To facilitate appropriate PTSD-assessment referral, screenings can be completed following a specific traumatic event or individually as case history or symptomatic presentation suggest (see Stamm, 1996, for reviews of screening tools). When PTSD is suspected, preliminary assessment and diagnosis can be conducted in the school setting by supplementing a psychoeducational assessment battery (i.e., cognitive, academic, and behavioral measures) with a PTSD-specific protocol. Posttrauma assessment involves a complete review of the child's pre- and posttrauma presentation based on multiple sources of input and using multiple formats (i.e., direct observation; oral-report; test, interview, and questionnaire data; and reports of those familiar with the child; March, 1999; Thornton, 2001; Yule, 2001). To assess the complete spectrum of trauma sequelae, administration of comprehensive structured and/or semistructured interviews as well as trauma-specific measures are recommended (Cohen et al., 2000; Yule, 2001). Finalized reports should include: (a) academic functioning (i.e., review of records; cognitive and academic assessments; and parent, child, and teacher reports); (b) behavioral functioning (i.e., behavioral assessments: observations; PTSD measures; and parent, child, and teacher reports); (c) symptom severity (i.e., PTSD measures); (d) diagnosis (i.e., comparison of child's presentation to age-specific diagnostic features, DSM-IV-TR criteria, and PTSD measures); and (e) developmentally sensitive recommendations including referral and/or in-school supports.
Although the quality and quantity of PTSD-specific assessment tools available for school psychologists have increased (Nader, 1997; Thornton, 2001), trauma assessment presents many unique challenges. For example, it can be threatening, even symptom inducing, for a child to explore traumatic events and/or symptoms during assessment (March, 1999; Perrin, Smith, & Yule, 2000). In addition, child survivors often find the trauma experiences and symptoms difficult to verbalize, resulting in underreporting (March, 1999). Moreover, symptoms such as avoidance, numbing, and increased arousal, as well as a stressor-related etiology can be indicative of and/or integral to several other clinical disorders (APA, 2000). It is important that psychologists conduct a careful differential diagnosis and consideration of comorbidity for clinical disorders such as: Mood Disorders, other Anxiety Disorders, Brief Psychotic Disorder, Conversion Disorder, Substance-Related Disorders, and Obsessive Compulsive Disorder (APA, 2000; Yule, 2001). Finally, assessment of PTSD in children requires examination of the developmental and cognitive nuances of symptom manifestation (Lipschitz, Rasmusson, Anyan, Cromwell, & Southwick, 2000; March, 1999; Tierney, 2000).
Symptoms and Development
As current diagnostic criteria are not developmentally sensitive (Tierney, 2000), diagnosis of PTSD in children and adolescents depends on the psychologist's careful integration of the current state of knowledge regarding child development and symptom expression. Generally, symptom manifestation becomes increasingly similar to that explicated by the adult criteria as children age.
Preschoolers. For the verbally developing preschooler, symptoms are expressed in nonverbal channels. This age-specific, developmental feature creates diagnostic difficulties because more than one-half of the DSM-IV criteria for PTSD require a verbal description of a subjective state (Scheeringa, Peebles, Cook, & Zeanah, 2001). Symptomatic expression may include: acting out or internalized behaviors, nightmares and disturbed sleep patterns, developmental regression, and clinging behavior (Pullis, 1998; Yule, 2001). Reexperiencing trauma may be expressed as generalized nightmares of monsters, rescuing others, or threats to self or others (APA, 2000; Yule, 2001). Traumatic play is often linked to themes of the traumatic events, is compulsive and repetitive in nature, and fails to relieve any of the accompanying anxiety (Cohen et al., 2000; Yule, 2001).
School-age children. At school-age, cognitive development presents with increasing verbal ability, formative temporal sequencing skills, and difficulty with abstract conceptualization. To a notable degree, symptoms continue to be expressed behaviorally and may include regressions (e.g., bed wetting, clinging behavior or anxious attachment, school refusal; Terr et al., 1999; Webb, 1994; Yule, 2001), less emotional regulation, and increases in externalizing or internalizing behavioral expression (e.g., fighting with peers, withdrawal from friends, poor attention, declining academic performance; Cook-Cottone, 2000; Yule, 2001). In addition, school-age children may not yet be capable of abstractly interpreting somatic, affective experiences inherent in PTSD symptomatology (e.g., anxiety, reexperiencing) and consequently describing these experiences by listing concrete physiological complaints (e.g., stomach aches and headaches; Cook-Cottone, 2000). Fears of going to sleep or being alone, sleep disturbance, clinging to others, and event-specific fears have also been reported (Cohen et al., 2000; Terr et al., 1999; Webb, 1994; Yule, 2001). Reexperiencing is often presented as elaborate enactment of the traumatic event or a preservative, verbal description absent of appropriate affective expression (Johnson, 1998). Traumatic play at this age is more complex and sophisticated; can involve specific themes; often includes writing, drawing, and pretending; and becomes script governed (Johnson, 1998; Terr et al., 1999). Although noted in clinical reports, studies of trauma sequelae rarely describe cognitive temporal distortions (Cohen et al., 2000).
Symptoms in preadolescents and adolescents. Terr and colleagues (1999) suggested that the reciprocal relationship between emotions and thought may account for reduced adolescent symptomatology. That is, preadolescents and adolescents are more able to cognitively process trauma integrating the experience into the context of life experiences. With age, symptoms become increasingly similar to adult manifestations (Cohen et al., 2000). However, for adolescents, abstract conceptions of identity, future, safety, and connection are vulnerable to alterations (Cook-Cottone, 2000; Johnson, 1998). For example, Yule (2001) described the adolescent's sense of foreshortened future (e.g., diminished expectations of getting married, establishing a career, and experiencing a normal life span). Those with chronic PTSD may present with self-injurious behaviors, suicidal ideation, conduct problems, dissociation, derealization, depersonalization, and/or substance abuse, which can mask the posttraumatic etiology of the disorder (Cohen et al., 2000; Johnson, 1998).
- Cook-Cottone, Catherine; Childhood Posttraumatic Stress Disorder: Diagnosis, Treatment, and School Reintegration; School Psychology Review, 2004, Vol. 33 Issue 1, p127-139
Reflection Exercise #6
The preceding section contained information
regarding diagnosing PTSD in children and adolescents. Write
three case study examples regarding how you might use the content of this section
in your practice.
What is a major challenge in diagnosing PTSD in preschoolers? Record the letter of the correct answer