Motivation and emotion/Book/2019/Post-traumatic stress effects on achievement motivation in adolescents
What effects does post-traumatic stress have on adolescent achievement motivation?
Overview[edit | edit source]
"Keep calm and carry on". An oft (mis)appropriation of British stoicism which has enjoyed a rather spectacular revival in modern society, in part due to the implicit concept that there is simply nothing for it but to square one's jaw. Though the importance of maintaining a functioning society in the face of adversity is intuitive, putting one foot in front of the other is not many people's concept of a life well-lived. This chapter explores motivational concepts as they relate to adolescents following a traumatic event, Improving our capacity for emotional intelligence through the understanding of the mechanisms PTSD and discussion of coping strategies employed by those affected with this disorder.
|“||Let me share with you parts of my story. It may be unfamiliar to those who have been born and grown up in a peaceful Australia...."
"...You must have a dream that takes you up and beyond any past trauma and turmoil"
Deng Adut delivers the 2017 Australia Day address with a concise yet poignant recount of his life in front of countless dignitaries and media officials. Stolen at the age of six from his grandfather's banana plantation, Adut endured countless tortures as part of an initiation to become a child soldier for the Sudan People's Liberation Army (SPLA). After 4 years of servitude, he was rescued by his older brother. Making his way to a refugee camp in neighbouring Kenya, Adut was eventually sponsored to relocate to Australia. From learning English during the midnight shift at a petrol station in Blacktown to earning a Masters degree in Law, Adut involved himself with criminal refugee cases, founding his own firm. Deng now works for members of the Sudanese community both domestic and abroad and in recognition of his storey, his struggles and his achievements, Deng was the recipient of the NSW Australian of the Year Award, 2017.
It is all too easy to consider polarising tales of determination such as these in the abstract. Perusing through media outlets and academic papers PTSD is apparent as it relates to warlike conditions and conflict zones. Less evident is the prevalence and epidemiology of this disorder within the Australian community.
The societal impacts of amotivation and PTSD[edit | edit source]
When considering the vast amount of literature exploring post-traumatic stress particularly as it relates to motivation, there is a dearth of studies examining achievement motivation as an outcome variable from trauma incidents. The manifestation of PTSD may reach far beyond the causal agents and permeate through almost all aspects of life.
There is convincing evidence to the relationship between amotivation and unemployment, underemployment and a lack of self-supporting. These factors compound to providing an economic burden on society (Tiggerman 1989). Conversely, there is overwhelming research showing the positive psychological and sociological impacts of persons employed in meaningful work (Tiggerman 1989, Maree 2008) In spite of the known psychological benefits, it has been demonstrated that persons presenting symptoms of PTSD are often provided positions of less meaningful work (Rametese et al 2018). Removing the stigma of what it means to have a trauma-related injury will assist in the employment and management of PTSD patients.
The impacts of PTSD and amotivation run deeper than financially, consider the below case study, contributions to the humanities and arts provide cultural additions to society which cannot be measured in currency.
As conscientious global citizens living within a multicultural society and connectivity has reached over 5 billion people, (UKAID, 2017) all manner of persons across all walks of life are within our sphere. Furthermore, it must be considered that as a mechanism of injury, warlike trauma accounts for a small minority of the PTSD cases.
Therefore as the teachers, managers, colleagues, coaches, mentors and friends, it is to all individuals to have an understanding and comprehension of the wide-reaching effects of PTSD and be prepared to understand and assist in the management of this disorder.
Boxer Isa prepares for the Australian national title, but what awaits in the ring cannot contend with the internal conflicts. Sparring a harrowing childhood as an abducted soldier of the Congo, Isa's journey to becoming a refugee and fighter in Brisbane is a compelling tale of courage, fear, hope and hate.
Drawing from his own experience as a Congolese refugee, Future D Fidel, a naturalised Australian citizen writes and produces his theatre production "Prizefighter" to acclaim across the country. The recipient of 'Best New Australian Work, 2016", "Best Play, 2016" and "Best production" at the 2019 Matilda Awards this piece contends with post-traumatic stress, racism and grit.
In spite of receiving a bachelor’s degree in electrical engineering and rising fame, Fidel continues to contribute to local and community projects to assist refugee troupes and dancers.
Discuss the importance of the humanities in expressing conflicts and self.
