Acta Psychiatr Scand 2015: 131: 279–289 All rights reserved DOI: 10.1111/acps.12316

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA PSYCHIATRICA SCANDINAVICA

The role of behavioral inhibition and parenting for an unfavorable emotional trauma response and PTSD Asselmann E, Wittchen H-U, Lieb R, H€ ofler M, Beesdo-Baum K. The role of behavioral inhibition and parenting for an unfavorable emotional trauma response and PTSD.

E. Asselmann1,2, H.-U. Wittchen1,3,

R. Lieb3,4, M. H€ofler1, K. Beesdo-Baum1,2

1

Objective: The role of behavioral inhibition (BI) and parenting for an unfavorable emotional trauma response (DSM-IV criterion A2) and post-traumatic stress disorder (PTSD) development is unclear. Method: A community sample of adolescents and young adults (aged 14–24) was followed up over 10 years (N = 2378). Traumatic events, criterion A2, and PTSD (according to DSM-IV-TR) were assessed using the M-CIDI. BI and parenting were assessed using the Retrospective Self-Report of Inhibition and the Questionnaire of Recalled Parenting Rearing Behavior. Multiple logistic regressions adjusted for sex, age, and number of traumata were used to examine associations of BI as well as maternal and paternal overprotection, rejection, and reduced emotional warmth with (i) criterion A2 in those with trauma (N = 1794) and (ii) subsequent PTSD in those with criterion A2 (N = 1160). Results: Behavioral inhibition (BI; odds ratio, OR = 1.32) and paternal overprotection (OR = 1.27) predicted criterion A2 in those with trauma, while only BI (OR = 1.53) predicted subsequent PTSD. BI and paternal emotional warmth interacted on subsequent PTSD (OR = 1.32), that is, BI only predicted PTSD in those with low paternal emotional warmth. Conclusion: Our findings suggest that BI and adverse parenting increase the risk of an unfavorable emotional trauma response and subsequent PTSD. Paternal emotional warmth buffers the association between BI and PTSD development.

Institute of Clinical Psychology and Psychotherapy, Technische Universit€at Dresden, Dresden, 2Behavioral Epidemiology, Technische Universit€at Dresden, Dresden, 3 Max Planck Institute of Psychiatry, Munich, Germany and 4Department of Psychology, Division of Clinical Psychology and Epidemiology, University of Basel, Basel, Switzerland

Key words: post-traumatic stress disorder; trauma; temperament; epidemiology; family burden Katja Beesdo-Baum, Institute of Clinical Psychology and Psychotherapy, Behavioral Epidemiology, Technische Universit€at Dresden, Chemnitzer Str. 45, Dresden 01187, Germany. E-mail: [email protected]

Accepted for publication June 23, 2014

Significant outcomes

• Both behavioral inhibition (BI) and unfavorable parenting were associated with an increased risk of • •

an unfavorable immediate emotional trauma response and subsequent development of post-traumatic stress disorder (PTSD). High levels of paternal emotional warmth buffered the association between BI and development of PTSD in those with unfavorable emotional trauma response. The role of parenting for pathways into PTSD partially differed in those with early (age ≤ 10) vs. later (age > 10) trauma.

Limitations

• BI and parenting were necessarily assessed retrospectively by self-report only; thus, our data may be subject to recall and evaluation biases.

• Aggregated data were used for the analyses and further prospective-longitudinal studies are necessary, which strictly control for the temporal sequence of predictor and outcome variables.

