Behavioral Issues

Post-Traumatic Stress Disorder (PTSD)

Introduction

Post-Traumatic Stress Disorder (PTSD) is a well recognized entity amongst adults, however familiarity in pediatrics is not as well established and much of what is known is derived from adult research.  As such, a Presidential Task Force on PTSD in Children and Adolescents was formed in 2008 to increase awareness and facilitate diagnosis, treatment and research in the field.

Just like adults, children and adolescents experience stressfull events which can affect them both emotionally and physically.  It is very important for patients, parents, care givers, family members, teachers and providers alike all be aware of the potential for PTSD following a traumatic event and to respond to symptoms quickly.  

With the sensitivity and support of families and professionals, children and teens with PTSD can learn to cope with the memories of the trauma and go on to lead healthy and productive lives.

Clinical Presentation

In order to have PTSD, there must be a traumatic event which either the child must report, or there must be compelling evidence present to suggest a truamatic event such as: 

  • The presence of a sexually transmitted infection in a young child
  • Reliable eyewitness report (e.g. police report) of a traumatic event
  • Findings on a forensic evaluation

In the absence of a child's report or compelling evidence of trauma, a PTSD diagnosis should not be made.

If a clinician has suspicion of trauma exposure but there are no confirmed reports, the child should be referred for forensic evaluation.

PTSD is common in children and adolescents after trauma of various types:

  • Natural disasters
  • Transplants
  • Cancer survivors
  • War survivors
  • Traffic accidents

Definitions:

  • Acute stress disorder:
    • Symptoms of severe anxiety, dissociative and other symptoms that occurs within 1 month after trauma exposure
  • Acute PTSD:
    • Clinically significant trauma re-experiencing, situation avoidance, and increased arousal symptoms for greater than 1 month but less than 3 months after trauma exposure
       
  • Chronic PTSD:
    • ​Clinically significant trauma re-experiencing, situation avoidance, and increased arousal symptoms for greater or equal to 3 months  after trauma exposure
               
  • Delayed Onset PTSD:
    • Onset of clinically significant trauma re-experiencing, situation avoidance, and increased arousal symptoms 6 months or more after trauma exposure.

PTSD Symptom Clusters

Through years of research, 17 PTSD symptoms have been identified. These are symptoms that can develop following the experience of a traumatic event and are listed in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (or DSM-IV).

These 17 symptoms are divided into three separate clusters. The three PTSD symptom clusters, and the specific symptoms that make up these clusters, are described below.  Also listed below are the required number of symptoms that must be present in order to fulfill a diagnosis of PTSD.

  1. Reexperiencing the trauma (at least 1):
  • Recurrent and intrusive:
    • Recollections
    • Nightmares
    • Other senses of reliving the traumatic experience
  • In young children, this may manifest as:
                         
    • Repetitive play (aspects or themes of trauma are expressed)
    • Trauma-specific reenactment
    • Frightening dreams without trauma-specific content
                                 
  1. Persistent avoidance of trauma (at least 3):
  • Efforts to avoid trauma reminders including talking about traumatic event or other trauma reminders
  • Inability to recall an important aspect of the trauma
  • Decreased interest or participation in previously enjoyed activities
  • Detachment or estrangement from others
  • Restricted affect
  • Sense of foreshortened future
  1. Persistent symptoms of hyperarousal (at least 2):
  • Difficulty falling or staying asleep
  • Irritability or angry outbursts
  • Difficulty concentrating
  • Hypervigilance
  • Increased startle reaction

Children may also demonstrate some of the following behaviors as well:

  • New aggression
  • Oppositional behavior
  • Regression in recently acquired developmental skills (toileting and speech)
  • New separation anxiety
  • New fears not obviously related to traumatic event (usually fear of dark or of going to bathroom alone)

Accurately diagnosing PTSD in children is challenging, and the DSM-IV-TR criteria may not be a valid diagnostic construct for children.  For example, the requirement of 3 avoidance/numbing symptoms is much debated as reporting of these symptoms for preadolescent children requires them to report on complex internal states that are too difficult for young children to comprehend and for parents to observe.

Epidemiology of PTSD

  • General youth population: 9.2%
  • 3.7% male adolescents
  • 6.3% female adolescents

Screening

  • Clinicians should routinely ask children about exposure to commonly experienced traumatic events, such as:
    • Child abuse
    • Domestic or community violence
    • Serious accidents
  • If exposure is endorsed, providers should screen the child for the presence of PTSD symptoms based on the DSM-IV-TR criteria
                  
    • ​It is sometimes helpful to obtain information from multiple informants (children, parents, other caretakers) as well.
  • There are a variety of tools that may be helpful in the screening of children with PTSD including:
  • UCLA PTSD Reaction Index (UCLA PTSD RI) (7 years & up) - self-report or given verbally. The test has excellent psychometric properties, and has been used across a variety of trauma types, age ranges, settings, and cultures
  • Child PTSD Symptom Scale (CPSS) (7 years & up) - can be administered as self-report or verbally, also available in Spanish.
       
  • Child Behavior Checklist (2 years & up) - parent-report questionnaire for preschool children.
  • Trauma Symptom Checklist for Children (8 years & up) - self-report survey
                       

Formal Evaluation

If screening is positive, or if there is a high suspicion for PTSD, formal evaluation is needed by a mental health professional with experience in diagnosing and treating PTSD.

Differential Diagnosis

A differntial should be included as part of the workup and evaluation for PTSD, and etiologies to consider includes:

  • Psychiatric conditions
                             
    • ADHD
    • Oppositional defiant disorder
    • Panic disorder
    • Anxiety disorders
      • Social anxiety disorder
      • OCD
      • Generalized anxiety disorder
      • Phobias
    • Major depressive disorder
    • Bipolar disorder
    • Primary substance-use disorder
    • Psychotic disorder           
                      
  • Physical conditions
              
    • Hyperthyroidism
    • Caffeinism
    • Migraine
    • Asthma
    • Seizure disorder
    • Catecholamine- or serotonin-secreting tumors             
                    ​
  • Prescription drugs with side effects
                 
    • Antiasthmatics
    • Sympathomimetics
    • Steroids
    • SSRIs
    • Antipsychotics 
    • Atypical antipsychotics            
                    
  • Nonprescription drugs
    • Diet pills
    • Antihistamines
    • Cold medicines

Treatment

Treatment should include various modalities including eeducation of the child and parents about PTSD, consultation with school personnel and primary care physicians, trauma-focused psychotherapies and possibly pharmacotherapy.

  • Trauma-focused psychotherapies
                    
    • These are superior to nonspecific or nondirective therapies in resolving PTSD symptoms (preschoolers through adolescents).
    • Goals of therapy are to:
                       
      • ​Directly address children's traumatic experiences
      • Include parents in treatment in some manner as important agents of change
      • Focus not only on symptom improvement but also on enhancing functioning, resiliency, and/or developmental trajectory
      • Some examples of these types of therapy are Cognitive Behavioral Therapy (CBT) as well as Psychodynamic Trauma-Focused Therapy
  • Medications
           
    • SSRIs - May be beneficial in children, though not well studied.  In general, these are added only if child's symptom severity or lack of response suggest a need for additional interventions.  Of note, these may be overly activating in some children (irritability, poor sleep, inattention)
    • Alpha (Clonidine) and beta (Propranolol)-adrenergic blocking agents - May help lower heart rate, anxiety, impulsivity, and PTSD hyperarousal.
    • Novel antipsychotic agents & mood stabilizing agents - May play a role as well

Resources

CLICK BELOW for a list of resources compiled by the US Department of Veteran Affairs.  Although there is information on living with a parent who has PTSD, there are many resources for young children up to teens affected with PTSD. 

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References

  1. American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter on assessment and treatment of children and adolescents with posttraumatic stress disorder can be found at J Am Acad Child Adolesc Psychiatry 2010 Apr;49(4):414
  2. American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter for psychodynamic psychotherapy with children can be found in J Am Acad Child Adolesc Psychiatry 2012 May;51(5):541 PDF or at National Guideline Clearinghouse 2012 Aug 13:36880
  3. American Academy of Pediatrics (AAP) guidance on psychosocial implications of disaster or terrorism on children can be found in Pediatrics 2005 Sep;116(3):787 full-text, summary can be found in Am Fam Physician 2006 Jan 15;73(2):344, commentary can be found in Pediatrics 2006 May;117(5):1865 full-text
  4. PTSD. In DynaMed [database online]. EBSCO Publishing. dynamed.ebscohost.com. Updated Feb 7, 2013. Accessed Feb 11, 2013.
  5. Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, and diagnosis. In UpToDate [database online]. UptoDate.com. Updated Jan 2013. Accessed Feb 11, 2013.
  6. Pharmacotherapy for posttraumatic stress disorder. In UpToDate [database online]. UptoDate.com. Updated Jan 2013. Accessed Feb 11, 2013.
  7. Psychotherapy for posttraumatic stress disorder. In UpToDate [database online]. UptoDate.com. Updated Jan 2013. Accessed Feb 11, 2013.