Feasibility and Preliminary Impact of a Community-Based Intervention for Maternal PTSD and Parenting: Parenting-STAIR Pilot.

Trauma exposure and post-traumatic stress disorder (PTSD) impact emotional and physical well-being, social functioning, and parent-child relationship quality. The effect of parental trauma on parenting and child maltreatment is often overlooked by current child welfare (CW) services. The novel intervention, Parenting-STAIR, was created to address maternal mental health, parenting skills, and child well-being outcomes. Parenting-STAIR is a combination of Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy and Parent-Child Care (PC-CARE). This open pilot study aimed to examine the feasibility and preliminary impact of Parenting-STAIR in reducing maternal PTSD and increasing positive parenting skills for mothers and families involved in the child welfare system. Parenting-STAIR was delivered to 111 mothers receiving family preservation services in New York City. Of these, 70 completed treatment; statistical and clinically significant changes were observed for maternal PTSD and depression as well as in parenting stress, parenting skills, and child behaviors. These findings provide encouraging initial evidence for the feasibility and impact of this novel PTSD intervention. An evaluation of maltreatment recidivism is needed, as well as implementation of a randomized controlled trial to establish efficacy of the intervention.

A randomized controlled trial to assess the efficacy of Parenting-STAIR in treating maternal PTSD to reduce maltreatment recidivism: protocol for the Safe Mothers, Safe Children study.

BACKGROUND: Child maltreatment recidivism substantially increases the likelihood of adverse life outcomes, but there is little evidence that family preservation services are effective at reducing recidivism. Mothers in child welfare have very high rates of trauma exposure; maternal post-traumatic stress disorder (PTSD) is an intervention target that has the potential to reduce abuse and neglect. The Safe Mothers, Safe Children (SMSC) intervention program involves the delivery of an innovative combination of interventions, including Skills Training in Affective and Interpersonal Regulation (STAIR) and Parent-Child Interaction Therapy (PCIT). The combined intervention, Parenting-STAIR (P-STAIR), targets maternal PTSD and comorbid depression symptoms to reduce the adverse effects of PTSD on parenting, improve positive parenting skills, and prevent maltreatment recidivism. METHODS: This study is a two-arm randomized controlled trial: P-STAIR (23 sessions) versus supportive counseling (23 sessions). Participants are mothers receiving child welfare family preservation services (FPS), with a child in the age range of 1-8 years old and meeting diagnostic criteria for PTSD (with/without depression). Clinical assessment occurs at pre-treatment (baseline), two in-treatment assessments (mid-assessment #1 after module 9 and mid-assessment #2 after module 15), post-treatment, and at a 6-month follow-up. Recidivism will be measured using the New York State Child Welfare Registry (NYSCWR). We will enroll a total of 220 participants over 4 years: half (N = 110) randomly assigned to the P-STAIR condition and half (N = 110) to the supportive counseling condition. DISCUSSION: This is the first RCT to investigate the efficacy of P-STAIR. The findings for the trial have the potential to contribute to the expansion of evidence-based practices for maternal PTSD, maltreatment, and child welfare.

Cardiometabolic profiles of adolescents and young adults exposed to the World Trade Center Disaster.

BACKGROUND AND OBJECTIVE: Few studies have examined the possible cardiometabolic consequences of World Trade Center-related exposures on children who lived and/or attended school near the disaster site. Our objective was to compare cardiometabolic profiles of participants in the World Trade Center Health Registry (WTCHR) with a matched comparison group. METHODS: We evaluated WTCHR enrollees who resided in New York City and were born between September 11, 1993 and September 10, 2001, and a matched comparison group. We assessed exposure to dust cloud, home dust, as well as traumatic exposure, and associations with blood pressure, arterial wall stiffness, body mass index (BMI), total cholesterol, triglycerides, HDL, and LDL. RESULTS: A total of 402 participants completed the study, 222 in the comparison group and 180 in the WTCHR group. In multivariable regression analysis, after adjusting for relevant confounders we detected a weak association between participation in the WTCHR group and lower BMI (-1.12kg/m2, 95% CI -2.11, -0.12; p = 0.03), which became non-significant after adjusting for multiple comparisons. With respect to traumatic and psychosocial exposures, the only association that persisted in our multivariable model, below our predefined level of significance, was between post-traumatic stress disorder and higher BMI (2.06kg/m2, 95% CI 0.37, 3.74; p = 0.02). CONCLUSIONS: Our findings do not support an association between self-reported exposures to the WTC disaster and adverse cardiometabolic profile. However, further longitudinal studies may better inform the full extent of WTC-related conditions associated with exposure to the disaster.

