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Trauma-Related Mental Illness in Children and Adolescents

  • Stephanie J. LewisEmail author
  • Andrea Danese
Living reference work entry
Part of the Mental Health and Illness Worldwide book series (MHIW)

Abstract

Traumas are stressful events that involve danger of death, injury, or sexual violation – ranging from accidents and illness to violence and abuse. These experiences are common in young people and are strongly associated with mental illness. In this chapter, we explore evidence that contributes to understanding the mental health burden of trauma in children and adolescents. We also consider evidence that informs the management of this burden, from initial response after trauma to treating trauma-related psychiatric disorders in children and adolescents. This evidence has important implications for current clinical practice and indicates the required direction of future research to further improve assessment, treatment, and prevention of trauma-related mental illness in children and adolescents.

Keywords

Trauma Post-traumatic stress disorder (PTSD) 

Introduction

The link between psychological trauma and mental illness was first recognized well over a century ago by neurologists Jean-Martin Charcot and then Sigmund Freud. Extensive research since this time has confirmed that trauma is an important risk factor for psychopathology. The current definition of a trauma is an event that involves exposure to actual or threatened death, serious injury, or sexual violation, which is either directly experienced, witnessed, learned about happening to a close member of the person’s social network, or experienced by enduring repeated or extreme exposure to details of the event (American Psychiatric Association 2013). These experiences occur most commonly in adolescence (Breslau et al. 1998, 2004), leading to concerns about their impact on young people’s mental health. Indeed, understanding and managing the mental health burden of trauma poses substantial challenges in child and adolescent mental health care. This chapter explores this important topic.

Understanding the Mental Health Burden of Trauma in Children and Adolescents

Prevalence of Trauma

Traumatic experiences are prevalent in children and adolescents. Population-based studies have found that 21–83% of young people report experiencing a trauma in their lifetimes, with lower rates generally found in European samples (Landolt et al. 2013; Lewis et al. 2019; Perkonigg et al. 2000), and higher rates in US samples (Breslau et al. 2004, 2006; Copeland et al. 2007; Giaconia et al. 1995; McLaughlin et al. 2013). The majority of these studies have found that the most common types of trauma experienced by young people are network events (learning of a death, injury, or sexual violation to a close member of the young person’s social network). However, other trauma types, including directly experiencing or witnessing accidents or interpersonal violence, are also common in young people. Furthermore, trauma-exposed young people have often experienced more than one traumatic event. Few population-based studies of trauma exposure in young people have been conducted in other parts of the world, but it is likely that trauma exposure is common in all populations, and that the prevalence of some trauma types varies by region, as occurs in adults (Benjet et al. 2016). For example, exposure to interpersonal violence may be more common in regions experiencing conflict, and exposure to natural disasters may be more common in regions prone to these events. The high prevalence of trauma exposure in young people highlights the importance of understanding trauma-related mental illness in those affected.

Trauma-Related Mental Illness

Immediately following traumatic events, most children and adolescents experience some psychological symptoms. For example, they may feel very upset, become clingy, be preoccupied with remembering the event, have difficulty concentrating or sleeping, or experience somatic symptoms such as headaches or abdominal pain (Danese and Smith 2018). While these responses usually subside within days to weeks, a proportion of young people who have been exposed to trauma go on to develop psychiatric disorders, with symptoms that are longer lasting and that interfere with their daily lives.

Indeed, trauma exposure is strongly associated with experiencing psychiatric disorders. Population-based studies in the USA and Europe have found that trauma-exposed young people are about twice as likely as their unexposed peers to experience a wide range of psychiatric disorders, including emotional, behavioral, and neurodevelopmental disorders, and psychotic symptoms (Copeland et al. 2007; Lewis et al. 2019; Perkonigg et al. 2000). A recent British study found that over half of trauma-exposed young people experienced a psychiatric disorder within the past year, most commonly depression, conduct disorder, alcohol dependence, and then post-traumatic stress disorder (PTSD) (Lewis et al. 2019). Although few population-based studies of trauma-related disorders have been conducted in other parts of the world, it is likely that trauma-exposed young people from other regions also experience high rates of psychopathology, and there may be cultural variations in how symptoms are experienced and expressed (Schnyder et al. 2016).

