A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents

https://doi.org/10.1016/j.cpr.2011.12.001Get rights and content

Abstract

Post-traumatic stress disorder (PTSD) is a complex and chronic disorder that causes substantial distress and interferes with social and educational functioning. Consequently, identifying the risk factors that make a child more likely to experience traumatic distress is of academic, clinical and social importance. This meta-analysis estimated the population effect sizes of 25 potential risk factors for PTSD in children and adolescents aged 6–18 years across 64 studies (N = 32,238). Medium to large effect sizes were shown for many factors relating to subjective experience of the event and post-trauma variables (low social support, peri-trauma fear, perceived life threat, social withdrawal, comorbid psychological problem, poor family functioning, distraction, PTSD at time 1, and thought suppression); whereas pre-trauma variables and more objective measures of the assumed severity of the event generated small to medium effect sizes. This indicates that subjective peri-trauma factors and post-event factors are likely to have a major role in determining whether a child develops PTSD following exposure to a traumatic event. Such factors could potentially be assessed following a potentially traumatic event in order to screen for those most vulnerable to developing PTSD and target treatment efforts accordingly. The findings support the cognitive model of PTSD as a way of understanding its development and guiding interventions to reduce symptoms.

Highlights

► Demographic and pre-event factors are only weakly associated with development of PTSD. ► Fear and perceived life threat have stronger correlation to PTSD than trauma severity. ► Post-event factors have stronger correlation to PTSD than pre-event factors. ► Thought suppression, blaming others and distraction are stronger predictors of PTSD. ► Female sex became a stronger risk factor as age increased.

Section snippets

Rationale for the present study

Knowing reliably which factors make a child more likely to develop traumatic distress (whether that is measured by a diagnosis of PTSD, or by severity of PTSD symptoms) is of both academic and clinical interest. Firstly if clinicians know which children and adolescents are most likely to be adversely affected following exposure to events, then those children and adolescents can be most closely monitored with a view to providing treatment as necessary before difficulties become chronic (Pine &

Existing reviews of research

There are a number of reviews of the literature that have attempted to increase our understanding of the development of child PTSD (Foy et al., 1996, Pine and Cohen, 2002). Pine and Cohen's review identified two factors consistently related to adverse outcome: trauma exposure and disrupted social support. Foy also argued that parental distress might act as a powerful mediating factor in the development of the child's symptoms. Whilst such reviews are helpful, a more systematic review and

Other meta-analyses of risk factors for PTSD

There are two meta-analyses of studies examining risk factors for PTSD in adults (Brewin et al., 2000 and Ozer, Best, Lipsey, & Weis, 2003). Brewin and colleagues conducted meta-analyses of 14 risk factors and analysed moderating effects of various sample and study characteristics. The effect size of all the risk factors was modest; but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had larger effect sizes (r = 0.23 to

Selection of studies for the meta-analysis

English-language articles published in peer-reviewed journals between 1980 (the first DSM definition of PTSD) and May 2009 were considered for inclusion. Various psychological and medical literature databases were searched, including the PILOTS database managed by the National Center for PTSD, Medline, PsychInfo, Embase and Web of Science. In addition, each issue of the Journal of Traumatic Stress was examined for relevant research. Secondary sources such as review articles, book chapters and

Characteristics of studies

The method described earlier generated 25 risk factors that were explored by two or more studies, which could then be entered into the meta-analysis. Sample sizes from individual studies ranged from 20 to 5687. Characteristics of the studies included in the meta-analysis (trauma type, sample size, measure of PTSD, whether the measure was an interview or questionnaire, age range, mean age, percentage of sample that were female, and location of study) are contained in Table 2.

Risk factor estimates

The main results of

Discussion

This meta-analysis involved investigating 25 risk factors for PTSD in children and adolescents aged 6–18 years, across 64 studies published between 1980 and May 2009. The combined sample size for the studies considered was very large (32,238). A small effect size was observed for race and younger age as risk factors for PTSD; a small to medium-sized effect was observed for female gender, low intelligence, low SES, pre- and post-trauma life events, pre-trauma psychological problems in the

References (118)

  • I. ⁎Giannopoulou et al.

    Post-traumatic stress reactions of children and adolescents exposed to the Athens 1999 earthquake

    European Psychiatry

    (2006)
  • A.K. ⁎Goenjian et al.

    Psychiatric comorbidity in children after the 1988 earthquake in Armenia

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1995)
  • A.K. ⁎Goenjian et al.

    Depression and PTSD symptoms among bereaved adolescents 6½ years after the 1988 spitak earthquake

    Journal of Affective Disorders

    (2009)
  • L.H. ⁎Jaycox et al.

    Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2002)
  • M. ⁎Korol et al.

    Children's responses to a nuclear waste disaster: PTSD symptoms and outcome prediction

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1999)
  • M.A. ⁎Landolt et al.

