Co-development of traumatic stress symptoms and externalising behaviour problems among foster children and the effect of complex trauma: a latent growth curve model.

OBJECTIVES: Foster children are disproportionately exposed to complex trauma, which may lead to multifaceted impairments that manifest in comorbid emotional and behavioural problems. As little is known about the interactions between comorbid disorders over time, the present study aims to explore the co-development of traumatic stress (TS) symptoms and externalising behaviour problems (EBP), as well as the influence of complex trauma operationalised as cumulative child maltreatment (CM). SETTING: As part of a 3-year longitudinal study, children from six foster care facilities in Lower Austria were interviewed at three measurement points. PARTICIPANTS: Of, in total, 263 participating children, the data of 124 children aged 10-18 years (M=13.5, 28% female) could be analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: Latent growth curve models were used to examine the co-development of TS symptoms (International Trauma Questionnaire) and EBP (Child Behaviour Checklist) over time; gender, age and cumulative CM (Childhood Trauma Questionnaire) acted as time-invariant covariates. RESULTS: While average TS symptoms decreased over time, EBP remained stable. Findings revealed that the initial severity of EBP was both related to the initial severity of TS symptoms and predictive of their rate of change. Cumulative CM was a significant predictor of initial TS symptoms and EBP even after controlling for age and gender, but not for the rates of change. CONCLUSIONS: Taken together, our results indicate that EBP and TS symptoms are not only cross-sectionally associated but interact with each other over time. Furthermore, an underlying complex trauma could at least partly determine the severity of the two symptom groups. In accordance with a trauma-informed care approach, our study highlights the importance of trauma-specific screening of high-risk children with complex or diffuse symptoms and argues for the benefits of treatments that focus on improving emotion regulation and social skills in addition to addressing trauma.

Resilience in the face of adversity: classes of positive adaptation in trauma-exposed children and adolescents in residential care.

Children and adolescents in residential care often face multiple traumatic experiences. However, some individuals show resilient adaptation. To depict this heterogeneity, the person-centered examination of different classes of adaptation is a powerful tool. Up to date, resilience was insufficiently addressed in this population. Data from 141 children and adolescents in residential care institutions in Austria regarding trauma history, psychopathology, behavioral adjustment, and protective factors were assessed with standardized self-report questionnaires. Distinct classes of adaptation after traumatic experiences were examined with Latent Class Analysis. Class differences regarding traumatic experiences and protective factors were analyzed with χ2 testing. Three classes were identified [resilience (66.18%), mixed psychopathology (13.97%, mixed), high psychopathology (19.85%, high)]. Only males were classified into the resilient class and only females into the high class. The high class differed significantly from the resilient class regarding cumulative trauma history and protective factors. The mixed class did not differ from the resilient class regarding trauma history, however, they differed significantly regarding protective factors. The resilient class was associated with protective factors. Strong gender differences show the relevance of a differentiated evaluation of gender-specific protective factors and resilience indicators. Fostering protective factors may be a suitable approach for tailored intervention measures.

What makes inpatient treatment for PTSD effective? Investigating daily therapy process factors.

OBJECTIVE: Therapeutic process factors including alliance and motivation are considered to play a key role in the treatment of post-traumatic stress disorder (PTSD). Yet, our understanding of change processes in therapy is mostly based on theoretical considerations with limited empirical evidence. In order to identify process characteristics of successful inpatient treatments of PTSD, we investigated the intraindividual, interindividual, and temporal associations of daily assessments of therapy process factors like motivation, alliance, and insight. METHOD: Therapy process questionnaire (TPQ) assessments were collected from 101 inpatients with PTSD over 50 days, resulting in 5050 assessments. Multilevel vector autoregressive (mlVAR) modelling was applied to investigate the networks of the TPQ factors in a subgroup with good outcome regarding PTSD symptomatology and a subgroup with less favourable outcome. RESULTS: The two subgroups differed markedly in their network models, suggesting that therapy processes might be different for those with good and those with poor treatment outcomes. CONCLUSIONS: Our results suggest that good treatment outcome is linked to a specific therapy process dynamic where mindfulness and insight lead to the kind of temporary well-being required to effectively engage with problems and negative emotions, while motivation to change ensures the continuity of confronting negative emotions and problems.

