Post-Traumatic Stress Disorder (PTSD)

What is post-traumatic stress disorder?
Post-traumatic stress disorder, or PTSD, is a mental health disorder affecting children, adolescents and adults who have survived a traumatic experience or series of traumatic events. Children with PTSD typically experience three types of symptoms: 

Re-experiencing the trauma

• The child continues to mentally re-live the traumatic experience, over and over again.

• He may have “flashbacks” of the event, feeling like he is actually going through the experience again. He may even hallucinate scenes, sounds or smells from the experience.

• He may have severe nightmares (either about the traumatic event or about other frightening things).

• He may feel the need to “hash out” the event verbally or in play.

• He cannot stop thinking about the traumatic experience, no matter what he does.

Avoidance

• The child deliberately avoids any thought, object, place or situation that is related to the traumatic experience or reminds him of the event in any way.

• He may have difficulty remembering details about the event (“blocking it out”).

• He may become numb to his feelings and surroundings in general as a coping mechanism.

Increased agitation

• The child feels as though he must constantly be “on guard,” in case the trauma happens again or another dangerous situation emerges.

• He might be easily startled or frightened.

• He may have trouble falling or staying asleep.

• He may experience difficulty concentrating on schoolwork and other routine tasks.

• He might have outbursts of unprovoked or excessive anger.

A very young child who cannot verbalize feelings or thoughts about a trauma may demonstrate the following after the experience:

• out-of-control, disruptive behavior
• extreme fear of being separated from the primary caregiver

What are some of the events that can cause PTSD in children?
While any traumatic event can cause a child to develop PTSD, the disorder most often results from:

• witnessing domestic violence in the home
• experiencing physical abuse
• experiencing sexual abuse
• sustaining a severe injury
• being involved in a serious accident
• witnessing or experiencing an act of violence in school or in the community (for example, a school shooting)

A child develops PTSD when:

• he perceives the experience as life-threatening or extremely dangerous
• he responds to the event with intense fear, helplessness or horror

Treatment for PTSD is complex, ongoing and depends very much on the child’s individual symptoms and circumstances. However, psychotherapy “(talk therapy”), family support and—in some cases—the addition of medication to the treatment regimen have all shown excellent results in helping kids with PTSD return to a normal, healthy life.

Children’s Hospital Boston has many years of experience in treating children and families affected by trauma, and we are here for you.

Causes

What can cause post-traumatic stress disorder in a child?
Any child who witnesses or goes through a life-threatening experience is at risk of developing PTSD. While any traumatic event can trigger PTSD symptoms, common traumas that have been linked to the disorder include:
 

• accidents, such as car or plane crashes
• natural disasters, such as floods or earthquakes
• acts of war or terrorism
• violent crimes, such as a home invasion, kidnapping or murder
• physical, emotional or sexual abuse (either of the child or of another family member in front of the child)
• neglect
• house fires
• exposure to violence at school or in the community
• suicide of a family member or friend

It’s important to note, however, that not all children who live through one of these traumas will develop PTSD.

Are there certain factors that can affect the likelihood of a traumatic event causing PTSD?
There are several factors that can contribute to developing or preventing PTSD, including:

• how close the child was to the trauma itself (was she physically affected? Did she witness the trauma while it was happening, or encounter the aftermath?)

• how close the child is to the people involved (did the trauma involve her immediate family?)

• the severity of the trauma

• how long the traumatic event lasted

• whether the trauma has recurred (for example, ongoing gang violence in a neighborhood)

• the coping skills of the child and her family

• the mental health history of the child’s family

• how much support the child is receiving at home, at school and in the community

Signs and symptoms

What are the symptoms of post-traumatic stress disorder?
If your child is suffering from PTSD, she is most likely working through extreme emotional, mental and physical distress. Symptoms of PTSD can emerge as early as three months after the event, or can take as long as a year to show up. (A child who develops symptoms immediately after the event—within four weeks—is considered to have acute stress disorder. Treatment for this disorder is very similar to treatments prescribed for PTSD.)

