IACAPAP Textbook of Child and Adolescent Mental Health

ANXIETY DISORDERS

Chapter

F.4

ACUTE AND CHRONIC REACTIONSTO TRAUMA IN CHILDREN AND
ADOLESCENTS
Eric Bui, Bonnie Ohye, Sophie Palitz, Bertrand Olliac, Nelly
Goutaudier, Jean-Philippe Raynaud, Kossi B Kounou &Frederick J Stoddard Jr
Eric Bui MD, PhD
Université de Toulouse,
Toulouse, France;
Massachusetts General
Hospital & Harvard Medical
School, Boston, USA
Conflict of interest: nonereported

Bonnie Ohye PhD
Massachusetts General
Hospital & Harvard Medical
School, Boston, USA
Conflict of interest: nonereported

Sophie Palitz, BA
Massachusetts General
Hospital, Boston, USA
Conflict of interest: nonereported

Photo Hamideddine Bouali
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2014. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Bui E, Ohye B, Palitz S, Olliac B, Goutaudier N, Raynaud JP, Kounou KB & Stoddard FJ Jr. Acute and chronic
reactions to trauma in children and adolescents. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2014.

Reactions to trauma

F.4

1

IACAPAP Textbook of Child and Adolescent Mental HealthAlthough the past few decades have seen important advances in theunderstanding and treatment of traumatic stress conditions, psychologicalstress reactions to trauma have been described from antiquity (Birmes etal, 2010). In his biography of famous lives, Plutarch wrote that the general andRoman consul Caius Marius (157-86 BC), when presented with a reminder of oneof his dreaded enemies, was gripped with an “overpowering thought of a new war, offresh struggles, of terrors known by experience to be dreadful” and “was prey to nightly
terrors and harassing dreams” (Plutarch, 1920).

Bertrand Olliac MD, PhD
Centre Hospitalier Esquirol,
Limoges, France
Conflict of interest: nonereported

Nelly Goutaudier PhD
Université de Toulouse,
Toulouse, France

Deriving from the Greek τραῦμα meaning “wound,” the word “trauma” hasbeen used for centuries as a medical term to designate “an injury to living tissuecaused by an extrinsic agent.” Nonetheless, it was not until 1889 when Oppenheim
first used the clinical descriptions of “traumatic neuroses” in victims of railroad
accidents, that the word also encompassed a psychological meaning.

Conflict of interest: nonereported

TRAUMATIC EVENTS

Kossi B Kounou PhD

Historically, a traumatic event has commonly been described as presenting
three characteristics:

Jean-Philippe Raynaud MD
Université de Toulouse,
Toulouse, France
Conflict of interest: nonereported
Université de Toulouse,
Toulouse, France & Universityof Lomé, INSE, Lomé, Togo•

Sudden and unexpected occurrence

Conflict of interest:none
reported•

Association with a threat to life or to physical integrity, andFrederick J Stoddard Jr MD•

Being outside of the normal range of life experiences.

Massachusetts General
Hospital & Harvard Medical
School, Boston, USA

These three features differentiate “trauma” from other distressing events suchas medical disease or relationship breakups. Lenore Terr defined two types ofpsychological trauma:•

Type I, associated with a time-limited single traumatic event (accident,
disaster, etc.), and•Type II, caused by long-standing or repeated exposure to traumatic
events (abuse, torture, combat situation, etc.) (Terr, 1991).

The evidence for a Type II trauma category was considered too weak to be
included in the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) (American Psychiatric Association 2013; Resick et al, 2012).
While in the fourth edition (DSM-IV) (American Psychiatric Association, 1994)
traumatic events were defined as “events that involve actual or threatened deathor serious injury, or a threat to the physical integrity of oneself or others” that areaccompanied by a feeling of “intense fear, helplessness, or horror,” DSM-5 dropped
the subjective reaction to the trauma required in DSM-IV (criterion A2) because
evidence did not support the need for it to make a diagnosis of acute stress disorder(ASD) and posttraumatic stress disorder (PTSD) (Stoddard et al, in press). In the
DSM-5 definition, traumatic events include not only direct exposure (i.e., beinga victim) and witnessing a traumatic event, but also learning that the traumatic
event(s) occurred to a close family member or close friend. The DSM-5 definition
also includes extreme and repeated exposure to aversive details of the traumatic events(e.g., first responders collecting human remains), but excludes exposure throughthe media unless it is work related (e.g., police officers repeatedly viewing picturesand recordings of assault).

Reactions to trauma

F.4

Conflict of interest: nonereported••

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IACAPAP Textbook of Child and Adolescent Mental HealthIn relation to children, an important addition to DSM-5 is the newcriterion: “negative alterations in cognitions and mood associated with thetraumatic event(s).” The “intrusive”, “avoidance”, and “arousal” categories of PTSD
symptoms are retained (see section on clinical features below and Table F.4.1).
ASD and PTSD are no longer listed under the chapter on anxiety disorders,
but as a distinct category: Trauma and stressor-related disorders (see Chapter A.9).
In addition to ASD and PTSD, this category includes reactive attachment disorder,
disinhibited social engagement disorder, and quite importantly, adjustment disorder.
Persistent complex bereavement disorder (also known as complicated grief or
prolonged grief disorder) has been included in DSM-5 in the section on conditions
for further study, but is also listed as a possible diagnosis as “specified trauma andstressor-related disorders” (APA, 2013).
The epidemiologic and clinical research data presented in this chapter islimited to studies utilizing DSM-IV or earlier criteria; little research using DSM-5
criteria is currently available.

THE SPECTRUM OF REACTIONS TO TRAUMA IN
CHILDREN AND ADOLESCENTS

Hermann Oppenheim, aGerman neurologist, wasthe first to conceptualize
psychological trauma in his 1891
treatise on “traumatic neuroses”(Weitere Mitteilungen überdie traumatischen Neurosen)
based on clinical observations ofrailway, factory, and construction
accident victims.

Exposure to a traumatic event in this age group may lead to the developmentof various reactions ranging from relatively mild, causing minor disruptions in thechild’s life, to severe and debilitating consequences. Most children and adolescents
exposed to traumatic events will develop some psychological distress, which is
generally short lived. In some, however, symptoms do not remit spontaneously
and instead become clinically significant, persistent and impairing.
Reactions to trauma exposure are defined according to their timeframe:
immediate or peri-traumatic (lasting minutes to hours), ASD (lasting between twodays and one month), and PTSD (when symptoms persist for more than one
month).
In this chapter we will review the different types of psychopathologicalreactions specific to trauma. However, children and adolescents may develop otherpsychiatric conditions after trauma exposure including depression, panic disorder,
specific phobias (distinctively related to some aspect of the trauma), as well as
behavioral and attentional problems (e.g., oppositional defiant disorder). Amongpreschoolers, other clinical presentations include developmental problems suchas loss of previously mastered skills (regression), as well as the onset of fears not
specifically associated with aspects of the trauma. Of significance in DSM-5 isthe addition of the developmentally modified PTSD subcategory of posttraumaticstress disorder for children 6 years and younger, which differs in important ways fromthe PTSD criteria for children older than 6 years. Especially significant for the
diagnosis of PTSD in children aged 6 years and younger is that instead of the 7
symptoms required in older children and adults, only 3 symptoms are required,
one each from the “intrusion”, “avoidance or negative cognitions” or “arousal”
group of symptoms (see Table F.4.1).

Reactions to trauma

F.4

Regression
Regression is a defense
mechanism common inchildren. When confronted bystressful events they revert
to an earlier or less maturepattern of coping, feeling or
behavior.

