An accurate research base for the prevalence of posttrau-matic stress disorder (PTSD) in very young children rep-resents a gap in our knowledge. Only one known largecommunity survey of psychiatric disorders that includedPTSD has been conducted in preschool children (aged2–5 years) and the prevalence of PTSD, by DSM-III-Rcriteria, was 0.1% (Lavigne et al., 1996). This is wellbelow the rate of 1% in large community surveys of adults

(Helzer et al., 1987) and far below the rate of 3%(Cuffe et al., 1998) to 6% (Reinherz et al., 1993) in ado-lescent samples. Speculations from these data include thatyoung children may be exposed to trauma less often, orthey may be more resilient to trauma, or the criteria forPTSD may be inadequate for young children.

In contrast, it has been established that very youngchildren unquestionably develop symptoms of PTSD(Gaensbauer, 1994; Terr, 1988). The traditional symp-toms—reexperiencing, avoidance/numbing, and hyper-arousal—are unmistakable, although detecting theirpresence in preverbal children may be more difficult thanin older children and adults (Scheeringa et al., 1995). Analternative set of criteria for PTSD in preschool-age chil-dren that is more developmentally sensitive has been pro-posed and tested preliminarily (Scheeringa et al., 1995,2001). These criteria were made less dependent on ver-balizations and more clearly operationalized on behavioralobservations. Some symptoms had to be developmentallymodified because they were derivative functions of mem-ory, abstract thought, emotional processing, or language,which are all in a state of emerging development in youngchildren. Several symptoms could not be used because

New Findings on Alternative Criteria for PTSD in Preschool Children

MICHAEL S. SCHEERINGA, M.D., M.P.H., CHARLES H. ZEANAH, M.D., LEANN MYERS, PH.D., AND FRANK W. PUTNAM, M.D.

ABSTRACT

Objective: An alternative set of criteria for posttraumatic stress disorder (PTSD) for preschool children was analyzed

for validity. Method: Sixty-two traumatized children and 63 healthy controls, aged 20 months through 6 years, were

assessed.The traumatic experiences included motor vehicle collisions, accidental injuries, abuse, and witnessing violence.

The number of symptoms required for clusters C and D and the utility of proposed symptoms were systematically ana-

lyzed. Results: No cases met the DSM-IV algorithm for PTSD. Cluster B was endorsed 67.9% of the time. The propor-

tion of cases meeting the cluster C threshold was 2% when three symptoms were required, 11% when two symptoms

were required, and 39% when one symptom was required. The rate of cluster D was 45% when two symptoms were

required and 73% when one symptom was required. Four novel symptoms did not substantially add to the diagnostic

validity of the criteria. The optimal algorithm (one cluster B symptom, one cluster C symptom, and two cluster D symp-

toms) diagnosed PTSD at a rate of 26%. Measures of comorbid symptoms concurrently provided convergent validation

to support this revised algorithm. Conclusion: Revisions to the DSM-IV PTSD criteria continue to be supported so that

highly symptomatic young children can be diagnosed. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(5):561–570. Key

Words: preschool, posttraumatic stress disorder, diagnostic validity.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003 561

Accepted December 4, 2002.From the Departments of Psychiatry and Neurology, Tulane University Health

Sciences Center, New Orleans (Drs. Scheeringa and Zeanah); Department ofBiostatistics, Tulane University School of Public Health and Tropical Medicine,New Orleans (Dr. Myers); and Mayerson Center for Safe & Healthy Children,Children’s Hospital Medical Center, Cincinnati (Dr. Putnam).

Supported by NIMH grant K08 MH01706 (Dr. Scheeringa) and the MacArthurFoundation Research Network on Early Experience and Brain Development (Dr.Zeanah). The authors thank the Medical Center of Louisiana Charity HospitalTrauma Center, the nursing staff of the Surgical Intermediate Care Area, CrescentHouse, Metropolitan Battered Women’s Program, the Tulane Hospital for ChildrenPediatric Hematology/Oncology program, Children’s Bureau of Greater NewOrleans, and the Jefferson Parish Head Start program.

Correspondence to Dr. Scheeringa, 1440 Canal Street, TB52, New Orleans, LA70112; e-mail: mscheer@tulane.edu.

0890-8567/03/4205–0561�2003 by the American Academy of Childand Adolescent Psychiatry.

DOI: 10.1097/01.CHI.0000046822.95464.14

they were inappropriate for the developmental capacitiesof young children (e.g., sense of a foreshortened future).The A(2) criterion (the person’s immediate response mustshow extreme emotional or behavioral reactions) was notrequired, because if the child is preverbal and an adult isnot present to witness the child’s reaction, then this symp-tom is undetectable. One completely new symptom—loss of previously acquired developmental skills such astoileting and speech—was added to cluster C. It was acommon symptom in prior studies and fit conceptuallywith the avoidance/numbing symptoms. An entirely newcluster was added that contained three symptoms thathad also been frequently observed: new separation anxi-ety, new aggression, and new fears that seemed unrelatedto trauma reminders. These symptoms did not fit con-ceptually into the existing clusters so they were placed ina new cluster for further research. Finally, the algorithmthreshold was changed so that only one avoidance/numb-ing symptom (cluster C) was needed instead of three.Only one hyperarousal symptom (cluster D) was neededinstead of two. One symptom from the new cluster wasneeded. Further details of the rationale for changes canbe found in Scheeringa et al. (1995) and Scheeringa et al.(2001). See Table 1 for details on the modifications.Changes from DSM-IV are highlighted with italics.

Diagnostic Validity of the Alternative Criteria

This alternative set of criteria was compared with theDSM-IV criteria on a sample of 12 cases younger than48 months of age (Scheeringa et al., 1995). Four ratersrated every symptom for all 12 cases from written casesummaries created for the study. The median Cohen κfor interrater reliability for individual alternative symp-toms was 0.67 compared with 0.50 for the DSM-IV symp-toms. The κ values ranged from 0.81 to 1.0 for the clustersin the alternative criteria compared with 0.17 to 0.39 forthe DSM-IV set. The mean κ between raters for PTSDdiagnosis for the alternative set was 0.75 compared with0.50 for the DSM-IV. These results suggested that themodifications to the wording of the symptoms resultedin greater reliability for the alternative criteria. The meannumber of PTSD diagnoses among the four raters was8.3 (out of 12) for the alternative criteria, compared with1.5 diagnoses for the DSM-IV criteria.

A replication of this study on a sample of 15 new casesshowed equal interrater reliability for both the alterna-tive and DSM-IV criteria (Scheeringa et al., 2001). Still,the alternative criteria were more sensitive to detecting

cases. The consensus ratings of two raters diagnosed ninecases by alternative criteria compared with three cases bythe DSM-IV criteria. The alternative algorithm was notmerely allowing mildly symptomatic cases to be diag-nosed because fewer symptoms were required; the meannumber of PTSD symptoms in the nine diagnosed caseswas 9.9 (compared with 4.0 in the six undiagnosed cases,p < .0001). This is comparable (or higher) with the meannumber of symptoms—7.4 symptoms—found in a largenational survey of adult male veterans with PTSD(Kulka et al., 1990). Furthermore, if the DSM-IV algo-rithm was used, three of the five most symptomatic casesdid not meet the threshold for the diagnosis.

One issue of validity that has not been previously testedis convergent validity. Convergent validity exists whenthe variable of interest is shown to associate moderatelywith another variable that is known to co-occur at a rea-sonably high rate, but not 100%. In the case of PTSD,it has been well established that in adults at least one otherdisorder is present at least 80% of the time (Kessler et al.,1995), with depression, generalized anxiety, and alcoholabuse being the most frequent. In contrast, disruptivebehavior disorders are common in traumatized children(Famularo et al., 1992). These associations have neverbeen tested before with PTSD in young children.

The present study tested the alternative criteria in alarger replication study of 62 traumatized subjects andan expanded age range (1–6 years) compared with pre-vious studies. The aims were as follows: (1) We examinedthe validity of the DSM-IV criteria and modifications tothe symptoms and the algorithm on a larger sample. Thefour modification issues were the number of symptomsrequired for cluster C, the option of including the “lossof developmental skills” symptom in cluster C, the num-ber of symptoms required for cluster D, and the utilityof the new cluster E (composed of three symptoms: sep-aration anxiety, aggression, and new fears). (2) Based onthe older child and adult literatures, we hypothesized thatthe PTSD group would have higher rates of comorbiddisorders, greater number of symptoms from each comor-bid disorder, and higher scores on the Child BehaviorChecklist (CBCL) broad bands (Internalizing, Externalizing,and Total scales) compared with a trauma/no PTSD groupand compared with a healthy control group. These wereconsidered tests of convergent validity for the alternativecriteria. The categorical designation of a comorbid dis-order was a more stringent test of comorbidity comparedwith the scalar measure of the number of symptoms of

SCHEERINGA ET AL.

562 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003

a disorder. Designation of a disorder requires meetingthe established thresholds in the DSM-IV for a minimumnumber of symptoms plus a determination of disability.

METHOD

ParticipantsSixty-two traumatized and 63 healthy control children who were

20 months through 6 years of age were recruited and assessed. Thetraumatized children were recruited over 16 months from an inten-

sive care inpatient unit of a level 1 trauma center (n = 21), three bat-tered women’s shelters (n = 19), an outpatient mental health programthat specializes in treating violence-exposed children (n = 9), a pedi-atric cancer program (n = 6), and word of mouth (n = 7). Inclusioncriteria were that the child (1) was between 20 and 83 months of ageat the time of the event and the assessment, (2) experienced an eventthat was life-threatening or witnessed a life-threatening event to his/herparent or sibling, (3) was English-speaking, and (4) showed at leastone PTSD symptom more than 2 months after the event. At least onesymptom was required to ensure that only symptomatic subjects wereenrolled. Because of the preliminary nature of trauma studies in young

PRESCHOOL PTSD CRITERIA

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003 563

TABLE 1Alternative PTSD Criteria for Preschool Children

Trauma HealthySubjects Controls

Alternative Criteria for Preschool Children n % n %

A. The person has been exposed 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. 62 100 0 0(A[2] is not required because preverbal children cannot report on their reaction at the time of the event and an adult may not have been present to witness the child’s reaction.)

