Group intervention for children bereaved by the suicide of a relative

OBJECTIVE: This study evaluated efficacy of a manual-based bereavement group intervention for children who suffered suicide of a parent or sibling. METHOD: Seventy-five families (102 children) were screened from medical examiners' lists of suicide victims. Fifty-two families (75 children) were eligible and assigned in alternating order to receive (27 families, 39 children) or not to receive (25 families, 36 children) the intervention. Intervention efficacy was evaluated as change in children's symptoms of anxiety, depression, posttraumatic stress, social adjustment, and parents' depressive symptoms from initial to outcome assessments. RESULTS: Changes in anxiety and depressive symptoms were significantly greater among children who received the intervention than in those who did not. A greater dropout of children assigned not to receive (75%) than to receive (18%) intervention led to an imbalance in retention of intervention and nonintervention participants. CONCLUSIONS: A bereavement group intervention focusing on reactions to death and suicide and strengthening coping skills can lessen distress of children bereaved after parental or sibling suicide. Such intervention may prevent future morbidities.     

Frontline treatment of combat stress reaction: a 20-year longitudinal evaluation study

OBJECTIVE: The purpose of the study was to evaluate the long-term (20-year) effectiveness of frontline treatment provided to combat stress reaction casualties. METHOD: A longitudinal quasi-experimental design was employed. Participants were combat stress reaction casualties of the 1982 Lebanon War who received frontline treatment (N=79), comparable combat stress reaction casualties who did not receive frontline treatment (N=156), and matched soldiers who did not experience combat stress reaction (N=194). Subjects were asked which of the frontline treatment principles (proximity, immediacy, expectancy) were applied in their treatment, whether or not they returned to their unit after frontline treatment, and if so, whether they returned before or after they felt completely recovered. Outcome assessments included measures of posttraumatic and psychiatric symptoms and of social functioning. RESULTS: Twenty years after the war, traumatized soldiers who received frontline treatment had lower rates of posttraumatic and psychiatric symptoms, experienced less loneliness, and reported better social functioning than similarly traumatized soldiers who did not receive frontline treatment. In addition, a cumulative effect of application of frontline treatment principles was documented: the more principles applied, the stronger the effect on psychiatric outcomes. CONCLUSIONS: Frontline treatment is associated with improved outcomes even two decades after its application. This treatment may also be effective for nonmilitary precursors of posttraumatic stress disorder.     

Violence exposure, posttraumatic stress, and personality in juvenile delinquents

OBJECTIVE: To assess posttraumatic stress and its relationship to comorbid psychopathology, violence exposure, and personality traits in Russian male juvenile delinquents. METHOD: Posttraumatic stress and comorbid psychopathology were assessed by a semistructured psychiatric interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version) in 370 delinquent youths during winter-spring of 1999. In addition, violence exposure, personality, and psychopathology were assessed by self-reports. RESULTS: Most delinquents reported some degree of posttraumatic stress: 156 subjects (42%) fulfilled partial criteria and 87 (25%) fulfilled full DSM-IV criteria for posttraumatic stress disorder (PTSD). Violence-related experiences (witnessing and victimization) were the most common types of trauma. Higher levels of posttraumatic stress were accompanied by higher rates of comorbid psychopathology, with the most striking differences occurring between the groups with full versus partial PTSD criteria. Violence exposure was related to temperamental behavior activation (novelty seeking), whereas PTSD symptom scores were predominantly related to behavior inhibition and poor coping (high harm avoidance and low self-directedness). CONCLUSIONS: Similar to findings from American samples, Russian juvenile delinquents represent a severely traumatized population, mainly due to high levels of violence exposure. Those with full PTSD are the most severely traumatized and have highest rates of psychopathology, as compared to those with no or partial PTSD, and they require the most clinical attention and rehabilitation. Both exposure to violence and levels of posttraumatic stress are related to personality traits, which influence degree of exposure and individual perception of stress. The latter should be considered in individualized approaches to rehabilitation.     