Source:'prizefighter, Future D Fidel
Relevant theories and concepts[edit | edit source]
Post-traumatic stress[edit | edit source]
Post Traumatic Stress Disorder is a universal psychobiological disorder with a broad range of symptoms and manifestations. In a 2014 article exploring PTSD in the ancient world, Abdul-Hamid & Hughes (2014) provide compelling evidence for the presence of PTSD in soldiers during the Assyrian dynasty 1300 BCE. In subsequent years this disorder has been known by several monikers and been treated with concern, apathy and disparagement whilst the symptoms have remained relatively consistent. A controversial inclusion in the 1980 American Psychiatric Association's (APA) [[wikipedia:Diagnostic and Statistical Manual of Mental Disorders|Diagnostic and Statistics Manual of Mental Disorders]] (DSM) the introduction of PTSD as a diagnosable disorder provides a key element to the understanding with the provision of an external etiological agent (trauma).
A cursory search for PTSD in academic literature provides an overwhelming response of collective trauma studies such as those resulting from destabilised nations and conflict. Less apparent are those individual events that lead to PTSD. Warlike experiences account for a minority of diagnosed conditions in Australia with the majority of cases in both genders being caused by sexual abuse (McEvoy Et al. 2011). It is thought that approximately two-thirds of the Australian population will be exposed to traumatic events which satisfy part of the diagnostic symptoms (Anderson & Bang, 2012), with an estimated 4.4% prevalence rate over 12 months (McEvoy et al, 2011).
PTSD is diagnosed through certain cluster criteria:
- "Stressor", a key component to be diagnosed with PTSD is to experience a catastrophic event. For a diagnosis, this must be the antecedent condition.
- The second cluster related to symptoms. i. "Intrusive recollection" of the event. This symptom may last for years and is often internalised ii."Avoidance" The patient will show behavioural patterns to avoid exposure or recollection of the stimuli iii. "Negative mood cognitions" refer to the sudden and non-proportional change of moods and emotions. iv. Hyperarousal or reactivity" criterion relates to hypervigilance and startles actions. often the most recognisable agents.
- The final cluster determines a minimum length of symptoms (one month), that there must be an adverse effect on the patient's life and the symptoms must not be resultant of medication or substance abuse.
Motivation theory[edit | edit source]
Countless papers trace the lineage of motivation to the ancient Greeks and their rhetoric of the duality, though likely concepts of motivation have been around since the evolution of the shoulders and the cognitive ability to shrug them. Modern motivational theory is widely attributed to Abraham Maslow, whose influence need only be established through a cursory glance of this textbook and its editions, with 146 dedicated sections over 419 chapters on motivation. See  for reference.
A problem arises when considering which theory of motivation to measure a specific construct, particularly one with as much variance as PTSD. It is important to note that many of these theories are not mutually exclusive, and aspects of motivational theory are considered under two main banners. Content theory and Process theory. This section will provide a brief overview of these theories.
Content theory (Needs Theory)[edit | edit source]
Content theories look to the inherent factors in an individual which provide the causation, persistence and cessation of behaviour. A key component of the content theory is the 'need', motivating to drive behaviour. Content theory permeates through management literature as the focus is on 'what' motivates individuals, though there is inconclusive scientific support for many of the posits. Some key theories in Content motivation include.
Alderfer - 1969 - ERG- A development of Maslow's need theory summarising needs are relating to Existence (Individual), Relatedness (Social) and Growth (determination)
McGregor - 1950 - Management Assumptions (Theory X and Y Models) - An application of needs theory in the workplace, asserting that a managers assumptions and subsequent treatment of employees provides a self-fulfilling prophecy of efficacy.
McClelland - 1960 - Acquired needs Theory - Assert that all humans possess a need for achievement (NAch) a need for power (Npow) and a need for affiliation (NAff). McClelland argues that people will have different characteristics depending on their dominant motivator. These motivating factors have been claimed to be learned and are influenced by external factors (Events and social conventions) and intrinsic regulation. An important note when considering a high achievement motivation conflates with a need for competency, and that a high need for achievement will likely result in moderate to moderate high functioning rather than high achieving. This is in part due to the failure avoidance characteristic of those with a high need for achievement.
Process theory[edit | edit source]
Process theories are comprised of elements which attempt to explain how motivation occurs. A key component of process theory is causation or mediating effect on the action.
