Transcript Focus on Childhood and Adolescent Are Beslan*s Children

 Focus on Childhood and Adolescent Mental Health
Are Beslan’s Children Learning to Cope?
A 3 Year Prospective Study of Youths
Exposed to Terrorism
Ughetta Moscardino. PhD; Sarah Scrimin PhD; Fabia Capello, MA; &
Gianmarco Altoe, MS
 Focus on Childhood and Adolescent Mental Health
Treatment of Posttraumatic Stress
Disorder in Postwar Kosovar Adolescents
Using Mind-Body Skills Groups:
A Randomized Controlled Trial (RTC)
James S. Gordon, M.D.; Julie K. Staples, PhD.; Afrim Blyta, M.D.;
PhD.; Murat Bytyqi, B.A.; & Amy T. Wilson, PhD.
Posttraumatic Stress Disorder (PTSD)
 Post-traumatic stress disorder (PTSD) is a mental health
condition that's triggered by a terrifying event — either
experiencing it or witnessing it.

Symptoms may include flashbacks, nightmares and severe anxiety,
as well as uncontrollable thoughts about the event.
 In 2013, the American Psychiatric Association revised the
PTSD diagnostic criteria in the fifth edition of its
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5)
 The criteria below are specific to adults, adolescents, and
children older than six years.
Diagnostic Criteria for PTSD
 A history of exposure to a traumatic event
 That meets specific stipulations and symptoms from each of
four symptom clusters:
Intrusion
 Avoidance
 Negative alterations in cognitions and mood
 Alterations in arousal and reactivity




The 6th criterion concerns duration of symptoms
The 7th assesses functioning
The 8th criterion clarifies symptoms as not attributable to a
substance or co-occurring medical condition.
Criterion A: Stressor
 The person was exposed to: death, threatened death,
actual or threatened serious injury, or actual or
threatened sexual violence, as follows: (one required)



Direct exposure.
Witnessing, in person.
Indirectly: by learning that a close relative or close friend was
exposed to trauma.


If the event involved actual or threatened death, it must have been
violent or accidental.
Repeated or extreme indirect exposure to aversive details of the
event(s), usually in the course of professional duties
(e.g., first responders, collecting body parts; professionals repeatedly
exposed to details of child abuse).
 This does not include indirect non-professional exposure through
electronic media, television, movies, or pictures.

Criterion B: Intrusion Symptoms
 The traumatic event is persistently re-experienced in the
following way(s): (one required)

Recurrent, involuntary, and intrusive memories.


Traumatic nightmares.



Note: Children may have frightening dreams without content related
to the trauma(s).
Dissociative reactions (e.g., flashbacks) which may occur on a
continuum from brief episodes to complete loss of consciousness.


Note: Children older than six may express this symptom in repetitive
play.
Note: Children may reenact the event in play.
Intense or prolonged distress after exposure to traumatic reminders.
Marked physiologic reactivity after exposure to trauma-related
stimuli.
Criterion C: Avoidance
 Persistent effortful avoidance of distressing trauma-
related stimuli after the event: (one required)

Trauma-related thoughts or feelings.

Trauma-related external reminders (e.g., people, places,
conversations, activities, objects, or situations).
Criterion D: Negative Alterations in Cognitions & Mood
 Negative alterations in cognitions and mood that began or
worsened after the traumatic event: (two required)

Inability to recall key features of the traumatic event


Persistent (and often distorted) negative beliefs and expectations about
oneself or the world




(e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others


(e.g., "I am bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic
event or for resulting consequences.
Persistent negative trauma-related emotions


(usually dissociative amnesia; not due to head injury, alcohol, or drugs).
(e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
Criterion E: Alterations in Arousal & Reactivity
 Trauma-related alterations in arousal and reactivity
that began or worsened after the traumatic event:
(two required)


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
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Irritable or aggressive behavior
Self-destructive or reckless behavior
Hyper-vigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
Criterion F, G, & H
 Criterion F: Duration
 Persistence of symptoms (in Criteria B, C, D, and E) for more
than one month.
 Criterion G: Functional Significance
 Significant symptom-related distress or functional impairment

