Life threat and posttraumatic stress in school-age children.

One hundred fifty-nine children (14.5% of the student body) were sampled after a fatal sniper attack on their elementary school playground. Systematic self-reports of posttraumatic stress disorder (PTSD) symptoms were obtained by use of a child PTSD Reaction Index. Analysis of variance revealed significant differences by exposure but not by sex, ethnicity, or age. Additional analyses were conducted of individual item response, overall severity of PTSD reaction, symptom grouping, and previous life events. The results provide strong evidence that acute PTSD symptoms occur in school-age children with a notable correlation between proximity to the violence and type and number of PTSD symptoms. Sampling at approximately one month after the trauma provided adequate delineation among exposure groups. The symptom profile of highly exposed children lends validity to the diagnosis of acute PTSD in childhood.

A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders.

Empirical findings regarding childhood traumatic stress are placed within a developmental life-trajectory model that incorporates a tripartite etiology of posttrauma distress. This approach recognizes an intricate matrix of child-intrinsic factors, developmental maturation and experience, life events, and evolving family and social ecologies. Of central developmental importance in the field of traumatic stress is the ontogenesis of appraisal, emotional response, emotional and physiological regulation, and consideration of protective action with regard to danger. The complexity of traumatic situations and their aftermath suggests the relevance of multiple stress diatheses in understanding individual variability in proximal and distal effects. Neurobiological systems that subserve danger mature over childhood and adolescence. Neurophysiological and neurohormonal studies among traumatized children and adolescents suggest potential neurodevelopmental stage-related vulnerabilities within these systems. Advances in child development and traumatic stress provide tools for investigating proximal and distal interplay of psychopathology, disturbances in the acquisition and maintenance of developmental competencies, and life-trajectory outcomes. A developmental psychopathology model suggests different avenues by which dangerous circumstances, childhood traumatic experiences, and posttraumatic stress disorder (PTSD) can intersect with other anxiety disorders over the life span.

A behavioral animal model of posttraumatic stress disorder featuring repeated exposure to situational reminders.

The purpose of this study was to evaluate an animal model of posttraumatic stress disorder (PTSD) in mice. The model featured repeated exposures to situational reminders of a traumatic stress, which consisted of a brief electric shock, and included assessment of two behavioral parameters and the startle reflex. The findings indicated an initial, but unsustained, increase in locomotor activity in a neutral environment due to traumatic stress. Exposure to situational reminders was associated with a persistent bidirectional abnormal behavioral pattern in a fear-provoking environment and a progressive increase over time in the magnitude of the startle reflex. Exposure to situational reminders also produced an increase in aggressive behavior. This animal model appears to produce behavioral changes analogous to those seen in patients with PTSD.

Startle modulation in children with posttraumatic stress disorder.

Startle responses to bursts of white noise were recorded as blink reflexes 17-21 months after a traumatic event in six children with posttraumatic stress disorder (PTSD) and in six normal control children. A seventh child with PTSD was studied on four occasions during the 2 years following a stressful event. The startle responses were modulated by nonstartling acoustic prestimulation in order to study the inhibitory and facilitatory modulation of startle reaction by brainstem mechanisms. The children with PTSD experienced a significant loss of the normal inhibitory modulation of startle response, suggesting that the traumatic experience had induced a long-lasting brainstem dysfunction.

Use of joint consultations in inpatient psychiatry.

The coexistence of medical and psychiatric problems in psychiatric inpatients often causes compliance difficulties, based on either irrational and distorted fears of medical treatment or more rational concerns that proposed psychiatric treatment could adversely affect a preexisting medical condition. The authors propose the use of joint consultations, in which both the psychiatrist and the other medical specialist meet together with the patient, as a way of ameliorating such distortions and conflicts and thereby improving compliance with both medical and psychiatric treatment.

Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake in Armenia.

OBJECTIVE: This study was undertaken 1 1/2 years after the 1988 earthquake in Armenia to assess the frequency and severity of posttraumatic stress reactions among elderly and younger adult victims and to assess the relation of exposure, age, sex, and death of a family member to these reactions. METHOD: One hundred seventy-nine subjects of both sexes were evaluated with the Posttraumatic Stress Disorder (PTSD) Reaction Index. A subgroup of 60 individuals were also assessed for PTSD with the DSM-III-R criteria. RESULTS: There was a strong association between the presence of severe symptoms on the index and a DSM-III-R diagnosis of PTSD. Elderly and younger adult victims in cities closer to the epicenter (higher exposure) had significantly higher index scores than elderly and adult victims in more distant locations. In comparison with previous studies of natural disasters, much greater rates of chronic severe posttraumatic stress reactions were found among the highly exposed individuals. Although there was no difference in total mean score on the Posttraumatic Stress Disorder Reaction Index, a significant difference in symptom profile was found between the elderly and younger adults; the elderly scored higher on arousal symptoms and lower on intrusive symptoms. There was a positive correlation between loss of family members and severity of posttraumatic stress reaction. CONCLUSIONS: These findings indicate that after a major natural disaster with subsequent multiple adversities, a substantial proportion of the adult population may experience severe and chronic posttraumatic stress reactions. The risk factors identified in this study may prove useful in screening exposed individuals for appropriate treatment.

Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence.

OBJECTIVE: The authors sought to assess the severity and longitudinal course of posttraumatic stress, anxiety, and depressive reactions among two groups of adults differentially exposed to severe and mild earthquake trauma and a third group exposed to severe violence. They also examined interrelationships among these reactions and predictors of outcome and compared posttraumatic stress disorder (PTSD) symptom category profile and course between those exposed to earthquake and those exposed to violence. METHOD: Seventy-eight non-treatment-seeking subjects were assessed with self-report instruments approximately 1.5 and 4.5 years after the 1988 Spitak earthquake in Armenia and the 1988 pogroms against Armenians in Azerbaijan. RESULTS: The two groups that had been exposed to severe trauma (earthquake or violence) had high initial and follow-up PTSD scores that did not remit over the 3-year interval. Overall, depressive symptoms subsided. Posttraumatic stress, anxiety, and depressive reactions were highly intercorrelated within and across both time intervals. No significant differences in PTSD severity, profile, or course were seen between subjects exposed to severe earthquake trauma versus those exposed to severe violence. CONCLUSIONS: After exposure to severe trauma, either an earthquake or violence, adults are at high risk of developing severe and chronic posttraumatic stress reactions that are associated with chronic anxiety and depressive reactions. Clinical evaluation and therapeutic intervention should include specific attention to these reactions. Early mental health intervention is recommended to prevent their chronicity.

Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing.

OBJECTIVE: This clinical assessment was designed to identify middle and high school students in need of formal evaluation for posttraumatic response symptoms following the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City. METHOD: A clinical needs assessment instrument was developed and administered to grade 6 through 12 students 7 weeks after the bombing (N = 3,218). RESULTS: More than 40% of the students reported knowing someone injured, and more than one-third reported knowing someone killed in the blast. Posttraumatic stress symptoms at 7 weeks significantly correlated with gender, exposure through knowing someone injured or killed, and bomb-related television viewing. CONCLUSIONS: This study documents the intensity of community exposure to the bombing and the lingering symptoms of stress. The assessment was used in planning for clinical service delivery, training professional responders, and supporting funding requests.

Basal cortisol, dexamethasone suppression of cortisol, and MHPG in adolescents after the 1988 earthquake in Armenia.

OBJECTIVE: This study evaluated basal salivary cortisol, 3-methoxy-4-hydroxyphenylglycol (MHPG), and cortisol suppression following dexamethasone administration in adolescents exposed to two levels of earthquake-related trauma. METHOD: Five years after the 1988 earthquake, saliva samples were obtained from 37 adolescents from two cities in Armenia at different distances from the epicenter. Baseline saliva samples were obtained at 8:00 a.m., 4:00 p.m., and 11:00 p.m., following which 0.5 mg of dexamethasone was administered. Nine and 17 hours later, saliva samples were again obtained. Subjects were evaluated for posttraumatic stress and depressive reactions through use of self-report instruments. RESULTS: Significantly lower mean baseline 8:00 a.m. cortisol levels and greater day 24:00 p.m. cortisol suppression following dexamethasone were observed in the more symptomatic adolescents living in the city closer to the epicenter. Of the three symptom categories of posttraumatic stress disorder (PTSD), only intrusion (category B) symptoms were significantly correlated with basal morning cortisol levels and percent suppression by dexamethasone. The more highly exposed adolescents also exhibited a more rapid decline in MHPG levels over the course of day 1. CONCLUSIONS: The findings indicate that chronic posttraumatic stress reactions among adolescents exposed to catastrophic disaster are associated with hypothalamic-pituitary-adrenal (HPA) axis alterations. The findings are congruent with those previously described in adults with chronic PTSD. Persistent intrusion (category B) symptoms may constitute continued episodes of distress and evoke repeated physiological stress responses, which, over time, alter HPA axis function. The MHPG findings suggest that there may be diurnal changes associated with severity of posttraumatic stress symptoms.

Outcome of psychotherapy among early adolescents after trauma.

