Allvarliga livshändelser och posttraumatisk stress hos barn som utreds för ADHD och/eller autismspektrumstörningar, | Application
Allvarliga livshändelser och posttraumatisk stress hos barn som utreds för ADHD och/eller autismspektrumstörningar,
Registration number: LIVFOU-732581
Forskningsanslag för DOKTORANDER
Application started by: Mehmet Göncu, 2017-07-01
Professional title at the time of application: leg psykolog
Work place at the time of application: Barn och ungdoms psykiatri
Last updated / corrected by: Mehmet Göncu, 2017-09-04
Application received by: Centrum för klinisk forskning, Värmland
GrantedGranted
Applicant: Mehmet Göncu
leg psykolog, Barn och ungdoms psykiatri

A. Övergripande projektinformation

Sökandes verksamhetstillhörighet

Område öppenvård

Ange arbetsplats

Barn och ungdoms psykiatri

Doktorandens arbetstid i organisationen - % av heltid

50

Datum för antagning som doktorand

2017-01-01

Antagen som doktorand vid

Antagen som doktorand vid Institutionen för sociala och psykologiska studier Karlstads Universitet

Tutor

Kjerstin Almqvist
forskningsledare, Område öppenvård

Datum för planerad eller genomförd halvtidskontroll eller licentiatsavhandling

2019-11-01

Beräknat datum för disputation

2020-01-01

B. Avhandlingens innehåll

Sammanfattning

Sammanfattning
Betydelsen av svåra livshändelser för barns utveckling och psykiska hälsa har beskrivits i en rad forskningsstudier under de senaste decennierna. Särskild hög risk för bestående symtombild kopplad till regleringssvårigheter finns om barn utsätts för upprepande allvarliga livshändelser. Barn kan även få symtom när deras föräldrar har varit utsatta, vilket förknippas med att föräldrarnas posttraumatiska symptom påverkar deras föräldra- förmåga negativt, till exempel genom bristande trygghet i samspelet med barnet. Exempel på vanliga symptom hos barn som utsatts för psykiska trauma är uppmärksamhetsstörning och irritabilitet (tecken på förhöjt spänningstillstånd, ett av kriterierna i Post Traumatiskt Stressyndrom (PTSD). Detta symtom ingår även i ADHD. För att barn ska bedömas ha PTSD krävs dock flera andra symtom som inte ingår i diagnosen ADHD. Forskning om barn med ADHD och autism har även visat att de löper ökad risk att utsättas för allvarliga livshändelser. Idag saknas kunskap om hur vanligt det är att barn som utreds för ADHD och/eller ASD har symtom på PTSD.
Syftet är att undersöka om barn som utreds för ADHD/ASD har varit med om allvarliga livshändelser och har symtom på posttraumatisk stress så att det är kliniskt relevant att kartlägga detta. Vi vill även kartlägga om barnens föräldrar har varit utsatta för allvarliga livshändelser och har symtom på posttraumatisk stress. Bättre kännedom om detta kan bidra till att insatserna för barnen kan utvecklas.

