Etiologic factors in the development of posttraumatic stress disorder in children and adolescents

Structured group therapy for posttraumatic stress disorder in incarcerated male juveniles

This is the first study to evaluate the efficacy of a structured group therapy for posttraumatic stress disorder (PTSD) in incarcerated male juveniles. Ten groups of juveniles (n = 45) completed a 12-session intervention with pre- and postassessments composed of the Post Traumatic Stress Disorder Reaction Index (C. Frederick, 1985) and supplementary measures of anxiety, anger, and depression. Overall, group participants experienced significant reductions in self-reported PTSD symptoms. Supplemental analyses suggest that this treatment was most beneficial for youth with trauma related to gang and community violence.

Acute stress disorder in children related to violence

TOPIC

Unidentified and untreated acute stress responses in children may result in chronic posttraumatic stress disorder (PTSD), other serious psychiatric disorders, and/or developmental arrest.

PURPOSE

To review and identify gaps in current literature on acute stress disorder (ASD) in children and examine current treatments.

SOURCES

Review of the

CONCLUSIONS

More developmentally appropriate, standardized measurement instruments are needed. Future research must focus on prospective studies of children exposed to trauma in order to better understand the association between ASD and PTSD. Future studies must include children at different developmental stages.

Posttraumatic stress disorder in children: diagnosis, assessment, and associated features

Although a growing body of research has increased knowledge of the after-effects of trauma in children, including the development of PTSD, there are significant gaps in this knowledge concerning diagnosis, assessment, and associated features. With regard to diagnosis, variations in symptomatic expression of PTSD in children have been proposed; however, there have been few examinations of the validity of these variations in terms of course and consequence of PTSD defined in these ways. Several factors increase children's risk for development of PTSD or PTSD symptoms after trauma. Such information is potentially useful for identifying children who may benefit from more thorough or ongoing assessment after trauma. With regard to assessment, an array of increasingly sophisticated and clinically useful measures is being developed; however, currently there is a dearth of high quality data concerning the diagnostic use of different assessments. An area of general weakness concerning these assessments is the limited data on discriminant validity. A sizeable body of evidence indicates that trauma can produce diverse reactions in children, including a general increase in internalizing and externalizing symptoms. Clinically useful measures allow PTSD to be differentiated from this general reaction to traumatic events, much of which may reflect a nonpathologic response. With regard to associated features, limited information suggests that PTSD can have a cascading negative effect on children's development and functioning. More research is needed, however, to delineate factors that reflect risk for PTSD after trauma, factors that reflect consequences of PTSD, and mediating variables.

Adolescent understandings of political violence and psychological well-being: a qualitative study from Bosnia Herzegovina

The Harvard Trauma Questionnaire and Hopkins Symptoms Checklist (HSCL-25) were given to 337 13-15 year olds who had lived through the recent war in Bosnia Herzegovina, on opposite sides of the conflict. A gender-balanced sub-sample of 40 adolescents was selected on the basis of their combined symptom scores, including equal numbers of high and low scorers from each side. A year of participant observation in two cities and in-depth interviews were conducted with the sub-sample to explore their understandings of the war and their subjective perceptions of their psychological well-being. Case studies are presented to show that the degree to which an adolescent engaged in a search for meaning to the conflict is related to their psychological well-being. Searching for meaning did not appear to be protective. Less well adolescents in both cities were more engaged in searching for meaning. Well adolescents appeared to be more disengaged. Searching for meaning appeared to be associated with sensitivity to the political environment, and feelings of insecurity about the prospect of a future war. The particular local context had an important effect in mediating the manner in which disengagement and engagement occurred. These findings suggest that the more avoidant methods of coping with political violence warrant further investigation. Political engagement may be protective in low-level conflicts where there is a possibility for action. When there is little opportunity for active engagement, the search for meaning has a different effect. Adolescents engaged in the search for meaning recognise that their recovery is bound up with the recovery of their communities as a whole. Assistance and support may have to address the material, social and political difficulties that the search uncovers.

