A Comparative Analysis of the Children's Depression Inventory

A Comparative Analysis of the Children’s Depression Inventory Scores of Traumatized Youth With and Without PTSD Relative to Non-Traumatized Controls

Constance E. Dekis

Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences

COLUMBIA UNIVERSITY

2016

ABSTRACT

A Comparative Analysis of the Children’s Depression Inventory Scores of Traumatized Youth

With and Without PTSD Relative to Non-Traumatized Controls

Constance E. Dekis

This study compared the Children’s Depression Inventory (CDI) scores of traumatized youth with or without PTSD to the scores of a nonclinical comparison group. Diagnostic interviews identified children with PTSD (28), traumatized PTSD negatives (64), and a nonclinical comparison group (41). In the absence of major comorbid disorders, the CDI scores of children and adolescents with PTSD significantly exceeded the CDI scores of traumatized

PTSD negatives and controls on the CDI Total, Negative Mood, Ineffectiveness, and Anehdonia scales. The PTSD group also had significantly higher scores than the traumatized PTSD negatives on the Negative Self Esteem scale. Furthermore, as hypothesized, the CDI scores of the traumatized PTSD negatives and controls were not significantly different on any of the six subscales measured. On the other hand, there were three unexpected nonsignificant findings.

First, the PTSD group mean CDI Interpersonal Problems score did not significantly differ from the traumatized PTSD negative group. Second, the PTSD group mean CDI Interpersonal

Problems score also did not significantly differ from the control group. Finally, the PTSD group mean CDI Negative Self Esteem score did not significantly differ from the control group.

Overall, PTSD was associated with increased depression across the majority of the CDI scales and trauma exposure without PTSD was not. Implications for research and practice are considered.

TABLE OF CONTENTS

List of Tables...... v

List of Figures...... vi

CHAPTER I: The History of Posttraumatic Stress Disorder ...... 1

The DSM-I: 1952 ...... 7

The DSM-II: 1968...... 10

The DSM-III: 1980, Posttraumatic Stress Disorder ...... 13

The DSM-III-R: 1987 ...... 19

The DSM-IV and DSM-IV-TR: 1994 and 2000 ...... 22

The DSM-5: 2013 ...... 29

Chapter Summary ...... 34

CHAPTER II – Child and Adolescent PTSD: Epidemiology,

Comorbidity, and Risk Factors ...... 36

General Population Studies ...... 36

Prevalence of Exposure to Traumatic Events in Youth Populations ...... 38

Community-Based Surveys Examining Child-Adolescent PTSD Prevalence

Rates ...... 41

Empirical Studies by Stressor Type ...... 44

War-Related Studies of Child-Adolescent PTSD ...... 45

Criminal Victimization Studies of Child-Adolescent PTSD ...... 62

Disaster/Accident Studies of Child-Adolescent PTSD ...... 78

Comorbidity ...... 91

Risk Factors for PTSD ...... 98

Chapter Summary ...... 108

CHAPTER III – Methodology ...... 112

Depression and PTSD ...... 112

Background Information ...... 113

Statement of the Problem ...... 115

Purpose of the Study ...... 117

Need for the Study ...... 117

Theoretical Significance ...... 117

Clinical Significance ...... 118

Rationale and Hypotheses ...... 118

Rationale for Hypotheses 1-12 ...... 118

Rationale for Hypotheses 13-18 ...... 120

Methodology ...... 121

Recruitment Process...... 121

Inclusion Criteria ...... 121

Exclusion Criteria ...... 122

Sample...... 123

Diagnostic Measures ...... 125

Children’s PTSD Inventory (Saigh, 2003a) ...... 125

Diagnostic Interview for Children and Adolescents-Revised

(DICA-R; Reich, Leacock, & Shanfeld, 1995) ...... 125

DSM-IV Clinical Interviews ...... 126

Dependent Measures ...... 126

Children’s Depression Inventory (CDI; Kovacs, 1992) ...... 126

Assessment of Possible Intervening Variables ...... 129

Severity of Psychosocial Stress Scale: Children and Adolescents

(SPSS-CA) (APA, 1987b) ...... 129

Hollingshead Four Factor Index of Social Adjustment

(Hollingshead, 1975)...... 129

Examiners ...... 130

Research Design...... 130

Plans for Data Analysis ...... 131

Limitations ...... 132

CHAPTER IV – Results ...... 134

Descriptive Data...... 134

Descriptive Statistics for Traumatic Stressor Variables ...... 135

Exploratory Analyses ...... 137

Multivariate and Univariate Analyses ...... 139

Chapter Summary ...... 144

CHAPTER V – Conclusions ...... 145

Summary of Findings ...... 145

Discussion ...... 146

Significance of the Study ...... 151

Limitations ...... 154

Future Directions ...... 156

REFERENCES ...... 158

iii

Appendix A: APA Permission for Citation DSM-IV-TR ...... 214

Appendix B: APA Permission for Citation DSM-5 ...... 215

LIST OF TABLES

Table 1.1 DSM-IV-TR (APA, 2000) Diagnostic Criteria for PTSD ...... 24

Table 1.2 DSM-5 (APA, 2013) Diagnostic Criteria for PTSD ...... 31

Table 2.1 Child-Adolescent PTSD Rates Following War-Related Traumas ...... 58

Table 2.2 Child-Adolescent PTSD Rates Following Criminal Victimization Traumas...... 74

Table 2.3 Child-Adolescent PTSD Rates Following Natural Disasters or Accidents...... 87

Table 2.4 Prevalence of Comorbid Psychiatric Diagnoses with Child and Adolescent PTSD ...... 96

Table 4.1 Demographic Variables ...... 134

Table 4.2 Types of Traumas Reported by PTSD and Traumatized PTSD Negative Groups ...... 136

Table 4.3 Adjusted Means, Standard Deviations, and Univariate F-tests for CDI Total and Subscale Scores...... 142

Table 4.4 Bonferroni Post Hoc Comparisons for CDI Total and Subscale Scores ...... 143

LIST OF FIGURES

Figure 3.1 Schematic Representation of Research Design ...... 131

Figure 4.1 Graphical Depiction of Group Means ...... 138

Figure 4.2 Graphical Depiction of Group Means for Total Scale ...... 139

CHAPTER I

The History of Posttraumatic Stress Disorder

Symptoms of posttraumatic stress disorder (PTSD) were well documented in literature across the world for many centuries before PTSD was recognized as a formal diagnostic classification in 1980 (American Psychiatric Association, 1980). Homer's Iliad (Homer, trans.

1975) remains a legendary narrative of vitriolic combat experiences in which the characters

described symptoms similar to what today could be diagnosed as PTSD (Friedman, Keane, &

Resick, 2007; Shay, 1991). Similarly, Plutarch’s (trans. 2004) biography of Alexander the Great clearly described symptoms of PTSD that were reportedly presented by Cassander, a Greek

Hellenistic King. In this context, Plutarch represented that when Cassander viewed a statue of

Alexander the Great he “suddenly struck with alarm, and shook all over, his eyes rolled, his head

grew dizzy, and it was long before he recovered himself” (Plutarch, trans. 2004, p. 70).

Centuries later and in another part of the world, Shakespeare described the development

of subjective symptoms following a trauma in his play King Henry IV (circa 1596) (Davidson,

1996). In the famous play, Lady Percy describes the fretful sleep of the character Hotspur, who is tormented by nightmares of war imagery (Trimble, 1985). A few years later in 1667, Samuel

Pepys wrote of exposure to exceptional stress in his diary, 6 months after he witnessed the Great

Fire of London in September of 1666. Pepys’ autobiographical accounts detailed symptoms of hyperarousal, re-experiencing, phobic avoidance, and emotional constriction following the fire.

Specifically, Pepys wrote:

It is strange to think that how to this very day I cannot sleep a night without great

terrors of the fire; and this very night could not sleep to almost two in the morning

through great terrors of the fire. (Pepys, 1666, as cited in Daly, 1983, p. 66)

Records from the American Civil War have also offered insight into the psychological effects of traumatic events (Davidson, 1996; Kuszmar, Short, Barnes, & Strenhlow, 2000;

Pizarro, Silver, & Prause, 2006). Silas Weir Mitchell (1864) (as cited in Davidson, 1996) worked at an army hospital in Philadelphia for nervous diseases and provided clinical accounts of the aftermath of war. He noted that male veterans and female civilians who served as nurses suffered from recurrent nightmares and startle response, which sometimes led to self-medication using alcohol and opiates to relieve symptoms (Davidson, 1996; Kuszmar et al., 2000).

Pizarro, Silver, and Prause (2006) later examined military and medical records of Civil

War veterans with signs of cardiovascular, gastrointestinal (GI), or nervous disease. Cardiac disease included symptoms such as irregular pulse. GI disease included symptoms such as diarrhea or abdominal tenderness and nervous disease ailments included paranoia, psychosis, hallucinations, insomnia, confusion, hysteria, and memory problems. Nervous ailments also included additional mental health problems like anxiety, depression, attention deficits, or neurosis. These symptoms of nervous diseases during the Civil War era appear to mirror the

PTSD diagnostic classification utilized today (Pizarro et al., 2006).

Similarly, Jacob Mendez DaCosta, M.D. reported that many American Civil War soldiers presented with symptoms of increased arousal, irritability, and elevated heart rate (Jones &

Wessely, 2005; Saigh & Bremner, 1999). The constellation of these symptoms from combat were given various names such as “Da Costa’s Syndrome” (Paul, 1987; Saigh & Bremner,

1999), “soldier’s or irritable heart” (Jones & Wessely, 2005; Trimble, 1985), and “disordered action of the heart” (Jones & Wessely, 2005).

The industrial revolution of the 19th century led to an increase in the use of railway systems as a means of passenger transportation (Trimble, 1981). As train traffic increased so did

the number of railway accidents resulting in personal injury. For example, on June 9, 1865

Charles Dickens experienced a railway accident that resulted in delayed emotional distress.

Some time after the accident, he wrote:

I am not quite right within, but believe it to be an effect of the railway shaking. There is

no doubt of the fact that, after the Staplehurst experience, it tells more and more, instead

of, as one might have expected, less and less…. Driving in Rochester yesterday I felt

more shaken than I have since the accident. I cannot bear railway traveling yet. (quoted in

Trimble, 1981, p. 28)

In 1866, a physician named John Eric Erichsen suggested a unique pattern of symptoms associated with railway accidents, including insomnia, irritability, weakness, and fatigue

(Trimble, 1981). Erichsen wrote an influential book in 1882 entitled On Concussion of the Spine:

Nervous Shock and Other Obscure Injuries of the Nervous System in their Clinical and Medico-

legal Aspects. His thesis was that “concussion of the spine” led to physical symptoms in patients

following accidents. He felt there was organic pathology for these conditions and thus, the term

“railway spine” became part of the medical language. Patients with railway spine were labeled as

“fretful,” “irritable,” and unable to concentrate; their sleep was described as “restless and broken” and their “dreams … distressing and horrible” (Erichsen, 1867, p. 73).

In 1885, Page published a rebuttal to Erichsen’s ideas. In this context, he used the term

“nervous shock” to describe the resulting symptoms after certain railway accidents. Page

reported that he was unable to find evidence that railway spine was associated with organic

disease in the majority of cases and believed instead that the symptoms were essentially psychological in origin. In 1896, Emil Kraepelin, a German nosologist, coined the term

“schreckneurose” or fright neuroses to describe the clinical syndrome Erichsen and Page

identified as “multiple nervous and psychic phenomena arising as a result of severe emotional upheaval or sudden fright which would build up great anxiety; it can therefore be observed after serious accidents and injuries, particularly fires, railway derailments or collisions” (translated by

Jablensky, 1985, p. 737).

The First World War served as a catalyst for research regarding the deleterious effects of exposure to highly traumatic combat events. Individuals who presented with mental shock were classified as cases of “shell shock” and soldier’s heart during the First World War (Davidson,

1996; Howorth, 2000). Some psychiatrists believed that rigorous marching coupled with carrying heavy packs led to the condition (Cotton, Lewis, & Thiele, 1915). However, once it was understood that symptoms were psychological and not based on physical rigors of war, “combat neurosis” became an accepted term for such conditions (Cohen, 1998).

William Aldren Turner (1916) was a physician who wrote the following description of

British soldiers who evidenced nervous symptoms and mental breakdown after being exposed to highly traumatic events:

Cases of nervous and mental breakdown…could be classified into three main groups.

One group was recognized whose symptoms were due to the bursting of high-explosive

shells in the immediate vicinity of the patient or to the secondary effects of the explosion,

such as burial under earth and debris or the inhalation of noxious gases. The second

group included cases of general neurasthenic character (using this term in the widest

sense) attributable to exhaustion of the nervous system resulting from physical and

nervous strain, sleeplessness, anxiety, and harassing sights and experiences. The third

group included cases of mental breakdown – the milder as well as the more severe

psychoses – mental confusion, mania, melancholia, and delusional and hallucinatory

psychoses. (Turner, 1916, p. 1073)

Mott (1919) felt that a lesion of the brain caused shell shock. By 1919, Ernest Southard, an American physician, documented 589 cases of soldiers who experienced this condition. In one case study, an infantry sergeant reported, “Shells dropped on the dug-out and killed the other chaps. I have not slept properly since this. If I go to sleep, I wake up seeing people killed, shells dropping and all kinds of horrid dreams about the war” (Southard, 1919, p. 446).

While an understanding of the effect of trauma on adults was growing, Bender and Blau

(1937) took their research in a different direction and published one of the first articles involving the psychiatric distress of children exposed to extreme stress. Specifically, they worked at

Bellevue Hospital in New York City with children aged 5 to 13 years who reportedly were sexually abused. Blender and Blau made note of the children’s fear, irritability, nightmares, reminiscent re-enactments, and hypervigilance. Some children also reportedly presented with academic impairments.

Following Bender and Blau (1937) a number of researchers began to examine the

functioning of children exposed to extreme stress (Bodman, 1941; Brander, 1943; Carey-Trefzer,

1949; Friedman; 1948; Freud & Burlingham, 1943; Mercer & Despert, 1943). Bodman (1941)

surveyed 8,000 British youth between 5 and 14 years of age who were exposed to Nazi air raids.

Psychological or psychosomatic symptoms were found in 4% of his sample when there were

active air raids. These symptoms involved crying, nightmares, fears specific to the war,

psychophysiological reactivity upon exposure to war-related stimuli, avoidance behaviors, and

misconduct. Interestingly, Bodman followed up on this study 2 months later and found that 61%

of these children still exhibited symptoms.

Bradner (1943) examined the adjustment of Finnish families forced to leave their homes during the Russo-Finnish War. These families were presented with great uncertainty and stress.

Bradner reported that the children experienced posttraumatic fears, nightmares, blunted affect, avoidance, and psychological arousal on exposure to war stimuli. Even 12 months after the war ended, Bradner indicated that war-related stimuli caused the aforementioned symptoms to return spontaneously. For example, upon hearing sirens, children “interrupted their play immediately, to return pale and trembling to their homes” (Brander, 1943, p. 319). In a related work, Freud and Burlingham (1943) created in-depth case studies of English children exposed to war who similarly evidenced anxious and “cranky” behavior.

Abram Kardiner was a pioneer of the study of psychological trauma (Trimble, 1981). He chronicled detailed descriptions of his patients in his book, The Traumatic Neuroses of War

(1941). Kardiner reported that veterans with “traumatic neuroses” displayed hypervigilance and

were particularly sensitive to perceived environmental threat. He also described physiological

arousal in the patients he observed, as he reported, “these patients cannot stand being slapped on

the back abruptly” (p. 95, 1941). In addition to the physiological symptoms he described,

Kardiner (1941) noted that “pathological trauma syndrome” results in one’s fixation on the past

traumatic experience and having an abnormal dream life filled with nightmares and sleep

difficulties.

Psychiatrists Grinker and Spiegel (1945) studied the effects of combat stress during

World War II. They observed symptoms of restlessness, aggression, memory impairment,

depression, attention difficulties, suspicion, phobias, and nightmares among American aircrews

(Saigh, 1992). After World War II, Wolf and Ripley (1947) studied the functioning of American prisoners-of-war who were interned for approximately 3 years by the Japanese. Many of these

individuals were subjected to torture and experienced a variety of diseases, such as malaria. Wolf and Ripley found that approximately 23% of these survivors suffered severe emotional stress including trauma-related nightmares, blunted affect, irritability, psychosomatic symptoms, and cognitive cloudiness.

Within the context of the psychological consequences of war, Carey-Trefzer (1949) examined the effects of war-related stressors on a large sample of British children who attended a guidance clinic at the Hospital for Sick Children in London during and shortly after the war.

Carey-Trefzer followed these children to try to understand the prognosis of their disturbances.

Most of the children experienced air raids followed by forced evacuation, loss of schooling, and housing problems. Carey-Trefzer reported that approximately 16% of the sample (n = 212)

showed disturbances as a result of war experiences. The most common symptom was “change in behavior,” (e.g. more aggressive, inhibited, or generally nervous) followed by anxiety and fears.

Sleep disturbances and enuresis were also prevalent. In a related work, Friedman (1948) used the

term “Buchenwald Syndrome” to describe a cluster of symptoms he observed in Jewish youth

who survived Nazi death camps. Friedman found that 50 to 60% of the children studied in a

Cyprus detention center had somatic complaints like anxiety, sleep disturbance, and startle

response without any organic etiology.

The DSM-I: 1952

During the Korean Conflict, the first Diagnostic Manual of Mental Disorders (DSM-I;

American Psychiatric Association, 1952) was published. This manual included “Gross Stress

Reaction” under the category of “Transient Situational Personality Disorders,” diagnosed in

individuals who experienced extreme stressors involving civilian catastrophe (e.g. fire,

earthquake) or combat. Posttraumatic stress was conceptualized as a temporary response to an

overwhelming situation of an otherwise “normal personality” (APA, 1952, p. 40). A chronic form of the disorder was not indicated. If the disorder failed to remit, it was believed that the symptoms were due to a preexisting disorder (Davidson, 1996). However, Gross Stress Reaction was an ill-defined diagnosis. There were no operational criteria associated with the diagnosis and no mention of its presentation in children (Saigh, Green, & Korol, 1996).

Various studies with veterans from the Korean War took place after the publication of the

DSM-I (APA, 1952) (Noble, Roudebush, & Price, 1952; Temperau, 1956). Noble et al. (1952) interviewed 75 veterans of the Korean War who were patients in orthopedic wards in the United

States. Approximately 40 individuals (53%) presented with psychiatric symptoms, half of which were classified with “mild tension states.” Symptoms included startle reactions, slight stammering, combat dreams, and other evidence of tension. In a similar vein, Temperau (1956) performed psychiatric evaluations of the U.S. Air Force in Korea. Fifteen crew members who presented with a fear of flying were evaluated. Five individuals stated they no longer wished to

fly, seven demonstrated severe psychological or psychosomatic symptomatology, and three were

referred elsewhere because of serious behavior problems. Of note, some of the men were previously clinically well but developed a fear of flying after a traumatic incident.

Natural disasters during the 1950s and 1960s presented an impetus for research involving

the psychological impact of these disasters. On December 5, 1953 a tornado that struck

Vicksburg, Mississippi caused considerable property damage and many deaths. Within this

context, Bloch, Silber, and Perry (1956) conducted an analysis of parents, children, pediatricians,

school personnel, and community leaders. The psychiatrist ratings of the children studied were as

follows: 113 showed no emotional disturbance, 32 mild, 24 severe, and there was insufficient

data on 16. Emotional disturbance was defined as “the presence of overt anxiety, anxiety

equivalents, symptom formation or intensification of pathological character traits” (Bloch et al.,

1956, p. 418). The authors found that being aware of the tornado as it happened and being closer to the impact zone (i.e. in close proximity to the tornado) were significantly related to emotional disturbance.

Bennet (1970) investigated people’s health following a flood in Bristol, England, which caused approximately 3,000 properties to become immersed in water. In a comparison between

316 people who had been flooded and 454 who had not, Bennet found that 33% of flooded men reported new physical symptoms after the event compared to 16% of non-flooded men. Of the flooded women, 18% reported psychiatric symptoms while only 6% of the non-flooded women reported similar symptoms.

On July 25, 1956 a Swedish liner crashed into the Andrea Doria, an Italian passenger ship, causing many deaths. Friedman and Linn (1957) recorded symptoms among the ship survivors that were similar to those of concentration camp survivors. According to Friedman and

Linn (1957), many of the surviving passengers exhibited a compulsive need to retell their stories with an identical emphasis and tone. The repetitive narratives were likened to the repetitive nightmares found in trauma survivors. Langdon and Parker (1964) found similar symptoms such as anxiety, depression, acute fear, and depersonalization after the 1962 Alaskan earthquake.

After World War II, studies involving the long-term effects of trauma in survivors of war were published. Etinger’s (1962) examination of Norwegian concentration camp survivors showed that the large majority of his sample (80%) presented with chronic fatigue, irritability, and poor concentration. Further, he noted that individuals frequently had painful recollections of their traumatic past and were reminded of it via related and unrelated stimuli. Chodoff (1963) went on to study late effects of concentration camp syndrome, years after the war was over, as he

performed psychiatric examinations of patients seeking reparations from the German government

due to Nazi persecution. He found that 19 out of the 23 patients he studied had remarkably

similar symptoms such as irritability, restlessness, apprehensiveness, startle response, headaches,

cardiac palpitations, and depressive symptoms. Chodoff (1963) reported:

These cases are of interest because of the very similar, almost stereotyped

syndrome they display; because of the very long persistence of their

symptoms, and because of the light that they may shed on certain

theoretical problems in psychiatry – particularly the origin and nature of

traumatic neuroses. (Chodoff, 1963, pp. 323-324)

The DSM-II: 1968

In 1968 the APA Committee on Nomenclature and Statistics published the DSM-II,

marking the first revision of this manual (APA, 1968). Without any explanation the diagnosis of

Gross Stress Reaction was eliminated, leaving practitioners without a means to classify clinically

significant and persistent reactions to catastrophes. The diagnostic alternative provided was

“Transient Situational Disturbance,” which was applied to “transient disorders of any severity

(including those of psychotic proportions) that occur in individuals without any apparent

underlying mental disorders and that represent an acute reaction to overwhelming environmental

stress” (APA, 1968, p. 48).

Transient Situational Disturbance included a wide spectrum of adverse events, such as

unpleasant experiences, and thus trivialized the impact of traumatic exposure. There were some

similarities within this category from the DSM-I (APA, 1952) to the DSM-II (APA, 1968). For

example, the diagnosis was still considered a temporary and reversible condition. Likewise with

the previous edition, clearly stated symptoms to diagnose cases were not provided (Friedman,

Resick, Bryant, & Brewin, 2011; Saigh & Bremner, 1999). Unlike the DSM-I (APA, 1952), the

DSM-II (APA, 1968) included sub-classifications (e.g. adjustment reaction of adolescence), which was an improvement of sorts (Saigh & Bremner, 1999).

Increased attention was afforded to the psychological impact of rape in the 1970s. Within this context, Burgess and Holmstrom (1974) coined the term “rape trauma syndrome” to describe a two-stage model of recovery from rape, which included an acute and reorganization phase. The acute phase reportedly involved physical trauma and a vast range of emotional symptoms (e.g. self-blame, fear, humiliation, anger) while the long-term phase was said to be characterized by nightmares, increased motor activity, and phobias related to the traumatic experience 2 to 3 weeks later. With a predominantly female sample of 143 individuals, Burgess and Holstrom studied the symptoms associated with sexual assault and found that they were similar to those of war and natural disaster victims. Also within the context of sexual assault, Kiplatrick, Vernonen, and Resick (1979) analyzed the psychological effects of rape over time. They concluded that rape victims had higher levels of fear than non-rape victims 6 to 10 days after the event and 30 days after the event. Rape victims were found to be more fearful of perceived rape-related stimuli like strangers, emergency rooms, nude men, and being alone.

Interest in the psychological effects of natural disasters continued in the 1970s. Lacey

(1972) studied student survivors of a mudslide in Britain. Symptoms such as difficulty sleeping, enuresis, instability and an unwillingness to go outside or to school were observed among students 2 years later. Inclement weather conditions at times frightened the children, as it seemingly reminded them of the weather that preceded the mudslide. Titchner and Kapp (1976) also studied the effects of natural disasters after a dam collapse that caused a major flood in

Buffalo Creek, West Virginia. Over 4,000 individuals were left homeless and 125 were killed as

a result of the flood. The majority of the adults studied presented with clinically significant

symptoms of depression and anxiety. Newman (1976) found that many of the surviving children

from this disaster displayed nightmares, difficulty sleeping, and phobias related to the water.

During the same time, the Vietnam War allowed for continued research on the psychological adjustment of veterans and soldiers. Initial reports regarding the psychological

adjustment of Vietnam veterans painted a positive picture of their post-combat deployment

(Bloach, 1969; Bourne, 1970). However, it was determined that this assessment was premature

as multiple investigators later reported that Vietnam veterans were deeply troubled. For example,

Horowitz and Solomon (1975) concluded that the Vietnam veterans they assessed suffered from

“delayed stress response syndrome” (p. 67). This syndrome included nightmares, aggressive

moods, impaired social relationships, and behavioral psychopathology.

Information up until this point in time demonstrated a collection of severe psychiatric

symptoms that might occur after traumatic exposure. Although not included in the DSM-II

(APA, 1968), a multitude of syndromes had been described such as DaCosta’s syndrome (Paul,

1987; Saigh & Bremner, 1999), delayed stress response syndrome (Horowitz and Solomon,

1975), schreckneurose (Jablensky, 1985), shell shock (Mott, 1919; Southard, 1919), soldier’s

heart (Jones & Wessely, 2005; Trimble, 1985), trauma syndrome (Burgess and Holmstrom,

1974), etc. The varied terms to describe the same phenomenon not only lead to confusion, but

also hindered practice and research. While the DSM-I (APA, 1952) and DSM-II (APA, 1968)

contained diagnoses to try and capture the result of certain types of trauma, they were limited in

scope and failed to provide clear diagnostic symptoms (Saigh, 1992; Friedman et al., 2011).

The DSM-III: 1980, Posttraumatic Stress Disorder

After much criticism of the DSM-II (APA, 1968) based on scarce operational criteria, unreliability, and insufficient coverage of disorders, (Morey, Skinner, & Blashfield, 1986; Saigh,

1992) the APA modified the manual again. The DSM-III was published 1980 under the stewardship of Robert Spitzer, M.D. (APA, 1980). With the arrival of the DSM-III (APA, 1980), the aforementioned discrete syndromes suggested by researchers following a traumatic event were characterized by the newly named PTSD diagnosis (APA, 1980). The stressor concept for

PTSD was defined as “beyond the realm of normal human experience” (APA, 1980, p. 236). It could be either psychological, physical, or both indicating that divergent types of extreme stressors could potentially result in psychiatric morbidity (Saigh & Bremner, 1999). According to the DSM-III (APA, 1980), the PTSD stressor “would evoke significant symptoms of distress in most people and is generally outside the range of such common experiences as simple bereavement, chronic illness, business losses or marital conflict” (p. 236). There was no longer the preclusion of preexisting normality in order to receive this diagnosis (APA, 1980).

The PTSD symptoms were divided into three general categories of re-experiencing (e.g. nightmares), numbing of responsiveness (e.g. detachment), and cognitive or autonomic symptoms (e.g. memory/concentration impairment or sleep disturbance), only having developed after exposure to the traumatic stressor. Temporally, these symptoms were categorized as acute

(i.e. occurring within 6 months of the stressor), chronic (i.e. lasting longer than 6 months), or delayed (i.e. presenting more than 6 months after the traumatic event). Associated features of this disorder, including anxiety and depression, were described in the manual (APA, 1980). Although the diagnosis included discrete symptoms, it is important to note the lack of information regarding the unique expression of symptoms in children and adolescents (Saigh & Bremner,

1999).

The DSM-III (APA, 1980) provided a new framework to understand posttraumatic stress

and served to guide researchers after its publication. Within this context, Terr (1981) studied 20

children involved in a California school bus kidnapping that occurred in 1976. The study took place 3 to 5 months following the incident. Terr (1981) found that the children suffered from phobias related to the trauma, reenactment of the trauma, personality changes, nightmares, and

experienced posttraumatic play. Four years later, Terr (1983) followed up with the children

involved in the kidnapping and found that the severity of symptoms was related to each child’s past vulnerabilities, family structure, and community bonding. As time progressed, Terr

discovered that some symptoms of posttraumatic stress became more evident in certain children,

such as avoidance symptoms, numbing, memories of misperceptions, a sense of a foreshortened

future, nightmares, and increased posttraumatic play and reenactment.

Researchers continued to validate the PTSD diagnosis from the DSM-III (APA, 1980) in

a variety of contexts. Penk et al. (1981) compared the Minnesota Multiphasic Personality

Inventory (MMPI; Hathaway & McKinley, 1943) scores of Vietnam veterans who were exposed

combat (n = 87) and those who were not (n = 120). Their battery also included Progressive

Matrices (Raven, 1941), Benton Visual Retention Test (BVRT; Benton, 1974), the Family

Environment Scale (FES; Moos, 1974), a biographical inventory, and drug use history. The FES

was administered twice to ascertain adjustment from the participants’ past (i.e. family of origin)

and present. The veterans exposed to combat reported that they experienced more stress

responses along with more psychosocial problems after the war as compared to their peers who

were not exposed to combat. Importantly, adjustment after the war was not attributable to pre-

military adjustment differences. Contrary to predictions, combat veterans did not differ from

noncombat veterans on overall levels of adjustment on the MMPI. The authors concluded that

stress response can persist long after combat exposure and that more specific and sensitive

measures of stress reactions were needed beyond measures of personality and environment.

Kinzie, Frederickson, Ben, Fleck, and Karls (1984) studied Cambodian refugees who

survived up to 4 years in a concentration camp. Thirteen individuals participated in the study, all

of whom met DSM-III (APA, 1980) criteria for PTSD. Symptoms of startle response, avoidance,

emotional numbness, nightmares, and intrusive thoughts were present even 3 years after

imprisonment. Diagnosis and treatment were complicated by the self-reported shame the participants felt about the past along with extreme avoidance symptoms they experienced. This

study provided a cross-cultural validation for the PTSD diagnosis as the researchers worked with

a special non-Western population (Kinzie et al., 1984).

In a larger scale study, Kluznik, Speed, Van Valkenburg, and Magraw (1986) evaluated

188 prisoners-of-war who lived in and around Minneapolis. Three psychiatrists interviewed the participants and administered structured psychiatric examinations and a symptom checklist based

on the DSM-III (APA, 1980) criteria for PTSD. A lifetime diagnoses of PTSD was reported

among 67% of the veterans studied. Generalized anxiety disorder was diagnosed in 55% of the participants and major depression in 24%. Of note, prisoners-of-war with PTSD were not

significantly more likely to report other psychiatric diagnoses compared to those without PTSD,

which supported the distinction between PTSD as a disorder in the DSM-III (APA, 1980) from

other disorders (Kluznik et al., 1986).

Blanchard, Kolb, Gerardi, Ryan, and Pallmeyer (1986) studied the physiological

responses of Vietnam veterans, all of whom experienced combat while serving in Vietnam or

other parts of Southeast Asia. The analysis showed that veterans with PTSD had a heightened

cardiac response as well as a significantly higher resting heart rate compared to veterans without

PTSD. Cardiac responses of individual participants were shown to be a relatively useful

diagnostic tool since approximately 70% of PTSD veterans and approximately 88% of non-

PTSD veterans could be accurately identified through this method.

