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                                                      MONTHLY RESEARCH SPOTLIGHT

Post-traumatic stress disorder in a national sample of preadolescent children 9 to 10 years old: Prevalence, correlates, clinical sequelae, and treatment utilization

Abstract

Although posttraumatic stress disorder (PTSD) has been well characterized in adults, its epidemiology in children is unclear. The current study provides the first population-based examination of the prevalence of PTSD, sociodemographic and psychiatric correlates, clinical sequelae, and associations with psychiatric treatment in preadolescents 9-10 years old in the United States. Data from the Adolescent Brain and Cognitive Development (ABCD) Study (release 5.0) was analyzed. Participants (unweighted n = 11,875) were recruited from 21 sites across the United States. Current and lifetime PTSD prevalence were estimated, as was treatment use among children with PTSD. Sociodemographic, psychiatric correlates and sequelae of PTSD were analyzed using logistic regression, as was the association between PTSD and psychiatric treatment. After the application of propensity weights, lifetime prevalence of PTSD was 2.17%. Sexual minority status, being multiracial, having unmarried parents, and family economic insecurity were associated with greater odds of PTSD. Among psychiatric disorders, separation anxiety was most strongly associated with PTSD, although general comorbid psychopathology was associated with greater odds of PTSD. Prior history of PTSD predicted a new onset of other psychiatric disorders after PTSD remission. Nearly one in three children with lifetime PTSD did not receive psychiatric treatment, despite negative long-term outcomes of PTSD and significant psychiatric comorbidity. Even among preadolescents who experience full remission of PTSD, a significant risk for future psychiatric illness remains. Further, the current findings underscore the need for improved efforts to reduce unmet treatment needs among those with PTSD at this age.

Introduction

Post-traumatic stress disorder (PTSD) has been well characterized in adults. In the United States, national studies have found lifetime PTSD prevalence of 7.3% [1] and 7.8% [2]. In the one epidemiological study to date to examine this issue in adolescents, a lifetime prevalence of 4.7% was found [3].

Although PTSD has been widely reported to occur in younger children, the epidemiology of this disorder in preadolescents remains unclear. Indeed, most prior studies with this age group have featured very small samples [4], which tend to yield unstable prevalence estimates and limit generalizability of their findings. In perhaps the largest study to date of PTSD in a population-representative sample of preadolescent children, the lifetime prevalence was 0.1% [5]. Although based on a large community sample, these findings are representative of a regional population only and cannot be generalized to the national population. Furthermore, the small number of cases of PTSD precluded any determinations of associated sociodemographic factors, diagnostic correlates, and prevalence of psychiatric care. While research in adolescents and young adults has shown the development of comorbid psychopathology after PTSD diagnosis [6], the clinical sequelae of PTSD in preadolescents are unknown. Being able accurately to characterize PTSD and evaluate its clinical sequelae in this age group is especially important for understanding the development of this disorder and to inform prevention and intervention services.

The current study aimed to provide the first comprehensive assessment of PTSD in a population-based sample of preadolescent children 9-10 years old. Specifically, its objectives were: (i) to estimate the lifetime prevalence of preadolescent PTSD in the general population; (ii) to assess sociodemographic and psychiatric correlates of this disorder; (iii) to evaluate PTSD as a predictor of subsequent onset of new psychopathology; (iv) to generate estimates of the prevalence of lifetime psychiatric treatment among preadolescents with PTSD, thereby providing a sense of the scope of potential unmet treatment needs in the general population; and (v) to evaluate PTSD diagnosis in preadolescence in relation to psychiatric treatment utilization.

Methods

Sample and Procedure

Data for the current study were drawn from the Adolescent Brain and Cognitive Development (ABCD) dataset (release 5.0), a national study of adolescent brain development. Participants (unweighted n = 11,875) were recruited from 21 catchment sites across the United States. These catchment sites covered over 20% of the recruited population and the total population encompassed by these sites reasonably matched the sociodemographics of the U.S. population as a whole, but with certain groups (e.g., African American children) oversampled to ensure that site locations would not bias the sample and that the sample would reflect the sociodemographic variations of the U.S. population. Complete details about the sampling strategy and design, as well as weighting procedures, have previously been reported [7].

Children and parents were recruited and assessed when children were between 9 and 10 years old (at time of assessment, weighted M = 9.50 years old, SE = 0.01 years). Measures and procedures were standardized across recruitment sites. For parents, measures were a combination of computerized assessments about themselves, the family, and their child, and the children were given computerized assessments about themselves [8].

Measures

Sociodemographic characteristics

The following sociodemographic information was obtained from the parents: child sex, ethnicity (Hispanic or non-Hispanic), and race (Black, white, multiracial, American Indian/Alaskan Native, Asian, and other). Due to the small number of unweighted cases of PTSD for the American Indian/Alaskan Native and Asian racial groups, these groups were combined with “other” group such that the final categories for race were “Black,” “white,” “multiracial” and “other.” Parents also reported their education (collapsed into less than high school, high school or GED, some college, and college graduate), and parent marital status (collapsed into married and other). Sexual orientation was obtained from the children through a question asking if they were gay or bisexual, to which they could respond “yes,” “maybe,” “no,” or “I do not understand this question.” Responses of “yes” and “maybe” were combined to create a “gay, bisexual, or questioning” category, while responses of “no” formed a heterosexual category, and a third category was created of participants who did not understand the question. Family economic insecurity was calculated by summing the answers to seven questions regarding ability to pay for needed services (i.e., food, phone bill, rent or mortgage, eviction, utilities bill, doctors’ and dentists’ visits). This measure captures relative deprivation, a more sensitive indicator of the impact of economic circumstances than annual income [9]. Higher scores indicated greater economic insecurity.

Psychiatric diagnoses and treatment utilization

Lifetime and current diagnoses were determined using the youth version of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version for DSM-5 (K-SADS-PL) [1011]. Children and parents separately reported on child’s symptoms and behaviors for current (i.e., past 2 weeks) and past (i.e., prior to the past 2 weeks) psychopathology. Following standard clinical practice, a child was determined to have a psychiatric diagnosis if they met criteria based on parent report, child report, or both [5]. In addition to PTSD, diagnoses included in the present study were psychotic disorder, major depressive disorder, separation anxiety, social anxiety disorder, specific phobia, generalized anxiety disorder, conduct disorder, oppositional defiant disorder, obsessive-compulsive disorder, and eating disorders (i.e., anorexia nervosa, bulimia nervosa, and binge-eating disorder). Parents were presented with a standardized list of traumatic experiences and asked if their child had experienced any of the events. A trauma type count variable was calculated from the number of trauma types endorsed. In the K-SADS-PL, parents were asked if their child had ever received mental health treatment in their lifetime across a variety of modalities and treatment settings (e.g., psychotherapy, medication).

Statistical analyses

Analyses were conducted in Statistical Package for the Social Sciences (SPSS; version 25.0.0.0), and data were weighted using propensity weights (i.e., scores for each subject of the inverse probability of sampling relative to known population and study proportion according to demographic categories) [7] to generate population-representative estimates. Cross-tabulations were calculated to estimate current and lifetime prevalence of PTSD, as well as lifetime prevalence of PTSD for each sociodemographic factor and psychiatric diagnosis. Associations of PTSD with sociodemographic factors were analyzed first with a series of univariate logistic regression analyses with lifetime PTSD as the criterion variable, followed by a multivariate regression analysis with all sociodemographic factors and the number of traumatic events experienced included. Similarly, a series of univariate logistic regression analyses was conducted with lifetime psychiatric diagnoses as predictor variables and lifetime PTSD as the criterion variable. A multivariate logistic regression model was then generated with all psychiatric disorders included in the analysis, and child sex, sexual orientation, ethnicity, race, family economic insecurity, and traumatic event count entered as covariates. These sociodemographics were chosen as covariates based on previous literature providing evidence for their association with PTSD [1312,13,14]. Similarly, a bivariate logistic regression model was created with number of lifetime psychiatric disorders, excluding PTSD, as a predictor of lifetime PTSD. This was followed with a multivariate model that included child sex, sexual orientation, ethnicity, race, family economic insecurity, and traumatic event count as covariates.

Next, to evaluate the clinical sequelae of past PTSD, a bivariate regression analysis was conducted with past (i.e., prior to the past 2 weeks) PTSD as the predictor of interest and current first onset (i.e., past 2 weeks) of any psychiatric diagnosis (excluding PTSD) as the outcome variable. A multivariate logistic regression model was then generated with all past psychiatric disorders included in the analyses. Static sociodemographic characteristics (i.e., child sex, race, and ethnicity) were entered as covariates so as to maintain clean temporal separation between all predictors and the outcome variable. Additionally, to provide a stringent evaluation of the clinical sequelae of PTSD, we excluded from these analyses any children with past PTSD who still met diagnostic criteria for this disorder in the past 2 weeks, thus allowing a determination of whether PTSD in preadolescence is associated with negative clinical outcomes even after no longer meeting criteria for PTSD.

Cross-tabulations were then used to estimate the lifetime prevalence of psychiatric treatment utilization among children with lifetime PTSD. Finally, a bivariate logistic regression analysis was conducted with lifetime PTSD as a predictor variable and utilization of any mental health services as the criterion variable, followed by a multivariate logistic regression analysis predicting utilization of any mental health services with PTSD as the predictor of interest, and with all other psychiatric diagnoses, child sex, sexual orientation, ethnicity, race, family economic insecurity, and traumatic event count as covariates.

