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Stress and reactions to stress in children
Influences of psychopathology
Stress and reactions to stress in children
What’s new? • Stress in pregnant mothers can be transmitted to the fetus and cause enduring effects on offspring9
Guinevere Tufnell
• Diagnostic criteria are being revised to allow more rational diagnosis of complex trauma in children12 • Building resilience is recognized as key factor in the treatment of stress-related disorder21
Abstract
• Trauma-focused psychological therapy has been shown to be more effective than medication in the treatment of PTSD22
This article describes the ways in which our minds and bodies are adapted to respond to stress and danger, and the ways in which this can be applied to children. Young children respond differently from adults and the exact nature of a child’s response is determined by their developmental stage, the circumstances surrounding the stressful experience, and the support subsequently available. The immediate and longer-term effects of severely stressful experience are outlined and the importance of family and other environmental factors is highlighted. Stress and trauma can cause significant and sometimes long-lasting mental health problems. Identification of children at risk and provision of effective treatment can do much to prevent these difficulties. This article gives basic principles for a thorough assessment, as well as how to plan effective treatment.
system. Consequently, non-essential functions are inhibited, heart rate and respiration speed up, and the body is prepared for fight or flight. Sensations become more acute, attention becomes highly focused towards the potential danger, and reaction time speeds up. Pain sensation may be diminished as a consequence of the release of endorphins in the brain, even after severe injury. The release of noradrenaline and cortisol into the bloodstream
Hypothalamic–pituitary–adrenal axis and the response to threat
Keywords assessment; debriefing; fear; post-traumatic stress disorder; stress; trauma; treatment
Threat/stress
What is stress? It is increasingly recognized that stress cannot be fully defined in objective terms. The way in which an event is perceived as stressful or threatening also has a major effect on the way an individual will respond, and varies enormously between individuals. A child’s perception of an event is determined by: • his or her developmental stage • the circumstances surrounding and following the incident • the support subsequently available.
Hypothalamus (CRH, AVP)
Anterior pituitary (ACTH)
Psychophysiological response to stress
Inhibit Long-term mediation
When an event is perceived as stressful or threatening, our minds and bodies are programmed to respond in a specific way. The ability to perceive danger and to protect ourselves effectively from it is crucial for our day-to-day survival. Danger is a powerful stressor and produces an automatic psychophysiological response, enabling us to ‘fight or flee’.1 When danger is perceived, there is an immediate arousal response via the limbic system (Figure 1). The amygdala is stimulated, resulting in activation of the sympathetic nervous system and inhibition of the parasympathetic nervous
Stimulate Adrenal cortex (cortisol)
• Cardiovascular adaptation • Increased arousal, vigilance • Decreased vegetative function (catabolism) • Immune suppression • Growth suppression
Guinevere Tufnell MA (Cantab) FRCPsych is Consultant Child and Adolescent Psychiatrist at the Traumatic Stress Clinic, Great Ormond Street Hospital, London, UK. She trained at the Royal Free Hospital, London, and completed her psychiatric training at Guy’s Hospital and St George’s Hospital, London. Conflicts of interest: none declared.
PSYCHIATRY 7:7
Modulates, inhibits HPA axis
Stimulate
ACTH, adrenocorticotrophic hormone; AVP, arginine vasopressin; CRH, corticotrophin releasing hormone; HPA, hypothalamic–pituitary–adrenal
Figure 1
299
© 2008 Elsevier Ltd. All rights reserved.
