Practice Parameters For The Assessment And Treatment
AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
Practice Parameters for the Assessment and Treatment
of Children and Adolescents With Posttraumatic Stress Disorder
These parameters were developed by Judith A. Cohen, M.D., principal author,
and the Work Group on Quality Issues: William Bernet, M.D., Chair, and, John E.
Dunne, M.D., former chair, Maureen Adair, M.D., Valerie Arnold, M.D., R. Scott
Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and
David Rue, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The authors wish to thank
William Arroyo, M.D., Lucy Berliner, M.S.W., Esther Deblinger, Ph.D., Martin Drell,
M.D., Richard Famularo, M.D., David Finkelhor, Ph.D., William Friedrich, Ph.D.,
Bonnie Green, Ph.D., Arthur Green, M.D., Cheryl Lanktree, Ph.D., Anthony Mannarino,
Ph.D., John March, M.D., Susan McLeer, M.D., Bruce Perry, M.D., Robert Pynoos,
M.D., Rachel Ritvo, M.D., Ben Saunders, Ph.D., Eitan Schwarz, M.D., Ph.D., Frederic
Solomon, M.D., Frederick Stoddard, M.D., Lenore Terr, M.D., Vicky Wolfe, Ph.D., and
William Yule, Ph.D. for their thoughtful review. These parameters were made available
to the entire AACAP membership for review in October 1997 and were approved by the
AACAP Council on [3-26-98]. They are available to AACAP members on the World Wide
Web (www.aacap.org).
Reprint requests to AACAP Publications Department, 3615 Wisconsin Ave., N.W.,
Washington, DC 20016.
© 1998 by the American Academy of Child and Adolescent Psychiatry.
ABSTRACT
These practice parameters review the current state of knowledge about post-
traumatic stress disorder (PTSD) in children and adolescents. The parameters were
written to aid clinicians in the assessment and treatment of children and adolescents with
PTSD symptoms. A literature search and extensive review were conducted in order to
evaluate the existing empirical and clinical information in this regard. Expert consultation
was also solicited. The main findings of this process were that a wide variety of stressors
can lead to the development of PTSD symptoms in this population; the specific PTSD
symptoms manifested may vary according to the developmental stage of the child and the
nature of the stressor, and for this reason, the diagnostic criteria for PTSD in adults may
not adequately describe this disorder in children and adolescents; that several factors
appear to mediate the development of childhood PTSD following a severe stressor; and
that most of the therapeutic interventions recommended for children with PTSD are
trauma-focused and include some degree of direct discussion of the trauma.
Controversies and unresolved issues regarding PTSD in children are also addressed. Key
Words: posttraumatic stress disorder, trauma, trauma-focused therapy, children,
adolescents, evaluation, treatment, practice parameters, guidelines.
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Since the introduction of posttraumatic stress disorder (PTSD) as a diagnostic
category in DSM-III (American Psychiatric Association, 1980), there has been a growing
awareness that children and adolescents as well as adults can experience this disorder.
Because it is a relatively new diagnosis, because the diagnostic criteria have changed
with each DSM revision since 1980, and particularly because developmental factors may
significantly impact on the clinical presentation of this disorder, practice parameters can
be of value in assisting clinicians in the diagnosis and treatment of childhood PTSD, and
as a result, also be of value to the children and families of children who develop this
disorder.
These parameters are applicable to the evaluation of children and adolescents and
presumes familiarity with normal child development and the principles of child
psychiatric diagnosis and treatment (American Academy of Child and Adolescent
Psychiatry, 1997). In these parameters, the terms “child” and “children” refer to both
children and adolescents unless otherwise noted. The term “parent” refers to the child’s
primary caretaker, even if not a biological parent.
LITERATURE REVIEW
The list of references for these parameters was developed by searches of Medline
and Psychological Abstracts, reviewing the bibliographies of book chapters and review
articles, and soliciting source materials from colleagues with expertise in PTSD in
children. The searches of Medline and Psychological Abstracts were conducted in
February 1997 using the text terms: posttraumatic stress disorder, children, and
adolescents. The search covered the period 1992 through January 1997 and yielded
approximately 170 articles and chapters. References from the articles and chapters then
were reviewed. Twelve full-length books also were reviewed. A search of the National
Center on PTSD PILOTS database was conducted in July 1997. In addition, two authors,
L.C. Terr and R.S. Pynoos, were researched due to their expertise in this area. Only the
most relevant resources were included in this document.
PTSD refers to the development of characteristic symptoms following exposure to
a particularly severe stressor. The diagnostic criteria for this disorder have undergone
revisions from those originally proposed in DSM-III (American Psychiatric Association,
1980). For the purposes of these parameters, the DSM-IV (American Psychiatric
Association, 1994) criteria and definitions are used unless otherwise noted.
The definition of “traumatic stressor” in DSM-IV does not require that the event
be outside the realm of normal human experience as suggested by DSM-III. This revision
occurred in response to recognition that some stressors known to result in PTSD
symptoms are not rare (such as rape, child abuse, and exposure to domestic violence,
community violence, or conditions of war). The stressor must, however, be “extreme,”
i.e., it must involve either experiencing or witnessing an event capable of causing death,
injury, or threat to physical integrity to oneself or another person; or learning about a
significant other being exposed to such an event. This exposure constitutes the first
criterion for PTSD. The child’s reaction must include intense fear, horror, helplessness,
or disorganized or agitated behavior. DSM-IV includes a partial list of
several events that may fit the definition of an extreme traumatic stressor, but gives the
clinician latitude in making this determination depending on the specifics of the situation.
To meet criteria for PTSD, the child’s response must include a specific number of
symptoms from each of three broad categories: reexperiencing, avoidance/numbing, and
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increased arousal. There have been revisions in DSM-III-R and DSM-IV regarding the
specific symptoms included under each of these categories, with progressively more
attention given in each revision to alternative ways in which children may manifest these
symptoms. There also have been changes and ongoing debate on whether the required
number of symptoms in each category is appropriate for children (Benedek, 1985; Green,
1991; Green et al., 1991). The current requirements are that the child must exhibit at least
one reexperiencing symptom, three avoidance/numbing symptoms, and two increased
arousal symptoms to receive a DSM-IV PTSD diagnosis. These requirements are based
on current diagnostic criteria for adult PTSD, which may require amendment for younger
children.
Reexperiencing symptoms include recurrent and intrusive distressing memories of
the event, which in young children may be manifested by repetitive play with traumatic
themes; recurrent distressing dreams about the trauma or frightening dreams without
recognizable content; acting or feeling as if the trauma were recurring, including trauma-
specific reenactment (for example, reenacting sexual acts the child experienced during
sexual abuse); intense distress at exposure to cues that symbolize or resemble an aspect of
the trauma; and physiological reactivity at exposure to such cues.
Avoidance of stimuli associated with the event and numbing of general
responsiveness must not have been present prior to the trauma, and may be manifested by
efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to
avoid reminders of the trauma; amnesia for an important aspect of the trauma; diminished
interest or participation in normal activities; feeling detached or estranged from others;
restricted affective range; and a sense of a foreshortened future (e.g., believing one will
not live a normal life span).
Persistent symptoms of increased arousal must be newly occurring since the
trauma and include sleep difficulties, irritability or angry outbursts; difficulty
concentrating; hyper vigilance; and exaggerated startle response. These symptoms must
be present for at least 1 month and must cause clinically significant distress or
impairment in functioning.
Brief History
Although PTSD was not recognized formally as a mental disorder until 1980, it
was described under various other names for at least a century. A fascinating chapter by
Herman (1992) reviews the striking pattern of public recognition followed by repudiation
that has characterized this condition. Several prominent neurologists/psychiatrists
described the symptoms characteristic of PTSD (then called conversion or hysterical
neurosis) in the nineteenth century. Freud linked these symptoms in women to histories
of sexual exploitation in childhood, although he eventually became convinced that this
experience was not as prevalent as evidenced by disclosures of the symptomatic patients
he saw.
PTSD next entered public awareness as a result of World War I. During this
conflict, many soldiers developed “shell shock,” so named because these PTSD-like
symptoms were initially attributed to neurological damage secondary to exploding
ammunition shells. Eventually it became clear that the disorder originated from
psychological rather than physiological trauma, and was renamed “combat neurosis.”
After the end of World War I, professional and public interest in traumatic stress again
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waned, to resurface only during World War II. Kardiner (1941) and Kardiner and Spiegel
(1947) described the clinical manifestations of “traumatic neurosis” and suggested the
importance of consciously reliving and resolving the traumatic memories in therapy in
order to recover. Freud and Burlingham (1943) recognized that traumatic stress
symptoms also could occur in children exposed to conditions of war.
The most recent public and professional recognition of PTSD occurred as a result
of advocacy by Vietnam War veterans and feminists in the 1960s (Herman, 1992).
Significant numbers of Vietnam veterans developed PTSD symptoms (Figley, 1978) and
activists in antiwar veterans groups demanded greater attention to the psychological
damage caused by the war. This resulted in the first large scale empirical studies of PTSD
commissioned by the Veterans Administration (Egendorf et al., 1981). At the same time,
grassroots feminist groups opened rape crisis centers in recognition of the many women
experiencing “rape trauma syndrome” as a result of childhood sexual abuse, rape, and
domestic violence. Empirical studies were conducted to document the frequency of these
experiences in the general population (Russell, 1983) as well as the PTSD-type
symptoms frequently occurring in response to these experiences (Frank et al., 1980;
Kilpatrick et al., 1985).
In response to growing recognition of the traumatic etiology of these symptoms,
PTSD was formally recognized as a psychiatric diagnosis in DSM-III (American
Psychiatric Association, 1980). However, even when PTSD was acknowledged as a valid
adult psychiatric disorder, there was initial skepticism that children could also suffer from
it. The initial adult response to the impact of trauma on children is often denial (Handford
et al., 1986; Malmquist, 1986; Rigamer, 1986; Sack et al., 1986). Parents and teachers
may minimize traumatic impact in their desire to reassure themselves that children are
not “damaged” or to relieve vicarious distress over the child’s experience. Adults,
including mental health professionals, also have rationalized that children are too young
to remember traumatic events, or too developmentally immature to be traumatized
(Benedek, 1985). Children themselves may contribute to this misperception, often trying
to protect their parents from knowing how badly the trauma has affected them (Yule and
Williams, 1990).
