eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Posttraumatic Stress Disorder in Children

Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Contributor Information and Disclosures

Updated: Mar 4, 2008

Introduction

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 life-threatening or perceived to be likely to cause serious injury to self or others. In addition, the child or adolescent must have responded with intense fear, helplessness, or horror. Traumatic events can take many forms, including physical or sexual assaults, natural disasters, traumatic death of a loved one, or emotional abuse or neglect. Severe emotional trauma has widespread effects on children's development, in that it clearly obliterates the belief that their parents will protect them. The premature destruction of these beliefs can have profound negative consequences on development.

Traumatized children and adolescents are understandably frequently preoccupied with danger and vulnerability, sometimes leading to misperceptions of danger, even in situations that are not threatening. Multiple researchers (eg, Kardiner, van der Kolk¹ ) note that, once posttraumatic stress symptoms emerge, PTSD leads to neurophysiologic correlates that impact brain function in developing children and adolescents.

In 1980, the term PTSD first came into existence in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III).² Only in 1987 did the DSM series make reference to traumatized children. The first major studies of the effects of large traumas on children were Bloch's 1956 study of the effect of a tornado in Mississippi, Lacey's 1972 study of the effects of an avalanche on a Welsh school, Newman's 1976 work on the Buffalo Creek disaster,³ and Terr's 1979 research on the Chowchilla bus kidnapping.⁴

Pathophysiology

Evidence indicates a genetic predisposition for PTSD, suggesting that it may be linked to the individual's temperament and to reactivity of the hypothalamic pituitary axis.

Frequency

United States

Lifetime prevalence of PTSD is 8%.⁵ 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. After being kidnapped, witnessing the death of a parent, or suffering domestic violence, the rate of PTSD may be 95-100%. Following a sniper attack at school, 40% of children experienced moderate-to-severe PTSD. In one study of children in foster care, 64% who had experienced sexual abuse had PTSD, and 42% who had experienced physical abuse fulfilled the PTSD criteria. Moreover, 18% of the children who were not abused also met PTSD criteria, presumably because they had witnessed violence.

International

The prevalence in a location overwhelmingly depends on the endemicity of violence in the region.

Mortality/Morbidity

Alone, PTSD is not a fatal disorder. Nevertheless, it frequently leads to conduct disorder, substance abuse, depression, and risk-taking that poses considerable danger.

PTSD has a considerable morbidity rate, 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.

Race

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

Sex

PTSD is more common in women than in men.

Age

PTSD occurs in people of all ages, but younger and elderly persons are the most vulnerable.

Clinical

History

Diagnostic criteria

• Posttraumatic stress disorder (PTSD) arises subsequent to a serious traumatic event that causes or threatens serious harm, injury, or violation of bodily integrity. The individual experiences intense fear, helplessness, or horror in response. Children may experience disorganized or agitated behavior. The individual does not need to be the actual victim. The individual could have witnessed the traumatic event or have been told about it happening to a close associate. For example, a child who is told about the sexual abuse of another child can develop PTSD.
• The trauma results in the development of 3 types of symptoms. Category A refers to the initial response to the trauma, which involves the experience of horror, helplessness or fear, or disorganized behavior in children. Categories B, C, and D are as follows:
  • Category B - Intrusive recollections
  • Category C - Numbing and withdrawal
  • Category D - Persistent symptoms of increased arousal
• Diagnosis requires reexperiencing of the trauma in one or more of the following ways:
  • Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
  • Recurrent distressing dreams (In children, the dreams are frightening but may not have recognizable content.)
  • Acting or feeling as if the traumatic event is recurring
  • Intense psychological distress upon exposure to cues that symbolize or resemble an aspect of the traumatic event
  • Physiological reactivity upon exposure to cues that symbolize or resemble an aspect of the traumatic event
• Diagnosis requires persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
  • Efforts to avoid thoughts, feelings, or conversations associated with the trauma
  • Efforts to avoid activities, places, or people that arouse recollections of the trauma
  • Inability to recall an important aspect of the trauma
  • Markedly diminished interest or participation in significant activities (including regression and loss of skills such as toilet training)
  • Feeling of detachment or estrangement from others
  • Restricted range of affect (eg, unable to have loving feelings)
  • Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or normal lifespan)
• Diagnosis requires persistent symptoms of increased arousal (not present before the trauma), as indicated by 3 or more of the following:
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
• Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than one month
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnosing posttraumatic stress disorder in children

