Anke de Haan from the University Children’s Hospital in Zurich talks about the place that children’s post-trauma cognitions have in clinical practice:
Posttraumatic cognitions have been a topic in child trauma research for a few years now. Nevertheless, my impression is that they have not yet been established in clinical practice.
Why not? Are they not practically relevant? Are they too difficult to assess? Before I discuss these questions, I will briefly describe what I mean with dysfunctional posttraumatic cognitions.
The terms dysfunctional posttraumatic cognitions, negative cognitions, dysfunctional appraisals etc. can be traced to Ehlers and Clark’s cognitive model of posttraumatic stress disorder. This model suggests that appraising the traumatic event and its consequences as extremely negative creates a sense of serious current threat, with thoughts such as “the world is a scary place where I am highly vulnerable” or “I am an incompetent person, I will never be the same again.”
This sense of current threat is accompanied by intrusions and symptoms of arousal, anxiety, and other emotional responses. It also motivates behavioral and cognitive responses to reduce perceived threat and distress for a short period of time. Unfortunately, these have the long-term consequence of preventing cognitive change and, thus, of maintaining the disorder. Previous studies demonstrated the relevance of Ehlers and Clark’s model to childhood and adolescence.
With this background in mind, I will now discuss the two main questions.
Question 1: Are cognitions relevant in clinical practice?
Several studies have investigated the impact of dysfunctional posttraumatic cognitions in children and adolescents. These kind of dysfunctional cognitions were found to be highly correlated with acute stress, posttraumatic stress symptoms (PTSS), symptoms of depression and anxiety. They also correlated moderately with externalizing symptoms. Longitudinal research showed that dysfunctional cognitions predicted PTSS over time. Dysfunctional cognitions therefore seem to be relevant in both developing and maintaining psychological symptoms.
Furthermore, studies investigating the associations between trauma treatment, cognitions, and psychopathology showed that dysfunctional cognitions can be reduced by trauma therapy, and that the improvement in the overall psychopathology after trauma therapy might be caused by decreased levels of dysfunctional cognitions.
In my opinion, the studies underline the clinical relevance of dysfunctional posttraumatic cognitions. Established trauma therapies identify and treat dysfunctional posttraumatic cognitions as a key mechanism of recovery from posttraumatic stress. Additionally, dysfunctional cognitions were included in the DSM-5 as a new criterion within the posttraumatic stress disorder diagnosis, conceptualized as symptom cluster negative alterations in cognitions and mood.
Question 2: Can we assess dysfunctional cognitions in a patient- and therapist-friendly way?
So we know how relevant dysfunctional cognitions are and we may have already been treating them in our therapies. Nevertheless we do not seem to assess them properly before and during therapy or when evaluating our therapy progress. What could be reasons in the past and what have changed making it easier to assess cognitions now?
Speaking for my – German speaking – environment, we simply did not have a measure for a long time. Established German measures assessed dysfunctional cognitions by maximally three items. This situation changed when Meiser-Stedman and colleagues adapted the Child Posttraumatic Cognitions Inventory (CPTCI) in 2009 from the Posttraumatic Cognitions Inventory (PTCI). The PTCI was developed by leading trauma researchers including Edna B. Foa, Anke Ehlers, and David M. Clark over 15 years ago. Nowadays, we have validated versions of the CPTCI, for example in Chinese, Dutch and German.
In line with Ehlers und Clark’s model, which suggests that dysfunctional cognitions drive and maintain chronic stress, most studies have focused on cognitions’ impact on chronic stress. The results showed how relevant cognitions are, but did not help in giving practical advice to clinicians about which participants might be at risk of developing dysfunctional cognitions.
A few studies have examined predictors of the development or maintenance of dysfunctional cognitions. While females, especially female adolescents, appeared to be more at risk, research regarding impact of type of trauma or maltreatment yielded mixed results. Although further research is needed, it gives us a first impression regarding vulnerable patients.
The CPTCI assesses the constructs Permanent and disturbing change and Fragile Person in a scary world extensively. That is great for research but might be too long for a screening, keeping in mind that it only covers these two areas and for example nothing regarding the important construct of self-blame. Moreover, no cut-off scores existed in the first few years making the interpretation of results difficult. Fortunately, the research group of Meiser-Stedman have recently provided both a shorter more clinic-friendly version and cut-off scores for the long and short form.
I am guessing, but maybe due to a widely held view that assessing cognitions is too difficult for younger children, many clinicians did not consider it. And yes, it can be difficult to talk with younger children about their (dysfunctional) cognitions and sometimes further explanations are needed. However, results of validation studies showed that, for example, the CPTCI is applicable in young school-aged children. We know from practice that assessments in interview-form can help to check if the child understands the questions and if necessary to explain the items.
Summing up, there is still a gap between research and therapy, but much has been done already to use cognitions-measures more widely and systematically in assessment and treatment.