Coinciding with the introduction of PTSD in DSM-III, several studies of children
traumatized by various catastrophic situations began to appear. Terr (1979; 1983)
published a landmark study of children traumatized by the kidnapping and underground
burial of their school bus. Newman (1976) and Green et al. (1991) described PTSD
symptoms in children experiencing the 1972 Buffalo Creek dam collapse, and Pynoos et
al. (1987) documented PTSD in children exposed to a sniper attack in their school yard.
The 1980s also witnessed a marked increase in empirical studies regarding PTSD and
other psychological difficulties experienced by sexually abused children (Conte and
Schuerman, 1987; Friedrich et al., 1986; Goodwin, 1988; Mannarino et al., 1989). As the
clinical descriptive and empirical literature expanded, it became clear that PTSD as
defined by DSM-III did not adequately describe childhood variants of that disorder
(Garmezy, 1986). Clinical experts in childhood PTSD contributed to the preparation of
DSM-III-R (American Psychiatric Association, 1987), resulting in the addition of several
notes to the criteria for variations in symptom presentation in children. In DSM-IV, the
PTSD criteria reflect ongoing revisions based on increased understanding of the varied
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clinical manifestations of PTSD in children. It is anticipated that these criteria will be
refined further to more accurately reflect developmental variations.
EPIDEMIOLOGY
The evolution of diagnostic criteria for PTSD has complicated the task of
determining the prevalence of PTSD. Community-based studies have revealed a lifetime
prevalence of 1% to 14% (American Psychiatric Association, 1994). However, it is
probably less meaningful to examine PTSD prevalence in the general population than in a
cohort exposed to traumatic events. Studies of at-risk child populations have yielded
PTSD prevalence rates varying from 3% (Garrison et al., 1995) to 100% (Frederick,
1985), depending on the methods used to assess PTSD, the population sampled, and the
nature of and time passed since the traumatic event. Two community studies indicate that
PTSD may be a fairly prevalent disorder among children and teens exposed to traumatic
events. One random sample of non-referred urban youth exposed to community violence
revealed that 34.5% met full criteria for PTSD (Berman et al., 1996); another study of a
similar cohort demonstrated that 24% met PTSD criteria (Breslau et al., 1991).
Although some researchers have documented gender differences in the
development of PTSD symptoms following exposure to a traumatic event (Berton and
Stabb, 1996; Brent et al., 1995; Garbarino and Kostelny, 1996; Green et al., 1991;
Shannon et al., 1994; Shaw et al., 1996), others have not (Berman et al., 1996; Burton et
al., 1994; Nader et al., 1990; Pynoos et al., 1987; Sack et al., 1995; Shaw et al., 1995).
Some studies have indicated that girls develop more severe and long-lasting PTSD
symptoms when exposed to traumatic events, but that boys are more likely to be exposed
to such events (Helzer et al., 1987). While some studies have found that the age of the
child at the time of exposure significantly mediates development of PTSD symptoms
(Davidson and Smith, 1990; Hoffman and Bizman, 1996), these findings have not been
consistent (Garrison et al., 1995; Green et al., 1991) and may reflect developmental
differences in the clinical manifestation of PTSD rather than age-mediated differences in
prevalence. Studies of PTSD in adults have indicated the possibility of a genetic
predisposition for developing PTSD (True et al., 1993); no studies have examined this
theory in children.
Numerous studies have evaluated children of diverse ethnic backgrounds, and
have documented that PTSD occurs across cultural and ethnic groups, although cultural
factors may affect how PTSD is manifested (Ahmad and Mohamad, 1996; Diehl et al.,
1994; DiNocola, 1996; Jenkins and Bell, 1994; Manson et al., 1996). For example,
children of Latin American descent may manifest PTSD symptoms as susto, which is
described as a culture bound syndrome in DSM-IV (American Psychiatric Association,
1994).
Numerous studies have examined mediating factors regarding the development of
PTSD in children. Most authors acknowledge that, while every person will experience
psychological distress if the stressor is severe enough, the development of PTSD is
multifactorial (Berliner, in press; Yehuda and McFarlane, 1995). A review of 25 studies
indicates that three factors have been found to consistently mediate the development of
PTSD in children: the severity of the trauma exposure, parental trauma-related distress,
and temporal proximity to the traumatic event (Foy et al., 1996). However, these authors
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conclude that additional research is needed to confirm these findings and to identify other
possible mediating factors.
Studies documenting a positive relationship between self-reported exposure and
children’s PTSD symptoms include studies of exposure to community violence (Berton
and Stabb, 1996; Boney-McCoy and Finkelhor, 1996; Breslau et al., 1991; Burton et al.,
1994), peer suicide (Brent et al., 1995), natural disasters (Goenjian et al., 1995; LaGreca
et al., 1996; Lonigan et al., 1994; Newman, 1976; Vernberg et al., 1996), war (Macksoud
and Aber, 1996; Realmuto et al., 1992), man-made disasters (March et al., 1997; Milgram
et al., 1988; Nader et al., 1990; Pynoos et al., 1987), and sexual abuse (Mannarino et al.,
1991; Wolfe et al., 1994). Other studies have found that the severity of exposure does not
mediate symptom formation (Earls et al., 1988) or that the impact is variable (Finkelhor,
1990). Rutter (1987) postulated that the accumulation of multiple stressors in children
dramatically increases the risk of permanent developmental damage and the emergence
of PTSD symptoms.
Several studies have documented the impact of familial support and parental
emotional reaction to the trauma on the child’s PTSD symptoms. These include studies of
natural disasters (Bloch et al., 1956; Green et al., 1991; LaGreca et al., 1996; McFarland,
1987), community violence (Breslau et al., 1991; Burton et al., 1994; Wyman et al.,
1992); parental homicide (Burman and Allen-Meares, 1994), physical abuse (Anthony,
1986; Kolko, 1996), sexual abuse (Cohen and Mannarino, 1996c), serious medical illness
such as cancer and severe burns (Armstrong et al., 1994; Butler et al., 1996; Koocher and
O’Malley, 1981; Meyer et al., 1994; Nir, 1985; Rizzone et al., 1994; Stoddard, 1996;
Stuber et al., 1991), and war (Freud and Burlingham, 1943; Garbarino and Kostelny,
1996; Kinzie et al., 1986; Laor et al., 1997; Sack et al., 1995). In all of these studies,
familial support mitigated the development of PTSD in children, or parental distress
about the trauma and/or the presence of parental psychiatric disorders predicted higher
levels of PTSD in the child. In contrast, Parker et al. (1995) found no relationship
between child and parent PTSD symptoms after a roof blew off of an elementary school
building and killed one of the students. Lyons (1987) postulated that the single best
predictor of positive outcome for children surviving a traumatic event is the ability of
parents and other significant adults to cope with the trauma.
Although most studies indicate that some children spontaneously recover from
PTSD over time, there is evidence that PTSD symptoms can persist for many years.
CLINICAL PRESENTATION
PTSD can present with a wide variety of clinical features. Developmental factors
clearly play a strong role in these variations (Amaya-Jackson and March, 1995; Pynoos et
al., 1995).
In general, as children mature, they are more likely to exhibit adult-like PTSD
symptoms. Thus, adolescents with PTSD may meet strict DSM-IV criteria with re-
experiencing symptoms such as intrusive thoughts and nightmares; avoidance of
discussion of the traumatic event and places or people psychologically associated with
the event; amnesia for an important aspect of the trauma; withdrawal from friends or
usual activities; detachment from others and sense of foreshortened future; and hyper
arousal, such as sleep difficulties, hyper vigilance, and increased startle response.
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Adolescents with chronic PTSD who have experienced prolonged or repeated stressors
may present with predominantly dissociative features, including derealization,
depersonalization, self-injurious behavior, substance abuse, and intermittent angry or
aggressive outbursts (Goodwin, 1988; Hornstein, 1996; Terr, 1991).
Clinical reports have suggested that some elementary school-aged children may
not experience amnesia for aspects of the trauma, and with acute PTSD may not have
avoidant or numbing symptoms (Terr, 1985). They also may or may not have visual
flashbacks (Terr, 1985). Children in this developmental stage may show frequent
posttraumatic reenactment of the trauma in play, drawings, or verbalizations. They also
may have a skewed sense of time during the
traumatic event. Sleep disturbances may be especially common in prepubertal children
(Benedek, 1985). Terr (1983) also has described a high prevalence of “omen formation”
in these children, i.e., they come to believe that certain “signs” were warnings of the
traumatic event approaching and that if they are alert enough, they will be able to see
“omens” predicting future disasters. Due to the general inability of younger children to
have a future time perspective, questions about foreshortened future may be meaningless
in this age group.
Very young traumatized children may present with relatively few DSM-IV PTSD
symptoms. In part this may be because, as Scheeringa et al. (1995) point out, eight out of
18 DSM-IV criteria “require verbal descriptions from patients of their experiences and
internal states....limited cognitive and expressive language skills [in young children]
make inferring their thoughts and feelings difficult” (p. 191). Infants, toddlers, and
preschoolers therefore may present with generalized anxiety symptoms (separation fears,
stranger anxiety, fears of monsters or animals), avoidance of situations that may or may
not have an obvious link to the original trauma, sleep disturbances, and preoccupation
with certain words or symbols that may or may not have an apparent connection to the
traumatic event, rather than more typical DSM-IV manifestation (Drell et al., 1993).
Scheeringa et al. (1995) have proposed an alternative checklist to DSM-IV criteria for
detecting PTSD in young children. These authors differentiate between posttraumatic
play (which is compulsively repetitive, represents part of the trauma, and fails to relieve
anxiety) and play reenactment (which also represents part of the trauma, but is less
repetitive and more like the child’s pre-trauma play). Either of these may fulfill the
reexperiencing criteria, as can non-play recollections of the trauma (which are not
necessarily distressing) or nightmares. Scheeringa et al. (1995) also suggest that in the
avoidance/numbing category, only one of the following be required: constriction of play
(with or without posttraumatic play), social withdrawal, restricted range of affect, or loss
of acquired developmental skills. These authors further suggest that only one symptom of
increased arousal be required to diagnose PTSD in very young children, but suggest
requiring at least one item from an added category, new fears and/or aggression. Thus,
there is no clear consensus regarding the “typical” clinical presentation of PTSD in very
young children. Almquist and Brandell-Forsberg (1997) demonstrated that formal and
objective assessment of play content aided in the diagnosis of PTSD in preschoolers. This
area of investigation may benefit future attempts to standardize the assessment of PTSD
in this age group.
