Post-traumatic stress disorder (PTSD) in children and adolescents or pediatric PTSD refers to pediatric cases of post-traumatic stress disorder. Children and adolescents may encounter highly stressful experiences that can significantly impact their thoughts and emotions. While most children recover effectively from such events, some who experience severe stress can be affected long-term. This prolonged impact can stem from direct exposure to trauma or from witnessing traumatic events involving others.

When children develop persistent symptoms (lasting over one month) due to such stress, which cause significant distress or interfere with their daily functioning and relationships, they may be diagnosed with PTSD.

Signs and symptoms Children experiencing PTSD may exhibit a range of signs and symptoms, which vary depending on their age and developmental stage. These commonly include:

Re-experiencing the traumatic event: This can manifest as intrusive thoughts, flashbacks, or repetitive play that reenacts aspects of the trauma. Sleep disturbances: Nightmares and difficulty sleeping are common. Intense distress reactions: Children may become highly agitated or upset when exposed to reminders or triggers of the event. Negative alterations in mood and cognition include: Reduced ability to experience positive emotions. Persistent feelings of fear or sadness. Irritability and frequent angry outbursts. Social withdrawal or feelings of helplessness and hopelessness. Emotional numbness or denial of the event's occurrence. Hyperarousal and reactivity. Symptoms in this area involve: Heightened vigilance for potential threats. An exaggerated startle response. Avoidance: Children may actively steer clear of places, people, or activities associated with the traumatic event.

Some symptoms of traumatic stress, such as restlessness, fidgeting, and difficulties with attention and organization, can overlap with those of attention-deficit/hyperactivity disorder (ADHD). This overlap can sometimes lead to misdiagnosis if the child's traumatic history is not considered.

Differences between pediatric and adult PTSD The diagnosis of PTSD requires similar criteria for children and adults. However, evidence suggests that the appropriateness of this diagnostic model varies with age, with PTSD only becoming more "adult-like" later in adolescence. Consequently, these criteria have shown limited sensitivity in identifying PTSD in youth, particularly at younger ages. Psychiatric diagnosis often relies heavily on a patient's capacity to offer detailed insights into their own thoughts, feelings, and behaviors. The developing nature of advanced cognitive processes, such as metacognition, in younger individuals may restrict their ability to report symptoms fully. While obtaining diagnostic information from caregivers might seem like an alternative, parents' assessments of their children's PTSD symptoms often demonstrate limited accuracy in capturing certain aspects of the diagnostic criteria.

Children with PTSD may display some symptoms slightly different from adults. For instance, the dissociative subtype of PTSD, characterized by the additional symptoms of depersonalization or derealization is more common in children than in adults.

Trauma Post-traumatic stress disorder in children can arise from various highly distressing or life-threatening experiences. Almost two thirds of children and teenagers worldwide have experienced at least one serious negative event (adverse childhood experiences; ACEs) in their lives. The types and rates of these experiences differ depending on where children live and what kind of adversity is measured.

These traumatic events may include, but are not limited to:

Maltreatment: Physical, sexual, or emotional abuse or neglect. Violence and crime: Directly experiencing or witnessing acts of violence, assault, or other criminal activity. Loss and bereavement: The serious illness, unexpected death, or threatened death of a close family member or friend. Disasters: Exposure to natural disasters (e.g., earthquakes, hurricanes, floods) or human-made disasters (e.g., fires, bombings). Accidents: Severe incidents such as serious motor vehicle collisions. Medical trauma: Intensive or invasive medical procedures, particularly for very young children, or prolonged hospitalization.

Child sexual abuse Child sexual abuse is strongly linked to mental health issues throughout life, with PTSD being a common outcome. A large review found a significant connection between sexual abuse and PTSD in children, adolescents, and young adults. This link was similar for both boys (OR = 2.86) and girls (OR = 2.38), meaning that boys who experienced sexual abuse were about 2.86 times more likely to have PTSD than boys who did not, and girls were about 2.38 times more likely than girls who did not.

Pediatric Illness Studies on children in pediatric intensive care units show a wide range in the number of patients who develop PTSD, from 13% to 84.6%. Many studies reported PTSD prevalence between 20–40%. Factors increasing the risk of PTSD in pediatric intensive care unit patients include certain medical interventions, child-specific factors, and aspects of the family environment. Commonly used medications in the intensive care units such as opioids, benzodiazepines, and midazolam are linked to PTSD. This may be because prolonged use of opioids and benzodiazepines can lead to withdrawal, affecting well-being, while midazolam might interfere with how traumatic memories are processed. Invasive procedures like intubation, surgery, and blood draws are also strongly associated with PTSD in children, possibly due to the pain, fear, and feeling of helplessness they can cause, which may become lasting traumatic memories.

Risk factors Not all children and adolescents who are exposed to traumatic events will develop PTSD. Individual vulnerability, the nature and severity of the trauma, existing support systems, and other factors influence the likelihood of developing the disorder.

Child characteristics

Genetics It appears that both experiencing trauma and developing PTSD have some genetic component, meaning these aspects can run in families. Past research has looked at specific genes, but the results have not been very clear or consistent. More recent findings suggest that certain genes might interact with a person's experiences. For example, the FKBP5 gene seems to play a role: if someone has a particular version of this gene and experiences tough times early in life, it might affect how their body handles stress and potentially increase their risk for PTSD.

Demographics The influence of age at the time of trauma on PTSD development remains a subject of ongoing research. Current evidence suggests that rather than age affecting trauma impact differently, PTSD may manifest differently across various developmental stages.

Female children and adolescents demonstrate higher rates of PTSD than their male counterparts. The relationship between ethnicity and PTSD remains unclear, though some studies indicate elevated PTSD symptoms among minority populations. However, this disparity may reflect higher rates of trauma exposure rather than inherent ethnic differences in vulnerability.

Trauma characteristics Children and adolescents exposed to more severe traumas typically exhibit higher levels of PTSD symptoms. Additionally, children and adolescents who are more distant from the traumatic event generally report lower levels of distress.

A meta-analysis of 32 studies identified several factors during or immediately after a traumatic event that predict PTSD symptoms in children. Feeling highly threatened during the trauma and perceiving one's life to be in danger both showed a moderate connection to later PTSD. Other factors, such as feeling detached (dissociation) or confused during the trauma were also related to PTSD symptoms. For girls, the relationship between feeling threatened during the trauma and PTSD symptoms was stronger than for boys.

Interpersonal traumas, including sexual assault and physical violence, are associated with higher rates of PTSD compared to other trauma types. The risk of developing PTSD also increases with repeated trauma exposure.

Family characteristics A family's overall well-being and how it functions are closely linked to a child's experience with PTSD. Better family functioning, including positive aspects like how emotions are expressed, how members communicate, and how connected and supportive they feel, is associated with fewer or less severe PTSD symptoms in children. Conversely, negative elements such as family conflict are linked to more severe PTSD, and these negative elements can have a stronger and more lasting impact on a child's symptoms compared to positive ones.

Child post-traumatic stress symptoms following acute trauma are associated with specific parental responses, including overprotective behaviors, avoidance of trauma-related discussions and reminders, and encouragement of distraction from trauma-associated thoughts and stimuli.

Peer and family support are related to PTSD in children, but the effect is small.

Pathophysiology Key brain regions involved in adult PTSD include the circuit formed by the amygdala, hippocampus, and prefrontal cortex. This network is one of the most thoroughly understood in behavioral neuroscience. Research on pediatric PTSD indicates that it shares some brain abnormalities with adult PTSD, such as reduced volume in the ventromedial prefrontal cortex (vmPFC) and impaired activation of the lateral prefrontal cortex. However, other features commonly seen in adult PTSD, like reduced hippocampal volume and hyperactivity in the amygdala and insula, have not been consistently observed in pediatric PTSD.

One explanation for these differences appears to be the delayed neurodevelopmental effects in pediatric PTSD. This includes the hippocampus gradually decreasing in volume, the amygdala's reactivity increasing, and the coupling between the amygdala and medial prefrontal cortex (mPFC) decreasing with age. Therefore, PTSD in youth may differ from adults due to both the heightened stress sensitivity of developing neural systems and the delayed full expression of childhood trauma's effects.

Diagnosis According to the DSM-5, Post-traumatic stress disorder is defined as occurring after an individual experiences or witnesses an event that involved actual or threatened death, serious injury, or sexual violence. Following such an event, the individual experiences recurrent, involuntary, and intrusive recollections, nightmares, or dissociative reactions (such as flashbacks). They also have significant distress or physical reactions when exposed to triggers or reminders of the event.

In addition to these re-experiencing symptoms, individuals with PTSD also show:

Persistent avoidance: They avoid thoughts, feelings, people, places, or activities related to the trauma. Negative changes in thinking and mood: This can include being unable to recall important parts of the trauma (dissociative amnesia), having negative beliefs about themselves or the world, blaming themselves or others, experiencing negative trauma-related emotions, losing interest in activities, feeling detached from others, or having a reduced ability to express emotions. Changes in arousal and reactivity: Symptoms in this category include irritability, engaging in self-destructive or reckless behavior, being constantly on alert (hypervigilance), having an exaggerated startle response, difficulty concentrating, or problems with sleep.

All these symptoms collectively lead to significant distress for the individual.

PTSD for children 6 years and younger