PTSD in Children & Adolescents

A Guide for Primary Care Providers, Mental Health Professionals, and Families in Nevada and Beyond

Childhood trauma can profoundly affect emotional, behavioral, cognitive, and physical health. While many children recover with support and stability, some develop Post-Traumatic Stress Disorder (PTSD) or other trauma-related difficulties that interfere with daily functioning, relationships, learning, and long-term wellbeing.

This guide provides a concise overview of:

  • PTSD in child and adolescent populations,
  • Adverse Childhood Experiences (ACEs),
  • the relationship between ACEs and trauma-related disorders,
  • common signs and symptoms,
  • evidence-based treatments, and
  • resources for families and professionals.

What Is PTSD?

Post-Traumatic Stress Disorder (PTSD) is a mental health condition that may develop after a child or adolescent experiences or witnesses:

  • abuse or neglect,
  • violence,
  • serious accidents,
  • natural disasters,
  • medical trauma,
  • community violence,
  • sudden loss,
  • or other overwhelming or life-threatening events.

Children do not always respond to trauma in the same way adults do. Symptoms may emerge immediately or develop gradually over time.

According to the National Institute of Mental Health (NIMH), PTSD symptoms generally fall into four categories:

  1. Re-experiencing symptoms (intrusion) 

Involuntary, intrusive, and distressing memories of the traumatic event. Examples: nightmares, flashbacks, triggers.

  1. Avoidance symptoms 

Actively steering clear of reminders tied to the traumatic event. Examples: 

  • Internal avoidance - avoiding thoughts, feelings, and conversations about the trauma, and 
  • External avoidance - avoiding people, places, things, etc that trigger memories of the trauma.
  1. Cognition and mood symptoms 

Negative alterations in thoughts, beliefs, and feelings that developed or worsened after the trauma. Examples: memory gaps, distorted beliefs, emotional disconnect, negative changes in mood or thinking.

  1. Arousal and reactivity symptoms

Constant or sudden spikes in physical and emotional responses. Examples: hypervigilance, startle response, behavioral changes (trouble sleeping, reckless behavior, irritable outbursts, etc).    

PTSD symptoms in children & adolescents

PTSD symptoms in child and adolescent populations vary depending on developmental stage, personality, support systems, and trauma severity. As a recent National Institute of Mental Health guide to PTSD states: 

“Children and teens can have extreme reactions to traumatic events, but their symptoms may not be the same as those seen in adults. In children younger than age 6, symptoms can include: 

  • Wetting the bed after having learned to use the toilet 
  • Forgetting how to talk or being unable to talk 
  • Acting out the scary event during playtime 
  • Being unusually clingy with a parent or other adult 

Older children and teens usually show symptoms more like those seen in adults. They also may develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilt over not preventing injury or death, or have thoughts of revenge.”

PTSD detection difficulties

PTSD and trauma symptoms are not always obvious. Some children may appear “high functioning” while struggling internally.

Also, trauma-related symptoms are sometimes mistaken for other disorders, including:

  • ADHD,
  • oppositional behavior,
  • anxiety disorders,
  • depression,
  • learning problems,
  • or behavioral misconduct.

ADHD and PTSD - Complicating the task of diagnosis, it’s also possible for a child to have both PTSD and ADHD (and/or other co-occurring disorders). Children with ADHD are also more susceptible to PTSD. 

As the Child Mind Institute notes: 

“[C]hildren with ADHD who have a disturbing experience are four times as likely to develop PTSD than kids without the disorder. And they’re likely to experience more severe trauma symptoms than kids without ADHD.

Imaging studies show that ADHD and PTSD are associated with similar irregularities in brain functioning, which could explain the heightened risk. And that heightened risk means that children with ADHD need extra attention and support in case of a traumatic experience, and should be screened for PTSD… Kids diagnosed with PTSD should be screened for ADHD, too.”

What are Adverse Childhood Experiences (ACEs)?

Adverse Childhood Experiences (ACEs) are potentially traumatic experiences occurring before age 18.

The Centers for Disease Control and Prevention (CDC) provides examples of potential ACEs, which include: 

  • physical abuse,
  • emotional abuse,
  • sexual abuse,
  • neglect,
  • household substance misuse,
  • domestic violence,
  • parental incarceration,
  • caregiver mental illness,
  • family member suicide,
  • and parental separation/divorce.

ACEs are common. The CDC notes that “three in four high school students reported experiencing one or more ACEs, and one in five experienced four or more ACEs.”

The link between ACEs and PTSD

Not all children exposed to ACEs develop PTSD. However, repeated or severe adversity significantly increases the risk of:

  • PTSD,
  • anxiety,
  • depression,
  • substance misuse,
  • chronic medical illness,
  • suicidal behavior,
  • and difficulties with emotional regulation and relationships.

Research also shows that higher ACE scores are associated with increased risk for both mental and physical health problems across the lifespan. Chronic stress associated with ACEs can alter:

  • stress-response systems,
  • brain development,
  • immune functioning,
  • and emotional regulation. 

Children with chronic trauma exposure may develop:

  • hypervigilance,
  • emotional dysregulation,
  • attachment difficulties,
  • dissociation,
  • sleep disturbances,
  • and persistent feelings of danger or shame.

In light of this information, it’s important for clinicians and families alike to note that trauma responses are adaptive survival responses, not character flaws or personality defects! 