PTSD affects up to one in four trauma-exposed young people (Alisic et al. 2014; Lewis et al. 2019) and is a unique disorder because trauma exposure is included in its diagnostic criteria and linked to many of its symptoms. For instance, PTSD is characterized by reexperiencing the traumatic event as repeated, distressing, and unwanted memories or nightmares; avoiding reminders of the traumatic event, such as places, people, thoughts, or feelings; and experiencing increased arousal, including hypervigilance or heightened startle reactions. This constellation of symptoms has been described and studied for nearly four decades and has been reported across cultures (Hinton and Lewis-Fernández 2011; Koenen et al. 2017).

Current definitions of PTSD in the International Classification of Diseases Eleventh Revision (ICD-11) (World Health Organization 2018) and Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (American Psychiatric Association 2013) continue to include these key criteria, although PTSD definitions in these two classification systems have distinct features. On the one hand, the ICD-11 defines these PTSD symptom criteria narrowly, without symptoms that could overlap with other disorders (Stein et al. 2014). Additionally, the ICD-11 includes a new diagnosis of complex PTSD, characterized by PTSD as well as severe and persistent difficulties with affect regulation (e.g., heightened emotional reactivity or lack of emotion), self-concept (e.g., belief of being worthless), and relationships (e.g., difficulty feeling close to others). Complex PTSD is associated with complex types of trauma involving repeated interpersonal violence in childhood or adolescence, such as child abuse (Maercker et al. 2013). On the other hand, the DSM-5 defines PTSD symptom criteria more broadly and includes an additional criterion of negative alterations in cognition and mood (e.g., guilt, isolation, or detachment) (Friedman et al. 2011). Furthermore, the DSM-5 includes a separate set of criteria for PTSD in children aged 6 years and younger, which are more appropriate for the developmental stage of this age group (Scheeringa et al. 2011b). Finally, although the DSM-5 does not include a diagnosis of complex PTSD (Resick et al. 2012), it does include a new specifier of PTSD with dissociative features (a type of affect dysregulation), which has been linked to complex trauma exposure (Lanius et al. 2010). These new diagnoses of complex PTSD and PTSD with dissociative features were largely based on evidence in adults, and further research is needed to better understand the validity and utility of these diagnoses in children and adolescents.

Importantly, trauma-exposed young people, and particularly those with PTSD, often experience multiple difficulties. For instance, approximately three-quarters of young people with PTSD also meet the criteria for another psychiatric disorder, most commonly depression (Giaconia et al. 1995; Kilpatrick et al. 2003; Lewis et al. 2019; Rojas et al. 2017). Additionally, compared to unexposed young people, those exposed to trauma, and particularly those with PTSD, are more likely to perform poorly on tests of neuropsychological functioning (Malarbi et al. 2016), be out of education and employment, or harm themselves or others (Giaconia et al. 1995; Lewis et al. 2019). Crucially, if young people with PTSD do not receive treatment, their symptoms often persist: a meta-analysis of longitudinal studies found that children and adolescents with PTSD 6 months after a traumatic event were unlikely to recover without intervention (Hiller et al. 2016). Therefore, trauma-exposed young people are at increased risk of experiencing wide-ranging, co-occurring, impairing, and persistent mental illness and, thus, those affected require comprehensive assessment and treatment.

Despite this, few trauma-exposed young people use health services. In a recent population-based British study, only about one in ten trauma-exposed young people and one in five of those with PTSD had accessed mental health services in the past year (Lewis et al. 2019). Young people with trauma-related disorders from lower-income countries likely have even lower rates of service use, as is the case in adults (Koenen et al. 2017). This highlights that, throughout the world, trauma-exposed young people are likely to have high unmet mental health needs. Therefore, further research is needed to identify and address barriers to care provision for trauma-exposed young people with psychiatric disorders.

