Chapter 43. Posttraumatic Stress Disorder in Children and Adolescents Following a Single-Event Trauma

Single-event traumas experienced by children and adolescents include involvement in motor vehicle accidents, natural disasters, and other unexpected, paroxysmal events such as being assaulted or raped. In environments where the latter occur with unfortunate regularity, such as when a family experiences protracted domestic violence, ongoing sexual assault or lives in a war-zone, the individual is likely to be exposed to multiple traumatic experiences and the mental health sequelae are qualitatively different to the experience of a single-event trauma. Readers should consult the chapters on dissociative disorders, personality disorders, and references to sexual abuse to further understand the sequelae of exposure to multiple-event trauma. This chapter will focus on the mental health outcomes following exposure to a single-event trauma. Typical diagnoses include posttraumatic stress disorder (PTSD), other anxiety disorders including specific phobias, and depressive presentations. The Diagnostic and Statistical Manual, fourth edition, Text Revision, criteria for these conditions are detailed in Chapters 20, 41, and 38, respectively.

Two diagnostic considerations influence the chapter. The overarching frame is that of developmental psychopathology. Individuals function by integration of subsystems that interact vertically (e.g., gene to cell) and horizontally (person to person). 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, differential rates of development across subsystems, critical periods, and negotiating developmental challenges such as the changing relationship between parent and child. The developmental science 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 as deviance from a normal trajectory. The concept of a normal trajectory is very useful in understanding the impact of diverse traumatic events. Repetitive traumatic events and their sequelae are discussed elsewhere in this text (see Chapter 42 on Child Maltreatment). The cumulative adversity inherent to experiencing repetitive traumatic events leads to a picture of continuity of developmental abnormality. That is, the child has been symptomatic and functionally impaired for some time. The mental health sequelae of a significant isolated, single-event trauma is seen as a developmental discontinuity—a subjective deviation from the developmental norm. For a more comprehensive account of the developmental approach see Cairns and Angold (1996). The seminal paper of Lenore Terr advocated the useful nosology of type I trauma describing the developmental discontinuity, type II the developmental continuity (Terr, 1994).

An adverse mental health outcome following a single-event trauma is not limited to PTSD. Clearly PTSD is of central importance, however, researchers have long noted other postdisaster anxiety and depressive states. Current data consistent with greater disaster-related fear of death and event exposure being more likely to ...