• The diagnostic criteria for PTSD are designed for adults, not children. Children have limited verbal skills and different ways of reacting to stress. This means that children may not fulfill the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) criteria, even though they clearly have a psychiatric disorder analogous to adult PTSD.² In particular, children often do not have 3 of the adult signs of numbing and withdrawal because they lack the verbal skills to express these feelings. Children may also experience an alternation between hyperarousal and numbing/withdrawal.
• Scheeringa et al (1995) recommend altering the criteria for PTSD when assessing very young children, taking into account their ability to report symptoms and the types of symptoms they are likely to have.⁶ The altered criteria do not require that the child be able to report fear, helplessness, or horror in response to the trauma.
  • Diagnosis using the altered criteria requires that the very young child undergo one of the following types of reexperiencing:
    • Posttraumatic play
    • Play reenactment
    • Recurrent recollections
    • Nightmares
    • Episodes with objective features of a flashback or dissociation
    • Distress at exposure to reminders of the event
  • The altered criteria also require only one of the following symptoms of numbing/avoidance (instead of the 3 needed for adults):
    • Constriction of play
    • Relative social withdrawal
    • Restricted range of affect
    • Loss of acquired developmental skills
  • Furthermore, only one of the following symptoms of hyperarousal is required:
    • Night terrors
    • Difficulty going to sleep that is not related to fear of having nightmares or fear of the dark
    • Night waking not related to nightmares or night terrors
    • Decreased concentration
    • Hypervigilance
    • Exaggerated startle response
  • Scheeringa et al endorse an additional class of symptoms to replace the eased category C and category D criteria.⁷ Symptoms of fear and aggression marked by one of the following is required:⁸ :
    • New aggression
    • New separation anxiety
    • Fear of using the restroom alone
    • Fear of the dark
    • New fears of things or situations not obviously related to the trauma
• Posttraumatic play involves joyless repetitive play with traumatic themes. Children also may reenact what occurred or draw pictures related to the event. Posttraumatic dreams in children generally are vaguely formed dreams that the child may not be able to describe.
• In adolescents, the primary symptoms are likely to include invasive images (which they may not talk about), restlessness and aggression, difficulty sleeping, and difficulty concentrating. Other common symptoms include loss of interest in previously enjoyed activities, withdrawal from family and peers, and changes in significant life attitudes. Adolescents with chronic PTSD arising from repeated or prolonged trauma may suffer primarily from dissociative symptoms, numbing, sadness, restricted affect, detachment, self-injury, substance abuse, and aggressive outburst. When interpersonal abuse is the precipitant, the development of dissociative phenomena, somatic complaints, learned helplessness, loss of affect control, hostility, aggression, eating disorders, sexual acting out, personality change, change in belief system, self-destructive and impulsive behavior, substance abuse, social withdrawal, and impaired relationships are a significant possibility.⁸

Physical

• Numerous physical findings have been noted; however, whether these findings are a result of PTSD, predisposing factors, or the result of comorbid problems (eg, substance abuse) is unclear. Findings include the following:
  • Hippocampal volume is smaller in individuals with PTSD.⁹
  • Areas of the brain that are involved in threat perception (eg, amygdala) have altered metabolism in adult trauma survivors with PTSD.
  • Activity of the anterior cingulate (an area of the brain that inhibits the amygdala and other brain regions involved in the fear response) is decreased in people with PTSD.
  • Basal cortisol levels are low.
  • Cortisol response to dexamethasone is increased.
  • Concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus are increased.
• Some studies have shown that children who have been abused have elevated cortisol levels compared with control subjects. Studies also indicate that adults with PTSD who were abused as children have higher cortisol levels than those who were abused and did not develop PTSD. Research evidence also indicates that girls who have been sexually abused have increased catecholamine activity. Trauma survivors have pituitary adrenocortical hyperresponsivity to stress. PTSD leads to increased pulse, blood pressure, muscle tension, and skin resistance.
• One problem with the research is that studies tend to show that changes in physiological measures, such as heart rate and skin conductance, appear to be the same in individuals with current and prior PTSD. This indicates that the changes may represent either a predisposition or a permanent change resulting from PTSD (eg, trait rather than state).

Causes

• PTSD may be caused by exposure to a severe traumatic stress that threatens death or serious injury or threat to personal integrity, as follows:
  • Rape
  • Sexual and physical abuse
  • Car accidents
  • Fires
  • Experiencing war
  • Receiving a serious medical diagnosis
  • Being subjected to invasive painful treatment of medical problems
• Numerous factors increase the likelihood that a child will develop PTSD in response to a given stress, including the following:
  • Lack of social and parental support
  • Prior exposure to traumatic incidents
  • A preexisting psychiatric disorder
  • Repeated trauma
  • Trauma caused by a person (especially if by a trusted caregiver) rather than resulting from an accident
• Parental reaction is a critical factor affecting the child's reaction. Parents' anxiety and difficulty coping with life as the result of the trauma may overwhelm a child, whereas parental ability to cope and to provide a safe haven for a child may markedly affect the child's ability to deal with the stressor or the propensity to develop protracted PTSD.
• PTSD is particularly likely to develop if a child experiences dissociation at the time of the trauma.

• Search for CME/CE on This Topic »

• Post-traumatic Stress Disorder Causes
• Post-traumatic Stress Disorder Symptoms
• Children and Post-traumatic Stress Disorder
• Stress Overview
• What Is Post-traumatic Stress Disorder (PTSD)?
• Mental Health and Behavior Center