| Introduction
During the past few years, trauma has become a dominant
issue in the forefront of professional communication and
debate. Trauma itself has been known to manifest as an
array of psychological and physiological issues. While
the repercussions of specific traumas such as war, vehicular
accidents, robberies, hostile terrorist actions, and weather
related events have been clearly associated with Posttraumatic
Stress Disorder (PTSD), the relationship of PTSD to a
number of childhood experiences has not been as clearly
defined. The controversy is intensified with the inability
to conduct research on children who are preverbal or incapable
of comprehending the traumatic event. Research has indicated
that children have an inherent ability of being resilient,
thus this research intends on providing information that
clarifies why children have an inherent ability to be
resilient. It intends on clarifying why some children
are capable of rebounding, while others are not faceted
with the proper tools to rebound. In order to be diagnosable,
according to the Diagnostic Statistical Manual IV-TR,
the criterion specifies that an individual must have persistent
impairment for at least one month following a traumatic
event and that this must cause dysfunction of life and
functioning. This article will compare and contrast issues
central to trauma and the affect upon children. The article
intends on clarifying treatments that are most effective
and theories that are most beneficial in treating PTSD.
Posttraumatic Stress Disorder
The causation of Posttraumatic Stress Disorder (PTSD)
is the exposure to a trauma or a set of traumatic experiences.
The etiological hypothesis is that PTSD is caused by the
trauma. The type of trauma is not as significant as is
the frequency, intensity, severity, longevity, and the
duration with which the trauma is endured. The exposure
to a trauma may vary in intensity, severity, longevity,
and the frequency with which an individual experiences
the impact of the trauma. When an individual has been
exposed to a trauma and the impact of the trauma persist,
lasting an extend period of time; then the probability
that the individual has the diagnosis of PTSD is plausible.
PTSD is based on one’s primal fears and anxiety.
The severity of the stress associated with the trauma
may be the stimulus that perpetuates the PTSD. “There’s
a well-established dose-response relationship between
stress and its effects: the more severe the stress, the
more severe the symptoms.” (Allen, 2005, p. 182)
Furthermore, even if an individual endures extreme stress,
it does not mean they will develop PTSD symptoms. However,
if an individual does endure an extremely stressful event
and/or an intensely stressful situation they may be more
prone to develop PTSD.
Research has discovered that childhood victimization
and its connection to PTSD coincides with adult victimization.
(Brown, 2008) “As has been observed among adults,
child clinicians and researchers have discovered that
the presentation of PTSD in childhood can vary dramatically
with respect to the severity, chr onicity, and number
of symptoms expressed (Faust & Furdeall, 2002; Norman-Scott
& Faust, 2002; Faust & Katchen, 2004, p. 427).
Characteristically, children and adults who endure the
hardships of a trauma may have a vast array of symptoms
associated with the trauma. Symptomatologically, a victim
of PTSD may present with re-experiencing, intrusions,
distractibility, hyper-arousal, avoidance and numbing,
regression, sleep disorders, difficulty concentrating,
stimulus discrimination, hypervigilance, outbursts of
anger, social withdrawal, altered perceptions, dissociation
and somatization, exaggerated startle responses, and the
abuse of drugs, alcohol, or others substances. For younger
children, it is much rarer that they may present with
issues of drugs, alcohol, and/or other substance abuses,
it is important that clinicians take this into account.
“Like adults, traumatized infants (children) show
symptoms of sleep disturbance, nightmares, hyper-arousal,
intrusive memories, and personality changes.” (Allen,
2005, p. 173) The symptomological difficulties have been
shown to affect the individual at a variety of stages
in life despite their age, gender, intellectual quotient
(IQ), temperament, and socio-economic standing.
Children may develop a host of psychological and psychiatric
traits. They may develop fears and anxieties associated
with the trauma causing the onset of dissociated emotions
through disorganized or agitated behaviors, numbness,
re-experiencing, anxiety, stress, avoidance or depression.
Children and adults who are affected by the trauma may
have difficulty trusting in another person; relying upon
others; or associating with others. If a victim has to
associate themselves in events such as a court case, identifying
their perpetrator, and/or other legal proceedings, the
association may trigger a host of psychological difficulties,
even triggering memories associated with their original
traumatization. If they are forced to involve themselves
with their perpetrators or associates of their perpetrators,
it is important that the individual is reassured that
they are protected and not to fear their perpetrator.
Victims who are forced to face their perpetrators, it
has been shown that they may become drawn inwardly, even
showing signs of dissociation and depersonalization. Therefore,
it is vitally important that when children are forced
to face their perpetrators that “they” are
capable of feeling secure and reassured of their safety.
