Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Posttraumatic stress disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis

Katie McLaughlin, PhD
Section Editor
David Brent, MD
Deputy Editor
Richard Hermann, MD


Posttraumatic stress disorder (PTSD) is a debilitating and often chronic mental disorder that develops in some children and adolescents following exposure to a traumatic event. Traumatic events are experiences that involve serious harm or threat of harm to oneself or others, such as exposure to interpersonal violence, accidents, natural disasters, and injuries.

A majority of children and adolescents will experience a traumatic event by the time they reach adulthood, both in the United States and internationally. Although trauma exposure is common, only a minority of children who experience a traumatic event develop PTSD. PTSD is defined by four symptom clusters: intrusion, avoidance, negative alterations in cognition and mood, and hyperarousal [1]. The consequences of PTSD include elevated risk for other mental disorders and suicide, substantial impairment in role functioning, reduced social and economic opportunity, and earlier onset of chronic diseases, particularly cardiovascular disease.

The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of PTSD in children are discussed here. Pharmacotherapy and psychosocial interventions for PTSD in children are discussed separately, as is PTSD in adults. (See "Pharmacotherapy for posttraumatic stress disorder in children and adolescents" and "Psychosocial interventions for posttraumatic stress disorder in children and adolescents" and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis" and "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis" and "Psychotherapy for posttraumatic stress disorder in adults" and "Pharmacotherapy for posttraumatic stress disorder in adults".)


Trauma exposure — Studies have found high but varying rates internationally in the proportion of children and adolescents experiencing a traumatic event before the age of 18 [2,3]. As examples:

