New Thinking on Child Traumatic Stress
PTSD Criteria in DSM-5 Will Open Up Diagnosis, Treatment
Director of the Stress and Resilience Program; Clinical Psychologist, Anxiety and Mood Disorders Center
Child Mind Institute
The recent toll of Hurricane Sandy has had all of us thinking about how the stress and dislocation caused by a natural disaster can affect families and kids.
But Sandy also presents an opportunity to address our evolving understanding of traumatic stress reactions in young people. It is helpful to know what is on the horizon in the upcoming revision to the Diagnostic and Statistical Manual (DSM-5) and how the approach to child traumatic stress is turning towards less restrictive criteria, a more nuanced consideration of developmental stages, and the provision of effective short-term treatment to more children at risk.
The fact is that the psychotherapeutic interventions we have developed for traumatic stress reactions pose no risks to the child and have proven very effective in nurturing a healthy recovery. We can't hurt kids by intervening earlier and more often when a trauma impairs a child's ability to function—but we can do a world of good.
This issue was raised at the recent International Society for Traumatic Stress Studies (ISTSS) conference. A summary of the thinking of two or three leading clinicians in this area can clarify how to use this knowledge and ensure that we help more children sooner rather than later.
Michael Scheeringa, who does work on PTSD in preschoolers at Tulane, was central to reformulating the DSM approach, most notably relaxing the criteria for diagnosis in young people and making certain developmental modifications. Currently for a PTSD diagnosis, intrusive thoughts must be experienced as "distressing." However, young kids will often simply say something like, "Hey, did you know my dad hit my mom last night?" without any apparent distress—they don't seem bothered by it. But that is developmentally typical. They don't know how to label all their emotions. So that "distressing" criteria will change.
Another developmental difference that will be addressed concerns avoidance. Adults have to have multiple symptoms of avoidance or emotional numbing to be diagnosed, but that is a difficult concept to observe in children. In DSM-5 a child will only have to display one symptom.
The rationale behind these changes is particularly appropriate now. People in the field are finding that we're missing a lot kids who are having difficulty in the aftermath of a trauma by using adult diagnostic criteria and trying to apply them to children. This is simply developmentally ill-advised. We're missing kids who would benefit from care, and therefore clinicians need to keep an open mind and think holistically when evaluating children who have experienced a disturbing event or situation.
Additionally, Nancy Kassam-Adams at Children's Hospital of Philadelphia has been studying acute stress disorder, another timely topic. Her work has lead to new criteria that eliminate the need for symptoms of disassociation and simplify the symptom list, based on an analysis of the sensitivity and specificity of DSM-IV symptom criteria. The hope is that the new criteria will more accurately describe children with functional impairments secondary to significant stress and trauma exposure.
This means that we should be giving acute stress care to more kids. The idea here is not to pathologize typical reactions to stress, but that we are missing some children who can benefit from new, time-limited interventions that have demonstrated efficacy, such as Steven Berkowitz's Child and Family Traumatic Stress Intervention (CFTSI).
Finally, Scheeringa's research suggests that PTSD doesn't tend to go away in children. Kids don't "grow out of it." For this and many other reasons, it is more than worth it to intervene early, and we now have the tools to do so.
Published: November 27, 2012
A version of this article will appear in the December issue of the Journal of Child and Adolescent Psychopharmacology.