PMID: 19432391
The Diagnostic Interview Schedule for Children (DISC-IV) is a fully structured diagnostic instrument that assesses thirty-four common psychiatric diagnoses of children and adolescents. The DISC is designed for interviewer administration - either by lay interviewers (people with no formal clinical training) or by clinicians or by self-completion. The Posttraumatic Stress Diagnostic Scale (PDS) is a 49-item self-report measure designed to assess all the DSM-IV diagnostic criteria for PTSD. 22,23 The PDS, which is based on the self-report.
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Abstract
Children and adolescents experience high rates of potentially traumatic experiences. Many children subsequently develop mental health problems, including post-traumatic stress disorder (PTSD) symptoms. Accurately diagnosing PTSD in children is challenging. This paper reviews the following important issues: (i) the specificity of the PTSD diagnosis; (ii) children who are symptomatic and impaired but do not have enough symptoms for the diagnosis of PTSD; (iii) developmental considerations for preschool and schooi-age children; and (iv) a variety of assessment challenges that reflect the difficulty and complexity of interviewing children and caregivers about these symptoms. Despite these challenges, PTSD remains the best construct for clinical and research work with trauma survivors. Pediatric PTSD criteria are valuable for identifying children at risk and in need of treatment and can be even more helpful when developmentally modified in ways that are discussed.
Keywords: child, adolescent, post-traumatic stress disorder, DSM-IV-TR, trauma, diagnostic criterion, internalizing disorder, treatment
Abstract
Los niños y adolescentes presentan una alta frecuencia de experiencias potencialmente traumáticas. Con posterioridad a éstas muchos niños desarrollan problemas de salud mental que incluyen síntomas del trastorno por estrés postraumático (TEPT). La precisión del diagnóstico de TEPT en los niños constituye un desafío. Este artículo revisa los siguientes temas importantes: 1) la especificidad del diagnóstico de TEPT, 2) los niños que están sintomáticos y afectados, pero que no tienen síntomas suficientes para el diagnóstico de TEPT, 3) aspectos del desarrollo para niños en edad pre-escolary escolar y 4) una variedad de desafíos de evaluación que refleja la dificultad y complejidad de la entrevista de niños y de sus cuidadores respecte a estos síntomas. A pesar de estos desafíos, el TEPTsigue siendo el mejor constructo para el trabajo clínico y de investigación con sobrevivientes de traumas.
Résumé
Un taux élevé d'expériences potentiellement traumatiques peut être retrouvé chez les enfants et les adolescents. Beaucoup développent en retour des problèmes de santé mentale y compris des symptômes de stress post-traumatique (SPT), Établir un diagnostic précis de SPT chez l'enfant est difficile. Cet article propose une revue des questions importantes suivantes: (i) la spécificité du diagnostic du SPT; (ii) la prise en charge des enfants symptomatiques et touchés mais sans assez de symptômes pour le diagnostic de SPT; (iii) le problème du développement au cours de l'âge scolaire et préscolaire ; (iv) les objectifs de nombreuses tentatives d'évaluation qui montrent la difficulté et la complexité de l'interrogatoire des enfants et de leurs responsables au sujet de ces symptômes. En dépit de ces obstacles, le SPT reste la meilleure construction pour le travail clinique et de recherche avec les survivants d'un traumatisme. Les critères de syndrome de stress post-traumatique en pédiatrie sont fiables pour identifier les enfants à risque, nécessitant un traitement, et pourraient être encore plus utiles s'ils étaient orientés vers certaines voies discutées dans cette revue.
Most individuals who experience life -threatening traumas show some symptoms of post-traumatic stress disorder (PTSD) immediately Only approximately 30% have vulnerabilities to this disorder, and/or suffer the most chronic and terrifying events that maintain these symptoms as an enduring syndrome a month after the threats are gone. This is true for nearly all ages. Since the revision of PTSD in the Diagnostic: and Statistical Manual of Mental Disorders, Third Edition-Revised (DSM-III-R) in 1987 ,3 the diagnostic criteria have included special developmental considerations for children and adolescents. This special language was revised with the subsequent version of the DSM. Initially, skeptics doubted whether children could develop PTSD,4 but this is no longer debatable. More current concerns include whether the PTSD criteria adequately describe the psychopathology of children and adults who have experienced severe trauma. This paper will review the following important issues for assessing children who have experienced traumatic events: (i) the specificity of the PTSD diagnosis; (ii) recognizing children who are symptomatic and functionally impaired but do not have enough symptoms for the diagnosis; (iii) developmental considerations that impact on accurate diagnosis of PTSD; and (iv) a variety of assessment challenges that reflect the difficulty and complexity of interviewing children and caregivers about these symptoms.
Despitc these diagnostic challenges, many crucial benefits derive from attempting to accurately assess PTSD symptoms in children. This paper addresses the above challenges, and also explores reasons why despite these, clinicians should persist in exploring the possible presence ot PTSD symptoms lu children who have experienced traumatic life events.
DSM-IV-TR PTSD diagnostic criteria
The current diagnostic criteria for PTSD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR)6 require that children have experienced, witnessed, or learned of a traumatic event, defined as one that is terrifying, shocking, and potentially threatening to life, safety, or physical integrity of self or others. Children must also meet at least one re-experiencing criteria, three avoidant/numbing criteria, and two hyperarousal criteria, listed in Table I. Children must meet minimal duration criteria of at least 1 month, and they must show functional impairment in an important area (school, peers, family, etc).