Co-occurrence of severe PTSD, somatic symptoms and dissociation in a large sample of childhood trauma inpatients: a network analysis.

Co-occurrence of mental disorders including severe PTSD, somatic symptoms, and dissociation in the aftermath of trauma is common and sometimes associated with poor treatment outcomes. However, the interrelationships between these conditions at symptom level are not well understood. In the present study, we aimed to explore direct connections between PTSD, somatic symptoms, and dissociation to gain a deeper insight into the pathological processes underlying their comorbidity that can inform future treatment plans. In a sample of 655 adult inpatients with a diagnosis of severe PTSD following childhood abuse (85.6% female; mean age = 47.57), we assessed symptoms of PTSD, somatization, and dissociation. We analyzed the comorbidity structure using a partial correlation network with regularization. Mostly positive associations between symptoms characterized the network structure. Muscle or joint pain was among the most central symptoms. Physiological reactivation was central in the full network and together with concentrations problems acted as bridge between symptoms of PTSD and somatic symptoms. Headaches connected somatic symptoms with others and derealization connected dissociative symptoms with others in the network. Exposure to traumatic events has a severe and detrimental effect on mental and physical health and these consequences worsen each other trans-diagnostically on a symptom level. Strong connections between physiological reactivation and pain with other symptoms could inform treatment target prioritization. We recommend a dynamic, modular approach to treatment that should combine evidence-based interventions for PTSD and comorbid conditions which is informed by symptom prominence, readiness to address these symptoms and preference.

Foster children's complex psychopathology in the context of cumulative childhood trauma: The interplay of ICD-11 complex PTSD, dissociation, depression, and emotion regulation.

BACKGROUND: Foster children experience maltreatment at exceptionally high rates with increased risk to develop ICD-11 complex posttraumatic stress disorder (CPTSD). While rates of comorbidity between CPTSD and various disorders are high, the interplay between constituent aspects of psychopathology is not clearly understood. No study used network analysis to model the interplay between these aspects as potentially maintaining a stable condition of psychopathology, and research on the etiology and maintenance of CPTSD in children is especially scarce. METHODS: Altogether, 208 Austrian foster children completed a set of standardized measures, resulting in a final sample of N = 122 foster children meeting the inclusion criteria. Experiences of childhood trauma, ICD-11 CPTSD, depression, dissociation, adaptive, and maladaptive emotion regulation were assessed. Following an exploratory approach, analyses were conducted using latent single indicator factor scores in two network models. RESULTS: Domains of CPTSD, PTSD and disturbances in self-organization (DSO), evidenced as most central factors in children's complex psychopathology. Including cumulative childhood trauma did not influence the connectedness of factors in any relevant way. Shortest direct paths from cumulative childhood trauma to CPTSD included dissociation (PTSD) and adaptive emotion regulation (DSO) as mediating factors. LIMITATIONS: Results are based on a small sample of highly-traumatized foster children, potentially limiting current findings' generalizability. CONCLUSIONS: CPTSD identified as central in children's complex psychopathology, while the role of childhood trauma seems stronger for the onset than the maintenance of such psychopathology. The current network revealed central disorders and distinct mediating factors as important targets for treatment strategies and future research.

Comparing rates of ICD-11 and DSM-5 Posttraumatic Stress Disorder in Austrian children and adolescents in foster care: prevalence, comorbidity and predictors.

BACKGROUND: The diagnostic criteria for Posttraumatic Stress Disorder (PTSD) differ between the DSM-5 and the ICD-11, affecting prevalence and associated metrics of PTSD. OBJECTIVE: Investigating the effects of the diverging DSM-5 and ICD-11 PTSD conceptualizations on prevalence and comorbidity rates, as well as predictor impact in a sample of foster children and adolescents using manual-specific measures. METHOD: The sample consisted of n = 145 foster children and adolescents. PTSD rates were assessed and compared utilizing the International Trauma Questionnaire - Child and Adolescent Version (ICD-11) and the Child and Adolescent Trauma Screen (DSM-5). PTSD comorbidities with Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) were assessed. The predictive value of age, gender and cumulative trauma for PTSD was determined. RESULTS: A non-significant trend for higher DSM-5 (21.4%) vs. ICD-11 (16.7%) PTSD prevalence was observed. Significantly elevated DSM-5 vs. ICD-11 diagnostic rates were recorded in the re-experience (diff. = 18.3%) and hyperarousal (diff. = 10.1%) clusters. DSM-5 PTSD showed a non-significant trend for higher comorbidities with GAD and MDD. Gender and cumulative trauma predicted PTSD significantly and approximately equally according to both taxonomies. CONCLUSION: The study supports the assumption that utilizing manual-specific PTSD measures in children and adolescents leads to higher rates of DSM-5 PTSD compared to ICD-11 PTSD. The exact methodological reasons for diverging diagnostic rates need to be analysed.

