For PTSD to be present, the child must report (or there must be other compelling evidence of) a qualifying index traumatic event and specific symptoms in relation to that traumatic experience. Compelling evidence might include sexually transmitted infection in a young child, a reliable eyewitness report (e.g., a police report that a child was rescued from the scene of an accident), or a forensic evaluation confirming the likelihood that the child experienced a traumatic event. An inherent contradiction exists in that avoidance of describing traumatic experiences is a cor feature of PTSD, as indicated below; yet diagnosing PTSD requires that the child describe the traumatic event.
In the absence of child report or other compelling evidence of a qualifying index trauma, a PTSD diagnosis should not be made. Children should be referred for a forensic evaluation if the clinician has suspicion of trauma exposure but no confirmed reports. There are many differences between forensic and clinical evaluations; clinicians should not attempt to conduct forensic assessments in the context of a clinical evaluation.
Most individuals who experience truly life threatening events manifest posttraumatic symptomatology immediately. However, only about 30% on average tend to manifest enduring symptomatology beyond the first month. Therefore,
PTSD is not diagnosed until at least 1 month has passed since the index traumatic event occurred. Acute stress disorder, adjustment disorder, or another disorder may be diagnosed within the first month of exposure. Transient moderate psychological distress may be a normative reaction to traumatic exposure.
Acute PTSD is diagnosed if the symptoms are present after the first month and for less than 3 months after the index trauma; chronic PTSD is diagnosed if the symptoms persist beyond 3 months. There is clinical consensus that children with severe PTSD may present with extreme dysregulation of physical, affective, behavioral, cognition, and/or interpersonal functioning that is not adequately captured in current descriptions of PTSD diagnostic criteria. Some of these children may be misdiagnosed with bipolar disorder because of severe affective dysregulation related to PTSD; others may have true bipolar disorder but also need attention to their trauma symptoms.
PTSD Symptom Clusters
In addition to the presence of a known trauma, diagnosing PTSD requires the presence of symptoms in three distinct clusters. Reexperiencing of the trauma must be present as evidenced by at least one of the following symptoms: recurrent and intrusive recollections, nightmares, or other senses of reliving the traumatic experience. In young children this can take the form of repetitive play in which aspects or themes of the trauma are expressed, or traumaspecific reenactment may occur. Frightening dreams without trauma-specific content may also occur. Trauma reminders (people, places, situations, or other stimuli that remind the child of the original traumatic event) may lead to intense psychological or physiologic distress.
Persistent avoidance of trauma reminders and emotional numbing must be present as evidenced by at least three of the following symptoms: efforts to avoid trauma reminders including talking about the traumatic event or other trauma reminders; inability to recall an important aspect of the trauma; decreased interest or participation in previously enjoyed activities; detachment or estrangement from others; restricted affect; and a sense of a foreshortened future.
Persistent symptoms of hyperarousal must also be present as evidenced by at least two of the following symptoms: difficulty falling or staying asleep; irritability or angry outbursts; difficulty concentrating; hypervigilance; and increased startle reaction.
Young children also manifest new aggression, oppositional behavior, regression in developmental skills (toileting and speech), new separation anxiety, and new fears not obviously related to the traumatic event (usually fear of the dark or fear of going to the bathroom alone) as associated symptoms.
Risk Factors: Female gender, previous trauma exposure, multiple traumas, greater exposure to the index trauma, presence of a preexisting psychiatric disorder (particularly an anxiety disorder), parental psychopathology, and lack of social support.
Protective Factors: Parental support, lower levels of parental PTSD, and resolution of other parental trauma-related symptoms have been found to predict lower levels of PTSD symptoms in children.
Evaluation
Screening Questions: To screen for PTSD symptoms, clinicians must first determine whether children have been exposed to qualifying traumatic experiences.
