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Trauma and Terror in Childhood: The Neuropsychiatric Impact of Childhood Trauma
Bruce D. Perry, M.D., Ph.D. For: August 20, 2000 Childhood can be a very dangerous time. Each year in the United States alone more than 5 million children experience some form of traumatic experience (see Pfefferbaum, 1997: 1998; Perry 1994; 2000). Traumatic stress can have profound impact on the emotional, behavioral, cognitive, social and physical development of children, in some cases resulting in lifelong loss of potential and chronic mental and physical health problems. These injuries cost the individual, their family, community and, ultimately, society. The present chapter will review (1) the effects of exposure to trauma on the developing child; (2) describe the most common neuropsychiatric problems resulting from traumatic stress and (3) provide and overview of assessment and treatment issues. The Brain, Stress and Adaptation Our brain is designed to sense, process, store, perceive and act on information from the external and internal world to keep us alive. In order to do this, our brain has hundreds of neural systems, all working in a continuous, dynamic process of modulating, regulating, compensating - increasing or decreasing activity to control the body's physiology. Each of our many complex physiological systems has a rhythm of activity that regulates key functions. When blood sugar falls below a certain level, a set of compensatory physiological actions are activated. When tissue oxygen is low from exertion, when an individual is dehydrated, sleepy or threatened by a predator, still other sets of regulating activity will be turned on to respond to the specific need. For each of these systems there are 'basal' or homeostatic patterns of activity within which the majority of environmental challenges can be sustained. When an internal condition (such as dehydration) or an external challenge (an unpredictable and unstable employment situation) persists, this is a stress on the system.
Stress is a commonly used term in both lay and professional language. Unfortunately, there often is not agreement about what stress actually means. For the purposes of this chapter– and using a concept more commonly familiar to biologists – stress is any challenge or condition that forces the regulating physiological and neurophysiological systems to move outside of their normal dynamic activity. Stress occurs when homeostasis is disrupted (see Perry & Pollard, 1998). Traumatic stress is an extreme form of stress. It is important to understand that stress during development is not necessarily a bad thing. Indeed, the development of stress-response neural systems depends upon exposure to moderate, controllable levels of stress. The opportunity for a toddler to control his or her exploration, to discover and to experience moderated novelty is essential for healthy development. Children, when given the opportunity for moderate, controlled exposures to stress during childhood – with a consistent, available and safe caregiver to serve as "home-base," can become inoculated against future more severe stressors. Moderate, predictable levels of arousal and "stress" related to the novelty of healthy exploration and development helps create a resilient, healthy child.
With this said, however, dramatic, rapid, unpredictable, or threatening changes in the environment will activate the 'stress' response systems. These brain-mediated responses recruit a set of central and peripheral nervous system, neuroendocrine and immune responses that promote adaptive 'survival' functions and, later, a return to equilibrium or homeostatic patterns. Events that disrupt homeostasis are, by definition, stressful. If this stress is severe, unpredictable, prolonged or chronic, the compensatory mechanisms can become over-activated, or fatigued and incapable of restoring the previous state of equilibrium or homeostasis. The physiological system re-organizes its 'basal' patterns of equilibrium. An event is 'traumatic' if it overwhelms the organism, dramatically and negatively disrupting homeostasis. In a very real sense, trauma throws the organism 'off balance', and creates a persisting set of compensatory responses which create a new, but less functionally flexible state of equilibrium. This new, trauma-induced homeostasis is more energy consuming and maladaptive than the previous state. By inducing this "expensive" homeostasis and compromising full functional capability, trauma robs the organism. It has survived the traumatic experience, but at a cost. Threat and Adaptive Responses The Arousal Response The human body and human mind have a set of very important and very predictable responses to threat (for review see Perry, 1994; 1998; 1999). Threat may come from an internal (e.g., pain) or external (e.g., an assailant) source. One common 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. As the individual begins to feel threatened, the initial stages of a complex, total-body response will begin. The brain orchestrates, directs and controls this response. If the individual feels more threatened, their brain and body will be shifted further along an arousal continuum in an attempt to ensure appropriate mental and physical responses to the challenges of the threat. The cognitive, emotional and behavioral functioning of the individual will reflect this shift along the arousal continuum. During the traumatic event, all aspects of functioning of the individual change – feeling, thinking, behaving all change. Someone being assaulted doesn't spend a lot of time thinking about the future or making an abstract plan for survival. At that moment, their thinking, behaving and feeling is being directed by more 'primitive' parts of the brain (see Table 1). A frightened child doesn't focus on the words; they attend to the threat related signals in their environment – the non-verbal signs of communication such as eye contact, facial expression, body posture or proximity to the threat. The internal state of the child shifts with the level of perceived threat. With increased threat a child moves along the arousal continuum from vigilance through to terror. The alarm continuum is characterized by a graded increase in sympathetic nervous system activity, in turn, causing increased heart