I O I P L K M a b c d R A h 1 t nternational Journal of Clinical and Health Psychology (2020) 20, 46---53 www.elsevier.es/ijchp International Journal of Clinical and Health Psychology RIGINAL ARTICLE mplicit processing of emotional words by children with ost-Traumatic Stress Disorder: An fMRI investigation iliana Calderon-Delgadoa,∗, Mauricio Barrera-Valenciab,d, Ivette Noriegac, areem Al-Khalil c, Elizabeth Trejos-Castilloc, Jennifer Mosic, Breanna Chavezc, ichael Galvanc, Michael W. O’Boylec Universidad CES, Colombia Universidad de Antioquia, Colombia Texas Tech University, United States Hradec Králové University, Czech Republic eceived 20 July 2019; accepted 21 November 2019 vailable online 19 December 2019 KEYWORDS PTSD; fMRI; Brain activation; Experiment Abstract Background/Objective: In the last decade, socio-political violence in Colombia (South America) has created an environment of extreme/chronic stress. In this study, brain imaging technology (fMRI) and behavioral task performance were used to measure potential deficits in executive functioning for emotional processing in Colombian children. Method: Participants (22 Post-Traumatic Stress Disorder, PTSD and 22 neurotypical, NT) were asked to perform a word task with implicit emotional salience, which required them to report the color of the ink in which a positive, negative or neutral word was printed. Results: Mixed design analysis of variance showed no group differences in accuracy for deter- mining ink color when presented as a positive or neutral word. However, PTSD children were significantly less accurate (negative words) and notably slower (both positive and negative words) at determining ink color when presented in the context of an emotional word. PTSD processing of positive and negative words was associated with hypoactivation in the superior and middle frontal gyri of the right hemisphere in comparison to NT children. Conclusions: These results may reflect a deficit in executive functioning for emotionally laden stimuli, perhaps induced as a by-product of their traumatic experiences. © 2019 Asociación Española de Psicoloǵıa Conductual. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). ∗ Corresponding author: Calle 10A No 22-04, Medellín, Antioquia, Colombia. E-mail address: lcalderon@ces.edu.co (L. Calderon-Delgado). ttps://doi.org/10.1016/j.ijchp.2019.11.002 697-2600/© 2019 Asociación Española de Psicoloǵıa Conductual. Published by Elsevier España, S.L.U. This is an open access article under he CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.ijchp.2019.11.002 http://www.elsevier.es/ijchp http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijchp.2019.11.002&domain=pdf http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ mailto:lcalderon@ces.edu.co https://doi.org/10.1016/j.ijchp.2019.11.002 http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ Implicit processing of emotional words by children with Post-Traumatic Stress Disorder 47 PALABRAS CLAVE Trastorno de estrés postraumático; resonancia magnética funcional; activación cerebral; experimental Procesamiento implícito de palabras emocionales en niños con Trastorno de Estrés Postraumático: investigación con resonancia magnética funcional Resumen Antecedentes/Objetivo: En la última década, la violencia socio-política en Colombia, ha prop- iciado un ambiente generador de situaciones de estrés crónico/extremo. El presente estudio empleó resonancia magnética funcional, junto con tareas conductuales, para medir posibles déficits en el funcionamiento ejecutivo en una tarea de palabras con contenido emocional en una muestra de niños colombianos. Método: A los participantes (22 TEPT y 22 controles), se les pidió indicar el color de la palabra impresa, omitiendo el contenido emocional implícito positivo, neutro o negativo. Resultados: El análisis de varianza de diseño mixto, no arrojó diferencias entre los grupos, en número de aciertos al determinar el color en que estaban impresas las palabras positivas o neutras. Sin embargo, los niños con TEPT tuvieron más errores con las palabras de contenido emocional negativo y fueron más lentos que los controles con palabras de valencia positiva o negativa. En cuanto a las palabras positivas y negativas, el grupo con TEPT se asoció a hipoac- tivación de los giros superior y medio frontal del hemisferio derecho, al compararlos con los controles. Conclusiones: Estos resultados sugieren déficits en el funcionamiento ejecutivo para estímulos con contenido emocional, quizás como consecuencia de las experiencias traumáticas vividas por el grupo de TEPT. © 2019 Asociación Española de Psicoloǵıa Conductual. Publicado por Elsevier España, S.L.U. Este es un art́ıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/). s f l f t 2 e i d s