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Traumatic Events and Posttraumatic Stress in Childhood


Abstract and Figures

Traumatic events are common and are related to psychiatric impairment in childhood. Little is known about the risk for posttraumatic stress disorder (PTSD) across different types of trauma exposure in children. To examine the developmental epidemiology of potential trauma and posttraumatic stress (PTS) in a longitudinal community sample of children. A representative population sample of 1420 children aged 9, 11, and 13 years at intake were followed up annually through 16 years of age. Main Outcome Measure Traumatic events and PTS were assessed from child and parent reports annually to 16 years of age. Risk factors and DSM-IV disorders were also assessed. More than two thirds of children reported at least 1 traumatic event by 16 years of age, with 13.4% of those children developing some PTS symptoms. Few PTS symptoms or psychiatric disorders were observed for individuals experiencing their first event, and any effects were short-lived. Less than 0.5% of children met the criteria for full-blown DSM-IV PTSD. Violent or sexual trauma were associated with the highest rates of symptoms. The PTS symptoms were predicted by previous exposure to multiple traumas, anxiety disorders, and family adversity. Lifetime co-occurrence of other psychiatric disorders with traumatic events and PTS symptoms was high, with the highest rates for anxiety and depressive disorders. In the general population of children, potentially traumatic events are fairly common and do not often result in PTS symptoms, except after multiple traumas or a history of anxiety. The prognosis after the first lifetime trauma exposure was generally favorable. Apart from PTSD, traumatic events are related to many forms of psychopathology, with the strongest links being with anxiety and depressive disorders.
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Traumatic Events and Posttraumatic Stress
in Childhood
William E. Copeland, PhD; Gordon Keeler, MA; Adrian Angold, MRCPsych; E. Jane Costello, PhD
Context: Traumatic events are common and are re-
lated to psychiatric impairment in childhood. Little is
known about the risk for posttraumatic stress disorder
(PTSD) across different types of trauma exposure in chil-
Objective: To examine the developmental epidemiol-
ogy of potential trauma and posttraumatic stress (PTS)
in a longitudinal community sample of children.
Methods: A representative population sample of 1420
children aged 9, 11, and 13 years at intake were fol-
lowed up annually through 16 years of age.
Main Outcome Measure: Traumatic events and PTS
were assessed from child and parent reports annually to
16 years of age. Risk factors and DSM-IV disorders were
also assessed.
Results: More than two thirds of children reported at
least 1 traumatic event by 16 years of age, with 13.4% of
those children developing some PTS symptoms. Few PTS
symptoms or psychiatric disorders were observed for in-
dividuals experiencing their first event, and any effects
were short-lived. Less than 0.5% of children met the cri-
teria for full-blown DSM-IV PTSD. Violent or sexual
trauma were associated with the highest rates of symp-
toms. The PTS symptoms were predicted by previous ex-
posure to multiple traumas, anxiety disorders, and fam-
ily adversity. Lifetime co-occurrence of other psychiatric
disorders with traumatic events and PTS symptoms was
high, with the highest rates for anxiety and depressive
Conclusions: In the general population of children, po-
tentially traumatic events are fairly common and do not
often result in PTS symptoms, except after multiple trau-
mas or a history of anxiety. The prognosis after the first
lifetime trauma exposure was generally favorable. Apart
from PTSD, traumatic events are related to many forms
of psychopathology, with the strongest links being with
anxiety and depressive disorders.
Arch Gen Psychiatry. 2007;64:577-584
der (PTSD) is distinct from
most psychiatric disorders in
requiring an initiating
Early PTSD re-
search focused on Vietnam War veterans
and rape victims, leading to a narrow defi-
nition of the stressor criteria in the DSM-
Increased attention to
the subjective appraisal of potentially trau-
matic situations in the 1980s and early
1990s led to a broader view of what con-
stituted a stressor. The criteria were
amended in the DSM-IV to include a wider
range of events such as serious illnesses,
natural disasters, and exposure to com-
munity violence.
Research on PTSD with
younger samples has added to the list of
potentially traumatic events. For ex-
ample, Giaconia and colleagues
found that
a parent being sent to prison put adoles-
cents at the same risk of PTSD as rape did.
Additional childhood events identified as
potentially traumatic include sudden sepa-
ration from a loved one and learning of a
traumatic event occurring to a parent or
a loved one.
Many studies have looked
at the risk for PTSD in children, given ex-
posure to a specific trauma such as a natu-
ral disaster or a motor vehicle crash,
few have assessed exposure to a full range
of potentially traumatic events. Efficient
treatment and prevention strategies re-
quire knowledge of the conditional risk for
PTSD, given different event categories
across the full range of potentially vulner-
able groups. Only data from community
samples can provide this information.
The few studies that have looked at a
range of events in representative samples
supported moderate levels of PTSD in chil-
dren exposed to traumatic events,
some evidence of higher vulnerability in
girls than in boys.
These studies pro-
vided the first look at the epidemiology of
PTSD in adolescents, but each is limited
Author Affiliations: Center for
Developmental Epidemiology,
Department of Psychiatry and
Behavioral Sciences, Duke
University Medical Center,
Durham, NC.
©2007 American Medical Association. All rights reserved.
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by 1 of the following issues: (1) reliance on retrospec-
tive report, which tends to underestimate levels of trau-
matic events
; (2) use of small samples; or (3) assess-
ment of events and symptoms at a single time point only.
The present study examines the role of potentially
traumatic events in childhood PTSD and other DSM-IV
psychopathology. About one third of the sample par-
ticipants reported their first event exposure subsequent
to the first wave of data collection. This provided a
within-subject natural experiment to study predictors
of incident exposure to trauma and subsequent PTSD
symptoms. The study seeks to answer the following
1. What is the population prevalence of PTSD and
posttraumatic stress (PTS) symptoms in childhood and
2. Given the occurrence of a potentially traumatic
event, what are the conditional probabilities associated
with PTSD, related symptoms, and impairments?
3. What are the characteristics of children who are
vulnerable to developing PTS symptoms in response to
potentially traumatic events?
4. What is the lifetime co-occurrence of PTSD and PTS
symptoms and other DSM-IV childhood disorders?
5. What predicts the first potentially traumatic ex-
perience and response to it?
The Great Smoky Mountains Study is a longitudinal study of
psychopathology and use of medical services in child-
A multistage sample design was used to randomly se-
lect potential participants from a population of 20 000 chil-
dren in 11 counties in western North Carolina. Three cohorts
of children aged 9, 11, and 13 years were recruited at intake.
Potential participants were randomly selected from the popu-
lation using a household equal-probability, accelerated cohort
design. This means that each cohort reaches a given age in a
different year, thus controlling for cohort effects.
The initial
random sample of 4067 yielded 3896 (95.8%) screening ques-
tionnaires consisting of the externalizing (behavioral) prob-
lems scale of the Child Behavior Checklist completed by the
parent, on the telephone or in person. All children scoring above
a predetermined cutoff point (the top 25% of the total scores),
plus a 1-in-10 random sample of the rest, were recruited for
detailed interviews. The contribution of each participant is
weighted by the inverse of their selection probabilities, strati-
fied by age, sex, and race or ethnicity, to provide accurate preva-
lence estimates for the population of the study area.
Of 1796 children recruited, 79.1% (n=1420) agreed to par-
ticipate. Across annual waves, 83.4% of the 8002 possible in-
terviews have been completed with 75.0% to 94.2% of the sample
who participated in each wave. The data presented herein, based
on the first 8 annual waves of the study (1993-2000), consist
of 6674 interviews with participants through 16 years of age
and 1 parent. Funding constraints prevented our interviewing
the youngest cohort from January 1997 through June 1998. Be-
cause subjects were randomly selected, the cohort members in-
terviewed from July to December 1998 are a random sample
of the whole cohort. Data were collected on 1 cohort at 9 and
10 years of age; 2 cohorts at 11, 12, and 13 years of age; and all
3 cohorts at 14, 15, and 16 years of age.
The final sample consisted of 790 boys and 630 girls (weighted
percentages, 51.1% and 49.0% respectively). In the unweighted
sample, 69.2% (n =983) were white, 6.2% (n=88) were African
American, and 24.6% (n=349) were American Indian. When
weighted back to population probability of selection, the respec-
tive proportions were 89.5%, 6.9%, and 3.6%, respectively.
