The diagnosis of posttraumatic stress disorder (PTSD) was formally recognized as a psychiatric diagnosis in 1980. At that time little was known about what PTSD looked like in children and adolescents. Today, we know children and adolescents are susceptible to developing PTSD and that PTSD has different age-specific features. In addition we are beginning to develop child-focused interventions. Further information is provided below regarding: what events cause PTSD in children, how many children develop PTSD, risk factors, what PTSD looks like in children, other effects of trauma on children, treatment, and what you can do for your child.
What events cause PTSD in children?
The diagnosis of PTSD requires that an individual experience an event that involves a threat to one's own or another's life or physical integrity and that they respond with intense fear, helplessness, or horror. There are a number of traumatic events that have been shown to cause PTSD in children and adolescents. Studies document PTSD in child and adolescent survivors of: natural and man made disasters such as floods; violent crimes such as kidnapping, rape or murder of a parent, sniper fire, and school shootings; motor vehicle accidents such as automobile and plane crashes; severe burns; exposure to community violence; war; peer suicide; and sexual & physical abuse.
How many children develop PTSD?
Few studies have been conducted that examine rates of exposure and PTSD in children and adolescents from the general population. Results from these studies indicate that 15 to 43% of girls and 14 to 43% of boys have experienced at least one traumatic event in their lifetime. Of those children and adolescents who have experienced a trauma, 3 to 15% of girls and 1 to 6% of boys meet criteria for PTSD.
Rates of PTSD are much higher in children and adolescents recruited from at risk samples, varying from 3-100%. For example, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault, 90% of sexually abused children, 77% exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.
What are the risk factors for PTSD?
There are three factors that have been shown to increase the likelihood that children will develop PTSD: the severity of the traumatic event, the parental reaction to the traumatic event, and the temporal proximity to the traumatic event. In general, most studies find a strong relationship between children's reports of trauma severity and PTSD. As would be expected, children and adolescents who report having experienced the most severe traumas also report the highest levels of PTSD symptoms. Family support and parental coping has also been shown to effect PTSD symptoms in children. Studies show that children and adolescents with greater family support and less parental distress have lower levels of PTSD symptoms. Finally, children and adolescents who are farther away from the traumatic event report less distress.
There are several other factors that have been shown to be related to PTSD. Research suggests that interpersonal traumas such as rape and assault are more likely to result in PTSD than other types of traumas. Additionally, there is a relationship between the total number of previous traumas an individual has experienced and PTSD, with greater numbers of traumatic events increasing the risk of developing PTSD. In terms of gender, several studies suggest that girls are more likely than boys to develop PTSD. A few studies have examined the connection between ethnicity and PTSD. While some find that minorities report higher levels of PTSD symptoms, this has been shown to be due to other factors such as differences in levels of exposure. The impact of age at time of exposure and PTSD is less clear. While some studies find a relationship others do not. Differences may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels (see next section).
What does PTSD look like in children?
Researchers and clinicians are beginning to recognize that PTSD may not present itself in children in the same way as it does in adults (see what is PTSD?). This can be seen in reviewing the criteria for PTSD which now lists age specific features for some symptoms.
Very young children may present with few PTSD symptoms. It has been suggested that this is because eight of the PTSD symptoms require a verbal description of one's feelings and experiences. Instead, young children may report more generalized fears such as stranger or separation anxiety, avoidance of situations that may or may not be related to the trauma, sleep disturbances, and a preoccupation with words or symbols that may or may not be related to the trauma. These children may also display posttraumatic play in which they repeat themes of the trauma in. In addition, children may loose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event.
Clinical reports suggest that elementary school-aged children may not experience amnesia for aspects of the trauma or visual flashbacks. However, they do experience "time skew" and "omen formation" which is not typically seen in adults. Time skew refers to a missequencing of trauma related events when recalling the memory. Omen formation is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough they will recognize warning signs and avoid future traumas. School aged children also reportedly exhibit posttraumatic play or reenactment of the trauma in play, drawings, or verbalizations. Posttraumatic play is distinguished from reenactment in that posttraumatic play involves compulsively repeating some aspect of the trauma, is a literal representation of the trauma, and does not tend to relieve anxiety (e.g., an increase in shooting games after exposure to a school shooting) while posttraumatic reenactment is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).