It is important to recognize that most children’s
perpetrators are commonly associated with them (e.g. family,
friends, friends of family, religious leaders, etc.).
When working with younger children, it has been discovered
that play therapy, music therapy, and art therapy are
excellent venues for accessing information concerning
their perpetrators and their personal victimization. Through
such therapeutic orientations, children may actively relive
and act out events expressing themes associated with the
trauma. Furthermore, not unlike adults, children have
been known to re-experience their victimization through
their dreams; therefore, it may be important to monitor
their dream states as well.
Frequently, victims of trauma who meet the diagnosable
criteria of PTSD may avoid people, places, activities,
or things. In conjunction with their avoidance of people,
places, or things, they may sterilize themselves from
affection altogether. They may choose to limit the type
of affection, the amount of affection, the individuals
they show affection, and why they show affection. They
may have skewed ideological views on why affection should
be shown. They may also limit or reject affection from
others. PTSD victims may be inclined to view the future
as bleak and without merit.
Children may present with an inability to be manageable
in educational and organizational confines. They may prove
hostile towards peers and adult figureheads (e.g. teachers,
religious leaders, social leaders). Children may avoid
contact with peers, family, and other significant role
players in their life. Children may begin avoid aspects
of their life that they once loved, admired, and provided
them pleasure.
Diagnosing a child with PTSD may prove more difficult
than an adult. Although children and adults can prove
resilient when addressing trauma and traumatic events,
the difficulty becomes apparent when diagnosing a child
who has not developed language or verbal skills, or the
cognitive ability to comprehend the discussion. The obstacles
facing the diagnosis of a child will vary dependent upon
a number factors such as age, intellectual quotient (IQ),
educational level, developmental stages and environmental
factors. “It is important to note that most adults
and children are resilient in the face of trauma and do
not develop long-lasting emotional disturbances”
(Feeny, Treadwell, Foa, & March, 2004, p. 466). The
complexities of diagnosing an individual with PTSD, much
less a child with PTSD, can prove further difficult when
trying to gather information. If an individual has caused
the child to be traumatized, it may exaggerate the traumatic
issues because a child may resist discussing issues if
the perpetrator is a family member, friend or friend of
the family. Children may have greater complexities due
to recalling the trauma because of their age, IQ, educational
level, developmental stages, and environmental factors.
Therefore, the diagnostic concerns may be overlooked and
the depths of the traumatic impact may go without recognition.
Thus, allowing for the traumatic issue to become more
pronounced in the life of the individual.
Unfortunately, a child presenting with PTSD usually has
a direct link to some form of childhood abuse. Research
has indicated that a vast number of psychiatric patients
present with issues stemming from childhood abuse. “…50-60
percent of psychiatric inpatients and 40-60 percent of
outpatients report childhood histories of physical or
sexual abuse or both… Thus abuse in childhood appears
to be one of the main factors that lead a person to seek
psychiatric treatment as an adult” (Herman, 1997,
p. 122). It is unfortunate that children may endure childhood
abuse, but even greater an issue is that the childhood
abuse may go unchecked or undiagnosed until they are adults.
A child’s environment is core to a child’s
sense of personal security. A child that is incapable
of feeling secure may experience fractures within their
sheltered existence. Being sheltered is not to imply that
parents are confining them to a room, rather sheltering
is synonymous with protective factors (i.e. sheltering
from abuse, personal harm, or the perception of harm).
While childhood PTSD may be associated with a number of
issues, one of the prominent issues today is associated
with physiological health. A child’s resiliency
could be associated with longevity, a superman type of
existence, an invincibility, and youthfulness. Children
who become ill and no longer fall under the misconception
of their invincibility become genuinely aware of their
own human frailty. This too is often witnessed in victims
of rape, incest, molestation and kidnapping.
A child who has an opportunity to be raised in a secure
and safe environment may see their world in a pluralistic
fashion. A child who is raised in a secure and safe environment
with the proper attachments may have a positive personal
perception and worldview. A child who has been raised
in an environment that is pluralistic in its ideological
perspectives, may foresee a life of endless bliss and
optimal possibilities. If a child who has had a good familial
environment endures a trauma, they have been known to
seemingly thrive beyond those who have not had a good
familial environment. It is not to say that a child in
a good environment will thrive and others will not, rather
with the “proper” familial support and affection,
a child has a greater chance of returning close to the
“normal” life that they once knew or understood.
Whereas, a child without familial support or improper
affection may not have the boundaries whereby to gain
the support much needed to thrive and prove interpersonally
resilient.
A child who endures a trauma will experience a sudden
change of their worldview and perception of themselves.
