Investigating the dissociative subtype of post-traumatic stress disorder in single- and multi-event trauma-exposed youth: Prevalence, course, prognosis, severity and functional impairment.

OBJECTIVES: This study aimed, following both single- and multi-event trauma, to ascertain prevalence and course of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in youth; how well early PTSD-DS predicts later PTSD; and whether dissociation accounts for unique variance in post-traumatic stress symptoms (PTSS) and functional impairment over and above the effect of other post-trauma cognitive processing factors and PTSS respectively. DESIGN AND METHODS: This study is a secondary analysis of data from the Acute Stress Programme for Children and Teenagers study (n = 234) and the Coping in Care After Trauma study (n = 110) in which children had experienced single- and multi-event trauma respectively. RESULTS: PTSD-DS diagnosis was common in children with PTSD regardless of trauma experienced (>39.0%). PTSD-DS showed a similar trajectory of natural recovery to PTSD, and it was similarly predictive of later PTSD following single-event trauma. Finally, dissociation was a significant factor in PTSS and functional impairment. CONCLUSIONS: These results should be viewed in the context of several limitations including narrow sample of participants which reduces the generalizability of results, concerns around children's ability to conceptualize challenging concepts such as dissociation and the use of self-report measures to form diagnostic groups. The PTSD-DS diagnosis may offer clinical utility to the extant PTSD diagnosis in children and adolescents, as dissociation has been shown to be a contributory factor in the maintenance of both PTSS and functional impairment. Further research is required to inform further editions of the DSM and other diagnostic systems.

Trauma Memory Characteristics and Neurocognitive Performance in Youth Exposed to Single-Event Trauma.

Cognitive models of posttraumatic stress disorder (PTSD) highlight characteristics of trauma memories, such as disorganisation, as key mechanisms in the aetiology of the disorder. However, studies investigating trauma memory in youth have provided inconsistent findings. Research has highlighted that PTSD in youth may be accompanied by difficulties in neurocognitive functioning, potentially impacting ability to recall the trauma memory. The present study sought to investigate both trauma memory characteristics and neurocognitive functioning in youth aged 8-17 years. Youths exposed to single-event trauma, with (N = 29, Mage = 13.6, 21 female) and without (N = 40, Mage = 13.3, 21 female) a diagnosis of PTSD, completed self-report measures of trauma memory, a narrative memory task and a set of neurocognitive tests two to six months post-trauma. A group of non trauma-exposed youths (N = 36, Mage = 13.9, 27 female) were compared on narrative and neurocognitive tasks. Results indicated that trauma memories in youth with, versus without, PTSD were more sensory-laden, temporally disrupted, difficult to verbally access, and formed a more 'central' part of their identity. Greater differences were observed for self-reported memory characteristics compared to narrative characteristics. No between group differences in neurocognitive function were observed. Self-reported trauma memory characteristics highlight an important factor in the aetiology of PTSD. The observed lack of significant differences in neurocognitive ability potentially suggests that cognitive factors represent a more relevant treatment target than neurocognitive factors in single-event PTSD. Further research to understand the cognitive factors represented by self-reported trauma memory characteristics is recommended.

Trajectory of post-traumatic stress and depression among children and adolescents following single-incident trauma.

OBJECTIVE: Post-traumatic stress disorder and depression have high comorbidity. Understanding their relationship is of clinical and theoretical importance. A comprehensive way to understand post-trauma psychopathology is through symptom trajectories. This study aims to look at the developmental courses of PTSD and depression symptoms and their interrelationship in the initial months post-trauma in children and adolescents. METHODS: Two-hundred-and-seventeen children and adolescents aged between eight and 17 exposed to single-event trauma were included in the study. Post-traumatic stress symptoms (PTSS) and depression symptoms were measured at 2 weeks, 2 months and 9 months, with further psychological variables measured at the 2-week assessment. Group-based trajectory modelling (GBTM) was applied to estimate the latent developmental clusters of the two outcomes. Logistic regression was used to identify predictors associated with high symptom groups. RESULTS: The GBTM yielded a three-group model for PTSS and a three-group model for depression. PTSS trajectories showed symptoms reduced to a non-clinical level by 9 months for all participants (if they were not already in the non-clinical range): participants were observed to be resilient (42.4%) or recovered within 2 months (35.6%), while 21.9% experienced high level PTSS but recovered by 9 months post-trauma. The depression symptom trajectories predicted a chronic non-recovery group (20.1%) and two mild symptom groups (45.9%, 34.0%). Further analysis showed high synchronicity between PTSS and depression groups. Peri-event panic, negative appraisals, rumination and thought suppression at 2 weeks predicted slow recovery from PTSS. Pre-trauma wellbeing, post-trauma anxiety and negative appraisals predicted chronic depression. CONCLUSIONS: Post-trauma depression was more persistent than PTSS at 9 months in the sampled population. Cognitive appraisal was the shared risk factor to high symptom groups of both PTSS and depression.

