Depression in Trauma-Exposed Children and Adolescents

196 Pages·2017·4.56 MB·English

Depression in Trauma-Exposed Children and Adolescents: An Exploration of Risk Factors and
PTSD-Depression Comorbidity.

Jade Elizabeth Claxton

Doctoral Programme in Clinical Psychology
The University of East Anglia

Final submission: 5th September 2017

Word Count: 37327

This copy of the thesis has been supplied on condition that anyone who consults it is understood
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extract must include full attribution.
Abstract
Background: Whilst traumatic exposure appears common and the majority remain resilient,
some go on to develop depression and PTSD. Childhood and adolescence is a critical period for
more deleterious and long-term impacts of trauma exposure; but crucially to date research has
been limited. Post-traumatic depression and PTSD-depression comorbidity are particular facets
of child and adolescent trauma responses that require increased focus. Aims: This portfolio
presents two research elements: a synthesis of the literature aims to examine risk factors for post-
traumatic depression in children and adolescents; an empirical study aims to investigate
cognitive appraisals, cognitive avoidance and rumination as potential shared cognitive
vulnerabilities in PTSD and depression. Methods: a systematic keyword search of the literature
between 1980 and 2016 yielded 647 studies. Fifty-nine studies were identified for inclusion
(N=45,688) and meta-analyses were conducted for 12 potential risk factors for post-traumatic
depression. A community sample of 280 school-aged adolescents (12-15 years) reporting trauma
exposure completed measures of PTSS, depression, trauma-related and depressogenic appraisals,
cognitive avoidance and rumination. Findings: Pre-trauma and peri-trauma risk factors largely
generated small effect sizes (r=.10 – r=.21) whereas post-trauma risk factors largely generated
moderate to large effect sizes (r=.29 – r=.58). Comorbid PTSD was the most prominent risk
factor. Negative cognitive appraisals, cognitive avoidance and rumination were found to be
strong, equivalent correlates of PTSS and depression symptoms; endorsed by all probable
diagnostic groups; and significant predictors in hierarchical regression models of PTSS and
depression symptoms. Conclusions: post-trauma environment and responses appear important in
determining post-traumatic depression in children in adolescents. Cognitive appraisals, cognitive
avoidance and rumination are found to be shared cognitive vulnerabilities in PTSD and
depression and may underlie comorbidity. Targets for assessment, monitoring and treatment are
highlighted.
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Table of Contents
Abstract……………………………………………………………………………………………….. ii
Table of Contents….……………………………………….…………………………………………. iii
List of Tables……………………...………………………………………………………………….. vi
List of Figures……………………...…………………………………………………………………. vii
Acknowledgements……………………………………….………………..…………………………. viii
Chapter One: Meta-Analysis …………………………………………….……………………..……. 1
Risk Factors for Depression in Trauma-Exposed Children and Adolescents
Abstract……………………………………………………………………………..…………. 2
Introduction…………………………………………………….…………………...…………. 3
Method………………………………………………………….…………………...………… 6
Results…………………………………………………………..…………………...………… 14
Discussion……………………………………………………….…………………..………… 19
References……………………………………………………….…………………...……….. 29
Chapter Two: Empirical Study.....…………………………………………………………………... 40
Cognitive Appraisals, Cognitive Avoidance and Rumination as Shared Vulnerabilities for PTSD and
Depression in Trauma-Exposed Adolescents.
Abstract………………………………………………………….……………………………. 41
Introduction……………………………………………………..………………….…………. 42
Method…………………………………………………………..…………………..………… 47
Results…………………………………………………………..…………………………….. 51
Discussion……………………………………………………….………………….………… 61
References……………………………………………………….…………………..………... 68
Chapter Three: Extended Methodology………………………………….....………………………. 81
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Considerations of Sample Size……………….……………………………………..………... 81

Collaborative Working……………………….……………………………………..……… 81
Supplementary Information on Measures……………………….………………………….. 82
Supplementary Procedural Information……………………………………………..……… 83
Participant Wellbeing Screen……………………………………………………….……… 83
Meeting Thresholds………………………………………………………………….. 84
Approaching Thresholds………………………………………………….…………. 85
Processes Following the Wellbeing Screen………………………….…………….... 85
Ethical Considerations…………………………………………..…………………………. 86
Ethical Approval and Amendments…………………………………………………. 86
Use of Opt-out Consent……………………………….………………………….….. 87
Confidentiality and Withdrawal……………………….…………………………….. 89
Consideration of Potential Risks…………………………………………………...… 90
Chapter Four: Extended Results……………………………………………..…………………… 91
Assumptions of Normality…………………………………………………………………. 91
Exposed Sample…………………………………………………………………….. 91
Diagnostic groups……………………………………..…………………………….. 93
Further Assumptions of ANOVA……………………………….…………………………. 94
Assumptions of Multiple Regression………………………………………………………. 95
Hierarchical Regression models………………………………………………………….... 96
Chapter Five: General Discussion and Critical Evaluation…………………..………………….. 99
Overview of Findings………………..…………..…….....………………………………... 99
Links with Previous Research……………………..……….…………………………….... 100
Strengths…………………………………..……………………………………………….. 116
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Limitations………………………………………………………………………..………... 117
Clinical Implications……………………………………….……………………………… 120
Theoretical Implications……………………………………………………………..……. 123
Future Work…………………………………………………..………………………….... 126
Conclusion………………………………………………………………………….……... 127
References……………………………………………………………………………..……..….. 128
Appendices..………………………………………….………………………………………….. 147

