The manifestation of post-traumatic stress in children and young persons aged 7-14 years and implications for PTSD diagnosis

Abstract

Each year, millions of children are exposed to potentially traumatic events world-wide. Posttraumatic stress disorder (PTSD) is one of the most common disorders to be diagnosed in children following exposure to trauma (DiMauro, Carter, Folk, & Kashdan, 2014; Norris et al., 2002). PTSD causes substantial distress and has the potential to adversely impact children’s long-term social, emotional, and physical development and well-being (Fairbank & Fairbank, 2009; Pynoos et al., 2009; Seng, Graham-Bermann, Clark, McCarthy, & Ronis, 2005). Our knowledge regarding PTSD symptom expression in children aged 7-14 years is limited. Researchers and clinicians have raised doubts about the diagnostic validity of the Diagnostic and Statistical Manual of Mental Disorders (DSM) PTSD criteria for children and adolescents (Blom & Oberink, 2012; Carrion, Weems, Ray, & Reiss, 2002). Even though the DSM-5 introduced substantial changes to the PTSD diagnostic criteria which apply to children 7 years and older, the majority of these changes were not tested with children prior to their inclusion (Friedman, 2013; Kilpatrick et al., 2013; Miller et al., 2013). Consequently, it is not known whether these changes improve the validity of the diagnosis in children. This remains a key gap in knowledge which has the potential to hinder our ability to effectively identify and provide timely clinical intervention to trauma-exposed children aged 7-14 years in need of attention and care.The overall aim of this thesis was to:1) Advance empirical knowledge of PTSD expression in children and young persons aged 7-14 years and,2) Explore age-related differences in PTSD symptom expression.Research questions were examined by completing a series of secondary analyses on the PTSD after Acute Child Trauma (PACT) Data Archive. PACT is an international archive of de-identified data sets from prospective research studies of children exposed to an acute, potentially traumatic event. The final sample included 757 children drawn from nine different studies conducted in four countries (Australia, Switzerland, United Kingdom, and the United States). Chapter One provides a general overview of the literature and a rationale for the thesis. Chapter Two presents a systematic scoping review that discusses the most recent research examining PTSD symptom presentation in children aged 7-14 years. Chapter Three presents the findings from the first study which examined differences in the manifestation of PTSD symptoms between pre-adolescent (7-11 years) and adolescent (12-14 years) children. This study used univariate statistics to examine age-related differences in the frequency of individual symptoms. This study also used binary logistic regression and receiver operator characteristics (ROC) curve analyses to examine age-related differences in the association between PTSD symptoms and functional impairment. The findings from this study highlighted age-related differences in PTSD symptom presentation, the clinical importance of particular PTSD symptoms, and the importance of assessing functional impairment. Chapter Four presents findings from a study which used latent class analysis to explore differences in PTSD symptom profiles in three different age-groups: Young Group (7-9 years), Latency Group (10-11 years), and Adolescent Group (12-14 years). Findings from this study highlighted that PTSD symptom profiles vary according to developmental stage, and the profiles most associated with functional impairment do not appear to correspond to the DSM-5 PTSD algorithm. Chapter Five examined the developmental sensitivity of the new DSM-5 requirement to endorse one symptom of effortful avoidance to obtain a PTSD diagnosis, and the clinical significance of effortful avoidance symptoms in three age-groups of children. This study found that the new effortful avoidance requirement did not reduce the developmental sensitivity of the DSM-5 PTSD diagnosis for the majority of children. However, it also highlighted that the developmental sensitivity of this diagnosis was reduced for a small but clinically significant minority of children. The dissertation concludes in Chapter Six with a discussion of the overall findings, their diagnostic and clinical implications, and directions for future research. Two key contributions of knowledge which have emerged from this thesis are: 1) The importance of functional impairment in the assessment of trauma-exposed children, and 2) The need to consider alternative diagnostic models to better account for age-related differences in PTSD symptom presentation.