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IACAPAP Textbook of Child and Adolescent Mental Health

EPIDEMIOLOGY
Acute stress disorder (ASD)
Across studies of trauma-exposed adults, reported prevalence of ASD ranges
from 7% to 59% (Bryant et al, 2008; Elklit & Christiansen, 2010) with a mean
prevalence of 17.4% (Bryant, 2011). These figures, however, are somewhat lower
among children, with reported rates around 8-10% in industrialized countries(Kassam-Adams & Winston, 2004; Bryant et al, 2007; Dalgleish et al, 2008).

Posttraumatic stress disorder (PTSD)
In the US, between 7% and 10% of individuals may suffer from PTSD intheir lifetime, while reported 12-month prevalence among adults is approximately
4% (Kessler et al, 2005a; 2005b). In adults, incidence rate (percentage of newcases) of PTSD following a trauma vary greatly (Breslau et al, 1998), determinedby a range of factors such as the type of trauma, trauma severity, previous exposure
to trauma, the presence of prior mood or anxiety disorders, and elevated peritraumatic reactions (Brewin et al, 2000; Ozer et al, 2003). Rates of PTSD amongchild and adolescent survivors of disasters vary widely depending on the studied
population and the measures used to assess diagnosis, with rates ranging from 1%
to 60% (Wang et al, 2013).
While prior data found that as many as 36% of children and adolescents
exposed to a range of traumatic events were diagnosed with PTSD (Fletcher,1996c), a recent meta-analysis reported that the rate of PTSD among children
after trauma exposure is approximately 16% (Alisic et al, in press). A large
epidemiological survey in the US found a lifetime prevalence rate for PTSD of
4.7% among adolescents (McLaughlin et al, 2013), with higher rates amongfemales (7.3%) than males (2.2%).

Course and impact
It has been shown that PTSD symptoms in adults improve mostly during
the first 12 months following the traumatic event (Bui et al, 2010b), however datasuggest that the course of PTSD without treatment is largely a chronic one—
individuals may experience significant levels of symptoms and impairment even
decades later (e.g., O’Toole et al, 2009).
Similarly, data suggest that among pre-school children, the course of
PTSD may be chronic, with limited improvement over the two years following
the traumatic event (Scheeringa et al, 2004; 2005; 2006). Data among schoolage children, however, are mixed with some reporting no long term impact of
a disaster on PTSD rates (McFarlane & Van Hooff, 2009) and others reporting
elevated rates (Morgan et al, 2003). Finally, the scarce data in adolescents also
points to a possible chronicity of PTSD symptoms in this population (Yule et al,2000).

Risk factors
A meta-analysis of 64 studies assessing risk factors for PTSD among children
and adolescents aged 6 to 18 (Trickey et al, 2012) revealed that factors relating toReactions to trauma

F.4

Click on the picture to view ashort video describing PTSD

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IACAPAP Textbook of Child and Adolescent Mental Health

IACAPAP’s Dr Yoshiro Ono,
Japanese Child Psychiatrist
providing help in the aftermath ofthe earthquake and tsunami thatdevastated Northern Japan on
March 11, 2011

the subjective experience of the event (including peri-trauma fear and perceived lifethreat) and post-trauma variables (including low social support, social withdrawal,
psychiatric comorbidity, poor family functioning, and the use of certain cognitive
strategies such as distraction and thought suppression) accounted for medium-tolarge effect sizes in the prediction of PTSD, while pre-trauma factors (including
female gender, low intelligence, low socioeconomic status, pre-trauma life events,
pre-trauma low self-esteem, pre-trauma psychological problems in the youth andparents) accounted for only small-to-medium effect sizes.

CLINICAL FEATURES
Peritraumatic reactions
When confronted with a traumatic event, children and adolescents often
show immediate psychological responses. Reactions experienced during and
immediately after trauma are called peritraumatic and have been identified as robust
predictors of the development of PTSD in adults (Brewin et al, 2000; Ozer et al,2003). Two types of peritraumatic reactions have been described: peritraumatic
distress and peritraumatic dissociation.
Peritraumatic distress was introduced as a measure of the intensity of DSMIV PTSD (Brunet et al, 2001), and indexes emotional (e.g., fear, horror) andphysical (e.g., loss of bowel control) reactions experienced during or immediately
after exposure to a traumatic event. Peritraumatic distress can be measured with theReactions to trauma

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IACAPAP Textbook of Child and Adolescent Mental Health

13-item Peritraumatic Distress Inventory (PDI) (Brunet et al, 2001) that evaluates
feelings of helplessness, sadness, guilt, shame, frustration, fright, horror, passing
out, worry for others, loss of bowel and bladder control, physical reactions, andthoughts of dying (Appendix F.4.1).
Peritraumatic dissociation refers to alterations in the experience of time, place
and persons during or immediately after exposure to trauma (Marmar et al, 1994)
and is assessed by the 10-item Peritraumatic Dissociative Experiences Questionnaire(PDEQ). The PDEQ includes items measuring blanking out, a feeling that one
is on autopilot, time distortion (“slow motion”), depersonalization (feeling ofwatching oneself act while having no control over the situation), derealization (afeeling of strangeness and unreality of the external world), confusion, amnesia, andreduced awareness (Appendix F.4.2).
Both the PDI and the PDEQ have been validated in children (Bui et al,2011), and both peritraumatic distress and dissociation have been shown to be
associated with the development of PTSD symptoms in children (Bui et al, 2010a).

Acute stress reaction (ICD-10)/Acute stress disorder (DSM-5)
Early psychological reactions to trauma exposure are described under the label“acute stress reaction” (ASR) in the 10th edition of the International Classificationof Diseases (ICD-10) (World Health Organization, 1992), and under “acute stressdisorder” (ASD) in DSM-5. While both ASR and ASD descriptions are similar,
they differ slightly on their timeframe (onset two days post-trauma exposure for
ASR, three days for ASD). We focus on ASD as research and evidence-based
recommendations have been mostly conducted using DSM criteria.
ASD was introduced in DSM-IV in order to differentiate short-lived
distressing and impairing reactions to trauma from PTSD (Koopman et al, 1995),
as well as to identify individuals at risk for PTSD one month later (Spiegel et al,1996). In DSM-5, a diagnosis of ASD requires exposure to a traumatic event (i.e.,
exposure to death or threatened death, actual or threatened serious injury, or actualor threatened sexual violation) and the main diagnostic criterion requires meeting
9 of 14 symptoms (in any particular cluster), including symptoms of intrusion (i.e.,
recurrent distressing dreams, recurrent distressing memories of the trauma, intenseor prolonged distress upon exposure to reminders, and physiological reactions
to reminders); dissociative symptoms (i.e., derealization, emotional numbing andinability to remember an aspect of the trauma (typically dissociative amnesia));
avoidance symptoms (i.e., avoidance of internal or external reminders that arouserecollections of the traumatic event(s)); and arousal symptoms (i.e., irritable oraggressive behavior, exaggerated startle response, sleep disturbance, hypervigilance,and problems with concentration). The duration of the symptoms may run fromthree days to four weeks after trauma exposure, with clinically significant distressor impairment (see Table F.4.1).

Peritraumatic
reactions in an 11
year old child
Alan is an 11-year old boy
who lives with his parents
and one-year-old sister. One
night, while his parents werearguing in front of him, hisfather stabbed his motherin the abdomen. His motherwas taken to hospital andAlan, who came with her,
was seen by the psychiatrist
on call.
Alan told her what he had
witnessed and said thatduring the fight, he had felt
very frightened and that
his heart was pounding.
He remembered feeling as
if he should do something
to help his mother, but did
not know how to help, andfelt he couldn’t move his
legs. He also said that what
had happened seemed
unreal, almost as if he werein a movie. He told thepsychiatrist that when hethought of the scene again,
it seemed slowed down andout of focus. He rememberedthat he had screamed very
loudly when his motherwas injured, but could notremember anything afterthat.