rate, blood pressure, and respiration; a release of glucose stored in muscle and increased muscle tone. Changes in the central nervous system cause hypervigilance; the child tunes out all non-critical information. These actions prepare the child 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. These responses are highly adaptive and involve many coordinated and integrated neurophysiological responses across multiple brain areas such as the locus coeruleus, the amygdala, the hypothalamus and the brainstem nuclei responsible for autonomic nervous system regulation. This total body mobilization, the "fight or flight" response, has been well characterized and described in great detail for adults. These responses are highly adaptive and involve many coordinated and integrated neurophysiological responses across multiple brain areas, including the brainstem nuclei responsible for autonomic nervous system regulation. What does hyperarousal really mean? Hyperarousal is a multi-dimensional process, characterized by both mental and physical changes. These include an increase in the activity of those parts of the central and peripheral nervous system responsible for the perception and processing of potentially threatening information. This graded response also involves "action." During the hyperarousal process, many physiological systems required for survival are activated (e.g., stress response hormones such as cortisol and adrenaline). The many physiological changes during hyperarousal will influence the way a person thinks, feels and acts. Dissociation The most well characterized reaction to threat is the "fight or flight" response. A second common reaction pattern to threat is dissociation. It is increasingly clear that responses to threat can vary tremendously from individual to individual. This second major adaptative response to threat involves an entirely different set of physiological and mental changes, yet does not fall under the heading of either "fight" or "flight." Dissociation is not always a response to threat or trauma, though. It is a common mental mechanism used in many situations during a routine day. For example, meditation, Lamaze childbirth exercises, daydreaming and highway hypnosis are all mild forms of dissociation. Many common and "normal" mental states such as anxiety, dissociation, or anger are experienced by most of us to some degree. When any one of these becomes pervasive and ever-present, however, they begin to interfere with the rest of one's life. When this occurs, we often classify this problem as a neuropsychiatric disorder.
Children tend to use dissociation as an adaptation to threat more often than adults. Because of their small size and limited life experiences "fight or flight" is usually not an option for children in a threatening situation. When fighting or physically fleeing is not possible, the child may use avoidant and psychological fleeing mechanisms that are categorized as dissociative. Dissociation due to threat and/or trauma may involve a distorted sense of time, a detached feeling that you are "observing" something happen to you as if it is unreal, the sense that you may be watching a movie of your life. In extreme cases, children may withdraw into an elaborate fantasy world where they may assume special powers or strengths.
Like the alarm response, this "defeat" or dissociative response is graded along a continuum. The intensity of the dissociation varies with the intensity and duration of the traumatic event. Again, remember that even when we are not threatened, we use dissociative mental mechanisms, such as daydreaming, all of the time. The period between wakefulness and sleep is another example of dissociating from the present to your inner thoughts, ideas, fears, fantasies and, then, ultimately moving into the state of sleep. During a traumatic event, all children and most adults use some degree of dissociation. However, some individuals will use, and some kinds of trauma induce, dissociation as a primary adaptive response. For most children and adults, however, the adaptive response to an acute trauma involves a combination of hyperarousal and dissociation. During the actual trauma, a child will feel threatened and the arousal systems will activate. With increased threat, the child moves along the arousal continuum. At some point along this continuum, the dissociative response is activated. This results in a host of protective mental (e.g., decreases in the perception of anxiety and pain) and physiological responses (decreased heart rate: see Perry et al., 1995) that characterize the dissociative response (see Differential Response to Trauma figure, above). Table 1: How Fear Changes Thinking, Feeling and Behaving: Different children have different styles of adaptation to threat. Some children use a primary hyperarousal response some a primary dissociative response. Most use some combination of these two adaptive styles. In the fearful child, a defiant stance is often seen. This is typically interpreted as a willful and controlling child. Rather than understanding the behavior as related to fear, adults often respond to the 'oppositional' behavior by becoming angrier and more demanding. The child, over-reading the non-verbal cues of the frustrated and angry adult, feels more threatened and moves from alarm to fear to terror. These children may end up in a primitive "mini-psychotic" regression or in a very combative state. The behavior of the child reflects their attempts to adapt and respond to a perceived (or misperceived) threat. Adaptation During a Traumatic Event Individual adaptive stress responses during a trauma vary. The specific nature of a child's responses to a given traumatic event will depend upon the nature, duration and the pattern of trauma, and characteristics of the child and his or her family and social situation. (e.g., genetic predisposition, age, gender, history of previous stress exposure, presence of attenuating factors such as supportive caregivers).Whatever the individual response, however, the extreme nature of the external threat is often matched by an extreme and persisting internal activation of the neurophysiological systems mediating the stress. A primary adaptive feature of the threat-response system is single-trial "learning" – the capacity to generalize from a threatening event to other