Psychiatric comorbidity in childhood post traumatic stress disorder.

OBJECTIVE: The purpose of this study was to examine the psychiatric comorbidity between children presenting with Post Traumatic Stress Disorder (PTSD) and traumatized children not developing this disorder. DESIGN: One-hundred and seventeen severely maltreated children were examined for evidence of PTSD. Analyses probed for diagnostic relationship, between PTSD and other formal diagnoses on The Diagnostic Interview for Children and Adolescents, Revised Version (DICA-CR). PARTICIPANTS: All children presented before a juvenile/family court due to severe child maltreatment and psychological trauma. These children had been ordered removed from parental custody due to the trauma suffered by the child. For the purposes of analyses, this entire group of maltreated and traumatized children were dichotomized into a PTSD group and a non-PTSD group. Thirty-five percent (41 of 117) of the children met strict DICA criteria for PTSD. MEASUREMENTS: The children were examined by means of a structured clinical interview. The Diagnostic Interview for Children and Adolescents, revised version (DICA-Child-R), along with a more general psychiatric interview. The DICA-Child-R responses provided the only determination of whether the children met formal PTSD criteria. Data gathering on the sample also included a comprehensive review of risk factors for the development of PTSD, including demographics, and type(s) of trauma suffered. RESULTS: Findings revealed that the PTSD diagnosis was significantly correlated with: 1. Attention Deficit Hyperactivity Disorder (ADHD) 2. Other anxiety disorders 3. Brief Psychotic Disorder or Psychotic Disorder NOS 4. The presence of suicidal ideation 5. A trend toward mood disorders. There were no differences between the two samples on measures of age, race, and family income. CONCLUSIONS: Pediatric PTSD is a severe psychiatric disorder. In this study, PTSD was statistically related to other formal psychiatric diagnoses. The investigators attended to the issues relating to true comorbidity versus inaccurate diagnosis secondary to symptom overlap between different conditions. Applying strict criteria, the results suggest that the presence of PTSD in children confers a substantial likelihood of other formal diagnosis. Moreover, the symptom of suicidal ideation was overrepresented among PTSD subjects. Given these additional conditions, more extensive evaluation and specialized, multi-modal treatment should be considered in children presenting with PTSD.

Maternal and child posttraumatic stress disorder in cases of child maltreatment.

The purpose of this study was to examine the rates of posttraumatic stress disorder (PTSD) among a sample of severely maltreated children and their mothers, and to investigate the age of onset of documented maltreatment in these children. The sample consisted of 109 pairs of women and their children who were before a juvenile/family court due to maltreatment of sufficient severity to warrant removal of the child from parental custody. Children were examined using the PTSD Section of the Diagnostic Interview for Children and Adolescents, Revised 6th Version (DICA-6-R). The PTSD Module of the Structured Clinical Interview for DSM-III-R (SCID) was administered to all mothers. Clinical psychiatric interviews were also administered to all children and mothers. From the sample of 109 cases, 15.6% of the mothers met SCID criteria for a current presentation of PTSD, while 36.7% had a past history of PTSD. Of the 109 evaluated children, 35.8% met current DICA criteria for PTSD. Posttraumatic stress disorder is significantly overrepresented in the children of mothers diagnosed with PTSD (p = .001). The average age of maltreatment onset was 46.4 months among the children diagnosed as PTSD, and was 61.3 months in the group of seriously maltreated children who did not develop PTSD (p = .038). The onset of maltreatment is significantly earlier among children whose mothers meet PTSD criteria than among other maltreated children (p = .025). Intergenerational transmission of violence and developmental effects of traumatic experiences upon the young child are discussed.

Child maltreatment and the development of posttraumatic stress disorder.

