title: Posttraumatic stress disorder and physical comorbidity among female children and adolescents: results from service-use data.
abstract: OBJECTIVE
  In adults, posttraumatic stress disorder (PTSD) is associated with adverse health outcomes and high medical utilization and cost. PTSD is twice as common in women and is associated with increased risk for a range of diseases, chronic conditions, and reproductive-health problems. Little is known about the health effects of PTSD in children. The purpose of this study was to explore patterns of physical comorbidity in female children and adolescents with PTSD by using population data.
  
  
  METHODS
  This study was a cross-sectional, descriptive epidemiologic case-control analysis of a Midwestern state's Medicaid eligibility and paid-claims data for girls (0-8 years old) and teens (9-17 years old). Data were from 1994-1997. All those with the PTSD diagnostic code were compared with randomly selected controls in relation to 3 sets of outcomes: (1) International Classification of Diseases, Ninth Revision (ICD-9) categories of disease; (2) chronic conditions previously associated with sexual trauma and PTSD in women; and (3) reproductive-health problems. Analyses included bivariate odds ratios (OR) and logistic-regression models that control for the extent of insurance coverage and the independent associations of victimization and psychiatric comorbidity with the 3 sets of outcomes. The mental health covariate was categorical to allow consideration of a range of severity. There were 4 categories for the young girls: neither PTSD nor depression, PTSD without depression, depression without PTSD, and PTSD + depression. For the adolescent analysis, a fifth category reflecting a "complex PTSD" was added, defined as having PTSD complicated by a dissociative disorder or borderline personality disorder diagnosis.
  
  
  RESULTS
  There were 647 girls and 1025 adolescents with the PTSD diagnosis. Overall, PTSD was associated with adverse health outcomes in both age strata. Victimization was sometimes independently associated with adverse health outcomes, but PTSD often was a mediator, especially in the adolescent age stratum. The importance of PTSD diagnosis as a predictor of the ICD-9 categories of disease or chronic conditions seemed to increase with age. In the younger age stratum, the increased bivariate ORs of significant associations with PTSD ranged from 1.4 for digestive disorders to 3.4 for circulatory disorders. Among younger girls, PTSD diagnosis was associated with significantly greater bivariate odds for 9 of the 12 ICD-9 categories of disease but not for neoplasms, blood disorders, or respiratory disorders and with threefold increased odds for chronic fatigue. They also had 1.8 times greater odds for sexually transmitted infections, some of which could be from congenital transmission in this age group, which includes infants. In the multivariate models for the young girls, the mental health variable seemed to mediate the relationship between victimization and increased odds of infectious and parasitic diseases, endocrine/metabolic/immune disorders, circulatory diseases, skin and cutaneous tissue disorders, and having any 1 of the 5 chronic conditions. The mental health categories that were significantly associated with health outcomes varied across the conditions. There were no health outcomes in which the depression-without-PTSD category was the only one significantly associated with the outcome condition. Circulatory and musculoskeletal disorders were significantly associated with all 3 of the mental health categories. Having any 1 of the 5 chronic conditions was significantly associated only with simple PTSD (PTSD without depression). Genitourinary disorders and signs/symptoms/ill-defined conditions were significantly associated with both simple and comorbid PTSD. PTSD with comorbid depression, the most severe of the mental health categories in this younger age group, was the only category associated with the endocrine/metabolic/immune disorders and skin disorders outcomes. In the adolescent age stratum, the bivariate ORs significantly associated with PTSD ranged from 2.1 for blood disorders to 5.2 for irritable bowel syndrome. Adolescents with PTSD were nearly twice as likely to have a sexually transmitted infection and 60% more likely to have cervical dysplasia. However, their rate of pregnancy was lower (23% vs 31%), a one-fourth decreased odds. In the adolescent group, only 4 outcomes (nervous system/sense organ, digestive, and genitourinary disorders and signs/symptoms/ill-defined conditions) remained statistically significantly associated with victimization after the mental health variable was added, suggesting an additive model of risk for these outcomes but a mediating role for PTSD in relation to the majority of the health outcomes. Among the adolescent girls, the range of ORs for the ICD-9 and chronic-condition diagnoses generally increased across the categories of the mental health variable in a dose-response pattern. Compared with adolescents with neither PTSD nor depression, those with PTSD without depression had statistically significant ORs from 1.5 to 3.6. Those with depression without PTSD had statistically significant ORs from 1.9 to 4.4. The significant ORs for those with PTSD comorbid with depression were from 2.3 to 6.6, and those in the complex-PTSD category had significant ORs of between 2.5 and 14.9. Only blood disorders seemed to be more strongly associated with depression alone than with the comorbid and complex forms of PTSD. The simple-PTSD category was not significantly associated with blood disorders, chronic pelvic pain, fibromyalgia, or dysmenorrhea. Depression without PTSD was not significantly associated with chronic pelvic pain or fibromyalgia. Fibromyalgia was only significantly associated with complex PTSD.
  
  
  CONCLUSIONS
  In young girls who receive Medicaid benefits, PTSD was associated with increased odds of a range of adverse health conditions. The pattern and odds of physical comorbidity among adolescent recipients with PTSD was nearly as extensive as that seen in adult women. Overall, the pattern observed suggests that objective disease states (eg, circulatory problems, infections) may be associated with PTSD to an extent nearly as great as that of PTSD with more subjective somatic experience of loss of wellness. Using the concepts of allostatic load and allostatic support, professionals who work with children and adolescents may be able to decrease the toll that traumatic stress takes on health even if available interventions can only be thought of as supportive and fall short of completely preventing trauma exposure or completely healing posttraumatic stress. Clinical research to extend these exploratory findings is warranted.
authors.affiliation: Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI 48109-1290, USA. jseng@umich.edu
authors.forename: Julia S
authors.initials: JS
authors.lastname: Seng
authors.forename: Sandra A
authors.initials: SA
authors.lastname: Graham-Bermann
authors.forename: M Kathleen
authors.initials: MK
authors.lastname: Clark
authors.forename: Ann Marie
authors.initials: AM
authors.lastname: McCarthy
authors.forename: David L
authors.initials: DL
authors.lastname: Ronis
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003710:Demography; D005260:Female; D006304:Health Status; D006801:Humans; D007223:Infant; D038801:International Classification of Diseases; D016015:Logistic Models; D015999:Multivariate Analysis; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology*