The American Psychiatric Association will recognize traumatic stress in preschoolers younger than age six as a unique form of post-traumatic stress disorder when it releases its newest version of the Diagnostic and Statistical Manual at its annual conference in May. The DSM is the manual that is used by clinicians and researchers to diagnose and classify mental disorders.
Although PTSD — a traumatic stress response to exposure to actual or threatened death, serious injury or sexual violation — has been reported in preschool and school age children for many years, the current criteria used to diagnose the condition was developed and field tested for adults and adolescents (15 and older). Data from published studies provided evidence that the current standards for diagnosing PTSD in young children may be insufficient.
Many clinicians found the criteria difficult to apply to young children and not representative of the types of responses found following exposure to a traumatic event in early childhood. Consequently, the prevalence of the disorder in this age group was lower than expected, leading clinicians and researchers to question the way PTSD was being diagnosed in young children. As a result, new diagnostic standards have been revised.
For example, previous criteria required assessing for the presence of a "feeling of detachment or estrangement from others" in infants and toddlers. In the new DSM, this has been modified to "markedly diminished interest or participation in significant activities, including constriction of play."
By defining this response as an observable behavior, which can be noted by caregivers, the ability to assess the presence of this type of social withdrawal is increased.
Additionally, items such as "an inability to recall an important aspect of the trauma" and "sense of foreshortened future" will be excluded.
PTSD in preschool children is not considered a separate type of traumatic stress disorder, but rather a subtype of PTSD. Following direct exposure to an event, witnessing the traumatic situation as it occurred to others (especially caregivers), or learning that an event occurred to a parent or caregiver, four clusters of symptoms associated with the traumatic stressor are assessed. These include:
■ Intrusive symptoms such as nightmares, re-enacting the event in play or persistent avoidance of activities or people who remind the child of the event
■ Negative changes in cognition or mood
■ Changes such as increased irritability, sleep disturbance or tantrums
■ To be considered PTSD, preschool subtype, the symptoms must be present for at least one month.
Fortunately, there are effective treatments for young children who experience PTSD. Trauma-focused cognitive behavioral therapy is appropriate for children as young as three years of age, and child-parent psychotherapy targets children and caregivers under age five.
Relief from trauma symptoms is usually accomplished within the context of the parent-child relationship for young children, so parent or caregiver participation in these treatments is crucial.
The UK Center on Trauma and Children provides training on trauma-focused cognitive behavioral therapy to behavioral health professionals. For more information, contact Dr. Ginny Sprang at firstname.lastname@example.org or go to the center's website, www.uky.edu/ctac.
Dr. Ginny Sprang, executive director of the Center on Trauma and Children at the University of Kentucky.