Coefficients were exponentiated to create odds ratios (ORs) with 95% confidence intervals (CIs), and interpreted based on effect sizes following standard convention [15]. Statistical significance was set as p < 0.05 using a two-tailed test. Multiple comparisons in univariable analyses were corrected using the Benjamini-Hochberg procedure.

Results

Prevalence and sociodemographic correlates

Lifetime prevalence of PTSD in the current sample was 2.17% (SE = 0.16), and 2-week prevalence was 0.12% (SE = 0.04). In bivariate analyses (Table 1), no differences in lifetime prevalence of PTSD were found for sex or ethnicity. However, higher odds of PTSD were found for children who identified as gay, lesbian, or questioning, and children who were Black or multiracial. Among parental factors, having parents who had completed some college and were not married were associated with higher odds of PTSD, as was family economic insecurity. When all sociodemographic variables were considered together with count of traumatic events experienced in a multivariate analysis, sexual minority status, having unmarried parents, and family economic insecurity remained significant predictors of lifetime PTSD with small to medium-to-large effects.

Table 1 Associations between sociodemographic factors and lifetime posttraumatic stress disorder (unweighted n = 11,690).

Full size table

Psychiatric diagnostic correlates

Lifetime prevalence, unadjusted ORs, and ORs adjusted for all sociodemographic factors and traumatic event count were calculated for each psychiatric disorder (Table 2). Lifetime prevalence of PTSD for each psychiatric diagnosis varied, with specific phobia having the lowest prevalence of comorbid PTSD at 4.79% (SE = 0.45) and psychosis having the highest prevalence at 14.44% (SE = 3.23).

Table 2 Associations between psychiatric disorders and lifetime posttraumatic stress disorder (unweighted n = 11,690).

Full size table

Unadjusted ORs for each disorder were significant with medium-to-large effect sizes, with the odds of PTSD ranging from OR = 4.21 (95% CI = 3.13–5.66) for specific phobia to OR = 12.13 (95% CI = 9.00–16.35) for separation anxiety. In the multivariate analysis that included all psychiatric disorders, sociodemographic factors (child sex, sexual orientation, race, ethnicity, family economic insecurity), and trauma event count, reduced odds were observed across all disorders, but PTSD continued to be significantly predicted by separation anxiety, specific phobia, generalized anxiety disorder, oppositional defiant disorder, and obsessive-compulsive disorder. Among the psychiatric disorders that remained significant predictors of PTSD in the multivariate model, the strength of the association ranged from a small effect of OR = 1.67 (95% CI = 1.14–2.42) for specific phobia to a medium-to-large effect of OR = 3.60 (95% CI = 2.37–5.46) for separation anxiety. The high comorbidity between PTSD and psychiatric correlates was highlighted in a regression analysis finding a positive association between number of lifetime psychiatric disorders and lifetime PTSD, a finding that held in a multivariate analysis that included child sex, sexual orientation, race, ethnicity, family economic insecurity, and traumatic event count as covariates.

Clinical sequelae of PTSD

Analyses were conducted to further examine the relationship between PTSD and subsequent first lifetime onset of other psychiatric disorders (Table 3). In a bivariate model, past PTSD predicted greater odds of current (i.e., past 2 weeks) first onset of a new psychiatric disorder (excluding PTSD). After other past psychiatric diagnoses and static demographic characteristics (i.e., sex, race, and ethnicity) were accounted for, PTSD continued to be positively predictive of current first onset of a new psychiatric disorder, with an effect size in the small-to-medium range.

Table 3 Past posttraumatic stress disorder temporally predicting current onset of new psychiatric disorders (unweighted n = 11,677).a

Full size table

Treatment utilization

Among the children who had a lifetime PTSD diagnosis, 63.0% (SE = 3.5) received at least one type of mental health treatment in their lifetime. In a bivariate logistic regression analysis, lifetime PTSD diagnosis predicted greater odds of engaging with any mental health services (OR = 9.36, 95% CI = 6.91–12.68, p < 0.001). Further, PTSD remained a significant predictor of mental health services engagement even after accounting for comorbid psychiatric diagnoses, child sex, sexual orientation, race, ethnicity, family economic insecurity, and traumatic event count, with an effect size in the medium range (OR = 2.16, 95% CI = 1.43–3.24, p < 0.001).

Discussion

The current study presents the most comprehensive analysis to date of preadolescent PTSD. It evaluated the prevalence of PTSD, sociodemographic correlates, associations with other psychiatric diagnoses, and psychiatric treatment utilization in a population-based sample. When considered with lifetime prevalence estimates for PTSD from epidemiological studies with adolescents (4.7%) [3] and adults (7.3-7.8%) [1214], the lifetime prevalence in the current study (2.17%) fits within a pattern of increasing prevalence of PTSD across development.

