Mixed-Handedness in Identical Twins Discordant for Combat Exposure in Vietnam: Relationship to Posttraumatic Stress Disorder.

This study evaluated the degree of mixed-handedness in predominantly right-handed Vietnam combat veteran twins and their identical, combat-unexposed cotwins. The "high-risk" cotwins of combat veterans with combat-related posttraumatic stress disorder (PTSD) had more mixed-handedness (i.e., less right-handedness) than the "low-risk" cotwins of combat veterans without PTSD. Self-reported combat exposure in combat-exposed twins was a mediator of the association between handedness in their unexposed cotwins and PTSD in the twins themselves. We conclude that mixed-handedness is a familial risk factor for combat-related PTSD. This risk may be mediated in part by a proclivity for mixed-handed soldiers and Marines to experience heavier combat.

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

We examined the identification of trauma exposure and post-traumatic 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 one 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 under-identified by community clinicians, which may compromise clinicians' ability to respond to environmental risks and provide appropriate evidence-based treatments.

Violence associated with combat-related posttraumatic stress disorder: The importance of anger.

The importance of anger with regard to violence among veterans with combat-related PTSD has received little attention. We previously proposed that in PTSD the activation of threat-related cognitive networks strongly potentiates anger in a positive feedback loop and that inhibitory controls on aggression can be overridden when PTSD and anger activation are conjoined. We predicted that violence would be intensified when combat-related PTSD was conjoined with anger. We used the National Vietnam Veterans Readjustment Study (NVVRS) public use data set, selecting the male combat theater veterans, which entailed 1,200 from the main survey (Study 1) and 259 from the clinical interview component (Study 2). Anger indices were constructed from NVVRS variables. PTSD was assessed by continuous symptom scores and by clinical diagnostic measures. Conjoined anger and PTSD was associated with greatly increased violence. PTSD was not associated with violence in the absence of anger. This result was obtained using alternative measures of PTSD and of anger in both the main survey and the clinical interview component. These findings call for reconceptualizing the association of PTSD and violence. Concerted attention should be given to anger as a risk factor for violence in the assessment and treatment of combat-related PTSD, and as an important portal of entry for treatment.

Does a one-day educational training session influence primary care pediatricians' mental health practice procedures in response to a community disaster? Results from the reaching children initiative (RCI).

Although many children and adolescents need assessment and treatment for psychological problems, few get such treatment from mental health specialists after a community disaster Research suggests that a very large proportion of children are seen in pediatric primary care settings and that pediatricians can provide appropriate care for many social and emotional problems in children. However few pediatricians have received training in providing this help. The focus of this study was to assess whether brief training to increase the capacity of primary care pediatricians (PCPs) to respond to the social or emotional problems of children after the World Trade Center terrorist attacks improved the quality of services to disaster-affected children. Pediatricians (N = 137) attended a one-day training workshop covering best practice treatments for mental health problems with an emphasis on trauma, bereavement, and medication use. We surveyed attendees prior to training, immediately post-intervention, and 1- and 6-months later. At 6-months post-intervention, 64% of the primary care clinicians reported instituting practice changes recommended during training. Reported use of formal mental health screening instruments increased, but greater use of medications was more limited. Although participants in the immediate post-intervention survey indicated strong agreement with the desirability to implement specific practice changes, the perceived desirability of such changes declined substantially at the 6-month follow-up. Changes in PCPs 'mental health related practice procedures can be facilitated by brief educational interventions, but continued training and support may be needed. We discuss these results relative to preparedness for community disasters.

Maternal posttraumatic stress disorder and depression in pediatric primary care: association with child maltreatment and frequency of child exposure to traumatic events.

