Post-traumatic Stress Disorder (PTSD) in Children and Adolescents

ICD-10 Code: F43.10

Posttraumatic stress disorder (PTSD) is part of a cluster of diagnoses called the trauma and stressor-related disorders. Trauma and stressor-related disorders are a group of psychiatric conditions that include:

  • Posttraumatic stress disorder
  • Acute stress disorder
  • Reactive attachment disorder

These disorders are characterized by an adverse reaction to one or more traumatic or unusually stressful experiences.

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The Diagnostic and Statistical Manual of Mental Disorders-5th Edition defines traumatic events as situations in which the individual experiences, is threatened with, or witnesses serious injury, death, or sexual violence. Repeated exposure to extreme details of traumatic events as part of an individual's employment (e.g., a police officer or social worker who regularly encounters details of child abuse) also qualifies as a traumatic event.

PTSD and acute stress disorder are both characterized by a set of adverse cognitive, behavioral, and emotional changes that occur after experience of one or more traumatic events. Both disorders are characterized by intrusive and upsetting memories of the traumatic event(s), adverse cognitive and emotional changes (e.g., very negative beliefs about the world; persistent dysphoria or anger), avoidance behaviors (including avoiding thinking about the event), and increased autonomic reactivity. Acute stress disorder is diagnosed when the symptoms occur in the month following the traumatic event. PTSD is diagnosed when the symptoms persist for one month or longer following the traumatic event.

Reactive attachment disorder (RAD) is diagnosed only in children and is characterized by inhibited and emotionally withdrawn behaviors toward the child's caregiver(s), along with other social and emotional disturbances. RAD is an adverse reaction to neglect, repeated changes in caregivers (e.g., frequent changes in foster care), or rearing in adverse circumstances (e.g., institutions with inadequate availability of caregivers).

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What is Post-traumatic Stress Disorder?

PTSD is a psychiatric disorder that affects approximately 1 - 9% of children and adolescents, depending on the population sampled. The prevalence of traumatic events is significantly higher, affecting up to 39% of high-risk children and adolescents, and many children do not develop PTSD as a result of these experiences.

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Therefore, PTSD should be diagnosed only when the child experiences impairment or distress associated with the following symptoms in the aftermath of the traumatic experience:

  • Intrusions, including recurrent, involuntary, distressing memories or dreams related to the traumatic event, flashbacks in which the individual feels or acts like the traumatic event is reoccurring, intense or prolonged emotional distress in response to reminders of the traumatic event, or strong physiological reactions to reminders of the traumatic event.
  • Avoidance of reminders of the traumatic event, including avoiding distressing thoughts, feelings, or memories related to the traumatic event, or avoidance of external situations (e.g., people; places) that are associated with the traumatic event.
  • Negative changes in thoughts or moods following the traumatic event, including at least two of the following:
    • Amnesia for important parts of the traumatic event (not explained by use of substances or head injury sustained during the trauma)
    • Exaggerated and persistent negative views of oneself, others, or the world (e.g., "I can't trust anyone," "I'm damaged," "the world is a dangerous and scary place")
    • Persistent and distorted blaming of oneself or others for the trauma
    • Persistent negative emotional state (e.g., persistent fear, shame, or anger)
    • Significant loss of interest or reduced participation in significant activities
    • Feeling detached from other people
    • Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love)
  • Changes in autonomic arousal or reactivity following the traumatic event, including at least two of the following:
    • Irritability or angry outbursts
    • Reckless, impulsive, or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Impaired concentration
    • Sleep disturbances (e.g., difficulty falling asleep; disrupted sleep)

Developmental psychopathology research indicates that young children may express symptoms of PTSD somewhat differently than do older children. Therefore, the criteria for PTSD in children 6 years of age or younger are slightly modified, as follows:

  • Directly experiencing or witnessing actual or threatened death, serious injury, or sexual violence. Note that media exposure does not qualify as "witnessing" these events.
  • Intrusions, as evidenced by recurrent, intrusive distressing memories of the traumatic event (repetitive play where the trauma is reenacted), recurrent distressing dreams related to traumatic themes, dissociative flashbacks, intense or prolonged emotional distress or physiological reactions in response to being reminded of the trauma.
  • Avoidance of people, places, or things that remind the child of the trauma, or negative changes in cognitions, including an increased frequency of negative emotional states, loss of interest or lack of participation in play or other significant activities, socially withdrawn behavior, and persistent reduction in the expression of positive emotions.
  • Alterations in arousal, including irritable or angry outbursts or extreme temper tantrums, hypervigilance, exaggerated startle response, impaired concentration, or sleep disturbance (e.g., difficulty falling asleep or restless or disturbed sleep).

Many of these symptoms are normal responses to traumatic events, and will remit over time. Therefore, PTSD is diagnosed only when the symptoms last one month or longer and lead to clinically significant distress or impairment. Symptoms do not need to occur immediately following the trauma for a PTSD diagnosis to be warranted. Some individuals experience a delayed onset of PTSD, in which symptoms do not begin until weeks, months, or longer following the trauma. The specifier "with delayed onset" is applied when symptoms do not reach full diagnostic criteria until 6 months after the trauma.

