PTSD in Children and Adolescents

Jessica Hamblen, PhD and Erin Barnett, PhD

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, and treatments for PTSD (1).

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 or physical abuse.

Child protection services in the United States receive approximately 3 million referrals each year, representing 5.5 million children. Those figures may only represent a portion of the child maltreatment cases that occur; researchers estimate that two-thirds of maltreatment cases are unreported. Of those cases referred, about 30% are substantiated and occur in the following frequencies (2):

• 65% neglect
• 18% physical abuse
• 10% sexual abuse
• 7% psychological abuse

In addition, anywhere from 3 to 10 million children are exposed to domestic violence each year (3), 40-60% of which cases also involve child physical abuse (4).

How many children develop PTSD?

Studies of the general population have examined rates of exposure and PTSD in children and adolescents. Results from these studies indicate that 15-43% of girls and 14-43% of boys experience at least one traumatic event. Of those children and adolescents who have experienced a trauma, 3-15% of girls and 1-6% 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 3-100%. 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:

• Severity of the traumatic event
• Parental reaction to the traumatic event
• 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. 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.

There is less clarity in the findings connecting PTSD with ethnicity and age. 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 affects 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.

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. Criteria for PTSD now include age-specific features for some symptoms.

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. Several types of therapy have been suggested for PTSD in children and adolescents.

Cognitive-Behavioral Therapy (CBT)

Research studies show that CBT is the most effective approach for treating children. One of the best-researched therapies is Trauma-Focused CBT (TF-CBT). TF-CBT 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.

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 used for school-aged children and adolescents exposed to disasters and community violence and can be used in schools and traditional settings. Psychological First Aid involves providing comfort and support, normalizing the children's reactions, helping caregivers deal with changes in the child's emotions and behavior, teaching calming and problem-solving skills, and referring the most symptomatic children for additional treatment. See Manuals to learn more about Psychological First Aid.

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.

Specialized interventions. Specialized interventions may be necessary for children exhibiting particularly problematic symptoms or behaviors, such as inappropriate sexual behaviors, extreme behavioral problems, or substance abuse.

References

1. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder. (October, 1998). Journal of the American Academy of Child and Adolescent Psychiatry, 37:10 supplement.
2. US Department of Health and Human Services, ACF, 2006
3. Jouriles, E., McDonald, R., Norwood, W., & Ezell, E. (2001). Issues and controversies in documenting the prevalence of children's exposure to domestic violence. In S.A. Graham-Bermann & J.L. Edelson (Eds.), Domestic violence in the lives of children: The future of research, intervention, and social policy, 13-34, Washington: American Psychological Association.
4. Edelson, J. L. (2001). Studying the co-occurrence of child maltreatment and domestic violence in families. In S.A. Graham-Bermann & J.L. Edelson (Eds.), Domestic violence in the lives of children: The future of research, intervention, and social policy, 91-110, Washington: American Psychological Association