Posttraumatic Stress Disorder in Children

Etiology

Individuals who experience trauma may or may not develop long-term mental health sequela as a result of the trauma. However, the DSM-5-TR defines trauma as an essential characteristic of those who develop PTSD. Trauma, in the context of PTSD, is defined as exposure to actual or threatened death, serious injury, or sexual violence. This includes directly experiencing the traumatic event, witnessing a person experiencing trauma, or learning that the traumatic event occurred to a close family member or friend.[9] Children are particularly vulnerable to abuse and neglect, with the youngest children being most susceptible, which can have a lasting psychological impact on the developing brain.[10]

There are various psychological theories proposed to explain trauma's capacity to cause PTSD. The shattered assumptions theory was proposed by Janoff-Bulman in 1992.[11] This theory suggests that traumatic events can change how children view themselves and the world as compared to life before the traumatic experience. This theory has preliminary assumptions, including: "the world is benevolent," "the world is meaningful," and "the self is worthy." After trauma, the foundation for these inherent assumptions is weakened or "shattered."[11]

Psychodynamic psychology emphasizes the systematic study of how life experiences may relate to the current psychological forces on the mind, which impact behavior and emotions.[12] In 1890, Jean-Martin Charcot argued that psychological trauma was the origin of all mental illness.[13] Over time, this has been refuted, but it is acknowledged that trauma (and particularly early life trauma) can have a profound impact on the development of mental illness. A psychodynamic psychological view of posttraumatic stress relates particularly to unconscious decisions of trust. Children who experience trauma can have difficulty trusting that the world can be a safe place or trusting that individuals will not emotionally or physically hurt them.[14]

Behavioral scientists have also contributed to understanding trauma's impact on cognitive processes. A conditioned response of learned fear can occur after exposure to a significant stimulus, which is usually the case in the context of PTSD. Further, exposure to repeated traumas (such as those suffering from abuse or neglect) enhances a conditioned response to trauma.[15]

The presence or absence of support after trauma can both increase or decrease the risk of PTSD. Children who have a well-established support system are less likely to develop PTSD after a traumatic event. Likewise, children who feel isolated after trauma (poor social support) are more likely to develop an acute stress disorder with or without PTSD.[16] The risk of PTSD after a traumatic event is further increased by lower socioeconomic status, other childhood adversity, gender, race, physical injury (including traumatic brain injury), and initial severity of the reaction to the trauma.[17][18][19][20][21]

Epidemiology

The lifetime prevalence of PTSD ranges from 6.1% to 9.2% from national samples of the general adult population of the United States and Canada.[22][23] In children, the prevalence of trauma history is estimated at 31%, and the development of PTSD by the age of 18 years is estimated at 7.8%.[24] One study reports that up to 60% of children and adolescents have been exposed to a traumatic event.[25][26] The 1-year prevalence rates range from 3.5% to 4.7%.[23][27] In the Western Hemisphere, certain populations have been found to have a higher prevalence of PTSD, including indigenous peoples and refugees.[27][28] Lower prevalence rates of PTSD have been found outside of the Western Hemisphere, such as the Eastern Hemisphere, but the reason for lower PTSD rates in the Eastern Hemisphere is not well understood.[29] 

Intentional trauma has been found to have a greater association with PTSD than accidental trauma or nonviolent trauma.[30][31] Repeated trauma or abuse and increasing duration of trauma exposure are also associated with a higher risk of PTSD.[32] Males and females both commonly develop PTSD after trauma, but females are known to be more predisposed to PTSD, with slight variations depending on the type of traumatic experience.[33]

Pathophysiology

The initial response to trauma is directly associated with the pathophysiology of PTSD. The response is characterized by a surge of adrenaline from sympathetic nervous system stimulation. Physiologically, this can lead to tachycardia, rising blood pressure, and further neuroendocrine responses such as the release of cortisol and other catecholamines.[34] When the trauma stimulus is prolonged or repeated, a conditioned behavioral response leading to acute stress disorder with or without PTSD can occur. 