Mechanisms Underlying the Relationship Between Trauma and Mental Illness

Several mechanisms may help to explain why trauma is linked to mental illness. Three examples of potential mechanisms are outlined here. First, traumatic experiences may induce biological changes in the body’s stress-sensitive systems, including the highly integrated nervous, endocrine, and immune systems. These effects may be long-lasting and detrimental, particularly if traumas occur during sensitive periods in childhood and adolescence when these systems are developing. In turn, abnormalities in these biological systems may lead to mental illness. This possibility is supported by animal experiments and human observational studies, though further research is needed to better understand these mechanisms and how they can be targeted to minimize the effects of childhood trauma (Danese and Lewis 2016; Danese and McEwen 2012).

Second, traumatic experiences may affect psychological processes, including cognitive appraisals, memory, and coping responses. For example, Ehlers and Clark’s cognitive model proposes that trauma may result in excessively negative appraisals of the event, self, and future, such as “it was my fault,” “I’m going mad,” and “my life will never be the same again.” Additionally, this model proposes that trauma may result in a disturbance of memory for the traumatic event, including disorganized and fragmented memories. Maladaptive cognitive and behavioral coping strategies intended to control threats, such as avoidance, may prevent change in these negative appraisals and memory disturbances. This may lead to a prolonged sense of serious and current threat, presenting as mental illness (Ehlers and Clark 2000; Meiser-Stedman 2002). These processes are targeted and altered in trauma-focused cognitive behavioral therapies, which has been found to mediate the positive effects of this treatment (Jensen et al. 2018; McLean et al. 2015; Meiser-Stedman et al. 2017; Pfeiffer et al. 2017).

Finally, in addition to these causal mechanisms, trauma may also be associated with mental illness through non-causal mechanisms. For example, preexisting characteristics, such as genetic or early environmental influences, might predispose some young people to experience both trauma and subsequent mental illness. Longitudinal research and twin studies have found evidence to support this possibility, indicating the need for further research to better understand and address the influence of pre-trauma characteristics on trauma-related mental illness (Danese et al. 2017; Dinkler et al. 2017; Gilbertson et al. 2002).

Risk Factors for Trauma and Related Mental Illness

It is important to identify which children and adolescents are at greatest risk of experiencing trauma and developing related mental illness. Traumas do not tend to occur at random, but rather are more likely to be experienced by young people with certain child and family risk factors. For example, boys are more likely to experience traumas that involve physical assaults outside home and accidents, while girls are more likely to experience traumas that involve sexual assaults and network events (Breslau et al. 2004, 2006; Landolt et al. 2013; McLaughlin et al. 2013; Perkonigg et al. 2000). Additionally, young people with a history of psychopathology and those with a lower pre-trauma IQ are at increased risk of trauma exposure (Breslau et al. 2006; Copeland et al. 2007; McLaughlin et al. 2013; Perkonigg et al. 2000; Storr et al. 2007). Furthermore, those from disadvantaged or disrupted families are also more likely to experience trauma (Breslau et al. 2006; Copeland et al. 2007; Landolt et al. 2013; McLaughlin et al. 2013; Perkonigg et al. 2000).

Similarly, the onset of psychopathology is more common in trauma-exposed young people with certain child, family, and trauma-related risk factors. For example, girls, those who have a history of psychopathology, those with a lower pre-trauma IQ, and those who have experienced previous traumas, particularly victimization, are more likely to develop PTSD after trauma exposure (Breslau et al. 2006; Copeland et al. 2007; Giaconia et al. 1995; Landolt et al. 2013; Lewis et al. 2019; McLaughlin et al. 2013; Perkonigg et al. 2000; Storr et al. 2007). In addition, those from disadvantaged or disrupted families are at increased risk of PTSD following trauma (Breslau et al. 2006; Copeland et al. 2007; Landolt et al. 2013; Lewis et al. 2019; McLaughlin et al. 2013; Perkonigg et al. 2000). Importantly, those who have experienced direct interpersonal index traumas, particularly sexual assaults, are much more likely to develop PTSD than those exposed to other trauma types (Breslau et al. 2004; Copeland et al. 2007; Giaconia et al. 1995; Lewis et al. 2019; McLaughlin et al. 2013; Perkonigg et al. 2000). Furthermore, in line with psychological models mentioned above, young people’s negative perceptions of and responses to the trauma (e.g., perceived life threat, thought suppression, and social withdrawal) are associated with the development of PTSD (Trickey et al. 2012). Also, parents’ negative appraisals and avoidant coping following trauma are associated with PTSD onset in young people (Hiller et al. 2018).

