Does emotion regulation mediate the effect of stressful life events on depressive symptoms in adolescents?

INTRODUCTION: Adolescents' exposure to stressful life events (SLEs) is highly prevalent and increases their risk of developing depression considerably. A small number of studies have addressed the extent to which resilience factors, such as the ability to emotionally regulate, mediate the relationship between SLEs and depression. This study examined whether emotion regulation mediates and significantly attenuates the direct path between SLEs and depressive symptoms in a nonclinical sample of adolescents. METHOD: A sample of 235 first- and second-year high-school students completed the Depression Anxiety Stress Scale, the Risk Factor Questionnaire, and the Difficulties in Emotion Regulation Scale. Mean age was 16.9 (SD = 1.8) years, and 65 % (n = 152) of the participants were female. To assess for mediation, a regression-based path analysis approach was used. RESULTS: SLEs were significantly (t = 5.13, p < 0.001) associated with depressive symptoms, explaining 59.1 % of the total variance. Controlling for the mediation variable (emotion regulation), we found a reduced but statistically significant direct effect (t = 2.87, p = 0.005) between SLEs and depressive symptoms. A statistically significant indirect effect explaining 64.6 % of the total effect demonstrated partial mediation from stressful life events to depressive symptoms via emotion regulation. LIMITATIONS: Our analyses are based on correlational and cross-sectional data and thus exclude statistical examination of temporal causal relationships, and assessments of whether reported affects are stable over time. CONCLUSIONS: Our results indicate that interventions that can modify the ability to regulate emotions may help reduce depressive symptoms in at-risk adolescents.

Defense Style of Children and Adolescents: Differences and Ability to Discriminate Among Clinical Categories.

This study assessed the defense style of children referred to an outpatient clinic and examined what this style contributes to discriminating among various disorder categories, beyond internalizing and externalizing symptoms. A sample of 433 children and adolescents were grouped into four disorder categories: disruptive, depressive, anxiety, and attention deficit hyperactivity disorder. Their parents completed the Comprehensive Assessment of Defense Style (CADS: mature, self-oriented, and other-oriented) and the Child Behavior Checklist (CBCL: internalizing and externalizing symptoms). The disorder categories differed in the use of other-oriented defenses (e.g., acting-out, projection), whereas the CADS helped in properly discriminating most diagnostic categories beyond the CBCL. Information provided by the children themselves was missing, as was a subsample of nonclinical participants; these sources could strengthen the conclusions of the study. Assessing children's defense style together with their symptoms may result in better statistical discrimination among diagnostic categories.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Assessment, Prevention, and Intervention.

PURPOSE OF REVIEW: The goal of this paper is to review the research literature regarding the needs of preschoolers in the context of disasters and terrorism with the aim of understanding the existing methods for assessment, prevention, and intervention to provide recommendations and point out required research and development. RECENT FINDINGS: We differentiate between screening tools that provide initial evaluation and assessment tools for diagnosing preschooler children's pathology and review possible interventions that address the preschool child's needs before, during, and after the incident itself. We also emphasize the lack of dissemination and research of prevention programs and mass interventions for preschoolers. Programs for community mass prevention and intervention for preschoolers should be developed and evaluated and interventions should be adapted for individual and group delivery. Moreover, the increase in the number of children refugees requires cultural adaptations of assessment measures and interventions.

Addressing the Needs of Preschool Children in the Context of Disasters and Terrorism: Clinical Pictures and Moderating Factors.

PURPOSE OF REVIEW: This paper surveys the existent theoretical and research literature regarding the needs of preschool children in the context of disasters and terrorism with the aim of understanding (a) the consequences of such events for young children and (b) the main moderating variables influencing the event-consequence association to learn how to enhance their resilience. RECENT FINDINGS: Consequences include a variety of emotional, behavioral, and biological outcomes. Implications for refugee children are discussed. Main moderating variables were mother's sensitivity and mother's PTSD symptoms. Exposure to disasters and terrorism may have severe effects on the mental health and development among preschool children. Future research should explore the implications of different levels of exposure and the effects of moderating psychosocial and biological variables, including the parent-child triad, on the event-consequence relationship.

