Posttraumatic Stress Disorder in Infants, Toddlers, and Young Children:

Diagnostic Considerations
Yasik, Anastasia E., Journal of Earl Childhood and Infant Pscholog
Pre!alence of Trauma E"#osure
Young children are frequently exposed to traumatic events in the United States and throughout the world. An
appreciation of the prevalence of trauma exposure and the indicators of negative reactions to stress is critical for
professionals working with young children. According to the National Center for n!ury "revention and Control
#NC"C$ %&&'($ )&*$&&& children in the United States were at risk for or experienced a+use and or neglect in
%&&,. -he .ffice of the "ress Secretary of the United States reported that in %&&% approximately )&&$&&&
children were victims of a+use or neglect. "hysical a+use was evident among ,)/ of victims and ,&/ were
sexually a+used. Similarly$ the NC"C #%&&,( reports that approximately *&/ of rapes occur +efore the age of
,%.
0ith respect to accident related traumas a host of events #e.g.$ motor vehicle accidents$ dog +ites$ +icycle
accidents$ fires( have +een investigated and suggest high degrees of traumatic exposure in the early years of
life. 1or example$ the %&&* motor vehicle accident in!ury rate for children less than 2 years was *&& per
,&&$&&& and increased to *3% per ,&&$&&& +etween the ages of 24) years #National 5ighway -raffic Safety
Administration$ %&&'(. Nearly *,$&&& children +etween the ages of 24,' years accounted for pedestrian4related
in!uries in %&&% #NC"C$ %&&'(. 0ith regard to non4motor vehicle accidents the %&&* in!ury rates were ,2 per
,&&$&&& and 2) per ,&&$&&& for less than 2 years of age and 2 to ) years of age$ respectively. 6icycling
accidents account for approximately ,'&$&&& children under the age of ,2 who are treated for traumatic +rain
in!uries. 1urthermore$ the risk for dog +ites is greater among children$ with %.2/ of children per year +eing
+itten +y a dog #NC"C$ %&&,(. n addition$ '2/ of fireworks4related in!uries involved children +elow the age
of ,' years with children 2 to ) years old +eing at greatest risk. Similarly$ children under ' are at greater risk for
fire4related in!uries #NC"C$ %&&'(. 7iven the degree of exposure to traumatic events$ it is important to
understand the reactions infants$ toddlers$ and children may have to such traumatic events.
5istory of Stress 8eactions in Children
-he effects of traumatic experiences on young children have long +een of interest to clinicians and researchers.
As early as ,)*3$ 6ender and 6lau examined sixteen children at the Children9s 0ard of the "sychiatric :ivision
of 6ellevue 5ospital who had had sexual relations with adults. -he authors made specific reference to feelings
of fear$ avoidance$ irrita+ility$ nightmares$ trauma reenactments$ and hypervigilance. n some cases$ academic
impairment was also indicated. 0hereas a great ma!ority of literature during 0orld 0ar recorded the
symptoms of adults exposed to war4related stressors #Saigh$ ,))%($ several researchers #e.g.$ 6odman$ ,)',;
<ercer = :espert$ ,)'*( examined the psychiatric mor+idity of children who were exposed to compara+le
stressors.
n ,)',$ 1rank 6odman$ the :eputy :irector of the 6ristol Child 7uidance Clinic$ reported on the findings of a
survey examining the incidence of >strain> following the 6ritish air4raids on ?$&&& 6ritish school children
ranging in age from five to fourteen years. t was o+served that '/ presented with psychological #e.g.$
nightmares$ war4related fears$ psycho4physiological reactivity$ avoidance$ aggressive +ehaviors( or
psychosomatic #e.g.$ headaches$ enuresis$ encopresis$ indigestion( symptoms. 7iven that this survey was
conducted during a time when raids were still occurring$ 6odman conducted a follow4up study with 2' children
#age range % months to ,% years( who had +een evacuated from the Children9s 5ospital in 6ristol. According to
6odman #,)',($ >soldiers were crunching through a litter of +roken glass$ fallen plaster$ and +lown4in +lack4
out material$ picking children out of cots and +eds and$ tucking them under their arms$ running down the steps
and dumping them pell4mell into the lorry> #p. '?@(. Up to two months later$ @,/ of these children showed
symptoms that were attri+uted to the raids. Aleven percent evidenced symptoms seven months afterward.
