Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.11b Posttraumatic Stress Disorder of Infancy, Childhood, and Adolescence

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 Bernard K, Dozier M, Carlson E, Bick J, Lewis-Morrarty, Lindheim O. Enhancing attachment organization among maltreated children: Results of a randomized clinical trial. Child Dev. 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. 9 th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3636. 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. Child Maltreat. 2006;11:76. 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. Attach Hum Dev. 2006;8:63. Kay C, Green J. Reactive attachment disorder following maltreatment: Systematic evidence beyond the institution. J Abnorm Child Psychol. 2013;41:571–581. Kocovska E, Puckering C, Follan M, Smillie M, Gorski C. Neurodevelopmental problems in maltreated children referred with indiscriminate friendliness. Res Dev Disabil. 2012;33:1560–1565. Kocovska E., Wilson P, Young D, Wallace AM, Gorski C. Cortisol secretion in children with symptoms of reactive attachment disorder. Psychiatr Res. 2013; 209:74–77. Minnis H, Macmillan S, Pritchett R, Young D, Wallace B. Prevalence of reac- tive attachment disorder in a deprived population. Br J Psychiatry. 2013; 202:342–346. O’Connor TG, Marvin RS, Rutter M, Olrick J, Britner PA. The ERA Study Team. Child–parent attachment following early institutional deprivation. Dev Psycho- pathol. 2003;15:19–38. O’Connor TG, Zeanah CH. Attachment disorders: Assessment strategies and treat- ment approaches. Attach Hum Dev. 2003;5:223–244. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry. 2005;44:1206. Pritchett R, Pritchett J, Marshall E, Davidson C, Minnis H. Reactive attachment disorder in the general population: A hidden ESSENCE disorder. Sci World J. 2013;2013:818157. Task Force on Research Diagnostic Criteria: Infancy and preschool: Research diagnostic criteria for infants and preschool children. J Am Acad Child Adolesc Psychiatry. 2003;42:1504. Zeanah CH, Scheeringa MS, Boris NW, Heller SS, Smyke AT, Trapani J. Reac- tive attachment disorder in maltreated toddlers. Child Abuse Negl. 2004;28:877.

Zeanah CH, Smyke T, Dumitrescu A. Attachment disturbances in young children II: Indiscriminate behavior and institutional care. J AmAcad Child Adolesc Psy- chiatry. 2002;41:983. Zilberstein K. Clarifying core characteristics of attachment disorders: A review of current research and theory. Am J Orthopsychiatry. 2006;76:55.

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