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Posttraumatic Stress Disorder in Children

  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
 
Updated: May 19, 2016
 

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.[9]

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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Background

Posttraumatic stress disorder (PTSD) in children and adolescents occurs as a result of a child’s exposure to one or more traumatic events that were perceived to threaten serious injury to self or others and led the child to feel intense fear, helplessness, or horror. Traumatic events can take many forms, including accidents, painful medical procedures, physical or sexual assaults, natural disasters, traumatic death or injury of a loved one, and emotional abuse or neglect.[1, 2, 3, 4]

A 2005 survey of mental health clinicians who treat pediatric patients found interpersonal victimization to be the most prevalent form of trauma exposure; this includes physical abuse, sexual abuse, and emotional abuse, as well as exposure to domestic violence and the disorganization that results from parental substance abuse in the household.[5] The prevalence of childhood exposure to noninterpersonal trauma (eg, accidents, disasters, or illness) is significantly less.[6]

Traumatic events overwhelm the individual’s ability to cope and leave the child or adolescent feeling that the world is dangerous and out of control. The traumatic event deeply affects the child or adolescent’s view of himself or herself and of the world. The memory of the event is encoded differently from normal memories. Rather than thinking about it, the person reexperiences it when it comes to memory. The pain of reexperiencing leads the individual to be afraid of the memory, and not simply afraid of the event.

The key elements of PTSD are the intrusive recollections, numbing and withdrawal, cognitive changes, and hyperarrousal. Many individuals develop depression or an anxiety disorder after a traumatic event, rather than PTSD.

There are other impacts as well. Suffering a traumatic event or events fosters an external locus of control. The individual feels that he or she is at the mercy of the world rather than the master of one’s own fate. This has serious implications for how the individual leads his or her life in the future. Learned helplessness, a tendency to fail to escape from dangerous situations when escape is possible, also often results. Decreased resilience and increased vulnerability to future traumatic events also results.

Traumatic experiences, especially repeated ones, as occurs in child abuse, greatly increases the risk for the development of borderline personality disorder, oppositional defiant disorder, conduct disorder, and depression in adult years. Studies have shown a marked increase in medical costs in children who suffered abuse in childhood. Sexual abuse has wide-ranging impacts on the child’s ability to have stable and fulfilling romantic relationships during adult years. Dissociative disorders can also result.

Females are twice as likely to develop PTSD as males are, whereas males are more likely to exhibit conduct disorder, antisocial behavior, or criminal behavior after significant violent trauma.[7]

The main pathogenic elements in PTSD are the loss of control, the unpredictability, and the extremely aversive nature of the event(s). Most traumatized children do not develop long-term sequelae as a result of the trauma, but a significant minority respond in a way that has a long-lasting major impact on their emotions and behaviors. These children are at risk for PTSD, regardless of whether the trauma arose from a single event or from an ongoing pattern of abuse.

The family is known to pay a vital role in determining the eventual impact of the traumatic experience on the child, and parental support is often a key mediating factor in how the child experiences and adapts to the victimizing circumstances.[6] The support of a child’s family, along with adequate coping and emotional functioning of the child’s parents, may very well militate against the development of PTSD in a child exposed to trauma.

Severe emotional trauma has widespread effects on children’s development. These effects include undermining children’s sense of security in a reasonable and safe world in which they can grow and explore, as well as rendering them unable to believe that their parents can protect them from harm. The premature destruction of these beliefs can have profound negative consequences on development.

Traumatized children and adolescents are frequently preoccupied with danger and vulnerability, and this preoccupation sometimes leads to misperceptions of danger, even in situations that are not threatening. Multiple researchers (eg, Kardiner and van der Kolk[8] ) note that once posttraumatic stress symptoms emerge, PTSD leads to neurophysiologic correlates that impact brain function in developing children and adolescents.

Some forms of child maltreatment result in actual physical injuries that may call for intensive medical treatment that can be painful and frightening for the child. In such cases, the psychological impact encompasses the experiences of both the physical abuse and the medical treatment required. Accordingly, it is left to the child victim to define an event or experience as traumatic; the role of the health care professional who seeks to help such a child is to shoulder the responsibility of treatment and assistance.

For further information on the problem of child and adolescent maltreatment and disordered parent-child relationships, see Child Abuse & Neglect: Physical Abuse, Child Abuse & Neglect: Sexual Abuse, and Child Abuse & Neglect: Reactive Attachment Disorder.

Diagnostic criteria (DSM-5) in individuals older than 6 years

In the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), there are 8 specific diagnostic criteria for PTSD in adults, adolescents, and children older than 6 years.[9]

The first criterion is exposure to actual or threatened death, serious injury, or sexual violation in 1 or more of the following ways:

  • Direct experience of the traumatic events(s)
  • In-person witnessing of the event(s) occurring to others
  • Learning that the event(s) occurred to a close family member or close friend (in cases of actual or threatened death, the event[s] must have been violent or accidental)
  • Experience of repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains or police officers repeatedly exposed to details of child abuse)

The second criterion is the presence of 1 or more of the following intrusion symptoms in association with the traumatic event(s), beginning after the event(s) occurred:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); in children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed
  • Recurrent distressing dreams in which the content or affect of the dream is related to the event(s); children may have frightening dreams without recognizable content
  • Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring; children may carry out trauma-specific reenactment during play
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble any aspect of the traumatic event(s)
  • Marked physiologic reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

The third criterion is persistent avoidance of stimuli associated with the traumatic event(s), beginning after the event(s) occurred, as evidenced by either or both of the following:

  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Avoidance of or efforts to avoid external reminders (eg, people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

The fourth criterion is the presence of negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the event(s) occurred, as evidenced by 2 or more of the following:

  • Inability to remember an important aspect of the traumatic event(s) (typically a consequence of dissociative amnesia and not of factors such as head injury, alcohol or drugs)
  • Persistent and exaggerated negative beliefs or expectations about self, others, or the world
  • Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead individuals to blame themselves or others
  • Persistent negative emotional state (eg, fear, horror, anger, guilt, or shame)
  • Markedly diminished interest or participation in significant activities
  • Feelings of detachment or estrangement from others
  • Persistent inability to experience positive emotions (eg, happiness, satisfaction, or loving feelings)

The fifth criterion is the development of marked alterations in arousal and reactivity associated with the traumatic events(s), beginning or worsening after the event(s) occurred, as evidenced by 2 or more of the following:

  • Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
  • Reckless or self-destructive behavior
  • Hypervigilance
  • Problems with concentration
  • Exaggerated startle response
  • Sleep disturbance (eg, difficulty in falling or staying asleep or restlessness during sleep)

The sixth criterion is that the duration of the disturbance must exceed 1 month.

The seventh criterion is that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The eighth and final criterion is that the disturbance cannot be attributed to the physiologic effects of a substance (eg, a medication or alcohol) or another medical condition.

Additional specifiers that may be used include the following:

  • With dissociative symptoms - The patient shows persistent or recurrent symptoms of depersonalization or derealization
  • With delayed expression - Full diagnostic criteria are not met until 6 months after the traumatic event (though some symptoms may develop immediately)

Diagnostic criteria (DSM-5) in children aged 6 years or younger (preschool subtype)

DSM-5 list 7 specific diagnostic criteria for PTSD in children aged 6 years or younger.[9]

The first criterion is exposure to actual or threatened death, serious injury, or sexual violation in 1 or more of the following ways:

  • Direct experience of the traumatic events(s)
  • In-person witnessing of the event(s) occurring to others, especially primary caregivers
  • Learning that the event(s) occurred to a parent or caring figure

The second criterion is the presence of 1 or more of the following intrusion symptoms in association with the traumatic event(s), beginning after the event(s) occurred:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment
  • Recurrent distressing dreams in which the content or affect of the dream is related to the event(s); it may not be possible to establish that the frightening content is related to the traumatic event
  • Dissociative reactions (eg, flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring; children may carry out trauma-specific reenactment during play
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble any aspect of the traumatic event(s)
  • Marked physiologic reactions to reminders of the traumatic event(s)

The third criterion is the presence of 1 or more of the following symptoms, representing either persistent avoidance of stimuli associated with the trauma (the first 2 symptoms) or negative alterations in cognition and mood associated with the traumatic event(s) or worsening after the trauma (the last 4 symptoms):

  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Avoidance of or efforts to avoid people, places, conversations, or interpersonal situations that arouse recollections of the traumatic event(s)
  • Increased frequency of negative emotional states (eg, fear, horror, anger, guilt, or shame)
  • Markedly diminished interest or participation in significant activities, including constriction of play
  • Socially withdrawn behavior
  • Persistent reduction in expression of positive emotions

The fourth criterion is the development of alterations in arousal and reactivity associated with the traumatic events(s), beginning or worsening after the event(s) occurred, as evidenced by 2 or more of the following:

  • Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums)
  • Hypervigilance
  • Exaggerated startle response
  • Problems with concentration
  • Sleep disturbance (eg, difficulty in falling or staying asleep or restlessness during sleep)

The fifth criterion is that the duration of the disturbance must exceed 1 month.

