Posttraumatic Stress Disorder in Children/Adolescents
Post-traumatic stress disorder (PTSD) is a set of symptoms that can occur/persist in individuals after experiencing and/or witnessing a traumatic event, which has most recently been defined broadly to include any experience threatening death, injury, or violence (i.e., accident/injury, violence, abuse, medical diagnosis, natural disasters, war). American Psychiatric Association 2015
Most individuals will be able to rely on their resources and coping skills to adjust successfully following traumatic events; however a certain percentage will be at-risk for development of PTSD with its risks for continued disability, health costs/impact, and comorbid mental health conditions. (Stuber et al. (2003); Kean, Kelsay, Wamboldt, Wamboldt (2006); Cohen & WGQI, 2010).
A lifetime risk of 8.7% has been identified in adults (American Psychiatric Association, 2013) with 5% of adolescents experiencing PTSD in their lifetime (US Department of Veteran Affairs, n.d.), and it is important to note that even subthreshold symptoms can have a powerful, negative impact requiring intervention (Breslau, 2001; Cohen & WGQI, 2010).
Causes & Risk Factors
Risk or protective factors for PTSD have been thought of as occurring on three levels. APA, 2013; Udwin, Boyle, Yule, Bolton, & O’Ryan, 2000
Pre-trauma factors include prior psychopathology (i.e, anxiety, depression, behavior problems), prior traumas, female gender, younger age, and having fewer environmental supports.
Peri-traumatic risk/protective factors include the severity of the trauma, the subjective interpretation of the trauma (i.e. perceived life threat and impact), whether violence was involved, and immediate symptoms such as heart rate, pain, and dissociation.
Post-trauma risk/protective factors include the individual’s ability to cope positively, seek/use social support (i.e., parents, family, peers), and make more positive attributions about the trauma, and having functional impairment from the trauma.
American Psychiatric Association, 2013; Blanchard, Hickling, Taylor, Loos, Forneris, & Jaccard, 1996; Mayou, Ehlers, & Bryant, 2002
Symptoms & Types
Some distress is normal in the initial days following a traumatic experience and not indicative of a mental health disorder. For a diagnosis of PTSD, symptoms of traumatic stress must be present more than a month following the traumatic exposure, although they also may not develop until later in a smaller percentage of the population (i.e., more than 6 months later). Symptoms include multiple forms of intrusive symptoms of the traumatic event (memories, dreams, flashbacks), avoidance of stimuli reminding the individual of the trauma, negative changes in thoughts/mood since the trauma (i.e., persistent negative beliefs about the world, distortions about cause of trauma), and physiological reactivity (i.e., increased startle response, irritable behavior, hypervigilance, sleep problems, concentration problems).
It is important to note that young children (younger than 6 years of age) may have differing presentations, including repetitive trauma play, distressing dreams, behavioral regression (i.e., toileting, sleep), and behavioral tantrums. Additional specifiers are appropriate if an individual is experiencing significant dissociative symptoms and/or if there is a delay (at least 6 months later) in the experiencing of symptoms. American Psychiatric Association 2013
Diagnosis & Tests
A diagnosis of PTSD is not appropriate until symptoms are present for at least 1 month and cause significant impairment in the individual’s life. Symptoms may be evaluated through a clinical interview (structured and/or unstructured) and self-rating measures.
It is recommended to evaluate parental and child symptoms separately to best appreciate symptoms and avoid a reporter’s symptoms from contaminating his/her rating of the other person. In addition, assessing for associated conditions is necessary given a linkage between PTSD and other mental health conditions such as depression, anxiety, externalizing problems, and substance abuse.
Treatment & Care
The gold standard, empirically based practice (EBP) approach for treating PTSD is trauma-focused cognitive-behavioral therapy (TF-CBT). This technique has been demonstrated to be more effective than medication and includes anxiety management, correction of inaccurate thoughts, and exposure intervention (i.e., creation of a narrative about the trauma, working with trauma triggers, creation of a fear hierarchy related to the trauma). Psychoeducation regarding symptoms as well as parental support for managing behavior and supporting the child/adolescent is also vital.