Influences of psychopathology
helps to maintain the autonomic response and to ensure that the body remains able to cope with stress for a considerable period of time. Glycogen is mobilized from the liver to provide energy. The immune system is activated to respond to tissue damage. In extremis, a freeze response can occur, when pulse and respiration slow, and may even stop.2 Of course, not all stressful events will be experienced as extreme danger, and the associated stress response is likely to be modulated accordingly.
known. The effect of what is experienced will depend on individuals’ ability to cope and the support that is available, as well as on the event itself.7 There appears to be a very wide range of possible stress-related disorders, ranging from mild to severe (Table 1). At present, stressful experience is formally required only in dia gnostic criteria for adjustment disorders and post-traumatic stress disorder (PTSD). The conceptualization and understanding of stress response syndromes has changed enormously over the last century and remains a major focus for research. For example, it was only in the 1980s that criteria for PTSD were published in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), with the International Classification of Diseases, tenth revision (ICD-10), definition following in 1992. The experience of stress is not uncommon; traumatic stress is also common, especially in populations afflicted by violence or natural disaster. The prevalence of mental health disorders resulting from traumatic stress can only be guessed at, but is clearly considerable. For example, epidemiological studies of PTSD alone estimate a point prevalence of 1%, and 4–12% for a lifetime diagnosis.8 Rates in clinical populations, however, are likely to be much higher.
Later reactions: these are reactions occurring after the event, and depending on circumstances. In normal circumstances, recovery can be rapid, but where the situation involves dealing with separation, loss, and change, a very different type of response will be called for. For example, the death of a loved one may be followed by a bereavement response in which initial numbness gives way to separation anxiety, yearning, and grief. When death is unexpected and traumatic, however, the initial shock may be followed by intrusive thoughts and images that make it difficult to come to terms with the loss in the normal way. This may give rise to complicated and protracted grief reactions. Some traumatic events bring with them enormous changes for the individuals affected. Natural disasters or war, for example, disrupt the way of life of whole communities for protracted periods. But even changes on a smaller scale can result in catastrophic disruption of the individual’s assumptions about the world, including the framework for self-identity, understanding events, planning, and taking action. Repairing this damage and developing new ways of functioning may take considerable time.3
Stress reactions in children Children’s immediate reaction to extreme stress is usually one of distress, tearfulness, and fear. Once the event is over, it takes time for the child to adjust to and recover from what has happened. The nature and severity of the reaction will depend on characteristics of the event, factors affecting the child’s resilience,9,10 and the recovery environment. The type of stressful experience, the suddenness of the event, the amount of preparation that has been possible, the sensory exposure entailed, and the degree of secondary trauma all affect the impact of the event on the child (Table 2). The appraisal of the stressful event – what it means for the child and how this is processed cognitively – is one of the most important factors in determining how an individual responds and copes. Stressful experience that overwhelms the child’s coping abilities can be traumatizing even when not actually life threatening. Young children who experience overwhelming sensory exposure during the event may be unable to process this cognitively, which
Longer-term effects: much of what is known about stress and reactions to it comes from research in the USA with Vietnam veterans. This has shown that the effects of extreme, protracted, and repeated stress can be enduring. Mental health problems range from relatively mild and self-limiting to severe and long-lasting, and include substance abuse and disorders of personality, attachment, adjustment, and mood. Although they are necessary for survival, it seems that frequent neurobiological stress responses increase the risk of physical and mental health problems, particularly when experienced during periods of rapid brain development.4
Developmental issues Our bodies and brains respond automatically to dangerous situa tions without understanding or conscious awareness. For example, in a newborn any sudden change of sensation is sufficient to provoke a startle response. As young children grow older, what they learn about danger and safety lays the foundations for how they will understand and cope with stress in later life. The relationship between the child and its primary care-giver provides a particularly crucial learning environment. If this environment does not provide protection but instead exposes the child to repeated danger (e.g. domestic violence or abuse), there are likely to be long-term effects both on the child’s assumptions about the world and on their mental health.5,6
Differential diagnosis Stressful experiences can lead to: • Normal stress responses • Adjustment disorders • Psychiatric disorders, including: ○ mood disorders (anxiety states, post-traumatic stress disorder, depression) ○ dissociative states ○ psychosomatic complaints ○ eating disorders ○ attachment disorders ○ personality disorders in adulthood ○ substance abuse
Epidemiology and history Most people experience traumatic events at some time in their lives, although exact prevalence rates for stress disorders are not
PSYCHIATRY 7:7
Table 1
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© 2008 Elsevier Ltd. All rights reserved.
