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Stress and post-traumatic stress disorder

Margaret DeJong

Sinad Marriott
Margaret DeJong MDCM FRCPsych(Can) FRCPsych(UK) is a Consultant Child and Adolescent Psychiatrist in the
Department of Child and Adolescent Mental Health, Great Ormond Street Hospital, London, UK and Honorary Senior
Lecturer, Institute of Child Health/UCL. Conflicts of interest: none declared
Sinad Marriott BSc (Hons) DClin Psych C Psychol is a Consultant Clinical Psychologist in the Department of Child and
Adolescent Mental Health, Great Ormond Street Hospital, London, UK. Conflicts of interest: none declared

Abstract
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Abstract
Introduction
Definition
Diagnostic criteria
Epidemiology
Pathogenesis
Natural history
Assessment
Differential diagnosis
Role of the Paediatrician
Management and prevention
Psychological treatment
Pharmacological intervention
New developments in the field
Further reading
Copyright

Abstract
There is growing awareness and concern about the high prevalence of traumatic experience and its long-term impact
on the physical and mental health of children. Professionals working in the field of child health have a crucial role in
identifying children at risk and in providing support for resilience and recovery. This review provides a further update
to an earlier article on current research and evidence-based treatment.
Keywords: acute stress disorder, disaster, post-traumatic stress disorder (PTSD), stress, trauma

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Introduction
Paediatricians have an important role in the early recognition of stress symptoms, which may develop into posttraumatic stress disorder (PTSD). Some of their patients will be victims of stressful events such as life-threatening
illnesses, medical interventions, road traffic accidents, natural disasters or terrorist attacks. Others will develop
symptoms as a result of chronic trauma resulting from abuse, neglect and witnessing domestic violence.
Paediatricians who are alert to the possibility of trauma symptoms can do a great deal in a preventative capacity to
ensure that appropriate supportive care is put into place. If unrecognized and untreated, trauma symptoms can
persist for many months or years, impairing quality of life and development.
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Definition
Following stressful events it is not unusual for survivors, including children, to experience transient symptoms such as
difficulty sleeping, troubling memories and thoughts, and some disturbance in everyday functioning. An acute stress
disorder may be present if the stressor was highly threatening and the reaction continues for days or weeks. When
the disturbance lasts longer than 1 month and causes significant distress or impairment, it may meet criteria for
PTSD.
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Diagnostic criteria
Symptoms of PTSD cluster into three broad categories: re-experiencing, avoidance and hyperarousal (See Table 1).
These criteria are the same for adults and children, although need some modification for very young children.
Developmentally appropriate modifications have been proposed for pre-school children and will be included in DSM-V.
These rely less on the child's verbal descriptions and more on what can be observed.

Table 1. Screening for PTSD

Exposure and response


Has the individual witnessed or experience or heard of someone close to them experiencing an event involving actual or threatened death,
serious injury or sexual violation
Re-experiencing
Has the traumatic event been persistently re-experienced in one (or more) of the following ways:
Intrusive thoughts or memories or repetitive play
Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content
Dissociative reactions (flashbacks) a sense of re-living the experience
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Avoidance
Is there persistent avoidance of stimuli associated with the trauma including:
Efforts to avoid thoughts, feelings or conversations associated with the trauma
Efforts to avoid activities, places or people that arouse recollections of the trauma
Negative Alterations in Cognitions and Mood associated with the traumatic event as indicated by two or more of the following:
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect, e.g. unable to have loving feelings
Sense of a foreshortened future, e.g. does not expect to have a career, marriage, children or a normal lifespan
Persistent and exaggerated negative views about self and the world
Persistent, distorted blame of self or others about the cause of the event
Persistent negative emotional state
Persistent inability to experience positive emotions

Hyperarousal
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Recklessness
Duration of symptoms is more than 1 month, causes significant distress or impairment.