B. The traumatic event is persistently reexperienced in one (or more) of thefollowing ways:(1) Recurrent and intrusive recollection of the event (but not necessarily

distressing), including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 23 37 2 3

(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 16 26 3 5

(3) Objective, behavioral manifestations of a flashback are observed but the individual may not be able to verbalize the content of the experience. 4 6 0 0

(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 28 45 0 0

C. Persistent avoidance of stimuli associated with the trauma and numbing ofgeneral responsiveness (not present before the trauma), as indicated by one (or more) of the following:(1) Efforts to avoid activities, places, or people that arouse recollections

of the trauma. 23 37 0 0(2) Markedly diminished interest or participation in significant activities.

Note: In young children, this is mainly observed as constriction of play. 1 2 0 0(3) Feeling of detachment or estrangement from others. Note: In young

children, this is mainly observed as social withdrawal. 8 13 2 3(4) Restricted range of affect (e.g., unable to have loving feelings). 0 0 0 0(5) Loss of previously acquired developmental skills, such as toileting and speech. 16 26 2 3

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by one (or more) of the following:(1) Difficulty falling or staying asleep. 19 31 4 6(2) Irritability or outbursts of anger or extreme temper tantrums and fussiness. 29 47 7 11(3) Difficulty concentrating. 16 26 5 8(4) Hypervigilance. 20 32 1 2(5) Exaggerated startle response. 20 32 4 6

New cluster. At least one (or more) of the following:(1) New separation anxiety. 22 35 1 2(2) New onset of aggression. 28 45 9 14(3) New fears without obvious links to the trauma, such as fear of going to the

bathroom alone or fear of the dark. 25 40 11 17

Note: Modifications in wording to DSM-IV criteria are noted in italics. PTSD = posttraumatic stress disorder.

children, it is not yet entirely clear what constitutes a traumatic stres-sor. By requiring at least one symptom, we sought to make sure wewere not being too liberal in the types of traumas that were included.

Exclusion criteria were (1) disabling preexisting medical disorders,(2) severe developmental disorders, and (3) for the hospitalized injuryvictims, Glasgow Coma Scale score ≤6 in the emergency room. Nopotential subjects met the exclusion criteria. The control children wererecruited from neighbors of the trauma subjects (n = 25) and from aHead Start center (n = 37). No control subjects had experienced alife-threatening trauma. Two other control subjects had been in minorcar collisions, but no one had been injured. After complete descrip-tion of the study to the caregivers, written informed consent wasobtained. Voluntary assent was obtained from the children. The meanduration between the most severe trauma and assessment was 11.3months and the median was 7.5 months (SD 11.1, range 2–52 months).

MeasuresPosttraumatic Stress Disorder Semi-Structured Interview and Observational

Record for Infants and Young Children. The Posttraumatic Stress DisorderSemi-Structured Interview and Observational Record for Infants andYoung Children (Scheeringa and Zeanah, 1994; available from the firstauthor) is an examiner-based (i.e., semistructured) interview of theprimary caregiver. The interviewer read the stem question about eachsymptom. If the respondent endorsed the symptom, then the inter-viewer asked for specific examples until convinced that the symptomwas present and that the symptom caused some level of disability inthe child’s ability to function. For example, the stem question for thedissociation symptom was, “Has your child had flashbacks, where itlooks like he’s reliving the event and reacting to it?” If a parent was notsure what this meant, we used the example of a Vietnam veteran whohears a traffic helicopter in his hometown and dives for cover becausehe believes it is the Vietcong. We then used a case-specific example.For example, if the child had been in a vehicle collision, the interviewerasked whether the child had ever appeared to act as though he/she wasreliving the accident. This symptom was also scored if the child hadepisodes of appearing immobilized and unresponsive. Observationmay play a role in how the interviewer rates a symptom. The child isrequired to be in the room during the interview. The interviewer coulduse observations of the child to direct probes with the caregiver. Forexample, if a child is reenacting a collision with cars on the floor, theinterviewer may use this observation to ask the caregiver whether thisis how the accident happened and whether the child reenacts it athome. The interviewer had discretion to overrule a parent’s endorse-ment of a symptom (or lack of endorsement of a symptom). Symptomsmust have been present over the previous month. The wording of thesymptoms and the frequency of each symptom in the traumatizedgroup are shown in Table 1. The interview allows for a diagnosis to bemade either by the DSM-IV algorithm or by alternative algorithms.This interview was also used on the healthy control subjects to theextent possible. The reexperiencing symptoms could not be asked if achild had not experienced an event because these symptoms are tiedto an event. The avoidance/numbing and arousal symptoms of PTSDare mostly tied to the time of onset, not the nature of the event.Therefore, we could ask these questions of the control subjects in rela-tion to whether there had been a new onset. In a previous study, whentwo raters viewed the same videotape of a clinician administering thisinterview, the median κ for interrater reliability for individual symp-toms was 0.74 (range 0.29–1.0). The κ for endorsing the disorder ofPTSD was 0.74 (Scheeringa et al., 2001). A random sample of 18%of the PTSD interviews (n = 11) of the trauma subjects from the cur-rent study was coded by the principal investigator (PI) from videotapefor interrater reliability. The Cohen κ for all of the 18 PTSD symp-

toms was 0.75. The Cohen κ for scoring enough criteria to meet thealternative diagnosis was 0.79.