Table I.
A: Person was exposed to a traumatic event in which both were present: |
1) person experienced, witnessed or was confronted with event(s) involving actual or threatened death, serious injury, or threat to physical integrity of self or others |
2) person's response involved intense fear, helplessness or horror; in children may be expressed by disorganized or agitated behavior |
B: Traumatic event is persistently re-experienced in at least one of the following: |
1) recurrent and intrusive distressing recollections of the event including images, thought or perceptions; in young children repetitive play in which trauma themes are expressed |
2) recurrent distressing dreams of the event; in children frightening dreams with no recognizable content |
3) acting or feeling as if the traumatic event were recurring, reliving illusions, hallucinations, dissociative flashbacks; in young children trauma-specific re-enactment |
4) intense psychological distress at exposure to reminders of the traumatic event |
5) intense physiological distress at exposure to reminders of the traumatic event |
C: Persistent avoidance of trauma reminders and new numbing of general responsiveness, indicated by at least three of the following: |
1) efforts to avoid thoughts, feelings, or conversations about the trauma |
2) efforts to avoid activities, places, or people that arouse memories of the trauma |
3) inability to recall an important aspect of the trauma |
4) markedly diminished interest or participation in significant activities |
5) feeling of detachment or estrangement from others |
6) restricted range of affect |
7) sense of a foreshortened future |
D: Persistent new symptoms of increased arousal as indicated by at least two of the following: |
1) difficulty falling or staying asleep |
2) irritability or angry outbursts |
3) difficulty concentrating |
4) hypervigilance |
5) exaggerated startle response |
Challenge 1: specificity of pediatric PTSD diagnostic criteria
Some overlap exists between diagnostic criteria for PTSD and other childhood internalizing disorders. Four PTSD diagnostic criteria (decreased interest in activities, sleep disturbance, restricted range of affect, and decreased concentration) overlap with those for major depressive disorder (MDD). Three symptoms of PTSD (decreased concentration, irritability, and sleep disturbance) also overlap with symptoms of generalized anxiety disorder (GAD). Despite this overlap, there are pathognomonic symptoms of PTSD that make it distinct. No diagnoses other than acute stress disorder (ASD) include trauma-specific items such as criteria B 1-5 (specific to traumatic reexperiencing symptoms) or C 1-3 (specific to traumatic avoidance and numbing). Thus, 8 out of 17, or nearly half of the PTSD diagnostic criteria, are unique to PTSD or partly shared by ASD. It is literally impossible to be diagnosed with PTSD without trauma-specific criterion B symptoms. In this regard, a study conducted by Keane et al demonstrated that clinicians could readily distinguish PTSD from MDD or GAD despite several overlapping criteria, due to the presence of a number of discriminating items and dimensions that differentiate these respective disorders.
Nevertheless, in a debate that so far has been largely confined to the adult literature, the specificity of PTSD has been challenged because of concerns that persons who do not really have the disorder may be diagnosed (too many false-positives). For example, in one study of patients enrolling in treatment studies for depression, the group with true trauma events and the group with “minor traumas” both had nearly 80% rates of PTSD from structured interviews. That is, the “minor trauma” subjects endorsed enough criteria B, C, and D symptoms from their events to qualify for the diagnosis. However, the authors paid only glancing attention to the issue that this was a highly selective help-seeking depressed sample, suggesting that they had greater vulnerability to react to minor trauma and develop symptoms. Furthermore, no attempt was made to comparatively grade the severity of PTSD within each of those groups to explore the possibility that the “minor trauma” group may have had relatively less severe PTSD than the trauma group, which would not be a surprising finding if symptom severity follows from the severity of perceived life threat.
Speculating from these types of concerns, Spitzer and colleagues proposed modified diagnostic criteria for PTSD in an effort to restrict who can receive the diagnosis. The main suggestion was to eliminate five symptoms that overlapped with other disorders. In addition, the requirements for three out of seven symptoms from criterion C plus two out of five symptoms from criterion D were replaced with a single criterion (criteria C and D collapsed) with seven possible symptoms, of which four symptoms were required. Unfortunately, these changes were proposed in the absence of empirical data. Elhai and colleagues reviewed the data of 5692 participants in the National Comorbidity Survey Replication, and found that these recommendations made an insignificant impact. The recommendations lowered the rate of PTSD only from 6.81% to 6.42%. “ These authors concluded that ”little difference was found between the criteria sets in diagnostic comorbidity and disability, structural validity, and internal consistency“ (P597).
In contrast, concern about specificity has not been prominent in the child literature because historically the issue “in the trenches” clinically is that children have been under-recognized as having internalizing symptoms,4 rather than being overdiagnosed. In other words, the concern has been lack of sensitivity rather than lack of specificity. For example, one vocal group of child researchers argues that too many children who have been chronically and repeatedly traumatized, abused, and/or neglected are not being diagnosed with anything because they believe that their symptoms do not fit PTSD.12 In addition, when they are diagnosed with PTSD plus the inevitable comorbid disorder(s), this purportedly misleads clinicians to treat comorbid conditions rather than the trauma syndrome and “may run the risk of applying treatment approaches that are not helpful.”12 A new syndrome has been proposed, similarly to Spitzer et al, based on speculation in the absence of empirical data,12 but does not have opcrationalizcd symptoms and has far to go in achieving face validity. It is yet to be empirically documented that chronically and repeatedly traumatized youngsters are not adequately represented by PTSD, or that neglect (as opposed to trauma) leads to a novel syndrome.