Influences of psychopathology
attention deficit hyperactivity disorder, conduct disorder, or psychosis. As children get older, their reactions to extreme stress become more like those of adults. Adolescents may meet DSM or ICD criteria for PTSD and other disorders. Those exposed to prolonged or repeated stress may also present with dissociative symptoms, angry outbursts, self-injury, and substance abuse. Memory and concentration difficulties are common and can affect schoolwork and grades. Moodiness, anxiety, depression, and irritability can put pressure on peer and family relationships.
Factors affecting risk and resilience • Perceived severity of stress/trauma exposure • Parental mental health problems • Exposure to stress at a young age • Time elapsed since exposure (symptoms often reduce over time) • Pre-stress psychopathology • Social/cultural support Table 2
Assessment When asked to assess a child after a major stressful event, it may be helpful, before arranging to meet the child, to have a planning meeting with the parents or carers to discuss: • who needs to be involved in the assessment • what questions need to be answered • what type of assessment process is likely to be most helpful. Interviewing parents and child together about the child’s current circumstances and functioning is often a good place to start the assessment. Parents can also provide useful background information such as family history and developmental history of the child, including traumatic experiences. It may also be helpful to see the parents separately to obtain information about the parental developmental history (including trauma and attachments), marital relationship, and life experience of separations, abuse, illness, and other stressors or life events. The parental account of any traumatic event should include their own and the child’s reactions to the trauma, and how these have been managed. Interviewing the child individually is especially important following traumatic experience. Parents often lack crucial detailed information about their child’s experience and may therefore be unable to provide all the information needed. Children often speak more freely about their experiences when not afraid of causing distress to carers. It is usually necessary to ask the child direct questions about their experience of traumatic events and their symptoms. Asking the child about what has helped them to cope is also important. A semi-structured interview can be helpful (Table 3). Young children respond best to an approach using play and drawing to help them to express themselves.13
makes them particularly vulnerable to flashbacks and intrusive re-experiencing of the event. Other important moderating factors are the child’s: • age and maturity • sex • personality • previous experience of trauma • coping resources available. In the aftermath of extreme stress, the provision of timely and appropriate information and professional assistance can do much to reassure and calm both child and carer. If the consequences of the event are manageable and disruption is minimal, the child’s distress and upset may resolve within a few days or weeks. The ability of parents (who may themselves be distressed and traumatized) to provide adequate care, and the presence of a stable caring system around the child, are crucial in promoting recovery. When these are absent, significant mental health problems can develop. Of course, if traumatic experience is repeated there is a risk that chronic and complex responses will develop.11
Psychopathology Following a traumatically stressful experience, repetitive and intrusive memories of the trauma are common. A chance noise or other stimulus may trigger a flashback. Disturbing images may also occur at quiet moments such as bedtime, making it difficult for the child to settle to sleep. In very young children, sleep disturbances such as night terrors and night waking are common. Older children often report that their sleep is disturbed by bad dreams and nightmares. Children who are too young to be able to understand what has happened to them, or to express their thoughts and feelings in words, are likely to re-enact a traumatic event in their play or drawings. They often develop symptoms of hyperarousal, such as overactivity, irritability, difficulty concentrating, and hypervigilance. Signs of generalized anxiety are also common, including clinginess and fears of the dark. Language, toilet-training, and other developmental skills may regress or even be lost altogether. The child may become withdrawn or unresponsive and try to avoid situations, objects, or even words that remind them of the traumatic experience. When children are exposed to chronic and repeated stress such as abuse or domestic violence, many domains of development may be affected.12 Such children present a diagnostic challenge to the clinician, not uncommonly presenting with complex disorders of arousal, mood, and conduct. When trauma is not identified, such children may be diagnosed as suffering from
PSYCHIATRY 7:7
‘Winding down’: at the end of any interview about trauma, the interviewer needs to help the child wind down, to review and summarize the session, and to discuss anything that was particularly disturbing or helpful. Providing information about traumatic experience and its consequences may be useful, and may assist with normalizing the child’s reactions to the trauma. The child’s self-esteem will benefit if the interviewer acknowledges the child’s courage and the privilege of having shared the experience with them.
