Children, Community Violence and Post-Traumatic Stress

Deborah Wasserman

Department of Human Development & Family Science

The Ohio State University

Carol Ford Arkin, Ph.D.

Columbus Children's Hospital

Quick to anger, trouble paying attention, disinterested--these behaviors in children demand adult intervention. Problem behaviors in children derive from many sources. One potential factor affecting too many children today is the physiological and psychological aftereffects of witnessing or being a victim of a traumatic event.

Traumatic stress comes in many forms and a full range of intensities, as do children's responses to it. Not all children who have experienced or witnessed trauma will exhibit behavior problems. Increasing adults understanding of the effects of trauma hopefully will enable them to better help children who experience problems.

RESPONSE TO TRAUMA

Children's responses to trauma may vary according to the source and circumstances of the trauma and the circumstances of the child. Generally speaking, children who experience or witness extreme threat respond with symptoms that fit into four general categories (Terr, 1991; Pynoos and Nader, 1988):

• They may have strong memories that repeatedly intrude on their normal functioning.
• They may engage in endlessly repeated behaviors.
• They may develop trauma-specific fears.
• They may change their attitudes about friends, family, life in general, and the future. They also may desire to be unaware of their feelings.

Although these responses tend to be fairly consistent among children who have experienced traumatic stress, the way they manifest can differ substantially. Repetitive behaviors in one child, for example, may be highly aggressive, whereas in another they may be withdrawn or self-injurious. Some children exhibit few, if any, of these symptoms; others become almost completely debilitated, experiencing all of them persistently. In the latter case, children may be diagnosed with post-traumatic stress disorder (PTSD).

Most children who have experienced trauma will not develop PTSD, although many may demonstrate transitory symptoms. If disturbances persist for longer than one month, parents or caregivers should consult with a mental health professional or pediatrician experienced in working with traumatized children.

WHAT INFLUENCES CHILDREN'S RESPONSES TO TRAUMA?

Many factors, often interrelated, contribute to the type and severity of a child's response to traumatic stress. These factors include the persistence of the trauma, the relationship of the child to the perpetrator, the proximity of the child to the experience, the child's support system, and the basic beliefs the child brings to the task of understanding and coping with the trauma. To understand children's possible responses, it is helpful to consider:

• the child's age,
• whether the trauma was ongoing or one-time,
• the child's relationship to the perpetrator,
• whether the child was a victim, a witness, or connected in some way to the victim,
  adult support,
• other stress factors affecting the child.

THE CHILD'S AGE: Children's responses to traumatic stress tend to be consistent with their developmental age. Toddlers may manifest stress in changes in their relationship to their caregivers, either demanding more attention, showing signs of indifference, or both. Their motor activity may change, and they may become more aggressive (hitting, biting, pinching).

In addition to the behaviors exhibited by toddlers, preschoolers may have physical symptoms, such as headaches, stomachaches, or difficulty using a particular body part. They may engage in endlessly repetitive play; may physically and emotionally avoid any reminders of the incident; or may demonstrate fear, sadness, clingingness, regressive behaviors, and feelings of shame regarding their vulnerability. Children also may enter a dissociative state, which observers often describe as "being in a world of their own" or "being out of touch."

School-aged children typically are more susceptible to traumatic events outside the family and their effects on their caregivers, friends, and their community. They may also be more adult-like in exhibiting their sadness and other mood-oriented symptoms, such as anxiety, depression, guilt, increased inhibition, and hypervigilance. These states can result in changes in play, loss or change in interests, return of old or onset of new fears, sleep disorders, difficulty concentrating, and lack of initiative. School performance and learning may suffer. Often symptoms may mirror those of attention deficit hyperactivity disorder (ADHD) and may respond to ADHD treatment (Schwarz and Perry, 1994).

In addition to the symptoms experienced by younger children, adolescents may exhibit identity, eating, and personality (including multiple personality) disorders and seizure-like states. Suicide attempts, substance abuse, self- mutilation, delinquency, truancy, and destructive sexual behaviors also may occur.

WHETHER THE TRAUMA WAS ONGOING OR ONE-TIME: If the trauma was acute and unanticipated, as might be the case with a drive-by shooting, the child may experience acute and disturbing disruptions of thought patterns. If the trauma was chronic and anticipated, as is most often the case with sexual or physical abuse, researchers and clinicians report a more chronic absence of feeling, sense of rage, and generalized sadness along with fear (Terr, 1991). The two types of trauma can also overlap, resulting in a mixture of symptoms.

THE CHILD'S RELATIONSHIP TO THE PERPETRATOR: Traumas perpetrated by individuals whom a child has learned to trust or depend on create different effects than those perpetrated by strangers. Generally speaking, the more personal the relationship between perpetrator and victim, the more severe the symptoms of the victim.

