Post-Traumatic Stress Disorder (PTSD)

It is normal for kids to be scared after something frightening happens. They might have nightmares, get upset for no clear reason, or want to sleep near a caregiver at night. They might stay scared for a week or more. But if a child or teen is still having trouble one month or more after a scary event, they might have something more serious: Post-Traumatic Stress Disorder (PTSD).

PTSD is a mental health disorder that can affect kids who have gone through something very scary, traumatic, or life-threatening, like violence, abuse, natural disasters, or bad accidents. The child or teen does not even have to experience the event themselves, as PTSD can also happen after seeing something happen to someone close to them or even just hearing about it.

Kids with PTSD have extreme anxiety that might cause many issues, like being easily annoyed, having tantrums, trouble concentrating, trouble sleeping, nightmares, feeling guilty, or feeling detached from others. When a child has PTSD, they may avoid places or situations that remind them of the traumatic event, or they may have flashbacks.

Different kids may see and react to events in different ways, so not all children who go through a scary event experience it as trauma. PTSD can also look different depending on age: young children might not be able to say how they feel, while older kids may be more concerned with fairness, wondering why the trauma happened or feeling angry about it.

What are the symptoms of PTSD?

PTSD follows exposure to actual or threatened serious injury, physical or sexual violence, or threatened death, including the following:

– Direct experience with a traumatic event

– Witnessing a traumatic event happening to another

– Learning that a traumatic event has happened to a close family member or close friend

– Experiencing extreme or repeated exposure to upsetting details of traumatic events (Ages 7 and up only)

Children and teens with PTSD can have a variety of symptoms. Some of these symptoms may be easier for caregivers and teachers to notice, while others may be more subtle. Specific symptoms of PTSD include:

Core Symptoms of PTSD (Ages 7 and up)

One or more of the following, beginning after the traumatic event:

– Recurrent, involuntary, and intrusive memories of a traumatic event, including through repetitive play

– Recurrent nightmares related to the traumatic event

– Flashbacks giving the feeling that the traumatic event is happening again

– Intense or long-lasting distress after exposure to cues (even memories) related to the traumatic event

– Intense physical reactions (e.g., fast heartbeat, fast breathing, sweating, dry mouth) to cues (even memories) related to the traumatic event

Persistent avoidance of things related to the traumatic event:

– Avoidance or efforts to avoid memories, thoughts, or feelings related to the traumatic event

– Avoidance or efforts to avoid reminders (e.g., people, places, objects, activities) related to the traumatic event

Negative changes to thoughts or feelings about the traumatic event:

– Inability to remember important parts

– Persistent, exaggerated negative beliefs about oneself

– Persistent, distorted thoughts about the cause or consequences of the event, including self-blame

– Persistent negative feelings (e.g., fear, horror, anger, guilt, shame)

– Less interest or participation in activities

– Detached or estranged feelings

– Persistent inability to feel positive emotions (e.g., happiness, satisfaction, love)

Altered arousal and reactivity related to the traumatic event:

– Irritable behavior or angry outbursts

– Reckless or self-destructive behavior

– Hypervigilance

– Exaggerated startle response

– Problems with concentration

– Sleep issues

Core Symptoms of PTSD (Ages 6 and younger)

One or more of the following, beginning after the traumatic event:

– Recurrent, involuntary, and intrusive memories of a traumatic event, including through repetitive play

– Recurrent nightmares related to the traumatic event

– Flashbacks giving the feeling that the traumatic event is happening again

– Intense or long-lasting distress after exposure to cues (even memories) related to the traumatic event

– Intense physical reactions (e.g., fast heartbeat, fast breathing, sweating, dry mouth) to cues (even memories) related to the traumatic event

Persistent avoidance of things related to the traumatic event or negative changes to thoughts or feelings about the traumatic event:

– Avoidance or efforts to avoid memories, thoughts, or feelings related to the traumatic event

– Avoidance or efforts to avoid reminders (e.g., people, places, objects, activities) related to the traumatic event

– Persistent negative feelings (e.g., fear, horror, anger, guilt, shame)

– Less interest or participation in activities

– Socially withdrawn behavior

– Persistent reduction in showing positive emotions (e.g., happiness, satisfaction, love)

Altered arousal and reactivity related to the traumatic event:

– Irritable behavior or angry outbursts

– Seeming vigilant or on edge

– Exaggerated responses to surprises

– Problems with concentration

– Sleep issues

How is PTSD diagnosed?