Differential diagnosis Stressful experience can provoke a range of possible responses, both normal stress responses and a variety of PTSDs.14 A single, brief, unexpected stressor (e.g. an accident) is likely to produce a very different response from traumatic experience that is repeated, prolonged, and expected (e.g. sexual abuse). 301
© 2008 Elsevier Ltd. All rights reserved.
Influences of psychopathology
debriefing remains controversial owing to conflicting reports about its efficacy. It is a skilled procedure that should be carried out by a trained clinician and is most likely to be effective when used as part of a comprehensive stress management programme rather than as a stand-alone treatment.16
Trauma interview for older children and adolescents 1 Ask the patient: • ‘Have you ever [for example] been in a car accident… or a house fire… or thought you might get hurt or die?’ • ‘Have you ever seen someone else get hurt badly?’ • ‘Did someone important to you ever die, such as someone in your family or a good friend?’ 2 Having identified traumatic event/s, ask the child to tell their own story about it/them. Use free recall as much as possible • Assist recall with questions about context of the traumatic event (e.g. when/where/who; the child’s physical/ psychological responses at the time) 3 Track the course of symptoms from immediately after trauma to the present • Ask about attributions: the child’s feelings of guilt and being different, damaged, or isolated; reactions of others 4 Ask the child to describe their thoughts/plans about the future 5 ‘Wind down’ (see text)
Cognitive–behavioural therapy (CBT) can be very helpful for many types of PTSD. This approach essentially relies on helping the child to recall the distressing events (imaginal exposure) in such a way as to reduce distress (desensitization) and enable symptoms to be mastered (cognitive restructuring). Prerequisites for success include: • the establishment of a safe and supportive environment • a trusting and cooperative relationship with the therapist • ensuring that the child is not retraumatized as a result of the treatment. A number of studies have reported gains made during treatment which are well maintained at follow-up.8 Very young children, however, are unlikely to be able to make use of formal CBT, but can benefit from similar therapeutic approaches using play, drawing, and narrative techniques.
Table 3
Eye movement desensitization and reprocessing (EMDR) is a relatively new technique that has shown promising results so far in research with traumatized adults.17,18 To date, controlled trials with children are few. Symptom improvement is rapid and well maintained, even in very young children. EMDR uses many of the same elements as CBT but relies less on homework and verbal competency, and is particularly helpful with avoidant or very young children.
epending on the circumstances, a child may develop the sympD toms of a disorder (e.g. PTSD) but fall short of meeting the full criteria. The most common disorders are listed in Table 1. Comorbidity is common following severe trauma. Careful history-taking and clinical examination are crucial for accurate diagnosis. Traumatized children are often withdrawn, avoidant, or dissociative. This affects their ability to communicate, so that definitive diagnosis is likely to take time. Standard questionnaires can be helpful adjuncts to the detailed clinical interview.15
Medication is increasingly used as an adjunct to multidimensional psychological therapy packages for post-traumatic disorders.19 However, few studies have looked specifically at children.8 Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are effective, at least in the short term, in treating symptoms of hyperarousal, such as irritability and sleep disturbance, as well as those of depression. Night terrors, startle responses, avoidance reactions, and overactivity may respond to propranolol (a β-blocker) or clonidine (an α2-noradrenergic agonist).20 ◆
Effective management and treatment Management will depend on the specific circumstances and needs of the individual child and family. A broad, multisystemic approach may be needed in order to identify and address all of the child’s needs, especially following chronic or complex trauma.11 Situational factors such as family adjustment problems, school difficulties, or complex legal processes could cause significant ongoing stress and require practical help or advice. Clearly, given the range of possible stress-related disorders, a number of treatment approaches may be needed. What follows is just a brief outline of what may help a child to recover from severe stress.
