Portal de Periódicos da CAPES

Posttraumatic Stress Disorder

2008; American Academy of Pediatrics; Volume: 29; Issue: 3 Linguagem: Inglês

10.1542/pir.29-3-103

1529-7233

N. Copeland-Linder, J. R. Serwint,

Migration, Health and Trauma

Children and Trauma in America: A Progress Report of the National Child Traumatic Stress Network. National Child Traumatic Stress Network 2004. Available at www.nctsnet.org./nctsn_assets/pdfs/reports/NCTSNProgressReport2004.pdf. Accessed November 2006Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. American Psychiatric Association. Washington, DC: American Psychiatric Press; 2000:463–468Posttraumatic Stress Disorder in Children and Adolescents. Yule W. Int Rev Psychiatry. 2001;13:194–200Posttraumatic Stress Disorder: Clinical Guidelines and Research Findings. Scheeringa MS. In: Luby JL, ed. Handbook of Preschool Mental Health: Development, Disorders, and Treatment. New York, NY: Guildford Press; 2006:165–185Substance Abuse and Mental Health Services Administration Model Programs: Trauma-focused Cognitive Behavioral Therapy. Available at http://www.modelprograms.samhsa.gov/pdfs/model/TFCNT.pdf. Accessed December 2006.Violence and Risk of PTSD, Major Depression, Substance Abuse/Dependence, and Comorbidity: Results from the National Survey of Adolescents. Kilpatrick DG, Ruggiero KJ, Acierno R, Saunders BE, Resnick HS, Best CL. J Consult Clin Psychology. 2003;71:692–700Rape Trauma Syndrome. Burgess AW, Holmstrom LL. Am J Psychiatry. 1974;131:981–986Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Foa EB, Rothbaum BO. New York, NY: The Guilford Press; 1998According to the National Child Traumatic Stress Network, 25% of youth experience a traumatic event by the time they are 16 years old, including natural disasters (eg, hurricanes), violence (eg, rape, physical assault, witnessing violence), combat or war-related events, and traumatic events related to illness or injury. Youths' reactions to catastrophic events or major stressors can vary from temporary distress to severe forms of psychopathology. Factors that influence the development of severe stress reactions include the proximity, intensity, and duration of exposure to the stressor as well as the child's age, prior mental health, coping strategies, and quality of family support.A subset of youth exposed to a traumatic event develop posttraumatic stress disorder (PTSD), which is characterized by intense fear and the occurrence of three categories of symptoms following exposure. The first category involves re-experiencing the event. The trauma may be re-experienced in a number of ways, including intrusive thoughts, memories, flashbacks, recurring dreams, or nightmares. In addition, PTSD sufferers may experience intense emotional distress and physiologic reactions when exposed to cues or situations that remind them of the experience. In young children, this category of symptoms may be manifested by repetitive play and drawings that involve themes related to the event as well as by reenactments of aspects of the experience. In addition, children's sense of fear and helplessness may be manifested by agitated or disorganized behavior.The second category of symptoms relates to emotional numbing and avoidance of stimuli associated with the event. Sufferers of PTSD may feel disconnected or estranged from others, lose interest in participating in activities, and have difficulty expressing feelings. This category of symptoms also includes avoidance of thoughts, feelings, places, people, or activities that are reminders of the trauma. In addition, it is common to have difficulty remembering aspects of the event. Individuals may feel hopeless about the future.The third category of symptoms involves increased arousal, which may encompass sleep disturbances, irritability, poor concentration, hyperalertness, and easy startling. Criteria for diagnosing PTSD are the presence of at least one symptom related to re-experiencing, three or more emotional numbing/avoidance symptoms, and two symptoms of hyperarousal, with symptoms being present for more than 1 month.Additional symptoms associated with children's stress reactions include an increase in tantrums and aggressive behavior as well as new fears that are thematically unrelated to the traumatic event. Regressive behaviors, such as bedwetting and clinginess, often increase among young children, although an increase in physical complaints (headaches, stomachaches) also may occur. Children and adolescents may experience separation difficulties, needing to remain in close proximity to their parents. PTSD sufferers may feel guilty about surviving when others died or they may feel guilty about what they had to do to survive.PTSD can interfere with children's emotional, social, and cognitive development. Traumatized youth often have difficulties managing their