OBJECTIVE: The authors evaluated the effectiveness of brief trauma/grief-focused psychotherapy among early adolescents exposed to the 1988 earthquake in Armenia. METHOD: Posttraumatic stress and depressive reactions among treated and not treated subjects were evaluated pre- and postintervention, at 1 1/2 and 3 years after the earthquake, respectively. RESULTS: Severity of posttraumatic stress symptoms significantly decreased among the subjects given psychotherapy, while severity of these symptoms increased significantly among the subjects not treated with psychotherapy. The improvement in posttraumatic stress symptoms was attributable to improvement in all three symptom categories (intrusion, avoidance, and arousal) of posttraumatic stress disorder (PTSD). There was no change in severity of depressive symptoms among subjects given psychotherapy. However, depressive symptoms among subjects not treated with psychotherapy significantly worsened over time. The changes in severity of posttraumatic stress and depressive symptoms were positively correlated within both groups. CONCLUSIONS: The findings demonstrate the efficacy of trauma/grief-focused brief psychotherapy in alleviating PTSD symptoms and preventing the worsening of comorbid depression among early adolescents after a catastrophic disaster. The results support the broad use of such school-based interventions after major disasters and demonstrate the cross-cultural applicability of Western psychotherapeutic approaches.

Posttraumatic stress and depressive reactions among Nicaraguan adolescents after hurricane Mitch.

OBJECTIVE: This study determined the severity of posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch and the relationship of these reactions to objective and subjective features of hurricane exposure, death of a family member, forced relocation, and thoughts of revenge. METHOD: Six months after the hurricane, 158 adolescents from three differentially exposed cities were evaluated by using a hurricane exposure questionnaire, the Child Posttraumatic Stress Disorder Reaction Index, and the Depression Self-Rating SCALE: RESULTS: Severe levels of posttraumatic stress and depressive reactions were found among adolescents in the two most heavily affected cities. Severity of posttraumatic stress and depressive reactions and features of objective hurricane-related experiences followed a "dose-of-exposure" pattern that was congruent with the rates of death and destruction across cities. Level of impact (city), objective and subjective features, and thoughts of revenge accounted for 68% of the variance in severity of posttraumatic stress reaction. Severity of posttraumatic stress reaction, death of a family member, and sex accounted for 59% of the variance in severity of depression. CONCLUSIONS: After a category 5 hurricane, adolescents in heavily affected areas with extreme objective and subjective hurricane-related traumatic features of exposure experience severe and chronic posttraumatic stress and comorbid depressive reactions. The recovery of the severely affected Nicaraguan adolescents is vital to the social and economic recovery of a country ravaged by years of political violence and poverty. These findings strongly indicate the need to incorporate public mental health approaches, including systematic screening and trauma/grief-focused interventions, within a comprehensive disaster recovery program.

Children's memory and proximity to violence.

The study examined 133 school-age children's memory of a sniper attack at their elementary school. Researchers analyzed the role that spatial representation, memory markers, inner plans of action, and strategies of recall played in the memory process. In recalling the event, exposed children reduced their degree of life threat, while nonexposed children increased their proximity to the violence. Clinical and forensic implications are discussed.

When the earth stops shaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology.

OBJECTIVE: To examine risk and protective processes for posttraumatic stress reactions and negative sequelae following the Northridge earthquake (EQ) among youths diagnosed for pre-EQ psychopathology. METHOD: Symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety, and social impairment were evaluated using telephone interviews among 66 children participating in a family-genetic study of childhood-onset depression at the time of the EQ. RESULTS: Significant predictors of PTSD symptoms 1 year after the EQ included perceived stress and resource loss associated with the EQ, a pre-EQ anxiety disorder, and more frequent use of cognitive and avoidance coping strategies. PTSD symptoms were associated with high rates of concurrent general anxiety symptoms, depressive symptoms, and social adjustment problems with friends. The only significant correlation between sibling scores was on measures of sibling reports of objective exposure. CONCLUSIONS: Preexisting anxiety disorders represent a risk factor for postdisaster PTSD reactions. Postdisaster services need to attend to the needs of these youths as well as those of youths experiencing high levels of subjective stress, resource loss, and/or high exposure. That children within families show significant variation in postdisaster reactions underscores the need for attention to individual child characteristics and unshared environmental attributes.

Stress responses after pediatric bone marrow transplantation: preliminary results of a prospective longitudinal study.

This paper reports the preliminary findings of a longitudinal prospective study of young children undergoing bone marrow transplantation. Symptoms of post-traumatic stress were seen in these children up to 12 months after transplant. The bone marrow transplantation survivors demonstrated more denial and avoidance and fewer arousal symptoms than has been noted in children traumatized by a violent life threat, such as a sniper attack. These data suggest the use of post-traumatic stress as a model in understanding some of the symptoms of pediatric bone marrow transplantation survivors and may be applicable to other children exposed to the double life threat of serious illness and intensive medical intervention.

Psychiatric comorbidity in children after the 1988 earthquake in Armenia.

