Current Trauma Research: A Collaborative Review

Current Trauma Research: A Collaborative Review (This document reflects updates as of December 11, 2023.

For the latest updates, see the working document.)

The following is a working document created for and by the CAFO community. It contains the citations and abstracts of published articles that address current research related to trauma and trauma-informed models of care. Rachel Medefind, Director of the CAFO Institute for Family-Centered Healing & Health, serves as curator for the document, with submissions from researchers and practitioners from across the CAFO community and beyond.

INTRODUCTION Trauma-informed care is an emerging and dynamic field. It is rich in opportunity for fresh exploration, discovery, application, and debate.

Relative to many areas of scientific inquiry, the field and many of its current paradigms are quite young. Post-traumatic Stress Disorder (PTSD) became an official diagnosis in 1980 in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III)1. The Adverse Childhood Experiences (ACE) Study was published in 19982. The language of trauma-informed care began to be used in the years following the ACE Study, became more widely known between 2010-2015, and has increasingly become an expected approach for those serving vulnerable populations3.

1

North, C. S., Surís, A. M., Smith, R. P., & King, R. V. (2016). The evolution of PTSD criteria across editions of DSM. , 28, 3, 28(3), 197-208.

2 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.

3 US Department of Health and Human Services. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach.

As the field of trauma-related research continues to deepen and grow, researchers make significant discoveries on a regular basis, explore new lines of inquiry, and develop fresh means of application. This dynamic environment includes discussion and debate over many compelling questions. The following list includes some of the most consequential questions currently being explored by leading researchers in the field. (Note: Additional questions and respondent research will be added to this document as they emerge in the field.): I.

WHAT ARE THE MECHANISMS THROUGH WHICH CHILDHOOD MALTREATMENT AFFECTS MENTAL HEALTH? The traditional view has been that exposure to child trauma triggers a biological “toxic stress response” that alters brain function and ultimately contributes to psychopathology. Recent findings suggest that psychopathology is more strongly associated with the retrospective recall of childhood trauma (that is, subjective experience) than the actual exposure.

II.

WHAT CAN WE REASONABLY KNOW AND APPLY BASED ON RETROSPECTIVE RESEARCH (SELF-REPORTING), AND WHAT ARE THE LIMITATIONS? Researchers, clinicians, and professionals serving vulnerable populations have assumed that self-reported measures of childhood maltreatment and prospective measures (like official records and current interviews/questionnaires of parents, teachers, children, or other informants) identify similar groups of people. However, current research shows that they represent different populations and, therefore, must be treated differently when assessing for risk and treatment needs.

III.

WHAT OTHER FACTORS MAY CONTRIBUTE TO POOR OUTCOMES ALONGSIDE TRAUMATIC EVENTS? A. TO WHAT EXTENT DO GENETIC DIFFERENCES AND A LACK OF POSITIVE INPUTS CONTRIBUTE TO THE OUTCOMES WE ASSOCIATE WITH TRAUMA? B. WHAT ROLE DO POSITIVE INPUTS PLAY? Early adversity is not only associated with traumatic events but also with genetic risk factors that increase the probability of experiencing or interpreting events as traumatic. Additionally, lack of positive inputs and guidance typically surround early adversity and may account for a significant part of outcomes associated with trauma.

IV.

IT IS CLEAR FROM RESEARCH THAT STRESSORS ARE VITAL FOR HEALTHY GROWTH. HOW DO WE INCORPORATE THE REALITY

THAT ADVERSITY CAN ENABLE GROWTH INTO TRAUMA-INFORMED MODELS? Research focused on post-traumatic growth and resilience reveals that adversity is not only a source of harm but also has the potential to strengthen and grow an individual in ways that are uniquely catalyzed through negative experiences.

V.

DEFINITIONS VARY: WHAT IS TRAUMA? WHAT DO WE MEAN WHEN WE SAY TRAUMA-INFORMED CARE? Clear definitions matter immensely. In order for trauma-informed care research and practices to be effective and not contribute to unintended harm, it will be vital to form increasing clarity and consensus of definitions.

VI.

WHY IS COMPLEX DEVELOPMENTAL TRAUMA NOT YET A DIAGNOSIS? Complex Developmental Trauma or Developmental Trauma Disorder seeks to distinguish post-traumatic stress disorder, which is in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), from early and chronic trauma. Developmental Trauma is not an official diagnosis. Lack of consensus in understanding biological pathways, parameters of the diagnostic process, and treatment options have been part of the challenge.

I.

WHAT ARE THE MECHANISMS THROUGH WHICH CHILDHOOD MALTREATMENT AFFECTS MENTAL HEALTH?

Whitaker, R. C., Dearth-Wesley, T., Gooze, R. A., Becker, B. D., Gallagher, K. C., & McEwen, B. S. (2014). Adverse childhood experiences, dispositional mindfulness, and adult health.

Preventive medicine, 67, 147-153.

ABSTRACT: Objective: To determine whether greater dispositional mindfulness is associated with better adult health across a range of exposures to adverse childhood experiences (ACEs). Methods; In 2012, a web-based survey of 2160 Pennsylvania Head Start staff was conducted. We assessed ACE score (count of eight categories of childhood adversity), dispositional mindfulness (Cognitive and Affective Mindfulness Scale—Revised), and the prevalence of three outcomes: multiple health conditions (≥ 3 of 7 conditions), poor health behavior (≥ 2 of 5 behaviors), and poor health-related quality of life (HRQOL) (≥ 2 of 5 indicators). Results: Respondents were 97% females, and 23% reported ≥ 3 ACEs. The prevalences of multiple health conditions, poor health behavior, and poor HRQOL were 29%, 21%, and 13%, respectively. At each level of ACE exposure, health outcomes were better in those with greater mindfulness. For example, among persons reporting ≥ 3 ACEs, those in the highest quartile of mindfulness had a prevalence of multiple health conditions two-thirds that of those in the lowest quartile (adjusted prevalence ratio (95% confidence interval) = 0.66 (0.51, 0.86)); for those reporting no ACEs, the ratio was 0.62 (0.41, 0.94). Conclusion: Across a range of exposures to ACEs, greater dispositional mindfulness was associated with fewer health conditions, better health behavior, and better HRQOL. Danese, A., & Widom, C. S. (2020). Objective and subjective experiences of child maltreatment and their relationships with psychopathology. Nature human behaviour, 4(8), 811-818.

ABSTRACT: Does psychopathology develop as a function of the objective or subjective experience of childhood maltreatment? To address this question, we studied a unique cohort of 1,196 children with both objective, court-documented evidence of maltreatment and subjective reports of their childhood maltreatment histories made once they reached adulthood, along with extensive psychiatric assessment. We found that, even for severe cases of childhood maltreatment identified through court records, risk of psychopathology linked to objective measures was minimal in the absence of subjective reports. In contrast, risk of psychopathology linked to subjective reports of childhood

maltreatment was high, whether or not the reports were consistent with objective measures. These findings have important implications for how we study the mechanisms through which child maltreatment affects mental health and how we prevent or treat maltreatment-related psychopathology. Interventions for psychopathology associated with childhood maltreatment can benefit from deeper understanding of the subjective experience.

Danese, A., McLaughlin, K. A., Samara, M., & Stover, C. S. (2020). Psychopathology in children exposed to trauma: detection and intervention needed to reduce downstream burden. bmj, 371.

“Although the association between child trauma and psychopathology is well established and likely causal,8 the mechanisms explaining this association are the focus of much current research. The traditional view has been that exposure to child trauma triggers a biological “toxic stress response” that alters brain function and ultimately contributes to psychopathology.9 Recent findings suggest that psychopathology is more strongly associated with the retrospective recall of childhood trauma (that is, subjective experience) than the actual exposure, pointing to psychological mechanisms involving biases in memory, core beliefs, and decision making.10 In contrast, the association between child trauma and cognitive deficits likely emerges from non-causal mechanisms and particularly pre-existing and stable differences in cognitive abilities that are risk factors for exposure to some trauma types.7 Finally, the complex clinical picture likely varies based on particular profiles of risk exposure in individual children, which can include both threats and deprivation (such as neglect or poverty),11 highlighting the importance of dimensional models of risk measurement.”.... “develop accurate prediction models to identify which trauma-exposed children are at greatest risk of developing psychopathology. Pragmatically, risk prediction is generally based on identification of early emotional and behavioural symptoms through screening instruments (such as the Child Revised Impact of Events Scale (CRIES), the Revised Children’s Anxiety and Depression Scale (RCADS), and the Strengths and Difficulties Questionnaire (SDQ)).”

Smith, K. E., & Pollak, S. D. (2021). Social relationships and children’s perceptions of adversity. Child Development Perspectives, 15(4), 228-234.

ABSTRACT: Having sensitive, contingent, and supportive social relationships has been linked to more positive outcomes after experiences of early childhood adversity.

Traditionally, social relationships are construed as moderators that buffer children from the effects of exposure to adverse events. However, recent data support an alternative view: that supportive social relationships influence children’s later outcomes by shaping

their perceptions of safety and stress, regardless of the particular events to which children are exposed. This perspective has implications for understanding vulnerability and resilience in children. “High levels of childhood adversity are associated with a range of negative behavioral, learning, emotion-processing, psychological, and health outcomes across the lifespan. These long-term outcomes appear to be attenuated by the presence of sensitive and supportive relationships early in children’s lives (Gunnar et al., 2015; Jaffee, 2017). Traditionally, scientists have construed early social relationships as a moderator between exposures to events and children’s outcomes. This view suggests that sensitive and supportive relationships buffer the effects of adversity, thereby reducing negative developmental outcomes. These types of theories see the actual events in children’s lives as causal and pathognomonic, or characteristic of disease, with social relationships lessening the effects of negative events on long-term outcomes. An alternative conceptualization is that the presence of sensitive and supportive social relationships influences whether children experience or construe a particular event as being adverse (Smith & Pollak, 2020). In other words, events themselves are not pathognomonic, and biological and psychological responses to adversity do not occur until the child has interpreted their circumstances as being adverse. According to this perspective, the presence of social support may decrease the likelihood that a child construes events as adverse. In this article, we describe the ways in which dimensions of early social relationships, including social support, quality of caregiving relationships, and loneliness, contribute to children’s perceptions of safety. Focusing on the extent to which children perceive themselves as safe, protected, or having the capacity to face a challenge reframes our understanding of how early life stress might affect children’s biobehavioral development. This approach may also aid in elucidating the mechanisms underlying individual differences in children’s developmental outcomes….what meaningfully shapes the perception of stress?”