Skinner - Reinforcement Theory- Modeled from the concept of operant conditioning, Skinner's reinforcement theory asserts that behaviour is modified through the systematic issue of contingent consequences. Reinforcing behaviours may be positive or negative and may be moderated by punishment and extinction of these behaviours. Adut provides recounts of initiation where his cohort was not allowed to eat with the soldiers *sic unless they 'punished' the squad member with the worst performance of the day, thereby utilising both positive and negative reinforcers to condition. Similarly, it is often inferred to sexual abuse victims that the action was a result of a negative action performed by the victim (often to the detriment of the attacker) (Carey Et al, 2008)
Vroom - Expectancy Theory - Concerned with the process of motivation governing alternatives controlled by individual cognitions. That is, the effort is calculated using the following; self-efficacy of the task, the difficulty of the task and the control over the outcome.
Adam - Equity Theory - With a foundation of theory rooted deep in the canals of philosophical justice, Adams' equity theory is based on a reciprocating relationship where inputs (efforts) and outputs (results) are striving for either a balance or imbalance (in favour)
Locke - Goal Setting Theory - A cyclic model where the focus of setting an attainable and simple goal reinforces the competence of one's ability to set and attain goals. The process of setting these goals is set by the principals of Clarity, Challenge, Commitment, Feedback and Task complexity.
Quiz[edit | edit source]
The effect of PTSD on motivation in adolescents[edit | edit source]
Considering the global prevalence of PTSD in both developing and established nations, as well as the focus on academic and prosocial achievement in adolescents in cross-cultural settings, there is a comparative lack of literature regarding achievement motivation as an outcome variable of PTSD. This lack presents some difficulties in providing empirically tested cause and effect results.
Age and gender differences in motivation characteristics[edit | edit source]
There have been several independent studies which demonstrate a significant difference in the expression as well as the prevalence of PTSD with gender as a mediating factor. Gender differences, especially in the presentations of symptoms provide an important understanding of the alternate results in achievement and academic motivation. Al-Khayat (2013) provides a 10-year longitudinal case analysis of 90 students formerly of Iraq relocated to Jordan. Of the population sampled it was found that PTSD prevalence occurred at a rate of (0.55m) and (0.65f), providing support for the universality of the increased presentation of PTSD in females. This study also highlights gender differences in response to PTSD events, noting that adolescent males suffering from PTSD had elevated hyperactivity levels, whilst females experienced higher emotional levels as well as engaged in a less prosocial activity. Betancourt, et al. (2011) found these differences of expression in females (victims of sexual abuse) reporting heightened levels of arousal, sexual anxiety and personal vulnerability whereas adolescent males in the same village reporting aggression and heightened achievement motivation.
As well as gender, many studies have shown an effect on age differentiation even when considered over a small age bracket. A case study of one hundred and sixty-nine children and adolescents used a multi-variantanalysis to determine individual differences and developmental characteristics of PTSD and resilience (Feiring et al. 1999). This study also identified that Adolescents report higher levels of depressive symptoms comparative to children. In a cross-sectional analysis, students with diagnosed PTSD were classified as 'younger'(14) and 'older' (16) (.49 f). Sharma (2014) found that there was a significant positive difference in PTSD symptoms (severity) in older students. An interesting result from this study also found that younger females (14) and the older males (16) measured much higher for achievement motivation than converse peers. The implications for these findings contrast Brooks and Strawn (2014), who based on the isomorphic nature of adolescent and adult PTSD postulate the efficacy of psychopharmacological treatments .
[edit | edit source]
Academic and social development is very important through the adolescent years. A Canadian study of refugee (18-20) students migrating from various conflict areas sought to determine academic achievement in secondary studies in war afflicted students during acculturation. Results found that overwhelmingly, immigrants from war-zones performed well in spite of language and comprehension barriers. (Stermec et al, 2011) this paper discusses the effect of family support on the academic processing noting that those displaced by conflict average more years of formal education than those in resettled locations. With Similar findings in youths in the UK, Güngör & Perdu (2017) expanded in their discussion the cognitive dissonance that occurs when a member of a collectivist culture is presented with the need for competence through means of education (Autonomy) at the expense of the protective resource of the existing ethnic group (relatedness)
Interestingly enough, the Al-Khayat (2013) study noticed several positive effects of acute PTSD made apparent in self-report, other report and within talk therapy. These aspects were characterised as having full awareness of duties, responsibilities toward family as well as an increase in self-confidence. These findings have been correlated in a 2 year follow up study of resettled former child soldiers who had confirmed kills before the age of 16. Betancourt, et al. (2011) found that although these children had higher deviant behaviour and hostility rates, there was also elevated pro-social attitudes and far above norm confidence levels. Furthermore, conducting a mediation analysis on academic achievement and PTSD symptoms, Scott et al. (2013) find the support that acute symptoms of PTSD are reliable predictors of positive academic outcomes.
