Adolesc. Latinoam. v.3 n.2 Porto Alegre nov. 2002

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An overview of post-traumatic stress disorder in children and adolescents

When children and adolescents have experienced a frightening event, it can affect them in different ways. Some children recover immediately, while others may show a change in their behaviour for weeks or month afterwards. You may have noticed some of the following changes in your child since the traumatic event occurred.

• Avoiding places, people, things or conversations related to the trauma
• Easily startled/ frightened by loud noises and sudden movements
• Feeling/ acting on-guard or in danger all time
• Lack of interest in usual activities
• Irritability, outburst of anger or aggressive behaviour
• Misbehaving in school or at home in ways that are not typical for the child
• Poor concentration
• Noticeably more anxious and fearful than before
• Childlike behaviour (e.g. very clingy, following you around the house, bedwetting, refusing to go to school
• Feeling down, low depressed
• Nightmares, screaming during sleep
• Re-playing the trauma over and over again in their play activities
• Behaving recklessly or putting themselves in danger
• Frequent physical complaints (e.g. headaches, stomachaches)

If your child has displayed any of the above reactions, following the frightening event, then he or she may be suffering from a condition which is known as post-traumatic stress disorder, or PTSD for short. PTSD is a reaction to a very scary event, in which the person is in physical danger (e.g. a shooting, a car accident, or a rape). It is common among children and adults who have suffered a life-threatening trauma. It is the person’s way of trying to cope with a terribly frightening event.

PTSD is a psychological injury. It is different from a physical injury, like a broken arm, because you can’t always see that it is there - it is on the inside, not the outside. Like a broken arm, PTSD an prevent your child from participating in his or her usual activities. Like a broken arm, it needs to be looked after by a specialised doctor (called a psychiatrist or a psychologist) if it is to heal properly. And, like a broken arm, it takes time to mend, sometimes many month.

How can PTSD affect your child? Children with PTSD try very hard to avoid any reminders of the trauma (such as memories, people or places associated with the trauma). This can prevent them from participating in all their usual activities. For example, they may not want to walk down to the corner shop, or attend school, if the traumatic event happened near their places. When they are reminded of the trauma, they feel as if it was happening all over again - they feel this in their body (e.g. they become very tense) as well as in their mind (e.g. they may have a "flashback" - they "see" the event happening over again in their mind). Children with PTSD usualy also have a strong feelings of fear, sadness and helplessness, and not feel safe, even though the trauma is over. Some children also feel guilty that they did not do anything to prevent the trauma, or that they are somehow to blame for the trauma.

The symptoms of PTSD can occur soon after the event or many month later. PTSD can have a negative effect on your child’s performance at school and on his or her relationships with family and friends. If help is not provided, these difficulties can continue into adulthood . Is therefore very important that your child receive treatment and support as soon as possible.

Fortunately, there are several effective treatments for children who have PTSD. Firstly, it is vital that the child is given a chance to talk about what happened, in a safe environment. A psychiatrist or psychologist can help the child to do this. Sometimes parents want to protect their child by avoiding any mention of the trauma. But research has shown that in fact it is much better for the child to talk about what happened, preferably with a qualified doctor o psychologist - this gives children a chance to deal with their frightening memories and work out their feelings about what happened, so that they can put it behind them.

Secondly, certain medications have been found to help adults who suffer from PTSD. It is possible that these mediations will also be helpful for children. How can medication help? Medication may help to reduce your child’s anxiety, depression and sleeplessness, and to relieve the distressing effect of his or her traumatic memories. However, these mediations may take a few weeks to work, so don’t expect to see a change in your child immediately.

What you can do to help:

• It is important to help your child to feel as safe and protected as possible. Reassure your child that you will do everything possible to protect him or her from the future harm. Sit down with your child and develop an "action plan" in case there is another trauma in future(e.g. if something terrible happens at school, your child should phone you at work- make sure he or she has your work number written down in a safe place - and you will come and fetch from the school. Or, something happens outside , your child will come inside immediately and tell you or another adult in the house about it, and they will phone the police). As far as possible, make sure that your child does not go unaccompanied into areas that are unsafe.

