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ORIGINAL ARTICLE
Traumatic Events and Posttraumatic Stress
in Childhood
William E. Copeland, PhD; Gordon Keeler, MA; Adrian Angold, MRCPsych; E. Jane Costello, PhD
Context: Traumatic events are common and are re-
lated to psychiatric impairment in childhood. Little is
known about the risk for posttraumatic stress disorder
(PTSD) across different types of trauma exposure in chil-
dren.
Objective: To examine the developmental epidemiol-
ogy of potential trauma and posttraumatic stress (PTS)
in a longitudinal community sample of children.
Methods: A representative population sample of 1420
children aged 9, 11, and 13 years at intake were fol-
lowed up annually through 16 years of age.
Main Outcome Measure: Traumatic events and PTS
were assessed from child and parent reports annually to
16 years of age. Risk factors and DSM-IV disorders were
also assessed.
Results: More than two thirds of children reported at
least 1 traumatic event by 16 years of age, with 13.4% of
those children developing some PTS symptoms. Few PTS
symptoms or psychiatric disorders were observed for in-
dividuals experiencing their first event, and any effects
were short-lived. Less than 0.5% of children met the cri-
teria for full-blown DSM-IV PTSD. Violent or sexual
trauma were associated with the highest rates of symp-
toms. The PTS symptoms were predicted by previous ex-
posure to multiple traumas, anxiety disorders, and fam-
ily adversity. Lifetime co-occurrence of other psychiatric
disorders with traumatic events and PTS symptoms was
high, with the highest rates for anxiety and depressive
disorders.
Conclusions: In the general population of children, po-
tentially traumatic events are fairly common and do not
often result in PTS symptoms, except after multiple trau-
mas or a history of anxiety. The prognosis after the first
lifetime trauma exposure was generally favorable. Apart
from PTSD, traumatic events are related to many forms
of psychopathology, with the strongest links being with
anxiety and depressive disorders.
Arch Gen Psychiatry. 2007;64:577-584
P
OSTTRAUMATIC STRESS DISOR-
der (PTSD) is distinct from
most psychiatric disorders in
requiring an initiating
stressor.
1
Early PTSD re-
search focused on Vietnam War veterans
and rape victims, leading to a narrow defi-
nition of the stressor criteria in the DSM-
III and DSM-III-R.
2
Increased attention to
the subjective appraisal of potentially trau-
matic situations in the 1980s and early
1990s led to a broader view of what con-
stituted a stressor. The criteria were
amended in the DSM-IV to include a wider
range of events such as serious illnesses,
natural disasters, and exposure to com-
munity violence.
1
Research on PTSD with
younger samples has added to the list of
potentially traumatic events. For ex-
ample, Giaconia and colleagues
3
found that
a parent being sent to prison put adoles-
cents at the same risk of PTSD as rape did.
Additional childhood events identified as
potentially traumatic include sudden sepa-
ration from a loved one and learning of a
traumatic event occurring to a parent or
a loved one.
3,4
Many studies have looked
at the risk for PTSD in children, given ex-
posure to a specific trauma such as a natu-
ral disaster or a motor vehicle crash,
5-11
but
few have assessed exposure to a full range
of potentially traumatic events. Efficient
treatment and prevention strategies re-
quire knowledge of the conditional risk for
PTSD, given different event categories
across the full range of potentially vulner-
able groups. Only data from community
samples can provide this information.
12
The few studies that have looked at a
range of events in representative samples
supported moderate levels of PTSD in chil-
dren exposed to traumatic events,
3,4
with
some evidence of higher vulnerability in
girls than in boys.
4
These studies pro-
vided the first look at the epidemiology of
PTSD in adolescents, but each is limited
Author Affiliations: Center for
Developmental Epidemiology,
Department of Psychiatry and
Behavioral Sciences, Duke
University Medical Center,
Durham, NC.
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by 1 of the following issues: (1) reliance on retrospec-
tive report, which tends to underestimate levels of trau-
matic events
13-20
; (2) use of small samples; or (3) assess-
ment of events and symptoms at a single time point only.
The present study examines the role of potentially
traumatic events in childhood PTSD and other DSM-IV
psychopathology. About one third of the sample par-
ticipants reported their first event exposure subsequent
to the first wave of data collection. This provided a
within-subject natural experiment to study predictors
of incident exposure to trauma and subsequent PTSD
symptoms. The study seeks to answer the following
questions:
1. What is the population prevalence of PTSD and
posttraumatic stress (PTS) symptoms in childhood and
adolescence?
2. Given the occurrence of a potentially traumatic
event, what are the conditional probabilities associated
with PTSD, related symptoms, and impairments?
3. What are the characteristics of children who are
vulnerable to developing PTS symptoms in response to
potentially traumatic events?
4. What is the lifetime co-occurrence of PTSD and PTS
symptoms and other DSM-IV childhood disorders?