In a unique study on PTSD, Saigh (1988a) examined self-reported PTSD symptoms of 12

students from the American University in Beruit, Lebanon who were exposed to severe and

unexpected war-related stressors. The students were in West Beirut during a military bombardment, were forced to take shelter, deprived of sleep for over 24 hours, and testified to

the intensity and fearfulness of the situation. Saigh (1988a) collected data on the students self-

reported levels of anxiety, depression, and assertion 63 days before the war stressor and then 8,

37, and 316 days after the stressor. All of the students reported higher levels of situational

anxiety and depression, along with lower levels of assertion 8 days after the trauma, as compared

to beforehand. Only one student presented with PTSD who had been exposed to multiple trauma.

That student presented with chronic PTSD 316 days later with symptoms such as nightmares,

repeated thoughts of the bombardment, heightened startle response, and memory impairment.

The data from 37 and 316 days after the trauma did not differ significantly from the group

estimates 63 days before the stressor.

Within the context of PTSD as it applies to children, several case reports suggested that

the criteria as validated for adults (Horowitz, Wilner, Kultreider, & Alvarez, 1980), could also be

applied to physically abused children (Green, 1983), those attacked by a dog (Gislason & Call,

1982), and children who were kidnapped (Senior, Gladstone, & Nurcombe, 1982). Saigh (1989a)

was the first investigator to systematically examine the differential validity of the DSM-III

(APA, 1980) PTSD classification with children. Using the Children’s PTSD Inventory (Saigh,

1989b), he evaluated Lebanese children between the ages of 9 and 12 and determined that 273

children warranted a PTSD diagnosis and none met criteria for test phobia. Other measures

included the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond,

1978), Children’s Depression Inventory (CDI; Kovacs, 1981), and the Conners’ Teacher Rating

Scale (CTRS; Conners, 1969). An additional 32 children without PTSD who instead met criteria

for test phobia were examined. Finally, a control group of 35 children was included. Taken

collectively, results indicated considerable variations in depression, anxiety, and misconduct

amongst the three groups. The children with PTSD consistently had higher levels of depression,

anxiety, and misconduct as compared to the phobic and control groups. Further, the phobic group

showed higher levels of depression and anxiety than the control group. These outcomes provided

empirical support the validity of the DSM-III (APA, 1980) PTSD and specific phobia

classifications as applied to children.

Saigh, Mroueh, and Bremner (1997) further explored PTSD through the lens of scholastic

impairments. Specifically, they explored the connection between academic deficits and PTSD in

adolescents using the DSM-III (APA, 1980) version of the Children’s PTSD Inventory (Saigh,

1989b) along with the Metropolitan Achievement Test (MAT; Prescott, Balow, Hogan, & Farr,

1988). Three groups were studied: one group of adolescents with PTSD, one group who had been traumatized with a similar stressor to the first group without PTSD (PTSD negative), and a

non-traumatized control group. Controlling for IQ, it was found that achievement scores of the

PTSD subjects were significantly lower than the PTSD negative group and controls. No

significant differences were found between the achievement scores of the PTSD negative group

and the control group. These results indicate that PTSD is partially manifested by significant

functional impairments. The results also indicated that trauma exposure without a PTSD

diagnosis was not associated with academic problems.

Studies exploring a standard for treatment emerged after the publication of the DSM-III

(APA, 1980). Fairbank, DeGood, and Jenkins (1981) described a case study of a 32-year-old

woman who presented with posttraumatic “startle response” and anxiety 3 months after an

automobile accident, which occurred while the patient was driving. Treatment consisted of 3

weekly sessions of progressive muscle and autogenic relaxation using recorded cassette tapes. In

addition, there was a behavioral rehearsal component, which consisted of driving on a one-mile practice course along a two-lane highway twice daily for 2 weeks. By the second week of behavioral rehearsal the patient’s startle response decreased dramatically and eventually became

extinct. Self-reported anxiety while driving also diminished. At a 6 month follow up, the

researchers observed that the treatment effects did not decay over time.

Keane and Kaloupek (1982) were the first to examine the efficacy of exposure treatments

with combat veterans after the Vietnam War. This prolonged exposure behavioral technique was

referred to as “flooding” or exposing an individual to their most psychologically traumatic

experience repeatedly, which could be done in vivo, in person, or in vitro, through imagined

means. Kean and Kaloupek (1982) described in vitro flooding with a 36-year-old Vietnam

veteran with PTSD. The patient presented with anxiety, nightmares, insomnia, flashbacks,

depression, and problems with work. Three personal and specific events from the war made up

the majority of the patient’s intrusive thoughts, nightmares, and flashbacks. All of the details of

these events were obtained during intensive interviewing followed by treatment. During

treatment the researchers first engaged the patient in relaxation training and then gradually presented increasing details from each of the adverse scenes. When the patient became visibly

agitated, he was encouraged to continue thinking about the memory for as long as possible, until

it was no longer anxiety provoking. Results indicated that the patient reported a significant

decrease in anxiety and the frequency of his nightmares, while his work productivity increased.

Results were maintained at a follow up 3 and 12 months later.

Saigh (1987c) was the first to examine the efficacy of in vitro flooding with children who

met DSM-III (APA, 1980) criteria for PTSD, as measured by the Children’s PTSD Inventory

(Saigh, 1989b). Saigh described a case study of a 14-year-old Lebanese male referred because of

academic and behavioral problems after having been abducted 6 months prior by the Lebanese

militia for 48 hours. Saigh identified four specific anxiety-evoking scenes involving the

abduction and obtained extremely detailed information about them through a series of clinical

interviews. Treatment sessions began with 10 minutes of relaxation exercises followed by

approximately 60 minutes of in vitro flooding with an emphasis on the most agitating aspects of

the scene. After treatment, the patient reported no distress at all when presented with the various

scenes, which differed dramatically from his self-reported level of distress prior to treatment.

Further, he showed improvements in his levels of anxiety, depression, and aggression. The patient was also able to visit the area where the abduction took place without any self-reported

anxiety. Finally, the patient expressed considerable satisfaction with the treatment, indicating

strong ecological validity as well.

DSM-III-R: 1987

In 1987 the American Psychiatric Association published the DSM-III-R (APA, 1987a).

Within this edition, the three major categories of PTSD were organized in the following manner:

re-experiencing, numbing/avoidance, and psychophysiological reactivity. Although trauma was

still conceptualized as an event “outside the range of normal human experience” (APA, 1987a, p.

247), the unique manifestation of PTSD symptoms in children was mentioned for the first time.

Notably, age-specific features such as repetitive traumatic play, generalized nightmares, and a

sense of a foreshortened future in children were introduced to the diagnosis. The manual

recommended interviewing relevant third-party adults (e.g. teachers, parents, or observers) when

working with traumatized children, as they could help provide detailed information relevant to

the traumatic stressor and the child’s symptoms. Finally, the possibility of the presence of

somatic symptoms in children with PTSD was also reported in the new edition (APA, 1987a).

The publication of the DSM-III-R (APA, 1987a) resulted in a host of research utilizing

the updated diagnosis. For example, Hickling and Blanchard (1992) studied 20 patients, aged 18

to 55 years, who had been in a recent motor vehicle accident and were referred by physicians for

a psychological evaluation. According to DSM-III-R (APA, 1987a) diagnostic criteria, 10 patients had PTSD, 3 had subclinical PTSD, and 7 appeared free of most criteria related to a

PTSD diagnosis. Nine patients qualified for a diagnosis of major depression, indicating some

comorbidity with PTSD. In four patients dysthymic disorder seemed to predate the accident.

In a related effort, McNally, English, and Lipke (1993) conducted a study with 24 male

Vietnam combat veterans diagnosed with PTSD. They used an altered Stroop color-naming paradigm (Mathews & MacLeod, 1985) in order to assess intrusive cognition. The participants

were told to name colors aloud, in which emotional words were printed, and to ignore the

meanings of the words. The results indicated that the participants exhibited Stroop interference,

or delays responding, for words related to trauma (e.g. PTSD), but not for other positive or

neutral words. The researchers suggested that their Stroop task may be useful in detecting

intrusive cognition in traumatized individuals who may deny their symptoms, as semantic

activation that occurs with trauma-words is mostly involuntary.

McLeer and colleagues (1988, 1992, 1994, 1998) utilized DSM-III-R (APA, 1987a)

diagnostic measures over a span of 10 years in studies with children who had been sexually

abused. Very high rates of PTSD were found with this young population who had experienced

“sexual touching, with or without force, by anyone five or more years older” (McLeer,

Deblinger, Henry, & Orvaschel, 1992, p. 875). Many other researchers also found high rates of

PTSD, using DSM-III-R (APA, 1987) criteria, in young children who had experienced physical

abuse (Deblinger, McLeer, Atkins, Ralphe, & Foa, 1989; Pelcovitz et al., 1994).

Within the context of somatic responses, Orr, Meyerhoff, Edwards, and Pitman (1998)

explored physiological symptoms associated with the DSM-III-R (APA, 1987a) PTSD diagnosis.

They measured the heart rate and systolic and diastolic blood pressure of Vietnam veterans with

and without PTSD, three mornings in a row. Additionally, responses to three stressor challenges

were measured: orthostatic (i.e. arising from a recline position and standing for 5 minutes),

mental arithmetic, and placing a hand in a bucket of ice water as long as could be tolerated while

reclining. Results indicated that resting levels were not significantly different between groups.

The only significant group difference occurred during the orthostatic condition, as diastolic blood pressure increased over time among the non-PTSD veterans but not among those with

PTSD, suggesting a paradoxically reduced autonomic response in PTSD.

Many studies of interventions for PTSD, according to DSM-III-R (APA, 1987a) criteria,

have been conducted. Deblinger, McLeer, and Henry (1990) examined the effectiveness of a 12

session cognitive behavioral treatment (CBT) designed for sexually abused children with PTSD.

The participants were all female and ranged in age from 3 to 16 years. The intervention consisted

of a variety of cognitive behavioral methods, such as gradual exposure, coping, education,

modeling, and prevention skills training. Gradual exposure to abuse-related stimuli took place as

well. Pre and post intervention assessments of PTSD symptoms indicated very significant

clinical improvements across the PTSD subcategories of re-experiencing, avoidance, and

arousal. Improvements were observed in terms of internalizing behaviors, externalizing behaviors, anxiety, and depression symptoms.

In a pivotal treatment study, Foa and colleagues (1999) worked with 96 female assault

victims with chronic PTSD. The participants were randomly assigned to four treatment

conditions: Prolonged Exposure (PE), Stress Inoculations Training (SIT), Combined Treatment

(PE-SIT), or a Wait-List Control (WL). The PE condition involved imaginal exposure to the

traumatic event. In SIT, participants were taught coping skills to manage assault-related anxiety

and problems including deep muscle relaxation and other cognitive behavioral techniques. The

treatment consisted of nine individual sessions. The PE-SIT condition included both of the

aforementioned conditions, while the WL group was told they could receive treatment in 5

weeks. Independent evaluations were conducted at pretreatment, posttreatment, and 3, 6, and 12

month follow ups. Results of the Foa et al. (1999) study indicated that all three treatments

resulted in superior outcomes, such as reduction in PTSD and depression symptoms, as

compared to the WL group. The SIT and PE-SIT did not differ significantly from one another.

Interestingly, PE participants, the strictly behavioral group, scored significantly lower than the

SIT and PE-SIT groups on measures of anxiety. The PE group also scored significantly lower

than the PE-SIT group on a measure of depression and had the smallest amount of participant

attrition.

The DSM-IV and DSM-IV-TR: 1994 and 2000

The fourth edition of the DSM (APA, 1994) was released in 1994. The PTSD work group

relied mostly on literature reviews and clinical trials, as much scientific research on PTSD had been described in previous editions. The field trials took place at five different sites and involved

128 community subjects and 400 participants. The primary goal was to understand the

relationship between various stressors and PTSD symptoms (Saigh, 1992). Of importance, the

DSM-IV (APA, 1994) PTSD work group removed the DSM-III-R (APA, 1987a) provision that

the traumatic stressor in PTSD must be “outside the range of normal human experience” (APA,

1987a, p. 247). Instead, Criterion A was changed to require individuals to have, “experienced,

witnessed, or been confronted with an event or events that involve actual or threatened death or

serious injury, or a threat to the physical integrity of oneself or others” (APA, 1994, p. 428).

Further, Criterion A newly included that the stress response must have “involved intense fear,

helplessness, or horror” and children may express the response by “disorganized or agitated behavior” (APA, 1994, p. 428).

According to the DSM-IV (APA, 1994), traumatic events could lead to PTSD via direct experience or witnessing a variety of events such as a sexual assault, physical attack, military combat, natural disaster, or automobile accident. In addition, receiving information about the traumatic experiences of close family members was included as a potential pathway to the development of PTSD. The manual indicates that “violent personal assault, serious accident, or serious injury experienced by a family member or close friend; or learning that one’s child has a life threatening disease,” are manners in which one might develop PTSD (p. 424).

The DSM-IV (APA, 1994) indicated that PTSD is a highly comorbid disorder, such that individuals with PTSD were noted to be at increased risk for concurrently presenting with other anxiety disorders, Major Depressive Disorder, and substance-related disorders. Kessler, Sonnega,

Bromet, Hughes, and Nelson (1995) supported this notion with findings from their national comorbidity survey, which indicated that more than 50% of males and 28% of females with

PTSD met criteria for a substance abuse problem. Further, 48% of men and women with PTSD

had a lifetime history of Major Depressive Disorder while only 11.7% of PTSD-negative males

and 18.8% of PTSD-negative females did.

In terms of children and adolescents, the DSM-IV (APA, 1994) clearly specifies that,

“sexually traumatic events may include developmentally inappropriate sexual experiences

without threatened or actual violence” (APA, 1994, p. 424). Therefore, inappropriate sexual behaviors perpetrated on children without physical violence were recognized as traumatic events

that may lead to the development of PTSD. The manifestation of PTSD in children was reported

to potentially include re-experiencing symptoms such as traumatic play and trauma-specific re-

enactments. Children were noted to potentially experience a sense of a foreshortened future or believe they have the capacity to foresee negative events (APA, 1994).

No notable changes were made to the PTSD diagnostic criteria in the text revision of the

DSM-IV (APA, 1994), the DSM-IV-TR (APA, 2000). However, a Familial Patterns section was

newly included, indicating that having a first-degree relative with a lifetime diagnosis of

depression may increase the chances of a PTSD diagnosis if faced with a trauma. Table 1.1 presents the DSM-IV-TR (APA, 2000) criteria for PTSD.

Table 1.1

DSM-IV-TR (APA, 2000) Diagnostic Criteria for Posttraumatic Stress Disorder: 309.81

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma- specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Much research has been done on the validity of the DSM-IV (APA, 1994) PTSD

diagnosis. Saigh et al. (2002) examined the differential validity of the PTSD classification in

children and adolescents by studying youth diagnosed with PTSD, those who were traumatized but did not develop PTSD, and a control group. The diagnostic measures utilized were the

Children’s PTSD Inventory (Saigh, 2003) and the Diagnostic Interview for Children and

Adolescents – Revised (DICA-R; Reich et al., 1994), while the dependent measure was the Child

Behavior Checklist (CBCL; Achenbach, 1991a). The study determined that elevated CBCL

ratings were associated with PTSD and not exposure to a traumatic event in the absence of the

PTSD diagnosis. Furthermore, exposure to a traumatic event was not associated with higher rates

of psychiatric morbidity.

Golier et al. (2002) also evaluated the differential validity of the DSM-IV (APA, 1994)

PTSD diagnosis. Participants included survivors of the Nazi Holocaust, with and without a

diagnosis of PTSD, and healthy Jewish adults with no exposure to the Holocaust or other

traumas. Diagnostic assessments were made on the basis of structured interviews, the Clinician-

Administered PTSD Scale (Blake et al., 1995), and the Structured Clinical Interview for DSM-

IV Axis-I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1997). In addition, participants

completed an author-developed paired association test and a word stem task that measured

explicit and implicit memory, respectively. Finally, combined Vocabulary and Block Design

scaled scores from the Wechsler Adult Intelligence Scale - Revised (WAIS-R; Wechsler, 1981) were used to provide an approximate measure of IQ. Results indicated that Holocaust survivors with PTSD had poorer explicit memory compared to Holocaust survivors without PTSD and the control group. About one-third of the PTSD group performed at a level suggestive of cognitive impairment based on the memory measures given. Thus, the authors concluded that a relationship between explicit memory, associated with the hippocampal-dependent memory function in the brain, and a diagnosis of PTSD might exist.

In a similar vein, Saigh, Yasik, Oberfield, Halamandaris, and Bremner (2006) compared

IQ scores in youth with and without PTSD using the standard 10-subtest battery of the Wechsler

Intelligence Scale for Children – Third Edition (WISC-III; Wechsler, 19991), in lieu of the short form. Confounding psychiatric disorders and conditions were controlled. Results indicated that youth with a PTSD diagnosis had significantly lower scores on discrete measures of verbal intelligence compared to traumatized PTSD negatives and a non-exposed control group. No significant differences were found between traumatized PTSD negatives and the control group.

Saigh et al. (2006) reported that verbal functions are associated with the left hippocampus and thus one possible explanation is that PTSD-induced hippocampal changes may be linked to observed deficits. An alternative explanation may be that reduced hippocampal volume existed prior to the trauma. Golier et al. (2002) also posited an association between the hippocampus and

PTSD, as explained above. Finally, it is possible that disruptions in education due to trauma may account for the lower verbal subtest scores, which are related to school-based knowledge (Saigh et al., 2006).

Yasik, Saigh, Oberfield, and Halamandaris (2007) further documented memory impairment in individuals with PTSD. They examined youth with PTSD (n = 29), traumatized

PTSD negatives (n = 62), and non-traumatized controls (n = 40). Youth with major comorbid

conditions were excluded based on DSM-IV (APA, 1994) clinical and structured interviews.

Additionally, youth with limited English proficiency were excluded from the study. The Wide

Range Assessment of Memory and Learning (WRAML; Sheslow & Adams, 2003) was

administered to all participants to evaluate the ability of school-aged children to actively learn

and memorize different types of information. The study determined that memory and learning

impairments in children and adolescents were associated with PTSD and not trauma exposure in

the absences of PTSD.

Jamil, Nassar-McMillan, and Lambert (2004) also studied the differences between individuals with and without PTSD according to the DSM-IV (APA, 1994) criteria. They used the PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) on a convenience sample of Iraq Gulf War male veteran refugees in the United States. Among the sample, 59% scored above the cutoff for PTSD on the PCL-M. They found a significant association between PTSD, depression, and panic, as measured by the Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al., 1996).

Within the realm of childhood sexual abuse, Cohen, Deblinger, Mannario, and Steer

(2004) studied 229 children, 8 to 14 years of age, seeking treatment for sexual abuse. According to the Schedule for Affective Disorders of Schizophrenia for School-Age Children-Present and

Lifetime Version (K-SADS-PL; Kaufman, Birmaher, Brent, Rao, & Ryan, 1997), 89% of the sample met the full criteria for PTSD. Other psychological and behavioral problems were present in the children, as reported by their parents. On the Child Behavior Checklist (CBCL;

Achenbach, 1991a), 35% of the sample had scores representing severe psychopathology.

Finally, Blanchard, Rowell, Kuhn, Rogers, and Wittrock (2005) examined PTSD using

DSM-IV (APA, 1994) criteria in the context of the September 11, 2001 terrorist attacks with

1,306 undergraduate college students at three public universities (University of Albany, NY;

Augusta State University, GA; and North Dakota State University). The study occurred 12

months after the attacks. The participants completed the Beck Depression Inventory (BDI; Beck,

Ward, Mendelson, Mock, & Erbaugh, 1961), Life Events Checklist (Gray, Wang, Litz &

Lombardo, 2001), and the DSM-IV (APA, 1994) based PTSD Checklist (PCL; Weathers et al.,

1993). Results indicated that proximity to New York City and the World Trade Center was an important variable in terms of posttraumatic stress and depressive symptoms. Those whose home was in New York City reported average PCL scores that were 3.5 points higher than those who lived further away. Other researchers have also studied children and adolescents who resided in

New York City during the September 11, 2001 terrorist attack and found that they exhibited

DSM-IV (APA, 1994) PTSD symptoms (Fairbrother, Stuber, Galea, Fleischman, & Pfefferbaum,

2003; Hoven et al, 2005; Pfefferbaum, Stuber, Galea, & Fairbrother, 2006).

The DSM-5: 2013, The Most Recent Criteria

In May of 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-5; APA, 2013) was released, more than a decade after the DSM-IV-TR (APA,

2000). PTSD was previously classified as an anxiety disorder in the DSM-IV (APA, 1994). In

the most recent edition, PTSD, acute stress disorder, adjustment disorder, and reactive

attachment disorder are included in a new chapter on Trauma- and Stress-Related Disorders of

the DSM-5 (APA, 2013). The first PTSD criterion (Criterion A1) is broader, as there are now

four possible pathways to acquire PTSD rather than the three specified in the DSM-IV (APA,

1994). In addition to experiencing, witnessing, or learning of “actual or threatening death,

serious injury, or sexual violence,” (APA, 2013, p. 271) an individual may be diagnosed with

PTSD as a result of “experiencing repeated or extreme exposure to aversive details of the

traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly

exposed to details of child abuse)” (APA, 2013, p. 271). The new pathway does not apply to

exposure through various media or photographs, unless the exposure is work related (APA,

2013). Of note, the subjective reaction captured by Criterion A2 of the DSM-IV (APA, 1994) has been removed. In the DSM-5 an individual’s response to the traumatic event does not need to

involve intense fear, helplessness, or horror.

Criterion B regarding intrusion symptoms remains predominantly the same, but the

language has been augmented to emphasize intrusive rather than ruminative processes. The

DSM-5 (APA, 2013) divides avoidance and numbing symptoms (DSM-IV Criterion C, APA,

1994) into two separate categories resulting in four major symptoms clusters for PTSD. Criterion

C solely involves avoidance, while Criterion D encompasses negative alterations in cognition

and mood, such as numbing. There are seven symptoms listed under Criterion D, two of which

are new and reflect persistent negative appraisals and pervasive negative mood associated with

the syndrome (APA, 2013).

Criterion E involves heightened arousal and reactivity. This cluster includes two major changes, the addition of a symptom that deals with self-destructive behavior and an anger symptom that places an emphasis on aggressive behavior. The presence of a traumatic stressor

(Criterion A) along with a minimum of one symptom from Criterion B and C and two from

Criterion D and E are required. The criteria that dealt with duration and clinically significant distress remain unchanged. One may newly specify if the PTSD diagnosis includes “dissociative symptoms” or is a result of “delayed expression.” The former is applicable to individuals who

meet experience depersonalization or derealization symptoms, and the latter if the symptoms do

not occur until at least 6 months after the trauma. However, the “acute” and “chronic”

distinctions from DSM-IV (APA, 1994) have been removed (APA, 2013). Table 1.2 presents the

DSM-5 (APA, 2013) criteria for PTSD.

Table 1.2

DSM-5 (APA, 2013) Diagnostic Criteria for Posttraumatic Stress Disorder: 309.81(F43.10)

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). ! Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). ! Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). ! Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) ! Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether: • With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). o Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if: • With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Miller et al. (2013) analyzed the DSM-5 PTSD criteria in a nationally representative

community sample of American 2,953 adults and a clinical convenience sample of 345 U.S.

military veterans. Measures included the National Stressful Events Survey (NSES; Kilpatrick,

Resnick, Baber, Guille, & Gros, 2011), which was developed for the study to assess exposure to

various types of traumatic events along with the presence and severity of each of the DSM-5

(APA, 2013) symptoms. The 1-5 severity scale from the PTSD Checklist (PCL; Weathers et al.,

1993) was given to participants who endorsed a given symptom within the past month. PTSD prevalence rates were comparable when analyzing DSM-IV-TR (APA, 2000) and DSM-5 (APA,

2013) PTSD criteria. The four-symptom criteria in the DSM-5 (APA, 2013) were determined to be adequate through confirmatory factor analyses. However, a DSM-5 version of a “dysphoria” model (Simms, Watson, & Doebbeling, 2002), which has five intrusion and two avoidance symptoms loading on the same factor (combining DSM-IV criteria C and D), was somewhat superior. Further, item response theory and confirmatory factor analyses indicated that psychogenic amnesia and problems in the domain of self-destructive behavior might be better

conceptualized as “associated features” rather than core symptoms of PTSD. The DSM-5 (APA,

2013) does not list them as “associated features,” as was recommended by the authors.

Of note, the DSM-5 (APA, 2013) includes a separate PTSD diagnostic criteria for children ages 6 years or younger. It is the first developmental subtype of an existing disorder

(APA, 2013). Criterion A includes the original three pathways that one may obtain PTSD as outlined in the DSM-IV (APA, 1994), which are experiencing, witnessing, or learning of a traumatic event. Criteria B (intrusion symptoms) and C (avoidance or negative alternations in cognition) require a minimum of one symptom, while Criterion D (alterations in arousal and reactivity) requires two. Thus, the developmental criteria for children aged 6 and younger involve a three-cluster model.

Given the paucity of evidence to support the validity of the new classification as applied to children aged 6 to 17 years, it may be of some worth to recall that Quay and Werry (1986) advised that, “A disorder is empirically validated by determining its relationship to other variables… Of particular concern is differential validity; two putatively separate disorders ought not to be related in the same way to the same variable” (p. 37). Quay and Werry’s comments are particularly pertinent at this time as the process involving the development of the DSM-5 (APA,

2013) has been seriously questioned (British Psychological Association, 2011; Frances, 2013;

Lane, 2013) and as there is a need to make diagnoses on the basis of a valid nosology.

Chapter Summary

The deleterious effects of trauma have been documented for centuries across the world. A host of terms have been used to describe a cluster of symptoms including intrusive recollections of the traumatic stressor, irritability, emotional impairment, sleep disturbance, and general functional impairment. However, it was not until 1980 that the name posttraumatic stress

disorder (PTSD) was introduced and recognized as a formal clinical disorder by the APA in the

DSM-III (APA, 1980). A specific reference to the expression of PTSD in children only appeared in the DSM-III-R, published in 1987. This resulted in a plethora of research validating the diagnosis of PTSD in various populations. While many empirically driven revisions were made to the PTSD classification in the DSM-IV in 1994, the clinical and community-based field trials didn’t involve youth under the age of 15. In 2013, the APA published the DSM-5, introducing special, developmental criteria for PTSD in youth ages 6 and under. The revised PTSD criteria relaxed some of the requirements that were included in the DSM-IV (APA, 2004).

CHAPTER II

Child and Adolescent PTSD:

Epidemiology, Comorbidity, and Risk Factors

Saigh, Yasik, Sack, and Koplewicz (1999) refer to epidemiology as the “study of health and morbidity in human populations” (p. 18) with special attention given to prevalence, distribution, and risk factors of a disorder. The current chapter considers the epidemiology of

PTSD in children and adolescents across the world. Rates of exposure to traumatic stressors and the development of the disorder in the general population and special populations, comorbidity, and risk factors associated with the disorder are discussed.

Various electronic databases including JSTOR, Medline, Ovid, PsycINFO, Psyc Articles,

PubMed, and Science Direct were utilized for this literature review in order to identify research studies involving youth aged 2 to 21 years with PTSD. Primary search descriptors included:

PTSD, posttraumatic stress disorder, youth, child or adolescent. Furthermore, separate secondary descriptors included: trauma, criminal victimization, assault, mugging, war, natural disasters, earthquakes, hurricanes, and motor vehicle accidents. Additional research articles were located in previous written chapters on the epidemiology of child-adolescent PTSD by Saigh, Yasik, Sack, and Koplewicz (1999) and Spitalny (2004).

General Population Studies

Exposure to traumatic events in the United States (US) is common. The vast majority of individuals in the US, more than two-thirds of the general population, will experience at least one traumatic event severe enough to potentially lead to PTSD during their lifetime (Kessler et al., 1995). During any given year, up to one-fifth of individuals in the US may experience such an event (Breslau, David, Andreski, & Peterson, 1991; Breslau et al., 1998; Breslau, 2009;

Kessler et al., 1995; Norris, 1992; Resnick et al., 1993). Comparable figures have been reported in the Canadian community (Stein, Walker, Hazen, & Forde, 1997; van Ameringen, Mancini,

Patterson, & Boyle, 2008). Much lower rates of lifetime exposure to trauma, approximately 20% to 28%, have been reported in surveys in Germany and Switzerland (Breslau, 2009).

Breslau and colleagues (1998) studied a representative sample (N = 2,181) of individuals aged 18 to 45 years in the Detroit area to assess lifetime prevalence of trauma exposure. They used a random digit dialing procedure to select the sample and inquired about possible exposure to 19 types of traumatic events as based on the DSM-IV (APA, 1994) definition of trauma.

Measures included the Diagnostic Interview Schedule for DSM-IV (DIS-IV; Robins et al., 2000) and the World Health Organization’s (WHO) Composite International Diagnostic Interview

(CIDI; Kessler & Ustun, 2004). If a traumatic event was endorsed, the number of times the event occurred and the respondent’s age at the time were recorded. The overall lifetime prevalence of exposure to any traumatic event in their study was 89.6%, with a higher prevalence for men than women. This figure is supported by statistics from the American Red Cross (2012). In 2012, The

American Red Cross reported that a home fire was responded to every nine minutes.

Additionally in 2012 there were 109,396 overnight stays at hospitals, 6,883,648 relief items,

29,889 disaster deployments, and 141,164 health and mental health contacts provided in the US alone, further revealing the continued high rates of frequent exposure to traumatic events.

Only a small proportion of those exposed to a traumatic event will subsequently develop

PTSD (Saigh, 1992). By age 75, the lifetime risk for developing PTSD utilizing DSM-IV (APA,

1994) criteria is 8.7% (Kessler et al., 2005a). In the US, the prevalence during any given year is

3.5% (Kessler et al., 2005b). A multitude of surveys indicated that PTSD as defined by the

DSM-IV-TR (APA, 2000) is diagnosable across the world (APA, 2013); however prevalence

rates vary even when using the same diagnostic measure to assess for PTSD (Hinton & Lewis-

Fernandez, 2011). For example, all of the following studies utilized the WHO’s Composite

International Diagnostic Interview (CIDI; Kessler & Ustun, 2004) to diagnose 12-month PTSD prevalence rates in community samples. In the Yoruba-speaking provinces of Nigeria, Gureje,

Lasebikan, Kola, and Makanjuola (2006) found PTSD prevalence rates of 0%. In Asia, 12-month

community PTSD prevalence rates ranged from 0.2% (Shen et al., 2006), 0.4% (Kawakami et

al., 2005), and 0.7%(Cho et al., 2007) in China, Japan, and South Korea, respectively. Rates have been reported as 0.6% in Mexico (Medina-Mora et al., 2005) and South Africa (Williams et al.,

2008), 0.9% in Europe (Alonso et al., 2004), 1.3% in Australia (Andrews, Henderson, & Hall,

2001), and 2% in Lebanon (Karam et al., 2006). It is not clear why PTSD prevalence rates in the

United States are higher than in other countries although methodological variations may be a

contributing factor (Weathers & Keane, 2007).

Prevalence of Exposure to Traumatic Events in Youth Populations

Many studies assessing the risk for childhood PTSD have analyzed exposure to a specific trauma such as a motor vehicle crash but few have explored the full range of potentially traumatic events that can result in PTSD (Copeland, Keeler, Angold, & Costello, 2007). Yet youth experience a disproportionately high number of traumatic events each year relative to adults (Baum, 2005; Fitzpatrick & Boldizar, 1993). The US Department of Justice conducts a

National Crime Victimization Survey (NCVS) to monitor levels of violent crime in the US against those age 12 or older from a nationally representative sample of households. Baum (2005) conducted a study utilizing NCVS data from 1993-2003 to document trends of nonfatal violent victimization of youth aged 12 to 17 years. Definitions of violent crime included robbery, aggravated assault, rape, sexual assault, and simple assault. Results indicated that these youth

experienced relatively high levels of violent crime; on average, juveniles in this age group were

about 2.5 times more likely than adults to be the victim of a nonfatal crime. In other words, 8.4%

of youth compared to 3.2% of adults experienced nonfatal violent victimization. Furthermore,

Fitzpatrick and Boldizar (1993) reported that the victimization rate for adolescents, aged 12 to 19

years, is twice the rate for adults aged 25 and older in urban areas.