experiences with similar features. Unfortunately, this very adaptive capacity is at the core of the emotional, behavioral and physiological symptoms that develop following a traumatic experience. Case Samples: Individual Response to Trauma 1. Same Event, Different Adaptive Styles in Different Children: On a quiet Sunday morning outside of Waco Texas, the ATF raided the Branch Davidian compound. Most of us have seen the footage of this assault on the television. Thousands of bullets were fired into that building. More than 80 children were in that building on that morning. In the three days following the ATF assault, 21 children were released to the FBI and became temporary wards of the state of Texas, cared for by a clinical team directed by the ChildTrauma Academy. These 21 children had a variety of individualized adaptive responses to the same event; some using a primary hyperarousal response, others a primary dissociative response, but the majority used a combination of these two primary adaptive patterns. Hyperarousal: T was an 11-year-old boy. He described a sense of heightened awareness, no primary anxiety, racing heart, increased vigilance and was very, very focused on the location and behavior of the ATF agents. Only after the event did he say he felt afraid. He was primarily afraid that the shooting would start again. Dissociative: G was an 8-year-old girl. She reported crawling under her bed and kind of "falling asleep." She could not give significant details regarding the shooting. She reported that is didn't seem real - "It all was like a dream." KEY POINT: Individual adaptive responses will vary. Many factors appear to play a role in the individual response. Several important variables are age, sex and previous history of traumatic exposure. Young children and females are more likely to use dissociative adaptations. 2. Same Child, Different Event, and Different Adaptive Style: X is a 10-year-old boy. Over the course of a single year, he was exposed to two different kinds of traumatic events. The first was a shooting in the community. He was with a group of children playing in a neighborhood, an altercation broke out between two older boys. The younger children watched as these boys fought and then one went to his car to get a gun. X describes the increase in his heart rate, his sense of fear, vigilance and a conflict about whether he should run home. When the older boy returned with the gun, X turned and ran. He heard the gunshot and looked back to see one boy on the ground. He later returned to the sight of the shooting to see the blood on the ground. This was a classic hyperarousal response that resulted in his flight. Two months later, X was visiting family in another part of Texas. A severe storm and then a tornado threatened their home. He reports that he felt terrified and then immobilized. Unable to move, his uncle took him into a closet under the stairs. In contrast to the shooting, he has little recollection of the details of the storm except that it was dark, noisy and it seemed to last for a long time. After the event he remembers walking around the neighborhood looking at the damage – "Or maybe I dreamed that." This was an inescapable event. And his response was primarily dissociative in nature. KEY POINT: The nature of an event can determine which response pattern is most adaptive. In this case, to flee was protective in the shooting, but would have been foolish in the storm. In general, when direct physical assault (e.g., torture or the sexual assault of a child) or inescapable threat is present, dissociation will be adaptive. In events where the individual is capable of fighting (e.g., the assault is by someone smaller than you) or fleeing (i.e., you can actually run away from the threat), the hyperarousal response is most adaptive. 3. Same Child, Different Event: Developmental Differences in Adaptive Style: T is a twelve year old girl. From birth until age five she lived in a household characterized by domestic violence. During this time, she was noted to be quiet, compliant, "tuned out," daydreamed and generally "a good little girl." She reports little memory of the fighting but her mother describes finding her in her bed, rocking, with covers over her head after some of the fights in the home. At age 12, her mother re-married but unfortunately, episodes of domestic violence resumed in this household. This time, however, T was loud, combative, angry and would run away from the home each time these events took place. She was noted to have "attention" problems at school that turned out to be hypervigilance. Rather than "tuning out" and withdrawing into a dissociative shell, this child was sensitized to fighting and had dramatic and pronounced hyperarousal during conflict. KEY POINT: Traumatic events of the same nature can induce different adaptive responses in the same child at different times during the child's development. An infant and young child is not truly capable of fighting or fleeing – hyperarousal is not an adaptive response. However, by age twelve, fighting back and fleeing were adaptive. In this child, both adaptive styles were used at different times in life for the same kind of perceived threat. The Acute Post-traumatic Period As the traumatic event ends, the phase known as the acute post-traumatic period begins. During this time, the mind and body slowly move back down the arousal or dissociative continuum. The child moves from the brink of terror, through fear, alarm and, with time and support, back to calm (see The Acute Response to Trauma figure above). Heart rate, blood pressure and other physiological adaptations normalize. If a child can move back down the arousal continuum, their brain will resume baseline (pre-trauma) styles of thinking, feeling and behaving. Hypervigilance decreases and the mental mechanisms related to attention begin to normalize as well. The child that has dissociated will begin to pay attention once again to external stimuli. Conversely, the child that has been completely focused on external cues related to threat will actually pay attention once again to internal stimuli (e.g., feelings, thoughts, sensing their pounding heart or noticing the cut on their leg from diving under a desk during the shooting). During this acute post-traumatic period, the child will now perceive the sense of fear and anxiety. This is when they will actually feel the fear associated with the trauma. The individual will begin to process and think about what has happened, attempting to make sense out of the events just experienced. 