One doesn’t need a Ph.D. to realize that most children will be traumatized by a parent’s death or by rape; but there are other ‘less dramatic’ situations that are also traumatic. An experience that is only moderately difficult for one person may be unbearable and traumatic for another.
Thus we cannot always gauge whether situations will be traumatic or not without observing the reactions of those involved. These symptoms may appear at times seemingly unrelated to crisis. While some children may have acute situational reactions to critical incidents that may manifest at the time of the incident or in the hours or days just following, a different set of symptoms may occur in the weeks, months or even years after the incident, and these delayed reactions may take many forms.
A. Acute Situational Reactions to Crisis
Children’s immediate responses to critical incidents can range from hysteria to shock, but often there is no apparent reaction – a visible response may set in only later. This is usually the result of denial: The child cannot make sense of the relevant sensory information and simply shuts it out. Sometimes the child lacks the conceptual maturity to comprehend what has happened. In general, a child who is experiencing a traumatic reaction will show extremes of behavior, either under-responding or over-responding to the crisis situation. The signs and symptoms of acute stress in children can be grouped under the following classifications: Cognitive, Emotional, Physical, and Behavioral.
Sign and Symptoms of Situational Trauma
Sign and Symptoms of Delayed Response to Trauma
The delayed reactions listed here differ from immediate responses to trauma in some ways that might be expected. Yet the severity of the symptoms-sometimes years after the event-raises several interesting questions about posttraumatic stress reaction in childhood.
B. Posttraumatic Stress Disorder in Children
1. The Concept of PTSD
- Cognitive Psychology and Learning Theories are the two major contemporary theories that explain the process of posttrauma reaction. These theories are useful because they account for three common phenomena associated with posttrauma reactions: Denial and Numbing, Re-experiencing, and Depressive and Phobic symptoms.
Their are two major dynamics that account for the delayed nature of responses to trauma. The first dynamic is described as a “completion” tendency. In order to accommodate to a radically different situation that has changed as a result of a traumatic experience, memories, associated information, and implications are assimilated through a gradual process of integration. Primarily a cognitive process, this includes the intrusion of recurrent nightmares, daytime images and painful emotional re-experiences, unpleasant moods and emotional storms, and compulsive behavioral repetitions. This process may include secondary signs such as aggressive or self-destructive behavior, fear of loss of control over hostile or impaired social relationships. Often such behavior do not arise until years after the initial trauma event.
The second major dynamic is a “denial/numbing” tendency, serving as a defense against the intrusion of intolerable ideas and emotions. This tendency consists of denial, numbing, alienation, compartmentalization, and isolation of the traumatic experience from everyday life. The denial/numbing tendency is believed to interrupt the intrusion/repetition process, accounting for the delayed stress responses.
The intrusion/repetition process serves the healing function of integration and adaptation. The denial/numbing function appears to protect the individual from having to assimilate too much too soon. Difficulties in having to integrate pre- and post traumatic experience, into their day-to-day lives, leads to such psychological problems as low self-worth, shame, depersonalization, frustration and reactive rages, and various psychosocial disabilities.
- Neurobiological Brain Changes (Due to the release of Increased levels of Stress Hormones)
More recent studies done on understanding how trauma occurs, has focused upon neurobiological brain changes following overwhelming incidents and upon memory research. This research points out two types of neuro-abnormalities following trauma. The first consists of heightened responsiveness to trauma-specific stimulus (startle reaction to loud noises or other abrupt but trauma-neutral experiences). Reminders of the event can result in increased levels of those chemicals that trigger autonomic nervous system arousal. The second type of abnormality consists of over-arousal to intense stimuli that are not trauma-related. This over-activation of the autonomic nervous system results from a lack of integration of highly emotionally charged memories with the cognitive structuring of experience. Specific effects include the release of those neurohormones that accompany stress reactions, including the following:
- Increased levels of catecholamine (epinephrine and norepinepherine), resulting in increased sympathetic nervous system activity
- Decrease corticosteriods and serotonin; the lowered levels of cortisol and serotonin result in inability to moderate the catecholamine-triggered fight or flight response
- Increased levels of endogenous opioids, resulting in pain analgesia, emotional blunting, and memory impairment.