Forensic evaluation of trauma syndromes in children

There are significant differences between a clinical evaluation and a forensic evaluation [289-291]. These differences must be kept solidly in mind in performing the evaluation. The forensic evaluator needs to assess the validity of complaints, including the possibility of malingering and the child's ability to describe symptoms accurately, the connection between the symptoms and a given incident, and the potential long-term sequelae of a trauma. The goal of the interview is not to treat, but to obtain information. Assessing the validity of complaints is perhaps the greatest challenge. This requires obtaining and reconciling data from numerous sources, including interviews with the child and parents, and information from other sources, as well as rating scales and validity testing. One must be very cautious in asking leading questions and using standardized PTSD protocols, lest they teach the parents and child about the symptoms of PTSD and thereby distort the information they provide as a result. The forensic interviewer should consider what will be needed when called to testify in court. What data will convince the jury? How might the opposing attorney challenge the assessment? What scientific studies support the findings and conclusions concerning the diagnosis, functional impairment, and validity. The precise DSM-IV-TR diagnosis is not always key in a forensic evaluation. What is essential is establishing the connection between the trauma and ensuing emotional problems. All of the symptoms the individual has as a result of the trauma become important, whether or not they contribute to fulfillment of DSM-IV-TR criteria. This contrasts with a clinical evaluation in which one needs to demonstrate the existence of a DSM-IV-TR diagnosis for reimbursement purposes. Finally, the forensic evaluator should be familiar with current practice guidelines for examination of children with PTSD. Any deviation may need to be explained in court [264,292].

Acute stress disorder symptoms in children and their parents after pediatric traffic injury

OBJECTIVE

The American Academy of Pediatrics highlights the important role of pediatricians in recognizing adverse child responses to tragic events, such as traffic crashes. One challenge in effectively identifying children and their parents with troubling psychological responses to trauma is that little is known about the normal range of acute psychological responses in children and their parents in the immediate aftermath of traumatic events, making identification of adverse child responses difficult. Within the first month after a traumatic event, individuals may display reexperiencing, avoidance, and hyperarousal symptoms as well as dissociation (eg, feelings of unreality or emotional numbing). The presence of these responses, collectively known as acute stress disorder (ASD), alerts providers to those who may be at risk for ongoing difficulties. For beginning to develop an evidence base to guide pediatric care providers in addressing acute traumatic responses, the aim of the current investigation was to describe systematically the range and type of symptoms of ASD in children and their parents after pediatric traffic injury.

METHODS

A prospective cohort study was conducted of traffic-injured children, who were 5 to 17 years of age and admitted to the hospital for treatment of injuries from traffic crashes, and their parents. All children who met eligibility criteria between July 1999 and May 2000 were invited to participate in the study. After consent/assent was obtained, children and their custodial parents (or guardians) were interviewed within 1 month after injury via a structured assessment to determine the circumstances of the crash and the presence of ASD symptoms. Relevant demographic and clinical information (eg, age, race, gender, date of injury) was abstracted from the medical records of subjects. A survey instrument to assess the presence of ASD symptoms was completed by both the child and his or her guardian. All children completed the Child Acute Stress Questionnaire, and all parents completed the Stanford Acute Stress Reaction Questionnaire. Responses were scored for the presence of dissociation, reexperiencing, avoidance, and/or hyperarousal symptoms as well as broad distress (symptoms present in every category).

RESULTS

Symptoms of ASD were commonly observed in the children and parents. Eighty-eight percent of children and 83% of parents reported having at least 1 clinically significant symptom; this affected 90% of the families. Broad distress was observed for a large minority: 28% of children and 23% of parents. No statistically significant association was found between child broad distress and either child age (r = -0.12) or child injury severity score (r = -0.05). chi(2) analyses revealed no significant association between broad distress and child gender, child race, or mechanism of injury. No statistically significant association was found between parent broad distress and child age (r = -0.06) or child injury severity score (r = 0.09). chi(2) analyses revealed no significant association between parent broad distress and child gender or parent presence at the crash scene. Associations were found between parent broad distress and race in that fewer white parents reported broad distress. In addition, mechanism of injury was associated with parent broad distress: more parents reported broad distress when their children were involved in pedestrian-motor vehicle crashes, and fewer parents reported broad distress when their children were injured in a bicycle fall.

