TRAUMA ASSESSMENT TEAM
Post-traumatic Stress Disorders Programs

Department of Psychiatry and Behavioral Sciences
BAYLOR COLLEGE OF MEDICINE

APPENDIX II

The Effects of Traumatic Events on Children

INTRODUCTION

This brief description of the effects of traumatic events on children is part of the materials provided by our team for clinicians, parents, teachers and case workers working with children who have experienced traumatic events. A modified version of these materials is being prepared with specific reference to the children surviving the shoot-out at Ranch Apocalypse near Waco, Texas on February 28, 1993.

This description should prove useful to case workers, clinicians, families and other adults working with the children from Ranch Apocalypse. More detailed descriptions of post-traumatic stress disorders, the effects of trauma on children and neurodevelopment as well as specific recommendations for clinical approaches when working with traumatized children are available upon request.

A. THE ALARM STATE

The human body and human mind have a set of very important and very predictable responses to a traumatic threat. The reaction to danger or threat has been labeled the fight or flight reaction. In the initial stages of this reaction there is a response called the alarm reaction.

The alarm reaction is characterized by a large increase in activity of the sympathetic nervous system, resulting in increased heart rate, blood pressure, respiration, a release of stored sugar, an increase in muscle tone, a sense of hyper vigilance, and tuning out of all non-critical information. All of these actions prepare the body to fight with or run away from the potential threat.

This total body mobilization, the fight or flight response, has been well-characterized and described in great detail for adults (see Appendix III). All of these responses are highly adaptive, very primitive and universally observed in humans beings under threat.

B. THE ACUTE POST-TRAUMA REACTION [ Re-experiencing | Affective/emotional 'memory' and physiological hyperarousal ]
[ Avoidance, emotional numbing and dissociation ]

1. Re-experiencing: Immediately following the disappearance of the threat or the end of a threatening event such as the end of the shoot-out, the mind and body slowly leave the acute alarm state. Over time, the heart rate decreases, blood pressure decreases, the complete mobilization of sugars from throughout the body slows down, the state of hyper vigilance goes down somewhat, and the individual begins to actually pay attention to internal stimuli (e.g., feelings, thoughts) as opposed to being completely focused on the external threat.

   This means, for example, that the individual will now perceive the sense of fear and anxiety. The individual will begin to 'process' and think about what happen, attempting, if you will, to make sense out of and understand what has just happened. Because the traumatic event is so far out of the normal range of experience, there will be a variety of mental attempts to process and "master" this event.

   The event will play itself out in the mind of the child again and again. This set of re-living and re-experiencing phenomenon may include telling the story over and over again to friends, it may include acting this event out in play, it may include intrusive dreams, it may include drawing the events or elements of the events in free drawing, and it will certainly include series of intrusive recurring thoughts about the event.

   The normal and predictable mental mechanisms which are typically used to process all experiences will at times fail in the attempts to master and understand a traumatic event. Because the events have features which are so outside the range of normal experience, there are very few internal experiences with which to judge or make sense out of the event. The more outside the range of the normal experience and the more life-threatening the experience, the more difficult it will be for the normal mental mechanisms to work efficiently to process and master that experience. The sense of not being able to have control over the event or control over the intrusive thoughts about the event lead to a whole other set of predictable, mental and physiological responses.

2. Affective/emotional 'memory' and physiological hyperarousal: Unfortunately, as this event plays itself out again and again in the mind of the child, not only will the thoughts of the event be recalled, the emotions and feelings (fear, anxiety, pain) of being out of control and threatened will be re-experienced as well. Each intrusive thought, nightmare and re-enactment in play also re-evokes the emotional or affective memory of being in the midst of the threatening event.

   A classic set of predictable symptoms and physical changes seen in the acute post-traumatic period is related to the ability to very easily re-evoke the emotional and physiological memories of being in the traumatic event. This means very simply that in addition to having cognitive remembrances of the facts, the details, their thoughts, and what happened, that they will have a recollection and a reliving of the physiological changes that were present in the alarm reaction. This means that the children will be hyper vigilant, have an increased startle response, have increased muscle tone, have a fast heart rate (tachycardia), and may have increased blood pressure. Indeed, even at rest in the two weeks that we have been working with the children from the Ranch Apocalypse, we have observed in each of these children signs of physiological hyper arousal. All of these children have exhibited tachycardia or a fast heart rate. Despite their outward behaviors of appearing quite normal and quite age-appropriate in most situations, these children are internally agitated and quite stirred up. Again, this is evidenced by their inability to be physiologically calm.

   Persisting physiological and emotional distress is uncomfortable, physically and emotionally exhausting and often extremely painful. Because of the pain, energy and discomfort associated with the recurring intrusive thoughts and the physiological and emotional 'memories' associated with these thoughts, a variety of avoidance mechanisms are used to escape reminders of the original trauma.

