Victor G. Carrion

Attenuation of frontal asymmetry in pediatric posttraumatic stress disorder.

BACKGROUND Volumetric imaging research has shown abnormal brain morphology in adults with posttraumatic stress disorder (PTSD) when compared with matched control subjects. In this article, we present brain imaging findings from a study of children with PTSD symptoms. METHODS Twenty-four children between the ages of 7 and 14 with a history of trauma and PTSD symptoms were assessed with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). The sample underwent magnetic resonance imaging in a 1.5 T scanner. Brain images were analyzed by raters blind to diagnostic status using well-standardized methods, and images were compared with age- and gender-matched healthy control subjects. RESULTS The clinical group demonstrated attenuation of frontal lobe asymmetry and smaller total brain and cerebral volumes when compared with the control group. There were no statistically significant differences in hippocampal volume between clinical and control subjects. CONCLUSIONS Frontal lobe abnormalities may occur as a result of PTSD in children or, alternatively, be a risk factor for the development of the syndrome in this age group. The implications of the findings and their consistency with previous research are discussed.

Toward an empirical definition of pediatric PTSD: The phenomenology of PTSD symptoms in youth

OBJECTIVE To examine the frequency and intensity of posttraumatic stress disorder (PTSD) symptoms and their relation to clinical impairment, to examine the requirement of meeting all DSM-IV symptom cluster criteria (i.e., criteria B, C, D), and to examine the aggregation of PTSD symptom clusters across developmental stages. METHOD Fifty-nine children between the ages of 7 and 14 years with a history of trauma and PTSD symptoms were assessed with the Clinician-Administered PTSD Scale for Children and Adolescents. RESULTS Data support the utility of distinguishing between the frequency and the intensity of symptoms in the investigation of the phenomenology of pediatric PTSD. Children fulfilling requirements for two symptom clusters did not differ significantly from children meeting all three cluster criteria with regard to impairment and distress. Reexperience (cluster B) showed increased aggregation with avoidance and numbing (cluster C) and hyperarousal (cluster D) in the later stages of puberty. CONCLUSIONS Frequency and intensity of symptoms may both contribute to the phenomenology of pediatric PTSD. Children with subthreshold criteria for PTSD demonstrate substantial functional impairment and distress.

Diurnal salivary cortisol in pediatric posttraumatic stress disorder

BACKGROUND The hypothalamic-pituitary-adrenal (HPA) axis has been implicated in the pathophysiology of posttraumatic stress disorder (PTSD). Additional information on basal cortisol levels in children exposed to trauma and experiencing PTSD symptoms may contribute to the understanding of the role of this axis in PTSD. METHODS Fifty-one children (30 boys and 21 girls, mean age 10.7 years) with a history of exposure to trauma and PTSD symptoms were compared with 31 age- and gender-matched healthy control subjects. Salivary cortisol was obtained from participants during home measurements and was collected four times a day (prebreakfast, prelunch, predinner, and prebed) for up to 3 consecutive days. RESULTS The clinical group demonstrated significantly elevated cortisol levels when compared with the control group. In addition, exploratory analyses revealed that girls with PTSD symptoms had significantly elevated cortisol levels when compared with boys with PTSD symptoms. CONCLUSIONS The physiologic response of children with history of trauma and with PTSD symptoms may be characterized by heightened adrenal activity.

