| 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withdrawn and quiet in the classroom and somewhat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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