Physiologic Findings
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Although several authors have postulated a variety of neurophysiological changes
that may explain the development and maintenance of PTSD in children (Charney et al.,
1993; Perry, 1994), very few studies have empirically evaluated these theories. DeBellis
and colleagues (1994a, 1994b) reported changes in the hypothalamic-pituitary-adrenal
axis and catecholamine excretion of severely sexually abused girls; the changes were
similar to those seen in Vietnam veterans with PTSD and in some adults with major
depressive disorder (MDD). However, only one of these girls had a diagnosis of PTSD,
leading the authors to hypothesize that the findings may have been due to the effects of
severe stress rather than being specific to sexual abuse or PTSD. Ornitz and Pynoos
(1989) demonstrated that children with PTSD had a marked loss in the normal inhibitory
modulation of the startle response, suggesting a possible long-term change in brain stem
function in these children. Brent et al. (1995) and Stoddard et al. (1989) have noted the
significant overlap between PTSD and MDD symptoms, suggesting the possibility of
similar underlying psychophysiologic mechanisms in the two disorders. New research
findings in adults have demonstrated that there may be two distinct neurobiological
subgroups of PTSD patients, one with dysregulation of the noradrenergic system and the
other with dysregulation of the serotonergic system (Southwick et al., 1997). This
hypothesis has not been empirically evaluated in children.
Natural Course
There have been no well controlled studies examining the natural course of PTSD
in children. Several authors and researchers have addressed the question of symptom
persistence versus spontaneous remission, but none have adequately controlled for the
impact of treatment, other intervening stressors, or other factors as opposed to the mere
passage of time. Several investigators have performed longitudinal evaluations of PTSD
symptoms in children. For example, Famularo et al. (1996) found that while 40% of
severely maltreated children met full PTSD criteria soon after being removed from their
parents’ care, this percentage decreased to 33% 2 years later. Green et al. (1991)
documented that 2 years after the Buffalo Creek dam collapse, 37% of the children
evaluated met “probable” DSM-III-R PTSD criteria. A follow-up study (Green et al.,
1994) indicated that 7% of those re-evaluated 17 years later continued to meet full PTSD
criteria. LaGreca et al. (1996) evaluated children 3 months, 7 months, and 10 months
after exposure to Hurricane Andrew and found at least moderate PTSD symptoms in
86%, 76%, and 69% of these children respectively. Shaw et al. (1995) found no
differences in severity of PTSD symptomatology between 8 weeks and 32 weeks
following exposure to Hurricane Andrew. Laor et al. (1997) found a significant decrease
of PTSD symptoms in children displaced from their homes during SCUD missile attacks,
from 6 months to 30 months post-exposure. McFarland (1987) studied children exposed
to Australian bush fires, and found no decrease in PTSD symptoms from 8 months to 26
months after the fires. Milgram et al. (1988) evaluated children after a school bus disaster
and found that 50% of the children at the accident scene met full PTSD criteria 1 month
later but only 20% continued to meet criteria 9 months later. Pynoos et al. (1987) found
that 50% of children exposed to a fatal school ground sniper attack had PTSD 1 month
later. Although the entire cohort was not reevaluated, a follow-up study by Nader et al.
(1990) indicated that 74% of the highly exposed children continued to have high rates of
PTSD 14 months later.
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Several other authors have evaluated PTSD in children long after exposure to a
traumatic event to examine the persistence of these symptoms. Green (1985) found that
50% of physically abused children had persistent PTSD symptoms, which he attributed to
his findings that “the anticipation of the trauma (reoccurring) might be as traumatic as the
original event” (p. 145). Stoddard et al. (1989) found that 27% of severely burned
children had persistent PTSD symptoms on readmission to the hospital for reconstructive
surgery several years after the burns occurred. McLeer et al. (1992) found that 44% of
referred sexually abused children met full DSM-III-R PTSD criteria, and found no
relationship between the presence of this diagnosis and the length of time since the most
recent abusive episode. Hubbard et al. (1995) found that 15 years after exposure to Pol
Pot forced labor camps in Cambodia, 24% of youth aged 17 to 24 years met criteria for
PTSD. In a study of a similar cohort, Kinzie et al. (1986) found that 50% of Cambodian
adolescents exposed to these conditions met PTSD criteria 4 years post-exposure.
Macksoud and Aber (1996) also found that 43% of Lebanese children exposed to war
conditions met PTSD criteria, although the identified traumatic event had occurred up to
10 years previously. Schwarz and Kowalski (1991b) found that 27% of children exposed
to a fatal school shooting met DSM-III-R PTSD criteria when assessed 8 to 14 months
after exposure. Terr (1983) also documented the persistence of PTSD symptoms in
children 4 years after their school bus was kidnapped. Boyle et al. (1995) followed 200
(50%) of the child survivors of the sunken ship Jupiter. While 50% developed PTSD
soon after exposure, there was a gradual decrease in numbers of children experiencing
PTSD symptoms over time. At 5 to 7 years post-exposure, 15% continued to meet PTSD
diagnostic criteria. Taken together, these studies can be interpreted to indicate that while
PTSD symptoms spontaneously remit in a proportion of children, they persist for long
periods of time in a substantial proportion of children exposed to traumatic stressors.
Research has not consistently demonstrated protective or risk factors in this regard.
LaGreca et al. (1996) summarize current knowledge in this regard by stating “the course
of PTSD symptoms in children over time and their associated outcomes are not yet
known” (p. 722).
Clinically Relevant Subtypes
DSM-IV specifies three subtypes of PTSD. In the acute type, the duration of
symptoms is less than 3 months. In the chronic type, the symptoms have lasted for 3
months or longer. In the delayed onset type, at least 6 months have passed between the
traumatic event and the onset of symptoms. Due to the difficulty in eliciting some PTSD
symptoms from children, and the tendency of some parents to minimize PTSD
symptomatology in their children (which may contribute to a delay in having the child
evaluated), a careful history should be taken before using the delayed onset specified in
children. It also should be noted that if PTSD symptoms have appeared within 1 month
after exposure to an extreme traumatic stressor but have not lasted beyond 1 month, a
diagnosis of Acute Stress Disorder (ASD) should be made. If symptoms then extend
beyond 1 month, the diagnosis should be changed to PTSD.
Terr (1991) has conceptualized a different framework of PTSD subtypes,
determined by the type of trauma experienced. She suggested that Type I traumas (“one
sudden blow” trauma, such as a motor vehicle accident or sniper attack) result in the
classic DSM symptoms of reexperiencing, avoidance, and increased arousal, whereas
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children experiencing Type II traumas (variable, multiple, longstanding traumas such as
ongoing child physical or sexual abuse) result in denial, numbing, dissociation, and rage.
Famularo et al. (1996) also described distinct symptomatology between acute and chronic
types of PTSD, with the acute subtype having a predominance of sleep difficulties,
physiologic hyper arousal, and reexperiencing, and the chronic subtype having
dissociation, restricted affect, sadness, and detachment as more prominent symptoms.
Spiegel (1984) discussed the prevalence of dissociative symptoms in children with PTSD
who had experienced specific types of trauma. Although these differences have not been
consistently empirically documented, clinicians should be aware that subtypes of PTSD
may present with very different clinical features. Finally, it should be noted that although
the International Classification of Diseases, Tenth Revision (ICD-10) includes the same
three subtypes of PTSD as DSM-IV, it takes a different stance on some of the symptom
requirements and thus there is imperfect overlap in diagnostic criteria for PTSD between
the two classification systems.
Comorbidity
Several studies have documented significant comorbidity of childhood PTSD with
other psychiatric disorders. Brent et al. (1995) noted that there is a large overlap in
symptom criteria between PTSD and MDD, and went on to suggest that the “core
features” of PTSD may be much narrower than the DSM-IV criteria suggest. That study
as well as others (Goenjian et al., 1995; Green, 1985; Hubbard et al., 1995; Kinzie et al.,
1986; Kiser et al., 1991; Looff et al., 1995; Singer et al., 1995; Stoddard et al., 1989;
Weine et al., 1995; Yehuda and McFarlane, 1995; Yule and Udwin, 1991) have noted
comorbidity between PTSD and depressive disorders (MDD and dysthymic disorder).
Several authors have hypothesized that PTSD precedes and predisposes to the onset of
MDD (Goenjian et al., 1995; Yehuda and McFarlane, 1995) rather than the reverse.
Several investigators have documented comorbidity between PTSD and substance abuse
in children (Arroyo and Eth, 1985; Brent et al., 1995; Clark et al., 1995; Looff et al.,
1995; Sullivan and Evans, 1994). Comorbidity between PTSD and other anxiety
disorders (DSM-III-R overanxious disorder, agoraphobia, separation anxiety disorder, and
generalized anxiety disorder) has also been described (Brent et al., 1995; Clark et al.,
1995; Goenjian et al., 1995; Kiser et al., 1991; Lonigan et al., 1994; Singer et al., 1995;
Yule and Udwin, 1991).
The theoretical relationship between PTSD and externalizing behavioral disorders
may seem obscure. However, authors such as Malmquist (1986) have noted that numbing
or avoidance may take many forms in children, including restlessness, hyper alertness,
poor concentration, and behavioral problems. Anxiety in young children may be
manifested by hyperactivity, distractibility, and impulsivity, which are hallmarks of
attention-deficit/hyperactivity disorder (ADHD). This may explain why comorbidity has
also been found between PTSD and ADHD (Cuffe et al., 1994; Glod and Teicher, 1996),
and why traumatized children may present with ADHD symptoms rather than PTSD
(DeBellis et al., 1994a; Looff et al., 1995; McLeer et al., 1994). It also may explain why
PTSD is sometimes misdiagnosed as ADHD in younger children. Conversely, it is
possible that children with preexisting ADHD may be more vulnerable to developing
PTSD following a traumatic experience. High prevalence of other externalizing disorders,
such as conduct disorder and oppositional-defiant disorder, have also been noted in
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children with PTSD (Arroyo and Eth, 1985; Green, 1985; Steiner et al., 1997; Stoddard et
al., 1989). Steiner et al. (1997) suggest that PTSD may result in loss of impulse control
and diminished control of aggression and anger, which may explain this comorbidity.
