Posttraumatic Stress Disorder due to Child Abuse and Neglect Clinical Presentation

  • Author: Angelo P Giardino, MD, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Aug 23, 2011
 

History

Assessment of posttraumatic stress disorder (PTSD) begins with clinical interviews of the child and the caregiver. The interviewer should be aware that caregivers may also be involved in abuse.

For many reasons, the traumatic experience itself is not openly discussed. Parents may be unaware of or in denial of the traumatic event, and children may be afraid to disclose what happened to them. Clinicians should be aware that children are just as much at risk of victimization from people they know as from strangers.

The interview with caregivers should elicit the child's developmental history, family history, the abuse history (if known), and their perception of what has changed in the child since the traumatic event.

The symptoms of PTSD can be subtle and may resemble other psychiatric and behavioral disorders. Children who have experienced trauma may exhibit sleep difficulties, attention deficit disorders, aggressive and defiant behavior (leading to the misdiagnosis of a conduct disorder), anxiety symptoms, phobias, and social avoidance, as well as depression, agitation, or learning difficulties.

A formal diagnosis of PTSD requires that symptoms persist for more than 1 month (similar symptoms < 1 mo duration may meet criteria for acute stress reaction). The most common symptoms of PTSD include the following:

  • Re-experiencing the trauma: Children may re-experience the trauma in various ways.
    • Flashbacks and memories: These may be intrusive and may interfere with function at home or school. In children, intrusive memories are more common than flashbacks. Flashbacks are vivid experiences that include visual and auditory elements from the trauma; the child may feel like the trauma is happening all over again and may react with intense fear. Flashbacks may be more common among children who have depression in addition to PTSD.
    • Behavioral re-enacting: Children may act out aggressively toward others or do and say things that they witnessed. Children are often unaware that this behavior is connected to their abuse.
    • Re-enacting through play: The child may represent the traumatic experience through repetitive play. For example, he or she may repeatedly play exactly the same scene of people fighting, a car crashing, or a house burning down.
  • Symptoms of avoidance of memories or situations that remind the child of the traumatic event: The child may exhibit a general restriction in daily activities (eg, avoiding activities that could prompt excitement or fear) or may present with specific fears. They may lose previously acquired skills and show regression.
    • Avoidance: Children or adolescents with PTSD avoid thinking or talking about topics that could remind them of traumatic experiences. Some, especially young children, may refuse outright to acknowledge that the abuse occurred.
    • Triggers: Children may react to and attempt to avoid stimuli that trigger memories of the abuse. Some common triggers include phrases, songs, scenes on television, a perfume, or a person's appearance. Anniversaries, dates, and certain places may also trigger memories.
  • Sleep disturbance: Children may experience nightmares, fear of the dark, and fear of sleeping alone.
  • Physical contact: Children with PTSD may have difficulty managing physical contact because of a heightened sense of vulnerability or because it may be a reminder of abuse.
  • Emotional numbing: To manage difficult reactions to the abuse, children with PTSD may have to suppress memories and almost all emotional reactions. These children may seem emotionally numb. Normal human interactions appear not to resonate with them; they laugh less and show less human connection and empathy.
  • Sense of foreshortened future: PTSD is associated with a sense of pessimism about the future, with affected people occasionally feeling that there is no future for them. In children, this may manifest as the belief that they will never become adults or a lack of interest in planning for the future.
  • Dissociation: Dissociative episodes are periods of disconnection from the external environment. A dissociating child may appear to be absent and unresponsive for a few minutes. Events that remind the child of danger or threat may trigger these episodes. Children who experience dissociation soon after the disclosure of abuse are at significantly increased risk for developing PTSD. Some believe that this is because dissociation inhibits the appropriate level of experiencing and expressing their emotions concerning the abuse.
  • Symptoms of increased arousal and hypervigilance: The child may appear on edge, noticing small changes in the environment and closely tracking the behaviors of others. They may exhibit an increased startle response.
  • Cognitive function: A small study of neuropsychologic function in children with PTSD found deficits in sustained attention, problem solving, and abstract reasoning.
  • Sleep problems: The child may have much difficulty falling asleep. Many fears are experienced at night, such as imagining faces on the wall or eyes looking at the child. Many sleep disruptions, frequent nightmares, and awakenings at night can occur. Nightmares are common in children with PTSD. They may directly relate to the abuse or, more commonly, consist of frightening dreams with more generalized themes.
  • Behavioral inhibition: Some children with PTSD are inhibited and overly pleasing and attentive to their caregivers. This may be the case, particularly if the child has reason to fear that angering or disappointing the caregiver can trigger a negative encounter.
  • Delays in development and learning: In younger children, traumatic events, particularly long-standing trauma or high-stress living conditions, are more likely to delay the development of the child in several important domains, such as reciprocity, relatedness, cognitive abilities, and adaptive behavior in general. Traumatized children may appear almost autistic and may display great difficulties with learning.
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Physical

No specific physical signs of PTSD exist. The pediatrician may suspect PTSD in the child who is excessively frightened of being touched or approached by the doctor. When this circumstance arises, inquire about the child's history of traumatic experiences. In the case of physical or sexual abuse, the physician may detect the associated physical signs (see Child Abuse & Neglect: Physical Abuse and Child Abuse & Neglect: Sexual Abuse).

Studies have found that only a small minority of sexually abused children have physical evidence of abuse.

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Causes

Not every child or adolescent who experiences trauma such as child abuse or neglect develops PTSD. The development of PTSD is unpredictable following a traumatic event, and, as more research on the condition emerges, it appears that PTSD can be viewed as a phenomenon resulting from a gene-environment interaction. The onset of PTSD may be initiated through either direct or witnessed exposure to a single or chronic trauma.

See Frequency for more details related to specific types of traumatic events, such as sexual assault. Some differentiate trauma exposures into two types, as follows:

  • Type I: Single, acute, unpredictable stressor. One person may have repeated exposures to this kind of stressor.
  • Type II: Chronic, enduring stressors, such as ongoing physical or sexual abuse, characterize type II.

The frequency and total number of traumatic events experienced (ie, chronicity) appears to influence the presence and severity of psychological sequelae. This is also often complicated by further traumatic experiences; for example, children who experience abuse and neglect may later be taken into state custody and moved among foster homes and child protective services (CPS) placements. As another example of additive traumatic exposures, children who experience a traumatic accidental injury may subsequently undergo painful surgery and invasive procedures in the hospital, which may only compound the initial traumatic experience.

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Contributor Information and Disclosures
Author

Angelo P Giardino, MD, PhD  Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc

Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Coauthor(s)

Toi Blakley Harris, MD  Assistant Professor and Director of Diversity and Education, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Founder and Director, Texas Regional Psychiatry Minority Mentor Network

Toi Blakley Harris, MD, is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC  Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Specialty Editor Board

Carol Diane Berkowitz, MD  Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH  Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors acknowledge the encouragement and support of Dr. John Sargent, who has taught us much and who has set a standard for us in terms of his being an excellent mentor and modeling for us the highest degree of professionalism as a colleague who works tirelessly to ameliorate the effects of child abuse and neglect among the children and families we serve.

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