Dr. Foy is professor of psychology in the Graduate School of Education and Psychology at Pepperdine University in Culver City, Calif, and in the Headington Program of International Trauma at Fuller Theological Seminary in Pasadena.
Dr. Eriksson is adjunct assistant professor of psychology in the Headington Program of International Trauma at Fuller Theological Seminary.
Ms. Larson is a doctoral student in clinical psychology in the Headington Program of International Trauma at Fuller Theological Seminary.
Acknowledgments: The authors report no financial, academic, or other support of this work.
Why should primary care physicians (PCPs) learn about psychological trauma in children? PCPs are often the first nonfamily members to be told about recent traumatic experiences of young patients exposed to life-threatening events. Thus, it is important that they learn how to assess posttraumatic stress disorder (PTSD). Recent studies of PTSD epidemiology in children and adolescents show that the disorder is prevalent among youths exposed to such traumas as childhood physical and sexual abuse and deadly community violence perpetrated by peers. Natural disasters and motor vehicle accidents pose threats to youths as well as adults. In children, life-threatening experiences and symptomatic reactions vary with developmental stage. This article reviews the traumas, predictable reactions, screening methods, likely comorbid conditions, and available treatments from infancy through adolescence. The information is intended to help PCPs identify and manage the clinical needs of trauma-exposed young patients.
Posttraumatic stress disorder (PTSD) always begins with exposure to an identifiable life-threatening event or series of events. The disorder is unique because the diagnosis is made only when “normal” reactions to trauma (eg, patterns of intrusive thoughts, avoidance of reminders, and hyperarousal) have persisted beyond the predetermined diagnostic time frame of 30 days.
Even though PTSD was introduced into psychiatric nomenclature more than 20 years ago, only recently has etiologic research been published identifying the range of traumatic events for children and the implicated risk factors.1 These studies address five types of traumas:? childhood physical and sexual abuse, natural disasters, motor vehicle accidents, war, and community violence.2 Most recently, child PTSD studies identified a sixth type of trauma—witnessing domestic violence.3 Accordingly, it is important to provide updated information about psychological trauma so that primary care physicians (PCPs) are better able to recognize mental health needs of young patients exposed to traumatic events.
What do we know about the epidemiology of PTSD in children and adolescents? Like adults, children who are exposed to life-threatening events encounter risk for developing PTSD. Among youths exposed to the same trauma, girls may be more likely to develop PTSD (with higher symptom severity) than boys. Children of both sexes are susceptible to increased risk when their parents exhibit adverse posttrauma reactions.2 In studies where different ethnic groups are represented, ethnicity does not consistently emerge as a risk factor. However, living in poverty in crowded, inner-city environments poses additional risk for trauma exposure and PTSD regardless of ethnicity. Although adolescents are at greater risk for exposure to more types of trauma, younger children appear to be more susceptible to the disorder.4
There are developmental considerations for key aspects of childhood PTSD, including risk of exposure to different types of trauma, typical reaction patterns, and available treatments. Accordingly, we present basic information about psychological trauma in children according to four developmental stages: infancy/toddler, preschool, school-age, and adolescence.
Life-Threatening Experiences of Childhood
Table 1 presents an overview of the most frequent childhood traumas that meet the life-threat requirement (criterion A1) for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition5 (DSM-IV), and the relative risk of exposure for these traumas according to developmental stage. Risk for exposure is directly related to time spent in different environments and the types of traumas possible in those environments. For that reason, very young children are much more likely to be victimized in their own homes by adult caregivers. School-aged children are susceptible in both their homes and in their communities, and adolescents are at higher risk for community-based traumas. Other, less frequent traumas in the United States include dog bites and other animal attacks, kidnapping, severe burns, serious medical illnesses, and war.6
A second element in screening for PTSD includes consideration of the child’s subjective, emotional reactions when the trauma occurred (DSM-IV criterion A2).
For infants and preschoolers, extreme dependency, limited language skills, limited perceptive, cognitive, and emotional regulation abilities constrict their perceptions of danger and responses to a trauma. Consequently, the caregiver’s personal response to the trauma and ability to soothe and comfort the young child can greatly influence whether he or she develops PTSD.7 We recommend using alternative diagnostic criteria for children <4 years of age that eliminate the DSM-IV criterion A2 requirement that the child’s response “involved intense fear, helplessness, or horror,” because preverbal children cannot communicate subjective experiences (Table 2).8
Since parental report is a main source of diagnostic information for very young children, systematic parental interviewing is crucial. Screening for PTSD should include a brief review of the child’s developmental history, thorough details of the child’s traumatic experience and immediate reactions, review of the child’s current trauma-related symptoms (onset, frequency, duration, and severity) including any developmental regression or delay, and checking for PTSD symptoms in the parent(s). Observing the toddler’s play for evidence of trauma-related themes and obtaining information from other caregivers (eg, daycare providers) can also be helpful in making a diagnosis.7,8
For preschoolers and school-aged children, the clinical interview will be the primary assessment method. Because talking about their traumatic experiences might be difficult, developing rapport with the child is important before proceeding with the screening interview for PTSD.9 For adolescents and children >8 years of age, there are assessment measures for PTSD based upon either structured diagnostic interview or paper-and-pencil self-report measures.6
Core Symptoms andResponses
To better capture symptom expression in children 0–3 years of age, alternative diagnostic criteria have been developed focusing on behavioral symptoms in the three DSM-IV clusters (reexperiencing, avoidance/numbing of responsiveness, increased arousal) and an additional symptom cluster of “new fears and aggression.” Reexperiencing symptoms might include play reenactment of the trauma, while avoidance/numbing might involve developmental regression, particularly in language or toilet training.