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 traumatic event will play itself out in the mind of the child again and again. A host of intrusive images related to the trauma may swamp the child's thinking. This set of re-living and re-experiencing phenomena may include telling the story over and over again to friends. The child may act this event out in their play and drawings (see below) or experience intrusions (flashbacks or nightmares). In essence, these children have created memories of the traumatic memory. The death of a loved one, for example, is a trauma that often causes created memories. Over the six months following the loss, children (as well as adults) will often experience unusual visual, auditory or tactile sensations. A child may think they hear the deceased person's voice -- or they think they saw them in a crowd -- or out of the corner of their eye they may see their reflection in a window. At bedtime or when awakening, these misperceptions are more common. Such "memories" may be disturbing to parents, caregivers and the child. Reassure the child. These "visions" are often interpreted in context of a religious belief system -- "they came back to tell me it was ok -- they are still with me." This can be important for the child and there is no reason to undermine these feelings. These "hysterical materializations" are common and often mislabeled as visual or auditory "hallucinations". These types of memories are complex and multi-domain (Perry, 1999). Traumatic memory involves the storage and recall of information at several levels. The brain stores not only traditional cognitive information such as who, what, when and where but also emotional information, feelings such as fear, dread, and sadness. The old adage that "the body remembers" is referring to motor-vestibular information. An example of this might consist of a memory of the body's position during the rape. Finally, the brain contains a state memory, such as vigilance or physiological hyperarousal. The normal and predictable mental mechanisms that are used to process all experiences will, at times, fail in the attempts to master and understand a traumatic event. Because traumatic events have features that 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 inability to control elements of the traumatic event, or the intrusive thoughts that follow, lead to a set of predictable, mental and physiological responses. Following any traumatic event children will experience some persisting emotional, behavioral, cognitive and physiological signs and symptoms related to the, sometimes temporary, shifts in their internal physiological homeostasis. In general, the longer the activation of the stress-response systems (i.e., the more intense and prolonged the traumatic event), the more likely there will be a 'use-dependent' change in these neural systems. In some cases, the stress-response systems do not return to the pre-event homeostasis. In these cases, the signs and symptoms become so severe, persisting and disruptive that they reach the level of a clinical disorder. In a new context and in the absence of any true external threat, the abnormal persistence of a once adaptive response becomes maladaptive. Post-traumatic stress disorder and other neuropsychiatric symptoms that are seen following traumatic events are related to the symptoms that are present during the acute response to threat. Indeed, PTSD, a disorder, originates from the maladaptive persistence of appropriate and adaptive responses present during traumatic stress. Post-traumatic Stress Disorders Post-traumatic stress disorder (PTSD) is a clinical syndrome that may develop following extreme traumatic stress (Diagnostic and Statistical Manual, Version IV, American Psychiatric Association referred to as DSM IV). There are six diagnostic criteria for PTSD. The first is an extreme traumatic stress accompanied by intense fear, horror or disorganized behavior. The next three are symptom clusters: 1) persistent re-experiencing of the traumatic event such as repetitive play or recurring intrusive thoughts; 2) avoidance of cues associated with the trauma or emotional numbing; 3) persistent physiological hyper-reactivity or arousal. Finally the last two diagnostic criterion refer to how long and how disabling the symptoms are. Signs and symptoms must be present for more than one month following the traumatic event and cause clinically significant disturbance in functioning. A child is considered to have Acute Stress Disorder (DSM IV) when these criteria are met during the month following a traumatic event. PTSD is further characterized as Acute when present for less than three months, Chronic for more than three months or Delayed Onset when symptoms develop initially six months or more after the trauma. Clinical presentation
Children with PTSD may present with a combination of problems (see Terr, 1991; Mulder et al., 1998). In fact, two children may both meet diagnostic criterion for PTSD but have a very different set of symptoms. This can be somewhat confusing to the non-clinical professionals trying to understand traumatized children. In addition, the signs and symptoms of PTSD can look very similar to other neuropsychiatric disorders in children, including attention deficit hyperactivity disorder (ADHD) and major depression. Typical signs and symptoms of PTSD include impulsivity, distractibility and attention problems (due to hypervigilance), dysphoria, emotional numbing, social avoidance, dissociation, sleep problems, aggressive (often re-enactment) play, school failure and regressed or delayed development. In most studies examining the development of PTSD following a given traumatic experience, twice as many children suffer from significant post-traumatic signs or symptoms (PTSS) but lack all of the criteria necessary for the diagnosis of PTSD (Friedrich, 1998). In these cases, the clinician may identify trauma-related symptoms as being part of another neuropsychiatric syndrome (e.g., hypervigilance is often consider an attention problem and traumatized children will be diagnosed and treated as if they have ADHD).