Posttraumatic stress disorder (PTSD)
The diagnosis of PTSD, initially reserved for adults, was extended to youth
in 1987 with DSM-III. In DSM-IV, diagnostic criteria for PTSD for children
and adolescents are identical to those used for adults with a few caveats. There has

Reactions to trauma

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IACAPAP Textbook of Child and Adolescent Mental Healthbeen intense scientific debate over the use of adult DSM-IV criteria for PTSD inchildren and recent data suggest that youth might require fewer criteria based onfunctional impairment associated with PTSD symptoms, and may have somewhat
different expressions of distress, especially in those who are very young (Scheeringa
et al, 2003).
In DSM-5, the diagnosis of PTSD includes the same exposure criteria as
ASD (i.e., exposure to death or threatened death, actual or threatened serious
injury, or actual or threatened sexual violation). In addition, the adult andadolescent PTSD diagnosis requires:
•

•
•

•

One symptom of intrusion (criterion B) including recurrent distressing
dreams, recurrent distressing memories of the trauma, dissociative
reactions (e.g., flashbacks), or intense psychological or physiologicalreactivity to reminders of the trauma;
Persistent avoidance of internal or external stimuli associated with thetrauma (criterion C);
Two symptoms of negative alterations in cognitions and mood associatedwith the trauma (criterion D) including persistent, distorted blameof self or others, persistent negative emotional state (e.g., fear,
horror, anger, shame or guilt), diminished interest or participationin significant activities, detachment or estrangement from others, or
persistent inability to experience positive emotions (e.g., emotional
numbing); andTwo symptoms of alterations in arousal and reactivity (criterion E),
including irritability or aggressive behavior, reckless or self-destructive
behavior, hypervigilance, exaggerated startle, problems withconcentration, or sleep disturbance.

The diagnosis also requires symptoms to last more than one month, tobe associated with clinically significant distress or impairment, and not to be
associated with the effects of a substance or medical condition. In addition, DSM5 includes a subtype of PTSD for preschool children aged six or younger thathighlights significant differences including the still developing abstract cognitive

Relationship of ASD
with PTSD
ASD was introduced to
identify individuals at
risk for PTSD. So far, theliterature has reported that
ASD symptoms significantly
increase the likelihood ofdeveloping PTSD (McKibben
et al, 2008; Bui et al, 2010b;
Yasan et al, 2009). However,according to recent empirical
data among adults, while
the positive predictive powerof ASD was reasonable,
its sensitivity (proportion ofpeople meeting ASD criteria
who eventually develop
PTSD) was poor (20-72%),
suggesting that most trauma
survivors who subsequently
develop PTSD do not meetfull criteria for ASD (Bryant,2011).
In line with this, a large studyof child and adolescentsurvivors of motor vehicle
accidents failed to showthat dissociation symptoms
independently predictedsubsequent PTSD (Dalgleish
et al, 2008).
ASD is therefore to beconsidered as a clinical entitythat captures a significant
level of distress andimpairment, may help identify
youth who might requireclinical attention, and may
be indicative of a possible
subsequent PTSD.

Participants in the 1st Steering Committee Meeting, Jakarta September 19, 2012 of the Asian Partnership to Support Mental Resilience
During Crises.

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7

IACAPAP Textbook of Child and Adolescent Mental Healthand verbal expression capacities (Scheeringa et al, 2011a; Scheeringa et al, 2001b).
Three main modifications are made for this subtype:•••

Changes in the re-experiencing symptoms include rewording thecriterion B1 (i.e., recurrent and intrusive distressing recollections of
the event) which does not require the recollections to be distressing, as
a number of traumatized children feel either neutral or excited by therecollection.
With regard to avoidance symptoms and negative alterations in
cognitions and mood, the criteria for preschool children only requires
one symptom from these two clusters to be met, as it is usually difficultin this population to identify certain symptoms including “restricted
range of affect” and “detachment from loved ones.” In addition, two
symptoms were removed as they were not developmentally sensitive:“sense of a foreshortened future” and “inability to recall an important
aspect of the event.” Finally, in this cluster, two symptoms werereworded to improve validity among preschool children: diminishedinterest in activities may take the form of constricted play, while feelingsof detachment may manifest as social withdrawal.
With regards to hyperarousal, only one small change of wording was
made with “irritability or outbursts of anger” being modified to include“extreme temper tantrums.” (Table F.4.1)

Differential Diagnosis
Table F.4.1 summarizes the symptoms used for the diagnosis of ASD
and PTSD according to DSM-5. PTSD shares symptoms with numerous otherconditions, such substance intoxication, which should be ruled out as the cause or
should be excluded from a PTSD diagnosis. Also, PTSD can present concurrently
with mood and anxiety symptoms, and the presence of mood and anxiety disorders
should be ascertained. The main differential diagnoses to be considered are:•Adjustment disorder

•

ASD

•

Anxiety disorder

•

OCD

•

Major depression•

Dissociative disorders•

Conversion disorder•

Psychosis•

Substance intoxication•

Traumatic brain injury.

Posttraumaticstress disorder in a
6-year old child
Dolores, a 6-year-old girl,
was admitted to hospital witha 40% burn from a housefire in which a younger
sibling died. Her mother isat the bedside, her father
has been absent for several
years. She has a historyof early deprivation due tohomelessness and is in the
1st grade at school.
Dolores was in her bedroom
when she started smellingsmoke and saw the door
catch fire. She remembered
she was very frightened, wetherself, and screamed loudly.
She could not remember
anything else after that.
She was initially sedated
after the grafting of her burnwounds. When she wasweaned from IV morphineand midazolam she became
tearful and screamed when
her mother was absent for
short periods. She also
appeared anxious whenevernurses in uniform entered theroom fearing they would hurt
her. She developed insomnia
as well as nightmares inwhich she re-experienced
the fire, including episodesof sleep terror. She became
upset when her mother did
not stay with her even atnight. The mother reported
that Dolores had changed
since the fire; she was nolonger interested in playing
with dolls, was withdrawn,
edgy, and often displayed
angry outbursts.
She began to improve when
given control over some ofher dressing changes, andwith careful attention to
encouraging her mastery ofher fear and pain related toburn dressings, as well as
adequate, though reduced,
analgesia.

In contrast with PTSD, which requires symptoms to be present for at least
one month after trauma exposure, ASD is diagnosed during the first month. In
addition, PTSD diagnosis requires the presence of at least six symptoms from fourclusters (re-experiencing, avoidance, persistent negative alterations in cognitions
and mood, and hyperarousal), while ASD diagnosis requires only the presence ofnine out of 14 symptoms (see Table F.4.1).

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IACAPAP Textbook of Child and Adolescent Mental Health

Iranian soldier during Iran-Iraq
War.

Similar to PTSD and ASD, adjustment disorders require exposure toa stressful event, which results in clinically significant distress or impairment.
However, in adjustment disorders, the stressor does not need to be “traumatic”(i.e., as severe as for ASD or PTSD). FFurther, adjustment disorder does not
specify required symptoms and the patient’s condition should not be explained byanother disorder.
Although exposure to a traumatic event may precipitate the onset of a rangeof mood or anxiety disorders, these diagnoses are not as tightly conditioned by
the traumatic event as is the case with ASD and PTSD. While ASD and PTSD
share with anxiety disorders (including panic, general anxiety and social anxiety
disorders) symptoms of hyperarousal and avoidance, the clinical presentation

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9

Reactions to trauma

F.4

Negative mood& cognition
symptoms

Avoidance

Intrusion
symptoms

Exposure to a
traumatic eventOf distressing memories or feelings associated with event•Distinctly reduced interest in everyday activities or pastimes

Feelings of detachment

•

•





Persistent negative emotions such as horror, anger, or shame

•





Distorted impressions about the cause or effects of event•

Inability to experience positive emotions



Negative perception of the world, oneself, or others

•

•



Not able to remember aspects of event•Of external reminders of the event such as related people, places orsituations

•







Marked physiological reactions to internal or external cues

•





Distress brought about by internal or external cues related to the event





•



Recurrent nightmares related to the event

•







Recurrent intrusive memories of event•Flashbacks or other dissociative reactions



Repeated or extreme exposure to upsetting details of a traumatic event

•







PTSD

•



Finding out family or close friend have experienced a traumatic eventWitnessed a traumatic event occurring to others

•

•



Experienced the traumatic event directlyASD•

SYMPTOM DESCRIPTION
[e.g., social withdrawal]














[e.g., re-enacting theevent in play]
[e.g., in play][parent or caregiver]

PTSD in children< 6 years

Comparison of symptoms used for the diagnosis of ASD, PTSD, and PTSD in children <6 years according to DSM-5.