Pelcovitz et al. (1994) hypothesize that externalizing symptoms may be an initial
response to ongoing stressors such as physical abuse, and that there may be a “sleeper”
effect in the emergence of PTSD symptoms.
Finally, although not empirically documented, there may be comorbidity between
PTSD and borderline personality disorder (BPD), particularly in sexually abused
adolescents. Studies have indicated that 60% to 80% of females diagnosed as having
BPD report a history of childhood sexual abuse (Herman et al., 1989; Stone, 1990).
Goodwin (1985) and Herman and van der Kolk (1987) have suggested that BPD may
represent a very severe and chronic manifestation of PTSD. Other authors have indicated
the predominance of dissociative and interpersonal problems associated with chronic
PTSD (Famularo et al., 1996; Spiegel, 1984; Terr, 1991). For these reasons, Goodwin
(1985) recommends that diagnosis of personality disorders should be deferred until PTSD
symptoms have resolved.
Differential Diagnosis
In PTSD, the stressor must be of an extreme nature, although the clinician has
some latitude in determining whether a particular stressor is “extreme.” In contrast, the
stressor can be of any severity in an adjustment disorder. DSM-IV (American Psychiatric
Association, 1994) specifies that an adjustment disorder diagnosis should be given if the
response to an extreme stressor does not meet criteria for PTSD, or in situations in which
a PTSD symptom pattern occurs in response to a non-extreme stressor (such as the birth
of a sibling, moving to a new neighborhood, or starting a new school).
If avoidance, numbing, and increased arousal symptoms were present prior to
exposure to a traumatic event, a diagnosis of PTSD may not be appropriate after the
stressor. It is possible that the child was exposed to undetected stressors prior to
developing the symptoms; routine screening for exposure to domestic or community
violence, child abuse, and other common stressors is essential in making this
determination. Other diagnoses (e.g., a mood disorder or another anxiety disorder) should
be considered instead of PTSD if the stressor did not clearly precede the PTSD
symptoms. If the symptom pattern in response to this stressor meets criteria for another
mental disorder, such as MDD, ADHD, or mixed substance abuse, these diagnoses
should be given instead of PTSD. On the other hand, if the stressor clearly preceded the
onset of PTSD symptoms and the symptom pattern meets criteria for both PTSD and
another mental disorder, both diagnoses should be given.
ASD is distinguished from PTSD because the symptom pattern in ASD must both
occur and resolve within 4 weeks of the traumatic event.
Recurrent intrusive thoughts occur in obsessive compulsive disorder (OCD) but
are not related to an experienced traumatic event as in PTSD. In OCD, the intrusive
thoughts are generally experienced as inappropriate. Flashbacks in PTSD are
distinguished from other intrusive thoughts or memories of the trauma in that they
involve a feeling of actually reliving the event, with some degree of dissociation.
Flashbacks should be distinguished from illusions, hallucinations, and other perceptual
disturbances occurring in psychotic disorders unrelated to exposure to an extreme
stressor.
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As with all other child and adolescent psychiatric disorders, the diagnostic criteria
for PTSD include symptoms that may be reported as the result of contagion,
suggestibility, malingering, or for personal gain. It is highly unlikely that such factors
would cause a child to meet full criteria for PTSD. These factors should be considered,
however, when PTSD-like symptoms are observed without a discernible history of
trauma.
ASSESSMENT
The assessment of PTSD in children depends first and foremost on careful and
direct clinical interviews with the child and the parents. If a parent is the alleged
perpetrator of the child abuse or domestic violence that is the identified traumatic event,
the non-offending parent or another caretaker should be interviewed. Specific guidelines
for conducting this type of diagnostic interview are included in the outline following this
text. Briefly, both parents and child should be asked directly about the traumatic event,
and about PTSD symptomatology in detail. Specific questions related to reexperiencing,
avoidant, and hyperarousal symptoms as described in DSM-IV should be asked. Particular
attention should be given to the use of developmentally appropriate language when
asking the child about these PTSD symptoms. The clinician should be aware of
developmental variations in the presentation of PTSD symptomatology, particularly with
preschool children (Scheeringa et al., 1995), and should include questions about
developmentally-specific symptoms when interviewing young children.
There are many unanswered questions regarding how to assess children for the
presence of PTSD. Although several questionnaires and semi-structured interviews
purport to measure this disorder, there is no single instrument accepted as a “gold
standard” for making this diagnosis or monitoring its symptom course. In part, the
assessment of PTSD is complicated by the requirement of having a certain number of
symptoms from each of three categories (reexperiencing, avoidance/numbing, and
increased arousal). As a result, a single score on any instrument is not sufficient to
categorically diagnose PTSD (since a child could have extremely high levels of
symptomatology in one category but none in another, etc.). Parent reports tend to
minimize the child’s PTSD symptomatology (Handford et al., 1986; Malmquist, 1986;
Rigamer, 1986; Sack et al., 1986) and it is difficult to ascertain avoidant and numbing
symptoms from child self-reports, resulting in a significant risk of underdiagnosing this
disorder. Teachers and other adults may not observe or be aware of many salient PTSD
symptoms because they may not be manifested at school (e.g., sleep problems or
hypervigilance) or may not be obvious to the untrained observer. Physiologic measures of
hyperarousal are not adequately standardized in children; nor would such measures
adequately assess reexperiencing or avoidant symptoms. Thus, there are considerable
limitations inherent in assessing PTSD in children.
On the other hand, there is concern that some clinicians overdiagnose PTSD due
to a lack of awareness of the specific diagnostic criteria required, and a misperception
that the presence of reexperiencing and anxiety symptoms alone following exposure to an
extreme stressor are adequate to diagnose PTSD. This concern has led to recent attempts
to more rigorously educate clinicians regarding this disorder.
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One area of agreement among experts in assessing PTSD in children relates to the
need to directly ask the child about PTSD symptoms as they relate to the stressor. As
Wolfe et al. (1994) note, “Most children cannot report their psychological reactions to the
trauma unless they are specifically asked about aspects of the trauma”(p. 48). Pynoos and
Eth (1986) also state that an open discussion specifically about the trauma is necessary to
adequately assess as well as to resolve PTSD symptoms. Often clinicians do not directly
ask children about the traumatic event and its impact on the child, either for fear of
upsetting the child, because of the clinician’s own avoidance of painful discussions, or in
some cases, for fear of “tainting” the child’s description of the trauma (for example, if the
child will be testifying in court against the perpetrator in an abuse situation) (Benedek,
1985). It is likely that such clinicians will miss important PTSD symptoms. Almqvist and
Brandell-Forsberg (1997) have documented that information provided by young children
regarding their trauma-related symptoms significantly increased the prevalence of PTSD
diagnoses over that obtained from relying solely on parental reports of symptomatology.
Thus, there is empirical evidence to support the importance of asking children directly
about the traumatic event, as well as a strong clinical consensus that if children are not
asked, they are less likely to discuss their PTSD symptoms.
Pynoos and Eth (1986) describe a clinical interview with the child designed to
assess PTSD symptoms as well as to provide an initial intervention. They report that in
use with more than 200 children aged 3 to 16 years, this interview format was helpful in
diagnosing PTSD. No empirical data are presented on inter-rater reliability of diagnosis
using the suggested format.
Several semi-structured interviews are available to assess PTSD in children.
These are summarized in Table 1.
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TABLE 1
Semi-Structured Interviews Used to Assess PTSD in Children and Adolescents
DSM
Measure (Source)
Version
Reliability &
Used
Validity Data
Schedule for Assessment of Depression and
DSM-IV
High inter-rater
Schizophrenia - Present and Lifetime Version
reliability, good test-retest
for Children -PTSD Scale
reliability
(Kaufman et al., 1997)
Diagnostic Interview for Children and
DSM-III-R
None
Adolescents - PTSD
(Famularo et al., 1996)
Diagnostic Interview Schedule - PTSD
DSM-III-R
None
(Garrison et al., 1995)
Structured Clinical Interview for DSM-III-
DSM-III
None
PTSD
(Hubbard et al., 1995)
Clinician-Administered PTSD Scale for
DSM-IV
Currently being evaluated
Children and Adolescents, DSM-IV Version
(Nader et al., 1996)
Childhood PTSD Interview-Child Form
DSM-IV
High inter-rater
(Fletcher, 1997a)
reliability, strong
construct and convergent
validity
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Several self- and parent-report instruments that measure PTSD symptoms in
children, although none generate a single score that indicates the presence or absence of
this disorder. These instruments are described in Table 2 and Table 3.