The misdiagnosis of traumatized children with PTSD is common. Sometimes a clinician may be unaware of ongoing traumatic stressors (e.g., domestic violence or abuse). In other cases, the family brings in a child because of new symptoms such as school failure or social withdrawal but makes no association between the child's symptoms and events in the distant past (e.g., car accident, death of a relative, exposure to violence). Without any relevant trauma history to aid the clinician, PTSD may not be diagnosed and post-traumatic stress symptoms (PTSS) are classified as part of other conditions. Children with PTSD as a primary diagnosis are often labeled with Attention Deficit Hyperactivity Disorder (ADHD), major depression, oppositional-defiant disorder, conduct disorder, separation anxiety or specific phobia (see Perry & Azad, 1999). In some cases, with children with PTSD will meet diagnostic criterion for multiple diagnoses. This is especially so when examining co-morbidity (the co-occurrence of multiple DSM IV diagnoses) in children with chronic trauma such as physical or sexual abuse. In some studies, the majority of traumatized children met diagnostic criteria for three or more Axis I diagnoses in addition to PTSD. When children are evaluated multiple times over several years, the diagnostic confusion can get worse. The clinical presentation of trauma-related symptoms can evolve. In the typical evaluation process, the evaluating clinical team or clinician rarely has the benefit of complete history about the origin and evolution of symptoms. Histories are frequently based upon one caregiver's recollection and assessment is based upon a single clinical visit (e.g., a school-mandated evaluation). In these cases, the traumatized child may "accumulate" diagnoses. It is not unusual for a child with PTSD related to chronic traumatic exposure (e.g., sexual abuse, domestic violence, physical abuse) to have six, seven or eight diagnoses given over five or six previous evaluations. Unfortunately, there are often six, seven or eight different (and partial) treatment approaches that match these diagnostic impressions. This can be tremendously frustrating to the caregivers, teachers, caseworkers or other professionals trying to help these children. It is important to remember that DSM IV diagnostic criteria can yield multiple labels in traumatized children but these diagnoses rarely provide useful information about etiology, course, treatment response or prognosis. At present, despite an evolving clinical phenomenology, it is clear that PTSD is not the only, or an inevitable, outcome of traumatic events during childhood. Post-traumatic hyperarousal or dissociative-like symptoms often co-exist with these other Axis I disorders. Furthermore, severe early trauma appears to be an expresser of underlying constitutional or genetic vulnerability and may be a primary etiologic factor in the development of a broad range of disorders later in life. In short, traumatic events can result in a host of clinical syndromes including "pure" PTSD. However, except in discreet, single trauma events, the clinical presentation and evolution of trauma-related symptoms is typically complex. Incidence and prevalence When examining how widespread PTSD is in the adult population, studies find a lifetime incidence of PTSD ranging from 3 to 14 %. This incidence is a total population estimate. Similar studies in adolescents find incidence figures between 2 and 5 % (Cuffe et al., 1998). These figures refer to total population estimates. When examining a sample of children exposed to trauma, however, these figures skyrocket. Controlled studies document that between 15 to 90 % of children exposed to traumatic events develop PTSD. The percentage varies depending upon the nature of the event. Universally, however, the rates of children developing PTSD following traumatic events is higher than those reported for adults. This is consistent with the growing recognition that children are, if anything, more vulnerable to traumatic experiences than adults. A brief sampling of recent studies gives some feel for the incidence of PTSD following a traumatic event. Thirty five percent of a sample of adolescents diagnosed with cancer met criteria for lifetime PTSD (Pelcovitz, et al., 1998). Fifteen percent of children surviving cancer had moderate to severe PTSS (Stuber et al., 1997). Ninety three percent of a sample of children witnessing domestic violence had PTSD (Kilpatrick & Williams, 1998); over 80 % of the Kuwaiti children exposed to the violence of the Gulf Crisis had PTSS (Hadi and Llabre, 1998); more than 68 % of the children surviving the Branch Davidian Siege at Waco met criteria for PTSD (Perry et al., unpublished). Seventy three percent of adolescent male rape victims develop PTSD (Ruchkin et al., 1998); 34 % of a sample of children experiencing sexual or physical abuse and 58 % of children experiencing both physical and sexual abuse met criteria for PTSD (Ackerman et al., 1998). In all of these studies, clinically significant symptoms, though not full PTSD, were observed in essentially all of the children or adolescents following the traumatic experiences. Vulnerability and resilience Not all children exposed to traumatic events develop PTSD and those who do, don't all have the same severity of symptoms. A major research focus has been identifying factors (mediating factors) that are associated with increased (vulnerability) or decreased (resilience) risk for developing PTSD following exposure to traumatic stress (Kilpatrick & Williams, 1998). Factors related to risk are summarized in the table above. In brief, these factors can be divided into three broad categories: 1) characteristics of the child; 2) characteristics of the event and 3) characteristics of family/social system (see Table 2, below). Each of these mediating factors can be related to the degree to which they either prolong or decrease the child's stress-response activation resulting from the traumatic experience. Factors that increase stress-related reactivity (e.g., family chaos) will make children more vulnerable while factors that provide structure, predictability, nurturing and sense of safety will decrease vulnerability. Persistently activated stress-response neurophysiology in the dependent, fearful child will predispose to those 'use-dependent' changes in the neural systems mediated the stress response which underlie post-traumatic stress symptoms. There are apparent gender differences in the expression and development of PTSD. Clinical experience and recent studies suggest that females tend to exhibit more internalizing (i.e., anxiety, dysphoria, dissociation, and avoidance) and males more externalizing (i.e., impulsivity, aggression, inattention, hyperactivity) post-traumatic symptoms (Perry et al., 1994; Ackerman et al., 1998). In epidemiological studies of PTSD in the general adult population, females have higher rates of PTSD than males (Breslau et al., 1997). While lacking the extensive epidemiological data of these adult studies, a gender difference has been observed in several studies with children and adolescents. There appear to be gender differences in adaptive response in the acute event (females dissociate more than males) that may be related to this observed difference in development and expression of trauma-related symptoms.
