Tine K. Jensen

Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway

BACKGROUND Although youths in many countries have been exposed to terrorism, few studies have examined early risk and protective factors for the subsequent development of mental health problems. AIMS To investigate the levels of post-traumatic stress in survivors of the 2011 massacre on Utøya Island compared with the general population in Norway, and to identify predictive factors. METHOD Four hundred and ninety survivors were invited to participate. Structured face-to-face interviews were performed 4-5 months after the attack. RESULTS There were 325 study participants (response rate 66%). Survivors had been highly exposed to danger and loss. Post-traumatic stress levels were more than six times higher in survivors than in the general population. Predictors were female gender, minority ethnic status, high level of trauma exposure, pain, the loss of someone close and social support. CONCLUSIONS Survivor characteristics that can be assessed in the early aftermath of a terrorist attack strongly predict the subsequent mental health problems of exposed youths. The highly elevated symptoms observed were largely attributable to the traumatic experience and reflect the mental health costs of the terrorist attack.

A Randomized Effectiveness Study Comparing Trauma-Focused Cognitive Behavioral Therapy With Therapy as Usual for Youth

The efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) has been shown in several randomized controlled trials. However, few trials have been conducted in community clinics, few have used therapy as usual (TAU) as a comparison group, and none have been conducted outside of the United States. The objective of this study was to evaluate the effectiveness of TF-CBT in regular community settings compared with TAU. One hundred fifty-six traumatized youth (M age = 15.1 years, range = 10–18; 79.5% girls) were randomly assigned to TF-CBT or TAU. Intent-to-treat analysis using mixed effects models showed that youth receiving TF-CBT reported significantly lower levels of posttraumatic stress symptoms (est. = 5.78, d = 0.51), 95% CI [2.32, 9.23]; depression (est. = 7.00, d = 0.54), 95% CI [2.04, 11.96]; and general mental health symptoms (est. = 2.54, d = 0.45), 95% CI [0.50, 4.58], compared with youth in the TAU group. Youth assigned to TF-CBT showed significantly greater improvements in functional impairment (est. = −1.05, d = −0.55), 95% CI [−1.67, −0.42]. Although the same trend was found for anxiety reduction, this difference was not statistically significant (est. = 4.34, d = 0.30), 95% CI [−1.50, 10.19]. Significantly fewer youths in the TF-CBT condition were diagnosed with posttraumatic stress disorder compared to youths in the TAU condition, χ2(1, N = 116) = 4.61, p = .031, Phi = .20). Findings indicate that TF-CBT is effective in treating traumatized youth in community mental health clinics and that the program may also be successfully implemented in countries outside the United States.

A longitudinal study of posttraumatic stress reactions in Norwegian children and adolescents exposed to the 2004 tsunami

OBJECTIVE To investigate the prevalence of symptoms of posttraumatic stress disorder (PTSD) and factors related to level of these in children who experienced a catastrophe as tourists and were therefore able to return to the safety of their homeland. DESIGN Face-to-face semistructured interviews and assessments. SETTING Children and adults were interviewed in their homes 10 months and 2(1/2) years after the tsunami. PARTICIPANTS A volunteer sample of adults and children aged 6 to 17 years who were exposed to the 2004 tsunami (at 10 months, 133 children and 84 parents; at 2(1/2) years, 104 children and 68 parents). Main Exposure The tsunami in Southeast Asia on December 26, 2004. OUTCOME MEASURES University of California, Los Angeles (UCLA) PTSD Reaction Index. RESULTS Two children had scores indicative of PTSD at 10 months. There was a significant decrease in symptoms after 2(1/2) years, and no children had scores exceeding the clinical cutoff at this time. Only the death of a family member and subjective distress were independently and significantly associated with PTSD scores at 10 months, whereas sex, need for professional mental health services prior to the tsunami, and parental sick leave owing to the tsunami were independent predictors of PTSD symptoms at follow-up. CONCLUSIONS The children reported fewer symptoms of PTSD compared with children in other disaster studies. Predictor variables changed from disaster-related subjective distress to factors related to general mental health at follow-up. The findings indicate the importance of secondary adversities and pretrauma functioning in the maintenance of posttraumatic stress reactions.