5. What predicts the first potentially traumatic ex-
perience and response to it?
METHODS
SETTING AND SAMPLING
The Great Smoky Mountains Study is a longitudinal study of
psychopathology and use of medical services in child-
hood.
21,22
A multistage sample design was used to randomly se-
lect potential participants from a population of 20 000 chil-
dren in 11 counties in western North Carolina. Three cohorts
of children aged 9, 11, and 13 years were recruited at intake.
Potential participants were randomly selected from the popu-
lation using a household equal-probability, accelerated cohort
design. This means that each cohort reaches a given age in a
different year, thus controlling for cohort effects.
23
The initial
random sample of 4067 yielded 3896 (95.8%) screening ques-
tionnaires consisting of the externalizing (behavioral) prob-
lems scale of the Child Behavior Checklist completed by the
parent, on the telephone or in person. All children scoring above
a predetermined cutoff point (the top 25% of the total scores),
plus a 1-in-10 random sample of the rest, were recruited for
detailed interviews. The contribution of each participant is
weighted by the inverse of their selection probabilities, strati-
fied by age, sex, and race or ethnicity, to provide accurate preva-
lence estimates for the population of the study area.
Of 1796 children recruited, 79.1% (n=1420) agreed to par-
ticipate. Across annual waves, 83.4% of the 8002 possible in-
terviews have been completed with 75.0% to 94.2% of the sample
who participated in each wave. The data presented herein, based
on the first 8 annual waves of the study (1993-2000), consist
of 6674 interviews with participants through 16 years of age
and 1 parent. Funding constraints prevented our interviewing
the youngest cohort from January 1997 through June 1998. Be-
cause subjects were randomly selected, the cohort members in-
terviewed from July to December 1998 are a random sample
of the whole cohort. Data were collected on 1 cohort at 9 and
10 years of age; 2 cohorts at 11, 12, and 13 years of age; and all
3 cohorts at 14, 15, and 16 years of age.
The final sample consisted of 790 boys and 630 girls (weighted
percentages, 51.1% and 49.0% respectively). In the unweighted
sample, 69.2% (n =983) were white, 6.2% (n=88) were African
American, and 24.6% (n=349) were American Indian. When
weighted back to population probability of selection, the respec-
tive proportions were 89.5%, 6.9%, and 3.6%, respectively.
MEASURES
We based our analyses on the following 3 areas of information:
(1) psychiatric disorders, (2) potentially traumatic events and
associated PTS symptoms, and (3) risk factors. These areas were
assessed using the Child and Adolescent Psychiatric Assess-
ment (CAPA).
24,25
Symptoms are coded using an extensive glos-
sary, and diagnoses are generated by computer algorithms. With
the exception of attention-deficit/hyperactivity disorder symp-
toms, about which only the parent was interviewed, a symptom
is counted as present if it was reported by the parent, the child,
or both, as is standard clinical practice. The 2-week test-retest
reliability of the CAPA diagnoses in children and adolescents aged
10 to 18 years is comparable to that of other highly structured
interviews ( range for individual disorders, 0.56-1.00).
25
The
time frame of the CAPA for determining the presence of most
psychiatric symptoms is the 3 months immediately preceding
the interview to minimize recall bias.
Details of the construction and psychometric testing of the life
events and PTS sections of the CAPA are contained in another
report.
26
The life events section covered 17 areas of children’s lives
that could potentially induce PTS symptoms. The terms trauma
and traumatic events are used to describe these events in report-
ing our results, but this is not meant to imply that the events are
traumatic apart from the individual’s response to the event. These
events meet the DSM-IV PTSD criterion A, which stipulates that
the event must involve “actual or threatened death or serious in-
jury, or a threat to the physical integrity of self or others.”
1(p427)
The parent or the child is queried about lifetime occurrence of
each event and, where necessary, when it occurred. For each event,
the interviewer administered a screen to determine whether the
3 key symptoms of PTSD (painful recall, avoidance, and hyper-
arousal) required for a DSM-IV diagnosis have been present dur-
ing the past 3 months and are linked to the event under discus-
sion. Painful recall/reexperience is assessed first and, if endorsed,
the interviewer inquires about avoidance or hyperarousal. This
procedure was put in place to avoid false-positive responses as-
sociated with the more common and less specific behavior pat-
terns of hyperarousal and avoidance of painful stimuli. Painful
recall is coded as present if the child or the parent reports un-
wanted, painful, and distressing recollections, memories, thoughts,
or images of the life event, the occurrence of which the child can-
not prevent (including childhood manifestations such as night-
mares, reenactment, and repetitive play). Avoidance is defined as
avoiding situations that might provoke recall of the event, and
hyperarousal as an increased general level of awareness and alert-
ness toward the subject’s surroundings, in the absence of immi-
nent danger. If minimal levels of all 3 symptoms are endorsed,
then the detailed PTSD module is completed. Up to 2 detailed
PTSD sections could be completed, 1 for the most upsetting event
meeting 3 screens in the past 3 months, and 1 for the most up-
setting lifetime event. A reliability study with 58 parents and chil-
dren interviewed twice by different interviewers supported fair
to excellent test-retest reliability (interclass correlations, 0.58-
0.83, depending on the informant and type of event).
