PROFESSIONAL PERSPECTIVES OF TRAUMATIC EVENTS ASSOCIATED WITH
CHILDHOOD DIAGNOSES OF POSTTRAUMATIC STRESS DISORDER AND THE
INSTRUMENTS USED BY PROFESSIONALS TO ASSESS AND DIAGNOSE
POSTTRAUMATIC STRESS DISORDER IN CHILDREN AND ADOLESCENTS
Cathryn Buda
B.A., California State University, Sacramento, 2006
THESIS
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
PROFESSIONAL PERSPECTIVES OF TRAUMATIC EVENTS ASSOCIATED WITH
CHILDHOOD DIAGNOSES OF POSTTRAUMATIC STRESS DISORDER AND THE
INSTRUMENTS USED BY PROFESSIONALS TO ASSESS AND DIAGNOSE
POSTTRAUMATIC STRESS DISORDER IN CHILDREN AND ADOLESCENTS
A Thesis
by
Cathryn Buda
Approved by:
__________________________________, Committee Chair
Jude Antonyappan, Ph.D.
__________________________________, Committee Chair
Susan Taylor, Ph.D., M.S.W.
Date
ii
Student: Cathryn Buda
I certify that this student has met the requirements for format contained in the University
format manual, and that this thesis is suitable for shelving in the Library and credit is to
be awarded for the thesis.
, Graduate Coordinator
Teiahsha Bankhead, Ph.D., LCSW
Date
Division of Social Work
iii
Abstract
of
PROFESSIONAL PERSPECTIVES OF TRAUMATIC EVENTS ASSOCIATED WITH
CHILDHOOD DIAGNOSES OF POSTTRAUMATIC STRESS DISORDER AND THE
INSTRUMENTS USED BY PROFESSIONALS TO ASSESS AND DIAGNOSE
POSTTRAUMATIC STRESS DISORDER IN CHILDREN AND ADOLESCENTS
by
Cathryn Buda
This study examined traumatic events associated with childhood diagnoses of PTSD from
the perspective of professionals and investigated the prominent clinical diagnostic tools
used by practicing professionals to assess and diagnose children and adolescents with
PTSD. A total of 15 licensed mental health professionals who held content specific
degrees including MFT or LCSW who were currently treating children and/or
adolescents within their scope of practice were interviewed. All professionals studied
identified exposure to sexual and physical abuse and domestic violence as associated with
the development of PTSD in children and adolescents. Few professionals identified
parental drug use and illness of a family member as factors associated with childhood
PTSD. Marked differences in the instruments and methods used by professionals to
assess and diagnose PTSD in children and adolescents were observed. The DSM-IV-TR
was the only instrument consistently reported by professionals (93%). The majority of
professionals reported involving the parents in the assessment of PTSD (87%). This study
highlights the need for additional research to identify the tools used by professionals to
assess and diagnose children with PTSD and for the development of universal clinical
iv
assessment and diagnostic tools and treatments for PTSD in children and adolescents.
Future studies should focus on new or changing trends of traumatic events for the early
identification of PTSD symptomatology and development of interventions unique to the
emergent trauma response of children and adolescents.
__________________________________, Committee Chair
Jude Antonyappan, Ph.D.
____________________________
Date
v
ACKNOWLEDGMENTS
This project has been a long and difficult endeavor. I wish to thank my best
friend, Richard Hartman, for his unwavering crisis support during a few, okay maybe
slightly more than a few, tears and computer meltdowns. It is wholly attributable to him
that my computer never left the building via the window. He made me laugh when I felt
like crying and smiled and nodded, even when he had no idea what I was talking
about. Thank you, Rich, for sticking through the late nights and endless chatter and
giving me the strength to keep going, even when I wanted to quit.
Finally, I would like to thank my family whose presence helped make the
completion of my graduate work possible. Most importantly, I wish to thank my parents,
Robert and Vicki Buda. They bore me, raised me, supported me, taught me, and loved
me. It is thanks to my father for teaching me that the most enjoyable knowledge to have
is that which raises one’s eyebrows. I also express my deepest gratitude for my mother,
who was always a phone call away to give understanding, endless patience and comfort
when it was most needed. My parents always believed in me and provided unconditional
support to pursue my interests, even when the interests caused them to lose sleep. To
them I dedicate this thesis.
vi
TABLE OF CONTENTS
Page
Acknowledgments.............................................................................................................. vi
List of Tables .......................................................................................................................x
Chapter
1. THE PROBLEM .............................................................................................................1
Introduction ..............................................................................................................1
Background of the Problem .....................................................................................2
Statement of the Research Problem .........................................................................8
Purpose of the Study ................................................................................................9
Theoretical Framework ..........................................................................................11
Definition of Terms................................................................................................16
Assumptions...........................................................................................................18
Justification ............................................................................................................19
Limitations .............................................................................................................20
2. LITERATURE REVIEW ..............................................................................................21
Introduction ............................................................................................................21
Perspectives of Trauma by Professionals ..............................................................22
Posttraumatic Stress Disorder ................................................................................27
PTSD Diagnostic Tools .........................................................................................33
Exposure to Sexual Abuse .....................................................................................37
vii
Exposure to Physical Abuse...................................................................................41
Exposure to Domestic Violence.............................................................................43
International Perspective of Exposure to War .......................................................45
3. METHODOLOGY ........................................................................................................52
Study Design ..........................................................................................................52
Sampling/Data Collection Procedures ...................................................................53
Instruments .............................................................................................................55
Data Analysis Approaches .....................................................................................55
Protection of Human Subjects ...............................................................................56
4. RESULTS ......................................................................................................................58
Introduction ............................................................................................................58
Demographics ........................................................................................................58
Parental Involvement in Diagnosing PTSD ...........................................................64
Assessment Tools Used to Diagnose PTSD ..........................................................65
Traumatic Events and the Development of PTSD .................................................69
5. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ................................73
Summary ................................................................................................................73
Conclusions ............................................................................................................76
Recommendations ..................................................................................................81
Recommendations for Practice ..............................................................................81
Recommendations Relevant for Research .............................................................83
viii
Recommendations Relevant for Behavior/Theory Implementation ......................86
Recommendations for Policy .................................................................................87
Appendix A. Interview Questions......................................................................................90
Appendix B. Consent Form ...............................................................................................92
References ..........................................................................................................................94
ix
LIST OF TABLES
Page
1.
Professional Identity of the Study Participants ..........................................................59
2.
Cross Tabulation of Study Participants’ Professional Identity by
Gender Distribution ....................................................................................................59
3.
Cross Tabulation of Theoretical Orientation of Professionals by
Gender Distribution ....................................................................................................60
4.
Professional Competency Profile ...............................................................................61
5.
Correlations Between Professionals’ Work Experience, Years Since Highest
Degree, and Population Served ..................................................................................63
6.
Professional Identity and Perceptions of Professionals in Involving
Parents in the Assessment of PTSD in Children and Adolescents .............................65
7.
Crosstabulation of the Theoretical Orientation of Professionals with
the Professionals’ Felt Need for the Use of DSM-IV-TR to Assess and
Diagnose PTSD in Children and Adolescents ............................................................67
8.
Instruments Used to Assess and Diagnose PTSD in Children and Adolescents ........69
9.
The Professionals’ Assessment of Traumatic Events Associated with the
Development of PTSD in Children and/or Adolescents (Multiple Response) ...........72
x
1
Chapter 1
THE PROBLEM
Introduction
Posttraumatic Stress Disorder (PTSD) has increasingly been identified as an issue
affecting adults who have experienced traumatic events, however, in the past decade
diagnoses of PTSD have been given to trauma exposed children and adolescents in an
increasing manner (Hamblen & Barnett, 2009). According to the National Center for
PTSD, at least one traumatic event during the lifetime is experienced by 15 to 43% of
girls and 14 to 43% of boys (Hamblen & Barnett, 2009). Extensive research investigating
the post-traumatic stress reactions of adolescents exposed to trauma indicates that
traumatic childhood events are associated with the development of PTSD both in
childhood and adulthood (Duncan, Saunders, Kilpatrick, Hanson, & Resnick, 1996;
Kilpatrick & Williams, 1997; McLeer, Deblinger, Delmina, & Orvashel, 1992).
Identifying culminating factors that lead to PTSD in the early years is critical to the
development of early identification, and interventions, to prevent the occurrence of PTSD
in both childhood and later in life. Despite the rising number of children being diagnosed
with PTSD, little research has focused on professionals’ perspectives of the contributing
factors associated with the rising rate of childhood PTSD or the prominent tools used by
professionals to assess and diagnose PTSD in children. This study examines traumatic
childhood events associated with PTSD from the perspectives of professionals and the
tools used by professionals to assess and diagnosis children with PTSD.
2
Background of the Problem
Traumatic Events and Childhood PTSD
Research of the psychological impact of trauma exposure on children has
consistently found that children are particularly vulnerable to the development of
posttraumatic stress symptoms and PTSD following exposure to traumatic events
(Giannopoulou, Smith, Ecker, Strouthos, Dikaiakou, & Yule, 2006). During the last few
decades, studies have increasingly identified children’s direct and indirect exposure to
domestic violence, sexual abuse, physical abuse, and exposure to war as significant
contributing factors leading to diagnoses of PTSD among children (Kilpatrick &
Williams, 1997; McLeer et al., 1992; Thabet, Tawahina, Sarraj, & Vostanis, 2008).
Nationally, an estimated 3.2 million cases of child maltreatment were reported to
child protective services agencies in 2007, and of the near 25% of cases found
substantiated, 69% of children experienced neglect, 10.8% were victims of physical
abuse, and 7.6% were victims of sexual abuse (U.S. Department of Health & Human
Services [DHHS], 2007). Nearly half of the nation’s states reported domestic violence,
poverty and economic strain, and substance abuse as co-occurring problems of the
families reported to child protective services and children of single parent families had a
74% greater risk of suffering physical abuse, physical neglect, emotional abuse, and
severe injury from maltreatment (DHHS, 2007). These statistics of the context and family
demographics of abuse are particularly concerning since studies suggest that trauma has
3
cumulative effects in which children exposed to a combination or multiple traumas such
as, physical abuse and witnessing domestic violence, may develop and experience higher,
more severe, PTSD symptomatology than children who experience physical abuse or
domestic violence alone (Feerick & Haugaard, 1999). The relationship found between
family income levels and abuse, which indicate that “40 to 50 percent of all maltreatment
cases occur in the 15 percent of families earning less than the poverty level,”
demonstrates the urgency of our nation’s attention to the impact of the economy on
children’s trauma exposure and demands its response to this current sweeping social
problem (The National Child Traumatic Stress Network [NCTSN], n.d.b, slide 15).
Ramifications of the widespread political trauma on children show further dire
implications of the current economic downfall and world turmoil.
Despite alarming trends such as the number of children with military parents who
sought mental health care in 2009 having reached two million, double the number since
the beginning of the Iraq war, little research has examined the impact of indirect war
exposure of the more than one million U.S. children who have at least one parent serving
in the military (Hefling, 2009; Lamberg, 2004). The extensive studies of the impact of
children’s exposure to war trauma at an international level reveal the significant
association between the development and symptomatology of PTSD in children whose
exposure to war is both primary and secondary, and therefore has serious implications for
the assessment and diagnosis of PTSD among American children, whose diagnoses at
present, may be gravely underrepresented (Fawziyah & Ohaeri, 2008; Thabet et al.,
4
2008). Frightening statistics, which demonstrate childhood trauma exposure as a
catastrophic problem in our society, have significant clinical implications for the
assessment and diagnosis of childhood PTSD.
Childhood Trauma Exposure and PTSD
After analyzing numerous studies of at-risk children and adolescents, the National
Center for Posttraumatic Stress Disorder suggests that trauma exposed children show
significantly high and alarming rates of childhood PTSD diagnoses. Data from these
“studies have shown that as many as 100 percent of children who witness a parental
homicide or sexual assault... 90 percent of sexually abused children,… and 35 percent of
urban youth exposed to community violence develop PTSD” (Hamblen & Barnett, 2009,
¶ 4). It is estimated that 3 to 15% of children and adolescent girls and 1 to 6% of children
and adolescent boys who have experienced at least one traumatic event meet criteria for
PTSD diagnosis (Hamblen & Barnett, 2009). As witnesses and victims of domestic
violence, sexual abuse, physical abuse and neglect, these children bring a lot more than
color crayons and paper to school with them. Childhood trauma exposure from abuse or
neglect is associated with increased risk of chronic health problems, learning disorders,
misconduct or difficulty in school, language and cognitive impairments, and substance
abuse problems in adolescence and adulthood (NCTSN, n.d.b, slides 24-26). During the
last decade, the increasingly recognized neuroscience research in the area of trauma has
helped provide a deeper understanding of the impact of childhood trauma exposure and
5
indicates that trauma exposure and PTSD can be particularly detrimental in the early
years of life.
Etiological Understanding of Trauma through Neuroscience Research
Studies on the impact of trauma exposure during the early years suggest that
chronic high levels of stress resulting from trauma exposure and PTSD negatively
impacts, and even alters, brain development and functioning (Carrion, Reiss, & Weems,
2007; Siegel, 1999; Wolf, Reinhard, Cozolino, Caldwell, & Asamen, 2009). PTSD has
been found to impact the development of vital areas of the brain, particularly the
hippocampus and amygdala, causing further interference with the child’s ability to cope
with traumatic events (Bremner et al., 1995 as cited in Pederson, Maurer, Kaminski,
Zander, Peters, Stokes-Crowe et al., 2004; Bremner et al., 1997 as cited in Pederson et
al., 2004). The neuroplasticity of the brain enables the neural connections to change in
response to children’s experience with the social environment, therefore early childhood
experiences resulting in chronic stress can cause a “cascade of events” to occur in the
brain, causing crucial structural alterations of the brain (Siegal, 1999; Wolf et al., 2009).
Structural alterations of the brain resulting from chronic elevated stress hormones have
been identified by many studies who have found volumetric reductions of the
hippocampus’ of adults and children diagnosed with PTSD (Carrion et al., 2007; Bremner
et al., 1995 as cited in Pederson et al., 2004; Bremner et al., 1997 as cited in Pederson et
al., 2004). The vital areas of the brain affected by chronic stress and PTSD, such as the
hippocampus and amygdala, which are responsible for memory, encoding, and emotion
6
regulation, have dire implications of trauma exposures detrimental effects on children and
adolescent’s developmental outcome.
Lack of Universal PTSD Assessment Instruments
Providing a clearer clinical conceptualization of childhood PTSD is crucial to the
identification and proper diagnosis of PTSD, therefore, it is imperative that methods of
traumatic event assessment be examined. Universal standardized measures of child and
adolescent PTSD assessment do not exist and little is known about the prevalence of
PTSD instruments used by professionals trauma assessment of children and adolescents.
Investigating current instruments used by practitioners to assess children and adolescents’
responses to trauma and diagnose PTSD is essential to providing a foundation of
standardized assessment methods, which brings accountability to practice. In an e-mail
survey of 227 professionals who had significant experience practicing in the field of
trauma and were members of the International Society for Traumatic Stress Studies, 27%
of practitioners surveyed reported that their “typical trauma assessment involved”
children and adolescents, however, “child/adolescent test use was reported by few
participants... [and] ...trauma exposure measures were not frequently used with children”
(Elhai, Gray, Kashdan, & Franklin, 2005, p. 543).
