Nurses need to know the symptoms but might never know the cause
But in adolescence, Allen seemed to become two different kids. At times, Allen was “the curious, talented, happy son he’d been when he was younger,” Philo reported. “But at other times, he became a secretive, self-destructive teenager who sometimes just ‘ran away.'” Because Allen remained highly successful in school, teachers, counselors and therapists brushed aside the Philos’ concerns.
The pattern of running away continued until Allen was 26, and he asked his parents for help. Within a week of meeting with counselors and therapists at a cutting-edge outpatient clinic in Morgantown, WV, Allen was diagnosed with PTSD. Although he had not realized what was causing his self-destructive behavior, he told his mother, “For the first time in my life, I’m not looking over my shoulder, waiting for them to take me back to surgery.”
Philo went on to write a book on the subject, titled, “Does My Child Have PTSD? What to Do When Your Child Is Hurting from the Inside Out.” As her story illustrates, PTSD can very difficult to recognize and diagnose; in some cases, the source of the trauma may never be revealed.
Stress Is Normal; PTSD Is Not
“It’s important to note that intense stress as a biological response is normal,” said Sandra Pimentel, PhD, chief of child and adolescent psychology, associate director of psychology training and assistant professor of clinical psychology in the department of psychiatry and behavioral medicine at Montefiore Health System/Albert Einstein College of Medicine. “When a person feels threatened, they are going to have a very strong stress response.”
Some people may develop acute stress disorder (ASD) in the days immediately following a traumatic event. “This is when a person still feels ‘in shock’ by what happened. They might feel dazed or ‘out-of-it;’ they might be hypervigilant, tense and ‘on the lookout’ for new dangers; they might actively avoid thinking or talking about what is bothering them; and they actively avoid reminders of the trauma,” Dr. Pimentel enumerated. “ASD is diagnosed when these behaviors occur anywhere from 2 days to 30 days after experiencing a trauma.”
According to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), post-traumatic stress disorder (PTSD) can be diagnosed when the symptoms are still occurring more than 30 days after the event that caused them. “The only distinction is the duration of symptoms,” stated Dorothy Jordan, DNP, APRN, PMHNP-BC, PMHCNS-BC, assistant clinical professor at Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta, GA.
Causes in Children
Any number of things could trigger PTSD in a child. There are the large-scale traumas that are easily recognizable, such as if a child has been in a car accident, a fire, an earthquake, was held up at gunpoint, or witnessed a shooting. In these types of situations, it’s relatively easy to link new, troubling behaviors in a child to the cause that started them, and set about treating them. But PTSD does not always stem from one big, obvious, easy-to-pinpoint event. Often, it isn’t clear what is causing symptoms.
“The cause does not have to stem from one event,” relayed Dr. Jordan. “PTSD could arise from a continuous trauma: a cycle of domestic violence within the home, the repeated, ongoing verbal or sexual abuse of a child by one parent, living in a bad neighborhood and dealing with gang members every day, or simply being neglected for years.”
Dr. Jordan’s early clinical practice in pediatrics focused on children with chronic and life-threatening illnesses; today, she has a particular interest in providing psychiatric mental health care to homeless youth and families who are living in transitional shelters. “Both situations can trigger PTSD,” she stated.
The other thing that makes diagnosing PTSD difficult is that “symptoms can crop up long after the event has happened — years later,” Dr. Jordan noted. “Delayed responses are less common, but they do occur.” A case in point is the story told at the beginning of this article.
To add one more layer of complexity to a PTSD diagnosis is the fact that, “the trauma doesn’t even have to happen to you,” Dr. Pimentel reported. “It can be triggered in children if they learn that a loved one experienced a traumatic or violent incident, accident or other life-threatening event.”
Spotting the Symptoms
Recognizing the symptoms of PTSD in children is not straightforward. The DSM groups children’s responses into four different categories, called “clusters.” Dr. Pimentel explained that these include intrusion (in which memories of the event constantly invade a person’s thoughts); avoidance (in which a person tries to purposely and actively avoid thinking about the event); cognition and mood disturbances (in which a person begins to blame themselves for what happened or has recurring thoughts that they could’ve prevented it); and shifts in behavior caused by the arousal of the “fight or flight” response (in which the person feels hyper-vigilant or “keyed up” at all times).