Sports therapy motivation[edit | edit source]
Exercise and sports have a well established positive effect on psychological well being. In a seminal article measuring the direct effects of exercise in addition to standard intervention, Rosenbaum et al (2015) found that there were significant improvements in the exercise groups over the control groups. Following treatment, the exercise groups reported higher levels of continuing callisthenics, increased sleep quality and reduced PTSD symptoms. Conversely, a controlled study on yoga intervention in the physical activity, self-efficacy and motivation effects on women with PTSD found that there was no relationship between structured yoga intervention and the aforementioned characteristics (2015), in fact, the test reported a significant decrease in external motivation comparative to the control group. This may indicate that the nature of the activity is required to easily satisfy a need for competence and autonomy to establish behaviours resulting in prolonged benefits of the treatment.
Although the explanatory position of the benefits of exercise on PTSD has not been universally confirmed, there is little doubt of the efficacy of it.
A critical review of the limited literature of children and adolescents using anaerobic group and individual exercise found universal support in reducing negative emotions and reducing PTSD symptoms when used in conjunction with a treatment plan. (Motta et al,2012). There is a risk of user groups and exercise-related treatments in adolescents. In 1981 Roberts and colleagues provide an analysis of the role of motivation in children's sport. Although there is significant material providing for the subversion of aggressive tendencies, increased relatedness, autonomy as well as positive psychological functioning, this analysis provides insight into the delicate nature of perceived competence and autonomy as well as relatedness in competition concerning adolescents in sport. It could be concluded that careful supervision and management of group activities would be required when establishing group activities in adolescents
Quiz[edit | edit source]
Mediating variables and implications for the management and exploratory studies[edit | edit source]
Having discussed the relationship of post-traumatic stress on Achievement motivation and those factors moderating it, this section will explore mediating and moderating effects and briefly discuss the implications of developing models toward the management of motivation coaching in these cases.
Social Identity[edit | edit source]
There is an intrinsic link between the groups we belong to and how we perceive ourselves and others. (Ryff, 1989). Considering Social Identity (LINK) as a moderator of AM on PTSD allows for an interesting perspective on how the groups we belong may positively or negatively impact our motivating behaviours. A quantitative meta-analysis of sexually abused children in the united states found that undermining family integrity was provided as the lead deterrent for support seeking outside of the family unit . This chapter provides an expansion of victims prolonging abusive relationships. In a cultural centric review of college students, Joseph and Gray, (2009) to finding that African American adolescents with PTSD are more likely to self attribute blame than white *sic students. These authors provide compelling arguments that the perceived social stratification of the patient's caste has a significant impact on the person's perceived loci of control. It is important to note that a perceived social identity may not always prove advantageous in rehabilitation, Kizilhan J, Noll-Hussong M. (2018) found that it was not within the ability of a collective-oriented social mind to assist in the rehabilitation of child soldiers returning to their home province.
In a post-disaster screening of 804 children, Mcdermott et al (2012) found that children measuring low on social connectedness are 3.96 times more likely to develop severe to very severe PTSD symptoms following a calamitous event. This article provides a detailed analysis of the mechanism of PTSD and the inhibitive or enhancement factors which may be experienced through a particular trauma. Fig 3.0 demonstrates these pathways in a structural equations model using a natural disaster as an example.
An exploratory study on the forming of new groups in New Zealand provides support to the efficacy of forming nurtured groups to produce norms. This has implications to assist in the treatment of groups with negative tendencies through the forming of new groups and the setting of new norms to assist with the newcomers.