Only one assessment instrument was reported and used by a little more than 10%
of professionals in this study and many professionals identified the use of assessment
instruments that were not part of the 21 tests listed in the study; however, use of only two
of the non-listed instruments reported by professionals were used by more than 1% of the
7
professionals surveyed (Elhai et al., 2005). These alarming results indicate a vast lack of
commonality among, and ambiguity of, the diagnostic instruments used by professionals
to assess and diagnose PTSD among children and adolescents, and therefore leaves a
detrimental gap in research which facilitates the underrepresentation of PTSD among this
population. Standardized measures of assessing PTSD works to establish a universal
clinical understanding of the trauma response of children and adolescents and allows
researchers to compare study findings between similar assessment measures which
directs the development and identification of valid and reliable instruments for assessing
PTSD among children and adolescents however, current research focuses on the
psychometric properties of posttraumatic assessments of children and adolescents while
little is known about which of these instruments are prevalently used by professionals
(Ahmad, Sundelin-Wahlsten, Sofi, Oahar, & Von Knorring, 2000; Ohan, Myers, &
Collett, 2002). Furthermore, findings from the scarcity of existing studies reveal little
prevalence of posttraumatic assessment instruments used among practicing professionals
treating trauma exposed children and adolescents (Elhai et al., 2005).
Perhaps part of the complexity of tracking PTSD among children is that
predominant and mass traumatic experiences of children and adolescents evolve with the
state of the nation. Examination of traumatic events associated with childhood diagnoses
of PTSD from the perspectives of professionals adds to the professional knowledge of the
trauma response of children and adolescents, which enables the identification of new or
changing patterns of children’s trauma exposure, such as child abuse and the threat of
8
war, that may fluctuate with the presence of world turmoil and health of the economy.
Implications from this research are vital to combat trauma exposure from its detrimental
effects on children and adolescent’s developmental outcome. Clinical understanding of
the trauma response of children gained by the identification of commonly used trauma
exposure and PTSD instruments is essential for the development and use of universal
posttraumatic assessment instruments among practitioners treating children and
adolescents. This understanding and way of practice leads to practitioners’ universal and
early identification of PTSD symptomatology, which enables professionals to intervene
prior to the occurrence of PTSD to prevent the development of PTSD in childhood and
later in life.
Statement of the Research Problem
National child abuse and neglect statistics reveal childhood trauma exposure as a
catastrophic problem in our society and lends considerable empirical evidence linking
trauma exposure to an enhanced risk for PTSD. Although agencies and professionals
throughout the nation report increasing rates of children diagnosed with PTSD, all
identify the need for clinical unanimity in the identification of traumatic events and
diagnostic tools used by professionals to assess and diagnosis PTSD in children, which
do not currently exist. Factors affecting professionals’ diagnosis of PTSD among children
must be investigated to better understand the rising rates of children diagnosed with
PTSD and to identify any discrepancies in the diagnosis of childhood PTSD.
Professionals’ perspectives of a problem can change over time, what they identify as
9
traumatic, and variations among professionals’ choice of measurements used to assess
and diagnose a transforming problem can contribute to discrepancies in diagnosis. This
study examines traumatic events associated with childhood diagnoses of PTSD from the
perspective of professionals and investigates the prominent clinical diagnostic tools used
by practicing professionals to assess and diagnose children and adolescents with PTSD.
Purpose of the Study
The primary purpose of this study is to identify both the themes of traumatic
events associated with childhood diagnoses of PTSD relating from the perspective of
professionals, and the diagnostic tools used by professionals to assess and diagnose
children with PTSD. The focus of this study is to understand the relationship between
traumatic events associated with childhood diagnoses of PTSD from the perspective of
the professional, the common knowledge base of PTSD among professionals, and the
diagnostic tools used by professionals to assess and diagnose PTSD in children. This
study works to gain this understanding by the administration of questionnaires among
professionals, Licensed Clinical Social Workers and Marriage Family Therapists, treating
both adults and children with PTSD.
This study aims to advance the professional knowledge base of the assessment
and diagnosis of childhood PTSD through the identification of both themes of traumatic
events associated with childhood diagnoses of PTSD relating from the perspective of
professionals and the predominant diagnostic tools used by professionals to assess and
diagnosis children with PTSD. For the purpose of this study, traumatic events associated
10
with child diagnoses of PTSD are defined as scores rated by professionals treating
patients between the ages of 6-18 who carry a diagnosis of PTSD. Based on the
researcher’s extensive review of literature on childhood PTSD, this particular study
focuses on variables of children’s exposure to domestic violence, physical abuse, sexual
abuse, and parental service in the military. Identification of traumatic events leading to
childhood diagnoses through the lens of practicing professionals directs the creation of a
classification of traumatic stressors for clinical use, therefore, working to provide early
and universal clinical identification of childhood PTSD and its symptomatology.
Coinciding with the examination of professionals’ perspectives of culminating
factors leading to diagnoses of PTSD among children, this study investigates the
prevalent diagnostic tools used to assess PTSD in children, as reported by practicing
professionals. Identifying prominent screening instruments used by professionals to
assess the physiological impact on children exposed to traumatic events works to clear
the fuzzy conceptualization of childhood PTSD by exposing any differences in the
assessment tools used among practicing professionals that may contribute to disparities
between the diagnosis of PTSD in children. Disparity or similarity between PTSD
assessment tools used by practicing professionals paves the path for future research of the
psychometric properties of the identified PTSD assessment tools in an effort to establish
reliable and valid standardized measurements of PTSD assessment and therefore, works
towards a universal clinical understanding of the trauma response of children and
adolescents.
11
Although this study adds to the knowledge base of the posttraumatic stress
reactions of children and adolescents, practitioners awareness of this knowledge is key to
its application. To address this issue this study examines practitioners hours per week
spent doing clinical trauma assessment of children and adolescents and years worked
with trauma exposed children or adolescents to identify any correlation between a
practitioner’s level of PTSD knowledge, gained from his or her clinical practice, and his
or her diagnosis rate of patients diagnosed with PTSD. Implications may highlight the
value of specialized PTSD training among professionals and therefore, promote the future
allocation of funds for clinical training. For the purpose of this study, practitioners
knowledge of PTSD is operationalized as the practitioners’ scores identified by the
practitioners’ number of hours per week assessing trauma exposed children and/or
adolescents and years of practice with trauma exposed children and/or adolescents.
Practitioners experience working with trauma exposed children and adolescents may
indicate the need for future research to examine whether specialized training for
diagnosing PTSD may increase the likelihood of practitioners identification of PTSD
symptoms leading to a diagnosis of PTSD.
Theoretical Framework
A theoretical background provides the conceptual framework for understanding
the impact of interpersonal relationships and the deprivation of needs on childhood
trauma exposure and PTSD. Systems perspective evaluates the interactions between
systems and seeks to help the individual fit in with the current social order rather than
12
directly changing the social order (Payne, 2005). The individual is viewed as part of the
system in which it interacts. As the systems interact with one another, disruptions in one
system will affect the system as a whole. Interactions between systems give explanation
to human behavior and functioning (Payne, 2005). Trauma exposure resulting from the
functioning and interactions between the prominent systems in the child’s life, such as the
family and social relationships, impact the child’s development and well-being. The is
evidenced by the correlation between an increase in the reported incidents of child abuse
when unemployment rates increase and the dramatic increase of U.S. children seeking
mental health services since the start of the Iraq war (Gillham, Tanner, Cheyne, Freeman,
Rooney, & Lambie, 1998; Hefling, 2009).
Nationally, of the estimated 879,000 children who were victims of abuse in 2000,
83.3% of child abuse was perpetuated by at least one parent (Wolf et al., 2009). Theses
findings suggest, “that children are particularly at risk of experiencing abuse from their
parents” (Wolf et al., 2009, p. 49). The significant impact of the familial system on
childhood trauma is evidenced by Murray Bowen’s exploration of family relationships
through his research with families. This research led to the development of the Bowen
Family Systems Theory.
The theory works from a systems way of thinking to describe the complex
interactions within the family. As the functioning of one member changes, it has a
reciprocal affect on the functioning of each member, which affects the family as a whole.
Bowen’s early work began when he hospitalized entire family’s who had a member
13
suffering from schizophrenia (Nichols, 2007). He found that the unstable bond between
the mother and “emotionally disturbed offspring inevitably involved the entire family”
(Nichols, 2007, p. 86). This sparked him to further research and develop the Bowen
Family Systems Theory, which views the family as an emotional unit in which the
complex relationships among members form “the interplay of individuality and
togetherness using six interlocking concepts: differentiation of self, triangles, nuclear
family emotional process, multigenerational transmission process, emotional cutoff, and
societal emotional process” (Nichols, 2007, p. 87). These concepts describe the variations
of emotional interdependence and reactiveness within families, which facilitates the cycle
of connectedness and distance in a way that limits all members from autonomous
functioning and causes further disruptive functioning of the individual and family
(Nichols, 2007). Bowen’s theory describes family’s problems as “emotional fusion”
which requires “differentiation of self” for optimal individual and familial functioning
(Nichols, 2007). He argues that without differentiation, individuals “unresolved
emotional reactivity” to their parents is evident through the individual’s future abilities to
handle stress and emotions, and social relationships (Nichols, 2007, p. 87).
This theory helps to understand the impact of the interactions within the family on
childhood trauma and is supported by current neuroscience research of trauma. Recent
neuroscience studies have shown that interpersonal interactions impact the developing
brain by altering the neural structuring and impairing vital brain regions associated with
the inability to regulate emotions, “mood disorders, significant anxiety, hyperarousal,
14
suicidal ideation, self-mutilation, and socially inappropriate behaviors over the life span,”
which are more likely to occur among survivors of childhood trauma (Wolf et al., 2009,
p. 64).
Neuroimaging studies, which have found impairment of growth of the
hippocampal region of the brain in adults and children with PTSD, suggest, “the structure
and function of the developing brain are determined by how experiences, especially
within interpersonal relationships, shape the genetically programmed maturation of the
nervous system” (Siegel, 1999, p. 2). The significant impact of “patterns of relationships
and emotional communication” on the child’s ability to cope with traumatic events is
supported by studies in animals, which have found “that even short episodes of maternal
deprivation have powerful neuroendocrine effects on the ability to cope with future
stressful events” (Siegel, 1999, p. 4). Studies of child-parent attachment have similar
findings and show “that different patterns of child-parent attachment are associated with
differing physiological responses, ways of seeing the world, and interpersonal
relationship patterns” (Siegel, 1999, p. 4). The emotional connectedness within a family
delineates the patterns of interpersonal relationships between its members. Patterns or
experiences of trauma, such as witnessing domestic violence or parent-child separation
due to parental service in the military, elicit reciprocal changes in the functioning of all
family members, which in children and adolescents, may include a trauma response that
leads to the development of PTSD. Bowen Family Systems Theory is not part of systems
15
theory; however, it demonstrates the significance of the interactions between the child’s
system, such as childhood trauma exposure, and its impact on the child’s functioning.
From a humanistic perspective, which focus is on the interpersonal and
exploration of emotions and experiences to facilitate growth and development, Abraham
Maslow’s theory of motivation surrounds his ideas of self-actualization and human
potential, and led to his development of the Hierarchy of Needs. His theory holds that
individual’s are motivated by a universal hierarchy of needs by which higher needs such
as, esteem needs and social needs can not be met until lower needs such as psychological
needs are satisfied (Payne, 2005). The hierarchy of needs begins with basic needs leading
to the goal of self-actualization. The hierarchy beginning with the most basic needs is as
follows: psychological needs, safety needs, social needs, esteem needs, and selfactualization. Maslow believes that a person reaches their full potential in life when selfactualization is met. Maslow refers to self-actualization as an ongoing process
characterized by an individual’s ability to function from potentials, such as creativity,
problem solving skills, and objective views. Without gratification of a child’s basic
needs, such as the child’s security within the family and society, the child’s social need of
love and belonging through familial and social relationships cannot be reached.
This theory helps to understand the impact of the deprivation of needs on
childhood trauma. According to Maslow’s hierarchy of Needs, childhood PTSD resulting
from traumas, such as the threats associated with war, parental service in the military,
child abuse, or witnessing domestic violence, may inhibit the child’s ability to progress
16
through this hierarchy, as vital needs may be restricted by PTSD symptomatology or
ongoing trauma exposure. Childhood diagnoses of PTSD or its symptomatology may
hinder the fulfillment of basic needs, which has dire implications on child development
and detrimental effects of the failure to treat PTSD or continued exposure to trauma. In
Maslow’s Hierarchy of needs, the need for safety is the foundation upon which all other
needs rely. Childhood traumas, such as child abuse and neglect, diminish children’s
attainment of basic needs, such as the physiological need for food or shelter and needs of
safety and security, which restricts the acquisition of more abstract needs, such as selfesteem and interpersonal relationships. According to Maslow’s theory, childhood trauma
exposure may restrict children’s progression through this hierarchy of needs and impede
optimal child development and functioning.
Definition of Terms
The definition of terms used in this study are as follows:
Professional(s): Individuals who have content specific degrees and are licensed to
the Board of Behavioral Sciences of California. If unlicensed, these individuals are
collecting clinical hours through the Board of Behavioral Sciences of California.
Children or Adolescents: Persons between the stages of birth and younger than
the age of legal maturity, 18.
Trauma: Trauma refers to “...experiencing a serious injury to yourself or
witnessing a serious injury to or the death of someone else, [feeling intensely threatened
17
or] facing imminent threats of serious injury or death to yourself or others, or
experiencing a violation of personal physical integrity” (NCTSN, n.d.a, ¶ 1).
Child Abuse or Neglect: “Any recent act or failure to act on the part of a parent or
caretaker which results in the death, serious physical or emotional harm, sexual abuse, or
exploitation; or an act or failure to act which presents an imminent risk of serious harm”
(Child Welfare Information Gateway, 2008, ¶ 1).
Domestic Violence: “... A pattern of behavior used to establish power and control
over another person with whom an intimate relationship is or has been shared through
fear and intimidation, often including [actual or threatened]... use of violence...[which]
generally falls into one or more of the following categories: physical battering, [and]
sexual assault and emotional or psychological abuse...” (National Coalition Against
Domestic Violence, 2009, ¶ 1 and 3).
Child Sexual Abuse: “Child sexual abuse generally refers to sexual acts, sexually
motivated behaviors, or sexual exploitation involving children” (Child Welfare
Information Gateway, 2009, ¶ 1).
Physical Abuse: “... Refers to the infliction of physical harm on a child by a
parent or caregiver... [which may not necessarily be intentionally inflicted rather, in many
situations] physical abuse is the unintentional end result of harsh disciplinary methods or
corporal punishment that have escalated to [the] point of physical injury or risk of
physical injury” (Mann, Corell, Ludy-Dobson, & Perry, 2002, ¶ 1).
18
Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, Text
Revision (DSM-IV): The primary diagnostic tool used by mental health professionals in
the United States to assess, diagnose, and receive reimbursement for hours of clinical
treatment (American Psychiatric Association, 2000).
Posttraumatic Stress Disorder (PTSD): An anxiety disorder, which develops:
characteristic symptoms following exposure to an extreme traumatic stressor
involving direct personal experience of an event that involves actual or
threatened death or serious injury, or other threat to one’s physical integrity; or
witnessing an event that involves death injury, or a threat to the physical integrity
of another person; or learning about unexpected or violent death, serious harm, or
threat of death or injury experienced by a family member or other close
associate... [that elicits a response of] intense fear, helplessness, or horror (or in
children, the response must involve disorganized or agitated behavior). (American
Psychiatric Association, 2000, p. 463)
Assumptions
This study measures the perspectives, beliefs, and PTSD assessment use of
licensed clinical social workers (LSCW) and licensed marriage family therapists (LMFT)
whose clinical practice includes service to children and adolescents. The researcher
assumes that these variables can be measured and that the professionals to be sampled
will accurately report their use of PTSD assessment instruments. These assumptions
provide a framework to this exploratory study, which allows the researcher to advance
19
the knowledge base of the assessment and diagnosis of childhood PTSD. The
assumptions of this study are threefold:
1. Professionals do not utilize universal instruments to assess or diagnose PTSD
among children and adolescents.
2. The type of instruments used by professionals to assess PTSD among children and
adolescents are contingent on the provisions of the professional’s contracting
insurance company.
3. The prevalent childhood experiences identified by professionals as traumatic are
witnessing domestic violence, sexual and physical abuse, and parental service in
the military.
Justification
Children are not in a place to empower themselves because of their position in
society. This study’s examination of themes of traumatic events associated with
childhood diagnoses of PTSD relating from the perspective of professionals and the
diagnostic tools used by professionals to assess and diagnosis children with PTSD gives
voice to children whose trauma exposure may otherwise go overlooked and brings
accountability into practice. Studying the relationship between professional perspectives
of traumatic events associated with diagnoses of PTSD in children and identifying
instruments used by practicing professionals to assess PTSD symptomatology and
diagnosis children with PTSD is essential to understanding the increasing trend of
childhood PTSD. Investigation of these relationships adds to the professional knowledge
20
base to remain current and combat this social problem and directs professionals’ early
identification of PTSD symptomatology and the universal assessment and diagnosis of
PTSD among children. Bridging the gap between practicing professionals and this underrepresented and inconsistently served population this study therefore, upholds and
protects the rights of this vulnerable population.
Limitations
There are three methodological limitations to this study. First, practicing
professionals other than LCSWs and LMFTs will not be studied. Second, the study
sample of male and female LCSWs and LMFTs was obtained by means of snowball
sampling originating from the researcher’s local social network of practicing
professionals; therefore, the professional perspectives and other identified study variables
identified by this study are not representative of all practicing professionals, locally or
nationally. Because this was a nonrandomized sample of voluntary participation by
professionals, threats to the external validity of this study exist and limit the
generalizability of study findings. Third, the limited sample size impaired variability and
diversity of the study population, which limits the applicability of study findings to more
diverse populations and other geographic locations. Despite these limitations, study
findings suggest the need for future research to continue advancing the professional
knowledge base on the assessment and diagnosis of childhood PTSD in an effort to reach
a universal clinical understanding of the trauma response of children and adolescents.
21
Chapter 2
LITERATURE REVIEW
Introduction
The detrimental psychological effects of trauma exposure first swept public
attention during the 1970s when the return of Vietnam Veterans and the feminist
movement spread a new awareness of the prevalence of trauma such as, war, domestic
violence, childhood abuse and sexual assault, which served as the catalyst to the inclusion
of PTSD in the American Psychiatric Association’s publication of the DSM-III in 1980
(Courtois & Gold, 2009). Since its inclusion in the DSM-III, extensive research of the
adverse effects of trauma exposure has continued well into the 20th century. Most
recently, clinical exploration of the psychological impact of trauma has taken an
adaptable path that follows mass traumatic experiences following major events such as,
Hurricane Katrina (Hensley & Enrique, 2008; Scheeringa & Zeanah, 2008), the war on
terrorism (Barrett, Doebbeling, Schwartz, Voelker, Falter, Woolson et al., 2002; Erbes,
Westermeyer, Engdahl, & Johnsen, 2007), and childhood abuse (Dubner & Motta, 1999;
Feerick & Snow, 2005), which “have been increasingly framed through the lens of
trauma by both professionals and the news media” (Courtois & Gold, 2009, p. 3).
Research examining the post-traumatic stress reactions of adolescents exposed to
trauma which indicates, that when left untreated, adolescents exposed to severe trauma
are at increased risk for chronic PTSD (Goenjian, Walling, Steinberg, Karayan, Najarian,
& Pynoos, 2005) is supported by a multitude of studies showing that adults who had
22
experienced childhood traumas such as, sexual or physical abuse, have high rates of
PTSD in adulthood (Duncan et al., 1996; Feerick & Snow, 2005; Muller, Sicoli, &
Lemieux). Identification of traumatic childhood events associated with PTSD is essential
for the development of preventative and treatment methods to reduce trauma-related
psychopathology, namely, PTSD. In consequence of the current detrimental gap in
research, not many studies have focused on professionals’ perspectives of culminating
factors leading to childhood diagnoses of PTSD. Professionals’ perspectives are essential
for universal and proper diagnoses and treatment of childhood PTSD. The following
themes of traumatic events associated with childhood diagnoses of PTSD are identified
by current studies relating from perspectives of the professional; domestic violence,
sexual abuse, physical abuse and war exposure. Understanding trauma exposure and its
effect on children from the perspective of professionals provides a foundation to identify
predominant traumatic events that may lead to the development of PTSD in childhood as
well as exploring the knowledge base used by professionals to identify and diagnose
PTSD in children. Identifying culminating factors in the early years, which lead to
childhood diagnoses of PTSD, enables professionals to intervene prior to the occurrence
of PTSD and gives voice to, the most fragile members of society; children.
Perspectives of Trauma by Professionals
Daniel Siegel, an associate clinical professor of psychiatry at the University of
California, Los Angeles, provides an etiological understanding of trauma through the lens
of many scientific disciplines. Siegel (1999) suggests that the flow of both verbal and
23
nonverbal energy between a child and his or her attachment figure (i.e. usually the
parent), during even the earliest years of a child’s life, “literally shape the structure of the
child’s developing brain” (Siegel, 1999, p. 21). Siegel (1999) refers to the interactions
between the child and environment and the reciprocal patterns of communication
between the child and his or her attachment figure(s) as experience. “Experience for the
nervous system involves the activation of neural firing in response to a stimulus” (Siegel,
2007, p. 30). In response to the experience, neurons are activated and multiply to form
intricate connections that shape our “neural structure” (Siegel, 2007, p. 30). This
neuroplasticity of the brain enables neural connections to change in response to
experience, creating structural changes within the brain.
Neuroscientists working in the field of trauma propose that attachment
relationships between the child and caregiver “occur simultaneously with the growth of
brain areas, such as the limbic system... [which during development are forming
connections] to higher cortical regions ... [that] are eventually... responsible for
modulating affect and emotions” (Wolf et al., 2009, p. 57). In result, “neuroplastic
changes not only reveal structural alterations [of the brain], ...they are [also] accompanied
by changes in brain function, mental experience (such as feelings and emotional balance),
and bodily states (such as response to stress and immune function),” which interact to
shape the person (Siegel, 2007, p. 32). Recent neuroimaging studies have found “that
children who suffer from childhood abuse and maltreatment have significantly smaller
intracranial, cerebral, prefrontal cortex volumes, and prefrontal cortical white matter,”
24
and support current study findings which show that children exposed to trauma have
greater difficulty modulating affect and emotion and are “more likely to experience mood
disorders, significant anxiety, hyperarousal, suicidal ideation, self-mutilation, and
socially inappropriate behaviors over the life span” (Wolf et al., 2009, p. 57).
Research of “emotion suggests that nonverbal behavior is a primary mode in
which emotion is communicated,” indicating the detrimental effects of childhood
experiences in which witnessing an event, such as domestic violence or community
violence, is traumatic (Siegel, 2007, p. 21). Attachment relationships appear to be the
strongest indicator of the emotional communication shared between the parent and child
(Siegel, 1999). Siegel’s (2007) synthesis of research on the interaction between
relationships and the brain show that
these early reciprocal communication experiences are remembered and ... allow a
child’s brain to develop a balanced capacity to regulate emotions, to feel
connection to other people, to establish an autobiographical story, and to move
out into the world with a sense of vitality. (p. 21)
In an interview by Jon Carlson (2008), Daniel Siegel describes the exchange of verbal
and non-verbal signals, or “energy” of information, flowing from the parent to the child
to demonstrate the impact of such “energy” on the child’s brain development through the
following example:
Let’s say I’m your father and you’re my son. So the energy and information I’m
going to be taking in from you, processing in my own experience and giving back
25
to you is going to directly shape how your brain develops. If I’m just managing
your behavior as my son, I’m missing the opportunity to reflect on your mind. I’m
just addressing your outward, physical manifestation of behavior. Now, when I do
that, your mind will develop in a certain way so that you will not have the
capacity to reflect on your internal life. You won’t be as skilled at having
resilience; you won’t be as a skilled at reflecting on other people’s internal
worlds; your social functioning will be impaired; and your regulating of your own
emotions will not be as good. (p. 69)
This suggests that the child’s parental attachment relationships reflect the pattern
of communication experiences with the parent(s). Attachment research has shown that
“attachment relationships that offer children experiences that provide them with
emotional connection and safety, both in the home an in the community, may be able to
confer resilience and more flexible modes of adaptation in the face of adversity” (Siegel,
1999, p. 59). This research supports current neuroscience studies indicating interpersonal
experiences affect neural activity and shapes the neural circuitry of the brain in ways that
may influence a child’s response to trauma (Siegel, 2007). The significance of both
verbal and nonverbal experiences in structuring the neural framework of the brain during
pivotal periods of development is indicative of the detrimental effects of trauma exposure
on child development. The impact of trauma is also visible by the “direct toxic effects of
chronic stress on the brain” (Siegel, 1999, p. 59).
26
Research shows that the release of stress hormones and catecholamines during
periods of stress or traumatic experiences affects the hippocampus and amygdala, which
has been shown to directly affect memory (Siegel, 1999; Wolf et al., 2009). Current
research suggests that “... small amounts have a neutral effect on memory; moderate
amounts facilitate memory; and large amounts impair memory” (Siegel, 1999, p. 50).
Studies indicate that effects of high levels of stress hormones on the hippocampus can
cause the inhibition of neuronal growth and the deterioration of neural receptor sites,
which may initially be reversible, however “excessive and chronic exposure to stress
hormones may lead to neuronal death in this region, possibly producing decreased
hippocampal volume, as found in patients with posttraumatic stress disorder” (Siegel,
1999, p. 50). Researchers at the Stanford University School of Medicine and Lucile
Packard Children's Hospital, who studied children with diagnoses of PTSD resulting
from experiences of witnessing violence, separation or loss, or physical, emotional or
sexual abuse, found that children with more severe PTSD symptoms and higher levels of
the stress hormone, cortistol, had a reduction in the hippocampal volume of the brain over
a study duration of twelve to eighteen months (Carrion et al., 2007). Similar studies,
indicating the impact of PTSD on hippocampal volume and function, revealed volumetric
reductions of the left side of the hippocampus of women diagnosed with PTSD relating to
child abuse, and similar reductions of the right side and bilateral hippocampus of veterans
with combat related PTSD (Bremner et al., 1995 as cited in Pederson et al., 2004;
Bremner et al., 1997 as cited in Pederson et al., 2004). Given the crucial role of the
27
amygdala in “coordinating perceptions with memory and behavior” and the functions of
the hippocampus in learning and memory, damage to these vital areas of the brain due to
the body’s physiological response to stress resulting from traumatic events, have vital
implications for child development and untreated childhood PTSD (Siegel, 1999, p. 132).
Posttraumatic Stress Disorder
Currently, throughout the United States the American Psychiatric Association’s
(2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM-IV-TR) is the universal tool for mental health assessment and diagnosis
used by clinical practitioners in various fields of helping. According to the DSM-IV-TR
the following criteria characterizes the symptomatology, and must be met to apply a
diagnosis, of Posttraumatic Stress Disorder:
The essential feature of Posttraumatic Stress Disorder is the development of
characteristic symptoms following exposure to an extreme traumatic stressor
involving direct personal experience of an event that involves actual or threatened
death or serious injury, or other threat to one’s physical integrity; or witnessing an
event that involves death injury, or a threat to the physical integrity of another
person; or learning about unexpected or violent death, serious harm, or threat of
death or injury experienced by a family member or other close associate
(Criterion A1). The person’s response to the event must involve intense fear,
helplessness, or horror (or in children, the response must involve disorganized or
agitated behavior) (Criterion A2). The characteristic symptoms resulting from the
28
exposure to the extreme trauma include persistent reexperiencing of the traumatic
event (Criterion B), persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (Criterion C), and persistent symptoms of
increased arousal (Criterion D). The full symptom picture must be present for
more than 1 month (Criterion E), and the disturbance must cause clinically
significant distress or impairment in social, occupational, or other important areas
of functioning (Criterion F). (American Psychiatric Association [APA], 2000, p.
463)
Although the American Psychiatric Association’s (2000) publication of the DSMIV-TR acknowledges some differences in the trauma response between children and
adults, it does not clearly delineate manifestations or symptomatology of PTSD in
children. Because of this, clinical practitioners who utilize this tool for assessment and
diagnosis of PTSD in patients who are children, must use their discretion and clinical
knowledge to assess the unique and complex symptomatology of PTSD in children to
ensure proper diagnosis. Though very brief, the DSM-IV-TR differentiates the trauma
response of children from the criterion used to diagnosis PTSD as follows:
In younger children, distressing dreams of the event may, within several weeks,
change into generalized nightmares of monsters, of rescuing others, or of threats to self or
others. Young children usually do not have the sense that they are reliving the past;
rather, the reliving of the trauma may occur through repetitive play. In children, the sense
of a foreshortened future may be evidenced by the belief that life will be too short to
29
include becoming an adult. There may also be “omen formation” – that is, belief in an
ability to foresee future untoward events. Children may also exhibit various physical
symptoms, such as stomachaches and headaches (APA, 2000, p. 468).
In recent years researchers have questioned the validity of the DSM IV-TR’s
diagnostic criteria regarding its lack of sensitivity to the trauma response of young
children. Studies reveal inconsistent findings between the symptomatic expression of
PTSD between young children, middle childhood through adolescence and the
applicability of many of them to the PTSD diagnostic criteria of the DSM-IV-TR. To
characterize children’s posttrauamtic stress reactions, Anthony, Lonigan, and Hecht
(1999) “compared existing nosologic and empirical models of PTSD dimensionality and
determined the superior model was a hierarchical one with three symptom clusters
(Instrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal)” (as cited in
Anthony et al., 2005, p. 667). To examine whether this model “adequately describes the
posttraumatic stress reactions of adolescents and children,” Anthony, Lonigan, Verberg,
Greca, Silverman, and Prinstein’s (2005) study examined the posttraumatic stress
reactions of adolescents and children who experienced different traumatic events of
“natural disasters that differed substantially in severity of impact on the community and
in severity of impact on the individuals investigated” (p. 668).
Two modified versions of the self-report questionnaire version of the
Posttraumatic Stress Disorder Reaction Index (PTSD-RI) were used to gather data from
samples of 198 fifth graders who had experienced Hurricane Hugo in South Carolina and
30
198 fifth graders who experienced the more severe Hurricane Andrew in Florida
(Anthony et al., 2005). Although results yielded quantitatively different results, where
children who experienced “Hurricane Andrew reported significantly more severe PTSD
symptoms than children who experienced Hurricane Hugo,” qualitatively, the children’s
“posttraumatic stress reactions had consistent dimensionality across samples” (Anthony
et al., 2005, p. 672). Results support Anthony et al.’s (1999) model of children and
adolescents posttraumatic stress reactions and found these responses could be
characterized by “three symptom clusters [which] correspond to intrusive phenomena
coupled with active avoidance of such negative experiences, emotional numbing along
with passive avoidance of emotionally unrewarding activities, and arousal” (as cited in
Anthony et al., 2005, p. 672).