Living & Managing
Most individuals with PTSD will recover in the first 3 months post-trauma, but, as noted above, some individuals do not develop symptoms until later and others will present with more chronic symptoms (i.e., lasting longer than 12 months.
A recent focus has shifted to post-traumatic growth after traumatic events. Individuals have been noted to find meaning in the events they experienced that apply to their greater life/humanity. 5 common areas of growth have included greater life appreciation, improved relationships, improved self-efficacy, awareness of new possibilities, and spiritual progression. Future attention should be focused on how to support individuals following trauma exposure to allow for post-traumatic growth.
Associated Texas Children’s Clinic/Program/Center
References & Sources
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association.
Blanchard, E.B., Hickling, E.J., Taylor, A.E., Loos, W.R., Forneris, C.A., & Jaccard, J. (1996). Who develops PTSD from motor vehicle accidents? Behaviour Research and Therapy, 34, 1-10.
Breslau, N. (2001). The epidemiology of posttraumatic stress disorder: What is the extent of the problem? Journal of Clinical Psychiatry, 62, 16-22.
Cohen, J.A. & The Work Group on Quality Issues and the AACAP Work Group on Quality Issues (2010). 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, 49, 414-430.
Davis, L., & Siegel, L.J. (2000). Posttraumatic stress disorder in children and adolescents: A review and analysis. Clinical Child and Family Psychology Review, 3, 135-154.
Gerson, R., & Rappaport, N. (2013). Traumatic stress and posttraumatic stress disorder in youth: Recent research findings on clinical impact, assessment, and treatment. Journal of Adolescent Health, 52, 137-143.
Kassam-Adams, N., Garcia-España, J.F., Miller, V.A., Winston, F. (2006). Parent-child agreement regarding children's acute stress: the role of parent acute stress reactions. Journal of the American Academy of Child & Adolescent Psychiatry, 45, 1485-1493.
Kean, E.M., Kelsay, K., Wamboldt, F., & Wamboldt, M.Z. (2006). Posttraumatic stress in adolescents with asthma and their parents. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 78-86.
Landolt, M.A., Vollrath, M., Ribi, K., Gnehm, H.E., & Sennhauser, F.H. (2003). Incidence and associations of parental and child posttraumatic stress symptoms in pediatric patients. Journal of Clinical Psychology and Psychiatry, 44, 1199-1207.
Mayou, R.A., Ehlers, A., & Bryant, B. (2002). Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study. Behaviour Research and Therapy, 40, 665-675.
Meiser-Stedman, R., Smith, P., Glucksman, E., Yule, W., & Dalgleish, T. (2007). Parent and child agreement for acute stress disorder, post-traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed to single-event trauma. Journal of Abnormal Child Psychology, 35, 191-201.
Picoraro, J., Womer, J.W., Kazak, A.E., & Feudtner, C. (2014). Posttraumatic growth in parents and pediatric patients. Journal of Palliative Medicine, 17, 209-218.x
The Work Group On Quality Issues and the AACAP Work Group on Quality Issues (WGQI)
Stuber, M.L., Shemesh, E., & Saxe, G.N. (2003). Posttraumatic stress responses in children with life-threatening illnesses. Child and Adolescent Psychiatric Clinics of North America, 12, 195-209.
Udwin, O., Boyle, S., Yule, W., Bolton, D., & O’Ryan, D. (2000). Risk factors for long-term psychological effects of a disaster experiences in adolescence: Predictors of posttraumatic stress disorder. Journal of Child Psychology and Psychiatry, 41, 969-979.
US Department of Veterans Affairs (n.d.) PTSD: National Center for PTSD. PTSD in children and adolescents. Retrieved from website: http://www.ptsd.va.gov/professional/treatment/children/ptsd_in_children_and_adolescents_overview_for_professionals.asp