Neuroanatomically, the amygdala has significant responsibility for threat detection and fear response. Magnetic resonance imaging (MRI) studies of individuals with PTSD have revealed nonspecific findings, including reduced total brain volume in those with chronic PTSD, but the results are not consistent.[35][36] Evolutionarily, the amygdala is part of the ancient brain, meaning that its activation is primary and typically toned down by the frontal cortex as cognition and learned behaviors develop.[37] In PTSD, the toning down capacity of the frontal cortex is dysregulated compared to those without PTSD. It may partially explain the findings of reduced brain volume in those with chronic PTSD. Neurotransmitter levels have been investigated in those with PTSD, including serotonin, dopamine, epinephrine, norepinephrine, glutamate, and gamma-aminobutyric acid (GABA).[38] Neurotransmitter levels in PTSD have had inconsistent findings but still form the basis of an approach for treatment with psychotropic medications.[39]

History and Physical

The presentation of PTSD in children is variable in both the history of the illness and the clinical symptomatology. Trauma is broad, and risks for certain types of trauma and abuse vary depending on patient characteristics such as age, gender, geographical location, family status (such as foster care), and presence of a physical disability.[40] Types of trauma include sexual assault, mass political conflict and displacement (refugee), military or combat exposure, physical injury, and medical illness.[21] Due to the broad range of possible traumas, it is important to understand individual patient backgrounds and social history. Additionally, older children with PTSD commonly suffer from symptoms as a result of early childhood trauma, which can be in the distant past compared to the time of clinical evaluation.[41] Duration of symptoms since the traumatic event is necessary to note as this distinguishes PTSD from other psychiatric disorders (such as acute stress disorder).[42]

Dissociative symptoms may be present in patients with PTSD, and when these symptoms are present, they must be distinguished from a prior dissociative disorder. Dissociative symptoms include the following:

• Depersonalization: Feeling disconnected from one's body and feeling "lost" or "floating above my body"                 
• Derealization: Feeling as if the world around them is not real, such as watching the world from a dreamlike state [43]

Consent of the parent or guardian must be obtained before engaging in psychiatric evaluation with children. Parents and guardians can offer important insight into child behavioral changes, which may be the only sign of initial PTSD, particularly in younger children. Screening children regularly for abuse is appropriate, including obtaining the child's perspective on safety in the home and around family members. If signs or vocalizations about child abuse are uncovered, clinicians must report child abuse to their local reporting agency without delay. 

Discussing trauma with patients who are being evaluated for PTSD requires a sensitive approach.[44] In the context of sexual assault trauma, the gender of the provider and patient should be taken into consideration, as many patients who are survivors of sexual assault may have difficulty being in an interview room alone with the gender of their perpetrator. Some patients are able to talk about past trauma with ease, while others are not able to discuss details without experiencing acute symptoms. When engaging in a discussion of trauma details, it is essential to respect patient boundaries on the topic and ask how deeply or superficially the patient prefers to engage in the topic. These are foundational concepts of trauma-informed interventions.[44] Notably, the specific details of the trauma are usually not necessary for obtaining a PTSD diagnosis. Further, specific details of trauma are only necessary for certain types of psychotherapeutic treatments, which the patient and parent/guardian should consent to before initiating. General questioning about symptoms related to trauma is usually an optimal approach for a first diagnostic interview where developing therapeutic rapport is essential.[45] General questions can include the following:

• Do you think about the traumatic event more than you would like to?                                                               
• Do you have nightmares or flashbacks related to the trauma?                                                                           
• Do you avoid people or triggers associated with the trauma?                                                                          
• Are you struggling with feelings of persistent sadness?

The mental status examination (MSE), conducted during psychiatric evaluations, is crucial in assessing individuals with PTSD.[46] 

However, it is necessary to note that the specific elements and findings of the examination can vary depending on each case of PTSD. The mental status examination may be significant as follows:

• Appearance: Scars, wounds, and other deformities may be present as a result of prior traumatic experiences.                                                                                                                                             
• Attitude and behavior: PTSD can commonly lead to hypervigilant behavior. Eye contact should observed.                                                                                                                                                         
• Affect: Children with PTSD may present fearful, anxious, apathetic, or depressed. Affect may change depending on the conversation subject, and the range of affect should be observed. PTSD may present with constricted affect consistent with feeling numb.                                                                                         
• Thought content: Thought content should be evaluated to assess suicide ideations and behaviors.                                     
• Thought process: For patients with persistent and exaggerated negative beliefs after trauma, the thought process may deviate from linear.                                                                                                   
• Insight: Children with PTSD commonly have a fair understanding of their illness, but young children may not understand how past trauma connects to their symptoms.[47]

Physical examination is generally a minor component of the evaluation of PTSD. However, when children are prescribed medications for PTSD that impact blood pressure (ie, clonidine, prazosin, venlafaxine), it is important to monitor blood pressure to assess the need for any medication adjustments.[48] Further, the heart rate can be elevated when discussing trauma or when the patient is having flashbacks.