Findings reflect the DSM-IV-TR model of PTSD symptomatology, which includes
three clusters, and suggests a form of dimensionality of expression of symptoms from
middle childhood through adolescence and adulthood. In contrast to three symptom
clusters included in the DSM-IV-TR and supported by Anthony et al.’s (2005) study,
Evans and Oehler-Stinnett (2006) found six significant clusters when studying PTSD
symptomatology among 152 children aged 6-12 who had experienced the 1999 severe
and deadly tornado that hit Oklahoma. Evans and Oehler-Stinnett (2006) developed and
utilized a scale (OSU PTSD Scale-CF) to evaluate PTSD symptomatology according to
the DSM-IV-TR criteria for PTSD diagnosis by adapting questions from other
standardized children’s scales and their extensive review of literature on PTSD. Using the
31
DSM-IV-TR diagnostic criteria to assess PTSD symptoms, and “DSM-IV-TR yes/no
dichotomy,... [with] ratings from often to always [representing symptoms present], 40%
met Criteria B, 34% met Criteria C, 36% met Criteria D, and 25% met all criteria for a
diagnosis of PTSD” (Evans & Oechler-Stinnett, 2006, p. 290). However, Evans and
Oechler-Stinnett (2006) found that six factors, “avoidance, re-experiencing, interpersonal
alienation, interference with daily functioning, physical symptoms/anxiety, and
foreshortened future” were significant to PTSD symptomatology of children (p. 283).
Such findings may indicate the weakness of the DSM-IV-TR diagnostic criteria in
capturing full PTSD symptomatology unique to children. Also, PTSD in children may as
a consequence be highly underreported. Evans and Oehler-Stinnett (2006) suggest the
additional symptom clusters found in their study are likely a result of the instruments
used to assess PTSD. The authors recommended future research to evaluate PTSD
symptomatology unique to children as well as questioning the sensitivity of the PTSD
diagnostic criteria set forth in the DSM-IV-TR for diagnosing children.
Scheeringa, Zeanah, Drell, and Larrieu (1995) propose a set of alternative criteria
(AC) for infants and young children (less than for years of age) be added to the DSM-IVTR diagnostic criteria for PTSD. The authors developed an alternative set of
developmentally sensitive criteria composed of an extensive checklist of symptoms
which focused on behavioral manifestations of PTSD rather than on children’s report of
abstract thought and verbalization of PTSD symptomatology. The alternative criteria
closely mirrors the PTSD criteria currently outlined in the Diagnostic Classification of
32
Mental Health and Development Disorders of Infancy and Early Childhood: DC: 0-3R, a
set of developmentally based diagnostic categories used for diagnosing mental health and
developmental disorders in infants and toddlers. In their review of 23 case studies of
traumatized toddlers younger than four years of age, none of the toddlers met diagnostic
criteria for PTSD under DSM-IV-TR criteria due to the “lack of knowledge that the child
showed fear, helplessness or horror, failure to demonstrate three avoidance and numbing
symptoms, and failure to demonstrate two or more hyperarousal symptoms (Scheeringa et
al., 1995, p. 401). When comparing the DSM-IV-TR criteria to the AC to assess PTSD in
12 traumatized infants 18-48 months of age, Scheeringa et al. (1995) found that the AC,
which included symptoms such as loss of previously acquired developmental skills and
aggressive behaviors, was a more reliable and valid measure for capturing PTSD
symptomatology in infancy than the DSM-IV-TR criteria. On average, 1.5 of the 12
children met criteria of the DSM-IV-TR for a diagnosis of PTSD and 8.3 by the
alternative criteria (Scheeringa et al., 1995). In another study of 62 traumatized young
children, none of the children met criteria for PTSD diagnosis under DSM-IV-TR criteria,
whereas, 16 of the children were identified as having PTSD by alternative criteria
(Scheeringa, Stafford, & Zeanah, 2003). Considering 8 out of 19 criteria for diagnosis of
PTSD set forth by the DSM-IV-TR must be met by the individual’s subjective report of
symptoms, the applicability of the DSM-IV-TR criteria for diagnosis of PTSD among
young children is clearly questionable. Such studies propose additional diagnostic PTSD
33
criteria be added to the DSM to capture differences in PTSD symptomatology unique to
young children.
PTSD Diagnostic Tools
Considerable research links childhood trauma exposure to the development of
PTSD, however, the unresolved conceptualization of childhood PTSD among
practitioner's demands exploration of clinical diagnostic tools used by practitioner’s to
assess and diagnosis children with PTSD. Review of clinical and research literature
examining culminating factors leading to the diagnosis of PTSD among children reveals
the use of a myriad of diagnostic tools used by professional’s to assess and diagnosis
PTSD in children however, the Child Posttraumatic Stress Reaction Index (CPTS-RI) and
the Children’s Impact of Traumatic Events Scale (CITES) are “the two most frequently
used screening instruments in studies assessing the psychological impact on children of
exposure to traumatic events” and were were continually cited throughout the
researcher’s extensive review of literature (Giannopoulou et al., 2006, p. 1028).
The CPTS-RI is one of the most widely used measures of assessing post-traumatic
stress reactions in children and adolescents between the ages 6 and 17 (Ahmad et al.,
2000; U.S. Department of Veterans Affairs [DVA], 2009a). This structured interview was
originally developed to address DSM-III diagnostic criteria however, revisions of this
measure soon followed to assess PTSD diagnostic criteria of the DSM-III-R and later the
DSM-IV-TR, “as well as guilt, impulse control, somatic symptoms, and regressive
34
behaviors” (Ahmad et al., 2000; DVA, 2009a, p. 1). According to the National Center for
PTSD,
The CPTS-RI (also known as the Reaction Index) is a 20-item intervieweradministered scale. Items are rated on a five-point frequency scale (ranging from “none”
to “most of the time”). The CPTS-RI yields total scores ranging from 0 to 80 that reflect
the frequency of symptoms. Categories of degree of disorder (from doubtful to very
severe) can be assigned based on the total scale score. This interview is available in a
child’s and a parent’s report version (DVA, 2009a).
The UCLA PTSD Index for DSM-IV-TR (UPID) and the CPTS-RI Revision 2 are
two revisions of the CPTS-RI. The UPID “is a 48-item semi-structured interview that
assesses a child’s exposure to 26 types of traumatic events and assesses DSM-IV PTSD
diagnostic criteria” (¶ 2). The CPTS-RI Revision 2, also known as the PTSD Index for
DSM-IV, was developed to “increase the sensitivity of screening of trauma exposure and
criterion A1 and A2 and to provide more guidance for the interviewer and child
throughout the interview” (DVA, 2009a, ¶ 2).
Though its development aimed towards Western practice, the CPTS-RI has
acclimated cross-culturally through language translation (Ahmad et al., 2000). “It has
extensive research supporting its suitability for children of varying ages, cultures, and
traumatic experiences...” and consequently, “is one of the best studied and most used
scales for evaluating traumatized youth” (Ohan et al., 2002, p. 1406). For example, the
CPTS-RI has been used with physically and sexually abused American foster children
35
(Dubner & Motta, 1999), American children who witnessed domestic violence
(Kilpatrick & Williams, 1997), Kuwaiti children and adolescents who survived the Gulf
war (Nader, Pynoos, Fairbanks, & Al-Ajeel, 1993), Armenian children exposed to the
1988 Spitak earthquake (Goenjian et al., 2005), and Palestinian children exposed to war
while living on the Gaza Strip (Thabet & Vostanis, 1999; Thabet & Vostanis, 2000).
Several studies examining the psychometric properties of new instruments developed to
assess posttraumatic stress disorder in traumatized children, both cross-culturally and in
the United States, examine the reliability and validity of such instruments through crossvalidation with the CPTS-RI and therefore, work to establish convergent validity with the
CPTS-RI as a means of measuring the validity of preliminary instruments (Ahmad et al.,
2000; Foa, Johnson, Feeny, & Treadwell, 2001; Giannopoulou et al., 2006).
According to Ahmad et al. (2000), “In research and clinical work, children are
increasingly showing child-specific criteria that differ from adults’, both regarding
experiencing trauma and enduring posttraumatic reactions” (p. 288). A disadvantage of
this time consuming interview is that its assessment of PTSD-related symptoms derive
from the DSM-IV-TR diagnostic criterion and therefore, assess symptomatology assuming
uniform traumatic stress reactions of adults and children. On the other hand, the CPTS-RI
does not assess all of the DSM-IV-TR criterion for PTSD and includes measurements of
“decreases in subjective experiences, whereas the DSM asks about decreases in objective
experiences” and therefore, somewhat deviates from the DSM-IV-TR view of symptoms
(Ohan et al., 2002, p. 1405).
36
Unlike the ability of the CPTS-RI to assess the impact of a wide spectrum of
traumatic events, the Children’s Impact of Traumatic Events Scale (CITES), “is one of
the few scales designed specifically for children and adolescents to assess” PTSD
following specific trauma (Ohan et al., 2002, p. 1418). According to the National Center
for PTSD,
The CITES-2 (2002) is the most recent version of the CITES, a 78-item clinicianadministered scale developed to assess the effects of sexual abuse on youths
between the ages of 8 and 16 years old... Items are rated on a 3-point Likert scale
(“not true”, “somewhat true”, “very true”). The CITES-R is comprised of 4 main
scales and 11 subscales: (1) PTSD (Intrusive Thoughts, Avoidance, Hyperarousal,
and Sexual Anxiety); (2) Social Reactions (Negative Reactions from Others and
Social Support); (3) Abuse Attributions (Self-Blame and Guilt, Empowerment,
Personal Vulnerability, and Dangerous World); and (4) Eroticism (DVA, 2009b).
An additional version to the CITES-R is the CITES-Family Violence Form
(CITES-FVF), which is used to assess youth exposed to family violence (DVA, 2009b).
The CITES-FVF is also a clinician-administered structured interview and contains “25items asking children a series of assault-specific questions specifically related to the
presence of any PTSD symptoms” (Lehmann, 1997, p. 245). Simply put, the CITES-FVF
reworded questions of the CITES-R “to reflect the child witness experience rather than
the child sexual abuse survivor” and has reported high internal consistency when used in
studies of child witnesses of domestic violence (Lehmann, 1997, p. 245).
37
Exposure to Sexual Abuse
In recent years, a vast array of studies have brought light to the prevalence of
PTSD diagnoses among individuals who have experienced childhood sexual abuse.
Consequently, since much research has focused on the manifestations of PTSD in
adulthood, very few studies look at the prevalence of PTSD among child victims of
sexual abuse. Furthermore, prior studies on the prevalence of PTSD among sexually
abused children show inconsistent findings. Three studies (Dubner & Motta, 1999;
McLeer et al., 1992; Wolfe, Sas, & Wekerle as cited in Dubner & Motta, 1999) found a
significant correlation between childhood PTSD and sexual abuse, whereas, an older
study by Livingston (as cited in Dubner & Motts, 1999) did not find a correlation
between PTSD and sexually and physically abused children.
Levingston’s (as cited in Dubner & Motts, 1999) comparison of PTSD among 13
sexually abused and 15 physically abused children in an inpatient unit, revealed children
did not meet criteria for diagnoses of PTSD. Rather, half of the sexually abused children
received other mental health diagnoses such as ADD, psychosis, or depressive disorder.
This study was completed prior to the publication of the current DSM-IV-TR, therefore,
utilizing PTSD criteria from earlier developments of the DSM, and utilized a relatively
small sample of children whereas, the three studies who found significant connections
between sexual abuse and PTSD were conducted more recently and utilized large
samples of children.
38
Two of the three studies that found significant connections between sexual abuse
and PTSD sampled approximately 90 children with histories of sexual abuse and found
that nearly half of these children in both samples met full criteria for a diagnosis of PTSD
(McLeer et al., 1992; Wolfe, Sas, & Wekerle as cited in Dubner & Motta, 1999).
Furthermore, both studies found that children who did not meet full criteria for PTSD met
partial criteria. These children demonstrated symptoms of hyperarousal, avoidance, and
reexperiencing (McLeer et al., 1992; Wolfe, Sas, & Wekerle as cited in Dubner & Motta,
1999).
Results of Dubner and Motta’s (1999) study of 150 children who had been placed
in foster care for sexual or physical abuse supported these findings. Sixty-four percent of
children who experienced a history of sexual abuse and 42% of children who had
histories of physical abuse met criteria for diagnoses of PTSD as determined by results
from the Child Post-Traumatic Stress Reaction Index (CPTS-RI) and the Childhood
PTSD Interview (CPI). It must be noted that 18% of children who did not have reported
histories of sexual and physical abuse met criteria for diagnoses of PTSD. However,
children in this group had reported exposure to witnessing domestic violence and other
violent acts. This study supports prior findings of the relationship between the
development of PTSD following exposure to sexual abuse in addition to PTSD’s
association with other forms of trauma such as physical abuse (Dubner & Motta, 1999).
Studies of PTSD among college students with histories of childhood sexual abuse found
39
associations between specific correlates of this trauma and higher levels of PTSD
symptomatology.
Feerick and Snow’s (2005) study on female college students with histories of
sexual abuse and Ullman’s (2007) study of male and female college student’s with
histories of sexual abuse reveal abuse characteristics that contribute to differences in the
traumatic impact of sexual abuse on children. Ullman’s (2007) sample of 733 college
students, showed a significant relationship between post-abuse psychosocial factors, such
as a child’s disclosure of abuse versus not, social cognitive responses such as self-blame,
and the victim-perpetuator relationship, with PTSD symptomatology in adulthood.
Significantly higher rates of PTSD among victims who disclosed abuse during childhood
compared to those who did not disclose abuse were found. Additionally, victims who
were abused by family members experienced more PTSD symptoms than those who were
abused by non relatives. Those who had delayed disclosure of abuse by relatives also
experienced more symptoms of PTSD than those who delayed disclosure of abuse by non
relatives. Victims who disclosed the abuse by relatives during childhood received more
negative social reactions such as disbelief by others and showed more self-blame during
childhood. This suggests the trauma of sexual abuse has variations in the experience
which impact individuals’ PTSD symptomatology (Ullman, 2007). Muller et al. (2000)
study of 66 women with histories of childhood sexual abuse also suggests that the
internalization and interpretation of the traumatic events during childhood contribute to
influential variables, such as self-blame, and leaves some children more vulnerable to the
40
development of PTSD. Seventy-six percent of women sampled were found to have
insecure attachment styles in adulthood while those with one of the three identified
insecure attachment styles (dismissing, fearful, and preoccupied) had the most negative
view of self and experienced the highest levels of PTSD symptoms in adulthood (Muller
et al., 2000).
Supporting prior studies of college students, Feerick and Snow’s (2005) study
also found that students with a history of childhood sexual abuse experienced higher
levels of PTSD symptoms then those who had not. However, the experience of sexual
abuse at a younger age was associated with more social avoidance and anxiety in
adulthood and “fewer PTSD symptoms then those who were abused later in childhood”
(Feerick & Snow, 2005, p. 417). Although these results support prior research findings
on the association between the trauma of sexual abuse and PTSD, this study warrants
future research to examine differing symptomatology of PTSD in relation to the child’s
age when first exposed to trauma. Examination of coping skills developed by those who
experience sexual abuse at a younger age may implicate further venues of treatment and
prevention of PTSD in both childhood and adulthood. Furthermore, the significant
findings of these studies, which demonstrate the prevalence of PTSD among adult sexual
abuse survivors, calls for further studies to bridge the gap between research on children’s
trauma exposure to sexual abuse and childhood PTSD.
