgery intensive care unit (ICU) were assessed within 1 month after the trauma and 6 and 12 months later. Assessments included a clinical interview, the Freiburg Questionnaire of Coping with Illness, the patients' accident-related cognitions, the Clinician-Administered PTSD Scale, the 90-item revised Symptom Checklist (SCL-90-R), and the Sense of Coherence Questionnaire (SOC). Patients who met the criteria for either full or subsyndromal PTSD at least once over the observation period (36 subjects; 34.0%) were assigned to a highly symptomatic group (HSG), the remainder (70 subjects; 66.0%) to a less symptomatic group. RESULTS: Overall, active problem-focused coping was predominant immediately after the accident and declined over time, with a stronger decrease in the HSG. Patients in the HSG scored higher on the SCL Global Severity Index and lower on the SOC. The patients' subjective appraisal of accident severity was higher in the HSG, whereas there was no group difference with regard to accident-related variables such as type of accident, injury severity and mild to moderate traumatic brain injury. CONCLUSIONS: Active problem-focused coping, although utilized most frequently and often regarded as protective, might be an inadequate strategy in face of acute stress following a severe accident. Clinicians should not expect their patients to cope very actively in the acute ICU phase. In the subsequent rehabilitation, active coping seems to be more adaptive.     

Post-traumatic stress symptoms in an elite unit of Brazilian police officers: prevalence and impact on psychosocial functioning and on physical and mental health

BACKGROUND: Frequent exposure to traumatic situations put police officers under an increased risk for developing post-traumatic stress disorder (PTSD). The goals of this study were to determine the current prevalence of post-traumatic stress symptoms (PTSS) in Brazilian police officers and to compare groups with and without PTSS in terms of associated morbidity. METHODS: Police officers from an elite unit (n=157) were asked to fill out a socio-demographic questionnaire, the 12-item General Health Questionnaire and the Post-Traumatic Stress Disorder Checklist-Civilian Version. The latter's scores were used to establish the diagnoses of "full PTSD" and of "partial PTSD". RESULTS: Prevalence rates of "full PTSD" and "partial PTSD" were 8.9% and 16%, respectively. Compared with the "no PTSD" group, police officers with "full PTSD" were five times more likely to be divorced (21.6% vs. 4.3%, p=0.008), felt that their physical health was poorer (64.3% vs. 6%, p<0.001), had more medical consultations during the last 12 months [2.00 (+/-1.62) vs. 1.09 (+/-1.42), p=0.03] and reported more often lifetime suicidal ideation (35.7% vs. 5.2%, p=0.002). LIMITATIONS: The sample was relatively small. A screening tool was employed instead of a semi-structured interview. The cross-sectional design is unsuitable for ascertaining cause-effect relations. CONCLUSIONS: PTSD prevalence in our sample was comparable to those reported for North American and Dutch policemen. The presence of "full PTSD" was associated with evidences of considerable morbidity. These findings may contribute to the development of effective policies aimed at the prevention and treatment of PTSD in law enforcement agents.     

Relationship of cosmetic disfigurement to the severity of posttraumatic stress disorder in burn injury or digital amputation

BACKGROUND: The purpose of this study was to examine the relationships of physical factors including physical functioning and cosmesis to posttraumatic stress disorder (PTSD) symptoms in patients with burn injury and in patients with digital amputation. METHODS: Subjects were 56 patients with burn injury and 26 patients with digital amputation. In addition to assessments of physical factors, psychiatric interviews were administered to examine mental disorders including PTSD and major depression. RESULTS: The prevalence rates of PTSD and major depression were 33.9 and 7.1% in burn-injured patients and 18.5 and 7.4% in patients with digital amputation respectively. Multivariate analysis of variance (MANOVA) revealed that, regardless of the severity of burn injury such as percentage of total body surface burned, female victims with cosmetic disfigurement (i.e., facial burn) exhibited PTSD symptoms, in particular PTSD symptoms of avoidance and emotional numbing. For subjects with digital amputation, MANOVA indicated that, regardless of the degree of physical functioning after replantation, female victims with cosmetic disfigurement exhibited PTSD symptoms. DISCUSSION: These findings suggest that, in female victims with burn injury and/or digital amputation, the degree of cosmetic disfigurement is related to the manifestation of PTSD symptoms of avoidance and emotional numbing.     

Posttraumatic growth in adolescent survivors of cancer and their mothers and fathers

OBJECTIVE: To describe posttraumatic growth (PTG) following childhood cancer survival and its association with demographic and disease/treatment variables, perceived treatment severity and life threat, and posttraumatic stress symptoms (PTSS). METHOD: Adolescent survivors of cancer (N = 150, ages 11-19), at least 1 year after treatment, and their mothers (N = 146) and fathers (N = 107) completed self-report measures of perceived treatment intensity and PTSS and a semistructured interview designed to identify posttraumatic responses and indicators of PTG including perceived positive changes for self, relationships, and life goals. RESULTS: A majority of adolescents and their mothers and fathers reported PTG. Greater perceived treatment severity and life threat, but not objective disease severity, was associated with PTG. PTG and PTSS were positively associated for the adolescent cancer survivors. Diagnosis after age 5 resulted in more perceived benefit and greater PTSS for adolescent survivors. CONCLUSION: Clarification of the concept and measurement of PTG after childhood cancer is warranted, as are prospective studies of the association of PTG and PTSS and the role of demographic variables and illness-specific appraisals.