Article

Posttraumatic Stress Without Trauma in Children

William E. Copeland, Ph.D. Gordon Keeler, M.A. Adrian Angold, M.R.C.Psych. E. Jane Costello, Ph.D.
Objective: It remains unclear to what degree children show signs of posttraumatic stress disorder (PTSD) after experiencing low-magnitude stressors, or stressors milder than those required for the DSM-IV extreme stressor criterion. Method: A representative community sample of 1,420 children, ages 9, 11, and 13 at intake, was followed annually through age 16. Low-magnitude and extreme stressors as well as subsequent posttraumatic stress symptoms were assessed with the Child and Adolescent Psychiatric Assessment. Two measures of posttraumatic stress symptoms were used: having painful recall, hyperarousal, and avoidance symptoms (subclinical PTSD) and having painful recall only. Results: During any 3-month period, lowmagnitude stressors occurred four times as often as extreme stressors (24.0% compared with 5.9%). Extreme stressors elicited painful recall in 8.7% of participants and subclinical PTSD in 3.1%, compared with 4.2% and 0.7%, respectively, for lowmagnitude stressors. Because of their higher prevalence, however, low-magnitude stressors accounted for two-thirds of cases of painful recall and half of cases of subclinical PTSD. Moreover, exposure to low-magnitude stressors predicted symptoms even among youths with no prior lifetime exposure to an extreme stressor. Conclusions: Relative to low-magnitude stressors, extreme stressors place children at greater risk for posttraumatic stress symptoms. Nevertheless, a sizable proportion of children manifesting posttraumatic stress symptoms experienced only a low-magnitude stressor. (Am J Psychiatry 2010; 167:10591065)

esearchers have long debated the advantages and disadvantages of relatively broad or restrictive denitions of the stressor criterion for posttraumatic stress disorder (PTSD) (14). Prior to DSM-IV, the stressor denition reected the implicit view that only certain relatively rare and extreme events commonly elicit PTSD. Thus in DSMIII and DSM-III-R, the stressor criterion was dened in terms of a precipitating event with extreme, objective characteristics (5, 6). Subsequent studies challenged this view. Exposure to the extreme stressors dened by DSMIII and DSM-III-R appeared to be relatively common, occurring, for example, in approximately half of respondents in the National Comorbidity Survey (7), and such events did not invariably lead to PTSD symptoms. For example, the conditional risk for PTSD following trauma exposure was only 9.2% in the Detroit Area Survey of Trauma (8). Researchers also found that pretrauma factors moderated the risk for PTSD (7, 8). Finally, evidence suggested that milder stressors not meeting the extreme stressor denition could elicit PTSD. As a result, the stressor criterion was expanded in DSM-IV (9) and incorporated information about the individuals response to the event (4, 10). The DSM-IV eld trial (2) tested ve alternative stressor denitions, ranging from a nonrestrictive criterion, in which any event that was followed by the development of criteria B, C, and D was sufcient for a PTSD diagnosis, to the more stringent DSM-III-R denition. In a commuAm J Psychiatry 167:9, September 2010

nity sample, rates of lifetime PTSD varied only by 3%4% across these stressor denitions in criterion A. The authors concluded that the different stressor denitions in criterion A had minimal impact on PTSD prevalence across all proposed criteria and that the stressor denition should not be based on the rarity of the event. The implications for children and adolescents were unclear, since the trial included mostly adults, a few adolescents, and no children. Several lines of evidence suggest that the response to negative events differs between children and adults. Children possess immature social and cognitive capacities that might moderate the effects of trauma or inuence the expression of symptoms (11). Consistent with this possibility, a recent meta-analysis suggested that PTSD is rare in childhood, with an estimated rate of 0.6% (12). This could reect age-related differences either in symptom expression or in stress-related vulnerability. In any case, questions arise from such data about the manner in which children respond to a range of negative events. In particular, it remains unclear to what degree children develop signs of PTSD after experiencing relatively mild stressor events below the current DSM-IV extreme stressor threshold (1315). Previous community-based studies examining this issue generally considered only relatively severe events meeting the DSM-IV stressor criterion (1618). While this is understandable, inclusion of additional events would
ajp.psychiatryonline.org

