The present paper reviews pediatric posttraumatic stress disorder, emphasizing the relational basis of the disorder and highlighting the missing link between juvenile delinquency and trauma. The first part of the paper defines trauma and the diagnostic criteria for PTSD, noting child-specific features. The second part reviews the literature emphasizing the relational and attachment relevant nature of trauma. The third part explores psychological mechanisms for how attachment relations could affect trauma responses. Attachment relations (1) shape core schemas of the world, others, and the self and (2) foster emotional engagement or disengagement, both of which have been associated with traumatic responses. The most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), acknowledges the attachment figure's influence and includes treating and training the parent and conjoint child-parent discussion. The next section reviews the noteworthy link between juvenile delinquency and trauma history. More awareness of trauma and PTSD in children and adolescents is recommended to effectively address juvenile delinquency. The review ends with a few helpful points for practicing pediatricians regarding childhood trauma. 1. Introduction Trauma and PTSD in children occur in the context of the ongoing parent-child relation, and this lens may offer insights to the correlations which previous studies have uncovered, integrating the findings and adding a fuller contour to the picture of pediatric PTSD. This paper aims to review and integrate an understanding of PTSD in children and adolescents in an attachment context and organizes the article in several sections: defining PTSD in children; a review of parental influences on pediatric PTSD; psychological mechanisms for how attachment relations affect trauma responses; the link between PTSD and juvenile delinquency; a few take-away points for pediatricians. 2. Defining PTSD in Children Trauma is a profound experience of the loss of security and welfare evoking feelings of fear, helplessness, horror, and possibly disorganized agitation in children [1]. The description of PTSD in the Diagnostic and Statistical Manual of Mental Disorders has increasingly taken into account child-specific features of PTSD, and PTSD has evolved from a disorder first associated with Vietnam veterans in the 1970s [2] to one which has now been well documented in the general population at an estimated 7.8% [3] and in specific groups of children, particularly high-risk children such as adolescent
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington, DC, USA, 4th edition, 2000.
R. C. Kessler, A. Sonnega, E. Bromet, M. Hughes, and C. B. Nelson, “Posttraumatic stress disorder in the national comorbidity survey,” Archives of General Psychiatry, vol. 52, no. 12, pp. 1048–1060, 1995.
V. V. Ruchkin, M. Schwab-Stone, R. Koposov, R. Vermeiren, and H. Steiner, “Violence exposure, posttraumatic stress, and personality in juvenile delinquents,” Journal of the American Academy of Child and Adolescent Psychiatry, vol. 41, no. 3, pp. 322–329, 2002.
R. A. Kulka, W. E. Schlenger, J. A. Fairbanks et al., Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study, Brunner Mazel, New York, NY, USA, 1990.
P. K. Trickett and C. McBride-Chang, “The developmental impact of different forms of child abuse and neglect,” Developmental Review, vol. 15, no. 3, pp. 311–337, 1995.
K. C. Stovall-McClough and M. Cloitre, “Unresolved attachment, PTSD, and dissociation in women with childhood abuse histories,” Journal of Consulting and Clinical Psychology, vol. 74, no. 2, pp. 219–228, 2006.
J. A. Twaite and O. Rodriguez-Srednicki, “Childhood sexual and physical abuse and adult vulnerability to PTSD: the mediating effects of attachment and dissociation,” Journal of Child Sexual Abuse, vol. 13, no. 1, pp. 17–38, 2004.
M. S. Scheeringa and C. H. Zeanah, “A relational perspective on PTSD in early childhood,” Journal of Traumatic Stress, vol. 14, no. 4, pp. 799–815, 2001.
B. Andrews, C. R. Brewin, and S. Rose, “Gender, social support, and PTSD in victims of violent crime,” Journal of Traumatic Stress, vol. 16, no. 4, pp. 421–427, 2003.
A. Loukas, H. E. Fitzgerald, R. A. Zucker, and J. L. Krull, “Developmental trajectories of disruptive behavior problems among sons of alcoholics: effects of parent psychopathology, family conflict, and child undercontrol,” Journal of Abnormal Psychology, vol. 112, no. 1, pp. 119–131, 2003.
R. Meiser-Stedman, P. Smith, E. Glucksman, W. Yule, and T. Dalgleish, “Parent and child agreement for acute stress disorder, post-traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed to single-event trauma,” Journal of Abnormal Child Psychology, vol. 35, no. 2, pp. 191–201, 2007.
