“The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma.” Judith Lewis Herman, MD, Trauma and Recovery
Unfortunately, children are exposed to traumatic events—isolated ones such as natural disasters or serious accidents, and recurring traumas such as domestic violence and sexual abuse. However, throughout history, most people didn’t believe that children experienced lasting psychic trauma as a result of these events. It wasn’t until the publication of DSM-III-R in 1987 that we recognized in a formal way that some children go on to develop post-traumatic stress disorder (PTSD). Here, we will review the changes to the diagnosis of PTSD in DSM-5, with a focus on those specific to children and adolescents.
Big Moves and Big Changes
The biggest structural change is the removal of PTSD from the anxiety disorder section and its inclusion in a new section on trauma and stressor-related disorders. Perhaps more clinically pertinent is the removal of criterion A2, which in DSM-IV specified a subjective reaction of intense fear, helplessness, or horror (in children, this could have been disorganization or agitation). This criterion has been problematic for many of us who treat PTSD, especially for young children who may not be able to recall or describe their subjective reaction to a traumatic event. Instead, DSM-5 focuses more on the behavioral and affective symptoms and subjective reactions, while important to address in treatment, are not part of the diagnostic criteria.
In addition, Criterion A1, “exposure to actual or threatened death, serious injury, or sexual violence” (ie, directly experiencing the traumatic event), has been narrowed and refined, and in DSM-5 no longer includes the death of family or a close friend due to natural causes. It also explicitly includes sexual assault as a traumatic event, important for those working with children because of kids’ vulnerability to this type of mistreatment.
Symptom clusters have been rearranged and expanded from three to four, based on data showing that this four-factor model more accurately describes what we see clinically than does the three-factor model in DSM-IV (Friedman MJ et al, Depression and Anxiety 2011;28:750–769).
The avoidance symptom cluster has been separated into two clusters: avoidance and negative cognition/mood symptoms. Hyperarousal and re-experiencing symptom clusters remain distinct groups in the DSM-5. For assessment of re-experiencing in children, there is an emphasis on behavior and observable symptoms, such as repetitive play with themes of the trauma and frightening dreams without recognizable trauma. Further, there is no longer a distinction between acute and chronic phases of PTSD.
Finally, a new signifier, PTSD with prominent dissociative symptoms, was added because people with dissociative features (about one third of people with PTSD) seem to require more stabilization and support before they can benefit from exposure-based CBT treatment (Friedman MJ et al, Depression and Anxiety 2011:28:737–749).
Diagnostic Criteria for Children
There is a distinct set of diagnostic criteria for PTSD in children under six years in DSM-5. PTSD looks quite different in young kids, compared to older children and adults, and likely has been missed and underdiagnosed as a result of a misfit between the DSM criteria and the manifestation of the illness in preschool-aged kids (Scheeringa MS et al, Depression and Anxiety 2011;28:770–783).
Kids this age may not appear distressed by memories or discussion of the event, and may instead appear excited or excessively positive. In addition, PTSD symptoms that are experienced internally can be difficult to assess since children may not have the language or capacity to describe what they are experiencing. For example, it is nearly impossible for a young child to describe psychological avoidance of thoughts or feelings about a trauma, and they may not have the ability to recall the symptoms they are experiencing or convey the burden of memories.
CCPR's Verdict: The changes to PTSD in DSM-5 reflect a greater understanding of the impact of trauma on children, and set the stage for increased recognition and improved treatment.