Posttraumatic
Stress Disorder
In Childhood and Adolescence: A Review
Eva Yona Deykin, DrPH
Medscape
Mental Health, a
Medscape eMed Journal[TM], (ISSN
1532-043X)
Volume 4, Number 4; July/August 1999
© 1999
Medscape, Inc.]
<Read
It On The Internet>
Abstract
PTSD occurs at a high rate in children and
adolescents, and this rate appears to be rising. Because this syndrome can
have long-lasting effects when it occurs before adulthood, early
recognition and treatment are vital.
Introduction
Posttraumatic stress disorder
(PTSD) is a prolonged, pathologic anxiety that may occur following a
severe trauma in both adults and adolescents. According to the
current definition in the fourth edition of the American Psychiatric
Association's Diagnostic and Statistical Manual (DSM-IV), PTSD
occurs subsequent to a trauma that constitutes a threat to life or
physical integrity and elicits intense fear, horror, or helplessness. In
order to meet full criteria for PTSD, the individual must subsequently
have the feeling of re-experiencing the trauma and have symptoms of
avoidance, numbing, and hyperarousal. The symptom cluster must have been
present for a least a month following the traumatic event.
Although such symptoms have been recognized for
centuries as an extreme reaction to trauma,
it was only with the 1980 publication of the third edition of the Diagnostic
and Statistical Manual (DSM-III) that PTSD was designated as a
psychiatric disorder in the psychiatric nomenclature. The inclusion
of this disorder as an official psychiatric classification was prompted,
in part, by the large number of Vietnam veterans who were suffering from a
predictable symptom cluster following combat experience. These
symptoms were of long duration, subjectively painful, functionally
impairing, and were often associated with alcohol/drug abuse as well as
with diminished impulse control.
Prevalence of PTSD Among Adults
The establishment of clear diagnostic criteria for
PTSD made possible for the first time the assessment of its prevalence. In
the early 1980s, the National Institute of Mental Health launched the Epidemiologic
Catchment Area (ECA) studies, which were designed to quantify the
lifetime and current prevalence of discrete psychiatric disorders among
adults in five large US communities. PTSD was among the disorders
assessed. The data from these surveys indicated that the
lifetime prevalence of PTSD was approximately 1% in the population as a
whole, with a prevalence 0.8% among males and of 1.2% among females.[1]
The ECA surveys were soon followed by The
National Vietnam Veterans Readjustment Study (NVVRS), consisting of
in-depth investigations on the occurrence, risk factors, correlates, and
outcome of PTSD among Vietnam veterans.[2]
Results from this comprehensive study showed that the
lifetime prevalence of PTSD was 15% among combat troops. The
information from the NVVRS clearly documented both the high frequency of
PTSD among Vietnam veterans as well as the deleterious mental, physical,
and social consequences of PTSD.[3]
More recently, The National Comorbidity Study,
based on a representative national sample of 5877 persons aged 15-54,
reported the lifetime prevalence of PTSD to be 7.8%.[4]
Prevalence of PTSD Among Adolescents
The onset of PTSD in adolescence, a pivotal phase of
human development, has a particularly damaging impact, since it may impair
the acquisition of life skills needed for independence and
self-sufficiency. Mastery of these skills occurs within a limited time and
must be accomplished in order to meet the demands of the adult world. If
these skills are not achieved before the onset of adulthood, the
impairment can be lifelong. The Task Force on
Adolescent Assault Victim Needs has stressed the importance of
recognition and treatment of the adolescent victim of violence for these
very reasons.[5] The Task
Force stated, "The major tasks of adolescence are separation and
emancipation, development of identity, mastery of tasks and development of
vocational interests. In late adolescence, assaults and violence can
disrupt the consolidation of skills developed in early adolescence with
disastrous consequences."
The findings of the ECA and of the NVVRS prompted further study of PTSD
not only among adults but also in groups of youths and adolescents. Much
of what is currently known of the risk factors and consequences of PTSD
among adolescents comes from research on clinical samples, or on groups of
youths who have experienced a shared trauma such as a natural disaster,
war experience, or other life-threatening events. However, there are now
three prevalence studies that document the frequency of PTSD in
nonclinical adolescent populations.
