Treatment of Traumatic Stress Disorder in Children and Adolescents

We all experience stress throughout our lives; this can be beneficial because stress inoculation aids in the development of many of our biological systems.¹ Stress also helps the development of our psychological well-being. Learning to cope with adversity is an important part of develop-ing one’s sense of effectiveness and coping. Our bodies are built to manage stressful events and, in fact, our performance may improve, in certain situations, when we are stressed. However, this applies only up to a certain point. That point differs for each individual and depends on genetic and environmental factors, which influence stress vulnerability. When stressors are overwhelming and activate our fear mechanism in a way that over-sensitizes it to future stress, that is traumatic stress.² Different events in our life can act as trauma: natural and man-made disasters, accidents, and traumatic loss.

For some individuals, traumatic stressors can be acute: a bushfire, a shooting. For others, they may be more chronic: ongoing war, child abuse. Acute trauma can lead to secondary stressors, initiating a chronic process of adjustment. Traumatic events and other stressors may accumulate in an “allostatic load” to our systems.³ When the “load” overwhelms our coping mechanisms (psychological and physiological), PTSD may develop.

Traumatic stress in children can lead to difficulties in social, emotional, and cognitive development. Approximately 25% to 30% of children who experience inner-city violence develop symptoms of PTSD.⁴ Although a number of children are resilient to traumatic experiences, there are no methods to identify and measure what constitutes true resilience. Problems may not develop in some children shortly after a traumatic event; however, the allostatic load may be building, pushing them closer to a threshold where specific vulnerabilities may eventually manifest clinically.

Preventive interventions for youths exposed to chronic stressors or at risk for traumatic stress are critical. Many people believe that being a child by itself constitutes a protective factor against the effects of trauma; however, there is no evidence to support this. In fact, the evidence points toward the contrary: children are particularly vulnerable to the effects of trauma.⁵ Epidemiological studies indicate that children exposed to trauma are at much greater risk for PTSD.⁶

The impact of trauma on cognitive processing, as demonstrated by difficulties with learning and memory, renders many children with posttraumatic symptoms to be less successful in school. Emotional regulation, social development, and behavior can also be affected. The phenomenology differs depending on the child’s developmental age.

What new information does this article provide?

■ The authors discuss the different manifestations of traumatic stress; treatment considerations for childhood PTSD; and the existing interventions, including a new hybrid psychotherapy.

What are the implications for psychiatric practice?

■ Clinicians will be better informed about diagnosis of childhood PTSD and selection of appropriate interventions.

Although we use PTSD as a construct to understand children’s response to trauma, children with subthreshold symptoms can also have the same degree of functional impairment.⁷ Alternative criteria have been suggested for the diagnosis of PTSD in young children.⁸