Memory bias for emotional information in children and adolescents with posttraumatic stress disorder: a preliminary study

Studies with adult participants with emotional disorders have revealed an explicit memory bias in favor of recalling negative emotional information, particularly if the information is related to the participants' emotional concerns. This process was investigated in a preliminary study with children and adolescents with posttraumatic stress disorder and control participants. Participants were presented with sets of negative, neutral, and positive words and asked to recall them after a short retention interval. Posttraumatic stress disorder participants showed poorer overall memory performance compared with control participants. They also showed a bias in favor of recalling negative information, but there was no evidence of any specificity beyond this for threat-related material. Regression analyses revealed no relationship between mood, memory bias, and age. Results are discussed in terms of the adult literature and with respect to issues of the developmental continuity of posttraumatic stress disorder.     

Prospective study of displaced children's symptoms in wartime Bosnia

Background: This study examines the psychological symptoms of Bosnian children exposed to war and trauma, and detects changes in these symptoms over time. Method: A total of 147 displaced children residing in refugee centers in Bosnia completed self-report assessments of anxiety, depressive, and posttraumatic stress symptoms at two time points. Results: Symptoms of posttraumatic stress, anxiety, and depression showed a greater decrease in boys relative to girls over time. Conclusion: Gender may be an important factor in the natural course of trauma-related symptoms among war traumatized children. Further research is needed to better understand the psychological effects of war trauma on children, and the natural course of posttraumatic symptoms, so as to improve interventions targeted to this vulnerable population. Accepted: 10 June 1999     

The Effectiveness of Parent Management Training—Oregon Model in Clinically Referred Children with Externalizing Behavior Problems in The Netherlands

The present study examined the effectiveness of parent management training—Oregon model (PMTO) as a treatment for children with externalizing behavior problems in The Netherlands. Clinically referred children (N = 146) aged 4–11 years and their parents were partly randomized to either PMTO (n = 91) or Care As Usual (CAU; n = 55). Families were assessed at four time points: at pretreatment, and after 6, 12, and 18 months. Results showed that both PMTO and CAU were effective in reducing child externalizing behavior, parenting stress and parental psychopathology, with no significant differences between the two treatment conditions. PMTO and CAU interventions also produced some improvements in self-reported parenting skills, but not in observed parenting skills. According to the Reliable Change Index, 16.9 and 45.8 % of the children within the PMTO group showed full recovery or improvement in externalizing behavior, respectively, versus 9.7 and 42.8 % in the CAU condition. Finally, the effect size of PMTO on parent-reported externalizing behavior problems as found in the present study was comparable to that found in previous studies evaluating PMTO as an intervention for this type of child psychopathology.     

Anger in former East German political prisoners: relationship to posttraumatic stress reactions and social support

Anger is a salient symptom of traumatized victims and a major sign for posttraumatic stress disorder (PTSD). However, the causes for the increased level of anger remain almost unknown. The present study investigates the interrelationship of anger, posttraumatic stress reactions, and social support in a group of former East German political prisoners (N = 91). Assessments included the German version of the Anxiety Disorders Schedule (DIPS) as well as measures of anger (STAXI), posttraumatic stress reactions (IES-R), and social support (SSQ). As expected, participants reported a high level of anger. Most measures of anger, posttraumatic stress reactions, and social support were significantly correlated. Within structural equation modeling, trait-anger was shown to be directly activated by the experience of chronic posttraumatic intrusions. Social support appeared to lessen the level of anger. The results confirm findings from studies on other traumatic events and provide additional information on the relationship between posttraumatic anger and social support. The findings indicate that treatments for PTSD might be effectively supplemented by addressing anger and social support.     

