Posttraumatic Stress Disorder Shifting Toward a Developmental Framework

Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford School of Medicine, Stanford University, 401 Quarry Road, Stanford, CA 94305, USA.
Child and adolescent psychiatric clinics of North America (Impact Factor: 2.88). 07/2012; 21(3):573-91. DOI: 10.1016/j.chc.2012.05.004
Source: PubMed

ABSTRACT This article reviews the current classification of posttraumatic stress disorder and its limitations when applied to youth. Distinctions are made between single-event and multiple-event traumas. Diagnosis, neurobiology, treatment development, and treatment outcomes are presented. A summary of current empirical interventions is provided. The authors present implications for future research and for clinical practice.

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    ABSTRACT: While the evidence with regard to trauma therapy in adults is quite good, this is still not the case in children due to the unsatisfactory quality of many treatment studies. Establishing such evidence requires standardised treatment protocols and randomised controlled trials. Although various guidelines (e.g. NICE guidelines, AACAP practice parameters, ISTSS guidelines, etc.), reviews and meta-analyses (e.g. Gillies et al. 2012 ; Leenarts et al. 2013 ) on effectiveness of child trauma therapy are currently available, recommendations across these documents are quite inconsistent. This is largely due to different definitions of evidence levels and different inclusion and exclusion criteria for studies. Nevertheless, the evidence clearly suggests that psychotherapy is considered the first choice of treatment. Medication may be used as a second line if psychotherapy is not available or if the child has a comorbid condition. One psychotherapeutic treatment that is recommended in all guidelines and that has been found to be effective in all meta-analyses is CBT, specifi cally trauma-focused CBT (TF-CBT), and to some extent Child–Parent Psychotherapy, a psychodynamic treatment approach for young children (Lieberman and Van Horn 2005 ). Current evidence is insufficient to determine the effectiveness of EMDR, play therapy, family therapy and pharmacological therapy in children and adolescents. Notably, all current treatments that proved to be effective employ methods such as behavioural and emotional regulation, cognitive processing and coping strategies, and they all directly address the traumatic experience (mostly through exposure and creation of a narrative) and include caregivers. Currently, there is no evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others (Gillies et al. 2012 ). However, evidence regarding specific treatments of children with complex trauma is still lacking. Future studies are needed to clarify how these children can be effectively treated. Also we need more studies on preschool-age children, specifi cally below the age of 4 years. Finally, as highlighted by Carrion and Kletter ( 2012 ), future treatment protocols should better integrate current fi ndings on neurobiological mechanisms in trauma with psychotherapy. This may especially be promising with regard to early interventions after trauma.
    Evidence Based Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians, Edited by U. Schnyder & M. Cloitre, 01/2015: chapter 19: pages 363-380; Springer.
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    ABSTRACT: IntroductionHypothalamic-pituitary-adrenal (HPA) axis activity is related to childhood disruptive behavior disorders and to exposure to abuse and neglect. This study explores the relationship of diurnal salivary cortisol levels with oppositional defiant disorder (ODD) and caregiver attitudes toward physical punishment among boys in Mongolia.Methods Salivary cortisol was collected in the home or institution 4 times daily for 4 days from 46 boys, aged 4-10 years, in Ulaanbaatar, Mongolia. Caregivers rated child disruptive behavior symptoms, attitudes toward physical punishment, and community violence exposures. Mixed effects models were used to estimate the association of psychopathology and caregiver attitudes with salivary cortisol levels.ResultsBoys meeting criteria for ODD displayed consistently lower diurnal salivary cortisol levels compared to boys without ODD diagnoses. Controlling for ODD diagnosis, boys with depression showed higher cortisol levels throughout the day. No other diagnosis was associated with cortisol levels. Psychiatric diagnosis accounted for 17% of between individual variations in cortisol levels unexplained by the covariates. In a separate model, caregivers’ beliefs regarding physical punishment accounted for 11% of between individual differences: boys with caregivers who stated physical punishment was necessary for discipline displayed hypocortisolism. Institutionalization did not associate with cortisol levels.DiscussionSalivary cortisol data from a non-Western naturalistic setting support an association of reduced basal HPA activity with disruptive behavior disorders and caregiver attitudes toward discipline. These findings suggest HPA functioning may be a reflection of or mediate disruptive behavior disorders in children across ethnic and cultural settings.
    Asia-Pacific Psychiatry 06/2014; 7(1). DOI:10.1111/appy.12141 · 0.42 Impact Factor
  • Clinical Pediatrics 07/2014; DOI:10.1177/0009922814540793 · 1.26 Impact Factor


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May 15, 2014