Child Trauma Exposure and Posttraumatic Stress Disorder: Identification in Community Mental Health Clinics.

We examined the identification of trauma exposure and post-traumatic stress disorder (PTSD) in help-seeking urban children (N=157) presenting for care in community mental health clinics. Children and their parents completed a standard intake assessment conducted by a community clinician followed by a structured trauma-focused assessment conducted by a study clinician. Clinicians provided ratings of child functional impairment, parents reported on internalizing/externalizing problems, and children provided self-reports of PTSD symptom severity. Although community clinicians were mandated by clinic policy to ask about exposure to physical abuse, sexual abuse, and witnessed domestic violence, they identified exposure to these at significantly lower rates than study clinicians. Rates of PTSD based on community clinician diagnosis (1.9%) were also much lower than rates obtained by study clinicians (19.1%). A review of clinical charts one year after intake revealed no change in PTSD diagnosis rate following additional clinical contacts. Clinician-rated impairment, parent-rated emotional/behavioral problems, and child-rated PTSD symptom severity measures provided support for the validity of trauma exposure and PTSD as identified by study clinicians. Trauma exposure and PTSD diagnosis among help-seeking urban youth appear to be under-identified by community clinicians, which may compromise clinicians' ability to respond to environmental risks and provide appropriate evidence-based treatments.

Mixed-Handedness in Identical Twins Discordant for Combat Exposure in Vietnam: Relationship to Posttraumatic Stress Disorder.

This study evaluated the degree of mixed-handedness in predominantly right-handed Vietnam combat veteran twins and their identical, combat-unexposed cotwins. The "high-risk" cotwins of combat veterans with combat-related posttraumatic stress disorder (PTSD) had more mixed-handedness (i.e., less right-handedness) than the "low-risk" cotwins of combat veterans without PTSD. Self-reported combat exposure in combat-exposed twins was a mediator of the association between handedness in their unexposed cotwins and PTSD in the twins themselves. We conclude that mixed-handedness is a familial risk factor for combat-related PTSD. This risk may be mediated in part by a proclivity for mixed-handed soldiers and Marines to experience heavier combat.

Association between facial expression and PTSD symptoms among young children exposed to the Great East Japan Earthquake: a pilot study.

"Emotional numbing" is a symptom of post-traumatic stress disorder (PTSD) characterized by a loss of interest in usually enjoyable activities, feeling detached from others, and an inability to express a full range of emotions. Emotional numbing is usually assessed through self-report, and is particularly difficult to ascertain among young children. We conducted a pilot study to explore the use of facial expression ratings in response to a comedy video clip to assess emotional reactivity among preschool children directly exposed to the Great East Japan Earthquake. This study included 23 child participants. Child PTSD symptoms were measured using a modified version of the Parent's Report of the Child's Reaction to Stress scale. Children were filmed while watching a 2-min video compilation of natural scenes ('baseline video') followed by a 2-min video clip from a television comedy ('comedy video'). Children's facial expressions were processed the using Noldus FaceReader software, which implements the Facial Action Coding System (FACS). We investigated the association between PTSD symptom scores and facial emotion reactivity using linear regression analysis. Children with higher PTSD symptom scores showed a significantly greater proportion of neutral facial expressions, controlling for sex, age, and baseline facial expression (p < 0.05). This pilot study suggests that facial emotion reactivity, measured using facial expression recognition software, has the potential to index emotional numbing in young children. This pilot study adds to the emerging literature on using experimental psychopathology methods to characterize children's reactions to disasters.