References 1 Ledoux J. The emotional brain. New York: Simon & Schuster, 1996. 2 Porges SW. The polyvagal theory: phylogenetic contributions to social behavior. Physiol Behav 2003; 79: 503–13. 3 Morgan L, Scourfield J, Williams D, et al. The Aberfan disaster: 33- year follow-up of survivors. Br J Psychiatry 2003; 182: 532–6. 4 Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14: 245–58. 5 Glaser D. Child abuse and neglect and the brain – a review. J Child Psychol Psychiatry 2000; 41: 97–116. 6 Bradley SJ. Stress, trauma and abuse. In: Affect regulation and the development of psychopathology. New York: Guilford Press, 2000.
Immediate measures: for any child who has been exposed to life-threatening danger, the most immediate requirements are safety and security. Much distress in the immediate aftermath can be alleviated by providing information and practical help. Later, screening to identify those at risk of developing mental health problems can also be valuable. Psychological first aid is an early intervention that aims to promote healthy recovery from traumatic stress by ensuring that support can be accessed, thus optimizing the ability to cope and enhancing resilience. An approach known as psychological
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Influences of psychopathology
7 Lauterbach D, Koch EI, Porter K. The relationship between childhood support and later emergence of PTSD. J Trauma Stress 2007; 20: 857–67. 8 National Institute for Clinical Excellence. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London: NICE, 2005. 9 Yehuda R, Engel SM, Brand SR, et al. Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. J Clin Endocrinol Metab 2005; 90: 4115–18. 10 Bonanno GA, Galea S, Bucciarelli A, Vlahov D. What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. J Consult Clin Psychol 2007; 75: 671–82. 11 Cook A, Spinazzola J, Ford J, et al. Complex trauma in children and adolescents. Psychiatr Ann 2005; 35: 390–8. 12 van der Kolk BA. Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories. Psychiatr Ann 2005; 35: 401–8. 13 Pynoos R, Eth S. Witness to violence: the child interview. In: Chess S, Thomas S, Hertzig M, eds. Annual progress in child psychiatry and child development 1987. Philadelphia: Brunner/Mazel, 1987. 14 Yule W, Perrin S, Smith P. Post-traumatic stress disorders in children and adolescents. In: Yule W, ed. Post-traumatic stress disorders: concepts and therapy. London: Wiley, 1999. 15 Perrin S, Smith P, Yule W. The assessment and treatment of post-traumatic stress disorder in children and adolescents. J Child Psychol Psychiatry 2000; 41: 277–89. 16 Bisson JI, MacFarlane AC, Rose S. Psychological debriefing. In: Foa EB, Keane TM, Friedman MJ, eds. Effective treatment for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press, 2000. 17 Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols, and procedures, 2nd edn. New York: Guilford Press, 2001.
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18 Spector J, Read J. The current status of eye movement desensitisation and reprocessing (EMDR). Clin Psychol Psychother 1999; 6: 165–74. 19 Stein DJ, Zungu-Dirwayi N, van der Linden GJ, Seedat S. Pharmacotherapy for posttraumatic stress disorder. Cochrane Database Syst Rev 2000; (4): CD002795. 20 Donnelly CL. Post-traumatic stress disorder. In: Martin A, Scahill L, Charney DS, Leckman JF, eds. Pediatric psychopharmacology: principles and practice. New York: Oxford University Press, 2003. 21 Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 2004; 59: 20–8. 22 van der Kolk BA, Spinazzola J, Blaustein ME, et al. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. J Clin Psychiatry 2007; 68: 37–46.
Further reading Black D, Newman M, Harris Hendricks J, Mezey G, eds. Psychological trauma: a developmental approach. London: Gaskell, 1997.
Practice points • Traumatic experiences are common and can have long-lasting psychological effects • Children are especially vulnerable to the effects of extreme stress • Parental accounts are unreliable – it is therefore important to interview the child • Specific treatments work best as part of a multimodal intervention
303
© 2008 Elsevier Ltd. All rights reserved.
