AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Child abuse is an all too common problem; it results in many long-term physical and emotional effects, including posttraumatic stress disorder (PTSD). This topic discusses the problem of PTSD and how it manifests in children.

Children face trauma that threatens their integrity, safety, or even life. The loss of control, the unpredictability, and the extremely aversive nature of the event(s) are the main pathogenic elements.

The range of normal emotional responses to trauma is broad, encompassing fear, anger, sadness, and humiliation. Most traumatized children do not develop long-term sequelae from trauma, but a significant minority may experience a long-lasting, major impact on their emotions and behaviors. These children are at risk for PTSD. This risk is present whether the child is subjected to a single trauma or an ongoing pattern of abuse.

The essential features of PTSD include the following:

• A child is exposed to an actual or threatened death or serious injury to himself or herself or to another person and has a reaction to this event that includes intense fear, horror, or, particularly in children, disorganized or agitated behavior.
• The child re-experiences the event (eg, through flashbacks or nightmares). In children, nightmares may have general frightening themes rather than one that specifically involves the abuse. Re-experiencing may take on the form of repetitive play.
• The child avoids stimuli associated with the trauma, has a numbing of emotional responsiveness, and experiences diminished interest and a sense of a foreshortened future. Children may not report diminished interest, but caretakers may observe it. In children, a sense of a foreshortened future may manifest as a belief that they will never become adults.
• Children may also have somatic symptoms, such as stomachaches and headaches.
• The child has increased physical arousal with exaggerated startle response.

In this article, the nature of the effects of traumatic experiences on the psychic functioning and emotions of children is examined, as well as the effects of traumatic experiences on the child's physiology, the clinical picture of these conditions (ie, how to recognize them), and several intervention strategies for children of different ages. Other topics are devoted to the problem of child and adolescent maltreatment and disordered parent-child relationships (see Child Abuse & Neglect: Physical Abuse, Child Abuse & Neglect: Sexual Abuse, Child Abuse & Neglect: Reactive Attachment Disorder).

Posttraumatic stress phenomena in children and adolescents have been recognized only in the past few decades. In adults, the effects of exposure to violence and witnessing atrocities were first clinically described after World War I. Severe anxiety symptoms such as persistent and frightening recollections, flashbacks, and constant anxiety were described as war neurosis or shell shock syndrome. After the Vietnam War, many veterans sought help because of the constant anxiety and re-experiencing of war scenes, which, in some cases, continued for years after they returned home.

Until recently, immaturity was believed to protect children from long-term sequelae of trauma. Traumatic experiences that occurred during infancy and preschool years were thought to be forgotten, and older children were thought to recover quickly.

More recent research demonstrates that children do experience PTSD. Lenore Terr made a groundbreaking contribution to the understanding of PTSD in children. Terr interviewed children who had suffered a tremendous trauma when they were kidnapped in a bus and buried in the ground for an extended period. She found that a considerable proportion of children had troubling recollections, felt a great deal of anxiety, and re-experienced the traumatic event. Her report called attention to the reality that children can be traumatized and can experience incapacitating anxiety after such events.

Pathophysiology

The immediate physiologic response to trauma can be significant and may set the stage for lasting PTSD symptoms. Alterations in the noradrenergic and dopaminergic neurotransmitter systems and the stress response of the hypothalamic-pituitary-adrenal axis are well documented in PTSD. Some evidence suggests that chronic PTSD, perhaps through these physiologic changes, can lead to changes in brain microarchitecture.

Risk and protective factors for developing PTSD after trauma

Personal threat: The degree to which the child actually feels frightened or personally threatened by the traumatic experience(s) is known as personal threat. PTSD is more likely with higher degrees of violence and personal threat.

Developmental state: Younger children are less able to process traumatic experiences verbally and less able to narrate them and understand their meaning; in some cases, this may mitigate their risk for PTSD.

Relationship to perpetrator: Being abused by a known and trusted person undermines the child's sense of safety and increases the likelihood of PTSD.

Support: Traumatized children who are developing in a secure and supportive environment are less susceptible to PTSD than children who endure ongoing abuse. The caregiver's response is also critical. If the caregiver reassures the child, the outcome of the trauma is better than if the caregiver is also shaken, devastated, or withdrawn.