Suarez-Jimenez, B., Lazarov, A., Such, S., Marohasy, C., Small, S., Wager, T., ... & Neria, Y. (2022). Sequential Fear Generalization and Network Connectivity in Trauma Exposed Humans With and Without Psychopathology.

ABSTRACT: While impaired fear generalization is known to underlie a wide range of psychopathology, the extent to which exposure to trauma by itself results in deficient fear generalization and its neural abnormalities is yet to be studied. Similarly, the neural function of intact fear generalization in people who endured trauma and did not develop significant psychopathology is yet to be characterized. Here, we utilize a generalization fMRI task, and a network connectivity approach to clarify putative behavioral and neural markers of trauma and resilience. The generalization task enables longitudinal assessments of threat discrimination learning. Trauma-exposed participants (TE; N = 62),

compared to healthy controls (HC; N = 26), show lower activity reduction in salience network (SN) and right executive control network (RECN) across the two sequential generalization stages, and worse discrimination learning in SN measured by linear deviation scores (LDS). Comparison of resilient, trauma-exposed healthy control participants (TEHC; N = 31), trauma exposed individuals presenting with psychopathology (TEPG; N = 31), and HC, reveals a resilience signature of network connectivity differences in the RECN during generalization learning measured by LDS. These findings may indicate a trauma exposure phenotype that has the potential to advance the development of innovative treatments by targeting and engaging specific neural dysfunction among trauma-exposed individuals, across different psychopathologies. [Note from R. Medefind: Additional quote from the paper: “Addressing the question of whether trauma exposure is associated with a distinct neural signature across psychopathologies such as those previously listed may advance our understanding of the corresponding neural dysfunction. Yet, efforts to advance knowledge regarding trauma-related neural aberrations have been hampered by adhering to traditional diagnostic systems, such as the Diagnostic and Statistical Manuals of Mental Disorders (DSM)8, neglecting more objective markers including those clarified by brain imaging9. Furthermore, extant research examining neural biomarkers of trauma exposure has focused almost solely on patients with PTSD, limiting our understanding of potential shared mechanisms across psychopathologies versus trauma-exposed healthy controls….To thoroughly elucidate behavioral and neural markers of trauma exposure and resilience, we utilized a generalization/discrimination task previously tested in patients with PD14, GAD25 and PTSD21. These studies show that psychiatric patients, compared to normal controls, exhibit stronger generalization, implicating it as a putative marker of disrupted threat discrimination13,14,15,23,25,26,27. However, no study to date has assessed this neural marker among people exposed to trauma with psychiatric illnesses or among resilient participants who were exposed to trauma, but did not develop any significant psychiatric symptoms. In addition, no study to date has looked at how trauma exposed individuals learn to discriminate between cues over time. Learning to discriminate is an essential process whereby exposure to cues creates different neural representations for each cue. Understanding how these representations are built over time can give us an insight into how psychopathology develops and is maintained and how resilient trauma-exposed counterparts overcome it.”]

Mayer, S. E., Surachman, A., Prather, A. A., Puterman, E., Delucchi, K. L., Irwin, M. R., ... & Epel, E. S. (2022). The long shadow of childhood trauma for depression in midlife: examining daily psychological stress processes as a persistent risk pathway. Psychological medicine, 52(16), 4029-4038.

ABSTRACT: Background Childhood trauma (CT) increases the risk of adult depression.

Buffering effects require an understanding of the underlying persistent risk pathways.

This study examined whether daily psychological stress processes – how an individual interprets and affectively responds to minor everyday events – mediate the effect of CT on adult depressive symptoms. Methods Middle-aged women (N = 183) reported CT at baseline and completed daily diaries of threat appraisals and negative evening affect for 7 days at baseline, 9, and 18 months. Depressive symptoms were measured across the 1.5-year period. Mediation was examined using multilevel structural equation modeling.

Results Reported CT predicted greater depressive symptoms over the 1.5-year time period (estimate = 0.27, S.E. = 0.07, 95% CI 0.15–0.38, p < 0.001). Daily threat appraisals and negative affect mediated the effect of reported CT on depressive symptoms (estimate = 0.34, S.E. = 0.08, 95% CI 0.22–0.46, p < 0.001). Daily threat appraisals explained more than half of this effect (estimate = 0.19, S.E. = 0.07, 95% CI 0.08–0.30, p = 0.004). Post hoc analyses in individuals who reported at least moderate severity of CT showed that lower threat appraisals buffered depressive symptoms. A similar pattern was found in individuals who reported no/low severity of CT. Conclusions A reported history of CT acts as a latent vulnerability, exaggerating threat appraisals of everyday events, which trigger greater negative evening affect – processes that have important mental health consequences and may provide malleable intervention targets. [Note from R. Medefind: Additional quote from the paper: “That CT predicts poorer mental health in general is not new. But determining how, on a daily basis, this is working, is novel. We were able to directly test mediation in our study of daily stress processes. Results showed that greater reported CT predicted elevated depressive symptoms through greater daily threat appraisals and greater daily negative affect. Notably, more than half of this indirect effect on depressive symptoms was explained by how individuals appraised everyday stressors as having a greater negative impact on their lives. Post hoc analyses showed that greater threat appraisals were associated with elevated depressive symptoms in participants who reported at least moderate CT severity; conversely, lower threat appraisals were linked with lower depressive symptoms – to the extent that scores were asymptomatic and comparable to participants who reported no/low CT severity. A similar gradient relationship between threat appraisals and depressive symptoms was also found in participants with no/low reported CT severity. These data suggest that daily threat appraisals constitute a risk and resilience factor for those with and without a reported history of CT and may provide a promising target for depression interventions.”]

II.

WHAT CAN WE REASONABLY KNOW AND APPLY BASED ON RETROSPECTIVE RESEARCH (SELF-REPORTING), AND WHAT ARE THE LIMITATIONS?

Hardt, J., & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. Journal of child psychology and psychiatry, 45(2), 260-273.

ABSTRACT: Background: Influential studies have cast doubt on the validity of retrospective reports by adults of their own adverse experiences in childhood.

Accordingly, many researchers view retrospective reports with scepticism. Method: A computer-based search, supplemented by hand searches, was used to identify studies reported between 1980 and 2001 in which there was a quantified assessment of the validity of retrospective recall of sexual abuse, physical abuse, physical/emotional neglect or family discord, using samples of at least 40. Validity was assessed by means of comparisons with contemporaneous, prospectively obtained, court or clinic or research records; by agreement between retrospective reports of two siblings; and by the examination of possible bias with respect to differences between retrospective and prospective reports in their correlates and consequences. Medium- to long-term reliability of retrospective recall was determined from studies in which the test–retest period extended over at least 6 months. Results: Retrospective reports in adulthood of major adverse experiences in childhood, even when these are of a kind that allow reasonable operationalisation, involve a substantial rate of false negatives, and substantial measurement error. On the other hand, although less easily quantified, false positive reports are probably rare. Several studies have shown some bias in retrospective reports.

However, such bias is not sufficiently great to invalidate retrospective case-control studies of major adversities of an easily defined kind. Nevertheless, the findings suggest that little weight can be placed on the retrospective reports of details of early experiences or on reports of experiences that rely heavily on judgment or interpretation. Conclusion: Retrospective studies have a worthwhile place in research, but further research is needed to examine possible biases in reporting.

Baldwin, J. R., Reuben, A., Newbury, J. B., & Danese, A. (2019). Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis. JAMA psychiatry, 76(6), 584-593.

ABSTRACT: Importance Childhood maltreatment is associated with mental illness.

Researchers, clinicians, and public health professionals use prospective or retrospective measures interchangeably to assess childhood maltreatment, assuming that the 2 measures identify the same individuals. However, this assumption has not been comprehensively tested. Objective To meta-analyze the agreement between prospective and retrospective measures of childhood maltreatment. Data Sources MEDLINE, PsycINFO, Embase, and Sociological Abstracts were searched for peer-reviewed, English-language articles from inception through January 1, 2018. Search terms included child* maltreatment, child* abuse, child* neglect, child bull*, child* trauma, child* advers*, and early life stress combined with prospective* and cohort. Study Selection Studies with prospective measures of childhood maltreatment were first selected. Among the selected studies, those with corresponding retrospective measures of maltreatment were identified. Of 450 studies with prospective measures of childhood maltreatment, 16 had paired retrospective data to compute the Cohen κ coefficient. Data Extraction and Synthesis Multiple investigators independently extracted data according to PRISMA and MOOSE guidelines. Random-effects meta-analyses were used to pool the results and test predictors of heterogeneity. Main Outcomes and Measures The primary outcome was the agreement between prospective and retrospective measures of childhood maltreatment, expressed as a κ coefficient. Moderators of agreement were selected a priori and included the measure used for prospective or retrospective assessment of childhood maltreatment, age at retrospective report, sample size, sex distribution, and study quality. Results Sixteen unique studies including 25 471 unique participants (52.4% female [SD, 10.6%]; mean [SD] age, 30.6 [11.6] years) contained data on the agreement between prospective and retrospective measures of childhood maltreatment. The agreement between prospective and retrospective measures of childhood maltreatment was poor, with κ = 0.19 (95% CI, 0.14-0.24; P < .001). Agreement was higher when retrospective measures of childhood maltreatment were based on interviews rather than questionnaires (Q = 4.1521; df = 1; P = .04) and in studies with smaller samples (Q = 4.2251; df = 1; P = .04). Agreement was not affected by the type of prospective measure used, age at retrospective report, sex distribution of the sample, or study quality.

Conclusions and Relevance Prospective and retrospective measures of childhood maltreatment identify different groups of individuals. Therefore, children identified prospectively as having experienced maltreatment may have different risk pathways to mental illness than adults retrospectively reporting childhood maltreatment. Researchers, clinicians, and public health care professionals should recognize these critical measurement differences when conducting research into childhood maltreatment and developing interventions.