Antecedentes: Los criterios de diagnóstico para el trastorno de estrés postraumático (TEPT) difieren entre el DSM-5 y el CIE-11, lo cual afecta la prevalencia y las métricas asociadas al TEPT.Objetivo: Investigar los efectos de las conceptualizaciones divergentes del TEPT entre el DSM-5 y el CIE-11, utilizando medidas específicas del manual, en las tasas de prevalencia y comorbilidad, así como el impacto predictor en una muestra de niños y adolescentes en condición de acogida familiar temporal.Método: La muestra consistió en un n = 145 niños y adolescentes en condición de acogida familiar temporal. Las tasas de TEPT se evaluaron y compararon utilizando el Cuestionario Internacional de Trauma - Versión para Niños y Adolescentes (CIE-11) y la Prueba de Detección del Trauma para Niños y Adolescentes (DSM-5). Se evaluaron las comorbilidades del TEPT, trastorno de ansiedad generalizada (TAG) y trastorno depresivo mayor (TDM). Se determinó el valor predictivo para TEPT de las variables edad, género y trauma acumulativo.Resultados: Se observó una tendencia, no-significativa, de una mayor prevalencia de TEPT para el DSM-5 (21.4%) comparado con el CIE-11 (16.7%). Se registraron tasas de diagnóstico significativamente elevadas en los grupos de re-experimentación (dif. = 18.3%) e hiperactivación (dif. = 10.1%) para el DSM-5 versus el CIE-11. El TEPT en el DSM-5 mostró una tendencia mayor, no-significativa, para las comorbilidades TAG y TDM. El género y el trauma acumulativo predijeron el TEPT de manera significativa, y aproximadamente equivalente en ambas taxonomías.Conclusión: El estudio apoya el supuesto de que la utilización de medidas TEPT específicas para el manual en niños y adolescentes conlleva tasas más altas de TEPT para el DSM-5 en comparación con el CIE-11. Es necesario analizar las razones metodológicas precisas para estas tasas de diagnóstico divergentes.

The relationship between cumulative traumatic experiences and ICD-11 post-traumatic symptoms in children and adolescents in foster care: The mediating effect of sense of coherence.

BACKGROUND: Children and adolescents in foster care show a high prevalence of cumulative traumatic experiences (CTE), symptoms of posttraumatic stress disorder (PTSD) and symptoms related to disturbances in self-organization (DSO). PTSD and DSO constitute the ICD-11 diagnosis Complex PTSD (CPTSD). Sense of coherence (SOC) has been shown to alleviate the impact of CTE. OBJECTIVE: This study aimed to investigate the mediating role of SOC in the relationship between CTE, PTSD, and DSO. PARTICIPANTS AND SETTING: Trauma history (CTE), PTSD, DSO and SOC were assessed in a sample of 140 children and adolescents in foster care aged 10-18 using self-report questionnaires. METHOD: Mediation analysis determined the direct, indirect and total effect of the mediation of SOC in the relationship between CTE, PTSD and DSO. RESULTS: The results showed no mediation of SOC in the relationship between CTE and PTSD symptoms (indirect effect of b = -.001, 95 %CI: -.088-.086). However, SOC mediated the relationship between CTE and DSO symptoms (indirect effect b = .128, 95 %CI: 0.045-.211). CONCLUSIONS: Those results may point to a promotive function of SOC for the overall development and different areas of self-organization, but not for PTSD symptoms. It is possible that the influence of the trauma on symptoms of PTSD is too pervasive for the promotive function of SOC. The present findings strengthen the assumption that PTSD and DSO are separate second-order factors, which characterize different groups of trauma survivors. The present findings are vital to inform tailored prevention and intervention strategies for survivors of early CTE.

