Principal Author: Judith A. Cohen, M.D. This summary was developed by the Work Group on Quality Issues: William Bernet, M.D., Chair, and John E. Dunne, M.D., former Chair; Maureen Adair, M.D., Valerie Arnold, M.D., R. Scott Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and David Rue, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder is available to Academy members on the World Wide Web (www.aacap.org) and appears in the October 1998 Supplement to the Journal. The full text of these parameters was reviewed at the 1997 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council on April 1, 1998. Reprint requests to AACAP, Communications Department, 3615 Wisconsin Avenue N.W., Washington, DC 20016. © (1998) by the American Academy of Child and Adolescent Psychiatry.
ABSTRACT
This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder. Major recommendations include the use of clinical interviewing with specific questioning about posttraumatic stress symptoms to diagnose this disorder; recognition of developmental considerations that may impact on how posttraumatic stress disorder symptoms manifest in children; and the use of trauma-focused treatment interventions. Limitations and controversies regarding the present state of knowledge in the area of childhood posttraumatic stress disorder are also discussed. Key Words: posttraumatic stress disorder, trauma, trauma-focused therapy, children, adolescents, evaluation, treatment, practice parameters, guidelines.
These guidelines offer the practitioner direction in diagnosing and treating posttraumatic stress disorder (PTSD) in children and adolescents. Recommendations are based on extensive review of the scientific literature and clinical consensus among experts in the subject. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1998). Since the introduction of PTSD as a diagnostic category in 1980, there has been a growing awareness that children and adolescents as well as adults can experience this disorder. Because it is a relatively new diagnosis, because the diagnostic criteria have changed with each DSM revision since 1980, and particularly because developmental factors may significantly impact on the clinical presentations of this disorder, practice guidelines can be of value in assisting clinicians in the diagnosis and treatment of childhood PTSD, and as a result, also be of value to the children and families of children who develop this disorder. There is controversy regarding the assessment of PTSD in children, which contributed to the decision to develop practice guidelines for this disorder. The first controversy relates to the number of symptoms from each PTSD symptom category (reexperiencing, avoidance, and increased arousal) which must present to diagnose PTSD in children. Perhaps an even more basic issue is whether children who meet full diagnostic criteria are different in some significant way from children who meet "partial" PTSD criteria (i.e., exhibit several PTSD symptoms but do not meet criteria as defined by DSM-IV). Is PTSD at full criteria a discrete disorder in any functional way, or do PTSD symptoms occur on a continuum of frequency and severity, with "full" criteria representing an arbitrary cut-off point rather than a clinically meaningful dividing point? There are no empirical data that directly address these issues, although it has been documented that the percentage of children diagnosed with PTSD varies greatly depending on which DSM (III, III-R, or IV) criteria are used and whether a liberal or conservative threshold is used to define "persistent" symptoms. Children may experience long periods of reexperiencing that alternate with long periods of avoidance and numbing, rather than experiencing both in the same time period. This may lead to significant underdiagnosis of PTSD in children. If avoidance and affective numbing are highly effective, the child may appear to be unaffected by the trauma, or reexperiencing symptoms may be masked. Thus, although DSM-IV diagnostic criteria are used to diagnose PTSD in children, there is ongoing debate regarding how accurately these criteria fit childhood PTSD. Many authors have suggested the need for developmental stage-specific diagnostic criteria for PTSD, since there is some evidence that children of different developmental stages display different PTSD symptom clusters. Extensive field trials are thus needed to evaluate the validity of current PTSD criteria for children and adolescents. Another controversy regarding PTSD is whether this disorder represents a normal reaction to abnormal stress or rather is a relatively rare psychiatric disorder with clear predisposing factors and distinct physiologic abnormalities. In other words, are trauma survivors with PTSD psychiatrically damaged or are they experiencing normal adaptation? Although this controversy is far from resolved, it would appear that one can recognize predisposing risk factors and the psychiatric comorbidity of PTSD without blaming the victim of trauma. A reasonable practice parameter in this regard is to offer treatment to children with clinically significant PTSD symptoms (i.e., severe enough to impair functioning in at least one important domain), whether or not they meet strict DSM-IV PTSD diagnostic criteria.
