Eve G. Spratt

Neuropsychological Findings in Childhood Neglect and their Relationships to Pediatric PTSD

Although child neglect is the most prevalent form of child maltreatment, the neurocognitive effects of neglect are understudied. We examined IQ, reading, mathematics, and neurocognitive domains of fine-motor skills, language, visual-spatial, memory/learning, and attention/executive functions in two groups of nonsexually abused medically healthy neglected children, one with DSM-IV posttraumatic stress disorder (PTSD) and one without, and a demographically similar healthy nonmaltreated control group. Significantly lower IQ, reading, mathematics, and selected differences in complex visual attention, visual memory, language, verbal memory and learning, planning, problem solving, and speeded naming were seen in Neglect Groups. The Neglect with PTSD Group performed worse than controls on NEPSY Design Copying, NEPSY Tower, and Mathematics; and performed worse than controls and Neglect without PTSD on NEPSY Memory for Faces-Delayed. Negative correlations were seen between PTSD symptoms, PTSD severity, and maltreatment variables, and IQ, Academic Achievement, and neurocognitive domains. Neglected children demonstrated significantly lower neurocognitive outcomes and academic achievement than controls. Lower IQ, neurocognitive functions, and achievement may be associated with more PTSD symptoms (particularly re-experiencing symptoms), greater PTSD severity, and a greater number of maltreatment experiences. Trauma experiences may additionally contribute to subsequent neurodevelopmental risk in neglected children. (JINS, 2009, 15, 868-878.).

Reactive Attachment Disorder: what we know about the disorder and implications for treatment.

In recent years, there has been an increase in the number of children diagnosed with Reactive Attachment Disorder (RAD). There is considerable disagreement about what this entity actually entails and, in particular, what types of assessments and interventions to use with these children and families. Children with a history of maltreatment (i.e., physical, sexual, emotional abuse, and/or severe neglect) are particularly likely to receive this diagnosis, because the behavior problems often seen in these children are presumed to stem from the maladaptive relationships they have had with abusive caregivers. However, many children are receiving this diagnosis because of behavior problems that clearly extend beyond the DSM-IV criteria for RAD. Perhaps the most concerning consequence of the RAD diagnosis is the emergence of novel treatments that lack a sound theoretical basis or empirical support, and may potentially be traumatizing and dangerous to the child. Thus, the purpose of this article is to review and synthesize what is known about RAD and attachment disorders and to discuss implications for treatment.

Enhanced Cortisol Response to Stress in Children in Autism.

Children with Autism often show difficulties in adapting to change. Previous studies of cortisol, a neurobiologic stress hormone reflecting hypothalamic–pituitary–adrenal (HPA) axis activity, in children with autism have demonstrated variable results. This study measured cortisol levels in children with and without Autism: (1) at rest; (2) in a novel environment; and (3) in response to a blood draw stressor. A significantly higher serum cortisol response was found in the group of children with autism. Analysis showed significantly higher peak cortisol levels and prolonged duration and recovery of cortisol elevation following the blood-stick stressor in children with autism. This study suggests increased reactivity of the HPA axis to stress and novel stimuli in children with autism.

Neurodevelopmental biology associated with childhood sexual abuse

Child maltreatment appears to be the single most preventable cause of mental illness and behavioral dysfunction in the United States. Few published studies examine the developmental and the psychobiological consequences of sexual abuse. There are multiple mechanisms through which sexual abuse can cause post-traumatic stress disorder, activate biological stress response systems, and contribute to adverse brain development. This article will critically review the psychiatric problems associated with maltreatment and the emerging biologic stress system research with a special emphasis on what is known about victimization by sexual abuse.

PTSD and the HPA axis: differences in response to the cold pressor task among individuals with child vs. adult trauma.

Hypothalamic pituitary adrenal (HPA) axis and subjective stress response to a cold-water immersion task, the cold pressor task (CPT), in individuals (N=89) with post-traumatic stress disorder (PTSD) were examined. All tests were conducted at 08:00h after an overnight hospital stay. Plasma adrenocorticotrophin hormone (ACTH), cortisol, and subjective stress were examined at baseline and five post-task time points in controls (n=31), subjects with PTSD as a result of an index trauma during childhood (i.e. before age 18; n=25), and subjects with PTSD as a result of an index trauma as an adult (n=33). Approximately, 50% of individuals in both trauma groups were alcohol dependent, and the impact of this comorbidity was also examined. Subjects with PTSD, regardless of age of index trauma, had a less robust ACTH response as compared to controls. Regardless of the presence or absence of comorbid alcohol dependence, subjects with childhood trauma had lower cortisol at baseline and at all post-task measurement points and did not demonstrate the decrease in cortisol over the course of the 2h monitoring period seen in subjects with adult index trauma and controls. The findings reveal differences in the neuroendocrine response to the CPT in individuals with PTSD compared to control subjects, and differences in PTSD subjects when examined by age of index trauma.