Stress and reactions to stress in children
What’s new? • Stress in pregnant mothers can be transmitted to the fetus and cause enduring effects on offspring9
Guinevere Tufnell
• Diagnostic criteria are being revised to allow more rational diagnosis of complex trauma in children12 • Building resilience is recognized as key factor in the treatment of stress-related disorder21
Abstract
• Trauma-focused psychological therapy has been shown to be more effective than medication in the treatment of PTSD22
This article describes the ways in which our minds and bodies are adapted to respond to stress and danger, and the ways in which this can be applied to children. Young children respond differently from adults and the exact nature of a child’s response is determined by their developmental stage, the circumstances surrounding the stressful experience, and the support subsequently available. The immediate and longer-term effects of severely stressful experience are outlined and the importance of family and other environmental factors is highlighted. Stress and trauma can cause significant and sometimes long-lasting mental health problems. Identification of children at risk and provision of effective treatment can do much to prevent these difficulties. This article gives basic principles for a thorough assessment, as well as how to plan effective treatment.
system. Consequently, non-essential functions are inhibited, heart rate and respiration speed up, and the body is prepared for fight or flight. Sensations become more acute, attention becomes highly focused towards the potential danger, and reaction time speeds up. Pain sensation may be diminished as a consequence of the release of endorphins in the brain, even after severe injury. The release of noradrenaline and cortisol into the bloodstream
Hypothalamic–pituitary–adrenal axis and the response to threat
Keywords assessment; debriefing; fear; post-traumatic stress disorder; stress; trauma; treatment
Threat/stress
What is stress? It is increasingly recognized that stress cannot be fully defined in objective terms. The way in which an event is perceived as stressful or threatening also has a major effect on the way an individual will respond, and varies enormously between individuals. A child’s perception of an event is determined by: • his or her developmental stage • the circumstances surrounding and following the incident • the support subsequently available.
Hypothalamus (CRH, AVP)
Anterior pituitary (ACTH)
Psychophysiological response to stress
Inhibit Long-term mediation
When an event is perceived as stressful or threatening, our minds and bodies are programmed to respond in a specific way. The ability to perceive danger and to protect ourselves effectively from it is crucial for our day-to-day survival. Danger is a powerful stressor and produces an automatic psychophysiological response, enabling us to ‘fight or flee’.1 When danger is perceived, there is an immediate arousal response via the limbic system (Figure 1). The amygdala is stimulated, resulting in activation of the sympathetic nervous system and inhibition of the parasympathetic nervous
Stimulate Adrenal cortex (cortisol)
• Cardiovascular adaptation • Increased arousal, vigilance • Decreased vegetative function (catabolism) • Immune suppression • Growth suppression
Guinevere Tufnell MA (Cantab) FRCPsych is Consultant Child and Adolescent Psychiatrist at the Traumatic Stress Clinic, Great Ormond Street Hospital, London, UK. She trained at the Royal Free Hospital, London, and completed her psychiatric training at Guy’s Hospital and St George’s Hospital, London. Conflicts of interest: none declared.
PSYCHIATRY 7:7
Modulates, inhibits HPA axis
Stimulate
ACTH, adrenocorticotrophic hormone; AVP, arginine vasopressin; CRH, corticotrophin releasing hormone; HPA, hypothalamic–pituitary–adrenal
Figure 1
299
© 2008 Elsevier Ltd. All rights reserved.
Influences of psychopathology
helps to maintain the autonomic response and to ensure that the body remains able to cope with stress for a considerable period of time. Glycogen is mobilized from the liver to provide energy. The immune system is activated to respond to tissue damage. In extremis, a freeze response can occur, when pulse and respiration slow, and may even stop.2 Of course, not all stressful events will be experienced as extreme danger, and the associated stress response is likely to be modulated accordingly.