Table 2: Risk and Attenuating Factors for the Development of PTSD Treatment IssuesTreatments usually incorporate three elements: 1) review and recollection of the traumatic experience; 2) information about the normal and expected processes of post-traumatic functioning and 3) focus on specific symptoms. There are many ways to do this. The unfortunate reality however, is that most traumatized children do not get any help what so ever. This is in part due to the adult world's lack of understanding about childhood trauma and the destructive false belief that children are "resilient." Those children who do get services often have limited access and brief contacts. To date, few treatment outcome studies in children with PTSS and PTSD have been published. Despite this dearth of objective data, a wealth of clinical experience and subjective treatment approaches has been published (see Pfefferbaum, 1997; 1998). The nature of these reported clinical approaches depends upon the theoretical perspective of the author. At present the mechanism-based conceptual frameworks explaining the development of PTSD fall into four main categories: 1) psychoanalytic; 2) cognitive behavioral; 3) developmental and 4) neurodevelopmental. Each of these offers certain insights but none provides a complete and unambiguous treatment approach. Therefore, the treatment of children with PTSD varies greatly depending upon the specific clinician's training, perspective and experience. This can be confusing to non-mental health professionals or caregivers trying to help the traumatized child. They may often get conflicting recommendations or information about how traumatic events should be handled. Some may hear that talking about the event is most important; others may recommend not talking about the trauma and focusing on the current set of functional problems the child may have (e.g., the social or academic problems that have resulted from the PTSD symptoms). The best recommendation we can give about this is to try and find a professional team that has experience with traumatized children. And a clinician or clinical team willing to listen to you and learn from the resources you may bring to the situation. In some cases, caregivers or other professionals working routinely with traumatized children may be more familiar with clinical advances in this area than a mental health clinician with limited experience with trauma. Despite these drawbacks, the nature and severity of specific symptoms (e.g., impulsivity, withdrawal, hypervigilance, dissociation, dysphoria, and aggression) will define treatment approach rather than the diagnosis. A major consideration in treatment is distinguishing between a single discreet traumatic event (e.g., car accident or witnessing an assault) and chronic or pervasive trauma (e.g., chronic abuse). Symptoms following a single event (e.g., motor vehicle accident) tend to be fewer and less treatment-resistant compared to the more complex symptom clusters associated with chronic or pervasive traumatic stress (e.g., a combination of physical and sexual abuse). There are a host of clinical treatments used with traumatized children including family therapy, group therapy, EMDR (eye-movement desensitization and re-programming), music and movement therapies, "play" therapy and art therapy among many others. Four of the major therapeutic approaches used alone or in combination are discussed below. Acute post-traumatic interventions: secondary preventi onIn the immediate post-traumatic period, several models of intervention have been used to diminish the acute distress and improve post-traumatic outcome. One of the most important is psychoeducation. Telling the family and child what the expected signs and symptoms are following a traumatic event can help diminish anxiety, increase sense of competence and provide a baseline from which parents and children can be aware of abnormally intense or prolonged symptoms requiring further clinical attention. Several modifications of a critical incident stress-debriefing paradigm have been reported though efficacy has not yet been determined. In some cases, clinicians have used anti-anxiety agents or clonidine to decrease the level of physiological hyperarousal and distress in the acute post-traumatic period. While clinically helpful during this period, it is not yet clear that any of these post-acute interventions actually alter the development, course or severity of PTSD (see insert clinical vignette). Acute prophylactic treatment of traumatic hyperarousal: Dominic is a seven-year-old boy. Five days prior to evaluation, he had been in a car accident in which his mother was killed. Immediately following the accident, he was trapped in the car with his mother's body. She had been significantly disfigured by the accident –including a near decapitation. For the hour that the EMS attempted to cut him out of the car, he was immobilized with only a view of his dead mother's now disfigured face. On evaluation, he had not been able to sleep, his resting heart rate was 136. He was noted to be withdrawn but resistant to the medical treatment necessary for his multiple broken bones. Treatment included psychoeducation for the family and clonidine (a medication that helps decrease the reactivity of the stress-response neural systems). His resting heart rate fell to 90. Sleep normalized and he was able to cooperate with medical treatments. Individual therapy focused on loss and trauma was started on discharge. Six months following the accident, Dominic had a resting heart rate of 100 when tapered off the clonidine. He had continuing, and expected, sadness over the loss of his mother, but did not meet criterion for PTSD. Pharmacotherapy There are very few published trials with psychotropic medications in childhood PTSD. Despite this, extensive clinical experience would strongly suggest that medications could be very helpful in diminishing the symptoms of PTSD. Empirical clinical judgment and experience guide the selection of specific medication. The primary symptoms in PTSD appear to respond to psychotropic agents proven to be useful for those same symptoms in other neuropsychiatric disorders (e.g., depakote and