Shortly thereafter$ <ercer and :espert #,)'*( examined the effects of war on 1rench children. -hese children
were reported to suffer from increased heart rate$ enuresis$ nightmares$ trauma4related recollections$ memory
impairment$ and academic impairment.
Su+sequent to 0orld 0ar $ Carey4-refBer #,)')( followed ,$%&* 6ritish school children who were exposed to
war4related stressors such as air4raids$ evacuation$ change in family life$ loss of schooling$ and housing
pro+lems. .f these$ %,% #,3.@/ of the sample( presented with >distur+ances caused or aggravated +y war
experiences> #Carey4-refBer$ ,)')$ p. 22@(. Symptoms included irrita+ility$ concentration impairment$ memory
impairment$ sleep distur+ance$ and avoidance +ehaviors. n addition$ *&.@/ of the affected youth experienced
academic difficulties. Carey4-refBer concluded that these impairments reflect >the degree to which emotional
distur+ances affect the capacity to learn> #p. 2'@(.
6loch$ Sil+er$ and "erry #,)2@( explored the emotional reactions to ,?2 students attending a pu+lic school in
Cicks+urg$ <ississippi. .n Saturday :ecem+er 2$ ,)2*$ these youth were exposed to extreme stress when a
tornado hit their community causing considera+le damage. 1orty4seven youth #%2.'/ of the sample( presented
with mild to severe symptoms related to the tornado. Symptoms included trauma specific re4enactments #e.g.$
tornado games($ irrita+ility$ hypervigilance$ avoidance$ and enuresis.
0ithin the context of criminal victimiBation$ -err #,)3)$ ,)?*$ ,)),( interviewed %@ school children #ages 24,'
years( who had +een kidnapped in Chowchilla$ California. Children reported a variety of symptoms such as
fears$ play reenactments of the trauma$ personality changes$ hallucinations$ enuresis$ and anniversary reactions.
6ased on her work with traumatiBed children$ -err proposed four categories of symptoms common to many
children exposed to trauma. -hese categories includedD ,( repetitive memories of the traumatic event; %(
repetitive +ehaviors #e.g.$ play$ traumatic reenactments(; *( trauma4specific fears; and '( changed attitudes
a+out people$ life$ and the future. -err went on to divide childhood traumas into two +asic types. -ype trauma
involves single incident$ acute traumas. -ype traumas were descri+ed as involving repeated exposure to
traumatic events such as a+use. -err further indicated that characteristics of +oth types of childhood trauma
could exist side +y side. -his represents one of the early attempts at classify children9s reactions to traumatic
events.
Since that time$ more formal diagnostic classifications have developed and +een implemented in clinical and
research settings. -he literature on child and adolescent posttraumatic stress disorder has flourished examining
children exposed to war4related stressors$ criminal victimiBation #e.g.$ sexual a+use$ sexual assault($ accidents$
and natural disasters #Saigh$ Yasik$ Sack$ = EoplewicB$ ,)))(. -he great ma!ority of these studies have utiliBed
diagnostic criteria esta+lished for adults to formulate diagnoses and have not typically included children
younger than the ages of @ or 3. As such$ a consideration for the similarities and differences among availa+le
diagnostic criteria is undertaken with implications for diagnosing posttraumatic stress in young children
#including infants and toddlers(.
Current :iagnostic Classifications
0ith the pu+lication of the :iagnostic Statistical <anual4 #A"A$ ,)?&( the diagnostic category of
posttraumatic stress disorder #"-S:( was introduced into the diagnostic nomenclature. Not until the :S<448
#A"A$ ,)?3($ however$ were children considered in the diagnostic classification of "-S:. Currently two
diagnostic classification systems are utiliBed in the United States for classifying stress reactions in infants$
toddlers$ and young children. -hese classification systems are the :S<4C #A"A$ ,))'( and the :iagnostic
Classification of <ental 5ealth and :evelopmental :isorders of nfancy and Aarly Childhood #:C &4*; Fero to
-hreeGNational Center for Clinical nfant "rograms$ ,))'(.