Psychophysiological Reactivity in Child Sexual Abuse.

Sexual abuse has physiological and emotional implications. The purpose of this study is to evaluate the neurobiological sequels of childhood sexual trauma by monitoring physiological variables among sexually abused girls and women compared to controls. We assessed posttrauma and traumatic life events of 35 females sexually abused in their childhood (age range 7-51 years) and 25 control females (age range 7-54 years). Electroencephalography, frontalis electromyography, electrodermal activity, and heart rate parameters were recorded while watching sets of pictures representing neutral and trauma-suggestive stimuli. A minority of participants met the Diagnostic and Statistical Manual of Mental Disorders criteria for post-traumatic stress disorder. Abused females displayed significant elevations in heart rate, electromyography, and electroencephalography while viewing allusive stimuli and elevated heart rate while viewing neutral stimuli. The dysfunctional regulation of the physiological stress system associated with child sexual abuse may endanger the victims with various stress and anxiety disorders.

Enhancing Children's Resilience in Schools to Confront Trauma: The Impact on Teachers.

BACKGROUND: Children's exposure to stressful events requires effective interventions to strengthen adaptive development. Expanding the teachers' role to deliver resilience-focused interventions has been shown to enhance children's coping and to have a positive impact on the teachers themselves. METHOD: This study compared the self-efficacy and perceived performance of 48 teachers following the implementation of such an intervention with 52 control teachers. RESULTS: Trained teachers reported higher self-efficacy and perceived performance. Associations between years of experience, perceived performance and self-efficacy are discussed. CONCLUSIONS: This study provides further evidence on the positive impact of teacher-delivered interventions on teachers' performance and self-efficacy. Future studies should replicate this design with a larger sample to examine stages of professional experience, grades, before-after measures, association with students' coping and include male teachers.

Assessing the Use of the Child Attachment Interview in a Sample of Israeli Jewish Children.

BACKGROUND: This manuscript assesses the use of the Child Attachment Interview (CAI) in a sample of Israeli Jewish children in middle childhood in order to add to empirical data on this measure. METHOD: Forty-one children between the ages of 7 and 13 were consecutively recruited to the study. The clinical sample included 29 children diagnosed with anxiety disorder, major depression or ADHD. The Father Focused Referral (FFR) sample included 12 children whose father was unavailable to them. Participants were administered the CAI and coded by certified personnel. RESULTS: 81.4% concordance was found between maternal and paternal secure-insecure attachment classifications in the clinical sample; 100% of the children in the FFR group were classified as insecurely attached to their fathers suggesting convergent validity for the classification of father attachment; 45.4% of the children in the FFR sample were also classified as insecurely attached to their mothers, pointing to the difference that can be found between the two parental attachment classifications in relevant cases, and therefore to sufficient discriminant validity between the two classifications. CONCLUSIONS: The clinical sample concordance rate, which was lower than in previous studies, indicates that parental concordance rates should be further investigated using different samples and countries. The study's findings regarding the difference that can be found between parental attachment classifications show the instrument's relevance in cases which the parental representations may differ. In these cases, using an instrument that does not examine the attachment toward both parents might not suffice. Study limitations and further implications are discussed.

Preschool Israeli Children Exposed to Rocket Attacks: Assessment, Risk, and Resilience.

Preschool children are among the most vulnerable populations to adversity. This study described the effects of 4 weeks of daily exposure to rocket attacks on children living on Israel's southern border. Participants enrolled in this study were 122 preschool children (50% boys) between the ages 3 and 6 years from 10 kindergartens. We assessed mothers' report of children's symptoms according to the DSM-IV and alternative criteria resembling the DSM-5 criteria for posttraumatic stress disorder (PTSD), general adaptation, traumatic exposure, and stressful life events 3 months after the war. The prevalence of PTSD was lower when the diagnosis was derived from the DSM-IV (4%) than from the DSM-5 criteria (14%). Mothers of children with 4 or more stressful life events reported more functional impairment in social, occupational, and other important areas of functioning compared to children with 0 or 1 stressful life event. Children with more severe exposure showed more severe symptoms and mothers had more concerns about the child's functioning (η(p)(2) = .09-.25). Stressful life events and exposure to traumatic experiences accounted for 32% of the variance in PTSD and 19% of the variance in the adaptation scale. Results were explored in terms of risk and resilience factors.