known. The effect of what is experienced will depend on individuals’ ability to cope and the support that is available, as well as on the event itself.7 There appears to be a very wide range of possible stress-related disorders, ranging from mild to severe (Table 1). At present, stressful experience is formally required only in dia gnostic criteria for adjustment disorders and post-traumatic stress disorder (PTSD). The conceptualization and understanding of stress response syndromes has changed enormously over the last century and remains a major focus for research. For example, it was only in the 1980s that criteria for PTSD were published in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), with the International Classification of Diseases, tenth revision (ICD-10), definition following in 1992. The experience of stress is not uncommon; traumatic stress is also common, especially in populations afflicted by violence or natural disaster. The prevalence of mental health disorders resulting from traumatic stress can only be guessed at, but is clearly considerable. For example, epidemiological studies of PTSD alone estimate a point prevalence of 1%, and 4–12% for a lifetime diagnosis.8 Rates in clinical populations, however, are likely to be much higher.
Later reactions: these are reactions occurring after the event, and depending on circumstances. In normal circumstances, recovery can be rapid, but where the situation involves dealing with separation, loss, and change, a very different type of response will be called for. For example, the death of a loved one may be followed by a bereavement response in which initial numbness gives way to separation anxiety, yearning, and grief. When death is unexpected and traumatic, however, the initial shock may be followed by intrusive thoughts and images that make it difficult to come to terms with the loss in the normal way. This may give rise to complicated and protracted grief reactions. Some traumatic events bring with them enormous changes for the individuals affected. Natural disasters or war, for example, disrupt the way of life of whole communities for protracted periods. But even changes on a smaller scale can result in catastrophic disruption of the individual’s assumptions about the world, including the framework for self-identity, understanding events, planning, and taking action. Repairing this damage and developing new ways of functioning may take considerable time.3
Stress reactions in children Children’s immediate reaction to extreme stress is usually one of distress, tearfulness, and fear. Once the event is over, it takes time for the child to adjust to and recover from what has happened. The nature and severity of the reaction will depend on characteristics of the event, factors affecting the child’s resilience,9,10 and the recovery environment. The type of stressful experience, the suddenness of the event, the amount of preparation that has been possible, the sensory exposure entailed, and the degree of secondary trauma all affect the impact of the event on the child (Table 2). The appraisal of the stressful event – what it means for the child and how this is processed cognitively – is one of the most important factors in determining how an individual responds and copes. Stressful experience that overwhelms the child’s coping abilities can be traumatizing even when not actually life threatening. Young children who experience overwhelming sensory exposure during the event may be unable to process this cognitively, which
Longer-term effects: much of what is known about stress and reactions to it comes from research in the USA with Vietnam veterans. This has shown that the effects of extreme, protracted, and repeated stress can be enduring. Mental health problems range from relatively mild and self-limiting to severe and long-lasting, and include substance abuse and disorders of personality, attachment, adjustment, and mood. Although they are necessary for survival, it seems that frequent neurobiological stress responses increase the risk of physical and mental health problems, particularly when experienced during periods of rapid brain development.4
Developmental issues Our bodies and brains respond automatically to dangerous situa tions without understanding or conscious awareness. For example, in a newborn any sudden change of sensation is sufficient to provoke a startle response. As young children grow older, what they learn about danger and safety lays the foundations for how they will understand and cope with stress in later life. The relationship between the child and its primary care-giver provides a particularly crucial learning environment. If this environment does not provide protection but instead exposes the child to repeated danger (e.g. domestic violence or abuse), there are likely to be long-term effects both on the child’s assumptions about the world and on their mental health.5,6
Differential diagnosis Stressful experiences can lead to: • Normal stress responses • Adjustment disorders • Psychiatric disorders, including: ○ mood disorders (anxiety states, post-traumatic stress disorder, depression) ○ dissociative states ○ psychosomatic complaints ○ eating disorders ○ attachment disorders ○ personality disorders in adulthood ○ substance abuse
Epidemiology and history Most people experience traumatic events at some time in their lives, although exact prevalence rates for stress disorders are not
PSYCHIATRY 7:7
Table 1
300
© 2008 Elsevier Ltd. All rights reserved.