27
Discrimi-
nant validity was established through comparisons of general popu-
lation and clinic-referred subjects.
27
The PTSD section of the CAPA inquires in detail about the
3 main symptom clusters. Coping mechanisms such as nor-
mal, obsessional, and compulsive suppression are explored; ques-
tions are asked about autonomic effects such as panic attacks;
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and other associated features are queried (eg, “omen forma-
tion” and engagement in dangerous activities). Diagnoses of
PTSD are computed using DSM-IV algorithms. Further details
can be found in a previous publication.
27
PROCEDURES
Children were first interviewed as closely as possible to their
9th, 11th, or 13th birthday and were interviewed annually un-
til 16 years of age, at home or in a location convenient for them.
Before the interviews began, the parent and child signed in-
formed consent forms approved by the institutional review board
of the Duke University Medical Center. They were then inter-
viewed in separate rooms. Each parent and child was paid $10
after the interview was completed. Interviewers attempted to
interview the primary caregiver, who was usually the biologi-
cal mother (83.2% of the time).
Interviewers were residents of the area in which the study took
place. All had at least bachelor’s-level degrees. They received
1 month of training and constant quality control, maintained by
postinterview reviews of each schedule by experienced inter-
viewer supervisors and study faculty (A.A.). Interviewers were
trained by the Department of Social Services staff per North Caro-
lina’s requirements for reporting abuse or neglect, and all sus-
pected cases were referred to the appropriate agency.
DATA MANAGEMENT AND ANALYSIS
Scoring programs for the CAPA, written in SAS statistical soft-
ware,
28
combined information about the date of onset, dura-
tion, and intensity of each symptom to create DSM-IV diag-
noses. Prevalence estimates, odds ratios, and group comparisons
were computed using the SAS program GENMOD.
28
We used
general estimation equations to account for the sampling de-
sign and within-subject correlation. In general estimation equa-
tions, the subject is introduced as a cluster (class) variable, and
the sampling weights are introduced as a scale vector that mul-
tiplies the subject’s wave-to-wave correlation matrix. We also
used the robust variance estimates (ie, sandwich-type esti-
mates), together with sampling weights, to adjust the stan-
dard errors of the parameter estimates to account for the mul-
tiphase sampling design. The use of multiwave data with the
appropriate sample weights thus capitalized on the multiple ob-
servation points over time while controlling for the effect on
variance estimates of the repeated measures. For predictive analy-
ses, logistic regression using the SAS procedure GLIMMIX
28
ex-
amined the effects of 1-year–lagged variables on current func-
tioning. Models were evaluated with the Bayesian information
criteria, an index that balances model fit with complexity.
29
RESULTS
POPULATION PREVALENCE
OF PTSD AND PTS SYMPTOMS
We derived the following 3 categories of PTS symp-
toms: (1) meeting all diagnostic criteria for DSM-IV PTSD;
2) endorsing at least 1 symptom each of painful recall,
hyperarousal, and avoidance symptoms but not meet-
ing full PTSD criteria (subclinical PTSD); and (3) report-
ing painful recall only.
Table 1 displays 3-month and
cumulative prevalence estimates for trauma exposure and
the 3 symptom categories. Two thirds of the sample re-
ported exposure to 1 or more events by 16 years of age.
Trauma exposure was more common in adolescence than
childhood (z=1.99; P=.05).
Full-blown DSM-IV PTSD was rare across all sex, age,
and ethnic groups (n =6; weighted prevalence, 0.5%).
Painful recall and subclinical PTSD were more com-
mon, with cumulative rates of 9.1% and 2.2%, respec-
tively, by 16 years of age in the full sample. Subclinical
PTSD was more common in adolescence than child-
hood (z=2.24; P=.02). Rates of painful recall and sub-
clinical PTSD did not differ across sex or ethnic groups.
Because full-blown PTSD was so rare, the few cases were
included in the painful recall and subclinical PTSD groups,
but not analyzed separately.