If Screening Indicates Significant PTSD Symptoms, the Clinician Should Conduct a Formal Evaluation To Determine Whether PTSD Is Present, the Severity of Those Symptoms, and the Degree of Functional Impairment. Parents or Other Caregivers Should Be Included in This Evaluation Wherever Possible.
DD:
1. Hyperarousal symptoms in children such as difficulty sleeping, poor concentration, and hypervigilant motor activity also overlap significantly with typical ADHD symptoms, and unless a careful history of trauma exposure is taken in
relation to the timing of the onset or worsening of symptoms, these conditions may be difficult to distinguish.
2. . PTSD may also present with features more characteristic of oppositional defiant disorder due to a predominance of angry outbursts and irritability; this may be particularly true if the child is being exposed to ongoing trauma reminders.
3. PTSD may mimic panic disorder if the child has striking anxiety and psychological
and physiologic distress upon exposure to trauma reminders and avoidance of talking about the trauma.
4. PTSD may be misdiagnosed as another anxiety disorder including social anxiety
disorder, obsessive-compulsive disorder, general anxiety disorder, or phobia due to avoidance of feared stimuli, physiologic and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle
reaction.
5. PTSD may also mimic major depressive disorder due to the presence of self-injurious behaviors as avoidant coping with trauma reminders, social withdrawal, affective numbing, and/or sleep difficulties. PTSD may be misdiagnosed as bipolar disorder, as discussed above, due to children’s hyperarousal symptoms and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo-manic statements.
6. PTSD may be misdiagnosed as a primary substance-use disorder because drugs and/or alcohol may be used to numb or avoid trauma reminders. Conversely, it is important to remember that there are many youths with a history of trauma who have primary substance-use disorders with few trauma symptoms; these youths will typically benefit more from receiving treatment for substance use than for PTSD.
7. Children with PTSD may have unusual perceptions that should be differentiated from the hallucinations of a psychotic illness.
8. Physical conditions that may present with PTSD-like symptoms include hyperthyroidism, caffeinism, migraine, asthma, seizure disorder, and catecholamine- or serotonin-secreting tumors.
9. Prescription drugs with side effects that may mimic aspects of PTSD include antiasthmatics, sympathomimetics, steroids, selective serotonin reuptake inhibitors (SSRIs), antipsychotics (akathisia), and atypical antipsychotics.
10. Nonprescription drugs with side effects that may mimic PTSD include diet pills, antihistamines, and cold medicines.
11. Posttraumatic stress disorder is often associated with somatic symptoms such as headaches and abdominal complaints. A mental health assessment should be considered early in the medical evaluation of youths with somatic complaints, particularly those with a known history of trauma exposure.
Treatment
Trauma-Focused Psychotherapies Should Be Considered First-Line Treatments for Children and Adolescents With PTSD. Among psychotherapies there is convincing evidence that trauma-focused therapies, that is, those that specifically address the child’s traumatic experiences, are superior to nonspecific or nondirective therapies in resolving PTSD symptoms. There is growing support for the use of trauma-focused psychotherapies that (1) directly address children’s traumatic experiences, (2) include parents in treatment in some manner as important agents of change, and (3) focus not only on symptom improvement but also on enhancing functioning, resiliency, and/or developmental trajectory.
