31.11b Posttraumatic Stress Disorder of Infancy, Childhood, and Adolescence
1221
can then be viewed and modifications can be suggested to
increase positive engagement. The third modality for clinical
intervention is through individual work with the child. Working
with the child and caregiver together is often more effective in
producing more emotionally meaningful exchanges than work-
ing with parent or child individually.
Psychosocial interventions for families in which a child has
reactive attachment disorder or disinhibited social engagement
disorder include (1) psychosocial support services, including
hiring a homemaker, improving the physical condition of the
apartment, or obtaining more adequate housing; improving the
family’s financial status; and decreasing the family’s isolation;
(2) psychotherapeutic interventions, including individual psy-
chotherapy, psychotropic medications, and family or marital
therapy; (3) educational counseling services, including mother–
infant or mother–toddler groups, and counseling to increase
awareness and understanding of the child’s needs and to develop
parenting skills; and (4) provisions for close monitoring of the
progression of the patient’s emotional and physical well-being.
Sometimes, separating a child from the stressful home environ-
ment temporarily, as in hospitalization, allows the child to break
out of the accustomed pattern. A neutral setting, such as the hos-
pital, is the best place to start with families who are genuinely
available emotionally and physically for intervention. If inter-
ventions are unfeasible or inadequate or if they fail, placement
with relatives or in foster care, adoption, or a group home or
residential treatment facility must be considered.
R
eferences
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attachment organization among maltreated children: Results of a randomized
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2012;83:623–636.
Boris NW, Zeanah CH. Reactive attachment disorder of infancy, childhood and
adolescence. In: BJ Sadock, VA Sadock, Ruiz P, eds.
Kaplan & Sadock’s Com-
prehensive Textbook of Psychiatry.
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Chaffin M, Hanson R, Saunders BE, Nichols T, Barnett D, Zeanah C, Berliner
L, Egeland B, Newman E, Lyon T, LeTourneau E, Miller-Perrin C. Report of
the APSAC task force on attachment therapy, reactive attachment disorder, and
attachment problems.
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Heller SS, Boris NW, Fuselier SH, Pate T, Koren-Karie N, Miron D. Reactive
attachment disorder in maltreated twins follow-up: From 18 months to 8 years.
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Kay C, Green J. Reactive attachment disorder following maltreatment: Systematic
evidence beyond the institution.
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problems in maltreated children referred with indiscriminate friendliness.
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31.11b Posttraumatic Stress
Disorder of Infancy, Childhood,
and Adolescence
Posttraumatic stress disorder (PTSD), formerly grouped with
anxiety disorders, currently falls under a new chapter in the
Fifth Edition of the American Psychiatric Association’s
Diag-
nostic and Statistical Manual of Mental Disorders
(DSM-5)
called trauma- and stressor-related disorders, a group compris-
ing disorders in which exposure to a traumatic or stressful
event is a diagnostic criterion. PTSD is characterized by a set
of symptoms including intrusive memories of the trauma, per-
sistent avoidance of stimuli that are reminders of the traumatic
event, persistent negative alterations in cognition and mood, and
alterations in arousal, mainly seen as hyperarousal and irritabil-
ity following the traumatic event. In DSM-5, the traumatic event
criterion is defined as exposure to actual or threatened death,
serious injury, or sexual violence, whether directly, by witness-
ing it, learning of a traumatic event to a family member, or expe-
riencing repeated exposures to trauma precipitated by social or
natural disasters. Exposure to trauma through electronic media,
movies, television or photographs is excluded from the crite-
ria. In children 6 years or younger, diagnostic criteria fall under
the “preschool subtype,” in which either persistent avoidance of
trauma-evoking stimuli or negative alterations in cognitions suf-
fice as indications for PTSD.
In the United States, the rates of children and adolescents
being exposed to violence and traumatic events are extremely
high. In a nationally representative sample of children and
adolescents, exposure to a traumatic event was reported to be
60.4 percent, with a lifetime rate ranging from 80 to 90 per-
cent. A significant number of children and adolescents who are
exposed to traumatic events, ranging from direct experiences
with physical or sexual abuse, domestic violence, motor vehi-
cle accidents, severe medical illnesses, or natural or human-
created disasters, will develop PTSD. In children younger than
the age of 6 years, spontaneous and intrusive memories may be
expressed in play, or occur in frightening dreams; these intru-
sive thoughts may not be easily identified as related to the trau-
matic event.
Although posttraumatic stress symptoms have been described
in adults for more than a century, PTSD was first officially rec-
ognized as a psychiatric disorder in 1980 in the DSM, Third
Edition (DSM-III). Recognition of the frequency of PTSD in
children and adolescents has increased over the last decade.
Reports indicate that up to 6 percent of youth are likely to
meet full criteria for PTSD at some point in their development.
Developmental factors strongly influence the manifestations of
symptoms of PTSD. In children and adolescents, reexperiencing
of a traumatic event is often observed through play, recurrent
nightmares without recall of the traumatic events, and behaviors