Children’s and parents’ posttraumatic stress reactions after the 2004 tsunami

This study examined the association between parents’ and children’s posttraumatic stress reactions after the tsunami disaster in Southeast Asia in 2004. Parents of 319 Norwegian children and adolescents aged 6–18 years reported on children’s exposure to the tsunami and children’s immediate subjective responses. The Child Stress Disorder Checklist was used to measure children’s posttraumatic stress reactions 6–8 months after the tsunami, and the Impact of Event Scale Revised measured parental PTSD. Results indicated that parents’ posttraumatic stress reactions significantly predicted PTSD reactions in their children. The strongest association was found for parental intrusive reactions and hyperarousal. Highly exposed children seemed to be more vulnerable to parental distress compared to children with lower levels of exposure. The study demonstrates that parental distress can endure and worsen the impact of a disaster in children. In assessments of trauma-related consequences and in therapeutic work with children clinicians need to expand the focus to include their parents and family.

The Therapeutic Alliance in Treatment of Traumatized Youths: Relation to Outcome in a Randomized Clinical Trial

OBJECTIVE We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU]). METHOD Participants were 156 youths (M age = 15.1 years, range = 10-18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children-Revised (TASC-R). RESULTS Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d = 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance × Treatment Group interaction: Alliance ratings were significant predictors of reduction in PTSS (Est. = -0.53, p = .003, 95% confidence interval [CI] = -0.87 to -0.18) and additional outcomes measured in TF-CBT but not in TAU (PTSS posttreatment: Est. = 0.01, p = .647, 95% CI = -0.29 to 0.47). CONCLUSION This study was the first to investigate the contribution of alliance to outcome among adolescents with posttraumatic symptoms, treated with TF-CBT or TAU. Our findings indicated that there was an important interaction between alliance and therapeutic approach, as alliance predicted outcome in TF-CBT, but not in the nonspecific treatment condition. A positive working relationship appeared to be especially important in the context of this evidence-based treatment, which requires youth involvement in specific therapy tasks. Further, findings showed that use of a manual did not compromise alliance formation.

Development of mental health problems - a follow-up study of unaccompanied refugee minors

BackgroundStudies have shown that unaccompanied refugee children have elevated symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and externalizing problems. Few studies have examined change in this group’s mental health symptoms after resettlement in a new country, particularly for those who arrive to a host country when being under the age of 15.MethodThe sample included 75 unaccompanied refugee children (mean age 16.5 years, SD =1.6; 83% boys) who settled in Norway. We examined change in the number of stressful life events, symptoms of PTSD (Child PTSD Symptom Scale; CPSS), and symptoms of anxiety, depression and externalizing problems (Hopkins Symptom Checklist; HSCL-37A) from 6 months after arrival (T1) to 1.9 years (SD =0.6) later (T2) using paired samples t-tests. Linear regression models were used to examine whether length of stay, level of education or change in the number of experienced stressful life events predicted symptom change.ResultsThere was a small and non-significant change in the mean scores of both symptom scales between T1 and T2, although there was considerable variation among the participants. The number of children who remained above the clinical cut-off value from T1 to T2 was as follows: 28 of 47 (59.6%) on the CPSS and eight of 16 (50.0%) on the HSCL-37A. There was a significant increase in the number of reported stressful life events from T1 to T2. An increase in reported stressful life events predicted an increase in PTSS (β =1.481, 95% CI .552 to 2.411). Length of stay, increase in stressful life events and level of education did not predict changes in the HSCL-37A.ConclusionsThere was no average change in the level of PTSS, depression, anxiety, or externalizing problems in this group of unaccompanied refugee children from shortly after arrival to nearly two years later. The large variation in change scores across informants indicates a need for monitoring the development of mental health problems and securing that the youth’s primary psychosocial needs are met. The high rate of children above clinical cut-off on the symptoms scales and with suicidal ideation indicates that many may be in need of treatment.