We based our analyses on the following 3 areas of information:
(1) psychiatric disorders, (2) potentially traumatic events and
associated PTS symptoms, and (3) risk factors. These areas were
assessed using the Child and Adolescent Psychiatric Assess-
ment (CAPA).
Symptoms are coded using an extensive glos-
sary, and diagnoses are generated by computer algorithms. With
the exception of attention-deficit/hyperactivity disorder symp-
toms, about which only the parent was interviewed, a symptom
is counted as present if it was reported by the parent, the child,
or both, as is standard clinical practice. The 2-week test-retest
reliability of the CAPA diagnoses in children and adolescents aged
10 to 18 years is comparable to that of other highly structured
interviews ( range for individual disorders, 0.56-1.00).
time frame of the CAPA for determining the presence of most
psychiatric symptoms is the 3 months immediately preceding
the interview to minimize recall bias.
Details of the construction and psychometric testing of the life
events and PTS sections of the CAPA are contained in another
The life events section covered 17 areas of children’s lives
that could potentially induce PTS symptoms. The terms trauma
and traumatic events are used to describe these events in report-
ing our results, but this is not meant to imply that the events are
traumatic apart from the individual’s response to the event. These
events meet the DSM-IV PTSD criterion A, which stipulates that
the event must involve “actual or threatened death or serious in-
jury, or a threat to the physical integrity of self or others.”
The parent or the child is queried about lifetime occurrence of
each event and, where necessary, when it occurred. For each event,
the interviewer administered a screen to determine whether the
3 key symptoms of PTSD (painful recall, avoidance, and hyper-
arousal) required for a DSM-IV diagnosis have been present dur-
ing the past 3 months and are linked to the event under discus-
sion. Painful recall/reexperience is assessed first and, if endorsed,
the interviewer inquires about avoidance or hyperarousal. This
procedure was put in place to avoid false-positive responses as-
sociated with the more common and less specific behavior pat-
terns of hyperarousal and avoidance of painful stimuli. Painful
recall is coded as present if the child or the parent reports un-
wanted, painful, and distressing recollections, memories, thoughts,
or images of the life event, the occurrence of which the child can-
not prevent (including childhood manifestations such as night-
mares, reenactment, and repetitive play). Avoidance is defined as
avoiding situations that might provoke recall of the event, and
hyperarousal as an increased general level of awareness and alert-
ness toward the subject’s surroundings, in the absence of immi-
nent danger. If minimal levels of all 3 symptoms are endorsed,
then the detailed PTSD module is completed. Up to 2 detailed
PTSD sections could be completed, 1 for the most upsetting event
meeting 3 screens in the past 3 months, and 1 for the most up-
setting lifetime event. A reliability study with 58 parents and chil-
dren interviewed twice by different interviewers supported fair
to excellent test-retest reliability (interclass correlations, 0.58-
0.83, depending on the informant and type of event).
nant validity was established through comparisons of general popu-
lation and clinic-referred subjects.
The PTSD section of the CAPA inquires in detail about the
3 main symptom clusters. Coping mechanisms such as nor-
mal, obsessional, and compulsive suppression are explored; ques-
tions are asked about autonomic effects such as panic attacks;
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and other associated features are queried (eg, “omen forma-
tion” and engagement in dangerous activities). Diagnoses of
PTSD are computed using DSM-IV algorithms. Further details
can be found in a previous publication.
Children were first interviewed as closely as possible to their
9th, 11th, or 13th birthday and were interviewed annually un-
til 16 years of age, at home or in a location convenient for them.
Before the interviews began, the parent and child signed in-
formed consent forms approved by the institutional review board
of the Duke University Medical Center. They were then inter-
viewed in separate rooms. Each parent and child was paid $10
after the interview was completed. Interviewers attempted to
interview the primary caregiver, who was usually the biologi-
cal mother (83.2% of the time).
Interviewers were residents of the area in which the study took
place. All had at least bachelor’s-level degrees. They received
1 month of training and constant quality control, maintained by
postinterview reviews of each schedule by experienced inter-
viewer supervisors and study faculty (A.A.). Interviewers were
trained by the Department of Social Services staff per North Caro-
lina’s requirements for reporting abuse or neglect, and all sus-
pected cases were referred to the appropriate agency.
Scoring programs for the CAPA, written in SAS statistical soft-
combined information about the date of onset, dura-
tion, and intensity of each symptom to create DSM-IV diag-
noses. Prevalence estimates, odds ratios, and group comparisons
were computed using the SAS program GENMOD.
We used
general estimation equations to account for the sampling de-
sign and within-subject correlation. In general estimation equa-
tions, the subject is introduced as a cluster (class) variable, and
the sampling weights are introduced as a scale vector that mul-
tiplies the subject’s wave-to-wave correlation matrix. We also
used the robust variance estimates (ie, sandwich-type esti-
mates), together with sampling weights, to adjust the stan-
dard errors of the parameter estimates to account for the mul-
tiphase sampling design. The use of multiwave data with the
appropriate sample weights thus capitalized on the multiple ob-
servation points over time while controlling for the effect on
variance estimates of the repeated measures. For predictive analy-
ses, logistic regression using the SAS procedure GLIMMIX
amined the effects of 1-year–lagged variables on current func-
tioning. Models were evaluated with the Bayesian information
criteria, an index that balances model fit with complexity.
We derived the following 3 categories of PTS symp-
toms: (1) meeting all diagnostic criteria for DSM-IV PTSD;
2) endorsing at least 1 symptom each of painful recall,
hyperarousal, and avoidance symptoms but not meet-
ing full PTSD criteria (subclinical PTSD); and (3) report-
ing painful recall only.
Table 1 displays 3-month and
cumulative prevalence estimates for trauma exposure and
the 3 symptom categories. Two thirds of the sample re-
ported exposure to 1 or more events by 16 years of age.
Trauma exposure was more common in adolescence than
childhood (z=1.99; P=.05).
Full-blown DSM-IV PTSD was rare across all sex, age,
and ethnic groups (n =6; weighted prevalence, 0.5%).
Painful recall and subclinical PTSD were more com-
mon, with cumulative rates of 9.1% and 2.2%, respec-
tively, by 16 years of age in the full sample. Subclinical
PTSD was more common in adolescence than child-
hood (z=2.24; P=.02). Rates of painful recall and sub-
clinical PTSD did not differ across sex or ethnic groups.
Because full-blown PTSD was so rare, the few cases were
included in the painful recall and subclinical PTSD groups,
but not analyzed separately.
Table 2 displays the prevalence rates for all potentially
traumatic events and the likelihood of developing symp-
toms when exposed to particular events. Events are grouped
into the broad categories of violence, sexual trauma, other
injury or trauma, witness to trauma, and learning about
trauma. By 16 years of age, similarly sized groups of chil-
Table 1. Three-Month and Cumulative Prevalence Estimates of Traumatic Events, Posttraumatic Stress Disorder (PTSD),
and Related Symptoms
Prevalence Estimate, Percentage (SE)
3-Month Lifetime
Trauma Painful Recall Subclinical PTSD PTSD Trauma Painful Recall Subclinical PTSD PTSD
Total 5.9 (0.5) 2.2 (0.3) 0.5 (0.1) 0.1 (0.1) 68.2 (2.1) 9.1 (1.2) 2.2 (0.6) 0.4 (0.2)
Age, y
9-13 4.8 (0.7) 2.0 (0.4) 0.2 (0.1) 0.03 (0.02) 54.0 (2.4) 5.4 (1.0) 0.9 (0.4) 0.1 (0.04)
14-16 6.6 (0.7) 2.3 (0.4) 0.6 (.2) 0.1 (0.1) 68.2 (2.1) 9.1 (1.2) 2.2 (0.6) 0.4 (0.2)
Male 5.9 (0.7) 2.1 (0.5) 0.6 (.2) 0.01 (0.01) 67.9 (2.9) 8.1 (1.7) 2.8 (1.1) 0.1 (0.1)
Female 6.0 (0.7) 2.4 (0.4) 0.3 (0.1) 0.2 (0.1) 68.4 (3.0) 10.2 (1.8) 1.6 (0.5) 0.7 (0.5)
White 5.7 (0.5) 2.2 (0.3) 0.4 (0.1) 0.1 (0.1) 67.1 (2.3) 9.1 (1.3) 2.1 (0.6) 0.4 (0.3)
Native American 5.0 (0.6) 2.3 (0.4) 0.4 (0.1) * 73.9 (2.4) 9.7 (1.6) 1.7 (0.7) *
*Indicates no cases.