Objetivo: El trastorno de estrés postraumático y la depresión tienen una alta comorbilidad. Comprender su relación es de importancia clínica y teórica. Una forma integral de comprender la psicopatología postraumática es a través de las trayectorias de los síntomas. Este estudio tiene como objetivo observar los cursos de desarrollo del TEPT y los síntomas de depresión y su interrelación en los primeros meses posteriores al trauma en niños/ñas y adolescentes.Métodos: Se incluyeron en el estudio 217 niños/ñas y adolescentes de ocho a diecisiete años expuestos a un evento traumático único. Los síntomas de estrés postraumático (SEPT) y los síntomas de depresión se midieron a las 2 semanas, 2 meses y 9 meses, con otras variables psicológicas medidas en la evaluación de 2 semanas. Se aplicó un modelo de trayectoria basado en grupos (MTBG) para estimar los grupos de desarrollo latentes de los dos resultados. Se utilizó la regresión logística para identificar predictores asociados con grupos de síntomas elevados.Resultados: El MTBG arrojó un modelo de tres grupos para SEPT y un modelo de tres grupos para depresión. Las trayectorias de SEPT mostraron síntomas reducidos a un nivel no clínico en 9 meses para todos los participantes (si ellos aún no estaban en el rango no clínico): se observó que los participantes eran resilientes (42,4%) o se recuperaron en 2 meses (35,6%), mientras que el 21,9% experimentó un SEPT de alto nivel pero se recuperó a los 9 meses después del trauma. Las trayectorias de los síntomas de depresión predijeron un grupo crónico de no-recuperación (20,1%) y dos grupos de síntomas leves (45,9%, 34,0%). Un análisis posterior mostró una alta sincronicidad entre los grupos de SEPT y depresión. El pánico peri-evento, las evaluaciones negativas, la rumiación y la supresión del pensamiento a las 2 semanas predijeron una recuperación lenta del SEPT. El bienestar pre-traumático, la ansiedad post-traumática y las valoraciones negativas predijeron la depresión crónica.Conclusiones: La depresión post-traumática fue más persistente que el SEPT a los 9 meses en la población muestreada. La evaluación cognitiva fue el factor de riesgo compartido para los grupos de síntomas altos tanto de SEPT como de depresión.

The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds.

BACKGROUND: The introduction of developmentally adapted criteria for posttraumatic stress disorder (PTSD) has improved the identification of ≤6-year-old children with clinical needs. Across two studies, we assess predictors of the development of PTSD in young children (PTSD-YC), including the adult-led acute stress disorder (ASD) diagnosis, and provide proof of principle for cognitive-focused therapy for this age range, with the aim of increasing treatment options for children diagnosed with PTSD-YC. METHOD: Study 1 (N = 105) assessed ASD and PTSD-YC diagnosis in 3- to 8-year-old children within one month and at around three months following attendance at an emergency room. Study 2 (N = 37) was a preregistered (www.isrctn.com/ISRCTN35018680) randomized controlled early-phase trial comparing CBT-3M, a cognitive-focused intervention, to treatment-as-usual (TAU) delivered within the UK NHS to 3- to 8-year-olds diagnosed with PTSD-YC. RESULTS: In Study 1, the ASD diagnosis failed to identify any young children. In contrast, prevalence of acute PTSD-YC (minus the duration requirement) was 8.6% in the first month post-trauma and 10.1% at 3 months. Length of hospital stay, but no other demographic or trauma-related characteristics, predicted development of later PTSD-YC. Early (within one month) diagnosis of acute PTSD-YC had a positive predictive value of 50% for later PTSD-YC. In Study 2, most children lost their PTSD-YC diagnosis following completion of CBT-3M (84.6%) relative to TAU (6.7%) and CBT-3M was acceptable to recipient families. Effect sizes were also in favor of CBT-3M for secondary outcome measures. CONCLUSIONS: The ASD diagnosis is not fit for purpose in this age-group. There was a strong and encouraging signal of putative efficacy for young children treated using a cognitive-focused treatment for PTSD, and a larger trial of CBT-3M is now warranted.