r b t f o a t 2 t t f t o W ( p Childhood maltreatment is a major risk factor for psy- chopathology (Ohashi et al., 2019) with recent research (Malarbi, Abu-Rayya, Muscara, & Stargatt, 2017) indicating that chronic exposure to such trauma during childhood has negative implications for neurodevelopmental outcomes. For example, Cisler et al. (2014) collected longitudinal data from a representative sample of United States adolescents and found a strong correlation, such that risk for PTSD as well as depression, binge drinking, cigarette smoking, and delinquent behavior, all increased as a function of chronic exposure to early traumatic experiences. In Colombia (South America), early traumatic experi- ences are closely related to instances of maltreatment, abuse, and neglect in both children and adolescents. During 2017, a total of 20,663 children and adolescents were vic- tims of sexual abuse, another 10,385 suffered from domestic violence and 14,454 lived through multiple episodes of social violence (Instituto Nacional de Medicina Legal y Ciencias Forenses, 2017). Moreover, despite the implementation of the current Colombian peace process, new forms of vio- lence have emerged that have reinforced the vicious circle of violence begetting more violence. As the Director of the National Institute for Legal Medicine and Forensic Sciences has said, Ïn Colombia, violence does not disappear, it trans- forms’’ (Guerrero & Fandiño-Lozada, 2017, p. 9). This is particularly true for children chronically exposed to such violence, who when becoming adults, often exhibit a ten- dency to resolve their conflicts using violence as well (Felitti et al., 2019; Spano, Rivera, & Bolland, 2006). In the United States, one of the more common clinical outcomes stemming from early traumatic experi- ence is PTSD. Children and adolescences are particularly & p d t usceptible to developing PTSD with the incidence ranging rom 20% to 80% (Jovanovic, 2017). In socio-political vio- ence contexts like Colombia, PTSD is often associated with eelings of fear, helplessness, and/or horror in response to he chronic threat of injury or death (Yehuda & LeDoux, 007). According to Hart et al. (2018) childhood PTSD, what- ver the source, is a strong predictor of future mental health ssues that negatively affect peer interactions, decrease or elay academic achievements, and creates a reoccurring ource of emotional distress for all family members. From a physiological perspective, early traumatic expe- iences have been shown to disrupt experience-dependent rain development during critical periods. These disrup- ions are thought to adversely affect neural structure and unction, as well as creating a delay in the overall course f neurodevelopment (Malarbi et al., 2017). Particularly ffected by trauma are the frontal lobes, which are some of he last brain regions to fully develop (Gogtay & Thompson, 010; Sinnamon, 2019). Indeed, it has been suggested that he cognitive processing difficulties, behavior abnormali- ies, and deficits in affect regulation and other executive unctions as exhibited by children with PTSD may be par- ially due to the dysfunction of the dorsolateral prefrontal, rbitofrontal, and anterior cingulate cortices (Carrion & eems, 2017; Li et al., 2019). Currently, there are mixed results regarding activation or not) of the aforementioned regions during emotion rocessing in PTSD children as well as in adults (Carrion Weems, 2017; McNab et al., 2008). Somewhat sur- risingly, PTSD altered brain development and related eficits in executive functioning are underexplored in he pediatric population living in Colombia, despite the http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ 4 L. Calderon-Delgado et al. f p C t s b c o M P T M s P a p o U D e p ( t s p 9 s < t o d I T ( a e 8 g d c d e t s s i o r t F T c a v Emotional word processing task Pensar(think) Jugar(play) Matar(kill) Figure 1 Examples of neutral, positive, and negative word stimuli. N r 0 fl u i v v u c B a a F F e b s a t d fi W S r s s t s F ( o C p o a R B F j F o c s w 8 act that the latter country reports an extremely high revalence of PTSD affected children (Barrera-Valencia, alderón-Delgado, Trejos-Castillo, & O’Boyle, 2017). Thus, he current research aims to address this knowledge gap by pecifically focusing on Colombian children, exploring their ehavioral performance on an implicit emotional word pro- essing task, while taking concomitant measures (using fMRI) f related brain activation. ethod articipants wenty-two children with PTSD living in and around edellin, Colombia (2 boys and 19 girls: ages 9-14), with cores > 24 (mean = 46.3, SD = 7.8) on the Child Scale of TSD Symptoms (Bustos, Rincón, & Aedo, 2009) served s participants and were given individual psychiatric