1. California State University, Los Angeles
Arousal And Startle In Maltreated Children With And Without Posttraumatic Stress Disorder
Cynthia Perez
Laura Mickes
Danielle Morgan
Veronica Reamon
Dr. Mitchell Eisen
California State University, Los Angeles

2. What is Posttraumatic Stress Disorder (PTSD)?
The development of characteristic symptoms following exposure to an extreme traumatic stressor.
PTSD can develop when a person has been exposed to a traumatic event.
Diagnostic and Statistical Manual of Mental Disorders 4th edition text revision.
(2000) American Psychiatric Association.

3. Diagnostic features of PTSD Includes 5 Classes of Symptoms
Persistent symptoms of increased arousal including:
Difficulty falling or staying asleep
Irritability or outburst of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Diagnostic and Statistical Manual of Mental Disorders 4th edition text revision.
(2000) American Psychiatric Association

4. Background
There have been many studies examining different types of physiological arousal responses in adults with PTSD.
Sample: Vietnam Veterans
Physiologic arousal : startle paradigm
Exaggerated startle response has been studied both in relation to conditioned stimuli, like trauma-related cues and unconditioned stimuli, like loud tones.
(Orr, Lasko, Shalev, Pitman, 1995:Shalev, Orr, & Pitman 1997; Shalev et al. 1992; Metzger, et al. 1999)

5. Background
There have been many studies examining different types of physiological arousal responses in adults with PTSD.
Sample: Vietnam Veterans
Physiologic arousal : startle paradigm
Exaggerated startle response has been studied both in relation to conditioned stimuli, like trauma-related cues and unconditioned stimuli, like loud tones.
Results from these studies show that Vietnam Veterans with PTSD have elevated resting heart rates and a higher startle response to unannounced tones than Veterans without PTSD.
(Orr, Lasko, Shalev, Pitman, 1995:Shalev, Orr, & Pitman 1997; Shalev et al. 1992; Metzger, et al. 1999)

6. Assessing PTSD in Children
There is much disagreement as to how PTSD is presented in children.
While hyperarousal is seen as one of the most prominent symptoms in diagnosing children with PTSD there are NO studies validating increased arousal in this group.
There is only one study examining children with PTSD. (Orniz & Pynoos, 1989)

7. Study of Children with PTSD
Sample: 6 children with PTSD and 6 children with no PTSD.
Results are inconsistent with findings in the adult literature.
Namely, that children show lower rates of arousal and startle.

8. Study of Children with PTSD
Sample: 6 children with PTSD and 6 children with no PTSD.
Results are inconsistent with findings in the adult literature.
Namely, that children show lower rates of arousal and startle.
Overall , PTSD is NOT well understood in children.
Research validating commonly held assumptions on how PTSD is expressed in children is desperately needed.

9. Questions?
Do children with PTSD present the same way as adults with PTSD?
Do maltreated children with PTSD present differently from maltreated children without symptoms of PTSD?

10. Hypotheses
Children with PTSD will show increased arousal in a resting state resulting in larger heart rate levels when compared to maltreated children without PTSD.
The PTSD group will show a greater amplitude of startle response when compared to maltreated children without PTSD.

11. Participants
All children were recruited through the Los Angeles Dependency Court and through attorney referrals.
Research assistants make daily visits to the court to recruit children through incoming faxes: referrals for treatment.
They then contact the CSW, read scripts approved by the court to the CSW and caregiver, and finally schedule an appointment for the child here at CSULA.

12. Participants
Recruited over 40 children with a verifiable history of maltreatment
Some children were dropped because they had serious burns, opted not to participate, or there were problems with the psychophysiological monitoring.
Only able to use data for 19 (12 males, 7 females) children.
Age ranged from 6 – 12 years (M =9.67, SD = 1.88).
11 children with PTSD( 6 males, 5 females)
8 children with no PTSD(6 males, 2 females).

13. Procedures Child assent form
Hearing Test: each child’s hearing was assessed before running startle.
Memory for Sentences subtest, from the Stanford- Binet Standardize Intelligence Test

14. Procedures
Our procedures and equipment for assessing arousal and startle were identical to those used by Orr et al. (1995).
Used Coulbourn Lablic Progammable Digital to Analog Converter
Participants listen to a series of announced and unannounced tones.
Dependent physiologic measures were the same as those used by Orr et al. and included Eye blink (EMG), Skin conductance (SC), and Heart Rate (HR).

15. STARTLE PARADIGM
Instructed participants to wash their hands, arms and face.
Testing took place in an isolated room connected through cables to an adjoining room in which the experimental apparatus were located
We started the startle paradigm by showing the kids a video so that they could relax while we abraded their skin and hooked up the electrodes.

16. STARTLE PARADIGM
We slightly abraded the children’s skin to increase the reliability of readings: arms (HR) and under their eye lids (EMG).

17. STARTLE PARADIGM Eye blink response (EMG)
Placed two electrodes over the orbicularis oculi muscle to measure eye blink response (EMG).

18. STARTLE PARADIGM Skin Conductance (SC)
Placed two electrodes over the hypothenar surface of the participant’s hand to measure skin conductance (SC).

19. STARTLE PARADIGM
Heart Rate (HR)
Heart rate (HR) was recorded from the standard limb electrocardiogram leads.
We checked readings by asking the child to take a deep breath and scrunch up their face.
We put a Velcro band lightly around the child’s wrists.

20. STARTLE PARADIGM
We placed headphones on the child and instructed him or her to sit still and watch a relaxing dolphin video while we gathered resting HR levels.
Once resting HR levels were recorded we again instructed kids to sit still and keep their eyes open.

21. STARTLE PARADIGM Run 15 trials
Startle was measured by increased heart rate and skin conductance when the unannounced tones were introduced.
Research assistant monitors the child through an unobtrusive video camera.

22. Additional Testing Depression: Child Depression Inventory (CDI-S)
PTSD: Posttraumatic Stress Structure Interview for Children (PT-SIC)
Anxiety: State and Trait Anxiety Inventory for children (STAIC)
Intelligence: A short form of the Wechsler Intelligence Scale for Children 3rd edition (WISC III)

23. Results
As you can see there are no differences in resting heart rate between the groups.
Both groups averaged about 79 beats per minute
Resting heart rate scores were averaged during the baseline period.

24. Results
As you can see there was a difference in the magnitude of startle response between the groups. The PTSD group had larger startle responses to the loud tones than the no PTSD group.
HR response scores were calculated using the method of Orr et al (1995). We obtained the final score by subtracting pre and post tone mean hr levels. HR responses were averaged across the 15 tone presentation and a square root transformation was performed to reduce heteroskedasticity.

25. Discussion
Our hypothesis that children with PTSD would show a larger startle response to loud tones than children without PTSD was supported.
Our findings support clinical assumptions of an exaggerated startle response in children with PTSD.
Our study is significant considering there is a dire need for research with PTSD children.
Future research should continue address the presentation of PTSD in children.

26. California State University, Los Angeles
Arousal And Startle In Maltreated Children With And Without Posttraumatic Stress Disorder
Cynthia Perez
Laura Mickes
Danielle Morgan
Veronica Reamon
Dr. Mitchell Eisen
California State University, Los Angeles