National Institute of Mental Health Diagnostic Interview Schedule forChildren, Version 4.0. The National Institute of Mental Health DiagnosticInterview Schedule for Children, Version 4.0 (DISC-IV) (Shaffer et al.,1996), a well-known structured diagnostic interview, was used to assessthe symptoms of four comorbid disorders: separation anxiety disor-der (SAD), major depressive disorder (MDD), attention-deficit/hyper-activity disorder (ADHD), and oppositional defiant disorder (ODD).Interviews were conducted by the PI or trained research assistants.

Child Behavior Checklist. Depending on the age of the child, the 2–3-year-old version or the 4–16-year-old version of the CBCL (Achenbachand Edelbrock, 1983) was used. The bands that were analyzed were theTotal, Internalizing, and Externalizing scores. These were scored beforeupdated preschool forms and profiles became available in 2000.

Procedure

The assessments were conducted in the laboratory and were video-taped. Parents were paid for their participation. The child was in theroom during the interviews. Either the PI or trained research assis-tants conducted all interviews. Interviewers were not blind to traumastatus because knowledge of the traumatic event is necessary to con-duct an interview for PTSD symptoms.

Data Analysis

Descriptive statistics, such as frequency counts and percentages,were used to analyze the frequency of symptoms, clusters, and the diag-nosis. We assessed for the diagnosis by both the DSM-IV algorithmand alternative algorithms. Since there is no simple or establishedmethod for comparing the validity of the different possible changes inthe symptoms or the algorithm, we approached the options for mod-ifying the criteria in a stepwise fashion based on the strength of actualfindings for each issue. The four issues were the number of symptomsrequired for cluster C, the option of including the “loss of develop-mental skills” symptom in cluster C, the number of symptoms requiredfor cluster D, and the utility of the new cluster E (composed of threesymptoms: separation anxiety, aggression, and new fears). The fre-quency of clusters C and D were analyzed by changing the number ofsymptoms required for each. The frequency of cluster C was calcu-lated with and without the “loss of developmental skills” symptomincluded. The results of these descriptive analyses were used to deter-mine the optimal final algorithm, and then the trauma group was sub-divided with this new algorithm into those with PTSD and thosewithout PTSD. The three resultant groups (trauma/PTSD, trauma/noPTSD, and healthy controls) were compared on demographic vari-ables and then used for formal hypothesis-testing with the convergentmeasures (comorbid disorders, comorbid symptoms, and CBCL scales)using the χ2 test for categorical data and the Kruskal-Wallis test forcontinuous data. Pairwise tests were conducted with the χ2 or Wilcoxonrank sum tests to investigate significant effects, with Bonferroni adjust-ment to control Type I error with pairwise contrasts. Comparisons ofsubgroups of the trauma sample by age (1–3 years compared with 4–6years) were conducted with the χ2 and Wilcoxon rank sum tests. Allanalyses were conducted with SAS version 8.0.

RESULTS

Cluster and Diagnosis Frequencies

The frequencies of each cluster and the rate of diag-nosis for varying algorithm thresholds are listed in Table

SCHEERINGA ET AL.

564 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003

2. Cluster B (reexperiencing) was common (68%). ClusterC (avoidance/numbing) based on the DSM-IV thresholdof three or more symptoms was extremely rare (2%) butbecame much more common when the threshold waslowered to one symptom (39%). Cluster D (arousal) wascommon when the DSM-IV threshold of two symptoms(45%) was used, and it was more common when onlyone symptom was required (73%). The new cluster fromthe alternative set (one symptom required) was the mostcommon cluster endorsed (79%).

None of the 62 traumatized children met the diagno-sis of PTSD by the DSM-IV criteria. Changes in the clus-ter C threshold produced the most marked increases inthe rate of diagnosis. The diagnosis rate rose from 0%when three cluster C symptoms were required, to 8%when two symptoms were required, and to 26% whenone symptom was required.

The following steps describe how we approached theoptions for modifying the criteria in a stepwise fashionbased on the strength of actual findings for each issue.The four issues were the number of symptoms requiredfor cluster C, the option of including the “loss of devel-opmental skills” symptom in cluster C, the number ofsymptoms required for cluster D, and the utility of thenew cluster E.

Step 1: Usefulness of Novel Cluster E

Cluster E was the most common cluster (79%) andwas significantly more common compared with clustersC (one symptom required 39%, χ2 = 20.8, p < .0001)and D (two symptoms required 45%, χ2 = 15.1, p =.0001). The requirement for cluster E to be present actu-ally prevented one subject from meeting the diagnosis,regardless of which algorithm were used for the otherclusters. This suggested that cluster E was not markedlyhelpful in discriminating cases of PTSD from noncases.Therefore, it was judged that cluster E not be includedin further analyses of the diagnostic algorithm.