ASSESSMENT
To meet DSM-IV criteria for PTSD, the child must have been exposed to an "extreme" stressor, and the child's response to that stressor must include a specific number of symptoms from each of three broad categories: reexperiencing, avoidance/numbing, and increased arousal. There have been revisions in DSM-III-R and DSM-IV regarding the specific symptoms included under each of these categories, with progressively more attention given in each revision to alternative ways in which children may manifest these symptoms. As noted above, there have also been changes and ongoing debate with regard to whether the required number of symptoms in each category is appropriate for children. The current requirements are that the child must exhibit at least one reexperiencing symptom, three avoidance/numbing symptoms, and two increased arousal symptoms to receive a DSM-IV PTSD diagnosis. Reexperiencing symptoms include recurrent and intrusive distressing memories of the event, which in young children may be manifested by repetitive play in which traumatic themes occur; recurrent distressing dreams about the trauma or for children, frightening dreams without recognizable content; acting or feeling as if the trauma were recurring, including trauma-specific reenactment; intense distress at exposure to cues which symbolize or resemble an aspect of the trauma; and physiological reactivity at exposure to such cues. Avoidance of stimuli associated with the event and numbing of general responsiveness must not have been present prior to the trauma, and are manifested by efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid reminders of the trauma; amnesia for an important aspect of the trauma; diminished interest or participation in normal activities; feelings of detachment or estrangement from others; restricted affective range; and a sense of a foreshortened future. Persistent symptoms of increased arousal must be newly occurring since the trauma and must include sleep difficulties, irritability or angry outbursts; difficulty concentrating; hypervigilance; and exaggerated startle response. Symptoms must be present for at least 1 month and cause clinically significant distress or impairment in functioning. Further information on the clinical manifestations of PTSD symptoms at different developmental stages is included in the complete parameters. Cultural factors may also influence the manner in which PTSD symptoms are manifested. Clinicians should be aware of developmental and cultural variations in evaluating children for the presence of PTSD. The assessment of PTSD in children depends first and foremost on careful and direct clinical interviews with the child and the parent or primary caretaker. (If a parent is the alleged perpetrator of child abuse or domestic violence which is the identified traumatic event, the nonoffending parent or other caretaker should be interviewed.) Briefly, both parent and child should be asked directly about the traumatic event, and about PTSD symptomatology in detail. This should include specific questions related to reexperiencing, avoidant, and hyperarousal symptoms as described in DSM-IV. Particular attention should be given to the use of developmentally appropriate language when asking the child about these PTSD symptoms. The clinician should be aware of developmental variations in the presentation of PTSD symptomatology, particularly with preschool children, and should include questions about these symptoms when interviewing young children. PTSD is unique among psychiatric disorders because diagnosing it requires the presence of an etiologic event, i.e., an extreme stressor or traumatic event. Historically, clinicians have never had to prove exposure of the patient to the trauma to diagnose PTSD, beyond ascertaining the patient's self-reported exposure. Self-report has been the standard for establishing the presence of the traumatic event in adults with PTSD, and most empirical studies have depended on self-reported exposure in studying PTSD. There are several important differences between clinical and forensic evaluations; these practice parameters apply to clinical rather than forensic assessments. In some situations it may be optimal for a child to receive an independent forensic evaluation prior to receiving a clinical evaluation and treatment, and in some cases such a forensic assessment may directly address the issue of the child's credibility regarding self-reported exposure to traumatic events. However, there is strong consensus that these two roles (forensic evaluator vs. clinician) should remain separate. There are many unanswered questions regarding how to assess children for the presence of PTSD. Although there are several questionnaires and semi-structured interviews that purport to measure this disorder, there is no single instrument that is accepted as a "gold standard" in making this diagnosis or monitoring its symptom course. In part, the assessment of PTSD is complicated by the requirements of having a certain number of symptoms from each of three categories (reexperiencing, avoidance/numbing, and increased arousal). As a result of this requirement, a single score on any instrument is not sufficient to categorically diagnose PTSD (since a child could have extremely high levels of symptomatology in one category but none in another, etc.). Since parent reports tend to minimize the child's PTSD symptomology, and there are particular difficulties in ascertaining avoidant and numbing symptoms from child self-reports, there is a significant risk of underdiagnosing this disorder. Teachers and other adults may not observe or be aware of many of the salient PTSD symptoms because they may not be manifested at school or may not be obvious to the untrained observer. Physiologic measures of hyperarousal are not adequately standardized in children, nor would such measures adequately assess reexperiencing or avoidant symptoms. Thus, there are considerable limitations inherent in trying to assess PTSD in children. On the other hand, there is concern that some clinicians overdiagnose PTSD due to a lack of awareness of the specific diagnostic criteria required, and a misperception that the presence of reexperiencing and anxiety symptoms alone following exposure to an extreme stressor are adequate to diagnose PTSD. One area of agreement among experts in assessing PTSD in children relates to the need to directly ask the child about PTSD symptoms as they relate to the stressor. Often clinicians do not directly ask children about the traumatic event and its impact on the child, either for fear of reminding the child of things he or she may be better off forgetting, because of the clinician's own avoidance of painful discussions, or in some cases, for fear of tainting the child's description of the trauma (for example, if the child will be testifying in court against the perpetrator). It is likely that such clinicians will miss important PTSD symptoms. There is a strong clinical consensus that if children are not asked, they are less likely to tell about their PTSD symptoms. Several semi-structured interviews and several self- and parent-report instruments for assessing PTSD related symptoms may be helpful in assessing PTSD in children. These are described in the full practice parameters. None of the existing self- or parent-report measures is optimal. Several authors have emphasized the need for multisource, multiscore assessment instruments that measure PTSD across different areas of functioning. Although some of the available assessment instruments may have great value in evaluating and following the clinical course of children with PTSD symptoms, they cannot take the place of a careful and direct clinical interview in assessing PTSD diagnostic criteria. The use of semi-structured interviews with documented reliability and validity of the PTSD section, although cumbersome and time-consuming to administer, may be of value to clinicians without extensive clinical experience in assessing children for PTSD symptoms. However, to date, only three of these semi-structured interviews have been modified to correspond to DSM-IV criteria and none has been extensively psychometrically evaluated with regard to DSM-IV PTSD diagnosis. Assessment of PTSD symptoms continues to rely primarily on the clinical interview of the child and parent. When assessing younger children, it is essential to be aware of developmentally determined variations in clinical presentation of PTSD, and alternative assessment strategies may be necessary.