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List of Tables and Supplementary Material
Tables
Chapter One: Meta-Analysis
Table 1: Characteristics of included studies…………………………….…………………………… 10
Table 2: Summarised individual meta-analyses of risk factors……………………………………... 15
Table 3: Comparisons with PTSD meta-analysis …………………………………………………… 24
Chapter Two: Empirical Paper
Table 1: Zero-order correlations….………………………………………………………………… 53
Table 2: Demographic characteristics of diagnostic groups and their differences.....……………… 54
Table 3: ANOVA analysis and group comparisons across study variables………..……………… 55
Table 4: Summary of hierarchical regression analysis: predictors of PTSS and depression
symptoms …………………........................................................................................…………….. 57
Table 5: Comparison of predictor regression beta weights and structure coefficients…….……………… 58
Table 6: Summary of unique and common variances of predictors in PTSS and depression symptoms….. 60
Table 7: Commonality analysis: variance partitions in depression and PTSD symptoms …………. 60
Table 1: Summary of Skewness and Kurtosis Statistics for overall exposed sample………………. 92
Table 2: Summary of Skewness and Kurtosis Statistics for diagnostic groups ……………………. 94

Supplementary Material
Supplementary Material Meta-analysis: Risk of bias assessment checklist…………….…..,……… 37
Supplementary Material Meta-analysis: Risk of bias assessment criteria and scoring ……….……. 37
Supplementary Table 1 Meta-analysis: Risk of bias assessment summary of study ratings………... 38

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List of Figures
Chapter One: Meta-Analysis
Figure 1: PRISMA Flow Diagram of included and excluded studies……………………………….. 7
Figure 2: Forest plot of all risk factors with overall effect size and 95% confidence …………...….. 14
Chapter Two: Empirical Paper
Figure 1: Venn diagram delineating unique and comorbid diagnostic cases………………………... 52
Additional Chapters
Figure 1: Histogram depiction of regression model residuals for depression symptoms…………... 97
Figure 2: Histogram depiction of regression model residuals for PTSD…………………………… 98

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Acknowledgements

I would like to say a huge thank you to all the pupils and schools who participated in my research
and the members of staff whom supported the undertaking of the data collection. Without your
time, effort and enormous support for young people’s mental health this research would not have
been possible. To my research supervisor Richard Meiser-Stedman, a special thank you for your
endless encouragement, expertise and humour! Without doubt, your support and direction saved
me from losing the plot many a time! Appreciation and thanks goes out to Alice, Leila and
Viktoria for your time, contributions and support in my research. To my friends and family who
have been there despite my absence! Loving me, keeping me sane, and cheering me on, an
infinite thank you to you all. To my fellow ClinPsyD Trainee’s for your kindness and
understanding through this journey! Oh what a journey it’s been! A special thanks to Alex and
Sophie, for being there every step of the way with boundless support through Thesis Malaise!
And finally to Rich, for keeping me fed and taking on all the things I had no capacity to do, for
putting up with my life in my study cave and loving me still, for being my rock, I am eternally
grateful.

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Risk Factors for Depression in Trauma-Exposed Children and Adolescents:
A Meta-analysis.

Jade Claxton
Trainee Clinical Psychologist, Norwich Medical School, University of East Anglia
Dr Richard Meiser-Stedman
Clinical Reader, Norwich Medical School, University of East Anglia
Viktoria Vibhakar
Research Associate, RECOVER Injury Research Centre, University of Queensland
Leila Allen
Research Assistant, Norwich Medical School, University of East Anglia

Contributions:
Study design and data acquisition: Viktoria Vibhakar, Leila Allen, Jade Claxton
and Dr Richard Meiser-Stedman
Analysis and interpretation of data: Jade Claxton
Drafting manuscript: Jade Claxton
Critical revision of the manuscript: Richard Meiser-Stedman

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Abstract
Whilst Post Traumatic Stress Disorder has been the most frequently studied sequela in the
aftermath of trauma, post-traumatic depression is at least as prevalent, if not more so. The
impacts of depression are wide-ranging, deleterious and potentially long-term, thus
understanding the risk factors for depression following trauma-exposure in children and
adolescents appears fundamental. The presented meta-analysis provides pooled effect sizes
for 12 risk factors from 59 studies (N=45,688) contributing 135 effect sizes. Small effect
sizes were largely found for pre-trauma variables (age, gender, income and prior trauma
exposure) and trauma-related risk factors (trauma severity and peri-traumatic distress);
whilst moderate to large effect sizes were found for post-trauma variables (comorbid PTSD
symptoms, avoidant coping and low social support) and bereavement (considered both a
trauma-related and post trauma variable with lasting impacts). These findings suggest that
the post-traumatic responses and environment of children and adolescents may be prominent
factors in influencing those that experience post-traumatic depression in the aftermath of
trauma exposure. This highlights potential targets for assessment and monitoring those most
at risk and may also inform treatment.

Keywords: Post-traumatic depression, risk factors, children, adolescents, trauma

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