Projektbeskrivning

Kort beskrivning av forskningsplan
INTRODUCTION
Post-traumatic stress disorder (PTSD) is an emotional reaction to traumatic events and a long-term consequence of psychological trauma (Foa et al., 2009). The risk factors that have been shown to increase the development of PTSD are the severity of the traumatic event, the reaction and the temporal closeness to the traumatic event (NICE, 2006). Interpersonal trauma, such as violence, rape and assault, is more likely to result in PTSD than other types of trauma (Norris et al. 2002). Childhood abuse is a powerful predictor of future PTSD in children, adolescents (Kearney et al., 2009) and adults (Ozer et al., 2003). It has been estimated that, on average, one in ten children are neglected or psychologically abused annually and approximately 4% to 16% are physically abused (Gilbert et al., 2008). The adjusted odds ratio for a lifetime diagnosis of PTSD following childhood maltreatment has been estimated to be 4.86% (Scott et al., 2010). In their longitudinal study from a community based sample of 1,420 children and adolescents, Copeland et al. (2007) showed that violent or sexual trauma were associated with the highest rates of PTSD symptoms. Afifi et al. (2009) found that a combination of childhood abuse and parental divorce significantly increased the likelihood of a diagnosis of lifetime PTSD in adulthood.
There is also considerable evidence that the effects of trauma experiences are often transmitted across generations, affecting the children and grandchildren of those that were initially victimised (Amy et al., 2009; Hirsch, 2001). In a review of secondary trauma and PTSD, Hilarski (2004) found that exposure to parental trauma and negative parental responses to trauma, such as PTSD and substance abuse, can have a dramatic effect on children’s and adolescents’ mental health and adjustment. Davidson and Mellor (2001) conducted a study that compared three groups of children: children whose fathers were Vietnam veterans with PTSD, children whose fathers were Vietnam veterans without PTSD, and a control group of children whose parents had not taken part in combat. Significant differences in family functioning were found among the three groups. The lowest levels of family functioning were reported by children of veterans with PTSD. Research on sexually abused mothers has shown significant associations between childhood sexual abuse and several aspects of parenting, including anxiety over intimate aspects of parenting, higher overall stress as a parent, more negative self-views of parenting, difficulty establishing boundaries, higher likelihood of using physical discipline and higher risk of physically abusing one’s children (DiLillo & Damashek, 2003; Ruscio, 2001).
A longitudinal follow-up study of children with ADHD also documented a significant risk for PTSD in adolescence when compared with a control group without this disorder (Ford et al 2009). In another research study, Laslie (2001) found that 14% of the children with ADHD met the PTSD criteria according to the parents’ reports and 5% met the criteria according to the children’s reports. The results thus indicate that there is a relationship between parents’ PTSD diagnosis and the children’s ADHD and PTSD symptoms.
In a Swedish study, Daud and Rydelius (2009) indicated that ADHD and PTSD cover similar aspects of inattention and hyperactivity/impulsivity. This could explain why 65% of the boys and 30% of the girls in the experimental group fulfilled the DSM-IV-TR criteria for both sets of syndromes.
Despite several published studies on the comorbidity of PTSD, ADHD and other psychological disorders, there is still a lack of studies on the comorbidity of severe life events, PTSD and autism spectrum disorder (ASD). There are many good reasons why rates of psychiatric comorbidity in autism are not known and why comorbidity is often unrecognised clinically or difficult to diagnose. One of the reasons is that communication with the patient is universally impaired to some degree in autism (Ovsanna et al., 2006).
Autistic disorder is lifelong neurodevelopment disorders are characterized by impairments in persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays. Following, restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).Symptoms together limit and impair everyday functioning(APA, 2013). In comorbidity studies, researchers found rates for at least one comorbid disorder that varied between 63.3% (Amr et al. 2012) and 96.4% (Mukaddes et al. 2010). Mandel et al. (2005) reported trauma exposure in 30.7% of the individuals with an autism diagnosis. They also reported that 18.5% of children with autism had been physically abused and 16.6% had been sexually abused. Mehtar and Mukaddes (2010) found that 26.1% of their sample had a history of trauma, and the prevalence of PTSD was 17.4%.
For more detailed information regarding the introduction, see Annex 2.
Aim and questions
The aim of this study is to examine severe life events and PTSD symptoms in children who will be investigated for suspected ADHD and ASD symptoms. Moreover, we will examine the experiences of the children and parents within a transgenerational framework.
Based on these aims, this study has four questions:
1. To what extent have the children who will be investigated for ADHD and ASD been exposed to severe life events?
2.To what extent have the children who will be investigated for ADHD and ASD developed post-traumatic symptoms?
3.To what extent have the parents whose children will be investigated for ADHD and ASD been exposed to severe life events?
4. To what extent have the parents whose children will be investigated for ADHD and ASD developed post-traumatic symptoms after severe life events?
METHODS
Participants
Each year about 1,200 children attend the Child and Adolescent Psychiatry (CAP) in Karlstad. Approximately 350 of them are referred to the unit for Neuropsychiatric (NP) assessments, where the participants for this study will be recruited.
The children who are referred to the NP unit show symptoms such as lack of language, inconsistencies in responsiveness, lack of interest in others, failures in empathy, resistance to change, restricted interests, impulsivity, hyperactivity, inattention, anxiety, depression etc., and the first assessment of them has concluded that they need an assessment focused on the diagnoses ADHD and/or ASD. Most referrals come from parents, school, medical doctors, educational psychologists, nurses and other caregivers.