Danese, A. (2020). Annual Research Review: Rethinking childhood trauma‐new research directions for measurement, study design and analytical strategies. Journal of child psychology and psychiatry, 61(3), 236-250.

ABSTRACT: Childhood trauma is a key modifiable risk factor for psychopathology. Despite significant scientific advances, traumatised children still have poorer long-term outcomes than nontraumatised children. New research paradigms are, thus, needed. To this end, the review examines three dominant assumptions about measurement, design and analytical strategies. Current research warns against using prospective and retrospective measures of childhood trauma interchangeably; against interpreting cross-sectional differences in putative mediating mechanisms between adults with or without a history of childhood trauma as evidence of longitudinal changes from pre-trauma conditions; and against directly applying explanatory models of resilience or vulnerability to psychopathology in traumatised children to forecast individual risk in unseen cases. The warnings equally apply to research on broader measures of adverse childhood experiences (ACEs). Further research examining these assumptions can generate new insights on how to prevent childhood trauma and its detrimental effects.

Salganik, M. J., Lundberg, I., Kindel, A. T., Ahearn, C. E., Al-Ghoneim, K., Almaatouq, A., ... & McLanahan, S. (2020). Measuring the predictability of life outcomes with a scientific mass collaboration. Proceedings of the National Academy of Sciences, 117(15), 8398-8403.

ABSTRACT: How predictable are life trajectories? We investigated this question with a scientific mass collaboration using the common task method; 160 teams built predictive models for six life outcomes using data from the Fragile Families and Child Wellbeing Study, a high-quality birth cohort study. Despite using a rich dataset and applying machine-learning methods optimized for prediction, the best predictions were not very accurate and were only slightly better than those from a simple benchmark model. Within each outcome, prediction error was strongly associated with the family being predicted and weakly associated with the technique used to generate the prediction. Overall, these results suggest practical limits to the predictability of life outcomes in some settings and illustrate the value of mass collaborations in the social sciences. Significance Hundreds of researchers attempted to predict six life outcomes, such as a child’s grade point average and whether a family would be evicted from their home. These researchers used machine-learning methods optimized for prediction, and they drew on a vast dataset that was painstakingly collected by social scientists over 15 y. However, no one made very accurate predictions. For policymakers considering using predictive models in settings such as criminal justice and child-protective services, these results raise a number of

concerns. Additionally, researchers must reconcile the idea that they understand life trajectories with the fact that none of the predictions were very accurate.

Baldwin, J. R., Caspi, A., Meehan, A. J., Ambler, A., Arseneault, L., Fisher, H. L., ... & Danese, A. (2021). Population vs individual prediction of poor health from results of adverse childhood experiences screening. JAMA pediatrics, 175(4), 385-393.

ABSTRACT: Importance Adverse childhood experiences (ACEs) are well-established risk factors for health problems in a population. However, it is not known whether screening for ACEs can accurately identify individuals who develop later health problems.

Objective To test the predictive accuracy of ACE screening for later health problems.

Design, Setting, and Participants: This study comprised 2 birth cohorts: the Environmental Risk (E-Risk) Longitudinal Twin Study observed 2232 participants born during the period from 1994 to 1995 until they were aged 18 years (2012-2014); the Dunedin Multidisciplinary Health and Development Study observed 1037 participants born during the period from 1972 to 1973 until they were aged 45 years (2017-2019).

Statistical analysis was performed from May 28, 2018, to July 29, 2020. Exposures: ACEs were measured prospectively in childhood through repeated interviews and observations in both cohorts. ACEs were also measured retrospectively in the Dunedin cohort through interviews at 38 years. Main Outcomes and Measures: Health outcomes were assessed at 18 years in E-Risk and at 45 years in the Dunedin cohort. Mental health problems were assessed through clinical interviews using the Diagnostic Interview Schedule. Physical health problems were assessed through interviews, anthropometric measurements, and blood collection. Results: Of 2232 E-Risk participants, 2009 (1051 girls [52%]) were included in the analysis. Of 1037 Dunedin cohort participants, 918 (460 boys [50%]) were included in the analysis. In E-Risk, children with higher ACE scores had greater risk of later health problems (any mental health problem: relative risk, 1.14 [95% CI, 1.10-1.18] per each additional ACE; any physical health problem: relative risk, 1.09 [95% CI, 1.07-1.12] per each additional ACE). ACE scores were associated with health problems independent of other information typically available to clinicians (ie, sex, socioeconomic disadvantage, and history of health problems). However, ACE scores had poor accuracy in predicting an individual’s risk of later health problems (any mental health problem: area under the receiver operating characteristic curve, 0.58 [95% CI, 0.56-0.61]; any physical health problem: area under the receiver operating characteristic curve, 0.60 [95% CI, 0.58-0.63]; chance prediction: area under the receiver operating characteristic curve, 0.50). Findings were consistent in the Dunedin cohort using both prospective and retrospective ACE measures. Conclusions and Relevance: This study suggests that, although ACE scores can forecast mean group differences in health, they have poor accuracy in predicting an

individual’s risk of later health problems. Therefore, targeting interventions based on ACE screening is likely to be ineffective in preventing poor health outcomes.

Nivison, M. D., Vandell, D. L., Booth-LaForce, C., & Roisman, G. I. (2021). Convergent and discriminant validity of retrospective assessments of the quality of childhood parenting: Prospective evidence from infancy to age 26 years. Psychological Science, 32(5), 721-734.

Abstract: Retrospective self-report assessments of adults’ childhood experiences with their parents are widely employed in psychological science, but such assessments are rarely validated against actual parenting experiences measured during childhood. Here, we leveraged prospectively acquired data characterizing mother–child and father–child relationship quality using observations, parent reports, and child reports covering infancy through adolescence. At age 26 years, approximately 800 participants completed a retrospective measure of maternal and paternal emotional availability during childhood.

Retrospective reports of childhood emotional availability demonstrated weak convergence with composites reflecting prospectively acquired observations (R2s = .01–.05) and parent reports (R2s = .02–.05) of parenting quality. Retrospective parental availability was more strongly associated with prospective assessments of child-reported parenting quality (R2s = .24–.25). However, potential sources of bias (i.e., depressive symptoms and family closeness and cohesiveness at age 26 years) accounted for more variance in retrospective reports (39%–40%) than did prospective measures (26%), suggesting caution when using retrospective reports of childhood caregiving quality as a proxy for prospective data. [Note from R. Medefind: This study draws from a cross-section of the broader population, not only those who experienced early adversity.

It found that differences between the recollections of individuals as adults and the information collected in their childhood were partly explained by current circumstances such as depression and family closeness and cohesiveness. The original 1998 ACE Study is retrospective. Researchers continue to investigate the strong associations between poorer outcomes and ACEs by bringing in longitudinal/prospective data to better understand causal factors and best interventions.]

Berman, I. S., McLaughlin, K. A., Tottenham, N., Godfrey, K., Seeman, T., Loucks, E., ... & Sheridan, M. A. (2022). Measuring early life adversity: A dimensional approach.

Development and psychopathology, 34(2), 499-511.

ABSTRACT: Exposure to adversity in childhood is associated with elevations in numerous physical and mental health outcomes across the life course. The biological embedding of early experience during periods of developmental plasticity is one pathway that contributes to these associations. Dimensional models specify mechanistic pathways

linking different dimensions of adversity to health and well-being outcomes later in life.

While findings from existing studies testing these dimensions have provided promising preliminary support for these models, less agreement exists about how to measure the experiences that comprise each dimension. Here, we review existing approaches to measuring two dimensions of adversity: threat and deprivation. We recommend specific measures for measuring these constructs and, when possible, document when the same measure can be used by different reporters and across the lifespan to maximize the utility with which these recommendations can be applied. Through this approach, we hope to stimulate progress in understanding how particular dimensions of early environmental experience contribute to lifelong health. [Note from R. Medefind: This paper highlights options for measuring the dimensional quality of adversity, presented as an alternative to the common approach to measuring adversity, the cumulative risk measure, which uses discrete numbers without regard for type, timing, severity, or chronicity.]

III.

WHAT OTHER FACTORS MAY CONTRIBUTE TO POOR OUTCOMES ALONGSIDE TRAUMATIC EVENTS? A. TO WHAT EXTENT DO GENETIC DIFFERENCES AND A LACK OF POSITIVE INPUTS CONTRIBUTE TO THE OUTCOMES WE ASSOCIATE WITH TRAUMA?

Danese, A., Moffitt, T. E., Arseneault, L., Bleiberg, B. A., Dinardo, P. B., Gandelman, S. B., ... & Caspi, A. (2017). The origins of cognitive deficits in victimized children: implications for neuroscientists and clinicians. American journal of psychiatry, 174(4), 349-361.

ABSTRACT: Objective: Individuals reporting a history of childhood violence victimization have impaired brain function. However, the clinical significance, reproducibility, and causality of these findings are disputed. The authors used data from two large cohort studies to address these research questions directly. Method: The authors tested the association between prospectively collected measures of childhood violence victimization and cognitive functions in childhood, adolescence, and adulthood among 2,232 members of the U.K. E-Risk Study and 1,037 members of the New Zealand Dunedin Study who were followed up from birth until ages 18 and 38 years, respectively. Multiple measures of victimization and cognition were used, and comparisons were made of cognitive scores for twins discordant for victimization. Results: Individuals exposed to childhood victimization had pervasive impairments in clinically relevant cognitive functions, including general intelligence, executive function, processing speed, memory, perceptual reasoning, and verbal comprehension in adolescence and adulthood. However, the observed cognitive deficits in victimized individuals were largely explained by cognitive deficits that predated childhood victimization and by confounding genetic and environmental risks. Conclusions: Findings from two population-representative birth cohorts totaling more than 3,000 individuals and born 20 years and 20,000 km apart suggest that the association between childhood violence victimization and later cognition is largely noncausal, in contrast to conventional interpretations. These findings support the adoption of a more circumspect approach to causal inference in the neuroscience of stress. Clinically, cognitive deficits should be conceptualized as individual risk factors for victimization as well as potential complicating features during treatment.

King, L., Jolicoeur-Martineau, A., Laplante, D. P., Szekely, E., Levitan, R., & Wazana, A. (2021). Measuring resilience in children: a review of recent literature and recommendations for future research. Current opinion in psychiatry, 34(1), 10-21.

ABSTRACT: Understanding variability in developmental outcomes following exposure to early life adversity (ELA) has been an area of increasing interest in psychiatry, as resilient outcomes are just as prevalent as negative ones. However, resilient individuals are understudied in most cohorts and even when studied, resilience is typically defined as an absence of psychopathology. This review examines current approaches to resilience and proposes more comprehensive and objective ways of defining resilience. Recent findings Of the 36 studies reviewed, the most commonly used measure was the Strengths and Difficulties Questionnaire (n = 6), followed by the Child Behavior Checklist (n = 5), the Resilience Scale for Chinese Adolescents (n = 5), the Rosenberg Self-Esteem Scale (n = 4), and the Child and Youth Resilience Scale (n = 3). Summary This review reveals that studies tend to rely on self-report methods to capture resilience which poses some challenges.

We propose a complementary measure of child resilience that relies on more proactive behavioral and observational indicators; some of our preliminary findings are presented.

Additionally, concerns about the way ELA is characterized as well as the influence of genetics on resilient outcomes prompts further considerations about how to proceed with resiliency research. [Note from R. Medefind: This paper points out that resilience is poorly defined in research and that important factors like genetics (and genetic interaction with the environment) and the choices of the child (prosocial behavior) are rarely considered but recognized to be important contributors.]

Ratanatharathorn, A., Koenen, K. C., Chibnik, L. B., Weisskopf, M. G., Rich-Edwards, J. W., & Roberts, A. L. (2021). Polygenic risk for autism, attention-deficit hyperactivity disorder, schizophrenia, major depressive disorder, and neuroticism is associated with the experience of childhood abuse. Molecular psychiatry, 26(5), 1696-1705.

ABSTRACT: People who experience childhood abuse are at increased risk of mental illness. Twin studies suggest that inherited genetic risk for mental illness may account for some of these associations. Yet, the hypothesis that individuals who have experienced childhood abuse may carry genetic loading for mental illness has never been tested with genetic data. Using polygenic risk scores for six psychiatric disorders—attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), bipolar disorder (BPD), major depressive disorder (MDD), neuroticism, and schizophrenia—we tested whether genetic risk for mental illness was associated with increased risk of experiencing three types of childhood abuse: physical/emotional abuse, physical assault, and sexual abuse, in a cohort of white non-Hispanic women (n = 11,315). ADHD and MDD genetic risk scores were associated with a higher risk of experiencing each type of childhood abuse, while neuroticism, schizophrenia, BPD, and ASD genetic scores were associated with a higher risk of experiencing physical/emotional abuse and physical assault, but not sexual abuse.

Sensitivity analyses examining potential bias from the differential recall of childhood

trauma, parental socioeconomic status, and population stratification were consistent with the main findings. A one-standard-deviation increase in genetic risk for mental illness was associated with a modestly elevated risk of experiencing childhood abuse (OR range: 1.05–1.19). Therefore, inherited genetic risk may partly account for the association of childhood abuse with mental illness. In addition, future treatments for mental illness will benefit from taking into consideration the co-occurrence of childhood trauma and genetic loading.

Peel, A. J., Purves, K. L., Baldwin, J. R., Breen, G., Coleman, J. R., Pingault, J. B., ... & Eley, T. C. (2022). Genetic and early environmental predictors of adulthood self-reports of trauma.

The British Journal of Psychiatry, 221(4), 613-620.

ABSTRACT: Background Retrospective self-reports of childhood trauma are associated with a greater risk of psychopathology in adulthood than prospective measures of trauma.

Heritable reporter characteristics are anticipated to account for part of this association, whereby genetic predisposition to certain traits influences both the likelihood of self-reporting trauma and of developing psychopathology. However, previous research has not considered how gene–environment correlation influences these associations.

Aims To investigate reporter characteristics associated with retrospective self-reports of childhood trauma and whether these associations are accounted for by gene–environment correlation. Method In 3963 unrelated individuals from the Twins Early Development Study, we tested whether polygenic scores for 21 psychiatric, cognitive, anthropometric and personality traits were associated with retrospectively self-reported childhood emotional and physical abuse. To assess the presence of gene–environment correlation, we investigated whether these associations remained after controlling for composite scores of environmental adversity across development.

Results Retrospectively self-reported childhood trauma was associated with polygenic scores for autism spectrum disorder (ASD), body mass index (BMI), post-traumatic stress disorder (PTSD) and risky behaviours. When composite scores of environmental adversity were controlled for, only associations with the polygenic scores for ASD and PTSD remained significant. Conclusions Genetic predisposition to ASD and PTSD may increase liability to experiencing or interpreting events as traumatic. Associations between genetic predisposition for risky behaviour and BMI with self-reported childhood trauma may reflect gene–environment correlation. Studies of the association between retrospectively self-reported childhood trauma and later-life outcomes should consider that genetically influenced reporter characteristics may confound associations, both directly and through gene–environment correlation.

Benca, R. M., Obermeyer, W. H., Thisted, R. A., & Gillin, J. C. (1992). Sleep and psychiatric

disorders: a meta-analysis. Archives of general psychiatry, 49(8), 651-668.

ABSTRACT: We reviewed the literature on sleep in psychiatric disorders and evaluated the data by meta-analysis, a statistical method designed to combine data from different studies. A total of 177 studies with data from 7151 patients and controls were reviewed.

Most psychiatric groups showed significantly reduced sleep efficiency and total sleep time, accounted for by decrements in non-rapid eye movement sleep. Rapid eye movement sleep time was relatively preserved in all groups, and percentage of rapid eye movement sleep was increased in affective disorders. Reduction in rapid eye movement sleep latency was seen in affective disorders but occurred in other categories as well.

Although no single sleep variable appeared to have absolute specificity for any particular psychiatric disorder, patterns of sleep disturbances associated with categories of psychiatric illnesses were observed. Overall, findings for patients with affective disorders differed most frequently and significantly from those for normal controls.

Verburgh, L., Königs, M., Scherder, E. J., & Oosterlaan, J. (2014). Physical exercise and executive functions in preadolescent children, adolescents and young adults: a meta-analysis. British journal of sports medicine, 48(12), 973-979.

ABSTRACT: Purpose The goal of this meta-analysis was to aggregate available empirical studies on the effects of physical exercise on executive functions in preadolescent children (6–12 years of age), adolescents (13–17 years of age) and young adults (18–35 years of age). Method The electronic databases PubMed, EMBASE and SPORTDiscus were searched for relevant studies reporting on the effects of physical exercise on executive functions. Nineteen studies were selected.Results There was a significant overall effect of acute physical exercise on executive functions (d=0.52, 95% CI 0.29 to 0.76, p<0.001).

There were no significant differences between the three age groups (Q (2)=0.13, p=0.94).

Furthermore, no significant overall effect of chronic physical exercise (d=0.14, 95%CI −0.04 to 0.32, p=0.19) on executive functions (Q (1)=5.08, p<0.05) was found.

Meta-analytic effect sizes were calculated for the effects of acute physical exercise on the domain's inhibition/interference control (d=0.46, 95% CI 0.33 to 0.60, p<0.001) and working memory (d=0.05, 95% CI −0.51 to 0.61, p=0.86) as well as for the effects of chronic physical exercise on planning (d=0.16, 95% CI 0.18 to 0.89, p=0.18).

Conclusions Results suggest that acute physical exercise enhances executive functioning.

The number of studies on chronic physical exercise is limited and it should be investigated whether chronic physical exercise shows effects on executive functions comparable to acute physical exercise. This is highly relevant in preadolescent children and adolescents, given the importance of well-developed executive functions for daily life functioning and the current increase in sedentary behaviour in these age groups.

Kandola, A., Lewis, G., Osborn, D. P., Stubbs, B., & Hayes, J. F. (2020). Depressive symptoms and objectively measured physical activity and sedentary behaviour throughout adolescence: a prospective cohort study. The Lancet Psychiatry, 7(3), 262-271.

ABSTRACT: Background Identifying modifiable risk factors is essential to reduce the prevalence adolescent depression. Self-report data suggest that physical activity and sedentary behaviour might be associated with depressive symptoms in adolescents. We examined associations between depressive symptoms and objectively measured physical activity and sedentary behaviour in adolescents. Methods From a population-based cohort of adolescents whose mothers were invited to participate in the Avon Longitudinal Study of Parents and Children (ALSPAC) study, we included participants with at least one accelerometer recording and a Clinical Interview Schedule-Revised (CIS-R) depression score at age 17·8 years (reported as age 18 years hereafter). Amounts of time spent in sedentary behaviour and physical activity (light or moderate-to-vigorous) were measured with accelerometers at around 12 years, 14 years, and 16 years of age. Total physical activity was also recorded as count per minute (CPM), with raw accelerometer counts averaged over 60 s epochs.

Associations between the physical activity and sedentary behaviour variables and depression (CIS-R) scores at age 18 years were analysed with regression and group-based trajectory modelling. Findings 4257 adolescents from the 14 901 enrolled in the ALSPAC study had a CIS-R depression score at age 18 years. Longitudinal analyses included 2486 participants at age 12 years, 1938 at age 14 years, and 1220 at age 16 years. Total follow-up time was 6 years. Total physical activity decreased between 12 years and 16 years of age, driven by decreasing durations of light activity (mean 325·66 min/day [SD 58·09] at 12 years; 244·94 min/day [55·08] at 16 years) and increasing sedentary behaviour (430·99 min/day [65·80]; 523·02 min/day [65·25]). Higher depression scores at 18 years were associated with a 60 min/day increase in sedentary behaviour at 12 years (incidence rate ratio [IRR] 1·111 [95% CI 1·051–1·176]), 14 years (1·080 [1·012–1·152]), and 16 years of age (1·107 [1·015–1·208]). Depression scores at 18 years were lower for every additional 60 min/day of light activity at 12 years (0·904 [0·850–0·961]), 14 years (0·922 [0·857–0·992]), and 16 years of age (0·889 [0·809–0·974]). Group-based trajectory modelling across 12–16 years of age identified three latent subgroups of sedentary behaviour and activity levels. Depression scores were higher in those with persistently high (IRR 1·282 [95% CI 1·061–1·548]) and persistently average (1·249 [1·078–1·446]) sedentary behaviour compared with those with persistently low sedentary behaviour, and were lower in those with persistently high levels of light activity (0·804 [0·652–0·990]) compared with those with persistently low levels of light activity.