In the first of these, Giaconia and colleagues assessed
the prevalence of PTSD in a nonreferred Massachusetts community sample of
384 adolescents (mean age, 17.9 years) who were participating in an
ongoing longitudinal study that began when the subjects were 5 years old.[6]
Lifetime prevalence of PTSD was determined by the Diagnostic Interview
Schedule, the same instrument of data collection used in the adult ECA
studies. The investigators found that 6.3% of the adolescents met full
criteria for a lifetime diagnosis of PTSD.
A second prevalence study, undertaken by Cuffe
and coworkers in a population of 490 South Carolina adolescents
enrolled in a longitudinal study of depression and suicidal behaviors,
reported that the lifetime occurrence of PTSD was 3.5% overall, with
approximately 3% of females and 1% of males meeting DSM-IV diagnostic
criteria.[7] Last, a
soon-to-be-published telephone survey based on a national sample of 4023
adolescents aged 12-17 indicates that the lifetime prevalence is 8.1%.[8]
Despite some variation in the estimates among these three studies, it
is apparent that the lifetime prevalence of PTSD
among adolescents today greatly exceeds that found by ECA studies of
adults in the 1980s. The occurrence of PTSD in these young
populations probably reflects the well-documented increase of
interpersonal violence in recent years.[9]
Differences in the prevalence of PTSD in the three surveyed populations
are largely due to variations in the frequency of trauma exposure. The
South Carolina sample had about half the prevalence of PTSD of the
Massachusetts adolescents (3.5% vs 6.3%), but this observed difference
disappears when the risk of developing PTSD is compared among those who
experienced trauma. In the Massachusetts sample, 43% had experienced a
qualifying trauma and 14.5% of the traumatized adolescents developed PTSD;
in comparison, only 16.3% of the South Carolina adolescents had
experienced a qualifying trauma, but 21.3% of those suffered subsequent
PTSD. Since, by definition, PTSD cannot occur among persons who have not
experienced a trauma, the level or frequency of
trauma in a population is the prime determinant of the prevalence of PTSD.
However, not all persons who have suffered a qualifying trauma go
on to develop the disorder. Current evidence strongly suggests that a
number of other factors in addition to trauma experience influence the
probability of developing PTSD. Among these are the characteristics of the
trauma, characteristics of the individual and the environment, and the
nature of support following the trauma. These variables play an
important role in either enhancing or diminishing the risk of PTSD. This
article will critically examine what is known of the risk factors for
adolescent PTSD, its consequences, and the current treatment strategies.
Risk Factors and Correlates of PTSD Among Adolescents
Nature of the Traumatic Experience
Considerable evidence indicates that the probability of developing PTSD
varies with the nature of the experienced trauma, with interpersonal
violence being a strong causative factor. Giaconia and associates[6]
reported that in their community survey, rape was the event most likely to
lead to PTSD. Similarly, Deykin and colleagues found that in a sample of
297 adolescents receiving treatment for dependence on alcohol or other
drugs, rape was the trauma most likely to cause PTSD.[10]
Although rape was far more common among the female subjects (40%), the few
males who experienced rape (3.6%) had an almost identical risk of PTSD
(76.7% vs 75.0%).
Apart from rape, other forms of assault, even if only witnessed, impart
a high risk of subsequent PTSD. Kilpatrick and associates reported that
children who had witnessed domestic violence, but were not victims
themselves, had significantly higher scores on a PTSD screening instrument
than children who had not witnessed such violence.[11]
The researchers suggest that the marked difference in the two groups may
in part be due to the fact that the aggressor was frequently the father,
thus creating an irresolvable conflict of loyalty.
Last, the effects of interpersonal violence are not limited to the
victims; they may have a deleterious impact on the perpetrators as well.