PTSD in adolescents may begin to more closely resemble PTSD in adults. However, there are a few features that have been shown to differ. As discussed above, children may engage in traumatic play following a trauma. Adolescents are more likely to engage in traumatic reenactment in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.
Besides PTSD, what are the other effects of trauma on children?
Besides PTSD, children and adolescents who have experienced traumatic events often exhibit other types of problems. Perhaps the best information available on the effects of traumas on children comes from a review of the literature on the effects of child sexual abuse. In this review it was shown that sexually abused children often have problems with: fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self esteem, difficulty in trusting others, and substance abuse. These problems are often seen in children and adolescents who have experienced other types of traumas as well. In addition, children who have experienced traumas often have relationship problems with peers and family members, behavioral acting out, and problems with school performance.
Along with associated symptoms, there are a number of psychiatric disorders that are also commonly found in children and adolescents who have been traumatized. One commonly co-occurring disorder is major depression. Other disorders include: substance abuse; other anxiety disorders such as separation anxiety, panic disorder; and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.
How is PTSD treated in Children and Adolescents?
Although some children show a natural remission in PTSD symptoms over a period of a few months, there are a significant number of children for whom PTSD persists for years if untreated. Few treatment studies have been done examining which treatments are most effective for children and adolescents. A review of the adult treatment studies of PTSD shows that cognitive behavioral treatment (CBT) is the most effective approach. CBT for children generally includes: exposure (child directly discusses the traumatic event), anxiety management techniques such as relaxation and assertiveness training and correction of inaccurate or distorted trauma related thoughts. Although there is some controversy regarding exposing children to the events that scare them, exposure based treatments seem to be most relevant when the child is distressed by trauma-related memories or reminders. Exposure can be done gradually and can be paired with relaxation such that children can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be scared of their memories. CBT also involves challenging children's false beliefs such as the belief that "the world is totally unsafe." The majority of studies that have been conducted using CBT for children with PTSD have found that it is safe and effective.
CBT is often accompanied by psychoeducation (i.e., education about PTSD symptoms and its effects) and parental involvement. Psychoeducation is the process of learning about the symptoms of PTSD. It is equally important for parents and caregivers to understand the effects of PTSD. In addition, research shows that the better parents cope with the trauma and the more they support their children, the better their children will function. Therefore, at times it is important for parents to seek treatment to develop the necessary coping skills to support their children.
Several other types of therapy have been suggested for the treatment of PTSD in children and adolescents. Play therapy can be used to treat young children with PTSD who are not able to deal with the trauma more directly. The therapist uses games, drawings, and other techniques to help the child process their traumatic memories. "Psychological first aid" has been described for children exposed to community violence and can be used in school as well as traditional settings and involves: clarifying trauma related facts, normalizing the children's PTSD reactions, encouraging the expression of feelings, teaching problem solving skills, and referring the most symptomatic children for additional treatment. Twelve step approaches have been described for adolescents with substance abuse and PTSD. Eye movement desensitization and reprocessing (EMDR) has been used which combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating some adults with PTSD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change. Medications have also been used with some children with PTSD However, due to the lack of research in this area, it is too early to evaluate its effectiveness.
Finally, specialized interventions may be necessary for children exhibiting particularly problematic behaviors or PTSD symptoms. For example, a specialized intervention might be required for inappropriate sexual behavior or extreme behavior problems.
What can I do to help my child?
Reading this fact sheet is a first step towards helping your child. Gather information on PTSD and pay attention to how your child is functioning. Watch for warning signs such as: sleep problems, irritability, avoidance, change in school performance, and peer problems. Consider having you child evaluated by a mental health professional with experiences in treating PTSD in children and adolescents. Many therapists with this experience are members of the International Society for Traumatic Stress Studies, whose membership directory contains a geographical listing of those who treat children and adolescents Ask how they typically treat PTSD and choose a practitioner with whom you and your child feel comfortable. Consider whether you might also benefit from talking to someone. The most important thing that you can do now is to support your child.
Based in part on the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, Journal of the American Academy of Child and Adolescent Psychiatry, 37:10 supplement, October 1998.