Step 2: Number of Symptoms Required for Cluster D

When two symptoms were required (as in the DSM-IV), the prevalence of cluster D in the trauma group was45%, compared with 73% when one symptom wasrequired. Changing the threshold from two symptomsto one symptom in cluster D translated into four moresubjects reaching the diagnosis of PTSD (20 diagnosesversus 24 diagnoses) when cluster C required one symp-tom and “loss of developmental skills” was included. Thisdifference in diagnosis rates was significant by the McNemartest (p < .05). However, this change in cluster D trans-lated into only two more subjects reaching the diagnosis

PRESCHOOL PTSD CRITERIA

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003 565

TABLE 2Frequencies of Each Cluster and the PTSD Diagnosis Using Different Algorithm Thresholds for the Clusters (N = 62)

Cluster PTSD Diagnosis

No. % No. %

Cluster B. Reexperiencing1 symptom required 42 68 0a 0

Cluster C. Avoidance/numbing≥3 symptoms required 1 2 0b 02 symptoms required 7 11 5b 81 symptom required 24 39 16b 26

Cluster C. “loss of developmental skills” symptom included

≥3 symptoms required 3 5 0b 02 symptoms required 13 21 9b 151 symptom required 32 52 20b 32

Cluster D. Arousal≥2 symptoms required 28 45 16c 261 symptom required 45 73 18c 29

Cluster E. New symptoms1 symptom required 49 79 15d 24

Note: PTSD = posttraumatic stress disorder.a Based on DSM-IV algorithm of three symptoms required for cluster C and two symptoms required for cluster D.b Based on two symptoms required for cluster D. Cluster E not required.c Based on one symptom required for cluster C (“loss of developmental skills” symptom not included). Cluster E not

required.d Based on one symptom required for cluster C and two symptoms required for cluster D.

of PTSD (16 diagnoses versus 18 diagnoses) when “lossof developmental skills” was not included in cluster C.This difference in diagnosis rates was not significant bythe McNemar test (p = .16). Therefore, because clusterD was reasonably common even when two symptomswere required (45%), it was judged that maintaining theDSM-IV requirement of two symptoms for cluster D wasthe most appropriate, conservative threshold.

Step 3: Usefulness of the “Loss of Developmental Skills”Symptom in Cluster C

Table 2 shows the increase in the prevalence of clus-ter C as the threshold is lowered from three symptomsto two symptoms and then to one symptom. This is shownwith “loss of developmental skills” both included andexcluded. When this symptom was included (and onesymptom was required), the rate of PTSD increased from26% to 32%, which was significant by the McNemar test(p < .05) (similar results were obtained when two symp-toms were required). This suggests that the addition ofthis symptom is helpful to identify more cases of PTSD.However, it is notable that when only one symptom wasrequired, and this symptom was not included in clusterC, the rate of PTSD diagnosis was a respectably high26%. One conclusion at this point could be that the mostconservative strategy would be to drop this symptom andrequire only one symptom in cluster C. This would elim-inate the need to add a completely new symptom that isnot part of the DSM-IV and has not been investigatedin a factor analysis with the other symptoms. This ten-tative conclusion, plus the other options, will be furtherinvestigated below in the analysis of comorbidity as ameasure of convergent validity.

Step 4: Number of Symptoms Required for Cluster C

The requirement of three symptoms for cluster C wasmet by only one subject in the trauma group (2%) androse little when “loss of developmental skills” was addedas an option (5%). Because these children were quitesymptomatic as a whole (mean 3.3 ± 2.6, range 0–9 PTSDsymptoms), and the prevalence of the other clusters weredramatically higher, it was judged that the threshold ofthree symptoms was too high to include as an option infurther analyses.

As noted in step 3, the most conservative strategy wouldbe to require only one cluster C symptom and drop the“loss of developmental skills” symptom. This would resultin a prevalence of cluster C of 39% and a prevalence of

PTSD of 26%. The prevalence rates for other optionsare listed in Table 2.

In summary, this stepwise analysis tentatively suggeststhat the most conventional conclusion is that cluster Dought to require two symptoms, cluster E ought not tobe included (but should be retained for further study),cluster C ought to require only one symptom, and the“loss of developmental skills” symptom ought to be dropped(rate of PTSD 26%). Competing options for the optimalset of criteria are to include “loss of developmental skills”in cluster C and require one symptom (rate of PTSD 32%)or two symptoms (rate of PTSD 15%).

Revised Alternative Criteria: Convergent Validity

Based on the findings above, the alternative criteriawere revised for formal hypothesis-testing with the healthycontrol group included. Using these revisions, 16 casesout of 62 traumatized children were diagnosed withPTSD, resulting in a prevalence of 26%. This PTSDgroup had significantly more PTSD symptoms (mean =6.1 ± 1.6) compared with the trauma/no PTSD group(mean = 2.3 ± 2.0) (Wilcoxon pairwise, p < .0001), andcompared with the healthy control group (mean = 0.4 ±0.8) (Wilcoxon pairwise, p < .0001). The trauma/noPTSD group also had more symptoms than the healthycontrol group (Wilcoxon pairwise, p < .0001).