Among sociodemographic factors associated with PTSD, sexual minority status had the largest effect, and the lifetime prevalence of PTSD in this group was nearly three times that for the general population. This is a critical finding, as sexual orientation has been predominantly studied in relation to mental health outcomes in adolescence and adulthood. Indeed, it has not been previously assessed in relation to PTSD in individuals younger than 12 years old [16], despite research showing differences in sexual orientation begin to emerge at eight years old [17]. This finding suggests that sexual minority individuals in the age group potentially most vulnerable to PTSD are also the least studied. Our findings therefore highlight the need for greater research on PTSD and potential processes relevant to risk and resilience in preadolescent sexual minority children.

Another notable sociodemographic factor associated with lifetime PTSD was family economic insecurity. This finding is consistent with prior literature [1819]. In particular, for adolescents, living in a low socioeconomic status (SES) environment has been associated with higher levels of PTSD [20]. Further, within a sample of children and adolescents exposed to trauma, those who came from lower SES had higher rates of PTSD when compared to those who came from higher SES, suggesting that SES contributes to unique risk over and above that of the traumatic experience [19]. Additionally, adolescents from backgrounds of higher economic insecurity have been found to have poorer recovery from PTSD [3], which may relate in part to research on PTSD which has found limited finances and access to transportation to be barriers to accessing care [21]. In sum, those who have high economic insecurity are not only at risk for PTSD, they also may be least likely to have the resources to mitigate risk and to access treatment.

These findings may also be driven by differences in the experience of the traumatic events based on SES, as research has shown that lower SES is associated with exposure to a higher number of potentially traumatic experiences [22]. This includes differential exposure to potentially traumatic events, such as youth in impoverished conditions having increased odds of witnessing domestic violence and other physical assault (e.g., being mugged or threatened with a weapon) compared to other youth [3]. These differences also include perception of the traumatic event. One study found that across youth, the higher perceived danger of the traumatic event was associated with higher levels of PTSD, and this relationship was stronger for adolescents from low SES compared to high SES backgrounds [20]. Finally, repeated exposure of traumatic events (e.g., chronic maltreatment) may be associated with lower family income compared to experiences of single traumatic events [23]. These findings suggest that for youth who have high economic insecurity, the risk for PTSD may begin even before the potentially traumatic event has occurred.

The absence of a sex difference in PTSD in the present study is notable as it contrasts with epidemiological studies with adolescents [3] and adults [2] as well as meta-analytical work [24] which found greater prevalence of PTSD among females. However, risk for PTSD associated with being female increases with age [13]. Thus, our findings suggest that sex differences in risk for PTSD are not yet apparent in preadolescence, and instead emerge in adolescence. Identifying determinants of this emergence of sex difference in PTSD in adolescence is important for informing risk identification and prevention strategies.

PTSD was associated with most other psychiatric disorders in the multivariate analysis even when accounting for prior trauma exposure, with separation anxiety emerging as the single strongest diagnostic predictor of PTSD. This pattern of high psychiatric comorbidity is consistent with findings from population-based studies with adults [225]. Further, the relative non-specificity in correlated psychiatric disorders speaks to the challenge of identifying risk for PTSD based on the presence of other psychiatric diagnoses alone and that identifying underlying transdiagnostic indices of risk may be a fruitful avenue for future investigation.

A notable finding was the low 2-week prevalence of PTSD (0.12%) relative to lifetime prevalence (2.17%), suggesting that PTSD tends not to follow a chronic course during preadolescence. This differs from the finding that this disorder often follows a chronic course in adults, with a median time to remission of 36 months among those who received treatment in this age group and 64 months among those who do not, and furthermore, over a third of adults do not experience remission even after many years, regardless of receiving treatment [2]. PTSD has similarly been found to follow a persistent course in adolescents [6]. We caution against interpreting the contrastingly high remission rate for PTSD in the current study as indicative that PTSD is less of a clinical concern in preadolescents because of its tendency to remit over relatively brief periods of time. Rather, our finding that a past history of PTSD, even after remission is achieved, temporally predicts first lifetime onset of other psychiatric disorders suggests that some measure of clinical risk persists past diagnostic remission and thus that a prior history PTSD may serve as an important marker of risk for future mental health problems.

 

A significant proportion of preadolescents with PTSD (37.0%) did not receive any mental health treatment. This is concerning given the aforementioned findings of risk for new psychiatric disorder onset associated with past PTSD and because untreated PTSD in youth can lead to increased healthcare costs, decreased performance in school, and lower rates of high school graduation [26]. Research has shown that these impairments carry into functional impairments in young adulthood, including isolation, social loneliness and not working or in school [14]. Therefore, reducing untreated PTSD in preadolescence is critical to reduce its potential long-term negative outcomes. Future research should identify factors associated with unmet treatment needs in this population, as well as strategies to address these needs.