Comorbidity is an issue that seems to drive concerns about lack of specificity for adults and lack of sensitivity for children. Implicit in the arguments of Spitzer et al is that comorbidity is clouding the picture; specifically, that non-PTSD symptoms are being misidentified as part of PTSD because they overlap. In both adult and child populations, 80% to 90% of the time PTSD occurs with at least one other disorder. In adults, the common comorbid conditions are depression, anxiety, and substance abuse.
However, viewing comorbid disorders simply as overlap with PTSD has been rejected generally when examined empirically in adults. In McMillen et al's study of 162 adult flood survivors, those with the overlap symptoms that developed after the flood did not have MDD or GAD. They had PTSD, indicating that the symptoms are part and parcel of the PTSD syndrome.
Furthermore, the temporal relations between comorbid disorders have simply not been asked about in most prior studies. It appears that this lack of data has led some observers to assume that the non-PTSD disorders developed after traumas in the absence of PTSD. But when the onsets were tracked, the relationships were clear. McMillen et al tracked the onsets of all disorders, and found that all of the survivors diagnosed with a new nonPTSD disorder also had the PTSD diagnosis or substantial PTSD symptoms that did not meet the diagnostic algorithm. This finding was replicated with preschool children and their caregivers following Hurricane Katrina. This suggests that all post-trauma disorders have an underlying connection to PTSD. 'ITtte issue of comorbidity takes a developmental twist with younger children, but the fundamental conclusion about the validity of PTSD is the same as in adults.
In preschool children, the most common comorbid disorders are oppositional defiant disorder (ODD) and separation anxiety disorder (SAD)., The issue in older children and adolescents is less well-documented. Since the comorbid conditions seen with childhood PTSD are more observable than the situationally triggered or highly internalized symptoms of PTSD, the concern is that these conditions may be erroneously targeted for treatment without full appreciation of the concurrent PTSD symptomatology.
It is worth noting that if confusion exists from the presence of comorbidity, it is not inherently a flaw of the taxonomy system in general or PTSD specifically. Good history-taking about the timing of symptom onset, and knowledge of the research that PTSD is the underlying basis of new disorders after trauma exposure should contribute substantially to accurate diagnosis and treatment planning.
It is also worth noting that not all comorbidity codevelops with PTSD following trauma. Findings from studies that examined subjects prospectively prior to exposure to traumatic events showed that a proportion of the comorbid conditions predate (and perhaps serve as vulnerability factors for) the development of PTSD. For example, when studied prior to traumatic events, 100% of adults who had PTSD in the last year at age 26 had met criteria for another mental disorder between the ages of 11 to 21 years.
Overall, we sec contrasting trends between developmental periods. The adult field has focused relatively more on PTSD, leading to too many false-positives (lack of specificity) because, in part, a faction views the overlap of symptoms as illogical and want a more restrictive syndrome. In contrast, a faction in the child field has focused on PTSD as insufficient, because it purportedly does not adequately diagnose those with chronic and repeated trauma and/or neglect, and they arc opting for a broader, more inclusive new syndrome. In fact, the data show PTSD to be one of the most well-studied and validated disorders in longitudinal, neurobiological, and treatment response studies. Some clinicians, scholars, and other observers may be dissatisfied with the complexity and messiness of post-traumatic responses, but the data do not support a wholesale deconstruction of PTSD based on false-negatives or false-positives.
Strategies for addressing this challenge
Overlap of a portion of PTSD symptoms with other disorders is neither a dense conundrum nor careless taxonomy Clinicians should be careful to assess children based on the criteria provided, and not assume that children have stress-related disorders based on the presence of general negative affectivity symptoms (eg, hyperarousal symptoms, detachment, decreased interest or participation in activities). Clinicians should attend to the high proportion of children who have PTSD symptoms along with other comorbid conditions, while at the same time not mistakenly misdiagnosing children who have general negative affectivity.
Challenge 2: symptomatic and impaired, but not diagnosed
One function of diagnostic criteria is to differentiate groups of individuals according to clinically meaningful levels of severity or impairment. That is, people who have a diagnosis should differ significantly from people without that diagnosis in terms of how functionally impaired they are. There is growing evidence that the current PTSD diagnostic criteria actually underestimate the number of children and adults with symptom-related functional impairment.- One study found that children who met PTSD diagnostic criteria in two but not three diagnostic clusters had the same level of functional impairment as children who had full PTSD diagnoses. One problem with the current criteria is that they do not give adequate consideration to the intensity of symptoms, despite the fact that clinical impairment is often more closely associated with the intensity of symptoms rather than with the number or frequency of symptoms. In a prospective longitudinal study of preschool children, 47 children were followed 1 year after their first assessment, and significantly more were impaired in at least one domain (48.9%) than had the full diagnosis of PTSD (23.4%). For the 35 children that were followed after 2 years, the gap was even greater, with 74.3% impaired compared with 22.9% with the full diagnosis. The following two cases illustrate this discrepancy.