-he :S<4C descri+es "-S: as the development of characteristic symptoms following exposure to >an event
or events that involve actual or threatened death or serious in!ury$ or a threat to the physical integrity of oneself
or others> #A"A$ ,))'$ p. '%?(. n order to diagnosis "-S: via :S<4C criteria the person must also present
with situational reactivity descri+ed as >intense fear$ helplessness$ or horror> to the event. -he three symptom
areas for "-S: in the :S<4C includeD reexperiencing of the traumatic event$ avoidance of and or num+ing
related to traumatic reminders$ and increased arousal. 0ith respect to diagnosing "-S: in children the :S<4C
presents three diagnostic notes for reexperiencing symptoms. Specifically$ >n young children$ repetitive play
may occur in which themes or aspects of the trauma are expressed>. Also$ >n children$ there may +e frightening
dreams without recogniBa+le content> and >n young children trauma4 specific reenactment may occur>. :espite
the thorough process #i.e.$ clinical and community +ased field trials( that went into developing these criteria$ it
is of critical importance to those working with young children to recogniBe that the :S<4C field trials for
"-S: did not include youth +elow the age of ,2 years #Eilpatrick et al.$ ,))?(. -hus the applica+ility of these
criteria for children younger than the age of ,2 has not +een firmly esta+lished.
n an attempt to develop a diagnostic nomenclature appropriate for very young children$ the :iagnostic
ClassificationD &4* #:CD &4*; Fero to -hree$ ,))'( utiliBed -ask 1orces comprised of clinicians and researchers
who gathered information from infant and child mental health programs throughout the US$ Canada$ and
Aurope to esta+lish diagnostic criteria for a variety of disorders evidenced at this early age #e.g.$ traumatic stress
disorder$ disorders of affect$ anxiety disorders of infancy and early childhood$ mood disorders(. nitial
diagnostic formulations were developed from +ehavioral case descriptions and recurring patterns of +ehavioral
pro+lems evidenced. :iscussion regarding the information gathered ensued with the development of diagnostic
categories +ased on expert consensus.
As noted in the :CD &4*D
6ecause an infant or young child$ in comparison with an adult$ is
capa+le of only a limited num+er of +ehavioral patterns or
responses to various stresses or difficulties #e.g.$ somatic
symptoms$ irrita+ility$ withdrawal$ impulsivity$ fears$ and
developmental delays($ some overlap is inevita+le. -he primary
diagnosis should reflect the most prominent features of the
disorder #p. ,@(.
n esta+lishing a diagnosis according to the :CD &4* a hierarchy of considerations is indicated. Specifically$ if
the infant or child has experienced a clear stressor a diagnosis of >traumatic stress disorder> should +e
considered first. Similar to the :S<4C this diagnosis is considered when >an infant or toddler9s direct
experience$ witnessing$ or confrontation with an event or events that involve actual or threatened death or
serious in!ury to the child or others$ or a threat to the psychological or physical integrity of the child or others>
#:CD &4*$ ,))'$ p. ,)(. 5owever$ in contrast to the :S<4C$ the requirement of situational reactivity is not
included in the :CD &4*.
Similar to the diagnostic structure of the :S<4C the :CD &4* classification of traumatic stress disorder
includes consideration for re4experiencing$ num+ing$ and increased arousal symptoms; however$ differences
exist with respect to the exact symptom threshold required for diagnosis. 0hile the :S<4C requires the
presence of one re4experiencing$ three avoidance and num+ing$ and two increased arousal symptoms$ the :CD
&4* requires the presence of only one per symptom cluster to diagnosis traumatic stress disorder. 1urthermore$
symptoms are descri+ed in more developmentally appropriate terminology. 8eexperiencing symptoms includeD
post4traumatic play$ recurrent recollections of the traumatic event #e.g.$ statements or questions a+out the
event($ repeated nightmares$ distress upon exposure to traumatic reminders$ and flash+acks or dissociation
o+!ectively noted +y o+servers. -he second symptom area includes the following aspects of num+ingD increased
social withdrawal$ restricted range of affect$ loss of previously acquired developmental skills$ and a decrease or
constriction of play. ncreased arousal is evidenced +y night terrors$ difficulty going to sleep$ difficulty staying
asleep$ hypervigilance$ and startle response.