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TABLE 2
Instruments That Measure All PTSD Symptoms in Children and Adolescents
DSM
Version
Reliability &
Measure (Source)
Format
Used
Validity Data
Age
Comments
PTSD Reaction Index
20-item self-report
DSM-III
High correlation with
Not specified
Adapted from adult
(Friedrich, 1985;
(may also be used
clinical diagnosis
version
Goenjian et al., 1995;
as semi-structured
Most commonly used
Pynoos et al., 1987)
interview)
instrument in published
research studies
Composite score indicates
severity of PTSD
symptoms
Child PTSD Symptom
17-item self-report
DSM-IV
High internal
Not specified
Based on adult scale
Scale
consistency, test-retest
(Foa et al., 1995)
(Johnson et al., 1996)
reliability and
Currently being field tested
convergent validity
Specifically designed for
with RI
research as well as clinical
use
Children’s PTSD
Self-report with
DSM-IV
High inter-rater
Not specified
Only instrument that
Inventory
five subscales
reliability, sensitivity
provides discrete diagnosis
(Saigh, 1988, 1989;
(exposure,
and specificity of
of no PTSD or acute,
March, in press)
reexperiencing,
diagnosis, high
chronic, or delayed-onset
avoidance,
correlation with
PTSD
hyperarousal,
clinical diagnosis
degree of distress)
Checklist for PTSD
Clinician rated
DSM-IV None
0–3
years Alternative
symptom
Symptoms in Infants and
symptom inventory
checklist for diagnosing
Young Children
PTSD in infants and
(Scheeringa et al., 1995)
toddlers
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Posttraumatic Stress
30-item interview
DSM-IV
High internal
4–8 years
Specifically designed for
Inventory for Children
consistency,
use in younger children
(Eisen, 1997)
preliminary
convergent validity
When Bad Things
95 item self-report
DSM-IV
High internal
3rd grade
Includes a parent report
Happen Scale
consistency and
version (Parent Report of
(Fletcher, 1997b)
convergent validity
Child’s Reaction to Stress)
PTSD Checklist/Parent
17-item parent
DSM-IV
High internal
Not specified
Standardized on pediatric
Report
report
consistency, good
medical trauma population
(Ford et al., 1996)
inter-rater reliability,
strong convergent and
construct validity
Checklist of Child
25-item self-report
DSM-III-R
High inter-rater and
6–17 years
Specifically designed for
Distress Symptoms
concurrent validity
use in children
(Martinez and Richters,
Has a parallel parent-report
1993)
version
CCDS-Parent Report
28-item parent-
DSM-III-R
High inter-rater and
6–17 years
Parallels child version
(Richters and Martinez,
report
concurrent validity
1990)
“Levonn”
40-item self-report
DSM-III-R
None
<6 years
Only self-report instrument
(Richters et al., 1990)
pictorial/visual
for preschoolers
thermometer rating
scale in response to
questions read to
child
Child Stress Reaction
35-item parent,
DSM-IV
High preliminary
Not specified
Standardized on acutely
Checklist
teacher or medical
inter-rater reliability
burned children
(Saxe et al., 1997)
staff report
and construct validity
Also measures Acute
Stress Disorder
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Trauma Symptom
54-item self-report
DSM-IV
High test-retest
8–17 years
Measures sequelae of
Checklist
reliability and internal
trauma on six subscales
for Children
consistency of
PTSD subscale primarily
(Briere, 1995)
subscales
measures reexperiencing
Sensitive to treatment
effects (Deblinger et al.,
1996; Lanktree and Briere,
1995)
Age and gender specific
norms available
Children’s Impact of
52-item self-report
DSM-III-R
High internal
Not specified
Particularly applicable to
Traumatic Event Scale
consistency and
sexually abused children
(Wolfe et al., 1989)
independence of
subscales
Child Sexual Behavior
45-item self report
N/A
High test-retest
2–18 years
Measures repetitive
Inventory
reliability and internal
sexualized behaviors
(Friedrich et al., 1992)
consistency
Specifically applicable to
sexually abused children
Age and gender specific
norms available
Sensitive to treatment
effects
Weekly Behavior Report
22-item parent
DSM-IV
High test-retest
3–7 years
Measures anxiety,
(Cohen and Mannarino,
report
reliability, convergent
avoidance, sleep problems
1996b)
validity and internal
and pre-occupation with
consistency
sexual abuse-related words
and behaviors
Specifically applicable to
sexually abused young
children
Sensitive to treatment
effects
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TABLE 3
Instruments That Measure Specific Aspects of PTSD in Children and Adolescents
DSM
Version
Reliability &
Measure (Source)
Format
Used
Validity Data
Age
Comments
Trauma Symptom
54-item self-report DSM-IV
High test-retest
8–17 years
Measures sequelae of
Checklist for Children
reliability and internal
trauma on six subscales
(Briere, 1995)
consistency of
PTSD subscale primarily
subscales
measures reexperiencing
Sensitive to treatment
effects (Deblinger et al.,
1996; Lanktree and Briere,
1995)
Age and gender specific
norms available
Children’s Impact of
52-item self-report DSM-III-R
High internal
Not specified
Particularly applicable to
Traumatic Event Scale
consistency and
sexually abused children
(Wolfe et al., 1989)
independence of
subscales
Child Sexual Behavior
45-item self report
N/A
High test-retest
2–18 years
Measures repetitive
Inventory
reliability and internal
sexualized behaviors
(Friedrich et al., 1992)
consistency
specifically applicable to
sexually abused children
Age and gender specific
norms available
Sensitive to treatment
effects
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Weekly Behavior Report
22-item parent
DSM-IV
High test-retest
3–7 years
Measures anxiety,
(Cohen and Mannarino,
report
reliability, convergent
avoidance, sleep problems
1996b)
validity and internal
and pre-occupation with
consistency
sexual abuse-related words
and behaviors Specifically
applicable to sexually
abused young children
Sensitive to treatment
effects
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In summary, although there are several instruments available for assessing PTSD
related symptoms, none of the existing self- or parent-report measures is optimal. Saigh
et al. (1996) and Kratochwill (1996) emphasize the need for multi source, multi score
assessment instruments that measure PTSD across different areas of functioning.
Although instruments may have great value in evaluating and following the clinical
course of children with PTSD, instruments cannot take the place of a careful and direct
clinical interview in assessing PTSD diagnostic criteria. The use of semi-structured
interviews with documented reliability and validity of the PTSD section, although
cumbersome and time-consuming to administer, may be of value to clinicians who lack
extensive clinical experience in assessing children for PTSD symptoms. However, to
date, only three of these semi-structured interviews has been modified to correspond to
DSM-IV criteria and none has been extensively psychometrically evaluated with regard to
DSM-IV clinical PTSD diagnosis. Assessment of PTSD symptoms therefore continues to
rely primarily on the clinical interview of the child and parents.
PTSD is unique among psychiatric disorders because diagnosing it requires the
presence of an etiologic event (Koverola, in press). Historically, clinicians have never
had to prove exposure of the patient to the trauma to diagnose PTSD, beyond ascertaining
the patient’s self-reported exposure. Self-report has been the standard for establishing the
presence of the traumatic event in adults with PTSD, and most empirical studies have
depended upon self-reported exposure in studying PTSD. Although many studies of
PTSD in children have also solicited parent- and/or teacher-report of symptomatology,
and the parent’s perception of the child’s traumatic experience, most have relied on the
child’s own report regarding trauma exposure. At least one empirical study has indicated
that development of PTSD is predicted by self-reported exposure to violence rather than
by objective measures of actual levels of criminal violence (Berton and Stabb, 1996).
Reliance on self-reported exposure to trauma has not been called into question until
recently. Concerns that patients may be vulnerable to suggestive influences, whether in or
out of psychiatric settings, has led to the idea that the child’s self-reported exposure to the
traumatic event should be investigated or proven prior to diagnosing or treating PTSD.
Parent reports in this regard may not be reliable, either because the parent is unaware that
the trauma occurred or because (in the case where a parent is the alleged perpetrator) the
parent has a strong motivation not to corroborate the child’s traumatic experience.
There are several important differences between clinical and forensic evaluations
(Appelbaum, 1997; Greenberg and Shuman, 1997; Strasburger et al., 1997). These
practice parameters apply to clinical rather than forensic assessments. In some situations
it may be optimal for a child to receive an independent forensic evaluation prior to
receiving a clinical evaluation and treatment, and such a forensic assessment may directly
address the issue of the child’s credibility regarding self-reported exposure to traumatic
events (American Academy of Child and Adolescent Psychiatry, 1997) . However, there
is strong consensus that the roles of forensic evaluator and treating clinician should
remain separate. It should be emphasized that practitioners in either clinical or forensic
roles must comply with state reporting requirements with regard to child abuse
allegations.
One area of controversy relates to the number of symptoms from each category
(reexperiencing, avoidance, and increased arousal) that need to be present to diagnose
PTSD in children (Saigh, 1988). Perhaps an even more basic issue is whether children
who meet full diagnostic criteria are different in some significant way from children who
meet “partial” PTSD criteria (i.e., exhibit several PTSD symptoms but do not meet
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criteria as defined by DSM-IV). Is PTSD at full criteria a discrete disorder in any
functional way, or do PTSD symptoms occur on a continuum of frequency and severity,
with “full” criteria representing an arbitrary cut-off point rather than a clinically
meaningful dividing point (Terr, 1991)? Empirical data to directly address these issues
are lacking, although it has been documented that the percentage of children diagnosed
with PTSD varies greatly depending on which DSM criteria (III, III-R, or IV) are used
(Schwarz and Kowalski, 1991a) and whether a liberal or conservative threshold is used to
define “persistent” symptoms (Schwarz and Kowalski, 1991b; Stoddard et al., 1989).
Several authors have suggested that the adult PTSD diagnostic criteria “may not be
wholly appropriate for children’s anxiety reaction to stress” (Garmezy, 1986, p. 391). For
example, it has been pointed out that while reexperiencing and avoidant symptoms may
occur in close temporal proximity, they are in many ways opposite symptoms, and thus,
children may experience long periods of reexperiencing alternating with long periods of
avoidance and numbing, rather than experiencing both at the same time (Horowitz, 1976;
Miller and Veltkamp, 1988; Rigamer, 1986; Schwarz and Kowalski, 1991a). Significant
under diagnosis of PTSD in children may result. Some authors also have indicated that if
avoidance and affective numbing are highly effective, the child may appear to be
unaffected by the trauma or reexperiencing symptoms may be masked (Arroyo and Eth,
1995; Stuber et al., 1991). As Green (1991) points out, assessing avoidant (denial)
symptoms is limited by definition, as is the child’s ability to link such symptoms to the
trauma. She argues that the requirement of three avoidant/numbing symptoms is therefore
too stringent for a PTSD diagnosis in children.
Earls et al. (1988), Frederick (1985), and Lyons (1987) discuss several other
methodological problems in assessing PTSD symptoms in children. Goodwin (1985)
suggests that maladaptive expressions of fear and anger may mask a PTSD diagnosis and
lead instead to a diagnosis of conduct disorder (with externalized aggression) or
borderline personality disorder (with self-injurious behavior), especially in adolescents.
Many authors have suggested the need for developmental stage-specific diagnostic
criteria for PTSD (Benedek, 1985; Drell et al., 1993; Eth and Pynoos, 1985; Green et al.,
1991; Horowitz, 1996; Terr, 1985; Terr, 1990). Thus, although DSM-IV diagnostic
criteria are used to diagnose PTSD in children, there is ongoing debate regarding how
accurately these criteria describe childhood PTSD. Extensive field trials are needed to
evaluate the validity of current PTSD criteria for children and adolescents.
A final controversy regarding PTSD is succinctly framed by Yehuda and
McFarlane (1995), who address the conflict between the desire to normalize victims (as
expressed by advocacy groups who pressed for the initial DSM-III recognition of PTSD
as a “normal reaction to abnormal stress”) and empirical evidence suggesting that PTSD
is a rare psychiatric disorder with clear predisposing factors and distinct physiologic
abnormalities. In other words, are trauma survivors with PTSD psychiatrically damaged
or are they experiencing normal adaptation? Although this controversy is far from
resolved, it would appear that one can recognize predisposing risk factors and the
psychiatric comorbidity of PTSD without blaming the trauma victim. A reasonable
practice is to offer treatment to children with clinically significant PTSD symptoms (i.e.,
severe enough to impair their functioning in at least one important domain), whether or
not they meet strict DSM-IV PTSD diagnostic criteria.