Steiner and coworkers studied a group of incarcerated juvenile delinquents
and found that 31.7% met criteria for current PTSD, and that for 5% of the
sample, the symptoms of PTSD resulted from violence they perpetrated on
others.[12]
While current data all point to high rates of PTSD following
interpersonal violence, the disorder can also occur following natural
disasters, including earthquakes, hurricanes, and accidents, as well as
war. Research on the consequences of natural disasters and accidents
suggests that in the initial phase, there can be considerable
trauma-related symptoms, but the effects tend to diminish faster than in
the case of interpersonal violence. Green and associates followed a cohort
of children who had experienced the burst of the Buffalo Creek dam 17
years previously, which resulted in extraordinary property loss as well as
some loss of life.[13] At
the initial evaluation, the prevalence of PTSD attributable to the flood
was 32%; at follow-up, it had decreased to 7%. In contrast, PTSD due to
trauma unrelated to the flood decreased only from 6% to 4%.
In a study of school-aged children who had experienced Hurricane Hugo
in 1989, Shannon and colleagues found that among the 5687 children and
adolescents aged 9-16 who had lived through the hurricane, more than 5%
had symptoms sufficiently severe to be classified as PTSD.[14]
The investigators stated that younger children and females of any age
reported more symptoms. In contrast to males, whose symptoms appeared to
be manifest in deficits of memory and concentration, females tended to
display symptoms involving repetitive thoughts of the hurricane, and
emotional avoidance and numbing. As might be expected, youth who were able
to remain in familial settings were less vulnerable to PTSD, even despite
property damage. The importance of familial supports in mitigating the
effects of natural disasters, accidents, and even war has been reported by
other investigators as well.
Subjects who were directly affected by natural disasters had the
highest risk of PTSD. In a follow-up investigation of the 5687 subjects
who had experienced Hurricane Hugo, Lonigan and colleagues reported that
the degree of PTSD symptoms was directly related to the level of the
hurricane's impact on the subjects.[15]
Subjects whose houses were damaged, became displaced, or whose parents
lost employment as a result of the hurricane were twice as likely to meet
criteria for PTSD as subjects who did not experience such events. However,
the investigators found that what appeared to be the most important
predictive factor was the level of a subject's trait anxiety and reported
emotional reactivity during the storm, suggesting that the intrinsic
emotional makeup of the youth studied played an important role in the
development of PTSD. Severity of exposure was most strongly associated
with PTSD symptoms of intrusive memories of the hurricane, and only weakly
associated with the symptom clusters of numbing/avoidance and
hyperarousal.
Similar findings were reported in a study of the consequences of an
industrial fire in North Carolina.[16]
The investigators assessed 1019 children/adolescents and
classified them according to the level of their exposure to the fire.
Those who had both lost a loved one and personally witnessed the fire were
classified as most exposed subjects. The other exposure groups were: those
who had lost a relative; those who only witnessed the fire; and those who
had neither witnessed the fire nor had a relative perish. Overall, nearly
12% of the study sample met full criteria for PTSD, with another 9.7%
displaying subclinical symptoms. However, the percent of both clinical and
subclinical PTSD diminished with each lower level of trauma experience.
Additional documentation pointing to a link between
the proximity of the trauma and the development of PTSD was
reported by Pynoos and associates, who studied children exposed to a
sniper attack at their school. Children who had been most exposed to the
threat of attack had the greatest amount of symptoms.[17]
In the case of war, however, not all studies have found a link between
the level of trauma and manifest symptoms. Ziv and Israeli studied the
anxiety level of 103 Israeli children who were residents of kibbutzim that
frequently received enemy shelling, and compared it with that of 90
children who lived in kibbutzim that had never been shelled.[18]
Contrary to their stated hypotheses, the findings did not support the
theory that children with exposure to shelling had a higher level of
anxiety. In fact, these findings tend to confirm the
role of family support, as cited above. The researchers suggest
that this might be the result of adaptation to the
recurring stressor which, over time, facilitated the development of
adaptive defenses. In addition, the children experienced the
shelling not as individuals, but as members of a cohesive group that
provided closeness, affiliation, and mutual support. These findings
contrast with those of Hubbard and colleagues, who assessed PTSD in a
sample of 59 Cambodian adolescent and young adult refugees who had
survived massive childhood trauma.[19]
They found that 24% met diagnostic criteria for current PTSD and 59% for
lifetime prevalence. High rates of major depression and social phobia were
found to accompany PTSD. Subjects with current PTSD had the highest number
of comorbid conditions, and those with no PTSD had the lowest.
