Post-traumatic stress disorder symptomatology, often non-recognized,
among psychiatric inpatient children and adolescents

Trauma has in recent years been recognized as a major risk factor for psychopathology among children and adolescents. Events and situations associated with trauma are either related to people e.g. physical/sexual abuse, or to natural catastrophes e.g. earthquakes. Studies have shown that 40-50% of children and adolescents up to the age of 18 years have a history of exposure to traumatic events and that 6% suffer of Post-Traumatic Stress Disorder (PTSD) while in clinical populations the numbers and proportions are higher. Yet severe psychopathology among children and adolescents admitted to an inpatient psychiatric unit may not be linked to traumatic experiences unless an in depth assessment is undertaken.

In the present study we investigated in depth 56 children and adolescents, admitted to the inpatient unit of the Department of Child Psychiatry, Athens University Medical School at the "Aghia Sophia" Children's General Hospital, Athens/Greece, over a three year period, with the view of identifying PTSD symptomatology among them. For the assessment a detailed history and the following measures were taken: the semistructured psychiatric interview for children and adolescents Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), the Children's Global Assessment Scale (C-GAS), and the Children's Depression Inventory (CDI). A diagnosis on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was also made. Results showed that 75% of the hospitalized children and adolescents had been exposed to violent events, either in their family or/and in the community; the mean number of violent traumatic events experienced by them were 1.45. Nineteen percent of the inpatients had developed PTSD (26% of all children and adolescents exposed to traumatic events) while larger number of this population had developed symptoms of PTSD i.e. not the full psychiatric disorder. Exposure to violence and PTSD were more common among girls than among boys (67% vs. 33% and 82% vs. 18% respectively).

Common among those with PTSD symptomatology was sexual abuse (82%) while from the cases with sexual abuse 89% exhibited PTSD. In all these cases, the sexual abuse was recurrent, usually intrafamilial (89%), violent (90%), with mean age of onset the 9.2 years. High rates of comorbidity were observed among those with PTSD; the main comorbid disorders found were mood disorders (3/4 of all cases), but also somatisation, conduct, generalised anxiety and in small percentages eating and psychotic disorders. En 73% of PTSD cases and in 48.4% of those exposed to traumatic events, suicidal attempts were reported (67% and 53% respectively had reported suicidal ideation) while at the same time the percentage of the inpatients with attempted suicides as a result of other psychiatric disorders was 19%. In addition, parents seemed to underreport PTSD symptoms in their children such as emotional numbness and reexperience the traumatic situation. It is concluded that severely disturbed children and adolescents admitted to a psychiatric unit should be investigated for PTSD symptomatology (but also for comorbid psychiatric disorders and suicidal behaviour) which may require specific treatment approaches and psychosocial interventions. We also suggest that all children and adolescents admitted to a psychiatric unit for suicidal behaviour should also be assessed for possible exposure to traumatic events and development of PTSD.

Key words: Post-traumatic stress disorder, sexual and physical abuse, inpatient therapy, children and adolescents.