A minimum of 65 children and their parents will be included the study. The inclusion criteria for the children are as follows:
(a)the child is referred to the NP unit for assessment of suspected ADHD and/or ASD,
(b)the age ranges between 7 to 16,
(c)the child is living with at least one of the biological parents and
(d)the child and at least one parent are able to speak Swedish fluently.
Exclusion criteria are if the child and/or parents
(a) have a traumatic brain injury,
(b) have a psychosis,
(c) are heavy drug users,
(d) have expressive language difficulties,
(e) have difficulties speaking Swedish fluently and
(f) if the child lives in foster care.
Procedure
The planned study will be carried out in connection with the regular NP assessment procedure, but will be designed as an additional option for parents and children who choose to participate in the study. The regular procedure for assessment at the NP unit starts with a letter of information that is sent to the family. The letter includes appointment times and lists those who are involved in the assessment procedure. It gives a brief description of the different investigations and assessments of the child that will be carried out: in all about 5–7 appointment times for the child and parents. To inform parents and children about the research study, an additional information sheet is included in the letter. The aim and the procedure of the study are described, as well as that both parents and child will be given additional information and be asked to consent to participate at their first visit to the NP Unit. The information sheet concerning the research clearly states that participation is voluntary (see appendix 1).
During the first meeting at the clinic, after receiving information about the regular neuropsychiatric assessment, the parents and the child will receive oral information about the research study and be asked if they have any questions and if they consent to participate. Participation in the study means that they will be given two additional appointment times (2 x 60 min) at the clinic – one for the child and one for the parent(s). If the child and parents choose to participate in this study, they sign the consent form (see appendix 2).
In the regular NP-assessment, the children are individually administered on the Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV; Wechler, 2003), the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2001) and the QbTest (Qbtech Ltd, 2002). The parents describe their child's behaviour on the Adaptive Behavior Assessment System – Second Edition (ABBAS-II; Harrison & Oakland, 2002), the Social Communication Questionnaire (SCQ; Routes et al., 2003) and the SNAP-IV Teacher and Parent Rating Scale (SNAP-IV; Swanson et al., 1983).
Instruments
The children will fill out three self-rating questionnaires: the Lifetime Incidence of Traumatic Events (LITE-A; Greenwald, & Rubin, 1999, Nilsson, Gustafsson, & Svedin, 2012), the Trauma Symptom Check list for children (TSCC; Briere, 1996) and the Strengths and difficulties questionnaires (SDQ; Goodman, 1997).
The parents will fill out three questionnaires concerning their child: The Lifetime Incidence of Traumatic Events (LITE-P; Greenwald R., 2010, Nilsson, Gustafsson, & Svedin, 2010), The Trauma Symptom Checklist for Young Children ( only for the younger children between 7-12 years old) (TSCYC; Briere et al., 2001; Nilsson, Gustafsson, & Svedin, 2012) and Strengths and Difficulties Questionnaire – Parents (SDQ-P; Goodman, 1997)
In addition, the parents will fill out the following three questionnaires concerning their own exposure to severe life events and post-traumatic symptoms: the Lifetime Incidence of Traumatic Events scale (LITE; Greenwald et al., 1999), The Impact of Event Scale-Revised ( IES-R; Creamer, Bell, & Failla, 2003; Vassar, Knaup, Hale, & Hale, 2011) and Hopkins Symptom Check List-25(HSCL-25; Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L, 1974) (Muller , Postert, Beyer,Furniss,&Achtergarde, 2010)
For more detailed information regarding the instruments, see Annex 2.
Ethical Considerations
To carry out research with children and parents in need of Child and Adolescent Psychiatric care is an ethical challenge. When informing parents and children, it is necessary to emphasize that participation in the research in no way will interfere with ordinary care, and that a denial to participate will have no negative effects for them in the current assessment or in their future contacts with the clinic. Children are a vulnerable group in general, and children who are referred for a neuropsychiatric assessment will be in an especially exposed position. On the other hand, most times both children and parents are interested to participate in research that will bring more knowledge to the health and behavioural problems that they suffer from. A thorough description of the study to both children and parents is needed for them to be able to make an informed decision concerning participation or not.
In the case of children taking part in research, it is a question to consider for both the children and their parents. Parents with legal custody of the child will first be asked for consent for the child’s – and their own – participation in the study. All custodians need to agree for the child to be able to participate. In addition, the child will be asked for consent to take part in the study. Only children who consent to participate, and whose parents agree, will be included in the study. Children 15 years or older will initially be asked for consent themselves; if they decide to participate, their parents are asked to participate. The study was approved by the regional ethical review board in Uppsala, Dnr 2016/053.
Statistical Analysis
The results of the prevalence of post-traumatic symptoms and adverse life experiences of children referred for assessment of ADHD and/or ASD, as well as of the prevalence of adverse life experiences and post-traumatic symptoms of their parents, will be presented in descriptive statistics. Prevalence at adverse life events and posttraumatic stress symptoms in children and parents will be compared with Swedish norms and/or relevant comparisons groups. The Statistical Package for the Social Sciences (SPSS; 2007) will be used for the analyses.

