Machine learning methods to predict child posttraumatic stress: a proof of concept study.

BACKGROUND: The care of traumatized children would benefit significantly from accurate predictive models for Posttraumatic Stress Disorder (PTSD), using information available around the time of trauma. Machine Learning (ML) computational methods have yielded strong results in recent applications across many diseases and data types, yet they have not been previously applied to childhood PTSD. Since these methods have not been applied to this complex and debilitating disorder, there is a great deal that remains to be learned about their application. The first step is to prove the concept: Can ML methods - as applied in other fields - produce predictive classification models for childhood PTSD? Additionally, we seek to determine if specific variables can be identified - from the aforementioned predictive classification models - with putative causal relations to PTSD. METHODS: ML predictive classification methods - with causal discovery feature selection - were applied to a data set of 163 children hospitalized with an injury and PTSD was determined three months after hospital discharge. At the time of hospitalization, 105 risk factor variables were collected spanning a range of biopsychosocial domains. RESULTS: Seven percent of subjects had a high level of PTSD symptoms. A predictive classification model was discovered with significant predictive accuracy. A predictive model constructed based on subsets of potentially causally relevant features achieves similar predictivity compared to the best predictive model constructed with all variables. Causal Discovery feature selection methods identified 58 variables of which 10 were identified as most stable. CONCLUSIONS: In this first proof-of-concept application of ML methods to predict childhood Posttraumatic Stress we were able to determine both predictive classification models for childhood PTSD and identify several causal variables. This set of techniques has great potential for enhancing the methodological toolkit in the field and future studies should seek to replicate, refine, and extend the results produced in this study.

Democratizing Implementation and Innovation in Mental Health Care.

Improvements in the quality of mental health care in the United States depend on the successful implementation of evidence-based treatments (EBT's) in typical settings of care. Unfortunately, there is little evidence that EBT's are used in ways that would approximate their established fidelity standards in such settings. This article describes an approach to more successful implementation of EBT's via a collaborative process between intervention developers and intervention users (e.g. providers, administrators, consumers) called Lead-user Innovation. Lead-user Innovation democratizes the implementation process by integrating the expertise of lead-users in the delivery, adaptation, innovation and evaluation of EBT's.

Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout.

BACKGROUND: This study aimed to obtain preliminary evidence for the extent to which a novel intervention embedded within a systems-oriented treatment model [trauma systems therapy (TST)] engages and retains traumatized children and their families in treatment. METHOD: Twenty youth who had prominent symptoms of posttraumatic stress were randomly assigned to receive TST or care as usual (CAU). RESULTS: At the 3-month assessment, 90% of TST participants were still in treatment, whereas only 10% of CAU participants remained. Within-group analyses of TST participants demonstrated significant reductions in posttraumatic stress and aggression as well as a slight improvement in home safety. CONCLUSIONS: These preliminary findings point to the need to utilize effective engagement approaches to retain traumatized children and their families in treatment.

Mental health progress requires causal diagnostic nosology and scalable causal discovery.

Nine hundred and seventy million individuals across the globe are estimated to carry the burden of a mental disorder. Limited progress has been achieved in alleviating this burden over decades of effort, compared to progress achieved for many other medical disorders. Progress on outcome improvement for all medical disorders, including mental disorders, requires research capable of discovering causality at sufficient scale and speed, and a diagnostic nosology capable of encoding the causal knowledge that is discovered. Accordingly, the field's guiding paradigm limits progress by maintaining: (a) a diagnostic nosology (DSM-5) with a profound lack of causality; (b) a misalignment between mental health etiologic research and nosology; (c) an over-reliance on clinical trials beyond their capabilities; and (d) a limited adoption of newer methods capable of discovering the complex etiology of mental disorders. We detail feasible directions forward, to achieve greater levels of progress on improving outcomes for mental disorders, by: (a) the discovery of knowledge on the complex etiology of mental disorders with application of Causal Data Science methods; and (b) the encoding of the etiological knowledge that is discovered within a causal diagnostic system for mental disorders.

Beyond PTSD: Client presentations of developmental trauma disorder from a national survey of clinicians.