Post-traumatic reaction of Israeli Jewish and Arab children exposed to rocket attacks before and after teacher-delivered intervention.

BACKGROUND: Belonging to ethnic minorities is a risk factor for traumatized children. this study investigated the influence of exposure to rocket attacks during the 2006 Lebanon War on Jewish and two groups of arab Israeli students and the effect of implementing a teacher-delivered intervention focusing on resilience enhancement. METHOD: Children from both ethnic groups (N = 1,372) were assessed for stressful life events, symptoms and parental concern regarding adaptation before the 16- week program (t1) and after its completion (t2). RESULTS: arab children reported more severe symptoms at t1. the three groups showed a significant decrease to the same level at t2. Both ethnic groups differed in the level of parental concern and in the way stressful life events affected children's symptoms. CONCLUSIONS: the results suggest that school-based programs with teachers as clinical mediators could be a valuable, cost-effective cross-cultural model of intervention after mass trauma, moderating vulnerabilities of ethnic minorities.

Teacher-delivered resilience-focused intervention in schools with traumatized children following the second Lebanon War.

The 2006 Lebanon War exposed children in the north of Israel to daily rocket attacks. To cope with the massive psychological needs, a teacher-delivered protocol focusing on enhancing personal resilience was implemented. Children were assessed for risk factors, symptoms, and adaptation before the 16-week program (Time 1; n = 983) and after its completion (Time 2; n = 563). At a 3-month follow-up (Time 3; n = 754) children were assessed together with a waiting-list comparison group (n = 1,152). Participating children showed a significant symptom decrease at Time 2 and significantly fewer symptoms than the control group at Time 3. Six or more risk factors were associated with greater symptoms and parental concern about the child's adaptive functioning. Teachers are valuable cost-effective providers for clinically informed interventions after mass trauma and disaster.

Preventing children's posttraumatic stress after disaster with teacher-based intervention: a controlled study.

OBJECTIVE: The psychological outcomes that the exposure to mass trauma has on children have been amply documented in the past decades. The objective of this study is to describe the effects of a universal, teacher-based preventive intervention implemented with Israeli students before the rocket attacks that occurred during Operation Cast Lead, compared with a nonintervention but exposed control group. METHOD: The study sample consisted of 1,488 students studying in fourth and fifth grades in a city in southern Israel who were exposed to continuous rocket attacks during Operation Cast Lead. The intervention group included about half (53.5%) of the children who studied in six schools where the teacher-led intervention was implemented 3 months before the traumatic exposure. The control group (46.5% of the sample) included six schools matched by exposure in which the preventive intervention was not implemented. Children filled out the UCLA-PTSD Reaction Index and the Stress/Mood Scale 3 months after the end of the rocket attacks. RESULTS: The intervention group displayed significantly lower symptoms of posttrauma and stress/mood than the control group (p < .001). Control children had 57% more detected cases of postraumatic stress disorder (PTSD) than participant children. This difference was significantly more pronounced among boys (10.2% versus 4.4%) and less among girls (12.5% versus 10.1%). CONCLUSIONS: The teacher-based, resilience-focused intervention is a universal, cost-effective approach to enhance the preparedness of communities of children to mass trauma and to prevent the development of PTSD after exposure.

A trauma-like model of political extremism: psycho-political fault lines in Israel.

This study examines a trauma-like model of potentially violent political extremism among Jewish Israelis. We study the psychosocial characteristics of political extremists that may lie at the root of sociopolitical instability and assess personal (gender, stressful life events, Holocaust family background, and political activism) and psychological parameters (self- and political transcendence, perceived political threats, in/out-group identification ratio) that may predict readiness to engage in destructive political behavior. We examine the ideological zeal of various political groups, the relationship between the latter and perceived political threats, and the predictors of extreme political activism. Results showed that the extreme political poles displayed high level of ideological and morbid transcendence. Right extremists displayed higher perceived threats to physical existence and national identity. Left extremists scored highest on perceived moral integrity threat. Higher perceived threats to national identity and moral integrity, risk, and self-transcendence statistically explain morbid transcendence. When fear conjures up extremely skewed sociopolitical identifications across political boundaries, morbid transcendence may manifest itself in destructive political activity.