This research suggests that groups of young people with certain risk factors are, on average, more likely to experience trauma or develop trauma-related psychopathology than other young people without these risk factors. However, there is significant within-group variability so that, for example, not all young people exposed to interpersonal trauma develop PTSD. As such, single risk factors cannot be used to accurately predict trauma-related psychopathology. Initial evidence suggests that known risk factors can be combined through modern computational approaches to inform individualized PTSD risk prediction (Lewis et al. 2019). Further development of prediction modeling approaches is important to inform screening programs, thereby enabling support to be targeted to trauma-exposed young people with the greatest clinical needs.

Managing the Mental Health Burden of Trauma in Children and Adolescents

Initial Response to Trauma

Immediately following trauma exposure, the priority is to ensure that all involved are safe. In large-scale disasters, this may require a planned and coordinated response to ensure that resources such as healthcare and shelter are prioritized and provided to those in need and that families are reunited. After trauma exposure, it is normal for those exposed to experience some psychological symptoms, and young people and their families should be supported to understand this. To reduce the perception of ongoing threat, young people should spend time with family and friends and return to usual routines if possible, including attending school. To help young people understand the traumatic event and their responses to it, parents and other trusted adults should be available to talk with them. Within these discussions, young people should be given a truthful explanation about what happened, which is age-appropriate and clear. Adults should acknowledge that what happened is very serious, and also recognize that it is very rare. These conversations should be encouraged and should not be avoided. However, young people should not be forced to talk about the trauma if they do not feel able to. If psychological symptoms persist for more than a month, or are very severe, young people and their families should seek support from health professionals, such as primary care doctors, who will consider referring to child and adolescent mental health services. Resources with advice for parents and carers are provided at the end of this chapter (Danese et al. 2016).

Assessment of Trauma-Related Mental Illness

During the child and adolescent mental health service assessment, trauma-exposed young people should be asked sensitively but directly about the traumatic events they have experienced, their reactions to these events, and their current symptoms and impairment. Clinicians should not avoid discussing these topics, because these questions rarely cause substantial distress (Becker-Blease and Freyd 2006; Zajac et al. 2011). Additionally, recognition and normalization of the young person’s experience can be therapeutically beneficial, and the information obtained will provide a more accurate understanding of the young person’s presentation. Both young people and their parents or carers should be interviewed, as both provide important and unique information (Meiser-Stedman et al. 2007; Shemesh et al. 2005; Stover et al. 2010). Additionally, clinicians should offer to interview young people separately to their parents or carers, as young people may hide aspects of their experience in front of their parents or carers for fear of upsetting them.

Because trauma-exposed young people can experience wide-ranging and co-occurring mental illness, accurately identifying their difficulties can be challenging. Therefore, the assessment should include a systematic review of possible trauma-related problems highlighted above, including broad psychopathology, impairment, and risk of harm. A comprehensive assessment will reduce the possibility of diagnostic overshadowing of some difficulties and ensure a more complete understanding of the young person’s presentation. This understanding should lead to a formulation including diagnoses, developed with the young person and their parents or carers, which should be used to guide treatment recommendations.