CONCLUSIONS

Pediatric care providers can expect to see some ASD symptoms in most children and parents in the immediate aftermath of traffic-related injury. Brief education is appropriate to explain that these symptoms are normal reactions that are likely to resolve. If symptoms persist for >1 month or are particularly distressing in their intensity, then referral for psychological care may be necessary for treatment of posttraumatic stress disorder. Given the high prevalence of pediatric traffic crashes and the underdiagnosis of posttraumatic stress disorder, probing for recent crash exposure might be appropriate during routine child health maintenance. The following are recommendations for pediatricians: 1) routinely call the family several days and 1 to 2 weeks after a traffic injury and ask about behavioral symptoms and family function; 2) make use of the ongoing physician-patient relationship to explore symptom presence and intensity and any functional impairment in the injured child; a brief office visit with the child and parents could serve this purpose; 3) be sure to explore the effect that the child's injury has had on the family; remember that the parent's experience posttraumatic stress symptoms after pediatric traffic-related injuries and these symptoms may limit the parent's ability to support the child; 4) provide supportive care and give families the opportunity to discuss the crash and their current feelings; do not force families to talk about the crash; 5) although any child in a traffic crash or his or her parent is at risk for posttraumatic symptomatology, regardless of injury severity, particular attention should be paid to the parents of child pedestrians who are struck by motor vehicles. These parents experience posttraumatic symptoms more commonly than parents of children in other traffic crashes.

Clinical predictors of posttraumatic stress disorder after closed head injury in children

OBJECTIVE

To describe injury, demographic, and neuropsychiatric characteristics of children who develop posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) after closed head injury (CHI).

METHOD

Ninety-five children with severe CHI and amnesia for the event were prospectively followed for 1 year. Structured interviews were administered twice to the parents: shortly after injury to cover the child's premorbid status, and 1 year after injury. The child was also interviewed twice: shortly after injury to cover current status, and 1 year after injury. Outcome measures were diagnostic status (PTSD by parent or child) and symptom severity (PTSS by parent or child).

RESULTS

Twelve children developed PTSD by 1 year after injury, 5 according to parent report, 5 according to child report, and 2 according to both parent and child report. Predictors of PTSD at 1 year post-CHI included female gender and early post-CHI anxiety symptoms. Predictors of PTSS at 1 year post-CHI were (1) premorbid psychosocial adversity, premorbid anxiety symptoms, and injury severity; and (2) early post-CHI depression symptoms and nonanxiety psychiatric diagnoses.

CONCLUSIONS

PTSD developed in 13% of children with severe CHI accompanied by traumatic amnesia. Predictors of PTSD and PTSS after CHI, according to parent and child report, are consistent with predictors of PTSD and PTSS that develop after non-head injury trauma.

Acute stress disorder symptomatology during hospitalization for pediatric injury

OBJECTIVE

To examine and identify predictors of acute stress disorder (ASD) and ASD symptomatology (ASDS) in children hospitalized for injuries.

METHOD

Fifty-four youths were assessed while hospitalized for injuries. Dependent variables were parent and nurse ratings of children's ASDS. Independent variables included children's prior trauma exposure and behavior problems, injury severity and permanence, brain injury, injury or death to family/friend(s), parental distress, and child reports of the injury/hospitalization experience as meeting criterion A for ASD.

RESULTS

A total of 92.6% of children felt the current experience met criterion A, compared with 64.8% of parents. According to parent questionnaires, 4 subjects (7.4%) met DSM-IV criteria for ASD while another 12 (22.2%) had clinically significant but subsyndromal ASDS. Children's ASDS, as reported by parents, correlated highly with parental distress and ratings of children's prior psychopathology, and modestly with injury severity and family/friend(s) injured or killed. Nurses' ratings of children's ASDS correlated strictly with injury- and accident-related variables, and not with parent ratings of children's ASDS.

CONCLUSIONS

Children perceive injuries and hospitalizations as stressful. ASDS is widely though divergently reported by parents and nurses in children hospitalized for injury. Parental distress, children's prior psychopathology, and injury-related factors may be useful predictors of children's postinjury ASDS.