The sixth criterion is that the disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or in school behavior.

The seventh and final criterion is that the disturbance cannot be attributed to the physiologic effects of a substance (eg, a medication or alcohol) or another medical condition.

Additional specifiers that may be used include the following:

  • With dissociative symptoms - The patient shows persistent or recurrent symptoms of depersonalization or derealization
  • With delayed expression - Full diagnostic criteria are not met until 6 months after the traumatic event (though some symptoms may develop immediately)
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Pathophysiology

The immediate physiologic response to trauma can be significant and may set the stage for persistent PTSD symptoms. Alterations in the noradrenergic and dopaminergic neurotransmitter systems and the stress response of the hypothalamic-pituitary-adrenal axis are well documented. The effects of these responses in the central nervous system (CNS) can affect later neurophysiologic responses.

Hyperarousal and overgeneralization of threat can evolve, prompting the child to react in an extreme fashion to events that resemble or remind the child of the original trauma. Some evidence suggests that chronic PTSD, perhaps through these physiologic changes, can lead to changes in brain microarchitecture.

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Etiology

PTSD may be caused by exposure to a severe traumatic stress that threatens death or serious injury or threat to personal integrity. However, not every child or adolescent who experiences trauma develops PTSD. The development of PTSD depends on the individual’s vulnerability versus resilience.

Children with preexisting mental health problems are more likely to be affected by a traumatic experience, particularly if they were previously anxious or are described as having a slow-to-warm-up temperament, or high reactivity. Limited intelligence decreases one’s coping mechanism and increases vulnerability. Parental support is also crucial.

PTSD may be initiated by either direct or witnessed exposure to a single or repeated traumatic event. Accordingly, some authorities divide trauma exposures into 2 broad types as follows[10] :

  • Type I exposure - A single acute, unpredictable stressor; an individual may have repeated exposures to this kind of stressor
  • Type II exposure - Chronic, enduring stressors (eg, ongoing physical or sexual abuse)

Types of traumatic events that may give rise to PTSD include the following:

  • Rape
  • Sexual and physical abuse
  • Car accidents [11]
  • Fires
  • Experiencing war
  • Receiving a serious medical diagnosis
  • Being subjected to invasive painful treatment of medical problems
  • Natural disasters with devastating impact [12]

Risk and protective factors

Numerous factors increase the likelihood that a child will develop PTSD in response to a given stress, including the following:

  • Previous exposure to traumatic incidents
  • Repeated trauma - The chronicity of the traumatic events experienced (ie, chronicity) appears to influence the presence and severity of psychological sequelae; these sequelae may then be exacerbated by further traumatic experiences (as in abused or neglected children who are taken into state custody and moved among foster homes and child protective services (CPS) placements or in children who experience a traumatic accidental injury and subsequently must undergo painful surgery and invasive procedures)
  • Personal threat - The degree to which the child actually feels frightened or personally threatened by the traumatic event(s) is known as personal threat; PTSD is more likely with higher degrees of violence and personal threat
  • Developmental state - Younger children are less able to process traumatic experiences verbally than older children and adults are, as well as less able to narrate them and understand their meaning; in some cases, this may mitigate their risk of PTSD
  • Relationship to perpetrator - Trauma caused by a person rather than resulting from an accident is more likely to lead to PTSD; in particular, being abused by a known and trusted person undermines the child’s sense of safety and increases the likelihood of PTSD
  • Parental support - Traumatized children who are developing in a secure and supportive environment are less susceptible to PTSD than children who endure ongoing abuse; parental reaction has a critical factor effect on the child’s reaction, in that parental difficulty coping with the trauma may cause the child to feel overwhelmed, whereas parental ability to cope and to provide a safe haven may markedly enhance the child’s own ability to cope, as well as reduce the chances of protracted PTSD
  • Extrafamilial support - The caregiver’s response is also critical; if the caregiver reassures the child, the outcome of the trauma is better than if the caregiver is also shaken, devastated, or withdrawn
  • Guilt - If the child feels guilty about the traumatic event or somehow responsible for it, the likelihood of more severe PTSD and depressive symptoms is increased
  • Resilience - Children with greater resilience (see below) have a decreased risk of PTSD
  • A preexisting psychiatric disorder
  • Symptoms at the time of the abuse - Eventual PTSD is more likely in children who have symptoms of avoidance, emotional constriction, and physiologic hyperarousal soon after the abuse; it is particularly likely to develop if a child experiences dissociation at the time of the trauma [13]
  • Physiologic response - Children who have an elevated heart rate in the period soon after the trauma (eg, those seen in an emergency department [ED]) are more likely to develop PTSD
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Resilience