OBJECTIVE: The emergence of updated Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association, 2013) criteria for posttraumatic stress disorder (PTSD), which includes modified criteria for young children, raises questions regarding the need for developmentally appropriate standalone psychiatric diagnosis encompassing complex trauma presentations in children. The present study addresses these questions by examining how DSM-5 PTSD and proposed developmental trauma disorder (DTD) diagnoses relate to functional impairment and trauma exposure using clinician-report surveys. METHOD: We surveyed psychotherapists across the United States, and asked them to report on the symptom characteristics, functional impairment, and trauma exposure of children, adolescents, and young adults under their care (n = 210; age range = 2-21). We fit symptom data to the draft criteria for (1) DTD, a proposed trauma diagnosis for children and (2) existing criteria for adult and child/preschool PTSD. RESULTS: Results indicated that comorbidity between DTD and PTSD was high (52.4% and 59.9% for adult and child/preschool criteria, respectively). Comorbid DTD/PTSD and DTD-alone groups had more functional domains impacted and greater exposure to some types of trauma relative to the other groups. CONCLUSIONS: These findings speak to the relationship between trauma complexity and wide-ranging symptom presentations, provide support for research and clinical emphasis on a developmentally informed diagnosis, and may support existing treatment approaches. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neighborhood characteristics and psychiatric disorders in the aftermath of mass trauma: A representative study of New York City public school 4th-12th graders after 9/11.

Studies of the relationship between neighborhood characteristics and childhood/adolescent psychopathology in large samples examined one outcome only, and/or general (e.g., 'psychological distress') or aggregate (e.g., 'any anxiety disorder') measures of psychopathology. Thus, in the only representative sample of New York City public school 4th-12th graders (N = 8202) surveyed after the attacks of 9/11/2001, this study examined whether (1) indices of neighborhood Socioeconomic Status, Quality, and Safety and (2) neighborhood disadvantage (defined as multidimensional combinations of SES, Quality and Safety indicators) are associated with eight psychiatric disorders: posttraumatic stress disorder, separation anxiety disorder (SAD), agoraphobia, generalized anxiety disorder (GAD), panic disorder, major depression, conduct disorder, and alcohol use disorder (AUD). (1) The odds ratios (OR) of psychiatric disorders were between 0.55 (AUD) and 1.55 (agoraphobia), in low and intermediate-low SES neighborhoods, respectively, between 0.50 (AUD) and 2.54 (agoraphobia) in low Quality neighborhoods, and between 0.52 (agoraphobia) and 0.65 (SAD) in low Safety neighborhoods. (2) In neighborhoods characterized by high disadvantage, the OR were between 0.42 (AUD) and 1.36 (SAD). This study suggests that neighborhood factors are important social determinants of childhood/adolescent psychopathology, even in the aftermath of mass trauma. At the community level, interventions on modifiable neighborhood characteristics and targeted resources allocation to high-risk contexts could have a cost-effective broad impact on children's mental health. At the individual-level, increased knowledge of the living environment during psychiatric assessment and treatment could improve mental health outcomes; for example, specific questions about neighborhood factors could be incorporated in DSM-5's Cultural Formulation Interview.

Computational causal discovery for post-traumatic stress in police officers.

This article reports on a study aimed to elucidate the complex etiology of post-traumatic stress (PTS) in a longitudinal cohort of police officers, by applying rigorous computational causal discovery (CCD) methods with observational data. An existing observational data set was used, which comprised a sample of 207 police officers who were recruited upon entry to police academy training. Participants were evaluated on a comprehensive set of clinical, self-report, genetic, neuroendocrine and physiological measures at baseline during academy training and then were re-evaluated at 12 months after training was completed. A data-processing pipeline-the Protocol for Computational Causal Discovery in Psychiatry (PCCDP)-was applied to this data set to determine a causal model for PTS severity. A causal model of 146 variables and 345 bivariate relations was discovered. This model revealed 5 direct causes and 83 causal pathways (of four steps or less) to PTS at 12 months of police service. Direct causes included single-nucleotide polymorphisms (SNPs) for the Histidine Decarboxylase (HDC) and Mineralocorticoid Receptor (MR) genes, acoustic startle in the context of low perceived threat during training, peritraumatic distress to incident exposure during first year of service, and general symptom severity during training at 1 year of service. The application of CCD methods can determine variables and pathways related to the complex etiology of PTS in a cohort of police officers. This knowledge may inform new approaches to treatment and prevention of critical incident related PTS.