After the trauma group was subdivided by diagnosiswith these revised criteria, they were compared on demo-graphic variables. The three groups (PTSD, trauma/noPTSD, and healthy controls) did not differ from eachother on age of the children, gender, race, mother’s age,father’s age, mother’s employment status, father’s employ-ment status, or duration of time from the last traumaticevent to the assessment. The groups differed on three vari-ables: mother’s years of education (means = 13.5, 11.9,and 12.3 years, respectively; Kruskal-Wallis test [2, n =124] = 11.6, p = .003); father’s years of education (means =13.2, 11.5, and 12.3 years, respectively; Kruskal-Wallistest [2, n = 105] = 10.1, p = .007); and number of parentsin the home (two-parent homes constituted 12.5%, 17.4%,and 52.0%, respectively; χ2 [2, n = 125] = 19.6, p < .0001).

The PTSD group had significantly higher rates of SADand ODD, had more symptoms of SAD and ODD, andscored higher on the CBCL Internalizing and Total scalescompared with the trauma/no PTSD group (Table 3).Differences on MDD, ADHD, and Externalizing werein the expected directions but did not reach conventionallevels of significance with the Bonferroni corrected level

SCHEERINGA ET AL.

566 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003

TABLE 3Analysis by Group (PTSD, Trauma/No PTSD, and Healthy Control) of Measures of Comorbidity

Trauma HealthyPTSD No PTSD Controls

(n = 16) (n = 46) (n = 63)Measure a b c χ2

% (n) % (n) % (n)

SAD disorder 63 (10) 13 (6) 5 (3) <.0001a vs. b***a vs. c***

MDD disorder 6 (1) 7 (3) (0) NSADHD disorder 38 (6) 22 (10) 14 (9) NSODD disorder 75 (12) 28 (13) 13 (8) <.0001

a vs. b**a vs. c***

Mean (SD) Mean (SD) Mean (SD) p (KW)

SAD symptoms 3.3 (1.8) 1.3 (1.5) 0.8 (1.1) <.0001a vs. b***a vs. c***

MDD symptoms 3.1 (2.1) 1.8 (2.1) 0.8 (1.3) <.0001a vs. c***b vs. c*

ADHD symptoms 7.1 (4.6) 5.6 (5.1) 3.3 (3.9) .003a vs. c*

ODD symptoms 5.0 (2.4) 2.7 (2.8) 1.5 (2.0) <.0001a vs. b*a vs. c***b vs. c*

n = 44 n = 61CBCL Total 69.1 (9.4) 58.4 (11.7) 47.1 (12.2) <.0001

a vs. b*a vs. c***b vs. c***

CBCL Internalizing 66.8 (11.7) 55.8 (12.6) 46.1 (11.0) <.0001a vs. b*a vs. c***b vs. c***

CBCL Externalizing 63.3 (11.6) 56.3 (10.8) 49.0 (11.6) .0001a vs. c**b vs. c*

Note: The p values are for the χ2 or Kruskal-Wallis tests between three groups. Pairwise comparisons p values are not shown.Pairwise comparisons adjusted by a Bonferroni correction for three pairwise comparisons—significant α set at .017. PTSD =posttraumatic stress disorder; SAD = separation anxiety disorder; MDD = major depressive disorder; ADHD = attention-deficit/hyperactivity disorder; ODD = oppositional defiant disorder; CBCL = Child Behavior Checklist; NS = not signifi-cant; KW = Kruskal-Wallis.

* p < .01; ** p < .001; *** p < .0001.

of p = .017. The PTSD group scored higher on all comor-bid variables compared with the healthy control groupexcept for the rates of MDD and ADHD.

These analyses of comorbid conditions were rerun withthe two competing options for cluster C. When “loss ofdevelopmental skills” was included and one symptomwas required for cluster C, the PTSD group scored sig-nificantly higher on 10 of the 11 comorbid conditions

(all except ADHD diagnosis) compared with either theno PTSD group or the healthy control group. When “lossof developmental skills” was included and two symptomswere required for cluster C, the identical results werefound. These results are not substantially different fromthe results when “loss of developmental skills” was excludedand one symptom was required (preceding paragraph),in which the PTSD group differed from either of the

PRESCHOOL PTSD CRITERIA

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003 567

other groups on 9 of the 11 comorbid conditions (allexcept MDD diagnosis and ADHD diagnosis). This sug-gested that including “loss of developmental skills” didnot add utility to the diagnostic criteria.

Age Analyses

Younger children (1–3 years, n = 22) did not differfrom the older children (4–6 years, n = 40) on the typeof traumatic experience (experienced directly versus wit-nessed domestic violence). Within the traumatized group,younger children manifested significantly higher rates ofcluster B (reexperiencing) symptoms; more symptoms ofPTSD, SAD, and MDD; and higher CBCL Internalizing,Externalizing, and Total scores compared with older chil-dren (Table 4). We then analyzed the four symptoms ofcluster B individually. The younger children manifestedhigher rates of intrusive recollections of the trauma (includ-ing play reenactments) (χ2 p = .03) and nightmares (χ2

p = .009) but did not differ on distress at exposure toreminders or on flashbacks.