WHETHER THE CHILD WAS A VICTIM, A WITNESS, OR CONNECTED IN SOME WAY TO THE VICTIM: Studies of one-time, acute events reveal that those physically and emotionally closest to the event's epicenter will have the most severe and longest-lasting symptoms. That is, victims who are emotionally, cognitively, and physically involved with the event and the perpetrator can be expected to respond more strongly than those who are physically, emotionally, or cognitively more distant (Pynoos and Nader, 1988; Schwarz and Perry, 1994; Terr, 1990). Relationship to the event may involve the victim's sense of control over the event; victims with less control may have a stronger symptomatic response (McCormack, Burgess, and Hartman, 1988).

ADULT SUPPORT: At the time of a traumatic event, attention and energy may be focused on the victim, perhaps making it difficult for children who are distressed by witnessing the event to receive the support they need. Moreover, adults who have close relationships with a child victimized by violence may be hampered by their own distress about the occurrence.

Difficulty receiving the support they need may be compounded for children who manifest their grief differently than adults. Children's sadness may be less apparent and less sustained. Some researchers have found that many children have never spoken to anyone about their grief reactions. These researchers surmise that because children's sadness tends to be more hidden, parents and teachers may have more difficulty appreciating the nature and intensity of children's grief reactions (Pynoos and Nader, 1988).

OTHER STRESS FACTORS AFFECTING THE CHILD. Although children have a wide range of response to various traumatic stresses, one fact seems to be well-established: rather than building children's resilience by giving them more expertise, recurrent or multiple traumas multiply the difficulty children experience (Fitzpatrick and Boldizar, 1993; Pynoos and Nader, 1988).

PROVIDING SUPPORT

In addition to providing "first aid" (see section at the end of this article) at the time of the trauma, parents and caregivers can provide ongoing support to children in the ways outlined in the remainder of this article.

HELPING CHILDREN REGAIN A SENSE OF CONTROL: Traumatized children have experienced themselves as helpless and not in control. Healing includes recognizing that those feelings occurred at the time of the trauma, but need not continue into the present. Barbara Oehlberg, in her discussion of "reempowerment" in Making It Better: Activities for Children Living in a Stressful World (1996), suggests asking children open questions, such "Then what happened?" or "I wonder what makes the daddy say that?" to help them process a story and gain a sense of mastery. Oehlberg's book also provides a number of open-ended activities intended to help children draw from their own resources to make sense of their world.

HANDLING DISRUPTIVE BEHAVIOR:Although adults may encounter difficulties when faced with agitated, defiant, or aggressive children, remembering that they are struggling and need adult help is extremely important. Behavior problems are unlikely to decrease through scoldings or appeals to "common sense," and harsh discipline is harmful and inappropriate. On the other hand, overly permissive parenting is not likely to help a child who needs guidance and help with coping. Children need consistent, loving support with clear limits and positive discipline to enforce them.

UNDERSTANDING REPETITIVE PLAY: The play of traumatized children may include acting out aspects of the event or themes from it. Some children may engage in endless, unvaried, repetition of the same play. Although self-expression may be constructive, caregivers need to balance between excessively encouraging or discouraging these activities (Schwarz and Perry, 1994). Caregivers should supervise play, for example, and be attuned to the possibility that it can become too disturbing for the child or for the child's playmates.

TUNING INTO THE CHILD'S NEEDS AND PACE FOR DEALING WITH STRESS: While providing opportunities for children to express themselves, parents and caregivers need to be careful not to push too hard to extract a story or otherwise pressure the child. Allow children to feel safe, accepted, and ready to talk at their own pace. On the other hand, putting the burden solely on children to bring up their feelings, or avoiding the subject altogether and assuming children will "work things out on their own" does not give children the support they need. If adults never broach a subject, children may think that it is somehow taboo or that their feelings are abnormal or bad and should not be discussed.

GOING BEYOND THE NUCLEAR FAMILY: Families that have experienced trauma may find it helpful to reach outside the family for supportive relationships for themselves and their children. An adult mentor, for example, can make an enormous difference in a child's life.

COPING OVER TIME: As children mature, gaining more sophisticated emotional and cognitive abilities, they may reprocess an earlier trauma. Caring adults should be aware of this possibility, and be ready to listen and possibly make referrals to appropriate professionals, whenever the need arises.