Prevalence and predictive value of ICD-11 post-traumatic stress disorder and Complex PTSD diagnoses in children and adolescents exposed to a single-event trauma.

BACKGROUND: The 11th edition of the International Classification of Diseases (ICD-11) made a number of significant changes to the diagnostic criteria for post-traumatic stress disorder (PTSD). We sought to determine the prevalence and 3-month predictive values of the new ICD-11 PTSD criteria relative to ICD-10 PTSD, in children and adolescents following a single traumatic event. ICD-11 also introduced a diagnosis of Complex PTSD (CPTSD), proposed to typically result from prolonged, chronic exposure to traumatic experiences, although the CPTSD diagnostic criteria do not require a repeated experience of trauma. We therefore explored whether children and adolescents demonstrate ICD-11 CPTSD features following exposure to a single-incident trauma. METHOD: Data were analysed from a prospective cohort study of youth aged 8-17 years who had attended an emergency department following a single trauma. Assessments of PTSD, CPTSD, depressive and anxiety symptoms were performed at two to four weeks (n = 226) and nine weeks (n = 208) post-trauma, allowing us to calculate and compare the prevalence and predictive value of ICD-10 and ICD-11 PTSD criteria, along with CPTSD. Predictive abilities of different diagnostic thresholds were undertaken using positive/negative predictive values, sensitivity/specificity statistics and logistic regressions. RESULTS: At Week 9, 15 participants (7%) were identified as experiencing ICD-11 PTSD, compared to 23 (11%) experiencing ICD-10 PTSD. There was no significant difference in comorbidity rates between ICD-10 and ICD-11 PTSD diagnoses. Ninety per cent of participants with ICD-11 PTSD also met criteria for at least one CPTSD feature. Five participants met full CPTSD criteria. CONCLUSIONS: Reduced prevalence of PTSD associated with the use of ICD-11 criteria is likely to reduce identification of PTSD relative to using ICD-10 criteria but not relative to DSM-4 and DSM-5 criteria. Diagnosis of CPTSD is likely to be infrequent following single-incident trauma.

The psychometric properties of the cognitive emotion regulation questionnaire (CERQ) in a clinical sample of adults with recurrent depression.

BACKGROUND: Affective dysregulation is central to depression. However, emotion regulation (ER) tendencies in depression remain poorly understood. It is critical, therefore, to validate measures of habitual ER in clinical populations. The current study aimed to validate the Cognitive Emotion Regulation Questionnaire (CERQ) in a sample of individuals with a history of recurrent depression who are currently in remission. METHOD: The CERQ measures ER tendencies with 36 self-report items that are divided into nine subscales. Each subscale is purported to assess one of five adaptive and four maladaptive ER strategies. The CERQ was administered to 476 adults (mean age = 46.76 years; 75% female) that were currently in remission with a history of recurrent depression, who were recruited from primary care settings. We first investigated the CERQ's nine factor structure, internal consistency, convergent and criterion validity. RESULTS: The nine-factor structure did not fit the CERQ structure in a sample of individuals with recurrent depression and convergent validity was poor. Instead, a five-factor structure fit the data best and showed acceptable convergent and criterion validity. LIMITATIONS: The generalisability of the findings may be limited due to relative lack of diversity in terms of gender and ethnicity of the sample. CONCLUSION: These results suggest that the taxonomic structure of the CERQ does not fit emotion regulation patterns in adults with a history of depression. These findings highlight the importance of validating measures in clinical samples.

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.

The Dimensionality of Proposed DSM-5 PTSD Symptoms in Trauma-Exposed Young Children.

