Accuracy of the Diagnostic Infant and Preschool Assessment (DIPA) in a Dutch sample.

BACKGROUND: To prevent negative effects of early-onset psychiatric disorders on children's development, structured diagnostics are needed. However, validated diagnostic instruments (based on DSM-5) for children aged 7 years and younger are scarce. The Diagnostic Infant and Preschool Assessment (DIPA) is a diagnostic interview developed in the USA for measuring 16 psychiatric disorders in young children. The psychometric properties of the American version of the DIPA have been validated. Here we determined the accuracy of the psychometric properties of the Dutch DSM-5 based version of the DIPA for the corresponding population. MATERIAL AND METHODS: Psychometric properties of the DSM-5 based version of the DIPA were determined based on a sample of 136 biological, foster, therapeutic foster and adoptive parents of clinically referred children and children involved in a serious accident (aged 1-7 years). In line with the American validation study, we included the following seven DIPA modules: posttraumatic stress disorder (PTSD), major depressive disorder (MDD), attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). We administered the DIPA, Trauma Symptom Checklist for Young Children (TSCYC) and Child Behavior Checklist (CBCL). Analyses were conducted with continuous outcomes (number of symptoms) and categorical outcomes (diagnoses). RESULTS: The Dutch DSM-5 based version of the DIPA showed good internal consistency and interrater reliability with both continuous and categorical variables. The concurrent validity was good; we found a good concordance between the DIPA and corresponding questionnaires on both the symptom and diagnoses level. In addition, the divergence on symptom level between the DIPA and non-corresponding questionnaires was adequate, which indicated adequate divergent validity. Due to a limited number of positive cases, we could not draw conclusions regarding its psychometric properties in the GAD and OCD modules. CONCLUSIONS: Our study shows promising initial results regarding the reliability and validity of the Dutch version of the DIPA, that is based on the DSM-5. Therefore, we recommend the use of the DIPA in research and clinical practice.

Short and Long-Term Parental Posttraumatic Stress After a Child's Accident: Prevalence and Associated Factors.

Studies on the long-term prevalence of parental posttraumatic stress symptoms (PTSS) following child accidental injury are scarce, and findings on risk factors vary. In this follow-up study (T2, n = 69) we determined the prevalence of parental PTSS 2-4 years after accidental injury of their child, compared with 3 months after the accident (T1, n = 135). Additionally, we examined the association between parental and child factors and PTSS severity. Children were 8-18 years old at the time of the accident. Parent and child PTSS was assessed by self-report. Other data were retrieved from medical records and a telephone interview. Parental PTSS was 9.6% at T1 and 5.8% at T2. Acute parental stress as measured within 2 weeks of the child's accident was significantly associated with parental PTSS severity (T1 and T2), as was the child's hospitalization of more than 1 day at T1 and the child's permanent physical impairment at T2. To prevent adverse long-term psychological consequences we recommend identifying and monitoring parents at risk and offering them timely treatment.

Long-Term Posttraumatic Stress Following Accidental Injury in Children and Adolescents: Results of a 2-4-Year Follow-Up Study.

In this study, we determined the long-term prevalence of posttraumatic stress disorder (PTSD) in children and adolescents after accidental injury and gained insight into factors that may be associated with the occurrence of PTSD. In a prospective longitudinal study, we assessed diagnosed PTSD and clinically significant self-reported posttraumatic stress symptoms (PTSS) in 90 children (11-22 years of age, 60% boys), 2-4 years after their accident (mean number of months 32.9, SD 6.6). The outcome was compared to the first assessment 3 months after the accident in 147 children, 8-18 years of age. The prevalence of PTSD was 11.6% at first assessment and 11.4% at follow-up. Children with PTSD or PTSS reported significantly more permanent physical impairment than children without. Children who completed psychotherapy had no symptoms or low levels of symptoms at follow-up. Given the long-term prevalence of PTSD in children following accidents, we recommend systematic monitoring of injured children. The role of possible associated factors in long-term PTSS needs further study.

The Association Between Acute Pain and Posttraumatic Stress Symptoms in Children and Adolescents 3 Months After Accidental Injury.