Analogously, national crime statistics from the Department of Justice (2006) reveal that

US adolescents and young adults experienced the highest rates of violent crime between 1973

and 2005. The United States Department of Transportation (2006) reported that approximately

640 US children were injured daily in 2005. In 2006, approximately 10% of motor vehicle

accident victims were children aged 17 and under. Lastly, the United States Department of

Transportation (2007) indicated that between 1996 and 2005 the highest rates motor vehicle

fatalities in the US occurred among those aged 16 to 20 years.

Research studies involving traumatic experiences of children and adolescents in the

United States supports the notion that they are disproportionately exposed to violence. Bell and

Jenkins (1993) surveyed 536 elementary school children and 1,035 students from four high

schools and two middle schools in Chicago. Astonishingly, 25% of the elementary students

reported that they had seen someone shot and 30% reported witnessing a stabbing. Among the

high school students, 75% had witnessed a robbery, stabbing, shooting, and/or murder.

Specifically 24% reported that they had seen someone murdered, 35% witnessed a stabbing, and

39% witnessed a shooting.

Kessler, Sonnega, Bromet, Hughes, and Nelson (1995) analyzed the general population

epidemiology of DSM-III-R (APA, 1987a) PTSD in the National Comorbidity Survey (NCS).

Nationally representative participants (N = 5,877) aged 15 to 54 were surveyed. Out of a

subsample of American males and females aged 15 to 24, 60.7% of males and 51.2% of females

reported exposure to one or more traumatic events. Kilpatrick and Saunders (1997) conducted a

similar survey using a nationally representative sample of 4,023 Americans aged 12 to 17 years.

They found that 39.4% of those surveyed had witnessed at least one incident involving serious

interpersonal violence. Furthermore, approximately 25% experienced serious physical or sexual

assault. Similarly, Schwab-Stone et al. (1995) examined levels of violence exposure and feelings

of safety in a sample of 6th, 8th, and 10th grade students (N = 2,248) in an urban public school system. More than 40% of those surveyed reported exposure to a shooting or stabbing in the past year.

Breslau, Wilcox, Storr, Lucia, and Anthony (2004) conducted a longitudinal study with a high-risk sample of urban American youth to assess rates of trauma exposure and PTSD.

Participants were recruited at the beginning of first grade in a public school system between

1985 and 1986. The original sample (N = 2,311) from 1985-1986 was interviewed between 2000 and 2002 when their mean age was 21 (n = 1,698). PTSD diagnoses were based on DSM-IV

(APA, 1994) criteria. Of the sample, 82.5% experienced at least one traumatic event. The most

common event was assaultive violence (42.7%), being threatened with a weapon (35.9%), or the

sudden unexpected death of a close friend or relative by homicide or murder (26.1%). Rape was

the event most associated with PTSD, as 40% of individuals who had been raped subsequently

met PTSD criteria. The lifetime occurrence of assaultive violence was higher for males (62.6%)

than for females (33.7%) but females had a higher risk of PTSD after an assaultive violence

occurrence than males.

In a similar vein, Finkelhor, Ormrod, Turner, and Hamby (2005) analyzed a nationally

representative sample of 2,030 children aged 10 to 17 years for possible exposure to 34 forms of

victimization experiences such as robbery, theft, kidnapping, and witnessing various types of

violence. In one year, 71% of the sample reported that they had been victimized. Of the

victimized sample, 69% had experienced multiple victimizations. The mean number of

victimizations in one year was 3.0, with the highest range being 15.

In a related effort, Copeland, Keeler, Angold, and Costello (2007) examined a

representative population sample of 1,420 children aged 9, 11, and 13 years at intake. Cases were

followed up with annually until they were16 years old using the Child and Adolescent

Psychiatric Assessment (CAPA; Angold & Costello 2000). Results indicated that exposure to

traumatic events was almost commonplace, as more than two-thirds of the sample reported at

least one traumatic event by 16 years of age, with 13.4% subsequently developing some PTSD

symptoms.

Community-Based Surveys Examining Child-Adolescent PTSD Prevalence Rates

Beyond prevalence rates for exposure to traumatic events, many community-based

surveys have reported child-adolescent prevalence rates for PTSD following traumatic events.

Using the DSM-III-R criteria (APA, 1987a), Giaconia et al. (1995) examined the prevalence of

PTSD in an ongoing longitudinal study with a community sample of 384 adolescents. The study began when the participants were 5 years of age with additional data collected at ages 9, 15, and

18, resulting in 1,990 interviews with adolescents. The National Institute of Mental Health

Diagnostic Interview Schedule III-R (DIS-III-R; Robins, Helzer, Cottler and Golding, 1989) was

administered to participants at age 18. More than 40% of the adolescents studied reportedly

experienced at least one DSM-III-R (APA, 1987a) trauma by the age of 18 and 14.5% of those

exposed to a trauma went on to develop PTSD (i.e. 6.3% of the total sample). Learning about

another’s sudden death or accident was the most commonly reported trauma (13%). Those with

PTSD at age 18 demonstrated behavioral, emotional, academic, physical, and mental

impairments. Eighty percent of adolescents with PTSD met criteria for at least one other disorder

and more than 40% had two or more additional lifetime disorders. Finally, those who were

exposed to rape or sexual assault as opposed to other traumas had a higher risk for PTSD.

Cuffe et al. (1998) also sought to determine the prevalence of PTSD in a community

sample of adolescents using DSM-IV (APA, 1994) criteria. The sample consisted of 290 12th grade students in a suburban school district in the Southeast United States. Measures included the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS;

Chambers et al., 1985), the Children’s Global Assessment Scale (CGAS; Shaffer et al., 1983), and a semistructured interview of the adolescent and one parent. Approximately 3% of females and 1% of males met criteria for PTSD. It is of note that females reported more traumatic events than males. The authors found that being female, experiencing rape or child sexual abuse, and witnessing an accident or medical emergency were associated with an increased risk of PTSD.

Perkonigg, Kessler, Storz, and Wittchen (2000) analyzed data from a representative community sample of 3,021 Germans aged 14 to 24 years for lifetime and 12-month prevalence of traumatic events and PTSD using DSM-IV criteria (APA, 2000). Based on the Munich

Composite International Diagnostic Interview (M-CIDI; Wittchen & Pfister, 1997), approximately 26% of males and 17% of females reported a traumatic event but only 7.8% of those traumatized, or 1% of males and 2.2% of females, qualified for a full diagnosis of PTSD.

Being female was a risk factor for both experiencing a traumatic event and a diagnosis of PTSD.

Furthermore, development of PTSD was most associated with sexual abuse or rape as well as the number of traumatic events that occurred before the participant was 12 years of age.

Kilpatrick et al. (2003) analyzed data from the National Survey of Adolescents (NSA), which consisted of a sample of 4,023 youth between 12 and 17 years of age. Through a highly regulated telephone interview the researchers gathered information regarding PTSD using an unstructured DSM-IV (APA, 1994) clinical interview along with demographic and familial variables. Overall, 4.8% of the sample met PTSD criteria. Approximately twice as many females,

6.3%, as males, 3.7%, met criteria for PTSD. Furthermore, nearly 75% of all adolescents diagnosed with PTSD had at least one comorbid diagnosis, such as a Major Depressive Episode

(MDE).

Breslau, Lucia, and Alvarado (2006) conducted a longitudinal study on a randomly selected sample of 713 individuals. The participants were assessed at ages 6, 11, and 17. A computerized version of the National Institute of Mental Health Diagnostic Interview Schedule,

Version III (DIS-III-R; Robins, Helzer, Cottler, & Golding, 1989) was used to assess exposure to traumatic events and PTSD diagnoses using DSM-IV (APA, 1994) criteria when the participants were 17 years of age. Of the 713 participants interviewed at age 17, 541 (75.9%) experienced one or more traumatic events. More males (79.2%) than females (72.9%) reportedly experienced one or more traumatic events. The overall level of exposure to any traumatic event, which ranged from one to nine, was higher in urban than suburban youth, 86% vs 65.3% respectively. Lastly, the lifetime prevalence of PTSD for the sample as a whole was 8.3%.

More recently, Storr, Ialongo, Anthony, and Breslau (2007) prospectively examined childhood precursors of trauma exposure to estimate PTSD risk among a sample of urban youth.

As part of a longitudinal study that began in 1985, 2,311 first grade students from various public schools within the same district were administered the PTSD module of the Composite

International Diagnostic Interview (CIDI; World Health Organization, 1997). Fifteen years later,

follow up evaluations occurred with 1,698 young adults from the original cohort. Results indicated that the estimated exposure to one or more DSM-IV (APA, 1994) qualifying traumatic events in the cohort was 82.5%. Males and older adolescents had higher rates of exposure assaultive violence as compared to females and younger adolescents. Of those who experienced a traumatic event, the estimated occurrence of PTSD was 8.8%.

In the aforementioned youth community studies, despite high rates of reported trauma exposure in the US ranging from 40% to 82.5% (Breslau et al., 2006; Giaconia et al., 1995;

Kilpatrick et al., 2003; Storr et al., 2007), the majority of children and adolescents did not develop PTSD. For example, Giaconia et al. (1995) reported that only 14.5% of youth exposed to a trauma subsequently developed PTSD, while Perkonigg et al. (2000) indicated that only 7.8% of traumatized youth developed PTSD. Similarly, Storr et al. (2007) reported that 8.8% of their sample of traumatized urban youth developed PTSD.

Alisic et al. (2014) conducted a meta-analysis of PTSD rates in children and adolescents exposed to trauma using 72 peer-reviewed articles with well-established diagnostic interviews.

The authors found that PTSD was diagnosed in 15.9% in trauma-exposed youth. Boys exposed to non-interpersonal traumas (e.g. disaster or injury due to accidents) displayed the lowest risk

(8.4%) compared to girls exposed to interpersonal traumas (e.g. war, terrorism, or violence) who displayed the highest risk (32.9%). Overall, it is important to note that a significant minority of children and adolescents develop PTSD following trauma exposure.

Empirical Studies by Stressor Type

This section focuses on child-adolescent PTSD prevalence rates following particular types of trauma exposure, including war-related traumas, criminal victimizations, natural disasters, and serious accidents.

War-Related Studies of Child-Adolescent PTSD

War trauma differs from other types of trauma exposure, as children often do not have the benefit of support from the community who may also be personally affected by the disaster at the

same time. Furthermore, children exposed to war are presented with a multitude of unfamiliar

experiences and events while coping with normal maturational tasks without typical levels of

support from their families (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Jensen & Shaw,

1993; Rizzone, Stoddard, Murphy, & Druger, 1994). Various disorders have been suggested to

occur after war exposure and PTSD is one of the most frequently cited (de Jong, Komproe, &

van Ommeren, 2003; Scholte et al., 2004; Vinck, Pham, Stover, & Weinstein, 2007). Studies

regarding the psychological function of children and adolescents exposed to war will be

reviewed. Specifically, the following section discusses prevalence rates of PTSD in children

associated with wars that took place in Africa, Asia, the Balkans, and the Middle East.

African Studies. In an investigation of youth traumatized during war, Geltman et al.

(2005) utilized the Harvard Trauma Questionnaire (HTQ: Mollica et al., 1992) and the Child

Health Questionnaire (CHQ; Landgraf, Abetz, & Ware, 1999) with 304 Sudanese refugee minors

one year after resettlement in the United States. All of the participants immigrated to the United

States after surviving the Sudanese civil war. In the late 1980s, war forced these very young

children to depart from their burning villages, as families were often killed. Many refugees

witnessed serious atrocities, such as the mutilation or stabbing of nuclear family members

(Duncan, 2000). Researchers determined that 20% of the sample met criteria for PTSD one year

after resettlement based on the HTQ (Mollica et al., 1992). A history of personal injury and

social isolation were associated with PTSD.

Schall and Elbert (2006) investigated the prevalence of PTSD in youth 10 years after the

1994 Rwandan genocide. In 1998, more than 300,000 children were living in child-headed households, as many lost most if not all of their family members to the genocide (Ntete, 2000).

All of the participants reportedly experienced the Rwandan genocide in 1994 and nearly all of the respondents (n = 68) lost both parents. At the time of the study, participants were between 13 and 23 years of age. Measures included the Event Scale (Dyregrov, Gupta, Gjestad, &

Mukanoheli, 2000) and the DSM-IV (APA, 1994) version of the Composite International

Diagnostic Interview (CIDI; World Health Organization, 1997). In total, 44% of the participants met full criteria for PTSD. Furthermore, living in a child-headed household during the time of the study was associated with PTSD compared to individuals living in an orphanage. Finally,

PTSD was more common among those who were older during the genocide (8 to 13 years) compared to those who were younger (3 to 7 years).

The rebel terror group called the Lord’s Resistance Army (LRA) has displaced approximately 1.4 million people in Uganda as a result of ongoing war. An estimated 25,000 children and adolescents have been forcefully recruited into the rebel forces (Coalition to Stop the Use of Child Soldiers, 2008). Bayer, Klasen, and Adam (2007) conducted a cross-sectional study of 169 former child soldiers, aged 11 to 18, in rehabilitation centers in Uganda and the

Democratic Republic of the Congo. The sample consisted of 141 males and 28 females who spent an average of 38.3 months as child soldiers. The most commonly reported traumatic event was witnessing a shooting. Of note, 54.4% reported having killed someone and 27.8% were reportedly forced into sexual activity. Symptoms of PTSD were evaluated using the Child

Posttraumatic Stress Disorder Reaction Index (CPTSD-RI; Pynoos et al., 1987), which corresponds to some of the DSM-IV (APA, 1994) PTSD criteria. The children’s openness to

reconciliation and their feelings of revenge were assessed separately by 2 questionnaires. Of the

former child soldiers, 59 (34.9%) were classified with probable PTSD.

Similarly, Klasen and colleagues (2010) examined 330 former Ugandan child soldiers

aged 11 to 17 years. On average, the participants spent 19.81 months in abduction and had

returned from the armed group for an average of 31.75 months at the time of the study. Using the

DSM-IV (APA, 1994) version of the Mini-International Neuropsychiatric Interview for Children

and Adolescents (MINI-KID; Sheehan et al., 1998), 33% met criteria for PTSD while 36.4% met

criteria for major depression, with 18.5% qualifying for both diagnoses. Younger adolescents,

aged 11-13, displayed significantly lower rates of PTSD (23.9%) than older adolescents, aged

14-17 (36.8%). Controlling for all other variables, higher age was a risk factor for PTSD and

high family SES was a protective factor.

Recently, Pfeiffer and Elbert (2011) utilized structured interviews to assess PTSD prevalence among former abductees in Northern Uganda. In May and June of 2005, 72

interviews were conducted with formerly abducted individuals. The sample consisted of 41 male

and 31 females, 62 whom were former child soldiers living in a reception center having only

escaped the rebel movement within the last few weeks. The duration of abduction was

significantly longer for females, 7.7 years, as compared to males, 4.9 years. All the participants

were abducted by LRA rebels and experienced an average of 16.5 traumatic events. The most

common events included combat situations, witnessing murders, beatings, and mutilations. The

threat of death was common. Results from the Posttraumatic Stress Diagnostic Scale (PDS; Foa,

1995) indicated that almost half (49%) of the sample met DSM-IV (APA, 1994) criteria for

PTSD.

Asian Studies. Much of the focus on child-adolescent PTSD prevalence involving war in

Asian countries has focused on the genocide in Cambodia in the 1970s. Under the Pol Pot

leadership, the Khmer Rouge violently attempted to restore a Marxist government in Cambodia.

Atrocious acts of war were committed such as torture, executions, and practiced social

engineering (Mollica et al., 1993). Within this context Kinzie and his colleagues (Kinzie, Sack,

Angell, Clarke, & Ben, 1989; Kinzie, Sack, Angell, Mason, & Ben, 1986) described the psychiatric effects of massive trauma under Pol Pot (1975-1979) on 40 Cambodian high school students in the United States. These participants endured intense trauma including witnessing many executions, separation from their families, forced labor, starvation, and personal injury.

Kinzie et al. (1986) administered standardized interviews using DSM-III (APA, 1980) criteria to the participants in the US approximately 2.5 years after the Pol Pot regime. During the first study

(Kinzie et al., 1986), 50% of the participants (n = 20) developed PTSD. Mild, but prolonged depressive symptoms were also common. Three years later in a follow up study (Kinzie et al.,

1989), 27 of the original 40 adolescents were reexamined. Results indicated that 48% of participants (n = 13) met criteria for PTSD using a DSM-III-R (APA, 1987a) diagnostic interview. It is important to note that of those who initially met criteria for PTSD in 1986, 61.5% still did at the three-year follow up. Sack et al. (1993) conducted a six-year follow-up on this group and administered the DSM-III-R (APA, 1987a) version of the Diagnostic Interview for

Children and Adolescents (DICA; Welner, Reich, Herianic, Jung & Amando, 1987) to 19 of the original 40 participants. The PTSD prevalence rates of those 19 participants across the three dates examined in 1984, 1987, and 1990 were 52%, 47%, and 32%, respectively. In addition, rates of depression in 1984, 1987, and 1990 were 50%, 41%, and only 6%, respectively.

Sack et al. (1994) continued further investigation with Cambodian adolescent refugees from the Pol Pot regime. They studied 209 Cambodian adolescent refugees living in Portland,

Oregon or Salt Lake City, Utah 13 years after leaving Cambodia. The researchers administered the PTSD portion of the DICA (Welner et al., 1987) and sections of the Schedule of Affective

Disorders and Schizophrenia for School-Age Children – Epidemiologic Version (K-SADS-E;

Puig-Antich, Orvaschel, Tabrizi, & Chambers, 1983) to the participants aged 13 to 25 who were exposed to a variety of wartime atrocities. The lifetime prevalence of PTSD was 21.5% while the current PTSD prevalence rate was 18.2%.

Also within the context of Cambodian refugees, Hubbard, Realmuto, Northwood, and

Masten (1995) examined 59 Cambodian young adults who survived massive war trauma in their native country. The participants ranged in age from 16 to 25 and were living near the University of Minnesota at the time of the study. The Structured Clinical Interview for DSM-III-R-Non-

Patient version (SCID-NP; Spitzer & Williams, 1986) was utilized to determine that 24% of the sample (n = 4) met criteria for PTSD at the time of the interview. In terms of lifetime prevalence,

59% (n = 35) met criteria.

Finally, Savin, Sack, Clarke, Meas, and Richart (1996) studied the prevalence of war- related PTSD among 99 Cambodian refugees living along the Thai-Cambodian border who survived the Pol Pot regime as children. The participants ranged in age from 18 to 25 at the time of the study, with a mean age of 22.27 years. Diagnostic measures included a Khmer version of the DSM-III-R (APA, 1987a) DICA (Welner et al., 1987). The point prevalence of PTSD was

26.3% (n = 25) while the lifetime prevalence was 31.3% (n = 31). Of note, only five participants had neither PTSD nor present or past episodes of depression.

Balkan Studies. Many researchers have looked into the psychological functioning of

individuals who were exposed to war in the Balkans (e.g. Husain, Allwood, & Bell, 2008;

Kashdan, Morina, & Priebe, 2009; Möhlen, Parzer, Resch, & Brunner, 2005; Priebe et al., 2010;

Zivcic, 1993) but few studies specifically examined PTSD prevalence rates of those children.

The war in the Balkans was a series of violent conflicts between 1991 and 2001 in the area

formerly known as Yugoslavia. The wars followed the dissolution of the country and are

considered to be a series of separate but related military conflicts (Nation, 2003). Many of those

affected by the war in Yugoslavia experienced a number of atrocities that ranged from participation in combat, imprisonment, destruction of their homes, death of loved ones, and being witness to bombings, murder, or torture (Arcel, Popovic, Kucukalic, & Bravo-

Mehmedbasic, 2003; Arcel & Simunkovic-Tocilj, 1998; Favaro, Maiorani, Colombo, &

Santonastaso, 1999; Schwarzwald, Weinsberg, Solomon, & Klingman, 1993).

In a small study, Weine et al. (1995) examined 12 Bosnian adolescents newly resettled in

the United States who experienced ethnic cleansing attacks in Bosnia-Herzegovina. Bosnian Serb

and Serbian forces reportedly attempted to eliminate Muslim and Croat civilians. The sample

consisted of five female and seven male adolescents who had all previously lived in Bosnia and

were ethnic Muslims. Detailed interviews were conducted and outcomes revealed none of the participants had developmental or academic problems prior to the war. Clinical diagnoses were made according to DSM-III-R (APA, 1987) criteria. Results indicated that that 25% (n = 3) of the sample met criteria for PTSD.

Goldstein, Wampler, and Wise (1997) examined 357 Bosnian children that were displaced due to war. The participants consisted of children aged 6 to 12 and their parents.

During the data collection, shelling was heard and there were direct hits on the city. Based on the

Bosnian War Trauma Questionnaire (Macksound, 1992), the Sead Picture Survey tool (Martinez

& Richters, 1993), and DSM-IV (APA, 1994) criteria for PTSD, 94% of the children met criteria for PTSD.

In a related effort, Allwood, Bell-Dolan, and Husain (2002) studied 791 Bosnian children and adolescents, aged 6 to 16 years, within one school district in Sarajevo, Bosnia during the war. A variety of measures were utilized, such as the Children’s Posttraumatic Stress Disorder

Reaction Index (CPTSD-RI; Pynoos et al., 1987), Impact of Events Scale (IES; Horowitz,

Wilner, & Alvarez, 1979), Child Behavior Checklist – Teacher Rating Form (CBCL-TRF;

Achenbach, 1991b), Children’s Depression Inventory (CDI; Kovacs, 1992), and a researcher created questionnaire to gather information regarding children’s exposure to war events. Results indicated that the most frequent adverse war condition involved experiencing the death of a friend or family member. Forty-one percent of the sample met criteria for PTSD and older children reported more symptoms. Teacher reported delinquent behaviors were significantly related to direct exposure to violence. In addition, teacher reported aggressive behaviors were related to having witnessed killings.

Eytan et al. (2004) estimated the prevalence of PTSD in a sample of the Albanian

Kosovar (N = 996) population more than two years after the culmination of the conflict.

Measures included the Mini International Neuropsychiatric Interview (MINI; Sheehan et al.,

1998), which is a structured and validated diagnostic interview using DSM-IV criteria (APA,

1994), the HTQ (Mollica et al., 1992), and the Medical Outcomes Study 36-Item Short Form

Health Survey (Ware & Sherbourne, 1992). More than two years after the end of the conflict the overall prevalence of PTSD was 23.5% using DSM-IV (APA, 1994) criteria. For those individuals between the ages of 16 and 24 at the time of the study (24.7% of the total sample),

the PTSD prevalence rate was 12.6%. Prevalence was significantly associated with exposure to

traumatic events, female gender, older age, and having left Kosovo during the war.

Middle Eastern Studies. From 1975 to 1990 a civil war took place in Lebanon that resulted in devastating violence, air raids, shelling, street combat, and the displacement of entire communities. Within this context Saigh and his colleagues (Saigh, 1988a, 1988b, 1989a; Saigh,

Mroueh, & Bremner, 1997) conducted several studies involving the youth of Lebanon affected by the conflict. In a unique study involving the epidemiology of PTSD, Saigh (1988a) studied self-reported PTSD symptoms of 12 students from the American University in Beirut, Lebanon who were exposed to severe and unexpected war-related stressors. The students were in West

Beirut during a military bombardment, forced to take shelter, deprived of sleep for over 24 hours, and testified to the intensity and fearfulness of the situation. Saigh collected data on the students

63 days before the war stressor and then 8, 37, and 316 days after the stressor. None of the participants had PTSD before the bombardment. However, 75% (n = 9) stated they experienced

symptoms warranting an acute PTSD diagnosis after the incident. He also reported that

symptoms spontaneously remitted within a month of the bombardment among all but one

student. That student (8.3% of the sample) presented with chronic PTSD 316 days later after

trauma exposure and had experienced secondary trauma exposure.

Saigh (1988b) continued to study PTSD with a group of 92 Lebanese adolescents. He

administered the DSM-III (APA, 1980) version of the Children’s PTSD Inventory (Saigh,

1987d) to adolescents who reportedly developed academic and psychological difficulties after

exposure to war-related stressors. While the interval between trauma exposure and the study was

not reported, Saigh found that 29.3% (n = 27) met criteria for PTSD. Saigh (1989a) also

conducted a large-scale PTSD study of 840 Lebanese children between the ages of 9 and 12. Red

Cross workers, mental health practitioners, physicians, and educators referred the children for an

assessment if they displayed emotional problems after exposure to war-related stressors. Using

the Children’s PTSD Inventory (Saigh, 1987d), it was determined that 32.5% (n = 231) of

children warranted a PTSD diagnosis. Similarly, Saigh, Mroueh, and Bremner (1997)

administered the Children’s PTSD Inventory (Saigh, 1987d) to 92 Lebanese 13 year olds. The participants were enrolled in English-speaking private Lebanese secondary schools. At the time

of the data collection, bombings and terrorist attacks were occurring. Results indicated that

14.7% (n = 14) of the total sample met DSM-III (APA, 1980) criteria for PTSD or 46.7% of

those participants exposed to extreme stress.

Within the context of Lebanese youth, Karam et al. (2000) investigated PTSD in a sample

of 386 Lebanese children and adolescents randomly selected from 25 schools. The participants

were exposed to the “Grapes of Wrath” military operation, which included shelling and bombardment by tanks, airplanes, and warships that lasted for 15 days. As a result, there were

hundreds of fatalities and thousands of casualties. Entire communities were displaced. Sections

of the Diagnostic Interview for Children and Adolescents-Revised (DICA-R; Reich, Leacock, &

Shanfeld, 1995) were administered to both parents and children. The presence of dysfunction

was required to make the criteria compatible with DSM-IV (APA, 1994). The point prevalence

of PTSD was 24.1% (n = 93).

Analogously, Almqvist and Brober (1999) analyzed the psychological functioning of 39

Iranian refugee children three and a half years after they left Iran. The participants ranged in age

from 4 to 8 years and had resettled in Sweden with their families. Semi-structured interviews

with one or both parents and an extensive child assessment based on DSM-IV (APA, 1994)

criteria for PTSD established that 18% of the participants met full criteria for PTSD. In a similar

vein, Ahmad, Sundelin-Wahlsten, Arinell, & von Knorring, 2000 (2000) analyzed PTSD rates in

45 randomly selected Kurdish families, 5 years after a genocidal campaign against Kurdish

individuals in Iraqi Kurdistan. The families were living in two displacement camps. Measures

included the DSM-III-R (APA, 1987a) version of the Posttraumatic Stress Symptoms for

Children (PTSS-C; Ahmad et al., 2000) and the Harvard Trauma Questionnaire (HTQ; Mollica

et al., 1992). Results indicated that 87% of the children and 60% of their caregivers met criteria

for PTSD. Childhood PTSD was found to be significantly associated with the duration of

captivity.

Khamis (2005) assessed the prevalence of PTSD among 1,000 Palestinian children aged

12 to 16. The participants were selected from private, government, and United Nations Relief

Work Agency schools in East Jerusalem or the West Bank and were under constant threat of

trauma exposure. A DSM-IV (APA, 1994) structured clinical interview was used to assess

PTSD. Slightly more than half of the sample, 54.7% (n = 547) experienced at least one lifetime

trauma. The most common traumatic events were traumas inflicted by the Israeli army (e.g. personal injuries, death of family member, home demolished). Approximately 30.9% of the

sample were traumatized in car accidents and 14.8% had been physically abused or assaulted. Of

the stress-exposed children, 62.3% (n = 341) met PTSD criteria, or 34.1% of the entire sample.

A few years later, Khamis (2008) studied 179 Palestinian adolescents males, aged 12 to

18, who were permanently disabled as a result of violent clashes between Palestinians and Israel.

The adolescents, who lived in the Gaza Strip or the West Bank, suffered from paraplegia,

quadriplegia, hemiplegia, paralysis of a limb, or visual impairments. Those who experienced

other types of traumatic events were excluded from the study to control for confounding effects

of multiple traumas. The time interval between injury and assessment ranged from 1 month to 27

months. PTSD was assessed through the use of a structured DSM-IV (APA, 1994) based clinical

interview. A large majority of the sample, 76.5% (n = 137) met full criteria for PTSD.

Approximately 29.9% (n = 41) of the PTSD cases had a delayed onset such that the symptoms

occurred more than six months after the trauma. The participants who met criteria for PTSD also

were at excess risk for chronic symptoms and comorbidity with anxiety and depression.

Elbedour, Onwuegbuzie, Ghannam, Whitecome, and Hein (2007) analyzed the psychological functioning 229 Palestinian youth between the ages of 15 and 19 years living in

the Gaza Strip during violent clashes between Palestinians and Israel in 2000. To assess for

PTSD the authors utilized the DSM-IV (APA, 1994) version of the Posttraumatic Stress Disorder

Inventory (PTSD-I; Watson, Juba, Manifold, Kucala, & Anderson, 1991). The most commonly

reported traumatic event was witnessing a friend or family member’s death. The results indicated

a PTSD prevalence rate of 68.9% with no significant differences between males and females in

regards to the diagnosis.

Thabet, El-Buhaisi, and Vostanis (2014) examined 358 adolescents randomly selected

from 10 schools in the Gaza Strip three months after war. Participants consisted of 158 boys

(44.1%) and 200 girls (55.9%) aged 15 to 18 years. Measures included the Gaza Traumatic Event

Checklist (GTECL; Thabet, Tawahina, El Sarraj, & Vostanis, 2008) and the University of

California at Los Angeles PTSD Index for DSM-IV: Adolescent Version (UCLA PTSD Index;

Rodriguez, Steinberg, & Pynoos, 1999). It was reported that the mean number of traumatic

events from the sample was 13.34. Specifically, 21.8% reported physical injury due to bombardment of their own home, 22.9% reported being arrested during the ground incursion,

24% reported being shot by bullets, rocket, or bombs, and 24.3% reported feeling threatened to

death when the army used them as human shields to arrest neighbors. Overall, 29.8% of the

sample met PTSD criteria according to DSM-IV-TR (APA, 2000) with significantly more girls

suffering from PTSD than boys. Furthermore, there was a strong association between total

number of traumatic events and a diagnosis of PTSD.

Regarding Israeli youth, Schwarzwald et al. (1993) conducted a study with a sample of

492 randomly selected Israeli children in the 5th, 7th, or 10th grade exposed to SCUD missile attacks approximately 3 weeks after the culmination of the Persian Gulf War. The participants repeatedly took shelter in a sealed room before and after missile attacks during the war and over the past 6 weeks prior to the study. The Child PTSD Reaction Index (CPTSD-RI; Pynoos et al.,

1987), with additional items added by the authors from the DSM-III-R (APA, 1987a) criteria for

PTSD was utilized to diagnose PTSD. Results indicate that 19.1% (n = 94) developed PTSD.

Solomon and Lavi (2005) examined PTSD and future orientation in 740 youth aged 11 to

15 living in Jerusalem, Gilo, or the Jewish settlements in disputed territories during the summer

of 2001, when terror events and political violence were extremely common. Measures included

the DSM-III-R (APA, 1987a) version of the Child Posttraumatic Stress Reaction Index (CPTSD-

RI; Frederick & Pynoos, 1988) and the Children’s Future Orientation Scale (Saigh, 1997). Youth

living in disputed territories were exposed to significantly more terrorist attacks as compared to

youth living in Jerusalem or Gilo. Similarly, those living in the settlements had higher rates of

PTSD (27.6%) than both Jerusalem youth (12.4%) and those living in Gilo (11.2%).