41
Exposure to Physical Abuse
Empirical studies show similar significance between the development of PTSD
and childhood physical abuse. Although in recent years increasing attention has been
given to research on the trauma response to childhood physical abuse, most studies focus
on trauma responses of PTSD in adult women with histories of physical abuse in
adulthood. Once again research on the prevalence of childhood PTSD among children
experiencing physical abuse is needed to bridge the gap of knowledge and practical
intervention and preventative measures of treatment for childhood PTSD associated with
childhood physical abuse. However, current research focusing on PTSD among women
with histories of abuse in adulthood and childhood are indicative of prevalence rates
between childhood PTSD among children victims of physical abuse.
In a nationwide sample of 4008 women, assessment of PTSD through utilization
of the National Women’s Study PTSD module, indicated women who reported serious
physical abuse during childhood were “almost five times more likely to have a lifetime
history, and ten times more likely to be currently experiencing PTSD than non-victims”
(Duncan et al., 1996, p. 443). These alarming statistics have important clinical
implications of childhood trauma that is left untreated. Research of the prevalence of
PTSD among women with histories of physical abuse by intimate partners yields similar
results.
In a study of 160 women currently experiencing, or having experienced, physical
and emotional abuse by an intimate partner, nearly 74% of women who were currently
42
experiencing abuse and 44% of those who had experienced abuse, exhibited PTSD
symptomatology. In contrast, only 6% of women who had not experienced abuse yielded
symptoms of PTSD. These results, which suggest an association between the
development of PTSD among women who experience physical abuse, concur with
findings of prior research of PTSD symptomatology among children who experience
physical abuse. Furthermore, results of this study showing that women who on average
had been out of a physically abusive relationship for nine years, continued to experience
PTSD symptoms, demonstrates the longevity and impact of PTSD throughout the life
cycle. These findings support the idea that PTSD associated with traumatic response of
physical abuse occuring in adulthood may development in childhood long before a
diagnosis is made (Woods, 2000).
Feerick and Haugaard (1999) found that the traumatic experiences of childhood
abuse and witnessing marital violence significantly contributed to symptoms of of PTSD.
However, individuals who experienced both traumatic events experienced significantly
higher levels of PTSD symptomatology than those who experienced abuse or witnessing
marital violence alone. This suggests cumulative effects of PTSD symptomatology arise
from the combination of traumatic events, childhood abuse and witnessing marital
violence, which attributes to the severity of PTSD symptoms (Feerick & Haugaard,
1999). Results of these studies, along with the prevalence of child abuse in homes where
domestic violence is present, demands attention of research evaluating the association
between children’s exposure to domestic violence and the development of PTSD.
43
Exposure to Domestic Violence
According to Margolin and Vickerman (2007), domestic violence occurs in
approximately 30% of children residing in two parent households and co-occurs with
child abuse approximately 40% of the time. Sadly, the detriment of witnessing domestic
violence is not often considered, or given worth, since it does not yield bruises visible to
the human eye. In particular, witnessing acts of domestic violence is no less damaging to
the child than direct physical abuse; although, it is often overlooked (California Attorney
General’s Office, 2008). According to Margolin and Vickerman (2007), domestic
violence occurs in approximately 30% of children residing in two parent households.
Although limited attention is given to the effects of witnessing domestic violence,
existing studies demonstrate the prevalence of PTSD among these children.
Prior studies on the correlation between childhood PTSD and the witnessing of
domestic violence though limited in number, show strong relationships between the
development of PTSD by children who have witnessed domestic violence. Although
research indicates a link between the development of PTSD among children who witness
domestic violence, studies differ in findings of full diagnoses of PTSD versus the
presence of significant symptoms of PTSD in these children. Two studies (Kilpatrick &
Williams, 1997; Lehmann, 1997) found a strong connection between the prevalence of
PTSD among children who had witnessed domestic violence, whereas one study
(Levendosky, Huth-Bocks, Semel, & Shapiro as cited in Sox, 2004) of preschool children
showed a high prevalence of PTSD symptoms by children who witnessed domestic
44
violence, with most children meeting the full criteria set forth by the DSM-IV-TR for a
diagnosis of PTSD.
The two studies which indicated a strong association between diagnosis of PTSD
and children’s witnessing domestic violence utilized samples of children between ages
six and twelve who had witnessed domestic violence and their mothers’ who were
victims of such violence. Of these two studies, Kilpatrick and Williams’ (1997) sample of
20 children who had witnessed domestic violence against their mothers, utilized the Child
Post-Traumatic Stress Reaction Index (CPTS-RI) and the revision of the Conflict Tactics
Scale (CTS, Form N), which revealed significantly higher levels of PTSD
symptomatology when compared to a sample of 15 children who had not witnessed such
violence. Furthermore, 19 out of the 20 children who had witnessed violent acts against
their mother met full requirements for a diagnosis of PTSD. Similarly, Lehmann’s (1997)
study of 84 children who accompanied their mothers’ to shelters for battered women
revealed more than 50% of children met criteria for diagnoses of PTSD based on the
utilization of the Children’s Impact of Traumatic Events Scale-Family Violence Form.
These studies suggest that children who witness domestic violence are at significantly
higher risk of developing PTSD. A similar study by Levendosky, Huth-Bocks, Semel,
and Shapiro (as cited in Sox, 2004), showed a significant presence of PTSD symptoms
experienced by a sample of sixty-two children from three to five years of age. The
majority of children did not however meet full criteria for a diagnosis of PTSD. A
significant presence of PTSD symptoms were identified in children who directly
45
witnessed domestic violence and by those who had not directly witnessed the violence
but resided in the households where domestic violence was present (Levendosky, HuthBocks, Semel, & Shapiro as cited in Sox, 2004). Results indicate the vulnerability of
young children’s response to domestic violence. Furthermore, this vulnerability and the
discrepancies between the above mentioned studies which utilized samples of children
six to twelve years of age, and this study of preschoolers, demonstrates the vital need for
further research on the prevalence of PTSD among infants and children. Overall, all
mentioned studies examining the effects of children witnessing domestic violence on
PTSD development, identified children’s exposure to domestic violence as a traumatic
event often preceding PTSD.
International Perspective of Exposure to War
While it is estimated that “about 1.5 million school-age children have military
parents who are on active duty [and] about 49,000 U.S. military families include two
parents on active duty,” the literature to date has focused primarily on the impact of war
exposure on children at an international level (Lamberg, 2004, p. 1541). Consequently,
the bulk of such research surrounds exposure to war trauma as a result of children living
within war zones of areas under ongoing acts of military violence. Thus, a critical area of
research is the more subtle effects of indirect exposure, that is, the “threat of war” outside
of the war zone, such as that experienced by children in U.S. military families” (RyanWenger, 2001, p. 237). Although research on U.S. children exposed to war trauma is
lacking, international studies suggesting both primary and secondary traumatization
46
relating to childhood exposure to war have serious clinical implications for the
assessment and diagnosis of PTSD among American children.
Fawziyah and Ohaeri (2008) investigated the relationship between Kuwaiti
fathers’ who suffered from combat PTSD following their military service in the Gulf War
and their wives’ characteristic on the psychosocial outcomes of their children (Fawziyah
& Ohaeri, 2008). Of the 489 children belonging to 166 military fathers and mother pairs
sampled, the children whose parents both suffered from PTSD or whose mother had
PTSD had significantly higher depression, anxiety, and aggression than those whose
father alone had PTSD. Results showed the mothers’ PTSD, anxiety, depression, and
family adjustment significantly impacted the child psychosocial outcomes at greater
levels than children whose fathers’ experienced PTSD. Though this study did not
evaluate the presence of PTSD in children of combat veterans, results support previous
findings which indicate a significant correlation between parental trauma response to war
exposure and child outcome variables. Specifically, current research on the impact of war
trauma on children supports the link between the development and symptomatology of
PTSD in children whose exposure to war is both primary and secondary.
Thabet et al. (2008) utilized a multitude of standardized scales (Gaza Traumatic
Events Checklist, Children’s Revised Impact of Traumatic Events Scale, Strengths and
Difficulties Questionnaire, Revised Children’s Manifest Anxiety Scale, Posttraumatic
Stress Disorder Checklist for Parents, and Taylor’s Manifest Anxiety Scale) to measure
PTSD and anxiety in a sample of 200 parents (100 fathers and 100 mothers) and 197
47
children aged 9-18 who lived along the Gaza Strip “in areas under going shelling and
other acts of military violence” (p. 191). Parents mental health response to war trauma
was investigated to evaluate its impact on the trauma response of the child. The parents
frequency and type of exposure to traumatic events such as witnessing wounded or
mutilated bodies on TV, hearing fighter planes and artillery shelling, hearing about the
killing of a friend or relative, and witnessing artillery fire on homes were similar to their
children. Approximately 35 of the 197 children had clinically significant anxiety
symptoms and 138 presented with PTSD. The authors reported that “Insomnia,
exaggerated startle, and trying to remove memories from their mind” were the most
common symptoms of PTSD among these children (pp. 194-195). In contrast, the most
reported trauma response experienced by parents were “flashbacks, intrusive memories,
and amnesia,” however, 120 parents presented with clinically significant PTSD
symptoms and 52 with severe to very severe anxiety symptoms” (p. 195). Findings
showed children’s PTSD and anxiety symptoms were predicted by both their trauma
exposure and parents’ PTSD and anxiety scores, with significant correlations between
parents’ and children’s scores of PTSD intrusion and arousal (but not avoidance) and
anxiety (Thabet et al., 2008, pp. 196-197). These correlations indicate parents’ trauma
response as a contributing factor to the development and expression of their children’s
PTSD and presentation of anxiety, which suggest serious clinical implementations for
American children, warranting further research investigating the impact of secondary
traumatization from parental war exposure. Additionally, results showing children’s
48
primary exposure to war trauma is significantly associated with PTSD, supports previous
findings suggesting PTSD as a direct consequence of childhood war trauma.
Lis-Turlejska, Luszczynska, Plichta, and Benigh (2008) examined the impact of
World War II, in relation to trauma exposure of parental loss and age at exposure to war
hostilities on 212 Jewish and non-Jewish survivors who were at least five years of age but
younger than eighteen years of age at the end of WWII. The Posttraumatic Diagnostic
Scale (PDS) was administered to all participants, who at the time of the study were sixtysix to eighty years of age, to measure severity of current PTSD symptoms. Results
revealed that 55% of Jewish child Holocaust survivors met diagnostic criteria for PTSD
and had “significantly higher number and more intensive symptoms” than non-Jewish
WWII child survivors, whereas, 33% of non-Jewish child survivors met diagnostic
criteria for PTSD (Lis-Turlejska et al., 2008, p. 373). However, the extent of traumatic
loss was a stronger predictor of PTSD symptoms, depression, and social isolation, than
participants group affiliation of Holocaust or non-Jewish survivors. “Among survivors
who were 5-17 years old when WWII ended, a traumatic loss of parent(s) increased the
likelihood of more severe PTSD, higher number of PTSD symptoms, higher social
isolation, and more severe depressive symptoms 60 years after WWII” (Lis-Turlesjska et
al., 2008, p. 374). Although findings revealed that younger survivors, those who were
less than seven years of age at the end of the war, experienced PTSD symptoms, which
does not support a direct effect of age at exposure to trauma, Lis-Turlejska et al. (2008)
suggest the notion that younger age at trauma exposure has a “protective effect” on
49
severity of PTSD symptomatology and development (p. 375). This notion was derived
from the fact that once exposure-related variables such as parental loss were controlled,
some subgroups of survivors who were younger (less than seven at the end of the war)
“presented with lower PTSD severity, lower number of symptoms, or lower social
isolation” (Lis-Turlejska et al., 2008, p. 375). Overall, results support pervious findings,
which indicate negative prolonged effects of childhood trauma involving war exposure
and “PTSD as a distinct consequence of trauma” (Lis-Turlejska et al., 2008, p. 373).
Research on the effects of war trauma in children in war-ridden countries provides
further linking of PTSD symptomatology and development in children exposed to the
trauma of war. Studies which reveal high rates of PTSD among Palestinian and Lebanese
children exposed to war trauma further identifies exposure to war as a distinct
culminating factor of PTSD (Thabet & Vostanis, 1999; Macksoud & Aber, 1996).
Thabet & Vostanis’s (1999) study of 239 Palestinian children ages six to eleven living in
various districts along the Gaza Strip, utilized several standardized scales (Gaza
Traumatic Event Checklist, Rutter A2 completed by child’s parent, Rutter B2 completed
by child’s teacher, and the CPTS-RI) to measure trauma-related factors correlation to
PTSD and the PTSD response of children exposed to war trauma. One hundred seventyfour out of the 239 children sampled,
reported post-traumatic stress reactions of at least mild severity: 76 reported mild
reactions, 85, moderate, and 13 severe PTSD reactions... with the most frequently
reported symptoms of thoughts and fear related to the trauma, anhedonia,
50
impaired concentration, and avoidance of situations that reminded them of the
trauma. (Thabet & Vostanis, 1999, p. 388)
In addition to showing significant correlation between the development of PTSD among
children exposed to war trauma, results indicated that the most significant predicting
factor of the presence and severity of PTSD was the number of experienced traumas.
Similarly, in their study of Lebanese children ages ten to sixteen, Macksoud and
Aber (1996) found the amount of exposure to war traumas had a culminating effect on
the development of PTSD and severity of PTSD symptoms. Specifically, “the number of
war traumas experienced by a child was positively related to PTSD symptoms; and
various types of war traumas were differentially related to PTSD, mental health
symptoms, and adaptational outcome” (Macksoud & Aber, 1996, p. 70). Finding support
the notion of PTSD as a consequence of exposure to war trauma among children, and
suggests specific correlates of war trauma are associated with specific PTSD
symptomatology.
One such correlate was parental separation from a child, which was associated
with higher symptoms of depression than children who had not experienced such
separation (Macksoud & Aber, 1996). The significance of this correlate of war trauma is
further supported by Lis-Turlesjska et al.’s (2008) study of WWII survivors, which
showed a significant correlation between the loss of a parent(s) due to war and higher and
more severe PTSD symptomatology among children. The correlation between parental
loss or separation due to war has serious clinical implementations of the assessment and
51
diagnosis of PTSD as a trauma response of American children whose parent(s) military
service involves deployment to war. Current research, which suggests a significant link
between the trauma response to children’s war exposure and PTSD symptomatology or
diagnoses, is limited. Evaluating professionals’ perspectives of war trauma as a
contributing factor to their PTSD diagnosis among children in their clinical practice, is
essential to adding to the professional knowledge base of childhood PTSD.
Although several studies have been conducted on examining culminating factors
of childhood diagnoses of PTSD, very few have focused on professionals’ perspectives
on these contributing themes. Research on the prevalence of childhood PTSD among
trauma-exposed children is needed to bridge the gap of knowledge and practical
intervention and preventative measures of treatment for childhood PTSD. This study
works to fill the research gap by delineating the perspectives of professionals and PTSD
assessment tools used by professionals for diagnosing and treating children with PTSD
and hopes to allocate the resources to enhance professional practice outcomes.