A diagnostic interview for acute stress disorder for children and adolescents.

The goal of this study was to develop a semistructured clinical interview for assessing acute stress disorder (ASD) in youth and test its psychometric properties. Youth (N = 168) with an acute burn or injury were administered the acute stress disorder module of the Diagnostic Interview for Children and Adolescents (DICA-ASD). The DICA-ASD demonstrated strong psychometric properties, including high internal consistency (alpha = .97) and perfect diagnostic interrater agreement (kappa = 1.00). Participants diagnosed with ASD scored significantly higher than those not diagnosed on validated traumatic stress symptomatology measures but not on other symptomatology measures, providing evidence of convergent and discriminant validity. Preliminary evidence supports the reliability and validity of the first semistructured clinical interview for diagnosing ASD in youth.

Editorial: In the Causal Labyrinth: Finding the Path From Early Trauma to Neurodevelopment.

Exposure to traumatic events early in life has been associated with significant adverse neurodevelopmental consequences.1,2 Ideally, protecting children from trauma would prevent these consequences. Unfortunately, once a child is exposed to early trauma, the only means of prevention requires implementing effective interventions toward the mechanisms known to have caused the consequences. Therefore, it is imperative to carefully define the true mechanistic pathways from which the neurodevelopmental consequences of early trauma result. The process of determining the correct pathway(s) is not a trivial matter, as is made clear from a valiant effort reported in this issue of the Journal titled, "Early Sexual Trauma Exposure and Neural Response Inhibition in Adolescence and Young Adults: Trajectories of Frontal Theta Oscillations During a Go/No-Go Task."3 This editorial reviews the effort to infer causal mechanism in this article, and introduces a literature that can improve the field's capacity to infer causes from observational data.

Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care.

OBJECTIVE: This study investigated pediatrician-reported practices in identifying, assessing, and treating traumatic exposure and posttraumatic stress disorder (PTSD) in children. METHOD: Focus groups guided the development of a survey that was mailed to primary care pediatricians in Massachusetts in 2005. Descriptive statistics and multivariate analyses were used to describe clinical practices and perceived barriers to care. RESULTS: A 60% (N=597) survey response-rate was obtained. On average, pediatricians reported that less than 8% of patients had psychological problems that may be related to traumatic exposure. Only 18% of pediatricians agreed that they had adequate knowledge of childhood PTSD. About 15% of pediatricians reported frequently learning about traumatic event(s) from direct inquiry in the past year. Only 10% of pediatricians reported frequent assessment and treatment of posttraumatic stress symptoms. Most pediatricians (72%) agreed that greater collaborations with mental health providers would improve pediatric assessment of PTSD. Finally, having received PTSD-specific training and believing that pediatricians should identify and manage PTSD were each significantly associated with learning about a traumatic event from direct inquiry. CONCLUSION(S): Providing PTSD-specific training and changing pediatricians' attitudes about childhood PTSD may be useful first steps in improving care for children.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms.

The purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on children's growth and development from birth to adolescence. At the 12-month visit, children's attachment status was scored from videotapes of infant-caregiver dyads in Ainsworth's strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale-Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to children's attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure-disorganized/insecure-other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in children's later development of posttraumatic stress symptoms following a traumatic event.

Asthma severity and PTSD symptoms among inner city children: a pilot study.

Although the association between posttraumatic stress symptoms and asthma severity among children has been hypothesized, it has yet to be explored rigorously. This study sought to describe the posttraumatic stress symptoms of children with asthma and explore the relationship between asthma severity and posttraumatic stress symptoms in an inner city sample with high rates of traumatic exposures. Children aged 7 to 17 years, with a clinician-defined asthma diagnosis, were recruited from an inner city outpatient asthma clinic. Caregivers completed measures assessing the child's asthma and posttraumatic stress symptoms and health care utilization. Children also completed measures of asthma, posttraumatic stress symptoms, and asthma-related quality of life. In all, 24 children-caregiver dyads were enrolled. The sample was 79% male and 83% African American, and the mean age was 11 years. Overall the sample had severe asthma, with 33% having been hospitalized over the past year. In addition, 25% of the sample met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for the diagnosis of posttraumatic stress disorder, and 74% of the sample experienced a traumatic event. Posttraumatic stress disorder symptoms were found to be significantly related to asthma severity, quality of life, and health care utilization. Assessing for and treating posttraumatic stress symptoms among children with severe asthma may help to improve their asthma course and quality of life. Further research should explore this relationship and related treatment implications.