A school-based mental health program for traumatized Latino immigrant children

OBJECTIVE: To pilot-test a school mental health program for Latino immigrant students who have been exposed to community violence. METHOD: In this quasi-experimental study conducted from January through June 2000, 198 students in third through eighth grade with trauma-related depression and/or posttraumatic stress disorder symptoms were compared after receiving an intervention or being on a waitlist. The intervention consisted of a manual-based, eight-session, group cognitive-behavioral therapy (CBT) delivered in Spanish by bilingual, bicultural school social workers. Parents and teachers were eligible to receive psychoeducation and support services. RESULTS: Students in the intervention group ( = 152) had significantly greater improvement in posttraumatic stress disorder and depressive symptoms compared with those on the waitlist ( = 47) at 3-month follow-up, adjusting for relevant covariates. CONCLUSIONS: A collaborative research team of school clinicians, educators, and researchers developed this trauma-focused CBT program for Latino immigrant students and their families. This pilot test demonstrated that this program for traumatized youths, designed for delivery on school campuses by school clinicians, can be implemented and evaluated in the school setting and is associated with a modest decline in trauma-related mental health problems.     

Combat exposure, posttraumatic stress symptoms and risk-taking behavior in veterans of the Second Lebanon War

Prior research has revealed heightened risk-taking behavior among veterans with posttraumatic stress disorder (PTSD). This study examined whether the risktaking behavior is a direct outcome of the traumatic exposure or whether this relationship is mediated by posttraumatic stress symptoms. The sample was comprised of 180 traumatized Israeli reserve soldiers, who sought treatment in the wake of the Second Lebanon War. Combat exposure was indirectly associated with risk-taking behavior primarily through its relationship with posttraumatic stress symptoms. Results of the multivariate analyses depict the implication of posttraumatic stress symptoms in risk taking behavior, and the role of self-medication and of aggression in traumatized veterans.     

Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial

OBJECTIVE: To evaluate the efficacy of individual trauma-focused cognitive-behavioral therapy (CBT) for treating posttraumatic stress disorder (PTSD) in children and young people. METHOD: Following a 4-week symptom-monitoring baseline period, 24 children and young people (8-18 years old) who met full DSM-IV PTSD diagnostic criteria after experiencing single-incident traumatic events (motor vehicle accidents, interpersonal violence, or witnessing violence) were randomly allocated to a 10-week course of individual CBT or to placement on a waitlist (WL) for 10 weeks. RESULTS: Compared to the WL group, participants who received CBT showed significantly greater improvement in symptoms of PTSD, depression, and anxiety, with significantly better functioning. After CBT, 92% of participants no longer met criteria for PTSD; after WL, 42% of participants no longer met criteria. CBT gains were maintained at 6-month follow-up. Effects of CBT were partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD. CONCLUSIONS: Individual trauma-focused CBT is an effective treatment for PTSD in children and young people.     

Predictive validity in a prospective follow-up of PTSD in preschool children

OBJECTIVE: To examine the predictive validity of an alternative to the DSM-IV for diagnosing posttraumatic stress disorder (PTSD) in preschool children and prospectively explore the course of PTSD symptomatology. METHOD: Sixty-two traumatized children, ages 20 months through 6 years, were assessed three times in 2 years with caregiver diagnostic interviews. RESULTS: PTSD diagnosis at visit 1 significantly predicted degree of functional impairment 1 and 2 years later and predicted PTSD diagnosis 2 years later but not 1 year later. The lack of 1-year diagnostic continuity may be explained by children with new traumas. Unexpectedly, overall PTSD symptoms did not remit over time, regardless of community treatment; however, reexperiencing symptoms decreased and avoidance/numbing symptoms increased with time, with avoidance/numbing symptoms increasing at a faster rate in children with PTSD at visit 1. The previous finding that arousal may cause emotional numbing was not replicated. Significantly more children were functionally impaired at visits 2 (48.9%) and 3 (74.3%) than were diagnosed with PTSD (23.4% and 22.9%, respectively). CONCLUSIONS: This study demonstrates predictive validity for the alternative method of diagnosing PTSD in preschool children. The unremitting course of PTSD symptomatology in preschool children and rates of impairment that are higher than rates of diagnosis indicate the need for efficacious treatment.     