TREATMENT
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Despite the paucity of empirical treatment-outcome studies, strong clinical
consensus among experts in the field suggests essential components of treatment for
children with PTSD, including direct exploration of the trauma, use of specific stress
management techniques, exploration and correction of inaccurate attributions regarding
the trauma, and inclusion of parents in treatment (Berliner, in press; Friedrich, 1996).
Very limited empirical support exists for various treatment interventions for
children with PTSD. Solomon et al. (1992) examined the treatment literature for PTSD
and found somewhat greater empirical support for the use of cognitive behavioral therapy
(CBT) than for other forms of psychotherapy or medication in treating this disorder.
However, this review was based entirely on studies with adult populations. Garmezy
(1986) critiqued the difficulties inherent in empirically studying the impact and treatment
of stress on children. Only four controlled studies have examined treatment of PTSD
symptoms in children.
Deblinger et al. (1996) used trauma-focused CBT to treat 100 sexually abused
children. Subjects were randomly assigned to one of four treatment conditions: child-only
receiving CBT, parent-only receiving CBT, child and parent receiving CBT, or
assignment to a community treatment control. Results indicated that although all groups
improved as measured by the Kiddie-SADS-E PTSD section, the two conditions in which
the child received direct treatment demonstrated significantly greater improvement in
PTSD symptoms than the other two conditions. This study also demonstrated that
including the parent in treatment produced significantly more improvement in
externalizing and depressive symptoms.
Cohen and Mannarino (1996a) evaluated trauma-focused CBT for sexually
abused preschoolers and their parents. Children were randomly assigned to either the
CBT intervention or a nondirective supportive therapy condition. Child PTSD symptoms
(as measured by the Weekly Behavior Report) and sexually inappropriate behaviors (as
measured by the Child Sexual Behavior Inventory) (Friedrich et al., 1992) significantly
decreased in the CBT group only; significant group x time interactions were found at
post-treatment (Cohen and Mannarino, 1996a).
A recent study by Goenjian et al. (1997) empirically examined the effectiveness
of school-based grief/trauma-focused psychotherapy in decreasing chronic PTSD and
depressive symptoms in adolescents following a highly destructive earthquake in
Armenia. Children in four schools near the epicenter of the earthquake were evaluated
1½ years after the earthquake; children in two schools were then provided with treatment
while children in the remaining two schools were untreated. Pretreatment levels of PTSD
(as measured by the Reaction Index) and depression were high in both groups. The
treatment included direct exploration of the trauma, relaxation and desensitization
procedures, resolution of grief through focusing on nontraumatic memories, and group
support through recognition of the commonality of PTSD symptoms among
peers. The treated group experienced significant improvement in PTSD and depressive
symptoms, whereas these symptoms significantly worsened in the untreated group.
Field et al. (1996) evaluated the impact of massage therapy with children exposed
to Hurricane Andrew. They randomly assigned 50 children to massage therapy or to a
video attention-control condition. Children completed the PTSD Reaction Index (RI) pre-
and post-treatment. Prior to treatment, both groups scored in the severe range on the RI.
The massage therapy group experienced significantly more improvement than the control
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group on post-treatment RI scores. This study thus supported the use of muscle relaxation
techniques for decreasing PTSD symptomatology.
The first three studies cited above lend empirical support to the use of CBT
interventions that include direct discussion of the trauma, desensitization and relaxation
techniques, cognitive reframing, and contingency reinforcement programs for
problematic behaviors in treating children with PTSD (Cohen and Mannarino, 1993;
Deblinger and Heflin, 1996).
PSYCHOTHERAPY
Direct exploration with the child of the traumatic event and its impact makes
intuitive sense if PTSD is conceptualized as a direct response to that event. However,
some clinicians avoid directly discussing the event for fear of transiently increasing the
child’s symptomatology or because of their own need to avoid the negative affect
associated with such discussion (Benedek, 1985). There is a powerful adult desire to “let
sleeping dogs lie” in children, even if PTSD symptoms suggest that the impact of the
trauma is not dormant. The child’s own avoidance of talking about the trauma also is
often a reason therapists hesitate to directly discuss it. Many therapists have been
discouraged from directly discussing certain traumatic events (e.g., child abuse) for fear
of tainting the child’s potential testimony in subsequent legal proceedings. This concern
has arisen from recent controversy regarding the suggestibility of children’s memories
and the idea that repeated suggestive questioning may change a child’s memory regarding
the factual aspects of an event (Ceci et al., 1996). However, even if this premise is
accepted, and empirical evidence is quite contradictory on this score, direct exploration of
the traumatic experience and its meaning to the child as used in psychotherapy does not
involve repeated suggestive attempts to alter the child’s description of what occurred.
Rather, it involves encouraging a child, through relaxation and desensitization
procedures, to describe the event with diminished hyper arousal and negative affect.
According to Benedek (1985), “Retelling is equivalent to reworking (and is) one attempt
at mastery of an experience” (p. 11). Terr (1990) believes that simply asking children
about the traumatic experience and how it affected them often seems to have a positive
effect. Pynoos and Eth (1986) state that an open discussion of the trauma is essential to
mastering anxiety and grief, and that such interventions produce almost immediate relief,
not further distress.
Authors vary in the degree to which they advocate explicit exposure techniques.
While Deblinger and Heflin (1996) and March et al. (1996) recommend systematic
gradual exposure to increasingly upsetting aspects of the trauma, other protocols do not
include hierarchical exposure. Regardless of the specific manner in which the trauma is
addressed, several authors consider some form of trauma-focused discussion and
reconsideration to be the most critical component of treatment for PTSD in children
(Azarian et al., 1996; Benedek, 1985; Berliner, in press; Friedrich, 1996; Galante and
Foa, 1986; Janoff-Bulman, 1985; Kardiner and Spiegel, 1947; Parson, 1995, 1997;
Pynoos and Eth, 1985, 1986; Pynoos and Nader, 1988; Rigamer, 1986; Saigh et al., 1996;
Saigh, 1986; Silvern et al., 1995; Snodgrass et al., 1993; Terr, 1990). Thus, strong clinical
consensus as well as limited empirical evidence (Cohen and Mannarino, 1996a;
Deblinger et al., 1996; Goenjian et al., 1997) support trauma-focused interventions for
these children.
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These results do not require therapists to insist on traumatized children
participating in exposure activities prior to treatment termination. Exposure-based
therapies are designed primarily for situations in which traumatic memories or avoidance
produce psychological distress. Persistent talking about traumatic memories with children
who are very embarrassed or highly resistant may not be indicated, and may in fact
worsen symptoms. Indirect methods of addressing traumatic issues, such as art and play
techniques, may be helpful in these situations. Children exposed to a known trauma who
are asymptomatic may not require treatment but may need monitoring for emergence of
delayed or “sleeper” symptoms (Mannarino et al., 1991; Pfeffer, 1997).
Stress management techniques frequently are paired with direct discussion of the
traumatic event. Siegel (1995) has provided a neuro-cognitive explanation of why stress
management may alleviate PTSD symptoms. Progressive muscle relaxation, thought-
stopping, positive imagery, and deep breathing are taught to the child prior to detailed
discussions of the trauma (Cohen and Mannarino, 1993; Deblinger and Heflin, 1996;
Parson, 1997; Saigh et al., 1996; Saigh, 1986; Snodgrass et al., 1993). Mastering these
skills gives the child a sense of control over thoughts and feelings rather than feeling
overwhelmed by them, and allows the child to approach the direct discussion of the
traumatic event with confidence that this will not lead to uncontrollable reexperiencing
symptoms and fear. Stress management techniques also are useful to the child outside of
the therapeutic context, if and when reexperiencing phenomena occur.
Another element common to most interventions for traumatized children involves
evaluation and reconsideration of cognitive assumptions the child has made with regard
to the traumatic event (Berliner, in press; Cohen and Mannarino, 1993; Deblinger and
Heflin, 1996; Joseph et al., 1993; Pynoos and Eth, 1986; Spaccarelli, 1995). Faulty
attributions regarding the trauma (e.g., “It was my fault,” “Nothing is safe anymore”)
should be explored and challenged, beyond mere reassurances. Challenging most often is
accomplished through step-by-step logical analysis of the child’s cognitive distortions
within therapy sessions. Other issues, such as survivor’s guilt and omen formation, also
should be challenged.
Expert consensus also indicates that inclusion of parents and/or supportive others
in treatment is important for resolution of PTSD symptoms. Parental emotional reaction
to the traumatic event and parental support of the child are powerful mediators of the
child’s PTSD symptomatology. Including parents in treatment helps them monitor the
child’s symptomatology and learn appropriate behavioral management techniques, both
in the intervals between treatment sessions and after therapy is terminated. In addition,
helping parents resolve their emotional distress related to the trauma, to which the parent
usually has had either direct or vicarious exposure, can help the parent be more
perceptive of and responsive to the child’s emotional needs (Burman and Allen-Meares,
1994; Rizzone et al., 1994). Many parents benefit from direct psycho education regarding
their child’s PTSD symptoms and how to manage these (Deblinger and Heflin, 1996;
Parson, 1997; Rigamer, 1986). Most authors describing treatments for children with
PTSD recommend including one or more parent-directed components (Berliner, in press;
Blom, 1986; Brent et al., 1995; Burman and Allen-Meares, 1994; Butler et al., 1996;
Cohen and Mannarino, 1993; Deblinger and Heflin, 1996; Friedrich, 1996; Galante and
Foa, 1986; Kolko, 1996; Macksoud and Aber, 1996; Parson, 1997; Rigamer, 1986;
Simons and Silveira, 1994; Terr, 1989).
Data on the efficacy of group versus individual therapy for children with PTSD
are scarce. A meta analysis of treatment outcome studies for PTSD in adult women
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survivors of childhood sexual abuse demonstrated a larger effect size for individual
therapy than group treatment across a variety of therapeutic approaches (Chard, 1994).
