Emotion Regulation Flexibility in Adolescents: A Systematic Review from Conceptualization to Methodology.

Considerable attention has been devoted to the concept of flexible emotion regulation, which de-emphasizes the importance of any specific regulatory strategy in favor of the flexible deployment of strategies in response to specific situational challenges. The bulk of research in this area has been conducted on adult samples. Research on emotion regulation flexibility (ERF) in youth has been documented in only a limited number of studies and using various definitions. This systematic review aims to gather and summarize different conceptualizations and methodological approaches of adolescent ERF. We incorporate these findings into a general framework to understand ERF and its role in adolescents' emotional, behavioral and social functioning. Adhering to the PRISMA guidelines, 11 studies were included in the review. While ERF has been defined in various and inconsistent ways, the included studies utilized conceptualizations from two overarching domains: the regulation of expressed emotion and the repertoire of emotion regulation strategies. Promising approaches and future directions will be highlighted.

The Flexible Regulation of Emotional Expression Scale for Youth (FREE-Y): Adaptation and Validation Across a Varied Sample of Children and Adolescents.

Flexible self-regulation has been shown to be an adaptive ability. This study adapted and validated the adult Flexible Regulation of Emotional Expression (FREE) Scale for use with youth (FREE-Y) in community and maltreatment samples. The FREE-Y measures the ability to flexibly enhance and suppress emotion expression across an array of hypothetical social scenarios. Participants (N = 654, 8-19 years) were included from three studies. Confirmatory factor analysis (CFA) confirmed a theoretically appropriate higher order factor structure. Using multiple-group CFAs, measurement invariance was achieved across maltreatment status, age, and gender. Reliabilities were adequate and construct validity was demonstrated through associations with measures of emotion regulation, psychopathology, IQ, and executive functioning. Group comparisons indicated lower Suppression and Flexibility scores for maltreated versus comparison participants. Findings suggest that the FREE-Y is a valid measure of expressive regulation ability in youth that can be applied across a range of populations.

Understanding posttraumatic stress trajectories in adolescent females: A strength-based machine learning approach examining risk and protective factors including online behaviors.

Heterogeneity in the course of posttraumatic stress symptoms (PTSS) following a major life trauma such as childhood sexual abuse (CSA) can be attributed to numerous contextual factors, psychosocial risk, and family/peer support. The present study investigates a comprehensive set of baseline psychosocial risk and protective factors including online behaviors predicting empirically derived PTSS trajectories over time. Females aged 12-16 years (N = 440); 156 with substantiated CSA; 284 matched comparisons with various self-reported potentially traumatic events (PTEs) were assessed at baseline and then annually for 2 subsequent years. Latent growth mixture modeling (LGMM) was used to derive PTSS trajectories, and least absolute shrinkage and selection operator (LASSO) logistic regression was used to investigate psychosocial predictors including online behaviors of trajectories. LGMM revealed four PTSS trajectories: resilient (52.1%), emerging (9.3%), recovering (19.3%), and chronic (19.4%). Of the 23 predictors considered, nine were retained in the LASSO model discriminating resilient versus chronic trajectories including the absence of CSA and other PTEs, low incidences of exposure to sexual content online, minority ethnicity status, and the presence of additional psychosocial protective factors. Results provide insights into possible intervention targets to promote resilience in adolescence following PTEs.

Individual and Social Risk and Protective Factors as Predictors of Trajectories of Post-traumatic Stress Symptoms in Adolescents.

The present study elucidates heterogeneity in post-traumatic stress symptoms (PTSS) across adolescence in a sample of youth who have experienced myriad types and combinations of potentially traumatic events (PTEs), including substantiated physical abuse, sexual abuse, neglect and/or at least one other self-reported PTE. A machine learning technique was used to assess a multivariate set of variables (e.g., PTEs, individual risk and protective factors, social risk and protective factors, and racial and ethnic minority status) as predictors of PTSS trajectory group membership. The sample included 498 maltreated (n = 275) and comparison (n = 223) 14-19-year-old female adolescents (M = 15.27, SD = 1.06 at Time 1) assessed annually until age 19. 45.7% of participants were White, 45.3% Black, 0.4% Native American, 0.8% Hispanic, and 7.7% other. Growth mixture modeling identified three distinct trajectories of PTSS: (1) recovery (56%); (2) moderate, chronic (25%); and (3) high, chronic (19%). An elastic net model was used to test predictors of membership in the recovery versus the high, chronic PTSS trajectory groups. Results demonstrated that the recovery trajectory was characterized by the absence of sexual abuse, physical abuse, and other traumas, higher self-esteem, less affective dysregulation, less risky peers, lower levels of parent depression, and being of racial/ethnic minority status. Findings help to characterize individual variation in trajectories of PTSS following PTEs by underscoring the unique trauma responses of racial and ethnic minority youth and offering possible targets of interventions to promote recovery from PTSS.

