Posttraumatic stress disorder (PTSD) is a psychiatric disorder that some children and adolescents develop in response to being the direct victim of or witnessing traumatic events (eg, child abuse; domestic, community, or school violence; vehicular or other accidents; fires or natural disasters; terrorism or war; traumatic medical conditions). In the Great Smokey Mountain Study, 25% of children and adolescents in North Carolina had experienced at least 1 serious traumatic event by their 16th birthday.[1] Among inner-city children, this proportion is even higher, with as many as 90% of inner-city adolescents reporting significant exposure to traumatic events.[2] The prevalence of PTSD after such events has been estimated based on studies of various types of stressful events, and thus, not surprisingly, the rates vary considerably by type of event. Other characteristics that are related to prevalence are demographics, family characteristics, and research methods. Among the few nationally representative studies, early studies of adolescents and young adults reported overall lifetime PTSD rates of 9.2%,[3] with some rates reported separately for boys (2.8%) and girls (10.3%).[4] A more recent study of adolescents (ages 12 to 17 years) reported different rates than previous studies, with slightly higher rates for boys (3.7%) and lower rates for girls (6.3%).[5] The rates of PTSD vary across types of traumatic events,[6] [7] [8] [9] [10] [11] such as exposure to acute physical injury (23%),[6] natural disasters (24%-39%),[7] [8] and community violence (27%).[9] Many children may not meet full criteria for PTSD but may show heightened posttraumatic stress symptoms after exposure to various events, including family violence (15%)[12] and natural disasters (24%).[7] [8]

PTSD is often underrecognized, particularly in young children who have difficulty reporting certain PTSD symptoms and in those who have experienced traumas associated with shame, secrecy, or stigma, such as sexual abuse or domestic violence or being the victim of bullying. Although reliance on parental reports of child's symptoms greatly improves diagnosis,[13] parents who are themselves traumatized or who are the perpetrators of the child's traumatic experience may not wish to provide accurate reports of children's trauma exposure or symptoms.

Left untreated, childhood trauma and PTSD are associated with serious and long-lasting negative outcomes, including impairments in learning, memory, and academic performance[14]; increased risk for depression, suicide attempts, and completed suicide in adolescence and adulthood[15]; increased risk for substance abuse, self-injury, and risky sexual behaviors[16] [17]; and impaired physical health and immunity with increased health care use in adulthood.[17] [18] Children who have significant PTSD symptoms without meeting the strict psychiatric criteria of this disorder often have comparable functional impairment to those with the full disorder.[19] However, these outcomes are not inevitable. Effective treatment is available for children with PTSD symptoms. If these children are identified and treated with optimal interventions, then PTSD symptoms generally remit relatively quickly and cost effectively and do not return. The most tested treatment leads to reduction of depressive, anxiety, shame, and behavioral difficulties in addition to remission of PTSD symptoms.[20]

Because many traumatized children do not spontaneously report their traumatic experiences or trauma symptoms, primary care physicians (PCPs) may be in the best position to identify these children and to influence developmental trajectory positively. For these reasons, PCPs should be aware of the high prevalence of child trauma exposure and be willing and able to assess children for the presence of PTSD symptoms in the primary care setting. This chapter presents basic information about assessing trauma exposure and PTSD symptoms in children and adolescents in the primary care setting, as well as referral sources for evidence-based treatments for PTSD.