SYMPTOM
GROUP

Table F.4.1

IACAPAP Textbook of Child and Adolescent Mental Health

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Reactions to trauma

F.4






Exaggerated startle response

Difficulty concentrating

Problems with sleep

Depersonalisation

Derealisation

•

•

•

•

•

>1 month

9 out of 14
symptoms

3 days to 1
month

Requirement for diagnosis

Duration of symptoms after trauma exposure











Hypervigilance

•







PTSD

Recklessness or self-destructivenessIrritability and outbursts of anger

ASD

•

•

SYMPTOM DESCRIPTION

Trauma +1 intrusion+1
avoidance+ 2 mood/
cognitions+2
arousal

Dissociation
symptoms

Arousalsymptoms

SYMPTOM
GROUP>1 month

Trauma + 1 intrusion+ 1 avoidance ormood/cognitions + 2
arousal










[e.g., extreme tempertantrums]

PTSD in children< 6 years

Table F.4.1 (Continuation) Comparison of symptoms used for the diagnosis of ASD, PTSD, and PTSD in children <6 years according to DSM-5.

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IACAPAP Textbook of Child and Adolescent Mental Health

Assessement and treatment of refugee children and adolescents
exposed to war-related trauma
Child and adolescent refugees who have fled war zones have been frequently exposed tomultiple trauma (including witnessing someone being injured, killed or tortured), as well as multiple
losses (Rutter, 2003). Although they are often resilient, many experience PTSD as well as other mental
health problems, including depression, anxiety and complicated or prolonged grief. Refugee-processing
practices, life in refugee camps, and the response of receiving countries, particularly if their entry
is illegal, further compound these problems. There seems to be a dose-effect relationship between
cumulative trauma and symptoms of emotional distress in refugee children and adolescents exposed
to war (Heptinstall et al, 2004; Mollica et al, 1997). Unaccompanied asylum-seeking children (i.e.,
individuals under 18 separated from both parents and not cared for by a responsible adult) display
higher psychological distress than those who are accompanied (Mckelvey & Webb, 1995).
Issues of loss are particularly important among these children because of the social isolation in
the host country. Challenges in assessing the impact of trauma among child and adolescent refugees
exposed to war include working with interpreters, medico-legal report writing, vicarious trauma exposure(among health care providers), and cross-cultural variations in clinical presentations (Ehntholt & Yule,2006). Among adults, it has been consistently shown that trauma-related distress can manifest byculturally bound symptoms. For example, in Asian and Southeast Asian cultures, traumatized individuals
often fear dysregulation of a “wind flow” in their body. It has thus been found that such culture-boundsyndromes as well as somatic complaints were prominent aspects of the experience of PTSD among
traumatized Cambodian refugees, which were much more salient than many of the traditional PTSD
symptoms (Hinton et al, 2013). Clinicians should therefore not only consider DSM or ICD criteria as
relevant.
Although evidence-based treatment approaches including CBT adapted to culture-boundsyndromes, eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy
are useful to alleviate PTSD symptoms among young refugees, a holistic approach is usually also
necessary (Papadopoulos, 1999). Because they are under important social and material stress, young
refugees frequently need to discuss current practical difficulties rather than past experiences. Finally,
they may also wish to focus on the future rather than reflect on the past, and such a focus should not be
discouraged (Beiser & Hyman, 1997).

A freezer truck containing fish is left leaning against a tree in the front yard of a destroyed residence after Hurricane Katrina in Plaquemines
Parish, Louisiana, US. FEMA photo/Andrea Booher

Reactions to trauma

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12

IACAPAP Textbook of Child and Adolescent Mental Healthof ASD and PTSD includes both a focus around a traumatic event and reexperiencing emotions and images of the trauma. A major depressive episodetriggered by a stressful experience may include concentration difficulties, insomnia,
social withdrawal or detachment similar to those found in PTSD; however theclinical presentation of depression will lack re-experiencing the trauma or related
avoidance.

DIAGNOSIS
Conducting the interview
Evaluation of young persons with possible PTSD should generally begin
with open-ended questions to elicit a narrative account of the trauma. For younger
children this will often be in a play context, including drawings; for adolescents,
in their own words with minimal input from the interviewer. While in adults thisnon-directive segment may be useful to minimize the risk of making an incorrect
PTSD diagnosis in malingering individuals who want to achieve some gain (e.g.,compensation), it can be helpful in young children also; it has been reported thatchildren’s reports of exposure to trauma and symptoms may be influenced by theway questions are asked (Bruck & Ceci, 1999). In particular, this is important in
the context of potential sexual or physical abuse, with significant legal implications.
Thus, it is recommended when assessing possible sexual or physical abuse, to use
open-ended questions, avoid suggesting answers, and avoid even asking the samequestion twice as children might change their answer believing they have answeredincorrectly the first time. Videotaping interviews is often advised in cases of possible
child abuse testimony for the clinician to show that questions were non-directive.

Click on the image to access theAmerican Academy of Child &Adolescent Psychiatry’s practiceparameter for the assessment
and treatment of children andadolescents with posttraumaticstress disorder.

Children and adolescents are usually dependent on their parents to accessclinical care. It is therefore important to engage and maintain a therapeutic alliancewith caregivers. If caregivers are not aware the child has been exposed to trauma,
they are unlikely to present the child for evaluation. Guidelines from the American
Academy of Child and Adolescent Psychiatry (AACAP) have recommended that
“Even if trauma is not the reason for referral, clinicians should routinely ask children
about exposure to commonly experienced traumatic events (…), and if such exposure
is endorsed, the child should be screened for the presence of PTSD symptoms” (Cohenet al, 2010).
As is the case for other mental disorders, children and adolescents’posttraumatic symptoms influence and are influenced by the family and
immediate environment. Assessment of posttraumatic symptoms in this age groupshould therefore include an assessment of their family (or environment). This isparticularly important as other family members may have been exposed to thesame traumatic event and may also be suffering from posttraumatic symptoms.
Finally, parents have been consistently found to under-report their children’s
traumatic experiences and posttraumatic symptoms (Meiser-Stedman et al, 2007;
Dyb et al, 2003; Shemesh et al, 2005) particularly among younger children (Dybet al, 2003). It is therefore not only important but also necessary to directly assesschildren’s symptoms and behaviors and not to rely solely on parental reports ofsymptoms.

