About Posttraumatic Stress Disorder in Children(PTSD)

by Robin F. Goodman, Ph.D. and Anita Gurian, Ph.D.
www.AboutOurKids.org

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Jessica, a 7-year-old girl, was withdrawn and quiet in the classroom and somewhat distant from her peers.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.