PTSD prevalence and symptom structure of DSM-5 criteria in adolescents and young adults surviving the 2011 shooting in Norway

BACKGROUND Diagnostic criteria for Posttraumatic Stress Disorder (PTSD) have been revised for DSM-5. Two key changes include alteration of the clustering of PTSD symptoms and new PTSD symptom criteria related to negative alterations in cognition and mood. In this study, we empirically investigated these changes. METHODS We interviewed 325 adolescents and young adults who survived the 2011 youth camp shooting at Utøya Island, Norway. The UCLA PTSD Reaction Index for DSM-IV was used to assess symptoms of PTSD. In addition, 11 questions were added to assess the four new symptom criteria within the new DSM-5 symptom categories. RESULTS PTSD prevalence did not differ significantly whether DSM-IV (11.1%) or DSM-5 (11.7%) criteria were used and the Cohen׳s Kappa for consistency between the diagnoses was 0.061. Confirmatory factor analyses showed that the four-factor structure of the DSM-5 fit the data adequately according to the conceptual model outlined. LIMITATIONS The homogeneity of this sample of highly exposed subjects may preclude generalization to less severely exposed groups. Also, we did not assess criterion G in regard to symptoms causing clinically significant distress and functional impairment. CONCLUSION The prevalence of PTSD was quite similar regardless of diagnostic system. The relatively low concordance between the diagnoses has implications for eligibility for a diagnosis of PTSD.

The Interpretation of Signs of Child Sexual Abuse

In this paper sign interpretation and interpretive repertoires are used as a framework for understanding why child sexual abuse is difficult for caregivers to detect. This framework offers an alternative to current, ‘mother-blaming’ theories. It redirects attention from the level of individual subjectivity to the interpretation process involved when caregivers construct an understanding of their childrens behavior. This approach makes it possible to study the cultural landscape of interpretations without losing sight of the individual. The results from a study using this perspective suggest an array of factors that contribute to making the processes of interpretation difficult for caregivers. These range from general aspects related to the arbitrariness involved in all modes of interpretation, to aspects that contribute to turning the process of interpretation within this area into a delicate, finely tuned and extremely difficult process. The richer picture this analysis creates underlines the value of a cultural psychological approach, particularly for understanding the complexities involved in interpreting culturally sensitive issues.

Stressful life experiences and mental health problems among unaccompanied asylum-seeking children.

Unaccompanied asylum-seeking children aged 10–16 years (N = 93, M = 13.8, SD = 1.4, 81% boys) were assessed 6 months after arrival in Norway (SD = 5 months). Participants originated from 14 countries (63% Asia; 36% Africa). Severe life events (SLE) and psychological symptoms were measured by self-report. Participants reported a mean of 5.5 SLE (SD = 2.4), the most prevalent being death of a close person (68%), witnessing violence (63%), and war (62%). Some 54% scored above clinical cutoff on posttraumatic stress symptoms, 30% on anxiety symptoms, 20% on depressive symptoms, and 7% on externalizing symptoms. Number of SLE was associated with posttraumatic stress disorder symptoms (r =.50, p < .001), depression (r =.27, p = .020), and anxiety symptoms(r =. 34, p = .003), but not externalizing symptoms (r =.02, p = .874). None of the symptom variables were associated with age or gender. Results indicate that many unaccompanied asylum-seeking children have experienced not only war-related traumas but several other severe life adversities as well. It may thus be helpful to conduct early assessments on this group of children to assess their need for treatment or other psychosocial interventions.

Social support barriers and mental health in terrorist attack survivors

BACKGROUND To expand our understanding of social support and mental health, we introduce a measure of social support barriers and investigate the relationship between these barriers, social support, mental health and gender in survivors of the terrorist attack on Utøya Island, Norway. METHODS Survivors (N=285) were interviewed face to face. We used confirmatory factor analysis (CFA) to assess the latent factor structure of the Social Support Barriers Scale and perceived social support (FSSQ), and linear regression analyses to investigate the associations between social support variables and mental health (PTSD-RI and HSCL-8). RESULTS The CFA indicated that social support barriers and perceived social support were two separable latent constructs. Social support barriers were highly associated with posttraumatic stress reactions (adjusted regression coefficient=0.38, 95% CI=0.29-0.47. p<0.001) as well as with psychological distress (adjusted regression coefficient=0.35, 95% CI=0.26-0.43, p<0.001). In contrast, neither perceived social support nor gender was associated with mental health after adjustment for barriers. LIMITATIONS Most analyses were based on cross-sectional data. This is the first study to use a quantitative measure of social support barriers. CONCLUSION Social support barriers may be a new opening to understand the relationship between social support and mental health and may have a role in explaining why women are at increased risk for mental health problems. Clinicians should explore not only perceived social support but also barriers to making use of these resources when consulting young people facing major life adversities.