Number of Traumas and the Risk of PTSD
In addition to the nature of the traumatic event, another important
predictor is the total number of previous traumas the individual
experienced. There is evidence suggesting that persons with a high number
of past traumas, even though they did not lead to PTSD, have a higher risk
of developing PTSD than persons with few or no lifetime traumas. Studies
of veterans have shown that soldiers with a history of childhood physical
or sexual abuse were more likely to develop PTSD than those without such a
history, even though both groups had sustained combat trauma of equal
severity. Persons who have had a series of low-risk traumas without
consequence appear to be more vulnerable to developing PTSD after another
low-risk trauma. The data seem to indicate a threshold effect that is
reached either by a single high-risk trauma such as rape or by a series of
low-risk traumas.
The cumulative effect of many traumas was noted by Deykin and coworkers[10]
among male subjects but not among females. In their sample of chemically
dependent adolescents, the risk of PTSD increased from 27% for males who
had only one previous trauma to 30.6% for those with two previous traumas,
and to 62.5% for those with three previous traumas. The risk of PTSD in
relation to the number of previous traumas may not have been present among
females, because most had developed PTSD subsequent to rape, the trauma
most likely to produce PTSD even in the absence of any other previous
trauma.
Duncan and associates surveyed a national sample of 4008 women to
determine the prevalence of childhood physical assault, major depression,
PTSD, and substance abuse.[20] The
researchers found that among the 2.6% who had experienced childhood
physical assault, there was a significantly higher prevalence of PTSD,
depression, and substance abuse, with the highest risk conferred on PTSD
and depression. These studies underscore the importance of the total
burden of traumatic episodes and are consistent with the work of Terr, who
proposed that there are two types of trauma leading to PTSD symptoms.[21]
Type I is characterized by exposure to a sudden, one-time event, whereas
type II results from repeated events which foster coping mechanisms of
denial and dissociation. It is possible that in the event of an additional
trauma these defenses are overwhelmed and lead to clinically observable
PTSD.
PTSD and Psychiatric Comorbidity
All empirical studies that have assessed PTSD and psychiatric
comorbidities have noted that PTSD occurs more frequently among persons
who have other psychiatric disorders. In a study of young adults enrolled
in a health maintenance organization, Breslau and coworkers reported that
the presence of coexisting psychiatric disorders specifically elevated the
probability of developing PTSD following trauma but not the probability of
experiencing a trauma.[22]
The same finding has been reported by Giaconia and colleagues.[6]
Deykin and associates[10]
found, in their sample of chemically dependent adolescents, that subjects
without any trauma history had the lowest occurrence of psychiatric
disorders; those with trauma experience but no PTSD had a slightly higher
occurrence of psychiatric disorders, but those with trauma and PTSD were
between 7 and 13 times as likely to have other psychiatric
classifications. Major depressive disorder was the most common psychiatric
comorbid condition. In this study it was impossible to assess the
association of PTSD with alcohol or drug abuse, since all subjects were
chemically dependent. Almost identical findings were reported by Warshaw
and associates, who found in their study of 688 adults with anxiety
disorders that major depression was present in 53% of subjects without
trauma, in 58% of those with a trauma history but no PTSD, and in 76% of
those who had developed PTSD following a trauma.[23]
The rates for alcohol abuse or dependence were 21%, 24%, and 38%,
respectively.
Since most research studies have been cross-sectional in nature, it has
been difficult to determine whether PTSD enhances the risk of depression
and/or substance abuse or whether the presence these comorbid conditions
increases vulnerability to PTSD. Deykin and associates[10]
attempted to untangle the temporal sequence of chemical dependence and
PTSD by comparing the age of the first episode of PTSD with the age at
which a subject first met full criteria for chemical dependence. They
found that in the whole sample, there was no clear pattern -- the onset of
PTSD was intertwined with the onset of substance dependence. However, when
the relationship was examined separately by gender, they found that PTSD
tended to precede the onset of chemical dependence among females, whereas
the reverse was true for males. The researchers proposed that females use
alcohol and other drugs as a way of deadening the psychic discomfort of
PTSD. Among males, substance dependence appeared to be the primary
disorder, leading to behaviors and interactions that enhance trauma
occurrence.