1059

POSTTRAUMATIC STRESS WITHOUT TRAUMA IN CHILDREN TABLE 1. Comparison of 3-Month Prevalence Estimates of Low-Magnitude Stressors, Extreme Stressors, Painful Recall, and Subclinical PTSD in 1,420 Children and Adolescentsa Low-Magnitude Stressors Event Group or Subgroup % SE Painful Recall % SE Subclinical PTSD % SE % Event SE Extreme Stressors Painful Recall % SE Subclinical PTSD % 0.2 0.2 0.2 0.1 0.3 SE 0.1 0.1 0.1 0.1 0.2

Total 24.0 1.1 1.0 0.2 0.2 0.1 5.9 0.5 0.5 0.1 Gender Female 25.0 1.6 1.2 0.3 0.3 0.2 5.9 0.7 0.7 0.2 Male 23.2 1.5 0.8 0.2 0.04 0.02 6.0 0.7 0.3 0.1 Age 913 years 21.8 1.4 0.9 0.3 0.2 0.1 4.8 0.7 0.4 0.2 1416 years 25.7 1.3 1.0 0.3 0.2 0.1 6.6 0.7 0.6 0.2 a Subclinical PTSD was dened as endorsing the presence of symptoms of painful recall, hyperarousal, and avoidance.

permit comparisons between such extreme stressors and other negative events of lower magnitude in terms of associated risk for PTSD symptoms. Several outcomes of such research are possible. First, consistent with the implicit approach in DSM-IV, both types of event could elicit negative outcomes, but only extreme stressors might elicit PTSD symptoms. Alternatively, both types of event could elicit both negative outcomes and PTSD symptoms, but the conditional risk from extreme stressors might be greater than that for low-magnitude negative events. Vulnerability to events might also differ as a function of prestress factors, as has been suggested by some (but not all [19]) previous studies (2022). Any study comparing response to extreme and lowmagnitude stressors must grapple with the fact that people experiencing any form of traumatic event are likely to experience multiple negative events (16, 23, 24). Thus, any association between a mild stressor and PTSD symptoms could reect the inuence of a more extreme stressor that occurred earlier and might have sensitized the individual to the later milder stressor. Adult and child studies of PTSD do indeed suggest that previously exposed individuals are sensitized to the effects of subsequent trauma (16, 25, 26). However, no community-based prospective studies of youths have examined the unique effects of multiple extreme stressors on a range of negative outcomes. In this study, we compared the strength of the association that low-magnitude and more extreme stressors manifest with PTSD symptoms (16). The study relied on a measure of PTSD symptoms but could not formally test associations with the diagnosis of PTSD, which was rare in our sample, as in previous community samples of children (12). Nevertheless, even subclinical symptoms of PTSD are important to recognize in children (2729), since children with such symptoms do not differ signicantly in terms of impairment or distress from children who meet full criteria for PTSD (29).

need for mental health services in rural and urban youths (30, 31). In 1993, a representative sample of 1,420 children ages 9, 11, and 13 at intake was recruited from 11 counties in western North Carolina. Potential participants were selected from the population of some 20,000 children, using a household equal probability, accelerated cohort design. American Indian children were oversampled to make up 25% of the nal sample. The nal sample consisted of 350 Indian children (81% of those recruited) and 1,070 non-Indian children (80% of those recruited); of the latter, 92.5% were white and 7.5% were African American. In the analyses, each individuals contribution was weighted proportionately to the probability of selection into the study, so that the results are representative of the whole population of children of this age. The average response rate over the several assessment waves was 83%. Attrition and nonresponse did not differ among the groups considered here and were not associated with psychiatric status. In this article, we present data on 6,674 parent-child pairs of interviews carried out across the child age range of 916 years.

Procedure
Children and their primary caregivers (the biological mother 83% of the time) were interviewed separately in their homes or another convenient location by trained interviewers who were residents of the study area. Interviewers were trained by Department of Social Services staff in the requirements for reporting abuse or neglect. Before the interviews began, parent and child signed informed consent or assent forms approved by the Duke University Medical Center Institutional Review Board.

