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
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.
Elementary school-aged children
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).
Adolescents and Teens
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.
Cognitive-Behavioral Therapy (CBT)
A review of the adult treatment studies
of PTSD shows that this is the most effective
approach for treating children. 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
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
Psychological first aid has been prescribed for children
exposed to community violence and can be used in schools and
traditional settings. It 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
This type of approach has been prescribed for adolescents
with substance abuse problems and PTSD.
Eye Movement Desensitization and Reprocessing (EMDR)
Another therapy, 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
Drugs 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 following
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.