and sychological evaluations both by psychiatrists and psychol- gists from the Center of Mental Health services of CES niversity to confirm their PTSD diagnoses (were used the SM-5 criteria diagnosis to do it). Each participant reported xperiencing at least one specific traumatic event, either hysical (e.g., sexual abuse) and/or psychological in nature e.g., witnessing an incident of domestic violence or a life hreating situation) in the prior six months. And, this PTSD ymptomatology was chronically expressed throughout this eriod. Twenty-two NT children (11 boys and 11 girls: ages -14) from public schools (in the same area and of similar ociodemographic characteristics) served as controls (Scores 8; mean = 5.4; SD = 3.5 on the Child Scale of PTSD Symp- oms). All participants were right-handed with no history f previous psychiatric disorders, head injuries, or learning isabilities. nstruments and procedure he Mini-International Neuropsychiatric Interview for Kids MINI Kids; Sheehan et al., 1998) was used to screen for nxiety. The Child Depression Inventory (Kovacs, 1992) was mployed to monitor depression (PTSD mean = 23.43; SD = .21/NT mean = 6.61; SD = 3.63). Note that while the two roups did differ on their CDI scores, clinical assessment eemed this difference to have been induced by their PTSD ondition rather than reflecting a pre-existing difference in epression levels between the two groups. Emotional Word Processing Task. Adapted from Thomaes t al. (2013), 72 emotional word trials (24 positive, 24 neu- ral, 24 negative words) were presented randomly via the canner rear projection system for 2.5 s with a jittered inter- timulus interval between 1 s---3 s. Participants identified the nk color that each of the words was printed in via fiber ptic button-press using their right hand: a word printed in ed (left button, index finger), word in green (middle but- on; middle finger), word in blue (right button, ring finger). igure 1. Imaging Acquisition. All images were acquired via a 3- esla Siemens MRI scanner (Skyra) with a 20-channel head oil. T1-weighted sagittal MPRAGE was used to acquire natomical brain scans using the following parameters: Total olumes = 176; repetition time = 2.3 s; voxel size = .98 × .98 x t i a a ote. Participants were asked, ‘‘Is the word printed in blue, ed, or green ink?’’. .98 mm; echo time =3 s; field of view = 250 mm x 250 mm; ip angle = 9◦. fMRI data (47 axial slices) were acquired sing gradient echo-planar imaging (EPI) with the follow- ng parameters: Total volumes = 184; repetition time = 2.5 s; oxel size = 2.5 × 2.5 × 3 mm; echo time = 20 s; field of iew = 200 mm x 200 mm; flip angle = 70◦. Imaging Data Processing and Analysis. FSL software was sed for the pre-processing and analysis of all anatomi- al and functional images. After brain extractions using ET, slice-timing correction was employed to temporally lign the fMRI slices. Motion correction of the data was lso conducted via MCFLIRT, and spatial smoothing with W HM of 5 mm was used to reduce the effects of noise. or each participant, functional images were initially lin- arly registered to his/her own structural image, followed y a transformation from their native space into MNI-152 tandard space. A first-level general linear model (GLM) nalysis was conducted using a double gamma convolution o correct for delay between the EPI signal and the hemo- ynamic response function (HRF). A higher-level GLM with xed effects (see Beckmann, Jenkinson, & Smith, 2003; oolrich, 2008; Woolrich, Behrens, Beckmann, Jenkinson, & mith, 2004) was conducted on the blood oxygenated (BOLD) esponses to the word stimuli as a function of group member- hip (i.e., PTSD vs. NT). Whole brain maps with clusters of ignificantly activated voxels as determined by family-wise -tests were analyzed, with activation non-parametrically et at z > 2.30 with a threshold of p < .05. Gaussian Random ield Theory was used to correct for multiple comparisons Worsley, Taylor, Tomaiuolo, & Lerch, 2004). The study was carried out according to the latest version f the Declaration of Helsinki, and the Ethics Committee of ES University gave its approval for the study. Based on the rotocol of the Institutional Human Subjects Review Board f CES University, all 44 participants signed an assent form nd their parents/guardians signed consent forms. esults ehavioral data or analysis of the accuracy data a 2 Group (Between Sub- ects Factor: PTSD vs. NT) x 3 Word Type (Within Subjects actor: positive, neutral, negative) mixed design Analysis f Variance (ANOVA) was conducted on the total number of orrect ink-color determinations. This analysis revealed a ignificant main effect for Group [F (1, 42) = 5.80, p < .02] ith the NT group being significantly more accurate than he PTSD