279

Asselmann et al. Introduction

Post-traumatic stress disorder (PTSD) is a serious, often chronic condition that causes substantial impairment, tremendous costs, and increases the risk of secondary disorders (1–7). Previous research examined a wide range of risk factors for PTSD (3, 8–10), including the role of behavioral inhibition (BI) (11–14). BI is a temperamental trait, which describes the tendency to react with initial withdrawal in unfamiliar social and nonsocial situations, develops early in life and remains relatively stable across childhood (15). BI was consistently found to increase the risk of anxiety disorders (16–23). Research suggests that especially behaviorally inhibited individuals may pay increased and selective attention toward potentially threatening stimuli, interpret ambiguous stimuli as threatening, and react with increased sensitivity and arousal towards threat (14, 24–26). For instance, individuals with high BI in toddlerhood and childhood were found to show heightened amygdala response during fear ratings of fearful faces (27) and increased attention biases toward threat (28). This implies that high levels of BI may predispose to response with intense fear, helplessness, or horror to traumatic events (DSMIV criterion A2) and to subsequently develop the full picture of DSM-IV PTSD. However, although BI was found to be associated with PTSD (11–14), no study separately investigated the role of BI for an unfavorable immediate emotional trauma response and subsequent PTSD development. It has further been shown that parental and family characteristics were associated with an increased (e.g., family conflict) or decreased risk (e.g., parental support) for PTSD (29–37). Little research, however, examined whether established adverse parenting dimensions (namely high overprotection, high rejection, and low emotional warmth) (20, 38–46) may increase the risk of an unfavorable emotional trauma response and subsequent PTSD. It is also unclear whether favorable parenting (i.e., low overprotection, low rejection, and high emotional warmth) may buffer the association between BI and both outcomes. Favorable parenting may foster a child’s self-efficacy, confidence, and mastery and thus promotes its ability to adequately react to and successfully cope with traumatic experiences. A few studies examined interactive effects between BI and parenting on predicting anxiety disorders and found that favorable parenting attenuated the association between heightened BI and anxiety disorders (47, 48). For instance, BI was shown to be only associated with 280

anxiety in the presence of maternal overcontrol (47), and shyness was shown to be more strongly linked to internalizing problems in the presence of highly fretful parenting and lack of warmth and support (48). Moreover, previous studies revealed that especially in early childhood, traumatic experiences were associated with prolonged neurobiological changes (primarily a disregulatory disorder of the hypothalamic-pituitary-adrenal axis) predisposing for psychopathology in adulthood (49–55). Therefore, it may be fruitful to differentiate between individuals with early vs. later trauma when examining associations of BI and parenting with PTSD development. Aims of the study

This prospective-longitudinal study aims to examine whether (i) behavioral inhibition (BI) and adverse parenting predispose for an unfavorable immediate emotional trauma response and subsequent post-traumatic stress disorder, and this varies depending on the number of experienced trauma types, (ii) more favorable parenting attenuates the association between BI and both outcomes, and (iii) the role of BI and parenting for both outcomes differs in those with early vs. later trauma (Fig. 1a,b).

Material and methods Sample

Data come from the Early Developmental Stages of Psychopathology Study (EDSP), a 10-year prospective-longitudinal study, which assessed mental disorder and associated risk/protective factors in a representative sample of adolescents and young adults. The study included one baseline (T0, 1995, N = 3021, response rate 70.8%) and three follow-up investigations (T1, 1996/97, only younger cohort aged 14–17 at baseline, N = 1228, response rate 88.0%; T2, 1998/99, N = 2548, response rate 84.3%; T3, 2003, N = 2210, response rate 73.2%). The sample was drawn randomly from the population registry office of the Munich area. Participants were aged 14–24 years at baseline and 21–34 years at last follow-up. To emphasize early stages of psychopathology, 14–15year olds were sampled at twice the probability of individuals aged 16–21 years, and 22–24-year olds were sampled at half this probability. Detailed descriptions of the EDSP along with information on methods and design responsiveness, and response rates have been previously presented (56,

Temperament, parenting, and PTSD (a)

BI Unfavorable parenting

BI Unfavorable parenting +

+

Trauma

Criterion A2

Criterion A2 in those with trauma Fig. 1. (a) Hypothesized main effects of behavioral inhibition (BI) and unfavorable parenting on predicting criterion A2 in those with trauma and subsequent development of posttraumatic stress disorder (PTSD); (b) Hypothesized interactive effects between BI and unfavorable parenting on predicting criterion A2 in those with trauma and subsequent development of PTSD.

PTSD

Subsequent PTSD

(b)

Favorable parenting – BI

57). The present analyses refer to those participants, who provided complete data on BI at T0 and parenting at T2 and additionally indicated to have experienced traumatic events (DSM-IV criterion A1 affirmed; N = 1794) or qualifying traumatic events (DSM-IV criterion A1 and A2 affirmed; N = 1160) at any assessment wave. Diagnostic assessment