K. A. Dowell and B. M. Ogles, “The effects of parent participation on child psychotherapy outcome: a meta-analytic review,” Journal of Clinical Child and Adolescent Psychology, vol. 39, no. 2, pp. 151–162, 2010.
M. D. S. Ainsworth, M. C. Blehar, E. Waters, and S. Wall, Patterns of Attachment: A Psychological Study of the Strange Situation, Lawrence Erlbaum, Oxford, UK, 1978.
S. J. Lupien, B. S. McEwen, M. R. Gunnar, and C. Heim, “Effects of stress throughout the lifespan on the brain, behaviour and cognition,” Nature Reviews Neuroscience, vol. 10, no. 6, pp. 434–445, 2009.
D. Baumrind, “The influence of parenting style on adolescent competence and substance use,” The Journal of Early Adolescence, vol. 11, no. 1, pp. 56–95, 1991.
E. B. Foa, “Psychological processes related to recovery from a trauma and an effective treatment for PTSD,” Annals of the New York Academy of Sciences, vol. 821, pp. 410–424, 1997.
E. B. Foa, “Failure of emotional processing: post trauma psychopathology,” in Proceedings of the World Congress of Behavioural & Cognitive Therapies, Copenhagen, Denmark, 1995.
E. Gilboa-Schechtman and E. B. Foa, “Patterns of recovery from trauma: the use of intraindividual analysis,” Journal of Abnormal Psychology, vol. 110, no. 3, pp. 392–400, 2001.
L. S. Greenberg and A. Pascual-Leone, “Emotion in psychotherapy: a practice-friendly research review,” Journal of Clinical Psychology, vol. 62, no. 5, pp. 611–630, 2006.
L. Roemer, B. T. Litz, S. M. Orsillo, and A. W. Wagner, “A preliminary investigation of the role of strategic withholding of emotions in PTSD,” Journal of Traumatic Stress, vol. 14, no. 1, pp. 149–156, 2001.
H. Fisher, “Lust, attraction, attachment: biology and evolution of the three primary emotion systems for mating, reproduction, and parenting,” Journal of Sex Education and Therapy, vol. 25, no. 1, pp. 96–104, 2000.
J. Bowlby, “The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. An expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976,” British Journal of Psychiatry, vol. 130, no. 3, pp. 201–210, 1977.
M. Dieperink, J. Leskela, P. Thuras, and B. Engdahl, “Attachment style classification and posttraumatic stress disorder in former prisoners of war,” American Journal of Orthopsychiatry, vol. 71, no. 3, pp. 374–378, 2001.
M. M. Fitzgerald and J. Cohen, “Trauma-focused cognitive-behavioral therapy,” in Handbook of Child Sexual Abuse: Identification, Assessment, and Treatment, pp. 199–228, John Wiley & Sons, Hoboken, NJ, USA, 2012.
E. Deblinger, A. P. Mannarino, J. A. Cohen, M. K. Runyon, and R. A. Steer, “Trauma-focused cognitive behavioral therapy for children: impact of the trauma narrative and treatment length,” Depression and Anxiety, vol. 28, no. 1, pp. 67–75, 2011.
J. P. Ryan and M. F. Testa, “Child maltreatment and juvenile delinquency: investigating the role of placement and placement instability,” Children and Youth Services Review, vol. 27, no. 3, pp. 227–249, 2005.
H. Steiner, I. G. Garcia, and Z. Matthews, “Posttraumatic stress disorder in incarcerated juvenile delinquents,” Journal of the American Academy of Child and Adolescent Psychiatry, vol. 36, no. 3, pp. 357–365, 1997.
P. Reebye, M. M. Moretti, V. J. Wiebe, and J. C. Lessard, “Symptoms of posttraumatic stress disorder in adolescents with conduct disorder: sex differences and onset patterns,” Canadian Journal of Psychiatry, vol. 45, no. 8, pp. 746–751, 2000.
J. A. Butts and P. Eileen, “Female offenders in the juvenile justice system: statistics summary,” National Criminal Justice Reference Service, 1996, https://www.ncjrs.gov/pdffiles/femof.pdf.
S. M. Tarolla, E. F. Wagner, J. Rabinowitz, and J. G. Tubman, “Understanding and treating juvenile offenders: a review of current knowledge and future directions,” Aggression and Violent Behavior, vol. 7, no. 2, pp. 125–143, 2002.
E. P. Mulvey, M. W. Arthur, and N. D. Reppucci, “The prevention and treatment of juvenile delinquency: a review of the research,” Clinical Psychology Review, vol. 13, no. 2, pp. 133–167, 1993.