Predicting posttraumatic stress after hospitalization for pediatric injury

OBJECTIVE

To determine the prevalence and predictors of posttraumatic stress disorder (PTSD) in children after hospitalizations for accidental injuries.

METHOD

Forty-eight children (aged 7-17 years) and their parents were assessed during hospitalization with measures of children's prior traumatization, prior psychopathology, injury severity, parental acute distress, and child acute distress. At outpatient follow-up at least 1 month later, children were evaluated for current PTSD diagnosis and PTSD symptomatology (PTSDS) by a child structured interview and for PTSDS by a parent questionnaire.

RESULTS

A total of 12.5% had the full syndrome of PTSD at follow-up, and an additional 16.7% had partial (sub-syndromal) PTSD. Full PTSD was associated with a higher level of prior psychopathology, higher parental acute distress, and higher rates of prior sexual abuse, compared with partial or no PTSD. Prior psychopathology, parental distress, and, to a lesser extent, children's acute distress as reported by parents and breadth of prior traumatization, predicted subsequent PTSDS.

CONCLUSIONS

Full or partial PTSD is relatively common in youths 1 month or more after hospitalization for injuries. Parents' acute distress as well as children's prior psychopathology, prior traumatization, and acute distress may be useful predictors of such injured children's subsequent PTSD or PTSDS.

A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders

Empirical findings regarding childhood traumatic stress are placed within a developmental life-trajectory model that incorporates a tripartite etiology of posttrauma distress. This approach recognizes an intricate matrix of child-intrinsic factors, developmental maturation and experience, life events, and evolving family and social ecologies. Of central developmental importance in the field of traumatic stress is the ontogenesis of appraisal, emotional response, emotional and physiological regulation, and consideration of protective action with regard to danger. The complexity of traumatic situations and their aftermath suggests the relevance of multiple stress diatheses in understanding individual variability in proximal and distal effects. Neurobiological systems that subserve danger mature over childhood and adolescence. Neurophysiological and neurohormonal studies among traumatized children and adolescents suggest potential neurodevelopmental stage-related vulnerabilities within these systems. Advances in child development and traumatic stress provide tools for investigating proximal and distal interplay of psychopathology, disturbances in the acquisition and maintenance of developmental competencies, and life-trajectory outcomes. A developmental psychopathology model suggests different avenues by which dangerous circumstances, childhood traumatic experiences, and posttraumatic stress disorder (PTSD) can intersect with other anxiety disorders over the life span.

Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing

OBJECTIVE

This clinical assessment was designed to identify middle and high school students in need of formal evaluation for posttraumatic response symptoms following the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City.

METHOD

A clinical needs assessment instrument was developed and administered to grade 6 through 12 students 7 weeks after the bombing (N = 3,218).

RESULTS

More than 40% of the students reported knowing someone injured, and more than one-third reported knowing someone killed in the blast. Posttraumatic stress symptoms at 7 weeks significantly correlated with gender, exposure through knowing someone injured or killed, and bomb-related television viewing.

CONCLUSIONS

This study documents the intensity of community exposure to the bombing and the lingering symptoms of stress. The assessment was used in planning for clinical service delivery, training professional responders, and supporting funding requests.

Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder

These practice parameters review the current state of knowledge about posttraumatic 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; that 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 seem 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.

Posttraumatic stress disorder in a clinical sample of adult survivors of childhood sexual abuse

One hundred seventeen help-seeking adult survivors of childhood sexual abuse (CSA) were assessed to investigate the relationship between the level of self-reported CSA and posttraumatic stress disorder (PTSD). CSA was measured utilizing the Sexual Abuse Exposure Questionnaire, a new research instrument. Further preliminary psychometric properties of the instrument were reported. CSA was operationalized to include severity, duration, age of onset, number of perpetrators, and use of force. PTSD diagnostic status was assessed utilizing a standardized instrument, the Structured Clinical Interview for DSM-II-R. Eighty-six percent of survivors met full DSM-III-R criteria for a PTSD diagnosis at some point during their lives. Multivariate analysis indicated that CSA severity and duration accounted for significant portions of the variance in PTSD symptoms, providing support for their role as traumagenic variables.