Brain entropy and human intelligence: A resting-state fMRI study.

Human intelligence comprises comprehension of and reasoning about an infinitely variable external environment. A brain capable of large variability in neural configurations, or states, will more easily understand and predict variable external events. Entropy measures the variety of configurations possible within a system, and recently the concept of brain entropy has been defined as the number of neural states a given brain can access. This study investigates the relationship between human intelligence and brain entropy, to determine whether neural variability as reflected in neuroimaging signals carries information about intellectual ability. We hypothesize that intelligence will be positively associated with entropy in a sample of 892 healthy adults, using resting-state fMRI. Intelligence is measured with the Shipley Vocabulary and WASI Matrix Reasoning tests. Brain entropy was positively associated with intelligence. This relation was most strongly observed in the prefrontal cortex, inferior temporal lobes, and cerebellum. This relationship between high brain entropy and high intelligence indicates an essential role for entropy in brain functioning. It demonstrates that access to variable neural states predicts complex behavioral performance, and specifically shows that entropy derived from neuroimaging signals at rest carries information about intellectual capacity. Future work in this area may elucidate the links between brain entropy in both resting and active states and various forms of intelligence. This insight has the potential to provide predictive information about adaptive behavior and to delineate the subdivisions and nature of intelligence based on entropic patterns.

Posttraumatic Stress Disorder Diagnosis in Young Children With Burns.

The primary aim of this study was to assess the prevalence of posttraumatic stress disorder (PTSD) in young children hospitalized for burns. A secondary aim was to assess partial PTSD in this population. PTSD diagnosis and symptoms were evaluated utilizing both the diagnostic interview for children and adolescents (DICA-P) module and the PTSD semistructured interview and observational report (PTSDSSI). PTSD symptomatology was assessed from parent interviews at 1 month after discharge from a major pediatric burn center. Four of the 42 participants who completed the DICA-P met full criteria for a diagnosis of PTSD (10%).Of the 39 who also completed the PTSDSSI, 1 (3%) met full criteria for PTSD diagnosis on that measure. Twenty-seven percentage of subjects met partial criteria on the DICA-P vs 16% on the PTSDSSI, without impairment. Furthermore, 67% of subjects met DICA-P criteria for the re-experiencing cluster and 54% met the PTSDSSI re-experiencing criteria. Although only a small percentage met full PTSD diagnostic criteria by either measure, a high percentage of young children with burns manifested some posttraumatic symptoms 1 month after discharge. Because PTSDSSI diagnosis is strongly linked to the diagnostic and statistical manual-5 (DSM-5) criteria for "PTSD in children 6 years and younger," these results may offer clues to current diagnoses of PTSD in young children. Future research is needed to improve care by determining the risk factors and course of PTSD to further refine the diagnostic criteria for identifying children most in need of intervention, such as those hospitalized for burn injuries.

Young burned children: the course of acute stress and physiological and behavioral responses.

OBJECTIVE: Symptoms of posttraumatic stress disorder (PTSD) are a focus of much research with older children, but little research has been conducted with young children, who account for about 40% of all pediatric burn injuries. This is a longitudinal study of 72 acutely burned children (12-48 months old) that assessed the course of acute posttraumatic symptoms and physiological reactivity. METHOD: Parents were interviewed shortly after their child was admitted to the hospital and 1 month after discharge. PTSD symptoms were measured with the Diagnostic Interview for Children and Adolescents (DICA) module. Nurses recorded the child's physiological data throughout the hospital stay. The child's physical and behavioral responses were assessed in a laboratory at about 1 month after discharge. RESULTS: Reduced social smiling in the children was related to PTSD symptoms, as measured by the DICA, and heart rate at 24 hours and 7 days. Reduced vocalization was related to the child's rating of pain at 24 hours. Smiling and vocalizations were also related to some DICA cluster scores but not avoidance. CONCLUSIONS: Preschool children admitted to a burn unit demonstrated PTSD symptoms and physiological reactivity. There was a relation to the frequency of smiles and vocalizations.

