Abstract

Approach to Current Review

The RDoC outlined by NIMH currently contains five domains and covers a broad array of areas. These domains include: Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Systems of Social Processes and Arousal/Regulatory Systems (NIMH Research Domain Criteria (RDoC), 2011). All of these domains have some relevance to pediatric trauma, but some are more salient and have already amassed some research, while others have not yet been the focus of much study. Many of the domains are relevant to the cognitive, adaptive and social impairment that can result from trauma exposure. This paper focused on literature that included symptom level analysis, which included studies of children at risk for trauma symptoms following a potentially traumatic event, as well as, those studies that required a PTSD diagnosis. This approach was chosen because together these studies have advanced our understanding of how different events are associated with symptoms.

Studies that took a broad definition of trauma exposure, reflective of the transition to DSM-5 diagnostic criteria for PTSD were also included. For example, criteria A-1 for PTSD was revised from DSM-IV to DSM-5 to remove the requirement of feelings of intense fear, helplessness or horror right after the event. More specific details have also been added about the types and nature of potential exposure that were not included previously (American Psychological Association, 2013). These changes evolved from the field’s increased understanding of what constitutes a trauma that may result in posttraumatic symptoms. Continued exploration of potentially traumatic events and their association to symptoms and functioning may further refine understanding in the future for PTSD and other disorders.

Further, the focus was on RDoC domains that were most closely associated with trauma related reactions. The pediatric PTSD and child trauma/maltreatment literature was reviewed, searching specifically for studies that had performed sub-analyses that are the same or similar to RDoC constructs. The following sections will review literature on pediatric trauma and PTSD that is demonstrative of both the ease and challenges that would be encountered for pediatric trauma science to incorporate RDoC principles in future research studies. The literature reviewed is meant to be illustrative and is in no way exhaustive.

Overview of RDoC Domains

RDoC Elements of Analysis, Trauma and Pediatric PTSD

With an understanding of some of the RDoC domains most relevant to pediatric trauma, we now turn to elements of analysis. Included in the RDoC matrix are specific elements of analysis that could be used to study the domains described above. Studies of brain changes, genetics and neuroendocrine functioning in child trauma that are associated with the negative valence and arousal domains fall into some of these categories. Studies examining units of analysis such as genes, molecules, cells, circuits and physiology have all been applied to trauma, however, for the most part, these studies have yielded inconsistent results with regards to pediatric PTSD. Some of that variation is likely due to small, heterogeneous populations at various developmental stages that have experienced a variety of types of traumatic experiences with a wide range of trauma burden. However, it is also possible that RDoC domains, when used in conjunction with PTSD diagnostic criteria, may be more likely to result in consistent results when examining changes in structure and/or function of the brain or the stress response system. Some examples of the current state of pediatric PTSD research in RDoC elements of analysis are included below to illustrate the complementary potential for utilizing both PTSD diagnosis and RDoC designs.

Implications for Treatment of Traumatized Youth

The field of child trauma treatment has been burgeoning over the last several decades with multiple new treatments developed and tested. Trauma Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2012), Child Parent Psychotherapy (CPP; Lieberman, Ghosh Ippen, & Van Horn, 2007), Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS; Habib et al., 2013), Trauma Affect Regulation Guide for Education and Therapy (TARGET; Ford et al., 2013), Attachment, Self-Regulation, and Competency (ARC; Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005) and the Child and Family Traumatic Stress Intervention (CFTSI; Berkowitz, Stover, & Marans, 2011) are some of the treatments that have been developed that are in various stages of developing their status as evidence based treatments. These treatments have been designed based on the current science of PTSD and other symptoms associated with childhood trauma with careful consideration of child developmental process.

The efficacy of TF-CBT has been studied in many randomized controlled trials and it is widely disseminated both nationally and internationally as a leading treatment for childhood PTSD and trauma related psychopathology (e.g. Cohen et al., 2012; Mannarino, Cohen, Deblinger, Runyon, & Steer, 2012). The treatment is designed to move children and their caregivers through a set of components intended to reduce symptoms of PTSD (e.g. hyperarousal and avoidance), but also to target some of the key domains outlined by RDoC. The relaxation and affective regulation skills components directly target the negative valence, regulatory systems and social process domains. The trauma narrative portion of the treatment, in which the child writes a story about their trauma with the guidance of the therapist, is likely targeting multiple domains as well. The repeated retelling of the trauma narrative in greater detail targets negative valence and regulatory systems as well as cognitive and social processes. The goals of narrative development are to reduce arousal and anxiety related to the trauma details, reduce symptoms of re-experiencing (unwanted thoughts about the trauma), and process cognitive distortions about the self and others as related to the trauma. Following the development and processing of the narrative with the therapist, the child shares their story with a non-offending caregiver. These conjoint sessions with a prepared and supportive caregiver likely impact the affiliation and attachment domains. In addition, a treatment application of TF-CBT for traumatic grief specifically targets the loss construct within the negative valence domain (Cohen, Mannarino, & Staron, 2006).