Child A experienced a rape at school 6 weeks ago. She has severe, recurrent, intrusive horrifying memories of the rape. She is afraid to go to sleep because she believes the rapist will break into the house when she is sleeping. She is extremely distressed psychologically and physically when she thinks of the event, demonstrated by the fact that she vomits several times a day and has lost 9 kg. She refuses to say the name of the rapist and is too afraid to return to school (avoidance of people, places, thoughts, conversations). She denies decreased interest, difficulty remembering important details about the rape, restricted range of affect, or foreshortened future. She endorses extreme difficulty sleeping and cannot sleep for more than an hour at a time. She jumps when she hears the slightest sound. She checks to make sure the door is locked at least 10 times a day. She is impaired in every aspect of her life. She has 8 PTSD symptoms but does not meet the criteria for PTSD (due to only meeting two avoidance criteria).
Child B experienced a car accident 6 weeks ago. She has scary dreams about the accident once or twice a week and gets a headache or becomes sad when reminded of the accident. She does not like to talk about the accident, forgets many details about it, and no longer wants to go to dance lessons, since she was on her way to dance when the accident occurred. She does not mind driving in the car otherwise. She continues to go to school and play with her friends. She has become irritable and is having some trouble falling asleep most nights because she is afraid of bad dreams. She also has 8 PTSD symptoms. She meets the criteria for PTSD.
It seems clear that Child A has more functional impairment than Child B, despite not meeting diagnostic criteria for PTSD, and that despite having the same number of PTSD symptoms, the severity of symptoms needs to be factored into the diagnostic criteria in a more comprehensive manner. Further research is needed to determine whether the current diagnostic criteria validly differentiate children from those who fail to meet diagnostic criteria in clinically meaningful ways.
Strategies for addressing this challenge
Current practice parameters recommend that children with clinically significant impairing levels of PTSD symptoms, regardless of diagnostic status, should be provided with evidence-supported treatment options. An alternative appropriate diagnosis (eg, adjustment disorder; anxiety disorder not otherwise specified [NOS], etc) should be used if PTSD diagnostic criteria are not met. This issue may be reflected in the future DSM-V since it has been suggested for adults to lower the threshold for cluster C from three to two symptoms,22 and for young children from three symptoms to one.
Challenge 3: developmental considerations in the diagnosis of pediatric PTSD
Growing research demonstrates that the current diagnostic criteria arc not sensitive enough for preschool children and perhaps also not sensitive enough for prepubescent children.,
Ten studies have examined the validity of the diagnostic criteria for PTSD in preschool children.,-, The consistent findings are that PTSD can be reliably detected in young children, they manifest most (but not all) of the items, and, most importantly, an alternative criteria algorithm appears more devclopmcntally sensitive and valid than the DSM-IV algorithm.
The alternative algorithm for PTSD in young children (PTSD-AA) includes modifications in wording for several items to make them more devclopmcntally sensitive to young children. For example, the DSM-IV item for irritability and outbursts of anger was modified to include extreme temper tantrums. However, the major change is a modification to lower the requirement for the C criterion (numbing and avoidance items) from three out of seven items to just one out of seven items because many of the C criterion items are highly internalized phenomena that appear to be either dcvelopmentally impossible in young children (eg, sense of a foreshortened future) or extremely difficult to detect even if they were present (eg, avoidance of thoughts or feelings related to the traumatic event, and inability to recall an important aspect of the event).
When the DSM-IV criteria are applied to samples and compared head-to-head to the PTSD-AA criteria, significantly higher rates of PTSD were consistently found with the PTSD-AA criteria. The rate of DSM-IV PTSD in nonclinical samples (non-help-seeking) from a gas explosion in Japan was 0%, and from a variety of traumatic events (mainly auto accidents and witnessing domestic violence) was 0% , whereas the rates of PTSD using the PTSD-AA criteria in those studies were 25% and 26% respectively. The rates of DSM-IV PTSD in clinic-referred children who witnessed domestic violence was 2%26 and from a variety of traumas in two small clinic studies were 1 3% and 20% , but the rates by the PTSD-AA criteria were approximately over 40%, 69%, and 60% respectively. These rates of PTSD found in young children with developmentally sensitive measures and criteria are consistent with rates found in older populations.
Because PTSD has been recognized formally in preschool children only relatively recently, it is noteworthy to mention the common comorbid disorders that codevelop with PTSD at this age. As noted earlier, the most common codcvcloping comorbid disorders are ODD and SAD. In one study, the comorbid rates with PTSD were 75% ODD and 63% SAD. In another study, the comorbid rates were 61 % ODD and 21 % SAD.
Prospective longitudinal data are among the strongest data for construct validity of syndromes. These data in youth have indicated that PTSD is a stable diagnosis, and that children do not simply “grow out of it” as if it were a normative reaction or a minor developmental perturbation. Meiser-Stedman et al, in a prospective design, showed that 69% of those children diagnosed with PTSD-AA at 2 to 4 weeks post-trauma retained the diagnosis 6 months later. Scheeringa and colleagues studied 62 children with mixed traumatic experiences 4 months (lime 1) after the trauma, and again at 16 months (Time 2) and 28 months (Time 3) after the trauma. They found significant stability of symptoms over the 2 years. At 4 months post-trauma, the group that had been diagnosed with PTSD-AA at visit 1 had an estimated mean of 6.1 PTSD symptoms. This number of symptoms did not diminish by even as much as one symptom over 2 years. Furthermore, PTSD diagnosis at lime 1 significantly predicted degree of functional impairment 1 and 2 years later.