Moderate-to-vigorous physical activity (per 15 min/day increase) at age 12 years (0·910

[0·857–0·966]) and total physical activity (per 100 CPM increase) at ages 12 years (0·941 [0·910–0·972]) and 14 years (0·965 [0·932–0·999]), were negatively associated with depressive symptoms. Interpretation Sedentary behaviour displaces light activity throughout adolescence, and is associated with a greater risk of depressive symptoms at 18 years of age. Increasing light activity and decreasing sedentary behaviour during adolescence could be an important target for public health interventions aimed at reducing the prevalence of depression.

Milder ADHD symptoms when more time is spent out of doors: Faber Taylor, A., & Kuo, F. E. (2011). Could exposure to everyday green spaces help treat ADHD? Evidence from children's play settings. Applied Psychology: Health and Well‐Being, 3(3), 281-303.

Mou, Y., Blok, E., Barroso, M., Jansen, P. W., White, T., & Voortman, T. (2023). Dietary patterns, brain morphology and cognitive performance in children: Results from a prospective population-based study. European Journal of Epidemiology, 1-19.

ABSTRACT: Dietary patterns in childhood have been associated with child neurodevelopment and cognitive performance, while the underlying neurobiological pathway is unclear. We aimed to examine associations of dietary patterns in infancy and mid-childhood with pre-adolescent brain morphology, and whether diet-related differences in brain morphology mediate the relation with cognition. We included 1888 and 2326 children with dietary data at age one or eight years, respectively, and structural neuroimaging at age 10 years in the Generation R Study. Measures of brain morphology were obtained using magnetic resonance imaging. Dietary intake was assessed using food-frequency questionnaires, from which we derived diet quality scores based on dietary guidelines and dietary patterns using principal component analyses. Full scale IQ was estimated using the Wechsler Intelligence Scale for Children-Fifth Edition at age 13 years. Children with higher adherence to a dietary pattern labeled as ‘Snack, processed foods and sugar’ at age one year had smaller cerebral white matter volume at age 10 (B = -4.3, 95%CI -6.9, -1.7). At age eight years, higher adherence to a ‘Whole grains, soft fats and dairy’ pattern was associated with a larger total brain (B = 8.9, 95%CI 4.5, 13.3), and larger cerebral gray matter volumes at age 10 (B = 5.2, 95%CI 2.9, 7.5). Children with higher diet quality and better adherence to a ‘Whole grains, soft fats and dairy’ dietary pattern at age eight showed greater brain gyrification and larger surface area, clustered primarily in the dorsolateral prefrontal cortex. These observed differences in brain morphology mediated associations between dietary patterns and IQ. In conclusion, dietary patterns in early- and mid-childhood are associated with differences in brain morphology which may explain the relation between dietary patterns and neurodevelopment in children.

O’neil, A., Quirk, S. E., Housden, S., Brennan, S. L., Williams, L. J., Pasco, J. A., ... & Jacka, F. N. (2014). Relationship between diet and mental health in children and adolescents: a systematic review. American journal of public health, 104(10), e31-e42.

ABSTRACT: We systematically reviewed 12 epidemiological studies to determine whether an association exists between diet quality and patterns and mental health in children and adolescents; 9 explored the relationship using diet as the exposure, and 3 used mental health as the exposure. We found evidence of a significant, cross-sectional relationship between unhealthy dietary patterns and poorer mental health in children and adolescents. We observed a consistent trend for the relationship between good-quality diet and better mental health and some evidence for the reverse. When including only the 7 studies deemed to be of high methodological quality, all but 1 of these trends remained.

Findings highlight the potential importance of the relationship between dietary patterns or quality and mental health early in the life span.

Nelson, S. K., Layous, K., Cole, S. W., & Lyubomirsky, S. (2016). Do unto others or treat yourself? The effects of prosocial and self-focused behavior on psychological flourishing.

Emotion (Washington, D.C.), 16(6), 850–861. https://doi.org/10.1037/emo0000178 When it comes to the pursuit of happiness, popular culture encourages a focus on oneself.

By contrast, substantial evidence suggests that what consistently makes people happy is focusing prosocially on others. In the current study, we contrasted the mood- and well-being-boosting effects of prosocial behavior (i.e., doing acts of kindness for others or for the world) and self-oriented behavior (i.e., doing acts of kindness for oneself) in a 6-week longitudinal experiment. Across a diverse sample of participants (N = 473), we found that the 2 types of prosocial behavior led to greater increases in psychological flourishing than did self-focused and neutral behavior. In addition, we provide evidence for mechanisms explaining the relative improvements in flourishing among those prompted to do acts of kindness—namely, increases in positive emotions and decreases in negative emotions. Those assigned to engage in self-focused behavior did not report improved psychological flourishing, positive emotions, or negative emotions relative to controls. The results of this study contribute to a growing literature supporting the benefits of prosocial behavior and challenge the popular perception that focusing on oneself is an optimal strategy to boost one’s mood. People striving for happiness may be tempted to treat themselves. Our results, however, suggest that they may be more successful if they opt to treat someone else instead.

B. WHAT ROLE DO POSITIVE INPUTS PLAY? Van IJzendoorn, M. H., & Juffer, F. (2006). The Emanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta‐analytic evidence for massive catch‐up and plasticity in physical, socio‐emotional, and cognitive development. Journal of child psychology and psychiatry, 47(12), 1228-1245.

ABSTRACT: Background: Adopted children have been said to be difficult children, scarred by their past experiences in maltreating families or neglecting orphanages, or by genetic or pre- and perinatal problems. Is (domestic or international) adoption an effective intervention in the developmental domains of physical growth, attachment security, cognitive development and school achievement, self-esteem, and behaviour problems?

Method: Through a series of meta-analyses on more than 270 studies that include more than 230,000 adopted and non-adopted children and their parents an adoption catch-up model was tested. Results: Although catch-up with current peers was incomplete in some developmental domains (in particular, physical growth and attachment), adopted children largely outperformed their peers left behind. Adoptions before 12 months of age were associated with more complete catch-up than later adoptions for height, attachment, and school achievement. International adoptions did not lead to lower rates of catch-up than domestic adoptions in most developmental domains. Conclusions: It is concluded that adoption is an effective intervention leading to massive catch-up. Domestic and international adoptions can be justified on ethical grounds if no other solutions are available. Humans are adapted to adopt, and adoption demonstrates the plasticity of child development.

Audet, K., & Le Mare, L. (2011). Mitigating effects of the adoptive caregiving environment on inattention/overactivity in children adopted from Romanian orphanages. International Journal of Behavioral Development, 35(2), 107-115.

ABSTRACT: We examined inattention/overactivity (I/O) over time and in relation to caregiving in three matched groups: (1) Romanian Orphans (RO) with a minimum of eight months’ deprivation prior to adoption, (2) Early Adopted (EA) children adopted from Romania prior to age four months, and (3) Canadian Born (CB) non-adopted children.

Comparisons among groups at 4.5, 10.5, and 17 years of age revealed significantly greater I/O in the Romanian Orphan than Canadian Born group at all ages, and greater than the Early Adopted group at ages 4.5 and 10.5. Canadian Born and Early Adopted groups did not differ. Rates of borderline clinical I/O among Romanian Orphans were significantly higher than rates found in the general population; Canadian Born and Early Adopted

groups did not differ from the general population. Among Romanian Orphans, I/O was positively related to duration of deprivation; this association did not attenuate over time.

Regressions indicated that I/O at age 10.5 was negatively related to warmth and stimulation in the adoptive home and attachment, after accounting for duration of deprivation and age 4.5 I/O. Authoritarian parenting was positively predictive of I/O in children with minimal deprivation and negatively predictive in children with extensive deprivation. Attachment was negatively predictive of I/O in children with less than 19 months’ deprivation but unrelated to I/O in those with more than 19 months’ deprivation.

Garvin, M. C., Tarullo, A. R., Van Ryzin, M., & Gunnar, M. R. (2012). Postadoption parenting and socioemotional development in postinstitutionalized children. Development and psychopathology, 24(1), 35-48.

ABSTRACT: Children adopted from institutions (e.g., orphanages) overseas are at increased risk of disturbances in social relationships and social understanding. Not all postinstitutionalized children exhibit these problems, although factors like the severity of deprivation and duration of deprivation increase their risk. To date, few studies have examined whether postadoption parenting might moderate the impact of early adverse care. Three groups were studied: postinstitutionalized and foster care children both adopted internationally and nonadopted children reared in their families of origin. The Emotional Availability (EA) Scales were assessed at 18 months in parent–child dyads.

Parent emotional availability was found to predict two aspects of social functioning shown in previous studies to be impaired in postinstitutionalized children. Specifically, EA positively correlated with emotion understanding at 36 months; in interaction with initiation of joint attention at 18 months and group, it predicted indiscriminate friendliness as scored from a parent attachment interview at 30 months. Among the postinstitutionalized children but not among the children in other groups, higher EA scores reduced the negative association between initiation of joint attention and indiscriminate friendliness, thus suggesting that parenting quality may moderate the effects of early institutional deprivation.

Barone, L., Lionetti, F., & Green, J. (2017). A matter of attachment? How adoptive parents foster post-institutionalized children’s social and emotional adjustment. Attachment & human development, 19(4), 323-339.

