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Posttraumatic Stress Disorder
In Abused Children
Keyla Stephens
Wake Forest University Department of Counseling
Abstract
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that
affects a person who has been exposed to a traumatic event in
which the following factors apply: 1) the person experienced or
witnessed an event that threatened death, injury, or physical
integrity of self or another person, and 2) the person’s response
involved intense fear, helplessness, or horror (American Psychiatric
Association, 2000).
In children, the
feelings may be
exhibited by
agitated behavior.
In addition, a
person might become detached from others and present a
restricted affect. PTSD is often misunderstood or misdiagnosed;
yet, the disorder has specific symptoms associated with it.
Symptoms of the disorder include: difficulty sleeping, irritability,
difficulty concentrating, hyper-arousal, and exaggerated response.
The disturbance caused by PTSD lasts for more than a brief time
and can cause significant impairment in functioning.
Introduction
Background
• posttraumatic stress disorder is a formal diagnosis under DSM-IV-TR of
the American Psychiatric Association
• classified as an anxiety disorder when symptoms occur for more than
30 days
• a person with PTSD is challenged with grief, anger or fear from a
traumatic event, and an inability to cope can affect the person’s
behavior without them being aware of it
• involves recurrent, distressing thoughts or recollection of the event.
• diagnosis of PTSD must involve a re-experience of symptoms, such as
avoidance and hyper-arousal, which interfere with daily life
• intense psychological distress and physiological reactivity to internal or
external associations of the event may occur
• finding support and establishing coping strategies can increase a
person’s resiliency and decrease vulnerability to the disorder following
trauma
• among the risk factors that cause a person to be more susceptible to
suffer PTSD is experiencing additional stress following a traumatic
event
Child abuse is defined as “any act or series of acts of commission or
omission by a parent or other caregiver that results in harm,
potential for harm, or threat of harm to a child” (Centers for Disease
Control and Prevention, 2012).
Significance
• Child maltreatment (physical, sexual, emotional abuse and neglect) is a
significant and consistent predictor of posttraumatic stress disorder
(PTSD) symptoms (Shenk, Putman, & Noll, 2012).
• Studies show that children are more vulnerable to PTSD symptoms than
adults (DeBellis et al., 2010).
• Abuse during childhood presents significant risk for PTSD in adulthood
(Binder et al., 2008).
• PTSD in adults may stem from a prolonged symptomatic reaction to prior
trauma, including child abuse and childhood adversity (Auxemery, 2012).
• Preliminary research suggests that child abuse may interact with
mutations in a stress-related gene to increase the risk of PTSD in
adulthood (Binder et al., 2008).
• Adolescents are at greater risk of experiencing trauma than adults, with
an average rate of nearly 14% among studies within the last decade
(Nooner et al., 2012).
• Data from one study showed that PTSD symptoms mediate the relation
between child sexual abuse and nonsuicidal self-injury among
adolescents (Weierich & Nock, 2008).
RESEARCH POSTER PRESENTATION DESIGN © 2012
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Method
Points of interest:
• PTSD symptoms
• treatment approaches
• comorbidity
• challenges in diagnosis
Sources:
• Diagnostic and Statistical Manual IV (American Psychiatric
Association, 2000)
• The National Institute of Mental Health (www.nimh.org)
• Centers for Disease Control (www.cdc.org)
• Databases: PsycInfo, PubMed
Keywords:
• “posttraumatic stress disorder”
• “child abuse”
Exclusions:
• Research based solely on children exposed to traumatic events such as
war or natural disasters
Results
Substantial rates of PTSD and related symptoms occur in youth removed from their home due to abuse or neglect (Wechsler-Zimring et al.,
2012). In a study by the Casey Foundation (2003), the rate of PTSD in foster care alumni was almost five times greater than the general
population. Perhaps this finding is contributed to the ongoing trauma experienced by children who have been abused and are taken from their
homes and placed in foster care. Research supports this theory as shown by a study of youth in residential care. In their study, Collin-Vezina et
al. (2011) found that youth with higher rates of trauma, or multiple types of maltreatment experienced, are more likely to “present symptoms
within the clinical range for depression, anger, posttraumatic stress, and dissociation.” PTSD is more likely to develop when children face
additional challenges or changes in their life following the trauma (Carr, 2004).
Furthermore, children from abusive families, as well as those in out-of-home care, are less likely to have support needed to build coping
strategies. Neglect can cause anxiety that leads to adverse brain development in children (DeBellis et al., 2009). The lack of coping skills along
with consequences of abuse and/or neglect may lead to PTSD symptoms. Children often display different symptoms than adults. In young
children, these symptoms can include: bedwetting that isn’t typical, having an inability to talk, acting out, and being clingy to adults. Older
youth may develop disruptive, disrespectful, or destructive behaviors (NIMH, 2013). Carr (2004) suggests that chronic trauma develops from
repeated traumatization and results in long-term adjustment problems. This type of trauma would be indicative of child abuse that is ongoing.
