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Consequences for children and adolescents regarding the ICD-11 proposal to drastically reduce PTSD symptoms

March 4, 2016

The classification of posttraumatic stress disorder (PTSD) underwent major changes between the different versions of the “International Classification of Diseases” (ICD) and the “Diagnostic and Statistical Manual of Mental Disorders” (DSM). Likewise the difference between normal and abnormal states in individuals has changed following revisions of the ICD and the DSM. Whereas the DSM-5 defined a broad spectrum of 20 different trauma-related symptoms, a working group of the “World Health Organization” (WHO) for stress-related disorders of the ICD-11 proposed a reduced set of six “core” criteria for diagnosing PTSD. The ICD-11 Working Group has included descriptions of age-related symptom presentations for children and adolescents in their proposal. However, neither child-specific symptom modifications nor child-specific diagnostic algorithms were specified. The generalization of diagnostic criteria developed for and with adults to children was criticized as not appropriate for minors who tend to develop different, fewer or less pronounced symptoms after exposure to traumatic stress compared with adults (Carrion, Weems, Ray, & Reiss, 2002; Cohen & Scheeringa, 2009; Scheeringa, Wright, Hunt, & Zeanah, 2006).

In many countries worldwide access to medical care and therapy is based on ICD criteria. We were interested how the reduction of symptoms planned for ICD-11 will affect the diagnostic presence of PTSD in children and adolescence compared to the ICD-10 and the DSM-IV algorithms. Our results show that in a clinical sample of children and adolescents the prevalence of PTSD is significantly affected by the use of different diagnostic systems. The use of the reduced set of symptoms proposed for ICD-11 resulted in 27.1% less diagnoses compared with ICD-10 and 15.1% less diagnoses compared with DSM-IV. The results of our study raise concerns whether the advantages of simpler "core" PTSD criteria go along with a significantly higher threshold for a full PTSD diagnosis in children and adolescents. It has to be considered that depending on the algorithm used, different patients will be included in studies and different individuals will gain access to medical care and therapy.

Reference Article

Sachser C, Goldbeck L. Consequences of the Diagnostic Criteria Proposed for the ICD-11 on the Prevalence of PTSD in Children and Adolescents. Journal of Traumatic Stress. 2016
 

Discussion questions

  1. Should developmental differences in PTSD phenomenology be considered for ICD-11 in form of more sensitive algorithms or different symptoms in children and adolescents?
  2. Who is aware of studies that might guide the development of child-specific PTSD criteria?
  3. Are there specific clinical observations that should be taken into account when developing child-specific PTSD criteria?

Author Biographies

Cedric Sachser, M.Sc., is doctoral student at the University of Ulm, Department for Child and Adolescent Psychiatry/Psychotherapy. His primary research interests include phenomenology of PTSD and treatment of traumatized children and adolescents.

Lutz Goldbeck, Ph.D. is professor for child and adolescent psychiatry/psychotherapy at the University of Ulm, Department for Child and Adolescent Psychiatry/Psychotherapy. His research is about adjustment of children, adolescents and adults to traumatic life events, and about the development and evaluation of psychological interventions for individuals and families.
 

References

Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002). Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. Journal of the American Academy of Child and Adolescent Psychiatry, 41(2), 166-173.

Cohen, J. A., & Scheeringa, M. S. (2009). Post-traumatic stress disorder diagnosis in children: challenges and promises. Dialogues in Clinical Neuroscience, 11, 91-99.

Scheeringa, M. S., Wright, M. J., Hunt, J. P., & Zeanah, C. H. (2006). Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. American Journal of Psychiatry, 163, 644-651.