Among the trauma-focused psychotherapies, TF-CBT has received the most empirical support for the treatment of childhood PTSD. In TF-CBTs the clinician typically provides stress-management skills in preparation for the exposure-based interventions that are aimed at providing mastery over trauma reminders. TFCBT components using the PRACTICE acronym: Psychoeducation (e.g., educating children and parents about the type of traumatic event the child experienced, e.g., how many children this happens to, what causes it to happen, etc.; common trauma reactions including PTSD and about the TF-CBT treatment approach); parenting skills (use of effective parenting interventions such as praise, positive attention, selective attention, time out, and contingency reinforcement procedures); relaxation skills (focused breathing, progressive muscle relaxation, and other personalized relaxation activities to reverse the physiologic manifestations of traumatic stress); affective modulation skills (feeling identification; use of positive self talk, thought interruption, and positive imagery; enhancing safety, problem solving, and social
skills; recognizing and self-regulating negative affective states); cognitive coping and processing (recognizing relations among thoughts, feelings, and behaviors; changing inaccurate and unhelpful thoughts for affective regulation); trauma narrative (creating a narrative of the child’s traumatic experiences, correcting cognitive distortions about these experiences, and placing these experiences in the context of the child’s whole life); in vivo mastery of trauma reminders (graduated exposure to feared stimuli); conjoint childparent sessions (joint sessions in which the child shares the trauma narrative with parents and other family issues are addressed); and enhancing future safety and development (addressing safety concerns related to prevention of future trauma, return to normal developmental trajectory). Different forms of TF-CBT interventions use different combinations and dosages of these PRACTICE components, depending on their target populations and types of trauma.
Eye Movement Desensitization and Reprocessing (EMDR) is an effective treatment for adult PTSD but most randomized controlled trials for child EMDR have had serious methodologic shortcomings.
PSYCHODYNAMIC TRAUMA-FOCUSED PSYCHOTHERAPIES: Aim to promote personality coherence, healthy development, and the achievement of traumatic symptom resolution. In younger children, these treatments have focused on the parent-child relationship to address traumatic situations in which the parent (typically the mother) was the victim of the trauma (e.g., domestic violence) or was so personally traumatized or emotionally compromised by the experience that she was unable to sustain the child’s development. For older children psychodynamic trauma-focused therapies provide an opportunity to mobilize more mature cognitive capacities, objectify and explain symptoms, identify trauma reminders, identify environmental factors that may complicate recovery— especially interactions that heighten regressive experience and make more explicit ways in which overwhelming fear and helplessness of the traumatic situation run counter to age-appropriate strivings for agency, competence, and self-efficacy.
SSRIs Can Be Considered for the Treatment of Children and Adolescents With PTSD. SSRIs may be overly activating in some children and lead to irritability, poor sleep, or inattention; because these are symptoms of PTSD hyperarousal, SSRIs may not be optimal medications for these children.
Antiadrenergic agents such as clonidine and propranalol may be useful in decreasing hyperarousal and reexperiencing symptoms, anticonvulsants may show
promise for treating PTSD symptoms other than avoidance, and benzodiazepines have not been found to be beneficial in treating PTSD-specific symptoms.
There is also evidence of increased adrenergic tone and responsiveness in children with PTSD. Both alpha- and beta-adrenergic blocking agents have been used with some success in children with PTSD symptoms. Clonidine has been found in two open studies to decrease basal heart rate, anxiety, impulsivity, and PTSD hyperarousal symptoms in children with PTSD. In a case study, clonidine treatment resulted in improved sleep and increased neural integrity of the anterior cingulate. Propranalol was found in an open study to decrease reexperiencing and hyperarousal symptoms in children with PTSD symptoms.
There is some evidence of increased dopamine presence in children and adults with PTSD, which is believed to contribute to the persistent and overgeneralized fear characteristic of PTSD. Dopamine blocking agents such as neuroleptics may therefore decrease some PTSD symptoms.
School-Based Accommodations: Children with significant PTSD symptoms may
have impaired academic functioning. This is often due to hypervigilance to real or perceived threats in the environment and may be a particular issue if trauma reminders are present in the school setting. One example of a school-based trauma reminder would be a sexual assault or bullying occurring at school, particularly if the perpetrator still attended the same school. Although every reasonable effort should be made to assist children in overcoming avoidance of innocuous trauma reminders (i.e., people, places, or situations that are inherently innocuous or safe, which only seem frightening to the child because of generalized fear), children should also be protected from realistic ongoing threats or danger whenever possible. Children who are experiencing significant functional impairment related to trauma reminders may benefit from school accommodations up to and including placement at an alternative school where reminders are not present.