Diversity, equity, and inclusivity in observational ambulatory assessment: Recommendations from two decades of Electronically Activated Recorder (EAR) research.

Ambient audio sampling methods such as the Electronically Activated Recorder (EAR) have become increasingly prominent in clinical and social sciences research. These methods record snippets of naturalistically assessed audio from participants' daily lives, enabling novel observational research about the daily social interactions, identities, environments, behaviors, and speech of populations of interest. In practice, these scientific opportunities are equaled by methodological challenges: researchers' own cultural backgrounds and identities can easily and unknowingly permeate the collection, coding, analysis, and interpretation of social data from daily life. Ambient audio sampling poses unique and significant challenges to cultural humility, diversity, equity, and inclusivity (DEI) in scientific research that require systematized attention. Motivated by this observation, an international consortium of 21 researchers who have used ambient audio sampling methodologies created a workgroup with the aim of improving upon existing published guidelines. We pooled formally and informally documented challenges pertaining to DEI in ambient audio sampling from our collective experience on 40+ studies (most of which used the EAR app) in clinical and healthy populations ranging from children to older adults. This article presents our resultant recommendations and argues for the incorporation of community-engaged research methods in observational ambulatory assessment designs looking forward. We provide concrete recommendations across each stage typical of an ambient audio sampling study (recruiting and enrolling participants, developing coding systems, training coders, handling multi-linguistic participants, data analysis and interpretation, and dissemination of results) as well as guiding questions that can be used to adapt these recommendations to project-specific constraints and needs.

Grief Instruments in Children and Adolescents: A Systematic Review.

Many children and adolescents experience the death of a close person, such as a family member or a friend. However, there is a scarcity of literature on the assessment of grief in bereaved youth. The use of validated instruments is essential to advance our knowledge of grief in children and adolescents. We conducted a systematic review, adhering to PRISMA guidelines, to identify instruments that measure grief in this population and explore their characteristics. Searches in six databases (Medline, PsycINFO, Embase, Emcare, Scopus, and Web of Science) identified 24 instruments, encompassing three categories: general-purpose grief scales, maladaptive grief scales, and specialized grief scales. We extracted data using a predetermined list of descriptive and psychometric properties. Findings indicate a need to direct research towards more stringent validation of existing instruments and the design of new instruments in line with developments in the understanding of grief in this population.

Moderating role of moral injury in the mental health of adolescent refugees.

OBJECTIVE: This study investigated whether moral injury appraisals moderated the relationships between trauma, postmigration living difficulties, resilience, and mental health outcomes in adolescent refugees. METHOD: Eighty-five adolescent refugees from a community sample completed an online survey. RESULTS: A significant interaction was found between moral injury and discrimination for externalizing and posttraumatic stress disorder (PTSD) symptoms; adolescents whom had experienced high levels of discrimination combined with high levels of moral injury had poorer mental health. A significant interaction was found between moral injury and resilience for internalizing symptoms: high levels of resilience appeared to buffer the association between moral injury and internalizing symptoms. Contrary to predictions, stressful life experiences and postmigration living difficulties did not interact significantly with moral injury to predict mental health. CONCLUSIONS: Discrimination may contribute to perpetuating poor mental health in adolescent refugees with high levels of moral injury. Resilience may buffer some of the negative effects of moral injury.

Think Big: A multinational collaboration to promote children's role as coresearchers in participatory research.

The field of participatory research with children developed largely thanks to shared learning between different cultures, places, and disciplines. However, grand narratives and power relationships in academia inherited from colonialism and imperialism can threaten to obstruct the transformative value of this approach. In this article, we present the case of Think Big, a multinational collaboration for participatory research with children that involved adult and child coresearchers from Australia, Chile, Colombia, and the United Kingdom. Our aim was to explore how this project helped build solidarities between adult researchers from different countries and disciplines. We applied a methodology of diffraction to explore the processes and outcomes of this collaboration and presented our insights using the metaphor of a tree to explain the roots (knowledges and frameworks), trunk (ongoing collaboration and communication between the teams from different countries), branches (local projects), and fruits (research outcomes) of our work. Based on our experience, we proposed that multinational collaborations for participatory research offer important opportunities for adult researchers to collaborate with children to generate more democratic knowledge about their lives and to generate more egalitarian relationships between adult researchers from different places and backgrounds. However, it is important to anticipate that multinational collaborations are more likely to be affected by social and political upheavals, and language barriers must be overcome to decentralize academia. Also, the organizations involved in these collaborations need to develop strategies that facilitate funding, ethics clearance, and international research agreements.

