Developmental Epidemiology

Background: Sexual violence against children is a major global health and human rights problem. In order to address this issue there needs to be a better understanding of the issue and the consequences. One major challenge in accomplishing this goal has been a lack of validated child mental health assessments in low-resource countries where the prevalence of sexual violence is high. This paper presents results from a validation study of a trauma-focused mental health assessment tool -the UCLA Post-traumatic Stress Disorder -Reaction Index (PTSD-RI) in Zambia. Methods: The PTSD-RI was adapted through the addition of locally relevant items and validated using local responses to three cross-cultural criterion validity questions. Reliability of the symptoms scale was assessed using Cronbach alpha analyses. Discriminant validity was assessed comparing mean scale scores of cases and non-cases. Concurrent validity was assessed comparing mean scale scores to a traumatic experience index. Sensitivity and specificity analyses were run using receiver operating curves. Results: Analysis of data from 352 youth attending a clinic specializing in sexual abuse showed that this adapted PTSD-RI demonstrated good reliability, with Cronbach alpha scores greater than .90 on all the evaluated scales. The symptom scales were able to statistically significantly discriminate between locally identified cases and non-cases, and higher symptom scale scores were associated with increased numbers of trauma exposures which is an indication of concurrent validity. Sensitivity and specificity analyses resulted in an adequate area under the curve, indicating that this tool was appropriate for case definition. Conclusions: This study has shown that validating mental health assessment tools in a low-resource country is feasible, and that by taking the time to adapt a measure to the local context, a useful and valid Zambian version of the PTSD-RI was developed to detect traumatic stress among youth. This valid tool can now be used to appropriately measure treatment effectiveness, and more effectively and efficiently triage youth to appropriate services.

Two divergent areas of study have focused on the experiences of grief, i.e., bereavement, and on trauma and its aftermath. The grief literature has its foundations in psychodynamic and relational theories, and thus treatment modalities have focused on resolving relationship issues through reminiscence and developing a new sense of the relationship and of the self, independent of the lost loved one. The trauma literature, while having some psychodynamic roots, has been founded primarily on biological and cognitive formulations. Again, while many different treatments are discussed, cognitivebehavioral approaches based on cognitive restructuring and symptom management dominate the practice efficacy literature. But trauma and bereavement/loss are not mutually exclusive, and when a practitioner is faced with a client suffering from both, it is necessary to attempt to integrate these divergent theories and at times antithetical treatment approaches. This paper therefore seeks to address the issue of treatment efficacy in traumatic loss and develop guidelines for evidence-based approaches to practice. [Brief Treatment and Crisis Intervention 4:289-309 (2004)]

Trauma is a complex, common, challenging, confounding and dynamic issue that has only recently begun to be understood from holistic perspectives (Suzuki et al 2014). People of all ages, backgrounds, cultures and genders can experience trauma. However, when trauma strikes in early childhood (early childhood trauma or ECT), and particularly when trauma is chronic as opposed to acute, it can result in complex symptoms that can confuse mental health care providers as well as the individual suffering with the issue, making it particularly hard to live with and treat (Suzuki et al, 2014). ECT can also cause lasting physiological as well as psychological developmental issues, especially when the trauma continues through adulthood, and sometimes results in PTSD (Suzuki et al, 2014). Recently, one study developed a self-report test called the Aversive Childhood Experiences (ACE) questionnaire to examine the type and degree of trauma experienced in order to further understand treatment with trauma-informed therapy (Starecheski, 2014). This self-administered questionnaire presents nominal-dichotomous items to evaluate and scale the possible abuse or neglect experienced as a child on a scale with high sensitivity (level one through ten based on ten questions) (Mitchell & Jolley, 2014).
This paper will describe an overview of the interaction of biopsychology and behavior and the conspiracy of factors that cause developmental issues with learning and memory, especially in children. Cutting-edge research on trauma and recovery will be summarized, as well as ideas for future studies. Finally, successful, empirically-supported treatment modalities of healing will be discussed with the hope of demystifying trauma.