    Predicting posttraumatic stress symptoms in children after road traffic accidents

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2005)
  • C.J. ⁎Lonigan et al.

    Children's reactions to a natural disaster: Symptom severity and degree of exposure

    Advances in Behaviour Research and Therapy

    (1991)
  • M.W. ⁎Otto et al.

    Posttraumatic stress disorder symptoms following media exposure to tragic events: Impact of 9/11 on children at risk for anxiety disorders

    Journal of Anxiety Disorders

    (2007)
  • B. Pfefferbaum

    Posttraumatic stress disorder in children: A review of the past 10 years

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1997)
  • B. ⁎Pfefferbaum et al.

    Posstraumatic stress responses in bereaved children after the Oklahoma City bombing

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1999)
  • D.S. Pine et al.

    Trauma in children and adolescents: Risk and treatment of psychiatric sequelae

    Biological Psychiatry

    (2002)
  • R.S. Pynoos et al.

    A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders

    Biological Psychiatry

    (1999)
  • R. Rosenthal

    The ‘File Drawer Problem’ and tolerance for null results

    Psychological Bulletin

    (1979)
  • K. Salmon et al.

    Posttraumatic stress disorder in children. The influence of developmental factors

    Clinical Psychology Review

    (2002)
  • J. ⁎Aaron et al.

    Posttraumatic stress in children following acute physical injury

    Journal of Pediatric Psychology

    (1999)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2000)
  • C.B. Begg

    Publication bias

  • C.R. Brewin et al.

    Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults

    Journal of Consulting and Clinical Psychology

    (2000)
  • C.R. Brewin et al.

    A dual representation theory of posttraumatic stress disorder

    Psychological Review

    (1996)
  • C.R. Brewin et al.

    Brief screening instrument for post-traumatic stress disorder

    The British Journal of Psychiatry

    (2002)
  • P.C. Broderick

    Early adolescent gender differences in the use of ruminative and distracting coping strategies

    The Journal of Early Adolescence

    (1998)
  • C.M. Cox et al.

    A meta-analysis of risk factors that predict psychopathology following accidental trauma

    Journal for Specialists in Pediatric Nursing

    (2008)
  • S.E. Cutler et al.

    Accounting for sex differences in depression through female victimization: Childhood sexual abuse

    Sex Roles

    (1991)
  • T. Dalgleish

    Cognitive theories of post-traumatic stress disorder

  • T. Dalgleish et al.

    Cognitive aspects of posttraumatic stress reactions and their treatment in children and adolescents: An empirical review and some recommendations

    Behavioural and Cognitive Psychotherapy

    (2005)
  • L. Davis et al.

    Posttraumatic stress disorder in children and adolescents: A review and analysis

    Clinical Child and Family Psychology Review

    (2000)
  • C. Dehon et al.

    Screening for preschool posttraumatic stress disorder with the Child Behavior Checklist

    Journal of Pediatric Psychology

    (2006)
  • J.A. Durlak et al.

    A practitioner's guide to meta-analysis

    American Journal of Community Psychology

    (1991)
  • T. Ehring et al.

    Do cognitive models help in predicting the severity of posttraumatic stress disorder, phobia, and depression after motor vehicle accidents? A prospective longitudinal study

    Journal of Consulting and Clinical Psychology

    (2008)
  • A.P. Field

    Meta-analysis of correlation coefficients: A Monte Carlo comparison of fixed and random-effects methods

    Psychological Methods

    (2001)
  • A.P. Field

    The problem in using fixed-effects models of meta-analysis on real-world data

    Understanding Statistics

    (2003)
  • A.P. Field

    Is the meta-analysis of correlation coefficients accurate when population effect sizes vary?

    Psychological Methods

    (2005)
  • A.P. Field et al.

    How to do a meta-analysis

    The British Journal of Mathematical and Statistical Psychology

    (2010)
  • K.E. Fletcher

    Childhood posttraumatic stress disorder

  • A.K. ⁎Goenjian et al.

    Posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch

    The American Journal of Psychiatry

    (2001)
  • A.K. ⁎Goenjian et al.

    A prospective study of posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after a catastrophic disaster

    The American Journal of Psychiatry

    (2005)
  • P. Hampel et al.

    Age and gender effects on coping in children and adolescents

    Journal of Youth and Adolescence

    (2005)
  • L.V. Hedges et al.

    Statistical methods for meta-analysis

    (1985)
  • L.V. Hedges et al.

    Fixed- and random-effects models in meta-analysis

    Psychological Methods

    (1998)
  • E. ⁎Heptinstall et al.

    PTSD and depression in refugee children: Associations with pre-migration trauma and post-migration stress

    European Child & Adolescent Psychiatry

    (2004)
  • Cited by (552)

    View all citing articles on Scopus
    1

    References marked with an asterisk indicate studies included in the meta-analysis.

    View full text