Assessing and Treating PTSD in Young Children 

Post-traumatic stress disorder (PTSD) in very young children has been difficult to identify in the past, partly because diagnostic criteria were developed for older children and adults. This matters because trauma shows up differently in young children.  

Instead of talking about intrusive memories or avoidance, young children are more likely to show signs of traumatic stress through their behaviour, play, emotions, sleep problems, separation anxiety or changes in development.  

To improve identification, researchers developed PTSD criteria specifically for young children. These were later included in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as a PTSD subtype for children aged 6 years and under. ^1,2

In this blog, we’ll explore what PTSD in young children looks like, the challenges of assessing trauma in young children, and what current research tells us about effective treatment approaches for PTSD in children aged 3-8 years.  

Why are PTSD symptoms in young children often missed? 

Recognising PTSD in young children can be challenging because the symptoms don’t always look the same as they do in older children or adults. Traditional PTSD criteria assume that a person can: 

• Describe their thoughts, feelings and memories 

• Identify reminders of the traumatic event 

• Explain experiences such as avoidance or flashbacks 

Young children often don’t yet have the language or self-awareness to communicate their experiences in these ways. Instead, trauma may be expressed through behaviour, emotions, play, sleep difficulties, separation anxiety or changes in development.  

For example, a child may: 

• Become more clingy 

• Have frequent emotional outbursts 

• Recreate aspects of the trauma during play 

• Show skills regression, such as bedwetting after having previously been toilet trained 

To address this gap between children’s PTSD symptoms and existing PTSD criteria, researchers developed criteria specifically for PTSD symptoms in young children. These criteria place less emphasis on verbal descriptions and more on children’s expressions of PTSD, allowing us to better identify trauma-related difficulties in younger children.² Let’s explore this research next.  

Do traditional PTSD criteria fit PTSD symptoms in children? 

To identify whether traditional PTSD criteria fit PTSD symptoms in children, we need to look at research by Cathy Hitchcock and colleagues. ³

These experts looked at children aged 3-8 years who were assessed within one month of attending an emergency department after trauma, and again around three months later. This age range is important because prior evidence suggested that developmentally adapted PTSD criteria may have clinical relevance beyond the preschool years and into early school age.^4,5

They examined which children met DSM-5 acute stress disorder criteria, whether they met developmentally adapted PTSD criteria in young children, and which factors might predict later PTSD.  

The findings showed a clear mismatch between traditional PTSD diagnostic criteria and how PTSD symptoms in young children appear. DSM-5 acute stress disorder did not identify any children in the acute phase.  

However, when researchers used an adapted version of DSM-5 PTSD criteria for young children (removing the usual time requirement), 8.6% of children met criteria in the first month, and 10.1% met PTSD in the young-child format at three months.³  

These findings suggest that acute stress disorder, as it’s currently defined, may not capture trauma responses in very young children.  

Can existing criteria predict PTSD symptoms in children?  

The study also found that most demographic and trauma-related factors did not predict which children went on to develop PTSD. These factors include: 

• Trauma type 
• Age 
• Gender 
• Ethnicity 
• Hospital admission 
• Loss of consciousness 
• Pain medication 

Length of hospital stay was the only factor that showed a significant association with later adult PTSD from childhood trauma.3 This shows the limits of relying on adult-focused factors to identify the risk of later PTSD in children.  

What is acute PTSD-YC criteria and how can it help? 

The research highlighted that acute PTSD-YC (Post-Traumatic Stress Disorder adapted for Young Children) may help identify young children who are at risk of developing longer-term post-traumatic stress disorder.  

Around half of the children who met acute PTSD-YC criteria within the first month after trauma still met the criteria three months later. On the other hand, children who did not meet the acute criteria were very unlikely to develop PTSD later on.³ This finding suggests that the measure may be effective at ruling out PTSD in young children who are not at risk.  

It’s not a perfect screening tool, but it can still be useful in practice. It suggests that child-focused PTSD criteria work better than adult-style acute stress disorder criteria when assessing young children. This fits with earlier research showing that DSM-5 preschool PTSD criteria are better at identifying young children who need support.²

For us as clinicians, the takeaway is that we shouldn’t assess young children who experience trauma using adult-based systems. Using developmentally appropriate tools helps ensure our very young child clients needing support are identified early.⁶  

CBT-3M for young children: Adapting PTSD treatment for ages 3-8 

The second part of the study from Cathy Hitchcock and colleagues looked at a cognitive-based treatment called CBT-3M – also known as the “Triple M” method. CBT-3M is adapted from cognitive behavioural therapy used with older children and teenagers, and previous research with very young children.^7-9

This approach is specifically tailored to children ages 3-8 years, and is built around three main areas: 

1. Meanings 
2. Memories 
3. Management 

In simple terms, it helps children and caregivers understand what happened, process the memory of the trauma and learn ways to manage distress. The approach is adapted for young children by using age-appropriate language, involving caregivers closely and avoiding complex abstract thinking.  

Children in the study were randomly assigned to either CBT-3M or usual treatment within the UK NHS, and the results were promising. Most children who received CBT-3M no longer met criteria for PTSD-YC after treatment.⁴ Families also reported high levels of satisfaction, saying the therapy made sense and was helpful, and that they would recommend it to others. 