ABSTRACT: The current study investigates the contribution of children’s age at adoption (M = 46.52 months, SD = 11.52 months) and parents’ attachment on post-institutionalized children’s attachment and social–emotional adjustment. A total of 132 subjects, 48

post-institutionalized children aged 3–5 years, and their adoptive parents, took part in the study. One year from adoption, children’s attachment distribution was as follows: 31% secure, 42% disorganized, and 27% insecure. Parents’ secure attachment increased children’s probability of presenting a secure attachment pattern; specifically, mothers’ attachment patterns were most strongly associated with those of their adopted children, with fathers’ making an additional contribution. Two years from adoption, secure children showed more adequate social competences than their insecure and disorganized peers and presented better emotional comprehension. The effect of age at adoption was delimited to a marginal association with behavioral problems. This pattern of associations suggests that attachment – both of adoptive parents and of children – substantially fosters social–emotional adjustment of post-institutionalized children who have experienced a period in emotionally neglecting environments beyond their first year of life, regardless of their age at adoption. Implications for policies and practices are discussed.

Pinquart, M. (2017). Associations of parenting dimensions and styles with externalizing problems of children and adolescents: An updated meta-analysis. Developmental psychology, 53(5), 873.

ABSTRACT: The present meta-analysis integrates research from 1,435 studies on associations of parenting dimensions and styles with externalizing symptoms in children and adolescents. Parental warmth, behavioral control, autonomy granting, and an authoritative parenting style showed very small to small negative concurrent and longitudinal associations with externalizing problems. In contrast, harsh control, psychological control, authoritarian, permissive, and neglectful parenting were associated with higher levels of externalizing problems. The strongest associations were observed for harsh control and psychological control. Parental warmth, behavioral control, harsh control, psychological control, autonomy granting, authoritative, and permissive parenting predicted change in externalizing problems over time, with associations of externalizing problems with warmth, behavioral control, harsh control, psychological control, and authoritative parenting being bidirectional. Moderating effects of sampling, child's age, form of externalizing problems, rater of parenting and externalizing problems, quality of measures, and publication status were identified. Implications for future research and practice are discussed.

DePasquale, C. E., Raby, K. L., Hoye, J., & Dozier, M. (2018). Parenting predicts strange situation cortisol reactivity among children adopted internationally.

Psychoneuroendocrinology, 89, 86-91.

ABSTRACT: The functioning of the hypothalamic pituitary adrenal (HPA) axis can be altered by adverse early experiences. Recent studies indicate that children who were adopted internationally after experiencing early institutional rearing and unstable caregiving exhibit blunted HPA reactivity to stressful situations. The present study examined whether caregiving experiences post-adoption further modulate children’s HPA responses to stress. Parental sensitivity during naturalistic parent-child play interactions was assessed for 66 children (M age= 17.3 months, SD = 4.6) within a year of being adopted internationally. Approximately 8 months later, children’s salivary cortisol levels were measured immediately before as well as 15 and 30 minutes after a series of brief separations from the mother in an unfamiliar laboratory setting. Latent growth curve modeling indicated that experiencing more parental sensitivity predicted increased cortisol reactivity to the stressor. Although half the families received an intervention designed to improve parental sensitivity, the intervention did not significantly alter children’s cortisol outcomes. These findings suggest that post-adoption parental sensitivity may help normalize the HPA response to stress among children adopted internationally.

Hawk, B. N., Mccall, R. B., Groark, C. J., Muhamedrahimov, R. J., Palmov, O. I., & Nikiforova, N. V. (2018). Caregiver sensitivity and consistency and children's prior family experience as contexts for early development within institutions. Infant mental health journal, 39(4), 432-448.

ABSTRACT: The current study addressed whether two institution-wide interventions in St. Petersburg, Russian Federation, that increased caregiver sensitivity (Training Only: TO) or both caregiver sensitivity and consistency (Training plus Structural Changes: T+SC) promoted better social-emotional and cognitive development than a No Intervention (NoI) institution during the first year of life for children who were placed soon after birth.

It also assessed whether having spent less than 9 versus 9-36 months with a family prior to institutionalization was related to children’s subsequent social-emotional and cognitive development within these three institutions. The Battelle Developmental Inventory was used to assess the social-emotional and cognitive functioning of children in NoI (n = 95), TO (n = 104), and T+SC (n = 86) at 2-3 time points during their first 6-12 months of residency. Results suggest that improving caregiver sensitivity can improve the cognitive development of infants in the first year of institutionalization, whereas improving caregiver consistency in addition to sensitivity is more beneficial for social-emotional development than sensitivity alone. Similarly, for children in T+SC, longer time with a family prior to institutionalization (consistent caregiver, unknown sensitivity) was associated with better social-emotional but not cognitive baseline scores and more rapid cognitive than social-emotional development during institutionalization. These results

suggest caregiver sensitivity is more highly related to cognitive development whereas caregiver consistency is more related to social-emotional development in the first years of life.

Valcan, D. S., Davis, H., & Pino-Pasternak, D. (2018). Parental behaviours predicting early childhood executive functions: A meta-analysis. Educational Psychology Review, 30, 607-649.

ABSTRACT: Recent research indicates that parental behaviours may influence the development of executive functions (EFs) during early childhood, which are proposed to serve as domain-general building blocks for later classroom behaviour and academic achievement. However, questions remain about the strength of the association between parenting and child EFs, more specifically which parental behaviours are most strongly associated with child EFs, and whether there is a critical period in early childhood during which parental behaviour is more influential. A meta-analysis was therefore conducted to determine the strength of the relation between various parental behaviours and EFs in children aged 0 to 8 years. We identified 42 studies published between 2000 and 2016, with an average of 12.77 months elapsing in the measurement of parent and child variables. Parental behaviours were categorised as positive (e.g. warmth, responsiveness, sensitivity), negative (e.g. control, intrusiveness, detachment) and cognitive (e.g. autonomy support, scaffolding, cognitive stimulation). Results revealed significant associations (ps < .001) between composite EF and positive (r = .25), negative (r = −.22) and cognitive (r = .20) parental behaviours. Associations between cognitive parental behaviours and EFs were significantly moderated by child age, with younger children showing a stronger effect size, whereas positive and negative parental behaviours showed a stable association with EFs across ages. We conclude that modest, naturally occurring associations exist between parental behaviours and future EFs and that early childhood may be a critical period during which cognitive parental behaviour is especially influential.

Koss, K. J., Lawler, J. M., & Gunnar, M. R. (2020). Early adversity and children's regulatory deficits: Does postadoption parenting facilitate recovery in postinstitutionalized children?. Development and psychopathology, 32(3), 879-896.

ABSTRACT: Children reared in orphanages typically experience the lack of stable, reliable caregivers and are at increased risk for deficits in regulatory abilities including difficulties in inhibitory control, attention, and emotion regulation. Although adoption results in a radical shift in caregiving quality, there remains variation in post-adoption parenting, yet little research has examined post-adoption parenting that may promote recovery in children experiencing early life adversity in the form of institutional care. Participants

included 93 post-institutionalized children adopted between 15 and 36 months of age and 52 non-adopted same-aged peers. Parenting was assessed four times during the first two years post-adoption (at 2, 8, 16, and 24 months post-adoption) and children’s regulation was assessed at age 5 (M age = 61.68 months) and during kindergarten (M age = 71.55 months). Multiple parenting dimensions including sensitivity/responsiveness, structure/limiting-setting, and consistency in routines were examined. Both parental sensitivity and structure moderated the effect of preadoption adversity on children’s emotion regulation while greater consistency was associated with better inhibitory control and fewer attention problems. Results support the notion that post-adoption parenting during toddlerhood and the early preschool years promotes better regulation skills following early adversity.

DePasquale, C. E., Lawler, J. M., Koss, K. J., & Gunnar, M. R. (2020). Cortisol and parenting predict pathways to disinhibited social engagement and social functioning in previously institutionalized children. Journal of abnormal child psychology, 48, 797-808.

ABSTRACT: Previously institutionalized children on average show persistent deficits in physiological and behavioral regulation, as well as a lack of normative reticence towards strangers, or disinhibited social engagement (DSE). Post-adoption parenting, specifically a combination of supportive presence and structure/limit-setting, may protect against DSE over time via better adrenocortical functioning. This study examined the impact of adrenocortical activity and post-adoption parenting on DSE across the first two years post-adoption (age at adoption: 16-36 months) and observed kindergarten social outcomes in previously institutionalized children (n = 94) compared to non-adopted children (n = 52). Path analyses indicated a developmental cascade from institutional care (operationalized as a dichotomous group variable, age at adoption, and months of institutionalization) to blunted adrenocortical activity, increased DSE, and lower kindergarten social competence. Consistent with a permissive parenting style, higher parental support was associated with increased DSE, but only when not accompanied by effective structure/limit-setting. Further, parental structure reduced the association between blunted adrenocortical activity and DSE behaviors.

Morris, A. S., Hays-Grudo, J., Zapata, M. I., Treat, A., & Kerr, K. L. (2021). Adverse and protective childhood experiences and parenting attitudes: The role of cumulative protection in understanding resilience. Adversity and Resilience Science, 2, 181-192.

ABSTRACT: Theory and research indicate that adverse childhood experiences (ACEs) are linked to negative parenting attitudes and behaviors. We posit that protective and compensatory experiences (PACEs) in childhood buffer the negative effects of ACEs on

later parenting. To test this premise, the present study examined associations between ACEs, PACEs, and attitudes towards nurturing and harsh parenting in an ethnically diverse sample of parents with children of various ages (N = 109; 65% mothers, 35% fathers; M age = 38). Parents completed a widely used parenting attitudes questionnaire and the ACEs and PACEs surveys. PACEs were negatively correlated with ACEs and positively correlated with nurturing parenting attitudes and parent income and education levels.

Linear regression models indicate that higher PACEs, ACEs, and family income and less harsh parenting attitudes predict nurturing parenting attitudes. In contrast, higher ACEs and less nurturing attitudes were correlated with harsh parenting attitudes. As expected, moderation analyses indicated that the association between ACEs and harsh parenting attitudes was conditional upon the level of PACEs. When PACE scores were low (M – 1 SD), but not when PACE scores were average or high (M + 1 SD), ACEs were associated with harsh parenting attitudes, suggesting a buffering effect of PACEs on negative parenting attitudes. These findings support the importance of including protective as well as adverse childhood experiences when assessing the role of childhood experiences on parenting attitudes and practices. Implications of these findings for researchers and practitioners are discussed, as well as new directions for PACEs research using a cumulative protection approach. [Note by R. Medefind: This paper provides a compelling and important addition to the literature, indicating that alongside adversity, positive inputs must be taken into account, both to gain an accurate account of all an individual has experienced and to offer the individual an understanding of their own history that captures the many forces - usually including many powerfully good ones - that have fed into their life. Here is a quote and helpful links: “This is one of the first studies to examine whether PACEs before age 19 buffer associations between ACEs and parenting attitudes.