Limitations of the current study should be noted. First, it was not possible to examine sociodemographic correlates and psychiatric comorbidity for current PTSD due to its low prevalence. Accurately characterizing correlates of current PTSD is critical for informing screening and intervention strategies. The importance of this lies in part in the aforementioned observation that most children with lifetime PTSD no longer met diagnostic criteria at the time of assessment, meaning that caution should be taken in assuming correlates of lifetime PTSD generalize to current PTSD in this population. This limitation notwithstanding, the current findings regarding lifetime PTSD are of clinical importance given the significant psychiatric sequelae of this disorder even after diagnostic remission is achieved.

This study was also limited to cross-sectional and retrospective temporal analyses. Although concerns regarding accurate retrospective recall of psychiatric diagnoses [27] is reduced given the age of the population, and it was possible to achieve clean temporal separation in analyses of clinical sequelae of PTSD, prospective longitudinal analyses are important for their potential to provide unique insight into the phenomenology of PTSD in this population. Given the high remission of PTSD in this age, for example, a prospective design is necessary to observe sufficient new onsets of PTSD to evaluate sociodemographic and clinical characteristics temporally preceding its occurrence. Additionally, to our knowledge, our work is one of the first to study sexual orientation as a predictor of PTSD in preadolescents, and found that identifying as a sexual minority youth connoted greater odds of developing PTSD compared to identifying as heterosexual. Given the strength of this association, further research is needed to delineate the mechanisms underlying risk for this population (e.g., within minority stress frameworks) [28].

Conclusion

Overall, the current findings reveal that although most children with PTSD no longer meet diagnostic criteria with time, it is nonetheless associated with significant negative long-term clinical sequelae, even after PTSD no longer meets diagnostic criteria, making the high proportion of untreated PTSD in this population a particular clinical concern. In contrast to the case of adolescents and adults, with PTSD more prevalent among females, our finding of the absence of a sex difference in PTSD prevalence suggests that comparable weight should be given to both males and females in identifying the risk of PTSD in preadolescents.

Data availability

All Adolescent Brain and Cognitive Development (ABCD) Study data is available through the National Institute of Mental Health Data Archive as dataset #2147.

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Author information

Authors and Affiliations

  1. University of Rochester, Department of Psychology, Rochester, NY, 14611, USA

    Rachel Y. Levin

  2. Massachusetts General Hospital, Department of Psychiatry, Boston, MA, 02114, USA

    Rachel Y. Levin & Richard T. Liu

  3. Harvard Medical School, Boston, MA, 02114, USA

    Richard T. Liu

Contributions

RYL and RTL designed the study. RYL analyzed the data and wrote the original draft; RTL revised the manuscript. All authors contributed to and have approved the manuscript.

Corresponding author

Correspondence to Rachel Y. Levin.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

A Novel Therapy, Using Writing, Shows Promise for PTSD

 

By Ellen Barry

Aug. 23, 2023​

The News

A comparatively quick treatment for post-traumatic stress disorder, in which a patient writes about traumatic experiences in five supervised 30-minute sessions, is as effective as the therapies most recommended by federal agencies, according to a study published on Wednesday.

The treatment, called written exposure therapy, involves asking clients to write down the thoughts and feelings that occurred during a traumatic event, and then speak with the therapist about the writing process. In later sessions, they are asked to write about how the event has affected their lives.

In the new study published in JAMA Psychiatry, 178 veterans with PTSD received either written exposure therapy or prolonged exposure therapy, which consists of eight to 15 therapy sessions that are 90 minutes long in which the patient vividly imagines the terrifying situation, and then, between sessions, confronts real-life reminders of it.

The two therapies were found to be equally effective, and only 12.5 percent of subjects dropped out of the written exposure group before completing a course of treatment, compared with 35.6 percent in the prolonged exposure group. In 2018, a study by the same team found that written exposure therapy was as effective as cognitive processing therapy, another first-line, or most highly recommended, PTSD treatment.

Writing down traumatic memories may be easier for some people, if they feel shame or embarrassment about what happened to them, said Denise Sloan, a psychologist who helped develop the treatment and is an author of the study. She said patients were asked to write by hand, which takes longer and allows them to engage with the memory.

“It’s a slower process, that allows them to better think through ‘what happened next, and who was there, and what did they say,’ because they’re writing about it,” said Dr. Sloan, associate director of the Behavioral Science Division of the National Center for PTSD. “It slows everything down, versus just saying it out loud.”

The therapy was inspired by the work of James Pennebaker, a Texas psychologist who, in the 1980s, began experimenting with what he called “expressive writing,” and found that people who regularly wrote about negative life experiences had stronger immune systems and paid fewer visits to the doctor.