OBJECTIVE--The purpose of this study was to compare the relative effects of various forms of maltreatment on the development of posttraumatic stress disorder (PTSD) in children. DESIGN--Children were randomly selected from a population of court-involved maltreated children. The children were then assigned to a PTSD group and a non-PTSD group on the basis of their responses to a structured interview. SETTING--A juvenile/family court in a large urban area. PARTICIPANTS--This study examined 101 children who were before a juvenile/family court because of severe child maltreatment. All children had been removed from parental custody as a result of the maltreatment. INTERVENTIONS--None. MEASUREMENTS AND RESULTS--Structured clinical psychiatric interviews were administered to each child and each parent, and all court records were reviewed. The major analyses assessed the extent to which the presence and duration of the most common types of severe maltreatment were associated with a diagnosis of PTSD. Thirty-nine children met criteria for PTSD. Those who were sexually maltreated and those who witnessed family violence had a much greater likelihood of developing PTSD than did those whose histories of maltreatment did not include these types of events. The duration of emotional abuse (psychological terror) also proved to be a significant factor in discriminating children diagnosed as having PTSD from other severely maltreated children. CONCLUSIONS--These findings delineate factors implicated in the cause of PTSD. Moreover, they provide information that will enable the protective service community to screen more effectively for PTSD among maltreated children.

Psychiatric diagnoses of abusive mothers. A preliminary report.

The Structured Clinical Interview for DSM-III-R diagnoses of 54 mothers who had maltreated their children were compared with those of 37 controls. The maltreatment group showed a significantly greater incidence of both current and past diagnoses. Maltreating mothers exhibited a significantly greater incidence of current mood disorder, alcohol abuse, and personality disorder than did controls. The results indicate that past abuse of cocaine, alcohol, other substances and past mood disorders were significantly more prevalent among the maltreatment sample than among controls. Mothers who had maltreated their children were significantly more likely to have histories of posttraumatic stress disorder than were controls.

Differences in neuropsychological and academic achievement between adolescent delinquents and status offenders.

OBJECTIVE: This study sought to determine whether neurocognitive factors could discriminate delinquents brought before a juvenile court in a large urban area from nondelinquent status offenders brought before the same court. METHOD: Psychological tests were administered to 216 adolescents, aged 13-15 years, presenting to a large urban juvenile court. One hundred ten delinquents (65 male and 45 female) were compared to 106 high-risk nondelinquents (65 male and 41 female) on the WISC-R subtests, the Wide Range Achievement Test, and the Memory for Designs Test. RESULTS: Discriminant analysis revealed that the male delinquents could not be discriminated from the comparison group of male status offenders on the basis of scores on any of the measures. Among the female subjects, scores on reading, arithmetic, digit span, and picture completion subtests and the Memory for Designs Test differed significantly between groups, with some of the findings favoring status offenders and others favoring delinquents. CONCLUSIONS: Overall, the findings did not support the hypothesis that inferior intelligence is an independent risk factor for delinquent behavior.

Medical and developmental histories of maltreated children.

This paper represents a first attempt at delineating and summarizing the issues in a child's medical and developmental history associated with the probability of suffering abuse. The sample consisted of 96 children between 5 and 10 years of age, 61 of whom had been maltreated and 35 of whom served as controls. There were 22 items about which the medical and developmental histories of the maltreated children revealed a significantly greater risk than those of the controls. A factor analysis revealed that 78% of the variance in these items can be represented by eight independent factors. None of these factors was dominant; rather, each accounted for a significant amount of the variation among the original items. The individual items tended to load on the four strongest factors in a coherent, interpretable manner: Factor 1 represented behavior problems; factor 2, neonatal issues and failure to thrive; factor 3, familial disruption, with the child suffering mental illness and/or head injury; and factor 4, a "difficult" temperament during the first year of life. We conclude there are numerous independent factors in the medical and developmental histories of maltreated children which should be considered by pediatricians involved in cases of child abuse and neglect.

Psychiatric diagnoses of maltreated children: preliminary findings.

The study sample consists of 96 children (61 maltreated, 35 controls) between 5 and 10 years of age. The two groups of subjects were compared on diagnoses as determined by the administration of the Diagnostic Interview for Children and Adolescents, Revised 6th Version (DICA-6-R) as well as clinical DSM-III-R diagnoses. Children who had suffered maltreatment exhibited significantly greater incidences of attention deficit hyperactivity disorder, oppositional disorder and post-traumatic stress disorder diagnoses than did controls, on both child and parent DICA interviews. The children's interviews revealed that maltreated children present with a significant incidence of psychotic symptomatology as well as personality and adjustment disorders. Conversely, conduct and mood disorders emerged as significant factors in the parent interviews, with the maltreated group showing significantly greater incidence of these diagnoses.