(e.g., social, occupational)
 Criterion H: Exclusion
 Disturbance is not due to medication, substance use, or other
illness.
In both specifications, the full diagnostic criteria for
PTSD must be met for application to be warranted.
Specify If: With Dissociative
Symptoms
 In addition to meeting criteria for
diagnosis, an individual
experiences high levels of either
of the following in reaction to
trauma-related stimuli:
 Depersonalization: experience
of being an outside observer of or
detached from oneself

(e.g., feeling as if "this is not
happening to me" or one were in a
dream).
 De-realization: experience of
unreality, distance, or distortion

(e.g., "things are not real").
Specify If: With Delayed
Expression
 Full diagnosis is not
met until at least six
months after the
trauma(s),

Although onset of
symptoms may occur
immediately.
Level Black: PTSD & The War at Home
https://www.youtube.com/watch?v=-Fc6_aTnRXQ
This is the story of Staff Sgt. Billy Caviness
 A four-tour Army veteran who suffers from severe PTSD
 This story was shot over the course of 2012, chronicling
SSG Caviness' struggles and triumphs at Schofield
Barracks, Hawaii.
 This story is especially relevant in today's Army as we all
attempt to help soldiers with PTSD overcome their
struggle.
 Focus on Childhood and Adolescent Mental Health
Are Beslan’s Children Learning to Cope?
A 3 Year Prospective Study of Youths
Exposed to Terrorism
Ughetta Moscardino. PhD; Sarah Scrimin PhD; Fabia Capello, MA; &
Gianmarco Altoe, MS
Objective
Longitudinal study aimed to assess the course of:


Psychological Symptoms
& Coping Behaviors
 In adolescents directly & indirectly exposed to:
The 2004 terrorist attack in Beslan, Russia
1,300 Children & Adults held hostage for 3 days
Crisis ended in extreme violence with at least 334 hostages
being killed (186 Children)
 Also investigated the role of coping in the development of
posttraumatic stress
Sample = 171
Students
• 89 Girls
•
•
•
•
82 Boys
Aged 14-17
Years
71 (42%) Held
Hostage
100 (58%) Not
At Time 1
(1.5 Years Post-Attack)
 Directly Exposed
 42 Girls
 29 Boys

Mean Age: 15.1 Years (SD = 0.90)
 Indirectly Exposed
 47 Girls
 53 Boys

Mean Age: 15.2 Years (SD = 0.96)
At Time 2 (3 Years Post-Attack)
Constraints imposed by local government:
 Only allowed maximum of 3 classes of adolescents in
small groups
 Classed randomly selected based on teacher’s
availability to collaborate
At Time 2 (3 Years Post-Attack)
62 Students Involved in Assessment
 33 also had participated in the Time 1 Assessment & thus
were included in present study


18 Boys
15 Girls
 48.5% (n=16) were in the school at the time of terrorist
attack (Direct Exposer Group)
 51.5% (n=17) were not (Indirect Exposer Group)
Participants were attending 10th & 11th grade


Mean age = 16 (SD = 0.80)
None of the subjects had received psychological treatment
At Both Time Points
 Adolescents completed a 45-minute battery of
questionnaires assessing:



Psychological Distress
Emotional and Behavioral Problems
Copying strategies

under the supervision of trained clinical psychologists & a
professional interpreter
Measures: Brief Symptom Inventory 18 (BSI 18)
 18-item self-report measuring psychological and
psychiatric problems
 Includes 3 subscales assessing symptoms of:

depression, anxiety, & somatization
 Adolescents indicated how frequently they had been
distressed/bothered by symptoms in the past month
 Using a scale ranging from 0(not at all) to 4(always)
 A global severity index was obtained by summing all
of the scores

With possible scores ranging from 0-72
Measures: Brief Symptom Inventory 18 (BSI 18)
 The questionnaire was translated into Russian for
purposes of the present study

Using the translation-backtranslation method
 The BSI 18 has been widely used with:
 Psychiatric
 Medical
 Community Populations
 Demonstrates good internal consistency and
reliability for adolescent samples
Method: Strength & Difficulties Questionnaire (SDQ)
 25-item self-report measure covering areas of
emotional & behavioral difficulties
 Includes 5 subscales of 5 items each, generating
scores of:
1.
2.
3.
4.
5.