Klara delarbeten / delrapporter

Arbetet pågår och cirka 40 barn och föräldrar är utred för svåra livshändelser och trauma symtom.
Forskningsplan upprättad
Etikprövningansökan godkänd
Jag har anmält mig till forskarkursen i Örebro nu i höst, psykologi del 1, 7,5 högskolepoäng.

Pågående delarbeten / delrapporter

Från 2016/03/23 till 2016/06/31 har jag gjort 15 planerade utredningar. Två av dessa utredda patienter /anhöriga ville inte delta i studien, medan 13 inkluderats av planerade 65 informanter. Inklusionstakten bedöms därmed motsvara det förväntade. Forskningsstudien dröjde eftersom etikprovningen godkändes först 2016/03/23 av Etiska nämnden i Uppsala, vilket innebär att en motsvarande förlängning av tidplanen bedöms krävas. Studien planeras vara färdigt våren 2018.
Time plan
The study is intended to be part of a doctoral thesis.Our time plan is 2016–2019. We plan to finish this project in a total of four years.
2016: Information from staff and clinic; the inclusion of children and parents begun
2016/03/23 and at end of the June 13 children were assessed.
2017: The inclusion of children and parents continues
2018: Analysis of research questions 1 and 2; Writing article I
2019: Writing articles II and III

Planerade delarbeten / delrapporter

The study will result in two articles for publication:
I: Severe life events and post-traumatic symptoms in children who are referred to assessment for ADHD and ASD
II: Severe life events and posttraumatic symptoms in parents of children who are referred to assessment for ADHD and ASD
Ett tredje delarbete baserat på annat datamaterial planeras att ingå i avhandlingen.

Klinisk betydelse

Studien kan bidra till att förbättra utredningar av barn med misstänkt neuropsykiatrisk problematik, genom att belysa om det är relevant att utreda allvarliga livshändelser eller ej i samband med utredningen.
Om det visar sig att det finns en betydande förekomst av posttraumatiska symtom bland barnen och/eller deras föräldrar kan insatser och vårdplanering anpassas och därmed förbättras.

Referenser

For more detailed information regarding the references , see Annex 2.

C. Ekonomisk översikt och äskande

DescriptionShort description of the costSum
LönekostnaderTjänstegöring,inklusive soc avg och semester ersättning osv.200 000
Sum 200 000

Ansvarsenhet och löneteam

Barn och ungdomspsykiatri i Karlstad

Decision

Decision date: 2017-11-01

Brief description of each costApplied sumDecision SEKDecision comment
Lönekostnader
Tjänstegöring,inklusive soc avg och semester ersättning osv.200 000200 000 
sum200 000200 000 

Allvarliga livshändelser och posttraumatisk stress hos barn som utreds för ADHD och/eller autismspektrumstörningar, | Application, from Centrum för klinisk forskning, Värmland
http://www.researchweb.org/is/liv/ansokan/732581