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.

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.

Reducing risk factors for child maltreatment: The Parenting-STAIR open pilot study.

BACKGROUND: Despite a large body of evidence linking the impact of trauma, parenting, and child maltreatment recidivism, current child welfare services often do not target maternal trauma and post-traumatic stress disorder (PTSD). Moreover, there is little evidence that traditional family preservation services (FPS) lower the rates of repeat incidences of child abuse and neglect. The novel intervention, Parenting-STAIR (P-STAIR), seeks to address maternal mental health and parenting skills in order to reduce punitive parenting behaviors. OBJECTIVE: This study analyzes the effects of P-STAIR on child maltreatment risk. PARTICIPANTS AND SETTING: P-STAIR was administered to 112 child welfare-involved mothers in New York City (NYC). The mothers were between 18 and 52 years old (M = 31.1, SD = 6.6) and were referred from 4 child welfare preventive service agencies in NYC. METHODS: To evaluate change over time in indicators of maltreatment risk, two-tailed paired sample t-tests compared 1) pre- and post-treatment scores and 2) pre-treatment and 3-month follow-up scores. RESULTS: Among the 71 mothers who completed treatment, significant improvements from baseline to post-assessment and pre- to 3-month follow-up were observed across total scores on the CTSPC and the AAPI-2. Improvements were evident in nonviolent disciple, psychological aggression, expectations, empathy, and parent-child family roles at both the post-assessment and 3-month follow-up which are proximal outcomes of P-STAIR (CTSPC: pre-post nonviolent disciple d = 0.70; pre-post psychological aggression d = 0.34; pre-follow-up nonviolent disciple d = 0.42; pre-follow-up psychological aggression d = 0.36; AAPI-2; pre-post expectations d = 0.31; pre-post empathy d = 0.39; pre-post parent-child roles d = 0.47; pre-follow-up expectations d = 0.33; pre-follow-up empathy d = 0.42; pre-follow-up parent-child roles d = 0.66). CONCLUSIONS: The improvement in indicators of maltreatment risk demonstrates promising support for the utility of P-STAIR within the child welfare system.

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.

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.

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.

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.

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.

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.

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.

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.

Age at diagnosis, gender, and metabolic control in children with type 1 diabetes.

OBJECTIVE: To examine whether age at diagnosis and gender affect early metabolic control in children with type 1 diabetes. DESIGN AND METHODS: Data on age at diagnosis, gender, pubertal status, and metabolic control were gathered by a retrospective chart review of children diagnosed between 1992 and 2005. Mean hemoglobin A1c (HbA1c) values were compared at five time points: at diagnosis and at 6, 12, 24, and 36 months after diagnosis. RESULTS: At diagnosis, girls aged 6-12 years presented with significantly higher HbA1c levels than girls diagnosed at older or younger ages. Their HbA1c at diagnosis was also significantly higher than that in boys of the same age. There was no gender difference among children diagnosed at ages 0-5 or 13+ yr. At 6 months after diagnosis, only age at diagnosis was associated with metabolic control, with children diagnosed when older presenting with lower HbA1c levels. At 12, 24, and 36 months after diagnosis, there were no significant effects of age at diagnosis or gender on glycemic status. CONCLUSION: At initial diagnosis, girls in the 6-12 age group presented with higher HbA1c levels compared with boys and girls of other age groups. Although endocrine changes associated with puberty may partly explain the findings, more investigation to elucidate mechanisms accounting for the interaction of age and gender with glycemic status is needed.

Impact of September 11 World Trade Center disaster on children and pregnant women.