This is one example of how an evidence based trauma treatment may be applied to RDoC to open up areas of future study. Does TF-CBT result in changes in those specific domains and if so, are those changes associated with more positive outcomes? If changes do not occur in certain areas, does that result in less successful treatment results? One area of future study is the examination of which components of the RDoC matrix are targeted by child trauma interventions and whether they might facilitate improvement in other components. Many trauma interventions start with psychoeducation (teaching) and then move into providing skills. These skills often target negative valence and regulatory systems domains (e.g. decrease arousal, improve sleep). Some treatments then move on to other target areas (e.g. avoidance by developing a narrative or attachment through conjoint sessions), but others focus more exclusively in the negative valence/regulatory areas. What is unclear is whether these “early” components of longer treatments that influence negative valence and regulatory systems may then impact other systems and allow for improvement in other capacities such as social processes. This may then allow for briefer or more targeted treatments.

One brief intervention for youth exposed to traumatic events has been developed that provides some evidence to support this notion. CFTSI (Berkowitz et al., 2011) is a five to eight session intervention for children aged seven through 18 developed specifically to fill the gap that exists between crisis intervention and longer-term evidence-based trauma treatments designed to address traumatic stress symptoms which have become established. Implemented in the peritraumatic period, CFTSI goals are to: 1) improve screening and initial assessment of children impacted by traumatic stress; 2) reduce traumatic stress symptoms and prevent chronic PTSD; and 3) assess need for longer-term treatment. Several of the central features of CFTSI work to: 1) increase communication between caregiver and child about the child’s traumatic stress reactions through conjoint sessions; 2) provide skills and strategies to families to help cope with traumatic stress reactions (e.g. relaxation skills, sleep hygiene and other coping skills); and 3) reduce external stressors resulting from the trauma (e.g. loss of housing or resources) through case management.

In terms of RDoC constructs, CFTSI targets areas of negative valence and regulatory systems through psychoeducation, teaching coping skills and enhancing affiliation and attachment through focus on communication with caregivers during conjoint sessions. This brief intervention has been shown to reduce the onset of both full and partial PTSD compared to a psychoeducational/support comparison condition (Berkowitz, Stover, & Marans, 2011). In an open trial chart review study of CFTSI, number of previous traumas experienced prior to the new incident that prompted implementation of CFTSI and severity of posttraumatic symptoms assessed at the outset of intervention were significantly associated with post-treatment outcomes (Hahn, Oransky, Epstein, Stover, & Marans, 2016). Broadening exploration of genetic and neurobiological markers (e.g. cortisol, acoustic startle) of negative valence, regulatory systems and attachment in addition to emotional/behavioral and symptom indicators in future studies of CFTSI could aid in determining how the intervention is impacting or interacting with these systems, leading to better identification of those youth who can most benefit from a brief early intervention and those that need to go directly into longer term trauma treatment.

Others have proposed the idea of stepped care for psychiatric problems (Bower & Gilbody, 2005). Zatzick and colleagues (2004, 2011, 2013) developed a stepped care intervention approach for PTSD for injured adult trauma survivors preventing worsening PTSD symptoms, but results in pediatric populations have been mixed. Kassam-Adams and colleagues did not show significant improvement for a stepped care approach over treatment as usual for children referred after a hospital visit due to an unintentional injury (Kassam-Adams et al., 2011).

In a community mental health setting, Salloum and colleagues did find positive outcomes for their parent trained, clinician assisted stepped care model for youth who had experienced a range of trauma types. Their studies assessed a phased approach to determine whether longer term treatment was needed by delivering an initial step of treatment first to determine if the child recovered (Salloum et al., 2014; Salloum, Scheeringa, Cohen, & Storch, 2013; Salloum & Storch, 2011). In their pilot study, Step One included 3 therapist lead sessions that accompanied an at home parent-child workbook. They found that 56% of the sample responded to this intervention without need for Step Two (implementation of TF-CBT) (Salloum et al., 2014). Additional studies designed with RDoC domains in mind could facilitate understanding of which children need all parts of a longer treatment intended to address PTSD or complex trauma versus those who need only some parts (e.g. psychoeducation and coping skills) in this kind of stepped approach.

