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Prevalence, assessment and diagnosis
Over 60% of US adolescents have experienced a potentially traumatic event, almost 8% of whom have associated PTSD
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  1. Marylene Cloitre
  1. New York University Langone Medical Centre, New York, New York, USA

https://doi.org/10.1136/eb-2013-101538

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    Question

    Question: What proportion of adolescents have been exposed to potentially traumatic events, and to what extent does this correlate with prevalence of post-traumatic stress disorder?

    Population: 6483 adolescents (aged 13–17 years) and their parents. Of these adolescents, 879 were members of households participating in the National Comorbidity Survey Replication (NCS-R) of adult mental health disorders, or recruited from schools in NCS-R sample areas. The study only included adolescent–parent pairs for whom full data was available.

    Setting: Community sample, USA; 2001 February to 2004 January.

    Assessment: Adolescents were interviewed in person to assess lifetime Diagnostic and Statistical Manual (DSM)-IV disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Parents provided information on child symptoms of mental health disorders using a long-form self-administered questionnaire.

    Outcomes: Lifetime exposure to potentially traumatic events (PTEs) and DSM-IV post-traumatic stress disorder (PTSD). The CIDI was used to assess 19 PTEs that qualified for the DSM-IV A1 criterion: 9 types of interpersonal violence; 5 types of accident; 3 types of witnessing and network events (such as unexpected death of a loved one); and 2 open-ended questions about PTEs not on the list or that the adolescent did not want to describe specifically. Adolescents who reported at least one PTE were asked a screening question about post-traumatic symptoms. Where adolescents confirmed that they had symptoms individual PTSD symptoms were assessed using DSM-IV criteria. Where there was more than one PTE, the ‘worst PTE’, the one associated with the most number of symptoms or failing this a randomly selected PTE was considered. Additional lifetime DSM-IV mental health disorders were also assessed. Survival analysis models were used to correlate each lifetime PTE with PTSD and PTSD recovery, with adjustment for measured sociodemographic factors.

    Methods

    Design: Cross-sectional study.

    Main results

    Almost two-thirds of adolescents (61.8%) reported at least one lifetime PTE; 29.1% reported one event, 14.1% reported two and 18.6% reported three or more. The most common PTE was unexpected death of a loved one (28.2%), followed by natural or man-made disasters (14.8%) and witnessing death or serious injury (11.7%). Lifetime prevalence of PTSD among all adolescents was 4.7%, and among those exposed to at least one PTE was 7.6%. Lifetime prevalence of PTSD varied significantly across those with different PTE exposures (p<0.001). Rape was the PTE most commonly associated with PTSD (39.3%), followed by kidnapping (37.0%), sexual assault (31.3%) and physical assault by partner (29.1%) and physical abuse by caregiver (25.2%). There were differences in type of PTE exposure by gender (women being more likely to experience assault by partner, rape/sexual assault and unexpected death of loved one, and men more likely to experience accident/physical assault or witness death/injury). Women had increased odds of experiencing PTSD. Pre-existing fear disorders, distress disorders and substance use disorders were associated with increased odds of experiencing various PTEs and increased odds of experiencing PTSD. Living with only one or no biological parents was also associated with increased odds of various PTEs and increased odds of PTSD.

    Conclusions

    Almost two-thirds of US adolescents have experienced at least one potentially traumatic event, and 7.6% of these adolescents meet DSM-IV criteria for PTSD.

    Abstracted from

    McLaughlin KA, Koenen KC, Hill ED, et al. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry 2013; 52 (8): 815– 30.OpenUrlCrossRefPubMed

    Commentary

    Past epidemiological studies regarding post-traumatic stress disorder (PTSD) have determined that exposure to traumatic stressors typically occurs for the first time in the childhood and adolescent years. This study advances on previous work by evaluating a wide range of potentially traumatic events (PTEs), sociodemographic characteristics and pre-existing mental health problems as risk factors for PTSD in a large sample of adolescents. Consistent with previous studies, 62% reported experiencing one or more PTEs by age 17, while 7.6% of those exposed developed PTSD.

    The study identified several risk factors for PTSD and discussed their developmental significance, yielding useful considerations for intervention and prevention programming. For example, the authors reported that living with fewer than two biological parents was strongly associated with PTSD. This status was also associated with exposure to multiple traumatic events, particularly interpersonal violence, witnessing of violence and a class of events described as ‘private’ (those that the adolescent did not wish to describe). The authors suggest that this association may reflect lower parental supervision and disrupted family structures as important determinants of exposure or greater risk of maltreatment (eg, sexual or physical abuse) because of the presence of step-parents or other non-related adults in the home. These findings indicate the relevance of family functioning as a risk factor for PTSD and the potential value of parenting, family cohesion and health programming as a preventive intervention.

    The study also identified age-related and mental health risk factors for both PTEs and PTSD. For example, interpersonal violence and automobile accidents tended to occur in late adolescence while witnessing domestic violence and life-threatening accidents or illnesses occurred during childhood or early adolescence. In addition, some types of pre-existing mental disorders (behavioural disorders, substance abuse) were associated with increased risk for PTEs while others (fear and distress disorders) were associated with PTSD. Overall, the study suggests that there is a cascade of multiple factors contributing to risk for PTSD across childhood. Fortunately, however, it also reveals that specific risk-outcome relationships can be characterised. These, in turn, can provide an empirical basis for intervention and prevention programme planning.

    Footnotes

    • Sources of funding The National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.

    Footnotes

    • Competing interests None.