Re-experiencing in young children often takes the form of post-traumatic play, characteristically displaying a reenactment of part of the trauma. Play may have a compulsive, rather stereotypic quality, and is less elaborated and
imaginative than usual play. Verbally competent young children may recall fragments of the experience not
necessarily showing any associated distress. There may be nightmares without an obvious trauma-specific content.
Emotional numbing can take the form of constricted play patterns, social and emotional withdrawal. Regression, in the
form of a loss of previously acquired skills (e.g. language, toilet training) or more immature behaviour can occur. Night
terrors, sleep difficulties, general fearfulness and aggression are common.
The cognitive model of trauma places increasing emphasis on the role of negative thoughts and beliefs in maintaining
trauma symptoms. This will be incorporated in DSM-V as an additional criterion. Symptoms of hyperarousal will
include reckless behaviour, which can be seen in adolescents.
Many clinicians expected DSM-V to include a diagnosis of Developmental Trauma Disorder. This is a proposed
diagnosis for individuals presenting with persistent dysregulation across several areas (including affect, physiology,
behaviour, attention, self and relationships) as a result of exposure to chronic or severe interpersonal trauma such as
abuse. There is ongoing controversy about its diagnostic validity and to date it has not been included in the DSM-V
proposed criteria.
Paul had just turned 3 years old when he witnessed his mother's partner fatally stab her. Paul continued to present as
a happy little boy who was compliant and well engaged at nursery. However he became increasingly aggressive with
his siblings and his play and drawings usually involved killings and being dead forever. He also repeated the details
of the killing to other family members who found this difficult and tried to change the subject. In therapy sessions he
displayed high levels of controlling behaviour and a somewhat manic, overly busy quality to his play.
Alex was knocked down on a zebra crossing outside school when he was 12 years old. He suffered a broken arm.
When Alex was referred for therapy at the age of 16 he had not travelled anywhere outside of the home without his
parents, not slept in a room without his mother, or played football since the accident 4 years earlier. Alex was
experiencing a repetitive nightmare of the event several times a week.
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Epidemiology
Community samples suggest a lifetime prevalence of PTSD of 412% and a point prevalence of 1%. Refugees and
children exposed to the trauma and losses of war will have much higher rates of PTSD, around 3040%. It is
estimated that one-third of children will develop PTSD after road traffic accidents. 69% of children diagnosed with
PTSD after an RTA still met criteria 6 months later. After a natural disaster very high rates (4050%) of PTSD can be
expected initially. Approximately one-third if untreated will continue to exhibit PTSD at 1 year, and as many as onethird will still have PTSD 58 years later.

