Posttraumatic Stress Disorder in Children and Adolescents: A Review and Analysis

Only recently has the mental health community recognized the applicability of diagnostic criteria for posttraumatic stress disorder (PTSD) in children and adolescents, including a consideration of specific age-related features. This paper provides a current review of the literature on PTSD pertaining to children and adolescents. Following a discussion of issues on diagnostic criteria and assessment of this affective disorder in this population, there is an overview of the existing literature on prevalence, comorbidity, risk factors, parental and family factors, and issues of gender and age of onset. The remainder of the paper focuses on the range of traumatic stressors in children and adolescents that can result in PTSD, including natural or human disasters, war and violence, chronic or life-threatening medical conditions, community violence and the witnessing of traumatic events, and physical and/or sexual abuse and other forms of interpersonal violence. Throughout the paper, there is an emphasis on the importance of considering developmental factors. Finally, implications of the existing literature for future areas of research are addressed.     

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.     

Early executive functioning in a global context: Developmental continuity and family protective factors

This study extends the methodological and theoretical understanding of executive functions (EFs) in preschoolers from low‐ and middle‐income countries (LMIC). First, the authors describe a rigorous process of adapting and evaluating six EF tasks to produce a culturally and developmentally appropriate measure of emerging EFs in a large sample of at‐risk children in rural Pakistan. Next, the authors identify critical developmental and family factors that relate to preschoolers’ EFs over the first 4 years of life. Direct assessment of children's general cognitive skills at age two showed developmental continuity with EFs at age four, and these early cognitive skills mediated the effect of an antecedent parenting intervention on EFs as well as associations of targeted individual and family factors with EFs. Furthermore, directly assessed maternal cognitive capacities and observed maternal scaffolding uniquely predicted EFs in preschoolers. This study is also the first to demonstrate a significant overlap between direct assessments of IQ and EFs in young children from LMIC. Children's general intelligence mediated the associations of EFs with antecedent physical growth and cognitive skills as well as concurrent family factors (maternal verbal intelligence, maternal scaffolding, and home stimulation). After controlling for shared variance between preschoolers’ general intelligence and EFs, three factors emerged as unique predictors of EFs: exposure to an early parenting intervention, physical growth status at age two, and number of older siblings. The findings have important implications for the design of interventions that aim to improve EFs in young children in LMIC. A video abstract of this article can be viewed at https://vimeo.com/316329544/5abde94cd7     

Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder

Although peritraumatic dissociation predicts subsequent posttraumatic stress disorder (PTSD), little is understood about the mechanism of this relationship. This study examines the role of panic during trauma in the relationship between peritraumatic dissociation and subsequent PTSD. Randomized eligible admissions to 4 major trauma hospitals across Australia (n = 244) were assessed during hospital admission and within one month of trauma exposure for panic, peritraumatic dissociation and PTSD symptoms, and subsequently re-assessed for PTSD three months after the initial assessment (n = 208). Twenty (9.6%) patients met criteria for PTSD at 3-months post injury. Structural equation modeling supported the proposition that peritraumatic derealization (a subset of dissociation) mediated the effect of panic reactions during trauma and subsequent PTSD symptoms. The mediation model indicated that panic reactions are linked to severity of subsequent PTSD via derealization, indicating a significant indirect relationship. Whereas peritraumatic derealization is associated with chronic PTSD symptoms, this relationship is influenced by initial acute panic responses.     

Adverse childhood experiences,religious/spiritual struggles,and mental health symptoms: examination of mediation models

Emerging research has documented greater risk for posttraumatic stress disorder (PTSD) and depression among young adults with prior adverse childhood experiences (ACEs). Building upon prior findings, we hypothesised that religious/spiritual (R/S) struggles may serve as an intervening pathway through which accumulation of ACEs impacts mental health symptom severity in this population. Young adults (N?=?458) were recruited from a southeastern university to complete an online self-report survey that assessed for ACEs, lifetime trauma exposure, R/S struggles, PTSD and depressive symptomatology. Bivariate correlations yielded significant positive relationships between ACEs and all six types of R/S struggles, depression, and PTSD. Additionally, when accounting for non-childhood trauma exposure, the mediational analyses indicated an indirect effect of struggles with ultimate meaning on the well-establish association between ACEs and mental health symptoms. Clinical implications (such as the importance of fostering meaning making), study limitations, and future research directions are discussed.     

A prospective study of appraisals in childhood posttraumatic stress disorder

This study investigated the predictors of posttraumatic stress disorder (PTSD) in children following a diagnosis of traumatic injury. Children (N=76) aged between 7 and 13 who were admitted to hospital following injury were assessed within a month of trauma for acute stress disorder (ASD), negative appraisals, as well as parental stress reactions. Children (N=62) were re-assessed 6-months later for PTSD and negative appraisals. The majority of the variance of chronic posttraumatic stress was accounted for by negative appraisals about future harm. This study supports cognitive models of PTSD, and suggests that younger children who exaggerate their vulnerability after trauma exposure are high risk for PTSD after trauma.     