DISCUSSION

The results of this study make several contributionsto understanding the diagnostic validity of PTSD inyoung children. First, validation was provided again fordevelopmentally modifying the DSM-IV criteria. Theoptimal (tentative) revision suggested by these findings

is lowering the threshold for cluster C from three symp-toms to one symptom. This results in a diagnosis rate of26%, which contrasts to the DSM-IV rate of 0%. The26% rate is much more consistent with studies of trau-matized older children and adults, which—although ratesof PTSD vary widely by type of trauma—are never 0%(reviewed by Kilpatrick and Resnick, 1993). This rate islower than that in two previous studies using alternativecriteria (69% and 60%) (Scheeringa et al., 1995, 2001),but those studies assessed exclusively help-seeking clinicpatients. When cases were diagnosed with this one-symptom threshold for cluster C, this cleaved the sam-ple into a PTSD group that was still extremely symp-tomatic (6.1 symptoms on average) and a non-PTSDgroup (2.3 mean symptoms), indicating that we are notmerely diagnosing mildly symptomatic individuals withthis method. The suggestion to lower the cluster C thresholdis not new, even for traumatized adults (reviewed byKilpatrick and Resnick, 1993).

Our prior suggestion to lower the threshold for clusterD from two symptoms to one symptom was not supported.All of the completely new symptoms that had been previ-ously proposed (loss of developmental skills, new aggres-sion, new separation anxiety, and new unrelated fears) werenot indispensable. Still, we believe these novel symptomsought to be retained in studies as associated symptomssince they have been among the most common symptomsmanifested by young children in this and prior studies

SCHEERINGA ET AL.

568 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003

TABLE 4PTSD and Comorbid Measures by Age Group in Traumatized Children Only

1–3 Years (n = 22) 4–6 Years (n = 40)% or Mean (SD) % or Mean (SD) p

(B) Reexperiencing cluster 91% 55% .004(C) Avoidance/numbing cluster a 45% 35% NS(D) Arousal cluster 55% 40% NSPTSD diagnosis 32% 23% NSNo. of PTSD symptoms 4.2 (2.4) 2.9 (2.6) .03SAD symptoms 2.5 (1.7) 1.5 (1.7) .01MDD symptoms 3.2 (2.7) 1.6 (1.5) .02ADHD symptoms 6.3 (4.9) 5.8 (5.1) NSODD symptoms 4.0 (2.3) 3.0 (3.2) NS

n = 38CBCL Total 66.5 (11.0) 58.3 (11.7) .008CBCL Internalizing 64.3 (10.7) 55.6 (13.6) .01CBCL Externalizing 63.3 (9.5) 55.2 (11.3) .004

Note: The presence of clusters and the diagnosis were analyzed with χ2 tests. The number of symptoms and CBCL scoreswere analyzed with Wilcoxon rank sum two-sided z tests. PTSD = posttraumatic stress disorder; SAD = separation anxietydisorder; MDD = major depressive disorder; ADHD = attention-deficit/hyperactivity disorder; ODD = oppositional defiantdisorder; CBCL = Child Behavior Checklist; NS = not significant.

a Avoidance/numbing cluster scored using the alternative threshold of one symptom required.

(Scheeringa et al., 1995, 2001). They may be useful indimensional assessment tools of PTSD or for other pur-poses such as predicting treatment outcome or correlatingwith neurobiological or parental variables.

Second, for the first time, the high rate of comorbid-ity that has been documented in older children and adults(e.g., Kessler et al., 1995) was replicated in young chil-dren. This spectrum of disorders includes anxiety, affec-tive, and disruptive behavior disorders. Similarly, thePTSD subjects also scored higher on all three CBCLbroad bands. This replication in a younger age group pro-vides additional support for the construct validity ofPTSD in general and for the alternative algorithm for thediagnosis in particular.

An unexpected finding was that the younger subgroup(1–3 years) of traumatized children manifested moresymptoms of cluster B, SAD, and MDD and were ratedhigher on the CBCL broad bands (Total, Internalizing,and Externalizing) compared with the older subgroup(4–6 years). Specifically, within cluster B, the youngerchildren manifested more intrusive recollections and morenightmares. A prior study found that traumatized chil-dren aged between 19 and 48 months showed signifi-cantly more reexperiencing symptoms compared withyounger children aged between 3 and 18 months (Scheeringaand Zeanah, 1995). This combination of results suggestsa developmental window between 18 and 48 months ofage in which a variety of symptoms, including reexperi-encing symptoms specifically, develop more often com-pared with both older and younger children followingtrauma. Laor et al. (1996) found no differences between3-, 4-, and 5-year old children following missile attackson number of general stress symptoms, CBCL Internalizingscores, or CBCL Externalizing scores, but specific PTSDsymptoms were not measured. It is not clear from thesepreliminary data why such a window should exist. Froma developmental perspective, we had expected that theolder children would manifest these symptoms more oftenbecause they have more advanced abstract thought andnarrative speech capacities. A direction for future researchwould be to characterize these symptoms by age groupsmore systematically, such as by the content of reexperi-encing, frequency, onset, and context.

Limitations

An important limitation of this study is the small sam-ple size, although this is the largest study to date of per-sonalized trauma in this age group. A possible limitation

of this study is that the interview measure for PTSD hasnot been subjected to large-scale use at multiple sites. Toreduce bias toward overendorsing symptoms in young chil-dren, we constructed the interview and trained the inter-viewers so that they had to ask for details of onset, duration,frequency, and intensity, and for examples of symptomsto convince themselves that a symptom was present. Anotherlimitation was that there is no gold standard, as with manyother psychiatric diagnoses, against which to test the sen-sitivity and specificity of the proposed criteria.