DIFFERENTIAL DIAGNOSIS
In PTSD, the stressor must be of an extreme nature, although the clinician has some latitude in determining whether a particular stressor is "extreme." In contrast, the stressor can be of any severity in an adjustment disorder. DSM-IV specifies that an adjustment disorder diagnosis should be given if the response to an extreme stressor does not meet criteria for PTSD, or in situations in which a PTSD symptom pattern occurs in response to a non-extreme stressor (such as the birth of a sibling, moving to a new neighborhood, starting a new school). If avoidance, numbing, and increased arousal symptoms were present prior to exposure to a traumatic event, a diagnosis of PTSD may not be appropriate after the stressor. Other diagnoses (e.g., a mood disorder or another anxiety disorder) should be considered if the stressor did not clearly precede the PTSD symptoms. However, careful questioning may be needed to ascertain the onset of chronic stressors such as ongoing child abuse or domestic violence. If the symptom pattern in response to this stressor meets criteria for PTSD and for another mental disorder, such as major depressive disorder, ADHD, or mixed substance abuse, these diagnoses should be given in addition to PTSD. Acute stress disorder (ASD) is distinguished from PTSD because the symptom pattern in ASD must both occur and resolve within 4 weeks of the traumatic event. Recurrent intrusive thoughts occur in obsessive compulsive disorder (OCD) but are not related to an experienced traumatic event as in PTSD. In OCD, the intrusive thoughts are generally experienced as inappropriate. Flashbacks in PTSD should be distinguished from illusions, hallucinations, and other perceptual disturbances occurring in psychotic disorders unrelated to exposure to an extreme stressor. Chronic PTSD may present with a preponderance of symptoms such as dissociation, self-injurious behaviors, substance abuse, and/or conduct problems, which may obscure the posttraumatic origin of the disorder. Awareness of this alternative presentation and careful history taking are necessary to avoid overlooking the presence of a PTSD diagnosis in these situations. As with all other child and adolescent psychiatric disorders, the diagnostic criteria for PTSD include symptoms that may be reported as the result of contagion, suggestibility, malingering, or for personal gain. It is highly unlikely that such factors would cause a child to meet full criteria for PTSD. These factors should be considered, however, when PTSD-like symptoms are observed without a discernible history of trauma.
TREATMENT
Very limited empirical support exists for various treatment approaches for children with PTSD. Three recent studies lend empirical support for the use of cognitive-behavioral therapy (CBT) in treating children with PTSD. Despite the paucity of empirical treatment outcome studies, there is generally strong clinical consensus among experts in the field regarding essential components of appropriate treatment interventions for children with PTSD. These components are: direct exploration of the trauma, use of specific stress management techniques, exploration and correction of inaccurate attributions regarding the trauma, and inclusion of parents in treatment. Due to the lack of empirical studies evaluating efficacy of treatment for PTSD in children, it is premature to recommend a hierarchy of interventions. However, outpatient psychotherapy generally is considered the preferred initial treatment, with psychotropic medications as an adjunctive treatment in children with prominent depressive or panic symptoms.
