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.

Water governance diversity across Europe: Does legacy generate sticking points in implementing multi-level governance?

The Water Framework Directive (WFD) aims to protect and improve water quality across Europe through an integrative and multi-level water governance approach. The goal is to ensure that water quality in Europe meets good ecological status by 2027. Whilst the WFD has been hailed as a cornerstone for governance innovation in water management, most EU member states (MS) still struggle to achieve good ecological status of their waters. The realignment to a multi-level governance structure under the WFD is discretionary, and has generated diversity in WFD multi-level governance implementation approaches and final governance arrangements across MS. This diversity may contribute to low goal achievement and weak compliance. This paper investigates how visual impressions of legislative structure across nine MS can illustrate and contribute to understanding the differences in multi-level implementation of WFD and associated water protection directives. We explore, in-depth, the drivers of visual differences in Portugal, Germany (Lower Saxony) and France. We hypothesise that many of the challenges of WFD implementation, and resulting governance arrangements can be explained in terms of the legacy effects of previous water governance choices. With this conceptual framework of investigating the history and legacy, we found the three in depth studies have had different starting points, paths, and end points in their water governance, with sticking points influencing the decision-making processes and compliance required by the WFD. Sticking points include the complexity of existing water governance structures, lobbying by different sectors, and the mandatory WFD timeline for implementation. Portugal had to resolve its focus on water infrastructure and engineering to enable a re-focus on water quality. France and Portugal experienced 'top down' governance at different points in time, slowing the shift to a multi-level governance system. Lower Saxony, representing just one of 16 federal state systems in Germany, highlighted the complex historic governance structures which cannot easily be restructured, generating a layering effect where new governance systems are fitted to old governance systems. We conclude that there is a need to implement a hybrid approach to water governance and WFD implementation including decentralisation (discretionary) to ensure collaboration and engagement of stakeholders at the local level. This hybrid governance system should run in parallel with a centralised (mandatory) governance and regulatory system to enable national environmental standards to be set and enforced. Such systems may provide the best of both worlds (bottom-up involvement of stakeholders meeting top-down goal achievements) and is worthy of further research.

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.

Protection of drinking water resources from agricultural pressures: Effectiveness of EU regulations in the context of local realities.

Over the last decades, nutrients and pesticides have proved to be a major source of the pollution of drinking water resources in Europe. Extensive legislation has been developed by the EU to protect drinking water resources from agricultural pollution, but the achievement of water quality objectives is still an ongoing challenge throughout Europe. The study aims to identify lessons that can be learnt about the coherence and consistency of the application of EU regulations, and their effects at the local level, using qualitative expert data for 13 local to regional governance arrangements in 11 different European countries. The results show that the complexities and inconsistencies of European legislation drawn up to protect drinking water resources from agricultural pollution come forward most explicitly at local level where cross-sectoral measures have to be taken and effects monitored. At this local level, rather than facilitate, they hamper efforts to achieve water quality objectives. The upcoming revision of the Water Framework Directive (WFD) should strengthen the links between the different directives and how they could be applied at local level. In addition, a more facilitated cross-sectoral approach should be adopted to improve stakeholder networks, between institutional levels and hydrological scales, to attain policy objectives at local level.

Dropout from randomised controlled trials of psychological treatments for depression in children and youth: a systematic review and meta-analyses.

BACKGROUND: Depression is a prevalent and disabling condition in youth. Treatment efficacy has been demonstrated for several therapeutic modalities. Acceptability of treatments is also important to explore and was addressed by investigating treatment dropout using meta-analyses. METHODS: A systematic search was conducted using MEDLINE, CINAHL and PsycARTICLES databases. Peer-reviewed randomised controlled trials investigating psychotherapy treatment of depression in children and youth (aged up to and including 18 years) were included. Proportion meta-analyses were used to calculate estimated dropout rates; odds ratios assessed whether there was greater dropout from intervention or control arms and meta-regressions investigated for associations between dropout, study and treatment characteristics. RESULTS: Thirty-seven studies were included (N=4343). Overall estimate of dropout from active interventions was 14.6% (95% CI 12.0-17.4%). Dropout was equally likely from intervention and control conditions, aside from family/dyadic interventions (where dropout was more likely from control arms). There was some suggestion that interventions offering more sessions and longer duration had less dropout and of less dropout from IPT than other interventions. There were no significant associations between dropout and study quality, CBT, family or individual versus other approaches. LIMITATIONS: Lack of consistent reporting decreased the factors which could be analysed. CONCLUSIONS: Dropout from depression treatment in children and youth was similar across different types of intervention and control conditions. Future treatment trials should specify minimum treatment dose, define dropout and provide information about participants who dropout. This may inform treatment choice and modification of treatments.

A randomised controlled trial of memory flexibility training (MemFlex) to enhance memory flexibility and reduce depressive symptomatology in individuals with major depressive disorder.

Successful navigation within the autobiographical memory store is integral to daily cognition. Impairment in the flexibility of memory retrieval can thereby have a detrimental impact on mental health. This randomised controlled phase II exploratory trial (N = 60) evaluated the potential of a novel intervention drawn from basic science - an autobiographical Memory Flexibility (MemFlex) training programme - which sought to ameliorate memory difficulties and improve symptoms of Major Depressive Disorder. MemFlex was compared to Psychoeducation (an evidence-based low-intensity intervention) to determine the likely range of effects on a primary cognitive target of memory flexibility at post-intervention, and co-primary clinical targets of self-reported depressive symptoms and diagnostic status at three-month follow-up. These effect sizes could subsequently be used to estimate sample size for a fully-powered trial. Results demonstrated small-moderate, though as expected statistically non-significant, effect sizes in favour of MemFlex for memory flexibility (d = 0.34, p = .20), and loss of diagnosis (OR = 0.65, p = .48), along with the secondary outcome of depression-free days (d = 0.36, p = .18). A smaller effect size was observed for between-group difference in self-reported depressive symptoms (d = 0.24, p = .35). Effect sizes in favour of MemFlex in this early-stage trial suggest that fully-powered evaluation of MemFlex may be warranted as an avenue to improving low-intensity treatment of depression. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT02371291.

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.

Study protocol for a randomised, controlled platform trial estimating the effect of autobiographical Memory Flexibility training (MemFlex) on relapse of recurrent major depressive disorder.

INTRODUCTION: Major depressive disorder (MDD) is a chronic condition. Although current treatment approaches are effective in reducing acute depressive symptoms, rates of relapse are high. Chronic and inflexible retrieval of autobiographical memories, and in particular a bias towards negative and overgeneral memories, is a reliable predictor of relapse. This randomised controlled single-blind trial will determine whether a therapist-guided self-help intervention to ameliorate autobiographical memory biases using Memory Flexibility training (MemFlex) will increase the experience of depression-free days, relative to a psychoeducation control condition, in the 12 months following intervention. METHODS AND ANALYSIS: Individuals (aged 18 and above) with a diagnosis of recurrent MDD will be recruited when remitted from a major depressive episode. Participants will be randomly allocated to complete 4 weeks of a workbook providing either MemFlex training, or psychoeducation on factors that increase risk of relapse. Assessment of diagnostic status, self-report depressive symptoms, depression-free days and cognitive risk factors for depression will be completed post-intervention, and at 6 and 12 months follow-up. The cognitive target of MemFlex will be change in memory flexibility on the Autobiographical Memory Test- Alternating Instructions. The primary clinical endpoints will be the number of depression-free days in the 12 months following workbook completion, and time to depressive relapse. ETHICS AND DISSEMINATION: Ethics approval has been granted by the NHS National Research Ethics Committee (East of England, 11/H0305/1). Results from this study will provide a point-estimate of the effect of MemFlex on depressive relapse, which will be used to inform a fully powered trial evaluating the potential of MemFlex as an effective, low-cost and low-intensity option for reducing relapse of MDD. TRIAL REGISTRATION NUMBER: NCT02614326.