A subtype of the posttraumatic stress disorder diagnosis for children 6 years and younger (PTSD-6Y) was introduced in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). This study utilized confirmatory factor analytic techniques to evaluate the proposed DSM-5 PTSD-6Y factor structure and criterion and convergent validity against competing models. Data for N = 284 (3-6 years) trauma-exposed young children living in New Orleans were recruited following a range of traumas, including medical emergencies, exposure to Hurricane Katrina and repeated exposure to domestic violence. The model was compared to DSM-IV, a 4-factor 'dysphoria' model that groups symptoms also associated with anxiety and depression, and alternate 1- and 2- factor models. Convergent validity was established against the Child Behavior Checklist (CBCL). Criterion related validity was established by comparing each model to a categorical rating of impairment. The Dysphoria and PTSD-6Y models offered the better accounts of symptom structure, although neither satisfied minimum requirements for a good fitting model. These two models also only showed small levels of convergence with CBCL dimensions. The 1-factor model offered the most compelling balance of sensitivity and specificity, with the 2-factor model and the Dysphoria model following closely behind. These CFA results do not support the symptom clusters proposed within the DSM-5 for PTSD-6Y. Although a 4-factor Dysphoria model offers a better overall account of clustering patterns (relative to alternate models), alongside acceptable sensitivity and specificity for detecting clinical impairment, it also falls short of being an adequate model in this younger age group.

A core role for cognitive processes in the acute onset and maintenance of post-traumatic stress in children and adolescents.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a common reaction to trauma in children and adolescents. While a significant minority of trauma-exposed youth go on to have persistent PTSD, many youths who initially have a severe traumatic stress response undergo natural recovery. The present study investigated the role of cognitive processes in shaping the early reactions of child and adolescents to traumatic stressors, and the transition to persistent clinically significant post-traumatic stress symptoms (PTSS). METHODS: A prospective longitudinal study of youth aged 8-17 years who had attended a hospital emergency department following single trauma was undertaken, with assessments performed at 2-4 weeks (N = 226) and 2 months (N = 208) post-trauma. Acute stress disorder and PTSD were assessed using a structured interview, while PTSS, depression severity and peritraumatic and post-traumatic cognitive processes were assessed using self-report questionnaires. On the basis of their PTSS scores at each assessment, participants were categorised as being on a resilient, recovery or persistent trajectory. RESULTS: PTSS decreased between the two assessments. Cognitive processes at the 2- to 4-week assessment accounted for the most variance in PTSS at both the initial and follow-up assessment. The onset of post-traumatic stress was associated particularly with peritraumatic subjective threat, data-driven processing and pain. Its maintenance was associated with greater peritraumatic dissociation and panic, and post-traumatic persistent dissociation, trauma memory quality, rumination and negative appraisals. Efforts to deliberately process the trauma were more common in youth who experienced the onset of clinically significant PTSS. Regression modelling indicated that the predictive effect of baseline negative appraisals remained when also accounting for baseline PTSS and depression. CONCLUSIONS: Cognitive processes play an important role in the onset and maintenance of PTSS in children and adolescents exposed to trauma. Trauma-related appraisals play a particular role when considering whether youth make the transition from clinically significant acute PTSS to persistent PTSS.

The Preliminary Development and Validation of a Trauma-Related Safety-Seeking Behavior Measure for Youth: The Child Safety Behavior Scale (CSBS).

Safety-seeking behaviors (SSBs) may be employed after exposure to a traumatic event in an effort to prevent a feared outcome. Cognitive models of posttraumatic stress disorder propose SSBs contribute to maintaining this disorder by preventing disconfirmation of maladaptive beliefs and preserving a sense of current threat. Recent research has found that SSBs impact children's posttraumatic stress symptoms (PTSS) and recovery. In this paper, we sought to develop and validate a novel 22-item Child Safety Behavior Scale (CSBS) in a school-based sample of 391 pupils (age 12-15 years) who completed a battery of questionnaires as well as 68 youths (age 8-17 years) who were recently exposed to a trauma. Of the sample, 93.1% (N = 426) completed the new questionnaire. The sample was split (n = 213), and we utilized principal components analysis alongside parallel analysis, which revealed that 13 items loaded well onto a two-factor structure. This structure was superior to a one-factor model and overall demonstrated a moderately good model of fit across indices, based upon a confirmatory factory analysis with the other half of the sample. The CSBS showed excellent internal consistency, r = .90; good test-retest reliability, r = .64; and good discriminant validity and specificity. In a multiple linear regression, SSBs, negative appraisals, and number of trauma types each accounted for unique variance in a model of PTSS. This study provides initial support for the use of the CSBS in trauma-exposed youth as a valuable tool for further research, clinical assessment, and targeted intervention.