IMPORTANCE: Maternal posttraumatic stress disorder (PTSD) may be associated with increased risk for child maltreatment and child exposure to traumatic events. Exposure to multiple traumatic events is associated with a wide range of adverse health and social outcomes in children. OBJECTIVE: To examine the association of probable maternal depression, PTSD, and comorbid PTSD and depression with the risk for child maltreatment and parenting stress and with the number of traumatic events to which preschool children are exposed. DESIGN: Cross-sectional observational design. We used analysis of variance to determine whether probable maternal psychopathology groups differed on child maltreatment, parenting stress, and children's exposure to traumatic events. Hierarchical regression analyses were used to examine the unique and interactive effects of depression and PTSD severity scores on these outcomes. SETTING: Urban pediatric primary care outpatient clinic. PARTICIPANTS: Ninety-seven mothers of children aged 3 to 5 years. EXPOSURE: Pediatric primary care visit. MAIN OUTCOMES AND MEASURES: Probable maternal depression and/or PTSD, parenting stress, child exposure to traumatic events, and child maltreatment. RESULTS: Mothers with probable comorbid PTSD and depression reported greater child-directed psychological aggression and physical assault and greater parenting stress. The children of mothers with PTSD (mean number of events the child was exposed to, 5.0) or with comorbid PTSD and depression (3.5 events) experienced more traumatic events than those of mothers with depression (1.2 events) or neither disorder (1.4 events). Severity of depressive symptoms uniquely predicted physical assault and neglect. Symptom scores for PTSD and depression interacted to predict psychological aggression and child exposure to traumatic events. When PTSD symptom severity scores were high, psychological aggression and the number of traumatic events children experienced rose. Depressive symptom severity scores predicted the risk for psychological aggression and exposure to traumatic events only when PTSD symptom severity scores were low. CONCLUSIONS AND RELEVANCE: Children of mothers with PTSD are exposed to more traumatic events. Posttraumatic stress disorder is associated with an increased risk for child maltreatment beyond that associated with depression. Screening and intervention for maternal PTSD, in addition to maternal depression, may increase our ability to reduce children's exposure to traumatic stress and maltreatment.

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.

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.

Does poor early metabolic control predict subsequent poor control in young children with type 1 diabetes: an exploratory study.

BACKGROUND: We sought to determine whether poor metabolic control during the early stages of type 1 diabetes mellitus predicts control during subsequent years. We hypothesized that poor control in the first year after diagnosis would predict poor control in the following year, and that poor control in the second year after diagnosis would predict poor metabolic control in subsequent years. METHODS: We conducted a retrospective review of a cohort of urban children treated for diabetes at our institution who were diagnosed between 1992 and 2005. We calculated odds ratios to determine whether control in year 1 or in year 2 predicted control in Years 3-6. Cox regression analyses were used to determine whether poor early control predicted progression to subsequent poor control. RESULTS: Metabolic control in the first year after diagnosis was not a good predictor of future control. However, poor metabolic control in the second year after diagnosis was highly predictive of poor control in subsequent years and predicted faster progression to poor control. CONCLUSION: The findings suggest that poor metabolic control in year 2 may be a predictor of subsequent poor metabolic control. Targeting prevention interventions to reduce non-adherence and to enhance metabolic control to families that show poor metabolic control in Year 2 may prove to be an optimum investment in terms of improved medical outcomes and enhanced quality of life.

Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services.

The role of parental trauma exposure and related mental health symptoms as risk factors for child maltreatment for parents involved with the child welfare (CW) system has received limited attention. In particular, little is known about the extent to which mothers receiving CW services to prevent maltreatment have experienced trauma and suffered trauma-related psychopathology. This study examined screening data collected from 127 mothers receiving CW preventive services. There were high levels of trauma exposure among screened mothers and their young children. Among mothers, 91.6% experienced at least one traumatic event (M = 2.60) and 92.2% reported their children had been exposed to one or more traumas (M = 4.85). Mothers reported high levels of trauma-related symptoms: 54.3% met probable criteria for posttraumatic stress disorder (PTSD) or depression (61.7%). Nearly half (48.8%) met criteria for co-morbid PTSD and depression. The large majority of the clients with trauma-related disorders were not receiving mental health services. Latina women had significantly more severe PTSD symptoms than African American women. Case planners reported that the screening process was useful and feasible. These findings underscore the feasibility and importance of trauma screening among parents receiving CW preventive services.

Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children's behavior.