n contrast to "-S: as descri+ed in the :S<4C$ traumatic stress disorder as descri+ed in the &4* classification
includes the additional category of newly developed symptoms that were not evidenced prior to the traumatic
event. -his symptom area encompasses several types of aggressive$ fearGanxiety$ and +ehavioral difficulties. A
summary of the symptoms comprising this category includesD aggressive +ehaviors towards peers$ adults$ or
animals; separation anxiety$ fear of toileting alone$ fear of dark$ or other fears; manipulative +ehaviors;
provocative +ehaviors that may provoke a+use; sexual and or aggressive +ehaviors; immediate nonver+al
reactions #e.g.$ somatic symptoms$ motor reenactments(; and other new symptoms. -a+le , presents a complete
description of the :CD &4* diagnostic criteria for traumatic stress disorder.
Scheeringa and colleagues #Scheeringa$ "ee+les$ Cook$ = Feanah$ %&&,; Scheeringa$ Feanah$ :rell$ = Harrieu$
,))2; Scheeringa$ Feanah$ <yers$ = "utnam$ %&&*( in a series of experiments have explored the validity of
these diagnostic criteria for use with preschool children relative to the utility of :S<C diagnostic criteria.
Specifically$ Scheeringa et al. #%&&*( examined sixty4two children aged %& months to six years who had +een
exposed to <CA9s$ in!uries$ a+use$ or witnessed traumas and sixty4three healthy$ non4traumatiBed children.
6ased on the "osttraumatic Stress :isorder Semi4Structured nterview and .+servation 8ecord for nfants and
Young Children #Sheeringa = Feanah$ ,))'($ none of the traumatiBed children met the :S<4C diagnostic
criteria for "-S:. 5owever$ @?/ of traumatiBed children evidenced at least one reexperiencing symptom and
'2/ evidenced two or more increased arousal symptoms. n contrast$ only %/ evidenced * or more :S<4C
avoidance and num+ing symptoms.
1urther exploration of the num+er of avoidance and num+ing symptoms required for diagnostic purposes was
conducted +y Scheeringa et al. #%&&*($ who also explored the utility of including loss of developmental skills
within that symptom domain. Accordingly$ ,,/ of children evidenced two or more avoidance and num+ing
symptoms and *)/ evidenced one or more symptoms. 0ith regard to the inclusion of loss of previously
acquired developmental skills$ %,/ of children lost two or more such symptoms and 2%/ had the loss of one or
more developmental skills. 6ased on this information$ it was proposed that there was insufficient evidence for
the inclusion of loss of developmental skills as a diagnostic criterion. 1urthermore$ a reduction from three to
one avoidance and num+ing symptom is considered most efficacious.
Along these same lines$ the inclusion of new fears in the :CD &4* relative to the :S<4C criteria was not
supported +y the work of Sheeringa et al. #%&&*(. n total$ 3)/ of traumatiBed children presented with new
symptoms not present +efore the trauma. -his was the most frequent symptom area and was not considered
useful in differentiating children with and without "-S:. As such$ the inclusion of this in diagnosing traumatic
stress disorder is in question.
1ollowing a petroleum gas leak explosion in a nursery school in Iapan$ .hmi et al. #%&&%( explored the utility
of the :S<4C criteria for diagnosing "-S: and alternative criteria #Scheeringa et al.$ ,))2$ %&&*( in
preschool children #aged *% to 3* months(. Symptom reports were +ased on maternal report at ,& days$ @
months and , year after the accident for all of the *% children present at the time of the explosion. At the @
month time point$ no child was considered to meet :S<4C criteria for "-S:. 5owever$ %2/ of children at @
months were considered to have "-S: +ased on the alternative criteria. -his data provides further support for
the lack of sensitivity of the :S<4C in diagnosing traumatic stress reactions in infants and toddlers. Clinicians
need to consider more age4appropriate diagnostic decision making for this age group.
Comor+idity ssues
Complicating the issue of diagnosis in infants and toddlers is the frequency with which hyperactive +ehaviors
are present in this age group. Young children are frequently referred for disorders of impulse control #e.g.$
attention deficit hyperactivity disorder JA:5:K( that result in overactivity which parents and caregivers find
difficult to manage. -hese most prominent symptoms however may +e masking important underlying
etiological factors. 1urthermore$ this inaccurate emphasis on externaliBing pro+lems may impede the
identification and implementation of an appropriate intervention.
