Problemática de la validación directa 42

The relationship between problematic, i.e., overly sensory, fragmented, incoherent, or disorganized, qualities of traumatic memories and PTSS has been studied in two traditions. In the first one, trauma survivors provide, in writing or orally, accounts or narratives of their traumatic experience, which researchers or independent judges then code and rate according to pre-defined criteria. In the second approach, trauma survivors answer questions about the quality of their memories as self-report.

Findings in the first tradition on features of the trauma narrative and PTSD symptomatology have been mixed and open to differing interpretations. Some studies have linked PTSD with more experimenter-rated incoherence or disorganization in trauma narratives among adults (Halligan, Michael, Clark, & Ehlers, 2003; Jelinek, Randjbar, Seifert, Kellner, & Moritz, 2009; Jones, Harvey, & Brewin, 2007). Still, differences in ratings in many studies have been small, and ratings of traumatic memories on average quite coherent and organized for both those with and without PTSD. Others have been totally unable to replicate these findings (e.g., Berntsen, Willert, & Rubin, 2003; Rubin, Deffler et al., 2016). Rubin, Deffler et al. (2016), employing a very wide variety of potential measures, found trauma memories to be at least as coherent as other important, positive memories, and no difference between people with and without PTSD in memory coherence.

Few studies on qualities of trauma narratives and their links with PTSS exist among children. Kenardy et al. (2007) found some preliminary evidence of association between temporal disorganization of trauma narratives and PTSS among children and adolescents exposed to physical injury trauma. Salmond et al. (2011),

studying trauma narratives of children with acute stress disorder (ASD) due to a single traumatic event, also found them to be more disorganized than those of controls without ASD. Level of narrative disorganization also predicted severity of stress symptoms. In contrast, Bray, Brewer, Cameron, and Nixon (2018), studying 7–17-year-old survivors of recent traumatic injury, found high PTSS to associate with more detail in their trauma narratives compared with memory of a positive event and no difference in narrative cohesion between those with high or low levels of PTSS or between narratives of trauma and positive events. In even more contrasting findings, O’Kearney, Speyer, and Kenardy (2007) found among 7–16- year-old children after traumatic injury that higher PTSS were associated with better conceptual understanding and quality of trauma narratives in terms of lexical structure and cohesion, as well as less sensory and perceptual impressions. Finally, in a prospective study among child and adolescent survivors of single-incident trauma, McKinnon, Brewer, Meiser-Stedman, and Nixon (2017) found temporal disorganization of trauma narratives to predict concurrent and later PTSS, but only when self-report quality of traumatic memories was not accounted for.

Summing the evidence, Brewin (2014) argued that at least studies using independent judges as raters have indeed found the trauma narratives of those with PTSD to be more disorganized than their non-trauma narratives and trauma narratives of those without PTSD. However, Rubin, Deffler et al. (2016) reviewing mostly the same evidence came to quite different conclusions and argued that there really is no evidence that trauma memories of people with PTSD are less coherent. What might explain these incongruent and even contradictory findings and interpretations? First, coherence is certainly a difficult concept to operationalize and measure, and different studies have used different conceptualizations. Beyond this, another alternative presented by Brewin (2016; 2018) is that fragmentation or disorganization do exist in traumatic memories, but only at the most upsetting moments or hot spots. Thus, they would only appear when trauma survivors focus on these moments in detail, not when they describe their experiences more generally. In the second tradition of self-reports about the quality of traumatic memories, which might also be characterized as meta-memory or perception of memory quality (Bedard-Gilligan & Zoellner, 2012; McKinnon et al., 2017), some studies are available among children and adolescents. Stallard and Smith (2007) did not find self- reported memory quality to significantly explain variance in PTSS beyond the effect of negative PTCs, among 7–17-year old survivors of traffic accidents. However, just two individual items were used to assess memory quality, and one of them, feeling

Using the more comprehensive Trauma Memory Quality Questionnaire (TMQQ; Meiser-Stedman, Smith, Yule, & Dalgleish, 2007), also employed in Study IV, Meiser-Stedman et al. (2007) found self-reported memory quality to mediate the relationship between trauma severity and symptoms of ASD for survivors of single- incident trauma. In another later study of child and adolescent survivors of single- incident trauma, Meiser-Stedman et al. (2019) found memory quality at two weeks post-trauma to associate with level of PTSS and PTSD diagnosis two months after the trauma. However, controlling for other factors such as negative PTCs, coping styles, and dissociation, memory quality did not predict later PTSS. McKinnon, Nixon, and Brewer (2008) found self-reported memory quality assessed with the TMQQ to mediate relationships between data-driven processing and fear during the trauma and later intrusive symptoms, though not avoidance or arousal symptoms, among 7–16-year-old children exposed to single-incident trauma. McKinnon et al. (2017) also found in child survivors of injury that self-reported trauma memory quality predicted PTSS both cross-sectionally and longitudinally, and accounted for variance initially explained by narrative characteristics. Improvement in self-reported memory quality also predicted reduction in PTSS, suggesting a role in (natural) recovery. This interpretation is supported by the findings of Hiller et al. (2019) that change in self-reported memory quality from one to seven months post-trauma associated with change in PTSS over the same period among school-aged survivors of single-incident trauma.

As these studies only assessed trauma memories, their findings may reflect more general memory disturbance or perception of memory problems in PTSD and not quality of traumatic memory per se. In their study of recent child survivors of single- incident trauma, Salmond et al. (2011) found those with ASD to report their memories overall to be more sensory and fragmented, and all children to report trauma memories as more sensory and fragmented than other memories. However, there was no interaction between ASD status and type of memory as would be expected if quality of trauma memory was uniquely linked to ASD symptoms, and self-reported quality of traumatic memory did not associate with symptom severity. In contrast, Bray et al. (2018) found child survivors of injury trauma with higher PTSS to report more sensory and less organized memories of their trauma compared with a positive event and with those with low PTSS.

In sum, findings on self-reported memory quality and its relation to PTSS among children and adolescents are somewhat mixed, but do overall suggest a link. In particular, the prospective studies by McKinnon et al. (2017) and Hiller et al. (2019) suggest that changes in self-reported memory quality might also be important for

changes in PTSS. Such findings and the significant emphasis the cognitive model of Ehlers and Clark (2000) and dual representation theory (Brewin et al., 1996) place on problematic qualities of traumatic memories as integral to the maintenance of PTSS motivate us to study changes in memories as a possible mechanism of change. Notably, however, all the above research concerns children and adolescents with single-incident trauma. The relevance of problematic qualities of trauma memories to PTSS among multiply traumatized children remains unclear, which is where Study IV particularly aims to contribute.