BACKGROUND: Children are uniquely sensitive to toxic exposures in the environment. This sensitivity reflects children's disproportionately heavy exposures coupled with the biologic vulnerability that is a consequence of their passage through the complex transitions of early development. METHODS AND RESULTS: To assess effects on children's health associated with the attacks on the World Trade Center (WTC) of September 11, 2001, research teams at the Mount Sinai School of Medicine and other academic health centers in New York City launched a series of clinical and epidemiologic studies. Mount Sinai investigators undertook a prospective analysis of pregnancy outcomes in 182 women who were pregnant on September 11, 2001, and who had been either inside or within 0.5 miles of the WTC at the time of the attacks; they found a doubling in incidence of intrauterine growth retardation (IUGR) among infants born to exposed mothers as compared to infants born to unexposed women in northern Manhattan. A Columbia research team examined pregnancy outcomes in 329 women who lived, worked or gave birth in lower Manhattan in the 9 months after September 11; they found that these women gave birth to infants with significantly lower birth weight and shorter length than women living at greater distances from Ground Zero. NYU investigators documented increased numbers of new asthma cases and aggravations of preexisting asthma in children living in lower Manhattan. Mount Sinai mental health researchers documented a significant increase in mental health problems in children who directly witnessed the attacks and subsequent traumatic events; these problems were most severe in children with a past history of psychological trauma. The New York City Department of Health and Mental Hygiene established a WTC Registry that has enrolled over 70,000 persons of all ages in lower Manhattan and will follow the health of these populations to document on a continuing basis the health consequences of September 11.

The relationship between PTSD arousal symptoms and depression among mothers exposed to the World Trade Center attacks.

Posttraumatic stress disorder (PTSD) is associated with greater risk of developing comorbid depression. However, little is known about the relationship between specific PTSD symptom clusters and comorbid depression. Approximately 4 years after the World Trade Center (WTC) attacks, we examined the association between PTSD symptom clusters and depression severity among 64 mothers directly exposed to the WTC attacks. Severity scores were computed for each PTSD symptom cluster by summing symptom frequency. Partial correlations with depression severity were calculated separately for PTSD symptom clusters, controlling for demographic variables, time elapsed since the attacks, WTC attack exposure, meeting PTSD criterion A, and the other cluster scores. Higher arousal symptom cluster scores were significantly correlated with persistent depression, but the re-experiencing and avoidance symptom clusters were not. Subsequent analyses isolating shared symptoms of PTSD and depression from those unique to PTSD suggest a complex interrelationship among symptoms of arousal, numbing, and depression.

Use of a psychosocial screen to detect children with symptoms of posttraumatic stress disorder: an exploratory study.

OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of the parent and youth versions of the 17-item Pediatric Symptom Checklist (PSC-17) for identifying children with symptoms of posttraumatic stress disorder (PTSD). METHODS: Cross-sectional convenience samples of children aged 8 to 10 years treated at a primary care pediatrics practice in New York City were recruited. The PSC-17 and its 5-item internalizing subscale were used in both parent- and youth-completed formats. Posttraumatic stress disorder symptoms were identified with the University of California, Los Angeles posttraumatic stress reaction index (UCLA RI), used as a structured interview with the child. RESULTS: One hundred fifty-six children enrolled in the study. Twenty-two percent of children met the UCLA RI cutoff for likely PTSD. The youth version of the PSC-17 and its 5-item internalizing subscale identified these children with sensitivities of 78% and 75% and specificities of 77% and 77%, respectively, relative to the UCLA RI. The parent version of the PSC-17 and the internalizing subscale had poorer sensitivities of 44% and 25% and similar specificities of 79% and 92%, respectively. CONCLUSIONS: Symptoms of PTSD can be identified using the youth self-report version of the PSC-17. A 5-item subscale of the PSC-17 also performed well and can readily be used in primary care settings.

A prospective study of trait anger and PTSD symptoms in police.

It is unknown whether anger is a risk factor for the development of posttraumatic stress disorder ( PTSD) symptoms, arises as a consequence of PTSD, or both. Two hypotheses were tested in 180 police recruits: Greater trait anger during training will predict greater PTSD symptoms at one year; greater PTSD symptoms at one year will predict greater state anger at one year. Both hypotheses were confirmed, suggesting that trait anger is a risk factor for PTSD symptoms, but that PTSD symptoms are also associated with an increase of state anger. Increased anger is important not only because of the impact it has on individual distress and physical health, but also because of its potential public health impact.

Risk-taking behaviors among Israeli adolescents exposed to recurrent terrorism: provoking danger under continuous threat?