Separation anxiety as a mediator between acute morphine administration and PTSD symptoms in injured children.

Emerging evidence suggests that individuals who receive morphine while hospitalized demonstrate a decrease in symptoms of posttraumatic stress disorder (PTSD). However, the mechanisms of effects are not yet well understood. The goal of the current study was to examine three possible mediators for this effect. Sixty-one injured (burns, motor vehicle accidents, falls, and assaults) children were assessed during hospitalization and again 3 months post discharge. Assessment included acute and follow-up child report measures of pain, PTSD, and anxiety symptoms, as well as a medical record review for medication administration and pulse during hospitalization. Pathway analyses were conducted to test the potential mediating roles of pain reduction, noradrenergic attenuation, and separation anxiety on the association between morphine and PTSD. Results suggest that a reduction in separation anxiety may mediate the association between morphine administration and PTSD symptom reduction at 3 months. These findings have implications for our understanding of morphine's effects on psychological functioning following an acute injury and for direct clinical care.

Acute stress symptoms in young children with burns.

OBJECTIVE: Posttraumatic stress disorder symptoms are a focus of much research with older children, but little research has been conducted with young children, who account for about 50% of all pediatric burn injuries. This is a 3-year study of 12- to 48-month-old acutely burned children to assess acute traumatic stress outcomes. The aims were to (1) assess the prevalence of acute traumatic stress symptoms and (2) develop a model of risk factors for these symptoms in these children. METHOD: Acute stress symptoms were measured using the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children. Children's responses were then assessed, including behavior and physiological measures for developmental/functional consequences. A path analysis strategy was used to build a model of risk factors. Risk factors assessed in this model included observed pain (Visual Analogue Scale), parent symptoms (Stanford Acute Stress Reaction Questionnaire), and magnitude of trauma (total body surface area burned). RESULTS: Of the 64 subjects meeting inclusion criteria, 52 subjects agreed to participate. These children were highly symptomatic; almost 30% of these children had acute stress symptoms. A path analysis model yielded two independent pathways to acute stress symptoms: (1) from the size of the burn to the mean pulse rate in the hospital to acute stress symptoms and (2) from the child's pain to the parents' stress symptoms to acute stress symptoms. This model accounted for 39% of the variance of acute stress symptoms and yielded excellent fit indexes. CONCLUSIONS: A high percentage of acute stress symptoms were identified in young children with burns. A model of risk factors, including the size of the burn, pain, pulse rate, and parents' symptoms, was identified.

The medical traumatic stress toolkit.

Children and their parents who are exposed to medical life-threat due to illness or injury are at risk for developing symptoms of posttraumatic stress. However, the prevention, detection, and treatment needed are often not available in the acute care settings of the hospital. The National Child Traumatic Stress Network and the Substance Abuse and Mental Health Services Administration have created a set of materials for use by hospital health providers and families that is available for download free from the National Child Traumatic Stress Network website, www.nctsn.org.

The long-term consequences of early childhood trauma: a case study and discussion.

There is a great need to better understand the impact of traumatic events very early in life on the course of children's future development. This report focuses on the intriguing case of a girl who witnessed the murder of her mother by her father at the age of 19 months and seemed to have no recollection of this incident until the age of 11, when she began to exhibit severe symptoms of posttraumatic stress disorder (PTSD) in response to a traumatic reminder. The case presentation serves as the basis for a discussion regarding pertinent issues involved in early childhood trauma. This case and accompanying discussion were originally presented at the 19th Annual Meeting of the International Society for Traumatic Stress Studies and were transcribed and revised for use in this article. Specific topics include early childhood memory and trauma, learning and the appraisal of danger, and PTSD and traumatic grief in early childhood. Clinical and public health implications are also discussed. This case illustrates the dramatic impact that "preverbal" traumatic memories can have on children's later functioning and speaks to the importance of assisting very young children in the immediate aftermath of traumatic events.