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Parental Anxiety Best Predictor of Outcomes in Children Exposed to Trauma

Jill Stein

July 9, 2009 (Paris, France) — A parental history of anxiety disorders is the best predictor of the development and persistence of posttraumatic stress disorder (PTSD) in children and adolescents who have undergone a traumatic event, according to data presented here at the 9th World Congress of Biological Psychiatry.

"Children and teenagers in whom 1 or both parents have a history of anxiety may be most vulnerable to PTSD,” said Ruby Castilla-Puentes, MD, DrPH, who has dual appointments as adjunct professor of psychiatry at the University of North Carolina, in Chapel Hill, and the University of Pennsylvania, in Philadelphia.

"In fact, our data showed that children with a parental history of anxiety disorders were 3 times as likely to have PTSD symptoms at 1 month and 2 times as likely to have symptoms that persisted at 5 years as children without a parental history of any anxiety disorder," Dr. Castilla-Puentes told Medscape Psychiatry.

She added that while some children and teenagers spontaneously recover from PTSD over time, the results suggest that victims with a parental history of anxiety disorders, including generalized anxiety disorders, obsessive-compulsive disorders, PTSD, and phobias, may deserve special attention from mental-health professionals, since they may be at heightened risk for developing PTSD after traumatic experiences.

Parents with an anxiety history should also undergo psychiatric evaluation and treatment, she said.

Mass Shooting

Dr. Castilla-Puentes and her colleagues examined PTSD symptoms in a cohort of 293 children and teenagers 1 month and 5 years after a traumatic exposure.

All participants in the study had witnessed a mass shooting by gunmen on motorcycles in a busy park in a small Colombian rural town. The shooting resulted in 2 deaths.

The main outcome measures were the change in PTSD symptoms and the change in anxiety (analyzed separately) between the 1-month and 5-year follow-up periods.

The presence of PTSD was documented during interviews by the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime version (K-SADS-PL). Anxiety levels in the children were evaluated using a cutoff score of 25 or more on the Screen for Child Anxiety-Related Emotional Disorders (SCARED) scale.

The investigators also collected data on subjects' family history of anxiety disorders. Children had a mean age of 13.2 years and a mean 7.2 years of school prior to the traumatic event.

Results showed that the most frequently endorsed symptom on both interviews was intrusive recollections, reported by 82% of participants. Other common symptoms were exaggerated startle reflex and insomnia, occurring in 76% and 74% of patients, respectively.

Barriers to Care

Overall, symptoms of PTSD and anxiety levels decreased significantly over time — 32.8% and 24.6% children had PTSD at 1 month and 5 years, respectively. Also, 82.6% of all subjects had anxiety on the SCARED scale at 1 month, and 62.4% had anxiety at 5 years.

Further analysis revealed that SCARED scores and PTSD symptoms were positively correlated in both the acute phase and at long-term follow-up.

A parental history of anxiety disorders was significantly associated with PTSD symptoms for children 1 month postincident (n = 293) and at 5 years (n = 261) (adjusted odds ratio, 3.6; 95% CI, 2.3 – 5.4; and adjusted odds ratio, 2.6; 95% CI, 1.0 – 3.7; P <.05, respectively).

Dr. Castilla-Puentes emphasized that parental anxiety makes children more vulnerable, thereby producing persistent PTSD symptoms. Factors that provide structure, predictability, and a sense of safety decrease vulnerability.

Finally, she said that even though the study was conducted in a small community in Colombia, the results can probably be extrapolated to other settings. "Children are exposed to trauma worldwide, and there will always be parents with an anxiety disorder," she said.

Notably, in the community where her study was conducted, neither the parents nor the children received mental-health interventions. In many communities worldwide, there are cultural barriers to psychiatric interventions, and psychiatric interventions are sometimes unavailable because of scarce resources. "It is important that communities overcome these obstacles," Dr. Castilla-Puentes said.

Effective Treatment

Session chair Pierre Thomas, MD, professor of psychiatry at the University of Lille, in France, told Medscape Psychiatry that the study "addresses an important topic, given scant information in the literature on the impact of PTSD in children."

He also echoed Dr. Castilla-Puentes's comments about the importance of overcoming cultural barriers to treatment and cited as an example Sierra Leone, where nongovernmental organization–sponsored treatment programs have been extremely helpful for child soldiers, who have an unusually high prevalence of PTSD. "Importantly, about 50% of child soldiers had PTSD at the start of the various programs vs about 10% a year later," he said.

In Sierra Leone, the government also undertook rigorous efforts "not to exclude" child soldiers from normal life and instead accorded them with ex-combatant status. "This meant that the child victims received all the benefits as well as the community respect given to ex-combatants, which turned out to be pivotal in treatment success," said Dr. Thomas.

Dr. Castilla-Puentes works as director of benefit/risk management with Johnson & Johnson Pharmaceutical Research and Development but had no financial disclosures associated with this study. Dr. Thomas had no relevant financial disclosures.

9th World Congress of Biological Psychiatry: Abstract FC-31-001. Presented July 2, 2009.