Guilt: Guilt about or feeling somehow responsible for the trauma predicts more severe PTSD and depressive symptoms.

Resilience: This refers to a person's ability to cope with difficult circumstances; it seems to be related to intelligence, the ability to talk about one's experiences, the ability to understand others, and the ability to seek help. People with greater resilience are at less risk for PTSD.

Symptoms at time of abuse: Eventual PTSD is more likely in children who have symptoms of avoidance, emotional constriction, and physiologic hyperarousal soon after the abuse.

Physiologic Response: Those who have an elevated heart rate in the period soon after the trauma (eg, those seen in an emergency department) are more likely to develop PTSD.

Frequency

United States

In adults, the prevalence of PTSD is 1-9%. Epidemiologic studies in children have been limited.

In the general US population of children and adolescents, an estimated 25% have experienced a high-magnitude traumatic event by age 16 years. These include events such as death of a loved one, serious accident, natural disaster, sexual abuse, or rape. Of the children interviewed, 6% reported such an event within the past 3 months.

Approximately 20% of those exposed to trauma eventually develop PTSD, with some exposures, such as child sexual abuse, being somewhat more likely to lead to PTSD.

International

Little information exists concerning the prevalence of PTSD in other countries.

In places where armed conflicts exist, children experience frequent trauma as direct victims, by witnessing violence, and by living in dangerous conditions.

Mortality/Morbidity

PTSD has no mortality rate; however, because of its comorbidity (see Complications) with substance abuse and dependence, depression, and interpersonal difficulties, PTSD may indirectly lead to self-inflicted damage or death through accidents or suicide. Neglect and abuse also increase morbidity and mortality.

Race

No racial predilection is known.

Sex

Males are more likely to be victims of physical assault, and females are more frequent victims of sexual assault.

Girls report higher PTSD symptoms after trauma and are at 2-6 times increased risk of PTSD after sexual abuse compared to boys. Women have a higher lifetime prevalence of PTSD, but it is unknown if this is related to rates and types of trauma exposure or to a particular vulnerability to PTSD.

The non-PTSD symptoms that abused and neglected girls experience may differ from those of boys. Among sexually abused children, boys have a higher risk for developing "externalizing behaviors" (oppositional behavior, impulsivity) and girls have a higher incidence of "internalizing behaviors" (depression, anxiety).

Age

Older children with language abilities are more likely to be able to recount traumatic episodes. In younger children, behavioral changes may be the only observable signs of trauma.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Assessment of PTSD begins with clinical interviews of the child and the caregiver. The interviewer should be aware that caregivers may also be involved in abuse.

For many reasons, the traumatic experience is not openly discussed. Parents may be unaware of or in denial of the traumatic event, and children may be afraid to disclose what happened to them. Clinicians should be aware that children are just as much at risk of victimization from people they know as from strangers. As use of the Internet grows, the risk of Internet-related sex crimes, such as cyber-stalking, increases. Police monitoring of sexual advances on the Internet accounts for 25% of arrests for child sexual abuse.

The interview with caregivers should elicit the child's developmental history, family history, the abuse history (if known), and their perception of what has changed in the child since the traumatic event.

The symptoms of PTSD can be subtle and may resemble other psychiatric and behavioral disorders. Children who have experienced trauma may exhibit sleep difficulties, attention deficit disorders, aggressive and defiant behavior (leading to the misdiagnosis of a conduct disorder), anxiety symptoms, phobias, and social avoidance, as well as depression, agitation, or learning difficulties.