Previous research suggests that acute pain is a risk factor for later posttraumatic stress symptoms (PTSS). In a prospective cohort study, we examined the association between acute pain from accidental injury and PTSS in children and adolescents, taking into account factors potentially related to pain or posttraumatic stress. Participants were 135 children and adolescents, 8-18 years old. We measured the worst experienced pain since the accident took place with a visual analogue scale. Three months after the accident, posttraumatic stress was assessed with a self-report measure. We found a positive association between acute pain and posttraumatic stress. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of PTSS. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later PTSS. Timely management of pain according to acute pain protocols in all phases and disciplines after accidental injury is therefore recommended.

Enhanced screening for posttraumatic stress disorder and comorbid diagnoses in children and adolescents.

BACKGROUND: Posttraumatic stress disorder (PTSD) can be a debilitating disorder and often co-occurs with other psychiatric disorders, such as mood, behavioral, and anxiety disorders. Early identification of PTSD and psychiatric comorbidity is highly relevant in order to offer children appropriate and timely treatment. The Children's Revised Impact of Event Scale (CRIES-13) is a reliable and valid self-report measure designed to screen children for PTSD. However, this measure is not useful as a screen for psychiatric comorbidity in children with probable PTSD. OBJECTIVE: This study evaluated the screening accuracy of the CRIES-Plus, that is, the CRIES-13 combined with 12 additional items to detect psychiatric comorbidity. METHOD: The CRIES-Plus was completed by 398 Dutch children (7-18 years) exposed to various traumatic events. Psychiatric diagnoses were assessed using the Anxiety Disorders Interview Schedule for DSM-IV: Child version. RESULTS: Six additional items were significantly associated with mood disorders, three items were associated with behavioral disorders, and five items with anxiety disorders. Additional items associated with mood and anxiety disorders demonstrated good discriminatory ability, with cut-off scores of ≥14 and ≥10, respectively. Items associated with behavioral disorders had poor to fair discriminatory ability, with no clear cut-off point. CONCLUSIONS: Our findings support the use of the CRIES-Plus to screen for PTSD and comorbid disorders which may help clinicians in assigning appropriate follow-up diagnostic and clinical care.

Predicting posttraumatic stress disorder in children and parents following accidental child injury: evaluation of the Screening Tool for Early Predictors of Posttraumatic Stress Disorder (STEPP).

BACKGROUND: Children and their parents are at risk of posttraumatic stress disorder (PTSD) following injury due to pediatric accidental trauma. Screening could help predict those at greatest risk and provide an opportunity for monitoring so that early intervention may be provided. The purpose of this study was to evaluate the Screening Tool for Early Predictors of Posttraumatic Stress Disorder (STEPP) in a mixed-trauma sample in a non-English speaking country (the Netherlands). METHODS: Children aged 8-18 and one of their parents were recruited in two academic level I trauma centers. The STEPP was assessed in 161 children (mean age 13.9 years) and 156 parents within one week of the accident. Three months later, clinical diagnoses and symptoms of PTSD were assessed in 147 children and 135 parents. We used the Anxiety Disorders Interview Schedule for DSM-IV - Child and Parent version, the Children's Revised Impact of Event Scale and the Impact of Event Scale-Revised. Receiver Operating Characteristic analyses were performed to estimate the Areas Under the Curve as a measure of performance and to determine the optimal cut-off score in our sample. Sensitivity, specificity, positive and negative predictive values were calculated. The aim was to maximize both sensitivity and negative predictive values. RESULTS: PTSD was diagnosed in 12% of the children; 10% of their parents scored above the cut-off point for PTSD. At the originally recommended cut-off scores (4 for children, 3 for parents), the sensitivity in our sample was 41% for children and 54% for parents. Negative predictive values were 92% for both groups. Adjusting the cut-off scores to 2 improved sensitivity to 82% for children and 92% for parents, with negative predictive values of 92% and 96%, respectively. CONCLUSIONS: With adjusted cut-off scores, the STEPP performed well: 82% of the children and 92% of the parents with a subsequent positive diagnosis were identified correctly. Special attention in the screening procedure is required because of a high rate of false positives. The STEPP appears to be a valid and useful instrument that can be used in the Netherlands as a first screening method in stepped psychotrauma care following accidents.

Comparing three diagnostic algorithms of posttraumatic stress in young children exposed to accidental trauma: an exploratory study.