Interestingly, the most optimistic youth were from the disputed territories.

More recently, Pat-Horenczyk et al. (2007) studied 409 Israeli adolescents between the

ages of 15 and 18 years. All of the adolescents experienced traumatic events, such as being present at the site of a terrorist attack. The UCLA PTSD Index (Rodriguez, Steinberg, & Pynoos,

1999) and additional items from the DSM-IV (APA, 1994) criteria for PTSD were included to

ensure accurate diagnosis. Functional impairment was measured by using items relevant to the

DSM-IV PTSD criteria (APA, 1994) from the Diagnostic Predictive Scales derived from the

Child Diagnostic Interview Schedule (DISC-PS; Lucas et al., 2001). Results indicate that 4.9%

(n = 20) of the sample met full criteria for PTSD.

The war-related studies presented in this section revealed PTSD prevalence rates ranging from 4.9% to 94%. Table 2.1 presents PTSD prevalence rates among children and adolescents following war-related traumas.

Table 2.1

Child-Adolescent PTSD Rates Following War-related Traumas

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence

African Conflicts Geltman et al. (2005) HTQ 304 refugee Mean Age: One year after 20.00% CHQ minors 17.6 years resettlement

Schaal & Elbert CIDI 33 males Mean Age: ~ 10 years 44.00% (2006) 35 females 17.72 years

Bayer et al. (2007) CPTSD-RI 141 males Mean Age: ~ 2.3 months 34.90% 28 females 15.3 years 58

Klasen et al. (2010) MINI-KID 170 males Mean Age: ~ 2.5 years 33.00% 160 females 14.44 years

Pfeiffer & Elbert PDS 41 males Mean Age: Not reported 49.00% (2011) 31 females 23.7 years Asian Conflicts

Kinzie et al. (1986) DSM-III 25 males Mean Age: 2.5 years 50.00% Diagnostic 15 females 14 years Interview

Kinzie et al. (1989) DSM-III-R DIS 16 males Mean Age: 5.5 years 48.00% 11 females 20 years

Table 2.1 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence

Sack et al. (1993) DSM-III-R DICA N = 19 Mean Age: 8.5 years 1984: 52.00% 23 years 1987: 47.00% 1990: 32.00%

Sack et al. (1994) K-SADS-E 104 males Mean Age: 13 years Current: 18.20% DICA 105 females 19.8 years Lifetime: 21.50%

Hubbard et al. (1995) DSM-III-R 29 males Mean Age: 15 years Current: 24.00% SCID-NP 30 females 19.5 years Lifetime: 59.00%

59 Savin et al. (1996) DSM-III-R DICA 89 males Mean Age: 10 years Current: 26.30% 10 females 22.27 years Lifetime: 31.30% Balkan Conflicts

Weine et al. (1995) PSS 7 males Mean Age: Not reported 25.00% 5 females 15.6 years

Goldstein et al. (1997) BTQ 167 males Age Range: Active war zone 94.00% Sead Picture 191 females 6-12 years Survey

Allwood et al. (2002) CPTSD-I 389 males Age Range: Active war zone 41.00% 402 females 6-16 years

Eytan et al. (2004) MINI 246 youth Age Range: 2 years 23.50% HTQ 6-24 years

Table 2.1 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence

Middle East Conflicts

Saigh (1988a) DSM-III 12 females Mean Age: 316 days 316 days: 8.30% Author-devised 18.2 years Interview

Saigh (1988b) DSM-III 42 males Mean Age: Not Reported 29.30% Children's PTSD 50 females 13 years Inventory

Saigh (1989a) DSM-III 403 males Age Range: 1-2 years 32.50% 60 Children's PTSD 437 females 9-12 years Inventory

Saigh, Mroueh, & DSM-III 48 males Mean Age: M = 4.2 years Stress Expose: 46.70% Bremner (1997) Children's PTSD 47 females 17.5 years Overall Sample: 14.70% Inventory

Karam et al. (2000) DICA-R 386 children and Not reported Not reported 24.10% adolescents

Almqvist & Brober DSM-IV Clinical 39 children Age Range: 3.5 years 18.00% (1999) Interview 4-8 years

Ahmad et al. (2000) HTQ 24 males Age Range: 5 Years 87.00% PTSS-C 21 females 7-17 years

Table 2.1 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence

Khamis (2005) DSM-IV Based 523 males Mean Age: Not Reported Entire Sample: 34.10% Clinical 477 females 14.18 years Stress Exposed: 62.3% Interview

Khamis (2008) DSM-IV Based 179 males Age Range: 1 - 27 months 76.50% Clinical 12-18 years Interview

Elbedour et al. (2007) PTSD-I 121 males Mean Age: Not Reported 68.90% 108 females 17.13 years

61 Thabet et al. (2014) UCLA PTSD 158 males Mean Age: 3 months after 29.80% Index 200 females 16.7 years war

Schwarzwald et al. DSM-III-R 227 males Grades 5, 7, and 3 weeks after Overall: 19.10% (1993) Based Clinical 265 females 10 end of Persian Interview Gulf War

Solomon & Lavi CPTSD-RI 358 males Age Range: Not reported Disputed Territories: (2005) 371 females 11-15 years 27.6% Jerusalem: 12.40% Gilo: 11.20%

Pat-Horenczyk et al. UCLA PTSD 192 males Age Range: Not Reported 4.90% (2007) Index 217 females 15-18 years

Criminal Victimization Studies of Child-Adolescent PTSD

A great deal of research has been conducted involving PTSD prevalence rates among youth who witnessed or experienced criminal acts such as murder, gang violence, robberies, shootings, and physical or sexual abuse. Child and adolescent exposure to violence in urban communities is common in America (Fitzpatrick & Boldizar, 1993; Jaycox et al., 2002; Mazza & Reynolds,

1999; Ozer & McDonald, 2006). For example, Fitzpatrick & Boldizar (1993) conducted a study examining the relationship between prolonged exposure to community violence and PTSD in a nonrandom sample of 221 low-income African American youth. The participants ranged in age from 7 to 18 and lived in eight housing communities in a large, southern central city during July

1991. The city in which these communities were located had the eighth highest homicide rate per capita in the United States in 1991. Of note, 35% of the homicide victims during this period were under the age of 19. Measures included a modified version of the National Institute of Mental

Health Screen Survey of Exposure to Community Violence (Richters, 1990) and a revised version of the Purdue Posttraumatic Stress Scale (Figley, 1989) which utilized DSM-III-R (APA,

1987a) PTSD criteria. More than 70% of participants were direct victims of violence and approximately 85% of the respondents witnessed at least one violent act. Overall, 27% (n = 54) of the sample met criteria for PTSD.

In a similar vein, Berman, Kurtines, Silverman, and Serafini (1996) studied the association between exposure to community violence and PTSD in 96 students at a greater

Miami/Dade County alternative high school aimed at dropout prevention. Ages of the diverse sample of participants ranged from 14 to 18 years. The Child Posttraumatic Stress Disorder

Reaction Index (CPTSD-RI; Frederick & Pynoos, 1988) was utilized to assess the degree of

PTSD symptomatology in relation to key traumatic events such as witnessing or experiencing a

mugging, knife attack, shooting, murder, or having seen a dead body. Results indicate that 34.5%

of the sample presented with PTSD according to DSM-III-R (APA, 1987a) criteria. Berton and

Stabb (1996) found similar prevalence rates of 29% in a sample of 103 high school juniors in the

same area. They utilized the DSM-III (APA, 1980) based Kean PTSD Scale (Keane, Malloy, &

Fairbank, 1984) and the Civilian Mississippi PTSD Scale (Vreven, Gudanowski, King, & King

1995). Mazza and Reynolds (1999) also examined the psychological impact of violence exposure

on 94 young adolescents from an inner city, low-income school in Brooklyn, New York. The participants consisted of 57 females and 37 males aged 11 to 15 years, who were predominantly

African American (70%) and Hispanic (22%). The Adolescent Psychopathology Scale –

Posttraumatic Stress Disorder Subscale (APS-PTS; Reynolds, 1988) was utilized to assess

PTSD, based on DSM-IV (APA, 1994) criteria. The sample of inner-city youngsters reported

exposure to an average of five violent events over the past year, with similar levels of violence

reported amongst boys and girls. Results indicated that 6.4% of the sample met criteria for

PTSD.

In the context of stress-exposed urban youth, Lipschitz, Rasmusson, Anyan, Cromwell, and Southwick (2000) studied the prevalence of PTSD in 90 female adolescents aged 12 through

21 years. The participants presented for routine medical care at a primary care clinic where they were administered the Child PTSD Checklist (Newman & Amaya-Jackson, 1996). A large majority, 92% (n = 83) indicated that they experienced at least one trauma. The most commonly

reported trauma was witnessing community violence such as a stabbing, shooting, or homicide,

(85.6%), followed by hearing about a homicide (67.8%). Results indicated that 13% of the

overall sample met DSM-IV (APA, 1994) criteria for PTSD. Of the 83 girls who reported

experiencing a qualifying PTSD trauma, 14.5% met full criteria for PTSD. Girls with PTSD

experienced their trauma at an earlier age as compared to those with partial or no PTSD

symptoms. Finally, participants with PTSD reported significantly higher rates of emotional and physical abuse and were significantly more depressed than those with partial or no PTSD

symptoms.

Foster, Kuperminc, and Prince (2004) studied trauma exposure and PTSD among 146

inner-city minority youth from a major metropolitan area in the Southeast United States. The participants, who ranged in age from 11 to 16 and were members of Boys and Girls Clubs,

completed the DSM-IV (APA, 1994) Trauma Symptom Checklist for Children (TSCC; Brier,

1996). Notably, all of the participants reported that they directly experienced at least one act of

violence and witnessed at least one act of violence. The self-reports indicated PTSD prevalence

rates of 11.8% for girls and 11.5% for boys.

With regard to incarcerated youth, Burton, Foy, Bwanausi, Johnson, & Moore (1994) examined 91 male juvenile delinquents with histories of serious and repeated crimes. All participants were serving up to one year of confinement in a locked facility. They ranged in age from 13 to 18 and the majority (81%) reported membership in inner-city street gangs. The

Symptom Checklist (Foy, Sipprelle, Rueger, & Carroll, 1984), based on DSM-III-R (APA,

1987a) indicated that 24% (n = 22) of the participants qualified for a diagnosis of PTSD.

Similarly, Steiner, Garcia, & Mathews (1997) assessed the prevalence of PTSD in a sample of 85 incarcerated male adolescents, between the ages of 13 and 20, who had committed violent offenses such as rape or robbery. The average length of incarceration at the time of examination was 13 months. A convenience sample of 79 adolescent males from a local high school served as a nonclinical comparison group. The PTSD module of the Psychiatric Diagnostic Interview –

Revised (PDI-R; Othmer, Penick, Powell, Read, & Othmer, 1981) was utilized to diagnose

PTSD based on DSM-III-R (APA, 1987a) criteria. Results indicated that 31.7% (n = 27) met

current criteria for PTSD while only 9.3% of the comparison group met lifetime criteria for

PTSD. The diagnosis did not vary as a function of ethnicity. The most commonly reported

traumatic events included interfamilial violence such as murder, grave injury, and abuse (27%),

followed by witnessing violent acts in the community that were typically gang related (21%).

Only 5% reported traumatization as a result of the violent offense they personally committed and

only 2% reported events of an extraordinary nature while incarcerated (e.g. rape).

Ruchkin, Schwab-Stone, Koposov, Vermeiren, & Steinger (2002) examined 370 Russian male juvenile delinquents using the PTSD module from the Schedule for Affective Disorders and

Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS; Kaufman et al., 1997). A very large majority of the participants, 96% (n = 351), had a history of trauma exposure and 24.8% (n = 87) met full criteria for PTSD using DSM-IV (APA, 1994) criteria.

Furthermore, 303 participants (82.3%) reported multiple traumas. The five most common types of traumatic events reported were witnessing domestic violence, confronting traumatic news, witnessing a violent crime, physical abuse, and being a victim of a violent crime.

In the context of recent immigrants’ exposure to community violence, Jaycox et al.

(2002) examined 1,004 school children, aged 8 to 15 years, who had immigrated to Los Angeles within the previous 3 years. The participants’ native languages included Russian, Korean,

Spanish, and Western Armenian. High levels of violence exposure (e.g. events involving knives or guns) were reported over the past year, with an average of 1.2 violent events experienced and three violent events witnessed in the past year. Specifically, 49% of the participants reported personal violent victimization and 80% reported witnessing violent events in the past year. Using the Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001) the authors indicated

that 29.4% of the sample met DSM-IV (APA, 1994) criteria for PTSD.

Seedat, Nyamai, Njenga, Vythilingum, and Stein (2004) found similarly moderate PTSD prevalence rates among South African youth following exposure to community violence. The

authors assessed 1,140 South African and 901 Kenyan students in the 10th grade, aged 14 to 22,

living near Cape Town and Nairobi, respectively. Measures included a trauma checklist adapted

from the Schedule for Affective Disorders and Schizophrenia in School-age Children – Present

and Lifetime version (K-SADS-PL; Kaufman et al., 1997) and an author-created structured

interview called the Child PTSD Checklist (Newman & Maya-Jackson, 1996) based on DSM-IV

(APA, 1994) criteria. Approximately 83% of the South African adolescents and 85% of the

Kenyan adolescents reported lifetime exposure of at least on DSM-IV (APA, 1994) trauma. For both groups, the most common traumas were witnessing community violence (63%) and being

robbed (35%). More individuals in the Kenyan group witnessed violence, were physically hurt or beaten by a family member, or were sexually assaulted as compared to the South African group.

The mean number of trauma exposures for each group was not statistically different. Of note, the prevalence of PTSD in the South African group, 22% (n = 253), was significantly higher than

the Kenyan group, 5% (n = 42). The authors were not able to provide an explanation for the

lower rate of PTSD in the Kenyan adolescents but suggested that culture may have been related

to the differences.

Domanskaité-Gota, Elklit, and Christiansen (2009) examined a representative sample of

183 ninth grade Lithuanian adolescents aged 13 to 17 years. The gender distribution was 55%

female and 45% male. Using the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992)

results indicated that 80% of participants had been exposed to a traumatic event including threats

of violence, near-drowning experiences, and robbery/theft. Overall, 6.1% met DSM-IV (APA,

1994) criteria for PTSD, 2.4% of boys as compared to 9.1% of girls. Female gender was positively associated with PTSD.

Luthra et al. (2009) assessed 157 youths at a mental health clinic aged 8 to 17 years in the

New York City metropolitan area using the K-SADS (Kaufman et al., 1997). The mean age of the sample was 12.2 years and 58% (n = 91) of the participants were males. The majority of the children, 88%, reported exposure to a minimum of one traumatic event, 45% of which met

Criterion A1within the DSM-IV (APA, 1994) criteria for PTSD. The most common types of traumatic events included being confronted with traumatic news, witnessing domestic violence or a crime, being involved in an accident, and experiencing physical abuse. A total of 19% (n =

30) of the sample met full diagnostic criteria for PTSD.

Regarding acts of terror in schools, Nader, Pynoos, Fairbanks, and Frederick (1990)

assessed 159 children between the ages of 5 and 13 years approximately 1 month after a shooting

in a Los Angeles elementary school playground. A sniper opened fire, killing one child and

injuring 14 other individuals. The Children’s PTSD Reaction Index (CPTSD-RI; Pynoos et al.,

1987) indicated that 60.4% of the sample met criteria for PTSD 1 month after the incident using

DSM-III-R (APA, 1987a) criteria. During a 14-month follow up, 100 children form the original

sample were assessed and results indicated that 29% met PTSD criteria. The authors indicated

that those who were directly exposed to the sniper attack evidenced higher rates of PTSD as

compared to those who were at home during the attack. Schwarz and Kowalski (1991) also

studied PTSD prevalence rates in 66 adults and 64 children after a woman with a psychiatric

history entered an elementary school, threatened various individuals, opened fire, wounded, and

killed children. The DSM-III-R (APA, 1987a) version of the Reaction Index (Pynoos et al.,

1987) was utilized to determine that the prevalence of PTSD was estimated as 27% among the

children 6 to 14 months after the event. PTSD diagnoses were associated with recalled intensity of emotional states on the day of the shooting but not with proximity to the shooting, acquaintance with the victims or the perpetrator, age, or sex.

On December 3, 1995 in Paris, France a man armed with a gun took a class of 29 elementary school children and their teacher hostage. Vila, Porche, and Mouren-Simeon (1999) assessed 26 of the 29 exposed hostages, aged 6 to 9 years. A DSM-IV (APA, 1994) clinical interview derived from the Kiddie-Schedule for Affective Disorders and Schizophrenia for

School Age Children (K-SADS; Puig-Antich et al., 1980) was conducted 1, 2, 4, 7, and 18 months later. After 1 month 11.5% of the sample (n = 3) met criteria for PTSD. Two months later 15.4% of the sample (n = 4) met criteria. At 4 months, only one case met criteria while two cases met criteria at 7 months. Finally, 18 months later there was one recorded case of PTSD.

Full PTSD criteria were met by 27% of the sample (n = 7) throughout the study. Three of the seven children who developed PTSD suffered from preexisting disorders including generalized anxiety disorder, social phobia, and dysthymic disorder.

Scrimin et al. (2006) assessed 22 children, aged 6 to 14, and 20 of their primary caregivers 3 months after a group of terrorists held the children hostage on first day of school in

Beslan, Russia. The terrorists held children and parents hostage in the school for 3 days without food or medication until the army intervened. In total, 330 individuals were killed, 186 of them children. All of the children in this study had spent 1 to 2 months at a pediatric hospital where they were treated for injuries received during the attack. The UCLA Posttraumatic Stress

Disorder Index for DSM-IV-TR (Steinberg, Brymner, Decker, & Pynoos, 2004) was used with the primary caretakers to assess the children’s trauma. Children were reportedly not interviewed directly because they were still highly shocked and many parents would not allow the researchers

to ask the children about the recent trauma directly. Results indicate that 27.3% of children (n =

6) had a moderate level of PTSD and 72.7% (n = 16) had a severe level of PTSD. In terms of the caregivers, 30.0% (n = 6) had a moderate level of PTSD and 70.0% (n = 14) had PTSD scores in the severe range. Overall, the entire sample showed high levels of ongoing PTSD symptoms, the majority of them severe.

Saigh, Yasik, Mitchell, and Abright (2011) investigated two groups of New York City preschool children 8 to 10 months after the September 11, 2001 terrorist attacks. One group (n =

31) was within 1 mile of the World Trade Center at the time of the attack and experienced traumatic incidents consistent with the DSM-IV (APA, 1994) PTSD definition for trauma exposure. The other group (n = 19) was between 2 to 14 miles away from the attack and did not experience traumatic incidents as reported by their parents. An author-devised and validated

DSM-IV (APA, 1994) PTSD questionnaire was utilized to assess for PTSD and none of the children in either group had a probable PTSD diagnosis. Moreover, there were no significant difference between the number of PTSD symptoms of the children who were in close proximity to the World Trade Center and those who were further away.

Regarding youth who have been sexually victimized, many researchers have demonstrated higher prevalence rates of PTSD among victimized youth compared to youth exposed to other types of trauma (Giaconia et al., 1995; Kessler et al., 1995; Norris, 1992;

Resnick et al., 1993). McLeer and colleagues (1988; 1992; 1994; 1998) conducted a number of studies where they examined the psychological functioning of sexually victimized youth. For example, McLeer, Deblinger, Atkins, Foa, and Ralphe (1988) assessed 31 children who had been sexually abused on at least one occasion using an author developed structured interview based on

DSM-III-R (APA, 1987a) criteria. Results indicated that 48.4% of the sample met criteria for

PTSD. Of note, none of the children who had been abused by an older child met criteria for

PTSD while 75% of the children abused by a natural father and 25% abused by trusted adults

did. No relationship was observed between the time interval between the last abusive episode

and the development of PTSD.

McLeer, Deblinger, Henry, and Orvaschel (1992) subsequently found very similar PTSD prevalence rates among a sample of 92 sexually abused children. Using structured interviews

developed by the investigators and standardized measures, such as the Kiddie Schedule for

Affective Disorders and Schizophrenia for School Age Children – Epidemiologic Version (K-

SADS-E; Orvaschel et al., 1982), 43.9% met DSM-III-R (APA, 1987a) criteria for PTSD.

Children abused by their fathers were more likely to develop PTSD as opposed to children

abused by other individuals. McLeer, Callaghan, Henry, and Wallen (1994) also compared the prevalence of psychiatric disorders in a clinical sample of sexually abused children (n = 26) to a

sample of non-sexually abused children (n = 23), all of whom were referred for an outpatient psychiatric evaluation. The children ranged in age from 6 to 16 years. Based on the K-SADS-E

(Orvaschel et al., 1982) 42.3% (n = 11) met PTSD criteria compared to 8.7% (n = 2) of non-

sexually abused children. Finally, McLeer et al. (1998) compared 80 non-clinically referred,

sexually abused children aged 6 to 16 years to clinical and nonclinical groups of non-abused

children matched by age, race, and socioeconomic status. Using the K-SADS-E (Orvaschel et al.,

1982) the researchers determined that 36.3% (n = 29) of the sexually abused youth met criteria

for PTSD.

In a similar vein, Merry and Andrews (1994) administered the Diagnostic Interview

Schedule for Children (DISC-2; Shaffer et al., 1989) to 95 children who experienced extra-

and/or intra-familial sexual abuse one year after the disclosure of the abuse. The participants

were from New Zealand and ranged in age from 4 to 16. Results indicated that 18.2% of the

children met DSM-III-R (APA, 1987a) criteria for PTSD. In a related paper, Wolfe, Sas, and

Wekerle (1994) assessed 90 sexually abused children whose mean age was 12.4 years using an

author developed DSM-III-R (APA, 1987a) PTSD Checklist and reported that 48.9% (n = 44) met criteria for PTSD. Within the context of sexual abuse in correctional settings, Cauffman,

Feldman, Waterman, and Steiner (1998) assessed 96 incarcerated female juvenile delinquents, aged 13 to 22, using the PTSD component of the Psychiatric Diagnostic Interview – Revised

(PDI-R; Othmer et al., 1981). In terms of traumatic stressors, the majority of the participants

(60%) reported being raped or having been in danger of being raped. Results indicated that

65.3% (n = 62) of the participants experienced PTSD at some point in their lives while 48.9% met current DSM-III-R (APA, 1987) criteria for PTSD.

Ackerman, Newton, McPherson, Jones, and Dykman (1998) compared PTSD rates

among 204 children, aged 7 to 13 years who had been sexually abused, physically abused, or

exposed to both types of abuse using the Diagnostic Interview for Children and Adolescents,

Revised Version (DICA-R; Reich et al., 1995). An overall PTSD prevalence rate of 34% was

found, with higher prevalence rates (54.9%) in those children who had been both sexually and physically abused compared to those who had solely sexually abused (31.8%) or physically

abused (25.4%). Similarly, Ruggiero, McLeer, and Dixon (2000) reported a PTSD prevalence

rate of 36.6% using DSM-III-R (APA, 1987a) criteria among a sample of 80 children, aged 6 to

16, 30 to 60 days after disclosure of sexual abuse. In a related effort, Silva et al. (2000) assessed

59 youth, aged 3 to 18, following sexual abuse, physical abuse, or having witnessed domestic

violence. Using the child version of the Structured Clinical Interview for DSM-IV Disorders

(Kid-SCID; Matzner, Silva, Silvan, Chowdury, & Natasi, 1997), the authors reported that in

total, 22.0% (n = 13) of the sample met criteria for PTSD. Furthermore, 15% of the sexually

abused youth, 21% of the physically abused group, and 17% of the youth that witnessed

domestic violence developed PTSD. Linning and Kearney (2004) also assessed a sample of

maltreated youth living in homeless shelters. The sample of 55 individuals ranged in age from 8

to 17 and reported exposure to sexual and/or physical abuse within the past two years. Based on

the Children’s PTSD Inventory (Saigh, 1997), 67.3% (n = 37) of the sample met DSM-IV (APA,

1994) criteria for PTSD.

D’Augelli, Grossman, and Starks (2006) examined PTSD prevalence rates following sexual, physical, and verbal assaults in 517 lesbian, gay, and bisexual youth, aged 15 to 19.

DSM-IV (APA, 1994) criteria for PTSD was assessed with the PTSD module from Version IV of the NIMH Diagnostic Interview Schedule for Children (DISC; Shaffer, Fisher, Lucas, Dulcan,

& Schwab-Stone, 2000), which indicated that 9% (n = 48) of the total sample met criteria for a diagnosis of PTSD in the past year. Three times the number of females (15%, n = 38) relative to males had a PTSD diagnosis (4%, n = 10). Allwood, Dyl, Hunt, and Spirito (2008) examined 377 adolescents aged 12 to 18 years in a psychiatric hospital, 47.9% who were reportedly maltreated.

PTSD diagnoses were derived from the DSM-IV (APA, 1994) version of the Children’s

Interview for Psychiatric Syndromes (ChIPS; Weller, Weller, Rooney, & Fristad, 1999). Final diagnoses were based on clinical team consensus (consisting of a psychiatrist, two psychologists, child psychiatry fellows, and unit nursing staff) utilizing all available information including medical records. Results indicated that 20.69% (n = 78) of the sample met criteria for PTSD. Of

note, adolescents with PTSD were most likely to be female and have experienced maltreatment

and out of home placement as a result of sexual abuse.

Scott, Smith, and Ellis (2010) examined 2,144 participants from the New Zealand Mental

Healthy Survey, aged 16 to 27 years, 221 of whom had records on a national child protection

agency database. The mean age at first child protection agency contact was 11.5 years. Measures

included the World Health Organization Composite International Diagnostic Interview (CIDI;

Kessler & Ustun, 2004) based on DSM-IV (APA, 1994) criteria. A child protection agency

history was strongly associated with a PTSD diagnosis, as 10.66% (n = 24) of children met 12- month criteria compared to 2.20% (n = 45) of those without a history. Furthermore, the lifetime prevalence of PTSD in the child protection agency group was 14.16% (n = 33) compared to

4.40% (n = 100) of those without a history. Finally, Frounfelker, Klodnick, Mueser, and Todd

(2013) examined 84 participants, aged 16 to 21 years, at a psychiatric rehabilitation agency in

Chicago. Approximately one half of the youth studied were in the custody of the State of Illinois.

Approximately 48.8% (n = 41) of the sample reported previous sexual abuse while 21.4% (n =

18) reported exposure to community violence. Overall, 94% of the participants (n = 79) reported

a history of trauma, 36% (n = 30) of whom qualified for a diagnosis of PTSD through

unstructured DSM-IV-TR (APA, 2000) interviews from psychiatrists and licensed master’s level

clinicians with at least 5 years of experience with the population. Sexual abuse was found to be

associated with a PTSD diagnosis.

Based on the aforementioned criminal victimization studies presented, PTSD prevalence

rates ranged from 3.8% to 72.7%. Table 2.2 provides a summary of the studies regarding

criminal victimization resulting in PTSD in children and adolescents.

Table 2.2

Child-Adolescent PTSD Rates Following Criminal Victimization Traumas

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Fitzpatrick & Perdue 102 males Mean Age: Not Reported 27.00% Boldizar (1993) Posttraumatic 119 females 11.9 years Stress Scale

Berman et al. (1996) CPTSD-RI 96 participants Age Range: Not Reported 34.50% 14-18 years

Berton & Stabb CM-PTSD 21 male Mean Age: Not Reported 29.00% (1996) Keane PTSD 78 females 17 years Scale

74 Mazza & Reynolds APS-PTS 37 males Age Range: Not Reported 6.40% (1999) 57 females 11-15 years

Lipschitz et al. DSM-IV Child 90 females Age Range: Not Reported Stress-Exposed: 14.50% (2000) PTSD Checklist 12-21 years Overall Sample: 13.00%

Foster et al. (2004) TSCC 84 males Mean Age: Not Reported Males: 11.50% 62 females 13.16 years Females: 11.80%

Burton et al. (1994) DSM-III-R 91 males Age Range: Not Reported 24.00% Symptom 13-18 years Checklist

Steiner et al. (1997) PDI-R 85 incarcerated Age Range: Not Reported 31.70% male adolescents 13-20 years

Table 2.2 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Ruchkin et al. K-SADS 370 Russian Age Range: Not Reported 24.80% (2002) male juvenile 14-19 years delinquents

Jaycox et al. (2002) Child PTSD 1,004 recent Age Range: Not Reported 29.40% Symptom Scale immigrant youth 8-15 years

Seedat et al. (2004) K-SADS-PL 1140 South Age Range: Not Reported South Africans: 22.00% Africans 14-22 years Kenyans: 5.00% 901 Kenyans

Domanskaité-Gota, HTQ 82 males Mean Age: Not Reported 6.10% 75 et al. (2009) 101 females 15.1 years

Luthra et al. (2009) K-SADS 91 males Mean Age; Not Reported 19.00% 66 females 12.2 years

Nader et al. (1990) CPTSD-RI 80 males Age Range: 1 month 60.40% 79 females 5-13 years 14 months 29.00%

Schwarz & DSM-III-R 32 males Mean Age: 6-14 months 27.00% Kowalski (1991) Reaction Index 32 females 8.6 years

Vila et al. (1999) K-SADS 14 males Age Range: 1 month 11.50% 12 females 6-9 years 2 months 15.40% 4 months 3.80% 7 months 7.70% 18 months 3.80%

Table 2.2 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Scrimin et al. (2006) UCLA PTSD-I 22 Beslan Age Range: 3 months Severe: 72.7% children 6-14 years Moderate: 27.3%

McLeer et al. (1988) DSM-III-R 6 males Mean Age: Not Reported 48.40% Structured 25 females 8.4 years Interview

McLeer et al. (1992) K-SADS-E 21 males Mean Age: Not Reported 43.90% 71 females 8.9 years

McLeer et al. (1994) K-SADS-E 92 sexually Mean Age: Not Reported 42.30%

76 abused children 9.0 years

McLeer et al. (1998) K-SADS-E 80 sexually Age Range: 1-2 months 36.30% abused children 6-16 years

Merry & Andrews DISC-2 11 males Age Range: 12 months 18.20% (1994) 55 females 4-16 years

Wolfe et al. (1994) DSM-III-R 21 males Mean Age: Not Reported 48.90% checklist 69 females 12.4 years

Cauffman et al. PDI-R 96 incarcerated Age Range: Not Reported Current: 48.90% (1998) female juvenile 13-22 years Lifetime: 65.30% delinquents

Ackerman et al. DICA-R 73 males Age Range: At least 1 month 34.00% (1998) 131 females 7-13 years

Table 2.2 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Ruggiero et al. DSM-III-R 15 males Age Range: 1-2 months 36.6% (2000) Clinical 65 females 6 to 16 Interview

Silva, Alpert, Kid-SCID 39 males Mean Age: Not Reported Overall Sample: 22.00% Munoz, Singh, 20 females 9.9 years Sexual Abuse: 15.00% Matzner, & Dummit Physical Abuse: 21.00% (2000) Witnessed Domestic Violence: 17.00%

Linning & Kearney CPTSDI 22 males Mean Age: 2 years 67.30% (2004) 33 females 12.7 years

77 D'Augelli et al. DISC 275 males Mean Age: Not Reported 9.00% (2006) 253 females 17.05 years

Allwood et al. ChIPS 108 males Mean Age: Not Reported 20.69% (2008) 229 females 14.9 years

Scott et al. (2010) CIDI 962 males Age Range: Not Reported Current: 10.66% 1182 females 16-27 years Lifetime: 14.16%

Frounfelker et al. DSM-IV-TR 37 males Age Range: Not Reported 36.00% (2013) interview 47 females 16-21 years

Disaster/Accident Studies of Child-Adolescent PTSD

Disasters (e.g. hurricanes, earthquakes, vehicle accidents) can affect large populations in an unprecedented manner. Results from the National Comorbidity Study (Breslau et al., 1998) indicated that 19% of men and 15% of women will experience a natural disaster at least once in their lives. Similarly, a survey of US residents by Burkle (1996) indicated that 13% of participants experienced a natural or human-generated disaster at some point in their lifetime.

