Post-Traumatic Stress Disorder and Traffic Accidents: Differential Diagnosis and Comorbid Conditions

By Mrdjenovich, Adam J. | International Journal of Child and Adolescent Health, April 1, 2018 | Go to article overview

Post-Traumatic Stress Disorder and Traffic Accidents: Differential Diagnosis and Comorbid Conditions


Mrdjenovich, Adam J., International Journal of Child and Adolescent Health


Introduction

More than 700,000 children experience traumatic events of abuse or neglect each year in the United States (1). Research involving a nationally representative sample of nearly 5,000 children and adolescents aged 0-17 years found that the majority (61%) of respondents had experienced or witnessed some type of victimization in the past year (2). Findings from another national study of more than 4,000 children and adolescents aged 12-17 years indicate that nearly half (47%) of the participants had been exposed to violence or had experienced trauma in the form of sexual or physical assault during their lifetime (3). A plurality of these children will develop conditions such as post-traumatic stress disorder (PTSD) that can significantly impair their social, emotional, and academic functioning. Residual sequelae of childhood trauma might persist and might contribute to psychological problems throughout life.

Childhood mental disorders: Diagnostic challenges and developmental considerations

The challenges of diagnosing mental disorders in children are widely recognized. Factors such as separation anxiety, disruptive behavior, or poor school performance can point to any number of conditions. The diagnostic process is complicated further by the potential for symptom overlap and psychiatric comorbidity. A diagnosis of PTSD, by definition, depends on a precipitating event (4). The manner in which children perceive and respond to traumatic events is influenced largely by the nature and duration of trauma, as well as their level of cognitive, emotional, and psychosocial development. Thus, the clinical presentation of PTSD varies considerably by developmental stage (5). This is evident in the triad of re-experiencing, avoidance, and hyper-arousal that characterizes the disorder, which does not necessarily manifest itself the same way in children as it does among adults (4, 5).

Diagnostic criteria and age-specific features

The most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (4) identifies diagnostic criteria for PTSD in eight areas: (A) exposure to a traumatic event; (B) re-experience such as flashbacks and nightmares; (C) avoidance of stimuli associated with the traumatic event; (D) negative alterations in cognition and mood such as dissociation, dysphoria, and emotional numbing); (E) increased arousal such as anger and hypervigilance; (F) duration of symptoms (more than one month for most); (G) significant distress or functional impairment; and (H) the disturbance cannot be attributable to the effects of a substance or another medical condition (6). Age-specific features are also described. For example, while school-aged children may not experience visual flashbacks or amnesia for aspects of a traumatic event, they do tend to experience "time skew," which refers to the mis-sequencing of trauma-related events, and "omen formation," which refers to the belief that warning signs predicted the trauma. These features are not typically observed among adults with post-traumatic stress disorder. Additionally, school-aged children tend to exhibit post-traumatic play (i.e., a literal representation that involves compulsive repetition of some aspect of the trauma) and re-enactment (i.e., a behavioral recreation of the trauma through verbalizations or drawings) (5, 7).

PTSD in preschool children

Based on research which suggested that the diagnostic criteria for post-traumatic stress disorder needed to be more developmentally sensitive and behaviorally anchored in order to detect the disorder in younger children, DSM-5 includes a new developmental subtype called "PTSD in preschool children." Some of the general criteria for post-traumatic stress disorder such as distress at the time of a traumatic event, an inability to recall important aspects of a traumatic event, and sensing a foreshortened future were deleted for purposes of this subtype due to the developmental challenges that are associated with the assessment of symptoms. …

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