BACKGROUND: Both the DSM-5 algorithm for posttraumatic stress disorder (PTSD) in children 6 years and younger and Scheeringa's alternative PTSD algorithm (PTSD-AA) aim to be more developmentally sensitive for young children than the DSM-IV PTSD algorithm. However, very few studies compared the three algorithms simultaneously. The current study explores diagnostic outcomes of the three algorithms in young child survivors of accidental trauma. METHODS: Parents of 98 young children (0-7 years) involved in an accident between 2006 and 2012 participated in a semi-structured telephone interview. Child posttraumatic stress symptoms (PTSS) were measured with the Anxiety Disorders Interview Schedule for DSM-IV-Child Version (ADIS-C/P), complemented with items from the Diagnostic Infant and Preschool Assessment (DIPA). Descriptive statistics were used to analyze the characteristics of the children, accident related information and PTS symptoms. We compared the three PTSD algorithms in order to explore the diagnostic outcomes. RESULTS: A total of 9 of the children (9.2 %) showed substantial PTSS. Of these children 2 met the criteria of all three algorithms, 7 met both the DSM-5 subtype for children 6 years and younger and the PTSD-AA algorithm, and 2 did not fully meet any of the algorithms (subsyndromal PTSD). CONCLUSIONS: For young children, the DSM-5 subtype for children 6 years and younger and the PTSD-AA algorithm appear to be better suited than the previous DSM-IV algorithm. It remains important that clinicians pay attention to children with subsyndromal PTSD.

A parental tool to screen for posttraumatic stress in children: first psychometric results.

The Children's Revised Impact of Event Scale (CRIES-13) is a brief self-report measure designed to screen children for posttraumatic stress disorder (PTSD). This study investigates the psychometric properties of a Dutch version of the CRIES-13-parent version and evaluates its correlation with the child version. A sample of 59 trauma-exposed children (8 years-18 years) and their parents completed an assessment including the CRIES-13 (child/parent version) along with the Anxiety Disorders Interview Schedule for DSM-IV: Parent version. Results demonstrated good internal consistency (α = .87) with acceptable values for the 3 subscales. A strong correlation (r = .73) with another measure of PTSD and lower correlations with a behavioral measure (r = .15 to .38) were found, confirming the convergent/divergent validity. A cutoff score ≥ 31 emerged as the best balance between sensitivity and specificity, and correctly classified 83.6% of all children as having a diagnosis of PTSD. This study provides support for the reliability and validity of the CRIES-13-parent version as a screening measure for posttraumatic stress in children.

Characteristics of the Children's Revised Impact of Event Scale in a clinically referred Dutch sample.

Early identification of posttraumatic stress disorder (PTSD) in children is important to offer them appropriate and timely treatment. The Children's Revised Impact of Event Scale (CRIES) is a brief self-report measure designed to screen children for PTSD. Research regarding the diagnostic validity of the CRIES is still insufficient, has been restricted to specific populations, and sample sizes have often been small. This study evaluated the reliability and validity of the 8-item (CRIES-8) and 13-item (CRIES-13) versions of the CRIES in a large clinically referred sample. The measure was completed by 395 Dutch children (7-18 years) who had experienced a wide variety of traumatic events. PTSD was assessed using the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent version. A cutoff score of 17 on the CRIES-8 and 30 on the CRIES-13 emerged as the best balance between sensitivity and specificity, and correctly classified 78%-81% of all children. The CRIES-13 outperformed the CRIES-8, in that the overall efficiency of the CRIES-13 was slightly superior (.81 and .78, respectively). The CRIES appears to be a reliable and valid measure, which gives clinicians a brief and user-friendly instrument to identify children who may have PTSD and offer them appropriate and timely treatment.