Survivors of disasters have an increased risk of physical and emotional distress, including posttraumatic stress disorder (Norris, Friedman, & Watson, 2002; Ziaaddini, Nakhaee, &

Behzadi, 2009).

Earthquakes. Pynoos et al. (1993) assessed 111 children affected by the 1988 Armenian earthquake for PTSD 1.5 years after the incident. Most of the participants, who ranged in age from 8 to 16, were in their classrooms at the time of the earthquake. Many schools were demolished and more than half of the children were killed in Spitak, a city near the epicenter.

Based on the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI; Pynoos et al.,

1987) 70.3% (n = 78) of the sample met DSM-III-R (APA, 1987a) criteria for PTSD. A significant relationship between proximity to the epicenter of the earthquake and PTSD prevalence was also reported. Two and a half years after the earthquake Najarian, Goenjian,

Pelcovitz, Mandel, and Najarian (1996) conducted a follow-up study on 25 trauma exposed children aged 11 to 13 utilizing the Diagnostic Interview for Children and Adolescents – Revised

(DICA-R; Reich et al., 1995) to assess for PTSD. Results indicated that 32% (n = 8) of the children who did not relocate and resided in a city damaged by the earthquake met criteria for

PTSD while 28% (n = 7) of the children that relocated met criteria.

Six weeks after the 1999 earthquake in Taiwan, Hsu, Chong, Yang, and Yen (2002)

assessed PTSD prevalence rates among 323 adolescents, 121 males and 182 females aged 12 to

14, in the worst affected region. The earthquake resulted in 2,415 deaths and 11,305 injuries,

destroying more than 100,000 homes. Five research psychiatrists utilized the Children’s

Interview for Psychiatric Syndromes (ChIPS; Rooney et al., 1999) to assess for PTSD, based on

DSM-IV (APA, 1994) criteria. Half of the participants’ homes had been destroyed and 3% had been trapped in the rubble. Furthermore, 27% witnessed the serious injury of other, 12%

sustained personal physical injuries, and 10% had close family members who died in the

earthquake. Results indicated that 21.7% (n = 70) met criteria for PTSD, with females diagnosed at a slightly higher rate.

In a similar vein, Laor et al. (2002) assessed 202 school-aged children directly exposed to the August1999 earthquake in Turkey 4 months after it occurred and compared them to a non- exposed control group (n = 101). The exposed group was displaced to a new village after the earthquake destroyed their homes. Using the Children’s PTSD Reaction Index (CPTSD-RI;

Pynoos et al., 1993), results indicated that 20.8% (n = 63) of the 303 children reported severe

DSM-III-R (APA, 1987a) PTSD symptoms. Similarly, Yorbik, Akbiyik, Kirmizigul, and

Sohmen (2004) examined PTSD rates among children and adolescents following the same

August 1999 earthquake in Turkey, along with another earthquake in Turkey during November of the same year. Thirty-five participants, aged 2 to 16 years, presented at the child and adolescent psychiatric department between September and December of 1999 with symptoms of

PTSD. An author developed PTSD symptom checklist that reflected the DSM-IV (APA, 1994) was utilized and indicated that 40% of the sample met PTSD criteria at least 30 days after the

earthquakes. None of the children between 2 and 6 years of age met full diagnostic criteria but

56.3% of the children between the ages 7 and 11 met criteria, as did 50% of those aged 12 to 16.

On September 7, 1999 an earthquake measuring 5.9 on the Richter scale stuck Athens,

Greece. Roussos and colleagues (2005) assessed PTSD symptoms of 1,937 students, aged 9 to 18

years, 3 months after the earthquake using the UCLA Posttraumatic Stress Disorder Reaction

Index (UCLA PTSD-RI; Rodriguez, Steinberg, & Pynoos, 1999). The students were referred

from 13 schools around the epicenter of the earthquake. Results indicated that 4.5% met DSM-

IV (APA, 1994) criteria for PTSD. Six months after the earthquake in Athens, Kolaitis and

colleagues (2003) assessed symptoms of PTSD in 115 exposed students in grades 4 to 6. A

control group of 48 children from Thessaloniki, Greece who were not affected by the earthquake

were also assessed. The Children’s PTSD Reaction Index (CPTSD-RI; Pynoos et al., 1987) was

utilized to indicate that 16.5% (n = 19) qualified for a PTSD diagnosis. Results further indicated that children injured during the earthquake scored highest on the intrusion and arousal scales of the instrument.

After a 2003 earthquake in Iran, Ziaddini, Nakhaee, and Behzadi (2009) assessed 466

adolescents and reported that 66.7% of the sample met criteria for PTSD using a structured

PTSD questionnaire and the Davidson Trauma Scale (Davidson, Tharwani & Connor, 2002).

Recently, Wei and colleagues (2013) investigated the prevalence of PTSD in 753 Chinese

youths, aged 9 to 18 years, 6 months after a 2010 earthquake in northwest China where 2,698 people were killed and 12,135 were injured. The University of California, Los Angeles PTSD

Reaction Index (UCLA Reaction Index; Steinberg, Brymer, Decker, & Pynoos, 2004) was used

to evaluate PTSD. Results indicated that 13.4% (n = 101) participants met criteria for probable

PTSD. It was found that sex, but not age, was a significant predictor for PTSD, such that more

females met criteria. Furthermore, having been injured, witnessed a death, and experienced

derealization were significant independent predictors of PTSD.

Ying, Wu, & Lin (2012) examined 200 adolescents 12 months after a 2008 earthquake in

China. During a follow-up 18 months after the earthquake, 97% (n = 194) of the original sample completed the survey. Finally, 24 months following the earthquake, 54.5% (n = 109) completed a final assessment. Measures included the Center for Epidemiologic Studies Depression Scale for

Children (CES-DC; Fendrich, Weissman, & Warner, 1990) and the Child PTSD Symptom Scale

(CPSS; Foa, Johnson, Feeny, & Treadwell, 2001). Results indicated that PTSD at Time 1 (12 months after the earthquake) was 17.5% and at Times 2 and 3 it was 19.0% and 16.5%, respectively. Rates of depression at Times 1, 2, and 3 were 82.5%, 85.6%, and 89.9%, respectively. Interestingly, comorbidity of PTSD and depression at Times 1, 2, and 3 was also

17.5%, 19.0% and 16.5%, respectively.

Finally, Kadak, Nasıroğlu, Boysan, and Aydin (2013) assessed for PTSD prevalence in

738 adolescents 6 months after an October 2011 earthquake in Turkey. Participants ranged in age from 13 to 17 and 18.56% (n = 137) respondents reported that their homes were destroyed in the earthquake. Results indicated that 40.7% (n = 295) of participants met criteria for PTSD using the Child Posttraumatic Stress Reactions Index (CPTS-RI; Pynoos et al., 1987). Of note, one- third of the sample suffered from a depressive disorder (33.7%). Being female, older in age, and having prior mental health problems was found to significantly predict the development of

PTSD.

Hurricanes and Floods. On the evening of September 21, 1989 Hurricane Hugo struck the US, resulting in over 6 billion dollars in property damage and many months of physical and emotional disruption (Shannon, Lonigan, Finch, & Taylor, 1994). Shannon et al. (1994) used the

Child PTSD Reaction Index (CPTSD-RI; Pynoos et al., 1987) with 5,687 children and adolescents, aged 9 to 19 years, 3 months after the hurricane. Results indicated that 5.42% (n =

308) had PTSD, with more females than males displaying symptoms. One year after Hurricane

Hugo, Garrison, Weinrich, Hardin, Weinrich, and Wang (1993) investigated the frequency of

PTSD in 1,264 adolescents aged 11 to 17 who resided in South Carolina at the time of the hurricane. An author created questionnaire that included a PTSD symptom scale based on the

DSM-III-R (APA, 1987a) criteria along with questions about disaster exposure was utilized. The majority of the sample, 71%, reported that they experienced fear of injury during the hurricane and 12% reported that they were forced to move out of their home for at least a week. Rates of

PTSD were lowest in black males (1.5%) and higher in the remaining groups of black females and white males and females (3.8-6.2%). Overall, approximately 5% of the sample reported symptomatology consistent with a DSM-III-R (APA, 1987a) PTSD diagnosis 1 year after the disaster. Experiencing other violent traumatic events, being white, and being female were significantly correlated with a diagnosis of PTSD.

Goenjian and colleagues (2001) investigated the prevalence of PTSD in adolescents 6 months after Hurricane Mitch, a storm that destroyed homes throughout Central America.

Participants consisted of 158 Nicaraguan adolescents from public schools with a mean age of 13.

PTSD was evaluated using the Children’s PTSD Reaction Index (CPTSD-RI; Pynoos et al.,

1987). Higher levels of exposure to the hurricane resulted in more DSM-IV (APA, 1994) PTSD symptoms with prevalence rates of 90% at the most affected city, 55% at the second most affected, and 14% at the least affected city.

Within the context of floods, Earls, Smith, Reich, and Jung (1988) utilized the Diagnostic

Interview for Children and Adolescents (DICA; Herjanic & Reich, 1982) to assess 32 children,

aged 6 to 17 years, affected by floods in rural Mississippi between 1982 and 1983. The severe

flooding forced all of the families in the sample to evacuate their homes and resulted in serious property damage. Interviews were carried out in the homes of families 1 year after the flooding, at which point in time all of the participants had returned to their homes post evacuation.

Interestingly, diagnostic criteria for PTSD were not met for any of the children, although some symptoms were reported.

Bokszczanin (2007) assessed 553 individuals, aged 11 to 21, 28 months following a flood in southwest Poland. A DSM-IV (APA, 1994) version of the Revised Civilian PTSD Scale

(Norris & Perilla, 1996) along with an author created checklist assessing the traumatic stressor were utilized to determine that 17.7% (n = 94) of the sample met diagnostic criteria for PTSD.

Furthermore, more PTSD symptoms were observed among girls than boys and in younger participants. Finally, Yang and colleagues (2011) assessed PTSD prevalence rates in a group of

271 displaced adolescents, aged 12-15 years, 3 months after Typhoon Morakot in Taiwan. The

typhoon together with the mudslides and floods resulted in the deadliest typhoon-related disaster

to impact Taiwan for approximately 50 years. The storms caused over 3 billion US dollars in

damages and 650 people were killed (Yang et al., 2011). The participants were trapped in mud,

witnessed death and serious injury of family members, and/or suffered physical injuries

themselves. Results from the administrations of the Mini-International Neuropsychiatric

Interview for Children and Adolescents (MINI-KID; Sheehan et al., 1998) indicated that 25.8%

(n = 70) adolescents met DSM-IV (APA, 1994) criteria for PTSD related to the typhoon.

Furthermore, 3.0% (n = 8) of the sample had PTSD related to previous traumatic events before

the typhoon. The participants who were female, physically injured, had family members in the

same house die or sustain serious injury were more likely to develop PTSD. Furthermore,

previously induced PTSD was associated with the development of post-Typhoon Morakot PTSD.

Finally, adolescents with PTSD had significantly higher depression scores.

Motor Vehicle Accidents. Many researchers have analyzed prevalence rates of PTSD

following motor vehicle accidents. For example, Di Gallo and colleagues (1997) examined a

cohort of 57 Scottish children, aged 5 to 18, who had survived injuries related to automobile

accidents, 3 to 4 months after their injuries. Measures included the Injury Severity Score (ISS;

Greenspan, McLellan, & Grelg, 1985), the Child Behavior Checklist (CBCL; Achenbach,

1991a), the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI; Pynoos et al.,

1987), and the Revised Impact of Event Scale (R-IES; Horowitz et al., 1979). Results indicated

that 35% (n = 17) had mild PTSD while 14% (n = 7) demonstrated moderate to severe levels of

PTSD. De Vries et al. (1999) used the PTSD Checklist for Children/Parent Report (PCL-C/PR;

Weathers & Ford, 1996) 7 to 12 months after child injury to assess 102 traffic-injured children

aged 3 to 18. Results indicated that 25% (n = 26) of the children met DSM-IV (APA, 1994) criteria for a PTSD diagnosis and 15% (n = 15) of the parents met criteria. Child and parent

PTSD scores were strongly correlated.

Similarly, Keppel-Benson, Ollendick, and Benson (2002) evaluated 50 children approximately 9 months after an accident using the Diagnostic Interview for Children and

Adolescents – Revised (DICA-R; Reich & Welner, 1988). Participants ranged in age from 7 to

16 years and the time interval between the stressor and assessment ranged from 2 to 18 months.

Most children were passengers in automobile accidents. In total 14% (n = 7) of the children met

DSM-III-R (APA, 1987a) criteria for PTSD. Zink and McCain (2003) found similar rates of

PTSD in their assessment of 143 children between the ages of 7 and 15 who experienced a motor vehicle related injury. Measures included the Diagnostic Interview for Children and Adolescents

(DICA-R; Reich & Welner, 1988) 2 and 6 months following the accident. Results indicated that

18% (n = 26) of the sample met PTSD criteria 2 months later. An additional six children developed PTSD 6 months following trauma exposure. Overall, 22% (n = 32) of the children met criteria with no significant differences reported relative to age or gender.

Landolt, Vollrath, Timm, Gnhem, and Sennhauser (2005) also investigated DSM-III-R

(APA, 1987a) PTSD rates after motor vehicle accidents in 68 crash victims. The participants ranged in age from 6.5 to 14.5 years and were interviewed approximately 1 month and again 12 months after their road traffic accidents. Using the CPTSD-RI (Frederick, Pynoos, & Nader,

1992), PTSD prevalence estimates of 16.2% were found during the initial assessment and 17.6% at follow-up. In a similar vein, Meiser-Stedman, Yule, Smith, Glucksman, and Dalgleish (2005) investigated rates of acute stress disorder and PTSD in 93 children and adolescents, aged 10 to

16, who were seen in the emergency department within 1 month of involvement in a motor vehicle accident. Six months later, 64 children were reinterviewed using the child version of the

Anxiety Disorders Interview Schedule for DSM-IV (ADIS; Silverman & Albano, 1996). At 1 month, 19.4% (n = 18) met full criteria for acute stress disorder while 12.5% (n = 8) met PTSD criteria at the 6 month follow-up assessment.

Finally, Jones-Alexander, Blanchard, and Hickling (2005) assessed 21 adolescents, aged

8 to 17 years after a motor vehicle accident using the Children’s PTSD Inventory (Saigh, 1995), the PTSD Checklist Child (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) and the

DICA-R (DICA-R; Reich et al., 1995). These participants were compared to 14 control participants matched for age and gender who had never been in an accident. Results indicated that 23% (n = 8) of the entire sample met DSM-IV (APA, 1994) criteria for PTSD.

Transportation Accidents. Yule (2000) assessed a group of individuals who survived a

shipping disaster in Greece as teenagers, 5 to 8 years previously. In 1988, school children from

the United Kingdom boarded the cruise ship “Jupiter” that sunk within 45 minutes of being

struck by another ship. Survivors (n = 217) were compared to a community control group (n =

87). Using the Clinician Administered PTSD Scale (CAPS; Weathers, Ruscio, & Keane, 1999),

it was determined that 51.7% (n = 111) of the survivors developed PTSD at some point during

the follow-up period, as compared to 3.4% (n = 87) of the control group. For the majority of

those that did develop PTSD, 90% developed it within 6 months of the disaster.

Analogously, Mirzamani, Mohammadi, and Besharat (2006) assessed 19 girls, aged 13 to

15, who survived a boat sinking in Tehran in 2002 approximately 18 months after the disaster.

Six schoolgirls and one boatman died as a result of the disaster. Using the Posttraumatic Stress

Disorder Symptoms Scale (PSS; Foa et al., 1993) 84.2% of participants (n = 16) were diagnosed with PTSD. Researchers also conducted unstructured clinical interviews based on DSM-IV

(APA, 1994) PTSD criteria and reported that 89.5% met criteria.

Examined collectively, PTSD prevalence rates in the aforementioned natural disaster and accident studies ranged from 0% to 90%. Table 2.3 presents a summary of research regarding the prevalence of PTSD after natural disasters and accident-related traumas.

Table 2.3

Child-Adolescent PTSD Rates Following Natural Disasters or Accidents

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence

Earthquakes Pynoos et al. (1993) DSM-III-R 111 children Mean Age: 1.5 years 70.30% Clinical 12.8 years Interview

Najarian et al. DICA-R 37 males Age Range: 2.5 years High Exposure: 33.00% (1996) 37 females 11-13 years Relocated: 28.00% Low Exposure: 4.00%

87 Hsu et al. (2002) SCL-90-R 121 males Mean Age: 6 weeks 21.70% ChIPS 182 females 13.3 years

Laor et al. (2002) CPTSD-RI 135 males Mean Age: 4 months 20.80% 168 females 8.5 years

Yorbik et al. (2004) DSM-IV 17 males Mean Age: 1-4 months 40.00% Checklist 18 females 9.2 years

Roussos et al. UCLA PTSD-RI 1,937 children Age Range: 3 months 4.50% (2005) and adolescents 9-18 years

Kolaitis et al. (2003) CPTSD-RI 115 children Grades 4, 5, & 6 6 months 16.50%

Ziaaddini et al. Davidson 466 adolescents Mean Age: 10 months 66.70% (2009) Trauma Scale 15.9 years

Table 2.3 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Ying et al. (2012) CPSS 76 males Mean Age: 12 months 17.50% 124 females 15 years 14 months 19.50% 24 months 16.5%

Wei et al. (2013) UCLA PTSD-RI 372 males Age Range: 6 months 13.40% 381 females 9-18 years

Kadak et al. (2013) CPTSD-RI 406 males Age Range: 6 months 40.69% 332 females 13-17 years Hurricanes and Floods Shannon et al. CPTSD-RI 2787 males Age Range: 3 months 5.42%

88 (1994) 2900 females 9-19 years

Garrison et al. DSM-III-R Based 600 males Age Range: 1 year 5.00% (1993) Questionnaire 664 females 11-17 years

Goenjian et al. CPTSD-RI 81 males Mean Age: 6 months High-Impact: 90.00% (2001) 77 females 13 years Medium-Impact: 55.00% Low-Impact: 14.00%

Earls et al. (1988) DICA 16 males Age Range: 1 year 0.00% 16 females 6-17 years

Bokszczani (2007) DSM-IV Revised 213 males Age Range: 28 months 17.70% Civilian PTSD 320 females 11-21 years Scale

Table 2.3 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Yang et al. (2011) MINI-KID 124 males Age Range: 3 months 25.80% 147 females 12-15 years Motor Vehicle Accidents Di Gallo et al. CPTSD-RI 38 males Age Range: 3-4 months Moderate to Severe: (1997) 19 females 5-18 years 14.00% Mild: 35.00%

De Vries et al. PCL-C 68 males Age Range: 7-12 months 25.00% (1999) 34 females 3-18 years

89 Keppel-Benson et al. DICA-R 29 males Age Range: 2-18 months 14.00% (2002) 21 females 7-16 years

Zink & McCain DICA-R 85 males Age Range 2 and 6 months 22.00% (2003) 58 females 7-15 years

Landolt et al. (2005) CPTSD-RI 37 males Age Range: 4-6 weeks 4-6 weeks: 16.20% 31 females 6-14 years 12 months 12 months: 17.60%

Meiser-Stedman et ADIS 60 males Age Range: 1 month 19.40% al. (2005) 33 females 10-16 years 6 months 12.50%

Jones-Alexander et CPTSDI 11 males Age Range: 1 month 23.00% al. (2005) PCL-C 10 females 8-17 years DICA-R

Table 2.3 (continued)

Study Measure(s) Participants Age Elapsed Time PTSD Prevalence Transportation Accidents Yule (2000) CAPS 217 stress Not Reported 5-8 years 51.70% exposed survivors

Mirzamani et al. PSS 19 females Age Range: 18 months 84.20% (2006) 13-15 years

Comorbidity

Studies have established associations between PTSD and other comorbid psychiatric

disorders (Cohen et al., 2010; Kessler et al., 1995; Kulka et al., 1990). In fact, epidemiological

surveys indicate that most individuals with PTSD also meet criteria for another psychiatric

disorder (Brady, Killeen, Brewerton, & Lucerini, 2000). Major Depressive Disorder is the most

common disorder occurring with PTSD, as approximately 35-50% of those in the general population with PTSD have depression (Breslau, Davis, Andreski, & Peterson, 1991; Breslau,

Davis, Peterson, & Schultz, 1997; Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes, &

Nelson, 1995). Specifically, Spitalny (2004) noted that PTSD symptoms overlap in part with

Major Depressive Disorder (MDD) symptoms in the DSM-IV (APA, 1994) criteria. There are

several jointly held characteristics between these diagnoses such as markedly diminished interest

in certain types of activities, insomnia or hypersomnia, irritability, difficulty concentrating, and

functional impairment. Understanding the symptoms of comorbid PTSD may result in richer

knowledge of the course and etiology of PTSD (Saigh, Yasik, Sack, & Koplewicz, 1999).

Kulka et al. (1990) indicated that 98.8% of PTSD positive Vietnam veterans also had

another DSM-III-R (APA, 1987a) comorbid disorder. Perkonigg and colleagues (2000) found

that 87.5% of those with lifetime PTSD had a minimum of one additional psychiatric diagnosis

while 77.5% had two or more. Kessler and colleagues (1995) indicated through the National

Comorbidity Survey that 88.3% of males and 79% of females with lifetime PTSD also presented

with another DSM-III-R (APA, 1987a) disorder. Estimates indicate that PTSD often occurs prior

to other comorbid disorders. For men, Kessler et al. (1995) reported that the most common PTSD

comorbid disorders were alcohol dependence (51.9%) followed by MDD (47.9%) and conduct

disorder (43.3%). For women, most common were MDD (48.5%), followed by simple phobia

(29.0%) and social phobia (28.4%). Compared to the general population without PTSD, only

11.7% of men and 18.8% of women were found to suffer from depression (Kessler et al., 1995)

Stein, McQuaid, Pedrelli, Lenox, and McCahill (2000) used the PTSD Checklist-Civilian

Version (PCL-C; Weathers et al., 1994) and select modules from the Comprehensive Diagnostic

Interview – Version 2.1 (CIDI 2.1; Wittchen, 1994), together with the CIDI Short Form (CIDI-

SF; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998), in 367 adults in primary care

medical settings. Of the patients who met DSM-IV (APA, 1994) criteria for PTSD, the majority

(61.1%) had comorbid major depressive disorder. Furthermore, 38.9% had comorbid generalized

anxiety disorder, 16.7% had comorbid panic disorder, and another 16.7% had comorbid social phobia. Within the last year, 22.2% presented with a substance use disorder. Thus, the majority

of adult patients with PTSD had a comorbid disorder.

Regarding comorbid PTSD in children and adolescents, Giaconia (1995) studied a

community sample of youth and found that “a lifetime diagnosis of PTSD by age 18 significantly

increased the risk of experiencing other lifetime psychiatric disorders by late adolescence,” (p.

1375). In her sample, youths with PTSD were seven times as likely as youths who had never been traumatized to meet DSM-III-R (APA, 1987a) criteria for at least one of five other major

disorders. In terms of youth who had been traumatized but did not develop PTSD, youth with the

PTSD diagnosis were four times as likely as traumatized adolescent to have a comorbid disorder.

Specifically, more than two fifths of adolescents with PTSD met criteria for major depression by

age 18, as compared to 8% of their peers without PTSD. Results indicated that PTSD preceded

or emerged simultaneously with major depression in 70% of the cases. The connection between

PTSD and substance dependence was also notable, as PTSD generally preceded or occurred at

the same age of substance use disorders in youth who had both disorders.

In two specialized studies with Cambodian youth who were severely traumatized between the ages of 8 and 12 by the Pol Pot Regime, Kinzie and colleagues (1986; 1989) found

very high rates of comorbid PTSD. Kinzie et al. (1986) initially studied 40 Cambodian students,

and then conducted a follow up study (Kinzie et al., 1989) with a portion of individuals from the

original sample. Results indicated that 50% of the Cambodian students initially met DSM-III

(APA, 1980) criteria for PTSD and 48% met criteria DSM-III-R (APA, 1987a) during the follow

up. Of note, 56% (n = 15) of the initial sample and 41% (n = 11) of the follow-up sample met

criteria for depressive disorders. Nine of the 15 cases of depression at Time 1 were associated

with PTSD (60% of initial depressed sample), while 10 of the 11 cases of depression were

associated with PTSD at Time 2 (90% of follow-up depressed sample).

Using the K-SADS-E (Puig-Antich et al., 1983), McLeer et al. (1994) assessed 26

children aged 6 to 16 who had been sexually abused compared to a control group of 23 children

who had not experienced abuse. Of the children who met criteria for PTSD, 23.1% presented

with comorbid PTSD and attention-deficit hyperactivity disorder (ADHD). Furthermore, 15.4% presented with comorbid PTSD and conduct disorder (CD) while 11.5% presented with PTSD,

ADHD, and CD. Similarly, Famularo et al. (1996) reported that 37% of 117 maltreated children

who received a DSM-III-R (APA, 1987a) diagnosis of PTSD also received an ADHD diagnosis based on the DICA (Welner et al., 1987). Comorbid CD or ODD was found with 24% of the

PTSD cases. Merry and Andrews (1994) found that in their sample of 95 sexually abused youth,

63.5% warranted one diagnosis and 36.4% warranted greater than one while 13.6% warranted

greater than two diagnoses. Vila and colleagues (1999) found that 27% (n = 7) of 26 elementary

students taken hostage at their school developed PTSD according to DSM-IV (APA, 1994)

criteria. Approximately 29% (n = 2) of the students with PTSD also presented with comorbid

MDD. Of note, 47% (n = 3) of the children with PTSD suffered from preexisting disorders

including generalized anxiety disorder, social phobia, and dysthymic disorder.

Saigh, Yasik, Oberfield, Halamandaris, and McHugh (2002) utilized the CPTSDI (Saigh,

1998) and the DICA-R (Reich et al., 1994) to examine 103 youth aged 7 to 18 years at Bellevue

Hospital Center in NYC who had been exposed to a wide range of traumatic events. In addition,

each participant received an unstructured DSM-IV (APA, 1994) interview by a psychologist and psychiatrist. In total, 38% (n = 39) of the sample met criteria for PTSD. Eight participants also

met criteria for MDD and one for substance dependence.

In Kilpatrick and colleagues’ (2003) national household probability sample of 4,023

adolescents, they found that 15.5% of boys and 19.3% of girls were diagnosed with PTSD, a

major depressive episode, or substance abuse/dependence (i.e. at least one of the three

aforementioned disorders). Nearly 75% of the adolescents with PTSD had at least one comorbid

diagnosis. As a point of comparison, less than 40% of those with a major depressive episode and

a substance abuse/dependence disorder had a comorbid diagnosis. Comorbidity for each pair of

diagnoses ranged from 1.1-1.8% for boys and 1.5-4.4% for girls. The highest comorbidity was

found between PTSD and MDE, as 29% of major depression cases also met PTSD criteria and

62% of PTSD cases also met criteria for major depression.

Allwood et al. (2008) reported that the mean number of diagnoses for adolescents with

PTSD was 2.46 as compared to 1.64 for those without PTSD. Only 7.7% (n = 6) of those with

PTSD were diagnosed with PTSD only. On the other hand, 55.1% of those diagnosed with PTSD

had comorbid Major Depressive Disorder, 19.2% had comorbid Oppositional Defiant Disorder,

17.9% had comorbid Conduct Disorder, and 11.5% had ADHD.

Regarding war studies, Khamis (2008) found significant differences between Palestinian adolescents with and without PTSD on depression and anxiety scales, such that adolescents with

PTSD were more likely to report higher levels of depression and anxiety. Klasen et al. (2010) found that among 330 former child soldiers in Uganda, 18.5% qualified for diagnoses of both

PTSD and Major Depressive Disorder. Similarly, Pfeiffer and Elbert (2011) studied 72 individuals who were formerly abducted in Northern Ugandan, 62 whom were former child soldiers. Almost half of the sample met DSM-IV (APA, 1994) criteria for PTSD while 71% and

60% had clinically relevant levels of depression and anxiety, respectively. Overall, more than a third of respondents (36%) met criteria for PTSD, depression, and anxiety simultaneously.

In short, children and adolescents with PTSD likely evidence high rates of comorbid disorders, as is the case regarding adults with PTSD. Depressive disorders are some of the most common comorbid PTSD diagnoses. Table 2.4 presents a summary of the data involving comorbidity from this chapter.

Table 2.4

Prevalence of Comorbid Psychiatric Diagnoses with Child and Adolescent PTSD

Study Diagnostic Prevalence of Comorbid Measure Disorder with PTSD War-Related Traumas Kinzie et al. (1986) SADS Panic Disorder: 15.00% Depressive Disorders: 85.00% Anxiety Disorders: 35.00%

Kinzie et al. (1989) SADS Panic Disorder: 7.70% Affective Disorders: 37.00%

Sack et al. (1993) K-SADS Anxiety Disorders: 15.00% DSM-III-R DICA Major Depressive Disorder: 60.00%

Sack et al. (1994) K-SADS-E Conduct Disorder: 10.50% Panic Disorder: 10.50%

Hubbard et al. SCID-NP Major Depressive Disorder: 21.00% (1995) Generalized Anxiety Disorder: 21.00% Social Anxiety Disorder: 21.00%

Klasen et al. (2010) MINI-KID Major Depressive Disorder: 18.50%

Pfeiffer & Elbert PDS Unspecified Depression and Anxiety (2011) Disorders: 36.00%

Physical/Sexual Assault

McLeer et al. (1994) KSADS-E ADHD: 23.10% Panic Disorder: 18.40% ADHD and Conduct Disorder: 11.50%

Famularo et al. DICA-C-R Anxiety Disorders: 39.00% (1996) ADHD: 37.00% Mood Disorders: 32.00% ODD and Conduct Disorder: 24.00%

Table 2.4 (continued)

Study Diagnostic Prevalence of Comorbid Measure Disorder with PTSD McLeer et al. (1998) K-SADS-E Separation Anxiety Disorder: 20.70% Major Depression: 13.8% Dysthymia:10.3% Disruptive Behavior Disorders: 10.3%

Vila et al. (1999) K-SADS Major Depressive Disorder: 29.00% Generalized Anxiety Disorder: 14.28% Social Phobia: 14.28% Dysthymic Disorder: 14.28%

Linning & Kearney ADIS-C ADHD: 35.10% (2004) Major Depressive Disorder: 35.10% Separation Anxiety Disorder: 35.10% Panic Disorder: 18.40%

Various Traumas Perkonigg et al. M-CIDI Depressive Disorders: 68.50% (2000) Agoraphobia With or Without Panic Disorder As Well As Substance Use or Dependence: 70.60%

Saigh et al. (2002) DICA-R Major Depressive Disorder: 20.51% Substance Dependence: 2.56%

Kilpatrick et al. DSM-IV Major Depressive Episode: 62.00% (2003) Structured Substance Abuse Disorder: 1.50% Interview

Allwood et al. (2008) ChIPS Major Depressive Disorder: 55.10% Oppositional Defiant Disorder: 19.20% Conduct Disorder: 17.90% ADHD: 11.50%

Ying et al. (2012) CES-DC Depressive Disorders: 16.50-19.00% CPSS

Risk Factors for PTSD

The following potential risk factors for the development of PTSD in children and

adolescents shall be discussed: (a) gender; (b) age; (c) race/ethnicity; (d) parental psychopathology; (e) child characteristics; (f) multiple exposure to traumatic stress; (g) intensity

of exposure to traumatic stress; (h) duration and frequency of exposure; (i) type and mode of

stressor; (j) relationship between victims and perpetrators; and (k) time interval between trauma

exposure and diagnostic evaluation.