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dren reported no event exposure (32.2%), exposure to
1 event (30.8%), or exposure to multiple events (37.0%).
The most common events were witnessing or learning
about a traumatic event—so-called “vicarious” events.
Averaging 3-month and lifetime prevalance rates, about
1 of every 10 subjects exposed to trauma reported pain-
ful recall and about 3% reported subclinical PTSD. The
highest rates of painful recall and subclinical PTSD were
associated with violent events or sexual trauma. Three-
month and lifetime conditional probabilities did not dif-
fer appreciably across most traumatic event categories.
In addition to event characteristics, a lifetime history of
multiple trauma exposures strongly predicted higher rates
of painful recall and subclinical PTSD.
Subjects and their parents were queried about recent
impairments related to their experience of the trau-
matic event. Impairments included a wide range of prob-
lems, including disruption of important relationships,
school problems, physical problems, and exacerbation
of emotional problems. Rates of impairments were gen-
erally double the rates of having any painful recall. Chil-
dren with any traumatic event reported impairment 21.9%
of the time. As with PTS symptoms, the rates of impair-
ment increased with the number of traumatic events ex-
perienced. Impairment rates were 20.4% for those ex-
posed to 1 event and 49.6% for children exposed to 2 or
more events. Additional breakdowns by type of trauma
and type of impairment are available by request from one
of us (W.E.C.).
To test the predictors of PTS symptoms in the presence
of a traumatic event, 4 sets of variables were entered
into a model: (1) sex and current developmental period
(ages 9-13 [childhood] vs 14-16 years [adolescence]);
(2) previous emotional and behavioral disorders (anxi-
ety disorders, depressive disorders, and disruptive
behavior disorders); (3) previous negative events; and
(4) previous environmental, family, and parental risk
factors. All predictors except sex and developmental pe-
riod were assessed 1 year prior to trauma exposure. Re-
sults of the logistic analyses are presented in
Table 3.
Adolescence was a strong predictor of both painful re-
call and subclinical PTSD, controlling for other predic-
tor variables. Other significant predictors varied across
symptom categories. Painful recall was predicted inde-
pendently by exposure to a previous trauma and being
previously diagnosed as having an anxiety disorder.
Previous diagnosis with a depressive disorder did not
independently predict trauma response. For subclinical
PTSD, the best-fitting model included only sex and age.
In the full model, previous environmental adversity,
such as coming from an impoverished or poorly edu-
cated home, predicted subclinical PTSD, although the
fit index supports a more parsimonious solution. These
models suggest that age, prior anxiety, and previous
trauma exposure are important determinants of trauma
response in the next year.
Table 2. Prevalence of Traumatic Events and Conditional Probabilities for PTS Symptoms
Type of Trauma
Rate, %
Rate, %
Violence 24.7 15.5 3.7 1.4 7.4 2.5
Violent death of loved one 2.4 39.9 14.1 0.04 24.2 18.4
Violent death of sibling/peer 14.5 12.0 0.6 0.7 3.5 1.2
War, terrorism 0.1 0 0 0 0 0
Cause of death or severe harm 0.6 5.3 0 0.1 0 0
Victim of physical violence 3.1 13.0 9.1 0.2 6.6 0
Physical abuse by relative 7.2 13.5 2.2 0.5 20.0 4.3
Captivity 0.9 7.0 3.5 0 0 0
Sexual trauma 11.0 10.0 3.9 0.2 16.4 6.4
Sexual abuse 10.9 8.4 3.4 0.2 17.4 6.8
Rape 1.2 33.2 17.1 0.02 65.6 34.4
Coercion 4.3 21.9 7.9 0.05 32.2 16.1
Other injury or trauma 32.8 4.5 1.8 1.8 7.7 6.7
Diagnosis of physical illness 11.0 3.6 2.4 0.7 9.6 8.3
Serious accident 11.6 7.6 2.7 0.4 20.4 18.0
Natural disaster 11.1 0.8 0.3 0.2 0 0
Fire 5.9 1.5 0 0.3 0 0
Exposure to noxious agent 3.3 0.3 0 0.3 0 0
Witness to life event 23.7 10.2 1.7 1.3 11.8 1.3
Learned about life event 21.4 6.7 1.5 1.4 2.5 0
Any trauma 67.8 13.4 3.3 5.9 8.7 3.1
No. of traumatic events
1 30.8 6.7 0.3 5.6 7.7 3.1
2 37.0 19.1 5.7 0.3 25.3 2.6
Abbreviations: PTS, posttraumatic stress; PTSD, PTS disorder.
*Reported as the percentage of individuals exposed to the event (ie, conditional probability). Lifetime probabilities refer to current responses to any previous
event, whereas the 3-month probabilities are limited to current response to recent events.
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Co-occurrence rates between common psychiatric dis-
orders, trauma exposure, and PTS symptoms are pre-
sented in
Table 4. Children exposed to trauma had al-
most double the rates of psychiatric disorders of those
not exposed. This effect was significant for all diagnos-
tic groups except substance use disorders. Higher levels
of PTS-related symptoms were associated with higher lev-
els of psychiatric disorders, with rates of 52.6% and 59.5%
for painful recall and subclinical PTSD, respectively. For
Table 3. Logistic Regression Analyses Predicting Painful Recall and Subclinical PTSD From 1-Year–Lagged Risk Factors
OR (95% CI)†
Painful Recall Subclinical PTSD
Model 1 Model 2 Model 3 Model 4 Model 1 Model 2 Model 3 Model 4
Sex 0.8 (0.4-1.5) 0.8 (0.4-1.5) 0.8 (0.4-1.4) 0.8 (0.5-1.6) 2.2 (0.7-7.2) 2.4 (0.7-7.8) 2.3 (0.7-8.0) 2.4 (0.7-8.5)
Age 1.8 (0.9-3.4) 2.0 (1.0-3.8)‡ 2.1 (1.1-3.9)‡ 2.1 (1.1-4.1)‡ 3.3 (1.4-9.5)‡ 3.5 (1.2-10.2)‡ 3.8 (1.4-10.6)‡ 4.0 (1.4-11.5)‡
Trauma § 2.4 (1.2-4.7)‡ 2.3 (1.2-4.4) 2.2 (1.2-4.3)‡ § 3.0 (0.9-9.3) 2.5 (0.8-8.0)‡ 2.6 (0.8-8.6)
Life events § 1.9 (1.0-3.6) 1.7 (0.9-3.3) 1.7 (0.8-3.3) § 2.9 (1.0-8.6)† 2.1 (0.7-6.3) 2.2 (0.7-6.8)
Environmental adversities § § 1.2 (0.5-2.4) 1.2 (1.0-1.4) § § 1.2 (1.0-1.5) 1.3 (1.0-1.5)‡
Family dysfunction § § 1.2 (0.7-2.2) 1.2 (0.8-1.4) § § 1.6 (0.8-3.3) 1.7 (0.8-3.8)
Parental psychopathology § § 1.3 (0.7-2.4) 1.2 (0.8-.14) § § 1.1 (0.7-1.8) 1.1 (0.7-1.8)
Anxiety disorder § § § 2.7 (1.3-5.4)‡ § § § 2.1 (0.5-8.1)
Depressive disorder § § § 1.5 (0.5-4.1) § § § 0.2 (0.1-1.1)
Behavioral disorder § § § 0.8 (0.4-1.6) § § § 0.4 (0.1-2.2)
BIC 9355.6 9364.61 9348.8 9439.6 11 493.8 11 613.9 11 704.2 11 945.4
Abbreviations: BIC, Bayesian information criterion (lower is better); CI, confidence interval; OR, odds ratio; PTS, posttraumatic stress; PTSD, PTS disorder.