PTSD may also be specified as occurring "with dissociative symptoms." Dissociative symptoms can include depersonalization, in which the person feels detached from him or herself or as though he or she is "out of body" in some way, or derealization, in which the person experiences his or her surroundings as dreamlike or unreal in some way.

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Understanding Post-traumatic Stress Disorder

PTSD severity can range from mild to debilitating. In severe cases, PTSD can lead to inability to go to school, or form or maintain satisfying relationships with peers or adults. Many children with PTSD also have or go on to develop other psychiatric conditions, most commonly depressive disorders, substance use disorders, anxiety disorders, and externalizing disorders such as attention deficit/hyperactivity disorder and oppositional defiant disorder.

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Comorbidity of PTSD with substance use disorders has been explained in terms of self-medication (i.e., individuals use substances to medicate painful PTSD symptoms), although withdrawal states may exacerbate PTSD symptoms.

PTSD is characterized by abnormalities of brain function which are thought to contribute to symptoms. In particular, evidence points to abnormalities in neuroendocrine systems (in particular the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes), neurotransmitter systems (in particular norepinephrine, serotonin, and corticotropin-releasing factor), and certain brain regions (in particular the amygdala and hippocampus) that are thought to underlie hyperarousal and other symptoms associated with PTSD. In addition, avoidance of trauma-related cues is thought to contribute to the persistence of PTSD by preventing fear extinction and new learning. Similarly, avoidance of trauma-related memories is thought to exacerbate the frequency and intensity of those memories. The disorder is thought to have a genetic component, although having a genetic predisposition to PTSD does not necessarily mean that someone will develop PTSD.

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How Is Post-traumatic Stress Disorder Treated?

PTSD is treatable. Published treatment guidelines for PTSD include those from the Society of Clinical Child and Adolescent Psychology, the American Academy of Child and Adolescent Psychiatry, and the National Institute for Clinical Excellence.

Of note, the first step when assessing and treating PTSD is to insure that the child is no longer in danger. Safety considerations, including involvement of appropriate child service agencies as warranted by ethics and law, should be addressed before the treatment recommendations below are applied.

First-Line Treatments

  • Trauma-focused cognitive-behavioral therapy (TF-CBT) consists of gradually exposing the child to feared thoughts, situations, and activities, and helping him or her to develop more accurate and helpful thoughts about him or herself, the trauma, and other people. Parent training is often included. Specific cognitive-behavioral therapies with a high degree of research support for children and adolescents include Trauma-Focused Cognitive Behavioral Therapy for Anxiety, Prolonged Exposure, Group CBT for Anxiety, and Seeking Safety (for adolescents with comorbid substance use disorders).

Additional Treatments to Consider

  • Child-parent psychotherapy is a relationship-based psychotherapy for young children (age 7 and younger) and their parents with demonstrated clinical efficacy. It is designed for children who have experienced family trauma such as domestic violence and incorporates elements of cognitive-behavioral therapy and psychodynamic therapies. Specific strategies include behavioral interventions such as modeling, providing emotional support, facilitating empathetic communication, and correcting distorted thoughts about the trauma.
  • Eye Movement Desensitization and Reprocessing is a variant of cognitive-behavioral therapy that pairs imagery with back-and-forth eye movements with some evidence of efficacy in children. Researchers have questioned the necessity of the eye movement component of this treatment, but it does not appear to interfere with the cognitive-behavioral elements of the treatment.
  • Other psychosocial interventions may be helpful in the event of unavailability of or non-response to first-line treatments. Interventions with at least some evidence of efficacy include Psychodynamic Therapy, Child-Centered Therapy, and Family Therapy for PTSD.
  • Antidepressant medications, particularly citalopram and sertraline, may be considered as monotherapy or as an addition to TF-CBT in the event of non-response to first-line treatment. However, although some trials have found a positive effect of these medications in children and adolescents, other trials have found no superiority to placebo. Additionally, pharmacotherapy can be associated with adverse effects; therefore, caution is warranted when considering medication treatment. The National Institute for Clinical Excellence advises against routinely prescribing medication for children and adolescents with PTSD.
  • Other medications have shown efficacy in adults with PTSD and at least some evidence of efficacy in children or adolescents in open trials. Specific medications with some evidence of efficacy in at least one open trial include imipramine, risperidone, clonidine, nefazodone, carbamazepine, guanfacine, and propranolol. However, side effect profiles should be weighed carefully against potential benefits. The National Institute for Clinical Excellence advises against routinely prescribing medication for children and adolescents with PTSD.

Of note, the first step when assessing and treating PTSD is to insure that the child is no longer in danger. Safety considerations, including involvement of appropriate child service agencies as warranted by ethics and law, should be addressed before the treatment recommendations below are applied.

First-Line Treatments

Additional Treatments to Consider

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