To evaluate whether conjoined maternal posttraumatic stress disorder (PTSD) and depression are associated with increased behavioral problems among terrorism-exposed preschool children (N = 116; 18-54 months), this study compared clinically significant child behavioral problem rates among the preschool children of mothers with PTSD and depression, depression alone, and neither disorder. Behavioral problems were independently rated by mothers and preschool teachers. Maternal depression and PTSD, relative to maternal depression alone, and to neither disorder, were associated with substantially increased child problems. Notably, maternal depression and PTSD were associated with increased emotional reactivity (relative risk [RR] = 5.9 by mother's and 3.4 by teacher's reports) and aggressive behavior problems (RR = 11.0 by mother's and RR = 5.9 by teacher's reports). This was corroborated by teacher ratings. Implications for intervening with terrorism-exposed preschool children are discussed.

Factors associated with service use among immigrants in the child welfare system.

This study investigated child, caregiver, and caseworker factors associated with greater use of family support services by immigrant families in the U.S. child welfare system. Among child factors, higher levels of internalizing behavior problems (Odds Ratio (O.R.)=3.60), externalizing behavior problems (O.R.=2.62) and a history of neglect (O.R.=4.23) were associated with greater family support service use. Among caregiver factors, prior reports of maltreatment (O.R.=6.77), a serious mental health problem of the caregiver (O.R.=6.86), cognitive impairments (O.R.=10.46) in the primary caregiver, the primary caregivers' history of arrests (O.R.=6.47) and domestic violence (O.R.=2.87), were associated with heavy service use. Caseworkers' training on cultural issues (O.R.=61.35), their concerns over bureaucracy (O.R.=25.38) and concern over rules and regulations (O.R.=6.08) were also associated with greater service use among immigrant families. This research suggests that use of family support services may be determined not only by the family's demographic factors and risk level but also by caseworkers' training in cultural competence and their perception of organizational problems.

Effect of maternal psychopathology on behavioral problems in preschool children exposed to terrorism: use of generalized estimating equations to integrate multiple informant reports.

OBJECTIVE: To examine whether the number of maternal psychopathologies is associated with increased clinically significant behavioral problems in preschool children exposed to disaster, using child behavior ratings from multiple informants. DESIGN: Cross-sectional study. SETTING: Lower Manhattan, New York, New York. PARTICIPANTS: One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks. EXPOSURES: Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none. MAIN OUTCOME MEASURES: Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems. RESULTS: The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls. CONCLUSION: Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

Substance use and functional impairment among adolescents directly exposed to the 2001 World Trade Center attacks.

The relationship between exposure to the World Trade Center (WTC) attacks, increased substance use, functional impairment and mental health service use, controlling for depression and post-traumatic stress disorder, was assessed through an in-school survey of directly exposed students (N = 1040) attending the five middle and five high schools nearest the WTC. The survey was conducted 18 months after the attacks. Students with one WTC exposure risk factor had a five-fold increase in substance use, while those with three or more exposure risks had a nearly 19-fold increase. Increased substance use was associated with impaired school work, school behaviour and grades. Students reporting increased substance use were nearly twice as likely to want help but were no more likely than asymptomatic students to receive services. Adolescents reporting increased substance use, without co-morbidity, were less likely to receive psychological services than others. Attention to the needs of substance-using adolescents exposed to disaster is needed.

Relationship between type of trauma exposure and posttraumatic stress disorder among urban children and adolescents.

This study examines the association between trauma exposure and posttraumatic stress disorder (PTSD) among 157 help-seeking children (aged 8-17). Structured clinical interviews are carried out, and linear and logistic regression analyses are conducted to examine the relationship between PTSD and type of trauma exposure controlling for age, gender, and ethnicity. Confrontation with traumatic news, witnessing domestic violence, physical abuse, and sexual abuse are each significantly associated with PTSD. Witnessing a crime, being the victim of a crime, and exposure to accidents, fire, or disaster are not associated with PTSD. These findings underscore the association between interpersonal violence and childhood PTSD.

Age at diagnosis, gender, and metabolic control in children with type 1 diabetes.

