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Research has shown that the first six months following trauma exposure in childhood is critical in the potential development of long-term posttraumatic stress disorder (PTSD), evidencing that beyond this initial six-month period natural decline in posttraumatic stress symptoms (PTSS) is unlikely (Hiller et al., 2016). PTSD in childhood has been associated with long-lasting impacts on the wider mental health and functional abilities of children (e.g., Lewis et al., 2019). As such, appropriate measurement of PTSS in the initial period following trauma exposure is critical to ensuring that appropriate interventions can be implemented.
While care providers emphasise that the widely regarded gold standard of evidence-based assessment, structured diagnostic interviews, are too resource intensive to administer in a clinical setting (Aboraya, 2009; Whiteside et al., 2016), rating scales offer practical, reliable, and valid methods of identifying, measuring, and tracking mental health symptoms (Silverman & Ollendick, 2005). Rating scales are typically administered to several informants, most commonly the child themselves and their parent/caregiver, and while they solve the issue of practicality they rely largely on the subjective perspective of the informant. Accordingly, research has shown that parent-child agreement on reports of child mental health symptoms is moderate at best (e.g., r = .20–.60; De Los Reyes et al., 2015), and understanding of the factors that contribute to this discrepancy is limited. In the present paper, we therefore aimed to expand our understanding of what can be learned from self- and parent-report measures of child PTSS by exploring the patterns of association among these report measures and child heart rate (HR) indices in an acute injury sample.
Our sample included 132 parent-child dyads (child age: 6–13 years; 91.7% White) recruited from four hospital emergency departments in England following the child’s exposure to an acute trauma (road traffic accident, fall, acute illness, sporting injury, assault).

The following were all assessed at one-month posttrauma:

  • Child PTSS (self- and parent-report) using the UCLA PTSD Reaction Index (PTSD-RI; Steinberg et al., 2004).
  • Parental PTSS related to their child’s trauma using the Posttraumatic Diagnostic Scale (PDS; Foa et al., 1997).
  • Child HR reactivity to trauma was measured during two trauma narrative tasks in which the child was asked to provide an account of their traumatic experience both alone and together with their parent. HR indices were averaged across the two narrative conditions and controlled for resting HR.

We evidenced poor-to-moderate agreement on child PTSS, consistent with existing literature, and additionally found that children reported significantly more PTSS than parents across the intrusion, avoidance, and hyperarousal PTSD symptom clusters. We also found parental PTSS to be an important factor for consideration, evidencing that parents with higher levels of PTSS report more symptoms in their children compared to parents with lower PTSS regardless of their child’s self-reported symptom levels or actual PTSD diagnostic status. In addition, we found that parental PTSS were also predictive of a higher discrepancy between child and parent reports of children’s symptoms, such that higher levels of parental distress predicted high parental ratings of child symptoms relative to child self-ratings. Finally, we found that child self-reported PTSS were associated with HR indices, particularly symptoms of hyperarousal, whereas parent reports of child PTSS did not account for variance in the same indices. Overall, these observations suggest that children, but not parents, may be attuned to elements of children’s posttraumatic distress that are reflected in their autonomic reactivity to trauma cues. Consequently, relying only on parental reports of children’s PTSS could fail to detect potentially significant aspects of children’s symptom profiles.
The current findings require replication with larger and more generalisable samples given that links between HR reactivity and PTSD are still being established in the children’s trauma field. Nonetheless, our findings provide significant insight into the multi-informant approach to assessing child PTSS following trauma exposure. To our knowledge, this is the first contribution to the literature to include an evaluation of the patterns of association between informant reports and child HR indices, evidencing the clinical utility of children’s self-reports. Additionally, our findings highlight that although parental distress is certainly not the only factor that may influence parent reports of child symptoms, it is one that can potentially be addressed. For instance, clinicians and researchers can provide parents with relevant information and guidance to help them understand that their child may not share the distress they themselves are feeling about their child’s traumatic experience. Finally, this study establishes a strong base upon which parents can seek guidance about how best to support their children following exposure to a potentially traumatic event.