Reactions to trauma

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13

IACAPAP Textbook of Child and Adolescent Mental HealthMaternal postpartum, PTSD and developmental issues
Research has shown that childbirth is a stressful event that may lead to negative psychologicalresponses and psychiatric disorders including postpartum depression (Robertson et al, 2004). A growing
body of research has focused on PTSD related to childbirth. Reported rates of childbirth-related PTSD
vary from 2.8% to 5.6% at six weeks postpartum (Creedy et al, 2000; Goutaudier et al, 2012). Whenconsidering sub-threshold PTSD, rates as high as 30% have been reported at 4–8 weeks postpartum(van Son et al, 2005). Further, a stressful delivery, such as preterm birth, significantly increases thelikelihood of developing PTSD (Jotzo & Poets, 2005). However, prevalence rates may not be reliable as
most studies in the perinatal field used self-report measures to diagnose PTSD when a valid diagnosis
cannot be made based solely on scale scores. Furthermore, as some studies use a cut-off score on aself-report questionnaire to make a diagnosis and do not confirm exposure to trauma (unless childbirthby itself is considered a “traumatic event” as required for PTSD), it is likely that some cases might be
misdiagnosed as postpartum PTSD when in fact suffering from other disorders such as postpartum
depression. It is also important to note that higher rates of postpartum PTSD have been found in at risk
samples (e.g., women with gynecological problems or a history of psychiatric disorder).
Nevertheless, childbirth-related PTSD is a potentially important problem as symptoms might
negatively impact the mother–infant relationship (Ballard et al, 1995), infants’ development, and their
future mental health (Pierrehumbert et al, 2003). In particular, PTSD following childbirth has been foundto be associated with attachment disorders. For example, symptoms of avoidance may lead mothers
not to bond with the infant, while hypervigilance may result in an over-anxious or over-protective
attachment (Bailham & Joseph, 2003). Postpartum PTSD symptoms are also associated with lesssensitive parenting and greater worries about intimacy with the baby (Schechter et al, 2004). Children of
depressed mothers have been found to be at risk for developing behavioral disturbance, and social andachievement deﬁcits (Anderson & Hammen, 1993). Several authors have hypothesized that there may
be a similar link between maternal postpartum PTSD and the infant’s social and behavioral development(e.g., Bailham & Joseph, 2003). Finally, postpartum PTSD symptoms may also have a negative impact
on the infant’s cognitive development (Parfitt et al, 2013). Systematic assessment of the psychologicalimpact of delivery on mothers may help identify those at increased risk for significant PTSD symptoms
and problematic parenting. Further, since fathers do not usually experience childbirth as traumatizing,
psychotherapeutic approaches involving the father in the postpartum might be helpful in dealing with
postpartum maternal PTSD symptoms.

Click on the image to accessthe Health Care Toolbox websitethat has information about how
to provide trauma-informed care.

Assessment tools
A number of assessment instruments are available to assist in the evaluationof ASD and PTSD in children and adolescents (Hawkins & Radcliffe, 2006;
March et al, 2012), however some have the limitation of having been adaptedfrom adult measures. Measures based on DSM-5 criteria are not yet available. A
detailed review of these instruments is beyond the scope of this chapter. Table F.4.2
summarizes some of the more commonly used measures, whether they are freely
available and where they can be found.
The most widely used instrument is the clinician-administered PTSD Scale
for Children and Adolescents (CAPS-CA) (Nader et al, 1996), an interview-based
instrument derived from the adult CAPS that is limited by the duration of theassessment and the requirement for the interviewer to receive training. Anotheroption is the Child Stress Disorders Checklist (CSDC) (Saxe et al, 2003).
A few diagnostic interviews that assess a range of disorders are available andcan be helpful in assessing PTSD (Scheeringa & Haslett, 2010; Egger et al, 2006).
For example, the Preschool Age Psychiatric Assessment (Egger et al, 2006) or the
Diagnostic Infant and Preschool Assessment Instruments may be used in preschoolers(Scheeringa & Haslett, 2010), while the Diagnostic Interview for Children andAdolescents (DICA) can be used for both children and adolescents (Reich, 2000).

Reactions to trauma

F.4

14

Reactions to trauma
6-17

7-18

6-18
7-18
3-12
4+

8-18

9-18
7-12,
13+
8-13

Clinician-Administered PTSD Scale forChildren & Adolescents (CAPS-CA) (Naderet al, 1996)

Children’s Impact of Traumatic Events
Scale-Revised (CITES-2) (Wolfe et al,
1991)

Children’s Posttraumatic Stress Disorder
Inventory (CPTSDI) (Saigh et al, 2000)

Trauma Symptom Checklist for Children(TSCC) (Briere, 1996)

Traumatic Events Screening Inventory(TESI) (Ribbe, 1996)

Child PTSD Symptom Scale (CPSS) (Foaet al, 2001)

My Worst Experiences Survey (National
Center for Study of Corporal Punishment
and Alternatives in Schools, 1992)

UCLA PTSD Index for DSM-IV (Pynoos etal, 1998)

When Bad Things Happen Scale (WBTH)(Fletcher, 1996b)

AGE
RANGE

F.4
10-20

15-20

20-30

10-15

10-30

20-30

15-20

30-45

30-120

15-20

N/A

Good

Good

Moderate to Good

Good

Good

Interviews

PSYCHOMETRICPROPERTIES

Moderate to Good

Excellent

Good

Good

Self-Reports

DURATION(MINUTES)

Yes

No

No

No

Yes

No

No

Yes

Yes

Yes

Contact author: Kenneth.Fletcher@umassmed.edu

Contact author: rpynoos@mednet.ucla.edu

http://www.wpspublish.com/app/

http://www.performwell.org/index.
php?option=com_mtree&task=att_
download&link_id=500&cf_id=24

http://www.ptsd.va.gov/professional/pages/
assessments/assessment-pdf/TESI-C.pdf

http://www4.parinc.com/Products/Product.
aspx?ProductID=TSCC

http://www.pearsonclinical.com/

http://www.clintools.com/victims/resources/
assessment/ptsd/cites-r.pdf

http://www.ptsd.va.gov/professional/
assessment/ncptsd-instrument-request-form.
asp

Contact author: rpynoos@mednet.ucla.edu

FREE TOWHERE TO FIND IT
USEInstruments to assess posttraumatic reactions in children and adolescentsChild PTSD Reaction Index (CPTS-RI)(Nader et al, 1990)

MEASURES

Table F4.2

IACAPAP Textbook of Child and Adolescent Mental Health15

IACAPAP Textbook of Child and Adolescent Mental Health

http://www4.parinc.com/Products/Product.
aspx?ProductID=TSCYC
Good
20-30
Trauma Symptom Checklist for YoungChildren (TSCYC) (Briere, 2005)

3-12

No

Contact author: Kenneth.Fletcher@umassmed.edu
Good
30-45
N/A

F.4

Parent Report of Child’s Reaction to Stress(Fletcher, 1996a)

Excellent
10
2-18

Yes

http://www.nctsnet.org/nctsn_assets/acp/
hospital/CSDC.pdf

Reactions to trauma

Child Stress Disorders Checklist (CSDC)(Saxe et al, 2003)

Parent Reports

Yes

FREE TOWHERE TO FIND IT
USEPSYCHOMETRICPROPERTIESDURATION(MINUTES)AGE
RANGE
MEASURES

Table F4.2 (continuation)

Instruments to assess posttraumatic reactions in children and adolescents

TREATMENT
Immediate interventions for all (less than 24hours after trauma)
Psychological approaches
Most children and adolescents will experience some
psychological or somatic symptoms in the immediate
aftermath of trauma. These symptoms do not necessarily
indicate a need for intervention as they generally resolve
spontaneously without professional help.
Critical incident debriefing, which requires individuals
to discuss details of the trauma–sometimes in a groupsetting–has been found to provide very little or no benefit(Australian Centre for Posttraumatic Mental Health, 2013).
Some data in adults suggest that group debriefing increases
PTSD symptomatology and may even increase rates of PTSD
(Rose et al, 2002; van Emmerik et al, 2002). Data from two
randomized controlled trials among children revealed thatdebriefing was not superior to usual care in reducing ratesof PTSD or other negative outcomes including behavioral
problems, depression or anxiety (Stallard et al, 2006; Zehnder
et al, 2010). Thus while children and adolescents in distressor seeking assistance should be offered the opportunity toventilate individually about the trauma if they wish to do so,
unrequested debriefing (in particular in a group setting) is
not recommended.
Recent data suggest that a 3-session exposure-based
intervention started in the emergency department within 12hours of a traumatic event may be helpful in decreasing ratesof PTSD among adults (Rothbaum et al, 2012), however, nodata are yet available on children and adolescents.
In conclusion, debriefing should not be routinely
provided to traumatized children and adolescents at risk for
PTSD. Exposure-based interventions delivered immediately
after trauma may help prevent PTSD in youth exposed totrauma, based on their efficacy in treating PTSD in children
and adolescents (see below) and in preventing PTSD among
adults. Finally, it is recommended to provide psychologicalfirst aid, including education about the usual course andnormal reactions to trauma, and ensure that basic medical
and safety needs are met, including shelter and food, increasesocial support, and provide appropriate referral.