PTSD symptoms can vary depending on the age of the child and the circumstances of the trauma, but tend to include: 

• intense anxiety when separated from family members or around strangers
• disturbances in sleep (unable to fall or stay asleep)
• sad, withdrawn mood
• feeling jittery, “on edge” or “on guard”
• easily startled, especially by sounds or sudden movements
• loss of interest in activities and subjects previously enjoyed
• physical or emotional detachment from family members and friends
• feeling or acting “numb”
• difficulty displaying affection
• excessive or illogical irritability
• aggressive (or even violent) attacks on others
• avoidance of particular places, situations or objects that bring back memories of the trauma
• “flashbacks” (feeling like the traumatic experience is happening again; may include seeing or hearing parts of the event that are not really occurring)
• inability to distinguish reality from thoughts or dreams
• constantly re-enacting the trauma through play, drawings, writings or conversation
• problems in school
• difficulty concentrating
• preoccupation with death and dying
• worrying about dying at an early age or losing other loved ones
• regressive behaviors (acting younger than their age), such as bedwetting or thumb-sucking
• physical complaints, such as stomachaches or headaches, with no identifiable medical cause

Many of these symptoms can also point to another mental health condition, such as depression or an anxiety disorder. Your child’s clinician will help determine the cause of her symptoms and develop an appropriate treatment plan to meet all of her needs.

FAQ

Q: Is post-traumatic stress disorder common among children?
A: While traumatic experiences affecting children are all too common, PTSD itself is not: According to the National Center for Post-Traumatic Stress Disorder, 15 to 43 percent of girls and 14 to 43 percent of boys have experienced a traumatic event in their lifetimes. However, only 3 to 15 percent of girls and 1 to 6 percent of boys suffer from PTSD.

Q: What is the difference between PTSD in kids and PTSD in adults?
A: The symptoms and feelings associated with PTSD are very similar in kids and adults—but the difference is that adults are usually better able to verbalize how they are feeling and what they are experiencing.

Children also have a more difficult time recognizing that the frightening thoughts and sensations they feel during flashbacks and memories of the trauma are not real—that the trauma is not actually happening again. A child with PTSD is more likely to physically react to these traumatic thoughts and feelings—for example, screaming, hiding or fighting—than an adult.

Q: Are some events more likely to cause more post-traumatic stress disorder than others?
A: While any traumatic experience can cause a child to develop PTSD, certain events are linked more strongly to the onset of the disorder. According to the National Center for Post-Traumatic Stress Disorder:

• as many as 100 percent of children who witness the murder or sexual assault of a parent develop PTSD
• 90 percent of children who are sexually abused develop PTSD
• 77 percent of children who are injured in, or witness, a school shooting develop PTSD
• 35 percent of children in urban areas who are exposed to community violence develop PTSD

Q: How long can post-traumatic stress disorder last? When will my child be back to normal?
A: How quickly your child goes back to normal depends on a variety of things, including the severity of the trauma and how soon you reach out for help after the event. Some kids with PTSD recover in as little as six months with treatment, while others may take much longer to begin a return to normalcy.

Q: Can post-traumatic stress disorder be prevented?
A: While you can try to protect your child from any potential harm, sometimes things are out of your hands despite your best efforts. The most critical actions you can take to reduce the chances of PTSD in your child include the following: 

• Teach your child that it’s okay to say NO to someone who tries to touch him in an uncomfortable way—even if that person is a “grown-up,” or even another family member.
• Teach your child to tell a trusted adult right away if someone does or says something that makes him feel uncomfortable.
• Create a strong family and community support network around your child, should a traumatic event occur.

Q: What if my child has been diagnosed with another mental health problem, in addition to PTSD?
A: Kids who have experienced a traumatic event may develop another mental health problem, such as depression or separation anxiety disorder. If your child has another condition requiring professional intervention, your Children’s clinician will work with you to treat both disorders at the same time.

