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 they are from strangers.
The caregiver interview with should elicit the child’s developmental history, family history, the abuse history (if known), and the caregiver’s perception of what has changed in the child since the traumatic event.
The symptoms of PTSD can be subtle and may resemble those of 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.
As noted (see Overview), a formal diagnosis of PTSD requires that symptoms persist for more than 1 month (similar symptoms of less than 1 month’s duration may meet the criteria for acute stress disorder [ASD]). The most common symptoms of PTSD include the following:
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Reexperiencing the trauma
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Symptoms of avoidance of memories or situations that remind the child of the traumatic event
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Sleep problems
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Emotional numbing
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Sense of foreshortened future
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Dissociation
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Symptoms of increased arousal and hypervigilance
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Altered cognitive function
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Behavioral inhibition
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Regression
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Suicidal ideation (for abuse)
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Difficulties with physical contact (for abuse)
Children may reexperience traumatic events in various ways, such as the following:
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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, though flashbacks may be more common in children who have depression in addition to PTSD; flashbacks are vivid experiences that include visual and auditory elements from the trauma, potentially causing the child to feel as if the trauma is happening all over again and triggering an intense fear
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Behavioral reenactment - Children may act out aggressively toward others or do and say things that they witnessed; they are often unaware that this behavior is connected to their abuse
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Reenactment through play - The child may represent the traumatic experience through repetitive play—for example, by repeatedly playing exactly the same scene of people fighting, a car crashing, or a house burning down
As a means of avoiding painful memories or situations, children may exhibit a general restriction in daily activities (eg, staying away from activities that could prompt excitement or fear) or may present with specific fears. They may lose previously acquired skills and show regression.
Children or adolescents with PTSD generally 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. Children may react to and attempt to avoid stimuli that trigger memories of the abuse. Common triggers include phrases, songs, scenes on television, a perfume, or a person’s appearance; anniversaries, dates, and places may also trigger memories.
Sleep problems are frequently noted. The child may find it very hard to fall asleep, may exhibit pronounced fear of the dark, or may be reluctant to sleep alone. 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, may consist of frightening dreams with more generalized themes.
Children with PTSD may have difficulty in managing physical contact, either because they have a heightened sense of vulnerability or because the contact serves as a reminder of abuse.
To manage difficult reactions to abuse, children with PTSD may have to suppress memories and almost all emotional reactions. As a result, 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.
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 pessimism may be manifested as a belief that they will never become adults or as a lack of interest in planning for the future.
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 appropriate experiencing and expression of children’s emotions concerning the abuse.
Children exhibiting increased arousal and hypervigilance 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 is commonly affected. A small study of neuropsychologic function in children with PTSD found deficits in sustained attention, problem solving, and abstract reasoning.
Some children with PTSD are inhibited with respect to behavior and are overly pleasing and attentive to their caregivers. This is particularly likely to be the case if a child has reason to fear that angering or disappointing the caregiver can trigger a negative encounter.
In younger children, traumatic events, particularly long-standing trauma or high-stress living conditions, are more likely to delay development in several important domains, such as reciprocity, relatedness, cognitive abilities, and adaptive behavior in general. Traumatized children may appear almost autistic and may experience great difficulties with learning.
Physical Examination
No specific physical signs of PTSD exist. The pediatrician may suspect PTSD in a child who is excessively frightened of being touched or approached by the doctor. When this circumstance arises, an inquiry should be made into the child’s history of traumatic experiences. In the case of physical or sexual abuse, the physician may detect the associated physical signs (see Physical Child Abuse and Child Sexual Abuse). Only a small minority of sexually abused children have physical evidence of abuse.
The lack of specificity notwithstanding, numerous physical findings have been noted in children with PTSD; however, it is not clear whether these findings are due to PTSD, to predisposing factors, or to comorbid problems (eg, substance abuse). Findings include the following:
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Hippocampal volume is smaller in individuals with PTSD [24]
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Areas of the brain that are involved in threat perception (eg, amygdala) have altered metabolism in adult trauma survivors with PTSD
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Activity of the anterior cingulate (an area of the brain that inhibits the amygdala and other brain regions involved in the fear response) is decreased in people with PTSD
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Basal cortisol levels are low
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Cortisol response to dexamethasone is increased
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Concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus are increased
Some studies have shown that children who have been abused have higher cortisol levels than control subjects do. Studies also indicate that adults with PTSD who were abused as children have higher cortisol levels than those who were abused and did not develop PTSD. Some research evidence indicates that girls who have been sexually abused have increased catecholamine activity. Trauma survivors have pituitary adrenocortical hyperresponsivity to stress. PTSD leads to increased pulse, blood pressure, muscle tension, and skin resistance.
A problem with the research is that changes in physiologic measures, such as heart rate and skin conductance, often appear to be the same in individuals with current PTSD and those with prior PTSD. This finding indicates that the changes may represent either a predisposition or a permanent change resulting from PTSD (eg, a trait rather than a state).
Complications
Children who are exposed to abuse and neglect are at an increased risk for psychiatric complications. For example, sexually abused children are 4 times more likely to develop psychiatric disorders. PTSD diagnosis in children correlates significantly with at least transient suicidal ideation. The following complications are noted:
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Anxiety and phobia - Approximately 30% of children with PTSD develop social anxiety or specific phobia
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Major depression and dysthymia - As many as 40% of children with PTSD develop major depression by age 18 years (compared with 8% of their unaffected peers)
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Aggression - Research findings are mixed as to whether children with PTSD are at increased risk for aggressive or oppositional behaviors
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Substance abuse and dependence - An estimated 46% of children with PTSD develop alcohol dependence, and 25% develop drug dependence
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Attention deficit hyperactivity disorder (ADHD) - The documented incidence of ADHD is higher in those with PTSD
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Suicide - People with PTSD have a higher risk of suicidal ideation, as well as an increased rate of death associated with suicide
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Physical comorbidities - In female children and adolescents, PTSD is associated with chronic fatigue, fibromyalgia, irritable bowel syndrome, chronic pelvic pain, and dysmenorrhea