Emotional Symptoms
Conduct Problems
Hyperactivity-inattention
Peer Problems
Prosocial Behavior
Items are rated on a scale ranging from 0 (not true)
to 2 (certainly true)
Method: Strength & Difficulties Questionnaire (SDQ)
 A total difficulty score is obtained by summing all of
the scale scores except the last

With scores ranging from 0-40
 In the present study the total difficulty scale was
used as an index of adolescents’ psychological
adjustment
Method: Brief COPE
 28 self-rating questions
 That yield 14 subscale scores describing a range of theoretically
based coping responses
 Respondents were asked to rate each item:


0 (I haven't been doing this at all) to 3 (I've been doing this a lot)
In relation to how they had been “dealing with stress in (their)
life, including stress related to the terrorist attack” during the
past month
 Scale scores calculated by adding item scores
Method: Brief COPE
 The 14 subscales were aggregated into 3 summary
scales
Active Coping (a = .78 at time 1, a= .60 at time 2)
1.

Included positive reframing, planning, taking action,
acceptance, & humor
Support Coping (a = .66 at time 1, a = .73 at time 2)
2.

Included seeking emotional & instrumental support and seeking
comfort from religion
Avoidant Coping ( a= .69 at time 1, a = .71 at time 2)
3.

Included behavioral disengagement, self-distraction, denial,
self-blame, venting, & substance use
 Is a self-report questionnaire
Method:
University of
California at
Los Angeles
Posttraumatic
Stress Disorder
Reaction Index
for DSM-IV,
Revision 1,
Adolescent
Version
assessing PTSD symptoms in
adolescent populations
 At Time 2: Participants asked to rate
frequency of 22 PTSD symptoms
experienced during the past month

On a 5-point Likert scale

Ranging from 0 (not at all) to 4 (most of
the time)
 A total posttraumatic severity
score was computed as the sum of
the responses to 20 of the 22
items, a = .87
Statistical Analysis
 Changes in scores on the BSI 18, the SDQ, & the Brief
COPE were realized by means of repeated measures
analysis of variance (ANOVAs)


With exposer group and gender as between-subject factors
And time as within-subject factor
 Multiple Regression Analysis:
 To evaluate the extent to which the severity of posttraumatic
symptoms at follow-up we predicted by:

Gender, exposer, & the endorsement of coping strategies between
Time 1 and Time 2
Statistical Analysis: BSI 18 & SDQ Total Scores
 Were stable overtime
 r = 0.53, P = .001
 r = 0.52, P = .002

Respectively
 Variables = significantly associated with
posttraumatic symptoms severity score

(r values ranging from 0.55 to 0.78)
 They were not included in the analysis
Statistical Analysis Continued
 Due to inter-correlations among coping strategies at
both time points

We estimated separate models for each coping strategy at Time
1 & Time 2
 6 Models were calculated
 In each regression model, Time 2 posttraumatic symptoms
were regressed on:
Gender
 Exposer to Terrorist Attack
 & Coping
 In each model, all of the predictor variables were entered
simultaneously in one step

Before Conducting these Analyses…
 Also created:
a) Exposer x Coping Interaction Term
In order to test whether coping moderated the relationship
between exposer & posttraumatic symptoms

Gender x Coping Interaction Term
b)

To examine whether coping moderated the relationship between
gender and posttraumatic symptoms severity scores
 The interaction terms were regressed on the main
outcome variable in each of the 6 regression models

But none of them emerged as a significant predictor

(excluded from subsequent analysis)
• Psychological
Distress
• Emotional &
Behavioral
Difficulties
• & Coping
strategies
1.5 and 3 years after
the terrorist attack
separately for


Directly &
Indirectly
exposed
Boys & Girls
Results: Table 1 Shows the Mean
scores for adolescents’ reported
BSI 18 Psychological Distress Score:
 Found a significant time x exposer interaction


Indirectly exposed group: moderate decrease in psychological
symptoms
Directly exposed group: a marked increase in BSI 18 scores between
Time 1 & Time 2

F1,29 = 4.20, P = .050, np2 = .126)
 Significantly differed as a function of gender

Girls = significantly more psychological symptoms than boys


F1,29 = 5.01, P = .033, np2 = .147)
Interaction between time and gender= Significant

F1,29 = 4.99, P = .033, np2 = .147)
 Overall:


Girls reported similar levels of psychological distress across time
points
Whereas boys became more distressed over time
SDQ Total Difficulties Score
 A marginally significant interaction effect of time
and exposer emerged