Two investigations have focused on the possible association of
cognitive impairment and PTSD. McNally and Shin found that in their sample
of 105 Vietnam combat veterans, intelligence, as measured by full-scale
WAIS-R test, accounted for 3% of the variability in the severity of PTSD
symptoms, even when the degree of combat experience was controlled for.[24] The investigators concluded that low intelligence may
be a risk factor for severe PTSD. While the results of this study are
intriguing and explore a previously unexamined area, one should be
cautious in drawing conclusions from this cross-sectional study, as the
results could equally support a hypothesis that severe PTSD impairs
functional intelligence. A second study by Vasterling and coworkers
examined attention and memory dysfunction in a group of Persian Gulf
veterans who were diagnosed with PTSD but were free of neurologic damage,
systemic illness, and alcohol/drug-related disorders.[25]
Veterans with PTSD performed less well on measures of attention, learning,
and memory than veterans without PTSD. However, similar to the McNally
study, this study also was cross-sectional in design, and although it
documented intellectual deficits among subjects with PTSD, it shows only
an association rather than a directional cause and effect.
The relationship of PTSD and intelligence has not been studied in
children and adolescence. To fully understand the connection of
intelligence with PTSD would necessitate a carefully constructed research
design in which measures of intelligence are available both before and
after traumatic exposures and confounding variables are assessed and
controlled.
Age, Gender, and Race
There are only sparse data that assess the differential effects of age
on the development of PTSD, possibly because individual studies focus on
narrow age ranges, making it difficult to compare outcomes for younger and
older children. However, Lonigan and associates[15]
found that in their study of children who experienced Hurricane Hugo,
younger children were more likely to develop PTSD; the researchers
cautioned, however, that this finding might have been due to the higher
levels of trait anxiety found in the younger subjects. Among younger
children, pathological responses to trauma have been found to mirror
parental responses. Earls and coworkers found that in a study of the
reactions of children to severe flooding in rural Missouri, the children
who were most adversely affected were those who had pre-existing disorders
and those whose parents reported a high number of symptoms for themselves.[26]
The study by Hubbard and colleagues[19]
that examined the occurrence of PTSD among the Cambodian survivors of the
Pol Pot atrocities found that trauma exposure was related to age, but that
age, in itself, did not predict symptoms.
In contrast to the generally negative findings concerning age, gender
was a strong predictor of PTSD. All studies that have investigated gender
as a risk factor have found that females are more likely than males to
develop PTSD, even when one considers trauma apart from rape.
As in the case of age, there are very few data comparing the effects of
trauma in different racial groups. The study by Shannon[14]
noted some differences in the types of symptoms experienced
by white, African-American, and other minority children in the aftermath
of Hurricane Hugo, but the differences were mainly due to level of
exposure, reporting biases, and possibly to a differential risk of PTSD
outcome. The most recent national survey by Kilpatrick[8]
found that race was unrelated to the risk of PTSD when exposure severity
was controlled. It appears, therefore, that if race is a risk factor for
PTSD, it is only so because it is a marker of traumatic exposures.
Consequences of Posttraumatic Stress Disorder
As was noted earlier, the onset of PTSD during
adolescent development could have serious negative implications for the
mastery of life skills. Data suggest that the symptoms of PTSD can
diminish adolescents' perception of self-efficacy as well as their
academic performance. Studying three groups of adolescents, Saigh and
coworkers found that traumatized adolescents who developed PTSD had lower
scores on various measures of perceived self-efficacy, compared either
with adolescents who had experienced serious trauma but did not develop
PTSD, or with normal comparison subjects.[27]
The same findings were noted in a subsequent study which examined the
academic performance of three groups of Lebanese teenagers. The group who
developed PTSD had appreciably lower scores on the Metropolitan
Achievement Test than either the traumatized adolescents without PTSD or
those without trauma.[28]
A lowered sense of self-efficacy and a diminished academic achievement
co-occurring with peer competition for educational/occupational
opportunities could have long-standing damaging effects. In addition, the
PTSD symptoms of avoidance and numbing may interfere with social
relationships and thus impair the ability to forge meaningful
interpersonal ties.
