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Post-Traumatic Stress Disorder: Preschool Subtype

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ABSTRACT
Posttraumatic Stress Disorder, like many diagnoses in the DSM, is a
disorder characterized by a grouping of symptoms, but what makes
PTSD unique is the exposure to a traumatic event that creates the
development of the symptoms. According to the U.S Department of
Veteran Affairs, in the past year PTSD has had a prevalence of 3.5%
in adults, with women having 9.7% lifetime prevalence and men,
3.6%. In the additions to the DSMs fifth edition, new diagnostic
criteria of PTSD in children 6 and under, as well as sexual violation
or abuse are included. While the research data of PTSD in children
is still minimal, it has also been found that, like adults, PTSD is
more prevalent in girls than boys.
This review include information on the diagnosis of PTSD, the
literature and research available on the topic, including the
changes brought forth in the DSM 5 and information on the
additions to the diagnostic criteria. More specifically, there will be
an overview of treatment options in the area of the preschool
subtype diagnosed with PTSD. Concluding, that will be attention
paid to the portions of research that are lacking and literature that
is missing on this topic in order to highlight the potential for further
research on PTSD for the preschool subtype.

INTRODUCTION
Post Traumatic Stress Disorder (PTSD), for the preschool subtype, is
defined by the DSM-5 as resulting from exposure to actual or
threatened death, serious injury, or sexual injury. Up until the
DSM-5, the diagnostic criterion has been listed specifically for those
over the age of six, and, amongst its many changes, added specific
criteria for children under the age of six. It has been debated in the
past as to whether or not children can be diagnosed with PTSD, but
according to Michael S. Scheeringa of Tulane University School of
Medicine, that is no longer debatable (Sheeringa, 2011). In 2008,
Sheeringa asked the question of the DSM-IV, Are the DSM-IV
criteria developmentally sensitive enough to diagnose the disorder
in this group (Sheeringa, 2008)?
PTSD has been a long debated diagnosis since its creation in the
DSM by the American Psychiatric Association in 1980. It was a
controversial diagnosis in adults, let alone in children. It wasnt
until Leone Terrs studies of kidnappings of children that the
consideration for diagnosing children came about. (Dyregrov&Yule,
2006).
In making the changes to the criteria of PTSD in DSM-IV and adding
the preschool subtype in DSM-5, it became apparent that there are
a more even amount of children as there are adults with PTSD,
where as before there were very few children in this age group
diagnosed. Michael Sheeringa and a group of many other colleagues
in the field researched and created the alternative criteria for
diagnosis as early as 2008, which was later used in the PTSD
preschool subtype criteria for the DSM-5. (Sheeringa,
Zeanah&Cohen, 2010)

RESEARCH POSTER PRESENTATION DESIGN 2011

www.PosterPresentations.com

METHODS
Databases

utilized to search for relevant sources:


Z. Smith Library
DSM-5
Google

Results of search:
From the Z. Smith Library resources, I
was able to find many articles on
treatment and the diagnosis of PTSD in
children
Key words and phrases used during search on databases:
Google provided information on more
PTSD and Children
holistic approaches to treatment, such
PTSD in Children and Treatment
as certain types of play therapy and
yoga.
PTSD in Children and Meditation

The
DSM-5 provided diagnostic
Limits:
information, as well as comparison notes
Lack of holistic treatment research
from its earlier addition, DSM IV.
Diagnosis too recent for up to date statistics

