PTSD in Children

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PART 2
Assessment
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ASSESSMENT

• Assessment serves a number of purposes for both
  individual children and groups through
• ? identifying children in need of services
• ? guiding treatment decisions
• ? informing service delivery policy and planning

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APPROACH TO ASSESSMENT

• Post-traumatic assessment approaches and tools
  differ, depending on
• ? the population being assessed
• ? potential uses of the assessment
• ? aspects of the stressor
• ? the post-disaster environment

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EXPOSURE LEVELS

• ? Children physically exposed or eyewitness to
  the event
• ? Children who lost a parent or close family
  member
• ? Children of directly exposed survivors
• ? Children of those secondarily exposed
  (eg, recovery workers)
• ? Children indirectly affected as members of the
  targeted community or society

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CHILDREN WITH GREATEST EXPOSURESUCH AS PERSONAL
OR FAMILY INVOLVEMENT

• Assessment
• ? Individual
• ? Small group

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INDIVIDUAL ASSESSMENT

• ? Parent report
• ? Child assessment
• ? Techniques
• - Clinical interview (parent and child)
• - Projective techniques

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INDIVIDUAL ASSESSMENT

• ? Parent report
• - Parents can provide objective information about
  the childs exposure, experiences, and reactions
• - Parents tend to underestimate the distress of
  their children

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INDIVIDUAL ASSESSMENT

• ? Child assessment
• - Children can describe their subjective
  perceptions of their exposure, experiences, and
  reactions

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ELEMENTS OF CHILD ASSESSMENT

• ? Identifying data (ID) and chief complaint (CC)
• ? History of present condition (HPC)
• ? Past medical history (PMH)
• ? Family history (FH)
• ? Social history (SH)
• ? Mental status examination (MSE)

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SMALL GROUP ASSESSMENT

• ? Small group work
• ?Accommodates larger numbers of children
• ?Promotes sharing of experiences
• ? Spend time with each child

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INDIRECTLY EXPOSED CHILD POPULATIONSSCREENING

• ? Screening provides information for
• ?case-finding and triage to formal evaluation
• ?planning services
• ?assessing populations rather than individuals
• ? Screening uses self-report or parent-report to
  assess
• ?subjective reactions
• ?current post-traumatic, anxious, and depressive
  symptoms
• ?general and current distress
• ? Screening instruments do not provide
  psychiatric diagnoses

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THE VALUE OF MENTAL HEALTH ASSESSMENT
Assessment is necessary before treatment can
begin. This is because ONE SIZE DOES NOT FIT
ALL. Do NOT attempt treatment until you know what
you are treating.
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DIAGNOSIS HOW DO YOU DO IT?

• ? No shortcut
• ? Questionnaires and self-report instruments do
  not diagnose
• ? Diagnose the old fashioned way
• ?assess all criteria, one by one

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DIAGNOSIS OF PTSD IN CHILDREN
A diagnosis of PTSD in children is made the same
way it is in adultswith some differences based
on development (see checklist in handouts)
MUST MEET ALL 6 CRITERIA A, B, C, D, E, AND F
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)
A. "STRESSOR A CRITERION" A sudden,
unexpected traumatic event 1. With threat to
life or limb 2. Evoking intense fear,
helplessness, or horror
Qualifying exposures 1. Physical presence 2.
Direct witnessing 3. Indirect through a
loved one's exposure
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)
B. INTRUSIVE RE-EXPERIENCE 1 or more of
the following related to the event ? Intrusive
memories of event - in children, may be
expressed as repetitive play ? Dreams /
nightmares of event - in children, content may
not be recognizable ? Flashbacks to event - in
children, may be expressed as re-enactment ?
Upset by reminders of event ? Physiologic
reactivity to reminders (racing heart,
tremors, sweating)
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)
C. AVOIDANCE AND NUMBING 3 or more of the
following NEW symptoms post-event ? Avoids
thoughts / feelings ? Avoids reminders ? Event
amnesia ? Loss of interest ? Detachment /
estrangement ? Restricted range of affect ?
Sense of foreshortened future
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)

• D. HYPERAROUSAL
• 2 or more of the following NEW symptoms
  post-event
• ? Insomnia
• ? Irritability / anger
• ? Poor concentration
• ? Hypervigilance
• ? Exaggerated startle

B, C, D symptoms must be new after the event to
qualify pre existing symptoms such as
irritability and poor concentration in the
population are not counted will yield inflated
estimates of PTSD rates
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)
E. DURATION ?more than one month
Note Delayed onset gt 6 months Chronic gt 3
months
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DSM-IV CRITERIA FOR PTSD
(adapted from American Psychiatric Association's
DSM-IV criteria, 1994)
F. DISTRESS AND FUNCTIONING ?Clinically
significant distress - or - ?Impaired
functioning
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IN VERY YOUNG CHILDREN
Before age 4, PTSD criteria are difficult to
establish Immature cognitive and language
development may prevent expression of ?
terror/horror (A2) ? intrusive recollection
(B) ? numbing symptoms (C)
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TOOLS FOR ASSESSING PTSD
NOTE Many popular questionnaires do
not ? consider the "Stressor A" criterion ?
separate new from pre-existing symptoms ?
require the one month duration ? assess for
clinically significant distress or impaired
functioning
These omissions all contribute to inflation of
PTSD estimates.
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PTSD ASSESSMENT FLOW CHART
Assess PTSD
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OTHER DISORDERS TO ASSESS

• ? Major depression
• ? Separation anxiety disorder
• ? Attention deficit hyperactivity disorder
• ? Oppositional defiant conduct disorders
• ? Alcohol and drug abuse

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COPING

• ? Assessment should cover coping, through
• ?Screening questionnaires
• ?Small groups
• ?Individual sessions
• ?Family work

? Determine ?What techniques the child uses ?How
successful are they
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RESILIENCE

• ? Most children are resilient in the face of
  disaster
• ? Children needing professional attention should
  be identified and treated as soon as possible