Knowledge gained by this study directs future research in the development of universal
clinical assessment, diagnosis, and treatment of PTSD in children and therefore, works to
reduce childhood trauma-related psychopathology such as PTSD.
52
Chapter 3
METHODOLOGY
Study Design
In response to the little research that has focused on professionals’ perspectives of
traumatic events associated with childhood and adolescent diagnoses of PTSD and the
diagnostic tools used by professionals to diagnosis PTSD in children and adolescents, this
study utilized an exploratory mixed methodology research design. This research design
allows the exploration of professionals’ perspectives of culminating factors leading to
childhood PTSD and the diagnostic tools used by professionals to diagnose children and
adolescents with PTSD. Familiarity with factors associated with childhood diagnoses of
PTSD brought forth by this exploratory design, provides a foundation of understanding,
which directs future research of this topic and the development of early interventions and
modalities of treatment to prevent the occurrence of PTSD. Use of this design allows
flexible investigation of many factors contributing to the diagnosis of PTSD among
children and adolescents, which may identify significant implications of unexpected
variables. Though the exploratory nature of this design enables a better understanding of
the research questions and directs formulation of untested hypotheses or theories for
future research, these findings do not provide definitive answers to the research questions
of this study.
Because this study aimed to capture the beliefs, opinions, and characteristics of
professionals’ and explores the instruments used by professionals to diagnose children
53
and adolescents with PTSD, a survey research design was used to address the research
questions of this study. The researcher individually administered questionnaires to
participants by method of face-to-face interviews. A questionnaire consisting of both
closed and open-ended questions was utilized (see Appendix A). Quantitative and
qualitative analysis of specific variables of interest to this study was permissible by the
data collected from the face-to-face interviews.
Sampling/Data Collection Procedures
The study population consisted of 15 licensed mental health professionals. To be
included in this study participants (1). Must treat children and/or adolescents within their
scope of practice and (2). Have content specific degrees of licensed marriage family
therapist or licensed clinical social worker through the Board of Behavioral Sciences of
California. Participants who did not meet these requirements were excluded from
participating in this study. For the purposes of this study, children and adolescents were
defined as persons between the stages of birth and younger than the age of legal maturity
(18 years of age).
A snowball sampling method was used to recruit participants. The researcher
began by asking interested colleagues and had them refer others who may have been
interested in participating and who met participant criteria. To avoid any conflict of
interest, the researcher had no prior supervision or supervisor relationship with any of the
participants or possessed any knowledge of case/client specific information. When the
researcher contacted potential participants, the researcher explained the nature of this
54
project, including voluntary participation and confidentiality and the risks and benefits.
Participation was entirely voluntary and posed no risk for the participant to complete the
interview. Upon the participants’ consent to participate, an interview was scheduled and
later conducted in a safe and confidential location of the participants’ choosing. Consent
forms were obtained immediately before the interview took place on the day of the
interview. Using the attached interview, face-to-face interviews were conducted. The
interviews took approximately one hour to complete. The researcher conducted all faceto-face interviews with the participants. The researcher used a set of interview questions,
including closed and open-ended questions, developed by the researcher for use in this
study. Each research participant read and signed an informed consent form prior to being
interviewed. A copy of the consent form can be found in Appendix B. Upon completion
of the interview, each participant was offered a $5.00 gift card for Starbucks. By
targeting professionals who work directly with children and adolescents, the interview
was used as a tool to identify professionals’ perspectives of traumatic events leading to
diagnoses of PTSD among children and adolescents as well as to identify instruments
used by professionals to assess and diagnose PTSD among this population. All interviews
were transcribed and content analysis was used to identify emergent themes. Posing
threats to the internal and external validity of this study, the nonrandomized sample
selection limits both the representativeness of the study sample and the generalizability of
the study findings.
55
Instruments
The questionnaire was developed by the researcher based on an extensive
literature review of published articles and books on PTSD in children and adolescents
which, (1) identified factors in their environment that may have contributed to the stress
leading to the development of PTSD and (2) identified prominent diagnostic instruments
used by professionals to diagnose PTSD among this population. The questionnaire
consists of a mixture of 21 open- and closed-ended questions. Closed-ended questions
enabled statistical measurement of specific variables, whereas, open-ended questions
captured respondents’ perspectives, attitudes and beliefs pertinent to the purpose of this
exploratory study. Questions 1-9 investigate participants’ personal and work related
demographics. Questions 10-18 consist of open- and closed-ended questions, which
examine the type of instruments and assessment methods used by professionals to assess
for, and diagnose children and adolescents with PTSD. Questions 19-21 consist of openand closed-ended questions, which evaluate professionals’ perspectives, attitudes, and
beliefs regarding variables of trauma and traumatic events in childhood and adolescence,
which lead to a diagnoses of PTSD. There was no other equipment, instruments, or any
drugs or pharmaceuticals used in this study.
Data Analysis Approaches
Statistical analysis was conducted through a quantitative database SPSS, which
measures relationships and patterns among various concepts related to professionals’
perspectives of traumatic events associated with diagnoses of PTSD in children and the
56
diagnostic tools used by professionals to assess and diagnose children and adolescents
with PTSD. Content analysis was used to examine the transcripts for emergent themes,
patterns, and associations. Higher level of analysis such as the Pearsons correlation and
the one-way t-test were used to identify any correlations among interval level variables
such as the hours per week the professional spends doing clinical trauma assessment of
children and adolescents and the number of times the professional had used an identified
PTSD diagnostic tool in his/her practice. Frequency distributions and cross-tabulations
were also used to look for associations between nominal and interval level data such as,
the prevalence of specific traumatic events identified by professionals as contributing to
PTSD in children and the professionals’ number of years in clinical practice with trauma
exposed children or adolescents. Descriptive statistics were used to analyze demographic
data and data obtained from closed-ended questions.
Protection of Human Subjects
Prior to the collection of data for this study the Protocol for the Protection of
Human Subjects was submitted to, and approved by, the California State University,
Sacramento, Division of Social Work as exempt research, posing no risk to the study
population. This study posed “no risk” on its participants because the participants were
not subject to any physical or emotional harm when deciding to participate in the
interview. Additionally, the study posed "no risk" on its participants because it dealt
directly with professionals who were operating within their scope of practice.
57
Through the informed consent to participate as a research subject document,
potential subjects were informed of the voluntary nature of their participation. To
preserve the participant’s anonymity, each interview took place at a safe and private
location of the participant’s choosing. This study is not anonymous, however
participant’s identity and information was kept confidential. All participants were given
alias identifiers, which were used in all related data and documents. All data was kept in
locked cabinets in the researcher’s home. Consent forms were stored in locked cabinets
separate from transcripts and any data. All data including the interview instruments were
destroyed upon completion of this study.
58
Chapter 4
RESULTS
Introduction
This chapter presents the findings that stemmed from the data analysis for this
study. The data analysis was conducted to answer the research question on the traumatic
events associated with childhood diagnoses of PTSD from the perspective of
professionals and to examine the prominent clinical diagnostic tools used by practicing
professionals to assess and diagnose children and adolescents with PTSD. In addition, the
diagnostic tools and methods used by professionals to assess and diagnose children and
adolescents with PTSD are discussed. The themes of traumatic events that professionals
interviewed for this study identified as leading to the development of PTSD in children
and adolescents, are also an essential component of this chapter. The demographics of the
study participants are also discussed.
Demographics
A total of 15 professionals were interviewed in this study. As demonstrated in
Table 1, 53% of participants were licensed clinical social workers (LCSW). Out of the 15
subjects of the study, nine professionals were female and six were male. As Table 2
indicates, of the participants sampled, more females than males practiced under an LCSW
degree.
59
Table 1
Professional Identity of the Study Participants
Frequency
Percent
Valid Percent
Cumulative Percent
8
53.3
53.3
53.3
MFT
3
20.0
20.0
73.3
MSW
4
26.7
26.7
100.0
Total
15
100.0
100.0
Valid LCSW
Table 2
Cross Tabulation of Study Participants’ Professional Identity by Gender Distribution
Gender of Professional
Professional identity
LCSW
Count
% within gender
MFT
Count
% within gender
MSW
Count
% within gender
Total
Count
% within gender
Male
Female
Total
3
5
8
50.0%
55.6%
53.3%
2
1
3
33.3%
11.1%
20.0%
1
3
4
16.7%
33.3%
26.7%
6
9
15
100.0%
100.0%
100.0%
60
In Table 3, the theoretical orientations of male and female practitioners’ are
compared. The majority of females practiced from a cognitive behavioral theoretical
orientation in contrast to 100% of males who used cognitive behavioral therapy. Of the
females who did not practice from a cognitive behavioral theoretical orientation, half
practiced from a psychodynamic perspective and the other half practiced from a systems
perspective.
Table 3
Cross Tabulation of Theoretical Orientation of Professionals by Gender Distribution
Gender of Professional
Theoretical Psychodynamic
Count
Orientation
% within gender
CBT
Count
% within gender
Systems
Count
% within gender
Total
Count
% within gender
Male
Female
Total
0
2
2
.0%
22.2%
13.3%
6
5
11
100.0%
55.6%
73.3%
0
2
2
.0%
22.2%
13.3%
6
9
15
100.0%
100.0%
100.0%
61
In Table 4, professionals’ years of clinical experience was examined. As the data
in Table 4 indicates, there was a wide variation in professionals’ years of experience
since the highest educational degree awarded. However, the average years in practice
indicate a high competency level among the professionals sampled. Furthermore,
professionals sampled had an exceptionally high level of years in practice with children
and worked an average of thirteen years with the trauma population. Specifically, 64% of
the professionals sampled fell within 5 and 21 years of working with trauma exposed
children and adolescents.
Table 4
Professional Competency Profile
N
Minimum
Maximum
Mean
Std. Deviation
15
2.00
35.00
14.0000
10.44031
15
2.00
35.00
15.0667
9.92448
15
4.00
30.00
14.2667
8.44703
15
4.00
30.00
13.0000
8.08879
15
2.00
22.00
8.6667
6.38823
Years since highest
educational degree
Years in practice
Years in practice with
children
Years worked with trauma
population
Hours spent in clinical
trauma assessment
Valid N (list wise)
15
62
As demonstrated in Table 5, of the professionals sampled, there was a strong
correlation between the number of years professionals’ worked with trauma exposed
children and adolescents and the years since the professionals’ highest degree awarded.
This suggests the participants in this study are highly motivated to work with the child
and adolescent trauma population and because of their accumulated years of experience,
are more likely to provide knowledgeable and expert service to this population. Similarly,
professionals’ years in practice with children and/or adolescents was highly correlated
with professionals’ years in practice with trauma exposed children and adolescents. These
results indicate that the majority of professionals sampled are experts in working with
trauma exposed children and adolescents and have a unique interest in offering service to
this population.
63
Table 5
Correlations Between Professionals’ Work Experience, Years Since Highest Degree, and
Population Served
Years since
highest
Years since highest
Pearson Correlation
educational degree
Sig. (2-tailed)
Years in practice
Years in
Years worked
educational
Years in
practice with
with trauma
degree
practice
children
population
1.000
.962**
.643**
.819**
.000
.010
.000
N
15.000
15
15
15
Pearson Correlation
.962**
1.000
.552*
.762**
.033
.001
Sig. (2-tailed)
N
Years in practice
Pearson Correlation
with children
Sig. (2-tailed)
N
Years worked with
Pearson Correlation
trauma population
Sig. (2-tailed)
N
.000
15
15.000
15
15
.643**
.552*
1.000
.898**
.010
.033
15
15
15.000
15
.819**
.762**
.898**
1.000
.000
.001
.000
15
15
15
** Correlation is significant at the 0.01 level (2-tailed).
* Correlation is significant at the 0.05 level (2-tailed).
.000
15.000
64
Parental Involvement in Diagnosing PTSD
In Table 6 professionals’ involvement of parents when assessing PTSD in
children and adolescents is examined. Nearly all professionals sampled preferred to use
therapeutic modalities that involve parents in the assessment of PTSD among children
and adolescents. As the data demonstrates, professional identity plays a role in whether or
not professionals involve parents in their assessment of PTSD in children and
adolescents. Of the professionals sampled, all MSWs involved the parents compared to
87.5% of LCSWs and 66.7% of MFTs. There was little variation between professionals
sampled, with only one MFT and one LCSW reporting that they do not include parents in
their assessments. These results suggest that professionals recognize the impact of the
family in the treatment of PTSD in children and adolescents. Furthermore, this supports
current literature on child and adolescent trauma exposure, which demonstrates that
managing trauma involves interactions with several systems.
65
Table 6
Professional Identity and Perceptions of Professionals in Involving Parents in the
Assessment of PTSD in Children and Adolescents
Professional identity
Involving
Yes
parents when
assessing
Count
% Within Professional identity
No
Count
LCSW
MFT
MSW
Total
7
2
4
13
87.5% 66.7% 100.0% 86.7%
1
1
0
2
.0%
13.3%
4
15
PTSD in
% Within Professional identity
12.5% 33.3%
children and
Total Count
8
3
adolescents
% Within Professional identity 100.0% 100.0% 100.0% 100.0%
Assessment Tools Used to Diagnose PTSD
Table 7 examines professionals’ use of the DSM-IV-TR to assess and diagnose
PTSD in children and/or adolescents. All professionals practicing from a CBT and
Systems theoretical perspective utilized the DSM-IV-TR in the assessment and diagnosis
of PTSD compared to only 50% of professionals practicing from a psychodynamic
orientation. Although the number of respondents is very small, this preliminary data
suggests that there seems to be an association between professionals who practice from a
psychodynamic theoretical orientation and the use of the DSM as a diagnostic tool for
PTSD in children and adolescents, which indicates that further study is needed.
66
Additionally, nearly all professionals sampled in this study indicated a felt need for the
use of the DSM-IV-TR to assess and diagnose PTSD in children and adolescents. Of the
professionals sampled, only one respondent did not utilize the DSM-IV-TR to assess and
diagnose PTSD in children and adolescents. While the sample size of this study is small,
this preliminary data suggests that professionals who work with trauma exposed children
and/or adolescents seem to utilize DSM-IV-TR to assess and diagnose PTSD in their
clinical practice with this population. As current literature indicates a lacking sensitivity
of the PTSD diagnostic criteria set forth in the DSM-IV-TR for diagnosing children and
adolescents, this data suggests a crucial need for future research to evaluate PTSD
symptomatology unique to children and adolescents, as well as examining the
applicability of the DSM-IV-TR criteria for diagnosis of PTSD among this population
(Scheeringa et al., 1995).
67
Table 7
Crosstabulation of the Theoretical Orientation of Professionals with the Professionals’
Felt Need for the Use of DSM-IV-TR to Assess and Diagnose PTSD in Children and
Adolescents
Theoretical Orientation
Use of DSM to assess Yes
Count
and diagnosis
%
children/adolescents
with PTSD
No
Count
%
Total Count
%
Psychodynamic
CBT
Systems
Total
1
11
2
14
50.0%
100.0% 100.0% 93.3%
1
0
0
1
50.0%
.0%
.0%
6.7%
2
11
2
15
100.0%
100.0% 100.0% 100.0%
Table 8 looks at the frequency of the five diagnostic tools that were used by
professionals within the past year: Child Posttraumatic Stress Reaction Index (CPTS-RI),
Children’s Impact of Traumatic Events Scale (CITES), Trauma Symptom Checklist for
Children, Trauma Symptom Checklist for Young Children, and the CITES-Family
Violence Form (CITES-FVF). As demonstrated in Table 8, over 60% of the professionals
sampled did not utilize the above five diagnostic instruments to assess and/or diagnose
PTSD in children and adolescents within the past year of practice. At least 80% of
professionals did not use the CITES, CITES-FVF, or the CPTS-RI within the past year.