Resilience, in its most general sense, may be defined as the ability to adapt positively to adversity.[14] It seems to be related to intelligence, ability to talk about one’s experiences, ability to understand others, and ability to seek help. Research into resilience in adolescence and adulthood after childhood maltreatment has identified essential components to resilience, including genetic, biologic, cognitive, and interpersonal factors.[15]

Earlier work on resilience noted that individual characteristics such as intelligence, physical attractiveness, and temperament are protective, in that they render the individual attractive to adults, who are thus motivated to provide support and care. Subsequent studies identified neurobiologic variables. For example, individuals with high levels of monoamine oxidase A are less likely to develop antisocial behavior after maltreatment in childhood.[16, 17, 14]

A longitudinal study following maltreated children through adolescence and midlife provided valuable insights into our understanding of how resilience emerges.[15] The dimensions of resilience evaluated were similar to those evaluated in other studies, including the following:

  • Presence or absence of major depressive disorder, recurrent depressive disorder, suicidality, suicide attempts, any anxiety disorder, PTSD, or substance-related disorder
  • Personality functioning
  • Relationship stability
  • Legal status
  • Self-rated health

With adversity experienced in adolescence controlled for, the maltreated patients were at greater risk for adult substance-related disorders, PTSD, suicidality, and recurrent depression than control subjects were[15] ; nevertheless, 44.5% were characterized as resilient. In addition, recovery and resilience appeared to occur in concert with parental support and encouragement. Positively perceived parental care, supportive adolescent peer relationships and adult romantic relationships, and positive personality factors all supported resilience.

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Epidemiology

United States statistics

The lifetime prevalence of PTSD is 8%.[18] The incidence and course of PTSD vary and depend on various factors, including the type of trauma, the proximity to the stressor, and the reaction of the child’s parents.

Epidemiologic studies of the incidence and prevalence of PTSD in children and adolescents remain limited. In the general US population of children and adolescents, approximately one third of children (range, 14%-43%) have experience a traumatic event before adulthood, including the death of a loved one, a serious accident, a natural disaster, sexual abuse, or rape.[19] Of children and adolescents who have had a traumatic experience, 3%-15% of girls and 1%-6% of boys could be diagnosed with PTSD.

Studies of PTSD in at-risk pediatric and adolescent populations (as opposed to the general US population) paint a different picture, reporting much higher rates of PTSD. For example, nearly all children who witness a parental homicide, approximately 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence go on to develop PTSD.

A National Institute of Justice report, based on an analysis of the 1995 National Survey of Adolescents, found the lifetime prevalence of PTSD to be 4-5 times higher among boys who had been sexually assaulted (28.3%) than in boys who had not (5.4%).[20] Rates in girls were similar (29.8% and 7.1%, respectively). The lifetime prevalence of PTSD was 27.4% in girls who were either physically assaulted or received physically abusive punishment and 6% in those who were not; rates in boys were 15.2% and 3.1%, respectively.

Internet-related PTSD

As the use of the Internet grows, the risk of Internet-related sex crimes, such as cyberstalking, increases. The Youth Internet Safety Survey, conducted first in 2001 (YISS-1[21] ) and then again in 2006 (YISS-2[22] ), collected survey data from nationally representative groups of children and adolescents aged 10-17 years who regularly used the Internet.

Although the percentage of children and adolescents who received unwanted sexual solicitations decreased between 2001 and 2006, from 19% to 13%, the percentage who encountered unwanted exposures to sexual material increased, from 25% to 34%.[21, 22] The percentage of participants who experienced online harassment also increased, from 6% to 9%.

Among solicited youths, 25% reported high levels of distress after the incident or incidents.[21] The participants most disturbed by the unwanted sexual solicitations included younger individuals (aged 10-13 years), those who were solicited on a computer away from their home, and those who experienced aggressive solicitations (defined as the solicitor attempting to make contact with the youth offline).

International statistics

Data on the prevalence of PTSD in countries outside the United States are sparse. Incidence and prevalence vary widely from country to country because of differences in data collection methods, as well as widely divergent cultural and societal factors. In a study by Hepp et al, which summarized a great deal of data from numerous countries, the lowest lifetime prevalence of PTSD (0.4%) was reported in German males aged 14-24 years, and the highest prevalence (43.8%) was reported in Algerian females older than 16 years.[23]

The prevalence of PTSD in a location overwhelmingly depends on the endemicity of violence in the region. In places where armed conflicts exist, children frequently experience trauma, whether as direct objects of violence, as witnesses to violence, or as incidental victims of dangerous surrounding conditions.