However, it’s important to note that this was an early-stage trial, not a final test of effectiveness. Even so, the results suggest CBT-3M has strong potential. Larger studies are needed to help develop our understanding.  

Why treatment access matters for childhood PTSD

Even when young children are identified as needing support, they do not always receive psychological treatment through routine services. 

So, assessment on its own isn’t sufficient. If we can identify PTSD in young children using developmentally suitable criteria, services must also have the right treatments in place. These interventions need to be evidence-based, practical to deliver and acceptable for families. 

CBT-3M offers one possible approach. It shows that cognitive-based treatments can be adapted for very young children when their age and development are taken into consideration. This is also supported by earlier trauma research showing that trauma-focused CBT can work well for young children.^9,10 

Assessing and treating PTSD in children 

The study shared has several important takeaways for us as clinicians and service-providers.  

Very young children can experience PTSD 

PTSD can occur in very young children and can significantly affect their daily lives. We shouldn’t assume that children under 6 are too young to experience serious trauma reactions. 

Tailor assessments to young children 

We need to adapt our assessments to suit their developmental stage. Research shows that developmentally appropriate PTSD-YC criteria are more useful for identifying difficulties in this age group.^2,3 So, it’s important that our assessments reflect this.  

Combine caregiver reports with observation 

Caregiver reports are important, but they do not give the full picture. Parents may not see all symptoms. So, when we assess, integrating careful observation of the child and age-appropriate clinical questioning are key.  

Follow identification with effective treatment 

Early identification should lead to access to treatment. The study suggests that cognitive-based treatments like CBT-3M can be adapted for young children and may work well for families. However, more research is needed before firm conclusions can be made.  

Recognising PTSD in young children 

Young children can and do develop PTSD, but it often looks different from adults. It’s more likely to show up in their behaviour, emotions and development, rather than words. 

Unfortunately, the standard DSM-5 acute stress disorder criteria do not work well for identifying PTSD in very young children.4 Instead, developmentally adapted PTSD-YC criteria are better at spotting early signs of trauma in this age group. 

For us as mental health clinicians, this means we need to tailor our assessment and treatment to our clients’ age, to avoid missing PTSD symptoms and ensure very young children get the right support, early on.  

Want to learn more about how to tailor your assessment and practice to your clients’ age group? Join us at our upcoming PTSD in children training, Trauma: Evidence, Practice, and Implementation Challenges.  

At this event, you’ll learn: 

• How current evidence is shaping trauma assessment and intervention in CYP 
• Common clinical challenges in identifying and treating trauma 
• How to apply research findings to your everyday practice 
• Ways to improve implementation of evidence-based trauma care 

Book now.   

References 

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 

1. Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012). Diagnosing PTSD in early childhood: an empirical assessment of four approaches. Journal of traumatic stress, 25(4), 359–367. https://doi.org/10.1002/jts.21723 

1. Hitchcock, C., Goodall, B., Wright, I. M., Boyle, A., Johnston, D., Dunning, D., Gillard, J., Griffiths, K., Humphrey, A., McKinnon, A., Panesar, I. K., Werner-Seidler, A., Watson, P., Smith, P., Meiser-Stedman, R., & Dalgleish, T. (2022). The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds. Journal of child psychology and psychiatry, and allied disciplines, 63(1), 58–67. https://doi.org/10.1111/jcpp.13460 

1. Danzi, B. A., & La Greca, A. M. (2017). Optimizing clinical thresholds for PTSD: Extending the DSM-5 preschool criteria to school-age children. International Journal of Clinical and Health Psychology, 17(3), 234–241. https://doi.org/10.1016/j.ijchp.2017.07.001 

1. Meiser-Stedman, R., Smith, P., Glucksman, E., Yule, W., & Dalgleish, T. (2008). The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. The American journal of psychiatry, 165(10), 1326–1337. https://doi.org/10.1176/appi.ajp.2008.07081282 

1. National Institute for Health and Care Excellence. (2018). Recommendations for management of PTSD in children, young people and adults. https://www.nice.org.uk/guidance/ng116/chapter/Recommendations#management-of-ptsd-in-children-young-people-and-adults 

1. Meiser-Stedman, R., Smith, P., McKinnon, A., Dixon, C., Trickey, D., Ehlers, A., Clark, D. M., Boyle, A., Watson, P., Goodyer, I., & Dalgleish, T. (2017). Cognitive therapy as an early treatment for post-traumatic stress disorder in children and adolescents: a randomized controlled trial addressing preliminary efficacy and mechanisms of action. Journal of child psychology and psychiatry, and allied disciplines, 58(5), 623–633. https://doi.org/10.1111/jcpp.12673 

1. Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish, T., & Clark, D. M. (2007). Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46(8), 1051–1061. https://doi.org/10.1097/CHI.0b013e318067e288 

1. Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: a randomized clinical trial. Journal of child psychology and psychiatry, and allied disciplines, 52(8), 853–860. https://doi.org/10.1111/j.1469-7610.2010.02354.x 

1. Salloum, A., Wang, W., Robst, J., Murphy, T. K., Scheeringa, M. S., Cohen, J. A., & Storch, E. A. (2016). Stepped care versus standard trauma-focused cognitive behavioral therapy for young children. Journal of child psychology and psychiatry, and allied disciplines, 57(5), 614–622. https://doi.org/10.1111/jcpp.12471