Our findings suggest that PACEs may buffer the negative associations between ACEs and harsh parenting attitudes. Like other studies examining adverse and protective childhood experiences (Afifi & MacMillan, 2011; Bethell et al., 2019; Yamaoka & Bard, 2019), our findings also support the premise that positive experiences in childhood should be considered along with adverse experiences when examining risk and resilience-related factors. Indeed, positive experiences matter, and examining experiences that predict resilience is an important piece of the story that is often missed in understanding adversity. Developmental science has a long history of studying resilience (Masten, 2001; Rutter, 1979; Sameroff et al., 1987). Unfortunately, the science of resilience has not been fully integrated with ACEs science until recently (see Hays-Grudo & Morris, 2020).... We argue that when examining ACEs in research and practice, protective and resilience-promoting factors should also be examined. Doing so helps researchers more fully understand developmental trajectories and outcomes, and helps practitioners gain a more robust understanding of early experiences. Importantly, having research participants or therapy clients complete surveys like the PACEs along with ACEs also gives

participants/clients a fuller, more nuanced perspective on their childhoods and potential opportunities for continued growth. Most individuals have at least one PACE (in fact, the mean PACE score in our study was 7.5 out of 10). Even if a PACE score is zero, practitioners can invite clients to identify PACEs to create for themselves and/or for their children. We have developed PACEs plans for adults and children of different ages, and clinicians can use these plans with clients to support healing and positive development (see Hays-Grudo & Morris, 2020). The list of PACEs for children (0–18), which we have found can be an informative parenting tool as well, is included in the Appendix.”]

Katsantonis, I., & McLellan, R. (2023). The role of parent–child interactions in the association between mental health and prosocial behavior: Evidence from early childhood to late adolescence. International Journal of Behavioral Development, 01650254231202444.

ABSTRACT: This study examined the association between internalizing and externalizing mental health and prosociality across four developmental transitions. The effects of parent–child interactions on mental health and prosociality were also explored. The data from a community sample of 10,703 children on mental health, prosociality, child maltreatment, parent–child relationships, parental mental health, and socioeconomic status were derived from the Millennium Cohort Study to cover the developmental periods from early childhood to late adolescence (ages 5, 7, 11, 14, 17). Adjusting for covariates, latent trait-state-occasion and cross-lag modeling were deployed. The results indicated that internalizing and externalizing mental health symptoms, and prosociality were more trait-like throughout adolescence. Only within-person increase in externalizing symptoms predicted decrease in subsequent within-person prosociality from middle childhood to late adolescence. Parent–child conflict and maltreatment had deleterious effects on children’s prosociality and mental health. Mental health professionals should screen for both possible mental health problems and deficits in prosociality. Interventions aiming to improve the quality of parent–child relationships could be beneficial for the development of child mental health and prosociality. [Note by R. Medefind: Here is a quote from the paper: “Most importantly, we also examined the impact of the parent–child interactions on children’s stable dispositions for internalizing and externalizing mental health symptoms, and prosociality. The analyses revealed that high-quality parent–child interactions in the form of increased closeness, reduced conflict, and physical and psychological maltreatment can be very important protective factors against internalizing and externalizing symptoms and can foster increased prosociality. Our findings corroborate with previous results from survey (Laursen et al., 1998; Lougheed et al., 2022; Yan et al., 2019) and behavior genetics (Burt et al., 2005) studies showing that having a conflicting parent–child relationship (e.g., struggling with

each other, sneaking or manipulative child behavior, bad mood) can harm children’s mental health and has been linked with membership to high-risk developmental trajectories. Similarly, being physically and/or psychologically maltreated has been linked with greater mental health difficulties (Coe et al., 2020) and reduced prosociality (Cicchetti & Toth, 2005; Yu et al., 2020). Nevertheless, there is a paucity of studies exploring the links between closeness and mental health symptoms, and prosociality, but the few studies suggest a protective effect (Ge et al., 2009), which is also confirmed here. However, past research has not clarified to what extent these early childhood parent–child interactions were predictive of stable internalizing and externalizing symptoms, and prosociality across the early years (ages 5–17). In other words, greater closeness has sustained long-lasting benefits, while greater conflict and maltreatment have deleterious long-lasting effects.”]

IV.

IT IS CLEAR FROM RESEARCH THAT STRESSORS ARE VITAL FOR HEALTHY GROWTH. HOW DO WE INCORPORATE THE REALITY THAT ADVERSITY CAN ENABLE GROWTH INTO TRAUMA-INFORMED MODELS?

Tedeschi, R. G., & Calhoun, L. G. (2004). " Posttraumatic growth: conceptual foundations and empirical evidence". Psychological inquiry, 15(1), 1-18.

ABSTRACT: This article describes the concept of posttraumatic growth, its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises.

It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life. Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative and that it is an ongoing process, not a static outcome. [Note from R. Medefind: This paper provides a compelling theoretical framework for conceptualizing posttraumatic growth. The grounding in ancient wisdom adds a helpful connection between research and long-standing human experience.]

Linley, P. A., & Joseph, S. (2004). Positive change following trauma and adversity: A review.

Journal of traumatic stress: official publication of the international society for traumatic stress studies, 17(1), 11-21.

ABSTRACT: Empirical studies (n = 39) that documented positive change following trauma and adversity (e.g., posttraumatic growth, stress-related growth, perceived benefit, thriving; collectively described as adversarial growth) were reviewed. The review indicated that cognitive appraisal variables (threat, harm, and controllability), problem-focused, acceptance and positive reinterpretation coping, optimism, religion, cognitive processing, and positive affect were consistently associated with adversarial growth. The review revealed inconsistent associations between adversarial growth, sociodemographic variables (gender, age, education, and income), and psychological distress variables (e.g., depression, anxiety, posttraumatic stress disorder). However, the

evidence showed that people who reported and maintained adversarial growth over time were less distressed subsequently. Methodological limitations and recommended future directions in adversarial growth research are discussed, and the implications of adversarial growth for clinical practice are briefly considered. [Note from R. Medefind: This review of the literature does not include a study focused on children. The term “adversarial” is a bit confusing and has not stood the test of time. However, the review remains elucidating: it guides toward common factors that support positive growth. These conclusions are consistent with later research specifically addressing children and early adversity.]

Joseph, S., & Linley, P. A. (2006). Growth following adversity: Theoretical perspectives and implications for clinical practice. Clinical psychology review, 26(8), 1041-1053.

ABSTRACT: A number of literatures and philosophies throughout human history have conveyed the idea that there is personal gain to be found in suffering, and it is an idea central to the existential-humanistic tradition of psychology. However, it is only relatively recently that the topic of growth following adversity has become the focus for empirical and theoretical work. In this paper, we review theoretical models of growth, and discuss the implications of growth for clinical practice. Three main theoretical perspectives are reviewed, the functional-descriptive model, the meta-theoretical person-centered perspective, and the biopsychosocial-evolutionary view. It is proposed that these three approaches to theory offer different but complementary levels of analysis, and that theoretical integration between them is possible. We then go on to explore the implications of this theoretical integration for clinical practice, and conclude with a consideration of the role of therapy in facilitating growth following adversity.

Lyons, D. M., & Parker, K. J. (2007). Stress inoculation‐induced indications of resilience in monkeys. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 20(4), 423-433.

ABSTRACT: The negative consequences of stress are well-recognized in mental health research. Exposure to early life stressors, for example, increases the risk for the development of mood, anger, anxiety, and substance abuse disorders. Interestingly, however, early life stressors have also been linked to the subsequent development of resilience. Variously described as inoculating, immunizing, steeling, toughening, or thriving, the hypothesis that early life stressors provide a challenge that, when overcome, induces adaptations that enhance emotional processing, cognitive control, curiosity, and neuroendocrine regulation is examined in this review of squirrel monkey research. [Note

from R. Medefind: This is another animal study. This could be a much longer discussion, but the conclusion of this paper echoes the human sentiment told in so many of our heroic stories: it is the orphan who becomes the superhero, abandoned Joseph who becomes Pharoah’s second in command, or Alexander Hamilton who went from destitute and alone to a Founding Father of America. The negative consequences of early adversity can be serious and must be addressed with devotion and the best therapeutic models.

Simultaneously, it is vital to recognize the incredible potential for growth and thriving post-trauma.]

Bonanno, G. A., & Mancini, A. D. (2008). The human capacity to thrive in the face of potential trauma. Pediatrics, 121(2), 369-375.

ABSTRACT: For decades, researchers have documented remarkable levels of resilience in children who were exposed to corrosive early environments, such as those in which poverty or chronic maltreatment were present; however, relatively little research has examined resilience in children or adults who were exposed to isolated and potentially traumatic events. The historical emphasis on psychological and physiologic dysfunction after potentially traumatic events has suggested that such events almost always produce lasting emotional damage. Recent research, however, has consistently shown that across different types of potentially traumatic events, including bereavement, serious illness, and terrorist attack, upward of 50% of people have been found to display resilience. Research has further identified substantial individual variation in response to potentially traumatic events, including 4 prototypical and empirically derived outcome trajectories: chronic dysfunction, recovery, resilience, and delayed reactions. Factors that promote resilience are heterogeneous and include a variety of person-centered variables (eg, temperament of the child, personality, coping strategies), demographic variables (eg, male gender, older age, greater education), and sociocontextual factors (eg, supportive relations, community resources). It is surprising that some factors that promote resilience to potentially traumatic events may be maladaptive in other contexts, whereas other factors are more broadly adaptive. Given the growing evidence that resilience is common, psychotherapeutic treatment should be reserved for those in genuine need.

Tough, P. (2012). How children succeed: Grit, curiosity, and the hidden power of character.

Houghton Mifflin Harcourt. [Note from R. Medefind: Though several years old, this book lays out a highly readable basis of research for the importance of both secure attachment and healthy stressors/high expectations.]