To inform the assessment and enable monitoring of progress, clinicians may use assessment tools, including questionnaires and structured interviews. To support the assessment of wide-ranging psychopathology, it can be helpful to use questionnaires that cover broad symptoms. To assess post-traumatic stress symptoms, useful questionnaires include the Children’s Revised Impact of Event Scale (CRIES; a brief PTSD screening tool) (Perrin et al. 2005) or the Child PTSD Symptom Scale (CPSS; a more detailed questionnaire used for PTSD assessment and outcome monitoring) (Foa et al. 2001, 2018; Nixon et al. 2013), both of which are completed by the young person and are suitable for those aged 8 years and over. To assess mood and anxiety symptoms, useful questionnaires include the Mood and Feelings Questionnaire (MFQ) (Angold et al. 1995), the Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al. 1997), and the Revised Child Anxiety and Depression Scale (RCADS) (Chorpita et al. 2000), which can be completed by the young person (from age eight) and their parent. To assess other symptoms, including behavioral symptoms, useful questionnaires include the Strengths and Difficulties Questionnaire (SDQ) (Goodman 2001) or the Development and Well-Being Assessment (DAWBA) (Goodman et al. 2000), which can be completed by the young person (from age 11), their parent, and their teacher. These questionnaires are widely used and have been found to demonstrate good reliability and validity. Many have been translated into multiple languages and are freely available; for example, the CRIES is available in several languages from the Children and War Foundation (http://www.childrenandwar.org). In most clinical settings, it would not be practical to undertake detailed structured interviews to cover all possible trauma-related psychopathology. However, structured interviews could be used to systematically assess symptoms identified as particular difficulties. For example, to assess PTSD diagnosis and symptom severity, the gold standard interview is the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) (Leigh et al. 2015; Nader et al. 1996; Pynoos et al. 2015). For structured interviews for other disorders, please see relevant chapters.

Treatment of Trauma-Related Mental Illness

Treatment recommendations for each trauma-exposed young person should be guided by their formulation and diagnoses identified at assessment. Because trauma-exposed young people can experience wide-ranging and co-occurring mental illness, developing treatment plans can be challenging. In general, young people with psychiatric disorders should be offered treatment based on recommendations for the disorders they experience. When a young person experiences comorbid disorders, if possible, these disorders should be treated in an integrated fashion. However, it may be necessary to prioritize focusing on the primary or most severe problems.

Trauma-focused treatments have mainly been considered for the treatment of PTSD. Psychological interventions that use cognitive and behavioral techniques to target PTSD symptoms have been found to be beneficial for young people with PTSD. These interventions include trauma-focused cognitive behavioral therapy (TF-CBT) (Cohen et al. 2004), cognitive therapy for PTSD (Smith et al. 2007), prolonged exposure (Foa et al. 2013), and narrative exposure therapy (Ruf et al. 2010). These therapies include some common components such as psychoeducation (providing information to young people and their families to help them to understand PTSD symptoms and the rationale for treatment); coping skills training (teaching methods to help manage emotions); gradual exposure to trauma memories and reminders (including supporting the young person to recount the trauma to develop a coherent narrative of the event and reducing avoidance); and cognitive restructuring (addressing misappraisals to develop a more realistic and updated meaning that is integrated into the trauma memory). These interventions aim to address cognitive and behavioral factors that contribute to the development and maintenance of PTSD. Several randomized-controlled trials conducted in multiple countries have found that these treatments improve PTSD and reduce PTSD symptoms (medium to large effects) in children and adolescents exposed to a range of traumatic events, compared to active control conditions, treatment as usual, or waitlist, and benefits remain at follow-up (Gillies et al. 2012; Gutermann et al. 2016; Mavranezouli et al. 2020; Morina et al. 2016; NICE 2018a; Smith et al. 2018). Very few studies included pre-school children, and therefore there is a need to adapt and evaluate treatments for this age group (Dalgleish et al. 2015; Scheeringa et al. 2011a). Additionally, there is limited but growing evidence that eye movement desensitization and reprocessing (EMDR), which involves recalling traumatic events whilst performing tasks that generate bilateral sensory stimulation, may be beneficial for young people with PTSD (Gillies et al. 2012; Gutermann et al. 2016; Mavranezouli et al. 2020; Morina et al. 2016; NICE 2018a; Smith et al. 2018). Finally, there is minimal evidence for pharmacological treatments for PTSD in young people (Cohen 2010; Danese 2018; NICE 2018b). Based on this evidence, the recently updated English National Institute for Health and Care Excellence (NICE) guideline for treating PTSD in children and adolescents recommends offering trauma-focused cognitive behavioral therapies as first-line treatment, considering EMDR only if there is no response to or engagement with trauma-focused cognitive behavioral therapies, and recommends against routinely offering medication to treat PTSD (NICE 2018c).