The first study of written exposure therapy as a treatment for PTSD appeared in 2012. It works, Dr. Sloan said, much the way other trauma-focused treatments do: by allowing the client to confront the traumatic memory, lessening their fear and avoidance, and allowing them to identify misconceptions like self-blame.

Why It Matters

Cognitive processing therapy and prolonged exposure therapy, the two treatments most highly recommended by the Departments of Veterans Affairs and Defense, have been in widespread use since the 1980s and are backed up by abundant research. A newer method, eye movement desensitization and reprocessing, is rapidly growing in popularity.

But all three are time-intensive, requiring sessions of 60 to 90 minutes for three months or more. A large number of patients — an average of 20 percent, and sometimes as high as 50 percent, studies have shown — drop out before completing a course of treatment.

Written exposure therapy, Dr. Sloan said, seems to achieve similar effects in fewer sessions.

“We have a lot of people that need mental health treatment, and we can’t accommodate the demand,” she said. “We need to revisit what we’re doing and how much is necessary for a good outcome. Because most people can’t go to treatment for 12 to 16 sessions.”

What’s Next

Data on the effectiveness of written exposure therapy is still emerging.

The studies comparing it to cognitive processing therapy and prolonged exposure therapy are non-inferiority trials — devised to demonstrate that a newer treatment is not worse than an established one — and “not as scientifically stringent” as trials devised to determine superiority, said Dr. Barbara Rothbaum, one of the developers of prolonged exposure therapy. She added that dropout rates at her clinic, at Emory University, were around 10 percent.

There is a reason, she said, that talk therapy has such a strong record of success in treating PTSD.

“There is something inherently healing about saying out loud the worse, most scary, most embarrassing, most shameful moment of your life to another human who is trying to be helpful,” she said. “Does it have to be that? No.”

Written exposure therapy was not endorsed as a first-line intervention by the Departments of Veterans Affairs and Defense in its most recent clinical practice guidelines, largely, Dr. Sloan said, because of the small number of published studies examining it.

That is likely to change over the next two years, she said, as a number of larger trials are completed. Clinicians, too, are going to have to get used to the idea of using writing, in addition to speech, to engage with patients on painful topics.

“Some people, they feel threatened by this, because it kind of challenges the crux of what they generally do,” she said. “It flies in the face of what they think is important in treatment.”

Ellen Barry covers mental health. She has served as The Times’s Boston bureau chief, London-based chief international correspondent and bureau chief in Moscow and New Delhi. She was part of a team that won the 2011 Pulitzer Prize for International Reporting. 

 

Posttraumatic Stress Disorder in Children in the Context of the COVID-19 Pandemic

J Am Acad Child Adolesc Psychiatry. 2022 Aug; 61(8): 957–959.

Published online 2022 Feb 24. doi: 10.1016/j.jaac.2022.02.007

PMCID: PMC8865911

PMID: 35219806

Betty Pfefferbaum, MD, JD∗

Author information Article notes Copyright and License information Disclaimer

 

With its global spread and protracted threat, mounting morbidity and mortality, pervasive social and economic ramifications, vital public health measures, and often compromised risk communication, the COVID-19 pandemic has increased the risk to children’s emotional health relative to more common biological, natural, and man-made events. Posttraumatic stress disorder (PTSD) and PTSD symptoms have been the primary focus of child disaster mental health research. The adult literature has questioned the appropriateness of focusing on PTSD in the context of the COVID-19 pandemic, because most of the extensive adult research on PTSD has not appropriately assessed all diagnostic criteria for the disorder.1 The pandemic experiences of participants in most studies examined in a recent review did not meet the PTSD exposure criterion,1 which requires that exposure be “directly” experienced, witnessed in person, secondary to the involvement of a close family member or friend, or “repeated or extreme” contact with “aversive details” of the event.2 Instead, participants’ experiences were primarily indirect (eg, media contact) and constituted fear related to contracting the disease.1 This concern extends to the relatively few empirical COVID-19 studies of PTSD in children and exemplifies a problem in many child disaster mental health studies, especially those assessing general population samples that primarily comprise children who do not meet the PTSD exposure criterion.

With its global spread and protracted threat, mounting morbidity and mortality, pervasive social and economic ramifications, vital public health measures, and often compromised risk communication, the COVID-19 pandemic has increased the risk to children’s emotional health relative to more common biological, natural, and man-made events. Posttraumatic stress disorder (PTSD) and PTSD symptoms have been the primary focus of child disaster mental health research. The adult literature has questioned the appropriateness of focusing on PTSD in the context of the COVID-19 pandemic, because most of the extensive adult research on PTSD has not appropriately assessed all diagnostic criteria for the disorder.1 The pandemic experiences of participants in most studies examined in a recent review did not meet the PTSD exposure criterion,1 which requires that exposure be “directly” experienced, witnessed in person, secondary to the involvement of a close family member or friend, or “repeated or extreme” contact with “aversive details” of the event.2 Instead, participants’ experiences were primarily indirect (eg, media contact) and constituted fear related to contracting the disease.1 This concern extends to the relatively few empirical COVID-19 studies of PTSD in children and exemplifies a problem in many child disaster mental health studies, especially those assessing general population samples that primarily comprise children who do not meet the PTSD exposure criterion.