Measures
Extreme stressors, other negative events, and associated posttraumatic stress symptoms were assessed using the life events and posttraumatic stress sections of the Child and Adolescent Psychiatric Assessment (32). The life events section includes 17 potentially traumatic events (i.e., those meeting DSM-IV PTSD criterion A extreme stressors, such as physical abuse and violent death of a loved one) and 15 events that do not meet criterion A and have commonly been associated with anxiety or depression in children (33, 34). The parent or child was queried about the occurrence of each event within the past 3 months and when it occurred. Criterion A events were also assessed for lifetime occurrence. A reliability study with 58 parents and children interviewed twice by different interviewers found fair to excellent testretest reliability (intraclass correlations ranged from 0.58 to 0.83, depending on the informant and the type of event) (34). A list of events and 3-month prevalence rates was presented in a previous publication (35). For each event, the interviewer asked screening questions to determine whether the three key symptom clusters of PTSD (painful recall, avoidance, and hyperarousal) were present dur-

Method
Sample
The Great Smoky Mountains Study is a longitudinal study of the development of psychiatric and substance use disorders and

1060

ajp.psychiatryonline.org

Am J Psychiatry 167:9, September 2010

COPELAND, KEELER, ANGOLD, ET AL. TABLE 2. Conditional Probabilities for Painful Recall and Subclinical PTSD for Low-Magnitude Stressors and Extreme Stressors in 1,420 Children and Adolescentsa Low-Magnitude Stressors Painful Recall Group or Subgroup % SE Subclinical PTSD % SE Extreme Stressors Painful Recall % SE Subclinical PTSD % SE 1.3 1.7 2.1 0.5 2.5

Total 4.2 0.9 0.7 0.5 8.7 2.1 3.1 Gender Female 5.0 1.4 1.2 0.9 13.2 3.8 3.5 Male 3.4 1.1 0.2 0.1 4.9 2.2 2.9 Age 913 years 3.9 1.1 0.6 0.4 8.7 3.1 1.0 1416 years 4.4 1.2 0.8 0.5 8.4 2.7 5.2 a Subclinical PTSD was dened as endorsing the presence of symptoms of painful recall, hyperarousal, and avoidance.

ing the past 3 months and were linked to the event under discussion. Painful recall/reexperiencing was assessed rst, and if it was endorsed, the interviewer inquired about avoidance and hyperarousal. Painful recall/reexperiencing is dened as unwanted, painful, and distressing recollections, memories, thoughts, or images of the event. In young children, this might involve repetitive play, trauma-specic reenactment, or nightmares. This procedure was used to avoid false positives and to reduce the length of the interview (32). If at least minimal or higher levels of all three symptoms were endorsed, then the detailed PTSD module was completed. Because few children met full diagnostic criteria for PTSD, two measures of PTSD symptoms were used: endorsing the presence of symptoms of painful recall, hyperarousal, and avoidance, which was dened as subclinical PTSD, and endorsing painful recall only.

Analyses
Prevalence estimates, odds ratios, and group comparisons were computed using the PROC GENMOD program of the SAS software package (SAS Institute, Cary, N.C.) with the general estimation equations option to account for both the sampling design and within-subject correlations. Robust variance estimates (i.e., sandwich-type estimates) were used, together with sampling weights, to adjust the standard errors of the parameter estimates to account for the multiphase sampling design. The use of multiwave data with the appropriate sample weights thus capitalized on the multiple observation points over time while controlling for the effect on variance estimates of repeated measures.

Results
Prevalence Table 1 lists 3-month prevalence estimates for both low-magnitude and extreme stressors and the two eventrelated outcomespainful recall only and subclinical PTSD. The rates for the event-related outcomes are base rates, considering all children in the sample, and therefore are not conditional on event exposure. During any 3-month period, about four times more children reported a low-magnitude stressor than an extreme stressor (24.0% versus 5.9%, p<0.001). This 4:1 ratio for low-magnitude relative to extreme stressor exposures, however, was not reected in the outcome data (Table 1). Despite the markedly greater rate of low-magnitude stressors, painful recall associated with low-magnitude stressors was only twice as common as painful recall associated with
Am J Psychiatry 167:9, September 2010