Because young people with PTSD often experience co-occurring mental illness, it is important to consider whether trauma-focused psychological interventions also reduce other symptoms in young people with PTSD. Indeed, some studies have found that psychological interventions reduce depression and anxiety symptoms, and emotional and behavioral problems, in young people with PTSD, compared to treatment as usual or waitlist (Gillies et al. 2012; Gutermann et al. 2016; Morina et al. 2016; NICE 2018a). Furthermore, because young people with PTSD may experience complex PTSD, it is important to consider whether trauma-focused psychological interventions also reduce additional complex symptoms in young people with complex PTSD. Preliminary evidence from one study found that TF-CBT was associated with a pre-post reduction in additional complex symptoms in young people with complex PTSD (Sachser et al. 2017). Further research is needed to better understand which treatments are most effective for young people with PTSD and co-occurring or complex symptoms. Currently, expert recommendations for the treatment of complex PTSD symptoms in young people suggest an extended phase-based approach, including a longer initial stabilization phase focused on teaching coping skills (Cohen et al. 2012), in line with guidelines for treating complex PTSD in adults (Cloitre et al. 2012).

Given that few trauma-exposed young people with psychiatric disorders use mental health services and that resources are often limited, innovative approaches are needed to improve access to treatment. One possibility is computerized trauma-focused cognitive behavioral therapies, which have shown some promise in adults with PTSD as they have led to reduced symptoms while having a low cost of delivery (NICE 2018d). Research is needed to consider whether similar approaches could be suitable and effective for young people with trauma-related psychiatric disorders.

Prevention of Trauma-Related Mental Illness

There has been substantial interest in the potential for interventions delivered after trauma exposure and before the development of trauma-related psychiatric disorders to prevent the onset of these disorders. Although single-session debriefing has not been found to be beneficial in young people (Stallard et al. 2006; Zehnder et al. 2010), evidence suggests that other early psychological interventions, particularly CBT-based approaches, may be effective at reducing PTSD symptoms and preventing the onset of PTSD in trauma-exposed young people (Gillies et al. 2016; NICE 2018e). Additionally, evidence specifically from low-resource humanitarian settings suggests that psychosocial interventions may reduce PTSD symptoms in trauma-exposed young people living in these settings (Purgato et al. 2018). Further research is needed to develop and implement effective approaches to prevent the onset of trauma-related psychiatric disorders in young people.

Conclusions

Trauma exposure is common in children and adolescents worldwide, and those affected are at increased risk of wide-ranging, co-occurring, impairing, and persistent mental illness. Therefore, trauma is associated with a large global mental health burden in young people. Because trauma-exposed young people often have multiple difficulties, those presenting to mental health services require comprehensive assessment and treatment. However, they also struggle to access mental health services and so need support to overcome barriers to care provision. Further research is needed to develop strategies to better identify trauma-exposed young people at greatest risk of developing mental illness and to prevent the onset of disorders in these young people.

Resources

Advice for parents and carers on supporting children and adolescents after trauma:
Introductory information on PTSD in children and adolescents:
Detailed practitioner reviews and guidelines for managing PTSD in children and adolescents:
Review of tools to assess PTSD in children and adolescents:
  • Leigh E, Yule W, Smith P (2015) Measurement issues: measurement of posttraumatic stress disorder in children and young people – lessons from research and practice. Child Adolesc Ment Health 21:124–35. https://doi.org/10.1111/camh.12124

Screening tool for PTSD symptoms in children and adolescents, the Children’s Revised Impact of Event Scale (available in several languages):

Cross-References

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Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & NeuroscienceKing’s College LondonLondonUK
  2. 2.Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & NeuroscienceKing’s College LondonLondonUK
  3. 3.Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & NeuroscienceKing’s College LondonLondonUK
  4. 4.Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & NeuroscienceKing’s College LondonLondonUK
  5. 5.National and Specialist CAMHS Trauma, Anxiety, and Depression ClinicSouth London and Maudsley NHS Foundation TrustLondonUK

Section editors and affiliations

  • John CM Wong
    • 1
  1. 1.Department of Psychological MedicineNational University Health SystemSingaporeSingapore

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