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Effects of Post-Traumatic Stress Disorder on School-Aged Children

Sarah E. Lipman
Stephanie M. Richards
California State University, Chico

When a child experiences a traumatic event it can seriously disrupt their school routine
and the learning process. Unless steps are taken to reach out to students and staff with support
and resources, there are typically emotional and behavioral disturbances and attendance issues
that arise. Students who have experienced a trauma due to violence or a catastrophic event are
found to have lower grade point averages, more negative remarks in cumulative files, and poorer
attendance compared to other students who have not had the same experience (Wolfgang 2013).
Additionally, they may have difficulties concentrating and learning at school and may behave
recklessly or aggressively toward peers and staff.
This packet is intended to be a resource for the mental health professional as well as any
school personnel in the position of helping students after experiencing a trauma. The topics
covered are the historical perspective on post-traumatic stress disorder (PTSD). Here, we have
opted to discuss the progression of diagnostic criteria. The current thinking on the disorder from
the researchers in the field as well as the American Psychological Association (APA). Primary
symptoms of school aged children are described by age group as well as comorbidity and
neurological factors that play a role in the development, persistence of, and potential resilience to
PTSD. The remainder of the paper will discuss etiology of the disorder which unlike the
symptomology, does not differentiate between age groups. We share with you the current
prevalence rates based upon national data. The developmental course of the disorder is
described, which reveals the change in the way the disorder is expressed as we age. This
impresses upon the mental health professional and school staff the importance of addressing
students needs proficiently prior to excessive emotional, social, and/or neural damage occurring.
The primary focus of the paper is the effects that PTSD has on academic performance, so these
points too are made. Lastly assessment and treatment options are proposed.

Historical perspective on the disease/disorder
This historical perspective is to show the progression of the diagnostic criteria used to
diagnose PTSD within the Diagnostic and Statistical Manual (DSM) from the disorders
inception to the present. In 1980, the American Psychiatric Association added PTSD to the
DSM-III. This controversial addition filled an important gap in psychiatric theory and practice. A
PTSD diagnosis has always hinged upon one primary criterion, trauma. This criterion and the
definition of a traumatic event which could be deemed a precursor to the disorder is what has
changed most through the years. Initially the types of trauma listed as the precursor to PTSD
were those of natural disaster and/or human-made disaster (war). By definition the DSM-III
dictated that difficulties with ordinary stressors such as rape, divorce, and serious illness would
be diagnosed as an adjustment disorder.
Flash forward to the current version of the DSM (DSM-V); we find one of the several
evidence-based revisions made was re-classifying PTSD as a trauma and stressor-related
disorder, no longer in the class of anxiety disorders. This means that the traumatic event must
precede the symptoms to be diagnosed with this disorder (Friedman, 2014). Due to the
aforementioned changes in diagnostic criteria, mental health professionals may be better able to
identify children suffering with PTSD and provide the help they need to recover.
Current thinking
Pediatric posttraumatic stress disorder is more prevalent than once believed. Research
finds that due to the developing brain of a child, the disorder manifests itself differently than in
adults (Hamblen, 2014). Until recently, most of the research on PTSD has been conducted on
adults. This, we know, is insufficient for determining cause/effect relationships, as well as
treatment options for children whose brains are fundamentally different from adults.

More research has been conducted in the last 15 years on the topic of the effects trauma
and PTSD have on the children. Due to the wave of interest in the topic, we find that the
maltreatment of children along with the development of PTSD has detrimental effects on a
childs cognitive and social development (Carrion, Kletter, Wong, 2012). Thankfully, children
are resilient and most recover to normal developmental levels within several weeks or months;
depending upon existing life stressors, psychiatric co-morbidities, safety issues, and access to
support and resources (American Psychological Association Presiential Task Force on Post
Traumatic Stress Disorder and Trauma in Children and Adolescents, 2008). There are also
factors of resiliency that play a role in the development and long term effects of PTSD. Ahmed
(2007) cites genetic, neurobiological, brain structure, and psychosocial factors which affect
whether an individual is more or less likely to suffer from PTSD.
Evidence shows that children exposed to trauma have weak social skills and have
increased rates of peer rejection (Baweja, 2012). Prolonged exposure to the traumatic stimulus
can cause abnormalities in brain development as described in the neurobiological factors section
below. All of these factors express the gravity of the impact that PTSD has not only on the
childs life in the present, but also in the future. There are still some deficits in our understanding
of this disorder and its impact, specifically in the realm of diverse populations and varying
trauma types as well as predictive outcomes.,
Primary symptoms/features/characteristics
Researchers and mental health professionals alike are beginning to recognize that
PTSD does not present itself in children the same way it does in adults. Criteria for PTSD
include age-specific features for some symptoms. PTSD in children and adolescents requires the
presence of re-experiencing, avoidance/numbing, and hyper-arousal symptoms. De Young