The developmental effects of these neurohormonal responses upon children, appear to include disruption of the functional areas of numerous cortical and subcortical areas, including loss of synchronization and integration. Left hemisphere activities seem to be more affected, impacting language and recall abilities in particular. Researchers have narrowed the search for the brain centers responsible for these posttraumatic biological changes down to two structures in the limbic system (the part of the subcortical brain responsible for self-preservation and survival). The amygdala evaluates the emotional meaning of incoming stimuli and integrates the representation of external events with emotional experiences associated with their memory. The hippocampus categorizes, relates, and stores incoming stimuli in memory, a vital part of the process of creating declarative memory. Research has linked posttrauma chemical activity as described above with shrinking of the hippocampus (due to increased levels of cortisol – a hormone toxic to the hippocampus) and increased activity in the right hemisphere, site of parts of the limbic system connected with the amygdala. This would correlate with findings that activity in these areas correspond with posttrauma symptomology.
2. Effects and Impact of PTSD on Children:
The severity of the impact of PTSD on children, mainly depend on the age of, and the duration of exposure to the initial trauma. The younger the child, and the longer the duration of the trauma, the more severe the long-term physical, emotional and psychological impact.
Particularly prominent in children with PTSD, are sleep disturbances, with inability to fall asleep, night terrors and nightmares (recurrent recollections). Daydreams, fantasies, and bahavioral changes linked to sudden visual and auditory stimuli that may remind children of the traumatic event (triggers). Traumatized children are described as regressing (loss of recently acquired developmental skills) such as: Loss of language skills, sucking their thumbs, and becoming enuretic (the uncontrolled or involuntary discharge of urine). Marked diminished interest in significant activities. In addition, children also demonstrate emotional numbing, which is in fact a defensive reaction.
- Posttraumatic features specific to preschool-age children include the following:
- Withdrawal: subdued and mute behavior
- Participation in re-enactments and unsatisfying plans involving traumatic themes
- Anxious attachment behaviors, incl. greater separation or stranger anxiety, clinging to previously cherished objects, whining, crying, clinging, and tantrums
- Regression to previous levels of functioning
- Relatively brief grieving period
- Denial of permanence of change
- Posttraumatic features specific to school-age children include the following:
- Lowered intellectual functioning; decline in school performance
- Inner plans of action (attempts at denial, compensation, reversal, or retribution through fantasy)
- Obsessive talking about incident
- Isolation of affect
- Constant anxious arousal
- Behavioral alterations
- Problems relating to peers
- More elaborate re-enactments
- Psychosomatic complaints (illness caused or aggravated by a mental factor such as stress)
- Five Additional Findings of Interest regarding posttraumatic reaction among children
- Ghosts: Children who have experienced sudden and shocking death sometimes see “ghosts,” attributed to posttraumatic misperception and hallucination
- Time distortion: While children prior to 12 years of age have not yet matured their time operations, observations of greater than expected time distortions are common among posttraumatic children. Overwhelming anxiety can distort time sense during critical incidents, leaving confusion and feelings of inadequacy later, particularly if the child must appear on the witness stand. In addition it can make sequencing in memory difficult. A related phenomenon is future foreshortening, or the perception that future possibilities do not exist or have been precluded.
- Symbolization: Parts of the traumatic experience may become associated by the child in forms more easily processed. What symbol is chosen and what part of the experience is chosen to be symbolized depend upon personal variables such as background experiences and issues, developmental level, and current situation.
- Condensation: Separate ideas, symbols, or objects can be symbolized together. These condensations can be confusing, and astute observation is required to sort them out.
- Pre-verbal memories: Experiences of children under the age of 2 are sometimes encoded non-verbally, consequently the children are unable to speak of a traumatic event. However, they can play out, re-enact, or even show in concrete modes of fear responses what has happened to them. These memories appear to be pre-verbal and pre-conceptual.