-homas and 7uskin #%&&,( explored the relationship +etween the :S<48GC and the :CD&4* diagnoses
among a sample of ?% children aged ,? to '3 months who had presented to an early childhood psychiatry clinic
due to disruptive +ehaviors. According to :S< criteria$ @?.*/ of the sample was diagnosed with an emotional
#e.g.$ separation anxiety$ anxiety disorder not otherwise specified JN.SK$ mood disorder N.S($ or +ehavioral
disorder #i.e.$ A:5:$ oppositional defiant disorder$ disruptive +ehavior disorder N.S(. .f the *'.,/ of
children with a +ehavioral disorder$ 3.,/ were diagnosed with traumatic stress disorder via :CD &4*. -raumatic
stress disorder was also diagnosed in *.3/ of children with a :S< diagnosis of emotional disorder and *.3/ of
those with a :S< diagnosis of ad!ustment disorder. All of the ,*.'/ of children diagnosed with "-S:
according to the :S< were also diagnosed with traumatic stress disorder via :CD &4*. n total$ %*.%/ of
children were diagnosed with a traumatic stress disorder. 1urther exploration of symptom presentation$
indicated that 2%.@/ of those with a traumatic stress disorder had C6CH AxternaliBing scores considered to +e
in the clinically significant range.
Along these same lines$ Scheeringa et al. #%&&*( reported that @*/ of preschoolers with "-S: had separation
anxiety disorder$ *?/ had A:5:$ and 32/ oppositional defiant disorder +ased on :S<4C diagnostic criteria.
Similarly$ those preschoolers with "-S: had significantly higher C6CH -otal$ nternaliBing$ and AxternaliBing
pro+lem +ehaviors relative to traumatiBed preschoolers without "-S: and healthy controls. Similarly$ Saigh$
Yasik$ .+erfield$ 5alamandaris$ and <c5ugh #%&&%( reported that @&.)/ of children and adolescents with
"-S: su+sequent to a variety of traumatic events #e.g.$ sexual assaults$ physical assaults$ motor vehicle
accidents( had scores that fell within the clinical range on the C6CH nternaliBing scale and '*.2/ had scores
in the clinical range on the AxternaliBing scale. Children with "-S: may present with a host of +ehavioral and
affective symptoms that may often divert attention from the possi+le etiological traumatic event.
8isk 1actors
0ithin a diagnostic decision making framework$ it is important to consider factors +eyond the traumatic event
that may increase the risk of a young child developing traumatic stress disorder. <any varia+les have +een
explored as risk factors for the development of "-S: in children. Some of these factors include$ +ut are not
limited to$ age and or developmental status$ gender$ intensity of the traumatic event$ proximity to the event$
personality characteristics of the child$ and parental psychopathology #8o!as = "apagallo$ %&&'; Saigh et al.$
,)))(. n the main$ much of the research exploring these risk factors has not included infants and toddlers.
7iven this particularly vulnera+le developmental stage$ how parents deal with the traumatic event can +e a
critical factor in how the child responds.
Haor$ 0olmer$ <ayes$ 7ershon$ 0eiBman$ and Cohen #,))3( conducted a longitudinal study of sraeli
preschoolers #aged *42 years( and their mothers exposed to Scud missile attacks during the 7ulf 0ar. -hese
families were divided into the following three groups for comparison purposesD families displaced from their
homes due to damage sustained during the war$ families not displaced as their homes remained intact$ and those
from an area not directly hit +y missiles. 8esults indicated that 3.?/ of preschoolers evidenced sufficient
symptoms of "-S: to warrant a diagnosis. 1urthermore$ displaced children as well as their mothers evidenced
significantly more "-S: symptoms than those in the other two groups. 1or the entire sample$ maternal
avoidance symptoms were the only significant predictor of children9s symptoms at *& months.
0ithin the displaced group$ the relationship +etween maternal and child symptoms was further examined +y
child9s age. Among the * year olds$ maternal intrusive and avoidant symptoms were significantly correlated
with the child9s posttraumatic symptoms. <aternal intrusive symptoms only significantly correlated with
symptoms in ' year old children. n contrast$ among 2 year olds there was a non4significant relationship
+etween maternal and child symptoms. n light of this information$ Haor et al. #,))3( concluded that older
children were less dependent on maternal reactions than younger children.