Challenges in the Use of RDoC in Pediatric Trauma Research

Despite advantages of an RDoC approach, there are also inherent challenges. A challenge within the RDoC matrix is the omission of two primary aspects of fundamental importance to the research and treatment of childhood trauma, specifically, development and environment. Mentioned within the RDoC framework as two important areas not specifically included within the RDoC matrix, the RDoC framework strongly encourages a systematic and careful focus on developmental and environmental aspects as they relate to specific circuits and functions.

Additional Directions for Future Research

Large scale retrospective and prospective studies could be designed to examine the impact of trauma exposure (differing types, duration, etc.) on a set of constructs given the literature reviewed above. This could aid in our understanding of the differential impact of traumas on both development and impairment in a broad array of areas. These findings would inform developmentally appropriate assessment measures that are not based solely on diagnoses but on a wider set of domains relevant to trauma. Additionally, and potentially most important, studies of this type could result in the identification of a set of phenotypes that are defined by the impact of trauma on the domains of negative valence, positive valence, cognitive systems, social processes, and regulatory systems based on neuroscience and emotional/behavioral indicators, allowing for the development of new interventions and treatments.

There are also several avenues in which RDoC constructs could be incorporated into current research with trauma-exposed youth. First, recognizing the heterogeneity of children who all meet criteria for PTSD, published data should include, at a minimum, breakdown of severity of specific PTSD criteria, acting as a bridge to a more formalized RDoC framework for future studies in traumatized children. By publishing and making available to researchers severity of PTSD symptom criteria and specific co-morbidity results (e.g. severity of depression symptoms), even non-significant findings can be hypothesis generating for future RDoC centered research.

Second, often studies designed to focus on a cohort of children with PTSD exclude conditions where participants have some symptoms of posttraumatic stress but do not meet full criteria. However, excluding children with some symptoms of posttraumatic stress is not representative of many children who experience trauma, where some posttraumatic stress symptoms are quite common (Scheeringa et al., 2012). This is the advantage of the RDoC system. Rather than recruit children with PTSD, samples of trauma exposed children can be entered into intervention or prevention studies, and specific constructs can be measured and followed during the course and after treatment, agnostic of any particular disorder. This method provides a greater opportunity for researchers to relate therapeutic interventions to particular systems of interest in the field.

Third, as has been highlighted throughout the research reviewed, future RDoC studies should strive to focus on specific developmental periods when studying the impact of trauma on children. Applying adult centered criteria to a wide range of pediatric developmental stages has been a challenge for pediatric PTSD in general, and RDoC constructs within the different domains may have different phenotypes depending on the developmental period. Consideration of age and development of the brain and neurophysiology is key to understanding the results of pediatric studies. Careful selection of age of the child at the time of trauma, for instance, is needed to understand the meaning of neurobiological findings as well as, cognitive, social and behavioral symptoms.

Fourth, unlike adult studies that examine remote or childhood trauma, pediatric RDoC studies should strive to control for time since exposure and exposure chronicity when evaluating traumatized children. Systematically controlling for time, as well as other covariates such as allostaic loading prior to the most recent trauma, will help determine the time x development x exposure interface, which is not currently well understood.

Last, by exploring specific constructs in large research studies without specification of disorder, the field can uncover neurobiological and other changes that cut across disorders. A study that measures structural and functional changes in the brain and regulatory systems, attachment, cognition and understanding of the self, as well, as the spectrum of psychiatric symptoms could uncover etiology and targets for prevention and treatment across a range of current disorders.

Conclusion

A great deal has been learned in the last several decades about the broad impact of trauma on children. In addition to studies that explore differences in children with and without PTSD, examination of cohorts of trauma exposed children and the resulting outcomes have led to a clearer understanding of factors associated with psychiatric difficulties and functional impairment after trauma exposure. Using this knowledge and applying constructs from RDoC to further the understanding of neurobiological domains impacted by trauma has the potential to greatly advance the field. Increased identification of the ways in which pre-existing factors (e.g. attachment, DAT genes) and neurobiological changes following trauma (e.g. HPA activity, startle response) lead to impairment following trauma exposure at different developmental stages will have direct implications for treatment through: a) identification of those at greatest risk for significant impairment following exposure to a wide array of trauma types allowing for development of the best possible early assessment approaches; and b) identification of the ways in which treatments are influencing neurobiological systems impacted by trauma resulting in decreased symptoms and dysfunction and better outcomes for children and youth.

Acknowledgements

Footnotes

Contributor Information

Carla Smith Stover, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33647, 813-974-6019 phone, 813-974-9327 fax, ude.fsu@revotsalrac.

Brooks Keeshin, University of Utah.

References