| Introduction
A child with Posttraumatic
Stress Disorder develops symptoms such as intense
fear, disorganized and agitated behavior, emotional
numbness, anxiety or depression, after being
directly exposed to or witnessing an extreme
traumatic situation involving threatened death
or serious injury, or hearing about such an
event involving a family member. Victims of
repeated abuse or children who live in violent
environments or war zones may experience PTSD.
Treatment includes community and family support
and psychotherapy.
Real Life Stories
During Hurricane Andrew which
destroyed 75,000 homes in Florida, 9-year-old
Stevie was at school. When he got home he found
that the roofs of most of the houses on his
street, including his own, had been blown off.
He could not find his parents and his sister,
who had been removed to a shelter. He desperately
searched the neighborhood and after several
hours was found by the police, who reunited
him with his family. The family stayed in the
shelter for two weeks until they were relocated,
and Stevie refused to eat or speak for several
days. Two months later Stevie was still afraid
to sleep alone at night, was not concentrating
in school, and was irritable whenever there
was a rain storm.
Jessica, a 7-year-old girl,
was withdrawn and quiet in the classroom and
somewhat distant from her peers. Although she
had previously been a top student, Jessica's
academic performance was faltering. On several
occasions, the teacher had observed her masturbating
while she was working at her desk. Jessica then
began to refuse to go to gym class because she
said she was afraid of the teacher, a male.
She also complained frequently that she was
tired, but she had trouble falling asleep at
night and was often awakened by nightmares about
strange men. When the school psychologist spoke
with Jessica, she learned that her mother had
recently remarried and on weekends Jessica was
left in the care of her stepfather while her
mother was at work. Jessica also stated that
when her stepfather had a "funny smell
on his breath" he would engage Jessica
in mutual genital stimulation.
Definition of a trauma
A traumatic situation is one
involving an actual or threatened death or serious
injury. Sometimes when people experience an
event so terrible and frightening that it is
difficult for most of us to imagine, they suffer
from shock. This can happen after a one-time
natural catastrophe like a hurricane or a flood
or after an experience like seeing a bomb attack
or seeing someone shot. Sometimes this kind
of shock can happen when an unpleasant experience
occurs time and time again in a child's life,
like being beaten or sexually abused repeatedly.
Particular signs of stress can occur after experiencing
an event directly, from witnessing an event,
or even hearing about such an event in regard
to a family member. People who suffer from a
prolonged reaction to such shock may be diagnosed
as having Posttraumatic Stress Disorder.
What are the symptoms
of PTSD?
Children's PTSD
symptoms fall into the following categories:
Re-experiencing
- moments when a child seems to replay
the event in his or her mind
- intrusion of recurrent memories of the
event or repetitive play about the event
- nightmares, scary dreams
Arousal
- disorganized and agitated behavior
- irritability or anger
- nervousness about everyone and everything
around the child, as when people get too
close
- jumpy when hearing loud noises
Avoidance
- avoidance of thoughts, feelings, or places
that remind the child of what happened
- numbing, or lack of, emotions
Other behaviors
- regression to earlier behavior, such
as clinging, bedwetting, thumb sucking
- difficulty sleeping or concentrating
- detached from others, social withdrawal
- excessive use of alcohol or other substances
to self medicate
To warrant a diagnosis of PTSD,
the reaction must be present for more than one
month and cause significant impairment in the
person's life and functioning.
Who is likely to have
it?
Until recently traumatic events
have been rare in the lives of most children,
each year three million children are diagnosed
as having Posttraumatic Stress Disorder. Following
a traumatic event such as the attack on the
World Trade Center in September 11, 2001, or
a natural disaster or trauma, children and teens
most at risk for PTSD are those who directly
witnessed the event, suffered from direct personal
consequences (such as the death of a parent,
injury to self), had other mental health or
learning problems prior to the event, and lack
a strong social network.
Why does it happen?
Not everyone who goes through
the same experience responds in the same way.
People are born with different biological tendencies
in how they respond to stress. Some are more
adaptable, others more cautious. Reactions and
recovery are affected by the length and intensity
of the traumatic event.
How is it treated?
Early intervention is imperative.
Parental support influences how well the child
will cope in the aftermath of the event. Parents
and professionals can help children by:
- maintaining a strong physical presence
- modeling and managing their own expression
of feelings and coping
- establishing routines with flexibility
- accepting children's regressed behaviors
while encouraging and supporting a return
to age-appropriate behavior
- helping children use familiar coping
strategies
- helping children share in maintaining
their safety
- allowing children to tell their story
in words, play or pictures to acknowledge
and normalize their experience
- discussing what to do or what has been
done to prevent the event from recurring
- maintaining a stable and familiar environment
Cognitive behavioral therapy
has been shown to be effective for children
with PTSD. Cognitive training helps children
restructure their thoughts and feelings so they
can live with out feeling threatened. Behavioral
interventions include learning to face your
fears so children no longer avoid people and
places that remind them of the event. Relaxation
techniques are used with supervised retelling
of the child's story about the event to help
teach the child how to handle fears and stress
effectively. Training parents to help the child
with new coping strategies and teaching adult
coping strategies is often included.
Questions & answers
If a child's parents
separate or divorce, would the child react with
PTSD?
Adivorce is certainly stressful
and the emotional health of the child should
be considered, but divorce would not be considered
a life-threatening traumatic event, and thus
the child would not be at particular risk for
developing PTSD. Divorce, however, may increase
the risk of PTSD for some children exposed to
traumatic events.
If a child's parent
or close relative dies, would the child suffer
from PTSD?
Agrief response is different
from a PTSD response. Grief responses may include
intrusive thoughts about the person who died
or sadness about activities associated with
that person, but grief responses are usually
worked through with time. Childhood traumatic
grief is a separate condition in which traumatic
thoughts and images interfere with the ability
to enjoy positive memories and accomplish typical
bereavement tasks.
What type of trauma
most often leads to PTSD?
Children who have witnessed
an act of violence or whose family member has
been reported missing or injured, who have been
the victim of a criminal act, such as abuses
or physical or sexual assault, are at a higher
risk than those who experienced a natural disaster.
This is possibly due to the fact that the violence
seems, and often is, intentional in comparison
to an unpredictable natural event.
What is the most common
age for a child to develop PTSD?
Children under the age of 11
are more vulnerable to developing PTSD. However,
it is difficult to diagnose in very young children
who have less developed language. Therefore
they cannot describe their internal state well
or report on whether they are having intrusive
thoughts or nightmares. PTSD can develop years
after an event, as we have seen in the case
of war veterans.
How long does someone
have PTSD?
Responses and reactions following
a traumatic event may last for weeks or months,
but they often show a relatively rapid decrease
after the direct impact subsides. It has been
estimated that for adults and children after
natural disasters with community-wide impact,
there is often close to complete symptom remission
after eighteen months to three years. In some
cases PTSD can remit spontaneously. But PTSD
also can develop years after an event. Some
children may not develop PTSD until a year or
more after the event; this is known as the "sleeper
effect." Left untreated for a period of
time, such as two years, PTSD can be chronic.
About the Authors
Robin F. Goodman, Ph.D.,
is a clinical psychologist specializing in bereavement
issues.
Anita Gurian, Ph.D
,Clinical Assistant Professor of Psychiatry,
NYU School of Medicine, Editor of the NYU Child
Study Center Letter and Executive Editor of
www.AboutOurKids.org.
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