A review of exposure characteristics, PTSD rates, and the assessment of diagnostic criteria in 6 COVID-19 studies that assessed PTSD in general child populations345678 evidenced the concerns raised in the adult literature.1 Only 2 papers provided much detail on participants’ COVID-19 experiences or exposure,5 , 6 and none clearly limited the diagnosis of PTSD to participants who met the exposure criterion. In a sample with a sizeable number of children who knew someone who tested positive for, or died of, COVID-19, 45% scored above the study’s threshold for PTSD.5 In another study, relatively few Saudi Arabian children personally suffered COVID-19 or had close relatives or friends with the disease, although the authors reported “potential PTSD” in 13.0% of the participants.6 Two other studies used scales to assess children’s pandemic experiences but provided minimal information on the items queried8 or the results.3 , 8 Reported rates of “probable PTSD” were 35.4% in a sample of adolescents in a “severely affected” area of China8 and 16.9% in a sample of students in a Chinese community after strict lockdown measures had been lifted.3 Two studies, which noted widespread public health restrictions but failed to describe participants’ COVID-19 exposures, found that 20.7% of children from regions across China scored above the study’s cutoff for PTSD4 and “high risk” for PTSD in 3.16% of a sample of Chinese school children in an area that was not severely affected by the disease.7

The 6 child studies varied in assessing other criteria needed to diagnose PTSD, including a specific constellation of symptoms anchored in the traumatic experience, clinically significant distress or impaired functioning, and symptoms for more than 1 month.2 All but 1 of the studies3 used well-established tools to assess PTSD. Unfortunately, for the most part, the papers failed to indicate whether and/or how these tools were modified. Only 2 of the scales used included all DSM-5 symptoms,7 , 8 and only 1 paper considered the requisite constellation of PTSD symptoms.7 One study clearly anchored symptoms in the pandemic experience,8 and 1 study queried children’s pandemic experiences and administered a scale that linked children’s symptoms to the coronavirus illness.6 The scales used in the other studies linked symptoms to a traumatic or stressful event, but the papers did not indicate whether the assessment referenced COVID-19.345 , 7 Most studies identified a cut-off score to indicate probable PTSD with scales that assessed the presence,3 , 5 frequency,6 , 8 or severity4 of endorsed symptoms. To indicate risk for PTSD, 1 study measured the frequency of symptoms and specified a score for the requisite number of symptoms in each of the 4 PTSD symptom clusters.7 The scales used in some studies assessed functioning3 or how distressed4 or bothered7 , 8 participants were by symptoms, but none of the papers explicitly mentioned measuring or scoring distress or functioning.345678 One study assessed symptoms “in the past month,”6 2 studies used scales that specified a 1-month duration,3 , 5 and others referenced8 or used scales4 with a shorter timeframe. The timeframe in 1 study was unclear.7

The extent to which children are likely to meet full criteria for a diagnosis of PTSD related to their COVID-19 experiences remains unclear. It is difficult to reconcile the PTSD rates in the 6 studies with the relatively low levels of DSM-5 qualifying exposure reported and with the fact that most of the studies did not assess all DSM-5 PTSD symptoms; most did not specify whether symptoms were linked to the children’s COVID-19 experiences; none explicitly reported including an assessment of distress or functioning in determining diagnostic status; and some did not document the required minimum 1-month duration of symptoms. Indirect experiences and concerns about the pandemic, even in severely affected communities, do not constitute the requisite exposure for PTSD. Moreover, clinical cutoff scores that simply sum endorsed symptoms, and even those that consider the specific number and distribution of symptoms across symptom clusters, do not establish clinically significant outcomes, especially if these symptoms do not cause distress or affect functioning. These concerns do not mean that the assessment of PTSD in general population samples is inappropriate; instead, they caution against overdiagnosis, which has implications for both clinical care and research. Notwithstanding the potential theoretical and clinical importance of individual posttraumatic symptoms and subthreshold outcomes, clinicians should avoid attributing clinical significance to symptoms that may represent normative distress rather than pathology, and researchers should be rigorous in investigating PTSD to avoid contaminating intervention science with misapplied approaches that produce misleading results and inaccurate conclusions.

