Title: Caregiver influences on child psychological adjustment following trauma; a longitudinal study of a high adversity South African population
Funder: Economic and Social Research Council

Abstract: Children exposed to trauma are vulnerable to developing posttraumatic stress disorder (PTSD) and other adverse mental health outcomes. In research conducted in the UK we have identified aspects of caregiver support that are predictive of child PTSD following acute trauma exposure. However, the UK children we studied experienced relatively low risk events for PTSD (e.g., car accidents, serious accidents) and had high overall levels of support and resource. In low-and-middle-income countries (LMICs), children are at elevated risk of exposure to severe trauma, and co-occurring adversities are common. We propose to expand our UK based work to the study of impoverished LMIC communities in South Africa, where children are highly vulnerable to trauma exposure due to poverty, insecure housing, limited policing, and markedly high levels of community violence. Although such groups have been identified as being at particular risk of PTSD and other adverse outcomes they are poorly represented in the extant literature. Understanding of the factors that promote or impede posttrauma recovery in such children is correspondingly limited. We have conducted preliminary research which indicates that caregiver support is highly relevant to such children following trauma. At the same time, environmental factors (e.g., prevailing high levels of risk, caregiver trauma exposure) may constrain both the way in which such informal support is provided, and the coping behaviours that are available to children. We aim to conduct a robust examination of the role of caregiver factors in influencing children's psychological outcomes following trauma exposure among families growing up in high adversity, settlement communities in South Africa. Although deprived, focal communities face many of the challenges that are typical for children growing up in LMIC contexts globally. Through a large-scale, longitudinal investigation of children and caregivers in the 6-months following trauma, we will gain systematic information about pathways to recovery versus persistent PTSD. Primary objectives a) To examine trauma related aspects of caregiver support as predictors of initial child PTSD symptoms posttrauma and symptom change over time: We will test whether caregiver expression/endorsement of negative trauma-related appraisals, and facilitation of avoidant coping behaviours (limiting trauma conversations, avoidance of trauma reminders) in the child are associated with higher initial levels of child PTSD symptoms and reduced recovery over time; and will examine whether positive use of faith based-support predicts better child outcomes. b)To examine child cognitive-behavioural processes as potential mediating variables: We will test whether the way that children recall and appraise the trauma, and the coping behaviours that they adopt, mediate any associations between caregiver support and child PTSD symptoms. c) To examine pathways from caregiver trauma and PTSD to child outcomes, via caregiver responding: We will also test whether mediated pathways are present from caregiver symptoms of PTSD to child PTSD via caregiver responding. Secondary objectives d) To obtain longitudinal information about risk of PTSD and extent of recovery in the acute phase posttrauma in a high adversity, LMIC population: Most of our knowledge of child posttrauma psychological recovery comes from lower risk populations, exposed to low risk types of events (disasters, accidental injuries). We will generate much needed information about the prevalence of initial PTSD and trajectories of recovery among children from a high-risk population, where more severe trauma (i.e., assaultive violence) is common. e) To test whether predictors of child PTSD symptoms also predict wider aspects of posttrauma mental health: We will examine other common posttrauma mental health difficulties, specifically symptoms of depression, anxiety and externalising problems.

Lay abstract: Children who experience very frightening or traumatic events (such as car accidents, assaults, serious injuries) are vulnerable to developing posttraumatic stress disorder (PTSD) and other psychological difficulties following their experiences. Such problems can be extremely distressing, and affect a significant proportion of trauma exposed children. One factor that has the potential to influence such outcomes is the informal support that children receive from their parents/caregivers posttrauma. In research we have conducted in the UK, we found that certain aspects of caregiver responses can have an impact upon children's psychological recovery following trauma. In particular, where caregivers encourage ways of coping in children that allow them to avoid being reminded of the trauma, and/or talk to children about what happened in a way that emphasizes high levels of threat associated with the trauma, children are more likely to experience persistent symptoms of PTSD. These caregiver responses may influence child symptoms as a consequence of children themselves then making more negative appraisals in relation to what happened, and by influencing child coping behaviours. We propose to extend our UK work to the study of a high adversity international population. To date, only a small proportion of PTSD research has been conducted in low-and-middle-income countries (LMICs). This omission is important, as LMIC children may be particularly vulnerable to trauma exposure for a variety of reasons (e.g., poverty, crime, regional conflict). It is essential to establish whether psychological and social processes that have been linked to child PTSD in lower risk settings still apply in contexts where levels of ongoing threat and the likelihood of exposure to recurrent traumas are high. In particular, although we know that caregiver support is a key predictor of child psychological recovery following trauma in high income countries, our understanding of the elements of support that can help children from high adversity, lower income contexts is almost non-existent. This is important, as such children are almost certain to rely on such informal support following trauma exposure, due to limited access to formal psychological services. To address this critical gap in our knowledge, we plan to study the psychosocial factors that contribute to PTSD in a group of children (aged 8-16 years) from a deprived community in South Africa, in which rates of serious trauma exposure are extremely high. We will recruit 250 children who have experienced trauma within 2 weeks following the event. We measure how caregivers provide support, as well as children's initial levels of symptoms. We will then follow-up children and caregivers 3 months and 6 months later, measuring their PTSD symptoms. We will examine whether there are particular elements of caregiver support in the aftermath of trauma that are associated with higher or lower levels of symptoms in children further down the line. We we also will test whether caregiver influences operate via changing key psychological processes (trauma appraisals, coping) in the child, and will take account of caregivers' own trauma-related distress in our study. In addition to helping us to understand what kind of social support is best for children who experience trauma, our project will provide much needed information about the development of PTSD in children from high adversity, low income communities. This is important: at the moment we are lacking even basic information about risk of PTSD in the acute aftermath of trauma among such children, including the proportion who will initially develop this disorder following trauma, the window of time during which children may recover naturally following the event, and the proportion likely to experience persistent disorder and need intervention. This is a major barrier to developing screening and intervention programmes, which our study will be able to address.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: MENTAL HEALTH