Age-related demographics

PTSD occurs in people of all ages, but younger and elderly persons are the most vulnerable. Older children with language abilities are more likely to be able to recount traumatic episodes. In younger children, behavioral changes may be the only observable signs of trauma.

Sex-related demographics

PTSD is more common in women than in men. Males are more likely to be victims of physical assault, and females are more frequently victims of sexual assault.

Girls report greater PTSD symptoms after trauma and are 2-6 times more likely to experience PTSD after sexual abuse than boys are. It is not known whether the higher lifetime prevalence of PTSD among females is related to rates and types of trauma exposure or to a particular vulnerability to PTSD.

The non-PTSD symptoms that abused and neglected girls manifest may differ from those noted in boys. Among sexually abused children, boys are more likely to develop externalizing behaviors (eg, oppositional behavior or impulsivity), whereas girls are more likely to develop internalizing behaviors (eg, depression or anxiety).

Race-related demographics

No major racial predominance is observed; however, PTSD is more common among individuals in low socioeconomic groups and among those living in areas where violence is endemic.

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Prognosis

The prognosis of PTSD is highly variable. Alone, PTSD is not directly fatal. Nevertheless, it frequently leads to significant comorbidity. In some cases, symptoms may reoccur months or years later, in response to subsequent stressful or life-changing events.

Although one half of individuals with PTSD recover within 3 months, some proceed to develop a long-term problem with a posttraumatic personality, including impulsive behavior, substance abuse, aggression, eating disorders, sexual acting out, labile mood, rage, panic attacks, and dissociation. Patients with chronic PTSD have an increased risk of suicidal ideation and mortality from suicide. Chronic PTSD is associated with work impairment, having an impact similar to that of major depression.

In general, the outcome of PTSD depends on the severity and chronicity of the trauma and the impact on the life of the child, the reactions and behavior of caregivers, and the opportunity to receive treatment. Long-term (type II) exposure to trauma has a far more serious prognosis exposure to individual traumatic events (type I).

The morbidity associated with PTSD is considerable, particularly for children. In addition to the symptoms of numbing, hyperarousal, and recollections of the event that adults experience, children suffer from a decreased ability to participate in the normal academic and social activities of childhood. Therefore, a traumatic event can send a child down a new developmental path, one that is less favorable than the one the child was previously on.

A host of emotional and behavioral problems frequently arise as a result of PTSD and are not part of the criteria for categorical diagnosis. These include disruptive behavior disorders, eating disorders, sexual acting out, other risk-taking activities, depression, the full range of anxiety disorders, dissociation, mood lability, violence, and difficulty concentrating.

Studies of adults who were sexually or physically abused as children demonstrate significantly higher rates of PTSD (72-100%) than studies of children who were abused (21-55%). This finding indicates that the full impact of abuse may not be experienced until a child reaches adulthood, engages in adult relationships and responsibilities, and develops more sophisticated cognitive capabilities.

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Patient Education

Children with PTSD should be encouraged to take part in their own treatment. They need to understand why treatment is required and that their difficulties are the result of traumatic events.

For patient education resources, see the Mental Health Center and the Children’s Health Center, as well as Post-traumatic Stress Disorder (PTSD), Child Abuse, and Sexual Assault.

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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD Private Practice

Roy H Lubit, MD, PhD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

Eileen R Giardino, RN, MSN, PhD FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Family Nursing, University of Texas Health Sciences Center Houston, School of Nursing

Eileen R Giardino, RN, MSN, PhD is a member of the following medical societies: American College Health Association, American Professional Society on the Abuse of Children, American Association of Nurse Practitioners, American Nurses Association, International Society for the Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Carol Diane Berkowitz, MD Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Angelo P Giardino, MD, PhD, MPH Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC Associate Professor of Nursing, Department of Family Nursing, University of Texas Health Sciences Center Houston, School of Nursing

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Toi Blakley Harris, MD Associate Professor, Psychiatry & Pediatrics, and Assistant Dean, Student Affairs & Diversity Baylor College of Medicine; Founder and Director, Texas Regional Psychiatry Minority Mentor Network

Toi Blakley Harris, MD, is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The authors acknowledge the encouragement and support of Dr. John Sargent, a colleague who has worked tirelessly to ameliorate the effects of child abuse and neglect among children and families. Dr. Sargent has taught us a great deal and has set a high standard for us, both as an excellent mentor and as an exemplar of the highest degree of professionalism.

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