OBJECTIVE: To determine current rates of posttraumatic stress disorder (PTSD), depressive disorder, and separation anxiety disorder (SAD) among children 1 1/2 years after the 1988 earthquake in Armenia; to determine current rates of comorbid PTSD and depressive disorder; and to assess the contribution of exposure, gender, loss of family members, and loss of residence. METHOD: Two hundred eighteen school-age children from three cities at increasing distances from the epicenter were evaluated using the Child Posttraumatic Stress Disorder Reaction Index, the Depression Self-Rating Scale, and the section on SAD from the Diagnostic Interview for Children and Adolescents. RESULTS: On the basis of these evaluations, high rates of current PTSD, depressive disorder, and their co-occurrence were found among victims residing in the two heavily impacted cities. SAD was comparatively less frequent, although symptoms of SAD had been pervasive throughout the region. Severity of posttraumatic stress and depressive reactions were highly correlated. Extent of loss of family members was independently correlated with each. CONCLUSION: After a catastrophic natural disaster, children are at risk for comorbid PTSD and secondary depression. Based on the findings, an interactive model is proposed of postdisaster psychopathology. Early clinical intervention is recommended to prevent chronic posttraumatic stress reactions and secondary depression.

Moral development and psychopathological interference in conscience functioning among adolescents after trauma.

OBJECTIVES: To compare moral development and psychopathological interference with conscience functioning (PI) among adolescents exposed to different degrees of earthquake-related trauma and to investigate the relationship of moral development and PI to exposure to trauma, severity of posttraumatic stress disorder (PTSD) symptoms, postearthquake adversities, and extent of loss of nuclear family members. METHOD: Adolescents (N = 193) from 2 cities at different distances from the epicenter were evaluated. The Stilwell Structured Conscience Interview was used to assess moral development and PI. Structured self-report instruments were used to obtain ratings of severity of earthquake-related trauma, posttraumatic stress symptoms, and postearthquake adversities. RESULTS: Adolescents in the city near the epicenter manifested advanced moral development as compared with their counterparts in the less affected city. Concomitantly, they endorsed responses indicating PI. Levels of PI were significantly correlated with severity of PTSD symptoms. CONCLUSION: In the aftermath of a catastrophic natural disaster, children assume greater responsibilities and confront a multitude of morally challenging interpersonal situations which may result in an advancement of their moral development. Yet, at the same time, PTSD symptoms and negative schematizations of self and others may give rise to disturbances in conscience functioning. The findings suggest that therapeutic consideration should be given to assisting children in integrating the horror of their traumatic experiences and the harshness of posttrauma adversities into an adaptive schema of good and evil in themselves and the world.

Posttraumatic stress responses in bereaved children after the Oklahoma City bombing.

OBJECTIVE: To investigate the responses of middle and high school students exposed to the 1995 Oklahoma City bombing across a spectrum of loss. METHOD: A questionnaire measuring exposure, personal consequences, initial response, and current posttraumatic stress and other symptoms was administered to 3,218 students 7 weeks after the explosion. RESULTS: More than one third of the sample knew someone killed in the explosion. Bereaved youths were more likely than nonbereaved peers to report immediate symptoms of arousal and fear, changes in their home and school environment, and posttraumatic stress symptoms. Retrospective measures of initial arousal and fear predicted posttraumatic stress symptoms at 7 weeks. CONCLUSIONS: The results support the literature addressing the role of initial response in posttraumatic stress symptom development. The study raises concern about the impact of television, and traumatized youths' reactivity to it, in the aftermath of disaster.

Cancer in a parent: the impact on mother and child. A consultation-liaison clinical case conference.

The following case presents a 31-year-old woman medically hospitalized during a relapse of acute myelocytic leukemia. A consultation-liaison clinical conference focused on the patient's concerns about the effects of her illness on her relationship with her young daughter and its impact on the child's development. The discussion illustrates the consultation-liaison psychiatrist's role in alerting parents to their child's needs and in providing them with tools for effective parenting in a crisis situation such a cancer.

A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis.

This preliminary study of Kuwaiti children confirms the significant impact of exposure to war atrocities on children. This pilot sampling provided evidence that: (1) many children who remained in Kuwait during the occupation had multiple war-related exposures; (2) more than 70 per cent of the children reported moderate to severe post-traumatic stress reactions; and (3) witnessing death or injury and the viewing of explicit graphic images of mutilation on television had measurable influence on severity of reaction. The highest mean Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI) score was found for those children who reported hurting someone else. Older children had both greater exposure to atrocities and higher CPTSD-RI scores. Findings suggest the need for public policy to minimize children's exposure to graphic depictions of war-related injury, death and mutilation.

An unusual case of self-inflicted death in childhood.

The authors report the details of the case of a ten year old boy whose self-inflicted death by gunshot featured the involvement of a nine year old companion. The authors examine the material from the viewpoints of a possible case of suicide, of a certain case of violent death, and of a case with repercussions on the other child and the community.