Posttraumatic Stress Disorder
in Childhood and Adolescence:
A Review
Eva Yona Deykin, DrPH
[Medscape Mental Health 4(4), 1999. © 1999 Medscape, Inc.]
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 nurture 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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