Children’s experiences (eg, direct exposure vs community effects) and outcomes (eg, psychiatric conditions vs distress) are key considerations in the choice of services used to address their needs. Clinicians must identify and treat those children with psychiatric conditions, whereas trained school personnel and paraprofessionals commonly deliver resilience-enhancing interventions in nonclinical community settings. Thus, diagnostic considerations are important in planning and delivering services, in selecting interventions, and in personnel decisions. With respect to the COVID-19 pandemic, children who themselves, or whose family members, contract the disease are more likely to require clinical services than those whose only contact with the pandemic reflects generalized concern. Children with pre-existing conditions and past trauma exposure are at heightened risk. It remains unclear whether the rate of PTSD is increasing in the context of this pandemic, but the stress occasioned by it is likely to have lasting implications for many children.

Epidemics, pandemics, and global and novel catastrophes suggest the importance of continued attention to what constitutes trauma exposure. The PTSD exposure criterion has been modified across successive editions of the DSM. To underscore the importance of diagnosis in the context of this and future pandemics, it would seem appropriate and prudent to re-examine and consider modifying the PTSD exposure criterion to clarify specifically which, if any, experiences with pandemics should qualify as trauma exposure. Because of the importance of diagnosis in guiding clinical care, researchers should opt for rigor when choosing outcome measures and should be circumspect in interpreting their results. Research is needed to examine whether and how increased stress may contribute to the incidence of PTSD in children in the future.

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Footnotes

The author has reported no funding for this work.

This article is part of a special Clinical Perspectives series shedding a new and focused light on clinical topics within child and adolescent psychiatry. The series covers problems, controversies, or tenets of the care of children and adolescents with psychiatric disorders from a new vantage point, including populations, practices or clinical topics that may be otherwise overlooked. The series was edited by Deputy Editor Schuyler W. Henderson, MD, MPH, and Editor-in-Chief Douglas K. Novins, MD.

Disclosure: Dr. Pfefferbaum has reported no biomedical financial interests or potential conflicts of interest.

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References

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November 2020

 

Did Media Coverage of 9/11 Increase Risk for PTSD in Children?

By: Matthew Tull, PhD 

The effects of the tragic events of September 11, 2001, were inescapable and may have increased risk for PTSD in children and adults. Even people far away from the terrorist attacks on the World Trade Center and Pentagon were exposed to upsetting and traumatic images. This was largely due to the extensive television coverage of the terrorist attacks. A study in the Journal of Anxiety Disorders, conducted by Dr. Michael Otto and colleagues at Massachusetts General Hospital and Harvard Medical School, examined whether this extensive media coverage may have put children at risk for the development of PTSD.​​

Kids and Media Coverage of 9/11: The Study

This study looked at 84 mothers and their 166 children (ages 7 to 15) from the Boston area who did not have a loved one killed in the 9/11 attacks. The majority of the children heard about the attacks either in the morning (53%) or afternoon (42%) of 9/11. In addition, many children were exposed to some television coverage of the events.

  • 13.8% did not watch any television coverage of the attacks.

  • 25.9% watched under an hour of television coverage of the attacks.

  • 22.3% watch one hour of television coverage of the attacks.

  • 30.7% watched 2 to 4 hours of television coverage of the attacks.

  • 4.8% watched 4 to 6 hours of television coverage of the attacks.

  • 2.4% watched over 6 hours of television coverage of the attacks.

 

PTSD Rates and Risk Factors for PTSD

They found that 5.4% of children and 1.2% of parents in the study had symptoms consistent with a diagnosis of PTSD stemming from indirect exposure to 9/11 events. An additional 18.7% of children and 10.7% of parents showed some symptoms of PTSD, but not enough for an official PTSD diagnosis).

Among all children, the amount of television watched on 9/11 was not linked with PTSD rates. However, when considering only children 10 and younger, the development of PTSD was related to the amount of television watched on the day of 9/11. Children who showed more distress during the week of 9/11 and identified more with the victims of 9/11 were more likely to develop symptoms of PTSD.

Looking Out For Our Children

When people think of PTSD, they often think that a person has to directly experience a traumatic event. However, this study shows that even indirect exposure to traumatic events can increase the likelihood of developing PTSD in populations that may be considered vulnerable, such as children.

The live television coverage of 9/11 meant that many children were exposed to distressing images that may have been hard for them to comprehend or cope with. In situations like this, it is important for parents to monitor what their children are watching and, at the same time, help them understand and cope with the situation.

The Sidran Institute, a nonprofit organization that provides resources on trauma and PTSD, provides some helpful tips for how parents can help their children cope with and understand a traumatic event.

  1. Otto, M.W., Henin, A., Hirshfeld-Becker, D.R., Pollack, M.H., Biederman, J., & Rosenbaum, J.F. (2007). Posttraumatic Stress Disorder Symptoms Following Media Exposure to Tragic Events: Impact of 9/11 on Children at Risk for Anxiety Disorders. Journal of Anxiety Disorders, 21, 888-902. doi:10.1016/j.janxdis.2006.10.008

 

https://www.sidran.org/resources

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