*All predictor variables except sex and age were assessed 1 year before trauma exposure. The age variable refers to childhood or adolescent status. Life events
includes low-magnitude events that did not meet the criteria as a DSM-IV extreme stressor. Environmental adversities includes a range of variables such as poverty ,
having a single parent, having 1 or more unemployed parents, and living in a dangerous community . Family dysfunction refers to parenting problems, marital conflict, or
frequent conflict between the child and a parent. The parental psychopathology variable includes mental health problems, substance abuse problems, and criminality .
†Models are described in the “Risk for PTS Symptoms” subsection of the “Results” section.
§Indicates variable not included in model.
Table 4. Lifetime Comorbidity Rates Between Psychiatric Disorders, Trauma Exposure, and Posttraumatic Stress Symptoms
Trauma, %
OR (95% CI)
Recall, %
OR (95% CI)
OR (95% CI)None Any None Any None Any
Any disorder 25.5 40.4 2.0 (1.3-3.0)* 33.9 52.6 2.2 (1.2-3.9)† 35.1 59.5 2.7 (0.8-9.2)‡
Affective disorders
Major depressive episode 2.2 1.7 0.8 (0.2-3.0) 1.5 5.5 3.8 (1.1-13.1)‡ 1.6 15.4 11.5 (2.3-57.8)†
Dysthymia 1.3 1.8 1.3 (0.3-6.3) 1.1 7.1 7.2 (1.8-29.1)† 1.1 26.3 33.4 (7.0-160.1)*
Depressive disorder NOS 3.2 9.5 3.2 (1.3-7.8)† 6.3 19.9 3.8 (1.8-7.8)* 6.9 35.6 7.5 (2.3-24.8)*
Any depressive disorder 3.3 9.8 3.2 (1.4-7.5)† 6.5 20.3 3.7 (1.8-7.6)* 7.1 37.1 7.7 (2.4-25.0)*
Anxiety disorders
Separation anxiety
1.1 6.7 6.3 (3.1-12.8)* 4.5 8.8 2.0 (1.1-3.8)‡ 4.8 12.9 3.0 (1.1-7.8)‡
Generalized anxiety
3.1 11.7 4.2 (1.7-10.1)* 6.7 31.4 6.4 (3.2-12.7)* 8.3 39.9 7.4 (2.3-23.3)*
Social anxiety disorder 1.2 2.6 2.2 (0.4-10.7) 1.7 6.2 3.8 (1.1-13.5)‡ 2.1 4.1 2.0 (0.5-8.2)
Any anxiety disorder 3.0 12.1 4.5 (2.2-9.3)* 7.6 24.8 4.0 (2.1-7.7)* 8.4 43.0 8.2 (2.7-25.3)*
Substance use disorders 6.4 10.6 1.7 (0.8-3.6) 8.3 18.4 2.5 (1.1-5.4)‡ 9.0 20.3 2.6 (0.9-10.9)
ADHD 2.3 3.8 1.7 (0.7-4.3) 3.2 4.0 1.3 (0.6-2.7) 3.2 10.2 3.5 (1.2-9.8)‡
Conduct disorder 3.9 10.8 3.0 (1.6-6.0)* 7.6 18.0 2.7 (1.3-5.3)† 8.2 23.2 3.4 (0.9-12.6)
ODD 5.6 11.7 2.2 (1.2-4.2) 9.6 11.6 1.2 (0.7-2.1) 9.5 19.5 2.3 (0.9-5.6)
Any DBD 9.4 19.2 2.3 (1.4-3.7)* 15.2 24.5 1.8 (1.0-3.3)‡ 15.6 35.6 3.0 (1.0-8.9)‡
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; DBD, disruptive behavior disorder; NOS, not otherwise specified;
ODD, oppositional defiant disorder; OR, odds ratio; PTSD, posttraumatic stress disorder.
©2007 American Medical Association. All rights reserved.
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both symptom groups, co-occurrence rates were signifi-
cant across a range of disorders, although the strength
of the association varied, suggesting both a general and
a specific pattern. Co-occurence odds ratios (ORs) were
highest for affective disorders and lower for substance
use and disruptive behavior disorders. The
Figure sug-
gests that the dose-dependent relation between trauma
and psychiatric disorders was similar to that observed for
trauma and PTS symptoms. This pattern, significant for
most diagnostic groups, was most pronounced for de-
pressive disorders.
Risk factors significantly predicting first trauma expo-
sure in the model were previous (1-year–lagged) envi-
ronmental adversity (OR, 2.2; 95% confidence interval
[CI], 1.4-3.5), previous parenting problems (OR, 1.8; 95%
CI, 1.1-2.8), and history of a depressive disorder (OR,
3.1; 95% CI, 1.0-9.8). The same constellation of vulner-
ability factors showed trends toward predicting painful
recall, but only previous exposure to nontraumatic life
events was significant (OR, 2.4; 95% CI, 1.6-9.6). Over-
all, 8.2% of the studied individuals reported painful re-
call and 1.4% reported subclinical PTSD in response to
their first trauma exposure.
Rates of psychopathology were compared between
individuals reporting PTS symptoms in response to
their first trauma and those with no symptoms. One
year before trauma exposure, psychopathology rates
did not differ between groups (13.6% for trauma expo-
sure only vs 17.6% for trauma exposure and PTS symp-
toms; F
=0.81; P =.37). No differences were noted for
anxiety or depressive disorders before trauma expo-
sure. Immediately after trauma exposure, rates of psy-
chiatric disorders were higher in the group experienc-
ing painful recall (31.1% vs 14.5%; F
The significant difference reflected increased levels of
anxiety disorders in the group with painful recall (2.2%
pretrauma vs 16.0% immediately following trauma ex-
posure). One year after trauma exposure, the 2 groups
did not differ on rates of psychopathology (F
P=.81). Overall, most children experienced few PTS
symptoms in response to their initial trauma exposure,
and those experiencing PTS symptoms were also at
highest risk of psychiatric morbidity.
The analyses of longitudinal data from a community-
based sample of children and adolescents showed that,
first, although exposure to traumatic events was almost
commonplace, full-blown DSM-IV PTSD was rare across
middle childhood and adolescence. Symptoms of PTS,
including painful recall and subclinical PTSD, were more
common, but very far from being expectable sequelae.
Second, children displaying PTS symptoms in response
to trauma exposure were more likely to be older, to have
a history of exposure to trauma, to have a history of anxi-
ety, and to come from an adverse family environment.
Third, higher levels of trauma exposure were related to
higher levels of most types of psychopathology, particu-
larly anxiety and depressive disorders, as well as other
impairments. Finally, the prognosis after a first lifetime
trauma exposure was generally favorable.
In this report, as in an earlier report covering a more
limited period,
our estimates of lifetime trauma expo-
sure in childhood and adolescence are generally slightly
higher than in previous community-based studies.
is attributable to a number of study characteristics in-
tended to improve accuracy of reporting. First, subjects were
interviewed at least 4 times during childhood and adoles-
cence about the immediate past, rather than relying on ret-
rospective recall in adulthood. At each assessment point,
both the parent and the child were interviewed. Each in-
terviewee was asked about each type of traumatic event (17
in all) separately, whereas some studies have asked gen-
eral questions about trauma exposure with a few ex-
The rate of PTSD after exposure to a traumatic event
was lower than that reported in studies of adults.
the same time, our results suggest that these children ex-
perienced PTS symptoms, higher rates of psychopathol-
ogy, and additional impairments. One explanation for
these findings has to do with the DSM-IV criteria them-
selves. These criteria were developed from the adult PTSD
and may not accurately reflect severe re-
sponses to trauma in children. Childhood studies indi-
cate low reliability for PTS symptoms
and low diag-
nostic efficacy for the arousal symptoms,
and factor
analytic studies have often failed to support the 3-symp-
tom clusters of painful recall, arousal, and avoidance de-
scribed in the adult literature.