Latent classes of childhood maltreatment in children and adolescents in foster care: associations with ICD-11 PTSD and complex PTSD.

Background: Children and adolescents in foster care often experience many co-occurring subtypes of maltreatment. However, little is known about different combinations of maltreatment subtypes, referred to as maltreatment classes. Furthermore, the association between those maltreatment classes and ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) has not been investigated in children and adolescents. In previous studies, classes characterized by cumulative maltreatment were associated with severe psychopathological symptoms. So far, no study investigated ICD-11 PTSD and CPTSD. Objective: The first aim of this study was the detection of distinct maltreatment classes by examining frequently co-occurring maltreatment subtypes. The second aim was the examination of the association between those maltreatment classes and ICD-11 PTSD and CPTSD. Method: Participants were 147 children and adolescents currently living in foster care institutions in Lower Austria. Maltreatment history, ICD-11 PTSD and CPTSD were assessed using standardized self-report questionnaires. Latent class analysis was applied to examine maltreatment subtypes. χ2 difference testing was used to examine class associations with PTSD and CPTSD. Results: Three latent classes that comprised different subtypes of maltreatment were identified (limited maltreatment, n = 49; high neglect, n = 53; cumulative maltreatment, n = 45). Cumulative maltreatment was associated with higher symptom severity of PTSD and CPTSD than the limited maltreatment and the high neglect class, with effect sizes ranging from 0.62 to 0.93. Conclusions: The association of the cumulative maltreatment class with the highest symptom severity of PTSD and CPTSD highlights the detrimental effect of cumulative maltreatment. The detection of a high neglect class identifies children and adolescents, who are at high-risk of experiencing future maltreatment because of their previous experiences of neglect and the associated lack of protection. The examination of the association of distinct maltreatment classes with ICD-11 PTSD and CPTSD might provide implications for targeted prevention, assessment and treatment.

Antecedentes: Los niños y adolescentes bajo cuidados alternativos a menudo experimentan muchos subtipos de maltrato concurrentes. Sin embargo, se sabe poco sobre las diferentes combinaciones de subtipos de maltrato, denominadas clases de maltrato. Además, la asociación entre esas clases de maltrato y el trastorno de estrés postraumático (TEPT) y el trastorno de estrés postraumático complejo (TEPTC) de la CIE-11 no se ha investigado en niños y adolescentes. En estudios anteriores, las clases caracterizadas por maltrato acumulativo se asociaron con síntomas psicopatológicos graves. Hasta ahora, ningún estudio investigó el TEPT y el TEPT-C de la CIE-11.Objetivo: El primer objetivo de este estudio fue la detección de distintas clases de maltrato mediante el examen de subtipos de maltrato que concurren con frecuencia. El segundo objetivo fue el examen de la asociación entre esas clases de maltrato y CIE-11 TEPT y TEPTC.Método: Los participantes fueron 147 niños y adolescentes que actualmente viven en instituciones de acogida en Baja Austria. Se evaluaron los antecedentes de maltrato, TEPT y TEPT-C de la CIE-11 mediante cuestionarios de auto-reporte estandarizados.Se aplicó un análisis de clases latentes para examinar los subtipos de maltrato. Se utilizó la prueba de diferencia de χ2 para examinar las asociaciones de clases con TEPT y TEPTC.Resultados: Se identificaron tres clases latentes que comprendían diferentes subtipos de maltrato (maltrato limitado, n = 49; alto nivel de negligencia, n = 53; maltrato acumulativo, n = 45). El maltrato acumulado se asoció con una mayor gravedad de los síntomas de TEPT y TEPTC que el maltrato limitado y la clase de alto nivel de negligencia, con tamaños de efecto que van de 0,62 a 0,93.Conclusiones: La asociación de la clase de maltrato acumulativo con la mayor gravedad de los síntomas de TEPT y TEPTC destaca el efecto perjudicial del maltrato acumulativo. La detección de una clase de alto nivel de negligencia identifica a los niños y adolescentes, que tienen un alto riesgo de sufrir maltrato en el futuro debido a sus experiencias anteriores de negligencia y la falta de protección asociada. El examen de la asociación de distintas clases de maltrato con TEPT y TEPTC de la CIE-11 podría proporcionar implicaciones para la prevención, evaluación y tratamiento específicos.