Pharmacological approaches
A possible approach to the prevention of PTSD could
be the administration of a medication immediately after16

IACAPAP Textbook of Child and Adolescent Mental Healthtrauma exposure; however, few data support the efficacy of any pharmacologicalagents for this indication. Immediate treatment with propranolol has yielded
mixed results in adults (Vaiva et al, 2003; Pitman et al, 2002; Hoge et al, 2012),
and a trial in children and adolescents was negative (Nugent et al, 2010). Morepromising, several studies of injured children and adults support the preventive
benefit of higher levels of early post-injury administration of opiates for pain on
later emergence of PTSD symptomatology (Saxe et al, 2001; Stoddard et al, 2009;
Holbrook et al, 2010; Bryant et al, 2009).

Benzodiazepines should be
avoided in the immediate
aftermath of trauma

Finally, despite their wide clinical use in seeking to relieve acute stresssymptomatology, minimal evidence in the adult literature—but more in animalstudies—suggests that benzodiazepines may not be helpful in the immediate
aftermath of trauma and may even worsen outcomes in trauma-exposed individuals(Gelpin et al, 1996; Mellman et al, 2002). As a result, several guidelines recommend
avoiding the use of benzodiazepines in the immediate aftermath of trauma.

Early intervention for ASD (symptoms lasting more than twodays but less than one month)
Psychotherapeutic approaches
For adults presenting with symptoms that do not remit rapidly, brief (fourto five sessions) trauma-focused cognitive behavioral therapy (CBT) may beeffective in treating ASD and in preventing the development of PTSD (Australian
Centre for Posttraumatic Mental Health, 2013). These CBT interventions include
education, breathing training, relaxation training, exposure-based exercises, andcognitive processing. In children and adolescents, these approaches may be usefulas early psychological intervention for ASD based on their efficacy in treating
PTSD. In any case, administration of these early psychological interventions islimited by the scarcity of professionals trained to administer them, particularly in
low income countries.
Other early interventions tested among children with limited or inconclusive
favorable results include self-help websites for children and information booklets
for parents (Cox et al, 2010), narrative exposure therapy, and relaxation meditation(Catani et al, 2009). A study reported that a caregiver-child psychosocial and stressmanagement intervention (child and family traumatic stress intervention) was
superior to child supportive counselling and psychoeducation in reducing rates of
PTSD and PTSD symptom severity among children with at least one cluster ofClick on the image to accessthe Australian Guidelines for
the Treatment of Acute Stress
Disorder and PosttraumaticStress Disorder.

traumatic stress symptoms (Berkowitz et al, 2011).
Pharmacological approaches

A trial of sertraline initiated in the hospital in the few days after trauma (andfor a duration of 24 weeks) in burnt children and adolescents (Stoddard et al, 2011)
yielded mixed results: no significant improvemnt in youth-rated PTSD symptoms
but significant reduction on parental reports of children’s PTSD symptoms. Basedon these as well as on the mixed results for antidepressants in the treatment of
PTSD, antidepressants are not generally recommended for the treatment of ASD.

Reactions to trauma

F.4

17

IACAPAP Textbook of Child and Adolescent Mental HealthInterventions for PTSD (symptoms lasting one month or
more)
Pharmacological treatment
No large or definitive pharmacological trials in pediatric PTSD are available
to date. Overall, trauma-focused psychotherapeutic approaches should be favoredin childhood PTSD.

AntidepressantsIn adults, selective serotonin reuptake inhibitors (SSRIs) are therecommended first-line pharmacological treatment for PTSD. Their efficacy iswell documented; they are usually well tolerated and may be useful in treating
comorbid depression. However, there is little evidence to support their effectivenessin treating PTSD in the young. While the efficacy of sertraline and fluoxetine has
been examined in young people, both failed to prove superior to placebo (Cohen etal, 2007; Robb et al, 2010; Robert et al, 2008). Thus, to date, evidence supporting
the use of SSRIs for the treatment of PTSD in children and adolescents is lacking.
The effectiveness of other antidepressants has not been investigated in
randomized controlled trials (e.g., serotonin–norepinephrine reuptake inhibitors)
or trials yielded limited or inconclusive results (e.g., monoamine oxidase inhibitors).
Given this lack of empirical evidence and their unfavorable side effect profile,including agitation and irritability, they are not recommended in the treatment ofchildhood PTSD.

In spite of important
advances in thepharmacological treatmentof adults with PTSD, todate there are no data
supporting the use ofpsychotropic medications in
the management of PTSD inchildren and adolescents.

Other pharmacological treatments
Although it might be tempting to prescribe benzodiazepines for PTSD
because of their anxiolytic effects, there are no robust data supporting their efficacy.
In addition, given that they may interfere with the extinction of learning processes—
important for the effectiveness of cognitive behavioral therapy particularly whenbenzodiazepines are prescribed on an “as needed” basis—and that individuals with
PTSD are at elevated risk for substance abuse and dependence, they are generally
not recommended in the treatment of PTSD in the young.
Building on the fact that PTSD is associated with increased autonomic
arousal, recent data suggest that anti-adrenergic medications including a- andß-adrenergic receptor blockers, may be useful (Management of Post-TraumaticStress Working Group, 2010). Results from open label studies conducted inchildren suggest that the a-adrenergic blocker clonidine (Harmon & Riggs, 1996),
and the ß-adrenergic blocker propranolol (Famularo et al, 1988) might be effectivein treating PTSD symptoms, although randomized controlled data is still needed.
Second generation antipsychotics have been studied with regards to theirpotential efficacy in treating PTSD in adults; a review suggests they may have amodest benefit (Ahearn et al, 2011). However to date, no randomized controlled
data support their use in children with PTSD and their side effects are significant.
Finally, several controlled trials of antiepileptic mood stabilizers on PTSD
have been conducted in adults. Overall, results have been mixed. Lamotrigine
may have some benefit (Hertzberg et al, 1999), but topiramate, tiagabine, anddivalproex have not been shown to be effective (e.g., Tucker et al, 2007; Hamner

Reactions to trauma

F.4

Click on the image to accessthe website of the International
Society for Traumatic StressStudies18

IACAPAP Textbook of Child and Adolescent Mental Healthet al, 2009). Data for children are more limited; so far only one randomized
controlled trial has shown some efficacy of sodium valproate for PTSD symptoms
in adolescents with comorbid conduct disorder (Steiner et al, 2007).
In summary, although the field has seen important advances in thepharmacological treatment of adults with PTSD, to date there are no data
supporting the use of psychotropic medications in the management of PTSD inchildren and adolescents.