(2011) notes that young children re-experience trauma via recurring nightmares, through posttraumatic play, and repetitive talk about the event.
Avoidance/numbing is expressed by efforts to avoid exposure to conversations, people,
objects, situations or places which may remind them of the trauma. Hyper-arousal symptoms in
young traumatized children are presented as disrupted sleep, increased irritability, extreme
fussiness and temper tantrums, a constant state of alertness to danger, exaggerated startle
response, and difficulties with concentration. The symptoms may vary based upon
age/development, as described below (De Young, 2011).
Elementary aged students may respond to trauma by experiencing stomachaches,
headaches, and pains. Their behavior may be inconsistent with their typical behavior, exhibiting
behavior and emotions such as increased irritability, aggression, and anger. These children may
show a change in school performance and have reduced attention and concentration, resembling
ADHD type behaviors, which is another reason that PTSD may go unnoticed. Late elementary
students may excessively talk and ask persistent questions about the event (Hamblen, 2014).
Students in middle or high school who are exposed to a traumatic event feel selfconscious about their emotional responses to the event. They often feel shame and guilt
surrounding the traumatic event and may even have fantasies about revenge and retribution. A
traumatic event for adolescents may radically change their perspective of the world. Some of
these adolescents may begin to engage in self-destructive behaviors such as drug and alcohol
abuse and cutting. Their relationships with family and friends may change as well (The National
Child Traumatic Stress Network, n.d. ).
School-aged children also reportedly exhibit posttraumatic play (re-experiencing) or
reenactment of the trauma in play, drawings, or verbalizations. Posttraumatic play is different

from reenactment in that posttraumatic play is a literal depiction of the traumatic event. It
involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety.
One example of this is a victim of a serious car accident may continuously draw scenes from the
accident. Young children may also re-experience trauma via distressing nightmares (De Young,
2011). The nightmares affect the childs ability to sleep, or cause them to fear going to sleep, all
of which play a role in their ability to perform in school.
PTSD in adolescents may begin to more closely resemble PTSD in adults. Adolescents
are more likely to engage in traumatic reenactment, in which they incorporate aspects of the
trauma into their daily lives. Adolescents are more likely than younger children or adults to
exhibit impulsive and aggressive behaviors. For example, behavior may become sexualized, or
the child may begin physically or verbally abusing their peers after experiencing these types of
abuse (Hamblen, 2014).
As you can see, the manifestation of this disorder is very much tied to development of the
individual, and so it is imperative that mental health providers, staff and other care providers be
familiar with the symptoms of the age group with which they are working to better serve their
Associated (comorbid) symptoms/disorders
One frequently co-occurring disorder is major depressive episode (MDE). Other
disorders that may be present as comorbidities include substance abuse/dependence (SA/D);
anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder;
and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant
disorder, and conduct disorder (Hamblen, 2014). A national household probability sample of
4,023 telephone interviewed adolescents provides prevalence rates of the comorbidity among

PTSD, MDE, and SA/D. They found that nearly three fourths of the children (ages 12-17) with
PTSD had at least one comorbid diagnosis (Acierno, 2003).
Neuropsychological factors
Due to differences in how individuals perceive the stimulus, people tend to vary in their
trauma thresholds, some are more protected from and some are more vulnerable to developing
clinical symptoms after exposure to extremely stressful situations (Friedman, 2014). In the last
15 years Magnetic Resonance Imaging (MRI) techniques have allowed for greater understanding
of the neuropsychological factors associated with pediatric PTSD. Results from neuroimaging
studies found differences in the brains of those children who had suffered maltreatment related
PTSD, including: total cerebral volume, prefrontal cortex, hippocampus, cerebellum, superior
temporal gyrus, and corpus callosum. Neuropsychological findings reveal deficits in attention,
executive function, learning, and memory that correspond to these brain regions (Carrion et al,
Research on the connection between PTSD and declarative memory (defined as the
ability to consciously remember and reproduce emotionally neutral material) dysfunction found
that pre-existing declarative memory dysfunction serves as a risk factor for the development of
PTSD following trauma (Samuelson, 2011). Research finds in some cases, subtle pre-existing
impairments in response inhibition and attention regulation serve as risk factors for the
development of PTSD and relate to the severity of symptoms (Aupperle, 2011).
Neurotransmitters such as dopamine and norepinephrine are released during times of
stress. When the HypothalamicPituitaryAdrenal (HPA) axis is activated and begins the fight or
flight response, these neuro-chemicals are associated with a prolonged hyper-arousal state (when
the child experiences prolonged exposure to the stress inducing stimulus) that can impede

