Post-traumatic stress disorder in children and adolescents

History

One of the earliest efforts to distinguish post-trauma symptoms between youth and adults came from Terr's reports on the 'Children of Chowchilla.' In July 1976, near Chowchilla, California, a school bus carrying 26 children and one adult was hijacked by three armed men and held for ransom in a buried box trailer. After the captives escaped, medical professionals and local authorities declared the children unharmed, suggesting psychological impact would be minimal, perhaps affecting only one child.

This view was considered reasonable at the time, as children were widely believed to be inherently resilient to trauma. However, many victims subsequently developed severe emotional, behavioral, and cognitive symptoms and remained untreated for months, partly because parents were reluctant to admit their child was affected. The expectation of complete resilience may have stemmed from a failure to recognize distinct symptoms in trauma-exposed children compared to adults.

Since PTSD was introduced in DSM-III, both adults and children have been acknowledged as vulnerable. The DSM-IV criteria faced criticism for being developed with adult populations, leading to underestimation of PTSD in infants and preschoolers. This prompted the PTSD-Alternative Algorithm (PTSD-AA), which modified symptoms to be more developmentally appropriate, improving diagnostic accuracy in very young children.

Risk factors

Not all children and adolescents exposed to trauma develop PTSD; individual vulnerability, trauma severity, support systems, and other factors influence the likelihood. Genetic components appear to play a role, with the FKBP5 gene potentially interacting with early-life adversity to affect stress regulation and PTSD risk. The influence of age at trauma remains under study, though PTSD may manifest differently across developmental stages. Female children and adolescents show higher PTSD rates than males.

The relationship between ethnicity and PTSD is unclear, but some studies report elevated symptoms among minority populations, possibly due to higher trauma exposure. More severe traumas are linked to higher symptom levels, and greater distance from the event is associated with lower distress. A meta-analysis of 32 studies identified feeling highly threatened or perceiving life danger during trauma as moderate predictors of later PTSD; dissociation or confusion during the event also predicted symptoms.

For girls, the link between feeling threatened and PTSD was stronger than for boys. Interpersonal traumas such as sexual assault and physical violence carry higher PTSD rates than other trauma types, and repeated trauma exposure increases risk.

Assessment

The British National Institute for Health and Care Excellence recommends that emergency department staff explain typical trauma reactions and possible PTSD symptoms—such as nightmares, repetitive trauma-related play, intrusive thoughts, avoidance, increased behavioral difficulties, concentration problems, hypervigilance, and sleep difficulties—to parents or caregivers of a child who has experienced a traumatic event. Parents should be advised to contact their general practitioner if symptoms persist beyond one month.

Several tools assess pediatric PTSD. The Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) is a structured interview for 8–15-year-olds, adapted from DSM-IV to DSM-5, with good internal consistency, excellent interrater reliability, and adequate convergent validity. The UCLA PTSD Reaction Index (UCLA PTSD-RI) for 6–18-year-olds shows excellent internal consistency and test–retest reliability, good convergent validity, and is quick to administer.

The Child PTSD Symptom Scale for DSM-5 (CPSS-5-I) is a 20-question screening tool taking about 20 minutes, with excellent internal consistency, test–retest reliability, and interrater reliability.

Management

A large review of 56 randomized controlled trials with 5327 patients comparing 14 psychotherapies and 3 control conditions found Cognitive Processing Therapy (CPT), Behavioral Therapy (BT), and individual trauma-focused cognitive-behavioral therapy (TF-CBT) to be the most effective psychotherapies for pediatric PTSD, significantly superior to supportive therapy. Eye movement desensitization and reprocessing and group TF-CBT were only better than no treatment.

Psychodynamic therapy and family therapy were not effective. Dropout rates for evidence-based trauma-focused treatments were around 12%, similar to non-trauma-focused treatments or control groups, indicating good tolerability. Cognitive Behavioral Therapy (CBT) effectively treats PTSD and related conditions like anxiety and depression, and significantly improves symptoms in children and adolescents aged 7 to 18 who have experienced sexual abuse or war-related trauma.

Trauma-Focused Cognitive Behavioral Therapies (TF-CBTs) are the first-line treatment recommendation, leading to significant symptom reductions across short, mid, and long terms. TF-CBT is considered 'probably efficacious' for preschool-aged children, with factors such as language and cognitive abilities, family environment, cultural background, and clinician expertise to be considered.

Did You Know?

• Almost two thirds of children and teenagers worldwide have experienced at least one serious adverse childhood experience.
• Medical trauma from intensive or invasive procedures, particularly for very young children, can cause PTSD.