A particularly important vulnerable group for paediatricians to be aware of is children who have had traumatic medical
experiences. High rates of PTSD (up to 21%) have been found in children who have been in a paediatric intensive
care unit (PICU), as well as in their parents. Children who are sub-threshold for a diagnosis of PTSD (34% post-PICU
in one study) may nevertheless have significant impairment.
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Pathogenesis
In situations of acute stress and danger there is an automatic psychophysiological response mediated by the
autonomic nervous system, which enables us to respond (fight, flight or freeze). As part of this response, the
hypothalamicpituitaryadrenal (HPA) axis releases noradrenaline (norepinephrine) and cortisol into the bloodstream,
prolonging the body's capacity to cope with stress. Symptoms of post-traumatic stress occur when the emergency
response system has been conditioned, as a result of the experience, to respond to stimuli which trigger memories of
the event. However, the trauma memories that are recalled are very different from normal memory. Normal event
memory is stored in the brain as information which is experienced as having occurred in the past; it includes
contextual information and can be retrieved at will, in narrative form, e.g. I remember going to my sister's wedding last
week Memories of this kind have been termed verbally accessible memory (VAM). In contrast, trauma memories
are stored in the form of the original sensations, are experienced as it is happening again, now. (i.e. re-living the
event) and lack a narrative form. They are retrieved involuntarily, being triggered by environmental cues, and have
therefore been termed situationally accessible memories (SAM). Normally, event information entering the amygdala
and the thalamus is converted to VAMs by means of processing in the hippocampus. However, in conditions of stress,
cortisol and noradrenaline (norepinephrine) inhibit the hippocampus from processing the event information in the
normal way, so that storage occurs without the addition of the contextual information characteristic of VAMs.
Chronic or repeated traumatization can lead to ongoing HPA axis dysregulation, contributing to long-term adverse
effects on mental and physical health. In chronic early trauma such as severe abuse there can be structural changes
to the brain including smaller brain size and corpus callosum.
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Natural history
Not all acute stress reactions will develop into PTSD and, of those that do, 1015% will be of delayed onset,
developing 6 months or more after the event. However, quite often symptoms will resolve after a few days or weeks.
Clinical and empirical studies have identified a number of factors that are associated with a heightened risk of
developing PTSD after a traumatic event including: previous mental health difficulties in the child or parent, poor
family functioning and inadequate social support, perceived life threat and the degree of fear that was associated with
the event, active avoidance of any thought about the event and being female.
If untreated, PTSD symptoms can persist for years. Follow-up of survivors of the Aberfan disaster after 33 years
found many to be suffering from PTSD. Traumatic experience is often accompanied by bereavement and other
significant losses which may involve major disruptions in a child's living situation. The traumatic loss of a loved one,
especially if unexpected, can lead to emotional numbing or intrusive thoughts and images, which can make it difficult
for normal grieving to take place.
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Assessment
It is useful to start with children and parents together. The interviewer should begin with current circumstances,
general development and functioning and then inquire directly about symptoms listed in the current DSM criteria or in
a standardized trauma questionnaire. Children will not necessarily volunteer information and may be reluctant to
disclose information in front of parents for fear of distressing them. Children who have experienced maltreatment may
not show an emotional response because they have become desensitized to the psychological impact upon them.
Parental accounts may not be completely reliable; they may themselves be traumatized and may underestimate the

degree to which their child has been affected. Interviewing the child individually and collecting information from other
settings is therefore also important.
Withdrawn, avoidant or dissociative behaviour can make it difficult to communicate with traumatized children. Clinical
observations are important: increased startle reflex or other hypervigilant responses, lapses in concentration or
dissociative spells may be observed during the interview. With younger children, play or drawing may be their
preferred means of expressing themselves. At the end of any interview about a traumatic experience, a child should
be helped to wind down by summarizing and reviewing what was said and praising them for their courage in
discussing such painful events.
Parents will often be able to provide useful background history. If they have shared in the traumatic experience they
should be screened for PTSD. Their mental health and coping skills will have a significant impact on their ability to
contain their child's anxiety and provide the support that the child needs.
The use of a screening instrument, such as the child version of the Impact of Events Scale (CR-IES), is a useful
adjunct to a clinical assessment involving single traumatic events. It is also recommended for routine use by
paediatricians after a known traumatic experience, such as organ transplant, PICU or a road traffic accident. Selfreport questionnaires are only considered valid in children over the age of 7 years. Complex trauma symptoms
stemming from interpersonal trauma such as abuse are harder to access and usually require specialist mental health
expertise.
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Differential diagnosis
Reactions to stress can take many forms, PTSD being one of them. There is a spectrum of responses, ranging from a
normal stress response to a self-limited adjustment disorder, to a range of psychiatric disorders including but not
limited to: anxiety, depression, dissociative states or somatization disorder.
Co-morbidity with PTSD is very common, particularly anxiety and depression, which should be looked for specifically.
Trauma symptoms may also mimic other conditions. Busy clinicians who are not alert to this may be tempted to
diagnose attention-deficit hyperactivity disorder (ADHD) in a child with hyperarousal and poor concentration, missing
the connection with traumatic experience. The increased arousal and mood swings can be confused with the manic
symptoms associated with bipolar disorder. Dissociative episodes can be mistaken initially for petit mal epilepsy.
Children with a background of abuse and neglect can present with a wide range of psychological problems, including
learning difficulties, self-harm, substance abuse, conduct problems and aggression, often leading to the development
of personality disorder as an adult. Exploring the possibility of traumatic experiences is vital, as it has important
implications for intervention.
David was 6 when he was referred for assessment of behaviour problems that were causing major problems in the
classroom. He had been diagnosed as having ADHD and was taking Ritalin twice daily, but the effect of this was
wearing off very rapidly. A detailed psychosocial history interview revealed that he had also witnessed significant
domestic violence between his parents. David's behaviour improved with incremental adjustments to his dose of
Ritalin and support for his mother in understanding and managing the effects of past trauma.
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Role of the Paediatrician