group. A main effect for Word Type was also signif- cant [F (2, 84) = 69.9 p < .0001]. Post-hoc comparisons using Least Significant Difference test (LSD) revealed that neg- tive words produced significantly less accurate responding Implicit processing of emotional words by children with Post-Tra 0 5 10 15 20 25 Positive words Neutral words Negative words PTSD NT N S b c t a t t f t v p F t f f w l o r t l r g i p g ( w i w D T c a w s l d Figure 2 Number of correct responses. (p < .05) compared to either positive or neutral words, while the latter two word types did not differ from each other. The Group x Word Type interaction was found to be marginally reliable [F (2, 84) = 2.78, p < .067]. Pre-planned comparisons of this interaction using an LSD test revealed that compared to the NT, the PTSD were less accurate for ink color deter- minations involving negative words (p < .05), while the two groups did not differ in accuracy on positive or neutral word types (Figure 2). For the analysis of reaction time data a similar 2 Group x 3 Word Type mixed ANOVA revealed a significant main effect for Group, [F(1,42) = 6.63, p < .05] with the PTSD responding more slowly than the NT group. A main effect was also found for Word Type [F (2, 84) = 4.02, p < .05] such that all parti- cipants exhibited significantly faster responses for positive words compared to neutral words (p < .05) and marginally faster responses compared to negative words (p < .10), but response times between negative and neutral words did not differ from each other. The Group x Word Type interaction was not significant (p < .12). However, based on the finding of a marginally reliable interaction for the accuracy data, pre-planned comparisons of the interaction for the reaction time data using an LSD test revealed that the PTSD group responded more slowly to both positive and negative words compared to the NT (p < .05 and p < .01, respectively). Reac- tion time to identify the ink color of neutral words was not significantly different between the two Groups (Figure 3). 0.9 0.95 1 1.05 1.1 1.15 1.2 1.25 Positive words Neutral words Negative words PTSD NT Figure 3 Reaction time (secs). n t e d a p i f Y t r t e l e w f m t umatic Stress Disorder 49 euroimaging imaging data ignificant differences in levels of activation in various rain locations for both the NT > PTSD and the PTSD > NT ontrasts appear in the top and bottom of Figure 4, respec- ively. Table 1 and Table 2 present the cluster activations nd peak coordinates for the NT > PTSD and PTSD > NT con- rasts, respectively. As can be seen in Figure 4 (top) for he NT > PTSD contrast, greater activation was prominent or the NT group in both anterior and posterior regions of he brain. Specifically, for positive words, selective acti- ation of these regions included the left and right frontal oles and bilateral activation of the superior frontal gyri. or negative words, NT participants exhibited significan- ly greater activation bilaterally in the middle and superior rontal gyri, which represent dorsolateral and medial pre- rontal cortices, respectively. Note that peak coordinates ere obtained for the right prefrontal cortices, but not the eft. Greater NT activation was also observed in a variety f other regions, including the angular gyrus bilaterally, the ight pre- and post-central gyri, the right paracingulate cor- ex, the left supramarginal gyrus, the left superior parietal obe, the left superior temporal gyrus, and the left infe- ior and superior occipital lobes. Note that for the PTSD roup, significant activations were generally restricted to nternal brain regions, and the pattern was similar for both ositive and negative word types. The selective regions of reater activation in the PTSD group included the thalamus right; negative words only), central operculum (positive ords only), pallidum (left, negative words only) and the nsula and putamen bilaterally for both positive and negative ord types (bottom of Figure 4). iscussion he focus of the present study was to investigate how hronic stress and exposure to trauma, affected the brain ctivity and executive functioning of Colombian children ith PTSD compared to NT children. To that end, our results how that those children with PTSD were significantly ess accurate than their NT counterparts when asked to etermine the ink color of presented words expressing egative affect. Additionally, PTSD children were slower han NTs when asked to determine the ink color of words xpressing positive or negative affect. Note that ink color etermination does not require the participant to actu- lly process the meaning of the word, and even if such rocessing for word meaning does occur, its influence is mplicit and indirect at best as participant attention is ocused