Alan M. Steinberg

Psychiatric Comorbidity in Children after the 1988: Earthquake in Armenia

OBJECTIVE To determine current rates of posttraumatic stress disorder (PTSD), depressive disorder, and separation anxiety disorder (SAD) among children 1 1/2 years after the 1988 earthquake in Armenia; to determine current rates of comorbid PTSD and depressive disorder; and to assess the contribution of exposure, gender, loss of family members, and loss of residence. METHOD Two hundred eighteen school-age children from three cities at increasing distances from the epicenter were evaluated using the Child Posttraumatic Stress Disorder Reaction Index, the Depression Self-Rating Scale, and the section on SAD from the Diagnostic Interview for Children and Adolescents. RESULTS On the basis of these evaluations, high rates of current PTSD, depressive disorder, and their co-occurrence were found among victims residing in the two heavily impacted cities. SAD was comparatively less frequent, although symptoms of SAD had been pervasive throughout the region. Severity of posttraumatic stress and depressive reactions were highly correlated. Extent of loss of family members was independently correlated with each. CONCLUSION After a catastrophic natural disaster, children are at risk for comorbid PTSD and secondary depression. Based on the findings, an interactive model is proposed of postdisaster psychopathology. Early clinical intervention is recommended to prevent chronic posttraumatic stress reactions and secondary depression.

A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders

Empirical findings regarding childhood traumatic stress are placed within a developmental life-trajectory model that incorporates a tripartite etiology of posttrauma distress. This approach recognizes an intricate matrix of child-intrinsic factors, developmental maturation and experience, life events, and evolving family and social ecologies. Of central developmental importance in the field of traumatic stress is the ontogenesis of appraisal, emotional response, emotional and physiological regulation, and consideration of protective action with regard to danger. The complexity of traumatic situations and their aftermath suggests the relevance of multiple stress diatheses in understanding individual variability in proximal and distal effects. Neurobiological systems that subserve danger mature over childhood and adolescence. Neurophysiological and neurohormonal studies among traumatized children and adolescents suggest potential neurodevelopmental stage-related vulnerabilities within these systems. Advances in child development and traumatic stress provide tools for investigating proximal and distal interplay of psychopathology, disturbances in the acquisition and maintenance of developmental competencies, and life-trajectory outcomes. A developmental psychopathology model suggests different avenues by which dangerous circumstances, childhood traumatic experiences, and posttraumatic stress disorder (PTSD) can intersect with other anxiety disorders over the life span.

Effectiveness of a School-Based Group Psychotherapy Program for War-Exposed Adolescents: A Randomized Controlled Trial

OBJECTIVE To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity. METHOD A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3). RESULTS Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions. CONCLUSIONS A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.

Psychometric Properties of the UCLA PTSD Reaction Index: Part I

This article presents psychometric characteristics of the UCLA PTSD Reaction Index for DSM IV (PTSD-RI) derived from a large sample of children and adolescents (N = 6,291) evaluated at National Child Traumatic Stress Network centers. Overall mean total PTSD-RI score for girls was significantly higher as compared with boys. Age-related differences were found in that overall mean total PTSD-RI scores and within sex groups were higher among those aged 7-9 years and 16-18 years. There were no significant differences in mean total PTSD-RI scores across racial/ethnic groups. The PTSD-RI total scale displayed good to excellent internal consistency reliability across age ranges, sex, and racial/ethnic groups (α = .88-.91). Correlations of PTSD-RI scores with PTS subscale scores on the TSCC-A for the entire sample and within sex, age, and ethnic/racial groups provided evidence of convergent validity, although not discriminant validity. In contradistinction to previously reported 4-factor models, an exploratory factor analysis revealed 3 factors that mostly reflected the underlying dimensions of PTSD in DSM IV. PTSD-RI scores were associated with increased odds ratios for functional/behavior problems (odds ratio [OR] = 1-1.80). These findings are striking in light of the wide range of trauma exposures, age, and race/ethnicity among subjects.

Trauma- and Grief-Focused Intervention for Adolescents Exposed to Community Violence: Results of a School-Based Screening and Group Treatment Protocol

Recent studies document high levels of community violence exposure among adolescents and link violence exposure to psychological distress and impaired academic achievement. This study assessed the prevalence of trauma exposure among middle school students and evaluated the effectiveness of a school-based, trauma/grief-focused group psychotherapy protocol in treating a sub-group of students with severe exposure, posttraumatic stress disorder (PTSD) and functional impairment. Using a stratified screening procedure, 812 students completed a screening survey, 58 students (7.1% of those surveyed) met criteria for group treatment, and 26 students participated in the group. Group participation was associated with improvements in posttraumatic stress and complicated grief symptoms, and in academic performance. Results suggest that students who are exposed to severe levels of community violence may not be typically identified or treated. The findings also suggest that severe PTSD in adolescence may be associated with impaired school functioning, and that a reduction in PTSD symptoms may be related to academic remediation.

