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May 23, 2012

PTSD in Children and Adolescents

A National Center for PTSD Fact Sheet
By Jessica Hamblen, Ph.D.

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 we know that PTSD has different age-specific features. In addition, we are beginning to develop child-focused interventions. This fact sheet provides information regarding what events cause PTSD in children, how many children develop PTSD, risk factors associated with PTSD, what PTSD looks like in children, other effects of trauma on children, treatment for PTSD, and what you can do for your child.

What events cause PTSD in children?

A diagnosis of PTSD means that an individual experienced an event that involved a threat to one's own or another's life or physical integrity and that this person responded with intense fear, helplessness, or horror. There are a number of traumatic events that have been shown to cause PTSD in children and adolescents. Children and adolescents may be diagnosed with PTSD if they have survived 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 and physical abuse.

How many children develop PTSD?

A few studies of the general population have been conducted that examine rates of exposure and PTSD in children and adolescents . 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 could be diagnosed with PTSD.

Rates of PTSD are much higher in children and adolescents recruited from at-risk samples. The rates of PTSD in these at-risk children and adolescents vary from 3 to 100%. For example, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault develop PTSD. Similarly, 90% of sexually abused children, 77% of children 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. These factors include the severity of the traumatic event, the parental reaction to the traumatic event, and the physical proximity to the traumatic event. In general, most studies find that children and adolescents who report experiencing the most severe traumas also report the highest levels of PTSD symptoms. Family support and parental coping have also been shown to affect 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 affect the occurrence and severity of PTSD. Research suggests that interpersonal traumas such as rape and assault are more likely to result in PTSD than other types of traumas. Additionally, if an individual has experienced a number of traumatic events in the past, those experiences increase 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 studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure. It is not clear how a child's age at the time of exposure to a traumatic event impacts the occurrence or severity of PTSD. While some studies find a relationship, others do not. Differences that do occur 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 the same way it does in adults (see What is PTSD? below). Criteria for PTSD now include age-specific features for some symptoms.

Very young children may present with few PTSD symptoms. This may be 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 addition, children may lose 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 visual flashbacks or amnesia for aspects of the trauma. However, they do experience "time skew" and "omen formation," which are not typically seen in adults. Time skew refers to a child mis-sequencing 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 different from reenactment in that posttraumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety. An example of posttraumatic play is an increase in shooting games after exposure to a school shooting. Posttraumatic reenactment, on the other hand, 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. Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.

Along with associated symptoms, there are a number of psychiatric disorders that are 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, a significant number of children continue to exhibit symptoms for years if untreated. Few treatment studies have examined which treatments are most effective for children and adolescents. A review of the adult treatment studies of PTSD shows that Cognitive-Behavioral Therapy (CBT) is the most effective approach. CBT for children generally includes the child directly discussing the traumatic event (exposure), 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 memories or reminders of the trauma distress the child. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories. CBT also involves challenging children's false beliefs such as, "the world is totally unsafe." The majority of studies have found that it is safe and effective to use CBT for children with PTSD.

CBT is often accompanied by psycho-education and parental involvement. Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function. Therefore, it is important for parents to seek treatment for themselves in order to develop the necessary coping skills that will help their children.

Several other types of therapy have been suggested for 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 children process their traumatic memories. Psychological first aid has been prescribed for children exposed to community violence and can be used in schools and traditional settings. Psychological first aid 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 prescribed for adolescents with substance abuse problems and PTSD. Another therapy, Eye Movement Desensitization and Reprocessing (EMDR), combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and 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 prescribed for some children with PTSD. However, due to the lack of research in this area, it is too early to evaluate the effectiveness of medication therapy.

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 behavioral problems.

What can I do to help my child?

Reading this fact sheet is a first step toward 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, changes in school performance, and problems with peers. It may be necessary to seek help for your child. Consider having your child evaluated by a mental-health professional who has experience treating PTSD in children and adolescents. Many therapists with this experience are members of the International Society for Traumatic Stress Studies, which has a membership directory containing a geographical listing of therapists who treat children and adolescents. Ask how the therapist typically treats PTSD, and choose a practitioner with whom you and your child feel comfortable. Consider whether you might also benefit from talking to someone individually. The most important thing 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.

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