“When a child is exposed to trauma, it can ‘reset’ the amygdala within their brain, so that they are in a constant state of arousal,” Dr. Jordan explained. “They are continually reacting to the trauma, even after it happens. This limits a person’s ability to think logically and rationally, and it affects their behavior. Then you see lots of behavior problems.”
The wide spectrum of symptoms that can manifest in children with PTSD can include being excessively sad, clingy, irritable, impulsive, argumentative, aggressive, overly fearful, overly anxious or untrusting. They might feel very alone and apart from others and demonstrate feelings of low self-esteem.
Confusing the issue of diagnosis is that symptoms of PTSD look different in children of different ages. So, toddlers may show their aggression by having tantrums or refusing to sit still in school; grade-school children might re-enact violent behaviors in their play. “One problem is that many of the PTSD symptoms either mimic or overlap the symptoms associated with ADHD,” Dr. Jordan informed. In teenagers, PTSD can cause out-of-place sexual behavior, abuse of alcohol and drugs, or other self-harming behaviors, such as cutting.
Techniques that Treat
The good news is, there are some effective treatments to help kids and teenagers affected by PTSD. “Trauma-focused cognitive behavioral therapy (TFCBT) has been shown to help both the children affected, and their parents as well,” Dr. Pimentel reported.
TFCBT is a structured treatment that includes various components. These include psychoeducation and teaching children about stress, trauma and anxiety, which helps to normalize some of their experiences and reactions. Children and teens are taught strategies, such as deep breathing, progressive muscle relaxation, and mindfulness to manage some of the emotional and bodily reactions they may be experiencing.
The cognitive portion of TFCBT includes teaching kids about their thinking, and the connection among their thoughts, feelings and behaviors. Following a traumatic experience, children (and sometimes, even their parents) can develop distorted views about themselves, the event, or the world. The treatment focuses on teaching kids to identify these thoughts, challenging the unhelpful or untrue ones — such as, “It’s all my fault,” “I should have done something different,” or “The world is unsafe.” This technique can be especially helpful when considering the painful thoughts that might emerge as the result of child sexual abuse.
Another important part of treatment includes addressing the avoidance of trauma-related places and reminders. Avoidance actually reinforces distress; so, over the course of treatment and in a gradual way, the therapist might work with the child or teen to approach previously-avoided trauma reminders. By doing this, the child can learn to tolerate some of the distress that comes with facing the trauma, challenge held beliefs about his or her own ability to handle such distress, and learn new connections among his or her own thoughts, feelings and behaviors.
The final stage of TFCBT involves helping the child develop a narrative for the trauma — a coherent telling of what happened before, during and after. This is not only an opportunity to “process” the event; it can serve as exposure if the child is avoiding internal reminders or talking about the trauma. It can also help pull forth some of the distorted thoughts and beliefs that may be contributing to the child’s distress. “This is where feelings of guilt and shame are discussed, and you can challenge and correct ‘unhelpful’ thinking,” Dr. Pimentel commented.
TFCBT also includes opportunities to coach parents on their reactions to the trauma, addressing things like parental shame and guilt, and teach them how to manage life after the trauma, discussing, for example, the importance of re-establishing routines and setting consistent rules and limits.
Dr. Jordan utilizes trauma resiliency model (TRM) training, one of the techniques created by Elaine Miller-Karas, MSW, LCSW, the co-founder and executive director of the Trauma Resource Institute in Claremont, CA. “TRM has been designed as both a trauma reprocessing treatment model as well as a self-care model,” Dr. Jordan explained. “You learn ways to re-set or rebalance the nervous system through a skills-based approach that can be practiced independently. The skills help develop a sense of personal mastery and self-management over intense physical and emotional states.”
Children learn to employ new responses to intense feelings, rather than just “popping off” in an angry outburst. “Children never really want to get in trouble; they truly want to be ‘their best selves,'” Dr. Jordan noted. “So they are very receptive to the notion of ‘finding their resilient zone.'”
Some of the specific coping tools children might use to find their way “back to the resilient zone” involve immediate, sensory approaches that teach children to “be present in the moment”: counting backwards from ten; counting everything in the room that’s red; or pressing their back against the wall.
“I know it seems simple, but this really works,” Dr. Jordan commented. “You can feel the tension draining away as the trauma resiliency skills are utilized.” Some of her patients have reported back to Dr. Jordan that they taught their siblings and parents to “find their resilient zone,” as well — so the entire family ends up using the new coping tool.
Of course, any treatment should be tailored to the age and developmental level of the child or adolescent.