A behavioral animal model of posttraumatic stress disorder featuring repeated exposure to situational reminders

The purpose of this study was to evaluate an animal model of posttraumatic stress disorder (PTSD) in mice. The model featured repeated exposures to situational reminders of a traumatic stress, which consisted of a brief electric shock, and included assessment of two behavioral parameters and the startle reflex. The findings indicated an initial, but unsustained, increase in locomotor activity in a neutral environment due to traumatic stress. Exposure to situational reminders was associated with a persistent bidirectional abnormal behavioral pattern in a fear-provoking environment and a progressive increase over time in the magnitude of the startle reflex. Exposure to situational reminders also produced an increase in aggressive behavior. This animal model appears to produce behavioral changes analogous to those seen in patients with PTSD.

DSM‐V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) should ensure systematic attention to age-specific manifestations and selective modifications of the diagnostic criteria for posttraumatic stress disorder (PTSD) among children and adolescents. The authors propose developmental refinements to the conceptual framework for PTSD based on an appreciation of the different neurosignatures of danger and safety, and maturational processes that underlie symptom presentation. This includes preliminary evidence for the developmental salience of additional dimensions for PTSD (e.g., recklessness and thrill-seeking). The authors provide conservative recommendations for DSM-V diagnostic criteria that primarily highlight age-related developmental manifestations that, if included in the accompanying text, would bring a richer appreciation of developmentally linked symptom presentations.

Longitudinal study of PTSD, depression, and quality of life among adolescents after the Parnitha earthquake

OBJECTIVE To investigate the course of PTSD, depression, and current quality of life among adolescents 32-months after the 1999 Parnitha earthquake in Greece. METHODS The follow-up was conducted among 511 adolescents originally evaluated at 3-months post-earthquake using the UCLA PTSD Reaction Index (PTSD-RI), Depression Self-Rating Scale (DSRS), and Quality of Life Questionnaire (QOLQ). RESULTS Mean PTSD scores for the whole sample had subsided to mild levels; however, 8.8% were still experiencing moderate to severe levels of symptoms, and 13.6% met criteria for clinical depression. Frequency of experiencing reminders of the earthquake in the past month best explained the variance (15%) in PTSD severity, followed by depression at 3-months (8%). The QOLQ domain scores were negatively correlated with PTSD and depression. Depression at 3-months was the best predictor of QOLQ at 32-months, explaining 16% of the variance. LIMITATIONS Self-report instruments were used; hence the responses may have been over- or under-estimated; also, the findings may not be generalizable to other ethnic groups. CONCLUSION Ongoing screening is recommended after disaster to identify adolescents who continue to experience moderate to severe levels of PTSD and depressive symptoms. Specific interventions to reduce reactivity to earthquake-related reminders should be a component of post-disaster recovery programs. A quality of life measure can provide important information in addition to traditional scales for monitoring the course of recovery among adolescents after disasters.

Mental Health in Sumatra after the Tsunami

OBJECTIVES We assessed the levels and correlates of posttraumatic stress reactivity (PTSR) of more than 20,000 adult tsunami survivors by analyzing survey data from coastal Aceh and North Sumatra, Indonesia. METHODS A population-representative sample of individuals interviewed before the tsunami was traced in 2005 to 2006. We constructed 2 scales measuring PTSR by using 7 symptom items from the Post Traumatic Stress Disorder (PTSD) Checklist-Civilian Version. One scale measured PTSR at the time of interview, and the other measured PTSR at the point of maximum intensity since the disaster. RESULTS PTSR scores were highest for respondents from heavily damaged areas. In all areas, scores declined over time. Gender and age were significant predictors of PTSR; markers of socioeconomic status before the tsunami were not. Exposure to traumatic events, loss of kin, and property damage were significantly associated with higher PTSR scores. CONCLUSIONS The tsunami produced posttraumatic stress reactions across a wide region of Aceh and North Sumatra. Public health will be enhanced by the provision of counseling services that reach not only people directly affected by the tsunami but also those living beyond the area of immediate impact.

Issues in the Developmental Neurobiology of Traumatic Stress

Over the last decade, significant advances have been made in characterizing the neurobiology of traumatic stress reactions among adults. Increasing evidence for a similar phenomenology of posttraumatic stress disorder (PTSD) symptoms in adults and school-age children and adolescents’-’ provides a compelling rationale for the possibility of common neurobiological alterations. If present, such alterations in children and adolescents would be of special concern in view of the potential adverse impact on a wide range of developmental processes. We recently presented a developmental psychopathology model of traumatic stress in ~hildhood.~ Such a model emphasizes the complex interrelationship of trauma and developmental progression and the essential linkage between disrupted and normal development. Analogously, investigation of the neurobiology of PTSD among children and adolescents will need to be embedded in a neurodevelopmental framework. This paper provides an overview of selected areas of neurodevelopment and recent findings relevant to this research enterprise. A key feature of our developmental model of childhood traumatic stress is the prominent role assigned to the trauma-related formation of expectations, as these are expressed in the thought, emotion, behavior, and biology of the developing child. Such traumatic expectations dramatically alter the sense of safety and security of the environment and interpersonal life and the child’s sense of personal integrity. Ultimately, a comprehensive neurodevelopmental approach to traumatic stress among children and adolescents will place such investigation within the broader context of the child’s evolving capacity for appraising, processing, and responding to danger, trauma, and posttrauma reminders.