Furthermore, re-
search with children suggests that the optimal algorithm
for PTSD may require substantially fewer symptoms than
is required for diagnosis of the disorder in adults.
studies suggest that different symptom clusters and dif-
ferent levels of symptoms are needed to predict impair-
ment in childhood samples. Although the present study
did not intend to evaluate the current DSM-IV PTSD cri-
teria, the findings suggest that the current criteria, when
applied to children, may not be developmentally sensi-
tive or that childhood PTSD is rare.
Psychopathology is strongly interrelated with trauma
and trauma symptoms. Across childhood, the children
No. of Events
Percentage of Subjects
Any Diagnosis
Any Anxiety Diagnosis
Any Depression Diagnosis
Any Behavioral Diagnosis
Figure. Effect of increasing trauma exposures on cumulative rates of
psychiatric diagnoses by age 16 years.
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who experience trauma are often those with anxiety, de-
pressive, and disruptive behavior disorders, a finding sup-
ported in the present study. This likely reflects common
liability conveyed from a limited set of family risk fac-
Furthermore, psychopathology, particularly de-
pression and anxiety, can serve as a risk for and sequela
of trauma exposure.
Our study indicated some speci-
ficity in the role of psychopathology as risk for trauma
and trauma exposure. Past depression best predicted first
trauma, but it was a history of anxiety disorders that best
predicted PTS symptoms in response to trauma expo-
sure. Both of these disorders are also common sequelae
of trauma exposure, with rates increasing dramatically
immediately after the first trauma exposure. This rela-
tionship is strongest in individuals who also display some
PTS symptoms (ie, at least painful recall).
Among potential sources of bias, a previous report sug-
gested little evidence of symptom attenuation (lower re-
ported symptom levels in subsequent data waves), co-
hort differences, and differential dropout in this sample.
Conversely, if bias were inflating estimates of traumatic
events, this would likely be reflected in similarly el-
evated psychopathology; however, psychiatric preva-
lence rates reported from this sample are consistent with
rates obtained from other community-based studies.
On the other hand, the study may underestimate life-
time rates of traumatic events because interviews began
when children were already in middle childhood.
A number of sources of bias may be specific to the life
events and PTSD module. Our screening structure was
intended to minimize cases in which the full PTSD mod-
ule is completed unnecessarily. The screening structure
requires the presence of painful recall symptoms (in-
cluding nightmares, thoughts, or images) before inquir-
ing about avoidance and hyperarousal symptoms. This
decision, made to increase diagnostic efficacy, gave some
primacy to painful recall during the less specific hyper-
arousal and avoidance symptoms. Subsequent studies sup-
port this decision, suggesting that symptoms involving
bad dreams and repetitive thoughts have the highest di-
agnostic efficacy for predicting full-blown PTSD in chil-
dren, along with behavioral and emotional avoidance
Hyperarousal symptoms, by contrast, have
the lowest levels of diagnostic efficacy.
There was no independent verification of the occur-
rence of the traumatic events reported; instead, we re-
lied on information from the parent and/or the child.
This could bias the estimate of the number of poten-
tially traumatic events leading to PTSD because infor-
mants may forget events that had no emotional sequelae
or suppress events that caused PTS symptoms. This is
probably an unavoidable problem in community-based
studies of PTSD that do not follow a specific event, such
as a hurricane or flood, because it is practically impos-
sible to verify not only the events reported but also ex-
posure to events not reported. The advantage that, we
believe, outweighs this drawback to general population
studies is that we were able to examine the interplay of
multiple different types of events, over time, on the risk
of PTSD.
Severe events such as sexual abuse may be under-
reported. In studies assessing for events at multiple time
points, it is not uncommon for an event reported at 1 time
point to be followed by a false-negative report.
results support the methods used in the current study
of assessing severe events at multiple time points. Also,
mandated reporting requirements might suppress re-
porting for physical and sexual abuse, events associated
with higher rates of PTS symptoms.
Finally, our study used subcategories of PTS symp-
toms (ie, subclinical PTSD and painful recall only) to
identify children with 2 symptom levels that might in-
fluence functioning. Other categories could have been
used (eg, DSM-IV criteria A, B, and E and criterion C or
D), and prevalence rates and other results would vary
depending on the stringency of the criteria. However,
increasing evidence suggesting that children with an
impairing response to trauma may be characterized by
fewer symptoms supports the use of categories with
relatively minimal requirements such as those used in
this study.
Studies of childhood trauma that use convenience
samples of children exposed to specific events and un-
dergoing assessment for PTS symptoms only provide
incomplete answers to questions about how common
trauma is in childhood and how children typically re-
spond to potentially traumatic events. The present
study followed up a large community sample of chil-
dren through middle childhood to adolescence with re-
peated assessments for trauma exposure and a range of
potential responses. The findings suggest that the ef-
fects of trauma are not symptom specific. Few children
exposed to trauma develop PTSD, and the few who dis-
play PTS symptoms can be identified through informa-
tion about their age, trauma history, anxiety history,
and family environment. Children exposed to traumatic
events also displayed higher rates of depression, anxiety
disorders, and other impairments.
Submitted for Publication: June 26, 2006; final revi-
sion received September 20, 2006; accepted October 1,
Correspondence: William E. Copeland, PhD, Center for
Developmental Epidemiology, Department of Psychia-
try and Behavioral Sciences, Duke University Medical Cen-
ter, Campus Box 3454, Durham NC 27710 (william
Author Contributions: Dr Copeland had full access to all
the data in this study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This study was supported by grants
MH63970, MH63671, and MH48085 from the National
Institute of Mental Health; grant DA/MH11301 from the
National Institute on Drug Abuse; and the William T.
Grant Foundation.
Acknowledgment: We thank John March, MD, and John
Fairbank, PhD, for their assistance in developing the life
events and PTSD measures used in this study.
©2007 American Medical Association. All rights reserved.
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1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders (Fourth Edition). Washington, DC: American Psychiatric Press; 1994.
2. March JS. What constitutes a stressor? The “Criterion A” issue. In: Davidson
JRT, Foa E, eds. Posttraumatic Stress Disorder: DSM-IV and Beyond. Washing-
ton, DC: American Psychiatric Press Inc; 1993:37-54.
3. Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E. Traumas
and posttraumatic stress disorder in a community population of older adolescents.
J Am Acad Child Adolesc Psychiatry. 1995;34:1369-1380.
4. Cuffe SP, Addy C, Garrison CZ, Waller JL, Jackson KL, McKeown RE, Chilappa-
gari S. Prevalence of PTSD in a community sample of older adolescents. JAm
Acad Child Adolesc Psychiatry. 1998;37:147-154.
5. Gold SL. An Investigation of Posttraumatic Stress Disorder and the Lives of For-
merly Homeless Children. Fresno: California School of Professional Psychology; 1995.
6. Nader K, Pynoos R, Fairbanks L, Frederick C. Children’s PTSD reactions one year
after a sniper attack at their school. Am J Psychiatry. 1990;147:1526-1530.
7. Pynoos RS, Goenjian A, Tashjian M, Karakashian M, Manjikian R, Manoukian G,
Steinberg AM, Fairbanks LA. Post-traumatic stress reactions in children after the
1988 Armenian earthquake. Br J Psychiatry. 1993;163:239-247.
8. Ahmad A, Sofi M, Sundelin-Wahlsten V, von Knorring A. Posttraumatic stress
disorder in children after the military operation “Anfal” in Iraqi Kurdistan. Eur
Child Adolesc Psychiatry. 2000;9:235-243.
9. March JS, Amaya-Jackson L, Terry R, Costanzo P. Posttraumatic symptomatol-
ogy in children and adolescents after an industrial fire. J Am Acad Child Adolesc
Psychiatry. 1997;36:1080-1088.
10. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder and
general psychopathology in children and adolescents following a wildfire disaster.
Can J Psychiatry. 2005;50:137-143.
11. Sack WH, Clarke GN, Him C, Dickason D, Goff B, Lanham K, Kinzie JD. A 6-year
follow-up study of Cambodian refugee adolescents traumatized as children.
J Am Acad Child Adolesc Psychiatry. 1993;32:431-437.
12. Fairbank JA, Ebert L, Costello EJ. Epidemiology of traumatic events and post-
traumatic stress disorder. In: Nutt D, Davidson JRT, Zohar J, eds. Post-
traumatic Stress Disorder: Diagnosis, Management and Treatment. London, En-
gland: Martin Dunitz Ltd; 2000:17-27.