Strategies for addressing this challenge
First, professionals must be aware that preschool children can develop PTSD. Only then can appropriate screening and referrals for assessment be triggered. Second, when conducting assessments, developmentally appropriate measures and criteria must be used so as not to miss the diagnosis. Third, because of the traditional under-recognition of PTSD, which may be overshadowed by the more beliaviorally observable comorbid symptoms of ODD and SAD, professionals must be on alert when children present with sudden onset of new symptoms to evaluate for past traumatic events and do a thorough PTSD assessment.
Challenge 4: assessment challenges
The accurate assessment of PTSD is perhaps more timeconsuming, difficult, and emotional than for any other disorder. Details of a proper assessment are beyond the scope of this paper, but this section highlights three particular challenges.
Interviewing burden and complexity for multiple traumatic events
While the DSM-IV criteria do not restrict making the diagnosis to a single traumatic event, diagnostic interviews and self-report instruments that assess PTSD often ask respondents to select “the worst” traumatic event that he or she experienced and to rate all PTSD symptoms in relation to that specific event. Many children have experienced multiple traumatic events. One recent study indicates that 68% of all children in the US have experienced at least one potentially traumatic event (PTE), and half of these children have experienced multiple PTEs. It is often difficult for children, particularly young children, to select only one traumatic event as “the worst” they have experienced. It is common for children who have experienced multiple PTEs to describe that they are experiencing some PTSD symptoms related to one trauma and other symptoms related to another trauma. No known study has specifically examined (i) children's PTSD symptoms related to any traumatic event; versus (ii) children's PTSD symptoms only related to the “worst” traumatic event they had experienced. A reasonable hypothesis is that significantly more symptoms would be reported in (i) than (ii).
Suppose such a child reported domestic violence, traumatic death of a brother, and sexual abuse exposure. This child reports one re-experiencing, one avoidance, and one hyperarousal symptom related to domestic violence; two re-experiencing, two avoidance, and two hyperarousal symptoms related to the traumatic death; and one re-experiencing, two avoidance, and one hyper-arousal symptom related to sexual abuse. None of these alone are enough to qualify the child for a “full-blown” PTSD diagnosis, but taken together (four rc-cxperiencing, five avoidance, four hyperarousal) symptoms, the child definitely qualifies.
Accuracy from information sources
Several issues make it difficult to obtain accurate information from respondents. First, asking about PTSD symptoms is relatively more abstract than other, more observable disorders. Children with PTSD may not appear symptomatic to most observers. This leads to a public health challenge because professionals and caregivers do not recognize PTSD or provide appropriate treatment. Complicating this issue is that PTSD is not in the normal lexicon of observable phenomenon for most people. Everyone knows what depression and hyperactivity look like. But most people in their ordinary experiences do not know what it is like to have overgeneralized fear responses to nonthreatening stimuli, or a constant state of hyperarousal in the absence of a present stressor. This illustrates one source of false-negatives in assessment. Another source of false-negatives arises from caregivers who minimize, deny, or are simply unaware of their children's symptoms, perhaps because of their own avoidance symptomatology. In order to minimize both false-positives and false-negatives, one must conduct a comprehensive, standardized, and rigorous interview of caregivers and, if old enough, the children. This means systematically enquiring about all 17 signs of PTSD. Specifically, one must ask from a menu of probes, ask for examples, and include onsets, durations, and frequencies. This type of educational interviewing gives respondents a frame of reference for the internalized and abstract items comprising signs of PTSD. This is in contrast to other types of symptomatology, such as hyperactivity or depression, which are readily observable and intuitively obvious to most people.
Second, children and parental agreement about symptoms is notoriously poor. Each provides different information. Three known studies have concurrently assessed the rates at which children and their parents report PTSD symptoms. All three studies sampled children who experienced motor vehicle accidents and other acute injuries from emergency departments. In a sample of 24 12- to 18-ycar-old adolescents, 8.3% met the threshold for the diagnosis by child report, 4.2% by parent report, and 37.5% by combined report. In a sample of 51 10- to 16-year-old children, 11.9% met the diagnosis by child report, and 13.0% by parent report (combined child-parent rates were not reported). In a sample of 51 7- to 10year-old children, 17.8% met the PTSD-AA diagnosis by child report and 18.8% by parent report, and 40.0% by combined report.
Contradiction in asking children to report avoidance symptoms
Inherent in the current diagnostic criteria for PTSD is the requirement that respondents report (either to a clinician or on self-report instruments) avoidance symptoms. However the very nature of successful avoidance is that it prevents children from acknowledging its presence, thus presenting a challenge to clinicians in distinguishing avoidance from normal functioning. When asked to describe something about a traumatic event, many children will say, “I don't want to talk about it” or “I don't think about it.” What is a clinician to make of this response? Does this mean the child has resolved any psychic pain about the potentially traumatic event; that the child is oppositional to your request; that the child is highly avoidant; or none of the above? A child who says he “never thinks about” his father murdering his mother, despite the fact that he witnessed his father killing his mother, may raise questions in the minds of most clinicians about the possibility of avoidance. In contrast, children who report that they “never think about” a serious car accident, being bullied, or a natural disaster, may easily be seen by clinicians as resilient children who are coping well with their traumatic experiences, and no more questions are asked. Yet, if a clinician were to ask further questions it may become clear that any of these children may be actively avoidant, and may have significant PTSD symptoms. In these types of cases, caregivers may provide more accurate information about avoidance, and expecting children to readily report avoidant symptoms is unrealistic.