Psychotherapeutic treatments
The most effective psychotherapeutic approaches to the treatment of PTSD
symptoms are those based on cognitive-behavioral principles, specifically exposureand remodeling of cognitive processes. Treatments specifically designed forchildren and teens first became available in the late 1990s, and have been shown
in randomized controlled studies to be more effective than supportive and nondirective therapies (Gerson & Rappaport, 2013; Schneider et al, 2013).
The best studied and most widely used is Trauma-Focused Cognitive
Behavioral Therapy (TF-CBT) (Schneider et al, 2013). TF-CBT has been shown
to reduce PTSD symptoms, trauma-related depression, and improve adaptivefunctioning in a variety of populations, including children and teens traumatizedby sexual abuse, terrorism, domestic and community violence, and traumatic loss
(Kowalik et al, 2011; Cary & McMillen, 2012). An adaptation of TF-CBT (PreSchool PTSD Treatment) has been tested in a sample of children ages three to six,with positive results (Scheeringa et al, 2011a).
TF-CBT is a time-limited (12-16 sessions) therapy that combines exposure,cognitive processing remodeling and enhancement of coping skills, delivered
sequentially in 10 components: psycho-education, parenting skills (parent),
relaxation skills, affect regulation skills, cognitive coping skills, trauma narrative,
processing cognitive distortions, in vivo mastery of trauma triggers, parent-childsessions, and skills to increase safety from future exposures to trauma. Pre-School
PTSD Treatment consists of 12 conjoint child-parent sessions and uses drawing
as a developmentally appropriate expressive modality for the child to identify
thoughts and feelings and to process the child’s trauma narrative (see Box in page
F.4.20).
As with adults, young people with PTSD may have co-occurring mental
health conditions such as substance abuse, aggression, delinquency, and psychosis.
TF-CBT may be effectively combined with substance abuse treatment to reduce
PTSD symptoms in adolescents abusing drugs or alcohol (Cohen et al, 2006;2010). There are no data currently to guide psychotherapeutic treatment forchildren or adolescents with PTSD and comorbid conduct, bipolar, or psychotic
disorder. Practice guidelines (e.g., Cohen et al, 2010) recommend integrating thetreatment for both the PTSD and the co-occurring condition.
In contrast to adult psychotherapy, psychotherapies for children andadolescents raise the question of whether to involve the parents in the treatment.
Evidence suggests that, when compared with treatment of the child or adolescentalone, parental involvement leads to better outcomes (Cohen et al, 2010). Further,parents’ involvement may reduce drop-outs (Chowdhury & Pancha, 2011) andprovide children an ally when completing homework assignments, in maintaining

Reactions to trauma

F.4

Cognitive-behavioral
principles for thetreatment of PTSD
CBT approaches basicallytarget cognitive processes
and avoidance.
Cognitive processing
A traumatized person’s
inaccurate beliefs(cognitions) about thecauses and consequencesof the traumatic event (e.g.,“I should have known the car
was not going to stop when
my friend was riding a bike
across the street”) play asignificant role undermining
the natural recovery fromtrauma. Cognitive processing
targets these maladaptive
cognitions and the negative
feelings associated withthem with the goal ofachieving a more accurate
appraisal of events, thereby
facilitating progress toward
recovery from the traumatic
experience.
Avoidance
A traumatized individual’s
fear and avoidance ofreminders of the traumatic
event (e.g., avoiding thephysical location where thetraumatic event occurred),prevent recovery fromtrauma and maintain
PTSD over time. Exposure
consists of two procedures,
imagined exposure to thetrauma memory and in-vivo
exposure to trauma-related
situations. Exposure is
implemented in a gradualmanner after the therapist
and patient collaboratively
develop a severity
hierarchy of such situations.
Systematic exposure aims
to reduce the distressing
emotional and physiologicalreactions evoked bytraumatic memories(“triggers”), thereby
preventing the avoidance
behaviors that maintain
PTSD symptoms.

19

IACAPAP Textbook of Child and Adolescent Mental Healtha positive outlook, and practicing skills to maintaingains post-treatment. Parent involvement in thetreatment of younger children is critical since anempathic, emotionally attuned relationship to parents
or other primary caregivers is essential to a child’s
recovery from trauma (Lieberman et al, 2011).
Finally, although the mechanism of actionis unclear, eye movement desensitization andreprocessing (EMDR) has been found to be effectivein adult PTSD. EMDR integrates elements ofpsychodynamic, cognitive-behavioral, cognitive,
interpersonal, systems, and body-oriented therapies,
as well as a bilateral brain stimulation component(e.g., eye movements). The current literature suggeststhat EMDR is effective in adult PTSD (Bisson et al,2007). In youth, the evidence for the effectiveness of
EMDR is not as strong as it is for CBT (Gillies et al,2012).

CONCLUSION
Since the formal introduction of the diagnosis
of PTSD in children in 1981, research has increased
our understanding of the risk factors, phenomenology,
neurobiology, prevention, and treatment. It is now
widely accepted that PTSD is a common condition inyouth that causes much distress and disability.
Although significant advances in treatment
have been made, particularly with cognitive behavioral
approaches, the stigma and avoidance associatedwith PTSD, as well as children being dependent on
their parents to seek care is still a problem. In mostcountries, but particularly in low income ones, lack oftrained professionals is another, often insurmountablebarrier. Nonetheless, with continued research andprogress in the field, the current barriers to treatment
will presumably decrease••

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PLEASE GO TO APPENDIX F.4.3 FOR SELFDIRECTED LEARNING EXERCISES AND SELFASSESSMENT QUESTIONS

Reactions to trauma

F.4

Components of Trauma-Focused Cognitive
Behavioral Therapy•
Psycho-education
Provision of information about current symptoms, common
emotional and behavioral reactions to the type of trauma
experienced, the relationship between thoughts, feelings, andbehavior, current treatment, and strategies to manage current
symptoms.
•
Parenting skills
Teaching caregivers effective use of praise, selective attention,
time-out, and behavior charts to assist with contingency
reinforcement.
•

Relaxation skills

Teaching focused breathing, progressive muscle relaxation,
positive imagery, and aerobic activity.
•

Affect regulation

Aims to assist the young persons in identifying their feelings more
effectively through activities such as feeling charts or games, andthen help them develop a greater regulation of feelings throughacquisition of skills such as thought interruption, positive imagery,positive self-talk, problem-solving and social skills.
•

Cognitive coping skills

Provides coaching on “internal self-talk,” the influence between
cognition, feelings and behavior, and helping to create alternative,
more realistic thoughts in order to address and correct unhelpful
beliefs about the traumatic event, (e.g., If I had gone to the parkwith my brother, I could have stopped the car that hit him).
•

Trauma narrative

Aims to create a more consistent, coherent understanding of
the traumatic experience through gradual exposure to traumatic
memories through reading, writing, and expressive modalities
such as drawing, leading to a decrease in symptoms; the narrative
is shared with parents as an additional source of exposure andof relationship restoration and enhancement between the parent
and child•

Processing cognitive distortions

Seeks to further process and correct inaccurate and unhelpful
thoughts noted in the trauma narrative.
•

In vivo mastery of trauma triggers

Aims to address anxiety and avoidance developed as a protective
response to inherently innocuous trauma triggers through gradualexposure to the situations themselves.
•

Parent-child sessions

Seek to increase young persons’ comfort in discussing thetraumatic experiences with parents through conjoint meetings thattypically occur after cognitive processing and coping skills havebeen mastered by the young persons and the parents.
•

Increase safety for the future

Teaching skills that will enhance their preparedness and selfefficacy when facing situations with inherent risk to safety (e.g.,practicing how to communicate with adults about situations andexperiences that are frightening or confusing; paying attention to“gut reactions”; identifying trustworthy adults; practicing how to ask
for help).