Franklin, T. B., Saab, B. J., & Mansuy, I. M. (2012). Neural mechanisms of stress resilience and vulnerability. Neuron, 75(5), 747-761.

ABSTRACT: Exposure to stressful events can be differently perceived by individuals and can have persistent sequelae depending on the level of stress resilience or vulnerability of each person. The neural processes that underlie such clinically and socially important differences reside in the anatomical, functional, and molecular connectivity of the brain.

Recent work has provided novel insight into some of the involved biological mechanisms that promises to help prevent and treat stress-related disorders. In this review, we focus on causal and mechanistic evidence implicating altered functions and connectivity of the neuroendocrine system, and of hippocampal, cortical, reward, and serotonergic circuits in the establishment and the maintenance of stress resilience and vulnerability. We also touch upon recent findings suggesting a role for epigenetic mechanisms and neurogenesis in these processes and briefly discuss promising avenues of future investigation. [Note by R. Medefind: Researchers have long observed that stress is not detrimental independently but is related to how it is experienced by the individual. Animal studies are one way that researchers have developed a basis of literature showing that stress is important and beneficial in addition to potentially harmful. Here is a quote from this paper: “Consistent with the idea that severe stress can be detrimental, but moderate and controllable stress can be beneficial, neurogenesis was shown to be increased by predictable chronic mild stress in rats (Parihar et al., 2011). It is also higher in nonhuman primates who successfully cope with intermittent social stress (Lyons et al., 2010a)....Thus overall, neurogenesis may be part of a resilience repertoire that can be recruited in some animals, which for instance have high baseline neurogenesis or in which neurogenesis can be effectively activated. Conversely, successful coping may favor neurogenesis and thereby increase the chance for future successful coping.”]

Ramos, C., & Leal, I. P. (2013). Posttraumatic growth in the aftermath of trauma: A literature review about related factors and application contexts. Psychology, Community & Health, 2, 43-54.

ABSTRACT: Aim: In the face of one traumatic event, individuals may perceive, along with the inherent negative responses, a number of positive changes, which reveal posttraumatic growth. This concept has increased its expression in literature over the years, and it has been recognized that people exposed to highly traumatic events, such as bereavement, war combat, disasters, disease or other stressful or life-threatening events, may perceive positive changes from the struggling with those events. Thus, this literature review aims at exploring the definition of posttraumatic growth, associated factors and

application contexts. Method and Results: Electronic databases were used to search the relevant literature. Based on the analysis of empirical data, were found several studies that demonstrated a range of factors, such as distress, personality characteristics, self-disclosure, coping, social support, environmental characteristics, assumptive world, rumination, spirituality and optimism, that have contributed to the development of posttraumatic growth; however, some relationships remain inconclusive. Conclusion: Further research is required, to clarify the genesis and the development of posttraumatic growth, also, to extend the posttraumatic growth studies in health context, encompassing the patient as well as family and social network.

Brussoni, M., Gibbons, R., Gray, C., Ishikawa, T., Sandseter, E. B. H., Bienenstock, A., ... & Tremblay, M. S. (2015). What is the relationship between risky outdoor play and health in children? A systematic review. International journal of environmental research and public health, 12(6), 6423-6454.

ABSTRACT: Risky outdoor play has been associated with promoting children’s health and development, but also with injury and death. Risky outdoor play has diminished over time, concurrent with increasing concerns regarding child safety and emphasis on injury prevention. We sought to conduct a systematic review to examine the relationship between risky outdoor play and health in children, in order to inform the debate regarding its benefits and harms. We identified and evaluated 21 relevant papers for quality using the GRADE framework. Included articles addressed the effect on health indicators and behaviours from three types of risky play, as well as risky play supportive environments.

The systematic review revealed overall positive effects of risky outdoor play on a variety of health indicators and behaviours, most commonly physical activity, but also social health and behaviours, injuries, and aggression. The review indicated the need for additional “good quality” studies; however, we note that even in the face of the generally exclusionary systematic review process, our findings support the promotion of risky outdoor play for healthy child development. These positive results with the marked reduction in risky outdoor play opportunities in recent generations indicate the need to encourage action to support children’s risky outdoor play opportunities. Policy and practice precedents and recommendations for action are discussed. [Note from R. Medefind: Risky play often includes minor injuries, which proponents share can be a means of gaining resilience as children experience injury and then recovery, failure and then success, and the normalization of pain.]

Malhotra, M., & Chebiyan, S. (2016). Posttraumatic growth: Positive changes following adversity-an overview. International Journal of Psychology and Behavioral Sciences, 6(3), 109-118.

Garner, L. E., Steinberg, E. J., & McKay, D. (2021). Exposure therapy.

ABSTRACT: Exposure therapy is a major evidence-based intervention that is a standalone treatment or part of comprehensive treatment programs for anxiety disorders. The accumulated evidence suggests that the intervention produces large effect sizes for symptom reduction, has indirect benefits for other psychopathology, and changes core cognitive biases associated with anxiety disorders. Exposure therapy has been demonstrated as highly efficacious intervention, used primarily in the treatment of anxiety and obsessive-compulsive disorders and posttraumatic stress disorder. Its application has been evaluated as a stand-alone intervention and as component of broader program of cognitive behavioral therapy. This chapter reviews the history and underlying theory of exposure therapy and provides a description of primary procedures in exposure. The chapter summarizes the outcome data associated with the approach and highlights the mechanisms of change. It covers the application of exposure to diverse populations. The chapter concludes with future directions in the applications of exposure therapy. [Note from R. Medefind: Exposure therapy involves exposing the client to the thing they find distressing with the aim of desensitizing them to it. It has a very strong evidence base. The idea is that encountering hard things - especially triggers specific to the individual - is important and necessary for healing. This suggests that small measures of adversity are significant for overcoming adverse experiences. Additionally, it suggests that approaches to care that persistently treat triggers of fear as things to be avoided will likely miss the benefits that come through small, reasonable exposures that enable healing.]

V.

DEFINITIONS VARY A. WHAT IS TRAUMA?

Ancient Greek: “Wound” American Psychological Association: “Trauma is an emotional response to a terrible event like an accident, rape, or natural disaster.”

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5): Trauma is when an individual person is exposed “to actual or threatened death, serious injury, or sexual violence.”

SAMHSA: Trauma is “an event or circumstance resulting in: physical harm; emotional harm; and/or life-threatening harm.”

Center for Addiction and Mental Health: “Trauma is the lasting emotional response that often results from living through a distressing event.”

The National Child Traumatic Stress Network: “A traumatic event is a frightening, dangerous, or violent event that poses a threat to a child’s life or bodily integrity.”

Psychology Today: “Trauma is a person's emotional response to a distressing experience.

Few people can go through life without encountering some kind of trauma.”

Dictionary.com: “Trauma is considered a form of severe and lasting emotional stress, caused by an extremely unsettling experience that far exceeds one’s ability to cope.

Trauma throws its victims into a state of shock and denial immediately after the event and often keeps haunting them long after, with recurrent nightmares, sudden flashbacks, symptoms of panic, and long-term neurosis grouped under the category of posttraumatic stress disorder (PTSD), commonly overlapping and co-occurring with other psychiatric disorders.”

Pandell, L. (2022). How trauma became the word of the decade.

B. WHAT DO WE MEAN WHEN WE SAY TRAUMA-INFORMED CARE? Wilson, C., Pence, D. M., & Conradi, L. (2013). Trauma-informed care. In Encyclopedia of social work.

“Many organizations and authors have offered definitions or a list of elements about what constitutes trauma-informed care or the related concepts of trauma-informed practice, organizations, and systems.”

US Department of Health and Human Services. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach.

“A program, organization, or system that realizes the impact of trauma, recognizes the symptoms of trauma, responds by integrating knowledge about trauma policies and practices, and seeks to reduce re- traumatization.”

Center for Substance Abuse Treatment. (2014). Trauma-informed care in behavioral health services.

“An intervention and organizational approach that focuses on how trauma may affect an individual’s life and his or her response to behavioral health services from prevention through treatment.”

Fallot, Roger D., and M. Harris. "Creating cultures of trauma-informed care." Washington DC: Community Connections (2009).

“Trauma-informed care is built on five core values: (1) safety, (2) trustworthiness, (3) choice, (4) collaboration, and (5) empowerment.”

Sweeney, A., Filson, B., Kennedy, A., Collinson, L., & Gillard, S. (2018). A paradigm shift: relationships in trauma-informed mental health services. BJPsych advances, 24(5), 319-333.

This approach will “move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?.... In a trauma-informed service, it is assumed that people have experienced trauma.”

Joshua, D. F. (2019). The 12 Core Concepts for Understanding Traumatic Stress Responses in Children and Families Adapted for Youth Who Are Trafficked.

A list of 12 core items relevant to trauma-informed care.

VI.

WHY IS COMPLEX DEVELOPMENTAL TRAUMA NOT YET A DIAGNOSIS?

Complex Developmental Trauma or Developmental Trauma Disorder seeks to distinguish post-traumatic stress disorder, which is in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), from early and chronic trauma. Developmental Trauma is not an official diagnosis. Lack of consensus in understanding biological pathways, parameters of the diagnostic process, and treatment options have been part of the challenge.

Perry, B. D., & Hambrick, E. P. (2008). The neurosequential model of therapeutics.

Reclaiming children and youth, 17(3), 38-43.

Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5.

European Journal of Psychotraumatology, 2(1), 5622.

Cruz, D., Lichten, M., Berg, K., & George, P. (2022). Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment. Frontiers in Psychiatry, 13, 800687.

JOURNALISM ON TRAUMA Carr D. (July 31, 2023). Tell Me Why It Hurts: How Bessel van der Kolk’s once controversial theory of trauma became the dominant way we make sense of our lives. New York Magazine.

Claes B. (November 28, 2023). Is the Trauma Narrative Helpful? The Gospel Coalition.

NEXT STEPS IN COLLECTING RESEARCH ● More relevant research in any of these and other areas would be valuable. ● Specifically, research is needed to show a strong evidence base for trauma-informed approaches. Ideally, these would be well-run studies of a reasonable size. Even better would be a review or meta-analysis.