The Parent Trauma Response Questionnaire (PTRQ): development and preliminary validation.

Background: Following a child's experience of trauma, parental response is thought to play an important role in either facilitating or hindering their psychological adjustment. However, the ability to investigate the role of parenting responses in the post-trauma period has been hampered by a lack of valid and reliable measures. Objectives: The aim of this study was to design, and provide a preliminary validation of, the Parent Trauma Response Questionnaire (PTRQ), a self-report measure of parental appraisals and support for children's coping, in the aftermath of child trauma. Methods: We administered an initial set of 78 items to 365 parents whose children, aged 2-19 years, had experienced a traumatic event. We conducted principal axis factoring and then assessed the validity of the reduced measure against a standardized general measure of parental overprotection and via the measure's association with child post-trauma mental health. Results: Factor analysis generated three factors assessing parental maladaptive appraisals: (i) permanent change/damage, (ii) preoccupation with child's vulnerability, and (iii) self-blame. In addition, five factors were identified that assess parental support for child coping: (i) behavioural avoidance, (ii) cognitive avoidance, (iii) overprotection, (iv) maintaining pre-trauma routines, and (v) approach coping. Good validity was evidenced against the measure of parental overprotection and child post-traumatic stress symptoms. Good test-retest reliability of the measure was also demonstrated. Conclusions: The PTRQ is a valid and reliable self-report assessment of parenting cognitions and coping in the aftermath of child trauma.

Antecedentes: Luego de una experiencia de trauma infantil, se piensa que la respuesta de los padres juega un papel importante, ya sea facilitando o dificultando su ajuste psicológico. Sin embargo, la capacidad de investigar el papel de las respuestas de los padres en el período posterior al trauma se ha visto obstaculizada por la falta de medidas válidas y confiables. Objetivos: El objetivo de este estudio fue diseñar y proporcionar una validación preliminar del cuestionario de respuesta parental al trauma (PTRQ), una medida auto-aplicada de las apreciaciones de los padres y el apoyo para el afrontamiento de los niños, después del trauma infantil. Métodos: Administramos un conjunto inicial de 78 ítems a 365 padres cuyos hijos, de entre 2 y 19 años, habían experimentado un evento traumático. Realizamos el eje principal y luego evaluamos la validez de la medida reducida frente a una medida general estandarizada de sobreprotección parental y mediante la asociación de la medida con la salud mental postraumática del niño. Resultados: El análisis factorial generó tres factores que evalúan las evaluaciones desadaptativas de los padres: (i) cambio/daño permanente, (ii) preocupación por la vulnerabilidad del niño, y (iii) auto-culpa. Además, se identificaron cinco factores que evalúan el apoyo de los padres para el afrontamiento infantil: (i) evitación del comportamiento, (ii) evitación cognitiva, (iii) sobreprotección, (iv) mantenimiento de las rutinas previas al trauma y (v) enfoque de afrontamiento. Se evidenció una buena validez frente a la medida de la sobreprotección parental y los síntomas de estrés postraumático infantil. También se demostró una buena fiabilidad test-retest de la medida. Conclusiones: El PTRQ es una evaluación autoaplicada válida y confiable de las cogniciones de los padres y del afrontamiento posterior al trauma del niño.

The impact of treatment delivery format on response to cognitive behaviour therapy for preadolescent children with anxiety disorders.

BACKGROUND: Several delivery formats of cognitive behaviour therapy (CBT) for child anxiety have been proposed, however, there is little consensus on the optimal delivery format. The primary goal of this study was to investigate the impact of the child's primary anxiety diagnosis on changes in clinical severity (of the primary problem) during individual CBT, group CBT and guided parent-led CBT. The secondary goal was to investigate the impact of the child's primary anxiety diagnosis on rates of remission for the three treatment formats. METHODS: A sample of 1,253 children (5-12 years; Mage = 9.3, SD = 1.7) was pooled from CBT trials carried out at 10 sites. Children had a primary diagnosis of generalised anxiety disorder (GAD), social anxiety disorder (SoAD), specific phobia (SP) or separation anxiety disorder (SAD). Children and parents completed a semistructured clinical interview to assess the presence and severity of DSM-IV psychiatric disorders at preintervention, postintervention and follow-up. Linear mixture modelling was used to evaluate the primary research question and logistic modelling was used to investigate the secondary research question. RESULTS: In children with primary GAD, SAD or SoAD, there were no significant differences between delivery formats. However, children with primary SP showed significantly larger reductions in clinical severity following individual CBT compared to group CBT and guided parent-led CBT. The results were mirrored in the analysis of remission responses with the exception that individual CBT was no longer superior to group CBT for children with a primary SP. The difference between individual and group was not significant when follow-up data were examined separately. CONCLUSIONS: Data show there may be greater clinical benefit by allocating children with a primary SP to individual CBT, although future research on cost-effectiveness is needed to determine whether the additional clinical benefits justify the additional resources required.