solely on processing the ink color of the word. et, even under such implicit and indirect conditions, he emotional valence of the word affected processing, esulting in reduced accuracy and increased latency for he PTSD children. This was particularly evident for words xpressing negative emotions. Thus, even at a non-explicit evel, stimuli that evoke emotion (particularly negative motions although positive emotions appear affected as ell) appear to have unusual influence on the cognitive unctioning of children with PTSD. This is important because ental health professionals treating PTSD children need o be aware of the saliency of stimuli exhibiting emotional 50 L. Calderon-Delgado et al. Figure 4 Sagittal (left) and axial (middle), and cortical (right) views of between group activation for NT (top) and PTSD (bottom) participants for negative (orange) and positive (blue) words. Table 1 Brain regions (and coordinates) showing selectively greater activation for the NT participants compared to the PTSD for positive and negative words. Condition Cluster size (voxels) z x y z Region NT-PTSD Positive words 1107*** 3.69 −2 52 38 Left Superior Frontal 3.67 6 52 46 Right Frontal Pole 3.53 14 50 46 Right Frontal Pole 3.45 −6 54 42 Left Frontal Pole 3.44 6 44 36 Right Superior Frontal 3.42 24 50 42 Right Frontal Pole Negative words 4826*** 4.62 2 34 42 Right Paracingulate 4.56 42 −20 66 Right Precentral/Postcentral 4.47 4 38 56 Right Superior Frontal 4.42 44 8 58 Right Middle Frontal 4.41 52 −44 60 Right Angular Gyrus 4.16 40 34 42 Right Middle Frontal 529** 3.71 −44 −50 60 Left Superior Parietal Lobule 3.42 −50 −50 58 Left Supramarginal 3.40 −42 −64 58 Left Superior LOC 3.33 −6 −64 70 Left Superior LOC 3.18 −24 −70 60 Left Superior LOC 3.17 −30 −74 60 Left Superior LOC 427* 3.79 −54 −48 14 Left Supramarginal 3.74 −44 −74 8 Left Inf LOC 3.69 −42 −74 4 Left Inf LOC 3.67 −56 −64 14 Left Superior LOC 3.53 −60 −58 14 Left Angular Gyrus 3.40 −58 −34 4 Left Superior Temporal Gyrus oxels and r v s a a i w Note. The cluster size is presented as the number encompassing v included are the intensity (z-scores), location (MNI coordinates), alence (particularly negative emotions), even when/if uch exposure is implicit. Thus, there is a need to develop nd tailor clinical interventions accordingly, i.e., evaluating nd remediating both the explicit as well as the implicit mpact of emotional stimuli on these PTSD children. It is i D n d with statistical significance: ***p < .001, **p < .01, *p < .05. Also egion of the peak voxels (maximum intensity). orth mentioning that processing of positive words also mplicitly impacted children with PTSD. Note that in the SM-5 there is a cluster of symptoms defined as ‘‘emotional umbing’’, which is characterized by emotional response eficits, feelings of detachment from others, and markedly Implicit processing of emotional words by children with Post-Traumatic Stress Disorder 51 Table 2 Brain regions (and coordinates) showing selectively greater activation for the PTSD compared to neurotypical partici- pants for positive and negative words. Condition Cluster size (voxels) z x y z Region PTSD-NT Positive words 545* 3.97 26 −10 6 Right Putamen 3.38 26 0 0 Right Putamen 3.14 40 4 8 Central Operculum 3.09 20 10 6 Right Putamen 3.06 36 12 0 Right Insula 2.88 28 16 −2 Right Insula 518* 3.75 −36 −12 4 Left Insula 3.73 −30 −12 4 Left Putamen 3.68 −18 10 4 Left Putamen 3.62 −36 2 8 Left Insula 3.45 −28 −16 2 Left Putamen 3.18 −26 0 0 Left Putamen Negative words 490* 3.70 20 0 0 Right Pallidum 3.35 24 −28 4 Right Thalamus 3.29 26 −12 4 Right Putamen 3.28 26 0 0 Right Putamen 3.22 26 2 4 Right Putamen 3.17 28 −4 2 Right Putamen 455* 3.68 −26 0 0 Left Putamen 3.64 −36 0 8 Left Insula 3.51 −28 −8 4 Left Putamen 3.40 −38 −12 2 Left Insula 3.03 −28 −16 4 Left Putamen 2.94 −26 −20 2 Left Pallidum oxels and r w l r n c d 2 s i e o d d i I a i P o r p h Note. The cluster size is presented as the number encompassing v included are the intensity (z-scores), location (MNI coordinates), diminished interest or participation in significant activities. This restricted range of affect has been reported by Kashdan, Elhai, and Frueh (2006), and thought to reflect a deficit in the ability to experience or process positive emotions. Recently, Fonzo (2018) highlighted the role of similar brain structures when processing positive and negative emotions. Thus, it may be that the PTSD children in the present study are experiencing a similar sense of emotional detachment. The brain imaging results presented here indicate that PTSD children exhibit selectively less activation of the frontal regions, known to play an important role in mediating executive functions. Thus, compared to NT children, those with PTSD may experience a deficit