A formal diagnosis of PTSD requires that symptoms persist for more than 1 month (similar symptoms <1 mo duration may meet criteria for acute stress reaction). The most common symptoms of PTSD are as follows:

• Re-experiencing the trauma: Children may re-experience the trauma in a variety of ways.
• • Flashbacks and memories: These may be intrusive and interfere with function at home or school. In children, intrusive memories are more common than flashbacks. Flashbacks are vivid experiences that include visual and auditory elements from the trauma; the child may feel like the trauma is happening all over again and he or she may react with intense fear. Flashbacks may be more common among children who have depression in addition to PTSD.
  • Behavioral re-enacting: Children may act out aggressively toward others or do and say things that they witnessed. Children are often unaware that this behavior is connected to their abuse.
  • Re-enacting through play: The child may represent the traumatic experience through repetitive play. For example, they may repeatedly play exactly the same scene of people fighting, a car crashing, or a house burning down.
• Symptoms of avoidance of memories or situations that remind the child of the traumatic event: The child may exhibit a general restriction in daily activities (eg, avoiding activities that could prompt excitement or fear) or may present with specific fears. They may lose previously acquired skills and show regression.
• • Avoidance: Children or adolescents with PTSD avoid thinking or talking about topics that could remind them of traumatic experiences. Some, especially young children, may refuse outright to acknowledge that the abuse occurred.
  • Triggers: Children may react to and attempt to avoid stimuli that trigger memories of the abuse. Some common triggers include phrases, songs, scenes on television, a perfume, or a person's appearance. Anniversaries, dates, and certain places may also trigger memories.
• Sleep disturbance: Children may experience nightmares, fear of the dark, and fear of sleeping alone.
• Physical contact: Children with PTSD may have difficulty managing physical contact because of a heightened sense of vulnerability or because it may be a reminder of abuse.
• Emotional numbing: To manage difficult reactions to the abuse, children with PTSD may have to suppress memories and almost all emotional reactions. These children may seem emotionally numb. Normal human interactions appear not to resonate with them; they laugh less and show less human connection and empathy.
• Sense of foreshortened future: PTSD is associated with a sense of pessimism about the future, with affected people occasionally feeling that there is no future for them. In children, this may manifest as the belief that they will never become adults or a lack of interest in planning for the future.
• Dissociation: Dissociative episodes are periods of disconnection from the external environment. A dissociating child may appear to be absent and unresponsive for a few minutes. Events that remind the child of danger or threat may trigger these episodes. Children who experience dissociation soon after the disclosure of abuse are at significantly increased risk for developing PTSD. Some believe that this is because dissociation inhibits the appropriate level of experiencing and expressing their emotions concerning the abuse.
• Symptoms of increased arousal and hypervigilance: The child may appear on edge, noticing small changes in the environment and closely tracking the behaviors of others. They may exhibit an increased startle response.
• Cognitive function: A small study of neuropsychologic function in children with PTSD found deficits in sustained attention, problem solving, and abstract reasoning.
• Sleep problems: The child may have much difficulty falling asleep. Many fears are experienced at night, such as imagining faces on the wall or eyes looking at the child. Many sleep disruptions, frequent nightmares, and awakenings at night can occur. Nightmares are common in children with PTSD. They may directly relate to the abuse or, more commonly, consist of frightening dreams with more generalized themes.
• Behavioral inhibition: Some children with PTSD are inhibited and overly pleasing and attentive to their caregivers. This may be the case, particularly if the child has reason to fear that angering or disappointing the caregiver can trigger a negative encounter.
• Delays in development and learning: In younger children, traumatic events, particularly long-standing trauma or high-stress living conditions, are more likely to delay the development of the child in several important domains, such as reciprocity, relatedness, cognitive abilities, and adaptive behavior in general. Traumatized children may appear almost autistic and may display great difficulties with learning.

Physical

No specific physical signs of PTSD exist. The pediatrician may suspect the condition in the child who is excessively frightened of being touched or approached by the doctor. When this circumstance arises, inquire about the child's history of traumatic experiences. In the case of physical or sexual abuse, the physician may detect the associated physical signs (see Child Abuse & Neglect: Physical Abuse and Child Abuse & Neglect: Sexual Abuse).

Studies have found that only a small minority of sexually abused children have physical evidence of abuse.

Causes

Not every person who is exposed to trauma develops PTSD. Development of PTSD is unpredictable following a traumatic event. Onset of the syndrome may be initiated through either direct or witnessed exposure to a single or chronic trauma. Some differentiate trauma exposures into 2 types, as follows:

• Type I: Single, acute, unpredictable stressor. One person may have repeated exposures to this kind of stressor.
• Type II: Chronic, enduring stressors, such as ongoing physical or sexual abuse, characterize type II.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Autism
Attention deficit disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory studies exist to make the diagnosis of PTSD. While this observation is not used clinically for diagnosis, research demonstrates exaggerated hypothalamic-pituitary-adrenal axis activity and increased overall adrenergic activity in acute PTSD.

