Development and Preliminary Validation of the University of Minnesota's Traumatic Stress Screen for Children and Adolescents (TSSCA).

Child and adolescent exposure to potential trauma experiences is pervasive. Given the prevalence, deleterious mental and physical effects, and economic cost of trauma exposure, child- and family-service systems are adopting trauma-informed approaches, including practices like trauma screening. Although a number of trauma-focused screening and assessment measures exist for youth, the majority are lengthy and inappropriate for universal administration. This study describes the development and preliminary validation of the Traumatic Stress Screen for Children and Adolescents (TSSCA), a six-item screening measure for trauma exposure and traumatic stress symptoms. Using two samples of youth presenting at community practice settings (n1 = 134, n2 = 137), reliability, discriminative validity, and criterion-related validity were calculated for the TSSCA. Results support the TSSCA as an empirically derived, reliable, and valid screening measure for exposure to trauma and symptoms of traumatic stress for youth ages 7 to 18.

Forensic Medical Evaluation of Children Seeking Asylum: A Guide for Pediatricians.

Applications for asylum in the United States have increased significantly in the past decade, including those by children fleeing persecution. Pediatricians may serve as a resource for children seeking asylum by participating in specialized training and performing forensic medical evaluations for use in the legal process. A forensic medical evaluation comprises an interview to elicit a narrative of reported abuse, a psychological assessment, and/or a medical assessment. Evaluators document an impression of the consistency of medical and psychological findings with the trauma, which forms the legal basis for a child's asylum claim. This article provides guidance to pediatrician evaluators with an emphasis on an age- and development-specific approach to a forensic medical evaluation of children seeking asylum. Collaboration with primary care pediatricians and community partners about asylum evaluations is important to building support for immigrant children who have experienced trauma. [Pediatr Ann. 2020;49(5):e215-e221.].

Appreciating the 4 "Ts" of Loneliness When Providing Psychiatric Care for the Lonely Patient.

Loneliness can be evaluated from a 4-concept viewpoint of territory, threat, trauma and trust (4 Ts). Territory refers to an area of ownership that is controlled on a daily basis and is fundamental to one's daily life. Lonely individuals often manage boundaries by gaining greater control over their physical environment by territorial behavior. They guard personal territory well as the only area where they can exert dominance and feel safe. Perceptions of social isolation or loneliness increase vigilance for threats, decrease trust, and heighten feelings of vulnerability. Clinical teams caring for the lonely must be especially attentive to a history of prior trauma. Clinicians who ask permission, who pay attention to nonverbal cues, distance, and speed as they enter the lonely person's space, and who respect boundaries may be more successful in gaining trust. Achieving trust diminishes the risk of physical harm, while allowing lonely persons the perceived control they need to permit health care interventions. Veterans are at higher risk for loneliness. Given their military training, they may be particularly attentive to boundaries, protecting the perimeter, watching for threats, and defending their space. In this article, we discuss the successful mental health treatment of a lonely male veteran in a Veterans Affairs Medical Center, by paying attention to the 4 Ts of loneliness. We used a 4-step approach of validation, mentalization, reality testing, and socialization to decrease the sense of threat as we sought acceptance to the patient's territory, followed by building trust and working on past trauma.

Screening for Adverse Childhood Experiences in Pediatric Primary Care: Pitfalls and Possibilities.

Addressing adverse childhood experiences (ACEs) in primary care pediatric practice is riddled with potential pitfalls that prevent most providers from implementing ACE or toxic stress screening in their practices. However, the growing body of literature and clinician experience about ACE screening shows how this practice is also ripe with possibilities beyond just the treatment of trauma-related diagnoses and for the prevention of intergenerational transmission of toxic stress. This article reviews the current state of screening for ACEs and toxic stress in practice, describes how pediatricians and clinics have overcome pitfalls during implementation of practice-based screening initiatives, and discusses possibilities for the future of primary care-based screening. [Pediatr Ann. 2019;48(7):e257-e261.].

New Approach to Pediatric Treatment Planning to Support Caregivers Living with Adversities.

Pediatric practitioners are called upon to identify adverse childhood experiences and social determinants of health, given the growing evidence of the prevalence, lifelong risk, and potentially preventable impact of adversities. Caregivers serve as a strong mediator of how adversities affect children, with toxic stress resulting from the lack of a buffering caregiver in the context of prolonged stress activation. In the context of family centered care, pediatric practitioners who identify adversities or diagnose related health conditions, will need to be adept at modifying treatment plans to respect the caregiver's circumstances. Pediatric practitioners will need to consider how adversities affect the caregiver's well-being and capacity to provide protective, buffering relationships to prevent toxic stress, and access to recommended treatments. This article proposes a reconsideration of traditional treatment planning to be adversity-informed to provide family centered care. [Pediatr Ann. 2019;48(7):e262-e268.].

Putting Your Trauma Lens On.

