The diagnosis of Posttraumatic
Stress Disorder (PTSD) was formally recognized
as a psychiatric diagnosis in 1980. At that
time, little was known about what PTSD looked
like in children and adolescents. Today, we
know children and adolescents are susceptible
to developing PTSD, and we know that PTSD has
different age-specific features. In addition,
we are beginning to develop child-focused interventions.
This fact sheet provides information regarding
what events cause PTSD in children, how many
children develop PTSD, risk factors associated
with PTSD, what PTSD looks like in children,
other effects of trauma on children, treatment
for PTSD, and what you can do for your child.
What events cause PTSD
A diagnosis of PTSD means that
an individual experienced an event that involved
a threat to one's own or another's life or physical
integrity and that this person responded with
intense fear, helplessness, or horror. There
are a number of traumatic events that have been
shown to cause PTSD in children and adolescents.
Children and adolescents may be diagnosed with
PTSD if they have survived natural and man made
disasters such as floods; violent crimes such
as kidnapping, rape or murder of a parent, sniper
fire, and school shootings; motor vehicle accidents
such as automobile and plane crashes; severe
burns; exposure to community violence; war;
peer suicide; and sexual and physical abuse.
How many children develop
A few studies of the general
population have been conducted that examine
rates of exposure and PTSD in children and adolescents.
Results from these studies indicate that 15
to 43% of girls and 14 to 43% of boys have experienced
at least one traumatic event in their lifetime.
Of those children and adolescents who have experienced
a trauma, 3 to 15% of girls and 1 to 6% of boys
could be diagnosed with PTSD.
Rates of PTSD are much higher
in children and adolescents recruited from at-risk
samples. The rates of PTSD in these at-risk
children and adolescents vary from 3 to 100%.
For example, studies have shown that as many
as 100% of children who witness a parental homicide
or sexual assault develop PTSD. Similarly, 90%
of sexually abused children, 77% of children
exposed to a school shooting, and 35% of urban
youth exposed to community violence develop
What are the risk factors
There are three factors that
have been shown to increase the likelihood that
children will develop PTSD. These factors include
the severity of the traumatic event, the parental
reaction to the traumatic event, and the physical
proximity to the traumatic event. In general,
most studies find that children and adolescents
who report experiencing the most severe traumas
also report the highest levels of PTSD symptoms.
Family support and parental coping have also
been shown to affect PTSD symptoms in children.
Studies show that children and adolescents with
greater family support and less parental distress
have lower levels of PTSD symptoms. Finally,
children and adolescents who are farther away
from the traumatic event report less distress.
There are several other factors
that affect the occurrence and severity of PTSD.
Research suggests that interpersonal traumas
such as rape and assault are more likely to
result in PTSD than other types of traumas.
Additionally, if an individual has experienced
a number of traumatic events in the past, those
experiences increase the risk of developing
PTSD. In terms of gender, several studies suggest
that girls are more likely than boys to develop
PTSD. A few studies have examined the connection
between ethnicity and PTSD. While some studies
find that minorities report higher levels of
PTSD symptoms, researchers have shown that this
is due to other factors such as differences
in levels of exposure. It is not clear how a
child's age at the time of exposure to a traumatic
event impacts the occurrence or severity of
PTSD. While some studies find a relationship,
others do not. Differences that do occur may
be due to differences in the way PTSD is expressed
in children and adolescents of different ages
or developmental levels (see next section).
What does PTSD look
like in children?
Researchers and clinicians
are beginning to recognize that PTSD may not
present itself in children the same way it does
in adults (see What is PTSD? below). Criteria
for PTSD now include age-specific features for
Very Young Children
Very young children may present
with few PTSD symptoms. This may be because
eight of the PTSD symptoms require a verbal
description of one's feelings and experiences.
Instead, young children may report more generalized
fears such as stranger or separation anxiety,
avoidance of situations that may or may not
be related to the trauma, sleep disturbances,
and a preoccupation with words or symbols that
may or may not be related to the trauma. These
children may also display posttraumatic play
in which they repeat themes of the trauma. In
addition, children may lose an acquired developmental
skill (such as toilet training) as a result
of experiencing a traumatic event.
Clinical reports suggest that
elementary school-aged children may not experience
visual flashbacks or amnesia for aspects of
the trauma. However, they do experience "time
skew" and "omen formation," which
are not typically seen in adults. Time skew
refers to a child mis-sequencing trauma related
events when recalling the memory. Omen formation
is a belief that there were warning signs that
predicted the trauma. As a result, children
often believe that if they are alert enough,
they will recognize warning signs and avoid
future traumas. School-aged children also reportedly
exhibit posttraumatic play or reenactment of
the trauma in play, drawings, or verbalizations.
Posttraumatic play is different from reenactment
in that posttraumatic play is a literal representation
of the trauma, involves compulsively repeating
some aspect of the trauma, and does not tend
to relieve anxiety. An example of posttraumatic
play is an increase in shooting games after
exposure to a school shooting. Posttraumatic
reenactment, on the other hand, is more flexible
and involves behaviorally recreating aspects
of the trauma (e.g., carrying a weapon after
exposure to violence).