in the ability to reg- ulate the processing of emotion-laden stimuli, particularly for those conveying negative affect. Furthermore, children with PTSD showed hypo-activation of the dorsolateral pre- frontal cortex (i.e., middle frontal gyri) during presentation of negative words, a pattern that has been empirically linked to reappraisal of emotionally salient stimuli (Golkar et al., 2012). Emotional reappraisal demands (i.e., neutral- izing one’s feelings) may be greater when processing the ink color of words expressing negative affect compared to words expressing more neutral affect. Therefore, children with PTSD incur executive processing deficits as reflected in less accuracy and slower reaction times compared to their NT counterparts, for tasks requiring modulation of emotional salience----particularly for those involving negative emotions. e i fi I with statistical significance: ***p < .001, **p < .01, *p < .05. Also egion of the peak voxels (maximum intensity). Although the present study was limited to emotional ord processing per se, it is also reasonable to specu- ate that other types of stimuli requiring similar emotion egulation and reappraisal, particularly those expressing egative affect, would also have special access to the ognitive systems of PTSD children. In fact, preliminary ata from our own ongoing pilot study (Calderon et al., 018) using positive, negative and neutral face stimuli uggests that the processing of such emotions expressed n human faces (particularly those expressing negative motions) is also accompanied by atypical engagement f the frontal lobes in these same Colombian PTSD chil- ren. The fact that selective brain activation of the PTSD chil- ren was restricted primarily to internal brain structures nvolved in emotion processing was somewhat anticipated. t is well documented that the insula, putamen, operculum nd pallidum are all primary mediators of emotion process- ng (Mechias, Etkin, & Kalisch, 2010). Moreover, the fact that TSD hyper-activation (relative to their NT counterparts) f these regions (along with the thalamus) was greater in esponse to the presentation of emotion laden words com- ared to neutral words suggests that their cognitive system as been sensitized to the processing of stimuli evoking motion. Additional evidence of PTSD sensitivity to stimuli mplicitly evoking negative emotion is observed in their dif- culty in accurately processing the font color of such words. ndeed, the latter sensitivity may well have been induced as 5 a s P w P 2 a p p s c a p c r t I c g r t s b t t o r e t p fi c R e a r b l F T f T ( 1 R B B B C C C F F G G G G H I J K K 2 byproduct of their exposure to an environment of chronic tress, and trauma. Regarding study limitations, it should be noted that the TSD group was disproportionally comprised of females, hich reflects the actual male/female incidence ratio of TSD in the Colombian pediatric population (Gaviria et al., 016). We did consider conducting an analysis using sex as covariate, however, given that there were only 2 male articipants, such an analysis was deemed statistically inap- ropriate. Thus, further research with a more balanced ample is required to examine the extent to which biologi- al sex of the individual selectively influences proneness to cquiring PTSD, as well as investigating the brain activation atterns and cognitive processes that impact PTSD male as ompared to female children. An additional factor that may have influenced the present esults is the fact that participant IQ was different between he two groups (PTSD mean IQ = 81.5, SD = 14.2; NT mean Q = 95.2, SD = 14.3). And while this difference was statisti- ally reliable (p < .05), it is relatively small. Note that both roups were quite successful at completing the simple and ather automatic ink-color identification task required by he study. Importantly, both groups produced a high (and imilar) percentage of correct ink-color determination for oth positive and neutral word types --- with a notable excep- ion of those trials involving negative words, suggesting hat IQ was not a significantly contributing variable to the btained effect. Finally, it should be noted that the type of trauma expe- ienced by our PTSD sample was primarily due to chronic xposure to a context of socio-political violence. However, here are a number of collateral stressors that may accom- any such exposure (e.g., sexual assault, etc.) and so the ndings reported here should not be interpreted as spe- ific to PTSD acquired solely in response to violence alone. ather, the current results are likely to be a composite ffect of violence exposure coupled with the impact of other ssociated traumatic stressors all acting in concert. 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