The computer-assisted personal interview (CAPI) version of the Munich Composite International Diagnostic Interview (DIA-X/M-CIDI) (58) was used repeatedly (T0/ T1/ T2/ T3) to assess traumatic events, immediate emotional trauma response (criterion A2), PTSD, and other mental disorders as well as information on onset, duration, and clinical/psychosocial severity. The M-CIDI is an updated version of the World Health Organization’s CIDI version 1.2 (59) with additional questions to cover DSM-IV (60) and ICD10 (61) criteria. The lifetime version was used at baseline, the interval version at follow-up. Detailed descriptions on psychometric properties of the M-CIDI have been previously presented (62, 63). Traumatic events, immediate emotional trauma response (criterion A2), and PTSD were assessed in the N-section of the DSM-IV/M-CIDI. First, participants were asked to indicate the presence of traumatic events (DSM-IV criterion A1) out of a

(a) Criterion A2 in those with trauma (b) Subsequent PTSD

list containing eight specified events (war experience, being physically attacked, rape, sexual abuse as a child, natural disasters, serious accidents, imprisonment, and witness of traumatic events to others) and one open category. Second, participants were asked whether they had felt intense fear, helplessness, or horror in response to one or more specific traumatic events (criterion A2). Third, whenever participants affirmed criterion A2, they were asked to indicate the most distressing qualifying traumatic event and its age of onset. At each wave, these questions referred to lifetime qualifying traumatic events. Participants with qualifying traumatic events were subsequently asked all DSM-IV criteria questions for PTSD. In case of multiple qualifying traumatic events, questions referred to the most distressing event. At baseline, questions referred to lifetime PTSD symptoms, whereas at follow-up, questions referred to PTSD symptoms after the last assessment wave. Detailed descriptions have been previously presented (3, 4). Assessment of BI

Behavioral inhibition (BI), a temperamental trait defined as the tendency to react with initial withdrawal in unfamiliar social and non-social situations (15), was assessed at T0 using the German version of the Retrospective Self-Report of 281

Asselmann et al. Inhibition (RSRI) (64). The RSRI contains 30 retrospective five-point scaled items (labeled from never to very often) that assess childhood (age 5– 16) behaviors in different situations. Detailed information and psychometric properties regarding the RSRI have been previously reported (64, 65). Higher scores indicate higher BI. Assessment of parental rearing

Recalled parental rearing (control/overprotection, rejection/punishment, and emotional warmth) was assessed at T1 in the younger cohort at T2 in the younger and older cohort using the German version of the Questionnaire of Recalled Parental Rearing Behavior (FEE) (66). The FEE is based on the Swedish EMBU-questionnaire and contains 24 four-point scaled items (labeled from no, never to yes, permanently) assessing recalled parental rearing separately for mother and father. Detailed descriptions of the psychometric properties of the FEE have been previously reported (66). Due to the larger sample size, the current analyses refer to parental rearing recalled at T2. Intraclass correlations between recalled parental rearing styles at T1 and T2 (in participants with complete data on parenting at both assessments, N = 945) ranged from 0.62 (paternal overprotection) to 0.70 (maternal and paternal emotional warmth), indicating a sufficient to good stability (67). For the current analyses, scores for parental emotional warmth were inverted so that higher scores on each dimension indicate more adverse parenting (i.e., higher control/overprotection, higher rejection/punishment, and lower emotional warmth). Statistical analyses

For the present analyses, an unfavorable emotional trauma response (criterion A2) and subsequent PTSD development were defined as outcomes, while BI and adverse parenting were defined as predictors. Age of onset for qualifying traumatic events refers to the most distressing qualifying trauma. In the few cases in which the most distressing qualifying trauma varied across assessment waves, age of onset refers to the earliest most distressing qualifying trauma. Onset of PTSD was determined by using the CIDI age of onset question that asks for the age at which at least some of the PTSD symptom criteria were present together for the first time. Statistical analyses with unfavorable emotional trauma response (criterion A2) as outcome were conducted in participants, who provided complete data on BI at T0 and parenting at T2 and reported 282

