Counseling Services of Barbara Reade, L.C.P.C.
Bel Air, Maryland 21014

Phone: 410-803-1510

Email: reade.lcpc@yahoo.com  

Diagnosing posttraumatic stress disorder in children

• The diagnostic criteria for PTSD are designed for adults, not children. Children have limited verbal skills and different ways of reacting to stress. This often leads a child to not fulfilling the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) criteria, even though they clearly have a psychiatric disorder analogous to adult PTSD. In particular, children often do not have 3 of the adult signs of numbing and withdrawal because they lack the verbal skills to express these feelings. Children also may experience an alternation between hyperarousal and numbing/withdrawal.
  
• Scheeringa et al (1995) recommend altering the criteria for PTSD when assessing very young children. This takes into account their ability to report symptoms and the types of symptoms they are likely to have. The altered criteria do not require that the child be able to report fear, helplessness, or horror in response to the trauma.
  

Diagnosis using the altered criteria requires that the very young child undergo one of the following types of reexperiencing:

• Posttraumatic play
•  Play reenactment
• Recurrent recollections
• Nightmares
• Episodes with objective features of a flashback or dissociation
• Distress at exposure to reminders of the event

The altered criteria also require only one of the following symptoms of numbing/avoidance (instead of the 3 needed for adults):

*Constriction of play
*Relative social withdrawal
*Restricted range of affect
* Loss of acquired developmental skills   

Furthermore, only one of the following symptoms of hyperarousal is required: 

Night terrors

Difficulty going to sleep that is not related to fear of having nightmares or fear of the dark

Night waking not related to nightmares or night terrors

Decreased concentration

Hypervigilance

 Exaggerated startle response

Scheeringa et al endorse an additional class of symptoms to replace the eased category C and category D criteria. Symptoms of fear and aggression marked by one of the following is required (Lubit, in press):

•   New aggression

•   New separation anxiety

•   Fear of using the restroom alone

•   Fear of the dark

•   New fears of things or situations not obviously related to the trauma

• Posttraumatic play involves joyless repetitive play with traumatic themes. Children also may reenact what occurred or draw pictures related to the event. Posttraumatic dreams in children generally are vaguely formed dreams that the child may not be able to describe.

• For adolescents, the primary symptoms are likely to include invasive images (which they may not talk about), restlessness and aggression, difficulty sleeping, and difficulty concentrating. Other common symptoms include loss of interest in previously enjoyed activities, withdrawal from family and peers, and changes in significant life attitudes. Adolescents with chronic PTSD arising from repeated or prolonged trauma may suffer primarily from dissociative symptoms, numbing, sadness, restricted affect, detachment, self-injury, substance abuse, and aggressive outburst. When interpersonal abuse is the precipitant, a significant possibility exists of the development of dissociative phenomena, somatic complaints, learned helplessness, loss of affect control, hostility, aggression, eating disorders, sexual acting out, personality change, change in belief system, self-destructive and impulsive behavior, substance abuse, social withdrawal, and impaired relationships (Lubit, in press).

Physical:

• A number of physical findings have been noted, but it often is not clear whether they are a result of PTSD or predisposing factors or the result of comorbid problems (eg, substance abuse). Findings include the following:  
• Hippocampal volume is smaller in individuals with PTSD.
• Areas of the brain that are involved in threat perception (eg, amygdala) have altered metabolism in adult trauma survivors with PTSD.
• Activity of the anterior cingulate (an area of the brain that inhibits the amygdala and other brain regions involved in the fear response) is decreased in people with PTSD.
• Basal cortisol levels are low.
• Cortisol response to dexamethasone is increased.
• Concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus are increased.
• Some studies have shown that children who have been abused have elevated cortisol levels compared to control subjects. Studies also indicate that adults with PTSD who were abused as children have higher cortisol levels than those who were abused and did not develop PTSD. Research evidence also indicates that girls who have been sexually abused have increased catecholamine activity. Trauma survivors have pituitary adrenocortical hyperresponsivity to stress. PTSD leads to increased pulse, blood pressure, muscle tension, and skin resistance.
• One problem with the research is that studies tend to show that changes in physiological measures, such as heart rate and skin conductance, appear to be the same in individuals with current and prior PTSD. This indicates that the changes may represent either a predisposition or a permanent change resulting from PTSD (eg, trait rather than state).

Causes:

• PTSD may be caused by exposure to a severe traumatic stress that threatens death or serious injury or threat to personal integrity, as follows:
•   Rape
•   Sexual and physical abuse
•   Car accidents
•   Fires and being in a war zone
•   Receiving a serious medical diagnosis
•   Being subjected to invasive painful treatment of medical problems

A number of factors increase the likelihood that a child will develop PTSD in response to a given stress, including the following:

•   Lack of social and parental support
•   Prior exposure to traumatic incidents
•   A preexisting psychiatric disorder
•   Repeated trauma
•   Trauma caused by a person (especially if by a trusted caregiver) rather than resulting from an accident
• Parental reaction is a critical factor affecting the child's reaction. Parents' anxiety and difficulty coping with life as the result of the trauma may overwhelm a child, while parental ability to cope and provide a safe haven for a child may markedly affect the child's ability to deal with the stressor or the propensity to develop protracted PTSD.
• PTSD is particularly likely to develop if a child experiences dissociation at the time of the trauma.
  
  If you are experiencing a life threatening emergency please call 911 or go to your nearest emergency room immediately!