New fears and aggression include any new fears of things or situations not obviously related to the trauma (such as separation anxiety or fear of the dark) and/or new aggression.8 Children 4–5 years of age might also display symptoms in these alternative criteria, but “grow into” DSM-IV symptom patterns as they develop.7
School-aged children might exhibit symptoms concordant with DSM-IV patterns of intrusion, avoidance, and hyperarousal. They might have intrusive thoughts during times of quiet or relaxation in response to reminders of the event or in the midst of heightened affective states.9 Nightmares might be generally frightening or have trauma-related content.6 A child’s new fears might be linked to specific reminders of the experience or they might be generalized to other contexts (eg, fear of separation).9,10 Parents and teachers might see traumatic themes in children’s play from early to middle childhood.11
Many school-aged children show obvious avoidance to traumatic reminders, but some children might seem unaffected or uncaring. This apparent lack of affect should not be easily dismissed as a healthy adjustment. Rather, it can represent avoidance or numbing.12 Hyperarousal symptoms are commonly seen in preschool and school-aged children as sleep disturbances, irritability, aggression, and hypervigilance,6 all of which can severely hinder school performance. Adolescents might show a sense of foreshortened future,4 along with other PTSD symptoms that generally follow the pattern outlined in DSM-IV.
Two disorders that might be comorbid with PTSD in infants and preschool children are reactive attachment disorder (RAD) and attention-deficit/hyperactivity disorder (ADHD).6,13 For traumatized infants and preschool children initially presenting with symptoms of either of these disorders, a differential diagnosis of PTSD should be considered and a PTSD screening assessment should be undertaken. The implications of such a differential diagnosis for effective treatment of the child are profound.
Depressive conditions are the most common disorders diagnosed comorbid with PTSD in adolescents and school-aged children, and there is considerable symptom overlap between the two diagnoses.11 The disruptive behavior disorders ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) are other complex areas for diagnosis.
The hyperarousal of PTSD might compromise a child’s ability to control angry or aggressive responses. Restlessness, concentration problems, and impulsivity can be a type of active avoidance or numbing.6,9 A school-aged child might be anxious about going to school (school phobia), worried about the safety of family and friends (separation anxiety), fearful of specific things (simple phobia), or prone to experiencing panic attacks.6,11 Both children and adolescents might use marijuana, alcohol, or other drugs to relieve discomfort associated with PTSD.
In addition to PTSD-specific reactions, child abuse/neglect has been associated with problems in self-esteem, social skills, cognitive development, adjustment to school, and healthy development.10
Parental involvement is critical for treatment in young children, both in therapy sessions and in responding helpfully to posttraumatic behaviors at home. Treatment during the first year of life might involve desensitizing the child during caregiving interactions, while older infants and preschoolers can be treated with play techniques.6,14 Cognitive-behavioral therapy (CBT) with parental involvement might be effective for children 4–5 years of age; such treatment was associated with decreased PTSD symptoms in a group of sexually abused preschoolers.6 Direct treatment of the parent(s) might be necessary for the infant or child to be successfully treated.
CBT has the strongest empirical evidence for resolving PTSD symptoms in children and adolescents.6,9 It is considered the first-line approach, involving four basic components: direct therapeutic discussion of the trauma, stress management skills training and utilization, challenge to distorted attributions related to the trauma, and parental education and involvement. Group treatment might also be beneficial for school-aged children and adolescents; didactic materials can help to contain a child’s affect, peers in the group can offer comfort and validation, and telling the trauma story to the group can create a sense of control or distance. Children 6–11 years of age are capable of processing information concretely; thus, group treatment for this age bracket should include a clear structure and planned activities or projects.15
For infants, preschool, and school-aged children in particular, a parent’s response to the trauma is an important determinant in the development of distress. Also, parental report of a child’s symptoms might be distorted for a variety of reasons. Parents might overemphasize behavioral symptoms and not be aware of the internalized distress,9 they might be distracted by their own reactions,16 or the child might not discuss his/her experiences due to avoidance symptoms or a wish not to upset the parent.6,9
Recommendations for Practice
The PCP holds an important role as educator for the family. The respected physician can help normalize psychiatric treatment and provide basic information about typical posttrauma symptoms. The PCP should also provide resources such as brochures, Web site information, or referrals for additional services.12 Referral and resource information can be found at the Web sites listed in Table 3.
When providing medical care for infants and children who have undergone trauma, PCPs should consider the possibility of PTSD and educate parents to keep an eye out for symptoms of PTSD specific to their child’s developmental level.
For infants and preschool children initially presenting with symptoms of RAD or ADHD, a differential or comorbid diagnosis of PTSD should be considered, especially if there is a history of trauma or domestic violence in the family. Infants should be assessed for PTSD using criteria of Scheeringa and colleagues,8 while DSM-IV should be used with children >2 years of age.
Physicians working with school-aged children and adolescents should pay particular attention to “masked” posttrauma symptoms. Absenteeism due to physical complaints might be a way to avoid violence at school, and symptoms of ADHD might represent a posttraumatic response. In addition, the child’s appraisal of an event and perception of threat or loss may influence his or her reactions. An event that might seem minor to an adult might cause an unexpected level of psychological distress in a child.16
When making referrals, PCPs can prepare parents for the reality that optimum treatment might require involvement in their child’s treatment and perhaps treatment for themselves.
PCPs need to know the main kinds of life-threatening experiences that children and adolescents are likely to have. They should be willing and able to screen for key symptoms of PTSD in their young patients, educate parents about PTSD in their children, and identify and refer to mental health professionals with specific competencies in diagnosing and treating PTSD in children. The condensed information in this article should enable PCPs to prevent developmental adversities in young patients who have experienced life-threatening events. References for authoritative, peer-reviewed sources that provide more extensive information about PTSD diagnosis and treatment in children and adolescents are useful as well. PP
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