- Developmental Impact:A psychological trauma can interrupt the normal progress of development, causing more difficult resolution of current life issues and impeding growth. How this transpires is interesting in the sense that it provides a framework for understanding why a trauma can have its particular effect upon a child’s later life. Human development consists of a gradual unfolding of personality wherein new learning and skills transform the individual from one phase to another. Each phase has certain inherent tasks that must be resolved to form the basis for further change.
Erickson (1968) describes these steps as “crises”, as each successive step has a potential crisis, because of a radical change in perspective (just like bricks crucially placed to form the foundation of a house). Each successive stage of development, resulting from the external demands of environment interfacing with internal readiness for new levels of functioning, causes a specific vulnerability. A stage is a time when a given capacity or set of skills, requisite to further development occurs-a turning point or crucial moment when the individual, as a result of both the acquisition of skills and capacities and the necessary cultural and biological pressure, must change. If the child experiences trauma during one of these ‘crisis’ stages in development, the individual will re-establish a previous level of functioning. The ‘crisis’ here denotes from these previously unattained levels of functioning. With other words the foundation of the house is incomplete.
Development, then, is a process of transformation through stages characterized by specific demands, opportuniteis, and vulnerabilities. Adverse conditions may affect development in stage-specific ways. This disruption afffects not only the stage during which the event occurred but also resolution of task in subsequent stages. These ‘incomplete bricks’ to their foundation, impacts their developmental patterns: Developmental anxiety and Premature structuring.
Developmental anxiety represents a reaction to the transition involved in the giving up of old forms of coping that worked at one level of development, and the acquisition of new ones appropriate to a new level of development. The acquisition of new forms of coping can be a prolonged process of differentiation and experimentation and generates considerable anxiety. Thus developmental anxiety increases or decreases across the life span of the individual as he/she attempts resolution of each new set of demands raised by changes of biological and societal expectations.
Premature structuring is a process by which character or personality formation of the child is accelerated due to the demands of the environment. These children have no other choice, they are forced by circumstances to grow up too quickly, deal with grown-up demands and stressors too early, and develop certain aspects of their personalities at the expense of others. They tend to become overspecialized and over-differentiated in a manner that provides immediate survival, but acts to constrict and close off further learning and balanced growth. This premature structuring has serious consequences when the child reaches adolescence.
Each life stage is characterized by a particular psychosocial crisis and that each crisis bears the risk of specific types of ego-regressive attributes. Trauma during a particular stage undermines the internal control mechanisms essential to development of the specific ego strength being formed during that period, or may exacerbate previously poorly developed ego strengths (such as mistrust, shame, and feelings of inferiority). Sufficient stress and trauma during a specific stage will increase the risk of failing to master the critical issues and of developing the related ego-regressive attributes (see the below table for specific attributes and stages).
Developmental Ego-Regressive Attributes
|Life Stage||Crisis||Ego-Regressive Attribute|
|Infancy||Trust versus Mistrust||Hopelessness, dependency, anxiety, withdrawal|
|Play age||Autonomy versus Shame/doubt||Over-control, Impulsiveness, order, structure, predictability, helplessness|
|Younger School Age||Initiative versus Guilt||Guilt, loss of rootedness, need for protectors, loss of purpose|
|Older School Age||Industry versus Inferiority||Sense of futility, work paralysis, incompetence|
|Adolescence||Identity versus Identity diffusion||Self-consciousness, lack of commitment, prolonged moratorium|
In conclusion trauma produces psychological disequilibrium that is anxiety provoking. attempt at coping with this anxiety affect the child’s ability to tolerate the normal anxiety created by developmental transitions. The resulting combination can block successful developmental task mastery. With this understanding of the manner in which crises affect children’s development, the way is cleared for Part 3 ~ An exploration of what we can do to minimize posttraumatic reactions and subsequent developmental difficulties.
Taken and adapted in part from: ‘Trauma in the Lives of children’ written by Kendall Johnson, PhD