Stress Predicts Brain Changes in Children: A Pilot Longitudinal Study on Youth Stress, Posttraumatic Stress Disorder, and the Hippocampus

OBJECTIVE. Does stress damage the brain? Studies of adults with posttraumatic stress disorder have demonstrated smaller hippocampal volumes when compared with the volumes of adults with no posttraumatic stress disorder. Studies of children with posttraumatic stress disorder have not replicated the smaller hippocampal findings in adults, which suggests that smaller hippocampal volume may be caused by neurodevelopmental experiences with stress. Animal research has demonstrated that the glucocorticoids secreted during stress can be neurotoxic to the hippocampus, but this has not been empirically demonstrated in human samples. We hypothesized that cortisol volumes would predict hippocampal volume reduction in patients with posttraumatic symptoms. PATIENTS AND METHODS. We report data from a pilot longitudinal study of children (n = 15) with history of maltreatment who underwent clinical evaluation for posttraumatic stress disorder, cortisol, and neuroimaging. RESULTS. Posttraumatic stress disorder symptoms and cortisol at baseline predicted hippocampal reduction over an ensuing 12- to 18-month interval. CONCLUSIONS. Results from this pilot study suggest that stress is associated with hippocampal reduction in children with posttraumatic stress disorder symptoms and provide preliminary human evidence that stress may indeed damage the hippocampus. Additional studies seem to be warranted.

The impact of adverse childhood experiences on an urban pediatric population.

OBJECTIVE The goal of this study was to investigate the adverse childhood experiences (ACEs) in youth in a low-income, urban community. STUDY DESIGN Data from a retrospective chart review of 701 subjects from the Bayview Child Health Center in San Francisco are presented. Medical chart documentation of ACEs as defined in previous studies were coded and each ACE criterion endorsed by a traumatic event received a score of 1 (range=0-9). This study reports on the prevalence of various ACE categories in this population, as well as the association between ACE score and two pediatric problems: learning/behavior problems and body mass index (BMI)≥85% (i.e., overweight or obese). RESULTS The majority of subjects (67.2%, N=471) had experienced 1 or more categories of adverse childhood experiences (ACE≥1) and 12.0% (N=84) had experienced 4 or more ACEs (ACE≥4). Increased ACE scores correlated with increased risk of learning/behavior problems and obesity. CONCLUSIONS There was a significant prevalence of endorsed ACE categories in this urban population. Exposure to 4 or greater ACE categories was associated with increased risk for learning/behavior problems, as well as obesity. PRACTICE IMPLICATIONS Results from this study demonstrate the need both for screening of ACEs among youth in urban areas and for developing effective primary prevention and intervention models.

Converging evidence for abnormalities of the prefrontal cortex and evaluation of midsagittal structures in pediatric posttraumatic stress disorder: An MRI study

Volumetric imaging research has shown abnormal brain morphology in posttraumatic stress disorder (PTSD) when compared with control subjects. We present results on a study of brain morphology in the prefrontal cortex (PFC) and midline structures, via indices of gray matter volume and density, in pediatric PTSD. We hypothesized that both methods would demonstrate aberrant morphology in the PFC. Further, we hypothesized aberrant brainstem anatomy and reduced corpus callosum volume in children with PTSD. Twenty-four children (aged 7-14) with history of interpersonal trauma and 24 age- and gender-matched controls underwent structural magnetic resonance imaging (sMRI). Images of the PFC and midline brain structures were first analyzed using volumetric image analysis. The PFC data were then compared with whole brain voxel-based techniques using statistical parametric mapping (SPM). The PTSD group showed significantly increased gray matter volume in the right and left inferior and superior quadrants of the PFC and smaller gray matter volume in the pons and posterior vermis areas by volumetric image analysis. The voxel-by-voxel group comparisons demonstrated increased gray matter density mostly localized to ventral PFC as compared with the control group. Abnormal frontal lobe morphology, as revealed by separate-complementary image analysis methods, and reduced pons and posterior vermis areas are associated with pediatric PTSD. Voxel-based morphometry may help to corroborate and further localize data obtained by volume of interest methods in PTSD.