Parental substance abuse and the nature of child maltreatment.

The authors reviewed 190 randomly selected records from the case load of a large juvenile court. These records involved cases in which the state took legal custody of the children following a finding of significant child maltreatment, based on a "clear and convincing" standard of evidence. Sixty-seven percent (127/190) of these cases involved parents who were classified as substance abusers. The results of this study revealed specific associations between (a) alcohol abuse and physical maltreatment and (b) cocaine abuse and sexual maltreatment. Logistic analyses, testing for the effects of polysubstance abuse, revealed that additional forms of substance abuse failed to add significantly to the effects of alcohol in predicting physical maltreatment or cocaine in predicting sexual maltreatment.

Posttraumatic stress disorder among children clinically diagnosed as borderline personality disorder.

Using the Diagnostic Interview for Children and Adolescents, Revised Version (DICA-C-R), the authors evaluated 19 children ages 7 to 14 who had recently been clinically diagnosed as borderline personality disorder by DSM-III-R criteria. The results reveal that 78.9% of these children reported significant traumatic experiences, with 36.8% fitting DICA-C-R criteria for posttraumatic stress disorder. These findings raise the possibility that a diagnosis of borderline personality in childhood can often represent posttraumatic stress disorder.

Child maltreatment histories among runaway and delinquent children.

The records of 378 children presenting to a juvenile court were reviewed for histories of child maltreatment, based on evidence from a formal investigative process by the Department of Social Services. The children came from two groups: delinquents, who had engaged in criminal activity, and status offenders, whose legal involvement was due to non-criminal behavior, such as running away and truancy. Fifty-five percent of the status offenders and 45% of the delinquents had substantiated histories of maltreatment. The percent of status offenders who had been sexually abused was seven times higher among runaways (35%) than among the other members of the group (5%). The percent of delinquents who had been physically maltreated was significantly greater among those convicted of committing violent crimes (27%) than among the non-violent delinquents (14%). Thus, maltreatment may contribute significantly to delinquent behavior.

Symptom differences in acute and chronic presentation of childhood post-traumatic stress disorder.

The authors report on 24 children diagnosed with post-traumatic stress disorder (PTSD) according to DSM-III criteria. Each child was designated as presenting with acute or chronic PTSD depending upon the duration of symptoms. Children with the acute form of PTSD presented with a relative increase in spontaneously acting as though the trauma were recurring upon real or symbolic exposure, difficulty falling asleep, hypervigilance, nightmares, exaggerated startle response, and generalized anxiety/agitation. Those presenting with the chronic form had relative increases in symptoms of detachment, restricted range of affect, dissociative episodes, sadness, and a belief that life will be too hard.

Parental compliance to court-ordered treatment interventions in cases of child maltreatment.

The authors reviewed 136 court cases representing 218 parents of children maltreated enough to warrant custodial transfer of the child from the parents to the state. The court's psychotherapeutic treatment orders were noted and parental compliance with those orders documented and analyzed. The court issued one or more specific treatment orders to 87.26% of all parents. The most common referrals were those for drug or alcohol treatment (61.9%), individual psychotherapy (60.6%), and family treatment (29.4%). Treatment compliance was significantly lowered in those parents presenting with substance abuse. Compliance was also significantly lower among those parents who sexually and/or physically maltreated their children than among parents who neglected but did not physically or sexually maltreat their children.

Propranolol treatment for childhood posttraumatic stress disorder, acute type. A pilot study.

We report 11 cases of posttraumatic stress disorder. Each child had been physically abused or sexually abused or both and presented in an agitated, hyperaroused state. Using a B-A-B (off-on-off) medication design in a clinical setting, the children were treated with the beta-adrenergic antagonist propranolol. Scores on an inventory of symptoms of posttraumatic stress disorder indicated that patients exhibited significantly fewer symptoms while receiving medication than either before or after they received medication.