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Kisiel, C., Fehrenbach, T., Liang, Li-Jung, Stolbach, B., McClelland, G., Griffin, G., Maj, N., Briggs, E.C., Vivrette, R.L., Layne, C.M., & Spinazzola, J. (2014). Examining Child Sexual Abuse in relation to Complex Patterns of Trauma Exposure: Findings from the National Child Traumatic Stress Network. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S29-S39. http://dx.doi.org/10.1037/a0037812

Abstract:

Chronic, interpersonal traumas within the caregiving system are associated with a range of symptoms, functional impairments, and trauma history profiles. This study utilized data from the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS) to examine the role of child sexual abuse in combination with other types of caregiver-related trauma (physical abuse, domestic violence, emotional abuse, neglect, and impaired caregiving). These trauma composites were assessed in relation to clinical profiles, including mental health symptoms, risk behaviors, and functional difficulties. Groups included multiply traumatized youth with a documented history of: (a) 3 or more caregiver-related traumas with co-occurring sexual abuse (CR  CSA group, N  501); (b) 3 or more caregiver-related traumas without co-occurring sexual abuse (CR group, N  1,108); and (c) 3 or more noncaregiver-related traumas (e.g., medical trauma, natural disaster, physical/sexual assault; non-CR group, N  142). Youth with caregiver related traumas had significantly earlier onset and longer duration of traumas compared to other traumatized youth. Child sexual abuse had an additive and potent predictive effect on clinical profiles, even in combination with other caregiver-related traumas. Although youth with caregiver-related traumas exhibited significant attachment problems, youth with sexual abuse in particular had higher levels of posttraumatic stress disorder (PTSD), and received higher ratings for symptoms of depression, suicidality, and sexualized behaviors in comparison with the other 2 groups. Findings suggest that careful mapping of trauma history, including age of onset, duration, and co-occurrence of trauma exposure in childhood, can provide a foundation for a more refined developmental approach to the scientific investigation, clinical assessment, and treatment of children with complex histories of trauma in childhood.

Keywords: child sexual abuse, complex trauma, complex PTSD, clinical profiles

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Steinberg, A.M., Pynoos, R.S., Gerrity, E.T., Layne, C.M., Briggs, E.C., Vivrette, R.L., & Fairbank, J. (2014). The NCTSN Core Data Set: Emerging findings, future directions, and implications for theory, research, practice, and policy. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S50-S57. http://dx.doi.org/10.1037/a0037798.

Abstract: The National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS) is the first national, web-based, data repository designed to answer key questions relevant to the field of child traumatic stress and policymakers. The CDS currently contains comprehensive information on trauma history and standardized assessments on 14,088 children seen between 2004 and 2010 in 56 NCTSN academic, hospital, and community service sites across the United States. Although the CDS does not include a representative national sample, it provides a window into the profiles of a large and diverse group of traumatized children for in-depth investigations of trauma histories; clinical and developmental sequelae associated with trauma exposure; the psychometrics and clinical utility of widely used assessment instruments; patterns of service utilization; treatment engagement, completion, and outcome; and issues specific to diverse service sectors, race/ethnicity, cultural groups, and special populations. We have provided an overview of initial published findings from the CDS in this article, described plans for future analyses, and discussed implications for building theory, refining research questions and methods, improving practice, and informing policy.

Keywords: National Child Traumatic Stress Network, child, adolescent, trauma, policy

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Layne, C.M., Greeson, J.K.P., Kim, Soeun, Ostrowski, S.A., Reading, S., Vivrette, R.L., Briggs, E.C., Fairbank, J.A., & Pynoos, R.S. (2014). Links between trauma exposure and adolescent high-risk health behaviors: Findings from the NCTSN Core Data Set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S40-S49. http://dx.doi.org/10.1037/a0037799


Abstract: Although links between adverse childhood experiences (ACEs) and problems in adulthood are well established, less is known regarding links between exposure to trauma during childhood and adolescence and high-risk behavior in adolescence. We tested the hypothesis that cumulative exposure to up to 20 different types of trauma and bereavement/loss incrementally predicts high-risk adolescent behavior beyond demographic variables. Adolescents reporting exposure to at least 1 type of trauma (n  3,785; mean age  15.3 years; 62.7% girls) were selected from the National Child Traumatic Stress Network Core Data Set (CDS). Logistic regression analyses tested associations among both demographic variables and number of types of trauma and loss exposure as predictors, and 9 types of high-risk adolescent behavior and functional impairment (attachment difficulties, skipping school, running away from home, substance abuse, suicidality, criminality, self-injury, alcohol use, and victim of sexual exploitation) as criterion variables. As hypothesized, hierarchical logistic regression analyses revealed that each additional type of trauma exposure significantly increased the odds ratios for each problem behavior (range  1.06–1.22) after accounting for demographic variables. Some demographic variables (female gender, public insurance eligibility, and older age) were also associated with increased likelihood for some outcomes. Study findings extend previously identified links between childhood trauma and problems later in life to include high-risk behavior and functional impairment during adolescence. The findings underscore the need for a trauma-informed public health approach to systematic
screening, prevention, and early intervention for traumatized and bereaved youth in child service systems.