This data does not support current literature, which suggests that the CITES and CPTS-RI
68
are two of the most commonly used instruments used by professionals to assess PTSD
among children and adolescents (Giannopoulou et al., 2006). On the other hand, 20% of
respondents reported using the Trauma Symptom Checklist for Children and the Trauma
Symptom Checklist for Young Children 20 or more times within the past year. The
disparity between the use of assessment instruments used by professionals supports
current research, which demonstrate a very low level of commonality among, and
ambiguity of, the PTSD assessment instruments used by professionals (Elhai et al., 2005).
Disparity between assessment tools used by professionals seems to suggest a lack of
universal clinical understanding of the trauma response of children and adolescents,
which warrants further research of the instruments used for assessing PTSD among
children and adolescents.
69
Table 8
Instruments Used to Assess and Diagnose PTSD in Children and Adolescents
Type of Instruments Used by Professionals
Trauma List Trauma
CITES-
Frequency of 0
Frequency
Instrument
Percent
Use Within
1-9
Frequency
the Past Year
Percent
10-19 Frequency
Percent
Young
List
CITES
FVF
CPTS-RI
Children
Children
13
12
12
11
9
80.0%
73.3%
60.0%
86.7% 80.0%
1
2
2
0
1
6.7%
13.3%
13.3%
0%
6.7%
1
1
0
1
2
6.7%
6.7
0%
6.7%
13.3%
0
0
1
3
3
20 or
Frequency
more
Percent
0%
0%
6.7%
20.0%
20.0%
Total
Count
15
15
15
15
15
100.0%
100.0%
100.0%
Percent
100.0% 100.0%
* 0 frequency means that the professional did not use the instrument
Traumatic Events and the Development of PTSD
Table 9 examines traumatic events associated with the development of PTSD in
children and adolescents from the perspective of professionals. All professionals sampled
70
for this study listed sexual and physical abuse as associated with the development of
PTSD in children and/or adolescents. Likewise, all professionals listed domestic violence
as reasons associated with the development of PTSD in children and adolescents. These
results support current research, which shows relationships between the development of
PTSD following exposure to sexual and physical abuse and domestic violence (Dubner &
Motta, 1999; Kilpatrick & Williams, 1997; Lehmann, 1997). Additionally, these results
warrant future research to examine the knowledge base used by professionals to identify
sexual and physical abuse and domestic violence, which prompt professionals’ to assess
children and adolescents for PTSD.
Unlike the high prevalence of respondents who identified sexual and physical
abuse and domestic violence as leading to the development of PTSD in children and
adolescents, only 6.7% of professionals listed parental deployment due to military service
as a factor that they have seen in their caseload. These results contrast current literature,
which demonstrates a significant relationship between parental loss or separation due to
war and the development of PTSD in children and adolescents (Thabet et al., 2008).
However, it is important to note that the vast majority of current research examines the
exposure to war trauma of children and adolescents who live within war zones of areas
under ongoing acts of military violence. In addition, the limited number of participants in
this study may provide explanation of the discrepancy between this data and current
literature. However, despite the fact that the sample size of this study may be too small to
make valid determinations, even this preliminary data suggests the development of PTSD
71
among children and adolescents seems to be associated with parental deployment due to
war. Current estimates indicate, “about 1.5 million school-age children have military
parents who are on active duty [and] about 49,000 U.S. military families include two
parents on active duty” (Lamberg, 2004, p. 1541). Therefore, due to the fact that current
literature focuses primarily on the impact of war exposure on children at an international
level, this data suggests a vital need for further study of the trauma response of American
children whose parent(s) military service involves deployment to war.
Of the professionals sampled, 20% listed an illness of a family member, and 40%
listed parental drug use, as factors that they have seen on their caseload, which lead to the
development of PTSD in children and adolescents. It is significant to note that both of
these factors were not listed in the interview instrument used in this study. Rather,
identification of these factors was made possible through the use of an open-ended
question posed by the researcher during each interview. The open-ended question
specifically asked professionals to report any traumatic events that were not listed by the
researcher that they see as contributing to the development of PTSD. Although the
number of participants is small, this preliminary data suggests that there seems to be a
relationship between the development of PTSD and children and adolescents exposure to
parental drug use and illness of a family member. Therefore, this data warrants further
research to explore the child and adolescent trauma response to family illness and
parental drug use.
72
Table 9
The Professionals’ Assessment of Traumatic Events Associated with the Development of
PTSD in Children and/or Adolescents (Multiple Response)
Responses
Traumatic
Sexual abuse associated with
Events
development of PTSD
N
Percent Percent of Cases
15
27.3%
100.0%
15
27.3%
100.0%
15
27.3%
100.0%
1
1.8%
6.7%
3
5.5%
20.0%
6
10.9%
40.0%
55
100.0%
366.7%
Physical abuse associated with
development of PTSD
Domestic violence associated with
development of PTSD
Parent deployment due to military
associated with development of
PTSD
Illness of family member associated
with development of PTSD
Parental drug use associated with
development of PTSD
Total
73
Chapter 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Summary
Few studies have investigated professionals’ perspectives of the contributing
factors associated with the rising rate of childhood PTSD and the prominent tools used by
professionals to assess and diagnose PTSD in children and adolescents. This gap in
research is significant because universal standardized PTSD assessment and diagnostic
instruments for child and adolescents do not exist. Thus, professionals utilize different
PTSD assessment and diagnostic instruments, which may vary depending on the
practitioners’ theoretical orientation or professional identity. The theoretical orientation
of practitioners’ varies across and within the gender of practitioners. Consequently, this
may facilitate further disparity between the interventions used by professionals to assess,
diagnose, and treat PTSD in children and adolescents. More research is needed to
determine relationships between professionals’ theoretical orientation and the assessment
and diagnostic tools and methods of intervention used by professionals who work with
the child and adolescent trauma population.
Similarly, the perceptions of practitioners’ in involving parents in the assessment
of PTSD in children and adolescents vary between the professional identities of the
practitioners. Although the differences are slight, there is indication that practitioners’
who practice under a Masters in Social Work may be more likely to involve the parents in
the treatment of PTSD in children and adolescents, than Licensed Clinical Social
74
Workers and Marriage Family Therapists. The impact of involving the family in the
treatment of children and adolescents with PTSD suggests dire implications of the
successful treatment of PTSD in children and adolescents whose parents are not part of
the treatment approach. Therefore, future research is needed to investigate the
relationship between practitioners’ professional identity and the preferred use of
therapeutic modalities that involve parents in the assessment of PTSD among children
and adolescents.
In the absence of standardized tools for assessing and diagnosing PTSD in
children and adolescents, many practitioners rely on the primary universal tool for mental
health assessment and diagnosis used by practitioners in various fields of helping
throughout the United States, the DSM-IV-TR. However, the DSM-IV-TR’s PTSD
diagnostic criterion was developed from the symptomatic expression of PTSD in adults
and therefore, assesses symptomatology assuming uniform traumatic stress reactions of
adults and children. Without diagnostic criteria that are sensitive to the patterns of
psychological correlates specific to children and adolescents with PTSD, the reliability
and validity of the DSM-IV-TR criteria for diagnosing PTSD among children and
adolescents is concerning (APA, 2000). Therefore, additional studies are needed to
determine the reliability and validity of the DSM-IV-TR diagnostic criteria in capturing
PTSD symptomatology unique to children and adolescents. Although the DSM-IV-TR
was the most widely reported PTSD assessment and diagnostic tool used by the
professionals sampled in this study, there was a large disparity between professionals’
75
use of PTSD assessment instruments other than the DSM-IV-TR. Although a plethora of
clinical and research literature suggests that the Child Posttraumatic Stress Reaction
Index (CPTS-RI) and the Children’s Impact of Traumatic Events Scale (CITES) are
highly reliable and valid PTSD assessment instruments that are prevalently used by
professionals, the majority of professionals sampled in this study did not utilize either of
these measures to assess post-traumatic stress reactions in children and adolescents.
Furthermore, there was no commonality among the PTSD assessment instruments used
by professionals. The inconsistency between screening instruments used by professionals
to assess the physiological impact on children and adolescents exposed to traumatic
events leads to disparities between the diagnoses of PTSD in children and adolescents.
Therefore, future research is needed to investigate current instruments used by
practitioners to assess the trauma response of children and adolescents’ and diagnose
PTSD.
Understanding culminating factors leading to childhood PTSD from the
perspective of professionals provides a foundation to identify predominant traumatic
events that may lead to the development of PTSD in childhood. Three themes of
traumatic events were identified by all professionals’ in this study, as leading to the
development of PTSD among children and adolescents. Congruent with the wealth of
current literature on traumatic childhood events associated with the development of
PTSD, the themes identified by professionals in this study included sexual and physical
abuse and witnessing domestic violence. In addition to listing themes of traumatic events
76
supported by current research, many professionals indicated a relationship between the
development of PTSD and children and adolescents’ exposure to parental drug use and
the illness of a family member. Professionals’ perspectives of a problem, and what they
identify as traumatic, can change over time. Thus, PTSD is a transforming problem as
childhood exposure to trauma evolves with time, which can contribute to discrepancies in
diagnosis. Therefore, additional research of professionals’ perspectives of traumatic
childhood events associated with the development of PTSD in childhood is needed to
determine new or changing trends of traumatic events that lead to the development of
PTSD among children and adolescents.
Conclusions
The researcher identified several major findings from the data presented in the
previous section. A theme exists between the respondents’ gender and theoretical
orientation. According to the data in Table 3, all male practitioners practiced from a
cognitive behavioral approach. In contrast, slightly more than 50% of females practiced
from this theoretical approach. Of the remaining female respondents, half practiced from
a psychodynamic perspective and half practiced from a systems perspective. This finding
is important because the variation of theoretical approaches used by practitioners who
treat children and adolescents with PTSD, suggests a lack of commonality among the
interventions used by practitioners to treat PSTD in this population. Consequently, this
finding poses significant concern that variations among the theoretical approach used by
professionals may contribute to discrepancies in the treatment of PTSD among this
77
population. Therefore, future research is needed to determine if professionals’ theoretical
orientation is associated with the interventions used by professionals to treat PTSD
among trauma exposed children and adolescents. This encourages the development of
standardized clinical interventions used to treat PTSD in children and adolescents, which
works to establish a universal clinical understanding of the trauma response of children
and adolescents.
Respondents were asked to specify the assessment methods along with the type
and frequency of instruments used within their scope of practice to assess and diagnose
PTSD in children and adolescents, which presented several notable themes in these
findings. Nearly all professionals reported involving the parents in their assessment of
PTSD in children and adolescents however, practitioners’ professional identity was
associated with whether or not practitioners involved the parents in their assessment.
According to the data in Table 6 of the professionals sampled, all practitioners who
possessed an MSW degree and were currently collecting clinical hours through the Board
of Behavioral Sciences of California involved the parents in their assessment. In contrast,
88% of LCSWs and only 67% of MFTs included the parents in their assessment. This
finding suggests that across the professional identities of practitioners who treat trauma
exposed children and/or adolescents within their scope of practice, there is a common
understanding that managing trauma involves interactions with several systems.
However, the data also indicates disparity among the methods used by professionals to
assess for PTSD in children and adolescents.
78
Another significant theme presented in the respondents’ use of the DSM-IV-TR to
assess and diagnose PTSD in children and adolescents (see Table 7). Nearly all
professionals indicated a felt need for the use of the DSM-IV-TR to assess and diagnose
PTSD in children and adolescents, with only one respondent who did not utilize the
DSM-IV-TR. Additionally, all respondents who practice from a CBT and Systems
theoretical perspective reported a felt need for the use of the DSM-IV-TR, compared to
only 50% of professionals who practiced from a psychodynamic orientation. Although
these findings suggests that professionals who work with trauma exposed children and/or
adolescents prevalently utilize the DSM-IV-TR to assess and diagnose PTSD in their
clinical practice with this population, it presents significant concerns that the diagnoses
PTSD may at present, be gravely underrepresented among this population, as a wealth of
current literature points to a lack of reliability and validity of the DSM-IV-TR to capture
diagnostic criteria that are sensitive to the patterns of psychological correlates specific to
children and adolescents with PTSD. In addition, differences in professionals’ theoretical
orientation may attribute to disparity of PTSD diagnoses among children and adolescents.
Respondents were also asked to report the frequency with which they used the
following five instruments to assess and diagnose children and adolescents with PTSD
within the past year: Child Posttraumatic Stress Reaction Index (CPTS-RI), Children’s
Impact of Traumatic Events Scale (CITES), Trauma Symptom Checklist for Children,
Trauma Symptom Checklist for Young Children, and the CITES-Family Violence Form
(CITES-FVF). According to the statistics in Table 8 there is a large disparity among
79
professionals’ use of these instruments. The data demonstrates that at least 80% of
respondents had not used the CITES, CITES-FVF, or CPTS-RI with the past year
however, the CITES-FVF and CPTS-RI were each utilized between one and nine times
by 13% of respondents. Similarly, the majority of respondents reported that they did not
use the Trauma Symptom Checklist for Young Children (73%) or the Trauma Symptom
Checklist for Children (60%) within the past year of practice. However, each instrument,
the Trauma Symptom Checklist for Children and the Trauma Symptom checklist for
young children, was used by 20% of respondents at least 20 times within the past. This
finding is important because is demonstrates a large disparity between the instruments
used by professionals to assess and diagnose PTSD in children and adolescents.
The last major finding of this study presented from professionals’ assessment of
traumatic events associated with the development of PTSD in children and/or
adolescents. All respondents identified sexual and physical abuse and exposure to
domestic violence as reasons associated with the development of PTSD in children and
adolescents. Congruent with current literature, which demonstrates childhood PTSD as a
common consequence of exposure to the above traumatic events, these findings suggest
that professionals who work with trauma exposed children and adolescents share a
universal clinical understanding of the impact of childhood exposure to sexual and
physical abuse and domestic violence. On the other hand, only 7% of professionals listed
parental deployment due to military service as a factor leading to the development of
PTSD that they have seen in their clinical practice with children and adolescents (see
80
Table 9). This data may be characteristic of this study’s small sample size however, even
this preliminary data suggests that there is a relationship between PTSD and the trauma
response of American children whose parent(s) military service involves deployment to
war. This finding is important because the bulk of current literature, which focuses on
exposure to war is at an international level, strongly indicates PTSD among children and
adolescents as a distinct consequence of this populations direct exposure to war.
Therefore, these findings are suggestive of a similar relationship between the
development of PTSD among children and adolescents who live in war zones of areas
under ongoing acts of military violence and the trauma response of American children
and adolescents, whose exposure to war are vastly indirect.
In addition to assessing respondents perspectives of the association between the
development of childhood PTSD and specific traumatic events, respondents were asked
to share any additional traumatic events that they associate with leading to the
development of PTSD in children and adolescents. A considerable number of respondents
reported a significant relationship between the development of PTSD and children and
adolescents’ exposure to parental drug use and illness of a family member (see Table 9).
These findings indicate PTSD as a transforming problem, which requires ongoing
research to identify emergent patterns of traumatic events that lead to the development of
PTSD in children and adolescents.