at least one traumatic event (meeting criterion A1) at any assessment wave (N = 1794). Statistical analyses with subsequent PTSD as outcome were conducted in participants, who provided complete data on BI at T0 and parenting at T2 and reported at least one qualifying traumatic event (meeting criterion A1 and A2) at any assessment wave (N = 1160). The software-package STATA (version 12.1) (68) was used for all analyses. Data (percentages, means, standard deviations, and odds ratios) are reported weighted to match the original distribution of the sampling frame; frequencies are reported un-weighted. Scores for BI and parenting were standardized (mean = 0, SD = 1). First, separate logistic regressions (BI or individual parenting dimensions as predictors) and multiple logistic regressions (BI and all parenting dimensions as predictors) were used to examine associations of BI and parenting with both outcomes (criterion A2 in those with trauma, N = 1794; subsequent PTSD in those with qualifying trauma, N = 1160). Second, an interaction term was introduced to test whether BI and parenting interacted with (i) the number of trauma types (i.e., number of event categories indicated in the M-CIDI PTSD module) on predicting criterion A2 in those with trauma (N = 1794) and (ii) the number of qualifying trauma types on predicting PTSD in those with qualifying trauma (N = 1160). Whenever the interactive effect reached significance (P-value < 0.05), the association between respective predictor and outcome was tested separately in those with different numbers of (qualifying) trauma types. Third, we tested interactive effects between BI and each parenting variable on predicting criterion A2 in those with trauma (N = 1794) and PTSD in those with qualifying trauma (N = 1160). In case of a significant interaction (P-value < 0.05), the association between BI and outcome was tested in the presence of low vs. high levels of the respective parenting variable. In addition, associations of BI and parenting (main and interactive effects) with subsequent PTSD were tested separately in individuals with early (age ≤ 10 during the earliest reported most severe qualifying trauma; N = 161) vs. later qualifying trauma (age > 10 during the earliest reported most severe qualifying trauma; N = 997). Associations of BI and parenting with criterion A2 could not be tested, as age of onset information was only available for qualifying traumatic events. All analyses were adjusted for sex and age at last assessment. Furthermore, analyses with ‘crite-

Temperament, parenting, and PTSD rion A2 in those with trauma’ as outcome were additionally adjusted for the number of different trauma types, while analyses with ‘PTSD in those with qualifying trauma’ as outcome were additionally adjusted for the number of different qualifying trauma types (except for analyses examining the role of a higher number of (qualifying) trauma types).

Results Frequencies of traumatic events, qualifying traumatic events, and PTSD

Of those with complete data on BI at T0 and parenting at T2 (N = 2375), 1794 individuals (75.7%) indicated traumatic events (males: 949, 78.0%; females: 845, 73.4%). Of those with traumatic events, 1160 (65.3%) indicated qualifying traumatic events (males: 580, 61.8%; females: 580, 69.0%). In 161 individuals (13.9%), the earliest reported most severe qualifying trauma had occurred until the age of 10, while in 997 individuals (86.1%), the earliest reported most severe qualifying trauma had occurred after the age of 10. Of those with qualifying trauma, 61 (6.0%) were diagnosed with PTSD (males: 18, 3.3%; females: 43, 8.6%; individuals with early qualifying trauma: 15, 11.8%; individuals with later qualifying trauma: 46, 5.1%). Additional sample characteristics are presented in Table 1. Associations of BI and parenting with criterion A2 in those with trauma

Table 2 presents associations of BI and parenting with criterion A2 in those with trauma: In separate logistic regressions with BI or individual parenting dimensions as predictors, BI (OR = 1.33), maternal overprotection (OR = 1.16), and paternal overprotection (OR = 1.24) predicted criterion A2. In a multiple logistic regression with BI and all parenting dimensions as predictors, only BI (OR = 1.32) and paternal overprotection (OR = 1.27) predicted criterion A2 (Table 3).

Table 1. Sample characteristics of the total sample, males, and females (N = 2375) Sample

Sample characteristics*

Total (N = 2375)

Males (N = 1224)

Age at baseline M (SD) 19.57 (3.27) 19.55 (3.30) Trauma, N (%) No 581 (24.3) 275 (22.0) Yes 1794 (75.7) 949 (78.0) Type of trauma, N (%) War experience 32 (1.5) 21 (1.7) Physically attacked 416 (16.5) 300 (23.8) Rape 46 (2.2) 0 (0.0) Sexual abuse as a child 58 (2.9) 6 (0.6) Natural disasters 53 (2.7) 30 (3.2) Serious accidents 318 (13.7) 205 (17.6) Imprisonment 8 (0.4) 5 (0.5) Witness 1594 (67.9) 832 (69.1) Other 111 (4.4) 50 (3.9) Qualifying trauma, N (%) No 1215 (50.6) 644 (51.8) Yes 1160 (49.4) 580 (48.2) Type of qualifying trauma, N (%) War experience 20 (0.9) 14 (1.2) Physically attacked 312 (12.4) 212 (16.7) Rape 41 (2.0) 0 (0.0) Sexual abuse as a child 53 (2.7) 6 (0.6) Natural disasters 31 (1.5) 12 (1.2) Serious accidents 219 (9.3) 130 (10.9) Imprisonment 5 (0.3) 2 (0.2) Witness 874 (37.6) 417 (35.6) Other 97 (3.8) 38 (2.9 Age of onset of the most severe qualifying trauma†,‡ M (SD) 17.28 (6.03) 17.34 (5.66) Range 1–32 1–31 PTSD, N (%) No 2314 (97.0) 1206 (98.4) Yes 61 (3.0) 18 (1.6) Age of onset of PTSD† M (SD) 19.39 (6.57) 19.91 (6.16) Range 6–32 8–31 Time interval between most severe qualifying trauma and PTSD† M (SD) 4.54 (6.49) 3.08 (4.48) Range 0–22 0–14

