Post-Traumatic Stress Disorder in Childhood
by Dr. Asa Don Brown, Ph.D., C.C.C.

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.

References

Allen, J. G. (2005) Coping with trauma, Hope through understanding (2nd ed) Washington, DC: American Psychiatric Publishing.

American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th ed., text revision) Washington, DC: Author.

American Psychological Association (2002) The American Psychological Association’s (APA’s)
Ethical Principles of Psychologists and Code of Conduct. Retrieved March 23, 2005, from http://www.apa.org/ethics/code2002.html.

Faust, J. & Katchen, L. B. (2004) Treatment of children with complicated posttraumatic stress reactions. Psychotherapy: Theory, Research, Practice, Training,. 41 (4), 426-437

Feeny, N. C., Treadwell, K. R. H., Foa, E. B., & March, J. (2004) Posttraumatic stress disorder in youth: A critical review of the cognitive and behavioral treatment outcome literature. Professional Psychology: Research and Practice, 35 (5), 466-476.

Goldsmith, R. E., Barlow, M. R., & Freyd, J. J. (2004) Knowing and not knowing about trauma: Implications for therapy. Psychotherapy: Theory, Research, Practice, Training, 41 (4), 448-463

Grella, C. E., Stein, J. A., & Greenwell, L. (2005) Associations among childhood trauma, Adolescent problem behaviors, and Adverse adult outcomes in substance-abusing women offenders. Psychology of Addictive Behaviors, 19 (1), 43-53

Henry, D. B., Tolan, P. H., & Gorman-Smith, D. (2004) Have there been lasting effects associated with the September 11th, 2001, Terrorist attacks among inner-city parents and children? Professional Psychology: Research and Practice, 35 (5), 542-547

Herman, J. (1997) Trauma and recovery, The aftermath of violence-from domestic abuse to political terror. New York, NY: Perseus Books Group

Kazak, A. E., Alderfer, M. A., Barakat, L. P., Streisand, R. Simms, S. Rourke, M. T., Gallagher, P., & Cnaan, A. (2004) Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: A randomized clinical trial. Journal of Family Psychology, 28 (18), 493-504

Ng-Mak, D. S., Salzinger, S., Feldman, R. S., & Stueve, C. A. (2004) Pathologic adaptation to community violence among inner-city youth. American Journal of Orthopsychiatry, 74 (2), 196-208

Oklahoma City National Memorial (n.d.) On American soil, Oklahoma City National Memorial. Retrieved March 26, 2005, from http://www.oklahomacitynationalmemorial.org

Osofsky, J. D., (Ed.) (2004) Young children and trauma, Intervention and treatment. New York, NY: The Guilford Press

Phillips, D., Prince, S., & Schiebelhut, L. (2004) Elementary school children’s responses 3 months after the September 11th terrorist attacks: A study in Washington, DC. American Journal of Orthopsychiatry, 74 (4), 509-528

Schiraldi, G. R. (2004) The posttraumatic stress disorder sourcebook, A guide to healing, recovery, and growth. Los Angeles, CA: Lowell House

van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (1996) Traumatic stress, The effects of overwhelming experience on mind, body, and society. New York, NY: The Guilford Press