SPECIAL SECTION

FIRST AID AT THE TIME OF STRESS

Coping with the traumatic stress of a child at the time of the stress is critical; unaddressed traumatic stress increases the likelihood of the child developing PTSD. The following suggestions by Pynoos and Nader (1988) include a list of "first aid" for trauma victims:

1. Provide support, rest, comfort, food, and the opportunity to play or draw.
2. Reassure children that they are safe and that you will help them.
3. Reassure children that the event was not their fault.
4. Help children understand what has happened by giving them opportunity to talk about the event. Clarify, then reclarify any existing confusions.
5. Give children the opportunity to talk about their feelings. Providing emotional labels for common reactions is helpful. Reassure children that it is okay for them to be upset.
6. Do not insist that children talk before they are ready or more than is comfortable for them.
7. Help children understand that the event is over, especially in the presence of physical reminders of the incident.
8. Encourage children to let their parents, teachers, or other adults they trust know about what happened.
9. Provide consistent and reassuring caretaking, such as picking children up from school or letting children know the whereabouts and availability of a significant adult.
10. Understand that children may exhibit behaviors they have already grown out of (for example, bedwetting) and tolerate those behaviors for a limited amount of time.
11. Help children dealing with death understand its finality. Do not talk about death with euphemisms, such as "He went away" or "She is sleeping."

REFERENCES

Fitzpatrick, K. M. & Boldizar, J. P. (1993). The prevalence and consequences of exposure to violence among African-American youth. JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY, 32, 424-430.

Garbarino, J. (1995). RAISING CHILDREN IN A SOCIALLY TOXIC ENVIRONMENT. Jossey-Bass; San Francisco.

Heergaard, M. (1991) WHEN SOMETHING TERRIBLE HAPPENS: CHILDREN CAN LEARN TO COPE WITH GRIEF. Woodland Press, Minneapolis.

Oehlberg, B. (1996). MAKING IT BETTER: ACTIVITIES FOR CHILDREN LIVING IN A STRESSFUL WORLD. St. Paul: Red Leaf Press.

Pynoos, R. S. & Nader, K. (1988). Psychological first aid and treatment approach to children exposed to community violence: research implications. JOURNAL OF TRAUMATIC STRESS, 1(4), 445-473.

Schwarz, E. D., & Perry, B. D. (1994). The post-traumatic response in children and adolescents. PSYCHIATRIC CLINICS OF NORTH AMERICA, 17 (2), 311-327.

Terr, L. C. (1991). Childhood Traumas: An outline and overview. AMERICAN JOURNAL OF PSYCHIATRY, 148, 10-20.

Original Article

PTSD in Children and Adolescents

A National Center for PTSD Fact Sheet

By Jessica Hamblen, Ph.D.

The diagnosis of Posttraumatic Stress Disorder (PTSD) was formally recognized as a psychiatric diagnosis in 1980. At that time, little was known about what PTSD looked like in children and adolescents. Today, we know children and adolescents are susceptible to developing PTSD, and we know that PTSD has different age-specific features. In addition, we are beginning to develop child-focused interventions. This fact sheet provides information regarding what events cause PTSD in children, how many children develop PTSD, risk factors associated with PTSD, what PTSD looks like in children, other effects of trauma on children, treatment for PTSD, and what you can do for your child.

What events cause PTSD in children?

A diagnosis of PTSD means that an individual experienced an event that involved a threat to one's own or another's life or physical integrity and that this person responded with intense fear, helplessness, or horror. There are a number of traumatic events that have been shown to cause PTSD in children and adolescents. Children and adolescents may be diagnosed with PTSD if they have survived natural and man made disasters such as floods; violent crimes such as kidnapping, rape or murder of a parent, sniper fire, and school shootings; motor vehicle accidents such as automobile and plane crashes; severe burns; exposure to community violence; war; peer suicide; and sexual and physical abuse.

How many children develop PTSD?

A few studies of the general population have been conducted that examine rates of exposure and PTSD in children and adolescents . Results from these studies indicate that 15 to 43% of girls and 14 to 43% of boys have experienced at least one traumatic event in their lifetime. Of those children and adolescents who have experienced a trauma, 3 to 15% of girls and 1 to 6% of boys could be diagnosed with PTSD.

Rates of PTSD are much higher in children and adolescents recruited from at-risk samples. The rates of PTSD in these at-risk children and adolescents vary from 3 to 100%. For example, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault develop PTSD. Similarly, 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.

What are the risk factors for PTSD?

There are three factors that have been shown to increase the likelihood that children will develop PTSD. These factors include the severity of the traumatic event, the parental reaction to the traumatic event, and the physical proximity to the traumatic event. In general, most studies find that children and adolescents who report experiencing the most severe traumas also report the highest levels of PTSD symptoms. Family support and parental coping have also been shown to affect PTSD symptoms in children. Studies show that children and adolescents with greater family support and less parental distress have lower levels of PTSD symptoms. Finally, children and adolescents who are farther away from the traumatic event report less distress.

There are several other factors that affect the occurrence and severity of PTSD. Research suggests that interpersonal traumas such as rape and assault are more likely to result in PTSD than other types of traumas. Additionally, if an individual has experienced a number of traumatic events in the past, those experiences increase the risk of developing PTSD. In terms of gender, several studies suggest that girls are more likely than boys to develop PTSD. A few studies have examined the connection between ethnicity and PTSD. While some studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure. It is not clear how a child's age at the time of exposure to a traumatic event impacts the occurrence or severity of PTSD. While some studies find a relationship, others do not. Differences that do occur may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels (see next section).