Females (N = 1151)

19.60 (3.25) 306 (26.6) 845 (73.4) 11 (1.3) 116 (9.3) 46 (4.3) 52 (5.2) 23 (2.1) 113 (9.7) 3 (0.4) 762 (66.6) 61 (4.9) 571 (49.4) 580 (50.6) 6 (0.7) 100 (8.1) 41 (4.0) 47 (4.8) 19 (1.8) 89 (7.7) 3 (0.4) 457 (39.7) 59 (4.8) 17.22 (6.38) 2–32 1108 (95.6) 43 (4.4) 19.21 (6.77) 6–32 5.06 (7.05) 0–22

PTSD, post-traumatic stress disorder. *Unweighted number of participants (weighted percentages, means, and standard deviations). †Slightly smaller numbers of participants due to missing information on age of onset. ‡Refers to the most distressing qualifying trauma, in cases in which the most distressing qualifying trauma varied across assessment waves, the age of onset refers to the earliest most distressing qualifying trauma.

Associations of BI and parenting with subsequent PTSD

The role of a higher number of (qualifying) trauma types

Table 4 shows associations of BI and parenting with subsequent PTSD (in those with qualifying trauma): In separate logistic regressions, BI (OR = 1.60), maternal rejection (OR = 1.28), paternal rejection (OR = 1.22), and low maternal emotional warmth (OR = 1.39) predicted PTSD. In a multiple logistic regression, only BI (OR = 1.53) predicted PTSD.

There was no evidence for BI or parenting to interact with the number of trauma types on predicting criterion A2 in those with trauma (all P-values > 0.05). However, testing interactions of BI and parenting with the number of qualifying trauma types revealed that maternal overprotection interacted with the number of qualifying trauma types on predicting subsequent PTSD in those with 283

Asselmann et al. Table 2. Associations of BI and parenting with criterion A2 in those with trauma (N = 1794) Criterion A2

BI / parental rearing BI Maternal rearing Overprotection/control Rejection/punishment Low emotional warmth Paternal rearing Overprotection/control Rejection/punishment Low emotional warmth

Separate models

Multiple model

No (N = 634) M (SD)*

Yes (N = 1160) M (SD)*

OR [95% CI]†

P

OR [95% CI]‡

P

2.04 (0.31)

2.14 (0.35)

1.33 [1.16; 1.52]

0.05). There were no interactive effects between BI and parenting on predicting criterion A2 in those with trauma (all P-values > 0.05) Separate analyses in individuals with trauma early vs. later in life

Interactions between BI and parenting

When testing interactive effects between BI and each parenting dimension on predicting both outcomes, we found that BI interacted with paternal emotional warmth on predicting subsequent PTSD in those with qualifying trauma (OR = 1.32; 95% CI: 1.01; 1.73; P = 0.040). That is, BI only predicted subsequent PTSD in those with low paternal emotional warmth 284

We further tested associations of BI and parenting with subsequent PTSD separately in individuals with early vs. later qualifying trauma. The following results were found for individual with early qualifying trauma (Table 4): In separate logistic regressions, BI (OR = 1.66) and low maternal emotional warmth (OR = 1.65) predicted PTSD, while in a multiple logistic regression, only BI (OR = 1.81) predicted PTSD.