13. Maughan B, Rutter M. Retrospective reporting of childhood adversity: issues in
assessing long-term recall. J Personal Disord. 1997;11:19-33.
14. Patten SB. Recall bias and major depression lifetime prevalence. Soc Psychiatry
Psychiatr Epidemiol. 2003;38:290-296.
15. Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol. 1990;43:87-91.
16. Pillemer DB, White SH. Childhood events recalled by children and adults. Adv
Child Dev Behav. 1989;21:297-340.
17. Harlow SD, Linet MS. Agreement between questionnaire data and medical rec-
ords: the evidence for accuracy of recall. Am J Epidemiol. 1989;129:233-248.
18. Som RK, ed. Recall Lapse in Demographic Enquiries. New York, NY: Asia Pub-
lishing House; 1973.
19. Raphael KG, Cloitre M, Dohrenwend BP. Problems of recall and misclassifica-
tion with checklist methods of measuring stressful life events. Health Psychol.
20. Widom CS, Shepard S. Accuracy of adult recollections of childhood victimiza-
tion, I: childhood physical abuse. Psychol Assess. 1996;8:412-421.
21. Costello EJ, Angold A, Burns BJ, Stangl DK, Tweed DL, Erkanli A, Worthman CM.
The Great Smoky Mountains Study of Youth: goals, designs, methods, and the preva-
lence of DSM-III-R disorders. Arch Gen Psychiatry. 1996;53:1129-1136.
22. Costello EJ, Farmer E, Angold A, Burns B, Erkanli A. Psychiatric disorders among
American Indian and white youth in Appalachia: the Great Smoky Mountains Study.
Am J Public Health. 1997;87:827-832.
23. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic Research: Principles
and Quantitative Methods. New York, NY: Van Nostrand Reinhold; 1982.
24. Angold A, Costello EJ. The Child and Adolescent Psychiatric Assessment (CAPA).
J Am Acad Child Adolesc Psychiatry. 2000;39:39-48.
25. Angold A, Costello EJ. A test-retest reliability study of child-reported psychiatric
symptoms and diagnoses using the Child and Adolescent Psychiatric Assess-
ment (CAPA-C). Psychol Med. 1995;25:755-762.
26. Costello EJ, Messer SC, Reinherz HZ, Cohen P, Bird HR. The prevalence of se-
rious emotional disturbance: a re-analysis of community studies. J Child Fam
Stud. 1998;7:411-432.
27. Costello EJ, Angold A, March J, Fairbank J. Life events and post-traumatic stress:
The development of a new measure for children and adolescents. Psychol Med.
28. SAS Institute. SAS/STAT User’s Guide, Version 6. Vol 1. 4th ed. Cary, NC: SAS
Institute Inc; 1994.
29. Raferty A. Choosing models for cross-classifications. Am Sociol Rev. 1986;51:
30. Costello EJ, Erkanli A, Fairbank JA, Angold A. The prevalence of potentially trau-
matic events in childhood and adolescence. J Trauma Stress. 2002;15:99-112.
31. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson C. Posttraumatic stress
disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:
32. Breslau N, Davis GC, Andreski P, Peterson EL, Schultz LR. Sex differences in
posttraumatic stress disorder. Arch Gen Psychiatry. 1997;54:1044-1048.
33. Summary of the practice parameters for the assessment and treatment of chil-
dren and adolescents with posttraumatic stress disorder. J Am Acad Child Ado-
lesc Psychiatry. 1998;37:997-1001.
34. Shannon MP, Lonigan CJ, Finch A, Taylor CM. Children exposed to disaster, I:
epidemiology of post-traumatic symptoms and symptom profiles. J Am Acad
Child Adolesc Psychiatry. 1994;33:80-93.
35. Vernberg EM, La Greca A, Silverman W, Prinstein M. Prediction of posttrau-
matic stress symptoms in children after Hurricane Andrew. J Abnorm Psychol.
36. Sack WH, Seeley JR, Clarke GN. Does PTSD transcend cultural barriers: a study
from the Khmer Adolescent Refugee Project. J Am Acad Child Adolesc Psychiatry.
37. Anthony JL, Lonigan C, Vermbeg E, La Greca A, Silverman W, Prinstein M.
Multisample cross-validation of a model of childhood posttraumatic stress dis-
order symptomatology. J Trauma Stress. 2005;18:667-676.
38. Anthony JL, Lonigan CJ, Hecht SA. Dimensionality of posttraumatic stress dis-
order symptoms in children exposed to disaster: results from confirmatory fac-
tor analyses. J Abnorm Psychol. 1999;108:326-336.
39. Scheeringa MS, Peebles CD, Cook CA, Zeanah CH. Toward establishing proce-
dural, criterion, and discriminant validity for PTSD in early childhood. J Am Acad
Child Adolesc Psychiatry. 2001;40:52-60.
40. Scheeringa MS, Zeanah C, Myers L, Putnam F. New findings on alternative cri-
teria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatry. 2003;
41. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pe-
diatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child
Adolesc Psychiatry. 2002;41:166-173.
42. Kendler KS, Gardner C, Prescott C. Personality and the experience of environ-
mental adversity. Psychol Med. 2003;33:1193-1202.
43. Kendler KS, Kuhn J, Prescott CA. The interrelationship of neuroticism, sex, and
stressful life events in the prediction of episodes of major depression. Am J
Psychiatry. 2004;161:631-636.
44. Bolton D, Hill J, O’Ryan D, Udwin O, Boyle S, Yule W. Long-term effects of psy-
chological trauma on psychosocial functioning. J Child Psychol Psychiatry. 2004;
45. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and develop-
ment of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry.
46. Angold A, Erkanli A, Farmer EMZ, Fairbank JA, Burns BJ, Keeler G, Costello EJ.
Psychiatric disorder, impairment, and service use in rural African American and
white youth. Arch Gen Psychiatry. 2002;59:893-901.
47. Shaffer D, Fisher P, Dulcan MK, Davies M. The NIMH Diagnostic Interview Sched-
ule for Children Version 2.3 (DISC 2.3): description, acceptability, prevalence rates,
and performance in the MECA study: Methods for the Epidemiology of Child and
Adolescent Mental Disorders Study. J Am Acad Child Adolesc Psychiatry. 1996;
48. Lonigan CJ, Anthony JL, Shannon MP. Diagnostic efficacy of posttraumatic symp-
toms in children exposed to disaster. J Clin Child Psychol. 1998;27:255-267.
49. Pynoos RS, Goenjian A, Tashjian M, Karakashian M, Manjikian R, Manoukian G,
Steinberg AM, Fairbanks LA. Post-traumatic stress reactions in children after the
1988 Armenian earthquake. Br J Psychiatry. 1993;163:239-247.
50. Fergusson DM, Horwood LJ, Woodward LJ. The stability of child abuse reports:
a longitudinal study of the reporting behaviour of young adults. Psychol Med.
51. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP. Childhood maltreat-
ment increases risk for personality disorders during early adulthood. Arch Gen
Psychiatry. 1999;56:600-606.
©2007 American Medical Association. All rights reserved.
at Duke University, on June 1, 2007 www.archgenpsychiatry.comDownloaded from
... Trauma or adversity have been common experiences for children in the USA for many years (Finkelhor, 2020;Sacks & Murphey, 2018). More than two-thirds of children report at least one traumatic event or instance of threatened death, serious injury, or sexual violence, by age 16 (Copeland et al., 2007). While most children who experience a traumatic event do not develop symptoms of post-traumatic stress disorder, those who do are at risk for problems related to learning and education, poor physical and mental health, and involvement with the justice system (Grummitt et al., 2021;Larson et al., 2017;Mandavia et al., 2016;Saunders & Adams, 2014). ...
... The high prevalence of trauma and toxic stress in children means that education staff will likely support students coping with these adversities on a regular basis (Copeland et al., 2007;Finkelhor, 2020). Secondary traumatic stress, or the experience of post-traumatic stress symptoms such as anxiety, nightmares, and withdrawal, can result from hearing about students' traumas (Baird & Kracen, 2006), and many school staff members receive limited preparation for dealing with this experience (Caringi et al., 2015;Christian-Brandt et al., 2020;Rankin, 2022;Simon et al., 2022). ...