Imaging Studies

• No specific imaging studies for PTSD exist; however, in the case of physical abuse or torture, the corresponding physical signs, such as old fractures, may be discovered. See Child Abuse & Neglect: Physical Abuse and Child Abuse & Neglect: Sexual Abuse.

Other Tests

• Several psychometric measures are used to evaluate PTSD in children, including the Child Post Traumatic Stress Reaction Index, the Impact of Events Scale, the Clinician Administered PTSD Scale-Child and Adolescent Version, and the Child PTSD Symptom Scale.
• Researchers have cautioned that children with PTSD symptoms who do not cross the traditional threshold for PTSD diagnosis may still suffer significant functional impairment.
• Some research suggests that more functional impairment is observed in children who report intense (although not necessarily frequent) avoidance symptoms and distress in response to triggers.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The first step of treatment is to provide a safe environment and to attend to urgent medical needs. Other treatment steps should include the following:

• Immediately after a traumatic event, children are likely to be frightened and distressed. A sense of security can be achieved with a combination of respect, compassion, containment, and helping the child experience consistency and opportunities for relaxation and positive experiences.
• The role of formal debriefing sessions after a traumatic event is not entirely clear, but the discussion of trauma in asymptomatic individuals may increase the long-term risk of PTSD symptoms. This may occur because the child becomes sensitized through exposure without enough treatment to process this stress.
• Interventions with caregivers: Caregivers and parents must be aware of the symptoms of PTSD, such as triggered memories, re-enactment, and hypervigilance. They should learn about the significance of these symptoms.
• Interventions with children
• • Cognitive behavioral therapy
  • • Of all treatments, cognitive behavioral therapy (CBT), especially CBT with a trauma focus (TF-CBT), has the greatest empirical evidence supporting its efficacy. It seems to help children with both acute and chronic PTSD with PTSD symptoms, as well as those with depression, shame, social skills, and behavioral disturbances. The improvements have been shown to persist for at least 2 years after treatment.
    • Involving caregivers in the treatment has also been effective, particularly in reducing the child's comorbid depressive symptoms and improving the caregiver's own depressed mood, abuse-related distress, and ability to support the child.
    • TF-CBT is a highly structured therapy that consists of manual-based sessions (eg, 10-18 sessions, each 1 h). The intervention focuses on stress management, education about symptoms, creating a narrative of the trauma (as a means of exposure), and cognitive reprocessing of the trauma and resultant symptoms.
    • Preliminary findings suggest that, after a disaster involving many children, a school-based cognitive-behavioral intervention by trained school-based mental health counselors significantly decreases future PTSD symptoms.
  • Eye movement desensitization and reprocessing
  • • Francine Shapiro originated and developed Eye Movement Desensitization and Reprocessing (EMDR), which involves rhythmic movements of the eyes to induce relaxation. Once the person is relaxed, the patient is asked to recount the traumatic experience. The repeated exposure to these memories in the setting of relaxation alleviates the symptoms of PTSD. This technique is proven to work in adults, and is used in children although its efficacy in this population has not yet been proven.
    • Other relaxation techniques, such as biofeedback, yoga, deep relaxation, self-hypnosis, or meditation, may be suitable for some children, but clinical evidence concerning their efficacy or use is not available.

Consultations

Consider consultation with a therapist to establish cognitive behavior treatments.

A child psychiatrist may also be helpful and can provide assessment and pharmacologic management for PTSD, as well as comorbid psychiatric conditions.

Physical complications may require the attention of physicians who specialize in orthopedic injuries or burns, depending on the nature of the concern (see Burns, Thermal). These issues are described in corresponding sections of this pediatric journal.

Diet

No restrictions are necessary unless clinically indicated.

