PTSD in Children and Adolescents: Causes and Interventions

In recent years, remarkable progress has been made in comprehending PTSD and coexisting disorders among children and adolescents.

Abstract

Traumatic stress reactions in this demographic often involve a complex interplay between the individual, a traumatogenic factor, and the broader social context. This paper endeavors to review and synthesize recent research on PTSD in early childhood and adolescence, with a particular emphasis on its implications for clinical practice. We will explore the epidemiology of trauma exposure and PTSD, examining its ties to coexisting disorders, scrutinize diagnostic criteria, assess implications for screening and evaluation of traumatic stress reactions, and evaluate treatment outcomes, including interventions for coexisting disorders.

The dissemination of effective treatments for acute and chronic PTSD will also be addressed, alongside recommendations for further research on substance abuse from childhood through adolescence. In conclusion, we aim to provide enhanced understanding and recommendations on clinical practice and suggest avenues for future research.

Epidemiology of Trauma

Our contemporary understanding of complex trauma extends back approximately 40 years, tracing its impact throughout childhood and adolescence. Studies indicate that 40-68% of children experience at least one traumatic event (Scheeringa, Zeanah, & Cohen, 2011). The epidemiology of trauma exposure, psychopathology, and developmental risks for children will be summarized through existing research. The enduring impact of trauma can span a lifetime, encompassing adverse childhood experiences (ACES), poly-victimization, and cumulative trauma (Grasso, Greene & Ford, 2013). Recent studies have elucidated the course of PTSD, a psychiatric disorder affecting as many as one in every 14 adolescents and one in 20 children before kindergarten. Within trauma-related disorders, PTSD and coexisting disorders rank as the second and third most costly health issues in the U.S. (Ford, Grasso, Elhai & Courtois, 2015). Originally, the term "trauma," derived from the Greek word for "injury" or "wound," was intended to describe physical injuries. Today, it encompasses "psychic wounds" with traumatic effects.

Stress Reactions and Diagnosis

Before PTSD was officially recognized, other stressors or coexisting disorders were deemed "outside the range of normal experience" and were categorized in DSM-III-R by the American Psychiatric Association. When PTSD appeared in DSM-III, it provided a detailed specification of stress reactions. The criteria for diagnosing PTSD in children or adolescents involve persistent re-experiencing of a traumatic stressor, avoidance of reminders, and symptoms of persistent arousal, which must last at least 30 days. Sometimes, there may be a "delayed onset" of symptoms, not manifesting until six months later.

Complex PTSD often intertwines with coexisting disorders, originating from anxiety disorders and extending to depression, substance abuse, panic disorder, OCD, and social phobia. In children and adolescents, DSM-IV and DSM-IV-TR rely heavily on clinicians' observations. Identifying complex trauma as a distinct subset of traumatic events impacts a child's core self, leading to personality and identity fragmentation. Coexisting disorders can emerge, affecting neurobiology, as each emotion, thought, and action reflects physiological changes in the brain.

Neurobiology and Coexisting Disorders

In every disorder, the mind and body are interconnected. PTSD entails complex changes in mental states, often leading to the emergence of other disorders such as anxiety, substance abuse, depression, and OCD. PTSD sufferers experience a radical shift in the brain and body’s stress response system. The National Institute of Mental Health launched Research Domain Criteria (RDoc) to integrate multiple scientific disciplines to identify fundamental behavioral components in mental health disorders (Ford, Grasso, Elhai & Courtois, 2015). Substance abuse often co-occurs with PTSD, as pharmacology sometimes leads to drug tolerance, likened to cocaine. Children and adolescents receiving drugs for coexisting disorders face risks of substance use problems and high-risk behaviors (Fortuna, Porche, & Padilla, 2018).

Assessment and Treatment

Assessing PTSD involves evaluating traumatic stressors and the likelihood of developing stress disorders. Assessment tools include questionnaires and in-depth clinical trials to uncover underlying problems. Confusion often arises, as 50-60% of individuals experience traumatic stressors, yet not all develop PTSD (Ford, Grasso, Elhai & Courtois, 2015). Evaluating patient history aids in discerning pre-existing disorders or ties to PTSD, avoiding incorrect diagnoses, particularly in children. Meta-analyses show 41% of children with PTSD symptoms need medication for concentration, leading to substance abuse, while 25% suffer from depression and 23% from anxiety (Simonelli, 2013). Diagnoses often follow DSM-IV, leading to alternative algorithms and criteria modifications.

Treating disorders with specific symptoms linked to others necessitates proper assessment and treatment. Recognition that not all children with traumatic stressors develop PTSD underscores the importance of accurate assessment. Treatment often involves medication, such as SSRIs and atypical antidepressants, as part of a two-pronged approach. PTSD’s coexisting disorders, including substance abuse, complicate treatment, as children may require increased dosages over time, posing future risks. Cognitive processing therapy, adapted for youth, and Child-Parent Psychotherapy (CPP) involve caregivers in therapy, crucial for young people. CPP helps parents understand their child's trauma impact. Understanding interconnected disorders aids in appropriate treatment, particularly as children continue to develop, potentially causing diagnostic confusion.

Conclusion

Defining and applying criteria for PTSD and coexisting disorders can address critical questions regarding diagnosis difficulty, cost, and the complex condition affecting millions. Understanding how specific traumatic stressors cause psychological trauma and coexisting disorders with long-term consequences is a crucial challenge for researchers, clinicians, and policymakers. As research advances, so too will treatments for PTSD and coping strategies for coexisting disorders, benefiting the younger generation facing daily traumatic events.

References

• Grasso, D., Greene, C., & Ford, J. D. (2013). Cumulative trauma in childhood. Treating complex traumatic stress disorders in children and adolescents: An evidence-based guide, 79-99.
• Scheeringa M. S, Zeanah C. H, Cohen J. A. PTSD in children and adolescents: towards an empirically based algorithm. Depression and Anxiety. 2011;28:770–782.
• Ford, J. D., Grasso, D. J., Elhai, J. D., & Courtois, C. A. (2015). Posttraumatic stress disorder: Scientific and professional dimensions. Academic press.
• Fortuna, L. R., Porche, M. V., & Padilla, A. (2018). A treatment development study of cognitive and mindfulness-based therapy for adolescents with co-occurring post-traumatic stress and substance use disorder. Psychology and Psychotherapy: Theory, Research, and Practice, 91(1), 42-62.
• Simonelli A. (2013). Posttraumatic stress disorder in early childhood: classification and diagnostic issues. European journal of psychotraumatology, 4, 10.3402/ejpt.v4i0.21357. doi:10.3402/ejpt.v4i0.21357

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