Negative Trauma Appraisals and PTSD Symptoms in Sri Lankan Adolescents

Negative Trauma Appraisals and PTSD Symptoms in Sri Lankan Adolescents Thyagi Ponnamperuma 0 Nancy A. Nicolson 0 0 T. Ponnamperuma Department of Community Medicine, Faculty of Medicine, University of Ruhuna , Matara , Sri Lanka 1 ) Department of Psychiatry & Psychology, School for Mental Health and Neuroscience, Maastricht University , Box 616, 6200 MD Maastricht , The Netherlands The cognitive model posits that negative appraisals play an important role in posttraumatic stress disorder, in children as well as in adults. This study examined correlates of negative appraisals in relation to trauma exposure and their relationship to posttraumatic stress symptoms (PTSS) in 414 Sri Lankan adolescents, aged 12 to 16, living in areas impacted in varying degrees by the 2004 tsunami. In 2008, participants completed measures of negative appraisals, lifetime traumatic events, posttraumatic stress symptoms, internalizing symptoms, ongoing adversity, and social support. The majority (70 %) of the participants reported multiple traumatic events; 25 % met DSM-IV criteria for full or partial PTSD. Adolescents who had experienced more severe events, abusive events, greater cumulative trauma, or greater current adversity reported more negative appraisals. In regression analyses controlling for known risk factors such as female gender, cumulative trauma, ongoing adversity, and low social support, negative appraisals were the best predictor of PTSS, explaining 22 % of the variance. This relationship appeared specific to PTSS, as negative appraisals did not predict internalizing symptoms. Findings confirm the link between negative cognitions concerning traumatic events and persistent PTSS in adolescents, but longitudinal studies are needed to determine whether appraisals contribute to symptom maintenance over time. PTSD; Negative appraisals; Cognitive model; Adolescents; Disaster; Internalizing symptoms - Traumatic experiences are common in the general population, but only a minority of exposed individuals develops traumarelated psychopathologies such as posttraumatic stress disorder (PTSD; Kessler et al. 1995). Of those who do develop PTSD, many recover within a few months, whereas others experience debilitating symptoms for years. The cognitive model, as formulated by (Ehlers and Clark 2000), posits that PTSD symptoms arise and are maintained when an individual processes the traumatic event in a way that leads to sense of current threat and subsequent anxiety. Maladaptive behavior and cognitive strategies result in temporary relief, but this prevents changes in negative appraisals and memory, thereby leading to persistent symptoms. Research, including a number of studies with prospective, longitudinal designs (Dunmore et al. 2001; Ehring et al. 2006), has provided empirical support for this model in adults. Results have demonstrated that negative appraisals of the trauma and its sequelae independently predicted long-term PTSD, over and above the initial symptom level. The cognitive model has been extended from adults to children and adolescents, taking possible developmental changes in how children encode and resolve trauma memories into consideration (Dalgleish et al. 2005; Meiser-Stedman 2002; Salmon and Bryant 2002). Similarly to adults, children may interpret traumatic experiences and subsequent symptoms (for example, intrusive thoughts and images) as evidence of personal weakness or permanent damage, and of the world as a dangerous place. Such maladaptive cognitions maintain a sense of ongoing threat and can thus lead to persistent PTSD symptoms, long after the traumatic event. Understanding the process by which negative appraisals arise and exacerbate PTSD symptoms is also key to designing effective interventions in children and adolescents. Previous research has shown that cognitive behavioral therapy leads to clinical improvement in childhood PTSD primarily through changing maladaptive appraisals (Dalgleish et al. 2005; Smith et al. 2007). Surprisingly little appears to be known about individual characteristics or features of traumatic experiences that increase the probability that a trauma-exposed child will develop negative cognitions concerning self and the world. Demographic characteristics such as gender and age, for example, might be relevant. In one study of children aged 713 years, younger children were more likely than older children to display maladaptive appraisals, as measured with the Childrens Posttraumatic Cognitions Inventory (CPTCI), 14 weeks after hospital admission for a traumatic injury (Salmon et al. 2007). In contrast, a validation study found no age differences on CPTCI total or subscale scores in a larger (n=563) sample aged 6-18 years (Meiser-Stedman et al. 2009b). Given that female adolescents show a greater tendency to ruminate in response to stressful events (Trickey et al. 2012), one might expect more negative cognitive appraisals in girls. However, it appears that few studies have specifically examined gender differences in appraisals in this age group. One study reported higher CPTCI total scores in girls compared to boys (MeiserStedman et al. 2009b), whereas other findings suggest that gender is only weakly associated with trauma appraisals (Stallard and Smith 2007). The relationship of trauma characteristics to negative appraisals is also largely unexplored. There is some evidence that more severe or life-threatening traumas are associated with more negative cognitions. For example, motor vehicle accident (MVA) victims who described their injuries as more severe displayed more negative appraisals (Tierens et al. 2012). Different types of traumatic experiences are thought to be more or less likely to give rise to negative appraisals, but here again there appear to be limited data. The vast majority of studies in children and adolescents have focused on single-incident trauma (most commonly motor vehicle and other accidents), with fewer investigations of longer-term exposures, for example to sexual or physical abuse. Events that affect large groups, like natural disasters or war, may be appraised differently than those affecting individuals; intentional acts of interpersonal violence may be interpreted more negatively than natural disasters or accidents (Bryant and Guthrie 2005; Meiser-Stedman et al. 2009b; Trickey et al. 2012). To our knowledge, only a handful of studies, in adults, have directly compared the effects of different types of trauma on either negative appraisals or psychopathological outcomes. In comparing accidents, disasters, assaults (both sexual and non-sexual), and life-threatening illness, a study among Chinese young adults found the highest PTCI total scores in assault victims (Su and Chen 2008). Grimm et al. (2012) compared adults responses to events ranging from terrorist attacks, floods, fire, and building collapse, concluding that sudden, violent events may lead to more negative cognitive processes than events (lik (...truncated)