Activity

No restrictions are necessary unless clinically indicated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

CBT, discussed in Medical Care, is the first-line treatment for PTSD in children. For children with persistent symptoms despite CBT or those who need additional help with control of symptoms, pharmacologic treatment may be considered. When medication treatment is undertaken, target symptoms should be defined and monitored for response.

No large-scale randomized clinical trials are available to guide choices for the treatment of PTSD in children. Clinical experience suggests that selective serotonin reuptake inhibitors (SSRIs) are helpful; SSRIs are a proven therapy for PTSD in adults.

Drug Category: Antidepressive agents

SSRIs inhibit CNS neuronal uptake of serotonin (5HT). Some have a weak effect on norepinephrine and dopamine neuronal reuptake. They have also been used to treat anxiety, phobias, and obsessive-compulsive disorders.

While randomized clinical trials are not available to test their efficacy in children with PTSD, they are thought to improve social and occupational functioning and decrease core symptoms of PTSD, such as avoidance, numbing, and dissociation. They have the added benefit of treating comorbid conditions.

Children should be started at a low dose with gradual dose escalation. Adverse effects include anxiety or agitation, headaches, hyperhidrosis, somnolence, GI upset, diarrhea, anorexia. Dosing depends on the medication and the age and weight of the child.

SSRIs do not carry the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use in persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in both treated and untreated patients with major depression, thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression from 1992 to 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the used of antidepressants. This is the largest study to date to address this issue.

Currently, evidence does not exist to associate obsessive compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Numerous authors have addressed the controversy concerning when and how to use SSRIs in children. When SSRIs are used, consultation with a child psychiatrist and close monitoring for suicidal ideation is important.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient psychiatric care should be considered for patients who are at risk of harming themselves or others. Children with PTSD are at increased risk of suicide.

Further Outpatient Care

• Most of the treatment of psychologically traumatized children is conducted on an outpatient basis; see Treatment recommendations.

In/Out Patient Meds

• See Medication.

Deterrence/Prevention

• A description of efforts to prevent child maltreatment and traumatization is beyond the scope of this article, as is the prevention of accidents in children.

Complications

• Children who are exposed to abuse and neglect have an increased incidence of psychiatric complications. For example, sexually abused children have a 4-fold increased lifetime risk for psychiatric disorders. PTSD diagnosis in children correlates significantly with at least transient suicidal ideation.
• Anxiety and phobia: Approximately 30% develop social anxiety or specific phobia.
• Major depression and dysthymia: As many as 40% of children with PTSD develop major depression by age 18 years (compared to 8% of their unaffected peers).
• Aggression: Research findings are mixed as to whether children with PTSD are at increased risk for aggressive or oppositional behaviors.
• Substance abuse and dependence: An estimated 46% develop alcohol dependence, and 25% develop drug dependence.
• ADHD: The documented incidence of ADHD is higher in those with PTSD.
• Suicide: People with PTSD have a higher risk of suicidal ideation as well as increased mortality from suicide.
• Physical comorbidities: In female children and adolescents, PTSD is associated with chronic fatigue, fibromyalgia, irritable bowel syndrome, chronic pelvic pain, and dysmenorrhea.

Prognosis

• The outcome depends on the severity and chronicity of the trauma and the impact on the life of the child, the reactions and behavior of caregivers, and the opportunity to receive treatment.
• In a longitudinal study of teenagers and young adults aged 14-24 years who were observed for 34-50 months, 48% with a diagnosis of PTSD experienced no significant remission of their symptoms. Those with ongoing PTSD had an elevated risk for additional traumatic events during the follow-up period.
• Those with chronic PTSD have an increased risk of suicidal ideation and mortality from suicide.
• • Chronic PTSD is associated with work impairment, with an impact similar to that of major depression.
  • Prognosis tends to be worse in those experiencing ongoing trauma.

Patient Education

• Children with PTSD should be encouraged to take part in their own treatment. They need to understand why treatment is required and that their difficulties are the result of traumatic events.
• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center and Children's Health Center. In addition, see eMedicine's patient education articles Post-traumatic Stress Disorder (PTSD), Child Abuse, and Sexual Assault.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Controversy exists concerning whether therapists can induce false memories of abuse in vulnerable patients. The literature on this issue is inconclusive.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Jul 17, 2006