Violence associated with combat-related posttraumatic stress disorder: The importance of anger.

The importance of anger with regard to violence among veterans with combat-related PTSD has received little attention. We previously proposed that in PTSD the activation of threat-related cognitive networks strongly potentiates anger in a positive feedback loop and that inhibitory controls on aggression can be overridden when PTSD and anger activation are conjoined. We predicted that violence would be intensified when combat-related PTSD was conjoined with anger. We used the National Vietnam Veterans Readjustment Study (NVVRS) public use data set, selecting the male combat theater veterans, which entailed 1,200 from the main survey (Study 1) and 259 from the clinical interview component (Study 2). Anger indices were constructed from NVVRS variables. PTSD was assessed by continuous symptom scores and by clinical diagnostic measures. Conjoined anger and PTSD was associated with greatly increased violence. PTSD was not associated with violence in the absence of anger. This result was obtained using alternative measures of PTSD and of anger in both the main survey and the clinical interview component. These findings call for reconceptualizing the association of PTSD and violence. Concerted attention should be given to anger as a risk factor for violence in the assessment and treatment of combat-related PTSD, and as an important portal of entry for treatment.

Does a one-day educational training session influence primary care pediatricians' mental health practice procedures in response to a community disaster? Results from the reaching children initiative (RCI).

Although many children and adolescents need assessment and treatment for psychological problems, few get such treatment from mental health specialists after a community disaster Research suggests that a very large proportion of children are seen in pediatric primary care settings and that pediatricians can provide appropriate care for many social and emotional problems in children. However few pediatricians have received training in providing this help. The focus of this study was to assess whether brief training to increase the capacity of primary care pediatricians (PCPs) to respond to the social or emotional problems of children after the World Trade Center terrorist attacks improved the quality of services to disaster-affected children. Pediatricians (N = 137) attended a one-day training workshop covering best practice treatments for mental health problems with an emphasis on trauma, bereavement, and medication use. We surveyed attendees prior to training, immediately post-intervention, and 1- and 6-months later. At 6-months post-intervention, 64% of the primary care clinicians reported instituting practice changes recommended during training. Reported use of formal mental health screening instruments increased, but greater use of medications was more limited. Although participants in the immediate post-intervention survey indicated strong agreement with the desirability to implement specific practice changes, the perceived desirability of such changes declined substantially at the 6-month follow-up. Changes in PCPs 'mental health related practice procedures can be facilitated by brief educational interventions, but continued training and support may be needed. We discuss these results relative to preparedness for community disasters.

Maternal posttraumatic stress disorder and depression in pediatric primary care: association with child maltreatment and frequency of child exposure to traumatic events.

IMPORTANCE: Maternal posttraumatic stress disorder (PTSD) may be associated with increased risk for child maltreatment and child exposure to traumatic events. Exposure to multiple traumatic events is associated with a wide range of adverse health and social outcomes in children. OBJECTIVE: To examine the association of probable maternal depression, PTSD, and comorbid PTSD and depression with the risk for child maltreatment and parenting stress and with the number of traumatic events to which preschool children are exposed. DESIGN: Cross-sectional observational design. We used analysis of variance to determine whether probable maternal psychopathology groups differed on child maltreatment, parenting stress, and children's exposure to traumatic events. Hierarchical regression analyses were used to examine the unique and interactive effects of depression and PTSD severity scores on these outcomes. SETTING: Urban pediatric primary care outpatient clinic. PARTICIPANTS: Ninety-seven mothers of children aged 3 to 5 years. EXPOSURE: Pediatric primary care visit. MAIN OUTCOMES AND MEASURES: Probable maternal depression and/or PTSD, parenting stress, child exposure to traumatic events, and child maltreatment. RESULTS: Mothers with probable comorbid PTSD and depression reported greater child-directed psychological aggression and physical assault and greater parenting stress. The children of mothers with PTSD (mean number of events the child was exposed to, 5.0) or with comorbid PTSD and depression (3.5 events) experienced more traumatic events than those of mothers with depression (1.2 events) or neither disorder (1.4 events). Severity of depressive symptoms uniquely predicted physical assault and neglect. Symptom scores for PTSD and depression interacted to predict psychological aggression and child exposure to traumatic events. When PTSD symptom severity scores were high, psychological aggression and the number of traumatic events children experienced rose. Depressive symptom severity scores predicted the risk for psychological aggression and exposure to traumatic events only when PTSD symptom severity scores were low. CONCLUSIONS AND RELEVANCE: Children of mothers with PTSD are exposed to more traumatic events. Posttraumatic stress disorder is associated with an increased risk for child maltreatment beyond that associated with depression. Screening and intervention for maternal PTSD, in addition to maternal depression, may increase our ability to reduce children's exposure to traumatic stress and maltreatment.