<ore recently$ Almqvist and 6ro+erg #,)))( examined risk and protective factors among 2& ranian refugee
preschoolers #aged '4? years( twelve months and three and a half years after they entered Sweden. At +oth
times periods$ ,?/ of the preschoolers meet :S<4C criteria for "-S: #Almqvist = 6randell1ors+erg$ ,))2$
,))3(. Similarly$ ,?/ evidenced symptoms of posttraumatic stress at twelve months with a decrease in
symptoms over time. <aternal mental health difficulties were found to +e a significant predictor of children9s
mental health pro+lems$ which included symptoms of "-S: plus other symptoms of >psychological
distur+ance> #Almqvist = 6ro+erg$ ,)))(.
Six to seven months following an industrial accident$ in which the ground caved in and there was threat of
+uilding collapse three groups of children #agesD '4,*( and their parents were assessed +y Cila$ 0itkowski$
-ondini$ "ereB4:iaB$ <ouren4Simeoni$ and Iouvet #%&&,(. -he three groups consisted of those who had +een
evacuated from their homes #>disaster>($ families from non4evacuated regions #>threatened>($ and families from
an area not in danger of ground collapse #>control>(. Children in the disaster group had significantly higher
levels of posttraumatic symptoms on the mpact of Avents Scale48evised compared to the threatened and the
control groups. -his difference was especially evident with respect to avoidance symptoms. "arents$ +oth
mothers and fathers$ from the disaster group reported poorer mental health on the 7eneral 5ealth Luestionnaire
compared to parents from the other two comparison groups. 1urthermore$ there was a significant positive
correlation +etween the mental health ratings of spouses such that as one spouse reported greater psychological
distress the other spouse9s distress also increased. "arental mental health also correlated with avoidance
symptoms in children. <aternal mental health correlated with intrusive symptoms in children.
-hese studies emphasiBe the importance of evaluating the reaction of all family mem+ers exposed to traumatic
events and not simply focusing on the referred child. "arents may serve as a +uffer and resource for traumatiBed
infants$ toddlers$ and children #8o!as = "apagallo$ %&&'(. 7iven parental psychological difficulties$ their
availa+ility to their child may +e impaired and thus impede the healing process for young children. .f particular
interest is that this relationship was evidenced for +oth mothers and fathers #Cila et al.$ %&&,(. "arental
participation is key to the treatment of stress reactions in children and factors that might influence such
participation #i.e.$ parental reactions to traumatic events( should +e considered.
Conclusions
6ased on the literature reviewed it is evident that the applica+ility of the :S<4C diagnostic criteria for "-S:
is insufficient for use with young children$ especially infants and toddlers. 6ased on much of the work +y
Scheeringa et al. #,))2$ %&&,$ %&&*($ it appears that the :S<4C criteria set symptom thresholds and the
requirement of situational reactivity that are insensitive to the presentation of traumatic stress reactions in
young children. nstead$ clinicians would +e well served to consider the :CD &4* diagnostic criteria for younger
children as evidence suggests these criteria have greater sensitivity for infants and toddlers compara+le to the
:S<4C system.
n addition$ to diagnostic criteria it is important to consider the context of the traumatic experience and the
involvement and reactions of parents. 7iven that parental psychopathology is denoted as a risk factor for
posttraumatic reactions in children #8o!as = "apagallo$ %&&'; Saigh et al.$ ,)))($ this is essential to consider as
the diagnosis of traumatic stress disorder in very young children is often +ased on parental report. 1urthermore$
parents and caregivers may +e focused on externaliBing +ehaviors that are disruptive within the home or school
environment. -hese acting out +ehaviors may reflect a manifestation of underlying traumatic reactions. Clearly$
further investigation into the presentation of traumatic reactions in infants and toddlers is necessary.
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Saigh$ ". A.$ Yasik$ A. A.$ .+erfield$ 8. A.$ 5alamandaris$ ". C.$ = <c5ugh$ <. #%&&%(. An analysis of the
internaliBing and externaliBing +ehaviors of traumatiBed ur+an youth with and without "-S:. Iournal of
A+normal "sychology$ *$ '@%4'3&.