Target Article 

Bailey, M.,  Meiser-Stedman, R.,  Hiller, R.,  Haag, K.,  Lobo, S., &  Halligan, S. L. (2023).  Child posttraumatic stress symptoms in an acute injury sample: Patterns of associations among child report, parent report, and child heart rate parameters. Journal of Traumatic Stress,  00,  1– 13. https://doi.org/10.1002/jts.22913

Discussion Questions

  1. Is there potential for biological indicators, such as heart rate reactivity, to become central to the evidence-based assessment of PTSD and other mental health problems?
  2. Should parental mental health be similarly assessed alongside their child to inform the support and guidance provided by clinicians?
  3. In light of the present findings, as well as prior research suggesting that structured diagnostic interviews are too resource intensive for use in clinical practice (e.g., Whiteside at al., 2016), should psychologists be reconceptualising what we consider to be the gold standard of evidence-based assessment, particularly in the assessment of children’s mental health?
  4. What further insight could potentially be gained from replicating the present study in low- and middle-income country populations?

About the Authors

Megan Bailey, MSc is a first year PhD researcher in the Department of Psychology at the University of Bath. Her PhD focuses on the psychological and physiological health of children and young people exposed to trauma in low- and middle-income countries.  
Richard Meiser-Stedman, PhD DClinPsy, is a Professor of Clinical Psychology at the University of East Anglia, where he mainly researches PTSD in children and adolescents. He completed his PhD and trained as a clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience, KCL. From 2009-2014 he was an MRC Clinician Scientist Fellow at the MRC Cognition and Brain Sciences Unit in Cambridge. From 2016 to 2020 he was an NIHR Career Development Fellow, through which he led the DECRYPT trial. 
Professor Meiser-Stedman can be contacted at r.meiser-stedman@uea.ac.uk 
Rachel Hiller, PhD is an Associate Professor at the University College London. Her research foucses on the mental health and wellbeing of young people who have been exposed to trauma or maltreatment, including the role of caregivers and professionals in providing support.
Dr. Katharina Haag, PhD completed her PhD focusing on parenting and child trauma at the University of Bath in 2020. She is currently a postdoctoral researcher at the Norwegian Institute for Public Health, researching the effects of attending high quality kindergarten on later life mental health and academic outcomes, using data from the Norwegian Mother Father and Child Cohort study.
Sarah E M Lobo, MSc, Department of Psychology, University of Bath.
Sarah Halligan, DPhil is Professor of Child and Family Mental Health at the University of Bath. Her research examines the development of psychological disorders, particularly posttraumatic stress disorder (PTSD), with a focus on young people. Professor Halligan has studied the cognitive-behavioural, biological and social factors that contribute to disorder following trauma exposure, working with both national and international populations. Prof Halligan can be contacted s.l.halligan@bath.ac.uk. 

References Cited

Aboraya, A. (2009). Use of structured interviews by psychiatrists in real clinical settings: Results of an open-question survey. Psychiatry (Edgmont), 6(6), 24–28. 

De Los Reyes, A., Augenstein, T. M., Wang, M., Thomas, S. A., Drabick, D. A., Burgers, D. E., & Rabinowitz, J. (2015). The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological Bulletin, 141(4), 858–900. http://dx.doi.org/10.1037/a0038498 

Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9(4), 445–451. https://doi.org/10.1037/1040-3590.9.4.445 

Hiller, R. M., Meiser‐Stedman, R., Fearon, P., Lobo, S., McKinnon, A., Fraser, A., & Halligan, S. L. (2016). Research review: Changes in the prevalence and symptom severity of child post‐traumatic stress disorder in the year following trauma–a meta‐analytic study. Journal of Child Psychology and Psychiatry, 57(8), 884–898. https://doi.org/10.1111/jcpp.12566

Lewis, S. J., Arseneault, L., Caspi, A., Fisher, H. L., Matthews, T., Moffitt, T. E., Odgers, C. L., Stahl, D., Teng, J. Y., & Danese, A. (2019). The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. The Lancet Psychiatry, 6(3), 247–256. https://doi.org/10.1016/S2215-0366(19)30031-8

Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 380–411. https://doi.org/10.1207/s15374424jccp3403_2 

Steinberg, A. M., Brymer, M., Decker, K., & Pynoos, R. S. (2004). The UCLA PTSD Reaction Index. Current Psychiatry Reports, 6, 96–100. https://doi.org/10.1007/s11920-004-0048-2

Whiteside, S. P., Sattler, A. F., Hathaway, J., & Douglas, K. V. (2016). Use of evidence-based assessment for childhood anxiety disorders in community practice. Journal of Anxiety Disorders, 39, 65–70. https://doi.org/10.1016/j.janxdis.2016.02.008