Evaluation

The psychiatric evaluation is the most important component when diagnosing PTSD. However, healthcare professionals can use validated rating scales to screen and diagnose PTSD, which is particularly helpful in settings where psychiatric specialists are not available. Self-report scales for screening PTSD include the PTSD Checklist for DSM-5 (PCL-5) and Trauma Symptom Checklist-40 (TSC-40).[49][50] The Clinician-Administered PTSD Scale (CAPS-5) is also available as a 30-item structured interview and corresponds to the DSM-5 criteria for PTSD.[51] 

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).[25][52]

To obtain a formal diagnosis of PTSD, individuals must meet the diagnostic criteria specific to the DSM-5-TR, which varies for children 6 years of age and younger versus older. The diagnosis involves a thorough evaluation that considers multiple sources of information, including personal history, collateral information, and an MSE. This comprehensive assessment allows clinicians to assess the individual's symptoms, functioning, and overall presentation concerning the established diagnostic criteria.

Posttraumatic Stress Disorder DSM-5-TR Criteria (for children older than 6 years of age)

Criterion A: Stressor

• Exposure to actual or threatened death, injury, or sexual violence in 1 (or more) of the following ways:
• They are directly exposed to the traumatic event.                                                                                           
• They witnessed the event in person as it occurred to someone else.                                                                   
• They learned about a close family relative or close friend being exposed to actual or threatened trauma, accidental or violent death. 
• Indirect exposure to distressing details of the traumatic event (professionals repeatedly exposed to the details of child abuse, collecting human remains, or pieces of evidence). This does not include exposure through television, movies, electronic devices, or pictures.

Criterion B: Intrusion Symptoms

Presence of 1 (or more) of the symptoms that are related to the traumatic event and began after the trauma occurred as follows:

• Recurrent, involuntary, and intrusive thoughts associated with the traumatic event. In children older than 6 years, this may be expressed using repetitive play in which the aspects of the trauma are expressed.
• Distressing nightmares that may be repetitive, with the content of the dream related to the traumatic event. Children may have frightening dreams where they may or may not recognize the content.     
• Dissociative reactions, such as flashbacks, in which the individual may feel or act as if the traumatic event is happening again. These reactions may occur as a continuum, ranging from brief reactions to complete loss of awareness of oneself or the surroundings.
• Children may re-enact such events in their play. Intense or prolonged psychological distress upon exposure to traumatic reminders. 
• Marked physiological reactivity such as increased heart rate and blood pressure on exposure to traumatic reminders.

Criterion C: Avoidance

Persistent avoidance of the stimuli related to the traumatic event, as evidenced by 1 or both of the following:

• Avoidance or efforts to avoid distressing memories or thoughts associated with the traumatic event                        
• Avoidance or efforts to avoid external reminders such as people, places, activities, conversations, or situations that arouse distressing memories or thoughts related to the traumatic event.

Criterion D: Negative Alterations in Mood

Negative alterations in mood and cognition that began or worsened after the traumatic event, as evidenced by 2 (or more) of the following:

• Inability to recall important aspects of the traumatic event. This can be due to dissociative amnesia, not due to head injury, drugs, or alcohol.                                                                                                   
• Persistent and distorted negative beliefs or expectations about oneself or the world, such as "I am bad" or "The world is completely dangerous."                                                                                                
• Persistent distorted cognition that leads the individual to blame themselves or others for causing the traumatic event.                                                                                                                                      
• Persistent negative emotional state, including fear, guilt, anger, or shame.                                                             
• Markedly diminished interest in significant activities that used to be enjoyable.                                                       
• Feeling alienated, estranged, or detached from others.                                                                                     
• Persistent inability to experience a positive emotion such as happiness, satisfaction, or love.

Criterion E: Alterations in Arousal and Reactivity

Alterations in reactivity and arousal that began or worsened after the traumatic event, as evidenced by 2 (or more) of the following:

• Irritable or aggressive outbursts with little or no provocation
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Problems in concentration
• Sleep disturbances (difficulty falling or staying asleep, restless sleep)

Criterion F Duration: Persistence of symptoms in Criterion B, C, D, and E for more than 1 month

Criterion G: The disturbance causes significant functional impairment or distress in various areas of life, such as social or occupational.

