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Clinical Care Guideline: Posttraumatic Stress Disorder (PTSD) in Children and Adolescents

AACAP finds that one in four children are exposed to a traumatic event before reaching adulthood. These traumatic events can range from domestic violence, divorce, foster care placement, sexual abuse, school violence (bullying), physical abuse by a caregiver, kidnapping, and other traumatic accidents. Although children are resilient, the Adverse Childhood Experiences (ACEs) study found that the more adverse experiences that occurred, the more likely an individual is to exhibit significant and potentially long-lasting mental health issues as well as health, and occupational issues in adulthood. 

 

This care guideline is intended to equip psychiatric providers with a brief summary of the evidenced-based, best-practice knowledge for the effective treatment of PTSD.

Diagnostic Considerations for PTSD in children and adolescents

The criteria below apply to  children older than 6 years, adolescents, and adults:

  • Exposure to actual or potential death, serious injury, or sexual violence in one (or more) of the following for more than one month:
    • Witnessing events as they occurred to others
    • Directly experiencing the traumatic event(s)
    • Experiencing repeated or extreme exposure to aversive details of traumatic events
    • Learning that the traumatic event(s) occurred to a close family member or friend
  • One or more of the following intrusive symptoms associated with traumatic event(s)
    • Intrusive memories 
      • Note: In children older than six years, repetitive play may occur in which themes of trauma are expressed. 
    • Physiological reactions to symbols or reminders of the event
    • Recurrent distressing dreams of the traumatic event(s)
      • Note: In children, there may be frightening dreams without trauma-specific subjects 
    • Dissociative reactions (flashbacks) - depersonalization or derealization
      • Note: In children, reenactment may occur in play.
    • Psychological responses to things that symbolize or resemble traumatic events
  • Avoidance of stimuli associated with the traumatic event, as evidenced by one or both of the following
    • Avoidance of reminders (people, places, conversations, activities, objects, situations)
    • Avoidance of memories, thoughts, or feelings about traumatic event
  • Negative alterations in cognition and mood, as evidenced by at least two of the following
    • Blocking out specific aspects of the event(s) (dissociative amnesia)
    • Negative beliefs about themselves or the world (“I am ruined”, “Danger is everywhere”)
    • Detachment from others
    • Loss of interests 
    • Distorted cognitions about the cause of traumatic events can lead to blaming oneself
    • Negative emotional state that doesn't seem to lift (fear, guilt, shame)
    • Difficulty experiencing positive emotions

 

  • Alterations in arousal and reactivity, as evidenced by at least two of the following
    • Irritable or angry behavior
    • Reckless or self-destructive behavior.
    • Hypervigilance/Exaggerated startle response.
    • Difficulty concentrating
    • Poor sleep Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
  • Note: In children, under the age of 6 years old, Avoidance/Negative alterations are combined and only need to have one symptom. 

 

Because younger clients cannot always express what they’re experiencing, “classic” symptoms of PTSD may not be as evident. For example, in children, symptoms of PTSD can present as irritability, social withdrawal, nightmares, persistent worry that the world is unsafe, or inability to attach to others.

 

Have the symptoms negatively impacted the patient’s ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc)?

 

It’s important to note that the above symptoms and experiences may also be attributable to an alternative disorder (such as acute stress disorder, dissociative disorder, ADHD, ODD, anxiety disorders, a neurological cause, or due to the direct physiologic effects of a substance). As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if PTSD is the clinically indicated diagnosis. 

 

For complete diagnostic criteria of Adjustment Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787

 

When documenting care, be sure to include the specific symptoms of PTSD experienced by the patient. This ensures your note reflects alignment with the diagnosis and demonstrates the medical necessity for the service.  
 

Symptom Screening and Monitoring

The use of Measurement Informed Care with child and adolescent clients holds immense clinical value. For clients ages 7-17, The Child and Adolescent Trauma Screen (CATS) - Youth Report questionnaire is a brief measure of potentially traumatic events and post-traumatic stress symptoms based on the DSM-5 criteria for PTSD. A score of 15–20 indicates the likelihood of moderate trauma-related distress. A score of 21 or greater indicates probable PTSD. Also, as mentioned above, conducting an ACES screener to understand what the patient has experienced can be helpful. 

 

Importance of Comprehensive Assessment:

It is important to consider differential diagnosis when looking at trauma disorders as they can look similar to other mental health disorders. Trauma in children and adolescents can sometimes present with symptoms that resemble ADHD or bipolar disorder, making it challenging to distinguish between these conditions.

To differentiate between trauma, ADHD, and bipolar disorder, it’s crucial to conduct a thorough assessment that includes:

  • Detailed History: Understanding the child’s background, including any exposure to trauma.
  • Behavioral Observations: Looking at when and how symptoms manifest (e.g., are they triggered by specific reminders of trauma?).
  • Screening for Trauma: Using specific tools to identify symptoms of trauma, which can help distinguish it from other disorders.