A cluster randomized controlled platform trial comparing group MEmory specificity training (MEST) to group psychoeducation and supportive counselling (PSC) in the treatment of recurrent depression.

Impaired ability to recall specific autobiographical memories is characteristic of depression, which when reversed, may have therapeutic benefits. This cluster-randomized controlled pilot trial investigated efficacy and aspects of acceptability, and feasibility of MEmory Specificity Training (MEST) relative to Psychoeducation and Supportive Counselling (PSC) for Major Depressive Disorder (N = 62). A key aim of this study was to determine a range of effect size estimates to inform a later phase trial. Assessments were completed at baseline, post-treatment and 3-month follow-up. The cognitive process outcome was memory specificity. The primary clinical outcome was symptoms on the Beck Depression Inventory-II at 3-month follow-up. The MEST group demonstrated greater improvement in memory specificity relative to PSC at post-intervention (d = 0.88) and follow-up (d = 0.74), relative to PSC. Both groups experienced a reduction in depressive symptoms at 3-month follow-up (d = 0.67). However, there was no support for a greater improvement in depressive symptoms at 3 months following MEST relative to PSC (d = -0.04). Although MEST generated changes on memory specificity and improved depressive symptoms, results provide no indication that MEST is superior to PSC in the resolution of self-reported depressive symptoms. Implications for later-phase definitive trials of MEST are discussed.

Cost-effectiveness of cognitive therapy as an early intervention for post-traumatic stress disorder in children and adolescents: a trial based evaluation and model.

BACKGROUND: Untreated post-traumatic stress disorder (PTSD) in children and adolescents is associated with a considerable economic burden on the health system, families and society. Recent research has demonstrated the potential efficacy of cognitive therapy as an early intervention for PTSD in children and adolescents. Children who experienced a single traumatic event in the previous two to six months and were randomized to cognitive therapy for PTSD (CT-PTSD) were significantly more likely to be PTSD-free compared to those randomized to usual care represented by waitlist control. The current study evaluated the economic impact of improvements in the treatment of PTSD in children and adolescents. METHODS: A cost-effectiveness analysis was conducted from the national health service/personal social services perspective with outcomes expressed as quality-adjusted life years (QALYs). Patient level costs and outcomes were collected during the 11 week clinical trial and extrapolated to a three year time horizon using economic modelling methods. Uncertainty was estimated using probabilistic sensitivity analysis and assumptions were tested using one way sensitivity analysis. RESULTS: The incremental cost-effectiveness ratio at 3 years was £2,205 per QALY with a 60%-69% probability of CT-PTSD being cost-effective compared to usual care at the UK £20,000 to £30,000 per QALY decision threshold. CONCLUSIONS: This study provides preliminary evidence for the cost-effectiveness of cognitive therapy in this treatment population. Larger pragmatic trials with longer follow-up are indicated.

The relationship between processing style, trauma memory processes, and the development of posttraumatic stress symptoms in children and adolescents.

