Posttraumatic stress disorder (PTSD) is a mental disorder that may develop in some children and adolescents after exposure to a traumatic event. Traumatic events may include incidents that involve serious harm to self or others and include accidents, natural disasters, sexual or physical trauma, natural disasters, and violence.
Since time immemorial, scientists have pursued the ever-elusive causal origins of disease processes. To the detriment of humanity, these endeavors frequently resulted in fruitless pursuits, as we still can only postulate the etiologies of many illnesses. Thus, the causal nature of posttraumatic stress disorder (PTSD) places it in the company of a scant few psychiatric diagnoses where etiology is known. The temporal association between the event exposure and the subsequent symptom manifestation is not simply a post hoc fallacy. Not to be misled by the putative simplistic nature of the etiology, the consequent psychiatric sequelae can, in turn, be debilitating. Moreover, recent studies have unmasked unsettling discoveries regarding pediatric considerations in the setting of PTSD. It has been suggested that a substantial number of children have gone inappropriately undiagnosed because of the insufficient sensitivities of previous guidelines. Children often react differently to stressful events, and because of this, the pediatric phenomenology of PTSD differs from that of the adults. The transition from DSM IV to DSM-V acknowledges this inconsistency, made evident by the additional criteria specific to PTSD for children six years or younger.
PTSD is defined by four symptom clusters, including avoidance, negative alterations in cognition and mood, intrusion, and hyperarousal per DSM-5. The consequences of PTSD are often deleterious with adverse outcomes in physical and mental health besides impaired social and occupational functioning.
One study reports that up to 60% of children and adolescents have been exposed to a PTE. Of this exposed population, an estimated 30% subsequently develop PTSD symptomatology; most will only experience ephemeral symptoms, whereas a few unfortunate individuals will experience more chronic life-long sequelae. Current estimates suggest 10% of children less than 18 years of age are diagnosed with PTSD, with girls four times more likely than boys to develop it.
Common to both the adult and pediatric population are the foundational elements of post-traumatic stress disorder: re-experiencing of the trauma through intrusive and recurrent thoughts, avoidance of associated stimuli, negative modifications in mood, and alterations in reactivity and arousal. However, the phenomenology of PTSD in younger demographics is often more complex and can mimic variant internalizing and externalizing disorders. It is likely that adults will relegate manifestations of PTSD as disagreeable youthful behavior.
Internalizing and externalizing symptomatology that can manifest in the setting of PTSD include separation anxiety, shame, guilt, low frustration tolerance, hyperarousal, impulsivity, temper outbursts, hostility, defiance, aggression, irritability, and mood changes. Moreover, complex trauma disorder can present even more ambiguously in children. Whereas a more discrete change in behavior transpires in acute PTE, exposure to protracted PTEs incites more insidious and pervasive complications.
It is critical in the evaluation of pediatric post-traumatic stress disorder that the clinician obtains both the child’s and caregivers’ reports. Once the respective histories have been elicited, the clinician will use diagnostic tools to assess for the existence of PTSD. In the transition to DSM-V, specific diagnostic criteria for PTSD in those less than six years of age were added.
DSM-V Diagnostic Criteria for Post-traumatic Stress Disorder for Children 6 years and Younger: [Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013].
With Dissociative symptoms:
(For children greater than six years old, the clinician will refer to DSM-V criteria for adults)
Additional evidence-based screening tools have been commonly implemented in the clinical setting. These include the UCLA Posttraumatic Stress Disorder – Reaction Index (UCLA-PTSD-RI), the Trauma Symptom Checklist for Children (TSCC), and The Screening Tool for Early Predictors of PTSD (STEPP).
Psychotherapy is encouraged by the American Academy of Child and Adolescent Psychiatry (AACAP) as the first-line treatment in the setting of pediatric PTSD. Trauma-centered cognitive-behavioral therapy currently has the most unequivocal evidence supporting its implementation in the treatment of pediatric PTSD. Eye movement desensitization and reprocessing therapy (EMDR) is a popular alternative. However, more research is required to properly assess its efficaciousness.
Other therapies include play therapy, psychological first aid, and multisystemic therapy. Because of developmental neurobiological differences between youth and adult patients, the consensus remains ambiguous regarding the administration of pharmacological agents. Of the psychotropic alternatives, selective serotonin reuptake inhibitors (SSRI) have the most support. Lastly, in moderate to severe cases, children should be referred to specialists who are trained to treat PTSD in the pediatric population.