Accurate diagnosis is essential for providing the most effective treatment and support.

 

 Here’s how trauma can mimic other disorders:

1. Trauma vs. ADHD:

  • Hyperactivity and Impulsivity: Children who have experienced trauma may be hypervigilant, constantly on edge, and have difficulty sitting still, which can look like the hyperactivity and impulsivity seen in ADHD.
  • Inattention: Trauma can cause difficulties in concentration and memory, making it hard for the child to focus on tasks. This can be mistaken for the inattentiveness characteristic of ADHD.
  • Behavioral Issues: Trauma may lead to disruptive behaviors, mood swings, and challenges in following directions, similar to what is seen in ADHD.

2. Trauma vs. Bipolar Disorder:

  • Mood Swings: Trauma can cause intense mood swings, including periods of extreme irritability or sadness, which might be confused with the mood fluctuations seen in bipolar disorder.
  • Emotional Dysregulation: Trauma often leads to difficulties in managing emotions, resulting in outbursts, anger, or tearfulness, resembling the manic or depressive episodes of bipolar disorder.
  • Arousal: Trauma can present with hyperarousal symptoms that may mimic hypomania, trauma reenactment that may mimic aggressive or hypersexual behavior, and maladaptive attempts and coping with trauma
  • Sleep Disturbances: Both trauma and bipolar disorder can disrupt sleep patterns, with trauma leading to nightmares, insomnia, or fear of sleeping, similar to the sleep disruptions seen during manic or depressive episodes.

Why the Confusion?

  • Overlap of Symptoms: The symptoms of trauma, ADHD, and bipolar disorder can overlap significantly, particularly in areas like mood instability, attention difficulties, and behavioral issues.
  • Misdiagnosis Risk: Without a careful assessment, the symptoms of trauma might be misinterpreted as ADHD or bipolar disorder, leading to an incorrect diagnosis and inappropriate treatment.

 

At follow-up visits, it is important to ask for improvement in symptoms that the patient was experiencing before seeing if there has been improvement. Also, assessing for any new traumatic events or triggers that may or may not have occurred. 

 

Comorbidities: Trauma disorders in children/adolescents are comorbid with reactive attachment disorder, social disinhibited engagement disorder, depression, anxiety, and substance use disorders. 

 

When asking patient’s children/adolescents about trauma, it may be good to separate the patient from the legal guardian so that the child/adolescent can feel that they can speak freely. Often, if the trauma is occurring at home, the patient may not feel comfortable expressing this. It is important to provide a safe space for the patient to open up to the psychiatric provider. If the psychiatric provider is treating younger children, they may not know what the word “trauma” means so it can be helpful to ask “Has someone done something to you that you didn’t like?” “Has someone hurt you” “Has someone touched you where they should not be?” “do you feel safe at home?” There are many ways to re-word so that a child can understand. 


In younger children, you may see irritable/aggressive behavior or reenactment of trauma with play or words. Also, you can see extremely withdrawn children/adolescents or unusually social and approachable strangers - this should be an indicator for the psychiatric provider to ask more questions about trauma.

 

If the patient is in immediate danger and/or a crime has been committed against a minor, it is the psychiatric provider’s responsibility to notify authorities by making a report to CPS.

 

 

Evidence-Based Approaches to Treatment 

The first line of treatment for PTSD in children/adolescents is Trauma-focused psychotherapy according to AACAP. 

Psychotherapy

  • Trauma-focused cognitive behavioral therapy (TF-CBT) - most empirical support 
  • Psychodynamic trauma-focused therapy - child/parent psychotherapy 
  • Attachment-based interventions 

 

Before starting trauma-focused treatment, patients and legal guardians should be specifically informed that most (if not all) of the evidence-based psychological treatments involve some degree of direct exposure, with the specific goal of re-processing emotions and cognitions to the point of symptom reduction and remission. In working to achieve this goal, patients might feel worse for some time before beginning to feel better, and if feeling worse puts them at risk in any way (i.e., increases their risk of harm to self or others, suicidality, return to substances, etc), adjustments should be made by the therapist regarding the pace or intensity of the treatment, stopping it altogether, or initiating a different treatment. This informed consent about treatment approaches results in shared decision-making between the patient/legal guardian and therapist.

Medication

Medications for PTSD are utilized in children/adolescents when there are immediate concerns or little progress in psychotherapy. SSRIs can be considered for the treatment of PTSD in children/adolescents especially with comorbid disorders such as depression/anxiety. It is important to note that there are no SSRIs FDA-approved for PTSD in children/adolescents:

  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)

 

In children/adolescents, trauma can present with increased hyperarousal symptoms as well as intrusive/reactive behaviors. There has been research to suggest increased dopamine tone as well as increased adrenergic tone and reactiveness in children/adolescents who have PTSD. It may be beneficial to use antiadrenergic or dopamine-blocking agents while heavily considering the risks vs. benefits as well as off-label usage. 