Gender. Numerous studies have indicated that men are more likely to experience a

traumatic event in their lifetime than females (e.g. Breslau, Davis, Andreski, & Peterson, 1991;

Darves-Bornoz et al., 2008; Rosenman, 2002), with some exceptions (Kessler et al., 1995; de

Vries & Olff, 2009). However, a majority of studies indicate that females have higher rates of

PTSD than men (Allwood et al., 2008; Breslau, Davis, Andreski, & Peterson, 1991; Cuffe et al.,

1993; Domanskaité-Gota, Elklit, & Christiansen, 2009; Eytan et al., 2004; Fitzpatrick &

Boldizar, 1993; Garrison et al., 1993; Hsu et al., 2002; Kessler et al., 1995; Pat-Horenczyk et al.,

2007; Perkonigg, Kessler, Storz, & Wittchen, 2000; Stein, Walker, Hazen, & Forde, 1997;

Thabet, EL-Buhaisi, & Vostanis, 2014; van Ameringen, Mancini, Patterson, & Boyle, 2008;

Yang et al. 2011). For example, Breslau and colleagues (1991) reported that 11.3% of women

and 6% of men had a lifetime history of PTSD. Analogously, Garrison et al. (1993) reported that being female was significantly correlated with a diagnosis of PTSD in their study of children

exposed to a hurricane. Schall and Elbert (2006) found that more females (60%) than males

(27%) exposed to war-related stressors during Rwandan genocide developed PTSD. D’Augelli et

al. (2006) indicated that three times the number of females (15%) than males (4%) met criteria

for PTSD in their study of lesbian, gay, and bisexual youth. Ziaaddini et al. (2009) reported that

girls were three times more likely to develop PTSD following a 2003 earthquake in Iran relative to boys. Finally, Thabet et al. (2014) indicated that 33% of girls compared to 26% of boys met criteria for PTSD even though boys reported more violence exposure than girls.

On the other hand, Khamis (2005) indicated that there were higher rates of PTSD in

Palestinian male students exposed to violence as compared to similarly exposed females (20% vs. 14.1%). Pfeiffer and Elbert (2011) echoed this finding as they reported that male respondents were more likely to develop symptoms of PTSD than females in their study of previously abducted individuals living in Northern Uganda.

Many other studies did not report significant gender differences regarding PTSD in youth

(e.g. Ahmad et al., 2000; Allwood et al., 2002; Elbedour et al., 2007; Foster et al., 2004;

Goenjian et al., 1995; Hubbard et al., 1995; Klasen et al., 2010; Saigh, 1988a; Saigh et al., 1995,

1997; Schwarz & Kowalski, 1991; Seedat et al., 2004; Silva et al., 2000; Yorbik et al., 2004;

Zink & McCain, 2003). Interestingly, Rosenman (2002) reported that female gender was initially a significant predictor of PTSD in the Australian National Survey of Mental Health and

Wellbeing. However, when controlling for the passage of time, number, and type of trauma, female gender was no longer a significant contributor to PTSD risk. Thus, gender as a risk factor for PTSD remains somewhat speculative.

Age. While the DSM-IV-TR (2000) did not mention prevalence rates with regard to youth populations, the DSM-5 (2013) indicates the prevalence of PTSD varies across developmental stage. PTSD prevalence estimates also varied in this chapter regarding age as a risk factor. Some research implied that younger children have higher PTSD prevalence rates

(Bokszczanin, 2007; Schwarzwald et al., 1993). Schwarzwald et al. (1993) reported that fifth graders were more likely to develop PTSD than seventh and tenth graders after they had

witnessed a missile attack, up to 1 year after the incident. Analogously, Bokszczanin (2007) reported that younger boys were more likely than older ones to develop PTSD after a flood.

A majority of research conversely indicates that adolescents are more susceptible to developing PTSD than younger children (e.g. Ahmad et al., 2000; Eytan et al., 2004; Garrison et al., 1995, Kadak et al., 2013; Klasen et al., 2010; Schall & Elbert, 2006; Schwarz & Kowalski,

1991; Wolfe et al., 1994; Yorbik et al., 2004). Perkonigg et al. (2000) reported that very few

German children from their study developed PTSD prior to age 11, as it was more common in the older children and adolescents. Similarly, Ahmad et al. (2000) indicated that rates of PTSD after experiencing military occupation and violence were more common in Kurdish children with a higher mean age. Yorbik et al. (2004) noted that no children between the ages of 2 and 6 exposed to an earthquake met full diagnostic criteria for PTSD while 56.3% of children between the ages of 7 and 11 and 50% of those aged 12 to 16 did, revealing a clear age effect with adolescents. Consistent with this, Copeland et al. (2007) reported that adolescence (ages 14 to

16), as compared to childhood (ages 9 to 13), was a strong predictor of both painful recall and subclinical PTSD when controlling for other predictor variables. Klasen et al. (2010) indicated that younger adolescents, aged 11 to 13, had lower rates of PTSD (23.9%) compared to older adolescents, aged 14 to 17 (36.8%).

In general, the lower rates found amongst children and adolescents, may be due to the lack of developmentally informed DSM criteria for PTSD (Scheeringa et al., 2011). On the other hand, it is important to note that some studies did not indicate any age differences regarding

PTSD prevalence (Landolt et al., 2005; Solomon & Lavi, 2005; Schaal & Elbert, 2006; Schwarz

& Kowalski, 1991; Wei et al., 2013; Yang et al., 2011; Zink & McCain, 2003).

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Race/Ethnicity. Estimating vulnerability of PTSD in culturally diverse groups is challenging and research findings have mixed. Caution must be exercised in drawing conclusions, as the definition of terms such as race, ethnicity, and culture may vary across sources. Furthermore, these terms integrate issues including multiple hereditary backgrounds and identities, and the status of a specific community upon a particular ethnic group, which is difficult to parse apart (Williams et al., 2002). Kessler et al. (1995) and Steiner et al. (1997) did not find ethnic differences in PTSD prevalence in their respective studies. Many criminal victimization-related PTSD studies also evidenced nonsignificant associations between PTSD and ethnicity race (Abram et al., 2004; Famularo et al., 1996; Linning & Kearney, 2004; Steiner et al., 1997), as did natural disaster and accident studies (De Vries et al., 1999; Shaw et al., 1995;

Zink & McCain, 2003).

On the other hand, Breslau and colleagues (1998) indicated that exposure to assaultive violence was higher among non-whites as compared to whites and found blacks to be at an increased risk for PTSD relative to whites in the Detroit Area Survey of Trauma. However, this effect did not hold when central city residence was controlled for. Some studies indicate that

Latinos, African American, and American Indian adults in the US have higher reported rates of

PTSD on average as compared to non-Latino whites while Asian Americans have the lowest rates (Beals et al. 2002; Hinton & Lewis-Fernandex, 2011; Perilla et al. 2002). Jones et al. (2002) demonstrated that PTSD in youth was predicted by Mexican American status after exposure to severe California wildfires. Whereas LaGreca, Silverman, Verberg, and Prinstein (1996) reported higher rates of PTSD in Hispanic and African American youth after Hurricane Hugo, Shannon et al. (1994) indicated only nonsignificant differences between these groups. Garrison et al. (1993)

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found that being white was significantly correlated with PTSD after Hurricane Andrew in

Florida.

Parental Psychopathology. There may be a parental or familiar component to the

development of PTSD in children (Krystal et al., 1989). Sack and colleagues (1993) reported

higher rates of PTSD in children whose parents also had PTSD (22.3%) as compared to children

who parents did not have the disorder (12.9%). If both parents were diagnosed with PTSD the point prevalence increased to 41.2%. In a similar vein, Yehuda, Schmeidler, Giller, Siever, and

Binder-Byrnes (1998) examined a cohort offspring whose parents were exposed to the Holocaust

(but the children were not). The offspring who were exposed to a unique, independent trauma

and also had a parent with PTSD were significantly more likely to develop PTSD themselves.

Five out of the 22 offspring met criteria for current or past PTSD and they all had parents with

PTSD. Tiet et al. (1998) found that youth exposed to a significant trauma had worse adjustment

if their mothers also suffered from psychopathology in a large epidemiological sample.

Similarly, Ahmad and colleagues (2000) found a positive correlation between caregiver and

child PTSD symptoms. Finally, Linning and Kearney (2004) found that parental drug and

alcohol dependence was positively associated with PTSD prevalence rates among children who

were victims of maltreatment.

Child Characteristics. Feelings of anxiety prior to exposure to a traumatic event may be predictive of PTSD as demonstrated by La Greca, Silverman, Vernberg, & Prinstein (1998) and

Silva et al. (2000). Fifteen months prior to Hurricane Andrew, LaGreca et al. (1996) examined

the functioning of 92 children. Three months after the hurricane, PTSD severity was predicted by baseline ratings of anxiety, inattention, and academic skills. At 7 months, only preexisting

anxiety scores predicted greater PTSD scores. Silva and colleagues (2000) also found that

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antecedent anxiety was related to the development of PTSD and it may amplify the expression of

PTSD. Additionally, the authors found that those with oppositional defiant disorder or conduct

disorder were significantly less likely to develop more elaborate forms of PTSD, likely because

of the externalizing nature of these disorders, indicating that these children may not manifest

symptoms internally. More recently, Kadak et al. (2013) reported that prior mental health problems significantly predicted PTSD in a sample of adolescents after an earthquake. Finally,

Johnson, Pike, and Chard, (2001) found that the development of PTSD among 89 female

survivors of child sexual abuse was correlated with dissociation around the time of the abuse.

Some studies indicate that higher intelligence quotients (IQ) scores are related to the

absence of PTSD after a trauma (Breslau Lucia, & Alvarado, 2006; Saigh, Yasik, Oberfield,

Halamandaris, & Bremner, 2006; Silva et al., 2000; Tiet et al., 1998). In their large sample of

1,285 children, Tiet and colleagues (1998) found that higher IQs bolstered the youths’

adjustment process. Similarly, Silva et al. (2000) indicated that higher verbal IQ was a strong

resiliency measure against the development of PTSD in a sample of inner city youth. Saigh et al.

(2006) analyzed Wechsler Intelligence Scale for Children-III (WISC-III; Wechsler, 1991) scores

of PTSD positive and traumatized PTSD negative children, and a non-traumatized control group.

After excluding cases with major comorbid disorders, the PTSD positive group scored

significantly lower than the comparison groups on verbal subtests. The PTSD negative and

control group scores did not differ significantly. Nonsignificant differences were observed between groups on all of the performance subtests. In a similar vein, Breslau et al. (2006)

reported that children with higher IQ scores (1 standard deviation above the mean) at age 6 had a

decreased risk of developing PTSD as compared to children with lower IQs (scores less than the

mean). Breslau and colleagues (2006) also reported that elevated externalizing behavior ratings

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from teachers in the 1st grade resulted in an increased risk for developing PTSD after exposure

to a traumatic event. It is important to note that the emotional symptoms of PTSD may have had

an impact on the IQ results in some of the samples above and analyses should be interpreted with

caution.

Multiple Exposures to Traumatic Stress. The literature suggests that prior trauma,

especially with a past diagnosis of PTSD, increases the likelihood of repeated episodes of PTSD.

The same holds true for post-trauma stressors. For example, Bremner, Southwick, Johnson,

Yehuda, and Charney (1993) indicated that individuals who were previously traumatized and re-

exposed to another traumatic event were caught in a “snowballing effect” leading to the

development of future PTSD symptoms. Likewise, Garrison and colleagues (1993) found that pre-hurricane history of exposure to stress such as abuse or assault was predictive of PTSD in

children who survived Hurricane Andrew.

Yang et al. (2011) reported that individuals who had PTSD related to previous traumatic

events were more likely to have a diagnosis of PTSD related to Typhoon Morakot. Similarly,

Saigh (1988a) indicated there was a strong association between secondary exposures to war-

related traumatic events and PTSD. Nishith, Mechanic, and Resick (2000) reported that prior

interpersonal trauma contributed to PTSD symptoms in female rape victims. In a similar vein,

Lipschitz et al. (2000) reported that PTSD among adolescent girls was significantly associated

with an earlier history of child abuse and physical neglect. Finally, Copeland et al. (2007)

indicated that PTSD symptoms were predicted by previous exposure to multiple traumas.

Intensity of Exposure to Traumatic Event. The exposure to intense traumatic stressors

seems to increase the development of PTSD in youth (March, 1993). Kilpatrick, Resnick,

Saunders, and Best (1998) indicated that those exposed to high index stressors are in greater

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danger of developing PTSD. In her 10-year review of PTSD in children, Pfefferbaum (1997)

indicated that the physical proximity of a traumatic event is of significance for the development

of PTSD. Similarly, Goenjian and colleagues (1995, 2001) found higher rates of PTSD in

children who were close proximity to the epicenter of an earthquake or hurricane, as compared to

children living further away. Johnson et al. (2001), Hsu et al. (2002), and Wei et al (2013)

reported that sustaining an injury after a traumatic event (e.g. sexual abuse or earthquake)

increased the risk for PTSD as compared to those who did not sustain an injury.

On the other hand, Koplewicz and colleagues (1994) indicated that stress exposure level

was not predictive of PTSD in their study of youth who experienced high and low life threat

during the World Trade Center bombing. Similarly, Shaw and colleagues (1995) found no

significant differences in PTSD rates of youth in high and low exposure areas during Hurricane

Andrew. Saigh et al. (2002) found that stressor severity did not predict PTSD prevalence while

DeVries et al. (1999) and Landolt et al. (2005) did not find an association between physical

injury and later PTSD diagnosis. Finally, Saigh and colleagues (2011) did not find differences in probable PTSD prevalence rates in preschoolers aged 3 to 5 years who were exposed to different

levels of traumatic stress following the September 11, 2001 attack.

Duration and Frequency of Exposure. Most research indicates that PTSD prevalence

rates are associated with longer durations and frequency of exposure. Wolfe and colleagues

(1994) found that children maltreated for greater than 1 year had higher PTSD prevalence rates

compared to children who experienced similar trauma for less than 1 year. Thabet and Vostanis

(1999) reported that the total number of traumas experienced by Palestinian children during war

was the strongest predictor of PTSD severity. Likewise, Ackerman et al. (1998) indicated that

children who experienced both sexual and physical abuse had higher rates of PTSD than those

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who experienced either sexual or physical abuse alone. In a related study, Silva and colleagues

(2000) found that children who had witnessed domestic violence and had also been personally

abused developed higher rates of PTSD as compared to children who experienced only one

trauma. Ruggiero et al. (2000) reported that increased duration and frequency of sexual abuse

was a significant predictor of PTSD. Regarding war traumas, Ahmad et al. (2000) indicated that

PTSD was positively correlated with duration of captivity in children. Exposure multiple war

traumas as compared to a single trauma resulted in a greater risk for developing PTSD (Schaal

and Elbert, 2006; Seedat et al., 2004; Thabet et al., 2014). However, Bayer and colleagues (2007)

indicated that duration of time spent as a child soldier during the African civil wars was not predictive of PTSD.

Type and Mode of Stressor. The literature indicates that the nature of the traumatic

stressor may be a risk factor for PTSD. Saigh (1991) studied 230 stress-exposed Lebanese youth

who met criteria for PTSD. He reported that 25.2% met criteria through direct experience (e.g.

gun shot wound), 55.6% developed PTSD though observation (e.g. witnessing murder of family

member), 5.6% through information transmission (e.g. learning about the actual or threatened

death of a family member), and 13.5% through a combination of the aforementioned pathways.

Regarding natural disasters, it seems that there are higher rates of PTSD after earthquakes

than in hurricanes. Bradburn (1991) assessed 22 children after an earthquake in San Francisco

and found that 63% met criteria for PTSD. Goenjian and colleagues (1995) similarly reported

that 61.5% of children met PTSD criteria after the 1988 Armenian earthquake. However,

Shannon et al. (1994) reported that approximately 5% of the 5,687 children exposed to Hurricane

Hugo met criteria for PTSD. Garrison et al. (1993) similarly reported that 3% of males and 9%

of females aged 12 to 17 met PTSD criteria following Hurricane Andrew in Florida.

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A higher rate of PTSD was found in sexually assaulted youth (20.3%) as compared to physically assaulted youth (15.1%) according to Lawyer et al. (2006). Similarly, Famularo,

Fenton, and Kinscherff (1990) indicated that abused children or those exposed to severe

domestic violence developed PTSD at higher rates than children who had been physically

maltreated or suffered parental neglect. McLeer et al. (1994) also found higher rates of PTSD

among sexually abused children (42.3%) compared to non-sexually abused children (8.7%).

Finally, the DSM-5 (APA, 2013) reports that rates of PTSD vary amongst different groups. Rates

are said to be highest amongst war veterans and those in professions with an increased risk of

traumatic exposure (e.g., “police, firefighters, emergency medical personnel”) (APA, 2013, p.

276). Survivors of rape, military combat and captivity, and genocide have some of the highest

reported rates (APA, 2013).

Relationship Between Victims and Perpetrators. McLeer and colleagues (1988)

indicated higher rates of PTSD in youth who were abused by their natural fathers (75%). Later

McLeer et al. (1994) reported that 25% of children abused by a trusted adult and 10% of those

abused by a stranger developed PTSD while none of the children abused by an older peer met

criteria. Lawyer et al. (2006) also found that PTSD prevalence differed as a function of the

victim-perpetrator relationship such that 27% of children who were sexually assaulted by

recognized non-acquaintances, 25.9% by acquaintances, 11.6% by family members, and 2.8% by

strangers developed PTSD. Regarding physically abused children in this study, 18.7% developed

PTSD after assault from recognized non-acquaintances, 17.8% from family members, and 16.5%

from acquaintances. In contrast, Ackerman et al. (1998) found the relationships between the

child and perpetrator were not significantly related to a positive PTSD diagnosis in sexually

abused children.

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Time Interval Between Trauma Exposure and Diagnostic Evaluation. The studies reviewed assessed for PTSD at discordant time intervals following exposure to trauma. This resulted in variance of observed prevalence rates, typically with a decreased prevalence of PTSD following longer time intervals between stress exposure and assessment. For example, Pynoos and colleagues (1987) indicated that 1 month following exposure to a school shooting 60.4% of youth presented with PTSD, as compared to 29% 14 months later. In a similar vein, Sack et al.

(1993) also reported decreasing rates of PTSD with the variable of time, such that 50%, 48%, and 38% of Cambodian youth met criteria for PTSD 5, 8, and 11 years after a traumatic event.

Vila et al. (1999) reported a decrease from 15.4% to 3.8% in youth who were victims of a school shooting 2 to 18 months after the event.

In contrast, Landolt and colleagues (2005) reported a slight increase in PTSD prevalence from approximately 1 month (16.2%) to 12 months (17.6%) following a motor vehicle accident.

McLeer et al. (1988) observed no relationship between time lapsed since the last abusive episode and the development of PTSD. Khamis (2008) indicated that 29.9% of his sample of disabled

Palestinian adolescents had delayed onset PTSD that occurred more than 6 months after the trauma. However, in Yule’s (2000) sample of survivors of a ship accident, the majority (90%) who were diagnosed with PTSD developed the disorder within six months of the disaster.

Chapter Summary

It is clear from the substantial amount of literature presented in this chapter that children and adolescents are frequently exposed to trauma through a variety of pathways and events, summarized in Tables 2.1 - 2.3. Fortunately, the majority of youth will not go on to develop

PTSD following exposure to a traumatic event (Alisic et al., 2014; Saigh, 1992). An overview of studies regarding war-related traumas leading to PTSD (Table 2.1) in this chapter indicates

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prevalence rates ranged from 4.9% to 94%. Regarding criminal victimization, PTSD prevalence

rates ranged from 3.8% to 72.7%. (Table 2.2), while natural disasters and accident studies

yielded prevalence that ranged from 0% to 90% (Table 2.3).

The variation in prevalence rates may be accounted for by a number of factors such as the

myriad of assessment measures used, age and gender of the samples, type and intensity of

stressors, time interval between the trauma and assessment, along with the changing PTSD

criteria over time with the publication of updated versions of the DSM. Specifically, studies that

utilized DSM-III (APA, 1980), DSM-III-R (APA, 1987a), and DSM-IV (APA, 1994) PTSD

criteria were all reviewed, which may have contributed to the variation.

The different measures used to diagnose PTSD must be given special attention, as the

instruments ranged from non-structured interviews, structured interviews, parent ratings, to self-

reports, for example. Naturally, psychometric properties vary greatly amongst different

instruments and thus, reliability and validity also varied. Spitalny (2004) indicated that the PTSD

Reaction Index (Frederick et al., 1992; Pynoos et al., 1987; Rodriguez et al., 1999) is one of the

most commonly used instruments in PTSD research with children. Spitalny reported that the

measure has undergone thorough examination for reliability and validity, specifically yielding a

high correlation with clinical diagnosis. However, the Reaction Index (Frederick et al., 1992;

Pynoos et al., 1987; Rodriguez et al., 1999) does not cover all of the DSM-IV (APA, 1994)

symptoms, nor does it allow a DSM diagnosis to be made. Instead, it provides users with a probable PTSD diagnosis or levels of PTSD severity. It also does not explicitly measure

functional impairment. Consequently, it is possible that studies utilizing the Reaction Index (e.g.

Bayer et al., 2007; Nader et al., 1990; Schwarzwald et al., 1993; Solomon & Lavi, 2005; Thabet

et al., 2014) may have inflated rates of PTSD.

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The literature reviewed indicates that children with PTSD often have comorbid

diagnoses. Depression, anxiety, ADHD, and externalizing behavior disorders commonly co-

occur. Comorbid diagnoses may confound the results of individual studies and make it difficult

to compare results across studies. As Saigh and Bremner (1991) indicated, more research is

needed regarding which disorders appear with child-adolescent PTSD and, more specifically,

how comorbid disorders affect the development and presentation of PTSD.

Finally, the risk factors of gender, age, race/ethnicity, parental psychopathology, child

characteristics, multiple exposure to traumatic stress, intensity of exposure to traumatic stress,

duration and frequency of exposure, type and mode of stressor, relationship between victims and perpetrators, and time interval between exposure and diagnostic event were all reviewed. The

majority of these studies, 19 in total, indicated that being female is a risk factor for PTSD and

that females had higher rates of PTSD (Allwood et al., 2008; Breslau et al., 1991; Cuffe et al.,

1993; D’Augelli et al., 2006; Domanskaité-Gota, Elklit, & Christiansen, 2009; Eytan et al., 2004;

Fitzpatrick & Boldizar, 1993; Garrison et al., 1993; Hsu et al., 2002; Kessler et al., 1995; Schall

& Elbert, 2006; Stein et al., 1997; van Ameringen et al., 2008; Pat-Horenczyk et al., 2007;

Perkonigg et al., 2000; Thabet et al., 2014; Wei et al., 2013; Yang et al. 2011; Ziaaddini et al.,

2009). However, two studies found higher rates of PTSD in males (Khamis, 2005; Pfeiffer &

Elbert, 2011). Importantly, 17 different studies that examined gender did not report significant

effects (Ackerman et al., 1998; Ahmad et al., 2000; Allwood et al., 2002; Elbedour et al., 2007;

Foster et al., 2004; Goenjian et al., 1995; Hubbard et al., 1995; Klasen et al., 2010; Saigh, 1988a;

Saigh et al., 1995, 1997; Schwarz & Kowalski, 1991; Schwarzwald et al., 1993; Seedat et al.,

2004; Silva et al., 2000; Yorbik et al., 2004; Zink & McCain, 2003).

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Nine studies indicated that adolescents or older children had a greater likelihood of developing PTSD (Ahmad et al., 2000; Eytan et al., 2004; Garrison et al., 1995, Kadak et al.,

2013; Klasen et al., 2010; Schall & Elbert, 2006; Schwarz & Kowalski, 1991; Wolfe et al., 1994;

Yorbik et al., 2004), while two studies indicated that younger individuals were more likely to develop PTSD (Bokszczanin, 2007; Schwarzwald et al., 1993). It is important to note that some studies did not indicate any age differences regarding PTSD prevalence rates (e.g. Landolt et al.,

2005; Wei et al., 2013; Yang et al., 2011).

There were inconsistencies regarding race/ethnicity as a risk factor (e.g. Beals et al.,

2002; Kessler et al., 1995; Perilla et al., 2002; Shannon et al., 1994). All of the studies examining the relationship between parental psychopathology and child PTSD consistently indicated the former was a risk factor of the latter (e.g. Sack et al., 1993; Tiet et al., 1998). Regarding child characteristics, baseline ratings of anxiety and prior mental health problems was found to be a significant predictor of PTSD (Kadak et al., 2013; Silva et al., 2000). Exposure to multiple traumas, along with the duration and intensity of trauma appear to be risk factors (e.g. Ackerman et al., 1998; Pfefferbaum, 1997; Thabet & Vostanis, 1999; Yang et al., 2011).

Overall, there is a plurality of epidemiological research regarding child and adolescent

PTSD rates. Obtaining precise estimates of exact prevalence rates is an ongoing challenge, especially with the provision of the DSM-5 (APA, 2013). Thus, there is a need for future research to closely analyze the complex associations between risk factors, traumatic stress exposure, the diagnosis of PTSD, and comorbid disorders.

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CHAPTER III

Methodology

Depression and PTSD

The DSM-IV (APA, 1994) and DSM-5 (APA, 2013) indicate that possible symptoms of posttraumatic stress disorder (PTSD) include problems with concentration, negative belief systems, guilty feelings, decreased interest in significant activities, and an inability to experience positive emotions such as happiness. These symptoms overlap with some of the criteria for major depressive disorder (MDD) in both manuals, including deficits in concentration, guilty feelings, and decreased interest or pleasure in significant activities. Furthermore, feelings of irritability and functional impairment are reflected by the criteria for both disorders in the DSM-IV (APA,

1994) and DSM-5 (APA, 2013). As previously discussed in Chapter II, high rates of comorbidity between PTSD and depressive disorders in youth have been reported, ranging between 13.8% and 85% (e.g. Hubbard et al., 1995; Kilpatrick et al., 2003; Kinzie et al., 1986; McLeer et al.,

1998; Pfeiffer & Elbert, 2011; Sack et al. 1993; Vila et al., 1999; Ying et al., 2012).

To date, few studies have investigated the role of depression among children and adolescents with PTSD while controlling for the possible influence of major comorbid disorders such as attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD). The present chapter presents a rationale for an investigation that seeks to determine if traumatized youth with and without PTSD and a non-traumatized control group differ on the Children’s Depression

Inventory (CDI; Kovacs, 1992) while controlling for major comorbid disorders. The investigation also seeks to establish if the CDI scores of traumatized children without PTSD differ from the scores of non-traumatized controls. The chapter includes background information regarding self-reported depression as a symptom of PTSD, a statement of the problem, the

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purpose of the study, hypothesis, methodology, anticipated data analysis procedures, and possible limitations.

Background Information

Associations between depressive symptoms and PTSD in youth have been observed

using a variety measures and research designs. Examined within this context, Saigh (1987a) used

in vitro flooding to treat a 14-year-old Lebanese male with PTSD referred by his principal after a

Lebanese militia abducted him for 48 hours. Four traumatic scenes were identified and stimulus-

response cues were presented while the patient rated his distress using a single-case multiple baseline design. The patient’s Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock,

& Erbaugh, 1981) scores decreased by 11.68% after the treatment concluded and by 12.88% at

follow-up. The results suggest that the in vitro flooding procedures had a positive influence on

the PTSD patient’s self-reported levels of depression. In related subsequent treatment studies

involving children and adolescents with PTSD, Saigh (1987b, 1987c) used the Children’s

Depression Inventory (CDI; Kovacs, 1981) as an outcome measure. In both studies, Saigh

reported clinically significant reductions in depression as reflected by the CDI following the use

of in vitro flooding.

The CDI was also used in a series of case-control studies (Armenian, 2009) that

examined the differential validity of the PTSD classification (Saigh, 1988b; 1989a; 1989b). For

example, Saigh (1988b) studied 13-year-old adolescents who met DSM-III (APA, 1980) criteria

for PTSD as measured by the Children’s PTSD Inventory (Saigh, 1987d), a second group who

met DSM-III (APA, 1980) criteria for simple phobia (e.g. test phobia), and a third group of

nonclinical controls. His results indicated that the PTSD group evidenced significantly higher

levels of depression on the CDI relative to their counterparts. Saigh (1989a) reported similar

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results with case-control investigations involving youth aged 9 to 12 years and with children aged 6 to 8 years (Saigh, 1989b).

In a study that explored the different expressions and antecedents of PTSD, Saigh (1991) identified 230 Lebanese children with PTSD using the Children’s PTSD Inventory (Saigh,

1989c). Of these cases, 58 had been traumatized through direct experiences, 128 through observation, 13 through verbal mediation, and 31 by combinations thereof. In addition, 35 nonclinical controls were identified. Results indicated that youth with PTSD had significantly greater CDI scores than the control group. Saigh (1991) also reported that the CDI scores of the various PTSD groups did not significantly differ.

McLeer et al. (1992; 1998) also compared trauma-exposed youth with and without PTSD as measured by the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age

Children – Epidemiologic Version (K-SADS-E; Orvaschel et al., 1982) and a semi-structured

DSM-III-R (APA, 1987) interview. Using the CDI, the results indicated that the PTSD group had higher depression scores. On the other hand, the differences were not statistically significant.

Analogously, Wolfe, Sas, and Wekerle (1994) compared 90 sexually abused youth with and without PTSD as measured by an author developed DSM-III-R (APA, 1987a) PTSD checklist.

The authors reported that the PTSD group had statistically significantly higher depression scores on the CDI as compared to PTSD negatives.

Goenjian and colleagues (2001) administered the Depression Self Rating Scale (DSRS;

Asarnow & Carlson, 1985) and the Children’s PTSD Reaction Index (CPTSD-RI; Pynoos et al.,

1987) to 158 Nicaraguan adolescents 6 months after a hurricane. Interestingly, the strongest predictor of depression in the sample was a PTSD diagnosis. The authors hypothesized that

PTSD was associated with the depression scores because the adolescents had severe hurricane

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exposures and had suffered loss and experienced adversity.

In a similar vein, Saigh, Yasik, Oberfield, Halamandaris, and McHugh (2002) assessed traumatized youth with PTSD, traumatized youth without PTSD (PTSD negatives), and nonclinical controls using the Child Behavior Checklist (CBCL; Achenbach, 1991a) and the

Children’s PTSD Inventory (Saigh, 1998). Results indicated that the mean Internalizing scores of the PTSD group were significantly higher than the means of the traumatized PTSD negatives and controls. Of particular interest to this dissertation was the finding that the PTSD group evidenced significantly higher CBCL Anxious/Depressed, Somatic Complaints, and Withdrawn ratings relative to the comparison groups. It is also important to note that the CBCL scores of the traumatized PTSD negatives and the control groups did not differ significantly.

Ying, Wu, and Lin (2012) also conducted a study involving 200 Chinese adolescent earthquake survivors using the Center for Epidemiologic Studies Depression Scale for Children

(CES-DC; Fendrich, Weissman, & Warner, 1990), which measured depressive symptoms or levels of depression, and the Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, &

Treadwell, 2001). The authors reported that even after controlling for overlapping DSM-IV

(APA, 1994) criteria for PTSD and major depressive disorder, the association between depressive symptoms and PTSD remained strong. Overall, the authors reported that depression symptoms were crucial in the expression of PTSD. Lastly, Kadak et al. (2013) assessed 738

Turkish adolescents 6 months after an earthquake. Using the Child Posttraumatic Stress

Reactions Index (CPTS-RI; Pynoos et al., 1987), the researchers reported a positive correlation between self-reported depression on the CDI and PTSD.