behavior, tolerating and expressing feelings, and trusting others. Such difficulties can have a negative impact on their ability to develop and sustain healthy relationships. Youth who have been raped or otherwise physically and mentally assaulted may feel permanently damaged, which may compromise their identity development. Among adolescents, symptoms of PTSD are associated with high rates of depression, suicidal ideation, and substance abuse.The lifetime prevalence of PTSD among adults has been estimated to be 8%. Among adolescents, the estimated prevalence is 3% to 6%, with higher rates reported among girls. Rates of PTSD vary considerably among individuals who have been exposed to trauma, based on the type of event, with some studies reporting rates as high as 90% among witnesses of domestic violence and rape survivors. Trauma symptoms are so common among rape survivors that prior to the introduction of PTSD in the Diagnostic and Statistical Manual of Mental Disorders, researchers described a constellation of trauma symptoms that they labeled rape trauma syndrome. Although this term sometimes is used, most researchers and practitioners agree that rape trauma syndrome is characterized best as PTSD.The appropriateness of applying some PTSD diagnostic criteria to young children continues to be debated. The numbing/avoidance symptoms are very difficult to detect among preverbal children because endorsement of such symptoms depends greatly on verbal abilities. Thus, this category of symptoms may be underreported in young children. Regardless of whether diagnostic criteria for PTSD are met, individuals who have been exposed to trauma warrant concern because they often are highly symptomatic and functionally impaired.Youth who have been exposed to trauma and are symptomatic should be referred to a mental health professional. A multi-informant approach is preferred and involves gathering information from the youth and the parents about the nature and frequency of the event and the severity, intensity, and duration of the symptoms. Validated symptom checklists and structured clinical interviews can aid in assessment. Direct observations of play may be incorporated into assessments of young children. Information from all modes of assessment should be examined, with special attention to the youth's age, developmental stage, prior history of trauma exposure, family history of psychopathology, support network, and protective factors.Cognitive behavioral therapy (CBT) has received the most empiric support as an effective treatment for PTSD. CBT aims to modify maladaptive thoughts and behaviors that have developed in response to the traumatic event. Most forms of CBT involve education about the nature of the trauma and symptoms, gradual exposure to feared stimuli (ie, recount memories, confront situations), and cognitive restructuring to address maladaptive thoughts. Trauma-focused CBT (TF-CBT) is an evidence-based intervention designed to help youth ages 3 to 18 years and their parents who have been affected by trauma. Youth components focus on factors such as identification of feelings, cognitive reframing, gradual exposure, and stress management. The intervention addresses issues such as low self-esteem, difficulty trusting others, and risky behavior. Combined parent-child sessions as well as separate parent sessions are used. Parent sessions help parents process their feelings and distress related to their child's traumatic exposure and assist them with effective parenting skills. TF-CBT consists of 12 to 16 sessions. It has been recognized as a model program by the Substance Abuse & Mental Health Services Administration and the United States Department of Health and Human Services and has been classified as "Selective and Indicated" by the Institute of Medicine.Comment: PTSD has been acknowledged more in the media since September 11, with the war in Iraq, and as acts of terrorism have become more common. However, events that occur in everyday life, such as motor vehicle crashes, homicides, intimate partner violence, or even invasive medical procedures also must be recognized and considered. Although the diagnosis can be more challenging in younger children because symptoms of distress may not be as obvious, PTSD may have more pronounced effects on younger children because of the vulnerability of a rapidly developing central nervous system. Societal barriers to mental health counseling exist, and some urban families may find the inciting events to be commonplace in their environments, but health-care practitioners must be vigilant for a suggestive history and symptoms of PTSD and should present therapy in a socially acceptable manner to help break the cycle and facilitate healing. Recognition and treatment of PTSD is imperative for the ultimate optimal function of children and families.