  • Guanfacine ER (Intuniv) - hyperarousal/intrusive symptoms
  • Clonidine - hyperarousal/intrusive symptoms 
  • Prazosin (nightmares)
  • Aripiprazole (Abilify) - extreme aggression and/or irritability - not first-line 
  • Risperidone (Risperdal) - extreme aggression and/or irritability - not first-line



Benzodiazepines (such as diazepam and clonazepam) are generally not recommended for the treatment of PTSD due to their high potential for dependence as well as their limited long-term effectiveness. Also, it is contraindicated in PTSD due to increasing symptoms of dissociation. 

 

Remember to start low and go slow with medications in children/adolescents. 


If you are going to use a medication that is considered ‘off label’ for children/adolescents make sure to document that this was discussed with a legal guardian and that treatment was consented to. 
 

It is important to discuss/document the SSRI FDA black box warning for all patients aged 24 years or younger. The Food and Drug Administration (FDA) requires a "black box" warning that antidepressant medications may sometimes increase suicidal ideation in children, adolescents, and young adults (aged 18–24) during initial treatment (generally the first 1–2 months) and at times of dose changes.  


Families and caregivers of patients being treated with antidepressants should be alerted about the need to monitor patients daily for the emergence of agitation, irritability, and unusual changes in behavior. 


Note: The overall rate of suicidal ideation is lower in patients treated with antidepressants compared to those given placebo, and this should be considered when discussing the risks and benefits of antidepressant therapy. 
 

 

Assessing Risk and  Higher Level of Care Needs

Research suggests people with a history of trauma and PTSD have a higher risk of suicidal thoughts, and nearly one in three people with PTSD have reported a suicide attempt. (3) Conducting routine screening of symptom severity, engaging regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, and group therapy) if clinically indicated are all critical components of supporting safety for patients who have experienced trauma. 

 

What if my patient has passive SI and/or chronic SI?

There are times when patients will endorse passive SI and/or chronic SI. It is important to complete the C-SSRS to determine the risk level of the patient, if the patient is not a high risk with active SI, then we can engage the patient in the following ways

  • The first step for a patient who is expressing passive and/or chronic SI is to identify protective factors and future orientation. 
  • Next, we should complete a safety plan in collaboration with the patient. We use the Stanley-Brown Safety Plan that can be found in the AMD note template. It is important to do this with the patient to engage them in their treatment. 
  • It is important to document that a safety plan was completed and that the patient agrees to safety
  • Sometimes patients may struggle to answer questions on the safety plan including internal coping skills, people they can ask for help when/if a crisis occurs, and/or places that provide distraction. 
    • We can offer coping skills that may be of use i.e. deep breathing, coloring, music, grounding techniques, etc. See what the patient likes to do to help ease their emotions. 
    • Sometimes patients may not have people but have pets that they can go to when in a crisis
  • It is important to assess SI at every follow-up visit as well as going over the safety plan to make adjustments, if needed. 
  • It may be that the patient would benefit from increased therapy sessions. We can collaborate with the therapists by asking the psych support team for their emails. 
  • We may want to see the patients more frequently than every month i.e. every 2 weeks until SI is stable.
  • It is important to ask if the patient is using substances, if they are, it is important to talk about decreasing substance usage as this can increase impulsivity. 
  • If the patient does not have resources or support, it is helpful to connect them to Resources for People who Think About Suicide (and their supporters) | NAMI Massachusetts.

Rula’s team of care coordinators is available to help your client access these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC).


However, if your patient is an acute risk to self or others i.e. active SI with plan, intent, or means then please follow this protocol here. Please reach out to the RNs and Lead NPs to help you in this situation for additional support. 
 

Cultural Considerations

The vulnerability of exposure to traumatic stressors (and increased likelihood of developing PTSD) is often influenced by cultural contexts, including those in poverty or who face stigma and discrimination, homelessness, abuse of all forms, political repression, communal/societal violence, forced immigration, and catastrophic disasters.(4) Additionally, the expression of PTSD symptoms often varies by culture as well and is at risk of misdiagnosis as a result. It is important to always consider the social and cultural contexts of a patient’s treatment needs as part of the diagnostic process. 

 

“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(5)

 

Tools/Resouces:

 

References

  1. American Academy of Child and Adolescent Psychiatry

https://www.jaacap.org/article/S0890-8567(10)00082-1/pdf

  1. American Psychological Association. https://www.apa.org/ptsd-guideline/ptsd.pdf

  2. The JED Foundation. https://jedfoundation.org/resource/how-are-trauma-ptsd-and-suicide-linked/

  3. National Institute of Health Ford JD, Grasso DJ, Elhai JD, Courtois CA. Social, cultural, and other diversity issues in the traumatic stress field. Posttraumatic Stress Disorder. 2015:503–46. doi: 10.1016/B978-0-12-801288-8.00011-X. Epub 2015 Aug 7. PMCID: PMC7149881.

  4. National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/ 



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