The frequency with which posttraumatic stress disorder (PTSD), depression, and other significant emotional or behavioral problems develop varies among these causes, but all can lead to deleterious outcomes. Traumatic stress and PTSD are more common following child physical and sexual abuse and after rape or other sexual traumas. Acute stress reactions are common in children, especially after violent or accidental injury. PTSD does not develop in all children who experience acute stress reactions. Psychological recovery often accompanies physical recovery and occurs in association with parental support and encouragement.
The frequency and total number of traumatic events, especially physical and sexual abuse, appear to influence the presence and severity of psychological sequelae, which themselves are often complicated by further traumatic experiences. Examples include moving a child to various foster homes and placement of the child by child protective services (CPS) in state custody following abuse.
Death or serious injury of a close relative affects a child in 3 distinct ways:
• The child is affected directly by the loss or serious injury.
• That relative is not available to support the child through his traumatic experience.
• There is frequently significant confusion, worry, and sadness in the child’s family as the family grieves or cares for a seriously injured family member, further decreasing support for the child.
Consequences of trauma
Children with preexisting mental health problems are frequently more affected by a traumatic experience than those without such issues. This is especially true if the child was previously anxious or fearful or has a slow-to-warm-up temperament. It appears that significant traumatic stress is more likely to develop in individuals with significant interpersonal sensitivity and marked emotional reactivity to either their own or others’ distress. In this light, PTSD can be viewed as a phenomenon that occurs as a result of a genetic-environmental interaction.
Witnessing or experiencing traumatic interpersonal violence may lead to traumatic stress in children with high interpersonal sensitivity. PTSD is twice as likely to develop in girls as in boys. In contrast, conduct disorder or antisocial or criminal behavior is more likely to develop in boys after significant violent trauma. Shame at the time of the trauma and self-blame about its cause worsen the psychological outcome (ie, “I must have led him on, causing him to rape me,” “I sought my stepfather’s attention, which must have made him sexually abuse me”).
The degree of attuned emotional support the child receives from supportive adults is the most important determinant of the level of psychological stress he or she will experience after trauma. These adults are usually parents, but they can be others with whom the child has meaningful relationships. Their support validates the child’s experience and helps him feel cared about and understood even he is terrified and overwhelmed. For example, the psychological outcome for children who have been sexually abused depends a great deal on the emotional support of the nonoffending parent.
Many factors affect the degree of emotional support available to the traumatized child. This child’s attachment relationship with his caregivers is crucial. The greater the security of attachment, the more the child will trust and rely on the support of others while coping with the arousal associated with trauma. A caregiver’s ability to manage his or her own distress associated with the child’s traumatic experience is also an essential element in his ability to be emotionally available to the child.
Assessing the child
Treatment begins with a thorough assessment of the child who has experienced trauma and has symptoms of traumatic stress. This includes obtaining a history of the child’s traumatic experiences and gaining an appreciation of the child’s strengths and capacities. In gathering this history, one needs to take care not to retraumatize the child; the use of ancillary historians is essential in this endeavor.
An assessment of symptoms is essential. These include the psychological symptoms of PTSD and depression as well as behavioral manifestations (eg, aggressiveness, impulsivity, substance use, sexual acting out, and self-harm). The evaluation also includes family relationships, family organization, family members’ understanding of the trauma, and the family’s ability to obtain the resources (eg, medical and mental health care) needed for recovery.
All health care providers must report abuse to the child protective system when it is suspected. If CPS is involved with the child, the clinician can continue to be connected by agreeing to provide support to the child and, if feasible, to support the family’s efforts to improve their situation. The clinician should explore the situations that trigger arousal for the child and that often result in impulsive, aggressive behaviors and also assess the ways in which the child calms himself when upset.
Several researchers have described approaches to the treatment of children who have experienced trauma and have psychological or behavioral difficulties.1,2 The National Child Traumatic Stress Network also presents a comprehensive review of Trauma Focused Cognitive Behavior Therapy on its Web site.3 The goals of treatment are to assist the child’s return to safe development and functioning and to help build the capacity of the child’s family and other important adults to support the child’s behavior and development.
During treatment, the child learns to integrate the memory of the trauma so that he does not need to avoid or reexperience it. Critical incident debriefing has been advocated as an effective method of assisting individuals who have experienced significant trauma. If this is a mandatory expectation, however, it often is not helpful. It appears that the lack of personal choice about participating in this debriefing may undermine the effectiveness of telling the story of the trauma. Regaining personal control after exposure to trauma appears to be an important aspect of recovery.