extreme stressors (1.0% compared with 0.5%, p<0.02). Moreover, low-magnitude and extreme stressors were associated with similar numbers of children with subclinical PTSD (0.2% in both cases), despite the markedly higher rate of low-magnitude stressors. Thus, while lowmagnitude stressors occur far more commonly than extreme stressors, these data suggest that they are far less likely to be associated with symptoms. Nevertheless, because of their high prevalence, low-magnitude stressors accounted overall for 68.9% of cases of painful recall and 47.9% of cases of subclinical PTSD. The consistency of this general pattern was compared across gender and age groups. Both types of stressor events were slightly more common in adolescence than in childhood (low-magnitude stressors: odds ratio=1.2, 95% condence interval [CI]=1.01.4, p=0.03; extreme stressors: odds ratio=1.4, 95% CI=1.02.0, p=0.05). Subclinical PTSD with extreme stressors was more common in adolescence (odds ratio=5.4, 95% CI=1.223.2, p=0.02), but rates of all other PTSD outcomes were invariant with age. Although rates of events did not vary by gender, girls had higher rates of both PTSD-related outcomes. Subclinical PTSD following low-magnitude stressors was much more common in girls than in boys (odds ratio=7.1, 95% CI=1.2 43.1, p=0.03), although the base rates for both boys and girls were below 0.5%. Conditional Rates Table 2 presents the rates for various outcomes only for children who reported exposure to a stressorthat is, conditional rates for the various outcomes. Low-magnitude stressors produced more cases of children with PTSD-related symptoms than did extreme stressors because of the high rate of low-magnitude stressors. However, the less common high-magnitude events were more potent predictors of symptoms: conditional rates were signicantly higher for extreme relative to low-magnitude stressors (painful recall: 8.7% compared with 4.2%, p=0.05; and subclinical PTSD: 3.1% compared with 0.7%, p<0.03). Girls were generally more vulnerable to both types of negative events. After extreme stressors, girls were more likely than boys to develop painful recall (odds
ajp.psychiatryonline.org

1061

POSTTRAUMATIC STRESS WITHOUT TRAUMA IN CHILDREN

FIGURE 1. Effect of Prior Event Exposures on Response to a Recent Low-Magnitude Eventa

Conditional Rates for Painful Recall 8

low-magnitude events is available on request from the rst author.) Multiple Exposures Children also were assessed for prior stress exposure. Exposure to multiple stressor events was common. Of those with a recent low-magnitude stressor, 17.4% (SE=1.5) reported no prior extreme stressor or low-magnitude stressor, 13.0% (SE=1.6) reported prior low-magnitude stressors only, 23.6% (SE=1.6) reported only prior extreme stressors, and 38.2% (SE=2.2) reported prior exposure to both extreme stressors and low-magnitude stressors. It is plausible that most symptomatic children exposed to recent low-magnitude stressors had also experienced prior exposure to extreme stressors. This possibility was evaluated, as shown in Figure 1. Figure 1 displays conditional risks for painful recall and subclinical PTSD after exposure to low-magnitude stressors. Even children with no prior exposure to an extreme stressor displayed PTSD symptoms. Exposure to a prior extreme stressor did not further increase risk for painful recall or subclinical PTSD. This result, however, could be inuenced by the time interval between the events, such that extreme stressors occurring in the distant past do not modulate the relationship between more recent lowmagnitude stressors and symptoms. We evaluated this possibility in logistic regression models predicting PTSD symptoms following low-magnitude stressors. In each model, predictors were included for both types of stressor occurring in the recent past (<1 year ago) or the distant past (>1 year ago). Results for these models are presented in Table 3. The models show that recent extreme stressors did increase risk for both types of posttraumatic stress following low-magnitude stressors.

6
Percent

0 No prior events Prior Prior extreme low-magnitude stressor only stressor only Prior both events

Conditional Rates for Subclinical PTSD

1.5

Percent

1.0

0.5

0 No prior events
a

Prior Prior extreme low-magnitude stressor only stressor only

Prior both events

Children who reported only a prior extreme stressor had signicantly lower rates of painful recall following a recent lower-magnitude event than those who had no prior exposures or exposure to both types of event.

ratio=3.1, 95% CI=1.19.1, p=0.04). Similarly, for lowmagnitude stressors, girls also had higher rates than boys for subclinical PTSD (odds ratio=6.5, 95% CI=1.040.9, p=0.04) but not for painful recall. There were no differences for either outcome by age. Not all low-magnitude stressor events had similar conditional rates. Some events almost never resulted in subsequent symptoms (conditional risk <1.0%; e.g., a new child in home, moving house), whereas risks associated with others were similar to or greater than the average response to extreme stressor events. In terms of painful recall, such high-risk, low-magnitude stressors included death of a loved one (6.5%; SE=5.1), parental separation (9.1%; SE=4.8), breaking up with a best friend (9.0%; SE=4.0), or breaking up with a boyfriend or girlfriend (6.6%; SE=2.8). Similarly, cases of subclinical PTSD in response to low-magnitude stressors were almost entirely accounted for by parental separation (4.1%; SE=3.5), breaking up with a best friend (2.1%; SE=2.1), and breaking up with a boyfriend or girlfriend (1.5%; SE=1.3). (A full list of conditional rates for both outcomes for each of the