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.

Dysfunctional posttraumatic cognitions, posttraumatic stress and depression in children and adolescents exposed to trauma: a network analysis.

BACKGROUND: The latest version of the International Classification of Diseases (ICD-11) proposes a posttraumatic stress disorder (PTSD) diagnosis reduced to its core symptoms within the symptom clusters re-experiencing, avoidance and hyperarousal. Since children and adolescents often show a variety of internalizing and externalizing symptoms in the aftermath of traumatic events, the question arises whether such a conceptualization of the PTSD diagnosis is supported in children and adolescents. Furthermore, although dysfunctional posttraumatic cognitions (PTCs) appear to play an important role in the development and persistence of PTSD in children and adolescents, their function within diagnostic frameworks requires clarification. METHODS: We compiled a large international data set of 2,313 children and adolescents aged 6 to 18 years exposed to trauma and calculated a network model including dysfunctional PTCs, PTSD core symptoms and depression symptoms. Central items and relations between constructs were investigated. RESULTS: The PTSD re-experiencing symptoms strong or overwhelming emotions and strong physical sensations and the depression symptom difficulty concentrating emerged as most central. Items from the same construct were more strongly connected with each other than with items from the other constructs. Dysfunctional PTCs were not more strongly connected to core PTSD symptoms than to depression symptoms. CONCLUSIONS: Our findings provide support that a PTSD diagnosis reduced to its core symptoms could help to disentangle PTSD, depression and dysfunctional PTCs. Using longitudinal data and complementing between-subject with within-subject analyses might provide further insight into the relationship between dysfunctional PTCs, PTSD and depression.

Listening to Family Life After Serious Pediatric Injury: A Study of Four Cases.

Following a serious child injury, the entire family can be affected. Gaining an understanding of family support, interactions, and stress levels can help clinicians tailor treatment. Presently, these factors are assessed mainly via self-reports and structured observations. We aimed to explore the value of naturalistic observation of postinjury parent-child interactions, in order to highlight how clinicians might use these data in their practice. Our qualitative study involved an in-depth analysis of four cases from the Ear for Recovery project, against the backdrop of the larger sample's characteristics. Children who had been hospitalized with a serious injury wore the Electronically Activated Recorder (EAR). Over a two-day period postdischarge, the EAR recorded 30-second audio "snippets" every 5 minutes. Families also completed self-report measures on family functioning, child stress and social support, parent stress, optimism, and self-efficacy. For each case, two coders independently used an ethnographic method, integrating self-report measures, family and injury characteristics, audio recordings, and transcripts to mimic integration of information within clinical practice. The coders then reached consensus on the main themes for each case through discussion. Families showed substantial variation in their communication in terms of content, tone, and frequency, including moments of conflict, humor, and injury-related conversations. We explored how these recorded interactions converged with and diverged from the self-report data. The EAR provided an opportunity for rich descriptions of individual families' communication and activities, yielding potential clinical information that may be otherwise difficult or impractical to obtain.

Después de una lesión pediátrica grave, toda la familia puede quedar afectada. Llegar a comprender el apoyo, las interacciones y los niveles de estrés de la familia puede ayudar a los profesionales a personalizar el tratamiento. Actualmente, estos factores se evalúan principalmente mediante autoinformes y observaciones estructuradas. Nuestra finalidad fue analizar el valor de la observación naturalista de las interacciones entre padres e hijos después de una lesión pediátrica a fin de destacar cómo los profesionales podrían usar estos datos en su práctica. Nuestro estudio cualitativo implicó un análisis profundo de cuatro casos del proyecto Ear for Recovery en el marco de las características de la muestra más grande. Los niños que habían sido hospitalizados con una lesión grave usaron la grabadora activada electrónicamente (Electronically Activated Recorder, EAR). Durante un periodo de dos días posteriores al alta, la EAR grabó fragmentos de audio de 30 segundos cada 5 minutos. Las familias también completaron medidas de autoinforme sobre funcionamiento familiar, estrés infantil y apoyo social, estrés de los padres, optimismo y autoeficacia. Para cada caso, dos codificadores usaron independientemente un método etnográfico, integrando medidas de autoinforme, características de la familia y la lesión, grabaciones de audio y transcripciones para imitar la integración de la información dentro de la práctica clínica. Los codificadores luego se pusieron de acuerdo sobre los temas principales de cada caso mediante una charla. Las familias demostraron una variación considerable en su comunicación en cuanto al contenido, al tono y a la frecuencia, incluidos los momentos de conflicto, de humor y las conversaciones relacionadas con la lesión. Analizamos cómo estas interacciones grabadas coincidieron y se diferenciaron de los datos autoinformados. La EAR brindó la oportunidad de obtener descripciones detalladas de la comunicación y las actividades de cada familia en particular, y facilitó posible información clínica que de lo contrario puede ser difícil o impráctico obtener.