BACKGROUND AND OBJECTIVES: Data-driven processing, peri-event fear, and trauma memory characteristics are hypothesised to play a core role in the development of Posttraumatic Stress Disorder. We assessed the relationships between these characteristics and Posttraumatic Stress (PTS) symptoms in a sample of youth. METHODS: Study 1 (N = 36, 7-16 years), involved a sample of children who had undergone a stressful orthopaedic procedure. One week later they answered a series of probed recall questions about the trauma (assessed for accuracy by comparison to a video) and reported on their PTS symptoms. They also rated confidence in their probed recall answers to assess meta-cognitive monitoring of their memory for the trauma. In Study 2, a sample of injured children (N = 57, 7-16 years) were assessed within 1-month of a visit to an Emergency Department, and then at 3-month follow-up. They answered probed recall questions, made confidence ratings, and completed measures of data-driven processing, peri-event fear, PTS and associated psychopathology. Memories were verified using witness accounts. RESULTS: Studies 1 and 2 did not find an association between PTS symptoms and trauma memory accuracy or confidence. In Studies 1 and 2 data-driven processing predicted PTS symptoms. LIMITATIONS: The studies had modest samples sizes and there were ceiling effects for some accuracy and confidence items. CONCLUSIONS: Data-driven processing at the time of a trauma was associated with PTS symptoms after accounting for fear at the time of the trauma. Accuracy of recall for trauma memories was not significantly related to PTS symptoms. No decisive conclusion could be drawn regarding the relation between confidence in trauma memories and PTS symptoms.

Translating the Cognitive Model of PTSD to the Treatment of Very Young Children: A Single Case Study of an 8-Year-Old Motor Vehicle Accident Survivor.

Posttraumatic stress disorder (PTSD) is a clinical condition that occurs after a discrete traumatic event, such as an accident or assault. Research into PTSD has primarily been adult-focused; however, there is a growing body of evidence evaluating the theory and treatment of PTSD in young children. Consequently, cognitive behavior therapy (CBT) interventions for PTSD in youth have been developed that focus on 3 core components of the cognitive model-a disorganized memory of the trauma, maladaptive appraisals of the trauma and its effects (meanings), and dysfunctional coping mechanisms (management). Here, we describe the extension of this treatment approach (termed CBT-3M) to very young children (3-8 years) through the case of Dylan, an 8-year-old motor vehicle accident survivor. This serves as an illustration of the underlying theory and its successful application. Further work is intended to provide evidence of the efficacy of this treatment via an ongoing treatment trial.

Acute stress disorder and the transition to posttraumatic stress disorder in children and adolescents: Prevalence, course, prognosis, diagnostic suitability, and risk markers.

BACKGROUND: Early recovery from trauma exposure in youth is poorly understood. This prospective longitudinal study examined the early course of traumatic stress responses in recently trauma-exposed youth, evaluated the revised DSM-5 acute stress disorder (ASD) and PTSD diagnoses and alternative diagnoses, and identified risk factors for persistent traumatic stress. METHOD: Participants were 8- to 17-year-old emergency departments attendees exposed to single incident traumas. Structured clinical interviews were undertaken at 2 (n = 226) and 9 weeks (n = 208) posttrauma. RESULTS: Using the revised criteria in DSM-5, 14.2% met criteria for ASD at week 2 and 9.6% met criteria for PTSD at week 9. These prevalences were similar to the corresponding DSM-IV diagnoses (18.6% ASD at week 2; 8.7% PTSD at week 9). Using the same diagnostic criteria (DSM-IV or DSM-5) across assessments (i.e., "2-week PTSD") suggested that caseness declined in prevalence by approximately half. Overlap between DSM-IV and DSM-5 ASD and DSM-5 preschool child PTSD diagnoses was considerable. Two diagnoses were strongly predictive of corresponding week 9 diagnoses. Youth with ASD who subsequently had PTSD reported more negative alterations in cognition and mood at 2 weeks than those youth who did not develop PTSD. CONCLUSIONS: Youth exposed to single-event traumas experience considerable natural recovery in the first months posttrauma. Using DSM-5 criteria, ASD may not capture all clinically significant traumatic stress in the acute phase and is only moderately sensitive for later PTSD. Future research needs to address the role and etiology of negative alterations in cognition and mood symptoms.

Genetic variation in the endocannabinoid system and response to Cognitive Behavior Therapy for child anxiety disorders.