In reviewing what is currently known of the neurobiologic response to
trauma, Pynoos and associates have stated that midadolescence is an age at
which major structural change occurs in the brain.[29] They suggest that trauma during this period of rapid
brain development may arrest development or produce a regression to an
earlier stage of neural structure. These investigators examined 37
adolescents five years after the Armenian earthquake, and found that those
with the most severe PTSD had a rapid decline of 3
methoxy-4-hydroxyphenylglycol levels and a greater suppression of cortisol
than age-comparable adolescents who had not experienced the earthquake.
Yet, it should be noted that only a few studies have examined the
intellectual and developmental status of adolescents with PTSD, and that
these studies have been based on small samples. Until additional data are
available, the precise mechanism of how such deficits occur remains
speculative. There is no question, however, that the
most serious consequence of PTSD during adolescence is its association
with the heavy use of alcohol and/or other drugs. Substance abuse has
immediate consequences in the form of increased accidents, injuries, and
long-term effects in terms of occupational and familial instability and
early mortality. Furthermore, substance abuse, in itself, is often a risk
factor for additional traumatic exposures either through accidents or
interpersonal violence.
Treatment of PTSD
Treatments for PTSD span individual therapy, group
therapy, family therapy, anxiety management, desensitization, and
relaxation techniques. However, most treatments for children and
adolescents have been primarily of a psychotherapeutic nature, helping the
individual to gain mastery over the trauma. Innovative therapies developed
primarily for veterans have not been widely used in adolescent samples.
Goenjian and coworkers employed brief trauma/grief psychotherapy with
young adolescents a year and a half after the Armenian earthquake of 1988,
and reported a significant diminution of PTSD symptoms but not depressive
symptoms among the treated subjects.[30]
Some pharmacotherapy, especially drugs that diminish anxiety, has been
found to be helpful in conjunction with psychotherapy. Flooding, a
technique which involves prolonged imaginal exposures to highly adverse
stimuli, was used with some success on two adolescents who had war-related
trauma, but has been used largely for combat veterans.[31]
Summary and Discussion
Recent epidemiologic data suggest that in the past 15
years there has been an increase in the lifetime prevalence of
PTSD for the population overall, with unusually high rates among
adolescents and young adults. A precipitous increase of a disorder over a
short period of time raises the question of whether the increase is real
or due to spurious factors such as better diagnostic measures or changes
in the defining criteria. In the case of PTSD, both factors seem to be
operating.
In all likelihood, there has been an actual increase in the lifetime
occurrence of PTSD resulting from the well-documented rise in the rate of
interpersonal violence, especially among adolescents. Interpersonal
assaults in adolescence are more common now because of rises in drug
dealing, widespread firearm ownership, and a general disinhibition towards
employing violence as a means of settling even minor disputes. As
interpersonal violence often constitutes a threat to life or physical
integrity -- a criterion for meeting the definition of a qualifying trauma
-- it is not surprising that the rate of PTSD among adolescents, and to a
lesser extent, among adults as well, has risen. Concurrent with more
frequent exposures to violence, there has also been a secular increase in
the incidence of major depressive disorder in adolescence. While it is not
clear whether a major depression predisposes one to developing PTSD or
whether PTSD lowers resistance to depressive illness, depression and PTSD
are frequently found to occur together. If depressive illness lowers one's
ability to withstand the long-term effects of severe trauma, then the
increase of PTSD may mirror the increase of depressive illness in
adolescence.
Second, the increased prevalence of PTSD can also result from a greater
willingness to report symptoms of PTSD. This is particularly relevant for
victims of rape who are more likely now than previously to divulge sexual
assaults, since the fear of recriminations and shame is less than it used
to be. If this is a major contributor to recent epidemiologic findings,
then one would expect to find that females are at higher risk of being
diagnosed with PTSD. In fact, this seems to be the case. Although even
early community-wide surveys have reported a slightly higher prevalence of
PTSD among females than among males, the gender differential has increased
in more recent studies.