Strategies for addressing this challenge
Assessments need to comprehensively cover all 17 symptoms with educational interviewing, and ideally, include both children and parent respondents. Clinicians should use clinical judgment in conducting assessments of children's PTSD symptoms regarding the need for treatment as in the above scenarios. In settings where children are completing self-report instruments, asking children to yoke PTSD symptoms to “the worst trauma” may significantly underestimate the prevalence of child PTSD symptoms. (Alternatively, it is possible, or perhaps even likely, that some children ignore the instructions and rate the symptoms they are experiencing related to several traumatic events). For children who endorse several traumatic events but report few symptoms on selfreport instruments, it is advisable for a mental health clinician to follow this up with a clinical interview to review PTSD symptoms related to any traumatic event. Clinical judgment can then be used to determine treatment needs.
Clinicians must probe further than asking “do you try to avoid thoughts about what happened?” or “tell me about what happened.” The child's response to such questions can mean almost anything. Clinical skill (and in most cases, several more follow-up inquiries) arc required in order to understand whether or not the child has avoidant symptoms. This is also true for self-report instruments. Some children who have significant PTSD avoidant symptoms may have very low scores on PTSD self-report instruments at the beginning of treatment (but parents or clinical interview reveals reason for concern). After they have received some initial therapeutic interventions their scores markedly increase. This docs not indicate that therapy is making them worse, but rather that therapy has begun to address their avoidant strategies to the point that they can start to acknowledge the severity of these symptoms.
Conclusion
The above discussion highlights challenges and strengths of using the present DSM-IV-TR diagnostic criteria for PTSD in children. Unlike the controversy about pediatric bipolar disorder, there has not been a challenge that too many false-positives of child PTSD are being made. Concern about false-positives (lack of specificity) has been raised in the adult literature, but these concerns and speculations have been forcefully rebutted with empirical data and do not appear to be widely held. In contrast, for child PTSD, the concern has been the opposite: that too few traumatized children are diagnosed whether due to insensitive criteria or due to the need for a novel syndrome. However, again, these are speculations that ignore the data that PTSD is the most common and underlying syndrome that develops after all types of lifethreatening trauma, and has shown validity across all ages, good predictive validity, and concurrence with preliminary neurobiologies measures.
In summary, PTSD remains a well-validated disorder, and is the most useful construct of child and adolescent post-trauma psychopathology for research and clinical purposes. The current PTSD diagnostic criteria should be revised to reflect current research about developmental manifestations of this disorder.
Acknowledgments
The authors thank Anthony Mannarino, PhD, Esther Deblinger, PhD, Robert Steer, EdD, Ann Marie Kotlik, the staff of AGH CTSCA, Charles Zeanah, MD, and all the children and families from whom we have learned. Funding for this project was provided in part by the US Substance Abuse and Mental Health Services Administration (SAMHSA) National Child Traumatic Stress Network, Grant No. SM 54319.
Contributor Information
Judith A. Cohen, Professor of Psychiatry, Drexel University College of Medicine; Medical Director, Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
Michael S. Scheeringa, Associate Professor, Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA.
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« Previous: 2 Diagnosis and AssessmentSuggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Although an optimal evaluation of a patient for PTSD consists of a face-to-face interview by a mental health professional trained in diagnosing psychiatric disorders, several instruments are available to facilitate the diagnosis and assessment of posttraumatic stress disorder (PTSD). These include screening tools, diagnostic instruments, and trauma and symptom severity scales. For example, there are brief screening tools, such as the 4-item Primary Care PTSD Screen, developed by the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder; self-report screening instruments, such as the Posttraumatic Diagnostic Scale; and structured or semi-structured interviews, such as the Clinician-Administered PTSD Scale (CAPS), the Structured Clinical Interview for DSM-IV (SCID), the Diagnostic Interview Schedule for DSM-IV (DIS-IV), and the Composite International Diagnostic Interview (CIDI), all of which might be used prior to or as a complement to the clinical interview. These instruments are discussed below. Such measures are used most frequently in research settings, some might be used clinically to provide additional sources of documentation, and others might be given to veterans at a health facility prior to their first interview with health professional. Screening tools can be useful in initiating a conversation about exposure to traumatic events or possible PTSD symptoms. However, as noted in Briere (2004) “no psychological test can replace the focused attention, visible empathy, and extensive clinical experience of a well-trained and seasoned trauma clinician.”
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
A health professional might use an unstructured interview to elicit information from a patient about symptoms related to each of the diagnostic criteria for PTSD. He or she might also use a structured or semi-structured diagnostic interview such as the CAPS, SCID, PTSD Symptom Scale-Interview Version (PSS-I), the Structured Interview for PTSD (SIP), the DIS-IV, or the CIDI. The use of those instruments can inform professional judgment in a clinical setting, but they are more commonly used in epidemiologic and treatment outcomes research.