What does PTSD look like in children?

Researchers and clinicians are beginning to recognize that PTSD may not present itself in children the same way it does in adults (see What is PTSD? below). Criteria for PTSD now include age-specific features for some symptoms.

Very young children may present with few PTSD symptoms. This may be because eight of the PTSD symptoms require a verbal description of one's feelings and experiences. Instead, young children may report more generalized fears such as stranger or separation anxiety, avoidance of situations that may or may not be related to the trauma, sleep disturbances, and a preoccupation with words or symbols that may or may not be related to the trauma. These children may also display posttraumatic play in which they repeat themes of the trauma. In addition, children may lose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event.

Clinical reports suggest that elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. However, they do experience "time skew" and "omen formation," which are not typically seen in adults. Time skew refers to a child mis-sequencing trauma related events when recalling the memory. Omen formation is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas. School-aged children also reportedly exhibit posttraumatic play or reenactment of the trauma in play, drawings, or verbalizations. Posttraumatic play is different from reenactment in that posttraumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety. An example of posttraumatic play is an increase in shooting games after exposure to a school shooting. Posttraumatic reenactment, on the other hand, is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).

PTSD in adolescents may begin to more closely resemble PTSD in adults. However, there are a few features that have been shown to differ. As discussed above, children may engage in traumatic play following a trauma. Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.

Besides PTSD, what are the other effects of trauma on children?

Besides PTSD, children and adolescents who have experienced traumatic events often exhibit other types of problems. Perhaps the best information available on the effects of traumas on children comes from a review of the literature on the effects of child sexual abuse. In this review, it was shown that sexually abused children often have problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, and substance abuse. These problems are often seen in children and adolescents who have experienced other types of traumas as well. Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.

Along with associated symptoms, there are a number of psychiatric disorders that are commonly found in children and adolescents who have been traumatized. One commonly co-occurring disorder is major depression. Other disorders include substance abuse; other anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

How is PTSD treated in children and adolescents?

Although some children show a natural remission in PTSD symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated. Few treatment studies have examined which treatments are most effective for children and adolescents. A review of the adult treatment studies of PTSD shows that Cognitive-Behavioral Therapy (CBT) is the most effective approach. CBT for children generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts. Although there is some controversy regarding exposing children to the events that scare them, exposure-based treatments seem to be most relevant when memories or reminders of the trauma distress the child. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories. CBT also involves challenging children's false beliefs such as, "the world is totally unsafe." The majority of studies have found that it is safe and effective to use CBT for children with PTSD.

CBT is often accompanied by psycho-education and parental involvement. Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function. Therefore, it is important for parents to seek treatment for themselves in order to develop the necessary coping skills that will help their children.

Several other types of therapy have been suggested for PTSD in children and adolescents. Play therapy can be used to treat young children with PTSD who are not able to deal with the trauma more directly. The therapist uses games, drawings, and other techniques to help the children process their traumatic memories. Psychological first aid has been prescribed for children exposed to community violence and can be used in schools and traditional settings. Psychological first aid involves clarifying trauma related facts, normalizing the children's PTSD reactions, encouraging the expression of feelings, teaching problem solving skills, and referring the most symptomatic children for additional treatment. Twelve Step approaches have been prescribed for adolescents with substance abuse problems and PTSD. Another therapy, Eye Movement Desensitization and Reprocessing (EMDR), combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and adults with PTSD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change. Medications have also been prescribed for some children with PTSD. However, due to the lack of research in this area, it is too early to evaluate the effectiveness of medication therapy.

Finally, specialized interventions may be necessary for children exhibiting particularly problematic behaviors or PTSD symptoms. For example, a specialized intervention might be required for inappropriate sexual behavior or extreme behavioral problems.

What can I do to help my child?

Reading this fact sheet is a first step toward helping your child. Gather information on PTSD and pay attention to how your child is functioning. Watch for warning signs such as sleep problems, irritability, avoidance, changes in school performance, and problems with peers. It may be necessary to seek help for your child. Consider having your child evaluated by a mental-health professional who has experience treating PTSD in children and adolescents. Many therapists with this experience are members of the International Society for Traumatic Stress Studies, which has a membership directory containing a geographical listing of therapists who treat children and adolescents. Ask how the therapist typically treats PTSD, and choose a practitioner with whom you and your child feel comfortable. Consider whether you might also benefit from talking to someone individually. The most important thing you can do now is to support your child.

Based in part on the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, Journal of the American Academy of Child and Adolescent Psychiatry, 37:10 supplement, October 1998.