The phenomenology of post traumatic stress disorder in the pediatric setting can mislead clinicians towards a misdiagnosis. Disorders that can mimic the aforementioned internalizing and externalizing features of PTSD include major depressive disorder, generalized anxiety disorder, oppositional defiant disorder, intermittent explosive disorder, conduct disorder, attention deficit hyperactivity disorder, and obsessive-compulsive disorder. Additional differentials in common with adult PTSD include adjustment disorder, acute stress disorder, panic disorder, depersonalization or derealization disorder, and malingering.
Complications arise secondary to functional impairments, resulting from psychic stress. With hopes to combat these impairments, patients commonly resort to self-medication; such a stratagem involves inappropriate use of anxiolytics, alcohol, or recreational drugs. Unfortunately, these immature coping mechanisms exacerbate the psychic illness, thus further debilitating the patient, precipitating an elegiac positive feedback loop.
Prior to initial exposure to post-traumatic events, providers and educators can implement proactive measures to equip the youth - especially those at high risk - with beneficial coping skills, safety planning, and psychoeducation. As most families will initially present to their primary care provider for assistance, it is imperative for clinicians to be cognizant of the phenomenology of PTSD in children. Primary healthcare teams are, for lack of a better colloquialism, ‘the first line of defense’ in the setting of PTE.
Providers suspicious of impending manifestations of PTSD in the acute aftermath of a PTE should ardently monitor the patient, as well as enlighten the family regarding salient features to be aware of in this condition. Furthermore, some studies suggest that those who do not meet the full diagnostic threshold for PTSD may benefit from a more flexible dimensional perspective, as they still may be at risk for developing undesirable psychiatric sequelae.
Post-traumatic stress disorder is a debilitating disorder. It can cause life-long impairment and dysfunction. In the pediatric setting, it can be even more deleterious, as it can go undiagnosed and thus untreated for an extended period of time. Because of the unique presentation in the pediatric population, it is exigent that healthcare workers remain vigilant and aware of the onset of symptomatology. Primary care physicians, pediatricians, nurse practitioners, psychotherapists, and licensed clinical social workers will often be the 'first line of defense,' as parents will often bring their children to them, before considering a psychiatrist. Thus, primary care providers must remain informed regarding the phenomenology in this population. They should not hesitate to refer to a specialist. Interprofessional relations will most benefit the patient.
"This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities."
|||Birkeland MS,Holt T,Ormhaug SM,Jensen TK, Perceived social support and posttraumatic stress symptoms in children and youth in therapy: A parallel process latent growth curve model. Behaviour research and therapy. 2020 Jun 1 [PubMed PMID: 32590214]|
|||de Vries AP,Kassam-Adams N,Cnaan A,Sherman-Slate E,Gallagher PR,Winston FK, Looking beyond the physical injury: posttraumatic stress disorder in children and parents after pediatric traffic injury. Pediatrics. 1999 Dec; [PubMed PMID: 10585980]|
|||Malejko K,Tumani V,Rau V,Neumann F,Plener PL,Fegert JM,Abler B,Straub J, Neural correlates of script-driven imagery in adolescents with interpersonal traumatic experiences: A pilot study. Psychiatry research. Neuroimaging. 2020 Jun 19 [PubMed PMID: 32585577]|
|||McDonald R,Jouriles EN,Ramisetty-Mikler S,Caetano R,Green CE, Estimating the number of American children living in partner-violent families. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43). 2006 Mar; [PubMed PMID: 16569098]|
|||Pronczuk J,Surdu S, Children's environmental health in the twenty-first century. Annals of the New York Academy of Sciences. 2008 Oct; [PubMed PMID: 18991913]|
|||Ramsdell KD,Smith AJ,Hildenbrand AK,Marsac ML, Posttraumatic stress in school-age children and adolescents: medical providers' role from diagnosis to optimal management. Pediatric health, medicine and therapeutics. 2015; [PubMed PMID: 29388603]|
