Continuing Education Activity

Posttraumatic stress disorder constitutes the exposure to a potentially traumatic event, followed by the manifestations of intrusive thoughts, avoidance of associated stimuli, negative modifications in mood, and alterations in arousal. This disorder can present differently in the pediatric population. This activity outlines the evaluation and management of posttraumatic stress disorder in children and reviews the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Identify the etiology of posttraumatic stress disorder in children.
• Review the evaluation of posttraumatic stress disorder in children.
• Outline the management options available for posttraumatic stress disorder in children.

Introduction

Posttraumatic stress disorder (PTSD) is a mental disorder that may develop in some children and adolescents after exposure to a traumatic event. Traumatic events may include incidents that involve serious harm to self or others and include accidents, natural disasters, sexual or physical trauma, natural disasters, and violence.[1]

Since time immemorial, scientists have pursued the ever-elusive causal origins of disease processes. To the detriment of humanity, these endeavors frequently resulted in fruitless pursuits, as we still can only postulate the etiologies of many illnesses. Thus, the causal nature of posttraumatic stress disorder (PTSD) places it in the company of a scant few psychiatric diagnoses where etiology is known. The temporal association between the event exposure and the subsequent symptom manifestation is not simply a post hoc fallacy. Not to be misled by the putative simplistic nature of the etiology, the consequent psychiatric sequelae can, in turn, be debilitating. Moreover, recent studies have unmasked unsettling discoveries regarding pediatric considerations in the setting of PTSD. It has been suggested that a substantial number of children have gone inappropriately undiagnosed because of the insufficient sensitivities of previous guidelines. Children often react differently to stressful events, and because of this, the pediatric phenomenology of PTSD differs from that of the adults.[2] The transition from DSM IV to DSM-V acknowledges this inconsistency, made evident by the additional criteria specific to PTSD for children six years or younger. 

PTSD is defined by four symptom clusters, including avoidance, negative alterations in cognition and mood, intrusion, and hyperarousal per DSM-5. The consequences of PTSD are often deleterious with adverse outcomes in physical and mental health besides impaired social and occupational functioning.[3]

Etiology

As mentioned in the introduction, there is a direct causal relationship between exposure to potentially traumatic events (PTEs) and the onset of PTSD. The most commonly reported PTEs in the pediatric population include physical injuries, domestic violence, and natural disasters.[4][5]

Epidemiology

One study reports that up to 60% of children and adolescents have been exposed to a PTE.[6][7] Of this exposed population, an estimated 30% subsequently develop PTSD symptomatology; most will only experience ephemeral symptoms, whereas a few unfortunate individuals will experience more chronic life-long sequelae. Current estimates suggest 10% of children less than 18 years of age are diagnosed with PTSD, with girls four times more likely than boys to develop it.[8]

History and Physical

Common to both the adult and pediatric population are the foundational elements of post-traumatic stress disorder: re-experiencing of the trauma through intrusive and recurrent thoughts, avoidance of associated stimuli, negative modifications in mood, and alterations in reactivity and arousal. However, the phenomenology of PTSD in younger demographics is often more complex and can mimic variant internalizing and externalizing disorders.[6] It is likely that adults will relegate manifestations of PTSD as disagreeable youthful behavior.[9]

Internalizing and externalizing symptomatology that can manifest in the setting of PTSD include separation anxiety, shame, guilt, low frustration tolerance, hyperarousal, impulsivity, temper outbursts, hostility, defiance, aggression, irritability, and mood changes.[10][11] Moreover, complex trauma disorder can present even more ambiguously in children. Whereas a more discrete change in behavior transpires in acute PTE, exposure to protracted PTEs incites more insidious and pervasive complications.[12][3][12]

Evaluation

It is critical in the evaluation of pediatric post-traumatic stress disorder that the clinician obtains both the child’s and caregivers’ reports.[13] Once the respective histories have been elicited, the clinician will use diagnostic tools to assess for the existence of PTSD. In the transition to DSM-V, specific diagnostic criteria for PTSD in those less than six years of age were added.

 DSM-V Diagnostic Criteria for Post-traumatic Stress Disorder for Children 6 years and Younger: [Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013].