OBJECTIVE: To examine whether age at diagnosis and gender affect early metabolic control in children with type 1 diabetes. DESIGN AND METHODS: Data on age at diagnosis, gender, pubertal status, and metabolic control were gathered by a retrospective chart review of children diagnosed between 1992 and 2005. Mean hemoglobin A1c (HbA1c) values were compared at five time points: at diagnosis and at 6, 12, 24, and 36 months after diagnosis. RESULTS: At diagnosis, girls aged 6-12 years presented with significantly higher HbA1c levels than girls diagnosed at older or younger ages. Their HbA1c at diagnosis was also significantly higher than that in boys of the same age. There was no gender difference among children diagnosed at ages 0-5 or 13+ yr. At 6 months after diagnosis, only age at diagnosis was associated with metabolic control, with children diagnosed when older presenting with lower HbA1c levels. At 12, 24, and 36 months after diagnosis, there were no significant effects of age at diagnosis or gender on glycemic status. CONCLUSION: At initial diagnosis, girls in the 6-12 age group presented with higher HbA1c levels compared with boys and girls of other age groups. Although endocrine changes associated with puberty may partly explain the findings, more investigation to elucidate mechanisms accounting for the interaction of age and gender with glycemic status is needed.

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.

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.

Conjoined effects of low birth weight and childhood abuse on adaptation and well-being in adolescence and adulthood.

OBJECTIVE: To characterize the conjoined effects of low birth weight (LBW) and childhood abuse on impaired adaptation and illness in adolescence and adulthood. DESIGN: Longitudinal study of a birth cohort. SETTING: Baltimore, Md. PARTICIPANTS: Children (N = 1748) were followed from birth to adulthood (mean age, 26 years) as part of the Johns Hopkins Collaborative Perinatal Study. MAIN EXPOSURES: Childhood abuse and LBW. MAIN OUTCOME MEASURES: Indicators of adaptation were delinquency, school suspension, repeating grades, academic honors, quality of life, and socioeconomic status. Indicators of psychiatric and medical problems were depression, social dysfunction, somatization, asthma, and hypertension. RESULTS: Participants with both LBW and subsequent childhood abuse, relative to those with neither risk, were at a substantially elevated risk for psychological problems: 10-fold for depression; nearly 9-fold for social dysfunction, and more than 4-fold for somatization. However, they were not at an elevated risk for medical problems in adulthood. Those exposed to childhood abuse were more likely to report delinquency, school suspension, repeating grades during adolescence, and impaired well-being in adulthood, regardless of LBW status. For those with LBW alone, the prevalence of those problems was comparable with that of individuals without either risk factor. CONCLUSIONS: Children with LBW and childhood abuse are at much greater risk for poor adaptation and psychiatric problems than those with LBW alone and those with neither risk. Preventive interventions should target families with LBW children who are at greater risk for childhood abuse.

Risk-taking behaviors among Israeli adolescents exposed to recurrent terrorism: provoking danger under continuous threat?

OBJECTIVE: This study aimed to assess 1) the relationship between risk-taking behaviors and exposure to terrorism, 2) the relationship between posttraumatic symptoms and risk-taking behaviors, and 3) gender differences in the type and frequency of risk-taking behaviors and their differential associations with posttraumatic symptoms. METHOD: The participants were 409 Israeli adolescents 15 to 18 years of age. Exposure to terrorism was assessed with a questionnaire developed specifically for the Israeli security situation. Posttraumatic symptoms were measured with the University of California at Los Angeles Reaction Index. Functional impairment was measured with the Diagnostic Interview Schedule for Children. Risk-taking behavior-and the adolescents' perceptions of such behavior-was assessed with a self-report questionnaire. RESULTS: Israeli adolescents exposed to continuous threats of terrorist attacks reported high levels of risk-taking behaviors. The severity of risk-taking was associated with greater terrorism exposure. Adolescents suffering from posttraumatic symptoms reported more risk-taking behaviors than nonsymptomatic adolescents. Although there was no gender difference in the degree of exposure to terrorism, boys reported taking more risks than girls. The association between posttraumatic symptoms and risk-taking behaviors was stronger in boys than girls. Functional impairment, gender, avoidance symptoms, level of exposure, and degree of fear predicted the severity of risk-taking behaviors. CONCLUSIONS: Clinicians and educators should be aware of the strong link between posttraumatic distress and risk-taking behaviors. Risk-taking behaviors may be a manifestation of functional impairment and posttraumatic distress, especially for boys exposed to terrorism.