Criterion H: The disturbance is not attributable to substance use, medication, or another medical illness.[5]

DSM-5-TR Diagnostic Criteria for Posttraumatic Stress Disorder for Children 6 Years of Age and Younger: 

Criterion A: Stressor

• In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in 1 (or more) of the following ways:                                                                                                                 
  • Directly experiencing the traumatic event(s)                                                                                             
  • Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. This does not include events witnessed only in electronic media, television, movies, or pictures.        
  • Learning that the traumatic event(s) occurred to a parent or caregiving figure.

Criterion B: Intrusion Symptoms

• Presence of 1 (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred as follows:                                                                                                 
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)                                           
  • Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s)                                                                                                                                 
  • Dissociative reactions in which the child feels or acts as if the traumatic event(s) were recurring                                                              
  • Intense or prolonged psychological distress on exposure to internal or external clues that symbolize or resemble an aspect of the traumatic event(s)                                                                                
  • Marked physiological reactions to reminders of the traumatic event(s)

Criterion C: Avoidance

• One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s).                                            
  • Persistent Avoidance of Stimuli                                                                                                              
    • Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s)                                                                                             
    • Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s)                                                                                              
  • Negative Alterations in Cognitions                                                                                                             
    • Substantially increased frequency of negative emotional states                                                       
    • Markedly diminished interest or participation in significant activities, including constriction of play                                                                                                                                           
    • Socially withdrawn behavior                                                                                                       
    • Persistent reduction in the expression of positive emotions

Criterion D: Alterations in Arousal and Reactivity

• Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic 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

Criterion E: Duration

Persistence of symptoms in Criterion A, B, C, and D for more than 1 month.

Criterion F:  The disturbance causes significant functional impairment or distress in various areas of life, such as social or educational.

Criterion G: The disturbance is not attributable to substance use, medication, or another medical illness.[53]

Treatment / Management

The treatment of PTSD in children requires a patient-specific approach, with first obtaining consent from the patient and guardian for any treatment. Many patients with PTSD are unwilling to pursue treatment, and some patients have symptoms resistant to treatment. In general, medication approaches for PTSD in children are not as efficacious as the same treatments in adults with PTSD.[54][55][56] Psychotherapy is encouraged by the American Academy of Child and Adolescent Psychiatry (AACAP) as the first-line treatment in the setting of pediatric PTSD.[25] However, patients with severe symptoms or comorbid illness may not be able to engage in meaningful therapy treatments initially. They can be started on a medication regime with a plan to integrate therapy in the future when more clinically stable. (A1)

Psychotherapeutic Approaches

Trauma-focused psychotherapy is the preferred treatment for PTSD. This includes cognitive behavioral therapy (CBT), exposure-based therapy, and Eye Movement Desensitization and Reprocessing (EMDR) therapy.[6][57][58][59] Clinical studies of patients who receive trauma-focused psychotherapy have demonstrated greater improvement in symptoms compared to those who do not receive treatment.[6] When trauma-focused psychotherapy is compared against pharmacotherapy for PTSD in adults, there may be slightly improved outcomes with therapy.[57][60] In children, the benefits of psychotherapy are usually superior to medication interventions.[54][55](A1)

CBT utilizes techniques to identify and correct distortive maladaptive beliefs, which can occur after a traumatic event. Specific techniques include education, relaxation exercises, the development of coping skills, and stress management.[61](A1)

Exposure-based therapy is a technique most commonly used to treat anxiety disorders such as specific phobias. The technique considers a conditioned fear response from learned behavior and involves a measured approach of reintroducing the stimulus to eventually achieve fear extinction. It requires consent for treatment and is not an applicable option for certain PTSD cases as it requires an intense workload on the patient.[62]

EMDR was developed after the discovery that certain saccadic eye movements reduce the intensity of disturbing thoughts. These eye movements can be voluntarily adjusted while thinking about a distressing memory, reducing the anxiety associated with it. EMDR has been shown to desensitize traumatic memories and has improved the appraised validity of a positive self-belief in those with PTSD.[63][64] The therapeutic neural mechanisms of EMDR remain unclear.[65](A1)

Supportive psychotherapy can be helpful in individuals who are dealing with acute trauma and those who have acute stress disorder.[66](A1)

In 2020, the FDA cleared a class II medical device that uses hardware of common smart-watches to monitor heart rate during sleep for individuals with PTSD, intending to correlate physiologic response (biofeedback) to PTSD-related nightmares.[67](B3)