How is post-traumatic stress disorder diagnosed?

Here at Boston Children’s Hospital, a psychiatrist, psychologist, social worker, or other mental health clinician will make the diagnosis after a comprehensive assessment — a series of interviews — with you and your child. During the interviews, the clinician will ask about:

• the traumatic experience your child suffered or witnessed
• your child’s symptoms
• your child’s school, social, and medical histories
• your family’s medical and mental health history

Together with the mental health clinician, you will arrive at a formulation or explanation of your child’s PTSD symptoms, which will lead directly to a mutually agreed-upon treatment plan.

If my child is diagnosed with PTSD, what happens next?

Your child’s mental health clinician will explain the diagnosis and answer any questions you or your child may have. The next step is developing a mutually agreed-upon treatment plan that works for you, your child, and your family. The plan may include one or more of the following therapies:

• psychotherapy (“talk therapy”) for the child
• psychotherapy for the family
• in some cases, a combination of therapy and medication

It’s essential to seek professional treatment for your child as soon as PTSD symptoms emerge. The disorder responds very well to therapies delivered by qualified mental health clinicians, but if left untreated, can cause longstanding emotional distress, relationship problems and academic failures for your child. These difficulties can continue well into adulthood if they are not properly addressed.

Psychotherapy

Psychotherapy, or “talk therapy,” is the mainstay of mental health treatment at Boston Children’s. Psychotherapy will teach a child with PTSD-specific coping strategies, including learning how to:

• identify feelings of fear
• manage fear and anxiety with relaxation techniques and self-soothing activities
• talk (or play-act, for very young children) through the traumatic event to release and understand buried feelings
• think about the traumatic event in ways that do not involve self-blame or guilt
• plan what to do if another traumatic event should occur
• restore trust in others and build hope for the future

If your child is very young, you will usually participate in the psychotherapy sessions alongside him. Family psychotherapy is also available to help all members of the family who have been impacted by the traumatic experience.

Trauma Systems Therapy (TST)

Boston Children’s Hospital clinicians have developed a therapeutic approach called Trauma Systems Therapy (TST). This treatment recognizes that a child’s traumatic stress often boils down to two factors:

• the child is unable to control his emotional or behavioral state
• the child is not receiving sufficient support from his surrounding environment to help him regulate these feelings

Our psychiatrists and psychologists have used TST to train other clinicians, as well as providers in health and community agencies, to:

• recognize when a child is struggling with loss of emotional control tied to a trauma
• take steps to address the problems in the child’s environment that continue to trigger these feelings

TST also teaches children themselves to develop skills for keeping emotional control during times of stress.

Medication

If a child is feeling severe anxiety, fear, and hopelessness, medication can be a useful addition to her psychotherapy for PTSD. Antidepressant or anti-anxiety medications can help the child feel calmer, more in control, and ready to apply the coping strategies she is learning in therapy.

Medication is not a “standalone” treatment; Boston Children’s always considers it part of a two-prong approach, with psychotherapy as a necessary component. Our Psychopharmacology Clinic is devoted to helping children, families, and clinicians decide whether medication might be a useful part of treatment.

Commonly prescribed antidepressant medications include:

SSRIs (selective serotonin reuptake inhibitors, which adjust the levels of serotonin — a chemical that regulates mood — in the brain)

• Celexa
• Lexapro
• Luvox
• Prozac
• Zoloft

Atypical antidepressants (drugs that impact both serotonin and other chemical messengers in the brain)

• Cymbalta
• Desyrel
• Effexor
• Remeron
• Serzone
• Wellbutrin

Commonly prescribed anti-anxiety medications include:

• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Diazepam (Valium)
• Clonazepam (Klonopin)
• Diphenhydramine (Benadryl)
• Hydroxizine (Vistaril)

Less commonly prescribed medications that can also treat fear and anxiety include:

• Buspirone (BuSpar)
• Zolpidem (Ambien)

Learn more about psychiatric medications.