Temperament, parenting, and PTSD Table 4. Associations of BI and parenting with subsequent development of PTSD in individuals with early qualifying trauma (N = 161)* PTSD

BI / parental rearing BI Maternal rearing Overprotection/control Rejection/punishment Low emotional warmth Paternal rearing Overprotection/control Rejection/punishment Low emotional warmth

Separate Models

Multiple Model

No (N = 146) M (SD)†

Yes (N = 15) M (SD)†

OR [95% CI]‡

P

OR [95% CI]§

P

2.18 (0.41)

2.68 (0.72)

1.66 [1.01; 2.74]

0.046

1.81 [1.02; 3.22]

0.043

14.50 (3.70) 10.34 (3.80) 16.03 (4.99)

15.11 (4.11) 13.63 (5.38) 21.10 (6.81)

1.25 [0.67; 2.34] 1.24 [0.90; 1.71] 1.65 [1.06; 2.58]

0.473 0.182 0.028

1.54 [0.94; 2.53] 1.04 [0.61; 1.79] 1.87 [0.98; 3.59]

0.085 0.879 0.059

12.51 (3.31) 10.66 (4.10) 18.63 (5.65)

10.66 (4.10) 9.96 (2.74) 20.26 (4.95)

0.70 [0.36; 1.34] 0.77 [0.48; 1.24] 1.20 [0.75; 0.92]

0.278 0.286 0.455

0.76 [0.42; 1.37] 0.71 [0.28; 1.78] 0.82 [0.47; 1.42]

0.358 0.456 0.471

BI, behavioral inhibition; PTSD, post-traumatic stress disorder; OR, odds ratio; CI, confidence interval. *Age ≤ 10 during the most distressing qualifying trauma (in cases in which the most distressing qualifying traumata varied across assessment waves, age of onset refers to the earliest most distressing qualifying trauma). †Weighted means and standard deviations. ‡Logistic regressions with BI or individual maternal/paternal rearing dimensions as separate predictors; adjusted for sex, age, and number of different specific qualifying traumata. §Logistic regression with BI and all maternal/paternal rearing dimensions as multiple predictors; adjusted for sex, age, and number of different specific qualifying traumata.

The following results emerged for individuals with later qualifying trauma (Table 5): In separate logistic regressions, BI (OR = 1.51), maternal rejection (OR = 1.27), paternal rejection (OR = 1.48), and paternal overprotection (OR = 1.30) predicted PTSD, while in a multiple logistic regression, only BI (OR = 1.42) predicted PTSD. When testing interactive effects between BI and parenting separately in individuals with early vs. later qualifying trauma, we found that BI only interacted with paternal emotional warmth on predicting PTSD in those with early qualifying trauma (OR = 1.75; 95% CI: 1.17; 2.62; P = 0.006), but not in those with later qualifying trauma (P-value > 0.05).

Discussion

This study revealed the following core findings: (i) In separate logistic regressions, BI, maternal overprotection, and paternal overprotection were associated with an increased risk of an unfavorable emotional trauma response (criterion A2) in those with trauma, while BI, maternal rejection, paternal rejection, and low maternal emotional warmth were linked to an elevated risk of subsequent PTSD development. (ii) In multiple logistic regressions, BI and paternal overprotection were related to an unfavorable emotional trauma response in those with trauma, while merely BI was associated with subsequent PTSD development. (iii) BI interacted with

Table 5. Associations of BI and parenting with subsequent development of PTSD in individuals with later qualifying trauma (N = 997)* PTSD Separate models BI / parental rearing BI Maternal rearing Overprotection/control Rejection/punishment Low emotional warmth Paternal rearing Overprotection/control Rejection/punishment Low emotional warmth

Multiple model

No (N = 951) M (SD)†

Yes (N = 46) M (SD)†

OR [95% CI]‡

P

OR [95% CI]§

P

2.12 (0.32)

2.28 (0.37)

1.51 [1.08; 2.12]

0.017

1.42 [1.00; 2.00]

0.048

14.07 (3.20) 9.79 (2.28) 15.69 (4.07)

14.53 (3.16) 10.55 (2.58) 16.42 (5.31)

1.12 [0.87; 1.45] 1.27 [1.00; 1.60] 1.23 [0.88; 1.72]

0.369 0.047 0.232

0.94 [0.63; 1.42] 1.06 [0.75; 1.50] 0.97 [0.69; 1.38]

0.781 0.734 0.873

13.18 (3.19) 9.79 (2.30) 18.15 (4.83)

14.43 (3.85) 11.14 (3.22) 19.57 (6.13)

1.30 [1.02; 1.67] 1.48 [1.18; 1.87] 1.32 [0.94; 1.84]

0.038 0.001 0.108

1.06 [0.70; 1.63] 1.34 [0.93; 1.94] 1.11 [0.76; 1.63]