RESULTS
DIAGNOSiS:
The diagnosis of PTSD for children under the age of six
requires that the child be exposed to actual or
threatened death, serious injury, or sexual violence
through direct experience, learning about such an event
happening to a parent or caregiver, or witnessing such
traumatic events. The symptoms required for each
criterion are noticeably fewer for this particular subtype.
(DSM-5, p. 272)
In the new DSM-5, an algorithm for diagnosis was added
for the preschool subtype. Rather that relying the one in
DSM-IV (1 B/1 C/2 D), the new algorithm for this
particular subtype is 1 B/1 C or D/2 E. The algorithm
explains how clinicians are to go about diagnosing PTSD in
children 6 and under differently from those who fall into
the general PTSD diagnosis. Due to the developmental
stages found during this age range, children in this
subtype are not always capable of describing or
expressing the information needed for the prior
diagnostic algorithm for PTSD. (Friedman, p. 553)
An interesting note about diagnosis is that it is
specifically noted under Criteria A that witnessing does
not include events that are witnessed only in electronic
media, television, movies or pictures (DSM-5, p.273). It
could be assumed that this was added due to the cultural
conversation of the impact of violent media on children.
Difficulties & Controversies
An interesting note about the DSM-V and its addition of the preschool
subtype is that sexual exploitation, kidnapping and being taken hostage
are all considered traumatic experiences in Criterion A for general
PTSD. However, they are not listed as traumatic events for the
preschool subtype. According to the U.S. governments Office of
Juvenile Justice and Delinquency Prevention has stated, amongst other
prominent organizations, there is an epidemic of Commercial Sexual
Exploitation of Children (CSEC) in this country and children under the
age of six have fallen victim to this. (www.ojjdp.gov)
Diagnosing PTSD in children can be difficult
due to their developmental limitations. This
makes the subtype, though an obvious addition
to some, more difficult to accept for others.
Many symptoms of PTSD overlap with other
childhood disorders, namely ADHD, depression,
conduct disorder, oppositional defiant disorder,
and substance abuse (AACAP, 1998). It is also
co-morbid with many conditions, which makes
differentiation difficult when trying to
diagnosis. (Indian Journal of Psychiatry, 2002)

TREATMENT:
Psychopharalogic Interventions
Has both been successful, and failed, in the area of treating
children with PTSD. SSRIs have been found to not be
successful in younger children, but tend to work with
adolescents and youth. Dr. Jeffery Strawn, after
considering all the pharmacologic information about
treating children with PTSD, recommends trauma-focused
cognitive behavioral therapy (TF-CBT) as a first-line
intervention, but as far as medications are concerned,
says that antiadrenergics, second generation
antipsychotics, and antiepileptic agents may be
beneficial. (Leonard, 2010)
Cognitive Behavioral Therapy
Treatment can include scheduling, writing and drawing
about the trauma, visiting the trauma site, and other
behavioral elements. It is a therapy particularly effective
with PTSD due to sexual abuse and has been known to
reduce the symptoms, such as anxiety and inability to
ascertain healthy coping skills. (Smith, Yule, Perrin Tranah,
Dalgleish&Clark, 2007
CBT Writing
In this particular form, the children are asked to write
down, or the therapist types up, the trauma in a storyline
fashion. In a somewhat narrative therapy format, the child
adds to the story where they are now, how they are feeling
and how they want to feel or act in the future. The therapy
goes through each step of writing a story (title, body,
ending) during each therapy session. Again, this particular
therapy works well with children who have been diagnosed
with PTSD due to sexual abuse. (Van der Oord, Lucassen,
Emmerick, Emmelkamp, 2010)
Flexible Sequential Play Therapy
The treatment option specifically listed for the age group
of the preschool subtype. This therapy uses coping play
strategies such as the coping tree, copecakes, five-count
breathing, and coping bubble wrap. The goal of this
particular treatment is to provide children with safe space
as well as coping techniques to deal with their PTSD.
(Goodyear-Brown, Paris and Me)
Seeking Safety Therapy
a treatment option that has been used with adolescent girls
with PTSD. Although it is not specifically linked to children
under the age of six, this coping skills management therapy
could be altered to treat younger children. Seeking Safety
has five principles: (1) safety as the priority; (2)
integrated treatment of both disorders; (3) a focus on
ideals; (4) four content areas: cognitive, behavioral,
interpersonal, and case management; and (5) attention to
therapist processes (Najavits, Gallop&Weiss, 2006).

