Traumatic Stress in Children and AdolescentsEight Steps to Treatment

Traumatic experiences are common in childhood and adolescence and can have significant psychological effects on the child’s emotional well-being and overall development. Outcomes can be affected positively or negatively depending on responses and interventions.

This article reviews common responses of children to trauma, variables that influence the nature of psychological responses to trauma, and protective factors that can ameliorate deleterious effects. It also outlines an 8-stage approach to treating children who have had traumatic experiences.

Causes of traumatic stress
Traumatic stress refers to the physical and emotional response to events that threaten the life or physical or psychological integrity of the child or someone critically important to the child. A traumatic experience is unexpected and unpredictable, uncontrollable, and terrifying. Emotional responses to traumatic experience are often overwhelming and may include terror, helplessness, and extreme phys­­io­log­ical arousal that do not lead to purposeful and effective reactions. These emotional responses often coincide, leading the child to feel overwhelmed, confused, and out of control.

CNS effects of this set of responses can affect later neurophysiological responses. Hyperarousal and overgeneralization of threat assessment can evolve, leading the child to react in an extreme fashion to events that resemble or remind the child of the original trauma. The degree and frequency of significant arousal responses also reinforce the avoidance of discussion or consideration of traumatic memories.

In addition, children often reexperience the traumatic event during flashbacks, nightmares, and intrusive images. Manifestations vary based on the child’s developmental stage. Separation problems and somatic complaints predominate in young children. Difficulty with affect regulation and aggressiveness are common in older children and adolescents.

The affected individual is always the person who labels an experience as traumatic. It is the responsibility of others (including mental health professionals) to help the distressed individual. These traumatic experiences vary in a number of ways:

• Proximal cause.
• Number of traumatic experiences (dose effect).
• Degree of physical effect, both im­mediate and long-term.
• The occurrence of subsequent disruptive events

Proximal causes include natural disasters, attachment trauma (physical and/or sexual abuse perpetrated by a caregiver), community violence (sexual assaults, injury of the child, or violence witnessed by the child), domestic violence (with or without phys­ical abuse). Accidental injury and serious illness often require invasive and painful treatment procedures. The pain and unpredictability of these procedures as well as any uncertainty in the medical prognosis heighten the possibility of traumatic stress for children with serious illness or injury.

A growing literature addresses the development of traumatic symptoms following potentially noxious medical interventions for severe illnesses. Other highly traumatizing experiences include war, ethnic cleansing and genocide, torture, displacement leading to a refugee experience, and the experience of being abducted and trafficked or being a child soldier.

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.

Treatment approaches
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.

The opportunity to voluntarily participate in a debriefing discussion with a trained professional may be helpful for those who freely choose to discuss their traumatic experience. Treatment is designed to develop and maintain expectations of safety and predictability, reestablish self-control and self-direction, and build the child’s capacity for resilience in future experiences of adversity. A final goal of treatment is to help prevent the child from regarding himself with limited self-respect and self-regard.

The Table presents the 8 steps for treating traumatic stress. These steps are appropriate for acute treatment after traumatic injury, acute abuse, or natural disaster. They are also appropriate for children with PTSD and for those who have experienced repeated trauma and who evidence complex traumatic stress.

Step 1: Safety
The first step involves ensuring the child’s physical safety. Compassionate and caring involvement of police, rescue workers, health care professionals, and child protective workers maximize the likelihood that the child will feel psychologically supported. The clinician should ensure that a traumatized child feels safe at home and in the therapist’s office. Some abused children lack a sense of safety and may need to learn relaxation techniques to become comfortable with their therapist and to participate in therapy. The therapist can help the patient associate safety with the experience of calmness and begin to search out safety and avoid dangerous situations. In some cases of domestic or community violence, the therapist may need to help parents ensure their child’s safety.

Step 2: Basic needs
The next step is attention to the child’s basic needs for food, shelter, sleep, and medical care. After traumatic injury, this may include surgery and hospital care. After a natural disaster, this may include temporary housing and relief provisions. For children removed from abusive homes, the state is responsible for certifying that foster homes have the resources needed to care for the child.

Adequate nutrition and sleep are essential aspects of treatment for both acute and chronic traumatic stress. Psychopharmacology to assist with sleep, and to allay severe anxiety and significant hopelessness and withdrawal is also often useful. SSRIs are most commonly used with appropriate informed consent and monitoring. Use of these agents for children and adolescents with PTSD is currently off-label. However, sertraline has been FDA-approved for children with other anxiety disorders, such as obsessive-compulsive disorder. Sertraline has also been approved for PTSD in adults. Both sertraline and fluoxetine have been approved for use in depression in adolescents.

Depression is frequently comorbid with PTSD in children and adolescents. Informed consent by parents and consistent monitoring for sui­­cidal ideation in youths treated with SSRIs are essential. When psychosocial treat­ments alone do not lead to recovery, I prescribe either sertraline or fluoxetine for children older than 10 years in conjunction with psycho­therapy and parental involvement.

Step 3: Knowledge
It is essential that the child and family understand as fully as possible all aspects of trauma recovery. In acute situations, this involves providing information about treatment, recovery, and expectations for the future. The therapist must make sure that the family and child understand the psychological effects of trauma and how behavioral symptoms may be a response to traumatic experiences. Parents will need to learn the importance of validating their child’s emotional experience and to set consistent limits in a firm but caring manner.

