Posttraumatic stress disorder in early childhood: classification and diagnostic issues

Figures & data

Table 1 DSM-IV criteria for posttraumatic stress disorder (PTSD) (American Psychiatric Association, 2000b )

A: Person was exposed to a traumatic event in which both were present:
(1) person experienced, witnessed or was confronted with event(s) involving actual or threatened death, serious injury, or threat to physical integrity of self or others;
(2) person's response involved intense fear, helplessness or horror; in children may be expressed by disorganized or agitated behavior.
B: Traumatic event is persistently re-experienced in at least one of the following:
(1) recurrent and intrusive distressing recollections of the event including images, thought or perceptions; in young children repetitive play in which trauma themes are expressed;
(2) recurrent distressing dreams of the event; in children frightening dreams with no recognizable content;
(3) acting or feeling as if the traumatic event were recurring, reliving illusions, hallucinations, dissociative flashbacks; in young children trauma-specific re-enactment;
(4) intense psychological distress at exposure to reminders of the traumatic event;
(5) intense physiological distress at exposure to reminders of the traumatic event.
C: Persistent avoidance of trauma reminders and new numbing of general responsiveness, indicated by at least three of the following:
(1) efforts to avoid thoughts, feelings, or conversations about the trauma;
(2) efforts to avoid activities, places, or people that arouse memories of the trauma;
(3) inability to recall an important aspect of the trauma;
(4) markedly diminished interest or participation in significant activities;
(5) feeling of detachment or estrangement from others;
(6) restricted range of affect;
(7) sense of a foreshortened future.
D: Persistent new symptoms of increased arousal as indicated by at least two of the following:
(1) difficulty falling or staying asleep;
(2) irritability or angry outbursts;
(3) difficulty concentrating;
(4) hypervigilance;
(5) exaggerated startle response.

Table 2 0–3 Classification criteria for posttraumatic stress disorder (PTSD) in early childhood (0–3, Zero to Three, 2005)

(1) The child has been exposed to a traumatic event that threat to the physical or psychological integrity of the child or another person
(2) The child shows evidence of re-experiencing the traumatic event(s) by at least one of the following symptoms:
(a) Posttraumatic play that represent a reenactment of some aspects of the trauma, is compulsively driven, fails to relive anxiety and is more literal and less elaborate and imaginative than usual.
(b) Recurrent and intrusive recollections of the traumatic event outside play.
(c) Repeated nightmares the content of which may or may not be linked to the traumatic event.
(d) Physiological distress expressed in language or behavior.
(e) Recurrent episodes of flashback or dissociation.
(3) The child experiences a numbing of responsiveness or interference with developmental momentum by at least one of the following symptoms:
(a) Increased social withdrawal;
(b) Restricted range of affects;
(c) Diminished interest or participation in significant activities;
(d) Efforts to avoid activities, places or people that arouse recollection of the trauma, including thoughts, feelings, and conversations associated with the trauma.
(4) A child may exhibit at least two of the following symptoms of increased arousal, after traumatic event:
(a) Sleep difficulty;
(b) Difficulty concentrating;
(c) Hypervigilance;
(d) Exaggerate startle response;
(e) Increased irritability, anger or extreme fussiness, or temper tantrums;
(5) Persistence of this pattern of symptoms for at least 1 month.

Table 3 DSM-IV-R criteria for posttraumatic stress disorder (PTSD) showing alternative algorithm changes (adapted by Scheeringa, Zeanah, & Cohen, 2011)

Diagnostic criteria for posttraumatic stress disorder
A. The person has been exposed to a traumatic event in which the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (no change from DSM-IV).
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play or repetitive behaviors may occur in which themes or aspects of the trauma are expressed.
Furthermore, recollections may appear not to be distressing in young children
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content;
(3) acting or feeling as if the traumatic event was recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur;
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event;
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistence avoidance of stimuli associated with the trauma and numbing of responsiveness (not present before the trauma), as indicated by one or more of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma;
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma;
(3) inability to recall an important aspect of the trauma;
(4) markedly diminished interest or participation in significant activities. Note: In young children, this may be manifest as constriction in play;
(5) feeling of detachment or estrangement from others (e.g., unable to have loving feelings). Note: In young children, this may be manifest as social withdrawal;
(6) restricted range of affect
(7) sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep;
(2) irritability, outbursts of anger, or extreme temper tantrums in young children;
(3) difficulty concentrating;
(4) hypervigilance;
(5) exaggerated startle response.
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Table 4 Criteria for developmental trauma disorder (DTD; adapted by van der Kolk, 2005a)

A. Exposure
(a) Multiple or chronic exposure to one or more forms of developmentally adverse interpersonal trauma (e.g. abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death)
(b) Subjective experience (e.g. rage, betrayal, fear, resignation, defeat, shame)
B. Triggered pattern of repeated dysregulation in response to trauma cues
Dysregulation (high or low) in the presence of cues. Changes persist and do not return to baseline; not reduced in intensity by conscious awareness.
Affective
Somatic (e.g. physiological, motoric, medical)
Behavioral (e.g. re-enactment, cutting)
Cognitive (e.g. thinking that is happening again, confusion, dissociation, depersonalization)
Relational (e.g. clinging, oppositional, distrustful, compliant)
Self-attribution (e.g. self-hate, blame)
C. Persistently altered attributions and expectancies
Negative self-attribution
Distrust of protective caretaker
Loss of expectancy of protection by others
Loss of trust in social agencies to protect
Lack of recourse to social justice/retribution
Inevitability of future victimization
D. Functional impairment
Educational
Familiar
Peer
Legal
Vocational

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 2000b; Washington, DC: American Psychiatric Press. (4th and Rev. ed.).

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Zero to Three. Diagnostic classification 0–3R: Diagnostic classification of mental health and developmental disorders in infancy and early childhood (Rev. ed.). 2005; Washington, DC: Zero to Three Press.

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Scheeringa M. S., Zeanah C. H., Cohen J. A. PTSD in children and adolescents: towards an empirically based algorithm. Depression and Anxiety. 2011; 28: 770–782.

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Van der Kolk B. A. Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals. 2005a; 35: 401–408.

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