development during maturation, which in turn compromises cognitive functioning (Carrion et al,
2012). There is an abundance of evidence to support the fact that children who suffer this type of
trauma, although resilient, do suffer lasting effects from continued exposure to the traumatic
stimulus or the symptoms of the disorder.
The physical and psychological stressors of PTSD can be caused by any event that
presents a real or imagined threat to the childs life or physical well-being. This includes sexual
or physical abuse. Other examples include natural or man-made disasters (fires, hurricanes, or
floods), violent crimes (kidnapping or school shootings, etc.), motor vehicle accidents or plane
crashes. PTSD can also be caused by a child witnessing, or even learning of any of these events
having occurred to a loved one (Hamblen, & Barnett, 2014).
Not all children who experience a traumatic event will develop PTSD. The research
seems to suggest that the difference between a child who will develop PTSD after a traumatic
event, and those that do not, involve factors of resiliency (Husain, 2012). Specifically, a
correlational study by Powers (2011) found that that the higher a child scored on resiliency
scales, the lower the severity of their PTSD symptoms.
There seems to be an overwhelming majority of children who are exposed to traumatic
events. The American Psychological Association reports that more than 60% of children in a
community sample reported experiencing a trauma by the age of 16 (American Psychological
Association Presiential Task Force on Post Traumatic Stress Disorder and Trauma in Children
and Adolescents, 2008). In 2011, Child Protective Services (CPS) reports showed that about 6.2
million children were referred for having experienced traumatic situations. Similarly, a national

survey sampling 4,549 children found that over 60% of children had experienced or witnessed
some traumatic event within that past year. Despite that there is a strikingly large number of
children that have experienced trauma, the actual prevalence of those that develop PTSD is
relatively small. The national comorbidity survey replication (NCS- R) sampled over 10,000
adolescents aged 13 to18 in 2012. They found that of that age group, 3.9% met the criteria for
PTSD (Kessler, 2012). Interestingly, it was more common in females than among males, and in
older children than younger (Merikangas, 2010). There is little to no recent data collected for
school aged-children between the ages of 6 to 13.
Developmental course
The research on PTSD in children indicates that, if left untreated, there are slight changes
in symptoms, but as a whole, the disorder is persistent. One longitudinal study followed children
ages 2 through 10 for 6 months and found that 75% of those diagnosed with PTSD still met
criteria for diagnosis at the end of the 6 months (Meiser-Stedman et al. 2008). Two longitudinal
studies, one lasting two years (Scheeringa et al. 2005), and another lasting five years (Laor et al.
1996, 1997, 2001) found slight changes in the expression of symptoms. Over time, there was a
decrease in re-experiencing and externalizing symptoms. Hyper-arousal remained stable through
the two-year study, but decreased by the fifth year in the other study. There was an increase in
avoidance symptoms throughout both studies. These studies suggest that left untreated, the
developmental course of PTSD in children may result in less noticeable symptoms, but a
pervasive withdrawal that interferes with typical healthy development.

Associated school related problems
Higher overall symptom severity has been found to be associated with lower social
competency. Specifically, higher scores on avoidance subscales are significantly associated with
lower social functioning. The arousal and re-experiencing behaviors on the other hand, are not
related to social functioning (McLean, Rosenbach, Capaldi, & Foa, 2013). Based on the
developmental findings of PTSD, we can infer that the longer a child suffers from PTSD without
treatment, the more their social functioning declines.
Children diagnosed with PTSD perform worse than those without PTSD on measures of
attention, abstract reasoning and higher level processing such as planning, problem solving,
inhibition, and mental flexibility. They tend to perform poorly on multiple cognitive domains
including language, reading and attention. They have been found to exhibit slower and less
effective learning (Carrion et al., 2012). Additionally, it was found that, regardless of PTSD
diagnosis, those who experienced a trauma scored significantly lower on IQ and achievement
tests than those who had not experienced a trauma (De Bellis, Woolley, & Hooper, 2013). It
should be noted that there is some research that suggests an insignificant association between
PTSD symptoms and academic performance (McLean, Rosenbach, Capaldi, & Foa, 2013).
Assessment/ diagnostic indicators
The diagnostic criterion for labeling a child with PTSD is found in the DSM V. This fifth
edition includes four areas of diagnostic indicators. The first states that children must have been
exposed to an event that involved or threatened death, serious injury, or sexual violence. This
exposure can be directly experienced by the individual, witnessed by them, or a learned event of
a close loved one.