PTSD in adolescents may begin
to more closely resemble PTSD in adults. However,
there are a few features that have been shown
to differ. As discussed above, children may
engage in traumatic play following a trauma.
Adolescents are more likely to engage in traumatic
reenactment, in which they incorporate aspects
of the trauma into their daily lives. In addition,
adolescents are more likely than younger children
or adults to exhibit impulsive and aggressive
Besides PTSD, what
are the other effects of trauma on children?
Besides PTSD, children and
adolescents who have experienced traumatic events
often exhibit other types of problems. Perhaps
the best information available on the effects
of traumas on children comes from a review of
the literature on the effects of child sexual
abuse. In this review, it was shown that sexually
abused children often have problems with fear,
anxiety, depression, anger and hostility, aggression,
sexually inappropriate behavior, self-destructive
behavior, feelings of isolation and stigma,
poor self-esteem, difficulty in trusting others,
and substance abuse. These problems are often
seen in children and adolescents who have experienced
other types of traumas as well. Children who
have experienced traumas also often have relationship
problems with peers and family members, problems
with acting out, and problems with school performance.
Along with associated symptoms,
there are a number of psychiatric disorders
that are commonly found in children and adolescents
who have been traumatized. One commonly co-occurring
disorder is major depression. Other disorders
include substance abuse; other anxiety disorders
such as separation anxiety, panic disorder,
and generalized anxiety disorder; and externalizing
disorders such as attention-deficit/hyperactivity
disorder, oppositional defiant disorder, and
How is PTSD treated
in children and adolescents?
Although some children show
a natural remission in PTSD symptoms over a
period of a few months, a significant number
of children continue to exhibit symptoms for
years if untreated. Few treatment studies have
examined which treatments are most effective
for children and adolescents.
A review of the adult treatment
studies of PTSD shows that this is the most
effective approach for treating children. CBT
for children generally includes the child directly
discussing the traumatic event (exposure), anxiety
management techniques such as relaxation and
assertiveness training, and correction of inaccurate
or distorted trauma related thoughts. Although
there is some controversy regarding exposing
children to the events that scare them, exposure-based
treatments seem to be most relevant when memories
or reminders of the trauma distress the child.
Children can be exposed gradually and taught
relaxation so that they can learn to relax while
recalling their experiences. Through this procedure,
they learn that they do not have to be afraid
of their memories. CBT also involves challenging
children's false beliefs such as, "the
world is totally unsafe." The majority
of studies have found that it is safe and effective
to use CBT for children with PTSD.
CBT is often accompanied by
psycho-education and parental
involvement. Psycho-education is education
about PTSD symptoms and their effects. It is
as important for parents and caregivers to understand
the effects of PTSD as it is for children. Research
shows that the better parents cope with the
trauma, and the more they support their children,
the better their children will function. Therefore,
it is important for parents to seek treatment
for themselves in order to develop the necessary
coping skills that will help their children.
Several other types of therapy
have been suggested for PTSD in children and
Play therapy can be used to
treat young children with PTSD who are not able
to deal with the trauma more directly. The therapist
uses games, drawings, and other techniques to
help the children process their traumatic memories.
Psychological first aid has
been prescribed for children exposed to community
violence and can be used in schools and traditional
settings. It involves clarifying trauma related
facts, normalizing the children's PTSD reactions,
encouraging the expression of feelings, teaching
problem solving skills, and referring the most
symptomatic children for additional treatment.
Twelve Step approaches
This type of approach has been
prescribed for adolescents with substance abuse
problems and PTSD.
Eye Movement Desensitization
and Reprocessing (EMDR)
Another therapy, EMDR, combines
cognitive therapy with directed eye movements.
While EMDR has been shown to be effective in
treating both children and adults with PTSD,
studies indicate that it is the cognitive intervention
rather than the eye movements that accounts
for the change.
Drugs have also been prescribed
for some children with PTSD. However, due to
the lack of research in this area, it is too
early to evaluate the effectiveness of medication
Finally, specialized interventions
may be necessary for children exhibiting particularly
problematic behaviors or PTSD symptoms. For
example, a specialized intervention might be
required for inappropriate sexual behavior or
extreme behavioral problems.
What can I do to help
Reading this fact sheet is
a first step toward helping your child. Gather
information on PTSD and pay attention to how
your child is functioning. Watch for warning
signs such as sleep problems, irritability,
avoidance, changes in school performance, and
problems with peers. It may be necessary to
seek help for your child. Consider having your
child evaluated by a mental-health professional
who has experience treating PTSD in children
and adolescents. Many therapists with this experience
are members of the International Society
for Traumatic Stress Studies, which
has a membership directory containing a geographical
listing of therapists who treat children and
adolescents. Ask how the therapist typically
treats PTSD, and choose a practitioner with
whom you and your child feel comfortable. Consider
whether you might also benefit from talking
to someone individually. The most important
thing you can do now is to support your child.
Based in part on the
Practice Parameters for the Assessment and Treatment
of Children and Adolescents with Posttraumatic
Stress Disorder, Journal of the American
Academy of Child and Adolescent Psychiatry,
37:10 supplement, October 1998.