Posttraumatic stress disorder in children: The influence of developmental factors

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Abstract

Despite the prevalence of childhood trauma, there are currently no developmentally oriented cognitive theories of posttraumatic stress disorder (PTSD). This paper outlines the definitional issues of PTSD in children, reviews the incidence of PTSD in children, and compares PTSD profiles in children and adults. We propose that a cognitive theory of childhood PTSD needs to accommodate developmental factors, including knowledge, language development, memory, emotion regulation, and social cognition, in addition to contextual factors such as family interactions. Implications of these developmental factors for assessment and treatment of traumatized children are discussed.

Introduction

Posttraumatic stress disorder (PTSD) was officially recognized in DSM-III (American Psychiatric Association, 1980), primarily as a result of the requirement that American psychiatry manage the psychological needs of Vietnam veterans (Brett, 1996). This initial attention to the effects of trauma on combat troops has been responsible, in part, for the predominant focus on adult trauma reactions. It was not until 1987 that diagnostic formulations recognized that children's reactions to trauma may differ from those of adults (DSM-III-R; American Psychiatric Association, 1987). Despite the frequency of childhood trauma, there is currently little theory to understand childhood PTSD. This paper responds to recent calls for a developmental perspective in understanding childhood PTSD (Horowitz, 1996) by (a) reviewing the available evidence concerning PTSD in children; (b) highlighting the potentially significant developmental differences between child and adult reactions to trauma; (c) pointing to the core issues that need to be accommodated in a cognitive model of childhood PTSD; and (d) highlighting implications for assessment and treatment.

Section snippets

Definition of PTSD

In describing PTSD, DSM-IV (American Psychiatric Association, 1994) acknowledges that the disorder can be manifested differently in children and adults. To satisfy criteria for PTSD, one must initially have been exposed to a traumatic event. In defining a trauma, DSM-IV stipulates that: “the person experienced, witnessed, or was confronted with an event or events that involve actual or threatened death or serious injury; or a threat to the physical integrity of himself or herself or others”

Encoding the traumatic event

Encoding is the first stage in the information processing sequence, involving the deployment of attention among various cues, the appraisal of the event, and the attribution of meaning (Stein, Wade, & Liwag, 1997). The ability of even very young children to remember information about stressful and nonstressful events after delays of months or years suggests that they encode considerable amounts of information about their experiences (e.g., Bahrick et al., 1998, Howe et al., 1994, Howe et al.,

Distinguishing developmental and pathological responses

The child's stage of emotional and cognitive development must be considered before gaps in autobiographical memory and failure to discuss an experience or to express an emotional reaction are attributed to psychopathological reactions. For example, there is currently considerable emphasis placed on dissociative responses as a defensive mechanism in the individual's response to trauma (van der Kolk & van der Hart, 1989). These reactions are considered to involve alterations in memory,

Implications for treatment

There is little research investigating treatment of PTSD in children and very limited support for various treatment interventions (Bryant, 1999). Clinical consensus suggests that treatment should involve direct exploration of the trauma, stress management techniques, identification and correction of inaccurate attributions about the trauma, and involvement of parents Berliner, 1997, Cohen, 1998. The relative weightings of each of these components and the mode of communication with the child are

Conclusions

This review has indicated that diagnosis of psychopathology in a child must be made with recognition of normal developmental processes. Further, contextual factors are critically important in conceptualizing, assessing, and treating PTSD. Empirical research is needed to identify the extent to which developmental factors are a risk or a protective factor in children's response to trauma. Current conceptualizations of childhood PTSD are some distance away from a genuinely developmental approach

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