lithium for aggressive behavior; fluoxetine for depressive symptoms).Many of the symptoms of PTSD can be traced to the core symptoms of physiological hyperarousal. These symptoms include sleep problems (including difficulties following asleep, early night awakening, nightmares, night terrors), generalized anxiety, behavioral impulsivity or hyper-reactivity of the sympathetic nervous system including tachycardia, hypertension, increased muscle tone, respiratory problems and body temperature dysregulation. Clonidine, an alpha-2 adrenergic partial agonist, which modulates the reactivity of the locus coeruleus and decreases the physiological hyper-reactivity associated with PTSD, has been shown to be an effective agent in children with PTSD. Other agents altering the biogenic amine neurotransmitter systems in the brain (i.e., serotonin, dopamine, and norepinephrine) may also modulate the symptoms of PTSD. In this regard, preliminary reports support the efficacy of propranolol and fluoxetine in children with anxiety and PTSD. Individual psychotherapy The core hyperarousal symptoms result in a cascade of secondary, inter-related problems. Inability to engage in appropriate intimacy leads to difficulties with peer and adult relationships, inability to perform adequately in school leads to poor self-esteem, resulting in a variety of learned behaviors which both mask and defend against these core deficits driven by their physiological hyper-reactivity. The resulting vicious cycle of poor performance, poor self-esteem, development of maladaptive problem-solving styles, in turn, are difficult to treat as long as the underlying physiological hyper-reactivity impairs the ability to modulate anxiety, concentrate on academic or social learning tasks, and contain behavioral impulsivity. Successful treatment, therefore, often requires 'containing' or modifying this core physiological dysregulation with medications and using other psychotherapeutic interventions to address issues related to self esteem, competence, social skills and mastery of specific fears. Cognitive-behavioral therapies Cognitive-behavioral therapy (CBT) is the most studied and, likely the most effective, therapeutic intervention in adults with single-event related PTSD. The few CBT studies in children and adolescents are very promising and studies demonstrate the efficacy of CBT following a single traumatic event (Deblinger et al., 1990; March et al., 1998). CBT, unfortunately, is difficult to apply in the same fashion to very young children or to children with chronic pervasive trauma. Long-term costs of childhood trauma PTSD is a chronic disorder. Untreated, PTSS and PTSD remit at a very low rate. Indeed the residual emotional, behavioral, cognitive and social sequelae of childhood trauma persist and appear to contribute to a host of neuropsychiatric problems throughout life (Fergusson & Horwood. 1998) including attachment problems (Bell & Belicki. 1998; Alexander, Anderson, Brand, Schaeffer, Grelling, & Kretz. 1998; O'Connor et al., 2000), eating disorders (Rorty & Yager. 1996), depression (Winje & Ulvik. 1998; Fergusson & Horwood. 1998), suicidal behavior (Molnar, Shade, Kral, Booth, & Watters. 1998), anxiety (Fergusson & Horwood. 1998), alcoholism (Fergusson & Horwood. 1998; Epstein, Saunders, Kilpatrick, & Resnick. 1998), violent behavior (O'Keefe. 1995), mood disorders (Kaufman. 1991) and, of course, PTSD (Ford & Kidd. 1998; Schaaf & McCanne. 1998).Childhood trauma impacts other aspects of physical health throughout life, as well (Hertzman & Wiens. 1996; Orr, Lasko, Metzger, Berry, Ahern, & Pitman. 1998; Felliti, Anda, Nordenberg, et al. 1998). Adults victimized by sexual abuse in childhood are more likely to have difficulty in childbirth, a variety of gastrointestinal and gynecological disorders and other somatic problems such as chronic pain, headaches and fatigue (Rhodes & Hutchinson. 1994). The Adverse Childhood Experiences study (Felliti, Anda, Nordenberg, et al. 1998) examined exposure to seven categories of adverse events during childhood (e.g., sexual abuse, physical abuse, witnessing domestic violence: events associated with increase risk for PTSD). This study found a graded relationship between the number of adverse events in childhood and the adult health and disease outcomes examined (e.g., heart disease, cancer, chronic lung disease, and various risk behaviors). With four or more adverse childhood events, the risk for various medical conditions increased 4- to 12-fold. Clearly studies of this sort will help clarify the true costs of childhood maltreatment. SummaryExposure to traumatic stress during childhood can impact a child for life. This impact can range from increasing risk for heart disease or alcoholism to actually causing a chronic neuropsychiatric disorder such as PTSD. Children are not born resilient; they are made resilient by virtue of having opportunities in early childhood to have elements of safety, predictability and nurturing. Yet even children with these opportunities, given a sufficiently intense or repeated traumatic stress will be at risk. Children are, in fact, born malleable. They are shaped by their experiences in ways that can follow them for a lifetime. The very same neurobiological mechanisms that make children so capable of absorbing new experiences in such a short time (e.g., language, motor skills) make them more vulnerable to bad experiences. There is a cost to traumatic stress in childhood. 