NICE guidelines (2005) advise that healthcare professionals should inform parents about the risk and common
symptoms of PTSD after a child has been treated in A&E and that they should contact their GP if the symptoms
continue after a month.
Paediatricians have a crucial role in enabling children and their parents to recover. Simple reassurance, information
and advice are needed:

helping to restore a sense of safety


providing information about help available
normalizing trauma symptoms and reassuring about recovery
advising on the need to restore basic routine and consistency
suggesting practical strategies for dealing with troubling symptoms such as hyperarousal and sleep disturbance
encouraging family to identify and access sources of support within family and community
promoting self help by providing access to useful resources such as leaflets and websites (see below).

This approach, described as psychological first aid, may be sufficient to enable recovery to occur. It is, however,
important that the paediatrician remains involved in a monitoring role. The child or adolescent can be asked at followup appointments whether they continue to be preoccupied by the traumatic event(s) or troubled by symptoms. If
symptoms are very troubling and persist for more than 1 month, referral to a specialist will need to be considered.
Families and young people can be reluctant to access Child and Adolescent Mental Health Services (CAMHS), and a
supportive relationship with a paediatrician can greatly assist the referral and engagement process.
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Management and prevention


Establishing safety and security for the child and their parents is of immediate importance. This principle is equally
applicable after a natural disaster or in circumstances where a child has been witnessing severe domestic violence.
The importance of each hospital and region having an up-to-date disaster plan, which makes provision for the mental
health needs of all those affected, was underlined by recent experience following the London bombings in 2005. It is
important that the particular needs of children are not overlooked by planners.
Psychological first aid (see above) carried out by a paediatrician or other professional is an important preventive
measure, and may be all that is required. Debriefing, a technique developed in the Vietnam War, is now considered
controversial and is not routinely recommended.
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Psychological treatment
Specialist psychological treatment may be required in a small number of cases. It is now established that brief
trauma-focussed psychological therapy is as effective in children as it is in adults, even in very young children.
Treatment of trauma may involve an initial stabilization phase focussing on enhancing coping mechanisms, and
ensuring a stable and effective support system is in place before proceeding to trauma-focussed desensitization work.
In complex cases, such as in developmental trauma, a great deal of stabilization work is often required and treatment
is longer.
Cognitive behavioural therapy (CBT) is a well-established trauma-focussed treatment with a solid evidence base in
children and young people. This approach involves helping the child to recall the distressing event in a safe way and
reducing unhelpful avoidant coping strategies (exposure & desensitization), accessing and modifying unhelpful
thoughts (cognitive restructuring). The sense that children make of their traumatic experiences (cognitive appraisal)
and the beliefs about themselves and the world is a key focus of treatment. Children from around 7 years of age can
usually engage in modified CBT. Very young children can be helped to establish a narrative of the events and make
sense of their difficult thoughts and feelings using play, drawing and story telling.