The change may be sudden or gradually experienced. It
is like the child has his or her curtains drawn revealing
that they are indeed not invincible, becoming knowledgeable
of the magnitude of their human frailty. Such change is
rarely sought out and is often forced upon the individual
through some sudden traumatic experience. Despite the
trauma, children most frequently remain as unconquerable
survivors. Moreover, unlike adults, a child is commonly
uncompromised and unblemished devoting themselves to a
childlike state. When the trauma occurs and the most egregious
event shatters their childlike state, the child becomes
fluently aware of their own humanity. Children who suffer
from a wide range of health issues when the onset is sudden
may suffer from symptoms of PTSD.
Cancer thrives on the human ability to survive. It literally
and figuratively devours the right to human survival.
Cancer is one of the most common of childhood illnesses.
While cancer may seem as bleak as any illness, the survival
rate amongst childhood victims remains encouraging. “The
current overall 5-year survival rate for childhood cancer
is 75% (Ries et al., 1999), with improved outcomes attributable
to more aggressive multimodal treatments” (Kazak,
Alderfer, Barakat, Streisand, Simms, Rourke, Gallagher,
& Cnaan, 2004, p. 493). When a child is suddenly impacted
by a health related issue, the suddenness of this disease
may leave children in a state of brokenness and disrepair.
“Posttraumatic Stress Symptoms (PTSS) (PTSS; Stuber,
Kazak, Meeske, & Barakat, 1998) have emerged as one
of the most important psychological consequences of childhood
cancer. The diagnosis of cancer represents a life threat,
which is core to the concept of traumatic stress”
(Kazak, et. al. 2004).
The debate surrounding diagnosing PTSD and other childhood
illnesses stems from a similar debate that permeates the
issues of childhood abuse. How can an individual suffer
from PTSD if they have not endured a true violent action
or life-threatening scenario? Conversely, how can a child
not be a victim of an illness or abuse if their own life
was securely attached prior to their victimization?
Trauma does not have to occur directly or personally
to affect you vicariously. It is important to recognize
that trauma affects not only those who have endured the
trauma, but those who are in the life of the victim. When
a child endures a trauma, the family will frequently reap
the impact of the trauma as well. Likewise, if a child’s
family endures a traumatic event, he/she too may experience
the trauma vicariously. Therefore, the trauma rarely impacts
just one individual. When a family member that has been
considered an anchor endures a trauma, it will frequently
cause a rippling affect throughout the family. Thus, when
a child sees that individual who has been a stable force
in their family traumatized, it may upheaval a variety
of emotional issues, including emotional distress, fears,
and anxieties.
All children are vulnerable to trauma and the possibility
of PTSD; however the physiological and psychological makeup
of the child may determine their own risk. “A child’s
risk of developing PTSD is related to the seriousness
of the trauma, whether the trauma is repeated, the child’s
proximity to the trauma, and his / her relationship to
the victim(s)” (AACAP, 1999, Online). Traumas that
lead to childhood PTSD are commonly associated with prolonged
and repeated traumatization. “Fortunately, most
persons who are exposed to potentially traumatic events
do not develop PTSD” (Allen, 2005, p. 173). Therefore,
if a trauma is not endured in a prolonged spectrum the
effect of the trauma is lessened.
When a child has the proper support mechanisms in place,
they are less likely to incur the full severity of the
trauma. The familial structure of a child’s home
may account for variations of cause-and-effect. If a child
is raised in a home based on a single parental figure,
“…there may be less child supervision, resulting
in greater exposure to community violence” (Ng-Mak,
Salzinger, Feldman, & Stueve, 2004, p. 198). The probability
that a child will be affected by a trauma is increased
when that child does not have the proper support mechanisms
in place. Even if a child has inconsistencies within the
confines of their care, the rate of their exposure to
traumatic experiences increases. The probability that
traumas will be eradicated is highly unlikely, thus it
is prudent that children and adults be provided with the
proper support and coping mechanisms.
The physical and psychological implications of trauma
can prove detrimental. If a group of individuals were
to face the same trauma, with the same intensity, severity,
longevity, and frequency the responses of those individuals
would differ drastically. The responses of the individuals
would vary due to their own personal makeup, ability to
prove resilient, and the protective parameters in place.
In fact, the manner with which they respond will vary
dependent upon how they have been raised to act and react.
You may see abroad array of responses in the nature of
their automatic response, the breathe of the response,
and longevity with which they respond. As individuals,
we are all equipped differently to respond to a trauma
or traumatic events. Thus, each individual receives their
ability or inability to cope to a trauma through two central
dynamics: nature and nurture.