Researcher engagement in policy deemed societally beneficial yet unrewarded.

Maintaining the continued flow of benefits from science, as well as societal support for science, requires sustained engagement between the research community and the general public. On the basis of data from an international survey of 1092 participants (634 established researchers and 458 students) in 55 countries and 315 research institutions, we found that institutional recognition of engagement activities is perceived to be undervalued relative to the societal benefit of those activities. Many researchers report that their institutions do not reward engagement activities despite institutions' mission statements promoting such engagement. Furthermore, institutions that actually measure engagement activities do so only to a limited extent. Most researchers are strongly motivated to engage with the public for selfless reasons, which suggests that incentives focused on monetary benefits or career progress may not align with researchers' values. If institutions encourage researchers' engagement activities in a more appropriate way - by moving beyond incentives - they might better achieve their institutional missions and bolster the crucial contributions of researchers to society.

How Do Mothers and Fathers Interact With Their Children After An Injury? Exploring the Role of Parental Acute Stress, Optimism, and Self-Efficacy.

OBJECTIVE: In the aftermath of a child injury, children and parents can jointly experience acute stress symptoms. Optimism and self-efficacy might buffer against post-traumatic stress disorder. Knowing that children are innately receptive to parent modeling, we were interested in exploring how parent acute stress, optimism, and self-efficacy might transpire in parent-child interactions and whether any differences existed between mothers and fathers. METHODS: We recruited 71 families of seriously injured children who were hospitalized for at least 24 hr. Parents completed self-report measures of acute stress, optimism, and self-efficacy. Children wore the Electronically Activated Recorder (EAR(2)); Mehl, M. R. [2017]. The electronically activated recorder (EAR): A method for the naturalistic observation of daily social behavior. Current Directions in Psychological Science, 26, 184-190) for a 2-day period postdischarge. The EAR recorded ambient sounds for 30 s every 5 min. The audio recordings were transcribed and coded. We derived a percentage of time spent with each parent (interaction time), and average ratings of the emotional tone of voice for each speaker. RESULTS: Overall, parental acute stress and self-efficacy were not associated with interaction time or emotional tone, and parents generally spent less time with older children. Compared to fathers, mothers spent significantly more time with their child, particularly for daughters, but mothers did not differ from fathers in emotional tone, acute stress, optimism, or self-efficacy. For mothers, optimism may be associated with greater interaction time and more positive emotional tone. CONCLUSIONS: The present study highlighted parent gender differences in time spent with children and enabled the inclusion of more fathers using a naturalistic observational tool.

Communication With Children and Families About Disaster: Reviewing Multi-disciplinary Literature 2015-2017.

PURPOSE OF REVIEW: To identify strategies for communicating with youth and children pre- and post-disaster in the context of a broader survey of child participation in disaster risk reduction as well as methods for communication with children. RECENT FINDINGS: Youth and children are capable of peer and community education and activism concerning disaster issues and such participation benefits the young actors. Family and sibling support are important in easing the impact of trauma on children. Contemporary forms of psychological first aid appear to do no harm and in line with current evidence. Generally, more evidence from evaluations is necessary to guide the development of communication strategies. Children are growing up in increasingly urban environments with less contact with nature and greater reliance on techno-social systems. Thus, young people may misunderstand natural hazards. Schools and conscious parenting can play important roles in building understanding and psychological resilience.

Development and Evaluation of the Thinking About Recovery Scale: Measure of Parent Posttraumatic Cognitions Following Children's Exposure to Trauma.

Researchers have recently suggested that parent posttraumatic appraisals potentially contribute to the development of posttraumatic stress in both parents and children following children's exposure to trauma. However, a single-instrument, multidimensional measure of parent posttraumatic cognitions as they relate to their child's recovery has yet to be operationalized. This study described the development and evaluation of a parent-report questionnaire of parent posttraumatic cognitions, designed to be used after a child's exposure to trauma. We generated an initial pool of items in reference to existing theories and subjected this list to an iterative process of item writing and revision. Items were subjected to expert review to maximize construct validity. The 33-item Thinking About Recovery Scale (TARS), which measures three domains (My child has been permanently damaged; The world is dangerous for my child; Parents should always promote avoidance) demonstrated good internal consistency (Cronbach's α = .74-88) and convergent validity (r 2 range = .08-.40) when piloted in a sample of 116 parents of children who had been exposed to a serious accidental injury. The TARS augments the available literature by providing a brief measure of parent posttraumatic cognitions, an area which is currently understudied in childhood posttraumatic stress and could have broad clinical and research use.