Clinical Implications

The potential clinical impact of these findings includesthat more highly symptomatic young children can receivethe diagnosis when alternative criteria rather than DSM-IV criteria are used. This may remove one barrier to receiv-ing clinical treatment and/or educational remedial services.In contrast to the Lavigne et al. (1996) epidemiologicalsurvey that found a prevalence of PTSD (0.1%) vastlybelow the rates for older children and adults, we believethat the use of this alternative set of criteria in future epi-demiological studies will more accurately identify the scopeof young children who need services for clinical-level psy-chopathology. We hope these findings also will encouragetreatment efficacy studies and clinical research on the impor-tant differential correlates of disorder, such as neurobio-logical variables, which have been rare in this age group.

Cluster C is the most problematic to assess clinically.Of the seven DSM-IV cluster C symptoms, two of them(partial psychogenic amnesia for the event and sense ofa foreshortened future) are not applicable to young chil-dren (Scheeringa et al., 1995). Another symptom—avoid-ance of thoughts, feelings, or conversations associatedwith the trauma—is extremely difficult to ascertain inyoung children.

Future directions for research ought to include furtherpsychometric evaluation of these criteria in multisite stud-ies with different trauma cohorts. The effects of age, gen-der, race, and socioeconomic status need to be examined.The sensitivity of the criteria to treatment and the degreeof correlation with existing scales of PTSD for older chil-dren and with neurobiological variables need to be inves-tigated.

REFERENCES

Achenbach T, Edelbrock C (1983), Manual for the Child Behavior Checklistand Revised Child Behavior Profile. Burlington: University of VermontDepartment of Psychiatry

PRESCHOOL PTSD CRITERIA

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003 569

Cuffe SP, Addy CL, Garrison CZ et al. (1998), Prevalence of PTSD in a com-munity sample of older adolescents. J Am Acad Child Adolesc Psychiatry37:147–154

Famularo R, Kinscherff R, Fenton R (1992), Psychiatric diagnoses of maltreatedchildren: preliminary findings. J Am Acad Child Adolesc Psychiatry 31:863–867

Gaensbauer TJ (1994), Therapeutic work with a traumatized toddler. PsychoanalStudy Child 49:412–433

Helzer JE, Robins L, McEvoy L (1987), Post-traumatic stress disorder in thegeneral population. N Engl J Med 317:1630–1634

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995), Posttraumaticstress disorder in the National Comorbidity Survey. Arch Gen Psychiatry52:1048–1060

Kilpatrick DG, Resnick HE (1993), Posttraumatic stress disorder associatedwith exposure to criminal victimization in clinical and community pop-ulations. In: Posttraumatic Stress Disorder: DSM-IV and Beyond, DavidsonJRT, Foa EB, eds. Washington, DC: American Psychiatric Press, pp 113–143

Kulka RA, Schlenger WE, Fairbank JA et al. (1990), Trauma and the VietnamWar Generation: Report of Findings From the National Vietnam VeteransReadjustment Study. Philadelphia: Brunner/Mazel

Laor N, Wolmer L, Mayes LC et al. (1996), Israeli preschoolers under Scudmissile attacks. Arch Gen Psychiatry 53:416–423

Lavigne JV, Gibbons RD, Christoffel KK et al. (1996), Prevalence rates andcorrelates of psychiatric disorders among preschool children. J Am AcadChild Adolesc Psychiatry 35:204–214

Reinherz HZ, Giaconia RM, Lefkowitz ES, Pakiz B, Frost AK (1993), Prevalenceof psychiatric disorders in a community population of older adolescents.J Am Acad Child Adolesc Psychiatry 32:369–377

Scheeringa MS, Peebles CD, Cook CA, Zeanah CH (2001), Toward estab-lishing procedural, criterion and discriminant validity for PTSD in earlychildhood. J Am Acad Child Adolesc Psychiatry 40:52–60

Scheeringa MS, Zeanah CH (1994), PTSD Semi-Structured Interview andObservational Record for Infants and Young Children. Department of Psychiatryand Neurology, Tulane University Health Sciences Center, New Orleans(available from M. Scheeringa, 1440 Canal Street, TB52, Tidewater Building,10th Floor, New Orleans, LA 70112)

Scheeringa MS, Zeanah CH (1995), Symptom expression and trauma vari-ables in children under 48 months of age. Infant Ment Health J 16:259–270

Scheeringa MS, Zeanah CH, Drell MJ, Larrieu JA (1995), Two approachesto the diagnosis of posttraumatic stress disorder in infancy and early child-hood. J Am Acad Child Adolesc Psychiatry 34:191–200

Shaffer D, Fisher P, Dulcan M et al. (1996), The NIMH Diagnostic InterviewSchedule for Children Version 2.3 (DISC-2.3): description, acceptability,prevalence rates, and performance in the MECA study. J Am Acad ChildAdolesc Psychiatry 35:865–877

Terr L (1988), What happens to early memories of trauma? A study of twentychildren under age five at the time of documented traumatic events. J AmAcad Child Adolesc Psychiatry 27:96–104

SCHEERINGA ET AL.

570 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42 :5 , MAY 2003