Children at all stages of life may develop PTSD as a
result of being exposed to violent acts; they may develop
it having endured an injury; they may develop it having
an association with someone or something that threatens
their sense of safety; the prevalence of trauma may be
rooted in physical, emotional, verbal, or sexual abuse;
and they may develop PTSD as a vicarious repercussion
of hearing or witnessing news and information about a
traumatic event. The traumatization of an individual may
be the causation of long-term internal struggles with
external and internal results.
When a trauma has been experienced vicariously, the manifestations
resulting from the trauma can prove ghost-like. Unless
it is recognized that a child has endured a trauma first
person, it is less likely that parental caregivers will
assess the effects as being directly correlated to the
traumatic event. The old premise was that unless there
are dire physiological issues, the assumption was that
a child could not have any major issues directly or indirectly
correlated to the trauma. Ironically, practitioners are
called to advocate for the victim and there are “many
professionals (who) may underestimate the prevalence and
impact of trauma and its association with distress and
mental disorders” (Goldsmith, et al. 2004, p. 449).
As a practitioner, we should consider all possibilities
including the impact on an individual who might otherwise
be presumed to unaffected. The practitioner should be
fully attentive and alert to the possibilities of vicarious
issues, with a clearer understanding and comprehension
of the direct and indirect effects of trauma. Children
are the most vulnerable to the repercussions of vicarious
trauma, for they are unaware how viewing traumatic events
can have a lasting detrimental effect upon their own lives.
It is worth noting that while all events are relevant
to our existence as members of humanity, they are not
all possibilities for our lives. For instance, if an individual
resides in Florida the likelihood of being affected by
a Tsunami is increased. On the other hand, if an individual
lives in Denver, Colorado the likelihood of enduring a
Tsunami is scientifically implausible. Children tend not
to rationally consider the distance between them and the
physical traumatic event, thus it is important that children
are capable of being debriefed following events such as
December 26, 2004 Tsunami.
The therapeutic relationship is about re-establishing
a sense of trust between the patient and their ability
to trust others. It is about developing cohesion within
the therapeutic relationship between the therapist and
patient. If a child has been the victim of abuse or prolonged
traumatization developing a connection may be difficult.
Since children’s issues are primarily developed
from childhood abuse it is important to recognize the
effects. “The effects of physical abuse…are
particularly devastating. Children under one year of age,
who comprise of 44% of all child fatalities from abuse
and neglect, represent the most at-risk segment of the
population. Children under age 6 account for 85% of children
killed by child abuse” (Osofsky, 2004, p. 261).
A child’s potential for recovery is typically high.
However if a child endures traumatic experiences over
an extended period of time, the likelihood of recovery
becomes lessened with each act of violence.
Children are resilient by nature. Proper nurturing harnesses
the positive aspects of resiliency and provides direction
for children who have been victimized. When facing obstacles
whether merely advancing developmentally learning to walk,
talk and expressing their emotions children are resilient.
Children have proved resilient in the face of the gravest
obstacles whether they are recovering from an illness
or they have been abused or witness to a trauma. An ability
to prove resilient is central to one’s ability to
recover. “Recovery, therefore, is based upon the
empowerment of the survivor and the creation of new connections.
Recovery can take place only within the context of relationships;
it cannot occur in isolation” (Herman, 1997, p.
133).
Children especially need to be capable of expressing fears
and anxieties associated and derived from their trauma.
Children are often prone to sealing information prudent
to their victimization in order to protect their perpetrator
or fears associated to disclosing such information.
Children must be capable of expressing and disclosing
the nature of their victimization. If a child is prevented
from disclosing or expressing the emotions around their
victimization, the consequence of the denial of expression
and disclosure is that they may be re-victimized. Recent
studies have indicated that children who are denied the
freedom to express and disclose may further perpetuate
issues central to their victimization. Thus, children
who have been victims of religious, educational, familial
and community cover-ups are beginning to gain prominent
ground in their right to express and disclose the extent
of their victimization. Moreover, the difficulty remains
in gaining the rapport of the victim so that they will
feel secure enough to disclose prudent information related
to their victimization. “Exposure to childhood trauma
and abuse is posited to lead to substance abuse through
various mechanisms, including as a maladaptive coping
strategy, self-medication or self-destructive impulses
stemming from low self-esteem (Widom, et al., 1999)”
(Grella, Stein, & Greenwell, 2005, p. 44). A child’s
disclosure and expression of the effects of traumatic
events is necessary.