Childhood Sexual Abuse and Exposure to Peer Bullying Victimization.

Females exposed to child sexual abuse (CSA) are at an increased risk of experiencing further victimization in adolescence. Associations between CSA and several forms of cyber and in-person peer bullying victimization were assessed in a prospective, longitudinal study. Females exposed to substantiated CSA and a matched comparison group (N = 422) were followed over a two-year period. Bullying experiences were assessed in both survey and qualitative interviews. Qualitative data were coded and used to describe the types (e.g., cyber, physical, verbal), and foci (e.g., threats, physical appearance) of bullying victimization. Logistic regression was used to assess the odds that CSA was associated with subsequent bullying victimization, adjusted for demographics, social networking use, and prior bullying. CSA-exposed females were at an increased risk of multiple forms of bullying victimization with a persistent risk of bullying victimization over time. Specifically, they had 2.6 times higher odds of experiencing any bullying at follow-up, 2.9 times higher odds of experiencing cyberbullying at follow-up, and 2 times higher odds of experiencing combined cyber/in-person bullying at follow-up. CSA-exposed females were more likely than comparison females to experience bullying regarding their appearance/weight and dating relationships. Findings provide further insight into the unique circumstances of the cyberbullying and in-person bullying experienced by CSA-exposed females. Females exposed to child sexual abuse (CSA) are at an increased risk of experiencing bullying victimization, specifically cyberbullying and combined cyber/in-person bullying, as well as bullying about their appearance and dating relationships. These findings indicate that bullying prevention needs to include trauma-focused components to target these uniquely vulnerable females.

An observational study of Internet behaviours for adolescent females following sexual abuse.

Child sexual abuse (CSA) is associated with revictimization and sexual risk-taking behaviours. The Internet has increased the opportunities for teens to access sexually explicit imagery and has provided new avenues for victimization and exploitation. Online URL activity and offline psychosocial factors were assessed for 460 females aged 12-16 (CSA = 156; comparisons = 304) with sexual behaviours and Internet-initiated victimization assessed 2 years later. Females who experienced CSA did not use more pornography than comparisons but were at increased odds of being cyberbullied (odds ratio = 2.84, 95% confidence interval = 1.67-4.81). These females were also more likely to be represented in a high-risk latent profile characterized by heightened URL activity coupled with problematic psychosocial factors, which showed increased odds of being cyberbullied, receiving online sexual solicitations and heightened sexual activity. While Internet activity alone may not confer risk, results indicate a subset of teens who have experienced CSA for whom both online and offline factors contribute to problematic outcomes.

Topical Review: Medical Trauma During Early Childhood.

OBJECTIVE: Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0-6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness. METHODS: Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood. RESULTS: There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness. CONCLUSIONS: This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.

Development and validation of the Functional Posttraumatic Cognitions Questionnaire (FPTCQ) in children and adolescents exposed to accidental trauma.