What makes a life event traumatic for a child? The predictive values of DSM-Criteria A1 and A2.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders (DSM)-Criteria A1 and A2 for posttraumatic stress disorder (PTSD) have been discussed extensively, with several studies in adults or adolescents supporting the removal of Criterion A2. However, solid research in children is missing. OBJECTIVE: This study evaluated the DSM-Criteria A1 and A2 in predicting posttraumatic stress in children. METHOD: A sample of 588 Dutch school children, aged 8-18 years, completed a self-report questionnaire to determine if they met Criteria A1 and/or A2. Their posttraumatic stress response was assessed using the Children's Revised Impact of Event Scale. RESULTS: The contribution of Criterion A2 to the prediction of posttraumatic stress in children is of greater importance than the contribution of Criterion A1. Children who met Criterion A2 reported significantly higher levels of posttraumatic stress and were nine times more likely to develop probable PTSD than children who did not meet Criterion A2. When Criterion A1 was met, a child was only two times more likely to develop probable PTSD as compared with those where Criterion A1 was not met. Furthermore, the low sensitivity of Criterion A1 suggests that children may regularly develop severe posttraumatic stress in the absence of Criterion A1. The remarkably high negative predictive value of Criterion A2 indicates that if a child does not have a subjective reaction during an event that it is unlikely that he or she will develop PTSD. CONCLUSIONS: In contrast to most adult studies, the findings of this study emphasize the significant contribution of Criterion A2 to the prediction of posttraumatic stress in children and raise fundamental questions about the value of the current Criterion A1.

Heart rate responsivity to script-driven imagery in posttraumatic stress disorder: specificity of response and effects of psychotherapy.

OBJECTIVE: Previous psychophysiological studies of posttraumatic stress disorder (PTSD) have found heightened physiological responsivity to trauma-specific stimuli, but mostly in combat veterans with high comorbidity rates and with psychiatric medication. Our aim was to investigate psychophysiological responses in two new populations while excluding those confounding influences and to assess the effects of psychotherapy on such responses. METHODS: Thirty-nine subjects with PTSD (24 civilian outpatients and 15 police officers) and 15 trauma-exposed, non-PTSD control subjects underwent psychophysiological assessment while listening to neutral, stressful, and trauma scripts. Psychophysiological measures were heart rate (HR) and blood pressure in combination with subjective anxiety ratings. In a randomized clinical trial, 20 of the civilians were then assigned to treatment or waitlist groups. Psychophysiological assessment was repeated on them after the treatment stage. RESULTS: Both civilians and police with PTSD showed significantly higher HR responses to trauma scripts than the control subjects. After successful psychotherapy with the civilians, HR responsivity to the trauma scripts was significantly reduced, and it correlated positively with PTSD clinical symptoms. CONCLUSIONS: We confirmed previous findings of heightened psychophysiological responses in PTSD for two new populations while minimizing comorbidity and medication as confounding factors. Successful psychotherapy normalized HR response to trauma imagery.

Cortisol, learning, memory, and attention in relation to smaller hippocampal volume in police officers with posttraumatic stress disorder.

BACKGROUND: A proposed explanation for memory impairments in posttraumatic stress disorder (PTSD) is stress-induced hippocampal damage due to elevated cortisol levels. We have previously reported smaller hippocampi in police officers with PTSD. In this study, we examined changes in and associations between cortisol, learning, memory, attention, and hippocampal volume in PTSD. METHODS: In a case-matched control study, 12 police officers with PTSD and 12 traumatized police officers without lifetime PTSD were examined with magnetic resonance imaging (for hippocampal volume), salivary cortisol tests, and neurocognitive assessments. RESULTS: Significantly smaller hippocampi and higher early morning salivary cortisol levels were found in PTSD. Subjects with PTSD performed worse on a delayed visual memory recall task at trend level, and made more perseverations and intrusions on a verbal memory task. Negative correlations were found between PTSD symptom severity and immediate recall function, and between re-experiencing symptoms and left hippocampal volume. A positive correlation was found between salivary cortisol level in early morning and right hippocampal volume; however, hippocampal volume did not correlate with memory. CONCLUSIONS: Smaller hippocampi, higher cortisol levels, and memory impairments were associated with PTSD but were not directly correlated to one another. Memory impairments in PTSD do not seem to be a direct consequence of hippocampal size.

Effects of brief eclectic psychotherapy in patients with posttraumatic stress disorder: randomized clinical trial.

Brief Eclectic Psychotherapy (BEP) is a manualized psychotherapy for posttraumatic stress disorder (PTSD) which has proven effective for police officers. This article reports on a randomized clinical trial using BEP to treat other types of PTSD patients recruited from an outpatient clinic. Twenty-four patients were randomly assigned to a treatment or a waitlist group. Assessment of PTSD was made before and after the treatment period (4 months). No significant differences between the groups were observed at pretest. By posttest, BEP had effectively reduced PTSD as well as general anxiety symptoms in the treated group of outpatients as compared to the waitlist group.