Friedrich (1996) concluded that, in general, a trauma-focused approach that treats the
child’s specific symptoms is more important than the treatment modality (group, family,
individual) used. Although most treatment descriptions emphasize individual child
therapy, several authors have focused on the efficacy of providing crisis intervention to
parents, teachers, and/or children in groups at school, in the hospital, or in other
community settings (Blom, 1986; Galante and Foa, 1986; Goenjian et al., 1997; LeGreca
et al., 1996; Pynoos and Nader, 1988; Rigamer, 1986; Stallard and Law, 1993; Stoddard,
1996; Sullivan and Evans, 1994; Yule and Udwin, 1991). Many of these interventions
used convenience samples of schools or towns exposed to a common traumatic event.
Group interventions in such situations provide the most timely intervention to the largest
possible number of exposed children, and should be strongly considered. The rationale
for crisis intervention following this type of trauma is that timely direct discussion of the
event and its impact may prevent the development of avoidance and other PTSD
symptoms in large numbers of exposed children.
Treatment of the dissociative symptoms described in some children with chronic
PTSD is more complex. Clinicians should be aware that some children with PTSD have
prominent dissociative symptoms that may take the form of hallucinations or
disorganized thinking and behavior. These symptoms may be difficult to distinguish from
psychotic states, and should be understood as manifestations of PTSD rather than a form
of psychosis. In the case of sexually and physically abused children, the use of physical
restraint or forcible medication administration may produce further trauma or worsen
symptoms. Clinicians should be cautious in using these interventions or in diagnosing
psychosis in children and adolescents with a history of significant trauma. Because of the
complexity of treating PTSD complicated by dissociative symptoms, clinicians should
consult additional references, such as Putnam (1997), Lewis and Putnam (1996), and
Silberg (1996).
Not all behavioral and emotional problems in children with PTSD are necessarily
related to the trauma. In treating children with PTSD, it is essential that the clinician
recognize the presence of preexisting and comorbid psychiatric disorders, and provide
appropriate interventions for these difficulties in conjunction with trauma-focused
treatment.
OTHER PSYCHOSOCIAL TREATMENTS
Several alternative treatment techniques have been described for use in children
with PTSD. Pynoos and Nader (1988) describe a “psychological first aid” approach for
children exposed to community violence, which may be offered in schools as well as in
traditional treatment settings. This model emphasizes clarifying the facts about the
traumatic event, normalizing children’s PTSD reactions, encouraging expression of
feelings, teaching problem-solving techniques, and referring for ongoing treatment for the
most symptomatic children. Chemtob et al. (1997) describe a similar intervention,
psychological debriefing, for use in disaster situations. Sullivan and Evans (1994)
advocate a treatment approach that integrates trauma-focused interventions with 12-step
interventions for use in adolescents with PTSD and chemical dependency. Lowenstein
(1995) has described the use of a therapeutic activity book, the Resolution Scrapbook, as
an aid to treating children with PTSD. Many authors advocate the use of psycho
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education for parents and teachers to enlist their support for traumatized children (Blom,
1986; Butler et al., 1996; Galante and Foa, 1986; LaGreca et al., 1996; Molta, 1995; Nir,
1985; Rigamer, 1986). Education about the traumatic experience (common emotional
reactions to this kind of event, how to respond/protect oneself if this event were to recur,
etc.) may also be beneficial to children. Some have advocated psychoanalytic
interventions for children with PTSD (Gaensbauer, 1994). No empirical studies have
documented the efficacy of these interventions, which may be of significant value in
certain clinical situations.
Additional specialized interventions may be necessary for children exhibiting
particularly problematic PTSD symptoms, such as inappropriate sexual behavior.
Specific treatment protocols are available (MacFarlane and Cunningham, 1986); and
referral to specialized treatment programs may be appropriate in these situations.
Eye movement desensitization and reprocessing (EMDR) is an intervention that
combines cognitive therapy components with directed eye movements. There is some
empirical support for the effectiveness of EMDR in reducing PTSD symptoms in adults
(Forbes et al., 1994; Wilson et al., 1995). One study demonstrated that an EMDR
intervention with no eye movement was as effective as standard EMDR, indicating that
the cognitive interventions rather than eye movement per se may account for EMDR's
impact on PTSD symptoms (Pitman et al., 1996). No controlled studies have evaluated
the risks and benefits of EMDR in children and adolescents.
PSYCHOPHARMACOLOGY
As noted above, a few studies have indicated that some children with PTSD
exhibit physiologic abnormalities similar to those seen in adults with PTSD. Although
findings are preliminary, these reports have led clinicians to prescribe a variety of
medications for children with PTSD, despite a lack of randomized trials supporting
efficacy. Looff et al. (1995) reported that carbamazepine at serum levels of 10.0 to 11.5
ug/mL resulted in complete remission of symptoms in 22 out of 28 children with PTSD.
These findings were complicated by the fact that several of the children were
concurrently taking Ritalin, clonidine, selective serotonin reuptake inhibitors (SSRIs), or
tricyclic antidepressants. Famularo et al. (1988) demonstrated significant decreases in
PTSD symptomatology in 11 sexually and/or physically abused children following a 5-
week course of propranolol. Neither study used a control group or randomization of
treatment.
Marmar et al. (1993) and DeBellis et al. (1994a) suggested but did not empirically
evaluate the possibility that an -2 adrenergic agonist such as clonidine might be more
effective than psychostimulants for ADHD symptoms in sexually abused and other
children with comorbid PTSD. Horrigan (1996) reported a single case study in which a
long acting -2 agonist, guanfacine, was successful in reducing nightmares in a 7-year-old
child with PTSD. Harmon and Riggs (1996) reported a decrease in at least some PTSD
symptoms in all seven children included in an uncontrolled clinical trial using clonidine
patches. Brent et al. (1995) suggested that antidepressants may be helpful for some
children with PTSD, particularly those with a predominance of depressive or panic
disorder symptoms. To date, there have been no empirical studies of antidepressants for
PTSD in children.
At this time there is inadequate empirical support for the use of any particular
medication to treat PTSD in children (March et al., 1996). Drawing from the adult
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literature, it appears that the use of conventional psychotropic medication for PTSD is at
most mildly effective (Davidson and March, 1997). Due to the lack of adequate empirical
data, clinicians must rely on judgment to determine the appropriateness of
psychopharmacologic interventions in children with PTSD who have prominent
depressive, anxiety, panic, and/or ADHD symptoms. As a general practice medication
should be selected on the basis of established practice in treating the comorbid condition
(e.g., antidepressants for children with prominent depressive symptoms). Because of their
favorable side effect profile and evidence supporting effectiveness in treating both
depressive and anxiety disorders, SSRIs often are the first psychotropic medication
chosen for treating pediatric PTSD. Imipramine also is used frequently with children with
comorbid panic symptoms.
Due to the lack of empirical studies evaluating efficacy of treatment for PTSD in
children, it is premature to recommend a hierarchy of interventions. However, outpatient
psychotherapy is generally considered the preferred initial treatment, with psychotropic
medications used as an adjunctive treatment in children with prominent depressive or
panic symptoms.
CONFLICT OF INTEREST
As a matter of policy, some of the authors to these practice parameters are in
active clinical practice and may have received income related to treatments discussed in
these parameters. Some authors may be involved primarily in research or other academic
endeavors and also may have received income related to treatments discussed in these
parameters. To minimize the potential for these parameters to contain biased
recommendations due to conflict of interest, the parameters were reviewed extensively by
Work Group members, consultants, and Academy members; authors and reviewers were
asked to base their recommendations on an objective evaluation of the available
evidence; and authors and reviewers who believed that they might have a conflict of
interest that would bias, or appear to bias, their work on these parameters were asked to
notify the Academy.
SCIENTIFIC DATA AND CLINICAL CONSENSUS
Practice parameters are strategies for patient management, developed to assist
clinicians in psychiatric decision-making. These parameters, based on evaluation of the
scientific literature and relevant clinical consensus, describe generally accepted
approaches to assess and treat specific disorders, or to perform specific medical
procedures. The validity of scientific findings was judged by design, sample selection and
size, inclusion of comparison groups, generalizability, and agreement with other studies.
Clinical consensus was determined through extensive review by the members of the
Work Group on Quality Issues, child and adolescent psychiatry consultants with expertise
in the content area, the entire Academy membership, and the Academy Assembly and
Council.
These parameters are not intended to define the standard of care; nor should they
be deemed inclusive of all proper methods of care or exclusive of other methods of care
directed at obtaining the desired results. The ultimate judgment regarding the care of a
particular patient must be made by the clinician in light of all the circumstances presented
by the patient and his or her family, the diagnostic and treatment options available, and
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available resources. Given inevitable changes in scientific information and technology,
these parameters will be reviewed periodically and updated when appropriate.
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Outline of Practice Parameters for the Assessment and Treatment
of Children and Adolescents With Posttraumatic Stress Disorder
I. Diagnostic
assessment.
A.
Interview with parent or primary caregiver (Note: If a parent is the alleged
perpetrator of child abuse or domestic violence that is the identified traumatic
event, the non-offending parent or other primary caretaker should be
interviewed. Interview of the alleged perpetrator is not required to diagnose
and treat PTSD in the child.)
1.
Obtain report of the traumatic event(s) and determine whether it
qualifies as an “extreme” stressor.
a.
Note the nature of the event, when it occurred, the parents’
perception of the child’s degree of exposure to the event.
2.
Obtain report of any preceding, concurrent, or more recent stressors in
the child’s life.
a.
Child abuse or neglect.
b.
Significant conflict, separation, or divorce.
c.
Frequent
moves,
school changes, or other significant
disruptions.
d.
Family deaths, illnesses, disabilities, or substance abuse.
e.
Exposure
to
domestic or community violence.
f.
Serious traumatic events in the parents’ lives of which the child
has knowledge.
3.
Obtain report of DSM-IV PTSD symptomatology in the child, with
particular attention to developmental variations in clinical
presentation.
a. Reexperiencing
symptoms.
b.
Avoidant and numbing symptoms.
c.
Increased
arousal
symptoms.
4.
Obtain report of any other significant current symptomatology, with
particular attention to disorders with high comorbidity with PTSD.
a. Depressive
symptoms
including self-injurious behavior.
b.
Non-PTSD
anxiety
symptoms,
including
panic
attacks.
c.
ADHD and conduct symptoms.
d.
Substance
abuse.
5.
