Caregiver influences on child psychological adjustment following trauma; a longitudinal study of a high adversity South African population "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. "
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