Reduced Hippocampal Activity in Youth with Posttraumatic Stress Symptoms: An fMRI Study

OBJECTIVE Youth who experience interpersonal trauma and have posttraumatic stress symptoms (PTSS) develop cognitive deficits that impact their development. Our goal is to investigate the function of the hippocampus in adolescents with PTSS during a memory processing task. METHODS Twenty-seven adolescents between the ages of 10-17 years (16 with PTSS and 11 healthy controls) encoded and retrieved visually presented nouns (Verbal Declarative Memory Task) while undergoing fMRI scanning. RESULTS The PTSS group demonstrated reduced activation of the right hippocampus during the retrieval component of the task. Further, severity of symptoms of avoidance and numbing correlated with reduced left hippocampal activation during retrieval. CONCLUSIONS Decreased activity of the hippocampus during a verbal memory task may be a neurofunctional marker of PTSS in youth with history of interpersonal trauma. The results of this study may facilitate the development of focused treatments and may be of utility when assessing treatment outcome for PTSS.

Decreased Prefrontal Cortical Volume Associated with Increased Bedtime Cortisol in Traumatized Youth

BACKGROUND The purpose of this study was to investigate prefrontal cortex (PFC) volumes in youth with posttraumatic stress symptoms (PTSS) and explore the relationship between cortisol secretion and PFC volumes. METHODS Total brain tissue volumes, segmented areas of the PFC, and diurnal cortisol secretion were examined in a sample of 33 youth aged 10 to 16 years. Cerebral volumes were available for 45 subjects (30 PTSS and 15 control subjects). RESULTS Youth with PTSS had significantly decreased total brain tissue and total cerebral gray volumes in comparison with healthy control subjects. While controlling for total cerebral gray volume, the PTSS group demonstrated decreased left ventral and left inferior prefrontal gray volumes. A significant negative association was found between prebedtime cortisol levels and left ventral PFC gray volumes for the full sample. CONCLUSIONS Findings suggest associations between posttraumatic stress and PFC neurodevelopment. Findings also suggest a link between PFC development and cortisol secretion.

Can traumatic stress alter the brain? Understanding the implications of early trauma on brain development and learning

BACKGROUND Youth who experience traumatic stress and develop post-traumatic symptoms secrete higher levels of the glucocorticoid cortisol than youth with no trauma history. Animal research suggests that excess corticosterone secretion can lead to neurotoxicity in areas of the brain rich in glucocorticoid receptors such as the hippocampus and the prefrontal cortex (PFC). These two areas of the brain are involved in memory processing and executive function, both critical functions of learning. METHODS In this article, we summarize findings presented at the National Summit for Stress and the Brain conducted at Johns Hopkins Universitys Department of Public Health in April 2011. The presentation highlighted structural and functional imaging findings in the hippocampus and PFC of youth with post-traumatic stress symptoms (PTSS). RESULTS Youth with PTSS have higher levels of cortisol. Prebedtime cortisol levels predict decreases in hippocampal volume longitudinally. Cortisol levels are negatively correlated with volume in the PFC. Functional imaging studies demonstrate reduced hippocampal and PFC activities on tasks of memory and executive function in youth with PTSS when compared with control subjects. CONCLUSIONS Effective interventions for youth with PTSS should target improved function of frontolimbic networks. Treatment outcome research using these potential markers can help develop more focused interventions that target the impaired learning of vulnerable youth experiencing traumatic stress.

A Prospective Test of the Association Between Hyperarousal and Emotional Numbing in Youth With a History of Traumatic Stress

Investigated the hypothesis that emotional numbing may develop as a result of hyperarousal using a prospective design. Forty-two children between the ages of 7 and 14 with a history of trauma and posttraumatic stress disorder (PTSD) symptoms were assessed with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA; Nader et al., 1996) and were reassessed 1 year later. Results indicated that hyperarousal symptoms were concurrently positively correlated with emotional numbing at both time points. Moreover, Time 1 hyperarousal symptoms were associated with emotional numbing at Time 2 and predicted Time 2 emotional numbing even when controlling for each of the other symptom clusters of PTSD at Time 1 as well as other concurrent (i.e., Time 2) PTSD symptoms. Results are discussed in terms of the implications of the findings for enhancing the understanding of PTSD symptoms in youth.