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POST

TRAUMATIC STRESS DISORDER


Literature Review on Post Traumatic Stress Disorder - Preschool Subtype


Patricia Garrett
Wake Forest University

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Abstract

Posttraumatic Stress Disorder (PTSD), like many diagnoses in the DSM, is a disorder
characterized by a grouping of symptoms, but what makes PTSD unique is the exposure to a
traumatic event that creates the development of the symptoms. According to the U.S Department
of Veteran Affairs, in the past year PTSD has had a prevalence of 3.5% in adults, with women
having 9.7% lifetime prevalence and men, 3.6%. In the additions to the DSMs fifth edition, new
diagnostic criteria of PTSD in children 6 and under, as well as sexual violation or abuse are
included. While the research data of PTSD in children is still minimal, it has also been found
that, like adults, PTSD is more prevalent in girls than boys.
This review include information on the diagnosis of PTSD, the literature and research
available on the topic, including the changes brought forth in the DSM 5 and information on the
additions to the diagnostic criteria. More specifically, there will be an overview of treatment
options in the area of the preschool subtype diagnosed with PTSD. Concluding, that will be
attention paid to the portions of research that are lacking and literature that is missing on this
topic in order to highlight the potential for further research on PTSD for the preschool subtype.

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Introduction

Background
Post Traumatic Stress Disorder (PTSD), for the preschool subtype, is defined by the
DSM-5 as resulting from exposure to actual or threatened death, serious injury, or sexual injury.
Up until the DSM-5, the diagnostic criterion has been listed specifically for those over the age of
six, and, amongst its many changes, added specific criteria for children under the age of six. It
has been debated in the past as to whether or not children can be diagnosed with PTSD, but
according to Michael S. Scheeringa of Tulane University School of Medicine, that is no longer
debatable (Sheeringa, 2011). In 2008, Sheeringa asked the question of the DSM-IV, Are the
DSM-IV criteria developmentally sensitive enough to diagnose the disorder in this group
(Sheeringa, 2008)?
PTSD has been a long debated diagnosis since its creation in the DSM by the American
Psychiatric Association in 1980. It was a controversial diagnosis in adults, let alone in children.
It wasnt until Leone Terrs studies of kidnappings of children that the consideration for
diagnosing children came about. (Dyregrov&Yule, 2006).
In making the changes to the criteria of PTSD in DSM-IV and adding the preschool
subtype in DSM-5, it became apparent that there are a more even amount of children as there are
adults with PTSD, where as before there were very few children in this age group diagnosed.
Michael Sheeringa and a group of many other colleagues in the field researched and created the
alternative criteria for diagnosis as early as 2008, which was later used in the PTSD preschool
subtype criteria for the DSM-5. (Sheeringa, Zeanah&Cohen, 2010)

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Methods

I conducted my initial research through the use of the 5th edition of the Diagnostic and
Statistical Manual of Mental Disorders. Through this, I found the diagnostic information for
PTSD, specifically for the preschool subtype. Due to the new diagnostic nature of the preschool
subtype of PTSD, articles specific to this subtype were somewhat difficult to ascertain. This may
be due to the prevalence statistics within this age group, in which the DSM-5 states, This may
be because previous criteria were insufficiently developmentally informed (American
Psychiatric Association, p.276).
Along with the DSM-5, other resources such as the Wake Forest University Z. Smith
Library online search resources and Google were used in order to find literature and research on
the topic, particularly in the area of background information and treatments. Within the library
search, the key terms that were used to find articles and journals included PTSD and Children,
PTSD in Children and Treatment, and PTSD in Children and Meditation. The first two key
word searches provided enough research and articles to provide for the requirements of this
paper. However, the third set of key words did not come up with any results in the way of
treatment for children, just adults.
Having had some experience with the use of yoga as a form of therapy for children with
PTSD, I used the search terms PTSD in Children and Yoga and Meditation in my Google
searches in hopes of finding more research than was available through my other search methods.
Unfortunately, there is very little research available on the use of yoga and meditation for
children. Strangely, there were plenty of organizations willing discuss their successes with such
treatments with children, but not in an academic or journal medium.

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Results

Diagnostic Criteria
The diagnosis of PTSD for children under the age of six requires that the child be
exposed to actual or threatened death, serious injury, or sexual violence through direct
experience, learning about such an event happening to a parent or caregiver, or witnessing such
traumatic events. The symptoms required for each criterion are noticeably fewer for this
particular subtype, which will be discussed next. (DSM-5, p. 272)
In the new DSM-5, an algorithm for diagnosis was added for the preschool subtype.
Rather that relying the one in DSM-IV (1 B/1 C/2 D), the new algorithm for this particular
subtype is 1 B/1 C or D/2 E. The algorithm explains how clinicians are to go about diagnosing
PTSD in children 6 and under differently from those who fall into the general PTSD diagnosis.
Due to the developmental stages found during this age range, children in this subtype are not
always capable of describing or expressing the information needed for the prior diagnostic
algorithm for PTSD. (Friedman, p. 553)
An interesting note about diagnosis is that it is specifically noted under Criteria A that
witnessing does not include events that are witnessed only in electronic media, television,
movies or pictures (DSM-5, p.273). It could be assumed that this was added due to the cultural
conversation of the impact of violent media on children.