Directly Exposed Group: reporting more total difficulties
Indirectly Exposed Group: showed a decrease in SDQ scores
over time
 Significant differences between girls and boys
 Girls scored higher than boys in total difficulties
 Interaction between time & gender = Significant
 Girls = Decrease in emotional and behavioral problems
 Male counterparts = an increase in SDQ total scores between
Time 1 and Time 2
Adolescents’ Endorsement of Coping Strategies
 Interaction between time and exposer = significant for
active coping
 Endorsement of this strategy became:


Less frequent among directly exposed adolescents
More frequent among indirectly exposed counterparts over time
 Significant gender differences:

Boys reporting use of active coping more frequently than females
peers
 Significant time x gender interaction for avoidant coping

Endorsement of this strategy decreased for girls and increased for
boys over the 18 month interval
Coping emerged
as a significant
predictor of
PTSD symptoms
Explained 27% of
the sample
variance in Time
2 posttraumatic
symptoms
(F3,27= 3.25, P= .037)
Table 2 Presents the Regression
Coefficients of the Model
Results Indicate
 Direct Exposer to the traumatic event
AND
 The endorsement of avoidant coping 1.5 years after the
trauma
SIGNIFICANTLY
 Predicted severity of posttraumatic symptoms 3 years
after the attack
Conclusion
Findings highlight the importance of conducting
follow-up studies


To monitor long-term psychological functioning
To screen for adolescents who may need additional referral for
trauma treatment
The long-term detrimental effects of avoidant coping
on youths’ psychological well-being underscore the
need to implement early psycho-educational
interventions

To minimize adverse outcomes and prevent the chronicity of
posttraumatic reactions
 Focus on Childhood and Adolescent Mental Health
Treatment of Posttraumatic Stress
Disorder in Postwar Kosovar Adolescents
Using Mind-Body Skills Groups:
A Randomized Controlled Trial (RTC)
James S. Gordon, M.D.; Julie K. Staples, PhD.; Afrim Blyta, M.D.;
PhD.; Murat Bytyqi, B.A.; & Amy T. Wilson, PhD.
History:
 War in Kosovo began in early 1998
 Fighting, burning of houses, forced expulsion of residents,
murdering, beating, rapes, and systematic massacres of
Albanian civilians
 Continued through June 1999
 Suhareka (fertile agricultural region) particularly hit
hard by the war


90% of homes destroyed
20% of students in Jeta e Re (“New Life”) High School lost 1 or
both parents

Teachers and students were killed
Objective:
 To determine whether participation in a mind-body
skills group


Based on psychological self-care, mind-body techniques, and selfexpression
Decreases symptoms of posttraumatic stress disorder (PTSD)
Method: Participants
 259 Students were screened for eligibility

177 did not meet the inclusion criteria for PTSD according to the
Harvard Trauma Questionnaire (HTQ)
 Required a score of 3 or 4 on at least 1 of the 4 re-
experiencing symptoms (criterion B), at least 3 of the 7
avoidance/numbing symptoms (criterion C), & at least 2
of the 5 arousal symptoms (criterion D)
 Exposer to a traumatic event that involved actual or
threatened death or serious injury (criterion A1)
 And that involved a response of fear, helplessness, or
horror (criterion A2)

Deemed to have been met by all the students in this area
Method
 82 adolescents meet the criteria
 More female students met the criteria than males (40% screened
females, 19% males)
 62 female students & 20 male (aged 14-18, mean age=16.3 years)
 All students agreed to participate in this study
 Study was conducted at the Jeta e Re (“new Life”) High School
in Suhareka from September 2004-May 2005
 Program conducted by high school teachers in consultation
with psychiatrists and psychologists

Included: meditation, guided imagery, & breathing techniques; selfexpression through words, drawings, & movement
 Students were stratified according to gender and randomly
assigned (using random number generation)

List of assigned groups was then given to the teachers who then notified
students on their group assignments
Intervention
The Center for Mind-Body Medicine (CMBM) approach for
this study
 Combines a number of mind-body modalities and a
variety of forms of self-expression


Through the spoken and written word and in drawing and movement
And is offered in a replicable, small-group format in a school setting
 The mind-body skills group was taught by 4 of the
school’s teachers who had been trained by Washington,
D.C. – based faculty of the CMBM
 Teachers were supervised by CMBM’s Kosovo faculty of
psychiatrists and psychologists
 The format is designed to provide a supportive,
nonjudgmental, empathic environment