A United States nationwide study of over 6000 adolescents reported that 62 percent of youths experienced at least one traumatic event in their lifetime, including interpersonal violence, serious accidents or injuries, natural disaster, and death of a loved one; 19 percent have experienced three or more such events.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2017. | This topic last updated: Aug 11, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  2. Finkelhor D, Ormrod R, Turner H, Hamby SL. The victimization of children and youth: a comprehensive, national survey. Child Maltreat 2005; 10:5.
  3. McLaughlin KA, Koenen KC, Hill ED, et al. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry 2013; 52:815.
  4. Orozco R, Borges G, Benjet C, et al. Traumatic life events and posttraumatic stress disorder among Mexican adolescents: results from a survey. Salud Publica Mex 2008; 50 Suppl 1:S29.
  5. Perkonigg A, Kessler RC, Storz S, Wittchen H -U. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr Scand 2000; 101:46.
  6. Breslau N, Wilcox HC, Storr CL, et al. Trauma exposure and posttraumatic stress disorder: a study of youths in urban America. J Urban Health 2004; 81:530.
  7. Davydow DS, Richardson LP, Zatzick DF, Katon WJ. Psychiatric morbidity in pediatric critical illness survivors: a comprehensive review of the literature. Arch Pediatr Adolesc Med 2010; 164:377.
  8. Storr CL, Ialongo NS, Anthony JC, Breslau N. Childhood antecedents of exposure to traumatic events and posttraumatic stress disorder. Am J Psychiatry 2007; 164:119.
  9. Koenen KC, Moffitt TE, Poulton R, et al. Early childhood factors associated with the development of post-traumatic stress disorder: results from a longitudinal birth cohort. Psychol Med 2007; 37:181.
  10. Vermeiren R, Schwab-Stone M, Deboutte D, et al. Violence exposure and substance use in adolescents: findings from three countries. Pediatrics 2003; 111:535.
  11. McCart MR, Zajac K, Kofler MJ, et al. Longitudinal examination of PTSD symptoms and problematic alcohol use as risk factors for adolescent victimization. J Clin Child Adolesc Psychol 2012; 41:822.
  12. Turner HA, Finkelhor D, Ormrod R. Family structure variations in patterns and predictors of child victimization. Am J Orthopsychiatry 2007; 77:282.
  13. Giles-Sims J. Current knowledge about child abuse in stepfamilies. Marriage Fam Rev 1998; 26:215.
  14. With 15 million children caught up in major conflicts, UNICEF declares 2014 a devastating year for children. 2014. http://www.unicef.org/media/media_78058.html (Accessed on June 17, 2016).
  15. Jensen PS, Shaw J. Children as victims of war: current knowledge and future research needs. J Am Acad Child Adolesc Psychiatry 1993; 32:697.
  16. Leaning J, Guha-Sapir D. Natural disasters, armed conflict, and public health. N Engl J Med 2013; 369:1836.
  17. Alisic E, Zalta AK, van Wesel F, et al. Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. Br J Psychiatry 2014; 204:335.
  18. Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 2007; 64:577.
  19. Vernberg EM, Silverman WK, La Greca AM, Prinstein MJ. Prediction of posttraumatic stress symptoms in children after hurricane Andrew. J Abnorm Psychol 1996; 105:237.
  20. Pynoos RS, Frederick C, Nader K, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry 1987; 44:1057.
  21. Nader K, Pynoos R, Fairbanks L, Frederick C. Children's PTSD reactions one year after a sniper attack at their school. Am J Psychiatry 1990; 147:1526.
  22. La Greca A, Silverman WK, Vernberg EM, Prinstein MJ. Symptoms of posttraumatic stress in children after Hurricane Andrew: a prospective study. J Consult Clin Psychol 1996; 64:712.
  23. Trickey D, Siddaway AP, Meiser-Stedman R, et al. A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clin Psychol Rev 2012; 32:122.
  24. Attanayake V, McKay R, Joffres M, et al. Prevalence of mental disorders among children exposed to war: a systematic review of 7,920 children. Med Confl Surviv 2009; 25:4.
  25. Almqvist K, Broberg AG. Mental health and social adjustment in young refugee children 3 1/2 years after their arrival in Sweden. J Am Acad Child Adolesc Psychiatry 1999; 38:723.
  26. Thabet AA, Vostanis P. Post-traumatic stress reactions in children of war. J Child Psychol Psychiatry 1999; 40:385.
  27. Bayer CP, Klasen F, Adam H. Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. JAMA 2007; 298:555.
  28. Derluyn I, Broekaert E, Schuyten G, De Temmerman E. Post-traumatic stress in former Ugandan child soldiers. Lancet 2004; 363:861.
  29. Kilpatrick DG, Ruggiero KJ, Acierno R, et al. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: results from the National Survey of Adolescents. J Consult Clin Psychol 2003; 71:692.
  30. Koenen KC, Moffitt TE, Caspi A, et al. The developmental mental-disorder histories of adults with posttraumatic stress disorder: a prospective longitudinal birth cohort study. J Abnorm Psychol 2008; 117:460.
  31. Morris A, Gabert-Quillen C, Delahanty D. The association between parent PTSD/depression symptoms and child PTSD symptoms: a meta-analysis. J Pediatr Psychol 2012; 37:1076.
  32. Pina AA, Villalta IK, Ortiz CD, et al. Social support, discrimination, and coping as predictors of posttraumatic stress reactions in youth survivors of Hurricane Katrina. J Clin Child Adolesc Psychol 2008; 37:564.
  33. Ehlers A, Mayou RA, Bryant B. Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study. Behav Res Ther 2003; 41:1.
  34. Lengua LJ, Long AC, Meltzoff AN. Pre-attack stress-load, appraisals, and coping in children's responses to the 9/11 terrorist attacks. J Child Psychol Psychiatry 2006; 47:1219.
  35. Jenness J, Jager-Hyman S, Heleniak C, et al. Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a terrorist attack. Depress Anxiety 2016.
  36. Kaplow JB, Dodge KA, Amaya-Jackson L, Saxe GN. Pathways to PTSD, part II: Sexually abused children. Am J Psychiatry 2005; 162:1305.
  37. Saxe GN, Stoddard F, Hall E, et al. Pathways to PTSD, part I: Children with burns. Am J Psychiatry 2005; 162:1299.