Resilience[edit | edit source]
Psychological resilience refers to one's ability to adapt to adverse conditions and returning to a pre-crisis state with little external intervention. A key factor of motivation is the sustainability of the behaviours. As discussed earlier in the chapter, there is a significant factor of resilience recorded as an outcome variable of violent post-traumatic stress, particularly with young children. Expanding on their case study, Anderson & Bang (2011) interview women who experienced domestic abuse when children to determine me. their resilience to the events as it was happening ii. the learned resilience to life's events as an adult. These studies provide interesting results which suggest that a lack of family integrity, such as single mothers or an incarcerated parent are very strong predictors of resilience. These findings appear to be supported in a critical review of the literature on resilience, stating that many of the theoretical modes of resilience are not supported by empirical evidence. (Brenda, 2018) The table below provides details on resilience coping strategies.
|Active Coping Style||Involves an awareness of the stressor and the ability to reduce the negative emotions brought about by the event|
|Social Support||Developing social connectedness - maintaining multiple identities engaging in rewarding and reciprocal relationships,|
|Cognitive flexibility||Remaining flexible to creative problem solving and engaging in optimistic thinking|
|Fitness and exercise||maintaining a good level of physiological health|
|Emotional Intelligence||the ability to recognise, process and manipulate your own and others emotions|
To Summarise[edit | edit source]
We began this chapter with a metaphor and a vignette. The metaphor, a message to a stricken country to continue working the factories no matter what falls around. During a large portion of recorded history, persons suffering from stress and trauma-related injuries were either relieved of their duties or diminished in the eyes of their colleagues. PTSD is a clinically recognised condition which can present in a variety of ways with vast variances in the severity of the symptoms. Although there is a common reference to war-like exposure as a mechanism of PTSD, the prevalence in society is predominately due to sexual abuse or traffic incidents. The vignette, an opening sortie of how tenacity and motivation can overcome even the most adverse conditions. Motivation is grouped into two overarching theoretical constructs, content (what) and process (how) theories. These theories provide a framework for how we may measure and manage motivation, though there is a myriad of factors both internal and external which will affect any application of these concepts.
The relationship of PTSD and motivation, particularly in adolescents is in the embryonic stages of research, though it would likely surprise many to find that there is often a positive relationship between PTSD, achievement motivation and prosocial outcomes. though this is why we test our boundaries of knowledge, to proclaim these findings and slowly whittle the stigma from our colleagues, our students, our children and ourselves so that we may,
|“||Keep calm and carry on...
...and on, and on"
Quiz[edit | edit source]
See also[edit | edit source]
- Stress and achievement motivation (Book chapter, 2015)
- Personality and achievement motivation (Book chapter, 2015)
References[edit | edit source]
2016, Transcript; Deng Thiak Aduts's acceptance speech on the award of Australian of the year, Australian National Archives
Abdul-Hamid, W., Hughes, J., & Abdul-Hamid, W. (2014). Nothing new under the sun: post-traumatic stress disorders in the ancient world. Early Science and Medicine, 19(6), 549–557. https://doi.org/10.1163/15733823-00196p02
Anderson, K., & Bang, E. (2012). Assessing PTSD and resilience for females who during childhood were exposed to domestic violence. Child & Family Social Work, 17(1), 55–65. https://doi.org/10.1111/j.1365-2206.2011.00772.x
Betancourt, Borisova, Williams, Brennan, Whitfield, La Soudiere, Williamson & Gilman, (2010) ' Sierra Leone's Former Child Soldiers: A Follow-Up Study of Psychosocial Adjustment and Community Reintegration'. Child Development, 81 (4): 107
Carey, P., Walker, J., Rossouw, W., Seedat, S., & Stein, D. (2008). Risk indicators and psychopathology in traumatised children and adolescents with a history of sexual abuse. European Child & Adolescent Psychiatry, 17(2), 93–98. https://doi.org/10.1007/s00787-007-0641-0
Joseph, J., & Gray, M. (2010). The adaptiveness of trauma attributions as a function of ethnicity. Annals of the American Psychotherapy Association, 13(4). Kelmendi, B., Adams, T., Yarnell, S., Southwick, S., Abdallah, C., & Krystal, J. (2016). [Review of PTSD: from neurobiology to pharmacological treatments]. European Journal of Psychotraumatology, 7(1), Article 31858. https://doi.org/10.3402/ejpt.v7.31858
Khan, Tabasum, and Jahan, Musaddiq. (2015) “Psychological Well-Being and Achievement Motivation Among Orphan and Non-Orphan Adolescents of Kashmir.” Indian Journal of Health and Wellbeing, 6. 769–773. Web.