Trauma exposure in children with and without ADHD: prevalence and functional impairment in a community-based study of 6-8-year-old Australian children.

Both ADHD and trauma exposure are common childhood problems, but there are few empirical data regarding the association between the two conditions. The aims of this study were to compare lifetime prevalence of trauma exposure in children with and without ADHD, and to explore the association between trauma exposure and outcomes in children with ADHD. Children aged 6-8 years with ADHD (n = 179) and controls (n = 212) recruited from 43 schools were assessed for ADHD, trauma exposure and comorbid mental health disorders using the Diagnostic Interview Schedule for Children IV. Outcome data were collected by direct child assessment, parent report and teacher-report, and included ADHD symptom severity, internalizing and externalizing problems, quality of life, and academic functioning. Logistic and linear regression models were used to examine differences adjusted for child and family socio-demographics. Children with ADHD were more likely than controls to have ever experienced a traumatic event (27 vs 16%; OR: 1.99; 95% CI 1.21, 3.27). This difference remained significant in the adjusted model (OR: 1.76, 95% CI 1.03, 3.01) accounting for child factors (age and gender) and family socio-demographic factors (parent age, parent high school completion and single parent status). Among those with ADHD, trauma-exposed children had higher parent-reported ADHD severity and more externalizing problems than non-exposed children, however, this effect attenuated in adjusted model. Children with ADHD were more likely to have experienced a traumatic event than controls. The high prevalence of trauma exposure in our sample suggests that clinicians should evaluate for trauma histories in children presenting with ADHD.

Perspectives of hospital emergency department staff on trauma-informed care for injured children: An Australian and New Zealand analysis.

AIM: To examine Australian and New Zealand emergency department (ED) staff's training, knowledge and confidence regarding trauma-informed care for children after trauma, and barriers to implementation. METHODS: ED staff's perspectives on trauma-informed care were assessed using a web-based self-report questionnaire. Participants included 468 ED staff (375 nursing and 111 medical staff) from hospitals in Australia and New Zealand. Data analyses included descriptive statistics, χ2 tests and multiple regressions. RESULTS: Over 90% of respondents had not received training in trauma-informed care and almost all respondents (94%) wanted training in this area. While knowledge was associated with a respondent's previous training and profession, confidence was associated with the respondent's previous training, experience level and workplace. Dominant barriers to the implementation of trauma-informed care were lack of time and lack of training. CONCLUSIONS: There is a need and desire for training and education of Australian and New Zealand ED staff in trauma-informed care. This study demonstrates that experience alone is not sufficient for the development of knowledge of paediatric traumatic stress reactions and trauma-informed care practices. Existing education materials could be adapted for use in the ED and to accommodate the training preferences of Australian and New Zealand ED staff.

Perceived support at work after critical incidents and its relation to psychological distress: a survey among prehospital providers.

INTRODUCTION: Prehospital providers are at increased risk for psychological distress. Support at work after critical incidents is believed to be important for providers, but current guidelines are in need of more scientific evidence. This study aimed to investigate: (1) to what extent prehospital providers experience support at work; (2) whether support at work is directly associated with lower distress and (3) whether availability of a formal peer support system is related to lower distress via perceived colleague support. METHODS: This cross-sectional study surveyed prehospital providers from eight western industrialised countries between June and November 2014. A supportive work environment was operationalised as perceived management and colleague support (Job Content Questionnaire), availability of a formal peer support system and having enough time to recover after critical incidents. The outcome variable was psychological distress (Kessler 10). We conducted multiple linear regression analyses and mediation analysis. RESULTS: Of the 813 respondents, more than half (56.2%) were at moderate to high risk of psychological distress. Participants did not consistently report support at work (eg, 39.4% were not aware of formal peer support). Perceived management support (b (unstandardised regression coefficient)=-0.01, 95% CI -0.01 to 0.00), having enough time to recover after critical incidents (b=-0.07, 95% CI -0.09 to -0.04) and perceived colleague support (b=-0.01, 95% CI -0.01 to 0.00) were related to lower distress. Availability of formal peer support was indirectly related to lower distress via increased perceived colleague support (ß=-0.04, 95% CI -0.02 to -0.01). CONCLUSIONS: Prehospital providers at risk of psychological distress may benefit from support from colleagues and management and from having time to recover after critical incidents. Formal peer support may assist providers by increasing their sense of support from colleagues. These findings need to be verified in a longitudinal design.