3. Avoidance, emotional numbing and dissociation: Avoiding direct reminders of the trauma sometimes is extremely difficult. In that case, children will withdraw in to themselves in a variety of ways. This inward focused withdrawal basically means that they will have fewer opportunities to be provoked into having more intrusive thoughts about the event, and therefore, they can thereby avoid pain.

   Sometimes these avoidant and psychological fleeing mechanisms result in what we call dissociation. Dissociation is basically a mental mechanism by which one withdraws attention from the outside world and goes to an 'inside world' or worlds. Daydreaming is an example of a dissociative event. The period between wakefulness and sleep is another example of dissociating from the here and now, the present, to being focused inward to ultimately move into a different state, sleep. In all children and in most adults, the capability of dissociating is present and will be used in a variety of situations. Traumatized children, when faced with reminders of the original traumatic event (e.g., family visits in jail or visits to the FBI Command Post), may experiences so much pain and anxiety that they become overwhelmed. In these situations when they cannot physically withdraw from those reminders, they frequently will dissociate. Children will appear to be gazing off into nowhere. They will not respond to questions by adults. Their answers to questions will seem unclear, unfocused or evasive -- they are, however, off in another place. The great majority of children who experienced the shoot-out at Ranch Apocalypse were observed to have significant dissociative behaviors during the time they were observed by our staff after being released from the Ranch.

   In the first days and weeks following the traumatic event, the symptoms listed above, 1) re-experiencing phenomena, 2) attempts to avoid reminders of the original event and 3) physiological hyper-reactivity are all relatively predictable, and indeed, highly adaptive physiological and mental responses to a trauma. Unfortunately, it appears from our work and work of others, that the more prolonged the trauma and the more pronounced the symptoms during the immediate post-traumatic period, the more likely there will be long term chronic and potentially permanent changes in the emotional, behavioral, cognitive and physiological functioning of the child.

C. POST-TRAUMATIC STRESS DISORDERS

Children and adults surviving traumatic events very frequently will have persistence of the acute post-traumatic stress response beyond six months. When this occurs, the child or adult is then considered to be suffering from post-traumatic stress disorder. Post-traumatic stress disorder is a diagnostic label which has been traditionally associated with combat veterans. More recently however, it has been very well described in children who have been survivors of physical abuse, sexual abuse, exposure to community or domestic violence and other children exposed to any variety of traumatic event. The three major clusters of symptoms as described above are observed in a variety of forms of post-traumatic stress disorder.

In brief however, children who survive a traumatic event and have persistence of this low level fear state, may be behaviorally impulsive, hypervigilant, motorically hyperactive, withdrawn or depressed, have sleep difficulties (including insomnia, restless sleep and nightmares) and anxious. In general, these children may show some loss of previous functioning or a slow rate of acquiring new developmental tasks. In addition, many of these children have persisting physiological hyper-reactivity with resulting fast heart rate or borderline high blood pressure.

Whether or not someone develops post-traumatic disorder following a traumatic event is related to a variety of factors. The more life-threatening the event, the more likely someone is to develop PTSD. The more the event disrupts their normal family or social experience the more likely someone is to develop PTSD. Having a supportive, nurturing and predictable family setting to help a child after a traumatic event is a relative protective factor.

Unfortunately, the great majority of children who survive the Ranch Apocalypse shoot-out also have a concomitant major disruption in their way of life, their sense of community, their family structure, and will be exposed to a variety of ongoing provocative reminders of the original event (e.g., ongoing legal actions, high press visibility). The frequency with which children develop post-traumatic stress disorders following comparable traumatic events is relatively high (45-60 %). Based upon the prolonged and extensive nature of the 'stressors' and the level of acute post-traumatic symptoms seen in the children from Ranch Apocalypse a very high prevalence of post-traumatic stress disorders is likely to be seen.

Children who survive traumatic events and exhibit this diverse set of symptoms and physical signs are frequently also able to meet diagnostic criteria for attention-deficit hyperactivity disorder, anxiety disorder NOS, major depressive disorder, conduct disorder, and a variety of Axis I DSM III-R diagnoses. Keeping in mind, however, that these children have been traumatized and that the symptoms of anxiety, depression and behavioral impulsivity are reflective of core changes related to the traumatic event helps one provide better diagnostic, prognostic and the therapeutic services for these children. In a separate Appendix, specific recommendations regarding clinical work with traumatized children is available.

Bruce D. Perry, M.D., Ph.D.
Associate Professor and Vice-Chairman for Research, Psychiatry and Behavioral Sciences
Chief of Psychiatry, Texas Children's Hospital
Director, Post-traumatic Stress Disorders Clinical Research Team, Houston VAMC
Baylor College of Medicine

March 25, 1993
Version 1.0
Traumatic Experiences and Children: Koreshian Children