Khayat M, 2013, 'The relationship between Post Traumatic Stress Disorder and Achievement motivation in a Sample of Irawui students living in Jordan, European Journal of Social Sciences Vol 38, pp25-34',
Kizilhan J, Noll-Hussong M. (2018) "Post-traumatic stress disorder among former Islamic State child soldiers in northern Iraq' The British Journal of Psychiatry, 213(1), 425-429
Klasen, oettingen, Daniels, Post, Hoyer & Adam, (2010), 'Posttraumatic Resilience in Former Ugandan Child Soldiers', Child Development, Vol 81 4 pp 1096-1113
Martin, E., Dick, A., Scioli-Salter, E., & Mitchell, K. (2015). Impact of a Yoga Intervention on Physical Activity, Self-Efficacy, and Motivation in Women with PTSD Symptoms. Journal of Alternative and Complementary Medicine (New York, N.Y.), 21(6), 327–332. https://doi.org/10.1089/acm.2014.0389
Mcdermott, B., Berry, H., & Cobham, V. (2012). Social connectedness: A potential aetiological factor in the development of child post-traumatic stress disorder. Australian & New Zealand Journal of Psychiatry, 46(2), 109–117. https://doi.org/10.1177/0004867411433950
Mcevoy, P., Grove, R., & Slade, T. (2011). Epidemiology of Anxiety Disorders in the Australian General Population: Findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, 45(11), 957–967. https://doi.org/10.3109/00048674.2011.624083
Motta, R., Mcwilliams, M., Schwartz, J., & Cavera, R. (2012). The Role of Exercise in Reducing Childhood and Adolescent PTSD, Anxiety, and Depression. Journal of Applied School Psychology, 28(3), 224–238. https://doi.org/10.1080/15377903.2012.695765
Rosenbaum, S., Sherrington, C., & Tiedemann, A. (2015). Exercise augmentation compared with usual care for post‐traumatic stress disorder: a randomized controlled trial. Acta Psychiatrica Scandinavica, 131(5), 350–359. https://doi.org/10.1111/acps.12371
Roberts, G., Kleiber, D., & Duda, J. (1981). An Analysis of Motivation in Children’s Sport: The Role of Perceived Competence in Participation. Journal of Sport Psychology, 3(3), 206–216. https://doi.org/10.1123/jsp.3.3.206
Safwat Y. M. Diab, Marja Guillaume, and Raija-Leena Punamäki, "Ecological Approach to Academic Achievement in the Face of War and Military Violence: Mediating and Moderating Role of School, Family, and Child Characteristics," The Elementary School Journal 119, no. 1 (September 2018): 1-28.\ https://doi.org/10.3402/ejpt.v3i0.18560
Scott, B., Lapré, G., Marsee, M., & Weems, C. (2014). Aggressive Behavior and Its Associations With Posttraumatic Stress and Academic Achievement Following a Natural Disaster. Journal of Clinical Child & Adolescent Psychology, 43(1), 43–50. https://doi.org/10.1080/15374416.2013.807733
Sharma, S. (2014). Exposure to community violence: Post-traumatic stress disorder symptoms, impairment functioning and achievement motivation among grade 8th and 10th adolescents. International Journal of Education and Management Studies, 4(4), 300–307. Retrieved from http://search.proquest.com/docview/1680503325/
Simmen-Janevska, K., Brandstätter, V., & Maercker, A. (2012). The overlooked relationship between motivational abilities and posttraumatic stress: a review. European Journal of Psychotraumatology, 3(1), Article 18560.
Stermac, L., Elgie, S., Clarke, A., & Dunlap, H. (2012). Academic experiences of war-zone students in Canada. Journal of Youth Studies, 15(3), 311–328. https://doi.org/10.1080/13676261.2011.643235 Trumbull, Elise & Rothstein-Fisch, Carrie. (2011). The Intersection of Culture and Achievement Motivation. School Community Journal. 21.
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- Carey, P., Walker, J., Rossouw, W., Seedat, S., & Stein, D. (2008). Risk indicators and psychopathology in traumatised children and adolescents with a history of sexual abuse. European Child & Adolescent Psychiatry, 17(2), 93–98. https://doi.org/10.1007/s00787-007-0641-0