Mixed lateral preference in posttraumatic stress disorder

Recent research indicates that adults with posttraumatic stress disorder (PTSD) have a higher incidence of mixed laterality with respect to handedness than the rest of the population. To test if this relationship also occurs early in life, we evaluated children with history of interpersonal trauma. Fifty-nine traumatized children were evaluated with the Clinician Administered PTSD Scale for Children and Adolescents and the Edinburgh Handedness Inventory. Forty matched healthy controls were used for comparison. Increased mixed laterality was found in all children exhibiting symptoms of PTSD when compared with healthy controls, and children who met DSM-IV diagnostic criteria for PTSD had more mixed laterality than the subthreshold traumatized group (F = 7.71; df = 2,96; p = 0.001). Within the entire traumatized group, there was a positive correlation between PTSD symptom severity and mixed laterality. Mixed laterality was positively associated with PTSD symptoms in traumatized children, suggesting that neurological abnormalities may be related to degree of PTSD symptom expression.     

Avoidance in trauma: conscious and unconscious defense, pathology, and health

Drawing from our work with children seen following the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, this article describes clinical aspects of avoidance in traumatized children and their families. Avoidance in traumatized children and their families seems a final common pathway arising from a number of diverse factors. The importance of particular factors for assessment and treatment is emphasized.     

The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma?

OBJECTIVE: The presence of posttraumatic stress disorder (PTSD) in trauma survivors has been linked with family dysfunction and symptoms in their children, including lower self-esteem, higher disorder rates and symptoms resembling those of the traumatized parent. This study aims to examine the phenomenon of intergenerational transfer of PTSD in an Australian context. METHOD: 50 children (aged 16-30) of 50 male Vietnam veterans, subgrouped according to their fathers' PTSD status, were compared with an age-matched group of 33 civilian peers. Participants completed questionnaires with measures of self-esteem, PTSD symptomatology and family functioning. RESULTS: Contrary to expectations, no significant differences were found between the self-esteem and PTSD symptomatology scores for any offspring groups. Unhealthy family functioning is the area in which the effect of the veteran's PTSD appears to manifest itself, particularly the inability of the family both to experience appropriate emotional responses and to solve problems effectively within and outside the family unit. CONCLUSION: Methodological refinements and further focus on the role of wives/mothers in buffering the impact of veterans' PTSD symptomatology on their children are indicated. Further effort to support families of Veterans with PTSD is also indicated.     

Increased cortisol concentrations in hair of severely traumatized Ugandan individuals with PTSD

Previous research has mostly suggested general hypocortisolism in posttraumatic stress disorder (PTSD). However, PTSD is a complex disorder and opposite neuroendocrinological changes have also been reported. Amongst other things, heterogeneous results might be related to differences in sample characteristics as well as methodological factors associated with the assessment of cortisol. The current study used the novel method of hair cortisol analysis to examine cumulative long-term cortisol secretion in a severely traumatized PTSD sample. Hair samples of 10 traumatized individuals with PTSD and 17 traumatized controls without PTSD from a civil war area of Northern Uganda were analyzed. Results revealed that hair samples of PTSD participants contained higher cortisol levels than those of traumatized controls (p<.05). Furthermore, a positive association between hair cortisol levels and the number of lifetime traumatic events was found (p<.05). The current hair cortisol findings suggest that PTSD in severely traumatized individuals who continue to live under stressful conditions might be associated with general hypercortisolism. Future research examining participants after traumatic events at different follow-up periods is needed to determine the specific influence of time interval since traumatization.     

Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic

OBJECTIVE: To identify clinical and functional correlates of posttraumatic stress disorder (PTSD) in trauma-exposed urban adolescent girls. METHOD: Ninety female adolescents aged 12 to 21 years (mean 17.3 years) who presented for routine medical care at an adolescent primary care clinic were assessed with self-report questionnaires and interviews for trauma exposure, posttraumatic stress symptoms, other psychopathology, and psychosocial, family, and school function. RESULTS: Ninety-two percent (n = 83) endorsed at least one trauma. Witnessing community violence (85.6%) and hearing about a homicide (67.8%) were the most common traumatic events endorsed. Twelve (14.4%) and 10 (11.6%) traumatized girls met DSM-IV symptom criteria for full and partial PTSD, respectively. Compared with traumatized girls without PTSD, girls with PTSD were significantly more depressed, used more cigarettes and marijuana, and were more likely to have failed a school grade, been suspended from school, or been arrested. CONCLUSIONS: Urban adolescent girls are exposed to multiple types of trauma. Whereas most develop at least one posttraumatic stress symptom, girls who meet full symptom criteria for PTSD show evidence of other psychopathology, increased cigarette and marijuana use, and poorer school performance. Further research is needed to identify and treat inner-city girls with PTSD.     