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The current study analyzed 502 responses from members of the education workforce on the Resilience at Work (RAW) scale and other measures of health and job satisfaction as part of an initiative offering training and technical assistance to support student and staff well-being. A latent profile analysis using scores on components of the RAW identified three resilience profiles: lower, moderate, and higher capacities for resilience. Profiles were differentiated across components related to resilience capacity including alignment of work and personal values, level of social support, and ability to manage stress. Differences between profiles were observed across days of poor physical health, days of poor mental health, days of activity restriction, general health rating, and domains of burnout, compassion satisfaction, and secondary traumatic stress. These findings reinforce calls to support the education workforce through changes that allow access to meaningful work, an evaluation of demands including workload, relevant training on emotional wellness, positive experiences, connections with others, and stress management.
... Finally, this study advances existing knowledge by exploring the link between supervision approaches with clinicians' delivery of TF-CBT, an EBT for posttraumatic stress, depression and disruptive behaviors among children exposed to traumatic events (20,21). Trauma exposure is pervasive among youth, with nearly two-thirds of children in the United States experiencing a traumatic event before adulthood (22,23). Treatment for trauma-exposed youth in routine practice settings often lack key evidence-based elements, notably the proportion of traumaexposed youth receiving exposure has ranged from 14−22% (24). ...
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Objective Observational studies of practices used in clinical supervision-as-usual can be leveraged to advance the limited research on workplace-based supervision as an evidence-based treatment (EBT) implementation strategy. This exploratory observational study examined the presence of supervision approaches (comprised of supervision techniques) and whether these predicted clinicians’ EBT technique delivery. Methods Participants included 28 supervisors, 70 clinician supervisees, and 60 youth clients and guardians from 17 public mental health organizations. Data included audio recorded supervision-as-usual sessions over 1 year, audio recorded Trauma-focused Cognitive Behavioral Therapy (TF-CBT) treatment sessions with youth for 6 months, and youth-reported post-traumatic stress severity scores. Audio recordings of 438 supervision sessions were coded for session duration and the presence of 13 supervision techniques and intensity of their coverage. Audio recordings of 465 treatment sessions were coded for presence and intensity of coverage of TF-CBT practice elements. Agglomerative hierarchical cluster analysis examined the presence of clusters of supervision technique use, termed supervision approaches. Generalized estimating equations estimated the relation between supervision approaches and delivery of TF-CBT elements. Results Two supervision approaches were identified– Supportive – Directive and Supportive – that discriminated between use of five supervision techniques. Clinicians who received a higher proportion of supportive – directive supervision sessions had greater odds of delivering the trauma narrative with a client. Conclusion Findings suggest that patterns of supervision techniques can be identified and may shape EBT delivery. Supervision approaches show some evidence of being tailored to individual clinicians. Implications for the development of supervision implementation strategies and future directions are discussed.
... Many children and adolescents will experience a potentially traumatic event before reaching adulthood, with two thirds of children reporting exposure to at least one traumatic event by age 16 (Copeland et al., 2007;McLaughlin et al., 2013;SAMHSA, 2022). Such events include child abuse and neglect, witnessing domestic violence, homelessness, community or school violence, natural disasters, or medical trauma. ...
Objective Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment to reduce child disruptive behaviors and has been used for children with co-occurring posttraumatic stress symptoms (PTS). However, many families are faced with barriers that interfere with treatment completion. Engagement and attrition issues remain a continuous concern for families accessing needed services for youth. Furthermore, these issues are exacerbated for children in foster care. Methods The present study explored differences in behavioral outcomes and graduation rates for children in foster care, (n = 206), non-foster care children with a history of trauma (n = 249), and non-foster care children without a history of trauma (n = 1,522) who participated in PCIT. Data was collected in community mental health agencies across the state of Oregon. Results There was a significant decrease in caregiver reported disruptive behavior scores for all groups following PCIT. There were no significant differences found in graduation rates and average number of sessions attended between the groups; however, the graduation rate for this sample was low (17.8%). Conclusions Results demonstrate that PCIT can be similarly effective in reducing problematic behaviors for children placed in foster care when compared to children not in foster care. Practical Implications: Given the low graduation rate, is imperative that we continue to investigate strategies to enhance treatment engagement and reduce barriers to services.
... İnsanlık tarihi kadar eskiye dayanan çocukluk çağı travması, bireyin 18 yaşından önce maruz kaldığı ve ruh sağlığı üzerinde olumsuz etkileri olan olaylar olarak tanımlanmaktadır (Herman, 2011). Amerika'da yapılan bir çalışmada çocukların üçte ikisinden çoğunun 16 yaşından önce en az bir travmatik olaya maruz kaldığı ve bu çocuklardan %13.4'ünün travma sonrası stres bozukluğu semptomlarından (TSSB) bazılarını geliştirdiği bulunmuştur (Copeland, Keeler, Angold ve Costello, 2007). 96 ülkeden toplanan 38 raporun incelendiği bir araştırmada yaşları 2-17 arasında olan yaklaşık 2 milyar çocuktan en az 1.4 milyardan fazlasının bir önceki yıl fiziksel, duygusal ya da cinsel istismara maruz kaldığı tespit edilmiştir (Hillis, Mercy, Amobi ve Kress, 2016). ...
Bu araştırmanın amaçlarından biri ebeveynlerdeki çocukluk çağı travma yaygınlığını belirlemektir. Çocukluk çağı travmasına maruz kalan ebeveynlerin sağlıklı aile-ebeveyn olmadaki risk faktörlerini incelemek ise diğer amaçtır. Çalışmanın örneklemini, kolay örnekleme yöntemiyle ulaşılan 5-17 yaş aralığında çocuğu olan 411 ebeveyn (314 anne, 97 baba) oluşturmuştur. Katılımcılara Demografik Bilgi Formu, Çocukluk Çağı Travmaları Ölçeği (ÇÇTÖ) ve Sağlıklı Aile Ebeveynlik Envanteri (SAEE) çevrimiçi ortamda uygulanmıştır. Araştırma verilerinin analizinde frekans analizi ve Pearson ki-kare testi kullanılmıştır. Bulgulara göre ebeveynlerin ihmale/istismara uğrama oranları %6.8 ile %16.3 arasında değişmektedir. Duygusal ihmale maruz kalan ebeveynlerle duygusal ihmale maruz kalmayan ebeveynler arasında SAEE’nin tüm alt boyutlarında anlamlı farklılık saptanmıştır. Ayrıca tüm ihmal ve istismar türlerinde SAEE’nin depresyon ve rol memnuniyeti alt boyutlarında fark olduğu tespit edilmiştir. Sonuç olarak, çocukluk çağı travmalarının bireylerin hayatını etkilediği, bu etkinin ebeveynlik rolüne de yansıdığı görülmektedir. Bu deneyimlerin nesilden nesile aktarıldığı düşünüldüğünde ailelerle çalışan uzmanların çocukluk çağı travmalarını gözardı etmemesi gerekir.
... This is because children and adolescents who have experienced trauma are more likely to show aggression and defiance at school, and therefore are more likely to face suspension and expulsion from school (Perfect et al. 2016). Research has shown that two-thirds of children and adolescents experience at least one traumatic event before 18 years of age (Copeland et al. 2007), and that these young people are at greater risk of academic, social, emotional, and behavioural issues in childhood and adolescence, and disadvantage and mental and physical disability in adulthood (Kezelman et al. 2015). Children and adolescents who have experienced a traumatic event, or multiple traumatic events, are more likely to have dysregulated physiological, psychological, and behavioural reactions towards figures of authority, including teachers, and when exposed to unfamiliar situations or people (Porges 2011;Rotenberg and McGrath 2016). ...