|||Finkelhor D,Ormrod RK,Turner HA, Lifetime assessment of poly-victimization in a national sample of children and youth. Child abuse [PubMed PMID: 19589596]|
|||Miller-Graff LE,Howell KH, Posttraumatic stress symptom trajectories among children exposed to violence. Journal of traumatic stress. 2015 Feb; [PubMed PMID: 25644072]|
|||Ziegler MF,Greenwald MH,DeGuzman MA,Simon HK, Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers. Pediatrics. 2005 May; [PubMed PMID: 15867033]|
|||Dykman RA,McPherson B,Ackerman PT,Newton JE,Mooney DM,Wherry J,Chaffin M, Internalizing and externalizing characteristics of sexually and/or physically abused children. Integrative physiological and behavioral science : the official journal of the Pavlovian Society. 1997 Jan-Mar; [PubMed PMID: 9105915]|
|||Kletter H,Weems CF,Carrion VG, Guilt and posttraumatic stress symptoms in child victims of interpersonal violence. Clinical child psychology and psychiatry. 2009 Jan; [PubMed PMID: 19103706]|
|||Cloitre M,Stolbach BC,Herman JL,van der Kolk B,Pynoos R,Wang J,Petkova E, A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. Journal of traumatic stress. 2009 Oct; [PubMed PMID: 19795402]|
|||Kassam-Adams N,García-España JF,Miller VA,Winston F, Parent-child agreement regarding children's acute stress: the role of parent acute stress reactions. Journal of the American Academy of Child and Adolescent Psychiatry. 2006 Dec; [PubMed PMID: 17135994]|
|||Schellong J,Hanschmidt F,Ehring T,Knaevelsrud C,Schäfer I,Rau H,Dyer A,Krüger-Gottschalk A, [Diagnostics of posttraumatic stress disorder according to DSM-5 and ICD-11]. Der Nervenarzt. 2019 Jul [PubMed PMID: 30643956]|
|||Winston FK,Kassam-Adams N,Garcia-España F,Ittenbach R,Cnaan A, Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA. 2003 Aug 6; [PubMed PMID: 12902368]|
|||Cohen JA,Mannarino AP, A treatment outcome study for sexually abused preschool children: initial findings. Journal of the American Academy of Child and Adolescent Psychiatry. 1996 Jan; [PubMed PMID: 8567611]|
|||Seidler GH,Wagner FE, Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological medicine. 2006 Nov; [PubMed PMID: 16740177]|
|||Pervanidou P, Biology of post-traumatic stress disorder in childhood and adolescence. Journal of neuroendocrinology. 2008 May; [PubMed PMID: 18363804]|
|||Glod CA,Teicher MH, Relationship between early abuse, posttraumatic stress disorder, and activity levels in prepubertal children. Journal of the American Academy of Child and Adolescent Psychiatry. 1996 Oct; [PubMed PMID: 8885593]|
|||Radoš SN,Matijaš M,Anđelinović M,Čartolovni A,Ayers S, The role of posttraumatic stress and depression symptoms in mother-infant bonding. Journal of affective disorders. 2020 May 1 [PubMed PMID: 32174471]|
|||Copeland WE,Keeler G,Angold A,Costello EJ, Traumatic events and posttraumatic stress in childhood. Archives of general psychiatry. 2007 May; [PubMed PMID: 17485609]|
|||Zatzick DF,Jurkovich GJ,Fan MY,Grossman D,Russo J,Katon W,Rivara FP, Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Archives of pediatrics [PubMed PMID: 18606935]|
|||Zatzick DF,Jurkovich GJ,Gentilello L,Wisner D,Rivara FP, Posttraumatic stress, problem drinking, and functional outcomes after injury. Archives of surgery (Chicago, Ill. : 1960). 2002 Feb; [PubMed PMID: 11822960]|
|||Pfefferbaum B,Varma V,Nitiéma P,Newman E, Universal preventive interventions for children in the context of disasters and terrorism. Child and adolescent psychiatric clinics of North America. 2014 Apr; [PubMed PMID: 24656585]|
|||Davidson EJ,Silva TJ,Sofis LA,Ganz ML,Palfrey JS, The doctor's dilemma: challenges for the primary care physician caring for the child with special health care needs. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association. 2002 May-Jun; [PubMed PMID: 12014983]|
|||Leslie LK,Sarah R,Palfrey JS, Child health care in changing times. Pediatrics. 1998 Apr; [PubMed PMID: 9544178]|
|||Broman-Fulks JJ,Ruggiero KJ,Green BA,Smith DW,Hanson RF,Kilpatrick DG,Saunders BE, The latent structure of posttraumatic stress disorder among adolescents. Journal of traumatic stress. 2009 Apr; [PubMed PMID: 19319918]|