Obtain report of whether the symptoms began prior to or following the
identified traumatic event(s). (Note: This determination may be
difficult if the stressor has been longstanding or ongoing; e.g., physical
abuse).
6.
Obtain report of the parents’ and other significant others’ emotional
reaction to the traumatic event.
a.
Ascertain whether the parent or primary caregiver was directly
exposed to the trauma (e.g., driving when a motor vehicle
accident occurred) or experienced only vicarious exposure
(e.g., child disclosed sexual abuse by a stranger).
b.
Obtain report of the presence of parental PTSD symptoms
following the traumatic event.
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c.
Obtain perception of how much support has been available to
the child since the event.
7.
Obtain report of child’s past psychiatric history.
a.
Outpatient
psychotherapy.
b.
Partial
or
inpatient
hospitalization.
c.
Psychotropic
medications.
d.
Symptom
course.
8.
Obtain medical history.
a.
Significant
current
or
past medical problems, somatic
complaints, surgery, significant injuries.
b.
Current or past medications.
c.
Current primary medical care provider.
9.
Obtain report of child’s developmental history, with particular
emphasis on reactions to normal stressors (e.g., birth of sibling,
beginning school) and child’s level of functioning prior to the
traumatic stressor.
10.
Obtain report of school history, with particular emphasis on changes in
school behavior, concentration, activity level, and performance since
the traumatic stressor.
11.
Obtain report of family history and family members’
medical/psychiatric history.
a.
PTSD symptoms or diagnosis.
b.
Mood
disorders.
c.
Anxiety
disorders.
d.
Family medical conditions including any that may present as
anxiety or mood disorders (e.g., thyroid disease).
B.
Interview with the child, including mental status exam.
1.
Obtain child’s report of the reason for referral.
2.
Encourage child to describe his or her memories of the traumatic
event. (Note: There is no consensus regarding the optimal degree of
detail, or whether certain kinds of leading questions are helpful or
harmful. Clinical consensus clearly indicates that requesting some
description of the stressor from the child is desirable but that the use of
highly suggestive questioning is not recommended.)
3.
Obtain the child’s report of trauma-related attributions and
perceptions.
a.
Who or what the child believes was responsible for the
traumatic event.
b.
Whether the child believes he or she had any responsibility for
causing or perpetuating the traumatic event.
c.
Whether the child believes he or she should have behaved
differently in response to the event.
d.
Whether the child feels ostracized, damaged, or negatively
judged by others as a result of being exposed to the stressor.
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e.
The
child’s
perception
of
how
emotionally distressed and supportive parents and significant
others have been since the traumatic event.
f.
In cases where the stressor was not public knowledge, child’s
perception of w
g.
The
child’s
perception
of
how “normal” his or her current
symptoms are in reaction to the stressor.
4.
Obtain child’s report of present symptomatology, with particular
emphasis on developmentally appropriate questioning regarding DSM-
IV PTSD criteria symptoms. (Note: Although it is important for the
evaluator to explore with the child the link between the traumatic
event and PTSD symptomatology, many children may not make this
connection. This should not deter the evaluator from diagnosing
PTSD if the temporal relationship between the event and symptom
formation as reported by child or parent supports this diagnosis.)
5.
Obtain child’s report of symptomology frequently associated with
PTSD.
a.
Depressive
symptoms,
including suicidal ideation.
b.
Substance abuse or self-injurious behavior (in older children
and adolescents).
c.
Dissociative
symptoms,
including fugue states, periods of
amnesia, depersonalization or derealization (in older children
and adolescents).
d.
Panic attacks and other non-PTSD anxiety symptoms.
6.
Observe the child for the elements of the mental status exam and for
behaviors that are found with PTSD.
a.
Increased
startle reaction or vigilance.
b.
Traumatic reenactment (in younger children).
c.
Observable
changes
in
affect or attention that may be
indicative of reexperiencing phenomena.
C.
Obtain information from school with appropriate release of information, if
clinically indicated. (Note: Although school reports may be helpful with
regard to confirming certain symptoms or post-traumatic changes, in many
cases, school reports are not necessary to diagnose or treat PTSD in children.)
1.
Academic functioning with particular attention to changes since the
traumatic event.
2.
Interactions with peers and involvement in non-academic activities,
with particular attention to changes since the traumatic event.
3.
Temporal appearance of ADHD symptoms (i.e., present prior to or
only after the traumatic event).
D.
Determine the need for additional evaluations (IQ testing, speech and
language evaluation, pediatric evaluation).
E.
Consider the usefulness of standardized interviews and rating scales. Although
semistructured interviews and parent- and child-rating scales of PTSD
symptomatology may be helpful in following clinical course of children with
PTSD, the diagnosis of PTSD is based primarily upon the clinical interview.
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The use of standardized interviews and scales is not necessary to make this
diagnosis.
1.
Semistructured interviews. The following semistructured interviews
include PTSD sections; none has established psychometric properties
for measuring DSM-IV PTSD symptoms in children.
a.
K-SADS-PL.
b.
Diagnostic
Interview
Schedule.
c.
Structured
Clinical
Interview
for
DSM-III-R.
d.
Clinician-Administered PTSD Scale for Children and
Adolescents.
2.
Child- and parent-rating forms that may be clinically useful for
following the course of PTSD symptoms in children.
a.
PTSD
Reaction
Index.
b.
Trauma Symptom Checklist for Children.
c.
Checklist of Child Distress Symptoms—
Child and Parent Report Versions.
d.
Children’s Impact of Traumatic Events Scale.
e.
Child PTSD Symptom Scale.
f.
Impact of Events Scale (Revised version for adolescents).
II. Differential diagnosis. Psychiatric disorders that may be comorbid with or
misdiagnosed as PTSD, or which PTSD may be misdiagnosed as.
A. Acute
stress
disorder.
B. Adjustment
disorders.
C. Panic
disorder.
D. Generalized
anxiety
disorder.
E. MDD.
F. ADHD.
G.
Substance use disorders.
H. Dissociative
disorders.
I.
Conduct
disorder.
J.
Borderline or other personality disorder.
K.
Schizophrenia or other psychotic disorder.
L. Malingering.
M. Factitious
disorder.
III. Establish the subtype of PTSD present.
A. Acute.
B. Chronic.
C.
With delayed onset.
IV. Treatment.
Formulate the treatment plan based on the clinical presentation of the child and to address
both PTSD symptoms and other behavioral and emotional problems the child is
experiencing. The course of PTSD and its particular symptom pattern in different
children is extremely variable. Short-term, long-term, or intermittent treatment may be
required. Different levels of care (outpatient, partial or inpatient hospitalization) and
modalities (individual, family, group, psychopharmacologic therapy) may be required for
different children or for a given child at different points in the course of the disorder.
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Comprehensive treatment for PTSD is generally multimodal and may include any or all
of the following components.
A.
Psychoeducation. Education of the child, parents, teachers, and/or significant
others regarding the symptoms, clinical course, treatment options, and
prognosis of childhood PTSD.
B. Individual
therapy.
1. Trauma-focused
therapy.
a.
Exploration
and
open
discussion of the traumatic event;
relaxation, desensitization/exposure techniques may be useful.
b.
Examination and correction of cognitive distortions in
attributions about the traumatic event.
c.
Behavioral interventions to address inappropriate traumatic
reenactment (e.g., sexually inappropriate behaviors following
sexual abuse; self-injurious, aggressive, and other behavioral
difficulties).
d.
Cognitive-behavioral techniques to help child gain control over
intrusive reexperiencing symptoms.
2.
Insight-oriented,
interpersonal,
and
psychodynamic/psychoanalytic therapeutic interventions may be
appropriate for treating PTSD in some children.
3.
Therapy to address non-PTSD behavioral and emotional difficulties, in
conjunction with trauma-focused interventions.
C. Family
Therapy.
1.
Trauma-focused parental therapy.
a.
Exploration and resolution of the emotional impact of the
traumatic event on the parent.
b.
Identification and correction of inaccurate parental attributions
regarding the traumatic event (e.g., self-blame, blaming the
child).
c.
Identification and implementation of appropriate supportive
parenting behaviors and parental reinforcement of therapeutic
interventions (e.g., teaching parents to help the child use
progressive relaxation techniques).
d.
Parent
training
on
management of inappropriate child
behaviors.
2.
Traditional family therapy with all immediate family members for
families with high conflict, harsh discipline, and/or when PTSD
symptoms are present in several family members. However, family
therapy generally should occur only after the child has received
individual intervention to optimize comfortable disclosure of traumatic
experiences and trauma-related symptoms. No empirical or clinical
consensus is currently available regarding the use of family therapy for
children with PTSD.
D. Group
Therapy.
1.
Trauma-focused groups for children of similar developmental levels
who have experienced similar traumatic exposure may be beneficial in
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encouraging open discussion of and appropriate attributions regarding
the event.
2.
School-based group crisis intervention may be particularly useful in
disaster situations.
3.
Adult psychoeducational groups may be helpful in addressing parental
and/or teacher concerns following exposure of groups of children to
disaster or community violence situations.
E. Psychopharmacology.
1.
Antidepressants (SSRIs, tricyclic antidepressants) may be useful for
children exhibiting concurrent major depressive or panic disorder
symptoms.
2. Psychostimulants
or
-adrenergic agonists (e.g., clonidine) may be
useful for children exhibiting concurrent ADHD symptoms.
3.
Antianxiety medications (benzodiazepines, propranolol) generally
have not been used to treat children with PTSD. There is no current
clinical consensus that use of these medications is effective for this
population.
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REFERENCES
References marked with an asterisk are particularly recommended.
Ahmad A, Mohamad K (1996), The socioemotional development of orphans in
orphanages and traditional foster care in Iraqi Kurdistan. Child Abuse Negl
20:1161-1173
Almqvist K, Brandell-Forsberg M (1997), Refugee children in Sweden: posttraumatic
stress disorder in Iranian preschool children exposed to organized violence. Child
Abuse Negl 21:351-366
Amaya-Jackson L, March JS (1995), Posttraumatic stress disorder. In: Anxiety Disorders
in Children and Adolescents, March JS, ed. New York: Guilford Press, pp 276-
300
American Academy of Child and Adolescent Psychiatry (1997a), Practice parameters for
the psychiatric assessment of children and adolescents. J Am Acad Child Adolesc
Psychiatry 36(suppl):4S-20S
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