Discussion
PTSD is one of the few DSM-IV disorders dened by its etiology. As such, the denition of the stressor criterion constrains the scope of the diagnosis. Among individuals exposed to low-magnitude stressors, a small proportion displayed PTSD symptoms compared with those exposed to extreme stressors. Nevertheless, because low-magnitude stressors are far more common than extreme stressors, they generated a greater proportion of the negative outcomes among the children in this study, accounting for half of those with subclinical PTSD and two-thirds of those reporting painful recall only. For most of the children who developed PTSD symptoms after exposure to low-magnitude stressors, the symptoms followed interpersonal loss: death of a loved one, parental separation, breakup with a best friend, or breakup with a boyfriend or girlfriend. Thus, while extreme stressors were the more potent risk factors for PTSD symptoms, low-magnitude stressors accounted for a signicant portion of children with symptoms.
Am J Psychiatry 167:9, September 2010

1062

ajp.psychiatryonline.org

COPELAND, KEELER, ANGOLD, ET AL. TABLE 3. Regression Models Predicting Conditional Risk for PTSD Symptoms Following a Low-Magnitude Stressor From Prior Exposuresa Painful Recall Variable
a

Subclinical PTSD 95% CI Odds Ratio 95% CI

Odds Ratio

Distant extreme stressor 0.3* 0.10.6 1.2 0.34.1 Distant low-magnitude stressor 1.6 0.73.6 1.4 0.82.4 Recent extreme stressor 3.0* 1.09.2 6.2* 1.427.2 Recent low-magnitude stressor 1.9 0.84.4 1.8 0.56.0 a Subclinical PTSD was dened as endorsing the presence of symptoms of painful recall, hyperarousal, and avoidance. Distant events occurred more than a year prior to the current event, and recent events had occurred within the past year. *p<0.05.

Many children had experienced multiple stressors over their lifetime, and most children who developed PTSD symptoms after low-magnitude stressor events had also experienced extreme stressors. Extreme stressors occurring more than a year before the recent event tended to have little impact on risk, but recent extreme stressors increased the risk threefold to sixfold after subsequent lowmagnitude events. These ndings are only partially consistent with data from adult samples (25, 26), although both sets of ndings emphasize the impact of recent stressors. One goal of this study was to inform efforts to classify antecedents of traumatic stress in children. A few recommendations are warranted. First, our results support the need to clearly distinguish extreme and low-magnitude stressors, since the risk for stress-related symptoms is distinctly higher with extreme stressors. At the same time, our results also suggest the importance of recognizing the risk associated with low-magnitude stressors. Although such events have a lower conditional probability of predicting PTSD symptoms than do extreme stressors, they have a high prevalence. Moreover, the relatively modest risk of low-magnitude stressors increases when children exposed to mild stress also have a history of signicant stress within the past year as well as for those who have a prior history of anxiety and an adverse family environment (16). Thus, determining a childs relative risk for PTSD symptoms should involve consideration of the event type, recent event history, and developmental context. This study compared the sequelae of different types of stressful events, yet very few children in the study met criteria for full-blown PTSD. This is clearly not because of lack of event exposure, since the majority of children had been exposed to an extreme stressor by age 16. The most likely explanation is that the DSM-IV cutoffs for criteria B, C, and D were derived from studies of adults, and the optimal algorithm for PTSD in children may require substantially fewer symptoms (2729). This is an issue currently under study for DSM-5. A number of other epidemiologic samples of PTSD in childhood have reported similarly low rates (16, 36, 37; see references 18 and 38 for population-based studies with higher rates). It is also possible, however, that the lower rates of PTSD are attributable to our use of screening questions. Participants had to display at least one general symptom from each sympAm J Psychiatry 167:9, September 2010

tom cluster (i.e., painful recall, hyperarousal, and avoidance) to proceed to the full PTSD module. For example, the screen for painful recall probes for unwanted, painful, and distressing recollections, memories, thoughts, or images of the life event (including repetitive play or traumaspecic reenactment). This screen overlaps with the rst three symptoms listed in criterion B, but not the last two. Therefore, some children may have met criterion B based on the symptoms not assessed. The use of screens likely results in a modest reduction in the studys sensitivity to detect full-blown PTSD. At the same time, the same screen structure was used after low-magnitude stressors and extreme stressors. Thus, even if our estimates for overall PTSD symptoms are low, this would have affected the groups with extreme stressors and low-magnitude stressors equally. Thus our primary conclusion that cases of posttraumatic stress symptoms may be underidentied with a strict application of the A1 criterion would not have been affected by use of the screen. It is also important to note that few studies can evaluate the stressor criterion because most began after publication of DSM-IV and thus only assess for PTSD symptoms after those events already codied in the stressor criterion. This study is unusual in its ability to inform our understanding of the differential effects of high-magnitude versus lowmagnitude stressor events in children, even if it cannot usefully speak to the risk for full-blown PTSD and may underestimate rates of PTSD symptoms overall.

Conclusions
PTSD is a relatively new addition to DSM, only appearing in 1980 (6). Since that time, much work has been done to better understand the risk for posttraumatic symptoms in adult community samples (7, 25, 39), but research on PTSD in children has often focused on clinical samples or groups of children exposed to a single traumatic event. This study supports the DSM-IV extreme stressors as most likely to elicit posttraumatic stress symptoms, but it also suggests as a troubling public health concern that many, if not most, children experiencing signicant levels of posttraumatic stress or PTSD symptoms will be unidentied if we fail to assess the impact of low-magnitude stressors.
ajp.psychiatryonline.org

1063

POSTTRAUMATIC STRESS WITHOUT TRAUMA IN CHILDREN

Received Feb. 6, 2009; revisions received April 10, 2009, and March 10 and March 19, 2010; accepted March 25, 2010 (doi: 10.1176/appi.ajp.2010.09020178). From Duke University Medical Center, Department of Psychiatry and Behavioral Sciences. Address correspondence and reprint requests to Dr. Copeland, Center for Developmental Epidemiology, Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Box 3454, Durham, NC 27710; william.copeland@duke.edu (e-mail). 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. The authors thank John March, M.D., Lisa Amaya-Jackson, M.D., and John Fairbank, Ph.D., for their assistance in developing the life events and posttraumatic stress disorder measures used in this study.

References
1. March JS: What constitutes a stressor? the criterion A issue, in Posttraumatic Stress Disorder: DSM-IV and Beyond. Edited by Davidson JRT, Foa E. Washington, DC, American Psychiatric Press, 1993, pp 3754 2. Kilpatrick DG, Resnick HS, Freedy JR, Pelcovitz D, Resick PA, Roth S, van der Kolk B: The posttraumatic stress disorder eld trial: evaluation of the PTSD construct: criteria A through E, in DSM-IV Sourcebook. Edited by Widiger T, Pincus HA, First MB, Ross R, Davis W. Washington, DC, American Psychiatric Press, 1998, pp 803844 3. Breslau N, Kessler RC: The stressor criterion in the DSM-IV posttraumatic stress disorder: an empirical investigation. Biol Psychiatry 2001; 50:699704 4. Solomon Z, Mikulincer M: Life events and combat-related posttraumatic stress disorder: the intervening role of locus of control and social support. Mil Psychol 1990; 2:241256 5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised (DSM-III-R). Washington, DC, American Psychiatric Association, 1987 6. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed (DSM-III). Washington, DC, American Psychiatric Association, 1980 7. Kessler R, Sonnega A, Bromet E, Hughes M, Nelson C: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:10481060 8. Breslau N, Kessler R, Chilcoat H, Schultz L, Davis G, Andreski P: Trauma and posttraumatic stress disorder. Arch Gen Psychiatry 1998; 55:626632 9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC, American Psychiatric Assocication, 1994 10. Helzer JE, Robins LN, McEvoy L: Post-traumatic stress disorder in the general population: ndings of the Epidemiologic Catchment Area Survey. N Engl J Med 1987; 317:16301634 11. Compas BE, Connor-Smith JK, Saltzman H, Thomsen AH, Wadsworth ME: Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research. Psychol Bull 2001; 127:87127 12. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children and Young Adults (Research Advances and Promising Interventions): Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC, National Academies Press, 2009 13. Sandberg S, Rutter M, Giles S, Owen A, Champion L, Nicholls J, Prior V, McGuinness D, Drinnan D: Assessment of psychosocial experiences in childhood: methodological issues and some illustrative ndings. J Child Psychol Psychiatry 1993; 34:879897

14. Williamson DE, Birmaher B, Anderson BP, Al-Shabbout M, Ryan ND: Stressful life events in depressed adolescents: the role of dependent events during the depressive episode. J Am Acad Child Adolesc Psychiatry 1995; 34:591598 15. Garrison CZ, Schoenbach VJ, Schluchter MD, Kaplan BH: Life events in early adolescence. J Am Acad Child Adolesc Psychiatry 1987; 26:865872 16. Copeland W, Keeler G, Angold A, Costello E: Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 2007; 64:577584 17. Cuffe SP, Addy CL, Garrison CZ, Waller JL, Jackson KL, McKeown RE, Chilappagari S: Prevalence of PTSD in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry 1998; 37:147154 18. Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E: Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 1995; 34:13691380 19. Angold A, Worthman CM, Costello EJ: Puberty and depression, in Gender Differences at Puberty. Edited by Hayward C. New York, Cambridge University Press, 2003, pp 137164 20. Fergusson DM, Horwood LJ, Lynskey MT: Maternal depressive symptoms and depressive symptoms in adolescents. J Child Psychol Psychiatry 1995; 36:11611178 21. Petersen AC, Sarigiani PA, Kennedy RE: Adolescent depression: why more girls? J Youth Adolesc 1991; 20:247271 22. Silberg J, Pickles A, Rutter M, Hewitt J, Simonoff E, Maes H, Carbonneau R, Murrelle L, Foley D, Eaves L: The inuence of genetic factors and life stress on depression among adolescent girls. Arch Gen Psychiatry 1999; 56:225232 23. Perkonigg A, Pster H, Stein MB, Her M, Lieb R, Maercker A, Wittchen H-U: Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry 2005; 162:13201327 24. Perkonigg A, Wittchen HU: Prevalence and comorbidity of traumatic events and posttraumatic stress disorder in adolescents and young adults, in Post-Traumatic Stress Disorder: A Lifespan Developmental Perspective. Edited by Maercker A, Schtzwohl M, Solomon Z. Seattle, Hogrefe & Huber, 1999, pp 113133 25. Breslau N, Chilcoat HD, Kessler RC, Davis GC: Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am J Psychiatry 1999; 156:902907 26. Davidson JRT, Hughes D, Blazer DG, George LK: Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med 1991; 21:713721 27. Scheeringa MS, Peebles CD, Cook CA, Zeanah CH: Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. J Am Acad Child Adolesc Psychiatry 2001; 40:5260 28. Scheeringa MS, Zeanah C, Myers L, Putnam F: New ndings on alternative criteria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 2003; 42:561571 29. Carrion VG, Weems CF, Ray R, Reiss AL: Toward an empirical denition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002; 41:166173 30. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A: Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003; 60:837844 31. Costello EJ, Angold A, Burns BJ, Stangl DK, Tweed DL, Erkanli A, Worthman CM: The Great Smoky Mountains Study of Youth: goals, design, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry 1996; 53:11291136

1064

ajp.psychiatryonline.org

Am J Psychiatry 167:9, September 2010

COPELAND, KEELER, ANGOLD, ET AL.

32. Costello EJ, Angold A, March J, Fairbank J: Life events and posttraumatic stress: the development of a new measure for children and adolescents. Psychol Med 1998; 28:12751288 33. Brown GW: Life events and affective disorder: replications and limitations. Psychosom Med 1993; 55:248259 34. Goodyer I: Recent life events and psychiatric disorder in school age children. J Child Psychol Psychiatry 1990; 31:839848 35. Costello EJ, Erkanli A, Fairbank JA, Angold A: The prevalence of potentially traumatic events in childhood and adolescence. J Trauma Stress 2002; 15:99112 36. Ford T, Goodman R, Meltzer H: The British Child and Adolescent Mental Health Survey, 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry 2003; 42:12031211

37. Lavigne JV, Gibbons RD, Christoffel KK, Arend R, Rosenbaum D, Binns H, Dawson N, Sobel H, Isaacs C: Prevalence rates and correlates of psychiatric disorders among preschool children. J Am Acad Child Adolesc Psychiatry 1996; 35:204214 38. Kilpatrick DG, Ruggiero KJ, Acierno R, Saunders BE, Resnick HS, Best CL: Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: results from the National Survey of Adolescents. J Consult Clin Psychol 2003; 71:692700 39. Breslau N, Davis GC, Andreski P, Peterson E: Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991; 48:216222

Am J Psychiatry 167:9, September 2010

ajp.psychiatryonline.org

1065