CONDITIONAL PROBABILITIES
Table 2 displays the prevalence rates for all potentially
traumatic events and the likelihood of developing symp-
toms when exposed to particular events. Events are grouped
into the broad categories of violence, sexual trauma, other
injury or trauma, witness to trauma, and learning about
trauma. By 16 years of age, similarly sized groups of chil-
Table 1. Three-Month and Cumulative Prevalence Estimates of Traumatic Events, Posttraumatic Stress Disorder (PTSD),
and Related Symptoms
Characteristic
Prevalence Estimate, Percentage (SE)
3-Month Lifetime
Trauma Painful Recall Subclinical PTSD PTSD Trauma Painful Recall Subclinical PTSD PTSD
Total 5.9 (0.5) 2.2 (0.3) 0.5 (0.1) 0.1 (0.1) 68.2 (2.1) 9.1 (1.2) 2.2 (0.6) 0.4 (0.2)
Age, y
9-13 4.8 (0.7) 2.0 (0.4) 0.2 (0.1) 0.03 (0.02) 54.0 (2.4) 5.4 (1.0) 0.9 (0.4) 0.1 (0.04)
14-16 6.6 (0.7) 2.3 (0.4) 0.6 (.2) 0.1 (0.1) 68.2 (2.1) 9.1 (1.2) 2.2 (0.6) 0.4 (0.2)
Sex
Male 5.9 (0.7) 2.1 (0.5) 0.6 (.2) 0.01 (0.01) 67.9 (2.9) 8.1 (1.7) 2.8 (1.1) 0.1 (0.1)
Female 6.0 (0.7) 2.4 (0.4) 0.3 (0.1) 0.2 (0.1) 68.4 (3.0) 10.2 (1.8) 1.6 (0.5) 0.7 (0.5)
Ethnicity
White 5.7 (0.5) 2.2 (0.3) 0.4 (0.1) 0.1 (0.1) 67.1 (2.3) 9.1 (1.3) 2.1 (0.6) 0.4 (0.3)
Native American 5.0 (0.6) 2.3 (0.4) 0.4 (0.1) * 73.9 (2.4) 9.7 (1.6) 1.7 (0.7) *
*Indicates no cases.
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dren reported no event exposure (32.2%), exposure to
1 event (30.8%), or exposure to multiple events (37.0%).
The most common events were witnessing or learning
about a traumatic event—so-called “vicarious” events.
Averaging 3-month and lifetime prevalance rates, about
1 of every 10 subjects exposed to trauma reported pain-
ful recall and about 3% reported subclinical PTSD. The
highest rates of painful recall and subclinical PTSD were
associated with violent events or sexual trauma. Three-
month and lifetime conditional probabilities did not dif-
fer appreciably across most traumatic event categories.
In addition to event characteristics, a lifetime history of
multiple trauma exposures strongly predicted higher rates
of painful recall and subclinical PTSD.
Subjects and their parents were queried about recent
impairments related to their experience of the trau-
matic event. Impairments included a wide range of prob-
lems, including disruption of important relationships,
school problems, physical problems, and exacerbation
of emotional problems. Rates of impairments were gen-
erally double the rates of having any painful recall. Chil-
dren with any traumatic event reported impairment 21.9%
of the time. As with PTS symptoms, the rates of impair-
ment increased with the number of traumatic events ex-
perienced. Impairment rates were 20.4% for those ex-
posed to 1 event and 49.6% for children exposed to 2 or
more events. Additional breakdowns by type of trauma
and type of impairment are available by request from one
of us (W.E.C.).
RISK FOR PTS SYMPTOMS
To test the predictors of PTS symptoms in the presence
of a traumatic event, 4 sets of variables were entered
into a model: (1) sex and current developmental period
(ages 9-13 [childhood] vs 14-16 years [adolescence]);
(2) previous emotional and behavioral disorders (anxi-
ety disorders, depressive disorders, and disruptive
behavior disorders); (3) previous negative events; and
(4) previous environmental, family, and parental risk
factors. All predictors except sex and developmental pe-
riod were assessed 1 year prior to trauma exposure. Re-
sults of the logistic analyses are presented in
Table 3.
Adolescence was a strong predictor of both painful re-
call and subclinical PTSD, controlling for other predic-
tor variables. Other significant predictors varied across
symptom categories. Painful recall was predicted inde-
pendently by exposure to a previous trauma and being
previously diagnosed as having an anxiety disorder.
Previous diagnosis with a depressive disorder did not
independently predict trauma response. For subclinical
PTSD, the best-fitting model included only sex and age.
In the full model, previous environmental adversity,
such as coming from an impoverished or poorly edu-
cated home, predicted subclinical PTSD, although the
fit index supports a more parsimonious solution. These
models suggest that age, prior anxiety, and previous
trauma exposure are important determinants of trauma
response in the next year.