Medication Approaches

Selective serotonin reuptake inhibitors (SSRI) such as sertraline and paroxetine are FDA-cleared for the treatment of PTSD in adults. In children, medication interventions are not as effective as therapy and often have similar outcomes as placebo.[54][55][68] Medications for PTSD in children are generally reserved for severe symptoms and are an off-label treatment approach. (A1)

For patients with prominent sleep disturbances or nightmares associated with PTSD, off-label medication treatment approaches are commonly used. Prazosin, an antihypertensive, is commonly used as monotherapy or, in combination, an SSRI. Prazosin competitively inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decreasing blood pressure. When used in PTSD-associated nightmares, the hypothesis for the mechanism of action is a toned-down sympathetic response, which can decrease the frequency or severity of nightmares. However, there are mixed results for prazosin efficacy for this specific use, and the findings are inconsistent.[69][70][71] Clonidine, another type of antihypertensive, is occasionally used for similar purposes. In patients prescribed blood pressure medications for PTSD, monitoring blood pressure at clinical visits is important, as well as weaning to discontinue to avoid rebound hypertension, which may occur with abrupt discontinuation of the medication.(A1)

Differential Diagnosis

Differentiating pediatric PTSD from other psychiatric conditions is crucial for accurate diagnosis and effective treatment. Pediatric PTSD shares symptomatology with various disorders. Conditions such as attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and reactive attachment disorder may also present overlapping features with PTSD in children. The differential diagnosis of pediatric PTSD includes the following:

Acute Stress Disorder

The symptoms of PTSD and acute stress disorder mostly overlap. The onset and duration of the symptoms help in making the final diagnosis. Acute stress disorder is diagnosed if the symptoms are present for less than 1 month, while PTSD symptoms are present for longer than 1 month.[42]

Dissociative Disorders

Primary dissociative disorders include dissociative identity disorder (DID), dissociative amnesia, and depersonalization/derealization disorder. Dissociative identity disorder describes the disruption of identity characterized by 2 (or more) distinct personality states. Dissociative amnesia describes an inability to recall important autobiographical information, such as important information about oneself or the people in one's life; notably, the information is usually of a sudden traumatic or stressful nature, but there are no other symptoms of PTSD. Depersonalization or derealization disorder shares symptoms of dissociation, such as feeling outside of one's self, with PTSD but is without the other symptomatology of PTSD.[72]

Major Depressive Disorder

Changes in affect are common in PTSD, and major depressive disorder (MDD) can be a comorbid condition with PTSD. Diagnosis of MDD requires at least 1 major depressive episode, which is persistent decreased mood for most or all of the day, for nearly every day for at least 2 weeks.[73]

Adjustment Disorder

Adjustment disorder describes the development of emotional or behavioral symptoms in response to an identifiable stressor (not necessarily trauma), occurring within 3 months of the stressor's onset. The symptoms may not persist for more than an additional 6 months and are otherwise considered to be classified to a more fitting chronic psychiatric diagnosis.[74] 

Prognosis

PTSD outcomes vary broadly from case to case due to several factors. Those who engage in PTSD treatments tend to have improved outcomes compared to those who do not engage in treatment.[6][7][8] Chronic PTSD is common, with estimates that one-third of patients still have symptoms 1 year after diagnosis, and another third of patients still have symptoms 10 years after diagnosis.[31]

Positive psychology, a fairly new branch of psychology, emphasizes psychological resilience after trauma and posttraumatic growth.[75] These concepts highlight the idea that positive changes in self-perception, interpersonal relationships, and philosophy of life can occur for individuals who recover from trauma and PTSD. These strengths can increase self-awareness, self-confidence, open attitudes, and appreciation for life.[76] Posttraumatic growth is an optimal but not a guaranteed outcome; in fact, it may even be an uncommon outcome. Research of positive psychology applications to trauma disorders in children remains limited and in need of further study.[77][78]

Complications

Although PTSD symptoms can resolve, they may lead to the development of other psychiatric comorbidity, as trauma is a known risk factor for major depressive disorder, borderline personality disorder, anxiety disorders, substance use disorders, psychotic disorders, and more.[79] Patients with PTSD are at increased risk for suicide and should have regular screenings for suicidal ideation by clinicians.[1] Individuals with PTSD are more likely to experience educational and occupational problems and have higher rates of disability than those without PTSD. Additionally, those with a history of sexual trauma report higher rates of problems with intimate relationships as adults.[80][81]