  38. Zatzick DF, Russo J, Pitman RK, et al. Reevaluating the association between emergency department heart rate and the development of posttraumatic stress disorder: A public health approach. Biol Psychiatry 2005; 57:91.
  39. Zatzick DF, Grossman DC, Russo J, et al. Predicting posttraumatic stress symptoms longitudinally in a representative sample of hospitalized injured adolescents. J Am Acad Child Adolesc Psychiatry 2006; 45:1188.
  40. Stallard P, Velleman R, Langsford J, Baldwin S. Coping and psychological distress in children involved in road traffic accidents. Br J Clin Psychol 2001; 40:197.
  41. Jovanovic T, Norrholm SD. Neural mechanisms of impaired fear inhibition in posttraumatic stress disorder. Front Behav Neurosci 2011; 5:44.
  42. Milad MR, Quirk GJ. Fear extinction as a model for translational neuroscience: ten years of progress. Annu Rev Psychol 2012; 63:129.
  43. Rauch SL, Shin LM, Phelps EA. Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research--past, present, and future. Biol Psychiatry 2006; 60:376.
  44. Quirk GJ. Memory for extinction of conditioned fear is long-lasting and persists following spontaneous recovery. Learn Mem 2002; 9:402.
  45. Bouton ME. Context and behavioral processes in extinction. Learn Mem 2004; 11:485.
  46. Milad MR, Orr SP, Lasko NB, et al. Presence and acquired origin of reduced recall for fear extinction in PTSD: results of a twin study. J Psychiatr Res 2008; 42:515.
  47. Milad MR, Pitman RK, Ellis CB, et al. Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder. Biol Psychiatry 2009; 66:1075.
  48. Lissek S, van Meurs B. Learning models of PTSD: Theoretical accounts and psychobiological evidence. Int J Psychophysiol 2015; 98:594.
  49. Jovanovic T, Ressler KJ. How the neurocircuitry and genetics of fear inhibition may inform our understanding of PTSD. Am J Psychiatry 2010; 167:648.
  50. Pitman RK, Rasmusson AM, Koenen KC, et al. Biological studies of post-traumatic stress disorder. Nat Rev Neurosci 2012; 13:769.
  51. Etkin A, Wager TD. Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. Am J Psychiatry 2007; 164:1476.
  52. Shin LM, Wright CI, Cannistraro PA, et al. A functional magnetic resonance imaging study of amygdala and medial prefrontal cortex responses to overtly presented fearful faces in posttraumatic stress disorder. Arch Gen Psychiatry 2005; 62:273.
  53. Rauch SL, Whalen PJ, Shin LM, et al. Exaggerated amygdala response to masked facial stimuli in posttraumatic stress disorder: a functional MRI study. Biol Psychiatry 2000; 47:769.
  54. Shin LM, Whalen PJ, Pitman RK, et al. An fMRI study of anterior cingulate function in posttraumatic stress disorder. Biol Psychiatry 2001; 50:932.
  55. Kitayama N, Vaccarino V, Kutner M, et al. Magnetic resonance imaging (MRI) measurement of hippocampal volume in posttraumatic stress disorder: a meta-analysis. J Affect Disord 2005; 88:79.
  56. Shin LM, Lasko NB, Macklin ML, et al. Resting metabolic activity in the cingulate cortex and vulnerability to posttraumatic stress disorder. Arch Gen Psychiatry 2009; 66:1099.
  57. Shin LM, Bush G, Milad MR, et al. Exaggerated activation of dorsal anterior cingulate cortex during cognitive interference: a monozygotic twin study of posttraumatic stress disorder. Am J Psychiatry 2011; 168:979.
  58. Gilbertson MW, Shenton ME, Ciszewski A, et al. Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nat Neurosci 2002; 5:1242.
  59. Keding TJ, Herringa RJ. Abnormal structure of fear circuitry in pediatric post-traumatic stress disorder. Neuropsychopharmacology 2015; 40:537.
  60. Wolf RC, Herringa RJ. Prefrontal-Amygdala Dysregulation to Threat in Pediatric Posttraumatic Stress Disorder. Neuropsychopharmacology 2016; 41:822.
  61. McLaughlin KA, Busso DS, Duys A, et al. Amygdala response to negative stimuli predicts PTSD symptom onset following a terrorist attack. Depress Anxiety 2014; 31:834.
  62. Admon R, Lubin G, Rosenblatt JD, et al. Imbalanced neural responsivity to risk and reward indicates stress vulnerability in humans. Cereb Cortex 2013; 23:28.
  63. Admon R, Lubin G, Stern O, et al. Human vulnerability to stress depends on amygdala's predisposition and hippocampal plasticity. Proc Natl Acad Sci U S A 2009; 106:14120.
  64. Pat-Horenczyk R, Peled O, Miron T, et al. Risk-taking behaviors among Israeli adolescents exposed to recurrent terrorism: provoking danger under continuous threat? Am J Psychiatry 2007; 164:66.
  65. Perkonigg A, Pfister H, Stein MB, et al. Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry 2005; 162:1320.
  66. Famularo R, Fenton T, Augustyn M, Zuckerman B. Persistence of pediatric post traumatic stress disorder after 2 years. Child Abuse Negl 1996; 20:1245.
  67. Morgan L, Scourfield J, Williams D, et al. The Aberfan disaster: 33-year follow-up of survivors. Br J Psychiatry 2003; 182:532.
  68. Elhai JD, Layne CM, Steinberg AM, et al. Psychometric properties of the UCLA PTSD reaction index. part II: investigating factor structure findings in a national clinic-referred youth sample. J Trauma Stress 2013; 26:10.
  69. Steinberg AM, Brymer MJ, Kim S, et al. Psychometric properties of the UCLA PTSD reaction index: part I. J Trauma Stress 2013; 26:1.
  70. Pynoos RS, Weathers FW, Steinberg AM, et al. Clinician-Administered PTSD Scale for DSM-5 - Child/Adolescent Version. 1996. http://www.ptsd.va.gov (Accessed on June 20, 2016).
  71. Scheeringa MS, Zeanah CH, Myers L, Putnam FW. New findings on alternative criteria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 2003; 42:561.
  72. Scheeringa MS, Zeanah CH, Myers L, Putnam FW. Predictive validity in a prospective follow-up of PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 2005; 44:899.
  73. Benjet C, Bromet E, Karam EG, et al. The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychol Med 2016; 46:327.
  74. Comer JS, Kendall PC. Terrorism: The psychological impact on youth. Clin Psychol 2007; 14:179.