Table 2. Prevalence of Traumatic Events and Conditional Probabilities for PTS Symptoms
Type of Trauma
Lifetime
3-Month
Prevalence
Rate, %
Painful
Recall*
Subclinical
PTSD*
Prevalence
Rate, %
Painful
Recall*
Subclinical
PTSD*
Violence 24.7 15.5 3.7 1.4 7.4 2.5
Violent death of loved one 2.4 39.9 14.1 0.04 24.2 18.4
Violent death of sibling/peer 14.5 12.0 0.6 0.7 3.5 1.2
War, terrorism 0.1 0 0 0 0 0
Cause of death or severe harm 0.6 5.3 0 0.1 0 0
Victim of physical violence 3.1 13.0 9.1 0.2 6.6 0
Physical abuse by relative 7.2 13.5 2.2 0.5 20.0 4.3
Captivity 0.9 7.0 3.5 0 0 0
Sexual trauma 11.0 10.0 3.9 0.2 16.4 6.4
Sexual abuse 10.9 8.4 3.4 0.2 17.4 6.8
Rape 1.2 33.2 17.1 0.02 65.6 34.4
Coercion 4.3 21.9 7.9 0.05 32.2 16.1
Other injury or trauma 32.8 4.5 1.8 1.8 7.7 6.7
Diagnosis of physical illness 11.0 3.6 2.4 0.7 9.6 8.3
Serious accident 11.6 7.6 2.7 0.4 20.4 18.0
Natural disaster 11.1 0.8 0.3 0.2 0 0
Fire 5.9 1.5 0 0.3 0 0
Exposure to noxious agent 3.3 0.3 0 0.3 0 0
Witness to life event 23.7 10.2 1.7 1.3 11.8 1.3
Learned about life event 21.4 6.7 1.5 1.4 2.5 0
Any trauma 67.8 13.4 3.3 5.9 8.7 3.1
No. of traumatic events
1 30.8 6.7 0.3 5.6 7.7 3.1
ⱖ2 37.0 19.1 5.7 0.3 25.3 2.6
Abbreviations: PTS, posttraumatic stress; PTSD, PTS disorder.
*Reported as the percentage of individuals exposed to the event (ie, conditional probability). Lifetime probabilities refer to current responses to any previous
event, whereas the 3-month probabilities are limited to current response to recent events.
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CO-OCCURRENCE OF PTS SYMPTOMS
WITH OTHER PSYCHIATRIC DISORDERS
Co-occurrence rates between common psychiatric dis-
orders, trauma exposure, and PTS symptoms are pre-
sented in
Table 4. Children exposed to trauma had al-
most double the rates of psychiatric disorders of those
not exposed. This effect was significant for all diagnos-
tic groups except substance use disorders. Higher levels
of PTS-related symptoms were associated with higher lev-
els of psychiatric disorders, with rates of 52.6% and 59.5%
for painful recall and subclinical PTSD, respectively. For
Table 3. Logistic Regression Analyses Predicting Painful Recall and Subclinical PTSD From 1-Year–Lagged Risk Factors
Variable*
OR (95% CI)†
Painful Recall Subclinical PTSD
Model 1 Model 2 Model 3 Model 4 Model 1 Model 2 Model 3 Model 4
Sex 0.8 (0.4-1.5) 0.8 (0.4-1.5) 0.8 (0.4-1.4) 0.8 (0.5-1.6) 2.2 (0.7-7.2) 2.4 (0.7-7.8) 2.3 (0.7-8.0) 2.4 (0.7-8.5)
Age 1.8 (0.9-3.4) 2.0 (1.0-3.8)‡ 2.1 (1.1-3.9)‡ 2.1 (1.1-4.1)‡ 3.3 (1.4-9.5)‡ 3.5 (1.2-10.2)‡ 3.8 (1.4-10.6)‡ 4.0 (1.4-11.5)‡
Trauma § 2.4 (1.2-4.7)‡ 2.3 (1.2-4.4) 2.2 (1.2-4.3)‡ § 3.0 (0.9-9.3) 2.5 (0.8-8.0)‡ 2.6 (0.8-8.6)
Life events § 1.9 (1.0-3.6) 1.7 (0.9-3.3) 1.7 (0.8-3.3) § 2.9 (1.0-8.6)† 2.1 (0.7-6.3) 2.2 (0.7-6.8)
Environmental adversities § § 1.2 (0.5-2.4) 1.2 (1.0-1.4) § § 1.2 (1.0-1.5) 1.3 (1.0-1.5)‡
Family dysfunction § § 1.2 (0.7-2.2) 1.2 (0.8-1.4) § § 1.6 (0.8-3.3) 1.7 (0.8-3.8)
Parental psychopathology § § 1.3 (0.7-2.4) 1.2 (0.8-.14) § § 1.1 (0.7-1.8) 1.1 (0.7-1.8)
Anxiety disorder § § § 2.7 (1.3-5.4)‡ § § § 2.1 (0.5-8.1)
Depressive disorder § § § 1.5 (0.5-4.1) § § § 0.2 (0.1-1.1)
Behavioral disorder § § § 0.8 (0.4-1.6) § § § 0.4 (0.1-2.2)
BIC 9355.6 9364.61 9348.8 9439.6 11 493.8 11 613.9 11 704.2 11 945.4
Abbreviations: BIC, Bayesian information criterion (lower is better); CI, confidence interval; OR, odds ratio; PTS, posttraumatic stress; PTSD, PTS disorder.