0.774 0.114 0.597

BI, behavioral inhibition; PTSD, post-traumatic stress disorder; OR, odds ratio; CI, confidence interval. *Age > 10 during the most severe qualifying trauma (in cases in which the most distressing qualifying traumata varied across assessment waves, age of onset refers to the earliest most distressing qualifying trauma). †Weighted means and standard deviations. ‡Logistic regressions with BI or individual maternal/paternal rearing dimensions as separate predictors; adjusted for sex, age, and number of different specific qualifying traumata. §Logistic regression with BI and all maternal/paternal rearing dimensions as multiple predictors; adjusted for sex, age, and number of different specific qualifying traumata.

285

Asselmann et al. emotional warmth on predicting subsequent PTSD in a way that paternal emotional warmth buffered the association between BI and PTSD. In separate and multiple models, we found that BI was associated with an increased risk to response with intense fear, helplessness, or horror to traumatic events and to subsequently develop PTSD, which is consistent with evidence for BI to be associated with PTSD (11–14). However, our study considerably extends previous research, as earlier studies rarely distinguished between an unfavorable immediate emotional trauma response (criterion A2) and subsequent PTSD development. In separate models, maternal and paternal overprotection were associated with an increased risk to response with intense fear, helplessness, or horror to traumatic events, while maternal and paternal rejection as well as low maternal emotional warmth were associated with an elevated risk of subsequent PTSD. In multiple models, merely paternal overprotection was linked to an unfavorable emotional trauma response in those with trauma, while none of the parenting variables was related to subsequent PTSD. Our results suggest that adverse parenting — albeit to a lower extent than BI — impact the developmental pathways into PTSD. This matches with findings that parental and family characteristics were related to an increased (e.g., family conflict) or decreased risk (e.g., parental support) of PTSD pathology (29–37), although few previous studies investigated the role of parenting for an unfavorable immediate emotional trauma response (criterion A2) and subsequent PTSD development. Analogously to unfavorable attachment, adverse parenting in childhood may impair a child’s capacity to cope with future stressors and thus facilitate pathways into PTSD after traumatic experiences (later in life) (69). Studies in rats found that early maternal care altered the neurobiological response to later stressors (70–72) and our findings that adverse parenting was related to an unfavorable emotional trauma response and PTSD development might be explained by similar neurobiological mechanisms. In the context of DSM-5 (73), the role of an unfavorable immediate emotional trauma response (DSM-IV criterion A2) as requirement for PTSD has been controversially discussed (74–80). Although criterion A2 was removed in DSM-5, research found that intense fear, helplessness, or horror in response to trauma was extremely predictive of PTSD (78–80). Our finding that specific parenting dimensions were differently associated with criterion A2 in those with trauma vs. subsequent PTSD in those with qualifying trauma suggests that con286

sidering criterion A2 as precondition for PTSD might help to reveal the complex developmental pathways into PTSD. Besides, there was evidence that maternal overprotection only increased the risk of PTSD development in those with less than three qualifying trauma types, but not in those with three or more qualifying trauma types. Possibly, individuals with highly adverse environmental experiences were at extreme risk of PTSD per se, and thus, maternal overprotection had no substantial additional effect respecting an increase in risk. Moreover, paternal emotional warmth buffered the association between BI and PTSD development in those with qualifying trauma: BI and paternal emotional warmth interacted on predicting PTSD in a way that BI only predicted PTSD development in the presence of low paternal emotional warmth, but not in the presence of high paternal emotional warmth. This result extends previous findings for favorable parenting to attenuate the association between temperamental liability and anxiety disorders (47, 48) and corresponds to findings in rats for early maternal care to alter later stress reactivity (70–72). Separating between individuals with early vs. later qualifying trauma revealed that in both groups, BI was associated with an increased risk for PTSD. However, the role of parenting appeared to be different in both groups: While low maternal emotional warmth increased the risk of PTSD in individuals with early qualifying trauma, maternal/paternal rejection and paternal overprotection increased the risk of PTSD in individuals with later qualifying trauma. Moreover, the interactive effect between BI and paternal emotional warmth on predicting PTSD was only evident in individuals with early qualifying trauma. These findings suggest that partially different risk factors (and perhaps mechanisms) are relevant for PTSD development in individuals with early vs. later trauma and that especially in those with early trauma, parental emotional warmth alters the risk for PTSD development. This matches with findings that particularly traumatic events in early childhood were associated with prolonged neurobiological changes (primarily a disregulatory disorder of the hypothalamic-pituitary-adrenal axis) predisposing for later psychopathology (49–55). Altogether, our findings suggest that especially individuals with high BI and/or unfavorable parental rearing experiences might profit from early, targeted preventive interventions (e.g., targeted debriefing) after traumatic experiences. Previous research found that brief preventive interventions that enhanced family support and coping skills

