Posttraumatic Stress Disorder in Preschool Children
A. The child (less than 6 years old) was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways:
1. Experiencing the event(s) him/herself
2. Witnessing the event(s) as it (they) occurred to others, especially primary caregivers
3. Learning that the event(s) occurred to a close relative or close friend*
NOTE: Witnessing does not include events that are witnessed only in electronic media, television, movies or pictures.
B. Intrusion symptoms that are associated with the traumatic event (that began after the traumatic event), as evidenced by 1 or more of the following:
1. Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event. Note: spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.
2. Recurrent distressing dreams related to the traumatic event (Note: it may not be possible to ascertain that the content is related to the traumatic event).
3. Dissociative reactions in which the individual feels or acts as if the traumatic event(s) were recurring (such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings).
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).
One item from C. or D. below:
C. Persistent avoidance of stimuli associated with the traumatic event (that began after the traumatic event), as evidenced by efforts to avoid:
1. Activities, places or physical reminders, that arouse recollections of the traumatic event.
2. People, conversations, or interpersonal situations that arouse recollections of the traumatic event
D. Negative alterations in cognitions and mood that are associated with the traumatic event (that began or worsened after the traumatic event), as evidenced by 1 or more of the following:
1. Substantially increased frequency of negative emotional states -- for example, fear, guilt, sadness, shame or confusion.*
2. Markedly diminished interest or participation in significant activities, including constriction of play.
3. Socially withdrawn behavior.
4. Persistent reduction in expression of positive emotions.
E. Alterations in arousal and reactivity that are associated with the traumatic event (that began or worsened after the traumatic event), as evidenced by 2 or more of the following:
1. Irritable, angry, or aggressive behavior, including extreme temper tantrums.
2. Reckless or self-destructive behavior.*
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance -- for example, difficulty falling or staying asleep, or restless sleep.
F. Duration of the disturbance (symptoms in Criteria B, C, D and E) is more than one month.
G. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings peers or other caregivers or school behavior.
* At present, there is not a consensus about including these items. Data relevant to their inclusion or exclusion are being sought.
Please see Proposal to Include Child and Adolescent Age Related Manifestations and Age Related Subtypes for PTSD in DSM-5.
Criterion A: Rationale is similar to the rationale for proposed changes in the adult PTSD criteria. There is no evidence that A2 (DSM-IV) meaningfully affects the diagnosis and it poses challenges for adult reporters. A3 in proposed criteria is being considered.
Criterion B: Similar to rationale for changes in the adult criteria. Studies have shown that recollections in preschool children are not necessarily distressing.
Criteria C (proposed C and D): This change in threshold is supported by 7 studies that used 1, 2 or 3 of the DSM-IV C signs (now divided into C and D). These have clearly indicated that a threshold of one yields the best criterion validity. There are also changes to describe developmental manifestations of how each criterion is described.
Criterion D (proposed E): All but item E2 were part of the former cluster D (DSM-IV). Seven studies have suggested that two is the proper threshold in young children. Item E2 is still being evaluated.
The impairment criterion has been revised to be more developmentally appropriate.
Reference: Review by Sheeringa, M. et al., Depression and Anxiety, in press
This disorder is not listed in DSM-IV as a distinct disorder, however, Posttraumatic Stress Disorder is in DSM-IV.
Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections 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 (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor