Children typically undergo extreme stress at some point in their lives, but recover well without undue delay. In some cases, however, children fail to recover, and develop symptoms of stress that persist long-term, preventing them from functioning normally or establishing good relationships.

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Signs and Symptoms

Children with PTSD develop symptoms, such as:

• Recurrent flashbacks and replaying the event over in behavior or thoughts
• Nightmares
• Sleep disruption
• Sadness and mood depression
• Inability to deal with anything that brings the traumatic event to mind
• Anger and irritability
• Intense fear
• Easily frightened and always on the alert for threats
• A helpless or hopeless attitude
• Denial of the event
• Social withdrawal
• Feelings of numbness
• Restlessness or fidgetiness
• Lack of concentration

Some symptoms may overlap with those of attention deficit-hyperactivity disorder (ADHD) especially in adolescents with PTSD.

Incidence

It is estimated that about 5% of adolescents show signs of PTSD at some point, and it is more common in girls than in boys (8% vs 2.3%), increasing with age. The prevalence in younger children is not known.

Causes or Risk Factors for PTSD in Children

An event is always necessary to trigger PTSD, such as:

• Physical/sexual/emotional abuse
• Experiencing violence
• Witnessing assault or crime
• Severe illness or death of a person close to the child
• Being involved in any calamitous event

Other risk factors include:

• Previous history of trauma
• Coexisting or prior mental disorders
• History of mental illness in the parents
• Lack of social support

Management

If a child shows symptoms that could suggest PTSD or any mental disorder, it is important to consult a professional health care provider to diagnose and treat the child. A history of an event that triggered the PTSD is always present in this condition. Getting this history is often difficult due to the child’s avoidance of the topic, and requires gentle and skilled handling.
The DSM-IV-TR criterial include three clusters of symptoms:

• Persistent re-experiencing through nightmares, flashbacks or playing out the event in a compulsive and anxiety-enhancing manner
• Avoidance of any reminders of the trauma including people or places, which bring up the memory, with a lack of general emotional response
• Chronic hyperarousal in the form of disrupted sleep, being easily startled, and excessively alert to possible threat

While such symptoms may occur following severe stress, they usually recede within a few weeks at most, leading to a diagnosis of acute stress disorder. When a specified number of symptoms from each of these clusters is present for a month or more, and responsible for poor functioning or significant distress, PTSD is diagnosed.

Following the diagnosis, the child must be given all opportunities to feel safe, ensuring support from family and school, as well as the child’s friends, as well as protection against repeated trauma as far as possible.

Treatment

Psychotherapy

Psychotherapy, giving the child a safe environment and age-appropriate ways to express feelings safely, by speaking about them, drawing, playing, or writing about them, is useful in drawing out the child, and may involve the family or a group as well.

Trauma-focused cognitive-behavioral therapy

Trauma-focused cognitive-behavioral therapy (TF-CBT) is the most useful technique in the treatment of this disorder. Here the child is helped to understand the present situation and then trained in ways to break the pattern of thoughts and feelings by changing the behavior in a planned manner. This helps significantly to keep worry and fear levels down by helping the child to cope in better ways with anxiety, recognize and change disturbing feelings and thoughts through preplanned behavioral changes, while functioning normally.

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a combination of CBT with directed eye movements, but it needs to be further studied in children. Its efficacy is believed to be probably due to the CBT component.

Other interventions

Special interventions may be needed for children who deal with PTSD by turning to drugs or other substances, indulge in inappropriate sexual behavior or have very disturbed behavioral patterns.

Medications

Pharmacotherapy is not generally recommended in children, because of the risk of increased irritability, further sleep disruption and poor attention.

Prevention of PTSD

While all children who undergo extreme stress do not develop PTSD, it is important to reduce its incidence by being on the lookout to prevent the triggering events, such as child abuse, injuries or violence. The type of event and the nearness of the child to the event are both significant in predicting the likelihood of PTSD in the child.

Psychological First Aid is a mode of supporting children present during natural or manmade calamities by comforting them, dealing properly with their emotional and behavioral expressions, and helping them learn to calm themselves and cope with the new demands of the situation. The children who need more care are then referred for specialized help.

Further Reading

• All Pediatrics Content
• Pediatrics – What is Pediatrics?
• Pediatrics Training
• Pediatric Skin Conditions
• Subspecialties of Pediatrics

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.