Associations of World Trade Center exposures with pulmonary and cardiometabolic outcomes among children seeking care for health concerns.

OBJECTIVE: Prior research on the physical health of children exposed to the World Trade Center (WTC) attacks has largely relied on parental report via questionnaire. We examined the impact of clinically-reported exposures on the physical health of children who lived and/or attended school in downtown Manhattan on September 11, 2001. STUDY DESIGN: We performed a cross-sectional study of 148 patients who presented to the WTC Environmental Health Center/Survivors Health Program, and were ≤ 18 years old on September 11, 2001. RESULTS: 38.5% were caught in the dust cloud from the collapsing buildings on September 11; over 80% spent ≥ 1 day in their home between September 11 and 18, 2001; and 25.7% reported home dust exposure. New-onset nasal/sinus congestion was reported in 52.7%, while nearly one-third reported new gastroesophageal reflux (GERD) symptoms. Prehypertension or hypertension was identified in 45.5%. Multivariable regression with exposure variables, body mass index category, and age as covariates identified strongest associations of dust cloud with spirometry (17.1% decrease in maximum midexpiratory flow). Younger children experienced increased peripheral eosinophils (+0.098% per year, p=0.023), while older children experienced more new-onset GERD (OR 1.17, p=0.004), headaches (OR 1.10, p=0.011), and prehypertension (OR 1.09, p=0.024). Home dust exposure was associated with reduced high-density lipoprotein (-10.3mg/dL, p=0.027) and elevated triglycerides (+36.3mg/dL, p=0.033). CONCLUSIONS: While these findings cannot be assumed to generalize to all children exposed to the WTC attacks, they strongly suggest the need for more extensive study of respiratory, metabolic, and cardiovascular consequences.

Relationship between handedness and persistent emotional distress in adults experiencing an earthquake.

AIM: Post-traumatic emotional distress follows exposure to trauma and may be affected by atypical cerebral lateralisation. We aimed to explore the relationship between handedness and emotional dysfunction in people exposed to a nat-ural disaster. METHODS: About 22 months after an earthquake, 326 exposed adults completed the Edinburgh Handedness Inventory, the Impact of Events Scale-Revised, and the Insomnia Severity Index. RESULTS: Mixed-handed people, compared to right-handed, had a 3.3 fold increase in odds to have emotional distress. Consistent left-handers scored higher than consistent right- and mixed-handers on the ISI scale. CONCLUSIONS: Findings support that lateral preference is associated with emotion-al distress in people exposed to trauma.

Israeli adolescents with ongoing exposure to terrorism: suicidal ideation, posttraumatic stress disorder, and functional impairment.