1. In children six years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
   1. Directly experiencing the traumatic event(s)
   2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers
      1. Does not include events that are witnessed only in electronic media, television, movies, or pictures
   3. Learning that the traumatic event(s) occurred to a parent or caregiving figure
2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred;
   1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
   2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s)
   3. Dissociative reactions in which the child feels or acts as if the traumatic event(s) were recurring
   4. Intense or prolonged psychological distress at exposure to internal or external clues that symbolize or resemble an aspect of the traumatic event(s)
   5. Marked physiological reactions to reminders of the traumatic event(s)
3. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s)
   1. Persistent Avoidance of Stimuli
      1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s)
      2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s)
   2. Negative Alterations in Cognitions
      1. Substantially increased frequency of negative emotional states.
      2. Markedly diminished interest or participation in significant activities, including constriction of play.
      3. Socially withdrawn behavior
      4. Persistent reduction in the expression of positive emotions
4. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
   1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums)
   2. Hypervigilance
   3. Exaggerated startle response
   4. Problems with concentration
   5. Sleep disturbance
5. The duration of the disturbance is more than one month.
6. The disturbance causes clinically significant distress or impairment [14]

Specify whether:

            With Dissociative symptoms:

• Depersonalization
• Derealization

Specify if:

• With delayed expression (not met until at least six months after the event)

(For children greater than six years old, the clinician will refer to DSM-V criteria for adults) 

Additional evidence-based screening tools have been commonly implemented in the clinical setting. These include the UCLA Posttraumatic Stress Disorder – Reaction Index (UCLA-PTSD-RI), the Trauma Symptom Checklist for Children (TSCC), and The Screening Tool for Early Predictors of PTSD (STEPP).[6][15]

Treatment / Management

Psychotherapy is encouraged by the American Academy of Child and Adolescent Psychiatry (AACAP) as the first-line treatment in the setting of pediatric PTSD.[6] Trauma-centered cognitive-behavioral therapy currently has the most unequivocal evidence supporting its implementation in the treatment of pediatric PTSD.[16] Eye movement desensitization and reprocessing therapy (EMDR) is a popular alternative. However, more research is required to properly assess its efficaciousness.[17]

Other therapies include play therapy, psychological first aid, and multisystemic therapy. Because of developmental neurobiological differences between youth and adult patients, the consensus remains ambiguous regarding the administration of pharmacological agents.[18] Of the psychotropic alternatives, selective serotonin reuptake inhibitors (SSRI) have the most support. Lastly, in moderate to severe cases, children should be referred to specialists who are trained to treat PTSD in the pediatric population.

Differential Diagnosis

The phenomenology of post traumatic stress disorder in the pediatric setting can mislead clinicians towards a misdiagnosis. Disorders that can mimic the aforementioned internalizing and externalizing features of PTSD include major depressive disorder, generalized anxiety disorder, oppositional defiant disorder, intermittent explosive disorder, conduct disorder, attention deficit hyperactivity disorder, and obsessive-compulsive disorder.[19] Additional differentials in common with adult PTSD include adjustment disorder, acute stress disorder, panic disorder, depersonalization or derealization disorder, and malingering.[20]

Prognosis

Chronic PTSD can cause significant distress in a child’s life and ultimately result in functional disabilities.[21][22] Fortunately, research suggests that prompt recognition and intervention in youths at risk can significantly obviate grim psychiatric sequelae.

Complications

Complications arise secondary to functional impairments, resulting from psychic stress. With hopes to combat these impairments, patients commonly resort to self-medication; such a stratagem involves inappropriate use of anxiolytics, alcohol, or recreational drugs. Unfortunately, these immature coping mechanisms exacerbate the psychic illness, thus further debilitating the patient, precipitating an elegiac positive feedback loop.[23]

Deterrence and Patient Education

Prior to initial exposure to post-traumatic events, providers and educators can implement proactive measures to equip the youth - especially those at high risk - with beneficial coping skills, safety planning, and psychoeducation.[24] As most families will initially present to their primary care provider for assistance, it is imperative for clinicians to be cognizant of the phenomenology of PTSD in children.[25] Primary healthcare teams are, for lack of a better colloquialism, ‘the first line of defense’ in the setting of PTE.[26]

Providers suspicious of impending manifestations of PTSD in the acute aftermath of a PTE should ardently monitor the patient, as well as enlighten the family regarding salient features to be aware of in this condition. Furthermore, some studies suggest that those who do not meet the full diagnostic threshold for PTSD may benefit from a more flexible dimensional perspective, as they still may be at risk for developing undesirable psychiatric sequelae.[27]

Enhancing Healthcare Team Outcomes

Post-traumatic stress disorder is a debilitating disorder. It can cause life-long impairment and dysfunction. In the pediatric setting, it can be even more deleterious, as it can go undiagnosed and thus untreated for an extended period of time. Because of the unique presentation in the pediatric population, it is exigent that healthcare workers remain vigilant and aware of the onset of symptomatology. Primary care physicians, pediatricians, nurse practitioners, psychotherapists, and licensed clinical social workers will often be the 'first line of defense,' as parents will often bring their children to them, before considering a psychiatrist. Thus, primary care providers must remain informed regarding the phenomenology in this population. They should not hesitate to refer to a specialist. Interprofessional relations will most benefit the patient. 

"This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities."