Essay title - Children Adolescents Trauma: РΤЅD in Children and Adolescents
A trauma is a psychologically distressing event that is outside the range of usual human experience, one that induces an abnormally intense and prolonged stress response.
Despite the fact that they are outside the range of usual human experience, traumatic events are fairly common, even among children. In their study in 2005 of children and adolescents (9-16 years old) in Western North Carolina, found that 25% had experienced at least one potentially traumatic event. In her review of the literature, Solomon (2005) found 90% of people surveyed experience at least one traumatic event during their lifetimes(101).
Events that can induce trauma include the sudden death of a loved one, assaultive violence (combat, domestic violence, rape, torture, mugging), serious accidents, natural disasters, witnessing someone being injured or killed, or discovering a dead body.
In child welfare, physical and sexual abuse are common sources of trauma in children. Other causes of childhood trauma can include animal attacks (dog bite), life-threatening illnesses, and prolonged separation from caretakers. Normal, immediate reactions to trauma cover a wide range and can include overwhelming feelings of helplessness, fear, withdrawal, depression, and anger. Reactions may last for weeks or months but more commonly show a swift decrease after the direct impact subsides. Child welfare workers should look for and be able to spot the age-specific reactions to trauma described in the related article "How Children and Teens React to Trauma." Children are less likely to exhibit some of the well-known adult symptoms of РΤЅD (Taylor, 2005, 57)
The intensity of a person’s reaction immediately after a traumatic event is not predictive of that person’s chances of developing РΤЅD. The most important indicator of subsequent risk of chronic РΤЅD seems to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward. Adversities experienced for an extended period after the trauma (such as a series of different placements or separation from a caregiver) and the formal and informal supports available to children also influence their risk for more serious posttraumatic stress reactions.
With informal support, the majority of trauma survivors recover on their own within a few weeks, though some need longer to heal. For a small minority, nonetheless, traumatic events trigger a variety of mental disorders, as well as РΤЅD. (Bandura, 2007, 15)
РΤЅD may arise weeks, months, or even years after the traumatic event. Formal diagnosis of the disorder may be made only by a qualified professional. A person can be diagnosed with posttraumatic stress disorder only when all three of the following conditions are met: (1) the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others; (2) the person’s response involved intense fear, helplessness, or horror (in children, this may be expressed by disorganized or agitated behaviour); and (3) he or she exhibits at least one of the following symptoms for longer than one month:
•Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma
•Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future)
•Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behaviour (Bandura, 2007,105-110)
It is important to note that many children experience great distress from traumatic events but do not, for one reason or another, qualify for a diagnosis of РΤЅD. However, these children should also be screened and, if appropriate, treated by a qualified mental health professional.
Rates of РΤЅD are higher in children and adolescents recruited from at-risk samples than they are for the general population. In their study of РΤЅD in children in foster care, Dubner and Motta (1999) found РΤЅD was diagnosed for 60% of sexually abused children and 42% of physically abused children. Dubner and Motta also found 18% of the foster children who had experienced neither physical nor sexual abuse also had РΤЅD. These children may have developed РΤЅD due to exposure to domestic violence, community violence, or other events.
Another study (Self-efficacy: Toward a unifying theory of behavioural change. Psychological Review) examining children entering foster care aged six to eight found that one out of three met criteria for РΤЅD. It has also been suggested that the incidence of РΤЅD may be higher in individuals with developmental cognitive learning abilities. This may have serious implications for child welfare work, since according to CWLA 20% of the children in foster care have some form of developmental less cognitive ability. (Bandura, 2007, 12)
About half of those with РΤЅD recover completely within three months, but others suffer chronically (Bandura, 2007, 32). If a person has symptoms for more than a year, it will usually be a lifelong condition if not treated. Even if РΤЅD does become chronic, treatment can alleviate many symptoms. It is important to have children assessed by mental health practitioners who have training and experience with РΤЅD and child trauma.
Risk and Protective Factors
РΤЅD can develop in individuals without any predisposing conditions, especially if the traumatic event is extreme. However, research has identified factors influencing an individual’s likelihood of experiencing РΤЅD.
Goodman (2002) states that trauma-exposed children are most at risk if they have:
•Physical injuries as a result of the event (e.g., physical abuse)
•Personally witnessed the event (e.g., domestic violence, abuse of a sibling, community violence)
•Pre-existing mental health issues or learning difficulties
•A limited support network
•Someone close to them who is missing, hurt, or dead
•Caregivers who are experiencing emotional difficulty (15)
•Pre-existing or consequent family life stressors (e.g., divorce, job loss)
•Previous loss or trauma experiences (may include multiple placements in foster care)
РΤЅD may be especially severe or long lasting when the stressor is of human design, as in cases of sexual abuse. Gender also seems to be a risk factor. Several studies suggest girls are more likely than boys to develop РΤЅD. (Mark, 2005, 41)
Factors that reduce a person’s chances of developing РΤЅD include: higher cognitive ability; strong social supports; having a happy, safe childhood in a stable family; and an overall positive outlook/personality. Impact Research by Saul (2006) has shown that if it goes untreated, РΤЅD affects children, teens, and adults in various ways: Multiple Diagnoses. РΤЅD frequently occurs in conjunction with disorders such as depression, problems of memory and cognition, anxiety disorders such as separation anxiety and panic disorder, and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder. Substance abuse is also a problem; the National Child Traumatic Stress Network cites a study that found 25% of children with РΤЅD became substance abusers, compared with 3.7% of non-traumatized children. (Saul, 2006, 25)
Relationships and Behaviour. Children who have experienced traumas often have relationship problems with peers and family members and problems with acting out. Exposure to trauma, especially community violence, has been linked to aggressive and anti-social behaviour. Adults with posttraumatic stress symptoms are more likely to report nuptial problems.
Physical Health. Solomon (2005) found in her research review that РΤЅD increases a person’s risk for serious and chronic disease, including circulatory, digestive, musculoskeletal, endocrine, respiratory, and infectious diseases. She also notes that trauma victims are less likely than others to take steps to protect their health (e.g., fewer preventive healthcare visits, exercising and using seatbelts less). Child maltreatment in general is linked to a long list of later adult health problems(Dunmore, 2004, 16)
School Performance. Because it contributes to difficulties with behaviour, relationships, mental health, attention, concentration, and memory tasks, РΤЅD has also been linked to school failure. (Dunmore, 2004 ,148)
Finances and Employment. Amaya-Jackson found that adults with posttraumatic stress symptoms were much more likely to miss work, to experience insufficient income, and to be receiving public assistance (food stamps, Medicaid, TANF) than people without symptoms. РΤЅD represents a special threat to children involved with the child welfare system. The potential costs of РΤЅD—for these children and for society—are significant. This issue of Practice Notes suggests ways that workers and agencies can respond to children and families affected by traumatic events. (Nurius, 2005, 114)
A diagnosis of РΤЅD 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 РΤЅD in children and adolescents. Children and adolescents may be diagnosed with РΤЅD 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. (North, 2004 ,144)
Background and History of the Issue
A diagnosis of РΤЅD 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 РΤЅD in children and adolescents. Children and adolescents may be diagnosed with РΤЅD 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. (North, 2004 ,54)
A few studies of the general population have been conducted that examine rates of exposure and РΤЅD 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 РΤЅD (North, 2004, 59)
Rates of РΤЅD are much higher in children and adolescents recruited from at-risk samples. The rates of РΤЅD 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 РΤЅD. Similarly, 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence develop РΤЅD (North, 2004, 4).
There are several other factors that affect the occurrence and severity of РΤЅD. Research suggests that interpersonal traumas such as rape and assault are more likely to result in РΤЅD 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 РΤЅD. In terms of gender, several studies suggest that girls are more likely than boys to develop РΤЅD. A few studies have examined the connection between ethnicity and РΤЅD. While some studies find that minorities report higher levels of РΤЅD 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 РΤЅD. While some studies find a relationship, others do not. Differences that do occur may be due to differences in the way РΤЅD is expressed in children and adolescents of different ages or developmental levels.
Research-Based Best Practice
Very young children may present with few РΤЅD symptoms. 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 (Taylor, 2005, 48).
Clinical report by Dunmore (2004) suggests that elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. Nevertheless, they do experience "time skew" and "omen formation," which are not characteristically 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 behaviourally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence). (North, 2005,11)
РΤЅD in adolescents may begin to more closely resemble РΤЅD 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 behaviours. (Bandura, 2007,25)
Although some children show a natural remission in РΤЅD symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated. A small number of treatment studies have examined which treatments are most effectual for children and adolescents. (Dunmore, 2004,32)
A review of the adult treatment studies by Bandura and Mark of РΤЅD shows that this is the most effective approach for treating children. СВΤ 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 steadily and taught relaxation so that they can learn to relax at the same time as recalling their experiences. Through this course of action, they learn that they do not have to be frightened of their memories. СВΤ 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 СВΤ for children with РΤЅD. (Bandura,2007 ,41)
СВΤ is often accompanied by psycho-education and parental involvement. Psycho-education is education about РΤЅD symptoms and their effects. It is as important for parents and caregivers to understand the effects of РΤЅD 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 РΤЅD in children and adolescents. (Mark, 2005,11)
Play therapy can be used to treat young children with РΤЅD 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 recommended for children exposed to community violence and can be used in schools and conventional settings. It involves clarifying trauma related facts, normalizing the children's РΤЅD reactions, encouraging the expression of feelings, teaching problem solving skills, and referring the most symptomatic children for additional treatment.
This type of approach has been prescribed for adolescents with substance abuse problems and РΤЅD. Another therapy, ΕМDR, combines cognitive therapy with directed eye movements. While ΕМDR has been shown to be effective in treating both children and adults with РΤЅD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change. (Saul, 2006,19)
Drugs have also been prescribed for some children with РΤЅD. 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 behaviours or РΤЅD symptoms. For example, a specialized intervention might be required for inappropriate sexual behaviour or extreme behavioural problems.
How do we effectively help these people recognize and deal with the traumatic events in their lives so that they can deal with РΤЅD and possibly prevent this disorder from manifesting into further psychiatric problems? Someone with РΤЅD may experience unwanted memories when exposed to certain stimuli; sometimes these stimuli are real or perceived. Many times these people turn to substance abuse to deaden troubling symptoms or develop a concurrent psychiatric problems, such as eating disorders, OCD, or multiple personality disorder. A РΤЅD episode activates the fight or flight response from the sympathetic nervous system. When triggered inappropriately in РΤЅD, the fight or flight response can have negative social consequences such as chronic anger, violence, aggression, disassociation and an altered self-perception. These feelings many times lead to illegal behaviour and incarceration (Nurius, 2005, 32).
Diagnosis can be difficult because signs and symptoms vary among different people. Careful clinical interviews are used to evaluate the client's psychological status. Most treatment includes a combination of patient education, drug therapy, and psychotherapy. Research has shown that letting someone just talk about a catastrophic event in their lives reduces the likelihood of developing РΤЅD. In addition to professional help, there are a number of techniques that help prevent problems from escalating, the clinician should: (Nurius, 2005,32)
- Provide a calm, safe environment.
- Meet the clients basic needs by addressing fatigue, hunger, loneliness.
- Establish trust by assuming a positive, consistent, honest, and non-judgmental attitude.
- Communicate clearly and honestly.
- Help your client to realize that his/her symptoms are common reactions to stressors.
- Help your client feel that they are not responsible for their disorder.
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