No single medication is effective in all children. Families should expect a trial-and-error process that can last weeks, or even months, as doctors find the drug regimen that works best.

Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

“Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

If your child is prescribed any medication during treatment for PTSD, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to address any concerns you may have.

Coping and support

The ups and downs experienced by a child — and family — living with the aftermath of a traumatic event can be frightening, draining, and hard to understand. In addition to the information provided here, you may find comfort and support from the following resources:

Patient and family resources at Children’s

Our Hale Family Center for Families is dedicated to helping families locate the information and resources they need to better understand their child’s particular condition and take part in their care. All patients, families, and health professionals are welcome to use the center’s services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.

Our Department of Spiritual Care (chaplaincy) a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members — representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian, and United Church of Christ traditions — who will listen to you, pray with you and help you observe your own faith practices during your child’s treatment.

The Psychiatry Consultation Service provides several services, including:

• short-term therapy for children admitted to one of our inpatient units
• parent and sibling consultations
• teaching healthy coping skills for the whole family
• educating members of the medical treatment team about the relationship between physical illness and psychological distress

The Behavioral Medicine Clinic helps children who are being treated on an outpatient basis at the hospital — as well as their families — understand and cope with their feelings about:

• being sick
• facing uncomfortable procedures
• handling pain
• taking medication
• preparing for surgery
• changes in friendships and family relationships
• managing school while dealing with an illness
• grief and loss

Our Integrative Therapies Team provides a number of services for hospitalized children, their families, and their caregivers, including:

• massage therapy
• acupuncture
• yoga
• therapeutic touch

Visit our “For Patients and Families” page for everything you need to know about:

• getting to Boston Children’s
• finding accommodations
• navigating the hospital experience

Helpful links

Please note that neither Boston Children’s Hospital nor the Department of Psychiatry and Behavioral Sciences unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

• Center for the Study of Traumatic Stress: For Children
• Helping Traumatized Children at School
• The Childhood Violent Trauma Center at Yale University
• National Center for PTSD: PTSD in Children and Teens
• National Child Traumatic Stress Network
• RAINN: Rape, Abuse & Incest National Network
• Trauma Systems Therapy
• U.S. Department of Justice: Help for Victims

At Boston Children’s Hospital, we’re dedicated to proving the effectiveness of our treatment approaches through rigorous scientific testing. Our research program is one of the largest and most active of any pediatric hospital in the world. 

Each day, we are working toward important discoveries to propel new advances in preventing, diagnosing, and treating mental and behavioral disorders. This research reinforces our ongoing commitment to enhancing mental health for all children and adolescents. 

Children’s research projects with promise for preventing and treating PTSD include:

• Michelle Bosquet Enlow, PhD, a psychology researcher at Children’s, is studying the link between maternal and infant mental health in order to create effective early mental health intervention programs for young children.

Learn more about research at Boston Children's.

Clinical trials

It’s possible that your child will be eligible to participate in one of Boston Children's Hospital's current clinical trials. These studies are useful for a multitude of reasons:

Some trials are designed to evaluate the effectiveness of a particular drug, treatment or therapy on a specific disease; others help doctors to better understand how and why certain conditions occur. At any given time, we have hundreds of clinical trials underway. Of course, your motives as a parent needn’t be entirely altruistic — you’ll naturally want to know how taking part in a trial can immediately benefit your child. If your child’s physician recommends participation in one of Children’s clinical trials, that likely means that your child’s physician believes that the plan outlined in that trial represents the absolute best, latest care your child can possibly receive.

And participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.

Find a clinical trial

To search current and upcoming clinical trials at Children’s, go to:
http://www.childrenshospital.org/clinical-trials

To search the NIH’s list of clinical trials taking place around the world, go to:
http://www.clinicaltrials.gov/ct2/search