Understanding PTSD in Children

Adults are certainly not the only ones who can experience PTSD after going through a traumatic event. Children and adolescents can experience the same emotional challenges and behavioral symptoms of post-traumatic stress disorder as adults.

More than two-thirds of children in the United States report having experienced at least one traumatic event by the age of 16 years old.

Of children who experience trauma, it is estimated that about 16 percent will end up struggling with PTSD.

Common examples of trauma that children and adolescents can experience include things like:

  • Sexual abuse/rape
  • School violence
  • Natural disasters
  • Military-family related stressors
  • Sudden or violent loss of a loved one
  • Neglect
  • Serious accidents
  • Life-threatening illnesses

Updates to PTSD Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is the most up-to-date version of the manual that clinical professionals use to diagnose mental health concerns. Not until this most recent revision were there specific criteria listed for diagnosing PTSD in children, specifically for children six years old or younger. As children continue to be exposed to traumatic events, it is important to recognize that they, too, can experience debilitating emotional challenges after going through trauma.

Diagnosing PTSD in Young Children

The general criteria for diagnosing PTSD applies to adults and any person over the age of six years old. The following are the new specific criteria outlined in the DSM-5 for the preschool specifier, or for those six years or younger

Criterion A

Children under the age 6 have been exposed to an event involving real or threatened death, serious injury, or sexual violence in at least one of the following ways:

  • The child directly experienced the event.
  • The child witnessed the event, but this does not include events that were seen on television, in movies, or some other form of media.
  • The child learned about a traumatic event that happened to a caregiver.

Criterion B

The presence of at least one of the following intrusive symptoms that are associated with the traumatic event and began after the event occurred:

  • Recurring, spontaneous, and intrusive upsetting memories of the traumatic event, which can be expressed through play
  • Recurring and upsetting dreams about the event
  • Flashbacks or some other dissociative response where the child feels or acts as if the event were happening again, which can be expressed through play
  • Strong and long-lasting emotional distress after being reminded of the event or after encountering trauma-related cues
  • Strong physical reactions, like increased heart rate or sweating, to trauma-related reminders

Criterion C

The child exhibits at least one of the following avoidance symptoms or changes in his or her thoughts and mood. These symptoms must begin or worsen after the experience of the traumatic event.

  • Avoidance of or the attempted avoidance of activities, places, or reminders that bring up thoughts about the traumatic event.
  • Avoidance of or the attempted avoidance of people, conversations, or interpersonal situations that serve as reminders of the traumatic event.
  • More frequent negative emotional states, such as fear, shame, or sadness
  • Increased lack of interest in activities that used to be meaningful or fun.
  • Social withdrawal
  • Reduced expression of positive emotions

Criterion D

The child experiences at least one of the below changes in his or her arousal or reactivity, and these changes began or worsened after the traumatic event:

  • Increased irritable behavior or angry outbursts. This may include extreme temper tantrums.
  • Hypervigilance, which consists of being on guard all the time and unable to relax
  • Exaggerated startle response
  • Difficulties concentrating
  • Problems with sleeping

In addition to the above criteria, these symptoms need to have lasted at least one month and result in considerable distress or difficulties in relationships or with school behavior. The symptoms also cannot be better attributed to ingestion of a substance or to some other medical condition.

Signs and Symptoms

It is important to keep in mind that not all children who experience trauma will go on to develop PTSD. Although there are specific clinical criteria that need to be met in order for a child to be accurately diagnosed with PTSD, there are a variety of things that parents, caregivers, and other adults can look for in children if they suspect that a child might be struggling.

If you see any of the following, or additional behaviors or symptoms that seem out of the norm for your child and are not listed here, it can be worth checking in with them to see if talking with a trained professional could be helpful.

Exhibiting unusual behaviors doesn't mean your child has PTSD, but it's important to be aware of possible warning signs, especially if your child has recently faced trauma of some kind.

Preschool

  • Cry or scream a lot
  • Eat poorly or lose weight due to loss of appetite
  • Experience nightmares or night terrors
  • Extraordinary fear of being separated from their parent or caregiver

School Age

  • Have a hard time concentrating at school
  • Difficulty sleeping—insomnia or nightmares
  • Feelings of guilt or shame
  • Anxious or fearful in a variety of situations

Teens

  • Eating disordered behaviors
  • Self-harm
  • Feeling depressed or alone
  • Begin abusing alcohol or drugs
  • Engage in risky sexual behavior
  • Make impulsive dangerous decisions
  • Isolating behaviors

College Students

  • Inability to concentrate
  • Missing classes
  • Poor grades
  • Dissociative tendencies
  • Withdraw from relationships
  • Trouble sleeping
  • Hyper aware of location and surroundings
  • On edge much of the time
  • Negative thoughts and emotions
  • Avoiding things they used to enjoy

Risk Factors

Traumatic events that were life-threatening or caused physical harm can be a risk factor that influences the development of PTSD. Events that involve interpersonal violence, such as a physical attack, sexual abuse, or rape, are more likely to influence someone experiencing PTSD after their trauma.

Research has shown that between 30 percent and 40 percent of children who experience physical or sexual abuse will end up developing PTSD.

Characteristic of the Child

As with adults, it is more common for someone to develop PTSD after a traumatic event when they have already been through a previous traumatic event. The emotional impact of trauma can have a cumulative effect, so even if a child didn't demonstrate PTSD symptoms after a previous traumatic experience, it is more likely that they will experience PTSD with each subsequent trauma.

Girls are two to three times more likely than boys to develop PTSD after trauma. Some researchers suggest that this difference is due to the likelihood of girls being exposed to a traumatic event—such as sexual abuse—earlier and more often than boys. Other elements to explain this difference in the rate of PTSD between girls and boys is still being researched.

Children and teens who have a previous diagnosis of a mood or anxiety related disorder are more likely to develop PTSD after a traumatic event than those with no prior mental health diagnosis.

Family Dynamics

There are some characteristics within the family that can be influential factors in a child or teen developing PTSD. For example, parent reactions to trauma can be a risk factor for children. There are times when the entire family has experienced the traumatic event together and the children witness their parents demonstrating symptoms of PTSD. Alternatively, there are times when only the child has experienced the traumatic event but the parent still develops symptoms of PTSD.

Children and teens with greater social support have been shown to be less likely to develop PTSD after a traumatic event. Although social support primarily involves parents and caregivers, the benefits of social support can include teachers and peers as well. Since many people who struggle with PTSD tend to do so in isolation, the secure and safe connections with others can help minimize the lonely feelings and the opportunities to isolate.

Responses to the Event

The following cognitive and emotional responses to the traumatic event have been shown to influence the development of PTSD in children and teens:

  • Anger about the event
  • Repetitive thinking about the event (ruminating)
  • Avoidance and suppression of the trauma related thoughts
  • Dissociation during or after the event
  • Higher heart rate at time of hospitalization if required due to injury during the event

Tips for Parents and Caregivers

Although we cannot always prevent our children from traumatic experiences, there are certain things that parents and caregivers can do to help their child find the support and resources they need to experience healing.

Education

Educating yourself on the signs and symptoms that can show up at various stages of development can be helpful. Often children do not want to open up about their experience due to feelings of guilt and shame. By noticing behaviors or symptoms that seem different or out of the norm for your child, you can create opportunities for children to open up about their experience. The safer a child feels to be free of judgment or criticism, the likelier they are to become more open about their experience and the struggles they are having.

Finding Resources

Take time to find resources. Many schools, from preschool programs to college campuses, can offer resources for students struggling with PTSD. If they don't offer the resources themselves, they can certainly help to connect you with appropriate programs in your area. Children sometimes don't understand what they need and are looking to adults to help guide the way. If you are uncertain where to begin, you can start with contacting the school or even speaking with your pediatrician or other healthcare provider.

Treatment

Keep an open mind about treatment. It is highly likely that your child will be encouraged to participate in counseling services as part of their treatment for PTSD. This can feel uncomfortable for parents and caregivers, especially if the child has not been in counseling before. Share concerns with the therapist and make sure to ask questions about what your child can expect in treatment and any ways that you can be of help. You may be asked to sit in and participate in sessions as well.

Medication

Depending on the situation and the age of your child, medication may also be discussed as part of treatment. It is important that medications be monitored closely by the prescribing professional. Making sure that your child is taking their medication as scheduled, and sharing with you any adverse reactions or experiences as a result of taking the medication, is critical.

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Article Sources
  • American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.