DSM-5: Recognizing the signs of trauma in kids

AbuseIn today’s installment of our blog series… Dissecting the DSM-5…What it Means for Kids and Families, we’ll explore the changes made in diagnostic criteria for Posttraumatic Stress Disorder (PTSD) and review how the changes are intended to provide clinicians with developmentally-sensitive tools to better identify the signs of trauma in children and teens.

As past of the DSM-5 review process, the diagnostic criteria for Posttraumatic Stress Disorder underwent significant revisions…

  • Sexual violence was identified as a specific threat under experiences that qualify as “traumatic” in addition to actual or threatened death and serious injury.
  • The types of exposures leading to PTSD were better delineated…direct experience of the event, witnessing (in person) the event as it occurred to others, learning that the traumatic event(s) occurred to a close family member or friend, and experience of repeated or extreme exposure to aversive detail(s) of the traumatic event(s)-this applies to first responders as opposed to those experiencing the event through media exposure.
  • Four symptom clusters for PTSD are now identified as opposed to three…intrusion symptoms (nightmares, flashbacks), avoidance, persistent negative alterations in cognitions and mood and alterations in arousal and reactivity.

Most importantly for the sake of our discussion, the symptom thresholds for establishing a diagnosis in children and teens have been changed to take into account differences in the ways that trauma is manifested in kids, and a unique set of diagnostic criteria have been established for identification of PTSD in kids ages six and under.

While the fear some conditions were being diagnosed too frequently in children (see our discussions of bipolar disorder and disruptive mood dysregulation disorder), many leading clinicians in the field raised concerns that in addition to the potential for overdiagnosis, PTSD may be underdiagnosed, or misdiagnosed as some other condition. Structured diagnostic interviews include measures to detect PTSD in children, but such interviews are rarely administered outside academic medical centers. Two large concerns led to the establishment of a unique set of criteria for younger children…

  • Nearly half of the diagnostic criteria in the DSM-IV required a verbal description of the patient’s internal states and experiences. Most preschool-age children lack the language skills to accurately describe their internal experiences.
  • Kids presenting with suspected PTSD frequently exhibit symptoms that weren’t captured in the previous diagnostic criteria. Some manifestations of PTSD unique to children would include the loss of recently acquired developmental skills (regression), onset of new fears or re-activation of old ones, separation anxiety, and increases in agitation, impulsive behavior and hyperactivity that may easily be confused with ADHD.

The new criteria for young children call attention to the differences in how PTSD may manifest in this population. Specifically, the new criteria point out that…

  • Intrusive memories (flashbacks) may not necessarily appear distressing and may be expressed through reenactment in play.
  • Constriction of play as an example of a negative alteration in cognition.
  • Passive reduction in expression of positive emotions.

The text that accompanies the criteria also points out that developmentally inappropriate sexual experiences without the experience of physical violence or injury are represent sufficient trauma to produce symptoms of PTSD. Most children with PTSD will meet criteria for at at least one other mental disorder, with Oppositional Defiant Disorder and Separation Anxiety Disorder co-occuring most commonly.

My one criticism of the new criteria is that there is no mention of one of the most common traumatic experiences we see among kids with disabilities leading to PTSD-like symptoms…the impact of chronic medical procedures for serious (but not necessarily life-threatening) medical conditions. Kids who need to experience multiple surgeries or hospitalizations and/or repeated blood draws often experience manifestations of PTSD, and the circle of mental health professionals equipped to help support affected kids and families is very small. But on the whole, developmentally appropriate diagnostic criteria for PTSD in children are a welcome improvement in the DSM-5.

Photo courtesy of http://www.freedigitalphotos.net.

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AACAPFor additional information on the impact of trauma in children, the American Academy of Child and Adolescent Psychiatry has an excellent resource center on child abuse. Included in the resource center are practice parameters summarizing the current standards for diagnosis and treatment of children with PTSD, rating scales for use in clinical practice, fact sheets for parents on sexual abuse, resources for adoptive and foster parents, and links to other organizations focused upon the impact of trauma in children.

About Dr. G

Dr. Stephen Grcevich serves as President and Founder of Key Ministry, a non-profit organization providing free training, consultation, resources and support to help churches serve families of children with disabilities. Dr. Grcevich is a graduate of Northeastern Ohio Medical University (NEOMED), trained in General Psychiatry at the Cleveland Clinic Foundation and in Child and Adolescent Psychiatry at University Hospitals of Cleveland/Case Western Reserve University. He is a faculty member in Child and Adolescent Psychiatry at two medical schools, leads a group practice in suburban Cleveland (Family Center by the Falls), and continues to be involved in research evaluating the safety and effectiveness of medications prescribed to children for ADHD, anxiety and depression. He is a past recipient of the Exemplary Psychiatrist Award from the National Alliance on Mental Illness (NAMI). Dr. Grcevich was recently recognized by Sharecare as one of the top ten online influencers in children’s mental health. His blog for Key Ministry, www.church4everychild.org was ranked fourth among the top 100 children's ministry blogs in 2015 by Ministry to Children.
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