Statement of the Problem

The aforementioned investigations indicate that the CDI and similar self-reported indices

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of depression are sensitive to the expression of PTSD following traumatic experiences. However, a variety of methodological and conceptual issues are apparent.

First, the majority of investigations reviewed in this chapter (Goenjian et al., 2001;

Kadak, 2013; McLeer, 1992; Saigh, 1987a; 1987b; 1987c; Wolfe, 1994; Ying et al., 2012) did not include a control group and therefore could not specify if traumatized youth without PTSD were at risk for depression. As indicated in Chapter II, most youth exposed to trauma do not develop PTSD (Breslau et al., 2004; Giaconia et al., 1995; Kessler et al., 1995; Saigh, 1992).

Theoretically it is possible that the trauma-exposed youth in the studies reviewed in this chapter may have had elevated levels of depression in the absence of a PTSD diagnosis. The absence of a non-traumatized control group leaves this question unanswered.

Second, the CDI is a multi-component test (Kovacs, 1992) and all the investigations

reviewed in this chapter only reported CDI total scores. This is a significant omission as the CDI

has five additional subscales that denote different components of depression. Finally, none of the

studies (Goenjian et al., 2001; Kadak, 2013; McLeer, 1992; 1998; Saigh, 1987a; 1987b; 1987c;

1988b; 1989a; 1989b; 1991; Wolfe, 1994; Ying et al., 2012), with the exception of Saigh et al.

(2002), controlled for the potentially confounding effects of comorbid disorders. This possible

confound is especially notable as depressive disorders frequently occur concurrently with PTSD

(Breslau et al., 1991; Kessler et al., 1995; Kilpatrick et al. 2003) and as ADHD, CD, and

substance dependence have been associated with elevated levels of depression (Haley, Fine,

Marriage, Moretti, & Freeman, 1985; Karustis, Power, Rescorla, Eiraldi, & Gallagher, 2000;

Lobovits & Handal, 1985; McCauley, Burkey, Mitchell, & Moss, 1988; Smith, Mitchell,

McCauley, & Calderon, 1990). Thus, it is unclear whether the elevated CDI scores that were

reported were associated PTSD or a combination of PTSD and comorbid disorders.

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Purpose of the Study

The proposed study seeks to: a) identify traumatized youth with and without PTSD and a

non-traumatized control group, b) exclude cases with major comorbid disorders (i.e., ADHD,

CD, MDD, and substance dependence), and c) compare the CDI scores of the three groups.

Need for the Study

Analyzing empirical data regarding self-reported depression in traumatized youth with and without a diagnosis of PTSD compared to a control group may offer a number of theoretical and clinical contributions by elucidating the expression of the disorder.

Theoretical Significance

The present investigation may help determine if self-reported symptoms of depression vary between traumatized youth with and without PTSD, clarifying whether depression is associated with traumatic stress in the absence of PTSD or PTSD. The anticipated outcomes may lend support for the DSM-5 (APA, 2013) contention that youth above the age 6 years who present with PTSD have “persistent and exaggerated negative beliefs or expectations about oneself, others, or the world,” “persistent negative emotional state,” “markedly diminished interest or participation in significant activities,” and “persistent inability to experience positive emotions” (APA, 2013, p. 271). The results may also lend empirical support for the use of the

CDI scale scores as pre and post treatment measures for PTSD intervention studies.

As noted above, none of the aforementioned studies that were considered in this chapter, except the Saigh et al. (2002) investigation, controlled for the potentially confounding effects of comorbid disorders (e.g. ADHD and MDD), which have been associated with elevated levels of self-reported depression. Accordingly, the exclusion of youth with these disorders will provide a more accurate index of depression following trauma exposure.

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Finally, the use of a non-traumatized comparison group will allow the investigator to establish if trauma exposure without PTSD is associated with increased depression. This information could offer an important contribution to our understanding of the adjustment of a large segment of the child population who are traumatized and do not develop PTSD.

Clinical Significance

Participants received several clinical benefits through participation in this study. The participants in this study were given free psychiatric and psychological evaluations that included

an IQ test, assessment of psychiatric morbidity, and rating scales from both the participant and

guardian assessing affective and behavioral functioning. The evaluations were coupled with a

comprehensive report provided to the guardians. When deemed appropriate, referral information

for mental health services was offered. As such, the comprehensive reports and referrals may

have provided a pathway for appropriate treatment to those in need, potentially offsetting some

of the negative impacts associated with various mental disorders including PTSD. The specific

CDI results may then have been used to plan age-appropriate treatments targeting depressive

symptoms in children and adolescents.

Rationale and Hypotheses

Rational for Hypotheses 1-12

It is expected that in the absence of major comorbid disorders, including MDD,

traumatized youth with PTSD will evidence significantly higher levels of depression, via self-

reported CDI scores, as compared to traumatized youth without PTSD and nonclinical controls.

This supposition is based on previous research indicating that youth with PTSD evidence higher

levels of depression relative to traumatized youth without PTSD (McLeer et al., 1992; Saigh et

al., 2002; Wolfe et al., 1994) and non-traumatized controls (McLeer et al., 1998; Saigh 1988b;

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1989a; 1989b). The outcomes from treatment studies citing reductions in CDI scores following treatment for PTSD provide further evidence for expected outcomes (Saigh, 1987a, 1987b,

1987c, 1989a). Specifically, the following hypotheses were tested:

Hypotheses 1-12.

Ho1: The CDI Total scores of traumatized youth with PTSD will be significantly higher

than the scores of traumatized youth without PTSD.

Ho2: The CDI Negative Mood scores of traumatized youth with PTSD will be

significantly higher than the scores of traumatized youth without PTSD.

Ho3: The CDI Interpersonal Problems scores of traumatized youth with PTSD will be

significantly higher than the scores of traumatized youth without PTSD.

Ho4: The CDI Ineffectiveness scores of traumatized youth with PTSD will be

significantly higher than the scores of traumatized youth without PTSD.

Ho5: The CDI Anehdonia scores of traumatized youth with PTSD will be significantly

higher than the scores of traumatized youth without PTSD.

Ho6: The CDI Negative Self Esteem scores of traumatized youth with PTSD will be

significantly higher than the scores of traumatized youth without PTSD.

Ho7: The CDI Total scores of traumatized youth with PTSD will be significantly higher

than the scores of nonclinical controls.

Ho8: The CDI Negative Mood scores of traumatized youth with PTSD will be

significantly higher than the scores of nonclinical controls.

Ho9: The CDI Interpersonal Problems scores of traumatized youth with PTSD will be

significantly higher than the scores of nonclinical controls.

Ho10: The CDI Ineffectiveness scores of traumatized youth with PTSD will be

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significantly higher than the scores of nonclinical controls.

Ho11: The CDI Anehdonia scores of traumatized youth with PTSD will be significantly

higher than the scores of nonclinical controls.

Ho12: The CDI Negative Self Esteem scores of traumatized youth with PTSD will be

significantly higher than the scores of nonclinical controls.

Rationale for Hypotheses 13-18

It is hypothesized that the CDI depression ratings of traumatized youth without PTSD will not significantly differ from those of nonclinical controls based on previous literature comparing these groups (Saigh 1988b; 1989a; 1989b; Saigh et al., 2002).

Hypotheses 13-18

Ho13: The CDI Total scores of traumatized youth without PTSD and the non-traumatized

controls will not significantly differ.

Ho14: The CDI Negative Mood scores of traumatized youth without PTSD and the non-

traumatized controls will not significantly differ.

Ho15: The CDI Interpersonal Problems scores of traumatized youth without PTSD and

the non-traumatized controls will not significantly differ.

Ho16: The CDI Ineffectiveness scores of traumatized youth without PTSD and the non-

traumatized controls will not significantly differ.

Ho17: The CDI Anehdonia scores of traumatized youth without PTSD and the non-

traumatized controls will not significantly differ.

Ho18: The CDI Negative Self Esteem scores of traumatized youth without PTSD and the

non-traumatized controls will not significantly differ.

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In sum, across all of the subscales it is anticipated that elevated ratings will be associated with PTSD and not trauma exposure without the diagnosis. In addition, elevated ratings of depression are anticipated across all of the subscales comprising the CDI.

Methodology Recruitment Process

The proposed study will be based on a preexisting data set collected by Philip A. Saigh,

Ph.D, at Bellevue Hospital Center in New York City. In order to recruit youth exposed to traumatic events, practitioners from Bellevue Hospital Center were informed of the study following official Institutional Review Board (IRB) approval. Practitioners referred youth who reportedly experienced, witnessed, or were confronted with an event that involved actual or threatened death or serious injury, a threat to their personal integrity or the physical integrity of others in accordance with the definition of a traumatic event defined by the DSM-IV (APA,

1994) PTSD criteria. At the same time, practitioners in the Department of Pediatrics were asked to refer youth without a history of trauma who were receiving routine outpatient medical services.

Inclusion Criteria

English-speaking youth between the ages of 7 and 18 years were included in this study.

Four different examiners including a child psychiatrist, a licensed child psychologist, and two advanced doctoral-level psychology graduate students independently conducted DSM-IV (APA,

1994) diagnostic assessments with each potential participant to determine overall diagnostic status. Specifically, each of the participants received two independent DSM-IV (APA, 1994) based clinical interviews for PTSD and MDD from the psychiatrist and psychologist, along with two independent administrations of the Children’s PTSD Inventory (Saigh, 2003a) by the doctoral students. A traumatized PTSD negative case was included upon four independent

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negative PTSD diagnoses. In addition, the participants for both the PTSD negative and positive

1 groups must have endorsed DSM-IV-TR (APA, 2000) A1 trauma exposure on the Children’s

PTSD Inventory (Saigh, 2003a). PTSD positive cases were included based on four concordant

and independent PTSD diagnostic assessments. Finally, non-traumatized controls were included

upon four concordant and independent negative PTSD diagnostic assessments in addition to a

negative endorsement of trauma exposure.

Exclusion Criteria

Children with a history of abuse or neglect by a parent or guardian were excluded as they may experience ongoing distress through court proceedings and/or foster care placements

(McLeer et al., 1994; Merry & Andrews, 1994; Zona & Milan, 2011). Accordingly, youth who were engaged in ongoing court proceedings were also excluded. However, youth abused by an individual other than a parent or guardians were included. Abuse or neglect was defined by the

New York State Family Court Act, Article 10, Section 1012 (1970), indicating it is a felony for a

“parent or guardian or other persons legally responsible for a child’s care to inflict or allow to be inflicted on a child physical injury … which causes or creates a substantial risk of death, or serious or protracted disfigurement, or protracted impairment of physical or emotional health or

… commits or allows to be committed, a sex offense against such a child” (p. 300).

Youth receiving medication that could influence cognitive functioning and children with a history of head trauma, assessed by a child psychiatrist, were excluded, as were youth unable to speak or understand English. Individuals with Wechsler Intelligence Scale for Children - Third

Edition (WISC-III; Wechsler, 1991) Full Scale IQs of 69 or lower were excluded as previous

1 DSM-IV-TR Criterion A1 specifies that during exposure to a traumatic event, “1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” and “2) the person’s response involved intense fear, helplessness, or horror” (APA, 2000, p. 467).

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research using the Children’s PTSD Inventory (Saigh, 2003a) concluded that cases with IQs at

69 or below had difficulty understanding test questions and verbalizing responses (Saigh,

2003b). Lastly, children who met DSM-IV (APA, 1994) diagnostic criteria for MDD, ADHD,

CD, or substance dependence as assessed by the Diagnostic Interview for Children and

Adolescents – Revised (DICA-R; Reich, Leacock, & Shanfeld, 1995) were excluded.

Sample

The participants were drawn from a study approved by the Bellevue Hospital Center IRB,

the Graduate School of the City University of New York IRB, and the Teachers College IRB.

This study used the same procedures and assessed some of the child participants described in a

series of case-control studies that used different dependent variables to examine the differential

validity of the DSM-IV (APA, 1994) PTSD classification (Saigh et al., 2002; Saigh et al., 2006;

Saigh et al., 2007; Saigh, Yasik, Oberfield, & Halamandaris, 2008; Yasik, Saigh, Oberfield, &

Halamandaris, 2007; Yasik et al., 2012).

Initially, 228 youth who had experienced trauma were referred and 69% (n = 157) of parents or guardians provided consent. Thirty-two percent (n = 50) of the consenting cases were

excluded due to head injury (n = 24), a WISC-III (Wechsler, 1991) IQ score at or below 69 (n =

16), difficulties understanding English (n = 8), and a history of child abuse or neglect by the parent or guardian (n = 2). One participant did not complete the entire research protocol and was

excluded. Regarding the remaining 106 potential participants, 35% (n = 37) met PTSD criteria

while 65% (n = 69) did not meet criteria. Nine cases within the PTSD group were excluded because they met criteria for a comorbid disorder using the DICA-R (Reich, Leacock, &

Shanfeld, 1995), namely eight for MDD and one for substance dependence. Five cases from the

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traumatized PTSD negative group were excluded as two met criteria for MDD, two for CD, and one for ADHD.

Clinicians from Bellevue Hospital Center referred 280 potential individuals to participate in the control group and consent was obtained for 28% (n = 78). Five cases were assigned to the traumatized participant pool after reporting that they experienced a traumatic event consistent with the DSM-IV (APA, 1994) PTSD definition. Forty-one percent (n = 32) of the cases were excluded due to difficulty understanding English (n = 15), current psychopharmacological

treatment that could influence cognitive functioning (n = 8), WISC-III (Wechsler, 1991) scores

at or below 69 (n = 7), and head injury (n = 2). After accounting for the exclusion criteria, the

final sample consisted of 133 participants composed of 28 PTSD positives, 64 traumatized PTSD

negatives, and 41 non-traumatized controls. The age range for participants was 7.08 to 18.42

years (M = 13.21, SD = 2.82). Overall, 75 males and 58 females participated 78 of whom

identified as Hispanic, 27 as African American, 18 as Caucasian, 9 as Asian, and 1 as Other.

Within the PTSD positive group, 42.9% endorsed exposure to a single traumatic event, another

42.9% endorsed exposure to two traumatic events, while 14.3% endorsed exposure to three or

more traumatic events. Of the events reported by participants, 25% (n = 7) endorsed physical assault, 21.4% (n = 6) sexual assault, 17.9% (n = 5) being shot, 14.3% (n = 4) motor vehicle accident, 7.1% (n = 2) smoke inhalation, 3.6% (n = 1) dog attack, 3.6% (n = 1) hand or foot injury, 3.6% (n = 1) witnessing a trauma, and 3.6% (n = 1) responded with “other.” Regarding the PTSD negative group, 75% endorsed exposure to a single traumatic event, 18.8% endorsed exposure to two traumatic events, and finally 6.3% endorsed exposure to three or more traumatic events. Specifically, 25% (n = 16) endorsed having experienced a motor vehicle accident, 21.9%

(n = 14) physical abuse, 20.3% (n = 13) hand or foot injury, 9.4% (n = 6) dog attack, 7.8% (n =

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5) being shot, 7.8% (n = 5) responded with “other,” 4.7% (n = 3) witnessing a trauma, and 3.1%

(n = 2) smoke inhalation.

Diagnostic Measures

Children’s PTSD Inventory (Saigh, 2003a)

The Children’s PTSD Inventory is a structured clinician-administered scale for individuals between 6 and 18 years of age that reflects DSM-IV (APA, 1994) criteria for PTSD.

It is considered a valid measure to derive diagnoses in youth when compared to clinical interviews and structured administrations of the PTSD modules from the Structured Clinical

Interview for DSM-IV (SCID; First, Gibbon, Williams, & Spitzer, 1996) and the DICA-R (Reich et al., 1995). At the diagnostic level, there is an internal consistency alpha of .95 (Saigh, 2003a).

A 98.0% level of diagnostic inter-rater reliability was indicated and the inter-rater intra-class correlation coefficient (ICC) was determined to be .98. The inter-rater reliability kappa was

reported as .96 at the diagnostic level. An agreement of 97.6% for diagnostic test-retest

reliability was observed, as were .91 and .90 in terms of test-retest kappa and ICC at the

diagnostic level, respectively. Using clinical diagnoses and diagnoses that were derived through

administrations of the Structured Clinical Interview for the DSM–IV (SCID; First, Gibbon,

Williams, & Spitzer, 1996) PTSD module, Yasik et al. (2001) reported moderate to high levels

of sensitivity (.91–1.00), specificity (.90–.97), positive (.68–.94) and negative (.95–1.00) predictive power, and diagnostic efficiency (.92–.95).

Diagnostic Interview for Children and Adolescents-Revised (DICA-R; Reich, Leacock, &

Shanfeld, 1995)

All participants were administered select modules from the DICA-R, a DSM-IV (APA,

1994) based semi-structured interview, including ADHD, CD, MDD, substance dependence, and

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psychotic symptoms by a trained examiner. Test-retest kappa coefficients for the various modules ranged from .32-.59 for ADHD, .92 for the CD, .32-.59 for MDD, .66-1.00 for substance dependence, and .76 for psychotic symptoms (Reich et al., 2000). Reich (personal communication to Professor Philip A. Saigh, February 5, 2001) indicated sensitivity coefficients of .85, .92, .82, 1.00, and 1.00 for ADHD, CD, MDD, substance dependence, and psychotic symptoms modules, respectively. Regarding specificity coefficients, .73, .71, .72, .80, and .72 were reported for theses respective modules.

DSM-IV Clinical Interviews

One of two experts, a board-certified child psychiatrist and a licensed child psychologist, administered two independent clinical interviews to each participant to determine if the participant met DSM-IV (APA, 1994) criteria for PTSD. The examiners utilized the DSM-IV

(APA, 1994) criteria during the diagnostic evaluations. Diagnostic agreement of PTSD occurred in 129 of 132 cases (kappa = .94) using the unstructured DSM-IV (APA, 1994) interview.

Agreement on 125 of the 132 cases was evidenced between clinician-derived diagnoses and those derived from the Children’s PTSD Inventory (Saigh, 2003a) resulting in a kappa of .86.

When diagnostic discordance occurred, case conferences were held to discuss the reported diagnostic symptoms and final diagnostic decisions were reached with full consent, resulting in inclusion of all seven discrepant cases.

Dependent Measure

Children’s Depression Inventory (CDI; Kovacs, 1992).

This 27-item self-report inventory measures symptoms of depression for school-aged children and adolescents, aged 7 to 17 years. It quantifies a range of depressive symptoms including disturbed mood, hedonic capacity, vegetative functions, self-evaluation, and

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interpersonal behaviors. Each item consists of three choices (keyed 0, 1, or 2) denoting absence of symptom, mild symptom, or definite symptom, with higher scores indicating increasing severity, ranging from 0 to 54. The Total score is composed of five factors, including Negative

Mood, Interpersonal Problems, Ineffectiveness, Anhedonia, and Negative Self Esteem. The measure is standardized by age and gender, which are both automatically accounted for in the norms for the CDI.

The five CDI factors are moderately correlated, between .34 -.59, while they correlated between .55-.82 with the CDI Total score. Amongst the five factors, the Interpersonal Problems subscale had the weakest correlation with the CDI Total score, .55. The reliability coefficients of the CDI Total score ranged from .71-.89, indicating good internal consistency of the instrument.

Kovacs (1985) found the total score coefficient alpha to be .86 for a heterogeneous psychiatric referred sample of children, .71 for a pediatric-medical outpatient group, and .87 for a large sample of public school children (N=860). Cronbach’s alpha for the five factors ranged from

.59-.68, which are acceptable for short factor subscales (Kovacs, 1985). Specifically, Cronbach’s alpha ranged from .62-.65 for Negative Mood, .59-.60 for Interpersonal Problems, .59-.63 for

Ineffectiveness, .64-.66 for Anhedonia, and .66-.68 for Negative Self Esteem.

Regarding discriminant validity, the CDI Total scores did not significantly differ between groups of children with major depressive disorder, dysthymic disorder, and adjustment disorder with depressed mood. Because major depressive and dysthymic disorders are phenomenologically similar, the lack of a between-group CDI difference is not surprising

(Kovacs, 1992). It is important to note that the validity of dysthymic disorder has been in question for some time (Blanco et al., 2010; Klein, Schwartz, Rose, & Leader, 2000; Rhebergen

& Graham, 2013), and accordingly it was removed as a disorder in the DSM-5 (APA, 2013). The

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CDI was found to distinguish nonclinical participants from clinical participants (Carey et al.,

1987; Saylor, Finch, Spirito, & Bennett, 1984). Furthermore, studies have found depressed psychiatric patients score significantly higher than non-depressed psychiatric patients on the CDI

(Haley, Fine, Marriage, Moretti, & Freeman, 1985; Lobovits & Handal, 1985; McCauley,

Burkey, Mitchell, & Moss, 1988).

Smith, Mitchell, McCauley, and Calderon (1990) reported good discriminant validity for

the CDI that was administered to 228 adolescent clinic patients aged 10 to 17 years. Specifically,

the results of a discriminant analysis also showed the CDI to be the single best discriminator of

diagnostic category between anxiety, major depression, bulimia or anorexia nervosa, conduct

disorder, academic or parent-child problems, and adjustment disorders. The first canonical

discriminant function explained 95% of the variability. Furthermore they indicated that using the

CDI, patients with only a psychiatric diagnosis and those with a combined medical/psychiatric

diagnosis had higher scores than those with only a medical diagnosis.

Hodges (1990) assessed the validity of the CDI on 70 psychiatric inpatient youth, aged 6

to 13 years and reported evidence in support of the convergent and discriminant validity of the

CDI. The intercorrelations between the CDI and RCMAS (Reynolds & Richmond, 1985) were

.70. Depressed children were found to score significantly higher than non-depressed children on

the CDI and the difference between the two groups was large. Furthermore, neither conduct-

disordered nor anxiety-disordered children scored significantly higher on the CDI than children

without these specific diagnoses.

Finally, Ivarsson et al. (2006) studied the validity of the CDI in two ways with 405

Swedish adolescents from four different schools, aged 13 to 16 years. A moderate correlation of

.40 was found between the CDI Total score with the Multidimensional Anxiety Scale for

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Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), thus indicating convergent validity for the CDI Total score. Some convergent validity was also found between the CDI sub-scales of Negative Mood, Anhedonia, and Negative Self Esteem with correlations of

.45, .35, and .34, respectively. The CDI was also found to be a good predictor of suicidal ideation, even when controlling for other known correlates of suicidal ideation like gender.

Lastly, elevated scores on the CDI were associated with “broken family,” which is a common correlate of depression in adolescence (Goddyer, Germany, Altham, & Gowrusankur, 1991;

Puig-Antich et al., 1993).

Assessment of Possible Intervening Variables

Severity of Psychosocial Stress Scale: Children and Adolescents (SPSS-CA; APA, 1987b)

This 6-point Likert-type scale assesses trauma severity, with 6 denoting the most intense stressor and 1 denoting absence of a significant stressor. “Breaking up with a boyfriend or girlfriend” is provided as an example of a 2, while “death of both parents” is provided as an example of a 6. The child psychiatrist and psychologist involved in this study independently read and rated all of the recorded stress-exposure responses from the Children’s PTSD Inventory

(Saigh, 2003a) using the SPSS-CA (APA, 1987b) resulting in a Pearson product movement correlation of .98 (p < .001). SPSS-CA (APA, 1987b) ratings were used to examine potential differences between traumatized youth with and without PTSD as various studies have shown that stressor severity is associated with increased psychiatric morbidity in children (Goenjian et al., 1995; 2001; Johnson et al., 2001; Hsu et al., 2002; Pynoos et al., 1993).

Hollingshead Four Factor Index of Social Adjustment (Hollingshead, 1975)

This measure contains questions regarding parental education, marital status, and occupations and assigns participants to one of four social class strata as an indication of

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socioeconomic status. Scores on the Hollingshead range between 8 and 66 points, such that, “the higher score of a family or nuclear unit, the higher status its members are accorded by other members of our society” (Hollingshead, 1975, p. 17). Class I represents the highest class and

Class IV representing the lowest class. Cirino and colleagues (2002) reported moderate (.73) to high (.95) inter-rate reliability coefficients. The highest coefficients were found in families with dual incomes (r = 0.95) and families with a sole male earner (r = 0.95), with slightly less reliability for families with sole female earners (r = 0.73). Convergent validity coefficients ranged from .42-.92 when scores were correlated with the Socioeconomic Index of Occupations

(Nakao & Treas, 1992), another SES measure. Cirino et al. (2002) also found correlations between IQ measures ranging from 0.22 to 0.47. Again, families with dual incomes had the highest coefficients while sole female earners had the lowest.

Examiners

A child psychiatrist and psychologist independently conducted a DSM-IV based (APA,

1994) unstructured evaluation in order to assess for PTSD and MDD. Doctoral-level school psychology students administered the Children’s PTSD Inventory (Saigh, 2003a), DICA-R

(Reich, Leacock, & Shanfeld, 1995), CDI (Kovacs, 1992), and the Hollingshead (1975) Four

Factor Index of Social Adjustment in a counterbalanced design in order to avoid an order effect.

Research Design

A three-group case-control design will be utilized consisting of traumatized youth with

PTSD (n = 28), a traumatized PTSD negative group (n = 63), and a non-traumatized control

group (n = 41). A case-control is design is ideal given the purpose of the study as it allows for a

comparison of a group with a condition to another group lacking the condition (Armenian, 2009).

The three experimental groups will serve as the independent variables and the CDI total scores,

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along with the corresponding five factor scores on the CDI (Kovacs, 1992), will represent the dependent variables. Cohen’s (1988) power analyses tables indicate that a minimum of 21 participants per cell is required to denote a large effect. Therefore, the current study will have satisfactory power to examine the aforementioned hypotheses. A visual representation of the research design is depicted in Figure 3.1.

Figure 3.1

Schematic Representation of Research Design

Non- Traumatized Children’s Depression Inventory PTSD Positives PTSD Negatives Control Group (CDI; Kovacs, 1992) (n = 28) (n = 64) (n = 41) CDI Total Score Negative Mood Interpersonal Problems Ineffectiveness Anhedonia Negative Self Esteem

Plans for Data Analysis

To test for possible significant differences with regard to gender, chi-square tests will be

conducted followed by an ANOVA to examine possible differences between the groups on

socioeconomic status using the Hollingshead Four Factor Index of Social Adjustment

(Hollingshead, 1975). Separate ANOVAs will also be used to test for significant age differences between groups and differences in stressor severity as measured by the SPSS-CA (APA, 1987b).

The CDI Total scores will be analyzed according to group using an ANCOVA to control for potential SES group differences. Because CDI standard scores in this analysis are standardized

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based on age and gender, these variables will not be included as covariates. Bonferroni post-hoc tests will be used to statistically identify significant comparisons. Furthermore, a separate

MANCOVA to control for SES will be conducted to assess for group differences across all of the dependent variables, the CDI total score and the five additional subscales that make up the CDI total score. If the MANCOVA is found to be significant at the alpha = .05 level then univariate

F-tests and Bonferroni post-hoc comparisons will be utilized to identify significant group

differences.

Limitations

There are certain limitations to the proposed research study that are important to note.

Possible outcomes must be tempered with the understanding that a relatively small sample will be examined and a conservative post hoc test will be used. It is also acknowledged that participant depression may have existed prior to trauma exposure. Moreover, participants with

major comorbid disorders were excluded and the external validity of the study will be limited to

individuals with similar demographic characteristics, trauma histories, and psychiatric backgrounds.

The proposed study involves a cross-sectional design and meaningful information regarding causality may be lost given that such studies offer a snapshot of a single moment in time. If significant results are found, it will be not be clear if PTSD induced depression or if the participants had high levels of depression before trauma exposure. Case control designs preclude randomization given the ex-post facto nature. Other investigators may wish to study the effects of trauma over time, which will not be possible given the methodology of the proposed study.

Self-report measures are useful with children as they may report information that is subjective and difficult for others to notice (Reynolds, 1994). However, Reynolds (1993) also

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indicated that self-report measures might be influenced by children’s impulse control, language skills, and experience with similar measures. Self-report measures are, at times, vulnerable to the influence of social desirability (Schaeffer, 2000).

Finally, it is important to note that the CDI was recently updated, (Kovacs, 2011). The results from the proposed study may not generalize to the revised instrument (Kovacs, 2011).

Furthermore, the outcomes from this investigation may not generalize to cases meeting the

DSM-5 (APA, 2013) criteria for PTSD, as the results from this study will be based on cases who met PTSD criteria as indicated in the DSM-IV (APA, 1994).

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CHAPTER IV

Results

Descriptive Data

This chapter presents information involving the demographic characteristics of the participants, the means and standard deviations for the comparison groups, and the statistical analyses. Table 4.1 presents a summary of the demographic background information for the participants.

Table 4.1

Demographic Variables

Traumatized PTSD Non-Traumatized Variable PTSD Negative Control Age (years) M 14.2 13.3 12.4 SD 2.9 2.9 2.5 Gender % % % Male 57.1 65.6 41.5 Female 42.9 34.4 58.5 Hollingshead % % % Social Class Class I 3.6 4.7 9.8 Class II 10.7 23.4 19.5 Class III 10.7 45.3 36.6 Class IV 46.4 18.8 24.4 Class V 28.6 7.8 9.8 Race/Ethnicity % % % African-American 10.7 28.1 14.6 Asian 3.6 12.5 0.0 Caucasian 7.1 17.2 12.2 Hispanic 78.6 42.2 70.7 Other 0.0 0.0 2.4

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A Chi-square test determined significant differences between the groups with regard to gender, χ2(2, N = 133) = 5.94, p < .05 and ethnicity, χ2(8, N = 133) = 19.80, p < .05. An ANOVA indicated that SES varied significantly across the three experimental groups, F(2, 130) = 6.93, p

< .01. Bonferroni post hoc analyses were used to determine significant group differences at the

alpha level of .017. This level was determined by dividing the original alpha of .05 by three, or

the number of comparison groups. The post hoc analyses indicated that the mean Hollingshead

SES ratings (Hollingshead, 1975) of the PTSD group were significantly lower than the ratings of

the traumatized PTSD negatives and controls. It was also determined that the traumatized PTSD

negative and control groups did not significantly differ. An ANOVA also identified significant

differences for age, F(2, 130) = 3.53, p = .03. Bonferroni post hoc tests indicated that the control

group was significantly younger than the PTSD group. All other age comparisons were non-

significant.

Descriptive Statistics for Traumatic Stressor Variables

Table 4.2 lists the type of traumatic events that were reported by the PTSD and traumatized

PTSD negative groups. The mean number of traumas reported by the PTSD group (M = 1.82, SD

= 0.98) was significantly greater than the mean number of traumas reported by the traumatized

PTSD negative group (M = 1.31, SD = 0.59), F(1, 90) = 9.49, p < .01. Among the PTSD group,

42.9% reported exposure to one traumatic event, 42.9% reported exposure to two, 7.1% to three,

3.6% to four, and finally 3.6% to five. In comparison, among the traumatized PTSD negative

group, 75.0% reported exposure to one traumatic event, 18.8% to two, and 6.3% to three.

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Table 4.2

Types of Traumas Reported by PTSD and Traumatized PTSD Negative Groups

Traumatized PTSD PTSDa Negativeb Stressor n % n % Sexual Assault 6 21.4 0 0.0 Physical Assault 7 25.0 14 21.9 Shot 5 17.9 5 7.8 Dog Attack 1 3.6 6 9.4 Motor Vehicle Accident 4 14.3 16 25.0 Hand or Foot Injury 1 3.6 13 20.3 Smoke Inhalation 2 7.1 2 3.1 Witnessed Trauma 1 3.6 3 4.7 Other 1 3.6 5 7.8

a n=28. b n=64.

The mean stressor severity ratings as measured by the SPSS-CA (APA, 1987) were 5.87

(SD = 0.29) for the PTSD group and 5.70 (SD = 0.42) for the traumatized PTSD negative group.