Trauma, the brain, and development

Trauma can affect developing brain systems involved in:

  • memory,
  • attention,
  • executive functioning,
  • emotional regulation,
  • and threat detection.

Thus, as The Child Mind Institute notes, trauma can impair concentration, impulse control, and learning, sometimes contributing to school difficulties or other behavioral concerns.

Children exposed to chronic adversity may remain in a persistent “fight, flight, or freeze” state. This can contribute to:

  • irritability,
  • emotional outbursts,
  • shutdown/withdrawal,
  • panic symptoms,
  • sleep disruption,
  • and physical discomfort.

Distinguishing PTSD from typical stress responses

Many children experience temporary distress after difficult events. PTSD involves symptoms that are: 

  1. persistent,
  2. impairing,
  3. and interfere with daily functioning.

Warning signs which indicate the need for professional/medical evaluation include:

  • prolonged emotional or behavioral changes,
  • nightmares or flashbacks,
  • social withdrawal,
  • decline in school functioning,
  • self-harm,
  • suicidal thoughts,
  • aggression,
  • dissociation,
  • severe anxiety,
  • or developmental regression.

When these signs are present, a comprehensive assessment is warranted.

PTSD screening in youth populations

If a primary care provider (PCP) has reason to suspect that a patient has or is being exposed to traumatic events, the Child and Adolescent Trauma Screen (CATS) is the gold standard screening tool. 

Important safety note for clinicians - Remember to always assess for safety. If there is suspected abuse or neglect, DO NOT investigate but DO report. If there is imminent danger to self or others, refer the patient to ED for an emergency assessment.

What is CATS? 

The Child and Adolescent Trauma Screen (CATS) (available here) is a brief, freely accessible questionnaire designed to assess potentially traumatic events and measure post-traumatic stress symptoms (PTSS) in youth. It is not an ACE (Adverse Childhood Experiences) tool itself, but a specialized screener for trauma exposure and PTSD. 

The CATS questionnaire is closely aligned with DSM-5 PTSD criteria and can be administered via self-report (ages 7-17) or through a caregiver report (for ages 3-6 and 7-17). It takes about 10–15 minutes to complete. 

Important details: 

  • A clinical diagnosis of PTSD should not be based on completion of the CATS alone.
  • Positive results on the CATS should be followed up with a semi-structured clinical interview.
  • Ages 3-6: Use a cutoff ≥ 16 on the total symptom score as indication of a clinically relevant level of symptoms in preschool children.
  • Ages 7-17: Use a cutoff ≥ 21 on the total symptom score as indication of a clinically relevant level of symptoms in this age cohort.

What about PEARLS? How is it different from CATS? 

The Pediatric ACEs and Related Life-events Screener (PEARLS) is used to screen children and adolescents ages 0-19 for ACEs. Simply put, PEARLS measures for risk while CATS measures for symptoms. 

  • What it is: PEARLS is a tool used to gauge a child's or adolescent's exposure to Adverse Childhood Experiences (ACEs) and other social risk factors. It goes beyond traditional ACEs (e.g., abuse, household challenges) to include social determinants of health like community violence, discrimination, and food or housing instability.
  • When to use it: It is primarily used proactively in pediatric primary care or wellness visits for ages 0–19 to identify patients at risk for toxic stress.
  • Goal: To spot risks early, provide preventative education, and connect families to vital support resources BEFORE severe behavioral or health issues arise. 

There are three versions of the tool available here, based on age and reporter. 

Evidence-based treatments for pediatric PTSD

For PTSD and trauma treatment recommendations, please see the NV PAL PTSD screening guide. 

Protective factors & resilience

Trauma does not determine a child’s future. Early diagnosis and intervention is critically important for improved lifetime outcomes. Other protective factors that improve outcomes include:

  • stable supportive relationships,
  • emotionally responsive caregivers,
  • safe school environments,
  • access to mental health care,
  • positive peer relationships,
  • healthy routines,
  • sleep,
  • physical activity,
  • and community support.

Resilience and recovery can be strengthened even after significant adversity.

Guidance for Parents & Caregivers

Families can help by:

  • listening calmly and nonjudgmentally,
  • validating emotions,
  • maintaining predictable routines,
  • avoiding shaming or punishment-based responses,
  • encouraging healthy sleep and nutrition,
  • limiting exposure to ongoing conflict or violence,
  • and seeking professional help when symptoms persist.

Children often benefit most when caregivers also receive support and education.

Guidance for Primary Care Providers

Primary care providers are often the first professionals to recognize trauma-related concerns.

Providers should consider:

  1. routine trauma-informed screening,
  2. monitoring behavioral and emotional changes,
  3. assessing suicide risk when indicated,
  4. coordinating with mental health professionals,
  5. and recognizing that trauma may contribute to physical symptoms such as headaches, gastrointestinal complaints, sleep disturbances, or chronic pain.

Likewise, pediatricians may not always know which of their patients and families have experienced trauma - that's why the American Academy of Pediatrics (AAP) recommends trauma-informed care (TIC) as a universal approach to pediatric care. 

Nevada-specific resources

Nevada generally reflects national concerns regarding youth mental health, trauma exposure, and access to behavioral healthcare, particularly in underserved and rural communities.

Helpful Nevada resources include:

In emergencies or situations involving suicidal thoughts, immediate crisis evaluation is warranted.

Printable Screening Guide