Millions of children all around the world are frequently exposed to all manner of traumatic experiences, from those of human design such as bearing witness to shootings, inner city violence, the effects of living in a war zone, or being the victims of child abuse, to enduring the consequences of exposure to natural disasters such as a hurricanes, earthquakes, or natural fires. So what is the impact of psychological trauma on children?
To understand more, I met with Dr. Victor Carrion, a Professor at the Stanford University School of Medicine and Director of the Stanford Early Life Stress Research Program at the Lucille Packard Children’s Hospital at Stanford. Dr. Carrion’s research focuses on the interplay between brain development and stress vulnerability. He has developed treatments that focus on individual and community based interventions for stress related conditions in children and adolescents that experience traumatic stress. In the first of this 3-part blog post, Dr. Carrion discusses the expected reactions to traumatic events in children and the typical manifestations of childhood PTSD.
SJ: If we consider the example of a child of elementary school age who is exposed to a horrific traumatic event such as the Sandy Hook Elementary School shooting in 2012, what, as a child psychiatrist, would you expect to see over the coming days and weeks, i.e., what would be a normal and expected reaction to such an event in an elementary school child?
VC: The school-aged kid is going to have a difficult time understanding his/her emotional life. So, they may somatise, e.g., complain of headaches and stomach aches, and they are going to want to not go to school. They may not be psychologically minded enough to verbalize what they are struggling with. Kids sometimes do not have the vocabulary to talk about a traumatic event and sometimes they are still very concrete in their thinking.
Also remember, because of media, even if we are not right where a trauma happened we can still be equally affected. An example would be 9/11, where kids in California were following, minute by minute, everything that was happening in the news, and when they started showing those pictures of people jumping from the towers that was traumatic for many kids. Our association, the AACAP (American Academy of Child & Adolescent Psychiatry), actually contacted the networks and they were very responsive and stopped showing those images as soon as we contacted them.
SJ: In your opinion, how best should parents, teachers, and caregivers respond to such normal reactions?
VC: It will be important to really encourage discussion after something traumatic happened, but not force it. Certainly, not even encourage it in very young kids that may not even know that something happened. Our belief now is that if the kid is 4 and 5 and this is not being discussed at school and they are not watching the news and they do not know that something terrible happened, there is no reason to talk to them about it.
Obviously, if they directly witnessed or experienced something, that is a different story because, as you know, exposure to trauma is one of the strongest predictors of PTSD.
It is important for caregivers to give children a message of safety - that they are being taking care of and that they will be protected and that nothing will happen to their caregivers. This message of safety is important.
Another piece of this is that children should not be expected to be tough. One of the things that parents can actually model is that it is okay to cry and it is okay to have distress, but parents have to be careful in how they balance that with maintaining their safety message and their authority message. They still have to give the message that I am okay enough to take care of you in a good way. But children certainly should be encouraged to express whatever feelings they may have about something that has occurred.
Most children exposed to trauma are going to have a normal response and be okay with time. With a very small group of these kids, the response is going to continue and is going to become maladaptive and they need extra help. One of the things that is important for caregivers to recognize is when a child’s response becomes maladaptive, chronic, or continuous. In that event, they should seek out professional help.
SJ: Let’s consider the more unfortunate scenario, that this child starts to develop signs/symptoms of a prolonged reaction to the trauma/an abnormal reaction: What are the typical manifestations of PTSD (posttraumatic stress disorder) in children of this age?
VC: Kids tend to show their re-experience of trauma through intrusive thoughts. This means thinking or talking about the trauma when they do not want to. So, they are playing basketball with friends and, all of a sudden, the images of the trauma do not let them enjoy the game or even play it. Or, they are doing their homework but they cannot because they are thinking about the traumatic event. Or they re-experience their trauma through what we call traumatic play. Traumatic play is a way for many children to communicate their experience especially if they are not that verbal.
Then there is avoidance. But with kids is it really avoiding or is it that the kid does not have the words to talk about what happened? There might be a cognitive inability to really talk about what happened, but certainly we also see an avoidance of trauma related triggers. For example, if something traumatic happened and it was a rainy day, then the next rainy day they may be particularly sensitive or nervous that day.
We see emotional numbing quite often also: kids say that they can no longer feel sad when something bad happens. They feel happy when something good happens but not as good as they used to feel. They may go to a birthday and it is okay but they used to love birthdays before.
The other type of symptom is the physiological hyperarousability. That is what leads many kids to receive a misdiagnosis (especially kids that live in environments where they are surrounded by violence) of ADHD. Now, this gets very complicated clinically, because kids that truly have ADHD are at increased risk of experiencing traumatic events. For example, they may not see the car coming and they go and cross the street. The kid that has ADHD is at increased risk of experiencing traumatic events, which means they may end up with PTSD also.
Then, another thing as I said is that traumas are stressors to the system and you develop whatever you are vulnerable to. It may be that you do not develop PTSD but you develop OCD/a phobia as a consequence of experiencing a traumatic event.
We have always known that having anxiety puts you at risk for developing PTSD, but what we have also seen in our data is that developing PTSD is a good predictor of developing other anxiety disorders after having PTSD.
What we also see is that children tend to be egocentric and naturally narcissistic. In kids it is a helpful drive because they get the necessary attention and all that, but that also means that if something bad happens, children take excessive responsibility for it and it creates this sense of guilt, and guilt is a very good predictor of developing PTSD. This is not survivor’s guilt. This is guilt over an act. For example, “there was a fire and I could have prevented it and I did not.” “I was abused and that is because I provoked it or I made it happen.” Whenever there is that sense of guilt after a kid experiences a traumatic experience it is good to start some clinical remediation to correct those cognitive distortions.
Stay tuned for Part 2 of this interview, which will discuss how childhood PTSD differs from adulthood PTSD, the neuroscience of childhood PTSD, and common misperceptions regarding the impact of traumatic stress on child development.
Copyright: Shaili Jain, MD. For more information, please see PLOS Blogs