Eye movement desensitization and reprocessing (EMDR) was developed in the 1990s and is included in the NICE
guidelines for adults with PTSD. The traumatic memory is desensitized via short bursts of imaginal exposure whilst
the therapist provides simultaneous bilateral stimulation such as tapping the patient's hands or asking them to track
the horizontal movement of the therapist's fingers. EMDR uses many of the same elements as CBT but requires less
talking, which makes it particularly helpful with avoidant or very young children. A recent metaanalysis found that
children with PTSD benefitted from EMDR and it was found to add a small but significant incremental value when
compared with CBT.
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Pharmacological intervention
Although medication (SSRI antidepressants) has proved useful in treating adults, there is insufficient research
evidence to support this in children. One small RCT of sertraline was unable to demonstrate a significant benefit and
other more favourable reports of successful pharmacological treatment come from case studies and small open label
trials. Clonidine, an alpha agonist, has been used to treat trauma symptoms including hyperarousal. Although some
form of psychotherapy remains the treatment of choice, medication may be indicated as an adjunct to ease acute
symptoms such as sleeplessness, to assist engagement in trauma work or to enhance response. It also has an
important role in treating co-morbid disorders such as depression or anxiety, for which there is an established
evidence base using SSRI medication.
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New developments in the field


Group CBT interventions in schools in areas where there are high levels of community violence or after large scale
disasters such as Hurricane Katrina.
Primary prevention of PTSD in medical settings such as PICU (COPE study, use of diaries).
Childparent psychotherapy and adolescent individual psychotherapy.

Practice points

Screening for trauma symptoms should be routine after traumatic medical experiences, stressful events and where
there are concerns about possible abuse and domestic violence
A detailed psychosocial and trauma history should be taken in conditions presenting with hyperarousal and affect
dysregulation, e.g. ADHD
Early interventions to support resilience and enhance coping can be highly effective in preventing long-term morbidity
Referral to specialist services should be made when PTSD symptoms persist for longer than 1 month

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Further reading

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AACAP practice parameter for the assessment and treatment of children and adolescents with posttraumatic
disorder.J Am Acad Child Adolesc Psychiatry. 2010;49:414430
Brewin CR. A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behav Res
Ther.2001;39:373393
Carrion V, Weems C, Ray R, Reiss A. Toward an empirical definition of pediatric PTSD: the phenomenology of
PTSD in youth.J Am Acad Child Adolesc Psychiatry. 2002;41:166173
Cohen JA, Kelleher KJ, Mannarino AP. Identifying, treating, and referring traumatized children: the role of pediatric
providers. Arch Pediatr Adolesc Med. 2008;162:447452
Cohen JA, Mannarino AP. Psychotherapeutic options for traumatized children. Curr Opin Pediatr. 2010;22:605609
DSM-V development. American Psychiatric Association (updated May
2012)www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165 (accessed 10 January 2013).
Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. J Am Acad Child Adolesc
Psychiatry.1996;35:12471249
McCrory E, De Brito S, Viding E. Research review: the neurobiology and genetics of maltreatment and
adversity. J Child Psychol Psychiatry. 2010;51:10791095
National Institute for Clinical Excellence . Post-traumatic stress disorder: the management of PTSD in adults and
children in primary and secondary care. London: NICE; 2005;
Rees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric intensive care unit (PICU)
admission: a cohort study. Intensive Care Med. 2004;30:16071614
Robb AS, Cueva JE, Sporn J, Yang R, Vanderburg DG. Sertraline treatment of children and adolescents with
posttraumatic stress disorder: a double-blind, placebo controlled trial. J Child Adolesc
Psychopharmacol. 2010;20:463471
Sheeringa M, Zeanah C, Cohen J. PTSD in children and adolescents: toward an empirically based
algorithm. Depress Anxiety.2011;28:770782
Stamakatos M, Campo JV. Psychopharmacologic treatment of traumatized youth. Curr Opin Pediatr. 2010;22:599
644
The National Child Trauma Stress Network is a major resource for parents and
professionals. http://www.nctsnet.org/ (accessed 10 January 2013).
The Royal College of Psychiatrists has a useful series of downloadable factsheets for parents and young
people.http://www.rcpsych.ac.uk/expertadvice/youthinfo.aspx (accessed 10 January 2013).
van der Kolk BA. Developmental trauma disorder: toward a rational diagnosis for children with complex trauma
histories.Psychiatr Ann. 2005;35:401408
In: Vasterling JJ, Brewin CR editor. The neuropsychology of PTSD: biological, cognitive and clinical
perspectives. New York: Guilford Press; 2005;