Should PTSD Diagnosis Guidelines Differ in Younger Children?

In a presentation given Saturday, Oct. 30, at the AACAP 57th Annual Meeting in New York, NY, William E. Copeland, PhD, of Duke University Medical Center, Durham, NC, examined the prevalence of posttraumatic stress disorder (PTSD) in preschool age children, and questioned whether the diagnostic criteria are sufficient for identifying PTSD in these patients.

Copeland first discussed the two primary classifications for stressful life events in children, as defined by the Preschool Age Psychiatric Assessment (PAPA) model:

• Low magnitude stressors—include moving to a new home, birth of a sibling, death of a pet, or separation from one parent
• High magnitude stressors—include death of a parent, life-threatening car accident, witnessing violence, natural disaster, or child abuse

Researchers recruited subjects from the Preschool Anxiety Study 2006-2010, conducted at Duke University, and conducted detailed interviews and assessments of all PTSD symptoms, including onset of duration and severity. According to Copeland, more than 50% of preschoolers reported a low magnitude event in the last three months, and t% reported a high magnitude event during their lifetime; these rates were “strikingly high,” he noted.

High magnitude events were more commonly seen in boys and in African American children (5-10%); prevalence was alarmingly common in children from poor families (11% or more). Children who were exposed to one or more low magnitude events exhibited higher rates of depression, behavioral disorders, and anxiety, while those who exposed to one or more high magnitude events were more likely to develop symptoms of behavior disorder and anxiety, and were significantly more likely to develop depressive symptoms.

“This was surprising,” said Copeland. “We expected higher rates of anxiety, not depression.”

What was even more interesting, he noted, was the fact that less than 1% of the children in the study met the full DSM-IV diagnostic criteria for PTSD, and only 8-9% exhibited any symptoms of PTSD using this benchmark.

“If we want to do a better job of understanding posttraumatic stress in young children, the criteria require a radical revision,” said Copeland, who believes that a stressor criteria is unwarranted, as children who are exposed to events that adults may not consider to be traumatic can still exhibit symptoms of PTSD.

Even modest levels of this disorder, he added, are problematic. “Hopefully these data will move the DSM-IV criteria in the direction of a subjective, person-oriented approach to the meaning of these events.”