Trauma in childhood is now understood to cause long-term effects on the brain and body. The pediatric provider, using a "trauma lens," which constitutes observing a child's attachment, resilience, and stress response, is well poised to identify and support children and families at risk. Fortunately, resilience is a dynamic process that can be learned, enhanced, and supported. Familiarity with the most common symptoms of traumatic stress will help the medical provider quickly recognize which children are impacted or FRAYED (Fits, Frets, and Fear; Regulation disorders; Attachment problems; Yawning and Yelling; Educational and developmental delays; Defeat and Dissociation). Once symptoms are identified, the caregiver can "focus" on attachment and resilience skills, the THREADS (Thinking & learning brain, with opportunity for continued growth; cognitive development; Hope, optimism, faith, belief in a future for one's self; Regulation [self-regulation, self-control]; Efficacy, or knowing one can impact their environment and situation; Attachment, secure; Development, or mastery of age-salient developmental tasks; Social context or the larger network of relationships in which one lives and learns) that can be woven together to promote resilience. Guiding families with empathy and positive regard, the medical provider can help the child and family rebuild resilience skills. Organizing practical guidance around the "3 R's"-Reassuring, Restoring routines, and Regulating-is a roadmap to recovery. [Pediatr Ann. 2019;48(7):e269-e273.].

Trauma-Informed Approaches to Adolescent Relationship Abuse and Sexual Violence Prevention.

Adolescent relationship abuse and sexual violence are prevalent throughout adolescence and are associated with serious physical and mental health consequences. Trauma-informed approaches to care balance adolescent confidentiality, autonomy, and a young person's safety. The provision of trauma-informed care can include universal education and brief counseling about healthy relationships with all adolescent patients during clinical encounters to promote healthy adolescent sexual relationships, ensure youth know about resources for relationship abuse and sexual violence, and facilitate connections to advocates who serve survivors of abuse. Providers can integrate evidence-based relationship abuse and sexual violence prevention into their work with adolescents. [Pediatr Ann. 2019;48(7):e274-e279.].

Heterogeneity in psychiatric diagnostic classification.

The theory and practice of psychiatric diagnosis are central yet contentious. This paper examines the heterogeneous nature of categories within the DSM-5, how this heterogeneity is expressed across diagnostic criteria, and its consequences for clinicians, clients, and the diagnostic model. Selected chapters of the DSM-5 were thematically analysed: schizophrenia spectrum and other psychotic disorders; bipolar and related disorders; depressive disorders; anxiety disorders; and trauma- and stressor-related disorders. Themes identified heterogeneity in specific diagnostic criteria, including symptom comparators, duration of difficulties, indicators of severity, and perspective used to assess difficulties. Wider variations across diagnostic categories examined symptom overlap across categories, and the role of trauma. Pragmatic criteria and difficulties that recur across multiple diagnostic categories offer flexibility for the clinician, but undermine the model of discrete categories of disorder. This nevertheless has implications for the way cause is conceptualised, such as implying that trauma affects only a limited number of diagnoses despite increasing evidence to the contrary. Individual experiences and specific causal pathways within diagnostic categories may also be obscured. A pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system.

Identification of differential item functioning by race and ethnicity in the Childhood Trauma Questionnaire.

BACKGROUND: The accurate assessment of childhood maltreatment (CM) is important in medical and mental health settings given its association to adverse psychological and physical outcomes. Reliable and valid assessment of CM is also of critical importance to research. Due to the potential of measurement bias when comparing CM across racial and ethnic groups, invariant measurement is an important psychometric property of such screening tools. OBJECTIVE: In this study, differential item function (DIF) by race and ethnicity was tested. Uniform DIF refers to the influence of bias on scores across all levels of childhood maltreatment, and non-uniform DIF refers to bias in favor of one group. METHOD: Participants were N=1,319 women and men (Mage=36.77, SDage=10.37) who completed the Child Trauma Questionnaire-Short Form; 42.7% were women, 57.3% were male; 58.9% were White-American, 22.1% Black-American, and 8.0% as other; 26.3% were Hispanic. RESULTS: Using empirical thresholds, non-uniform DIF was identified in five items by race, and no items by ethnicity. CONCLUSIONS: Uniform DIF is less problematic given that mathematical corrections can be made to adjust scores for DIF. However, non-uniform DIF can usually only be corrected by removing the DIF items from the scale. Further methodological research is needed to minimize measurement bias to effectively assess racially diverse populations.

ACOG Committee Opinion No. 777: Sexual Assault.

Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician-gynecologists and other women's health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

Reliability and Clinical Utility of ICD-11 Diagnostic Guidelines for Severe Mental Disorders in Nigeria.