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Diagnostic Controversies and Difficulties


An interesting note about the DSM-V and its addition of the preschool subtype is that
sexual exploitation, kidnapping and being taken hostage are all considered traumatic experiences
in Criterion A for general PTSD. However, they are not listed as traumatic events for the
preschool subtype. According to the U.S. governments Office of Juvenile Justice and
Delinquency Prevention has stated, amongst other prominent organizations, there is an epidemic
of Commercial Sexual Exploitation of Children (CSEC) in this country and children under the
age of six have fallen victim to this. Rather, the DSM-V generally states, For children, sexually
violent events may include developmentally inappropriate experiences without physical violence
or injury (DSM-5, p.274). (www.ojjdp.gov)
As mentioned before, diagnosing PTSD in children can be difficult due to their
developmental limitations. This makes the subtype, though an obvious addition to some, more
difficult to accept for others. Many symptoms of PTSD overlap with other childhood disorders,
namely ADHD, depression, conduct disorder, oppositional defiant disorder, and substance
abuse (AACAP, 1998). It is also co-morbid with many conditions, which makes differentiation
difficult when trying to diagnosis. (Indian Journal of Psychiatry, 2002)
Effective Treatments
The following section includes the treatments used effectively for children with PTSD.
Unfortunately, only one of them, Flexibly Sequential Play Therapy, has been listed for the
preschool subtype age group. However, due to the newer nature of PTSD diagnosis for this
subtype, it may be worth considering the treatments used on slightly older children as well.
While the treatments that will be considered here have been academically researched, one, Yoga,

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is a more culturally recognized treatment option. This particular treatment will be mentioned in
the research recommendations section. The others include Psychopharmalogic interventions,
Cognitive Behavioral Therapy and Seeking Safety Therapy.
Psychopharmalogic Interventions have both been successful, and failed, in the area of
treating children with PTSD. SSRIs have been found to not be successful in younger children,
but tend to work with adolescents and youth. Dr. Jeffery Strawn, after considering all the
pharmacologic information about treating children with PTSD, recommends trauma-focused
cognitive behavioral therapy (TF-CBT) as a first-line intervention, but as far as medications are
concerned, says that antiadrenergics, second generation antipsychotics, and antiepileptic agents
may be beneficial. (Leonard, 2010)
Cognitive behavioral Therapy, as was recommended by Dr. Strawn in the article
mentioned above, is a therapy that there is much research in regards to kids 8 and up. However,
it is among the therapies that there is not much literature on for kids 6 and under. Treatment can
include scheduling, writing and drawing about the trauma, visiting the trauma site, and other
behavioral elements. It is a therapy particularly effective with PTSD due to sexual abuse and has
been known to reduce the symptoms, such as anxiety and inability to ascertain healthy coping
skills. (Smith, Yule, Perrin Tranah, Dalgleish&Clark, 2007)
There is a specific form of Cognitive behavioral therapy that is focused on writing. In this
particular form, the children are asked to write down, or the therapist types up, the trauma in a
storyline fashion. In a somewhat narrative therapy format, the child adds to the story where they
are now, how they are feeling and how they want to feel or act in the future. The therapy goes
through each step of writing a story (title, body, ending) during each therapy session. Again, this

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particular therapy works well with children who have been diagnosed with PTSD due to sexual
abuse. (Van der Oord, Lucassen, Emmerick, Emmelkamp, 2010)
Flexibly Sequential Play Therapy (FSPT) is the treatment option specifically listed for the
age group of the preschool subtype. This therapy uses coping play strategies such as the coping
tree, copecakes, five-count breathing, and coping bubble wrap. The goal of this particular
treatment is to provide children with safe space as well as coping techniques to deal with their
PTSD. (Goodyear-Brown, Paris and Me)
Seeking Safety therapy is a treatment option that has been used with adolescent girls with
PTSD. Although it is not specifically linked to children under the age of six, this coping skills
management therapy could be altered to treat younger children. Seeking Safety has five
principles: (1) safety as the priority; (2) integrated treatment of both disorders; (3) a focus on
ideals; (4) four content areas: cognitive, behavioral, interpersonal, and case management; and (5)
attention to therapist processes (Najavits, Gallop&Weiss, 2006).
After researching each of these treatments, it is clear that the treatment needs to be as
unique as the trauma itself. Each patient, depending on their particular traumatic event and the
amount of time since the trauma, may need a different treatment plan than another child with a
similar case in order to successfully reduce the symptoms. Generalization of the needs could be
hazardous. (Smith, Yule, Perrin Tranah, Dalgleish&Clark, 2007)

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Discussion

In the future, research should be done in the area of holistic approaches and the impact
they are having therapeutically for children with PTSD. For example, many non-profits are
opening up around the country using trauma sensitive yoga for children and youth who have
experienced trauma and are diagnosed with PTSD. PTSD has been shown to physically affect the
brain in the frontal cortex of the brain and impact the cognitive abilities of a developing brain.
Mindfulness practices of yoga and meditation, and deep breathing, has shown success in helping
students with PTSD keep focus, learn to cope with stress, and continue to learn successfully.
Child yoga has become a popular cultural practice, and as a result, has given more opportunity
for researchers to look into the scientific and qualitative impact of such practices of children of
PTSD, if those opportunities are taken. (Brown, 2014)
The diagnostic criterion used in the preschool subtype of PTSD is limited in the area of
what are considered traumatic events for this age group. As mentioned before, the Commercial
Sexual Exploitation of Children is a global issue that is linked with the issue of human
trafficking in U.S. government verbiage. Research needs to be done in the area of PTSD in the
traumatic events left out of the preschool subtype criteria. As a result of such research, more
specific traumatic events, or those matching the general PTSD diagnosis should be added to this
particular subtype. Lack of specification could be limiting research opportunities.

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Reference List
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