Temperament, parenting, and PTSD in trauma-exposed youth effectively reduced PTSD symptoms (81). Such preventive interventions might be especially effective in individuals with temperamental liability for PTSD and lay an even stronger focus on parental rearing. Future research may replicate our findings, study putative underlying neurobiological mechanisms and test the efficacy of targeted preventive interventions in high-risk individuals with elevated BI and adverse parenting. Strengths and limitations

As one of the first studies, we examined the role of BI and parenting for an increased risk to response with intense fear, helplessness, or horror to traumatic events and to subsequently develop PTSD. Our study considerably extends previous research, as we (i) focused on traumatic events in a representative community sample of adolescents and young adults, (ii) distinguished between an unfavorable immediate emotional trauma response and subsequent development of PTSD as outcomes, (iii) investigated respective main and interactive effects of BI and parental rearing, (iv) examined the role of a higher number of (qualifying) trauma types, and (v) separated between individuals with early vs. later qualifying trauma. Nonetheless, our study is not without limitations: (i) BI and parenting in childhood were necessarily assessed retrospectively by self-report only. Thus, our data may be subject to recall and evaluation biases. (ii) To include individuals with early and later qualifying trauma, aggregated data were used for the current analyses. Thus, prospectivelongitudinal replications are necessary that strictly control for the temporal sequence of predictor and outcome variables. (iii) Because age of onset in the EDSP was only assessed for qualifying traumatic events, separate analyses in individuals with early vs. later qualifying trauma were only conducted using subsequent development of PTSD as outcome. (iv) Only information on the number of (qualifying) trauma types (i.e., number of event categories indicated in the M-CIDI PTSD module) was available in this study and of course, findings may be different for the overall number of traumata. Acknowledgements This study is part of the Early Developmental Stages of Psychopathology (EDSP) Study and is funded by the German Federal Ministry of Education and Research (BMBF) project no. 01EB9405/6, 01EB 9901/6, EB01016200, 01EB0140, and

01EB0440. Part of the field work and analyses were also additionally supported by grants of the Deutsche Forschungsgemeinschaft (DFG) LA1148/1-1, WI2246/1-1, WI 709/7-1, and WI 709/8-1. The first author (Eva Asselmann) was funded by a doctoral stipend of the German National Academic Foundation (Studienstiftung des Deutschen Volkes). Principal investigators are Dr. Hans-Ulrich Wittchen and Dr. Roselind Lieb. Core staff members of the EDSP group are: Dr. Kirsten von Sydow, Dr. Gabriele Lachner, Dr. Axel Perkonigg, Dr. Peter Schuster, Dr. Michael H€ ofler, Dipl.Psych. Holger Sonntag, Dr. Tanja Br€ uckl, Dipl.-Psych. Elzbieta Garczynski, Dr. Barbara Isensee, Dr. Agnes Nocon, Dr. Chris Nelson, Dipl.-Inf. Hildegard Pfister, Dr. Victoria Reed, Dipl.-Soz. Barbara Spiegel, Dr. Andrea Schreier, Dr. Ursula Wunderlich, Dr. Petra Zimmermann, Dr. Katja Beesdo-Baum, Dr. Antje Bittner, Dr. Silke Behrendt and Dr. Susanne Knappe. Scientific advisors are Dr. Jules Angst (Zurich), Dr. J€ urgen Margraf (Basel), Dr. G€ unther Esser (Potsdam), Dr. Kathleen Merikangas (NIMH, Bethesda), Dr. Ron Kessler (Harvard, Boston) and Dr. Jim van Os (Maastricht).

Declaration of interest Dr. Wittchen reports the following items that might be perceived as a potential conflict of interest: Dr. Wittchen is on the advisory board and has received grant support to his institution by Servier, Novartis, Lundbeck, Pfizer, Sanofi, and Hoffmann La Roche. E. Asselmann, R. Lieb, M. H€ ofler, and K. Beesdo-Baum declare to have no financial relationships that might be perceived as conflict of interest.

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