81
Recommendations
The findings from the previous section of this study suggest a significant disparity
in the current instruments and methods used by practitioners to assess children and
adolescents’ responses to trauma and diagnose PTSD. Additionally, the theoretical
orientation and gender of the professional was associated with the inconsistency between
the instruments and methods used by professionals to assess and diagnose PTSD in
children and adolescents. This indicates a clear need for the development of valid and
reliable universal instruments to assess and diagnose PTSD among children. An
additional finding that is in agreement with the findings from the literature review of this
study, presented when all respondents identified exposure to physical and sexual abuse
and domestic violence as traumatic events leading to the development of childhood
PTSD. However, some professionals’ also identified the illness of a family member and
parental drug use as factors that they have seen on their caseload, which lead to the
development of PTSD in children and adolescents. This suggests the need for ongoing
research to assess for new patterns of culminating events that lead to the development of
PSTD in childhood.
Recommendations for Practice
To address practice at the micro level, this researcher recommends increased
specialized training of professionals in new innovative approaches to assess and diagnose
PTSD in children and adolescents. Practitioners need more training on valid and reliable
measures of assessing and diagnosing PTSD to encourage professionals’ early
82
identification of PTSD symptomatology and the universal assessment and diagnosis of
PTSD in children and adolescents. Such training should also include parental
involvement in the assessment of PTSD, as current clinical interventions indicate an
involvement of the family in the treatment of childhood PTSD.
Social work implications at the mezzo level includes educating the community
about culminating factors that lead to the development of PTSD and the symptomatic
expression of PTSD that is unique to children and adolescents. This encourages the early
identification of PTSD symptomatology by family and community members, which
enables professionals to intervene prior to the occurrence of PTSD to prevent the
development of PTSD in childhood and later in life. Additionally, this researcher
recommends educating professionals in the importance of developing appropriate
networks with agencies in the area to stimulate further development of programs to serve
this population.
At the macro level, there needs to best practices about dealing with PTSD. The
development of a universal hotline just for trauma victims is necessary to address the
patterns of psychological correlates specific to PTSD. Currently, a great deal of
childhood trauma is addressed as child abuse. Nearly half of the nations’ states reported
domestic violence, poverty and economic strain, and substance abuse as co-occurring
problems of the families reported to child protective services and children of single
parent families had a 74% greater risk of suffering physical abuse, physical neglect,
emotional abuse, and severe injury from maltreatment (DHHS, 2007). These statistics of
83
the context and family demographics of abuse are particularly concerning due to the
overwhelming literature that demonstrate the cumulative effects of trauma in which
children exposed to multiple traumas such as, physical abuse and witnessing domestic
violence, may develop and experience higher, more severe, PTSD symptomatology than
children who experience physical abuse or domestic violence alone (Feerick & Haugaard,
1999). Child Protective Services is consequently the chief respondent for childhood
abuse; however, CPS takes an investigative role with very little therapeutic intervention.
Thus, to reduce the rising number of childhood trauma-related psychopathology such as
PTSD, the development of specialized mental health services for child and adolescent
victims of trauma is needed.
Recommendations Relevant for Research
At the micro level, research is needed to identify evolving patterns or experiences
of childhood trauma. As demonstrated in the findings presented in the literature review of
this study, familial experiences of trauma elicit reciprocal changes in the functioning of
all family members, which in children and adolescents’ may include a trauma response
that leads to the development of PTSD. Thus, patterns of children’s trauma exposure,
such as the threat of war and parent-child separation due to parental service in the
military, may fluctuate with the state of the nation and health of the economy. Additional
research to uncover new or changing trends of traumatic events is therefore, essential for
the early identification of PTSD symptomatology and development of interventions
unique to the emergent trauma response of children and adolescents.
84
At the mezzo level, research is needed to identify themes of traumatic events
associated with childhood diagnoses of PTSD relating from the perspective of
organizations that are prominent in the lives of children and adolescents, such as
educational and religious institutions. Similarly, research must examine how these mezzo
level entities view the symptomatic expression of PTSD in children and adolescents. This
research is essential for identifying areas of needed funding and education to better assist
the community in serving this population. Therefore, further research which aids the
community in serving trauma exposed children and adolescents, protects children and
adolescents whose trauma exposure may otherwise go overlooked.
On a macro level, more research is needed to investigate current instruments used
by practitioners to assess children’s and adolescents’ responses to trauma and diagnose
PTSD. Currently, little is known about the prevalence of PTSD instruments used by
professionals to assess and diagnose PTSD in children and adolescents however, current
literature reveals a vast lack of commonality among, and ambiguity of, the diagnostic
instruments used by professionals to assess and diagnose PTSD among children and
adolescents (Elhai et al., 2005). In a study of over 200 members of the International
Society for Traumatic Stress Studies, professionals who had significant experience
practicing in the field of trauma were asked to indicate the frequency that they used 21
listed instruments for assessing PTSD in children and adolescents (Elhai et al., 2005).
Only one assessment instrument was used by a little more than 10% of professional in
this study and many professionals reported the use of assessment instruments that were
85
not part of the 21 tests listed. Even the assessment instruments that were not part of the
provided list shared no commonality of use by professionals (Elhai et al., 2005). The
discrepancies of the instruments used by professionals to assess and diagnose PTSD in
children and adolescents facilitates the underrepresentation of PTSD among this
population. Therefore, additional research is needed to identify the tools used by
professionals to assess and diagnosis children with PTSD and for the development of
universal clinical assessment and diagnostic tools and treatments for PTSD in children
and adolescents.
Additional research is also needed to specifically examine the applicability of the
DSM-IV-TR criteria for diagnosing PTSD in children and adolescents (APA, 2000). The
DSM-IV-TR is currently the most widely used universal tool for mental health assessment
and diagnosis used by practitioners in various fields of helping throughout the United
States however, many studies reveal inconsistent findings between the symptomatic
expression of PTSD between young children, middle childhood through adolescence and
the applicability of many of the symptoms to the PTSD diagnostic criteria of the DSMIV-TR (Evans & Oehler-Stinnett, 2006). Thus, several studies propose additional
diagnostic PTSD criteria be added to the DSM to capture differences in PTSD
symptomatology unique to children and adolescents (Scheeringa et al., 1995). To protect
this under-represented and inconsistently served population and prevent children and
adolescents’ trauma exposure from going overlooked, future research assessing the
86
validity of the DSM IV-TR’s PTSD diagnostic criteria regarding its sensitivity to the
trauma response of children and adolescents (APA, 2000).
Recommendations Relevant for Behavior/Theory Implementation
At the micro level, agencies that serve children and families need to develop
preventative components aimed to reduce risk factors associated with the development of
PTSD. Patterns or experiences of trauma, such as witnessing domestic violence or parentchild separation due to parental military service, elicit reciprocal changes in the
functioning of all family members, which in children and adolescents may include a
trauma response that leads to the development of PTSD. Therefore, integrating
multidimensional interventions within agencies that serve children and families bolsters
the effectiveness of treatment of childhood trauma, as it addresses risk factors associated
with prominent systems in the child’s life. This is supported by current literature on child
and adolescent trauma exposure, which demonstrates that managing trauma involves
interactions with several systems.
At the mezzo level, trauma exposure resulting from the functioning and
interactions between the prominent systems in the child’s life, such as the family and
social relationships, impact the child’s development and well-being. Current
neuroscience research of the impact of trauma exposure during childhood indicates vital
brain regions are altered, which is associated with the inability to regulate emotions, as
well as increased rates of self-harm, anxiety and mood disorders, and difficulty following
social norms over the life span (Wolf et al., 2009). To meet micro level practice
87
objectives, professionals need to meet with various agencies within the community,
which provide services to families, and provide information on traumatic childhood
events leading to PTSD and the developmental impact of childhood trauma, in an effort
to promote agencies to refer children and adolescents to mental health services for
assessment and early intervention of PTSD.
At the macro level, this researcher recommends the development of a nationwide
database of mental health practitioners who specialize in working with the child and
adolescent trauma population, which is composed of practitioners’ perspectives of
culminating factors that lead to the development of PTSD and the instruments used to
assess and diagnose PTSD in children and adolescents. Making this information available
to local communities provides a clearer clinical conceptualization of childhood PTSD.
This provides a universal knowledge base of childhood PTSD, which may identify
prominent factors associated with childhood PTSD as well as any changes in patterns
associated with the development of PTSD in this population. Additionally, the database
may provide information to help identify PTSD treatment modalities used by
practitioners’ that indicate increasing success among trauma exposed children and
adolescents.
Recommendations for Policy
To address policy at the micro level, agencies need to develop policies concerning
how they refer children who have experienced events that may predispose them to PTSD.
The development of policy initiatives within the service systems, in which children are
88
present, facilitate proper provision of early mental health services for children and their
families. Additionally, relatively little knowledge exists on the impact of PTSD on
children and adolescents. Thus, agencies that work with children and families may
consider composing task forces to examine specific culminating events that can be
prevented before children are exposed to traumatic conditions.
Social work implications at the mezzo level indicate the need for policies to
address educating family members, therapists and professionals on the unique dimensions
of PTSD in children, particularly circumstances of domestic violence, that are rippled
with factors contributing to childhood PTSD. Such policies would increase families’ and
professionals’ ability to recognize these symptoms and warning signs. Therefore, the
development of policies that enable education promotes early prevention as well as
intervention.
At the macro level, legislators must consider the importance of developing bills
which will enable schools to create guidance centers on their premises that are staffed
with professionals who are educated in correlates of trauma and PTSD symptomatology
that are unique to children. Mental health service delivery in early childhood promotes
early identification of symptoms associated with PTSD. Thus, the development of such
legislation allows appropriate referrals to be made early on for the purposes of early
prevention and treatment of childhood PTSD.
89
APPENDICES
90
APPENDIX A
Interview Questions
Demographics:
1. Gender of Professional?
2. Professional Identify (Type of clinical degree)?
3. Theoretical Orientation (Typical Therapeutic Approach you use in your clinical
practice)?
4. Age group of client population you primarily work with?
5. Years since highest educational degree awarded?
6. Years in practice?
7. Years in practice with the children and/or adolescent population?
8. Over the course of your practice, how many years have you worked with trauma
exposed children or adolescents?
9. How many hours per week do you spend doing clinical trauma assessment of children
and adolescents?
Trauma Exposure and PTSD Instrument Used
10. Number of times used in the past year for clinical purposes?
______ Children’s Impact of Traumatic Events Scale (CITES/CITES-R/CITES-2)
______ CITES-Family Violence Form (CITES-FVF)
______ Child Posttraumatic Stress Reaction Index (CPTS-RI), also known as the
Reaction Index
______ Trauma Symptom Checklist for Children
______ Trauma Symptom Checklist for Young Children
______ Posttraumatic Stress Disorder Checklist for Parents
11. When assessing PTSD in children and adolescent clients do you involve the parents
in this assessment? Yes No
12. If yes, what instruments do you use with the parents?
91
13. What kinds of tools other than those listed in question 10, do you use to assess
children and adolescents for PTSD?
14. Do you have immigrant children on your caseload who experienced PTSD? Yes No
15. If yes, do you find that they experience more PTSD than children born in the United
States?
16. Does the assessment tool used change according to the trauma?
17. Does the assessment tool used change according to the gender of the child or
adolescent? Yes No
18. If yes, how?
19. Does the type of trauma leading to PTSD vary between male and female children
and/or adolescents? Yes No
20. If yes, how does the trauma leading to PTSD vary by gender?
21. In your practice with children and/or adolescents diagnosed with PTSD, do you see
the following traumatic events associated with the development of PTSD:
• Sexual Abuse
• Physical Abuse
• Domestic Violence
• Parental Involvement in the Military
• Parental Deployment Due to Service in the Military
• OTHER_____________________
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APPENDIX B
Consent Form
Informed Consent to Participate as a Research Subject
I hereby agree to participate in a study entitled, "Professional Perspectives of Traumatic
Events Associated with Childhood Diagnoses of Posttraumatic Stress Disorder and the
Instruments used by Professionals to Assess and Diagnose Posttraumatic Stress Disorder
in Children and Adolescents", and I understand that the participation in the study
involves the following:
Why is this study being conducted?
This study is conducted by Cathryn Buda, MSW II student at California State University,
Sacramento to explore traumatic events associated with childhood diagnoses of PTSD
from the perspective of professionals and the prominent clinical diagnostic tools used by
practicing professionals to assess and diagnose children and adolescents with PTSD.
Identification of traumatic events leading to childhood diagnoses through the lens of
practicing professionals directs the creation of a classification of traumatic stressors for
clinical use which works towards the development of early and universal clinical
identification of childhood PTSD and its symptomatology. Clinical understanding of the
trauma response of children and adolescents, gained by the identification of commonly
used trauma exposure and PTSD instruments, is essential for the development and use of
universal PTSD assessment instruments among practitioners treating children and
adolescents. This understanding and way of practice leads to practitioners universal and
early identification of PTSD symptomatology, which enables professionals to intervene
prior to the occurrence of PTSD to prevent the development of PTSD in childhood and
later in life.
What will you be asked to do?
You will be one of about 15 respondents in the Sacramento area who will be asked to
participate in a face to face interview with the researcher. You will be interviewed about
your perspectives, as a mental health practitioner, regarding traumatic events associated
with the development of Posttraumatic Stress Disorder among children and adolescents.
Additionally, you will be interviewed about the instruments you use in your professional
practice to assess and diagnose PTSD in children and adolescent clients. The interview
may generally take about 60 minutes and will take place in a confidential location of your
choosing. The interview will be tape recorded and transcribed. You can request that the
audio taping be stopped at any time in the interview without any negative consequence.
The tape recording and transcription will be destroyed upon completion of this study, no
later than July, 2010.
93
Is this voluntary?
Yes. you are under no obligation to participate. When you agree to participate, you can
ask the interviewer to skip any questions that you would rather not answer. You are also
free to stop the interview at any time.
What are the advantages of participating?
Participating in this study will be instrumental in identifying culminating factors which
lead to PTSD in the early years, and the tools used by practicing professionals to assess
and diagnosis children with PTSD. This is essential for the development of a universal
clinical assessment tool and the universal diagnosis and treatment of PTSD and therefore,
to reduce childhood trauma-related psychopathology such as PTSD. You will also receive
a $5 incentive for participating in this study as a token of appreciation for participating in
this study.
Is this confidential?
Yes. The study will remove identifying information from the interview form completed
by the interviewer. All records will be identified only by a number, and the link between
that number and professional’s name will be kept in a locked file that is available only to
the principal investigator. At the completion of the study all identifying information will
be destroyed and only the compiled content of the interviews will be kept. Any reports or
other published data based on this study will appear only in the form of summary
statistics or condensed account without the names of or other identifying information
about the participants.
What risks do I face if I participate?
There are no risks expected as the researcher is trained to ask the questions in a way that
ensures the dignity and privacy of the participant and each participant has the right to
answer or not answer any question during the interview.
Who do I contact if I have questions about this research?
If you have any questions about this research project or would like to inquire about the
findings from this research project, you may contact Cathryn Buda at (916) 792-4537 or
Cathryn_3@hotmail.com or by contacting the researchers’ thesis advisor, Dr. Susan
Taylor in the Division of Social Work at (916) 278-7176 or Taylorsa@csus.edu.
My signature below indicates that I consent to be interviewed, that I have been given a
copy of this consent form, and that I read and understood it.
Signature:
Date:
Name of the interviewer:
Date:
94
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