Therapeutically, the patient arrives with hesitation
and reservation about disclosing information revolving
around their victimization. The therapeutic environment
should be about instilling within the life of the patient
a sense of safety and care. “The therapy relationship
is unique in several respects. First, its sole purpose
is to promote the recovery of the patient…Second,
the therapy relationship is unique because of the contract
between patient and therapist regarding the use of power”
(Herman, 1997, p. 134). Third, it is about providing a
place of unconditional acceptance, safety and care. If
the patient feels threatened or feels as if the therapist
is casting a shadow of disapproval, the patient will ultimately
reject the therapist and never disclose information prudent
to their victimization. Children, who have endured their
victimization through the hands of another, might be hesitant
to disclose information central to their traumatization
because of implied threats by the perpetrator or the disbelief
implied by others, or fears and anxieties exacerbated
by their victimization.
Treatment for children affected by PTSD and trauma should
be based on a multimodal approach. Since the spectrum
of effect is broad, the therapeutic treatment plan must
be inclusive of all aspects involving the impact of the
trauma. Principally, “the foundation of treatment
is safety of the therapeutic relationship” (van
der Kolk, et al., 1996, p. 18). Victims of trauma must
feel as though they have entered a hall of safety and
security. “The organizing principle of our work
is the best interest of the child; that is, the needs
of these very young traumatized children are first and
foremost” (Osofsky, 2004, p. 260).
Treatments and instruments that have been key to recovery
have been: Expressive Art Therapy (which may “…include
visual arts (drawing, painting, sculpture, collages),
movement / dance; music; language arts (storytelling,
essays, poetry); drama; and play / sand-tray therapy),”
(Schiraldi, 2000, p. 255), Eye Movement Desensitization
and Reprocessing (EMDR), Cognitive Behavioral Therapy
(CBT), Subjective Units of Disturbance Scale (SUD), Beck
Depression Inventory (BDI), and Beck Anxiety Inventory
(BAI). Treatment objectives and instruments are as vast
as the needs plaguing patients. Because trauma is faceted
with a number of other psychological and physiological
manifestations, it is important to rule-out other possibilities.
Therefore, using instruments such as the BDI a practitioner
can determine and distinguish factors associated with
the PTSD and other psychological factors. In fact, the
treatments for therapeutic recovery are endless, but the
key is retrieving a treatment that will mesh with the
needs of the individual patient.
Play therapy can prove a productive resource of treatment
when addressing concerns of younger children. Through
the application of play therapy a child is capable of
exploring and providing accounts relevant to their traumatization.
“Play can be a very useful part of treatment for
both adults and children” (Schiraldi, 2000, p. 262).
For example, when addressing a child who has been the
victim of sexual abuse, the therapist may have the child
discuss how they might treat another through providing
them with a doll. The doll then becomes a representation
of how they have internalized the morals and ethics provided
unto them by their caregiver, as well as an outlet to
express their own victimization. A therapist may have
the child describe what was done to them by their perpetrator,
to what extent the perpetrator violated them, and how
the victimization made the child feel.
Safety is pinnacle for a child to fully thrive and recover.
“The practitioner must take into account real-world
variables and those previously identified in the literature
that have the propensity to complicate the trauma reaction
and render it less amenable to direct treatment”
(Faust & Katchen, 2004, p. 430). Faust & Katchen
(2004) discussed a number of factors that are critical
to recovery they are: having the ability to live in a
safe environment and having traumatizing stimuli garnished
in order that they may survive; relocating children to
a place of safety; if children are experiencing issues
of grief and loss these reactions must be dealt with prior
to dealing with issues of PTSD; and risk and protective
factors directly correlated to their trauma. Children
are most vulnerable to traumatic experiences that are
based in abuse. Faust & Katchen (2004) discuss how
a child under the age of 10 may develop graver concerns
central to the trauma because of the developmental processes.
“One can argue that this is the case because children
are attempting to master crucial and fundamental cognitive
and emotional developmental attainments within these years”
(Faust & Katchen, 2004, p. 430).
In the life of a child, trauma may be a reality. It is
the protective factors around the child that will create
an element of resiliency helping the child rebound from
a traumatic event. Traumatic experiences vary in the magnitude,
extent, and length with which they occur. The descriptive
nature of PTSD is how an individual may cope following
a traumatic event. Trauma is not a singular diagnosis
and the prognosis may vary from patient-to-patient. Determining
the degree with which an individual receives treatment
may vary dependent upon a number of variables. How a person
manages and copes following a traumatic event, may determine
what measures the practitioner takes in treatment. Environmental
factors, conditioning, socioeconomics, nurture and nature,
may determine which treatment procedures, techniques,
and theories are applied in therapy. While the therapeutic
approach of the practitioner might be chosen by preference
or style of the approach, the patient will be the ultimate
factor in deciding what approaches are a fit for his or
her life.
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