Evidence-Based Reviews

Traumatized children: Why victims of violence live out their nightmares

Current Psychiatry. 2003 January;2(1):30-39

Posttraumatic stress disorder presents differently in children and adolescents than in adults—comorbidity is the norm, and the risk is greatest when children experience violence in the home.

PDF Download

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: American Psychiatric Association, 1994

2. Frederick CJ. Children traumatized by catastrophic situations. In: Eth S, Pynoos RS (eds). Posttraumatic stress disorder in children. Washington, DC: American Psychiatric Press, 1985;71-100.

3. Garrison CZ, Bryant ES, Addy CL, Spurrier PG, Freedy JR, Kilpatrick DG. Posttraumatic stress disorder in adolescents after Hurricane Andrew. J Am Acad Child Adolesc Psychiatry 1995;34:1193-1201.

4. Scheeringa MS, Zeanah CH. Symptom expression and trauma variables in children under 48 months of age. Infant Ment Health J 1995;16:259-70.

5. Scheeringa MS, Zeanah CH, Drell MJ, Larrieu JA. Two approaches to diagnosing post-traumatic stress disorder in infancy and early childhood. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

6. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of posttraumatic stress disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1998;37(10,suppl):4S-26S.

7. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002;41(2):166-73.

8. Silva RR, Alpert M, Munoz DM, Singh S, Matzner F, Dummit S. Stress and vulnerability to posttraumatic stress disorder in children and adolescents. Am J Psychiatry 2000;157(8):1229-35.

9. Foy DW, Madvig BT, et al. Etiologic factors in the development of posttraumatic stress disorders in children and adolescents. J Sch Psychol 1996;34:133-45.

10. Famularo R, Fenton T, Augustyn M, Zuckerman B. Persistence of pediatric posttraumatic stress after two years. Child Abuse Negl 1996;20:1245-8.

11. De Bellis MD, Baum A, Birmaher B, Keshavan MS, Eccard CH, et al. Developmental traumatology part I: Biological stress systems. Biol Psychiatry 1999;45(10):1259-70.

12. De Bellis MD, Keshavan M, Clark DB, Casey BJ, Giedd JN, Boring AM, et al. Developmental traumatology Part II: Brain development. Biol Psychiatry 1999;45:1271-84.

13. Hart J, Gunnar M, Cicchetti D. Altered neuroendocrine activity in maltreated children related to symptoms of depression. Dev Psychopathol 1996;8:201-14.

14. King JA, Madasky D, King S, Fletcher KE, Brewer J. Early sexual abuse and low cortisol. Psychiatry Clin Neurosci 2001;55:71-4.

15. Carrion VG, Weems CF, Ray RD, Glaser B, Hessl D, Reiss AL. Diurnal salivary cortisol in pediatric posttraumatic stress disorder. Biol Psychiatry 2002;51(7):575-82.

16. De Bellis MD, Keshavan M, Frustaci K, Shifflett H, et al. Superior temporal gyrus volumes in maltreated children and adolescents with PTSD. Biol Psychiatry 2002;51:544-52

17. Carrion VG, Weems CF, Eliez S, Patwardhan A, Brown W, et al. Attenuation of frontal asymmetry in pediatric posttraumatic stress disorder. Biol Psychiatry 2001;50:943-51

18. De Bellis MD, Keshavan MS, Spencer S, Hall J. N-acetylaspartate concentration in the anterior cingulate of maltreated children and adolescents with PTSD. Am J Psychiatry 2000;157:1175-7.

19. Cohen JA, Mannarino AP. Treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry 1996;35(1):42-50.

20. Deblinger ES, Lippman J, Steer R. Sexually abused children suffering posttraumatic stress symptoms: initial treatment outcome findings. Child Maltreatment 1996;1:310-21.

21. Deblinger ES, Cohen JA. Cognitive behavioral treatment for sexually abused children and their nonoffending parents (workshop) Chicago: American Professional Society on the Abuse of Children, sixth national colloquium,1998.

22. Berliner L, Saunders BE. Treating fear and anxiety in sexually abused children: results of a controlled 2-year follow-up study. Child Maltreatment 1996;1:294-309.

23. Cohen JA, Mannarino AP. Treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry 1996;35 (1):42-50.

24. Cohen JA, Mannarino AP. Interventions for sexually abused children: initial treatment findings. Child Maltreatment 1998;3(1):17-26.

25. Goenjian AK, Karayan I, Pynoos RS, Minassian D, Najarian LM, et al. Outcome of psychotherapy among early adolescents after trauma. Am J Psychiatry 1997;154:536-42.

26. Famularo R, Kinscheiff R, Fenton T. Propranolol treatment for childhood PTSD, acute type: a pilot study. Am J Disabled Children 1988;142:1244-7.