Extinction learning is an important mechanism in the successful psychological treatment of anxiety. Individual differences in response and relapse following Cognitive Behavior Therapy may in part be explained by variability in the ease with which fears are extinguished or the vulnerability of these fears to re-emerge. Given the role of the endocannabinoid system in fear extinction, this study investigates whether genetic variation in the endocannabinoid system explains individual differences in response to CBT. Children (N = 1,309) with a primary anxiety disorder diagnosis were recruited. We investigated the relationship between variation in the CNR1, CNR2, and FAAH genes and change in primary anxiety disorder severity between pre- and post-treatment and during the follow-up period in the full sample and a subset with fear-based anxiety disorder diagnoses. Change in symptom severity during active treatment was nominally associated (P < 0.05) with two SNPs. During the follow-up period, five SNPs were nominally associated with a poorer treatment response (rs806365 [CNR1]; rs2501431 [CNR2]; rs2070956 [CNR2]; rs7769940 [CNR1]; rs2209172 [FAAH]) and one with a more favorable response (rs6928813 [CNR1]). Within the fear-based subset, the effect of rs806365 survived multiple testing corrections (P < 0.0016). We found very limited evidence for an association between variants in endocannabinoid system genes and treatment response once multiple testing corrections were applied. Larger, more homogenous cohorts are needed to allow the identification of variants of small but statistically significant effect and to estimate effect sizes for these variants with greater precision in order to determine their potential clinical utility. © 2016 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics Published by Wiley Periodicals, Inc.

Cognitive therapy as an early treatment for post-traumatic stress disorder in children and adolescents: a randomized controlled trial addressing preliminary efficacy and mechanisms of action.

BACKGROUND: Few efficacious early treatments for post-traumatic stress disorder (PTSD) in children and adolescents exist. Previous trials have intervened within the first month post-trauma and focused on secondary prevention of later post-traumatic stress; however, considerable natural recovery may still occur up to 6-months post-trauma. No trials have addressed the early treatment of established PTSD (i.e. 2- to 6-months post-trauma). METHODS: Twenty-nine youth (8-17 years) with PTSD (according to age-appropriate DSM-IV or ICD-10 diagnostic criteria) after a single-event trauma in the previous 2-6 months were randomly allocated to Cognitive Therapy for PTSD (CT-PTSD; n = 14) or waiting list (WL; n = 15) for 10 weeks. RESULTS: Significantly more participants were free of PTSD after CT-PTSD (71%) than WL (27%) at posttreatment (intent-to-treat, 95% CI for difference .04-.71). CT-PTSD yielded greater improvement on child-report questionnaire measures of PTSD, depression and anxiety; clinician-rated functioning; and parent-reported outcomes. Recovery after CT-PTSD was maintained at 6- and 12-month posttreatment. Beneficial effects of CT-PTSD were mediated through changes in appraisals and safety-seeking behaviours, as predicted by cognitive models of PTSD. CT-PTSD was considered acceptable on the basis of low dropout and high treatment credibility and therapist alliance ratings. CONCLUSIONS: This trial provides preliminary support for the efficacy and acceptability of CT-PTSD as an early treatment for PTSD in youth. Moreover, the trial did not support the extension of 'watchful waiting' into the 2- to 6-month post-trauma window, as significant improvements in the WL arm (particularly in terms of functioning and depression) were not observed. Replication in larger samples is needed, but attention to recruitment issues will be required.

The latent structure of Acute Stress Disorder symptoms in trauma-exposed children and adolescents.

BACKGROUND: The revision of Acute Stress Disorder (ASD) in the DSM-5 (DSM-5, 2013) proposes a cluster-free model of ASD symptoms in both adults and youth. Published evaluations of competing models of ASD clustering in youth have rarely been examined. METHODS: We used Confirmatory Factor Analysis (combined with multigroup invariance tests) to explore the latent structure of ASD symptoms in a trauma-exposed sample of children and young people (N = 594). The DSM-5 structure was compared with the previous DSM-IV conceptualization (4-factor), and two alternative models proposed in the literature (3-factor; 5-factor). Model fit was examined using goodness-of-fit indices. We also established DSM-5 ASD prevalence rates relative to DSM-IV ASD, and the ability of these models to classify children impaired by their symptoms. RESULTS: Based on both the Bayesian Information Criterion, the interfactor correlations and invariance testing, the 3-factor model best accounted for the profile of ASD symptoms. DSM-5 ASD led to slightly higher prevalence rates than DSM-IV ASD and performed similarly to DSM-IV with respect to categorising children impaired by their symptoms. Modifying the DSM-5 ASD algorithm to a 3+ or 4+ symptom requirement was the strongest predictor of impairment. CONCLUSIONS: These findings suggest that a uni-factorial general-distress model is not the optimal model of capturing the latent structure of ASD symptom profiles in youth and that modifying the current DSM-5 9+ symptom algorithm could potentially lead to a more developmentally sensitive conceptualization.