The effects of trauma exposure, if untreated, may lead to recurring trauma. Therefore, this discussion highlights the need for early intervention.
Diagnosis
• Children’s PTSD Inventory (Saig et al., 2000) uses an interview
approach to introduce Exposure and Situational Reactivity items and
record a subject’s responses.
• Children’s PTSD Inventory was developed in response to the need for a
test that was short and easy for children to understand (Saig et al.,
2000).
• Designed for youth ages 7 to 18.
Diagnostic Challenges
• Some argue that PTSD does not adequately address the severity and
complexity of traumatization in childhood.
• Chronic PTSD can manifest itself in different clinical forms and
patients may suffer in silence, determining a diagnosis could be
difficult (Auxemery, 2012).
• Neglect, often the leading cause of child placement into foster care,
is “a traumatic event whose magnitude and pervasiveness are often
overlooked” (Galanter, Jensen, & Ebooks Corp., 2009).
• Current diagnostic threshold may not be developmentally sensitive
(DeBellis et al., 2010).
• For young children, modification in the criteria is needed to include
loss of developmental skills and language to indicate avoidance (Carr,
2004).
• Auxemery (2012) suggests that PTSD is a pathology which interacts
with the societal context and changes with the evolution of society.
Comorbidity
• DeBellis, Hooper, Spratt, & Wooley (2009) hypothesized that the
traumatic experience of neglect, abuse, or witnessing violence may
lead to neurocognitive problems in children, resulting in PTSD
symptoms.
• Children often develop other disorders in addition to the symptoms
experienced when exposed to trauma. Carr’s study predicted that
“co-morbid anxiety and affective disorders will be common for
children with a diagnosis of PTSD” (2004).
• In addition to trauma-related psychopathology, many children
experience aggressive and violent behavior (Leenarts et al., 2012).
• Substance-use disorder is comorbid in more than 80% of those with
PTSD and typically begins in adolescence (Nooner et al., 2012).
Treatment
• Cognitive Behavioral Therapy (CBT) focuses on correcting patterns of
behavior and thought.
• Trauma-focused CBT (TF-CBT) found to be effective in treating PTSD
in children by increasing coping skills and decreasing symptoms
through gradual exposure to the trauma (Feather & Ronan, 2009).
• In cases of youth who have been complexly traumatized, a program
such as Attachment, Regulation, and Competency (ARC) could be
effective in developing and maintaining resiliency in order to cope
(Collin-Vezina et al., 2011).
• Gentling: according to Krill (2011), this therapy technique offers
individualized methods based on each child’s unique symptoms.
Discussion
• Research supports the theory that children who have been subjected to abuse or witnessed violence are susceptible to symptoms of
posttraumatic stress disorder.
• Children who have suffered abuse often face challenges to these basic human protective systems, and prevalently in the form of posttraumatic
stress disorder or other psychological disorders.
• Trauma-focused cognitive-behavioral therapy (TF-CBT) appears to be the most supported treatment for children following exposure to abuse
(Leenarts et al., 2012).
• The magnitude of challenges facing diagnosis and treatment of posttraumatic stress disorder in children who have been abused support the
need for further research.
• As suggested by Collin-Vezina et al. (2011), the need to identify an individual’s traumatic experience through a systematic method of screening
and apply a corresponding treatment program that addresses the trauma-related symptoms should be further explored.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
Text Revision). Washington, DC: Author.
Auxéméry Y. (2012). Posttraumatic stress disorder (PTSD) as a consequence of the interaction between an
individual genetic susceptibility, a traumatogenic event and a social context. Encephale, 38(5):3,7380. doi: 10.1016/j.encep.2011.12.003. Epub 2012 Jan 24. French. PubMed PMID: 23062450.
Binder EB, Bradley RG, Liu W, et al. (2008). Association of FKBP5 polymorphisms and childhood abuse with
risk of posttraumatic stress disorder symptoms in adults. The Journal of the American Medical
Association, 299(11):1291-1305. doi:10.1001/jama.299.11.1291
Caffo, Ernesto (2003, July). Psychological aspects of traumatic injury in children and adolescents. Child
and Adolescent Psychiatric Clinics of North America (1056-4993), 12(3), p.493. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/12910820
Carr, A. (2004). Interventions for post-traumatic stress disorder in children and adolescents. Pediatric
Rehabilitation, 7(4), 231-244.
Centers for Disease Control. (2012). Child Maltreatment. Retrieved February 17, 2013, from
http://www.cdc.gov/ViolencePrevention/childmaltreatment/consequences.html
Collin-Vezina, D., Coleman, K., Milne, L., Sell, J., & Daigneault, I. (2011, April). Trauma experiences,
maltreatment-related impairments, and resilience among child welfare youth in residential care.