Last, one should be aware of changes in the criteria for a diagnosis of
PTSD and in methods of data collection which might produce higher
estimates of prevalence. For example, the National Comorbidity Study in
1995 reported a prevalence of 7.8%, or about seven times that found by the
ECA study a decade earlier. However, in the National Comorbidity Study,
the prevalence of PTSD was assessed only in a second wave of interviews
which were designed to be heavily weighted with persons who, in the first
wave, had been found to have psychiatric disorders. As PTSD is more common
among those who have a diagnosis of depression or alcohol or drug abuse,
weighting the subject pool with persons known to have other disorders
would likely result in a biased high estimate of PTSD.
There is relatively little information available about whether children
and adults are equally vulnerable to the same types of trauma. Existing
evidence suggests that in the face of what is perceived to be a
life-threatening event, vulnerability to PTSD is not dependent on age or
stage of development. However, it is possible, even likely, that adults
may have a broader perception of what constitutes life-threatening danger.
In addition, there seems to be general agreement that the nature of PTSD
symptomatology may be quite different for children. Instead of the
subjectively painful re-experiencing of the trauma so common in adults,
children may instead engage in ritualistic play which focuses on the
traumatic event. Similarly, the characteristic
symptom of hyperarousal seen in adults is often substituted in children
with reckless behavior and somatic symptoms. The somewhat muted
symptoms seen in childhood may be due to the presence of supportive,
protective parents. It is likely that parental
nurturing in the immediate posttrauma phase could modify the expression of
PTSD symptoms in childhood. In adolescence, the manifestation of
PTSD tends to be more like that seen among adults.
The role of adult caretakers is supportive only in so far as the trauma
experienced is not caused by parents/caretakers. Research on veterans has
indicated that soldiers who have experienced
severe combat trauma are more likely to exhibit full-blown PTSD if they
had a prior history of child abuse. This suggests that abuse by
parental figures casts a long shadow on how one copes with trauma in later
life. In her article on childhood traumas, Terr[21]
points out that children who have experienced
chronic physical and/or sexual abuse by parents cope with the trauma by
relying heavily on the psychological defenses of denial and dissociation. It
is possible that such children have to cope with the insoluble ambiguity
in which their protector is also the perpetrator of the trauma. Gaining
mastery over the trauma would involve confrontation or disclosure, which
would potentially imply the loss of their protector. Children faced with
this opposing bind are likely to rely on denial and dissociation as the
most effective means of coping under the circumstances. While these are
reasonable adaptive mechanisms for children who have no other options,
they are counterproductive in adulthood. However, as all individuals tend
to rely on what was effective for them in the past, it is not surprising
that adults who were abused as children have such a difficult time gaining
mastery over subsequent severe trauma.
PTSD has serious long-term negative effects
on subjective well-being, on social and occupational adjustment, and on
the development of substance abuse. Because of these potential
consequences, PTSD that occurs during dynamic
phases of human development is particularly serious.
Reduction of PTSD could be achieved either
through preventive measures that curtail traumatic exposures, especially
in the realm of interpersonal violence, or by early, effective treatment. Since
PTSD often occurs in the context of other psychiatric disorders, its
presence may remain unrecognized especially if the symptoms of other
disorders are dominant. Clinicians treating youth for depression, anxiety,
or substance involvement should be cognizant of the possibility of
concurrent, underlying PTSD.
Research on treatment modalities has focused predominantly on adult
populations, and more work needs to be done on treatments for this
disorder in youth. Current treatments -- psychological, behavioral or
pharmacologic -- require objective assessment of their efficacy in
childhood and adolescence. Given the seriousness of PTSD when it occurs
prior to adulthood, and given the frequency of traumatic exposures that
can lead to PTSD, attention to effective treatment should be a priority.
Dr. Deykin is at the National Center for Posttraumatic
Stress Disorder, VA Medical Center, Boston, Mass.
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