A comparison of life events in suicidal and nonsuicidal adolescents and young adults with major depression and borderline personality disorder.

This retrospective study assessed the correlations between various types of stressful life events (SLE) and suicidal adolescents and young adults with major depressive disorder (MDD;22), borderline personality disorder (BPD;18), and nonsuicidal adolescents and young adults with MDD (20) and BPD (20). A community control group of 40 participants was also evaluated. The measurements used were Life Events Checklist, Childhood Sexual Abuse Questionnaire, Suicide Risk Scale, and Beck Depression Inventory. Suicidal participants experienced a greater number of total lifetime negative events compared with nonsuicidal participants, irrespective of diagnosis, including a greater amount of negative life events in the year before the suicide attempt compared with the year before referral in the nonsuicidal group. Participants with MDD reported more lifetime negative events than participants with BPD. Suicidal adolescents did not have more lifetime death-related SLE than nonsuicidal adolescents, but MDD adolescents experienced more lifetime death-related SLE than BPD adolescents. Suicidal BPD participants reported more lifetime sex abuse-related SLE compared with nonsuicidal BPD participants. The complexity of the relationships between SLE and the interplay of both suicidality and underlying psychopathology is discussed with the relevant treatment implications.

Risk and protective factors mediating psychological symptoms and ideological commitment of adolescents facing continuous terrorism.

This study evaluated symptoms, risk, and protective factors of adolescents from six Israeli schools exposed to continuous terrorism. All children in the grades selected at each school (7, 9, and 11) were administered anonymous assessment materials measuring posttraumatic, grief, and dissociative symptoms, as well as traumatic exposure, personal resilience, and family factors. A high number of risk factors increased the likelihood of negative symptoms. Perceived personal resilience served as a protective factor against symptom development, perhaps enforced by ideology. Girls living on the West Bank had less severe posttrauma and were more willing to make personal sacrifices for their country. Proactive interventions aimed at enhancing a child's personal resilience and ability to cope with continuous stress may help protect against later symptomatology following traumatic events. Facing terrorism, political ideology may serve a double edge sword: protecting against symptom development as well as contributing to the toxic cycle of violence.

Teacher-mediated intervention after disaster: a controlled three-year follow-up of children's functioning.

BACKGROUND: Child survivors of a catastrophic earthquake in Turkey were evaluated three and a half years after the event, and three years after a sub-group participated in a teacher-mediated intervention developed by the authors. The goal of this follow-up study was to determine the long-term effectiveness of the original intervention. METHODS: Subjects who participated in the intervention were compared with a control group of children similar in terms of demographics, risk and exposure. All children were evaluated in terms of posttraumatic, grief and dissociative symptomatology, as well as adaptive functioning (academic performance, social behavior and general conduct). RESULTS: The severity of post-traumatic, grief and dissociative symptoms of the two groups was comparable. Teachers blind to group assignment rated participating children significantly higher than the control group in terms of adaptive functioning. CONCLUSIONS: Early post-disaster intervention addressing children and their educational milieu provides children with significant symptomatic reduction, allowing the mobilization of adaptive coping, thereby enhancing their overall functioning as observed in school.

Psychiatric morbidity and quality of life in children with malignancies and their parents.

Recent improvements in prognosis necessitate considering the emotional responses of children with malignant diseases and of their parents. This prospective study assessed 20 children and adolescents and their 36 parents within 2 weeks of diagnosis and after 1 and 6 months. Fifty-three percent exhibited moderate to severe posttraumatic symptoms right after diagnosis that decreased significantly after 1 month. Children with high-risk disease reported the most severe symptoms. Unexpectedly, children with low-risk disease exhibited more severe symptoms than those with moderate risk. Depressive symptoms decreased significantly during the period, but anxiety symptoms did not. Moreover, quality of life did not change. Twenty percent of parents exhibited posttraumatic symptoms on initial evaluation. Mothers' symptoms did not change, but fathers' symptoms decreased with those of their children. Several procedures and experiences were identified as causes of traumatic stress responses.