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Terr, L. (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry, 148, 1-20. Winje, D., & Ulvik, A. (1998). Long-term outcome of trauma in children: The psychological consequences of a bus accident. J.Child Psychol.Psychiat., 39, 635-642. Glossary Amygdala: This is a structure in the forebrain. It is part of the limbic system and plays a major role in emotional memory and the response to threat.Autonomic Nervous System: The ANS is that part of the nervous system responsible for regulating the activity of the body's other organs (e.g., skin, muscle, circulatory, digestive, endocrine). Central Nervous System: This is the portion of the nervous system comprised of the spinal cord and brain. Cerebral Cortex: This is the outer most layer of the cerebral hemispheres of the brain. The cortex mediates all conscious activity including planning, problem solving, language and speech. It is also involved in perception and voluntary motor activity. Cognition: This refers to the mental process by which we become aware of the world and use that information to problem solve and make sense out of the world. It is somewhat oversimplified but cognition refers to thinking and all of the mental processes related to thinking. Dissociation: The mental process of disengaging from the stimuli in the external environment and attending to inner stimuli. This is a graded mental process that ranges from normative daydreaming to pathological disturbances that may include exclusive focus on an inner fantasy world, loss of identity, disorientation, perceptual disturbances or even disruptions in identity. Hippocampus: This is a thin structure in the subcortex shaped like a seahorse. It is an important part of the limbic systems and plays a major role in learning, memory and emotional regulation. Homeostasis: This is the tendency of a physiological system (i.e., a neuron, neural system or the body as a whole) to maintain its internal environment in a stable equilibrium Hyperarousal: Mental and physical changes caused by alterations in central and peripheral nervous system activation related to perceived or actual threat. This graded response includes increased sensory and perceptual focus on the threat, activation of physiological systems required for survival and corresponding changes in emotional and behavioral functioning. Hypothalamus: This is a group of important nuclei that mediate many important functions. It is located at the base of the brain and connected to the pituitary by a network of specialized blood vessels. The hypothalamic nuclei are involved in regulating many of the body's internal organs via hormonal communication. The hypothalamus is a key part of the hypothalamic-pituitary-adrenal (HPA) axis that is so important in the stress response. Limbic System: This is a group of functionally and developmentally linked structures in the brain (including the amygdala, cingulate cortex, hippocampus, septum and basal ganglia). The limbic system is involved in regulation of emotion, memory and processing complex socio-emotional communication. Neuron: A cell specialized for receiving and transmitting information. While neurons have tremendous heterogeneity in structure, they all have some form of dendritic projections that receive incoming information and axonal projections that communicate to other cells. Plasticity: This refers to the remarkable capacity of the brain to change its molecular, microarchitectural and functional organization in response to injury or experience. Play Therapy: A therapeutic intervention that uses play as the means to help children overcome their difficulties. Posttraumatic play: Activities (symbolic play, drawings) that reenact a traumatic event in a child's play. Posttraumatic Stress Disorder (PTSD): A neuropsychiatric disorder that may develop following a traumatic event that includes changes in emotional, behavioral, and physiological functioning. Trauma: A psychologically distressing event that is outside the range of usual human experience, often involving a sense of intense fear, terror and helplessness. Use-dependent: This refers to the specific changes in neurons and neural systems following activation. Repetitive, patterned stimulation alters the organization and functioning of neurons and neural systems and, thereby, the brain. Web-based Resources The ChildTrauma Academy: http://childtrauma.orgThe ChildTrauma Academy is a unique collaborative of individuals and organizations working to improve the lives of high-risk children through direct service, research and education. These efforts are in partnership with the public and private systems that are mandated to protect, heal and educate children. The work of the Academy has been supported, in part, by grants from Texas Department of Protective and Regulatory Services, the Children's Justice Act, the Court Improvement Act and through innovative partnerships with academic and corporate partners such as Powered, Inc., Scholastic, Inc. and Digital Consulting and Software Services. American Professional Society on the Abuse of Children (APSAC): http://www.apsac.org/ APSAC's mission is to ensure that everyone affected by child maltreatment receives the best possible professional response. This organization has many useful scholarly and clinical materials focused primarily at the professional audience. The National Center for PTSD: http://www.dartmouth.edu/dms/ptsd/The National Center for PTSD is a program of the U.S. Department of Veterans Affairs. The primary focus of the Center has been combat veterans and their families. Over the last few years, however, this focus has been expanded. There are many useful programs, activities and resources for anyone interested in the effects of traumatic stressors. The PILOTS database is an electronic index to the worldwide literature on PTSD and other mental-health sequelae of exposure to traumatic events. International Society for Traumatic Stress Study (ISTSS): http://www.istss.org The International Society for Traumatic Stress Studies (ISTSS), founded in 1985, provides a forum for the sharing of research, clinical strategies, public policy concerns and theoretical formulations on trauma in the United States and around the world. National Clearinghouse for Child Abuse and Neglect: http://www.calib.com/nccanchThe National Clearinghouse on Child Abuse and Neglect Information is a national resource for professionals seeking information on the prevention, identification, and treatment of child abuse and neglect, and related child welfare issues. David Baldwin's Trauma Information Pages: http://www.trauma-pages.comWithout question the best trauma-related resource that exists on the Web. Dr. Baldwin has done a remarkable job, collecting, sorting and commenting on this information. Supportive resources supplement the more academic or research information of interest to clinicians, researchers, and students. |