OBJECTIVE: Cognitive models of posttraumatic stress disorder highlight posttraumatic cognitions (PTCs) as a crucial mechanism of trauma adjustment. So far, only dysfunctional PTCs have been investigated in detail. Research on functional PTCs is scarce. This study addresses this gap by developing and validating a self-report measure called Functional Posttraumatic Cognitions Questionnaire (FPTCQ) in children and adolescents. METHOD: The questionnaire was administered to 114 children and adolescents aged 7 to 15 years who had experienced an acute accidental potentially traumatic event, such as a road traffic accident or a burn injury, and as a result received medical treatment. In addition to classical item analysis and exploratory factor analysis, reliability and construct validity of the FPTCQ were investigated. RESULTS: The exploratory factor analysis revealed a one-factor structure of the FPTCQ. The final 11-item questionnaire displayed satisfactory internal consistency (Cronbach's α = .78), irrespective of age. Functional PTCs were inversely related to dysfunctional PTCs, r = -.44, p < .001, posttraumatic stress symptoms, r = -.35, p < .001, depression symptoms, r = -.22, p < .05, and anxiety symptoms, r = -.43, p < .001, thus supporting construct validity. CONCLUSIONS: The FPTCQ is a reliable and valid measure for standardized assessment of functional PTCs among children and adolescents. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Preventive intervention for trauma reactions in young injured children: results of a multi-site randomised controlled trial.

BACKGROUND: Young children are at particular risk for injury. Ten per cent to twenty-five per cent develop posttraumatic stress disorder (PTSD). However, no empirically supported preventive interventions exist. Therefore, this study evaluated the efficacy of a standardised targeted preventive intervention for PTSD in young injured children. METHODS: Injured children (1-6 years) were enrolled in a multi-site parallel-group superiority prospective randomised controlled trial (RCT) in Australia and Switzerland. Screening for PTSD risk occurred 6-8 days postaccident. Parents of children who screened 'high-risk' were randomised to a 2-session CBT-based intervention or treatment-as-usual (TAU). Primary outcomes were PTSD symptom (PTSS) severity, and secondary outcomes were PTSD diagnosis, functional impairment and behavioural difficulties at 3 and 6 months postinjury using blinded assessments. Trials were registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000325606) and ClinicalTrials.gov (NCT02088814). Trial status is complete. RESULTS: One hundred and thirty-three children screened 'high-risk' were assigned to intervention (n = 62) or TAU (n = 71). Multilevel intention-to-treat analyses revealed a significant intervention effect on PTSS severity over time (b = 60.06, 95% CI: 21.30-98.56). At 3 months, intervention children (M = 11.02, SD = 10.42, range 0-47) showed an accelerated reduction in PTSS severity scores compared to control children (M = 17.30, SD = 13.94, range 0-52; mean difference -6.97, 95% CI: -14.02 to 0.08, p adj. = .055, d = 0.51). On secondary outcomes, multilevel analyses revealed significant treatment effects for PTSD diagnosis, functional impairment and behavioural difficulties. CONCLUSIONS: This multi-site RCT provides promising preliminary evidence for the efficacy of a targeted preventive intervention for accelerating recovery from PTSS in young injured children. This has important clinical implications for the psychological support provided to young children and parents during the acute period following a single-event trauma.

Posttraumatic Stress Disorder in Very Young Children: Diagnostic Agreement Between ICD-11 and DSM-5.

The prevalence of posttraumatic stress disorder (PTSD) in very young children depends on the diagnostic criteria. Thus far, studies have investigated the International Classification of Diseases (11th rev.; ICD-11) criteria for PTSD only in samples of children older than 6 years of age. The aim of this study was to test the diagnostic agreement between the ICD-11 and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for children who are 6 years old and younger. Caregivers of children aged 3-6 years in foster care in Germany (N = 147) and parents of children aged 1-4 years who had attended a hospital in Switzerland following burn injuries (N  = 149) completed a questionnaire about children's PTSD. Rates of PTSD were calculated according to ICD-11 (considering a specific and a more general conceptualization of intrusive memories) and DSM-5 criteria and were compared using McNemar's tests and Cohen's kappa. The proportion of children who met the ICD-11 criteria was 0.6-25.8% lower than the proportion of PTSD cases according to the DSM-5 criteria. The diagnostic agreement between each ICD-11 algorithm and DSM-5 was moderate, κ = 0.52-0.66. A systematic investigation of adaptions of the ICD-11 avoidance cluster identified alternative symptom combinations leading to higher agreement with the DSM-5 requirements. Furthermore, DSM-5 had higher predictive power for functional impairment than the ICD-11 algorithms. In conclusion, the findings suggest that the ICD-11 criteria show less sensitivity in very young children, which can be explained by the more stringent avoidance cluster.

Young Children's Acute Stress After a Burn Injury: Disentangling the Role of Injury Severity and Parental Acute Stress.

Objective: Although injury severity and parental stress are strong predictors of posttraumatic adjustment in young children after burns, little is known about the interplay of these variables. This study aimed at clarifying mediation processes between injury severity and mother's, father's, and young child's acute stress. Methods: Structural equation modeling was used to examine the relationships between injury severity and parental and child acute stress. Parents of 138 burn-injured children (ages 1-4 years) completed standardized questionnaires on average 19 days postinjury. Results: Sixteen children (11.7%) met Diagnostic and Statistical Manual of Mental Disorders, 5th edition, preschool criteria for posttraumatic stress disorder (excluding time criterion). The model revealed a significant mediation of maternal acute stress, with the effect of injury severity on a child's acute stress mediated by maternal acute stress. Paternal acute stress failed to serve as a mediating variable. Conclusions: Our findings confirm mothers' crucial role in the posttraumatic adjustment of young children. Clinically, mothers' acute stress should be monitored.

Coping with Accident Reactions (CARE) early intervention programme for preventing traumatic stress reactions in young injured children: study protocol for two randomised controlled trials.

BACKGROUND: Accidental injury represents the most common type of traumatic event experienced by children under the age of 6 years. Around 10-30 % of young injured children will go on to develop post-traumatic stress disorder (PTSD) and other co-morbid conditions. Parents of injured children are also at risk of PTSD, and this is associated with short- and long-term consequences for their children's physical and psychological recovery. Despite the significance of this problem, to date, the mental health needs of injured young children have been neglected. One reason for this is due to the uncertainty and considerable debate around how to best provide early psychological intervention to traumatised children and adults. To address these gaps, researchers and psychologists in Australia and Switzerland have developed the Coping with Accident Reactions (CARE) programme, which is a two-session early intervention designed to prevent persistent PTSD reactions in young injured children screened as 'at risk'. Two separate international studies are being conducted to evaluate the effectiveness and feasibility of this programme. METHODS/DESIGN: The study design for the two proposed studies will employ a randomised controlled trial design and children (aged 1-6 years) who are screened as at risk for PTSD 1 week after an unintentional injury, and their parents will be randomised to either (1) CARE intervention or (2) treatment as usual. Assessment will be completed at baseline (2 weeks) and 3 and 6 months post-injury. DISCUSSION: This international collaboration provides an excellent opportunity to test the benefit of screening and providing early intervention to young children in two different countries and settings. It is expected that outcomes from this research will lead to significant original contributions to the scientific evidence base and clinical treatment and recovery of very young injured children. TRIAL REGISTRATION: The Australian study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12614000325606 ) on 26 March 2014. The Swiss study was registered with ClinicalTrials.gov ( NCT02088814 ) on 12 March 2014.

Guilt is associated with acute stress symptoms in children after road traffic accidents.

BACKGROUND: Although previous research has consistently found considerable rates of acute stress disorder (ASD) in children with accidental injuries, knowledge about determinants of ASD remains incomplete. Guilt is a common reaction among children after a traumatic event and has been shown to contribute to posttraumatic stress disorder. However, its relationship to ASD has never been examined. OBJECTIVE: This study assessed the prevalence of ASD in children and adolescents following road traffic accidents (RTAs). Moreover, the association between peritraumatic guilt and ASD was investigated relying on current cognitive theories of posttraumatic stress and controlling for female sex, age, socioeconomic status (SES), injury severity, inpatient treatment, pretrauma psychopathology, and maternal posttraumatic stress symptoms (PTSS). METHODS: One hundred and one children and adolescents (aged 7-16 years) were assessed by means of a clinical interview approximately 10 days after an RTA. Mothers were assessed by questionnaires. RESULTS: Three participants (3.0%) met diagnostic criteria for full ASD according to DSM-IV, and 17 (16.8%) for subsyndromal ASD. In a multivariate regression model, guilt was found to be a significant predictor of ASD severity. Female sex, outpatient treatment, and maternal PTSS also predicted ASD severity. Child age, SES, injury severity, and pretraumatic child psychopathology were not related to ASD severity. CONCLUSIONS: Future research should examine the association between peritraumatic guilt and acute stress symptoms in more detail. Moreover, guilt appraisals in the acute phase after an accident might be a relevant target for clinical attention.