Gender differences in the effect of early life trauma on hypothalamic–pituitary–adrenal axis functioning†

Background: The objective of this study was to examine the modifying effect of gender on the association between early life trauma and the hypothalamic–pituitary–adrenal (HPA) axis response to a pharmacologic challenge and a social stress task in men and women. Participants (16 men, 23 women) were the control sample of a larger study examining HPA axis function. Individuals with major depressive disorder, posttraumatic stress disorder, bipolar disorder, or psychotic or eating disorders were excluded. Methods: In two test sessions, subjects received 1 µg/kg of corticotropin‐releasing hormone (CRH) intravenously and participated in the Trier Social Stress Test (TSST). Primary outcomes included plasma cortisol and corticotropin levels measured at baseline and more than five time points following the challenges. Predictors included gender and early life trauma, as measured by the Early Trauma Index. Using factor analysis, the domains general trauma, severe trauma, and the effects of trauma were established. Using regression, these constructs were used to predict differential HPA reactivity in men and women following the challenges. Results: The three factors accounted for the majority of the variance in the ETI. Following the CRH challenge, women had higher overall corticotropin response as dictated by the area under the curve analysis. There were no significant associations between trauma and neuroendocrine response to the TSST. Conclusions: CRH challenge results indicate that gender differences in the impact of early trauma may help explain the differential gender susceptibility to psychopathology following adverse childhood events. This may help explain gender differences in some stress‐sensitive psychiatric disorders. Depression and Anxiety, 2011.

Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation

We examined the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men.

Community-Dwelling Cocaine-Dependent Men and Women Respond Differently to Social Stressors versus Cocaine Cues

UNLABELLED There are likely to be gender differences in determinants of relapse to drug use following abstinence in cocaine-dependent individuals. Cocaine-dependent women are more likely to attribute relapse to negative emotional states and interpersonal conflict. Cocaine dependence has also been linked to dysregulation of stress response and the hypothalamic pituitary adrenal (HPA) axis which may differ between genders. Subjective and HPA-axis responses to a social evaluative stressor, the Trier Social Stress Test (TRIER), and in vivo cocaine-related cues were examined in the present study. RESULTS There were no gender differences in magnitude of craving responses to the TRIER or the CUE. Both genders had a greater craving response to the CUE than to the TRIER, but the magnitude of the difference was greater for men than women (p=0.04). Cocaine-dependent subjects, compared to the control group, had significantly higher response throughout the TRIER (p<0.0001) and CUE (p<0.0001) testing sessions. There were no gender differences and no gender by cocaine interaction for ACTH responses to the TRIER, although women had lower baseline ACTH (p=0.049). On the CUE task, in contrast, female cocaine-dependent subjects had a more blunted ACTH response than did the other three groups (p=0.02). Female cocaine-dependent subjects also had a lower odds of a positive cortisol response to the TRIER as compared to the other three groups (OR=0.84, 95% CI=[0.02, 1.01]). During the CUE task, cocaine-dependent subjects had overall higher mean cortisol levels (p=0.0001), and higher odds of demonstrating a positive cortisol response to the CUE (OR=2.61, 95% CI=[1.11, 6.11]). No gender differences were found in ACTH responses to the CUE. The results are reviewed in the context of the existing literature on gender differences in cocaine dependence and potential implications for treatment are discussed.

Depressive Symptoms in Adolescents with a Chronic Illness

Adolescents with various chronic illnesses were compared to healthy comparison controls and the normative population on self-reports of symptoms of depression. Overall, a higher percentage of adolescents with a chronic illness reported symptoms of moderate to severe depression; the frequency was highest in those adolescents with sickle cell disease. Adolescents who rated their chronic disease as moderate or severe reported more depressive symptoms than did those adolescents who rated their illness as mild. Within the limitations of our study, we recommend that future investigations examine patterns and symptoms of depression in adolescents coping with the stressors of a chronic illness.

Use of the pediatric symptom checklist in the pediatric neurology population

The purpose of this study was to evaluate the effectiveness of the Pediatric Symptom Checklist (PSC) as a mental health screening instrument in a busy pediatric neurology population in comparison with more lengthy, time-consuming assessment methods. One hundred two children were screened using the PSC. PSC results were compared with scores on the Child Behavior Checklist (CBCL), results from structured interviews, and ratings of adaptive functioning using the Childrens Global Assessment Scale (CGAS). Thirty-nine of the patients (38%) scored 63 or above on the CBCL, indicating psychosocial impairment. Using a cutoff score of 22, the PSC correctly identified 35 of these 39 positive cases (sensitivity 89.7) and 48 of the 63 children with CBCL scores below 63 (specificity 76.2). CGAS scores were significantly negatively correlated with PSC scores (r = -0.60, P < 0.05). The PSC correctly identified 85.9% of children who scored 70 or below on the CGAS. Among the 53 children with psychiatric diagnoses on the basis of the interview, 41 scored above the cutoff of 22 on the PSC. Results suggest that the PSC is an efficient and accurate screen for identification of mental health problems in the pediatric neurology population.