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 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 (note: all linked
to below).
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.
This article has been reproduced by permission of the National
Center for PTSD.
Please also check out the National
Center for PTSD website
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