Psychosocial Care for Injured Children: Worldwide Survey among Hospital Emergency Department Staff.

OBJECTIVE: To examine emergency department (ED) staff's knowledge of traumatic stress in children, attitudes toward providing psychosocial care, and confidence in doing so, and also to examine differences in these outcomes according to demographic, professional, and organizational characteristics, and training preferences. STUDY DESIGN: We conducted an online survey among staff in ED and equivalent hospital departments, based on the Psychological First Aid and Distress-Emotional Support-Family protocols. Main analyses involved descriptive statistics and multiple regressions. Respondents were 2648 ED staff from 87 countries (62.2% physicians and 37.8% nurses; mean years of experience in emergency care was 9.5 years with an SD of 7.5 years; 25.2% worked in a low- or middle-income country). RESULTS: Of the respondents, 1.2% correctly answered all 7 knowledge questions, with 24.7% providing at least 4 correct answers. Almost all respondents (90.1%) saw all 18 identified aspects of psychosocial care as part of their job. Knowledge and confidence scores were associated with respondent characteristics (eg, years of experience, low/middle vs high-income country), although these explained no more than 11%-18% of the variance. Almost all respondents (93.1%) wished to receive training, predominantly through an interactive website or one-off group training. A small minority (11.1%) had previously received training. CONCLUSIONS: More education of ED staff regarding child traumatic stress and psychosocial care appears needed and would be welcomed. Universal education packages that are readily available can be modified for use in the ED.

A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder.

BACKGROUND: Determinants of cross-national differences in the prevalence of mental illness are poorly understood. AIMS: To test whether national post-traumatic stress disorder (PTSD) rates can be explained by (a) rates of exposure to trauma and (b) countries' overall cultural and socioeconomic vulnerability to adversity. METHOD: We collected general population studies on lifetime PTSD and trauma exposure, measured using the WHO Composite International Diagnostic Interview (DSM-IV). PTSD prevalence was identified for 24 countries (86 687 respondents) and exposure for 16 countries (53 038 respondents). PTSD was predicted using exposure and vulnerability data. RESULTS: PTSD is related positively to exposure but negatively to country vulnerability. Together, exposure, vulnerability and their interaction explain approximately 75% of variance in the national prevalence of PTSD. CONCLUSIONS: Contrary to expectations based on individual risk factors, we identified a paradox whereby greater country vulnerability is associated with a decreased, rather than increased, risk of PTSD for its citizens.

Approaches to the Assessment of Children in the Context of Disasters.

Children exposed to disasters are a vulnerable population, making the assessment of children post-disaster an important issue. Utilizing a Multiple Gating Stepped Care framework, we highlight recent literature related to post-disaster assessment and intervention for children. In particular, we focus on screening, clinical evaluation, and feedback-informed service delivery. Screening allows large populations of children to be assessed at a relatively low cost. Children identified by screening as being at risk may then be assessed through more in-depth clinical evaluations, in order to assess clinical symptoms, strengths, and stressors, and to make determinations about appropriate interventions. Continued assessment during therapy provides important feedback for the delivery of appropriate care. New formats for assessment, as well as issues related to identifying sources for assessment, are discussed. Recommendations for future directions are provided.

Topical Review: Families Coping With Child Trauma: A Naturalistic Observation Methodology.

OBJECTIVE: To introduce a novel, naturalistic observational methodology (the Electronically Activated Recorder; EAR) as an opportunity to better understand the central role of the family environment in children's recovery from trauma. METHODS: Discussion of current research methods and a systematic literature review of EAR studies on health and well-being. RESULTS: Surveys, experience sampling, and the EAR method each provide different opportunities and challenges for studying family interactions. We identified 17 articles describing relevant EAR studies. These investigated questions of emotional well-being, communicative behaviors, and interpersonal relationships, predominantly in adults. 5 articles reported innovative research in children, triangulating EAR-observed behavioral data (e.g., on child conflict at home) with neuroendocrine assay, sociodemographic information, and parent report. Finally, we discussed psychometric, practical, and ethical considerations for conducting EAR research with children and families. CONCLUSIONS: Naturalistic observation methods such as the EAR have potential for pediatric psychology studies regarding trauma and the family environment.