In this study, we examined the relationships among terrorism exposure, functional impairment, suicidal ideation, and probable partial or full posttraumatic stress disorder (PTSD) from exposure to terrorism in adolescents continuously exposed to this threat in Israel. A convenience sample of 2,094 students, aged 12 to 18, was drawn from 10 Israeli secondary schools. In terms of demographic factors, older age was associated with increased risk for suicidal ideation, OR = 1.33, 95% CI [1.09, 1.62], p < .01, but was protective against probable partial or full PTSD, OR = 0.72, 95% CI [0.54, 0.95], p < .05; female gender was associated with greater likelihood of probable partial or full PTSD, OR = 1.57, 95% CI [1.02, 2.40], p < .05. Exposure to trauma due to terrorism was associated with increased risk for each of the measured outcomes including probable partial or full PTSD, functional impairment, and suicidal ideation. When age, gender, level of exposure to terrorism, probable partial or full PTSD, and functional impairment were examined together, only terrorism exposure and functional impairment were associated with suicidal ideation. This study underscores the importance and feasibility of examining exposure to terrorism and functional impairment as risk factors for suicidal ideation.

Adolescent exposure to the World Trade Center attacks, PTSD symptomatology, and suicidal ideation.

This study examined the associations between different types of trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation among New York City adolescents 1 year after the World Trade Center attacks. A sample of 817 adolescents, aged 13-18, was drawn from 2 Jewish parochial high schools (97% participation rate). We assessed 3 types of trauma exposure, current (within the past month) and past (within the past year) suicidal ideation, and current PTSD symptoms. Findings indicated that probable PTSD was associated with increased risk for suicidal ideation. Exposure to attack-related traumatic events increased risk for both suicidal ideation and PTSD. However, specific types of trauma exposure differentially predicted suicidal ideation and PTSD: knowing someone who was killed increased risk for PTSD, but not for suicidal ideation, and having a family member who was hurt but not killed, increased risk for suicidal ideation, but not for PTSD. This study extends findings from the adult literature showing associations between trauma exposure, PTSD, and increased suicidal ideation in adolescents.

Does poor early metabolic control predict subsequent poor control in young children with type 1 diabetes: an exploratory study.

BACKGROUND: We sought to determine whether poor metabolic control during the early stages of type 1 diabetes mellitus predicts control during subsequent years. We hypothesized that poor control in the first year after diagnosis would predict poor control in the following year, and that poor control in the second year after diagnosis would predict poor metabolic control in subsequent years. METHODS: We conducted a retrospective review of a cohort of urban children treated for diabetes at our institution who were diagnosed between 1992 and 2005. We calculated odds ratios to determine whether control in year 1 or in year 2 predicted control in Years 3-6. Cox regression analyses were used to determine whether poor early control predicted progression to subsequent poor control. RESULTS: Metabolic control in the first year after diagnosis was not a good predictor of future control. However, poor metabolic control in the second year after diagnosis was highly predictive of poor control in subsequent years and predicted faster progression to poor control. CONCLUSION: The findings suggest that poor metabolic control in year 2 may be a predictor of subsequent poor metabolic control. Targeting prevention interventions to reduce non-adherence and to enhance metabolic control to families that show poor metabolic control in Year 2 may prove to be an optimum investment in terms of improved medical outcomes and enhanced quality of life.

Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services.

The role of parental trauma exposure and related mental health symptoms as risk factors for child maltreatment for parents involved with the child welfare (CW) system has received limited attention. In particular, little is known about the extent to which mothers receiving CW services to prevent maltreatment have experienced trauma and suffered trauma-related psychopathology. This study examined screening data collected from 127 mothers receiving CW preventive services. There were high levels of trauma exposure among screened mothers and their young children. Among mothers, 91.6% experienced at least one traumatic event (M = 2.60) and 92.2% reported their children had been exposed to one or more traumas (M = 4.85). Mothers reported high levels of trauma-related symptoms: 54.3% met probable criteria for posttraumatic stress disorder (PTSD) or depression (61.7%). Nearly half (48.8%) met criteria for co-morbid PTSD and depression. The large majority of the clients with trauma-related disorders were not receiving mental health services. Latina women had significantly more severe PTSD symptoms than African American women. Case planners reported that the screening process was useful and feasible. These findings underscore the feasibility and importance of trauma screening among parents receiving CW preventive services.

Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children's behavior.