The CAPS is a semi-structured interview, developed by the Department of Veterans Affairs National Center for Post-Traumatic Stress Disorder. The CAPS should be administered by a trained health professional and can be used to determine whether a patient meets the DSM-IV diagnostic criteria for PTSD. It has the advantage of assessing the array of PTSD symptoms, as well as their severity (frequency and intensity), but it cannot be used to determine the presence of comorbid psychiatric disorders. The CAPS contains 34 questions, 17 of which measure symptom frequency and 17 measure symptom intensity. The CAPS generally takes at least 40 to 60 minutes to administer (Foa and Tolin 2000).
The SCID is a widely used structured clinical interview for psychiatric disorders that contains a PTSD-specific module with 19 items. Like the CAPS, the SCID-PTSD module has questions related to each of the DSM-IV diagnostic criteria; patients’ responses are listed as present, absent, or subthreshold. The SCID, like the CAPS, should be administered by a trained health professional. Unlike the CAPS, the SCID can be used to identify comorbid psychiatric disorders (Briere 2004); that is important because comorbid psychiatric disorders are common in PTSD patients. The SCID does not assess the severity of PTSD symptoms; the determination of whether a symptom passes a severity threshold is left to clinical judgment or further testing with a symptom-severity scale.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
The PSS-I is a semi-structured interview that also assesses PTSD symptoms according to DSM-IV and their severity (Foa and Tolin 2000). It contains 17 questions that correspond to each of the DSM criteria and participants’ responses are rated by a health professional from zero (not at all) to 3 (5 or more times per week/very much). It shows good agreement with the CAPS and the SCID in diagnosing PTSD. The PSS-I may be slightly better at detecting actual PTSD, whereas the CAPS is more accurate at ruling out false positives (Foa and Tolin 2000). This interview was developed for and has been tested on civilian populations with known trauma history, but has not been tested on combat veterans. The PSS-I has the advantage of taking only about 20 to 30 minutes to administer.
The SIP is a 19-item questionnaire that is also based on the DSM-IV criteria for PTSD (Davidson et al. 1989). Like the PSS-I, it identifies both PTSD symptoms and their severity and has two additional items on survivor and behavior guilt. The SIP has been tested on combat veterans with good correlation to other measures of PTSD but not to measures of combat exposure (Riggs and Keane 2006). The SIP can take 10 to 30 minutes to administer by a trained interviewer.
The DIS-IV is a structured interview for DSM-IV diagnoses designed to be administered by trained lay interviewers and is used in psychiatric research to assess psychiatric disorders (Friedman 2003). The CIDI is another structured diagnostic interview that can be used to assess many psychiatric disorders, but, as an international instrument, it is based on the International Criteria for Disease rather than the DSM. Like the DIS-IV, the CIDI can be administered by carefully trained lay interviewers for research purposes. The DIS-IV and the CIDI have both been used in major US population studies, such as the Epidemiologic Catchment Area program and the National Comorbidity Study, respectively (Helzer et al. 1987; Kessler et al. 1997). Both the DIS-IV and the CIDI can also be administered by clinicians. Those instruments aid in the diagnosis of PTSD and other disorders as well, but they do not assess symptom severity.
Structured interviews that were developed specifically for diagnosis of PTSD, such as the CAPS, will probably take longer to administer (an hour or more) but yield useful information, for example,
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
information regarding the intensity and frequency of symptoms, rather than simply whether the symptoms are present. Some of the diagnostic instruments, such as the PSS-I and SIP, can be used to determine not only whether a patient has PTSD symptoms but also symptom severity, comorbid psychiatric disorders, and whether a patient is malingering.
There are also several self-report instruments that can be used to help document symptoms and traumatic exposures. These include the Posttraumatic Diagnostic Scale (Foa et al. 1997), the Davidson Trauma Scale (Davidson et al. 1997), and the Detailed Assessment of Posttraumatic Stress (DAPS) (Briere 2004). Each of the instruments determines what symptoms of PTSD are present, as well as their frequency and intensity. The DAPS, which has 104 items, also assesses a broad range of psychologic functions and reactions. Although self-report instruments have utility for screening people with possible PTSD and in research settings, they should not substitute for a comprehensive diagnostic interview.
