Understanding predictors of post-traumatic stress after pediatric medical events

背景：儿科损伤是儿童最常见的心理创伤经历之一。每年有2000万美国儿童遭受意外伤害。虽然这些儿童中的大多数表现出短暂的情绪困扰，但大约19%（即380万）发展出明显的、持续的创伤后应激障碍（PTSD）症状。创伤后应激障碍症状是功能预后的关键预测因素，可能会干扰对医疗方案的最佳依从性，并与较差的总体健康结果和生活质量受损有关。识别导致创伤后应激障碍发展的变量是最大限度地提高二级预防计划的有效性以减少医疗事件后青少年创伤后应激障碍发病率的必要步骤。有证据表明父母和孩子的PTSD之间存在联系，但父母的症状如何影响孩子的症状还没有确定。先前的研究已经报道了创伤事件、应对行为和创伤后心理恢复的认知评价之间的联系。父母如何影响孩子的评价和随后的应对方式，以及这如何影响创伤后应激障碍的结果，并没有明确说明。虽然创伤性事件的初始生理反应与随后的创伤后应激障碍之间的关系已经确立，但很少有研究调查这些反应在儿童创伤前后认知评估中的作用，以及这些反应的评估如何有助于筛查创伤后应激障碍风险。该项目将显著加深我们对生物（心血管水平）、心理（儿童的评价和应对）和环境因素（父母如何影响孩子的评价和应对）之间相互作用的理解，以及这些因素如何导致儿童损伤后的创伤后应激障碍。本研究的主要目的是：1)研究儿童创伤前后认知评价和应对在预测儿童创伤后PTSD症状中的作用；2)阐明与创伤前后认知评价相关的创伤前后生物学因素（即心血管水平）在创伤后PTSD发展中的作用。3)通过检查创伤前后的亲子互动，以及亲子互动如何预测创伤后儿童PTSD症状，确定父母对儿童认知评价和应对的影响。方法：在研究1中，我们将对现有的3个儿童损伤样本数据集进行二次分析，探讨父母和儿童早期创伤症状、儿童应对以及父母应对援助对儿童PTSD发展的影响。我们将使用结构方程建模技术来检验交叉滞后回归模型、潜在增长曲线模型和潜在差异评分模型。在研究2中，我们将结合1)一个创新的实验设计（改编自焦虑障碍文献），其中儿童（7-13岁）和父母参与一个互动任务来评估一个模糊的场景并选择应对策略；2)儿童和父母自我报告评估，应对和创伤前后创伤后应激障碍症状；3)医疗图表回顾以获得儿童心率和损伤严重程度的数据。职业目标:K23奖将为候选人提供必要的培训和指导，使候选人能够获得研究设计和研究分析方面的专业知识，评估生物，心理，在经历医疗事件的儿童中PTSD的环境风险因素和使用先进的统计技术（结构方程模型）来检查PTSD的预测因素，2)开发新的方法技能，应用于PTSD的研究和预防（亲子互动的观察编码），3)在开发和测试急性医疗压力期间儿童和父母的PTSD预防干预措施方面获得专业知识（二级预防），4)提高在同行评议的科学期刊上发表研究成果的科学技能和资助。重要性：我未来研究计划的目标是开发预防干预措施，以减少急性儿科医疗事件后儿童PTSD的发生率。该项目推进了NIMH的战略目标，即绘制精神疾病轨迹，确定何时、何处以及如何通过识别可延展性和强大的风险因素进行干预，以及拟议的健康人群2020目标，即通过测试促进适应性应对和预防PTSD发展的策略来提高生活质量。

DESCRIPTION (provided by applicant): Background: Pediatric injuries are among the most common psychologically traumatic experiences for children. Twenty million American children suffer from unintentional injuries annually. While the majority of these children display transient emotional distress, approximately 19% (i.e., 3.8 million) develop significant, persistent symptoms of posttraumatic stress disorder (PTSD). PTSD symptoms are key predictors of functional outcomes, may interfere with optimal adherence to medical regimens, and have been linked to poorer general health outcomes and impaired quality of life. Identification of variables that contribute to the development of PTSD is an essential step in maximizing the effectiveness of secondary prevention programs to reduce the incidence of PTSD in youth following medical events. Evidence suggests an association between parent and child PTSD but how parents' symptoms influence children's symptoms has not yet been established. Prior research has reported associations among cognitive appraisals about the traumatic event, coping behavior, and psychological recovery following injury. The ways in which parents influence children's appraisals and subsequent coping and how this affects PTSD outcomes is not articulated. While the relation of initial physiological reactions to the traumatic event with subsequent PTSD has been established, little research has examined the role of these reactions as they relate to peri-trauma cognitive appraisals in children and how assessment of these reactions could help in screening for PTSD risk. The proposed project will significantly deepen our understanding of the interplay among biological (cardiovascular levels), psychological (child's appraisals and coping), and environmental factors (how parents influence their child's appraisals and coping) and how these factors contribute to PTSD following pediatric injury. The specific aims are to 1) examine the roles of children's cognitive appraisals and coping during the peri-trauma injury period in predicting post- trauma child PTSD symptoms 2) elucidate the contribution of peri-trauma biological factors (i.e.,cardiovascular levels) as associated with peri-trauma cognitive appraisals to the development of PTSD post-trauma, and 3) determine parents' influence on their child's cognitive appraisals and coping by examining parent-child interactions during the peri-trauma period and how this predicts post-trauma child PTSD symptoms. Methods: In study 1, we will conduct secondary analyses of three existing data sets of pediatric injury samples to examine the influence of parent and child early trauma symptoms, child coping, and parent coping assistance in the development of child PTSD. We will use structural equation modeling techniques to examine cross-lagged regression models, latent growth curve models, and latent difference score models. In Study 2, we will combine 1) an innovative experimental design (adapted from the anxiety disorder literature), in which children (ages 7-13 years) and parents engage in an interaction task to appraise an ambiguous scenario and choose a coping strategy, 2) child and parent self-report of appraisals, coping, and PTSD symptoms during the peri-trauma period, and 3) medical chart review to obtain data on the child's heart rate and injury severity. Career Goals: This K23 Award will provide necessary training and mentorship for the candidate to become an independent pediatric psychology researcher and leader in the field of PTSD prevention by allowing the candidate to 1) gain expertise in research design and analyses of studies evaluating the interplay between biological, psychological, and environmental risk factors for PTSD among children who experience medical events and use of advanced statistical techniques (structural equation modeling) to examine predictors of PTSD, 2) develop new methodological skills as applied to the study and prevention of PTSD (observational coding for parent-child interactions), 3) gain expertise in development and testing of PTSD preventive interventions for children and parents during a period of acute medical stress (secondary prevention), and 4) advance scientific skills in publication of research in peer-reviewed scientific journals and grantsmanship. Importance: The goal of my future research program is to develop preventive interventions to reduce the incidence of PTSD in children following acute pediatric medical events. This proposed project advances The NIMH's Strategic Objectives to chart mental illness trajectories to determine when, where, and how to intervene by identifying malleable and robust risk factors and the proposed Healthy People 2020 goals to promote quality of life by testing strategies to promote adaptive coping and prevent the development of PTSD.