OBJECTIVE: This study aimed to assess 1) the relationship between risk-taking behaviors and exposure to terrorism, 2) the relationship between posttraumatic symptoms and risk-taking behaviors, and 3) gender differences in the type and frequency of risk-taking behaviors and their differential associations with posttraumatic symptoms. METHOD: The participants were 409 Israeli adolescents 15 to 18 years of age. Exposure to terrorism was assessed with a questionnaire developed specifically for the Israeli security situation. Posttraumatic symptoms were measured with the University of California at Los Angeles Reaction Index. Functional impairment was measured with the Diagnostic Interview Schedule for Children. Risk-taking behavior-and the adolescents' perceptions of such behavior-was assessed with a self-report questionnaire. RESULTS: Israeli adolescents exposed to continuous threats of terrorist attacks reported high levels of risk-taking behaviors. The severity of risk-taking was associated with greater terrorism exposure. Adolescents suffering from posttraumatic symptoms reported more risk-taking behaviors than nonsymptomatic adolescents. Although there was no gender difference in the degree of exposure to terrorism, boys reported taking more risks than girls. The association between posttraumatic symptoms and risk-taking behaviors was stronger in boys than girls. Functional impairment, gender, avoidance symptoms, level of exposure, and degree of fear predicted the severity of risk-taking behaviors. CONCLUSIONS: Clinicians and educators should be aware of the strong link between posttraumatic distress and risk-taking behaviors. Risk-taking behaviors may be a manifestation of functional impairment and posttraumatic distress, especially for boys exposed to terrorism.

Conjoined effects of low birth weight and childhood abuse on adaptation and well-being in adolescence and adulthood.

OBJECTIVE: To characterize the conjoined effects of low birth weight (LBW) and childhood abuse on impaired adaptation and illness in adolescence and adulthood. DESIGN: Longitudinal study of a birth cohort. SETTING: Baltimore, Md. PARTICIPANTS: Children (N = 1748) were followed from birth to adulthood (mean age, 26 years) as part of the Johns Hopkins Collaborative Perinatal Study. MAIN EXPOSURES: Childhood abuse and LBW. MAIN OUTCOME MEASURES: Indicators of adaptation were delinquency, school suspension, repeating grades, academic honors, quality of life, and socioeconomic status. Indicators of psychiatric and medical problems were depression, social dysfunction, somatization, asthma, and hypertension. RESULTS: Participants with both LBW and subsequent childhood abuse, relative to those with neither risk, were at a substantially elevated risk for psychological problems: 10-fold for depression; nearly 9-fold for social dysfunction, and more than 4-fold for somatization. However, they were not at an elevated risk for medical problems in adulthood. Those exposed to childhood abuse were more likely to report delinquency, school suspension, repeating grades during adolescence, and impaired well-being in adulthood, regardless of LBW status. For those with LBW alone, the prevalence of those problems was comparable with that of individuals without either risk factor. CONCLUSIONS: Children with LBW and childhood abuse are at much greater risk for poor adaptation and psychiatric problems than those with LBW alone and those with neither risk. Preventive interventions should target families with LBW children who are at greater risk for childhood abuse.

Adolescent exposure to recurrent terrorism in Israel: posttraumatic distress and functional impairment.

This study examines the impact of exposure to ongoing terrorism on 695 Israeli high school students. Exposure was measured using a questionnaire developed for the security situation in Israel. Posttraumatic symptoms were measured using the UCLA PTSD Index for DSM-IV--Adolescent Version (N. Rodriguez, A. Steinberg, & R. S. Pynoos, 1999), functional impairment and somatic complaints were assessed using items derived from the Diagnostic Interview Schedule for Children (C. P. Lucas et al., 2001), and depression was measured with the Brief Beck Depression Inventory (A. T. Beck & R. W. Beck, 1972). According to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994), the prevalence of probable posttraumatic stress disorder was 7.6%. Girls reported greater severity of posttraumatic symptoms, whereas boys exhibited greater functional impairment in social and family domains. School-based screening appears to be an effective means of identifying adolescents who have been exposed to terror and are experiencing posttraumatic stress symptomatology and psychosocial impairment.