Gender differences in susceptibility to posttraumatic stress disorder

We examined data from a community survey of trauma exposure and DSM-IV PTSD in Winnipeg, Canada to explore factors associated with the higher rate of PTSD in women than men. Women were found to be at significantly increased risk for PTSD following exposure to serious trauma (odds ratio approximately 5), even when sexual trauma--which predominates in women--was excluded (odds ratio approximately 3). Adjusting for gender differences in the number of lifetime traumata, or in the likelihood of the trauma being associated with particular reactions to or consequences of the event (i.e. thinking that one would be killed or seriously injured; sustaining a serious physical injury; seeing someone else seriously injured or killed) did not result in a lessening of the PTSD risk in women. Women were found to be at increased risk for PTSD following nonsexual assaultive violence (e.g. mugging or other physical attack) but not following non-assaultive trauma (e.g. fire, witnessing injury to others). Understanding the basis of (and parameters for) this increased susceptibility to PTSD in women compared to men following trauma exposure should be a priority for future traumatic stress research.     

Understanding Social Factors in the Context of Trauma: Implications for Measurement and Intervention

One of the most important factors predicting the presence of posttraumatic stress disorder (PTSD) after trauma exposure is social support, yet the construct is theoretically complex and remains variably defined. To better inform the trauma literature on the impact of social factors, a theoretical review of social support and PTSD was conducted, and implications for measurement and intervention are outlined. Type of trauma, sex of participant, timing of social support, and support providers are described as significant moderators of the association between social factors and PTSD. The developmental trajectory of the association between social factors and PTSD occurrence is outlined, emphasizing the positive influence of social support initially following trauma, and the deterioration effect of PTSD symptoms on social support over the longer term. Possibilities for future research and intervention at multiple levels and at different time points are described.     

Trauma-Informed Care for Infant and Early Childhood Abuse

ABSTRACT

Trauma-informed care for those who experienced early childhood maltreatment is being developed to meet the needs of infant, toddler, and preschool victims of child abuse and neglect. This age group experiences a disproportionate amount of abuse, and the resultant toxic stress during this rapid developmental stage is more damaging than it is in later years. The concept of trauma-informed care in general is presented, followed by a focus on trauma care for early childhood abuse. Trauma-informed care for younger children is united by common principles and is seen as developmental, relational, sensory oriented, and evidence based in nature. Dissemination of knowledge about this unique population to every system that encounters survivors of any age has begun, although it must be broadened and increased. Evidence-based treatment programs for young children are available and effective but limited, especially for age 0–2. Home visiting programs for mothers and babies are effective and cost efficient. Major funding by U.S. Department of Health and Human Services to each state has significant potential for success because it targets mother-child attachment and care, as well as the disproportionate amount of damage resulting from early childhood abuse. Infants and preschoolers are in some ways comparable to children with disabilities due to their developmental limitations. The nature of this population requires a more rigorous and proactive awareness and identification process because these children are physically dependent on surrounding adults. Addressing child abuse in the first years of life offers an excellent opportunity to assist the most vulnerable victims and effectively reduce the impact to families and communities in the ensuing years.     

Gender differences in posttraumatic stress disorder

One of the most consistent findings in the epidemiology of posttraumatic stress disorder (PTSD) is the higher risk of this disorder in women. Explanations reviewed within a psychobiological model of PTSD suggest that women's higher PTSD risk may be due to the type of trauma they experience, their younger age at the time of trauma exposure, their stronger perceptions of threat and loss of control, higher levels of peri-traumatic dissociation, insufficient social support resources, and greater use of alcohol to manage trauma-related symptoms like intrusive memories and dissociation, as well as gender-specific acute psychobiological reactions to trauma. This review demonstrates the need for additional research of the gender differences in posttraumatic stress. Recommendations are made for clinical practice.     

Young Children’s Physiological Reactivity during Memory Recall: Associations with Posttraumatic Stress and Parent Physiological Synchrony

Autonomic reactivity is implicated in stress response and social engagement – both key components of posttraumatic stress disorder (PTSD) – but few studies have examined autonomic reactivity in pediatric samples, and no known studies have examined physiological synchrony among children with PTSD and caregivers. In a sample of 247 young children (94 girls, 153 boys), most (85%) of whom had exposure to trauma and 40% who met criteria for PTSD, we examined children’s patterns of respiratory sinus arrhythmia (RSA) at baseline and in response to a memory recall task, as well as correspondence between parents’ and children’s RSA. Children with PTSD demonstrated significantly higher reactivity than other groups during their recollection of a traumatic memory, but not during other memory tasks. Regarding synchrony, caregivers’ and children’s RSA were more significantly and positively correlated during the trauma recall task among children who had had exposure to a potentially traumatic event but did not meet PTSD criteria, suggesting physiological synchrony may be protective in contexts of trauma. Overall, findings demonstrate physiological reactivity differences among young children with PTSD. While more work is needed to understand the meaning of parent-child physiological synchrony, these data suggest that children’s psychopathology is associated with physiological synchrony processes among young children with exposure to trauma.     