In which self-expression, sharing, and listening are encouraged, but
discussion of specific traumas are not required
 The mind-body skills group program for students was
held for 2 hours twice per week for 6 weeks (12 sessions
total)

Small group sessions (10 students per group)
 Mind-body techniques taught included:

Guided imagery, relaxation techniques, several forms of meditation,
autogenic training, and biofeedback.
 They were also asked to report in the technique’s success
in helping them to reduce their level of stress
Outline of 12 Sessions
Measures
HTQ: used as the PTSD measure
 Total score= Sum of all 16 item score on a 1-to-4 item
Likert Scale Divided by the total number of items
 Screening score:

Was used as the baseline measure of the first intervention
group and the wait-list control group (first assessment)
 After the first group finished the 12 sessions, another
12-session mind-body skills program was held for
the wait-list control group
 Students in both groups were re-interviewed using
the HTQ at the following time points:
1.
Upon Completion
of 12-session
program by the
first intervention
group (second
assessment)
2.
Upon completion
of the 12-session
program by the
wait-list control
group (third
assessment)
Follow-up was not done
on the control group due
to lack of time remaining
in the school year
Students in both groups were reinterviewed using the HTQ at the
following time points:
Data Analysis
 All analyses were performed using SPSS software, version 14 (SPSS
Inc., Chicago, Ill)
 A mixed model repeated-measures analysis of variance (ANOVA)

Used to measure changes in PTSD scores over time between the intervention
group & the wait-list control group (group x time)
 A 1-way repeated-measures ANOVA with pairwise comparisons
using the Bonferroni method

Was used to measure the changes within each group over time
 Differenced in PTSD symptom clusters were measured using the X2
test for 2 independent samples
 The Cochran Q test was performed

To analyze changes in PTSD symptom clusters over time
 The McNemar test (2-tailed) with Bonferroni correction (adjusted
a=.05/3=0.17)

Was used as a post hoc analysis to determine differences between the assessment
points
Results: PTSD Scores
 Intervention Group: Significantly decreased PTSD scores following
the program


(Second Assessment)
Compared to the control group (F=29.8, df = 1,76;p<.001)
 PTSD scores remained decreased at the 3-month follow-up of the
first intervention group
 The PTSD score at the 3-month follow-up was not significantly
different from PTSD score immediately following the program
(p=.27)

& it remained significantly lower than the baseline score (p<.001)
 The mean change in the PTSD score from the second assessment to
the third assessment was -0.40 (95% CI= -0.57 to -0.23)
 The control group also had significantly reduced PTSD symptom
levels after participating in the program (p<.001)
 The mean change in PTSD score before and after participation in
the program was -0.38 (95% CI = -0.53 to -0.23)
Results: PTSD Symptom Clusters
Following the initial program (second assessment):
 PTSD cluster symptoms of both re-experiencing &
avoidance/numbing were significantly improved in the
intervention group compared to the control group:


Re-experiencing (X2= 10.6, df= 1, p= .001) & avoidance/numbing
(X2= 16.8, df= 78, p<.001)
Phi coefficients were 0.369 & 0.464, respectively

Indicating a medium sixe effect
 There was no significant improvement in arousal
symptoms:

(X2= 1.4, df= 1, p= .24)
Results: PTSD Symptom Clusters Continued
 Significant changes were measured across time for
all 3 PTSD symptom clusters in the first intervention
group:

Re-experiencing (p<.001); avoidance/numbing (p<.001);and
arousal (p<.001)
 There was a significant decrease in all 3 symptom
clusters immediately following participation in the
program (second assessment)
 There was no significant change from the second to
the third assessment in any of the symptom clusters

Indicating that the decrease was maintained at the 3-month
follow-up
Conclusion
This Randomized Control Trial (RCT)
 First to demonstrate success of a therapeutic model for
war-traumatized adolescents with PDSD
 Shows that the mind-body skills group program



Can be led by intensively (but briefly) trained and supervised
schoolteachers
Was effective in reducing levels of PTSD symptoms in wartraumatized high school students in the Suhareka region of Kosovo 5
years after the war ended
Small group participation of self-expression & personal sharing
combined with instructional use of meditative & imaginative mindbody techniques = significant reduction of PTSD symptoms.