• You can help your child by showing that you understand and accept his or her feelings of fear, sadness and helplessness - this is a normal reaction to a very frightening event. Even ordinary activities, like going shopping or driving in the car, may remind your child of the trauma and cause him or her to become upset. Do not expect the child to go back to being his or her usual self immediately. Give you child time to adjust to hat has happened and to respond to treatment.

• Let your child know that you are available if he or she wants to talk about the trauma. Telling the story over and over is a way of helping the child do deal with his or her memories. However, some children find it very hard to talk about what happened, or the behaviours listed on page 1 continue for longer than a month, then you should seek from a psychiatric or psychologist, who can help your child to talk about the trauma in a safe environment.

• Your child may think that he or she is bad and that is why the trauma happened. Tell your child that he or she is not bad person and is not being punished.

• Your child may need a little extra-support or comfort in the first few weeks after the trauma. Some children start to act younger than their age after a trauma. They become frightened, tearful, and afraid to be alone. This is also normal. Give your child lots of love and reassurance, but try to keep the child’s daily routine the same as it was before the trauma. It helps children to feel safe if everything else at home stays the same as it was before the trauma.

• Your child may develop nightmares and sleeping problems after trauma. They may want to sleep in the parent’s bed at night for a while. If your child has a nightmare, go to him or her, reassure your child that he or she is safe, that he or she just had had a bad dream about the accident, but its all over now.

• Try to encourage and support your child’s strengths. Find little ways of giving him or her praise and encouragement each day.

• The way children see and understand their parents’ response is very important. Children are aware to their parents’ worries most of the time but they are particularly sensitive to this during a crisis. The most important thing that helps children to recover from a trauma is how their parents cope with the trauma. It can be very upsetting for parents when their child has experienced a trauma. Sometimes parents fell guilty and responsible for the trauma. Remember, it is not your fault either . Parents can never watch their children at al times. Do not spend your energy feeling guilty This is the time to be focusing on your child’s feelings, and helping him or her to recover.

• I f you are struggling to deal with what has happened, you should seek the support of another adult or a professional. You can speak to the psychiatrist or psychologist who is treating your child if you feel you need help.

• It is okay to admit to your child that you are worried about hat has happened, but also stress your ability to cope with the situation and to protect the child as much as possible from further harm.

Treatment

The recognition and treatment of childhood and adolescence PTSD has not reached the same level of advancement as in adults. The treatment of PTSD in children and adolescents is largely based on clinical experience and borrowed treatments from other anxiety disorders. Current treatments include debriefing, cognitive behaviour therapy (CTB), play therapy, group therapy, family therapy, psychodynamic therapy, psychotherapy and pharmacotherapy. The core elements of all treatment intervention include talking openly to the child about the trauma, re-exposing the child traumatic cues under "safe" conditions, helping the child master faulty cognition which have attributed to the trauma and teach the child stress/anxiety management techniques.

Currently, there is little evidence that drug treatment has pivotal role to play in child and adolescents PTSD. There is no empirical support for the use o antidepressants in treating PTSD in this population, nor is there evidence for the appropriate duration of medication treatment. Pharmacotherapy, when it is used in clinical practice, is usually an adjunctive treatment for disabling co-morbid symptoms (depression, panic, attention deficit and hyperactivity)...

Soraya Seedat, D. Kaminer, R. Lochat and Dan J Stein
Departmen of Psychiatry, University of Stellenbosh,
Tygerberg, Cape Town - South Africa

Bibliografy

Seedat S, Kaminer D, Lockhat, Stein DJ. An overview of post-traumati stress disorder in children and adolescents. Primary Care Psychiatry 2000; 6 (2): 1-6.