20

IACAPAP Textbook of Child and Adolescent Mental Health

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21IACAPAP Textbook of Child and Adolescent Mental Health

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IACAPAP Textbook of Child and Adolescent Mental Healthdisorder: A double-blind, placebo-controlled trial.
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controlled trial. Child and Adolescent Psychiatry and
Mental Health 4:7.

Muzaffarabad, Pakistan (Nov. 1, 2005) – U.S. Army 1st Lt. Tory Marcon, assigned to the 212th MASH unit, helps a Pakistani child drink a
powered milkshake from a Meals Ready-to-Eat (MRE) in Muzaffarabad, Pakistan. The child has tetanus and the milkshake is the only food hecan manage to swallow because of muscle spasms. The United States was participating in a multi-national assistance and support effort led
by the Pakistani Government to bring aid to the victims of the devastating earthquake that struck the region on October 8th, 2005. U.S. Navy
photo by Photographer’s Mate 2nd Class Eric S. Powell

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25

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.4.1
PERITRAUMATIC DISTRESS INVENTORY-CHILD*
Please complete the sentences below by checking () the boxes corresponding best to what
you felt during and immediately after the event that took you to the hospital. If the sentence
doesn’t apply to how you felt, check the box “not true at all.”
Not trueat allSlightly
true

Somewhat
true

Very
true

Extremelytrue

1. I felt helpless, overwhelmed

0

1

2

3

4

2. I felt sadness and grief

0

1

2

3

4

3. I felt frustrated or angry I could not do
more

0

1

2

3

4

4. I felt afraid for my safety

0

1

2

3

4

5. I felt guilty

0

1

2

3

4

6. I felt guilty of my emotions, of the way
I felt

0

1

2

3

4

7. I worried for the safety of others(my parents, brother(s), sister(s),friends…)

0

1

2

3

4

8. I had the feeling I was about to lose
control of my emotions, of no longer
controlling what I was feeling

0

1

2

3

4

9. I felt like I needed to urinate (pee), to
defecate (poop)

0

1

2

3

4

10. I was horrified, frightened

0

1

2

3

4

11. I sweated, shook and my heart
pounded or raced

0

1

2

3

4

12. I felt I might pass out

0

1

2

3

4

13. I thought I might die

0

1

2

3

4

*Slightly modified; with permission from Dr Alain Brunet http://www.info-trauma.org/flash/media-e/triageToolkit.pdf
The total score is calculated by adding up ratings for all the items. Higher scores indicate increased risk for PTSD.
In adults, a score <7 indicates no need for monitoring; a score >28 indicates immediate care and follow-up isneeded; a score between 7 and 28 warrants follow up after a few weeks (Guardia et al, 2013). Bui et al (2011)provides further psychometric data.

Reactions to trauma

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26

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.4.2
PERITRAUMATIC DISSOCIATIVE EXPERIENCES QUESTIONNAIRECHILD*
Thank you for answering the following questions by checking () the answer that best
describes what happened to you and how you felt during ________________________ andjust after it. If a question doesn’t apply to what happened to you, please check “Not true at all”.
1. At times, I lost track of what was going on around me. I felt disconnected, “blanked out, “spaced out”
and didn’t feel part of what was going on
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

2. I felt as if on autopilot and I ended up doing things that I hadn’t actively decided to do.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

3. My sense of time was changed, as if things seemed to be happening in slow motion.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

4. What happened seemed unreal, as though I was in a dream or as if I was watching a movie, or as
if I was in a movie.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

5. I felt as though I was a spectator, as though I was watching from above what was happening to me,
as if I were observing from outside.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

6. There have been times in which the way I perceived my body was distorted or altered. I felt
disconnected from my own body or it seemed bigger or smaller than usual.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

7. I felt that things happening to others also happened to me like, for example, feeling in danger while
I wasn’t really in danger.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

8. I was surprised to ﬁnd afterwards that a lot of things happened at the time that I was not aware of,especially things I ordinarily would have noticed.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

10. I was disoriented, that is, at times I was not certain about where I was or what time it was.
1

2

3

4

5

Not true at all

Slightly true

Somewhat true

Very true

Extremely true

*Slightly modified; with permission from Dr Alain Brunet http://www.info-trauma.org/flash/media-e/triageToolkit.pdf
The total score is calculated by summing all the items. Elevated scores indicate increased risk for PTSD. Bui et al(2011) provides further psychometric data.

Reactions to trauma

F.4

27

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix F.4.3
SELF-DIRECTED LEARNING EXERCISES AND SELF-ASSESSMENT•

Interview a child or adolescent who has been exposed to a psychologically traumatic event.

•Write a letter to the family doctor or referring agent summarizing the above case(formulation), including a provisional diagnosis and a management plan (as per Chapter
A.10).

•

What are the differences in diagnostic criteria between PTSD and ASD? (for answer, see
Table F.4.1)•

Write a short essay about the factors that increase the likelihood of PTSD in refugee
children (for answer, see page 12).

•

List the 5 groups of symptoms that can be found in individuals who have experienced a
traumatic event (for answer, see Table F.4.1)•

List some of the components of trauma-focused cognitive behavioral therapy (for answer,
see Box in page 20).

MCQ F.4.1
What is the first line
treatment for posttraumatic stress disorderin children?
1. Critical incident debriefing
2. Tricyclic antidepressants
3. Selective serotonin reuptake inhibitors
4. Beta blockers
5. Trauma-focused cognitive behavioral
therapy
MCQ F.4.2
Which one of the answers
below is true regarding posttraumaticstress disorder in children under 6 years ofage?
1. It occurs only after 6 or more months
following the trauma
2. It usually involves feeling that the future
will be cut short
3. Re-experiencing (e.g. repetitive play) may
not be distressing to the child

MCQ F.4.3
Which one of the treatments
listed below administered immediately
after the traumatic event has been found to
reduce the development of PTSD?
1. Critical incident debriefing,
2. Benzodiazepines
3. Psychological first aid
4. Sodium valproate
5. Exposure-based intervention started in theemergency department.
MCQ F.4.4
Critical incident debriefingfor victims of a traumatic event should:
1. Not be provided systematically
2. Be provided but only in case of very
severe traumatic events
3. Be provided but only by trained personnel
4. Be provided but only for people exposed
to repeated traumatic events
5. Be provided in all cases.

4. It rarely involves nightmares of the trauma
5. It often involves self-destructive behaviors

Reactions to trauma

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IACAPAP Textbook of Child and Adolescent Mental HealthANSWERS TO MCQS•MCQ F.4.1•

MCQ F.4.2		
Answer: 3 (unlike in adults, re-experiencing the event may not be
distressing in children under the age of 6).

•

MCQ F.4.3
Answer: 5. Recent data suggest that a 3-session exposure-based
intervention started in the emergency department within 12 hours of a traumatic event may
be helpful in decreasing rates of PTSD among adults (Rothbaum et al, 2012), however, nodata are yet available on children and adolescents (page 16).

•

MCQ F.4.4
Answer: 1. Critical incident debriefing, which requires individuals to
discuss details of the trauma–sometimes in a group setting–has been found to provide
very little or no benefit (Australian Centre for Posttraumatic Mental Health, 2013). Some
data in adults suggest that group debriefing increases PTSD symptomatology and may
even increase rates of PTSD (Rose et al, 2002; van Emmerik et al, 2002). Data from two
randomized controlled trials among children revealed that debriefing was not superior tousual care in reducing rates of PTSD or other negative outcomes including behavioral
problems, depression or anxiety (Stallard et al, 2006; Zehnder et al, 2010). Thus whilechildren and adolescents in distress or seeking assistance should be offered the opportunity
to ventilate individually about the trauma if they wish to do so, unrequested debriefing (inparticular in a group setting) is not recommended.

Reactions to trauma

Answer: 1 (see page 19).

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