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Recognizing Posttraumatic Stress Disorder

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Recognizing and Predicting 

Posttraumatic Stress Disorder in Children

 Laura Arensmeyer

January 2005

I.  Introduction

1. PTSD is an anxiety disorder in which exposure to a trauma results in persistent re-experiencing of the event, avoidance of stimuli associated with the event, and increased arousal.  These symptoms must be present for more than one month and must cause impairment in functioning (APA, 1994).

2. Acute Stress Disorder, or ASD is an anxiety disorder in which exposure to a trauma results in at least three dissociative symptoms in addition to re-experiencing, avoidance and increased arousal.  These symptoms last for two days to four weeks and cause impairment in functioning (APA, 1994).

3.  “Given the high frequency of childhood injury and rates of PTSD in injured children ranging from 13-45%, injury is an important cause of traumatic stress in childhood” (Winston et al., 2003).  Clinicians need reliable tools for recognizing PTSD in children, whose symptoms may differ from adults.  Acute care clinicians need a tool to identify which children have increased risk of developing posttraumatic stress symptoms.

II.  Screening Tool for Early Predictors of PTSD   (STEPP)

1. The objective was to develop a screening tool for determining patients at high risk for persistent posttraumatic stress symptoms after an acute traumatic incident.

2. The STEPP consists of four questions for the parent, four questions for the child, and four questions to be answered using the patient’s medical record.

3. Eighty-five children had a positive STEPP screen (indicating increased risk for PTSD), however, only 21 of these children actually had persistent traumatic stress after three months.  Of the 62 children with a negative STEPP screen, only three actually had persistent traumatic stress symptoms after three months.

4. The specificity of the STEPP was 0.48, while the sensitivity was 0.88.  The STEPP appears to be a good screening tool, especially for identifying patients who are least likely to need follow-up for PTSD (Winston et al., 2003).

III.  Child Stress Disorders Checklist (CSDC)

1. Designed to be used as a measure of ASD symptoms when administered within one month of trauma, or as a measure of PTSD symptoms when administered after one month.  The CSDC takes approximately ten minutes and may be completed by social workers, teachers, nurses or parents.

2. Consists of 36 questions, including one trauma identifier, and five questions about the subject’s response to the trauma.  The remaining thirty questions are about symptoms of ASD and PTSD and fall into the categories of:  re-experiencing, avoidance, dissociation, increased arousal, and impairment in functioning.

3. The results from the CSDC correlated with results from other well-known measures of PTSD symptoms including TBSA burned, CPTSD-RI, CDC, and CBCL-PTSD.  However, the CSDC results did not correlate well with the CBCL-thought, which is not associated with PTSD symptomology.

4. The CSDC scores decreased over time, as would be expected for PTSD.  Also, the dissociation score was the most sensitive to change over time, which correlates with a higher score during the ASD period and a decrease in dissociation symptoms during the PTSD period (Saxe et al., 2003).

IV.  Does presence of ASD predict PTSD?

1. ASD symptoms were assessed within one month of injury using Child Acute Stress Questionnaire (CASQ).  PTSD symptoms were assessed after three months, but no more than twelve months using CAPS-CA.

2. Of the children that completed the study, 14% with positive criteria for ASD and 9% with subsyndromal ASD developed PTSD, versus 4% without ASD.  However, of the children that developed PTSD, 80% did not meet criteria for ASD and 60% were not classified as either ASD or subsyndromal ASD.

3. Based on this data, the presence of ASD or even subsyndromal ASD in children may not be a reliable predictor of future risk for PTSD (Kassam-Adams et al., 2004).

V.  Alternative Criteria for PTSD in Early Childhood

1. Traditional symptoms of PTSD may be difficult to ascertain in young, children without refined verbal skills.  The Alternative Criteria for PTSD, developed for this group, “...were made less dependent on verbalizations and more clearly operationalized on behavioral observations” (Scheeringa et al., 2003).

2. Both criteria included the child’s response to a traumatic event, a re-experiencing cluster, an avoidance cluster, and a hyper arousal cluster, however, the Alternative criteria presents a new fears and aggressions cluster, including new fears, new separation anxiety and new aggression.

4. The Alternative criteria appear to be more sensitive to PTSD symptoms in children under four, however, ongoing revisions to the DSM-IV criteria are necessary to provide proper diagnosis and treatment of PTSD in early childhood (Scheeringa et al., 2001).

VI.  Conclusion

1. Although recent advances have been helpful, additional research of criteria and development of screening tests are necessary to overcome the challenges involved in screening for and recognizing PTSD in children.

2.  “Untreated traumatic stress is a key determinant in poor health outcomes after injury, highlighting the importance of identifying and addressing psychological needs of injured children and their parents” (Winston et al., 2003).

VII.  References

1. American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4^th edition (DSM-IV).  Washington, DC: American Psychiatric Association

2. Kassam-Adams N, Winston F (2004), Predicting Child PTSD: The Relationship Between Acute Stress Disorder and PTSD in Injured Children.  J Am Acad Child Adolesc Psychiatry 43:403-411

3. Saxe G, Chawla N, Stoddard F, et al. (2003), Child Stress Disorders Checklist: A Measure of ASD and PTSD in Children.  J Am Acad Child Adolesc Psychiatry 42:972-978

4. Scheeringa M, Peebles C, Cook C, Zeanah C (2001), Toward Establishing Procedural, Criterion, and Discriminant Validity for PTSD in Early Childhood.  J Am Acad Child Adolesc Psychiatry 40:52-60

5. Scheeringa M, Zeanah C, Myers L, Putnam F (2003), New Findings on Alternative Criteria for PTSD in Preschool Children.  J Am Acad Child Adolesc Psychiatry 42:561-570

6. Winston F, Kassam-Adams N, Garcia-Espa_a F, Ittenbach R, Cnaan A (2003), Screening for Risk of Persistent Posttraumatic Stress in Injured Children and Their Parents.  JAMA 290:643-649

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