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Posttraumatic Stress Disorder in Children

Practice Essentials

Posttraumatic stress disorder (PTSD) in children and adolescents occurs as a result of a child’s exposure to 1 or more traumatic events: actual or threatened death, serious injury, or sexual violence. The victim may experience the event, witness it, learn about it from close family members or friends, or experience repeated or extreme exposue to aversive details of the event. Potentially traumatic events include physical or sexual assaults, natural disasters, and accidents.

The impact of single-incident trauma (such as a car accident or being beaten up) is different from that of chronic trauma such as ongoing child abuse. In addition to the symptoms of PTSD, sexual assaults have widespread impacts on the victim’s psychological functioning and development. Abuse by a caretaker also creates special problems.  

The impact of traumatic events on children is often more far reaching than trauma on an adults, not simply because the child has fewer emotional and intellectual resources to cope, but because the child’s development is adversely affected. If an adult suffers trauma and a deterioration in functioning, after time when the person heals, he can generally go back to his previous state of functioning, assuming that he has not done serious damage to his relationships, studies, and work. A child, however, will be knocked off of his developmental path and after healing from the trauma will be out of step with his peers and school demands. He will therefore suffer ongoing frustration and disappointments even when he has healed from the trauma.

Many individuals who suffer traumatic events develop depressive or anxiety symptoms other than PTSD. An individual who has some symptoms of PTSD but not enough to fulfill the diagnostic criteria is still adversely affected. The diagnosis of Unspecified Trauma- and Stressor-Related Disorder should be considerred.

Roughly, 15% to 43% of children suffer a traumatic incident. Of these children, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for interpersonal violence. Higher-intensiity events have a greater risk to induce PTSD.

See Posttraumatic Stress Disorder (PTSD), a Critical Images slideshow, to help recognize the symptoms of PTSD and to determine effective treatment options.

Signs and symptoms

The most common symptoms of PTSD include the following:

Reexperiencing the trauma (nightmares, intrusive recollections, flashbacks, traumatic play)

Avoidance of traumatic triggers, memories and situations that remind the child of the traumatic event

Exaggerated negative beliefs about onself and the world arising from the event

Persisitent negative emotional state or inability to experience positive emotions

Feelings of detachment from people

Marked loss of interest in or participation in significant activities

Inability to remember part of the traumatic event

Sleep problems

Irritability

Reckless or self-destructive behavior

Hypervigilence

Exaggerated startle

Concentration problems

Children may reexperience traumatic events in various ways, such as the following:

Flashbacks and memories

Behavioral reenactment

Reenactment through play

No specific physical signs of PTSD exist; however, various physical findings have been noted in children with PTSD, including the following:

Smaller hippocampal volume

Altered metabolism in areas of the brain involved in threat perception (eg, amygdala)

Decreased activity of the anterior cingulate

Low basal cortisol levels

Increased cortisol response to dexamethasone

Increased concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus

See Presentation for more detail.

Diagnosis

The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), lists the following diagnostic criteria for PTSD in adults, adolescents, and children older than 6 years:

Exposure to actual or threatened death, serious injury, or sexual violence (any undesired sexual activity is sexual violence.

Presence of 1 or more specified intrusion symptoms in association with the traumatic event(s)

Persistent avoidance of stimuli associated with the traumatic event(s)

Negative alterations in cognitions and mood associated with the traumatic event(s)

Marked alterations in arousal and reactivity associated with the traumatic events(s)

Duration of the disturbance exceeding 1 month

Clinically significant distress or impairment in important areas of functioning

Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition

DSM-5 criteria for PTSD in children aged 6 years or younger are as follows:

Directly experiencing the traumatic event, witnessing the event, or learning it occurred to a parent or caregiver

Intrusion symptoms associated with the event (recurrent memories, distressing dreams, dissociative reactions, marked distress or physiological reaction in response to exposure to traumatic triggers)

Avoidance of situations or things that arouse recollections of the trauma OR negative alterations in cognitions (increased negative emotions, decreased interest in significant activities, social withdrawal, decreased positive emotions)

Alterations in arousal and reactivity associated with the traumatic events (two of irritability, hyperigilance, exaggerated startle, concentration problems, sleep disturbance )

Duration of the disturbance exceeding 1 month

Clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or in school behavior

Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition

There are no specific laboratory studies or specific imaging studies that establish the diagnosis of PTSD. Several psychological tests may be helpful in PTSD, including the following:

Child and Adolescent Psychiatric Assessment: Life Events Section and PTSD Module (CAPA-PTSD)

Children’s PTSD Inventory (CPTSDI)

Child PTSD Symptom Scale (CPSS)

Abbreviated UCLA PTSD Reaction Index

Trauma Symptom Checklist for Children (TSCC)

Impact of Events Scale

Screen for Child Anxiety Related Disorders (SCARED)

Beck Depression Inventory

Mississippi Scale for Combat-Related PTSD

See Overview and Workup for more detail.

Management

The initial goals of treatment for children with PTSD are as follows:

Provide a safe environment

Reasurance, emotional support, nurturance

Attend to urgent medical needs

Psychological therapy for PTSD in children involves the following:

Helping the child gain a sense of safety

Addressing the multiple emotional and behavioral problems that can arise

Nonpharmacologic forms of therapy include the following:

Cognitive-behavioral therapy (CBT), especially trauma-focused CBT (TF-CBT) 

Dialectical Behavior Therapy (DBT)

Relaxation techniques (eg, biofeedback, yoga, deep relaxation, self-hypnosis, or meditation; efficacy unproven)

Play therapy

In children who have persistent symptoms despite CBT or who need additional help with control of symptoms, pharmacologic treatment may be considered, as follows:

Selective serotonin reuptake inhibitors (SSRIs) – Medications of choice for managing anxiety, depression, avoidance behavior, and intrusive recollections; however, not specifically approved by the FDA for treatment of PTSD in the pediatric population

Beta blockers (eg, propranolol)

Alpha-adrenergic agonists (eg, guanfacine and clonidine)

Mood stabilizers (eg, carbamazepine and valproic acid)

Atypical antipsychotics (infrequently used)

See Treatment and Medication more detail.

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