Robert Abramovitz

Impact of Conjoined Exposure to the World Trade Center Attacks and to Other Traumatic Events on the Behavioral Problems of Preschool Children

OBJECTIVES To examine the long-term behavioral consequences of exposure to the World Trade Center (WTC) attacks in preschool children and to evaluate whether conjoined exposure to disaster and to other traumatic events has additive effects. DESIGN Retrospective cohort study. SETTING Lower Manhattan, New York. PARTICIPANTS A total of 116 preschool children directly exposed to the WTC attacks. Main Exposures High-intensity WTC attack-related trauma exposure indexed by the child experiencing 1 or more of the following: seeing people jumping out of the towers, seeing dead bodies, seeing injured people, witnessing the towers collapsing, and lifetime history of other trauma exposure. Main Outcome Measure Clinically significant behavioral problems as measured using the Child Behavioral Checklist. RESULTS Preschool children exposed to high-intensity WTC attack-related events were at increased risk for the sleep problems and anxious/depressed behavioral symptom clusters. Conjoined exposure to high-intensity WTC attack-related events and to other trauma was associated with clinically significant emotionally reactive, anxious/depressed, and sleep-related behavioral problems. Children without a conjoined lifetime history of other trauma did not differ from nonexposed children. Risk of emotionally reactive, anxious/depressed, and attention problems in preschool children exposed to conjoined high-intensity WTC attack-related events and other trauma increased synergistically. CONCLUSIONS Conjoined other trauma exposure seems to amplify the impact of high-intensity WTC attack-related events on behavioral problems. Preschool children exposed to high-intensity events who had no other trauma exposure did not have increased clinically significant behavioral problems. The additive effects of trauma exposure are consistent with an allostatic load hypothesis of stress. More vigorous outreach to trauma-exposed preschool children should become a postdisaster public health priority.

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.

Using the Core Curriculum on Childhood Trauma to Strengthen Clinical Knowledge in Evidence-Based Practitioners

The high prevalence of trauma exposure in mental health service-seeking populations, combined with advances in evidence-based practice, competency-based training, common-elements research, and adult learning make this an opportune time to train the mental health workforce in trauma competencies. The Core Curriculum on Childhood Trauma (CCCT) utilizes a five-tiered conceptual framework (comprising Empirical Evidence, Core Trauma Concepts, Intervention Objectives, Practice Elements, and Skills), coupled with problem-based learning, to build foundational trauma knowledge and clinical reasoning skills. We present findings from three studies: Study 1 found that social work graduate students’ participation in a CCCT course (N = 1,031) was linked to significant pre–post increases in self-reported confidence in applying core trauma concepts to their clinical work. Study 2 found significant pre–post increases in self-reported conceptual readiness (N = 576) and field readiness (N = 303) among social work graduate students participating in a “Gold Standard Plus” educational model that integrated classroom instruction in core trauma concepts, training in evidence-based trauma treatment (EBTT), and implementation of that EBTT in a supervised field placement. Students ranked the core concepts course as an equivalent or greater contributor to field readiness compared to standard EBTT training. Study 3 used qualitative methods to “distill” common elements (35 intervention objectives, 59 practice elements) from 26 manualized trauma interventions. The CCCT is a promising tool for educating “next-generation” evidence-based practitioners who possess competencies needed to implement modularized, individually tailored trauma interventions by strengthening clinical knowledge, clinical reasoning, and familiarity with common elements.

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.

Mixed lateral preference and peritraumatic reactions to the World Trade Center attacks.

There is evidence that mixed lateral preference is a risk factor for developing more intense posttraumatic stress disorder symptoms. However, no research has examined whether mixed-handed persons experience greater threat of loss of life and physical injury and more intense emotional reactions (terror, helplessness, horror) during peritraumatic exposure. This study compared the intensity of ratings of perceived threat to life and physical injury and emotional reactions among mixed-handed and fully right-handed mothers directly exposed to the World Trade Center attacks. Controlling for exposure, mixed-handed mothers reported more intense ratings, indicating that mixed lateral preference may be associated with greater peritraumatic emotional distress.

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.

Building Agency Capacity for Trauma-Informed Evidence-Based Practice and Field Instruction

Through this article the authors describe how schools of social work offering a child and adolescent trauma specialization actively partnered with their community-based field placement agencies to achieve a dual purpose: help agencies sustain the capacity for evidence-based trauma treatment (EBTT) and provide sufficient EBTT MSW student field placement sites that support preparation of trauma-informed practitioners by schools of social work. Development and description of the specific conceptual framework used to inform the trauma-informed organizational change initiative is described. Results of an Organizational Readiness assessment undertaken at six agencies reflect a strong alignment between implementation drivers identified in the literature (Fixsen, Blase, Naoom, & Wallace, 2009) and the conceptual framework. The manner in which these results are being used by schools of social work and their agency partners in sustaining the implementation of evidence-based trauma treatment is reviewed, and implications for future research, education, and practice is discussed.

Child Trauma Exposure and Posttraumatic Stress Disorder: Identification in Community Mental Health Clinics

ABSTRACT We examined the identification of trauma exposure and posttraumatic stress disorder (PTSD) in help-seeking urban children (N = 157) presenting for care in community mental health clinics. Children and their parents completed a standard intake assessment conducted by a community clinician followed by a structured, trauma-focused assessment conducted by a study clinician. Clinicians provided ratings of child functional impairment, parents reported on internalizing/externalizing problems, and children provided self-reports of PTSD symptom severity. Although community clinicians were mandated by clinic policy to ask about exposure to physical abuse, sexual abuse, and witnessed domestic violence, they identified exposure to these at significantly lower rates than study clinicians. Rates of PTSD based on community clinician diagnosis (1.9%) were also much lower than rates obtained by study clinicians (19.1%). A review of clinical charts 1 year after intake revealed no change in PTSD diagnosis rate following additional clinical contacts. Clinician-rated impairment, parent-rated emotional/behavioral problems, and child-rated PTSD symptom severity measures provided support for the validity of trauma exposure and PTSD as identified by study clinicians. Trauma exposure and PTSD diagnosis among help-seeking urban youth appear to be underidentified by community clinicians, which may compromise clinicians’ ability to respond to environmental risks and provide appropriate evidence-based treatments.

Building a Trauma-Informed Workforce Capacity and Legacy

ABSTRACT Social workers encounter trauma in a majority of the populations they serve. It is therefore essential to train social work students to understand the impact of trauma, to assess trauma history and symptoms, and to effectively intervene with children and families. This article presents 3 qualitative research narratives that provide an in-depth analysis of factors contributing to successful implementation of an innovative trauma-informed educational model. The narratives identify common themes related to student knowledge and field readiness; personal and system context; organizational leadership; and vision, training, and partnerships/collaborations.