An ANOVA comparing stressor severity ratings for PTSD and traumatized PTSD negatives

denoted a non-significant group difference, F(1,90) = 3.75, p > .05. In addition, there was no

significant difference between the stressor severity ratings of males and females, F(2, 89) = .39, p > .05. Males had a mean stressor severity rating of 5.73 (SD = .40) and females had a mean

rating of 5.77 (SD = .39).

The amount of time that had passed since trauma exposure for the PTSD group (M = .68,

SD = .91) did not significantly differ from the time interval for the traumatized PTSD negatives

(M = .45, SD = .84), F(1, 90) = 1.45, p > .05. The mean age at the time of trauma for the PTSD

group was 14.23 years (SD = 2.91) and 13.26 years (SD = 2.85) for the traumatized PTSD

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negative group. The mean age at trauma exposure for the trauma exposed groups was not significantly different, F(1, 90) = 2.20, p > .05.

Exploratory Analyses

Figure 4.1 depicts the group means for the CDI Total, Negative Mood, Interpersonal

Problems, Ineffectiveness, Anhedonia, and Negative Self Esteem scores. Overall, this figure shows that the PTSD group mean scores were higher on all of the aforementioned scales as compared to the comparison groups. Furthermore, the traumatized PTSD negative and the control group means were similar to one another. Figure 4.2 depicts group means with regard to the CDI Total scale. In this context, the PTSD group was characterized by a remarkably higher mean score in comparison to the traumatized PTSD negative and control groups.

A correlation matrix indicated that the dependent variables were moderately correlated with one another. Thus, multicollinearity was ruled out, a requirement for MANCOVA (Field,

2009). Box’s M Test and Shaprio-Wilk test for normality were utilized to test further assumptions of both ANCOVA and MANCOVA. Results of the Box’s M test analyses indicated that either the covariances were not equal or that the data were not normally distributed (Box’s

M = 138.49, F = 3.05, p < .01), as a significant value indicates a deviation from normality

(Rencher & Christensen, 2012). Shapiro-Wilk test for normality was utilized to further assess the underlying assumptions (Rencher & Christensen, 2012).

The Shapiro-Wilk test was significant for each dependent variable, indicating a deviation from normality. The residuals for the CDI Total, W(133) = .94, p < .01, Negative Mood, W(133)

= .90, p < .01, Interpersonal Problems, W(133) = .91, p < .01, Ineffectiveness, W(133) = .91, p <

.01, Anhedonia, W(133) = .96, p < .01, and Negative Self Esteem, W(133) = .83, p < .01, scores were significantly different from a normal distribution. While the F-test used in the analyses is

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robust and may control for Type I error rate under conditions of skew, kurtosis, and non- normality (Donaldson, 1968; Field, 2009; Glass, Peckham, & Sanders, 1972), the variables appear to violate underlying assumptions, which may compromise significance tests.

All of the dependent variables on the CDI are considered indicators for psychopathology,

which are generally skewed due to their non-normal distribution in the population. As such, these

variables were log-transformed in order to improve normality and reduce bias in subsequent

analysis (Field, 2009). It is important to note that subsequent analyses did not find any

significant differences between findings for analyses that used original or log-transformed data.

This resulted in the use of the untransformed variables for ease of interpretation with their

original scale throughout the data analysis.

Figure 4.1: Graphical Depiction of Group Means for CDI Total, Negative Mood, Interpersonal Problems, Ineffectiveness, Anhedonia, and Negative Self-Esteem Scores

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Figure 4.2: Graphical Depiction of Group Means for the Total Scale

Multivariate and Univariate Analyses

To test for group differences with regard to the standardized CDI Total scores, a separate

ANCOVA procedure was conducted controlling for group differences related to SES. As the CDI

(Kovacs, 1992) scores used in the analyses are standardized based on age and gender, these variables were not included as covariates. Toothaker (1993) suggested using Bonferroni post hoc comparisons to address concerns about the possibility of Type I error. Accordingly, Bonferroni post hoc comparisons were employed to identify significant group comparisons and avoid Type I error. A separate MANCOVA controlling for SES was conducted to examine group differences across the six CDI scores. Given a significant MANCOVA, univariate F tests and Bonferroni post hoc comparisons were conducted.

Table 4.3 presents CDI Total and subscale scores (means and standard deviations) for the comparison groups as well as the univariate analyses. As seen in Table 4.4, Bonferonni post hoc comparisons revealed the mean CDI Total score of the PTSD group was significantly higher than

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the means of the traumatized PTSD negatives and controls. However, the means of the traumatized PTSD negatives and controls were not significantly different. A MANCOVA identified significant experimental group differences at the CDI subscale level, Wilks lambda,

F(12, 248) = 3.24, p < .01.

Univariate F tests denoted significant group differences on the CDI Total, F(2, 129) =

13.38, p < .01, Negative Mood, F(2, 129) = 7.07, p < .01, Ineffectiveness, F(2, 129) = 8.75, p <

.01, Anhedonia, F(2, 129) = 16.40, p < .01, and Negative Self Esteem scores, F(2, 129) = 3.60, p

= .03. There was not a significant difference between comparison groups on the CDI

Interpersonal Problems score F(2, 129) = 2.10, p = .13. Bonferroni post hoc comparisons (Table

4.4) at the alpha level of .003 determined that the mean CDI Total, Negative Mood,

Ineffectiveness, and Anhedonia scores of the PTSD group were significantly higher than those of

the traumatized PTSD negatives and the controls. The Negative Self Esteem score was an

exception; specifically, the PTSD mean score compared to the control group score approached but did not meet significance at the alpha = .05 level. Importantly, the mean scores of the traumatized PTSD negatives and controls did not differ on any of the CDI subscales.

Hypotheses 1-12 presented in Chapter III indicated that youth with PTSD would evidence significantly higher CDI scores on all six subscales relative to traumatized PTSD negatives and non-clinical controls. With reference to this set of hypotheses, Hypotheses 1-2, 4-8, and 10-11 were supported. Hypothesis 3 and 9 were not supported, as the Interpersonal Problems scores of the PTSD group were not significantly higher than the scores of the traumatized PTSD negatives or the controls. Hypothesis 12, which stated that Negative Self Esteem scores of the PTSD group would be significantly higher than the scores of controls, was not supported.

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Hypothesis 13-18 presented in Chapter III posited that the scores of traumatized PTSD negatives would not significantly differ from the ratings of the control group on any of the six

CDI subscales. The observed outcomes fully supported this set of hypotheses.

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Table 4.3

Adjusted Means, Standard Deviations, and Univariate F-tests for CDI Total and Subscale Scores

PTSDa Traumatized Controlc Univariate PTSD Negativeb Results CDI Scale M SD M SD M SD Fd p

Total 55.46 13.29 44.20 7.63 44.00 7.07 13.38 <.01

Negative Mood 54.29 13.08 45.06 8.08 46.46 8.74 7.07 <.01

Interpersonal 53.36 12.07 49.36 6.95 47.76 6.70 2.10 .13 Problems

Ineffectiveness 54.11 12.53 45.53 7.13 44.56 7.68 8.75 <.01

Anhedonia 56.75 12.17 44.75 8.61 44.49 6.72 16.40 <.01

Negative Self Esteem 49.89 10.68 44.42 7.01 44.93 7.18 3.60 .03

Note. a n=28. b n=64. c n=41. d df = (2, 129).

142 ! ! ! ! Table 4.4

Bonferroni Post Hoc Comparisons for CDI Total and Subscale Scores

PTSD vs. Traumatized Traumatized PTSD Post hoc PTSD Negative PTSD vs. Control Negative vs. Control Comparisons Scale Mean p Mean p Mean p Difference Difference Difference Total 10.18 <.01 10.46 <.01 .28 1.00 1>2***, 3*** Negative Mood 8.61 <.01 7.24 .01 -1.36 1.00 1>2**, 3* Ineffectiveness 7.57 <.01 8.61 <.01 1.04 1.00 1>2**, 3*** Anhedonia 11.37 <.01 11.68 <.01 .31 1.00 1>2***, 3***

143 Negative Self Esteem 4.94 .03 4.47 .09 -.47 1.00 1>2*, 3

Note: 1 = PTSD, 2 = Traumatized PTSD Negative, 3 = Control.

* p < .05, ** p < .01, *** p < .001

Chapter Summary

Data analyses indicated that, as hypothesized, the CDI scores of children and adolescents with PTSD significantly exceeded the CDI scores of traumatized PTSD negatives and controls with three caveats. First, the PTSD group mean CDI Interpersonal Problems score did not significantly differ from the traumatized PTSD negative group. Second, the PTSD group mean

CDI Interpersonal Problems score also did not significantly differ from the control group.

Finally, the PTSD group mean CDI Negative Self Esteem score did not significantly differ from the control group. On the other hand, as hypothesized, the CDI scores of the traumatized PTSD negatives and controls were not significantly different on any of the subscales measured. Overall,

PTSD was consistently associated with increased depression across the majority of the CDI scales and trauma exposure without PTSD was not.

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CHAPTER V

Conclusions

This chapter presents a discussion of the observed results and offers insights regarding how the study may be interpreted within the field of child psychopathology. The theoretical and clinical significance of the study will be reviewed, as well as limitations and implications for future research.

Summary of Findings

This investigation compared the self-reported depression ratings of a sample of traumatized urban youth with and without Posttraumatic Stress Disorder (PTSD) to non-clinical controls. In a departure from previous research, this study was unique as it controlled for the potentially confounding effects of the following major comorbid disorders: attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD), major depressive disorder (MDD), substance dependence, and psychosis. Furthermore, the study controlled for socioeconomic status (SES) and used a three-group case control design to analyze multidimensional depression estimates.

It was hypothesized that youth with PTSD would evidence significantly higher scores on the Children’s Depression Inventory (CDI; Kovacs, 1992) across all six indices (e.g., Total,

Negative Mood, Ineffectiveness, Anhedonia, Interpersonal Problems, and Negative Self Esteem) relative to traumatized PTSD negatives and non-clinical controls. It was also hypothesized that the depression ratings of traumatized PTSD negatives and non-clinical controls would not significantly differ. As predicted, the CDI scores of children and adolescents with PTSD significantly exceeded the scores of traumatized PTSD negatives and controls on the majority of the CDI indices, namely the CDI Total, Negative Mood, Ineffectiveness, and Anhedonia scales.

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The PTSD group also had significantly higher scores than the traumatized PTSD negatives on the Negative Self Esteem scale. In addition, and consistent with expectations, the CDI scores of the traumatized PTSD negatives and controls were not significantly different on any of the CDI subscales.

There were three exceptions to the predicted hypotheses. First, the PTSD group CDI

Interpersonal Problems score did not significantly differ from the mean score of the traumatized

PTSD negative group. Second, the PTSD group CDI Interpersonal Problems score did not significantly differ from the mean score of the control group. Finally, the PTSD group CDI

Negative Self Esteem score did not significantly differ from the mean score of the control group.

Overall, PTSD was associated with self-reported anhedonia and despondency while trauma exposure without PTSD was not.

Discussion

The number of traumatized youth that did not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) criteria for PTSD suggests important implications from an epidemiological perspective. Among all youth who reportedly experienced a DSM-IV

PTSD designated traumatic event (n = 92), 69.6% (n = 64) did not meet criteria for PTSD. This finding is consistent with the results of earlier studies indicating that the majority of traumatized children and adolescents did not meet criteria for PTSD (Broman-Fulks et al., 2007; deVries et al., 1999; Saigh, Sack, Yasik, & Koplewicz, 1999; Saigh, Yasik, Mitchell, & Abright, 2011,

Saigh et al., 2015). Clearly, trauma exposure did not lead to PTSD among the majority of trauma-exposed children that were sampled. Also consistent with earlier studies was the finding that the mean number of traumas reported by the PTSD group was significantly greater than the mean number of traumas reported by the traumatized PTSD negative group. This outcome is

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consistent with the literature suggesting that multiple traumatic experiences may increase the likelihood of developing PTSD (Bremner et al., 1993; Lipschitz et al. 2000; Saigh, 1988a; Yang et al. 2011).

Quay and Werry (1986) advised that, “A disorder is empirically validated by determining its relationship to other variables… Of particular concern is differential validity; two putatively separate disorders ought not to be related in the same way to the same variable” (p. 37). The results from this study provide strong empirical support for the differential validity of the DSM-

IV PTSD (APA, 1994) classification as it applies to youth. As hypothesized, there were significant differences between the CDI scores of youth with PTSD and traumatized PTSD negatives on the majority of indices (i.e., four out of six). Furthermore, as predicted, nonsignificant differences were found between traumatized PTSD negatives and controls on all of the indices.

As one would expect from a disorder characterized in part by diminished interest or participation in significant activities and a restricted range of affect (APA, 1994), youth with

PTSD had significantly higher ratings on the CDI Total, Negative Mood, Ineffectiveness, and

Anehdonia subscales as compared to traumatized PTSD negatives and controls. The significantly higher ratings of the PTSD group may reflect congruence between specific PTSD criteria and the subscale test items. With reference to the significantly higher CDI Negative Mood ratings of the

PTSD group relative to traumatized PTSD negatives and controls, the DSM-IV PTSD criteria make specific reference to a sense of foreshortened future, difficulty concentrating, and irritability. Correspondingly, the CDI Negative Mood subscale is composed of the following items: “I am sure terrible things will happen to me,” “I cannot make up my mind about things,” and “Things bother me all the time.”

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With regard to the significantly higher PTSD group scores on the CDI Ineffectiveness subscale as compared to the traumatized PTSD negatives and controls, the DSM-IV PTSD

(APA, 1994) criteria also reference intrusive recollections about the traumatic event, feeling as though the traumatic event is reoccurring, difficulty concentrating, and clinically significant distress or impairment in important areas of functioning (e.g., school). In line with this, two of the four CDI Ineffectiveness subscale items are as follows: “I have to push myself all the time to do my schoolwork” and “I do very badly in subjects I used to be good in,” perhaps reflecting the presence of intrusive thoughts while in school. It may also be said that the higher CDI

Ineffectiveness scores of the PTSD group, as compared to the traumatized PTSD negatives and controls, are congruent with the outcomes of past research indicating that children with PTSD had significantly lower scores on measures of academic achievement, intelligence, and verbal memory as compared to traumatized PTSD negatives and controls (Saigh et al., 1997; Saigh et al., 2006; Yasik et al., 2007).

Lastly, regarding the significantly higher scores of the PTSD group on the CDI

Anhedonia subscale as compared to the traumatized PTSD negatives and controls, it should be noted that the DSM-IV PTSD symptoms (APA, 1994) make reference to markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and a restricted range of affect. Correspondingly, the CDI Anhedonia subscale includes the following items: “Nothing is fun at all,” “I feel alone all the time,” “I never have fun at school,” and “I do not have any friends.” As such, it may be argued that the concordance between the aforementioned DSM-IV PTSD symptoms and the CDI Anhedonia subscale content contributed to the observed outcomes. It may also be said that the significantly higher CDI

Anhedonia scores for the PTSD group relative to traumatized PTSD negatives and controls are

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congruent with the past research indicating that PTSD is associated with health-related problems

(Bermann & Seng, 2004; Dirkzwager, van der Velden, Grievink, & Yzermans, 2007; Saigh et al., 2015; Seng, Clark, McCarthy, & Ronis, 2006; Yasik et al., 2012), as the Anhedonia subscale makes reference to somatic symptoms and as the DSM-IV PTSD criteria include sleep disturbance and increased arousal.

Overall, the significantly higher findings on the CDI Total, Negative Mood,

Ineffectiveness, and Anhedonia subscales as compared to traumatized PTSD negatives and controls are consistent with earlier reports indicating that individuals with PTSD evidence increased self-reported symptoms of depression (Goenjian et al., 2001; Kadak, et al., 2013;

McLeer, et al., 1992; McLeer, et al., 1998; Saigh, 1987a; Saigh, 1987b; Saigh, 1987c; Saigh,

1988b; Saigh, 1989a; Saigh, 1989b; Saigh, 1991; Saigh et al., 2002; Saigh et al., 2015; Wolfe,

1994; Ying et al., 2012).

The PTSD group demonstrated significantly higher CDI Negative Self Esteem scores

(denoting lower levels of self-esteem) as compared to the traumatized PTSD negatives. It is possible that the traumatized PTSD negative group was demonstrating resilience following adversity, as previous research has found that resilience moderates the relationship between trauma exposure and PTSD (Ahmed, 2007; Haglund, Cooper, Southwick & Charney, 2007;

Salami, 2001; Zahradnik et al., 2010). Moreover, previous studies reported that self-esteem was negatively related to PTSD (Bradley, Schwartz, & Kaslow, 2005; Hershberger & D’Augelli,

1995; Salami, 2001). Thus, self-esteem may moderate the relationship between trauma exposure and PTSD, which may explain why there was a significant difference between the traumatized groups on the CDI Negative Self Esteem subscale.

The nonsignificant differences between the PTSD group and controls on the CDI

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Negative Self Esteem subscale may have been a statistical artifact given the large number of

comparisons that were made in this study. However, the nonsignificant difference may also be partially ascribed to discordance between the test items and DSM-IV PTSD symptoms. Viewed

in this context, four out of the five items that comprise the Negative Self Esteem subscale (e.g.,

“I hate myself,” “I want to kill myself,” “I look ugly,” and “Nobody really loves me”) do not

reflect the diagnostic criteria for PTSD. The nonsignificant difference between the PTSD group

and controls on the CDI Negative Self Esteem subscale is also supported by past research (Saigh,

Yasik, Oberfield, & Halamandaris, 2008) that reported nonsignificant differences between youth

with PTSD and non-clinical controls on the Physical Appearance and Attributes scale and the

Popularity scale of the Piers Harris Children’s Self-Concept Scale 2 (Piers & Herzberg, 2002).

In a similar vein, discordance between the DSM-IV PTSD (APA, 1994) criteria and the

CDI Interpersonal Problems subscale items may serve to explain the nonsignificant difference

observed between the scores of the traumatized groups and the PTSD group and controls. Two

out of the four items that comprise the CDI Interpersonal Problems subscale make reference to

externalizing symptoms, (i.e., “I never do what I am told.” and “I get into fights all the time”)

and these items do not correspond to the symptoms for PTSD in the DSM-IV (APA, 1994). It is

of interest to note that Saigh et al. (2002) reported non-significant differences between

traumatized youth with or without PTSD and controls on the Child Behavior Checklist (CBCL;

Achenbach, 1991a) Delinquent Behaviors and Aggressive Behavior scales.

Overall, the significantly higher CDI Total, Negative Mood, Ineffectiveness, and

Anhedonia scores of the PTSD group relative to traumatized PTSD negatives and controls suggest that youth with PTSD, even after controlling for MDD, reported higher rates of despondency and distress on four out of six CDI scales, including the CDI Total scale. In effect,

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PTSD was associated with increased depression on four out of six CDI scales while trauma exposure without PTSD was not. These findings are concordant with research indicating that traumatized PTSD negatives and non-clinical controls do not differ on standardized measures of depression (Saigh et al., 2002), anxiety (Saigh et al., 2002; Yasik et al. 2012), anger (Saigh et al.,

2007), academic performance (Saigh et al., 1997), and cognitive ability (Saigh et al., 2006; Yasik et al. 2007). The cumulative evidence consistently suggests that trauma exposure in the absence of PTSD does not necessarily constitute a risk factor for child and adolescent psychopathology.

Significance of the Study

Past research documenting the sensitivity of self-reported depression to the expression of

PTSD following traumatic experiences is marked by methodological limitations (Goenjian et al.,

2001; Kadak, 2013; McLeer, 1992; 1998; Saigh, 1987a; 1987b; 1987c; 1988b; 1989a; 1989b;

1991; Saigh et al., 2002; Saigh et al., 2015; Wolfe, 1994; Ying et al., 2012). First, the majority of past studies did not include a control group and therefore could not specify if traumatized youth without PTSD were at risk for depression. This is a clinically significant omission as the minority of youth exposed to trauma develops PTSD (Breslau et al., 2004; Giaconia et al., 1995;

Kessler et al., 1995; Saigh, 1992). Theoretically, it is possible that the trauma-exposed youth studied in past research may have had elevated levels of depression in the absence of a PTSD diagnosis. In a departure from previous studies, this investigation identified traumatized children who clearly had or did not have PTSD with the addition of a nonclinical control group for comparison.

Second, none of the reviewed studies (Goenjian et al., 2001; Kadak, 2013; McLeer, 1992;

1998; Saigh, 1987a; 1987b; 1987c; 1988b; 1989a; 1989b; 1991; Wolfe, 1994; Ying et al., 2012), with the exception of Saigh et al. (2002), controlled for the potentially confounding effects of

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comorbid disorders. This is especially notable since depressive disorders frequently occur concurrently with PTSD (Breslau et al., 1991; Kessler et al., 1995; Kilpatrick et al. 2003).

Furthermore, ADHD, CD, and substance dependence have been associated with elevated levels of depression (Haley, Fine, Marriage, Moretti, & Freeman, 1985; Karustis, Power, Rescorla,

Eiraldi, & Gallagher, 2000; Lobovits & Handal, 1985; McCauley, Burkey, Mitchell, & Moss,

1988; Smith, Mitchell, McCauley, & Calderon, 1990). Thus, it is unclear whether the elevated

CDI scores reported in past research were associated with PTSD or a combination of PTSD and comorbid disorders. The method employed in the current study helped clarify that reported variations in CDI scores were a function of PTSD, rather than a combination of PTSD and other psychiatric disorders (e.g., ADHD, MDD), by controlling for major comorbid disorders.

Third, the CDI is a multi-component test (Kovacs, 1992). None of the studies mentioned above and reviewed in the aforementioned chapters offered information regarding CDI subscale variations beyond the CDI Total score. This is a significant omission as the CDI has five additional subscales that denote different components of depression. Variations within the subscales were found in the present study, as the PTSD group did not score significantly greater on the CDI Interpersonal Problems scale as compared to the traumatized PTSD negatives and the controls. In addition, nonsignificant differences were found between the PTSD group and the controls on the Negative Self Esteem scale.

Unlike studies that relied simply on the outcomes of self-reported questionnaires to denote diagnostic status (Bayer et al., 2007; Foster et al., 2004; Goenjian et al., 2001; Ying et al.

2012), the present study employed a very conservative approach to case identification. Each participant received two independent DSM-IV (APA, 1994) clinical interviews by a psychologist and psychiatrist in addition to two independent administrations of the Children’s PTSD

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Inventory (Saigh, 2003) by two doctoral students, in order to determine diagnostic status.

Therefore, there was considerable evidence from multiple sources that the cases in this study actually had PTSD, trauma exposure without PTSD, or were never traumatized and this adds to the internal validity of the outcomes.

It may also be said that the results of this study offer significant implications. Clinicians may need to carefully assess depression-related thoughts and mood among children and adolescents with PTSD by going beyond the standard trauma-specific diagnostic symptom assessments. Mental health clinicians may wish to utilize the findings from the CDI to develop treatment programs that are customized to meet the specific needs of traumatized youth with and without PTSD. Furthermore, it is important to note that all of the participants in the present study received comprehensive psychiatric assessments and their parents were given personal feedback and psychological reports denoting their child’s psychological functioning. Such information may have been particularly useful since it highlighted areas of concern and specified the possible need for psychological treatment when applicable.

The DSM-IV (APA, 1994) indicates that possible symptoms of PTSD include problems with concentration and sleep, negative belief systems, decreased interest in significant activities, and an inability to experience positive emotions. These symptoms overlap with some of the criteria for MDD. Furthermore, feelings of irritability and functional impairment are reflected by the criteria for PTSD and MDD in the DSM-IV. As discussed in Chapter II, high rates of comorbidity between PTSD and depressive disorders in youth have been reported, ranging between 13.8% and 85% (e.g. Hubbard et al., 1995; Kilpatrick et al., 2003; Kinzie et al., 1986;

McLeer et al., 1998; Pfeiffer & Elbert, 2011; Sack et al. 1993; Vila et al., 1999; Ying et al.,

2012). Given that MDD and a number of major comorbid disorders were systematically excluded

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in this investigation, the observed outcomes provide evidence that clearly supports the validity of the DSM-IV PTSD classification that is independent from MDD. Additionally, as depression in youth has been associated with negative educational and physical outcomes (Bohman et al.,

2012; Fröjd et al., 2008; Thapar, Collishaw, Pine, & Thapar, 2012; Yousefi et al., 2010), the

inclusion of the CDI within the framework of child-adolescent PTSD evaluations appears to be

quite warranted.

In comparing CDI scores of youth with and without PTSD and non-clinical controls, this

study made the important determination that overall higher levels of self-reported depression, as

measured by the CDI, were associated with PTSD and not trauma exposure alone. The results

also suggest that exposure to trauma in the absence of PTSD is not associated with higher

estimates of psychiatric morbidity. These findings are clinically relevant given that trauma

exposure is common in America (Breslau, David, Andreski, & Peterson, 1991; Breslau et al.,

1998; Breslau, 2009; Fitzpatrick & Boldizar, 1993; Kessler et al., 1995; Norris, 1992; Resnick et

al., 1993) and as the majority of traumatized children that have been studied did not develop

PTSD (Alisic et al., 2014; Breslau, Lucia, & Alvarado, 2006; Cuffe et al., 1998; Giaconia et al.,

1995; Kilpatrick et al., 2003; Saigh, 1992; Storr, Ialongo, Anthony, & Breslau, 2007).

Limitations

There are certain limitations that are important to note, as is crucial with any empirical

investigation. The outcomes must be tempered with the understanding that a relatively small

sample was examined and a conservative post hoc test was used. It is also acknowledged that participant depression may have existed prior to trauma exposure. Case control designs preclude

randomization given the ex-post facto nature of the study (Armenian, 2009). Moreover, participants with major comorbid disorders (e.g., ADHD, CD, MDD, substance dependence)

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were excluded, namely 13% of the selected traumatized sample. The results should be viewed accordingly, given that they may not generalize to populations with PTSD and multiple comorbid disorders. At the same time, additional DSM-IV (APA, 1994) comorbid disorders were not excluded and this may be viewed as a limitation.

Furthermore, the sample consisted of urban New York City youth and, thus, is highly representative of inner-city populations. The group with PTSD had significantly lower socioeconomic status (SES) ratings as compared to the traumatized PTSD negatives and controls.

Brewin, Andrews, and Valentine (2000) reported similar findings in a large meta-analysis of data from 77 studies involving risk factors for PTSD, such that low SES was found to be predictive of higher PTSD symptoms. Prior research also found that SES might be a risk factor for PTSD among youth who experienced physical or sexual abuse (Romero et al., 2009) and natural disasters (Norris et al., 2002). The external validity of this study is therefore limited to individuals with similar demographic characteristics, trauma histories, and psychiatric backgrounds.

Self-report measures are useful with children as they may report information that is subjective and difficult for others to notice (Reynolds, 1994). On the other hand, Reynolds

(1993) indicated that self-report measures might be influenced by children’s impulse control, language skills, and experience with similar measures. It should also be understood that self- report measures might be vulnerable to the influence of social desirability (Schaeffer, 2000).

Further, Kessler et al. (2000) suggested that motivation and the ability to understand assessment questions might influence the assessment of psychiatric disorders including PTSD.

Finally, it is important to note that the CDI was recently updated (Kovacs, 2011) and that the results from this study may not generalize to the revised instrument. Furthermore, the

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outcomes from this investigation may not generalize to cases meeting the DSM-5 (APA, 2013) criteria for PTSD, as the results from this study are based on cases that met PTSD criteria according to the DSM-IV (APA, 1994).

Future Directions

Future directions in the area of child and adolescent PTSD research should be considered.

First, significantly lower SES ratings were found in the PTSD group as compared to the traumatized PTSD negatives and non-clinical controls. Thus, future research may wish to examine demographic, familial, economic, or environmental factors in predicting PTSD in youth populations. Differences in PTSD prevalence rates as a factor of racial and/or ethnic differences may also be an area to explore. In addition, prospective researchers may wish to include a broader age span of youth (e.g. youth aged six and under) to provide insight into the course of

PTSD in a preschool population. This is especially relevant given the new developmental criteria for PTSD in youth aged six and under in the DSM-5 (APA, 2013).

Second, in a large meta-analysis Alisic et al. (2014) found higher rates of PTSD in individuals that experienced interpersonal, intentional traumas as compared to those who developed PTSD as a result of accidents or natural disasters. Females are especially affected by interpersonal stressors such as child abuse (Gavazzi, Lim, Yarcheck, Bostic, & Scheer, 2008) and, as indicated above, interpersonal traumas are differentially predictive of PTSD (Breslau,

Davis, Andreski, & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris,

1990, 1992; Ozer, Best, Lipsey, & Weiss, 2003; Resnick, Kilpatrick, Dansky, Saunders, & Best,

1993). Of note, delinquent girls are more likely than their male peers to report interpersonal traumas such as child abuse and sexual assault (Kerig, Ward, Vanderzee, & Arnzen Moeddel,

2009). Regarding PTSD, the DSM-5 indicates that, “The disorder may be especially severe or

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long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence.)”

(APA, 2013, p. 275). Therefore, future research should compare youth with PTSD who were traumatized interpersonally and intentionally versus accidentally and unintentionally.

Third, it is important to note that depressive disorders frequently occur concurrently with

PTSD (Breslau et al., 1991; Kessler et al., 1995; Kilpatrick et al. 2003) and ADHD, CD, and substance dependence have been associated with elevated levels of depression (Haley, Fine,

Marriage, Moretti, & Freeman, 1985; Karustis, Power, Rescorla, Eiraldi, & Gallagher, 2000;

Lobovits & Handal, 1985; McCauley, Burkey, Mitchell, & Moss, 1988; Smith, Mitchell,

McCauley, & Calderon, 1990). As 13% of cases of the selected traumatized sample were excluded due to comorbidity, future research should compare youth with PTSD to youth with other psychiatric disorders. A comparative analysis of depression ratings in youth with PTSD,

ADHD, CD, MDD, or substance dependence and non-clinical controls may further our understanding of depressive symptoms across diagnostic categories and increase the external validity of the present findings. In addition, as PTSD often co-occurs with other psychiatric disorders (Brady, Killeen, Brewerton, & Lucerini, 2000; Giaconia et al., 2000; Jacobsen,

Southwick & Kosten, 2001), it may increase generalizability and knowledge regarding the expression of PTSD to conduct studies involving youth with comorbid disorders and PTSD.

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Cecilia Stoute Rights Manager | American Psychiatric Publishing American Psychiatric Association 1000 Wilson Boulevard, Suite 1825 Arlington, VA 22209 703-907-8547 Office 703-907-1091 Fax [email protected] www.psychiatry.org http://www.appi.org/CustomerService/Pages/Permissions.aspx

AMERICAN PSYCHIATRIC PUBLISHING, INC.

REQUEST FOR PERMISSION TO REPRINT TEXT FROM APA/APPI BOOKS AND JOURNALS INCLUDING ALL EDITIONS OF THE DSM

194

Appendix B

APA PERMISSION FOR CITATION DSM-5

From: Cecilia Stoute Date: Mon, Feb 9, 2015 at 8:28 AM Subject: RE: Request for permission to reprint Text from APA/AP P. Permission Request Reference ID: PL597 To: [email protected]

Dear Ms. Dekis,

Permission is granted for use of the material as outlined in the request below for use in your dissertation only. Permission is granted under the following conditions:

In all instances, the source and copyright status of the reprinted material must appear with the reproduced text. The following notice should be used:

Sincerely,

AMERICAN PSYCHIATRIC PUBLISHING, INC.

REQUEST FOR PERMISSION TO REPRINT TEXT FROM APA/APPI BOOKS AND JOURNALS INCLUDING ALL EDITIONS OF THE DSM

195