A child-adolescent psychiatrist may diagnose a child or teen with PTSD after determining that their thoughts or feelings are linked to a specific event; they have trouble controlling their thoughts or feelings related to the event; their symptoms have lasted for at least one month; and their symptoms cause significant distress and problems in other parts of everyday life (e.g., social, family, school, etc.).

The psychiatrist may interview and/or assess both the child or teen and a caregiver to figure out the specifics of the child’s or teen’s distress. Many practitioners also use behavior and emotion rating forms to help with the diagnosis. The practitioner will also try to determine that the child’s or teen’s distress is not related to something unexpected.

PTSD facts

Worldwide frequency of the condition:
Rates vary, but it is estimated that 3.9% of the global population has PTSD. Among those who have experienced trauma, the prevalence rises to 5.6%. Among refugees and asylum seekers, it reaches 22.71%.

Burden of the condition in Brazil:
There is a lack of nationally representative data on the prevalence of PTSD in children and adolescents in Brazil. Local studies have found prevalence rates ranging from 0.1% to 0.3% in this age group.

Gender ratio:
Women are about twice as likely to be diagnosed with PTSD as men (2:1 ratio).

Peak age of onset😙
The peak age for onset of PTSD is approximately 15.5 years.

– Factors after a traumatic event:* These include exposure to repeated upsetting reminders, additional negative life events, financial hardship, forced migration following the event, and racial or ethnic discrimination.

What other disorders co-occur with PTSD?

Even though each child and teen is different, individuals who meet the criteria for PTSD sometimes also struggle with depression, bipolar disorder, anxiety, or substance use disorders.

How is PTSD treated?

The main treatment for PTSD in children and teens is psychotherapy. The four most supported types of psychotherapy for kids with PTSD are cognitive-behavioral therapy (CBT), trauma-focused cognitive-behavioral therapy (TF-CBT), prolonged exposure therapy (PE), and cognitive processing therapy (CPT).

CBT teaches individuals to manage their fear. In CBT, the child does not talk directly about the upsetting event but instead learns skills to deal with difficult feelings. Therapy for PTSD almost always includes a parent or other caregiver who takes care of the child.

TF-CBT is a more robust treatment that is now considered the gold standard treatment for children and teens with PTSD. TF-CBT has several parts, the first being teaching a child and their caregiver(s) about what trauma looks like. Next, TF-CBT helps kids learn how to deal with those symptoms. After building that skill base, treatment moves on to helping them talk about their trauma in as much detail as possible. Part of processing the event is creating what is known as a “trauma narrative.” These are often written stories that the child-adolescent psychiatrist can help the child create, but could also be cartoons, drawings, or PowerPoint presentations. By thinking and talking about what happened in a calm, safe space, the child learns that the more they can face the traumatic memory and talk about it, the less scary that memory becomes. That helps the child be better able to manage their feelings when the memory comes up.

PE is more suitable for teens than younger children. The treatment is designed to help individuals stop avoiding thinking about their traumatic experience or reminders of it. Instead, a therapist helps the individual confront their trauma memory by purposefully retelling their experience, creating a list of the things associated with the experience that they have been avoiding, and gradually adjusting to these things.

CPT is another treatment for young teens that helps them talk about what happened to them, but with a focus on identifying how the trauma changed their beliefs. After a trauma, people often develop new ways of thinking—or they adapt their old ways of thinking—to try to make sense of what happened to them. They get stuck on these points, which prevent them from recovering. In CPT, the therapist helps the individual examine how their beliefs have changed. They talk through what is true and what is not, with goals of developing a healthier view of what happened and moving past it.

While there is not much evidence that medication leads to significant improvement in PTSD symptoms in children and teens, some patients, especially when other anxious or depressive symptoms are associated with PTSD, might benefit from certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). Medications can have side effects, but they are safe for children to use with proper care from their doctor. A child or teen who is taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2021, September 7). Quick guide to Post-Traumatic Stress Disorder (PTSD) in kids. _https://childmind.org/guide/quick-guide-to-post-traumatic-stress-disorder-ptsd/_

– Ehmke, R. (2021, October 12). What is PTSD? The disorder looks different in children as they develop. _https://childmind.org/article/what-is-ptsd/_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6B40 Post Traumatic Stress Disorder. _https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/2070699808_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Blackmore, R., Gray, K. M., Boyle, J. A., Fazel, M., Ranasinha, S., Fitzgerald, G., Misso, M., & Gibson-Helm, M. (2020). Systematic Review and Meta-analysis: The Prevalence of Mental Illness in Child and Adolescent Refugees and Asylum Seekers. Journal of the American Academy of Child & Adolescent Psychiatry, 59(6), 705–714. _https://doi.org/10.1016/j.jaac.2019.11.011_