*All predictor variables except sex and age were assessed 1 year before trauma exposure. The age variable refers to childhood or adolescent status. Life events
includes low-magnitude events that did not meet the criteria as a DSM-IV extreme stressor. Environmental adversities includes a range of variables such as poverty ,
having a single parent, having 1 or more unemployed parents, and living in a dangerous community . Family dysfunction refers to parenting problems, marital conflict, or
frequent conflict between the child and a parent. The parental psychopathology variable includes mental health problems, substance abuse problems, and criminality .
†Models are described in the “Risk for PTS Symptoms” subsection of the “Results” section.
‡P⬍.05.
§Indicates variable not included in model.
Table 4. Lifetime Comorbidity Rates Between Psychiatric Disorders, Trauma Exposure, and Posttraumatic Stress Symptoms
Diagnosis
Trauma, %
OR (95% CI)
Painful
Recall, %
OR (95% CI)
Subclinical
PTSD, %
OR (95% CI)None Any None Any None Any
Any disorder 25.5 40.4 2.0 (1.3-3.0)* 33.9 52.6 2.2 (1.2-3.9)† 35.1 59.5 2.7 (0.8-9.2)‡
Affective disorders
Major depressive episode 2.2 1.7 0.8 (0.2-3.0) 1.5 5.5 3.8 (1.1-13.1)‡ 1.6 15.4 11.5 (2.3-57.8)†
Dysthymia 1.3 1.8 1.3 (0.3-6.3) 1.1 7.1 7.2 (1.8-29.1)† 1.1 26.3 33.4 (7.0-160.1)*
Depressive disorder NOS 3.2 9.5 3.2 (1.3-7.8)† 6.3 19.9 3.8 (1.8-7.8)* 6.9 35.6 7.5 (2.3-24.8)*
Any depressive disorder 3.3 9.8 3.2 (1.4-7.5)† 6.5 20.3 3.7 (1.8-7.6)* 7.1 37.1 7.7 (2.4-25.0)*
Anxiety disorders
Separation anxiety
disorder
1.1 6.7 6.3 (3.1-12.8)* 4.5 8.8 2.0 (1.1-3.8)‡ 4.8 12.9 3.0 (1.1-7.8)‡
Generalized anxiety
disorder
3.1 11.7 4.2 (1.7-10.1)* 6.7 31.4 6.4 (3.2-12.7)* 8.3 39.9 7.4 (2.3-23.3)*
Social anxiety disorder 1.2 2.6 2.2 (0.4-10.7) 1.7 6.2 3.8 (1.1-13.5)‡ 2.1 4.1 2.0 (0.5-8.2)
Any anxiety disorder 3.0 12.1 4.5 (2.2-9.3)* 7.6 24.8 4.0 (2.1-7.7)* 8.4 43.0 8.2 (2.7-25.3)*
Substance use disorders 6.4 10.6 1.7 (0.8-3.6) 8.3 18.4 2.5 (1.1-5.4)‡ 9.0 20.3 2.6 (0.9-10.9)
DBDs
ADHD 2.3 3.8 1.7 (0.7-4.3) 3.2 4.0 1.3 (0.6-2.7) 3.2 10.2 3.5 (1.2-9.8)‡
Conduct disorder 3.9 10.8 3.0 (1.6-6.0)* 7.6 18.0 2.7 (1.3-5.3)† 8.2 23.2 3.4 (0.9-12.6)
ODD 5.6 11.7 2.2 (1.2-4.2) 9.6 11.6 1.2 (0.7-2.1) 9.5 19.5 2.3 (0.9-5.6)
Any DBD 9.4 19.2 2.3 (1.4-3.7)* 15.2 24.5 1.8 (1.0-3.3)‡ 15.6 35.6 3.0 (1.0-8.9)‡
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; DBD, disruptive behavior disorder; NOS, not otherwise specified;
ODD, oppositional defiant disorder; OR, odds ratio; PTSD, posttraumatic stress disorder.
*P⬍.001.
†P⬍.01.
‡P⬍.05.
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both symptom groups, co-occurrence rates were signifi-
cant across a range of disorders, although the strength
of the association varied, suggesting both a general and
a specific pattern. Co-occurence odds ratios (ORs) were
highest for affective disorders and lower for substance
use and disruptive behavior disorders. The
Figure sug-
gests that the dose-dependent relation between trauma
and psychiatric disorders was similar to that observed for
trauma and PTS symptoms. This pattern, significant for
most diagnostic groups, was most pronounced for de-
pressive disorders.