Parents may feel guilty about their inability to protect their child. Accurate information may help them resolve their guilt and enable them to be available to support their child. Providing information is the first step in developing a recovery-oriented therapeutic collaboration with the child and family. By encouraging the family and child to ask questions and to build a thorough understanding of their situation and what can be expected in treatment, the therapist begins the process of empowerment and helps the child build self-control.

Step 4: Resuming behavioral routines
The establishment of behavioral competency is an important step in psychological recovery. This can occur, for example, as the child participates in physical therapy after injury. Exercises are taught, the child practices, and the physical therapist praises the child’s participation and reinforces the child’s role in his own recovery. The same can occur for children who have not been injured and for children who are experiencing chronic traumatic stress.

Encouraging the child to attend and achieve at school, to participate in school activities, and to complete chores successfully at home can help build the child’s sense of competency and self-control. The therapist can encourage the child and family to practice relaxation techniques, calming exercises, and deep breathing. The child and his family can use these skills to manage arousal and affective instability. This process further builds the engagement of the child and family in treatment and with the therapist. In addition, parents can use praise to support and reinforce their child’s competency.

Step 5: Affect exploration and identification
This step encourages the child and family to understand that trauma produces an immediate emotional response that may include fear and powerlessness and subsequent reactions such as continued fear, anger, sadness, and (possibly) shame. These emotions often occur simultaneously and can be confusing for the child and family. By identifying individual emotions and helping the child understand how each emotion is ap­propriate and understandable given the situation, the therapist helps the child’s emotional experience become predictable and understandable. The child learns to manage his emotions; parents have the opportunity to parent effectively, which builds their sense of control and competency. The child learns that he does not have to suppress emotion or avoid awareness of the experience.

Step 6: Supporting the supporters
The therapist creates an atmosphere of emotional support for all participants. Being involved with traumatized children can be arousing and upsetting for all involved-including the therapist. The goal for the therapist is to provide understanding and purposeful support to parents and relatives. Emotional support is also essential for first responders, hospital staff, child welfare workers, and other staff who work with traumatized children. Supervision or peer support for the therapist is an important aspect of the therapeutic process.

Step 7: Creating the trauma narrative
Organizing traumatic memories into a coherent narrative is an essential part of recovery. This helps the child appreciate what has happened and ultimately lets him master his recollections. The child is helped to recognize and cope with the anxiety attendant to recollecting the traumatic event while creating a step-by-step description of the event. One method is to encourage the child to develop an “emotion thermometer” with which to rate his level of arousal between 0 and 100. The thermometer lets the child recognize when his level of arousal is rising to a distressing level. The therapist can ask the child to stop telling the story and use relaxation skills to calm himself. When arousal decreases to an easily tolerable level, the child can begin to elaborate the trauma narrative again.

The goal is for the child to be able to tell his story and manage his arousal response. Simultaneously, the therapist strongly supports and reinforces this process. Ultimately, the child presents the trauma narrative to his parents. The parents, in turn, will need the therapist’s support to hear the story and also to encourage them to praise their child for his courage and persistence in being able to describe his experience. As the child organizes and manages his narrative, the overwhelming nature of the trauma becomes a memory over which the child has increasing control. The parents have a unique opportunity to understand, accept, and show love for their child. The resiliency of all is apparent and readily recognized.

Step 8: Making meaning of the trauma
There is always the opportunity to make unique meaning or significance of the trauma. This can be personal-through artistic expression, journal writing, or volunteer and professional activity. It can also be manifested through memorialization or efforts to improve the community (for example, through organizations such as Mothers Against Drunk Driving). National and international efforts to enhance social justice or respond to human rights abuses are also important responses to trauma. These efforts provide an opportunity for victims of trauma, as well as those who care for them, to grow.

Conclusion Traumatic experiences are common during childhood. Psychological sequelae can be persistent and can lead to further difficulties, enhanced symptoms, and poor developmental outcomes. In some children, intrinsic capacity and family response can lead to resilience and growth. By understanding the elements inherent in such resilience (eg, predictability, self-control, competence, meaningful emotional support) and working to enhance these elements in patients who have undergone traumatic stress, therapists can facilitate recovery.

Drugs Mentioned in This Article
Fluoxetine (Prozac, Sarafem)
Sertraline (Zoloft)

References:

1. Cohen JA, Mannarino AP, Deblinger E. TreatingTrauma and Traumatic Grief in Children and Adolescents.New York: Guilford Press; 2006.
2. Saxe GN, Ellis BH, Kaplow JB. Collaborative Treatmentof Traumatized Children and Teens: The TraumaSystems Therapy Approach. New York: GuilfordPress; 2007.
3. National Child Traumatic Stress Network. http://nctsnet.org/nccts/nav.do?pid=hom_main. Accessed September 8, 2008.

Evidence-Based References
Cohen JA, Mannarino AP, Deblinger E. Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford Press; 2006.
Saxe GN, Ellis BH, Kaplow JB. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. New York: Guilford Press; 2007.