This is our third post in our series on pediatric behavioral health conditions. For more, visit our posts on pediatric depression and pediatric anxiety.
Children experience trauma differently than adults. As a pediatric care provider, it’s important to understand these differences, how you can spot them, and best practices for treating them.
Keep reading for a discussion of the types of trauma and their prevalence, risk factors and protective factors for child and adolescent PTSD, review screening and assessment for PTSD in primary care, and the algorithm for treatment.
Almost half of children in the U.S. have experienced trauma
The survey on adverse childhood experiences by the National Survey of Children’s Health (NSCH) indicated that nearly 50% of children in the United States have experienced one or more types of serious childhood trauma. Most children are resilient after traumatic exposure, but a minority of children develop significant mental health problems as a result.
Traumatic experiences can impact a child’s neurological development, trust, emotional regulation, and social skills. These essential skills help children function, and your ability to help treat children for these PTSD-related conditions will aid their growth.
Also, remember that research has shown complex trauma impacts both the mental and physical health of children. Both short-term somatic effects and long-term effects on childhood development can result from complex trauma.
COVID-19 has been a mass, traumatic event for children
Children who had their lives interrupted during COVID-19 will be experiencing the repercussions for years and may respond to COVID-19 as a traumatic event. Anxiety and fears related to contracting the virus, economic challenges, and deaths of family members are all traumatic events in addition to the fallout from schedule changes and social isolation.
In the short and medium-term, children may experience symptoms similar to anxiety, depression, PTSD, dissociation, depersonalization, and emotional dysregulation. In the long term, these traumas can cause physical, social, and intellectual development problems. You may see violent and risky behaviors in children resulting from COVID-19 trauma.
Remember, these factors will all contribute to PTSD symptoms in children, and multiple traumas can interact together to form more complex experiences. Your care plan should take these events into account as you build a picture of how a child’s trauma may have affected them.
PTSD can develop after one year of age
Navigating the different types of pediatric stress and trauma disorders can be confusing, so be sure to review the definitions of unique DSM-5 stress and trauma disorders to support your patients adequately. Also, remember that children can develop PTSD after only one year of age and that a PTSD diagnosis can be surprising for families who don’t realize that PTSD can develop this early.
Even when children aren’t old enough to talk and verbalize symptoms, you may notice PTSD through unusual behaviors in play, such as new aggression. Remember that adults who re-experience childhood PTSD symptoms may face additional mental health challenges as they age, so diagnosing and treating PTSD in children will help a patient throughout their entire life cycle.
There are a range of risk factors for PTSD development
You’ll see children respond to trauma differently, but factors including gender, exposure to trauma, and pre-existing anxiety disorders can make it more likely that a traumatic event will result in PTSD development. Disasters are high-stress situations, and the specific experiences a child has during a disaster can affect risk factors for PTSD; for example, feeling one’s life is in danger or delayed evacuation may act as higher risk factors.
Fortunately, there are ways to help! Protective factors can decrease the risk of children developing PTSD after traumatic exposure. These include parental support, lack of parental PTSD, and resolution of parental trauma-related symptoms. It’s important to support parents throughout the aftermath of traumatic exposure, as they can significantly affect a child’s likelihood of developing PTSD.
And remember, PTSD isn’t the only condition that can result from traumatic exposure. Other disorders and medication side effects can also create symptoms that present similarly to PTSD. You’ll act as a detective to screen for PTSD if needed, but stay open-minded and wary of differential diagnoses too.
Evaluating and screening for PTSD
I recommend screening annually for PTSD with all primary care patients using the question “has anything really scary or upsetting ever happened to you or your family” for both children and parents or guardians. This question can elicit productive responses that may suggest you formally screen for PTSD.
Many other more formal tools exist for screening for PTSD. The CATS (Child and Adolescent Trauma Screen) test is an effective tool for primary care screening. You can either provide a caregiver report or youth report for patients and families to complete depending on the child’s age. This test differentiates normal, moderate, and probable by age.
Normal scores will encourage support, empathy, and productive habits for children. For moderate CAT scores, you should monitor children and assess for co-occurring depression or anxiety and schedule follow-up visits. With a probable PTSD score, you should assess for co-occurring depression and anxiety, refer for trauma-focused, evidence-based therapy, and closely monitor for suicidal ideation or self-injurious behavior with a scheduled follow-up visit.
Psychotherapy is the first line of treatment for PTSD, and your plan for treating PTSD should help the child progress developmentally and learn positive coping strategies to regulate emotions.
While you may see many acronyms and terms for evidence-based therapy, any psychotherapy plan involves:
- Caregiver involvement
- Developing skills for coping/relaxation
- Challenging negative cognitive distortions related to the trauma
- Building a trauma narrative
Treatment will allow children to integrate the traumatic event into their experience to the extent that they can retell the event without increasing distressing feelings.
Make sure you educate children and families that PTSD symptoms can reoccur following future traumatic experiences, and ensure the family understands that they may benefit from additional mental health treatment if this occurs.
At this time, no medications are FDA approved for PTSD in children and teens. However, you may consider medication if children are diagnosed with comorbid conditions or symptoms that are causing significant distress or functional impairment despite evidence-based psychotherapy.
If you are suggesting medication for children, you should target the symptom causing the most distress or functional impairment and remember that medications are supported by published evidence but are not FDA-approved.
Your goal is to safely withdraw treatment and monitor for symptom recurrence
PTSD treatment generally consists of three phases: an 8-12 week acute treatment phase, a 6-12 month maintenance phase, and a 3-6 month treatment discontinuation phase. In the third phase, you will aim to safely withdraw treatment and monitor for symptom recurrence.
Make sure you communicate regularly with the family during this phase and ensure they understand the benefits and risks of withdrawing treatment. If symptoms reoccur, you’ll have to make sure the family understands that this is not a failure of treatment but instead will require a slowing of the discontinuation pace.
Your role as a communicator in this phase is key!
Resources for you
PTSD is a complex condition to treat and may involve steps forward and backward in treatment. Stay patient, as your role is essential to helping children interact in the world as they work through their PTSD. More resources we recommend include:
- American Academy of Child & Adolescent Psychiatry (AACAP) Disaster and Trauma Resource Center
- National Child Traumatic Stress Network
As always, Iris Telehealth is here as a resource for providers who need support. If your organization is feeling the weight of increased numbers of patients experiencing pediatric stress disorders, contact us today. We’d love to talk to you about the difference telepsychiatry can make in your practice!