Posttraumatic play in young children exposed to terrorism: An empirical study

The phenomenon of “posttraumatic play” (PTP) has received much clinical recognition and little empirical support. The objective of this study was to examine various aspects of PTP in young children exposed to terror events and their relation to posttraumatic stress disorder (PTSD). Individual play sessions, conducted with 29 young Israeli children directly exposed to terrorism (M age = 5.47, SD = 1.34) and 25 matched unexposed children (M age = 5.62, SD = 0.87), were coded using the Children's Play Therapy Instrument–Adaptation for Terror Research (CPTI‐ATR; S.E. Chazan & E. Cohen, 2003). Analyses using these ratings showed (a) significant differences between the two groups, (b) significant associations with the caregiver's reports on child's exposure, and (c) significant associations with the caregiver's reports on the child's PTSD symptoms. Play activity ratings of predominant negative affects, frequent acting‐out/morbid themes, lowered developmental level, and reduced awareness of the child of him‐ or herself as a player significantly predicted more PTSD symptoms. PTP which included more coping strategies classified as “overwhelmed reexperiencing” and less “reenactment with soothing” was associated with a higher level of PTSD. Play analysis with the CPTI‐ATR may be helpful in identifying PTSD in children and also guide the selection of therapeutic techniques.     

Developmental considerations for assessment of trauma symptoms in preschoolers: a review of measures and diagnoses

Child maltreatment can lead to a unique set of trauma stress among young children that can be challenging to measure. The purpose of this review was to review measures of maltreatment-related trauma outcomes (trauma-related symptoms and post-traumatic stress disorders) in very young children (ages 0–6) and to examine research trends in how and if child development is accounted for in this area of measurement. A systematic search strategy was used to identify articles in two databases, CINAHL and PsychInfo. Articles were eligible for inclusion in the review if they measured trauma symptoms in children ages 0–6, were quantitative research reports of studies conducted in North America, and were published in English. The search resulted in 74 articles meeting prespecified inclusion criteria. Results suggested that recognition of the ways maltreatment trauma affects child development and the importance of developmental sensitivity in assessing trauma symptoms has grown in recent years. However, many research studies did not use developmental frameworks and applied adult-oriented trauma symptom frameworks in measurement and treatment. Behavioral symptoms were the primary outcome of interest for this age group. There was also incongruity and lack of consensus about diagnostic tools for post-traumatic stress disorders in young children. Further research is needed to resolve theoretical and empirical controversies related to measurement and diagnosis of trauma symptomatology in young children.     

Children's response to community violence: What do we know?

This article presents a framework for understanding the developmental significance of violence-related trauma in the lives of young children. It emphasizes the importance of the distinction between acute and chronic trauma. Acute trauma is more readily dealt with through “psychological first aid” and a “therapy of reassurance.” Chronic trauma requires a more systematic reconstruction of the child's “social map” of the world. The socioeconomic and demographic correlates of violent trauma predict an accumulation of risk factors in the child's life that compounds the problem of developmental disability. The problem community violence poses for the child must be understood in the larger context of greater risk for family disruption (including less than secure attachment) as well as domestic violence, poverty, and minority group status. The increasing incidence and prevalence of community violence poses a major challenge to the mental health of children.     

Gender differences in the sensitivity to posttraumatic stress disorder: An epidemiological study of urban young adults

The authors examine the relationship between 2 separate but interrelated findings in the epidemiology of posttraumatic stress disorder (PTSD): women's greater PTSD risk following traumatic events and the sensitizing effects of a prior trauma on the PTSD response to a subsequent trauma. Data come from a representative sample of 1,698 young adults from a large U.S. city. Analysis was conducted on the subset exposed to traumatic events. Women's risk for PTSD following assaultive violence was higher than men's. When assaultive violence preceded a later nonassaultive trauma in women, there was an increased risk (relative risk = 4.9) for PTSD, which was not observed in men. The relative risk estimate in women was significantly higher than in men. These findings suggest that assaultive violence elicits women's PTSD response directly and by sensitizing them to the effects of subsequent traumatic events of lesser magnitude.     

Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children

Young children who are exposed to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel interventions that are more accessible, efficient, and cost-effective are needed to improve access to evidence-based treatment. Stepped care models currently being developed for mental health conditions are based on a service delivery model designed to address barriers to treatment. This treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established evidence-based practice, was developed into a stepped care model for young children exposed to trauma. Considerations for developing the stepped care model for young children exposed to trauma, such as the type and number of steps, training of providers, entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting monitoring system, are discussed. This model of stepped care for young children exposed to trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped care approaches to treating other types of childhood psychiatric disorders. Future research needed on Stepped Care TF-CBT is discussed.     

Suicide Ideation in Female Survivors of Military Sexual Trauma: The Trauma Source Matters

Female veterans who have experienced military sexual trauma (MST) are at elevated suicide risk, yet knowledge is limited regarding correlates of suicide ideation (SI) in this population. MST is associated with a higher risk of posttraumatic stress disorder (PTSD) relative to other trauma types; however, no studies have examined whether experiencing SI differs based on the source of PTSD symptoms (MST‐related, non–MST‐related). Female service members/veterans (SM/Vs; n = 311) who screened positive for MST and reported exposure to a Criterion A event completed an online survey assessing self‐reported demographics, PTSD, depression, the source of their PTSD symptoms, and SI. Ninety‐one (29.3%) reported experiencing current SI, and 223 (71.7%) identified MST as the source of their current PTSD symptoms. Participants who identified MST as the source of their PTSD symptoms were over two times more likely to report SI, compared to those who described non–MST‐related events as the source of their PTSD symptoms. Compared to those who reported the source of their PTSD symptoms as combat‐/deployment‐related, those who identified MST as the source were at least three times as likely to report current SI. Results underscore the importance of efforts to address MST‐related PTSD symptoms when working with female SM/Vs.     

Examining the Prospective Relationship between Pre-Disaster Respiratory Sinus Arrhythmia and Post-Disaster Posttraumatic Stress Disorder Symptoms in Children

Previous studies have examined the concurrent relationship between posttraumatic stress disorder (PTSD) and a range of psychophysiological variables, including respiratory sinus arrhythmia (RSA). However, there is a lack of research examining the prospective development of trauma symptomatology, and the directionality of the association between RSA level and PTSD has yet to be determined. The current study is the first prospective study to examine whether RSA level and RSA reactivity are risk factors for PTSD symptoms in children. Assessments were conducted both prior to (Time 1) and following (Time 2) a natural disaster (i.e., Hurricane Katrina). Participants were 36 children who were 3–6 years-old during the Time 1 assessment. Structured diagnostic interviews were used to assess PTSD symptoms at both Time 1 and Time 2. RSA level during a neutral stimulus, RSA reactivity to emotional video stimuli (distress, joy, and trauma videos) and RSA reactivity to memory stimuli (remote happy memory, trauma memory, mother’s recall of the trauma memory) were also collected at both time points. Time 1 RSA level during a neutral stimulus was a significant predictor of Time 2 PTSD symptoms (controlling for age, Time 1 PTSD symptoms, Time 2 neutral RSA level), such that lower RSA during a neutral condition was related to higher PTSD symptoms. Also, Time 1 RSA reactivity in response to memory (but not video) stimuli, in the form of relatively less vagal withdrawal, was a significant predictor of more Time 2 PTSD symptoms (controlling for age, Time 1 PTSD symptoms, Time 2 RSA reactivity). This unique prospective study provides evidence for level of RSA and RSA reactivity as pre-existing clinical markers of stress sensitivity that predict psychopathology following a trauma.     

A Review of Reviews Examining Neurological Processes Relevant to Impact of Parental PTSD on Military Children: Implications for Supporting Resilience

In this study, 10 recent meta-analytic and systematic review studies were synthesized on the neurological underpinnings of stress and trauma with implications for the impact of parental post-traumatic stress disorder (PTSD) and resilience among military children. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) group guidelines and utilizing a validated quality assessment tool, this systematic review of reviews incorporated results from more than 35,971 individuals with stress exposures, effects, or disorders and healthy controls. This synthesis found support for important gene, physiology, and environment correlations and interactions that predict increased risk for stressful life events and PTSD, but not direct transmission, among military children. Future research is needed to determine if these constitute indirect pathways of intergenerational transmission in military children.     

Intimate Partner Violence Among Transitional-Aged Women With and Without Disabilities: Implications for Social Work Practice

Although women with disabilities are at increased risk for intimate partner violence (IPV), little is known about how this phenomenon impacts transitional-aged young women with disabilities who are still trying to master the developmental challenges of adolescence. This study explores risk factors for and prevalence of IPV by drawing on a population-based sample of women ages 18–21 with (N = 1,616,207) and without (N = 7,554,064) self-reported disabilities. Findings suggest that risk factors for IPV were more prevalent among sample members, as was past year experience of IPV. This study has implications for school social workers and disability service providers who interact with this population.