Testimony therapy: treatment method for traumatized victims of organized violence

Former political prisoners in Chile gave testimony of their traumatic experiences, which resulted in diminishing their posttraumatic symptoms. Based on this experience, testimony therapy has been developed and used in treatment of traumatized victims of war or other organized violence. This short-term therapy, as it applied in the treatment of traumatized asylum seekers and refugees in Centrum '45/De Vonk in the Netherlands, is described in this article. The therapy consists of 12 sessions in which patients tell their life stories, including the traumatic experiences. The narrative is reflected in a written document that, for example, can be read to family and friends, or be sent to a historical archive. This article discusses the preliminary research data on the effects of testimony therapy. Finally, hypotheses on the working mechanisms of testimony therapy are offered.     

The relationship of gender and trauma characteristics to posttraumatic stress disorder in a community sample of traumatized northern plains American Indian adolescents and young adults

OBJECTIVE: Previous studies have identified a high prevalence (25%-80%) of trauma among American Indian and non-American Indian adolescents and adults. However, only a fraction of traumatized individuals develop posttraumatic stress disorder (PTSD). This article examines the relationships of gender and trauma characteristics to a diagnosis of PTSD among a community sample of traumatized American Indian adolescents and young adults. METHOD: Complete data were collected from 349 American Indians aged 15 to 24 years who participated in a cross-sectional community-based study from July 1997 to December 1999 and reported experiencing at least 1 traumatic event. Traumatic events and PTSD were assessed using a version of the Composite International Diagnostic Interview. Logistic regression determined the relationships of gender, trauma type, age at first trauma, and number of traumas to the development of PTSD. RESULTS: Forty-two participants (12.0% of those who experienced a traumatic event) met criteria for lifetime PTSD. While all 4 of the independent variables noted above demonstrated univariate associations with PTSD, multivariate logistic regression analyses indicated that only experiencing a sexual trauma (odds ratio [OR] = 4.45, 95% confidence interval [CI] = 1.76 to 11.28) and having experienced 6 or more traumas (OR = 2.53, 95% CI = 1.06 to 6.04) were independent predictors of meeting criteria for PTSD. CONCLUSION: American Indian children and adolescents who experience sexual trauma and multiple traumatic experiences may be at particularly high risk for developing PTSD.     

Heart period and variability findings in preschool children with posttraumatic stress symptoms.

BACKGROUND: Traumatic experiences for young children might result in profound neurodevelopmental changes, compared with adults. Our aim was to examine autonomic control of heart rate in traumatized young children. METHODS: Sixty-two children who had suffered traumas and 62 nontraumatized control children, aged 20 months to 6 years, were assessed for posttraumatic stress disorder (PTSD) symptoms, interbeat interval, respiratory sinus arrhythmia (RSA), family rehearsal of the trauma, and parent-child relationship quality. RESULTS: Traumatized children with PTSD and traumatized children without PTSD both had decreased heart period in response to a trauma stimulus relative to the nontraumatized group (both p < .0167). there was no main effect for RSA change scores, however, there was a significant interaction effect between parental positive discipline with PTSD symptoms and RSA. The most sympathetic children had decreased RSA during the trauma stimulus when they had caregivers with less positive discipline during a clean-up nd family rehearsal with PTSD symptoms. CONCLUSIONS: These findings underscore that psychopathology in young children ought to be assessed in the context of psychophysiology and parent-child relationship to optimally understand the mechanisms of maladaptation during this complex developmental period.