FIRST TRAUMATIC EXPERIENCE
Risk factors significantly predicting first trauma expo-
sure in the model were previous (1-year–lagged) envi-
ronmental adversity (OR, 2.2; 95% confidence interval
[CI], 1.4-3.5), previous parenting problems (OR, 1.8; 95%
CI, 1.1-2.8), and history of a depressive disorder (OR,
3.1; 95% CI, 1.0-9.8). The same constellation of vulner-
ability factors showed trends toward predicting painful
recall, but only previous exposure to nontraumatic life
events was significant (OR, 2.4; 95% CI, 1.6-9.6). Over-
all, 8.2% of the studied individuals reported painful re-
call and 1.4% reported subclinical PTSD in response to
their first trauma exposure.
Rates of psychopathology were compared between
individuals reporting PTS symptoms in response to
their first trauma and those with no symptoms. One
year before trauma exposure, psychopathology rates
did not differ between groups (13.6% for trauma expo-
sure only vs 17.6% for trauma exposure and PTS symp-
toms; F
1
=0.81; P =.37). No differences were noted for
anxiety or depressive disorders before trauma expo-
sure. Immediately after trauma exposure, rates of psy-
chiatric disorders were higher in the group experienc-
ing painful recall (31.1% vs 14.5%; F
1
=8.82;P=.003).
The significant difference reflected increased levels of
anxiety disorders in the group with painful recall (2.2%
pretrauma vs 16.0% immediately following trauma ex-
posure). One year after trauma exposure, the 2 groups
did not differ on rates of psychopathology (F
1
=0.05;
P=.81). Overall, most children experienced few PTS
symptoms in response to their initial trauma exposure,
and those experiencing PTS symptoms were also at
highest risk of psychiatric morbidity.
COMMENT
The analyses of longitudinal data from a community-
based sample of children and adolescents showed that,
first, although exposure to traumatic events was almost
commonplace, full-blown DSM-IV PTSD was rare across
middle childhood and adolescence. Symptoms of PTS,
including painful recall and subclinical PTSD, were more
common, but very far from being expectable sequelae.
Second, children displaying PTS symptoms in response
to trauma exposure were more likely to be older, to have
a history of exposure to trauma, to have a history of anxi-
ety, and to come from an adverse family environment.
Third, higher levels of trauma exposure were related to
higher levels of most types of psychopathology, particu-
larly anxiety and depressive disorders, as well as other
impairments. Finally, the prognosis after a first lifetime
trauma exposure was generally favorable.
In this report, as in an earlier report covering a more
limited period,
30
our estimates of lifetime trauma expo-
sure in childhood and adolescence are generally slightly
higher than in previous community-based studies.
3,4
This
is attributable to a number of study characteristics in-
tended to improve accuracy of reporting. First, subjects were
interviewed at least 4 times during childhood and adoles-
cence about the immediate past, rather than relying on ret-
rospective recall in adulthood. At each assessment point,
both the parent and the child were interviewed. Each in-
terviewee was asked about each type of traumatic event (17
in all) separately, whereas some studies have asked gen-
eral questions about trauma exposure with a few ex-
amples.
The rate of PTSD after exposure to a traumatic event
was lower than that reported in studies of adults.
31,32
At
the same time, our results suggest that these children ex-
perienced PTS symptoms, higher rates of psychopathol-
ogy, and additional impairments. One explanation for
these findings has to do with the DSM-IV criteria them-
selves. These criteria were developed from the adult PTSD
literature
33
and may not accurately reflect severe re-
sponses to trauma in children. Childhood studies indi-
cate low reliability for PTS symptoms
34,35
and low diag-
nostic efficacy for the arousal symptoms,
36
and factor
analytic studies have often failed to support the 3-symp-
tom clusters of painful recall, arousal, and avoidance de-
scribed in the adult literature.
37,38
Furthermore, re-
search with children suggests that the optimal algorithm
for PTSD may require substantially fewer symptoms than
is required for diagnosis of the disorder in adults.
39-41
These
studies suggest that different symptom clusters and dif-
ferent levels of symptoms are needed to predict impair-
ment in childhood samples. Although the present study
did not intend to evaluate the current DSM-IV PTSD cri-
teria, the findings suggest that the current criteria, when
applied to children, may not be developmentally sensi-
tive or that childhood PTSD is rare.
Psychopathology is strongly interrelated with trauma
and trauma symptoms. Across childhood, the children
70
60
50
40
30
20
10
0
None
(32.2%)
1
(30.8%)
2
(22.4%)
3
(7.1%)
≥4
(7.5%)
No. of Events
Percentage of Subjects
Any Diagnosis
Any Anxiety Diagnosis
Any Depression Diagnosis
Any Behavioral Diagnosis
Figure. Effect of increasing trauma exposures on cumulative rates of
psychiatric diagnoses by age 16 years.
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who experience trauma are often those with anxiety, de-
pressive, and disruptive behavior disorders, a finding sup-
ported in the present study. This likely reflects common
liability conveyed from a limited set of family risk fac-
tors.
42
Furthermore, psychopathology, particularly de-
pression and anxiety, can serve as a risk for and sequela
of trauma exposure.
