The Power of a Child’s Subjective Response to Trauma

By now most of us know how pTsd looks in DSM-5. among a number of changes is the removal of criterion a2, which required a response to an eventto include “intense fear, helplessness, or horror.” Criterion A1—exposure to actual or threatened death, serious injury, or sexual violence—was slightly edited, but remains a diagnostic requirement for the disorder.It has been well studied in adults that criterion a1 (described in DSM-IV-TR as “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 oneself or others”) is more likely to predict the development of posttraumatic stress than meeting criterion a2. in fact, this is the rationale for the removal of the subjective reaction criterion in DSM-5.

However, the predictive power of these criteria was not well-studied in chil- dren. prior to the publication of DSM-5,a group of researchers in denmark set out to determine the predictive value of criterion a1 and a2 to see if they per- formed the same for children as they did for adults.

The study involved 533 school-age children (average age 13.6) who com- pleted classroom-based questionnaires about “the worst event they had ever experienced” that included a description of the event and their feelings following it. They were then assessed for prob- able PTSD using the Children’s Revised impact of event scale (cries-13), a stan- dard screening instrument for pTsd.

According to the scoring method used, 24% of events mentioned by the children were classified as a1 events (actual or threatened death or serious injury), while 59% met criterion A2 (the child reacted with fear, helplessness, or horror).

Surprisingly, in contrast to studies in adults, a subjective reaction of fear to an event was significantly more predictive of probable pTsd using the cries-13 than exposure to what is objectively defined as a “traumatic event.” When each criterion was looked at alone, children who met criterion a2 were nine times more likely to develop pTsd than those who didnot. Meeting criterion a1 doubled the chance of developing pTsd (Verlindere et al, European J Psychotraumatology 2013;4:20436).

CCPR’s Take: This study showed that children’s perception of threat can be incredibly meaningful in predicting PTSD—perhaps even more so than the actual risk from an event. While there was not strong enough evidence to keep criterion a2 in the new version of dsM, we should let this be a reminder to ask questions related to children’s subjective reactions to an event, even if thoseare no longer required for an official diagnosis.

Child Psychiatry