Journal of Mental Health and Addiction, 9, 577-589. doi:10.1007/s11469-011-9323-8
Dale, L. P., Carroll, L. E., Galen, G., Hayes, J. A., Webb, K. W., & Porges, S. W. (2009). Abuse history is
related to autonomic regulation to mild exercise and psychological wellbeing. Applied
Psychophysiology and Biofeedback, 34(4), 299-308. doi:10.1007/s10484-009-9111-4
De Bellis, M. D., Hooper, S. R., Woolley, D. P., & Shenk, C. E. (2010). Demographic, maltreatment, and
neurobiological correlates of PTSD symptoms in children and adolescents. Journal of Pediatric
Psychology, 35(5), 570-577. doi:10.1093/jpepsy/jsp116
De Bellis, M. D., Hooper, S. R., Spratt, E. G., & Woolley, D. P. (2009). Neuropsychological findings in
childhood neglect and their relationships to pediatric PTSD. Journal of the International
Neuropsychological Society, 15(6), 868-878. doi:10.1017/S1355617709990464
Feather, J. S., & Ronan, K. R. (2009). Trauma-focused CBT with maltreated children: A clinic-based
evaluation of a new treatment manual. Australian Psychologist, 44(3), 174-194.
doi:10.1080/00050060903147083
Galanter, C. A., Jensen, P. S., & Ebooks Corporation. (2009). DSM-IV-TR casebook and treatment guide for
child mental health. Washington, DC: American Psychiatric Pub.
Kaplow, J. B., Hall, E., Koenen, K. C., Dodge, K. A., & Amaya-Jackson, L. (2008). Dissociation predicts
later attention problems in sexually abused children. Child Abuse & Neglect, 32(2), 261-275.
doi:10.1016/j.chiabu.2007.07.005
Kramer, D. N., & Landolt, M. A. (2011). Characteristics and efficacy of early psychological interventions
in children and adolescents after single trauma: a meta-analysis. European Journal of
Psychotraumatology, 2:7858. doi: 10.3402/ejpt.v2i0.7858
Krill, W. r. (2011). Gentling: A practical guide to treating PTSD in abused children (2nd ed.). Ann Arbor, MI
US: Loving Healing Press.
Leenarts, L.E., Diehl,e J., Doreleijers, T.A., Jansma, E.P., Lindauer, R.J. (2012). Evidence-based
treatments for children with trauma-related psychopathology as a result of childhood maltreatment: a
systematic review. European Child & Adolescent Psychiatry, Dec 25. [Epub ahead of print] PubMed
PMID: 23266844.
National Institute of Mental Health. (n.d.). Post Traumatic Stress Disorder. Retrieved February 2, 2013,
from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/why-dosomepeople-get-ptsd-and-other-people-do-not.shtml
Nooner, K.B., Linares, L.O., Batinjane, J., Kramer, R.A., Silva, R., Cloitre, M. (2012). Factors related to
posttraumatic stress disorder in adolescence. Trauma Violence & Abuse, Jul;13(3):153-66.
doi:10.1177/1524838012447698. Epub 2012 Jun 4. Review. PubMed PMID: 22665437.
Pecora, P.J., Williams, J., Kessler, R.C., Downs, A.C., O'Brien, K., Hiripi, E., and Morello, S. (2003).
Assessing the Effects of Foster Care: Early results from the Casey National Alumni Study (Mental Health
Outcomes Report). Retrieved February 2, 2013, from
http://www.casey.org/Resources/Publications/pdf/CaseyNationalAlumniStudy_MentalHealth.pdf
Saigh, P. A., Yasik, A. E., Oberfield, R. A., Green, B. L., Halamandaris, P. V., Rubenstein, H., & McHugh, M.
(2000). The children's PTSD Inventory: Development and reliability. Journal Of Traumatic Stress, 13(3),
369-380. doi:10.1023/A:1007750021626
Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma- focused
cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: A
randomized clinical trial. Journal of Child Psychology and Psychiatry, 52(8), 853-860.
Schmid, M., Petermann, F., & Fegert, J.M. (2013). Developmental trauma disorder: pros and cons of
including formal criteria in the psychiatric diagnostic systems. BMC Psychiatry, 3;13(1):3. doi:
10.1186/1471-244X-13-3. PubMed PMID: 23286319; PubMed Central PMCID: PMC3541245.
Shenk, C. E., Putnam, F. W., & Noll, J. G. (2012). Experiential avoidance and the relationship between
child maltreatment and PTSD symptoms: Preliminary evidence. Child Abuse & Neglect, 36(2), 118-126.
doi:10.1016/j.chiabu.2011.09.012
Wechsler-Zimring, A., Kearney, C. A., Kaur, H., & Day, T. (2012). Posttraumatic stress disorder and
removal from home as a primary, secondary, or disclaimed trauma in maltreated adolescents. Journal of
Family Violence, 27(8), 813-818. doi:10.1007/s10896-012-9467-8
Weierich, M. R., & Nock, M. K. (2008). Posttraumatic stress symptoms mediate the relation between
childhood sexual abuse and nonsuicidal self-Injury. Journal of Consulting and Clinical Psychology, 76(1),
39-44.