The second category requires that as a result of the trauma, the child developed one or
more of the following symptoms: recurring, spontaneous and intrusive upsetting memories of the
traumatic event, recurring and upsetting dreams about the event, flashbacks or some other
dissociative response where the child feels or acts as if the event were happening again, strong
and long-lasting emotional distress after being reminded of the event or after encountering
trauma-related cues, and/or strong physical reactions (e.g., increased heart rate, sweating) to
trauma-related reminders.
The third category requires that a child develop, or have at least one of these symptoms
increase as a result of the trauma: avoidance of or the attempted avoidance of activities, places,
or reminders that bring up thoughts about the traumatic event, avoidance of, or the attempted
avoidance of people, conversations, or interpersonal situations that serve as reminders of the
traumatic event, more frequent negative emotional states, such as fear, shame, or sadness,
increased lack of interest in activities that used to be meaningful or pleasurable, social
withdrawal, and/or long-standing reduction in the expression of positive emotions.
The fourth category requires that a child also have or worsen in one or more of the
following symptoms: increased irritable behavior or angry outbursts (this may include extreme
temper tantrums), hypervigilance, exaggerated startle response, difficulties concentrating, and/or
problems with sleeping.
There is a battery of tests used to assess whether a child has experienced a traumatic event,
and to assess whether they should be diagnosed with PTSD in accordance with the above criteria
in the DSM. A list of these assessments can be found at:

Trauma focused psychotherapies have more empirical support than any other treatments
used for PTSD in children (Cohen, 2010; Foa, Keane, Friedman, & Cohen, 2009). Some of the
psychotherapies that have been researched are cognitive behavioral therapy (CBT), play therapy,
psychological first aid, eye movement and desensitization and reprocessing (EMDR),
medication, and specific interventions. Of these, CBT (specifically, trauma focused CBT) has
thus far been proven the most effective.
In Trauma Focused CBT (TF- CBT), the child is exposed to the memories of the
trauma by asking the child to discuss the trauma causing event. The automatic stress response
that has become conditioned with the trauma stimulus is replaced with relaxation or assertiveness
(defending) training. Thus, each time the trauma is experienced, whether real or imagined, the
child learns to see the stimulus as a cue to start the pattern of either relaxation or assertiveness.
This method also includes correction of distorted thinking (such as, I cant trust anyone,) and
the education and involvement of parents.
Some of the other methods used may be less supported, but hold important applicable
functions. The play therapy uses games, drawing and other similar techniques to help children
process and began to understand what they experienced. This method has been used when
children are not able to talk about what happened to them yet. Psychological first aid is another
method that is focused on those children who recently experienced the trauma. It involves
comforting the child and normalizing the way they are feeling. It also aims to teach caregivers
what changes to expect and how to deal with them. A third helpful method is the specific
interventions. This is not meant to heal the whole child. They are recommended when the

traumatic event results in the child developing problematic symptom behavior such as
inappropriate sexual behavior, or substance abuse.
There are other methods in use that have little support or applicable importance. EMDR
combines the cognitive behavior (correcting maladaptive thought processes) with directed eye
movements to add dual stimuli to focus on while the traumatic memories are in mind. Although
EMDR has been shown effective with adults, the results for children are less promising. Any
progress seems to be isolated with the cognitive part of the therapy, making the eye movement
procedure unnecessary. Another unsupported treatment is the use of SSRIs Selective Serotonin
Reuptake Inhibitors (SSRIs). They have been approved for use with children experiencing
PTSD. Not only is there insufficient evidence to support the benefits of SSRIs for these
children, but there is evidence to show it increases risk side effects. Children taking SSRIs have
become more irritable, less attentive, and had disturbed sleep (Hamblen, & Barnett, 2014).
Given our newfound understanding of pediatric PTSD, school personnel would benefit
from learning to recognize and/or treat children with PTSD. Children would benefit from
services targeting PTSD symptoms. Parents and families would also benefit from knowing that
there is help and having resources made available to them. Although prevalence rates suggest
that pediatric PTSD is uncommon, there are likely students suffering from PTSD who are going
unnoticed and untreated. For various reasons including the comorbidity and the different
expression of symptoms based on age or duration of suffering, it is possible that these students
are not recognized and therefore not referred for evaluation of PTSD. Educating school
personnel on pediatric PTSD will eliminate most of this confusion.

Children will not recover from this disorder alone. Their academics, social/emotional
development, and overall well-being suffer when PTSD diagnoses go unnoticed and therefore
untreated. As was discussed in the treatment section, there are several methods for helping
children reduce or eradicate symptoms. Counselors, psychologists, parents, teachers and
community members can all take part in this healing process. Armed with the right information,
we can all take part in lessening the burden that PTSD causes on individuals, families, and


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Retrieved April 01, 2015, from The National Child Traumatic Stress Network:

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Difficulties on Academic Achievement for Young Children. ProQuest LLC,