PSYCHOTHERAPY
There is strong clinical consensus, as well as limited empirical evidence, to support direct exploration of the traumatic event and its impact with the child, which makes intuitive sense if PTSD is conceptualized as a direct response to that event. However, some therapists avoid directly discussing the event for fear of transiently increasing the child's symptomatology or because of their own need to avoid the negative affect associated with such discussion. There is a powerful adult desire to "let sleeping dogs lie" in children, even if PTSD symptoms suggest that the impact of the trauma is not dormant. Many therapists have been discouraged from directly discussing certain traumatic events due to concern that this may taint the child's subsequent legal testimony. This concern has arisen from recent controversy regarding the suggestibility of children's memories and the idea that repeated suggestive questioning may change a child's memory regarding facts of the event. However, direct exploration of the traumatic experience and its meaning to the child as used in psychotherapy does not involve repeated suggestive attempts to alter the child's description of what occurred. Rather, exploration involves encouraging a child, through relaxation and desensitization procedures, to describe the event with diminished hyperarousal and negative affective states. Several authors consider trauma-focused discussion and reconsideration to be the most critical component of treatment for PTSD in children. Specific stress management techniques frequently are used in conjunction with direct discussion of the traumatic event. Neuro-cognitive models have been offered to explain why these interventions may be successful in alleviating PTSD symptoms. Often these techniques, such as progressive muscle relaxation, thought-stopping, positive imagery, or deep breathing are taught to the child prior to detailed discussions of the trauma. This enables the child to gain a sense of control over thoughts and feelings rather than feeling overwhelmed by them, and allows the child to approach the direct discussion of the traumatic event (desensitization procedures) with confidence that discussion will not lead to uncontrollable reexperiencing symptoms and fear. Stress management techniques also are useful to the child outside of the therapeutic context, if and when reexperiencing phenomena occur. Another element common to most interventions for traumatized children involves evaluation and reconsideration of cognitive assumptions the child has made with regard to the traumatic event. Attributional distortions regarding the trauma, such as "It was my fault," or "Nothing is safe anymore," should be explored in depth, and challenged in a manner that goes beyond mere reassurances. Challenging attributions most often is accomplished through step-by-step logical analysis of the child's cognitive distortions during therapy sessions. Related issues, such as survivor's guilt or omen formation, also should be addressed with these interventions. Consensus also exists that inclusion of parents and/or supportive others in treatment is important for resolution of PTSD symptoms. Strong empirical evidence shows that parental emotional reaction to the traumatic event and parental support of the child are powerful mediators of the child's PTSD symptomatology. It is also helpful to include parents in treatment so that they can monitor the child's symptomatology and learn appropriate behavioral management techniques, both in the intervals between treatment sessions and after therapy is terminated. Helping parents resolve their own emotional distress related to the trauma (to which the parent usually has had either direct or vicarious exposure) can help the parent be more perceptive of and responsive to the child's emotional needs. Many parents can benefit from direct psychoeducation regarding their child's PTSD symptoms and how to manage them. Most authors who have described psychotherapeutic interventions for children with PTSD have recommended the inclusion of one or more parent-focused or family techniques. There is little empirical evidence comparing the efficacy of group versus individual therapy for children with PTSD. It is likely that in general, a trauma-focused approach that treats the child's specific symptoms is more important than the treatment modality (group, family, individual) used. Although most treatment descriptions have emphasized individual child therapy, several authors have focused on the efficacy of providing crisis intervention to parents, teachers, and/or children in groups at school or other community settings. Many of these interventions used convenience samples of schools or towns exposed to a common traumatic event. Group interventions in such situations offer the advantage of providing the most timely intervention to the largest possible number of exposed children, and should be strongly considered in disaster situations. Eye movement desensitization and reprocessing (EMDR) is an intervention that has been used in adults with PTSD. There is some empirical support for its effectiveness in adults. The risks and benefits of EMDR have not been evaluated empirically in children and adolescents. Clinicians also should be aware that not all behavioral and emotional problems in children with PTSD are necessarily related to the trauma. In treating children with PTSD, it is essential to recognize preexisting and comorbid psychiatric disorders, and provide appropriate interventions for these difficulties in conjunction with trauma-focused treatment.
PSYCHOPHARMACOLOGY
Although several authors have postulated a variety of neurophysiological changes that may explain the development and maintenance of PTSD in children, very few studies have empirically evaluated these theories. In addition, despite a lack of randomized trials supporting the efficacy of psychotropic medications in treating PTSD, clinicians have prescribed a variety of medications for children with these disorders. Carbamazepine, propranolol, clonidine, and guanfacine have been reported to ameliorate PTSD symptoms in children, but none of these reports used a control group or randomization of treatment. It has been suggested that antidepressants may be helpful for some children with PTSD, particularly those with a predominance of depressive or panic symptoms, but to date, there have been no empirical studies of antidepressants for PTSD in children. At this time there is not adequate empirical support for the use of any particular medication to specifically treat PTSD in children. However, clinical judgment may be used to determine the appropriateness of psychopharmacologic interventions in specific children with PTSD who have prominent depressive, panic, and/or ADHD symptoms. As a general practice, in these situations, medication should be selected on the basis of established practice in treating the comorbid conditions (i.e., antidepressants for children with prominent depressive symptoms, etc.).
REFERENCE
American Academy of Child and Adolescent Psychiatry (1998), Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Amer Acad Child Adol Psychiatry 37(10suppl)
