Signs of PTSD in Children and Teens
Crystal L. Rainey, LCPC
EMDRIA Consultant
Little humans experience trauma too! Children and adolescents are resilient, but this does not mean they are immune to developing PTSD. They process differently than adults which means symptoms may present differently as well. These differences can sometimes lead to misdiagnosis and less effective treatment.
Diagnostic Criteria
The DSM-5-TR requires the presence of the following: Exposure, intrusive symptoms, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Duration of symptoms is more than one month, beginning or worsening after the onset of trauma, and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Sometimes diagnosing PTSD in children and adolescents is easy and clear cut. They are referred to therapy after experiencing a big T trauma such as a car accident and symptoms clearly relate to that trauma. They may have intrusive memories or nightmares about the accident, are afraid to get into cars and avoid going places where they would need to be in a car. They may become visibly distressed with the sound of sirens or mention of the accident. In these cases, the child, caregiver, and therapist are all aware that symptoms are directly connected to the accident and treatment focuses on resolving the trauma.
Typically, trauma is more complex than the above example. Many of the children, adolescents, and caregivers I have worked with are not able to easily identify and verbalize the connection between their symptoms and trauma. Kids and teens tell me things like “I wish I wasn’t always in trouble” (Alterations in arousal and reactivity) or “I am a bad kid” (Negative alterations in cognition). Parents, care givers, and teachers may report tantrums, defiance, problems with social/peer relationships, difficulty with focus and concentration, and not following directions. In these cases, it can be challenging to differentiate between PTSD and other diagnoses such as ADHD, ODD, anxiety, depression, DMDD, etc.… Understanding the role of trauma in symptom presentation helps ensure more effective treatment.
So, how do you know if it's PTSD or something else?
As a therapist, I have learned to ask more questions. (When did the symptoms start? Did anything in your/your child’s life change around that time? Have you/your child experienced any trauma? What was going on right before the tantrum started?) Basically, I get really curious with children, adolescents and their caregivers to understand more about the context of the symptoms. These questions help ascertain whether symptoms began or worsened after the onset of a traumatic event and if they are connected to avoidance or reactivity. Parents and caregivers are often surprised that there was a connection and sometimes feel guilty for not recognizing it. I think that it is important to normalize this experience. When children and adolescents experience trauma, other family members are impacted by it as well, whether or not they were directly involved.
Intrusive symptoms can present through the reenactment of trauma themes in play. Playing with children, observing play, and utilizing art or movement can provide important diagnostic information. Children and adolescents who are not able to communicate symptoms verbally may be able to do so through alternative outlets. This is where we get to be creative. Younger children may use dolls or animals to reenact trauma themes. Older children and teens may draw, paint, create a playlist, or choreograph a dance. Nightmares that may or may not appear to relate to the trauma are also indicators of intrusive symptoms. Asking kids, teens, and their caregivers about sleep and the content of the dreams will help assess sleep disturbance and intrusive symptoms.
For clinicians who prefer more structured methods of evaluation, the UCLA PTSD Reaction Index for Children/Adolescents is a thorough screening tool to help clinicians assess exposure to different types of trauma and PTSD symptoms. I often use children’s books for less structured assessment and psychoeducation. This method can be helpful with children who need some distance and can help them feel safer than they would with direct questioning. A few of my go to books are A Terrible Thing Happened by Margaret M. Holmes, All the Colors of Me by Ana M. Gomez and Sandra Paulsen, and Hey Warrior by Karen Young.