Keywords: adverse childhood experiences, adolescence, risk factor, bereavement, child traumatic stress

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Pynoos, R.S., Steinberg, A.M., Layne, C.M., Liang, L.J., Vivrette, R.L., Briggs, E. C., Kisiel, C., Habib, M., Belin, T.R., & Fairbank, J. (2014). Modeling constellations of trauma exposure in the National Child Traumatic Stress Network Core Data Set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S9-S17. http://dx.doi.org/10.1037/a0037767

Abstract: This article describes the features and utility of the Trauma History Profile (THP) component of the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS). The THP, which is derived from the Trauma History section of the University of California PTSD Reaction Index for DSM–IV, is a comprehensive tool to assist providers in identifying and characterizing a broad spectrum of 20 types of trauma experienced by children and adolescents. Additional questions assess the age during which each trauma type occurred and capture salient details about each experience. The THP allows for modeling of constellations of trauma history in ways conducive to risk stratification and triage, case conceptualization, treatment planning, and research. This article provides a conceptual background for the companion papers that are included in this special section. Selected illustrative findings from the NCTSN CDS (N = 14,088) are presented, including frequencies and mean duration of exposure to specific trauma types; distributions of age of onset by trauma type; frequencies of specific trauma exposure details relating to domestic violence; and a principal component analysis of clusters of co-occurring trauma types during childhood and adolescence. The article concludes with a discussion of implications of the THP for research and practice.

Keywords: adverse childhood experiences, NCTSN, trauma history, traumatic stress

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Layne, C. M., Briggs-King, E., & Courtois, C. (2014). Introduction to the Special Section: Unpacking risk factor caravans across development: Findings from the NCTSN Core Data Set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S1-S8. http://dx.doi.org/10.1037/a0037768

Abstract: In this overview, we discuss the utility of the concept of risk factor caravan (Layne et al., 2009) as a conceptual vehicle for depicting how constellations of various risk factors tend to co-occur, accumulate in number, accrue and cascade forward in their harmful effects, and “travel” with their host across development. We also propose the concept of risk factor caravan passageway as a tool for describing the disadvantaged, resource-poor, and often dangerous ecologies that give rise to and maintain risk factor caravans across the life course. These twin concepts build upon and complement the concepts of resource caravan and resource caravan passageway as advanced by conservation of resources theory (Hobfoll, 2011; 2012). Our aim is to promote the scientific study of the diverse ways through which youths’ physical and social ecologies may profoundly affect (for good or ill) their developmental trajectories, life experiences, and life attainments. We discuss ways in which the Trauma History Profile—a tool for assessing exposure to a broad variety of types of trauma and loss across childhood and adolescence (Pynoos et al., 2014), combined with the concepts of risk factor caravans and caravan passageways, add conceptual richness, balance, developmental perspective, and methodological rigor to the study of such complex phenomena as the ACE Pyramid (Felitti et al., 1998), complex trauma exposure, and complex traumatic stress disorder (Ford & Courtois, 2013). We conclude by discussing ways in which the five papers making up the special section illustrate key concepts and applications of these conceptual and assessment tools.

Keywords: childhood traumatic stress, adverse childhood experiences, complex trauma, developmental psychopathology, risk factor

Despite the evidence linking chronic early trauma with psychological distress, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) has excluded developmental trauma disorder from its taxonomy. This article considers developmental trauma from an attachment-based perspective and raises some of the difficulties professionals may experience conceptualising the trauma-attachment relationship. It explores the impact of the decision to exclude the diagnosis from DSM-5 on professionals, those who have had traumatic early experiences and their carers. Finally, it presents formulation as an alternative proposition which may better suit those who present to mental health services with attachment-and traumalinked difficulties.

Treatment interventions specifically targeting reenactment and risk-taking behaviors, a serious effect of trauma, are a much-neglected area of work with traumatized adolescents. This paper begins by reviewing group therapies for adolescents in general and then reviews specialized group therapies for adolescents who have been potentially traumatized by experiencing or witnessing family or community violence (e.g., sexual abuse, physical abuse, psychological effects of exposure, chronic exposure to community violence) and for adolescents who carry a diagnosis of PTSD. In his description of children who appeared numb in the face of trauma and who also appeared to engage in further violence, Richters (1993) asks: "What types of interventions might be developed and tested to prevent such a process from unfolding?" (p. 5). The potential benefits of cognitive-behavioral group therapy will be articulated, along with a specific focus on psychoeducational groups. Group treatment addressing the effects of violence and abuse, specifically the pernicious cycle of reenactment and risk-taking behaviors will be reviewed. Finally, protocols for developing a group or program in the school system will be reviewed.