BACKGROUND: An essential foundation for global mental health is the development of reliable, clinically useful and globally applicable diagnostic classification of mental disorders. AIM: This study is aimed at assessing the inter-rater reliability and clinical utility of the proposed diagnostic guidelines for severe mental disorders in the eleventh edition of the International Classification of Diseases and Related Health Problems (ICD-11) in Nigeria. METHOD: The study was conducted in Nigeria at 2 mental health facilities as part of a 13 country project coordinated by the World Health Organization. Following training, 32 clinician raters assessed the reliability and clinical utility of the proposed diagnostic guidelines for schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear-related disorders, and disorders specifically associated with stress. Using SPSS version 21, analysis of data was conducted at the Data Coordinating Center (DCC), Columbia University. RESULTS: For reliability, estimates of intraclass κ coefficients for diagnoses ranged between 0.71 (Schizoaffective disorder) and 0.93 (Schizophrenia). In ratings of the clinical utility, the guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e. having satisfactory goodness-of-fit), clearly understandable, and as providing useful guidance on distinguishing a disorder from normality and from other mental disorders. CONCLUSION: Overall, the reliability of the diagnostic guidelines was good in Nigeria, ranging from substantial to almost perfect. Utility ratings were generally satisfactory. The results support the suitability of the ICD-11 diagnostic guidelines for implementation at a worldwide level.

Applying a Trauma Informed School Systems Approach: Examples from School Community-Academic Partnerships.

Objectives: Schools can play an important role in addressing the effects of traumatic stress on students by providing prevention, early intervention, and intensive treatment for children exposed to trauma. This article aims to describe key domains for implementing trauma-informed practices in schools. Design: The Substance Abuse and Mental Health Administration (SAMHSA) has identified trauma-informed domains and principles for use across systems of care. This article applies these domains to schools and presents a model for a Trauma-Informed School System that highlights broad macro level factors, school-wide components, and tiered supports. Community partners from one school district apply this framework through case vignettes. Results: Case 1 describes the macro level components of this framework and the leveraging of school policies and financing to sustain trauma-informed practices in a public health model. Case 2 illustrates a school founded on trauma-informed principles and practices, and its promotion of a safe school environment through restorative practices. Case 3 discusses the role of school leadership in engaging and empowering families, communities, and school staff to address neighborhood and school violence. Conclusions: This article concludes with recommendations for dissemination of trauma-informed practices across schools at all stages of readiness. We identify three main areas for facilitating the use of this framework: 1) assessment of school staff knowledge and awareness of trauma; 2) assessment of school and/or district's current implementation of trauma-informed principles and practices; 3) development and use of technology-assisted tools for broad dissemination of practices, data and evaluation, and workforce training of clinical and non-clinical staff.

Social Support as a Mediator of Posttraumatic Embitterment and Perceptions of Meaning in Life among Danwon Survivors of the Sewol Ferry Disaster.

PURPOSE: Our research was designed to test and explore the relationships among embitterment, social support, and perceptions of meaning in life in the Danwon High School survivors of the Sewol ferry disaster. MATERIALS AND METHODS: Seventy-five Sewol ferry disaster survivors were eligible for participation, and were invited to participate in the study 28 months after the disaster. Forty-eight (64%) survivors (24 males, 24 females) completed questionnaires; the Posttraumatic Embitterment Disorder (PTED) scale, the Functional Social Support Questionnaire (FSSQ), and the Meaning in Life Questionnaire (MLQ). RESULTS: PTED scores were negatively correlated with scores on the FSSQ and the Presence of Meaning (MLQ-P) (r=-0.43 and -0.40, respectively). The hierarchical regression analysis showed that FSSQ scores may fully mediate the effects of PTED scores on MLQ-P scores, given that the indirect effect was significant whereas the direct effect was not (95% confidence interval=-0.5912 to -0.0365). CONCLUSION: These findings imply that therapies targeting embitterment may play a vital role in increasing positive cognitions, such as those related to perceived social support and the meaningfulness of life.

Usage of Riot Control Agents and other methods resulting in physical and psychological injuries sustained during civil unrest in Turkey in 2013.

Turkey has experienced a wave of demonstrations in the summer of 2013, called Gezi Park Demonstrations. Between 31 May and 30 August, 297 people who had been subjected to trauma by several methods of demonstration control and Riot Control Agents applied to the Human Rights Foundation of Turkey Rehabilitation Centers to receive treatment/rehabilitation and/or documentation. 296 patients except one 5-year-old child were included in the study. Of the 296 patients; 175 were male, 120 were female, and one was a transgender individual. The highest number of applications was received by the Istanbul center with 216 patients. The mean age of applicants was 33.85, and the age range was 15-71 years. While 268 of applicants (91%) stated that they had been exposed to Riot Control Agents, 62 patients suffered only chemical exposure who had no other traumatic injuries whereas 234 patients suffered at least one blunt trauma injury. Blunt trauma injuries are due to being shot by gas canisters in 127 patients (43%), by plastic bullets in 31 patients (10%). 59 patients (20%) were severely beaten, and 30 patients (10%) were injured by pressurized cold water ejected by water cannons. Thirteen patients (4.4%) suffered injuries that caused loss of vision or eye. Psychiatric evaluations were carried out for 117 patients while 43% of them were diagnosed with Acute Stress Disorder. Post Traumatic Stress Disorder and Major Depressive Disorder followed this diagnosis. This study includes the medical evaluation of injuries allegedly sustained during Gezi Park demonstrations in 2013 as a result of several methods of demonstration control and/or by being exposed to Riot Control Agents. The aim is to discuss different types of injuries due to those methods and health consequences of Riot Control Agents.