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disorderD "revalence$ risk factors and comor+idity. n ". A. Saigh = I. :. 6remner #Ads.($ "osttraumatic stress
disorderD A comprehensive text+ook #pp. ,?4'*(. 6ostonD Allyn = 6acon.
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and Adolescent "sychiatry$ '&$ 2%4@&.
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diagnosis of "-S: in infants and young children #&4'? months(. New .rleansD -ulane University School of
<edicine.
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American Iournal of "sychiatry$ ,'&$ ,2'*4,22&.
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Fero to -hreeG National Center for Clinical nfant "rograms #,))'(. :iagnostic Classification of <ental 5ealth
and :evelopmental :isorders of nfancy and Aarly Childhood. Arlington$ CAD Author.
Anastasia A. Yasik$ "h.:.
"ace University
All correspondence should +e addressed to Anastasia A. Yasik$ "h.:.$ "ace University$ "sychology :epartment$
', "ark 8ow$ New York$ NY ,&&*?. Amail may +e sent to ayasikOpace.edu
-a+le ,D :CD &4* :iagnostic Criteria for -raumatic Stress
:isorder
,. A re4experiencing of the traumatic event#s( as evidenced +y at
least one of the followingD
a. "ost4traumatic play44that is$ play that represents a
reenactment of some aspect of the trauma$ is compulsively driven$
fails to relieve anxiety$ and is literal and less ela+orate and
imaginative than usual. -his is seen instead of adaptive play
reenactment4that is$ play that represents some aspect of the
trauma +ut lacks the other characteristics of post4traumatic play.
+. 8ecurrent recollections of the traumatic event outside of play44
that is$ repeated statements of questions a+out the event that
suggest a fascination with the event or preoccupation with some
aspect of the event. :istress is not necessarily apparent.
c. 8epeated nightmares$ especially if content can +e ascertained
and has o+vious links to trauma.
d. :istress at exposure to reminders of the trauma.
e. Apisodes with o+!ective features of a flash+ack or dissociation
44that is$ reenactment of the event without any sense of where the
ideas for the reenactment are coming from$ i.e.$ the +ehavior is
dissociated from the child9s intentionality or sense of purpose.
%. A num+ing of responsiveness in a child or interference with
developmental momentum$ appearing after a traumatic event and
revealed +y at least one of the followingD
a. ncreased social withdrawal.
+. 8estricted range of affect.
c. -emporary loss of previously acquired developmental skills$
e.g.$ toilet training$ language$ relating to others.
d. A decrease or constriction in play compared to the child9s
pattern +efore the traumatic event.
*. Symptoms of increased arousal that appear after a traumatic
event$ as revealed +y at least one of the followingD
a. Night terrors4that is$ symptoms of an arousal disorder in
which the child starts from sleep with a panicky scream has
agitated motor movements$ is unresponsive and inconsola+le$ and
shows signs of autonomic arousal$ such as rapid +reathing$ racing
pulse$ and sweating. -he episodes tend to occur in the first third
of the night and last from one to five minutes. No content can +e
ascertained at the time or the following day.
+. :ifficulty going to sleep$ evidenced +y strong +edtime protest
or trou+le falling asleep.
c. 8epeated night waking unrelated to nightmares or night terrors.
d. Significant attentional difficulties and decreased
concentration.
e. 5ypervigilance.
f. Axaggerated startle response.
'. Symptoms$ especially fears or aggression$ that were not present
+efore the traumatic event$ including at least one of the
followingD
a. Aggression toward peers$ adults or animals.
+. Separation anxiety.
c. 1ear of toileting alone.
d. 1ear of the dark.
e. .ther new fears.
f. "essimism or self4defeating +ehavior$ manipulativeness #designed
to gain control($ or masochistic provactiveness #+ehavior that
provokes a+use(.
g. Sexual or aggressive +ehaviors inappropriate for a child9s age.
h. .ther nonver+al reactions experienced at the time of the trauma$
including somatic symptoms$ motor reenactments$ skin stigmata$
pain$ or posturing.
i. .ther new symptoms.
NoteD Criteria from Fero to -hreeG National Center for Clinical
nfant "rograms #,))'(. :iagnostic Classification of <ental 5ealth
and :evelopmental :isorders of nfancy and Aarly Childhood.
Arlington$ CAD Author. 8eprinted with permission.