ESSENTIALS OF DIAGNOSIS
Children and adolescents frequently experience single-event traumas, for example, involvement in motor vehicle accidents, natural disasters, and other unexpected traumatic events such as being assaulted or raped. The experience of a single-event trauma is qualitatively different from the mental health sequelae of exposure to multiple traumatic experiences like the experience of protracted domestic violence, ongoing sexual assault, or experiences inherent in living in a war zone. Readers should consult the chapters on dissociative disorders and personality disorders and references to sexual abuse to further understand the sequelae of exposure to multiple-event trauma. The mental health outcomes following exposure to a single event trauma include posttraumatic stress disorder (PTSD), other anxiety disorders including specific phobias, and depressive presentations. The Diagnostic and Statistical Manual 5th edition (DSM-5) criteria for these conditions are detailed in Chapters xx, yy, and zz, respectively.
Diagnostic changes in DSM-5 are important in this area. PTSD is no longer a member of the anxiety group. Rather, it is in an overarching group of trauma- and stress-related disorders that includes dissociative disorders. The new PTSD criteria include four phenotypes: fear-based, anhedonic-dysphoric, externalizing, and dissociative. There have been changes in what events meet criteria: indirect exposure is now not included; rather, an individual must witness a traumatic event. Finally, and importantly for this chapter, there is a new preschool subtype with a greater focus on behavior rather than symptoms that relate to the individual's perception of their internal world. Further, adult constructs such as feelings of detachment have been changed to reflect the preschool experience. In this example the criteria are more about social withdrawal.
A valuable framework to help understand the effects of single-event trauma in children and adolescents is that of developmental psychopathology. Individuals function by integration of subsystems that interact vertically (e.g., gene to cell to organism) and horizontally (person to person, person to society). Infants, children, and adolescents also need to organize across time. Time course introduces new developmental constructs: novelty of cause and effect of inputs at different developmental stages (for example, negotiating the entry into elementary and high schools), differential rates of development across subsystems, critical periods, and negotiating developmental challenges such as the changing relationship between parent and child. A developmental psychopathology perspective subsumes other useful heuristics such as a bio-psycho-social and a systemic perspective. Inherent is the conceptualization of an individual's trajectory over the infant-child-youth developmental span, and abnormality is understood as deviance from a normal trajectory. The cumulative adversity inherent in experiencing repetitive traumatic events leads to a picture of continuity of developmental abnormality. That is, the child has been symptomatic and functionally impaired (developmentally the child is "under the normal trajectory") for some time. The mental health sequelae of a significant isolated, single event trauma is seen as a developmental discontinuity; a recent, obvious, subjective deviation from the developmental norm. For a more comprehensive account of the developmental approach see Costello and Angold (1996). The seminal paper of Lenore ...