27. Looff D, Grimley P, Kuiler F, Martin A, Shunfield L. Carbamazepine for PTSD (letter). J Am Acad Child Adolesc Psychiatry 1995;34 (6):703-4.

28. Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. J Am Acad Child Adolesc Psychiatry 1996;35(9):1247-9.

29. Seedat S, Lockhat R, Kaminer D, Zungu-Dirwayi N, Stein DJ. An open trial of citalopram in adolescents with post traumatic stress disorder. Int Clin Psychopharmacology 2001;16(1):21-5.

30. Good C, Peterson C. SSRI and mirtazapine in PTSD. J Am Acad Child Adolesc Psychiatry 2001;40:263-4.

31. Domon S, Anderson M. Nefazodone for PTSD. J Am Acad Child Adolesc Psychiatry 2000;39(8):

Steven, age 6, lives in a foster home and attends an intensive day program for treatment of severe aggressive and violent episodes, for which he has been hospitalized several times. The boy has been separated from his biological mother for 2 years, and her parental rights have been terminated because of allegations of neglect and severe abuse.

Steven’s mother has a long history of substance abuse. Her boyfriend, who lived with her, abused Steven physically and sexually. He beat him, tortured him, and burned him. He once inserted a hot curling iron into the boy’s rectum, causing severe burns.

It is not unusual for psychiatrists to encounter children such as Steven who have experienced abuse, trauma, or a life-threatening event, but the psychological aftermath of these experiences has only recently been fully recognized. Diagnostic criteria continue to change with evidence that posttraumatic stress disorder (PTSD) manifests differently in children and adolescents than in adults. Now research is showing changes in brain physiology in children who have experienced maltreatment.

Based on our experience and recent evidence, we discuss important features of PTSD that are being recognized in children and adolescents and describe trends and acceptable practices in treating this chronic, debilitating illness.

Diagnostic criteria

PTSD is reported to occur in 1 to 14% of the general population of children¹ and in 3 to 100% of children at risk (those exposed to violence, trauma, or abuse).^2,3 As diagnostic criteria have changed over the years, so may have prevalence rates.

PTSD was recognized as a diagnostic entity in adults in DSM-III and in children and adolescents in DSM-III-R. PTSD in children has a somewhat different presentation and expression of symptoms than in adults. According to DSM-IV-TR diagnostic criteria:

A child’s response to a stressful event may be expressed as disorganized or agitated behavior instead of intense fear, helplessness, or horror.
Children re-experience and express the traumatic event or aspects of it through repetitive play.
Children’s dreams may be frightening but without recognizable content, or they may change into generalized nightmares of monsters, of rescuing others, or of threats to self or others.
Children also tend to have more psychosomatic complaints, such as headaches and stomachaches, than adults with PTSD.¹

Box 1

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion A: Exposure to trauma

The person has been exposed to a traumatic event in which both of the following are present:

The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
The person’s response involved intense fear, helplessness, or horror. Note: Children may express this by disorganized or agitated behavior.

PROPOSED CHANGE FOR YOUNG CHILDREN

Children need not exhibit intense fear at the time of the trauma.

Source: Adapted from DSM-IV-TR and Scheeringa et al. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

Age-related symptoms. Appropriate diagnostic criteria for childhood PTSD have been debated for some time, in part because of differences in children’s symptoms at different ages and developmental stages. Since DSM-IV was introduced in 1994, several researchers have recommended modifications to its diagnostic characterizations of childhood PTSD.

To accommodate the developmental stage of children younger than age 4, for example, Scheeringa et al suggested changes to DSM-IV criteria for PTSD.^4,5 These changes (Boxes 1-5) are included in the American Academy of Child and Adolescent Psychiatry’s guidelines for assessing and treating PTSD⁶ and may be a valuable tool for the clinician treating young children.

Subsyndromal cases. Children whose symptoms fall below the diagnostic criteria for PTSD may demonstrate substantial functional impairment and distress, according to Carrion et al.⁷ In fact, these researchers found that children who fulfill the requirements for two of three symptom clusters—Cluster B, re-experiencing (Box 2); Cluster C, avoidance and numbing (Box 3); and Cluster D, hyperarousal (Box 4)—do not differ significantly from children who meet criteria for all three symptom clusters. Therefore—the researchers reported—the absence of this triad does not necessarily indicate a lack of posttraumatic stress in children but may stem from “developmental differences in symptom expression.”

Vulnerability. Traumatic experience contributes to PTSD development, and the “vulnerable, anxious child who is exposed to violence appears to be at greater risk,” according to Silva et al.⁸ After a regression analysis of 59 traumatized children, the research team concluded that PTSD risk is greatest when violence occurs within the family.

A review of 25 studies found that three factors appear to mediate the development of PTSD in children:

the severity of the trauma exposure
trauma related to parental distress
temporal proximity to the traumatic event.⁹