Attitudes toward Arabs of Israeli children exposed to missile attacks: the role of personality functions.

BACKGROUND: This study examines the attitudes toward Arabs of Israeli children who were exposed to missile attacks during the Gulf War as related to exposure, early and present functioning, and appraisal of chances for peace. METHODS: A semi-structured interview assessed the attitudes, symptoms, defenses and prosocial behavior of 82 children who had been directly exposed to the missile attacks. RESULTS: The attitudes were not related to the displacement of the family during the war. A very negative attitude was associated with more problems with behavior modulation during the preschool years, an increase in externalizing and posttraumatic symptoms, and more immature defenses. A balanced attitude was associated with age, fewer symptoms, more mature defenses, and more prosocial behavior. CONCLUSION: Individual vulnerabilities in the face of traumatic experiences could lead to posttraumatic responses that may shape children's social attitudes and behaviors. The resolution of inter-group conflict requires implementation of psychotherapeutic and socio-educational interventions to transform hate and fear into empathy and hope.

Facing war, terrorism, and disaster: toward a child-oriented comprehensive emergency care system.

The combination of the overwhelming nature of disasters and the massive losses they engender gives rise to a complex clinical and social picture with longterm physical, psychological, and social effects on children, families, and communities. The authors suggest that to assess the damage properly, implement interventions on a large scale, keep tabs on rising needs, and restore societal function, mental health professionals must adopt an ecologic systems approach. This approach entails working within and together with related institutions (education, health, local government) and assisting other committed professionals within these institutions to mediate care. This is of utmost importance in the area of children's care because of their particular vulnerability and their special importance for families and society. For this reason, the authors suggest that emergency mental health systems be better designed and implemented while keeping children at the center of their focus. An essential component of the ecologic systems approach is improved education for mental health professionals, providing them the appropriate tools to cope with widespread disaster and the expertise to apply these tools. This approach, however, is not enough. A good outcome cannot be achieved without preparedness on the part of the other relevant institutions and the community as a whole. Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national, and international networking. In the current global village that is threatened by pervasive terrorism, no community must face it alone. The challenge of a disaster to one community is a challenge to all. By working together we can lessen the devastating impact of these events, save countless lives, prevent untold suffering, and maintain hope for a better world for children.

School reactivation programs after disaster: could teachers serve as clinical mediators?

Mental health interventions are known to prevent the progressive worsening of symptoms in young victims of disaster and, subsequently, to prevent a decline in their academic performance and self-esteem [8,46]. The tremendous needs that emerge after a disaster and the reluctance shown by most victims to seek professional help require mental health leaders to adopt a proactive stance and implement relief programs in the child's most natural setting. The school as institution and the teachers as empowered mediators offer the appropriate conditions for implementing an effective large-scale intervention program. Well-intentioned child professionals who deal with school administrators and teachers must take into account that, as stated by Pfefferbaum et al [25], "avoidance is at the core of the posttraumatic response, and it sometimes involves avoidance of treatment." For child mental health professionals, routine collaboration across systemic boundaries may prove critical for the rapid mobilization of resources during mass traumatic emergencies. Further studies are needed to identify the protective and risk factors that predict resilience and pathology, respectively, and factors that facilitate or aggravate factors that predict improvement, resistance, and deterioration in response to treatment.

Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes.

Grief and dissociation after traumatic exposures are among the most important predictors of posttraumatic stress disorder (PTSD). This article introduces the Traumatic Dissociation and Grief Scale (TDGS), a 23-item measure easily administered. The TDGS, the Child PTSD-Reaction Index (CPTSD-RI), and a questionnaire concerning risk factors related to the event (losses, injury, and witnessing death and injuries) were administered to school-aged children who had been directly exposed to the 1999 earthquakes in Turkey and to a nonexposed control group. Factor analysis of the TDGS yielded four factors: perceptual distortions, body-self distortions, irritability, and guilt and anhedonia. A moderate positive correlation was noted between the TDGS and the CPTSD-RI. Different sets of risk factors were associated with the different scale factors. The results suggest that the assessment of psychopathology in children following a disaster requires the complementary evaluation of symptoms of posttrauma, dissociation, and grief.