This chapter intends to present a new and novel perspective on inclusion and argue that inclusion can never be truly achieved without the presence of belonging. Both belonging and inclusion are linked to positive academic outcomes and general well-being of students. Belonging is described as a subjective and dynamic feeling while the definition of inclusion varies among different discourses. The aim of this chapter is to discuss the role of belonging to inclusion particularly among marginalised populations and groups. It highlights the usefulness of assessing an individual’s belonging as a true measure for inclusion and its importance as a social and ethical obligation. This chapter further explains that belonging is a vital component to inclusion, equity, and diversity. The chapter concludes with a conceptual model that has implications for future discourse and research.
... 6,8 By contrast, focusing on childhood trauma, Copeland and colleagues reported effect sizes 3 times the size of those found in the current study in a sample of US youth. 7 Nevertheless, the current study based on prospective data from a middle-income country demonstrates the importance of trauma exposure for understanding child psychopathology. ...
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Background Childhood trauma is a proposed transdiagnostic risk factor for psychopathology, but epidemiological evidence from low-income and middle-income countries (LMICs) is scarce. We investigated associations between trauma and child psychiatric disorders in a birth cohort in Brazil. Methods The 2004 Pelotas Birth Cohort is an ongoing, population-based, prospective birth cohort, including all hospital births occurring between Jan 1 and Dec 31, 2004, in the city of Pelotas, Brazil. When the children were aged 6 and 11 years, trained psychologists administered the Development and Well-Being Assessment clinical interview to caregivers to assess current child psychiatric disorders (anxiety disorders, mood disorders, ADHD and hyperactivity disorders, and conduct and oppositional disorders), and lifetime trauma exposure (ie, experiencing or witnessing life-threatening events) including interpersonal and non-interpersonal events. Analyses used multiple imputation and logistic regression models. Outcomes Of 4263 live births, 4231 children were included in the study sample, and 4229 (2195 [51·9%] boys and 2034 [48·1%] girls; 2581 [61·7%] with White mothers and 1600 [38·3%] with Black or mixed race mothers) were included in the imputed analyses. 1154 (34·3%) of 3367 children with complete data at age 11 years had been exposed to trauma by that age. After adjusting for confounders, at age 6 years, trauma was associated with increased odds of anxiety disorders (adjusted odds ratio 1·79 [95% CI 1·33–2·42]) and any psychiatric disorder (1·59 [1·22–2·06]), and at age 11 years, with any psychiatric disorder (1·45 [1·17–1·79]) and all four specific diagnostic classes of anxiety disorders (1·47 [1·04–2·09]), mood disorders (1·66 [1·08–2·55]), ADHD and hyperactivity disorders (1·47 [1·01–2·13]), and conduct and oppositional disorders (1·76 [1·19–2·61]). Interpersonal trauma and non-interpersonal trauma were each associated with increased odds of multiple psychiatric disorders, even when adjusting for their co-occurrence. Interpretation A considerable mental health burden associated with childhood trauma is already evident by middle childhood in this sample from Brazil. Evidence-based efforts to reduce the incidence of childhood trauma in Brazil and address its consequences are urgently needed. Funding Children's Pastorate, WHO, National Support Program for Centres of Excellence, Brazilian National Research Council, Brazilian Ministry of Health, São Paulo Research Foundation, University of Bath, Wellcome Trust. Translation For the Portuguese translation of the abstract see Supplementary Materials section.
Introduction : La Haute Autorité de santé (HAS) a publié une note de cadrage sur l’évaluation et la prise en charge des syndromes psychotraumatiques des enfants et des adultes. Cet écrit démontre l’enjeu majeur de santé publique pour lequel médecins libéraux, services de pédiatrie, de psychiatrie doivent être sensibilisés et impliqués. Bien que non cités par la HAS, les services de Protection maternelle et infantile (PMI), croisement du médical dans le champ de la périnatalité, du médicosocial et de la protection de l’enfance font partie de ces acteurs potentiels. Objectifs : L’objectif principal de cette étude est d’explorer le rôle que peuvent prendre les professionnels de santé exerçant en PMI dans la prévention, le repérage et l’orientation des syndromes psychotraumatiques afin de dégager des pistes d’amélioration sur ces trois champs. Méthode : Il s’agit d’une étude descriptive réalisée par voie numérique sur 164 professionnels de santé exerçant en PMI au Conseil départemental de l’Hérault. Résultats : La quasi-totalité des professionnels de santé perçoit l’importance de la psychotraumatologie en PMI, la très grande majorité perçoit avoir un rôle, que ce soit en termes de prévention, de repérage et d’orientation, tout en estimant avoir un niveau de maîtrise insuffisant du sujet justifiant des actions de formation et une meilleure connaissance des réseaux de prise en charge. Conclusion : Notre étude montre que la PMI représente bien un levier potentiel de première ligne dans la prévention, le repérage et l’orientation des syndromes psychotraumatiques à condition qu’elle soit outillée par de la formation et un réseau adapté.
New insights into the molecular biology of childhood leukemias have stimulated numerous advances in diagnostic methods, strategies for risk assessment and the development of novel therapy for genetic subtypes of the diseases. Fully revised and updated, this new edition of Childhood Leukemias provides the most comprehensive, clinically-oriented and authoritative reference dedicated to these diseases. Beginning with an overview of history, cell biology, and pathology, subsequent chapters review approaches in the evaluation and management of specific leukemias, new therapeutic development and the unique pharmacodynamics and pharmacogenetics of individual patients. New chapters include epigenetics of leukemias, leukemias in patients with Down syndrome and leukemia in adolescents and young adults. The final section covers the complications associated with the disease or its treatment and supportive care during and after treatment. Authored by leading experts, this is a 'must-have' for any physician or investigator who deals with leukemias in childhood.
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Factor analytic studies of trauma victims' posttraumatic stress disorder(PTSD) have offered conflicting hypotheses about how to conceptualize PTSD into symptom categories. The present study used confirmatory factor analyses of self-reported PTSD symptomatology from 5,664 child and adolescent victims of Hurricane Hugo to compare 10 models of PTSD dimensionality. PTSD was best represented by a 2nd-order PTSD factor that manifests in 3 symptom clusters (Intrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal). This model was cross-validated on 3 age groups (late childhood, early adolescence, and late adolescence), and results indicated factorial invariance across groups. PTSD symptoms varied in relative centrality to the underlying dimensions of PTSD, which differed in their relations with anxiety and degree of traumatic exposure. Implications for classification criteria and an empirically supported theory of PTSD are discussed.
This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder. Major recommendations include the use of clinical interviewing with specific questioning about posttraumatic stress symptoms to diagnose this disorder; recognition of developmental considerations that may impact on how posttraumatic stress disorder symptoms manifest in children; and the use of trauma-focused treatment interventions. Limitations and controversies regarding the present state of knowledge in the area of childhood posttraumatic stress disorder are also discussed.
The authors used an integrative conceptual model to examine the emergence of posttraumatic stress disorder (PTSD) symptoms in 568 elementary school-age children 3 months after Hurricane Andrew. The model included 4 primary factors: Exposure to Traumatic Events, Child Characteristics, Access to Social Support, and Children's Coping. Overall, 62% of the variance in children's self-reported PTSD symptoms was accounted for by the 4 primary factors, and each factor improved overall prediction of symptoms when entered in the analyses in the order specified by the conceptual model. The findings suggest that the conceptual model may be helpful to organize research and intervention efforts in the wake of natural disasters.
Using data from a study with prospective-cohorts design in which children who were physically abused, sexually abused, or neglected about 20 years ago were followed up along with a matched control group, accuracy of adult recollections of childhood physical abuse was assessed. Two hour in-person interviews were conducted in young adulthood with 1,196 of the original 1,575 participants. Two measures (including the Conflict Tactics Scale) were used to assess histories of childhood physical abuse. Results indicate good discriminant validity and predictive efficiency of the self-report measures, despite substantial underreporting by physically abused respondents. Tests of construct validity reveal shared method variance, with self-report measures predicting self-reported violence and official reports of physical abuse predicting arrests for violence. Findings are discussed in the context of other research on the accuracy of adult recollections of childhood experiences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Replies to the article by D. B. Grusky and R. M. Hauser (see record 1985-01026-001) and suggests that the likelihood-ratio test is ill-suited to the task of model selection, especially in large sample situations. An alternative statistical procedure (posterior odds) is proposed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)