I. Description of the problem. Trauma exposure is an international public health problem. Large-scale epidemiologic studies have reported extraordinarily high percentages of exposure to trauma. A national representative study found that up to 40% of children have experienced a traumatic event. This rate is much higher among inner-city children. Studies of the prevalence of posttraumatic stress disorder (PTSD) have varied widely depending on the type of trauma and the child’s proximity to it. In addition, the likelihood of a child getting PTSD if traumatized depends on many factors independent of the trauma itself. Consequently, the research literature has increasingly focused on constitutional factors within the child that determine resiliency or vulnerability to trauma.
A. Epidemiology. Prevalence studies suggest between 5%-70% of traumatized children qualify for a diagnosis of PTSD. Depending on the study, exposure to sexual assault or abuse yields a prevalence of PTSD between 40%-60%, disasters between 5%-70%, injuries 10%-30%, and war 20%-70%.
B. Etiology/contributing factors.
1. Genetic. Studies using twin registries of Vietnam veterans have found higher concordance rates in monozygotic twins. There is no doubt, however, of a complex polygenetic vulnerability to the effects of environmental trauma. Recent research has focused on a series of candidate genes. Our group found that variance on the FKPB5 gene was associated with traumatic stress responses in children hospitalized with injuries.
2. Environmental. Children with PTSD frequently grow up in environments saturated with ongoing stressors, including parental mental health and substance abuse problems, marital stress, and exposure to ongoing community and family violence. Each of these appears to increase the risk for contracting PTSD. Treatment must address both the child’s traumatic stress symptoms and the ongoing social environmental problems, which may perpetuate these symptoms.
3. Organic. A number of biochemical and neuroanatomical correlates to PTSD have been identified. For each, the research does not always distinguish which may be a cause of PTSD versus a consequence of PTSD. For example, a number of studies have found smaller hippocampal sizes in adults with PTSD. It remains undetermined whether this smaller hippocampal size is preexisting and predisposes an individual who is traumatized to get PTSD or whether this smaller hippocampal size is a consequence of PTSD (and some of the biochemical changes that occur with it). This cause or consequence problem is found in the other organic correlates of PTSD, such as lower levels of cortisol, hypersupression of cortisol with dexamethasone, and higher noradrenergic levels. Some of the emerging neurodevelopmental findings are particularly worrisome, such as studies reporting smaller brain sizes and larger ventricles in children with PTSD.
4. Developmental. PTSD has been diagnosed in children as young as 1 year. An alternative criteria set for PTSD has been developed for preschool children, which relies far less on verbal report of the child and more on report from the parent and on behavioral observations of the child. Younger children’s reactivity to traumatic reminders is much more likely to be observed in their behavior. School-aged children will begin to talk about their fears and anxiety. Adolescents will begin to focus on the meanings of the trauma for themselves, their world, and their future.
II. Making the diagnosis. Symptoms can look different depending on the developmental age of the child. See Table 64-1 for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.
A. Signs, symptoms, and behavioral observations.
1. Infant/toddler. Infants and preschool children are often unable to describe internal states or to know how or why they are responding to the environment. Accordingly, PTSD is assessed by observing behaviors in infants and toddlers. Very young children with PTSD will become aggressive, withdrawn, or very distressed at reminders
of the trauma. Frequently, children will repeatedly play about the trauma (posttraumatic play). There may be significant sleep disruption including nightmares (which may or may not be about the trauma).
Table 64-1. DSM-IV criterion for PTSD
A.
The person has been exposed to a traumatic event in which both of the following were present:
(1)
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
(2)
The person’s response involved intense fear, helplessness, or horror.
B.
The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1)
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
(2)
Recurrent distressing dreams of the event.
(3)
Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
(4)
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5)
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C.
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1)
Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
(2)
Efforts to avoid activities, places, or people that arouse recollections of the trauma.
(3)
Inability to recall an important aspect of the trauma. (4) Markedly diminished interest or participation in significant activities.
(5)
Feeling of detachment or estrangement from others.
(6)
Restricted range of affect (e.g., unable to have loving feelings).
(7)
Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
D.
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1)
Difficulty falling or staying asleep.
(2)
Irritability or outbursts of anger.
(3)
Difficulty concentrating.
(4)
Hypervigilance.
(5)
Exaggerated startle response.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed, text rev), Washington, DC: American Psychiatric Association, 2000.
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Posttraumatic Stress Disorder in Children
Posttraumatic Stress Disorder in Children
Glenn Saxe