DISCUSSION
In the future, research should be done in the area of holistic
approaches and the impact they are having therapeutically for
children with PTSD. For example, many non-profits are opening up
around the country using trauma sensitive yoga for children and
youth who have experienced trauma and are diagnosed with PTSD.
PTSD has been shown to physically affect the brain in the frontal
cortex of the brain and impact the cognitive abilities of a
developing brain. Mindfulness practices of yoga and meditation,
and deep breathing, has shown success in helping students with
PTSD keep focus, learn to cope with stress, and continue to learn
successfully. Child yoga has become a popular cultural practice, and
as a result, has given more opportunity for researchers to look into
the scientific and qualitative impact of such practices of children of
PTSD, if those opportunities are taken. (Brown, 2014)
The diagnostic criterion used in the preschool subtype of PTSD is
limited in the area of what are considered traumatic events for this
age group. As mentioned before, the Commercial Sexual
Exploitation of Children is a global issue that is linked with the
issue of human trafficking in U.S. government verbiage. Research
needs to be done in the area of PTSD in the traumatic events left
out of the preschool subtype criteria. As a result of such research,
more specific traumatic events, or those matching the general PTSD
diagnosis should be added to this particular subtype. Lack of
specification could be limiting research opportunities.

REFERENCES
Brown, J. (2014). Teaching students how to combat traumas of poverty on the yoga
mat [Television series episode]. In News Hour. East Palo Alto, CA: PBS. http://
www.pbs.org/newshour/bb/low-income-students-combat-stress-mindfulness/
Clark, D. M., Dalgleish, T., Perrin, S., Tranah, T., Smith, P., & Yule, W. CognitiveBehavioral Therapy For PTSD In Children And Adolescents. Journal of the American
Academy of Child & Adolescent Psychiatry, 46, 1051-1061.
Cohen, J. Practice Parameters for assessment and treatment of post-traumatic stress
disorder in children and adolescent. American Academy of Child and Adolescent
Psychiatry, 37.
Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed., ). (2013).
PTSD . Washington, D.C.: American Psychiatric Association.
Emmelkamp, P., Lucassen, S., Emmerick, A. V., & der Oord, S. V. Treatment Of Posttraumatic Stress Disorder In Children Using Cognitive Behavioural Writing Therapy.
Clinical Psychology & Psychotherapy, 17, 240-249. Retrieved , from
Friedman, M. Finalizing PTSD in DSM-5: Getting Here From There and Where to Go
Next. Journal of Traumatic Stress, 26, 548-556.
Gallop, R., Najavits, L. & Weiss, R. D. Seeking Safety Therapy For Adolescent Girls
With PTSD And Substance Use Disorder: A Randomized Controlled Trial. The Journal
of Behavioral Health Services & Research, 10, 453-463.
Goodyear-Brown, P. (n.d.). Flexibly Sequential Play Therapy (FSPT): New Model of
Trauma Treatment. Retrieved from http://www.newenglandplaytherapy.org/
paris_notes.pdf
Leonard, H. Managing PTSD in children and adolescents: Context for
psychopharmacology. Brown University Child & Adolescent Psychopharmacology
Update, 12, 5-6.
Gallop, R., Najavits, L. & Weiss, R. D. Seeking Safety Therapy For Adolescent Girls
With PTSD And Substance Use Disorder: A Randomized Controlled Trial. The Journal
of Behavioral Health Services & Research, 10, 453-463.
Office of Juvenile Justice and Delinquency Prevention (OJJDP). (n.d.). Office of
Juvenile Justice and Delinquency Prevention. Retrieved , from http://
www.ojjdp.gov/
Recognition & Clinical Assessment of Childhood PTSD. Indian Journal of Psychiatry ,
1, 82-87.
Scheeringa, M. S. Developmental Considerations for Diagnosing PTSD and Acute
Stress Disorder in Preschool and School-Age Children. American Journal of
Psychiatry, 10, 1237-1239.
Scheeringa, M. S. PTSD in Children Younger Than the Age of 13: Toward
Developmentally Sensitive Assessment and Management. Journal of Child &
Adolescent Trauma, 4, 181-197.
Sheeringa, M., Zeanah, C., & Cohen, J. PTSD IN CHILDREN AND ADOLESCENTS:
TOWARD AN EMPIRICALLY BASED ALGORITHM. Depression and Anxiety, 28, 770-782.
Yule, W., & Dyregrov, A. A Review Of PTSD In Children. Child and Adolescent Mental
Health, 11, 176-184.

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