Esa Palosaari

Intervention effectiveness among war-affected children: A cluster randomized controlled trial on improving mental health†

We examined the effectiveness of a psychosocial intervention in reducing mental health symptoms among war-affected children, and the role of peritraumatic dissociation in moderating the intervention impact on posttraumatic stress symptoms (PTSS). School classes were randomized into intervention (n = 242) and waitlist control (n = 240) conditions in Gaza, Palestine. The intervention group participated in 16 extracurriculum sessions of teaching recovery techniques (TRT) and the controls received normal school-provided support. Participants were 10- to 13-year-old Palestinian girls (49.4%) and boys (50.6%). Data on PTSS, depressive symptoms, and psychological distress were collected at baseline (T1), postintervention (T2), and 6-month follow-up (T3). Peritraumatic dissociation was assessed only at baseline. Regression analyses that took regression to the mean and cluster sampling into account were applied. The results on intervention effectiveness were specific to gender and peritraumatic dissociation. At T2, the intervention significantly reduced the proportion of clinical PTSS among boys, and both the symptom level (R(2) = .24), and proportion of clinical PTSS among girls who had a low level of peritraumatic dissociation. The results have implications for risk-specific tailoring of psychosocial interventions in war conditions.

Posttraumatic cognitions and posttraumatic stress symptoms among war-affected children: a cross-lagged analysis.

In a longitudinal study of war-affected children, we tested, first, whether posttraumatic cognitions (PTCs) mediated the relationship between initial and later posttraumatic stress symptoms (PTSSs). Second, we analyzed the relative strength of influences that PTCs and PTSSs have on each other in cross-lagged models of levels and latent change scores. The participants were 240 Palestinian children 10-12 years of age, reporting PTSSs and PTCs measures at 3, 5, and 11 months after a major war. Results show that PTCs did not mediate between initial and later PTSSs. The levels and changes in PTCs statistically significantly predicted later levels and changes in PTSSs, but PTSSs did not statistically significantly predict later PTCs. The results are consistent with the hypothesis that PTCs have a central role in the development and maintenance of PTSSs over time, but they do not support the hypothesis that initial PTSSs develop to chronic PTSSs through negative PTCs.

Trajectories of posttraumatic stress symptoms (PTSS) after major war among Palestinian children: Trauma, family- and child-related predictors

OBJECTIVE Research shows great individual variation in changes in posttraumatic stress symptoms (PTSSs) after major traumas of terrorist attacks, military combat, and natural disasters. Earlier studies have identified specific mental health trajectories both in children and adults. This study aimed, first, to identify potential PTSS-related trajectories by using latent class growth analyses among children in a three-wave assessment after the 2008/2009 War on Gaza, Palestine. Second, it analyzed how family- and child related factors (e.g., attachment relations, posttraumatic cognitions (PTCs), guilt, and emotion regulation) associate with the trajectory class membership. METHODS The sample consisted of 240 Palestinian children (49.4% girls and 50.6% boys) of 10-13 years of age (M=11.29, SD=0.68), who completed PTSS (CRIES) assessments at 3 (T1), 5 (T2), and 11 (T3) months after the war. Children reported their personal exposure to war trauma, attachment style, cognitive trauma processing, and emotion regulation, and their parents reported family war trauma exposure and attachment style. RESULTS Results revealed a three-trajectory solution, a majority of children belonging to the Recovery trajectory (n=183), and a minority belonged either to Resistant trajectory (n=29) or to Increasing symptoms trajectory (n=28). Low levels of negative posttraumatic cognitive appraisals, feelings of guilt and emotion regulation were characteristic of children in the Resistant trajectory as compared to Increasing symptoms trajectory. Father׳s attachment security was further associated with the Resistant trajectory membership. Children׳s attachment avoidance and high parental trauma were typical to children in Recovery trajectory (as compared to the Increasing symptoms trajectory).

Effectiveness of psychosocial intervention enhancing resilience among war-affected children and the moderating role of family factors

The study examines, first, the effectiveness of a psychosocial intervention based on Teaching Recovery Techniques (TRT) to increase resiliency among Palestinian children, exposed to a major trauma of war. Second, it analyses the role of family factors (maternal attachment and family atmosphere) as moderating the intervention impacts on resilience. School classes in Gaza were randomized into intervention (N=242) and control (N=240) groups. The percentage of girls (49.4%) and boys (50.6%) were equal, and the child age was 10-13 years in both groups. Children reported positive indicators of their mental health (prosocial behaviour and psychosocial well-being) at baseline (T1), post-intervention (T2) and at a six-month follow-up (T3). At T1 they accounted their exposure to war trauma. Mothers reported about their willingness to serve as an attachment figure, and the child reported about the family atmosphere. Resilience was conceptualized as a presence of positive indications of mental health despite trauma exposure. Against our hypothesis, the intervention did not increase the level of resilience statistically significantly, nor was the effect of the intervention moderated by maternal attachment responses or family atmosphere.

What explains violated expectations of parent-child relationship in transition to parenthood?

Parent-child relationship is created already in prenatal fantasies and expectations of the child-to-be. Negative violation of these expectations after the child is born is known to be harmful for the parent-child relationship. Yet, research is scarce about the medical and psychological factors contributing to violated expectations (VE). This study models the role of parent-, delivery- and infant-related underlying mechanisms for VE. It further compares parents with assisted reproductive treatment (ART) and spontaneous conception (SC), and primi- and multiparous couples. The couples (n = 743) separately filled in questionnaires concerning their prenatal expectations (T1) and 2 months postnatal representations (T2) of intimacy and autonomy in the relationship with their child, measured with Subjective Family Picture Test. A negative or positive discrepancy indicated violated expectations. The parent-related (mental health and marital quality), delivery-related (maternal and paternal birth experience, unplanned Caesarean, and amount of analgesia) and infant-related (infant health problems, difficult infant characteristics, and parental worry) factors were assessed at T2. Results show that among mothers, the associations were mostly indirect and mediated via mental health problems. Among fathers, the associations were direct, marital problems most crucially predicting VE. ART fathers were less susceptible to VE resulting from infant-related problems than SC fathers, but more susceptible to VE resulting from delivery problems. Delivery- and infant-related factors also predicted VE differently among primi- and multiparous mothers. Considering factors that contribute to VE is important when working with couples in transition to parenthood.

Can functional emotion regulation protect children's mental health from war trauma? A Palestinian study

Effective emotion regulation (ER) is expected to protect mental health in traumatic stress. We first analysed the protective (moderator) function of different ER strategies and the associations between ER and mental health. Second, we tested gender differences in the protective function of ER and the associations between ER strategies and mental health. Participants were 482 Palestinian children (girls 49.4%; 10-13 years, M = 11.29, SD = .68) whose ER was assessed by the Emotion Regulation Questionnaire and mental health by post-traumatic stress (Childrens Impact Event Scale), depressive, and psychological distress (Strengths and Difficulties Questionnaire) symptoms, and by psychosocial well-being (Mental Health Continuum-Short Form). War trauma involved 42 events. Results showed, first, that none of the ER strategies could protect a childs mental health from negative impact of war trauma, but self-focused ER was associated with low depressive symptoms, and other-facilitated ER with high psychological well-being. However, controlling of emotions formed a comprehensive risk for childrens mental health. Second, gender differences were found in the protective role of ER, as self-focused and distractive ER formed a vulnerability among boys. The results are discussed in the context of emotional and regulative demands of war and life-threat.