Agreement between adult caregivers and their children about the type of potentially traumatic events experienced by the child, the impact of these events and the resulting symptoms was variable and at times strikingly poor. Agreement was considered in the low range across most types of traumas reported. While some differences based on age and gender were found, correlations were moderately positive at best. Youth reported more events than parents, especially in categories of community violence. Not only did parents’ greatly underestimate their child’s exposure in certain categories, but their report of the impact of previous or recent PTEs on their children either at the time of the incident or at the time of the assessment was low. Correlations were not significant and the meaningful association was low (Hinkle, Wiersma & Jurs, 1988) indicating parents’ lack of understanding of the impact of events on their children. This was particularly true for females and adolescents. An outstanding conclusion from this study is that parent-child agreement on the numbers and types of potentially traumatic experiences and their subsequent impact is poor beginning in the acute peritraumatic period. In general, parent-child communication about youth experience of upsetting events and its accompanying distress appears to be lacking.
These findings are consistent with prior reports in the literature (Schreier, et al., 2005
) and are grounds for continuing concern. Family and social support has been found to be an essential protective factor in multiple explorations of exposure to traumatic events (Bal, De Bourdeaudhuij, Crombez, & Van Oost, 2004
; Kaufman, et al., 2004
). In childhood and adolescence reliance on adult caregivers for appropriate emotional support and attention is generally a necessity. Adolescents may have more opportunity and ability to access support from peers and other adults, but regardless of age, parental recognition of traumatic symptoms is a requirement in order for consultation or treatment to be obtained. Lack of parental understanding about the impact of the trauma experienced by the child is likely to be related to failure to seek intervention required to adequately address symptoms and subsequently, to poorer outcomes for the child.
There was similarly poor agreement between adult caregivers and their children regarding Early PTSD symptoms. Despite the recognition that their child had experienced a PTE and was symptomatic on screening (as was required for inclusion in the study), there was limited concordance on symptom reports. It is not surprising that caregivers reported less Avoidance symptomatology. As a primarily internalizing symptom, parental knowledge of this symptom is dependent upon reports from their children. It was surprising to find such poor agreement for Hyperarousal symptoms as those are more easily observable. There was greater agreement between males and their parents for PTSD Criteria D (Hyperarousal) and depressive symptoms. Boys are more likely to demonstrate externalizing symptoms of psychiatric disorders (Miner, Clarke-Stewart, 2008; Leadbeater, Kuperminc, Blatt, Hertzog, 1999) and parents tend to over report externalizing symptoms and under report internalizing symptoms (Kolko & Kazdin, 1993
). It is possible that normal reporting trends coincidently led to parents more accurately reporting externalizing symptoms that their male children also reported. The finding that there is greater concordance for boys and their parents on Depression items may be related to a behavioral change in activity level that depressed boys exhibit, but again, since the agreement was still generally low it is not an especially clarifying result and bears further investigation with a larger sample size.
The findings of low concordance between parent and youth reports in the period soon after a PTE and when the child has screened positive for posttraumatic symptoms points to the relatively high risk these children face for poor outcomes following exposure to a PTE. If caregivers are unaware that a PTE occurred, and uninformed about its potential impact, they cannot be expected to provide the support and guidance required. It is certainly understandable for caregivers and other adults to be unaware of children and youth’s suffering from non-trauma related psychological symptoms and disorders. However, when all have acknowledged the occurrence of a PTE and have had contact with various agencies as a result, this lack of recognition is remarkable. Clearly a greater role for agencies such as law enforcement, Child Welfare, Pediatric Emergency Departments and Inpatient units and others can be envisioned, in which more and better information about the potential for psychological injury after a PTE is provided to parents and caregivers in the immediate aftermath of the event. The provision of educational information about traumatic stress, and in particular about avoidance symptoms and dissociation in children could be a helpful addition to the general discharge instructions from hospitals. Law enforcement could provide such information with directions for follow up on the legal aspects of a criminal case, and Child Welfare Workers could directly aid caregivers in the assessment of posttraumatic symptomatology. Given the fact that children’s reports have been given less weight than parent reports in some circumstances, the provision of this information should be protocolized, rather than given out on what is perceived as an “as-needed” basis by the child-serving professional. While providing these resources is not a panacea, they may contribute to greater caregiver recognition of the exposed child’s symptoms and needs, which may in turn lead families to seek needed services.
Therapies for childhood PTSD have recognized the importance of parent-child communication and involvement in order to ameliorate posttraumatic symptoms. The most effective treatments for children with PTSD such as Trauma Focused-Cognitive Behavioral Therapy (TF-CBT; Cohen, Deblinger, & Mannarino, 2006), Child-Parent Psychotherapy (Lieberman, Ghosh Ippen, & Van Horn, 2006
; Lieberman, Van Horn, & Ippen, 2005
) all include parent education and involvement as a core component of treatment. Even Cognitive Behavior Therapy in Schools (CBITS) (Jaycox, 2003
; Kataoka, et al., 2003
; Stein, Elliott, et al., 2003
; Stein, Jaycox, et al., 2003
), which provides group treatment for older children, includes two sessions with parents and psychoeducational handouts for caregivers. Just as the inclusion of caregivers is generally accepted as a key component of treatment for childhood PTSD, it should be understood as a central element of models for early intervention.
Early intervention strategies for potentially traumatized children may be most effective when directly connected with organizations that serve or come into contact with children that have been exposed to a PTE and, when needed, promptly combine caregiver and child psychoeducation with the facilitation of bi-directional communication. If these two aims are accomplished, logically, caregiver support of the child should be an achievable outcome resulting in better rates of recovery. In addition, in high risk populations, such as those living in psycho-social adversity, with familial or personal histories of Psychiatric Disorders or chronically exposed to PTEs, early intervention models with these core components may serve to increase the early identification of children requiring mental health and other longer term treatments and interventions. It is possible that such early identification and subsequent treatment may actually decrease the later burden on stretched mental health resources for older adolescents and adults.
Limitations and Future Directions
The relatively small sample size included in this study resulted in a small number of participants for gender and aged based comparisons and did not allow for more specific analysis related to female adolescents versus male adolescents. The timing of the data collection (within 30 days of a potentially traumatic event) also prevents generalizing the findings for the concordance of PTSD symptom reporting. We were not able to report on the concordance between parent and youth report for full PTSD diagnosis since this diagnosis cannot be made within 30 days of an incident. We can only speak to the concordance of reporting within the peritraumatic or Acute Stress period. Since other studies have reported convergence in reports by caregivers and youth over time, longitudinal follow-up with a larger sample size to allow examination of gender and age differences in concordance would be beneficial. Other studies have also reported significant relationships between parents’ own symptoms and their report of their child’s symptoms (Kassam-Adams et al., 2006
), which may help explain some of the disagreement found in this sample. The issue of parents’ own reactions and symptoms and how parental history of trauma and posttraumatic reactions, as well as current reactions to their child’s experiences, may limit parental capacity to seek and participate in interventions designed to assist their children requires careful consideration as interventions for youth who have experienced a traumatic event are designed and implemented.