Several self-report instruments have been developed to document a veteran’s exposure to a war-zone traumatic event. Like the structured and semi-structured diagnostic interviews, they can be used in a clinical setting but have had more use as research tools. Table 3.1 lists some representative instruments that have been developed to assess exposure to traumatic events associated with military service. They might be used in conjunction with a diagnostic interview to document details of traumatic exposures. The instruments’ function is to obtain greater detail about an exposure than the health professional might initially be able to elicit from the patient. The selection of an instrument depends on the reported war-zone trauma.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
TABLE 3.1 Self-Report Measures of Exposure to Military-Related Potentially Traumatic Events
Scale Name | Numberof Items | References |
Abusive Violence Scale | 5 | Hendrix and Schumm 1990 |
Combat Exposure Index | 7 | Janes et al. 1991 |
Combat Exposure Scale | 7 | Keane et al. 1989 |
Deployment Risk and Resiliency Inventory | 201 | King et al. 2003 |
Graves Registration Duty Scale | 24 | Sutker et al. 1994 |
Military Stress Scale | 6 | Watson et al. 1988 |
Sexual Experiences Questionnaire—Department of Defense | 22 | Fitzgerald et al. 1999 |
Vietnam Era Stress Inventory—Specific Stressor Subscale | 46 | Wilson et al. 1980 |
War Events Scale | 84 | Unger et al. 1998 |
War Zone Stress Scale | 72 | King et al. 1995a |
Women’s Wartime Stressor Scale | 27 | Wolfe et al. 1993 |
SOURCE: Adapted with permission from Wilson et al. 2004. |
Several validated questionnaires are available to describe PTSD symptom severity in military personnel. Like the traumatic-event exposure instruments, they are self-report instruments that might be used as adjuncts to diagnostic interview instruments such as the CAPS or a comprehensive clinical diagnostic interview. Some of the instruments, such as the PTSD Checklist (PCL), the Posttraumatic Diagnostic Scale (Foa et al. 1997), and Davidson Trauma Scale (Davidson et al. 1997) discussed above, assess DSM-IV symptoms of PTSD as well as symptom severity; others, such as the Keane PTSD Scale of the Minnesota Multiphasic Personality Inventory (MMPI-PK), assess associated features of PTSD. With the PCL, patients use a 1–5 scale to rate the
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
frequency and intensity of their symptoms. The version developed for the military (PCL-M), which was validated on 123 male veterans, has a test-retest reliability of 96% (Blanchard et al. 1996; Weathers et al. 1991). The Mississippi Scale for Combat-Related PTSD has a test-retest reliability of 97% (Keane et al. 1988). The Impact of Event Scale-Revised (IES-R) is a widely used, 22-item, self-report instrument that measures a person’s response to a traumatic stressor. The revised version more closely conforms with the DSM-IV criteria for PTSD. The severity of each symptom, during the past week, is rated by the respondent; the scale takes approximately 10 minutes to complete (Riggs and Keane 2006). The IES (not revised), the MMPI-PK, and the Mississippi Scale for Combat-related PTSD were used in the National Vietnam Veterans Readjustment Study. The Los Angeles Symptom Checklist (King et al. 1995b) has also been used to measure PTSD symptoms in Vietnam veterans; it has a test-retest reliability of 90% for all 43 items. Table 3.2 lists some of the symptom-severity instruments that have been used in research settings.
It must be emphasized that the instruments for assessing symptom severity do not diagnose PTSD and should not be used in lieu of a comprehensive clinical interview. Their utility is in eliciting details about symptoms that might not be provided by a patient during a clinical interview and they might provide an additional source of documentation.
In general, screening instruments are helpful for identifying people who might have a disease but are not very useful for assessing disorder progression, prognosis, or treatment efficacy. Screening instruments might be of value when a population is too large for each person to be assessed individually; a screening instrument might be used to help identify people who indicate that they have some PTSD symptoms and who would then receive a full diagnostic assessment by a health professional.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
TABLE 3.2 Symptom-Severity Instruments for PTSD
Scale | Numberof Items | References |
PTSD Checklist | 17 | Blanchard et al. 1996 |
Mississippi Scale for Combat-Related PTSD | 35 | Keane et al. 1988; McFall et al. 1990 |
Impact of Event Scale-Revised | 22 | Horowitz et al. 1979 |
MMPI-PK | 49 | Keane et al. 1984 |
Self-Rating Inventory for PTSD | 22 | Hovens et al. 2002 |
Posttraumatic Diagnostic Scale | 49 | Foa et al. 1997 |
Davidson Trauma Scale | 17 | Davidson et al. 1997 |
War-Zone Related PTSD subscale of the Symptom Checklist 90-Revised | 25 | Derogatis and Cleary 1977 |
Los Angeles Symptom Checklist | 43 | King et al. 1995b |
Recently, the VA National Center for Post-Traumatic Stress Disorder has developed a four-question screening tool, the Primary Care PTSD Screen (Prins et al. 2003), that can be used by primary-care physicians and other health professionals (the questions are available at: http://www.ncptsd.va.gov/facts/disasters/fs_screen_disaster.html). The Primary Care PTSD Screen has a sensitivity of 78% and a specificity of 87% (Friedman 2006). Patients answering yes to three or more of the questions should be considered for further evaluation for PTSD.
Other self-report screening instruments for PTSD have been developed and used with community trauma patients, however, none have been validated on combat veterans. Among these are: a short screening scale containing seven questions keyed to the DSM-IV criteria for PTSD (Breslau et al. 1999); the 17-item PTSD Symptom Scale Self-Report that was developed to identify PTSD in patients with substance use disorder (Coffey et al. 1998); the Screen for Posttraumatic Stress Symptoms that assesses PTSD in patients who do not report exposure to a traumatic event (Carlson 2001); and the Psychiatric Diagnostic
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Screening Questionnaire, a 125-item questionnaire with a PTSD subscale (Zimmerman and Mattia 2001).
Several screening tools and diagnostic instrument are available to assist the clinician in making a PTSD diagnosis, documenting a traumatic event, and in assessing symptom severity. However, none of those instruments alone can provide a comprehensive diagnosis and assessment of a PTSD patient or replace a health professional trained in diagnosing psychiatric disorders. While assessment instruments are helpful, they are used primarily in research settings.
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Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
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Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'3 Assessment Instruments.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Next: Appendix A: Specific Questions Posed by the Department of Veterans Affairs to the Institute of Medicine »