43,44
Our study indicated some speci-
ficity in the role of psychopathology as risk for trauma
and trauma exposure. Past depression best predicted first
trauma, but it was a history of anxiety disorders that best
predicted PTS symptoms in response to trauma expo-
sure. Both of these disorders are also common sequelae
of trauma exposure, with rates increasing dramatically
immediately after the first trauma exposure. This rela-
tionship is strongest in individuals who also display some
PTS symptoms (ie, at least painful recall).
Among potential sources of bias, a previous report sug-
gested little evidence of symptom attenuation (lower re-
ported symptom levels in subsequent data waves), co-
hort differences, and differential dropout in this sample.
45
Conversely, if bias were inflating estimates of traumatic
events, this would likely be reflected in similarly el-
evated psychopathology; however, psychiatric preva-
lence rates reported from this sample are consistent with
rates obtained from other community-based studies.
46,47
On the other hand, the study may underestimate life-
time rates of traumatic events because interviews began
when children were already in middle childhood.
A number of sources of bias may be specific to the life
events and PTSD module. Our screening structure was
intended to minimize cases in which the full PTSD mod-
ule is completed unnecessarily. The screening structure
requires the presence of painful recall symptoms (in-
cluding nightmares, thoughts, or images) before inquir-
ing about avoidance and hyperarousal symptoms. This
decision, made to increase diagnostic efficacy, gave some
primacy to painful recall during the less specific hyper-
arousal and avoidance symptoms. Subsequent studies sup-
port this decision, suggesting that symptoms involving
bad dreams and repetitive thoughts have the highest di-
agnostic efficacy for predicting full-blown PTSD in chil-
dren, along with behavioral and emotional avoidance
symptoms.
48,49
Hyperarousal symptoms, by contrast, have
the lowest levels of diagnostic efficacy.
There was no independent verification of the occur-
rence of the traumatic events reported; instead, we re-
lied on information from the parent and/or the child.
This could bias the estimate of the number of poten-
tially traumatic events leading to PTSD because infor-
mants may forget events that had no emotional sequelae
or suppress events that caused PTS symptoms. This is
probably an unavoidable problem in community-based
studies of PTSD that do not follow a specific event, such
as a hurricane or flood, because it is practically impos-
sible to verify not only the events reported but also ex-
posure to events not reported. The advantage that, we
believe, outweighs this drawback to general population
studies is that we were able to examine the interplay of
multiple different types of events, over time, on the risk
of PTSD.
Severe events such as sexual abuse may be under-
reported. In studies assessing for events at multiple time
points, it is not uncommon for an event reported at 1 time
point to be followed by a false-negative report.
50,51
Those
results support the methods used in the current study
of assessing severe events at multiple time points. Also,
mandated reporting requirements might suppress re-
porting for physical and sexual abuse, events associated
with higher rates of PTS symptoms.
Finally, our study used subcategories of PTS symp-
toms (ie, subclinical PTSD and painful recall only) to
identify children with 2 symptom levels that might in-
fluence functioning. Other categories could have been
used (eg, DSM-IV criteria A, B, and E and criterion C or
D), and prevalence rates and other results would vary
depending on the stringency of the criteria. However,
increasing evidence suggesting that children with an
impairing response to trauma may be characterized by
fewer symptoms supports the use of categories with
relatively minimal requirements such as those used in
this study.
37,40
CONCLUSIONS
Studies of childhood trauma that use convenience
samples of children exposed to specific events and un-
dergoing assessment for PTS symptoms only provide
incomplete answers to questions about how common
trauma is in childhood and how children typically re-
spond to potentially traumatic events. The present
study followed up a large community sample of chil-
dren through middle childhood to adolescence with re-
peated assessments for trauma exposure and a range of
potential responses. The findings suggest that the ef-
fects of trauma are not symptom specific. Few children
exposed to trauma develop PTSD, and the few who dis-
play PTS symptoms can be identified through informa-
tion about their age, trauma history, anxiety history,
and family environment. Children exposed to traumatic
events also displayed higher rates of depression, anxiety
disorders, and other impairments.
Submitted for Publication: June 26, 2006; final revi-
sion received September 20, 2006; accepted October 1,
2006.
Correspondence: William E. Copeland, PhD, Center for
Developmental Epidemiology, Department of Psychia-
try and Behavioral Sciences, Duke University Medical Cen-
ter, Campus Box 3454, Durham NC 27710 (william
.copeland@duke.edu).
Author Contributions: Dr Copeland had full access to all
the data in this study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This study was supported by grants
MH63970, MH63671, and MH48085 from the National
Institute of Mental Health; grant DA/MH11301 from the
National Institute on Drug Abuse; and the William T.
Grant Foundation.
Acknowledgment: We thank John March, MD, and John
Fairbank, PhD, for their assistance in developing the life
events and PTSD measures used in this study.
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