Articles
New Findings on Alternative Criteria for PTSD in Preschool Children

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ABSTRACT

Objective

An alternative set of criteria for post‐traumatic stress disorder (PTSD) for preschool children was analyzed for validity.

Method

Sixty‐two traumatized children and 63 healthy controls, aged 20 months through 6 years, were assessed. The traumatic experiences included motor vehicle collisions, accidental injuries, abuse, and witnessing violence. The number of symptoms required for clusters C and D and the utility of proposed symptoms were systematically analyzed.

Results

No cases met the DSM‐IV algorithm for PTSD. Cluster B was endorsed 67.9% of the time. The proportion of cases meeting the cluster C threshold was 2% when three symptoms were required, 11% when two symptoms were required, and 39% when one symptom was required. The rate of cluster D was 45% when two symptoms were required and 73% when one symptom was required. Four novel symptoms did not substantially add to the diagnostic validity of the criteria. The optimal algorithm (one cluster B symptom, one cluster C symptom, and two cluster D symptoms) diagnosed PTSD at a rate of 26%. Measures of comorbid symptoms concurrently provided convergent validation to support this revised algorithm.

Conclusion

Revisions to the DSM‐IV PTSD criteria continue to be supported so that highly symptomatic young children can be diagnosed. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(5):561‐570.

Section snippets

Diagnostic Validity of the Alternative Criteria

This alternative set of criteria was compared with the DSM‐IV criteria on a sample of 12 cases younger than 48 months of age (Scheeringa et al., 1995). Four raters rated every symptom for all 12 cases from written case summaries created for the study. The median Cohen ê for interrater reliability for individual alternative symptoms was 0.67 compared with 0.50 for the DSM‐IV symptoms. The κ values ranged from 0.81 to 1.0 for the clusters in the alternative criteria compared with 0.17 to 0.39 for

Participants

Sixty‐two traumatized and 63 healthy control children who were 20 months through 6 years of age were recruited and assessed. The traumatized children were recruited over 16 months from an intensive care inpatient unit of a level 1 trauma center (n = 21), three battered women's shelters (n = 19), an outpatient mental health program that specializes in treating violence‐exposed children (n = 9), a pediatric cancer program (n = 6), and word of mouth (n = 7). Inclusion criteria were that the child

Cluster and Diagnosis Frequencies

The frequencies of each cluster and the rate of diagnosis for varying algorithm thresholds are listed in Table 2. Cluster B (reexperiencing) was common (68%). Cluster C (avoidance/numbing) based on the DSM‐IV threshold of three or more symptoms was extremely rare (2%) but became much more common when the threshold was lowered to one symptom (39%). Cluster D (arousal) was common when the DSM‐IV threshold of two symptoms (45%) was used, and it was more common when only one symptom was required

DISCUSSION

The results of this study make several contributions to understanding the diagnostic validity of PTSD in young children. First, validation was provided again for developmentally modifying the DSM‐IV criteria. The optimal (tentative) revision suggested by these findings is lowering the threshold for cluster C from three symptoms to one symptom. This results in a diagnosis rate of 26%, which contrasts to the DSM‐IV rate of 0%. The 26% rate is much more consistent with studies of traumatized older

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Supported by NIMH grant K08 MH01706 (Dr. Scheeringa) and the MacArthur Foundation Research Network on Early Experience and Brain Development (Dr. Zeanah). The authors thank the Medical Center of Louisiana Charity Hospital Trauma Center, the nursing staff of the Surgical Intermediate Care Area, Crescent House, Metropolitan Battered Women's Program, the Tulane Hospital for Children Pediatric Hematology/Oncology program, Children's Bureau of Greater New Orleans, and the Jefferson Parish Head Start program.

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