To evaluate whether conjoined maternal posttraumatic stress disorder (PTSD) and depression are associated with increased behavioral problems among terrorism-exposed preschool children (N = 116; 18-54 months), this study compared clinically significant child behavioral problem rates among the preschool children of mothers with PTSD and depression, depression alone, and neither disorder. Behavioral problems were independently rated by mothers and preschool teachers. Maternal depression and PTSD, relative to maternal depression alone, and to neither disorder, were associated with substantially increased child problems. Notably, maternal depression and PTSD were associated with increased emotional reactivity (relative risk [RR] = 5.9 by mother's and 3.4 by teacher's reports) and aggressive behavior problems (RR = 11.0 by mother's and RR = 5.9 by teacher's reports). This was corroborated by teacher ratings. Implications for intervening with terrorism-exposed preschool children are discussed.

Factors associated with service use among immigrants in the child welfare system.

This study investigated child, caregiver, and caseworker factors associated with greater use of family support services by immigrant families in the U.S. child welfare system. Among child factors, higher levels of internalizing behavior problems (Odds Ratio (O.R.)=3.60), externalizing behavior problems (O.R.=2.62) and a history of neglect (O.R.=4.23) were associated with greater family support service use. Among caregiver factors, prior reports of maltreatment (O.R.=6.77), a serious mental health problem of the caregiver (O.R.=6.86), cognitive impairments (O.R.=10.46) in the primary caregiver, the primary caregivers' history of arrests (O.R.=6.47) and domestic violence (O.R.=2.87), were associated with heavy service use. Caseworkers' training on cultural issues (O.R.=61.35), their concerns over bureaucracy (O.R.=25.38) and concern over rules and regulations (O.R.=6.08) were also associated with greater service use among immigrant families. This research suggests that use of family support services may be determined not only by the family's demographic factors and risk level but also by caseworkers' training in cultural competence and their perception of organizational problems.

Effect of maternal psychopathology on behavioral problems in preschool children exposed to terrorism: use of generalized estimating equations to integrate multiple informant reports.

OBJECTIVE: To examine whether the number of maternal psychopathologies is associated with increased clinically significant behavioral problems in preschool children exposed to disaster, using child behavior ratings from multiple informants. DESIGN: Cross-sectional study. SETTING: Lower Manhattan, New York, New York. PARTICIPANTS: One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks. EXPOSURES: Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none. MAIN OUTCOME MEASURES: Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems. RESULTS: The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls. CONCLUSION: Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

Substance use and functional impairment among adolescents directly exposed to the 2001 World Trade Center attacks.

The relationship between exposure to the World Trade Center (WTC) attacks, increased substance use, functional impairment and mental health service use, controlling for depression and post-traumatic stress disorder, was assessed through an in-school survey of directly exposed students (N = 1040) attending the five middle and five high schools nearest the WTC. The survey was conducted 18 months after the attacks. Students with one WTC exposure risk factor had a five-fold increase in substance use, while those with three or more exposure risks had a nearly 19-fold increase. Increased substance use was associated with impaired school work, school behaviour and grades. Students reporting increased substance use were nearly twice as likely to want help but were no more likely than asymptomatic students to receive services. Adolescents reporting increased substance use, without co-morbidity, were less likely to receive psychological services than others. Attention to the needs of substance-using adolescents exposed to disaster is needed.

Relationship between type of trauma exposure and posttraumatic stress disorder among urban children and adolescents.

This study examines the association between trauma exposure and posttraumatic stress disorder (PTSD) among 157 help-seeking children (aged 8-17). Structured clinical interviews are carried out, and linear and logistic regression analyses are conducted to examine the relationship between PTSD and type of trauma exposure controlling for age, gender, and ethnicity. Confrontation with traumatic news, witnessing domestic violence, physical abuse, and sexual abuse are each significantly associated with PTSD. Witnessing a crime, being the victim of a crime, and exposure to accidents, fire, or disaster are not associated with PTSD. These findings underscore the association between interpersonal violence and childhood PTSD.