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Koenen, K. C., Ratanatharathorn, A., Ng, L., McLaughlin, K. A., Bromet, E. J., Stein, D. J., Karam, E. G., Meron Ruscio, A., Benjet, C., Scott, K., Atwoli, L., Petukhova, M., Lim, C. C. W., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Bunting, B., Ciutan, M., de Girolamo, G., … Kessler, R. C. (2017). Posttraumatic stress disorder in the World Mental Health Surveys. Psychological Medicine, 47(13), 2260–2274. _https://doi.org/10.1017/S0033291717000708_

– Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., Friedman, M. J., & Fullerton, C. S. (2013). A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events. PLoS ONE, 8(4), e59236. _https://doi.org/10.1371/journal.pone.0059236_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature. The Canadian Journal of Psychiatry, 51(2), 100–113. _https://doi.org/10.1177/070674370605100206_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. _https://doi.org/10.1002/wps.20894_

– Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. _https://doi.org/10.1016/j.jad.2020.12.134_

– DiGangi, J. A., Gomez, D., Mendoza, L., Jason, L. A., Keys, C. B., & Koenen, K. C. (2013). Pretrauma risk factors for posttraumatic stress disorder: A systematic review of the literature. Clinical Psychology Review, 33(6), 728–744. _https://doi.org/10.1016/j.cpr.2013.05.002_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Smith, P., Dalgleish, T., & Meiser‐Stedman, R. (2019). Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents. Journal of Child Psychology and Psychiatry, 60(5), 500–515. _https://doi.org/10.1111/jcpp.12983_

– Tortella-Feliu, M., Fullana, M. A., Pérez-Vigil, A., Torres, X., Chamorro, J., Littarelli, S. A., Solanes, A., Ramella-Cravaro, V., Vilar, A., González-Parra, J. A., Andero, R., Reichenberg, A., Mataix-Cols, D., Vieta, E., Fusar-Poli, P., Ioannidis, J. P. A., Stein, M. B., Radua, J., & Fernández de la Cruz, L. (2019). Risk factors for posttraumatic stress disorder: An umbrella review of systematic reviews and meta-analyses. Neuroscience & Biobehavioral Reviews, 107, 154–165. _https://doi.org/10.1016/j.neubiorev.2019.09.013_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Debell, F., Fear, N. T., Head, M., Batt-Rawden, S., Greenberg, N., Wessely, S., & Goodwin, L. (2014). A systematic review of the comorbidity between PTSD and alcohol misuse. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1401–1425. _https://doi.org/10.1007/s00127-014-0855-7_

– Saha, S., Lim, C. C. W., Cannon, D. L., Burton, L., Bremner, M., Cosgrove, P., Huo, Y., & McGrath, J. (2021). Co‐morbidity between mood and anxiety disorders: A systematic review and meta‐analysis. Depression and Anxiety, 38(3), 286–306. _https://doi.org/10.1002/da.23113_

Interventions

– Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I., Kessler, R. C., & Kossowsky, J. (2017). Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74(10), 1011. _https://doi.org/10.1001/jamapsychiatry.2017.2432_

– McGuire, A., Steele, R. G., & Singh, M. N. (2021). Systematic Review on the Application of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Preschool-Aged Children. Clinical Child and Family Psychology Review, 24(1), 20–37. _https://doi.org/10.1007/s10567-020-00334-0_

– Plaisted, H., Waite, P., Gordon, K., & Creswell, C. (2021). Optimising Exposure for Children and Adolescents with Anxiety, OCD and PTSD: A Systematic Review. Clinical Child and Family Psychology Review, 24(2), 348–369. _https://doi.org/10.1007/s10567-020-00335-z_

– Smith, P., Dalgleish, T., & Meiser‐Stedman, R. (2019). Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents. Journal of Child Psychology and Psychiatry, 60(5), 500–515. _https://doi.org/10.1111/jcpp.12983_

– Thielemann, J. F. B., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2022). A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents. Child Abuse & Neglect, 134, 105899. _https://doi.org/10.1016/j.chiabu.2022.105899_

– Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in Behavioral Neuroscience, 12, 258. _https://doi.org/10.3389/fnbeh.2018.00258_

– Xiang, Y., Cipriani, A., Teng, T., et al. (2021). Comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder in children and adolescents: a systematic review and network meta-analysis. Evid Based Mental Health, 24(4), 153-160. _https://doi.org/10.1136/ebmental-2021-300346_