Influences of psychopathology
attention deficit hyperactivity disorder, conduct disorder, or psychosis. As children get older, their reactions to extreme stress become more like those of adults. Adolescents may meet DSM or ICD criteria for PTSD and other disorders. Those exposed to prolonged or repeated stress may also present with dissociative symptoms, angry outbursts, self-injury, and substance abuse. Memory and concentration difficulties are common and can affect schoolwork and grades. Moodiness, anxiety, depression, and irritability can put pressure on peer and family relationships.
Factors affecting risk and resilience • Perceived severity of stress/trauma exposure • Parental mental health problems • Exposure to stress at a young age • Time elapsed since exposure (symptoms often reduce over time) • Pre-stress psychopathology • Social/cultural support Table 2
Assessment When asked to assess a child after a major stressful event, it may be helpful, before arranging to meet the child, to have a planning meeting with the parents or carers to discuss: • who needs to be involved in the assessment • what questions need to be answered • what type of assessment process is likely to be most helpful. Interviewing parents and child together about the child’s current circumstances and functioning is often a good place to start the assessment. Parents can also provide useful background information such as family history and developmental history of the child, including traumatic experiences. It may also be helpful to see the parents separately to obtain information about the parental developmental history (including trauma and attachments), marital relationship, and life experience of separations, abuse, illness, and other stressors or life events. The parental account of any traumatic event should include their own and the child’s reactions to the trauma, and how these have been managed. Interviewing the child individually is especially important following traumatic experience. Parents often lack crucial detailed information about their child’s experience and may therefore be unable to provide all the information needed. Children often speak more freely about their experiences when not afraid of causing distress to carers. It is usually necessary to ask the child direct questions about their experience of traumatic events and their symptoms. Asking the child about what has helped them to cope is also important. A semi-structured interview can be helpful (Table 3). Young children respond best to an approach using play and drawing to help them to express themselves.13
makes them particularly vulnerable to flashbacks and intrusive re-experiencing of the event. Other important moderating factors are the child’s: • age and maturity • sex • personality • previous experience of trauma • coping resources available. In the aftermath of extreme stress, the provision of timely and appropriate information and professional assistance can do much to reassure and calm both child and carer. If the consequences of the event are manageable and disruption is minimal, the child’s distress and upset may resolve within a few days or weeks. The ability of parents (who may themselves be distressed and traumatized) to provide adequate care, and the presence of a stable caring system around the child, are crucial in promoting recovery. When these are absent, significant mental health problems can develop. Of course, if traumatic experience is repeated there is a risk that chronic and complex responses will develop.11
Psychopathology Following a traumatically stressful experience, repetitive and intrusive memories of the trauma are common. A chance noise or other stimulus may trigger a flashback. Disturbing images may also occur at quiet moments such as bedtime, making it difficult for the child to settle to sleep. In very young children, sleep disturbances such as night terrors and night waking are common. Older children often report that their sleep is disturbed by bad dreams and nightmares. Children who are too young to be able to understand what has happened to them, or to express their thoughts and feelings in words, are likely to re-enact a traumatic event in their play or drawings. They often develop symptoms of hyperarousal, such as overactivity, irritability, difficulty concentrating, and hypervigilance. Signs of generalized anxiety are also common, including clinginess and fears of the dark. Language, toilet-training, and other developmental skills may regress or even be lost altogether. The child may become withdrawn or unresponsive and try to avoid situations, objects, or even words that remind them of the traumatic experience. When children are exposed to chronic and repeated stress such as abuse or domestic violence, many domains of development may be affected.12 Such children present a diagnostic challenge to the clinician, not uncommonly presenting with complex disorders of arousal, mood, and conduct. When trauma is not identified, such children may be diagnosed as suffering from
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‘Winding down’: at the end of any interview about trauma, the interviewer needs to help the child wind down, to review and summarize the session, and to discuss anything that was particularly disturbing or helpful. Providing information about traumatic experience and its consequences may be useful, and may assist with normalizing the child’s reactions to the trauma. The child’s self-esteem will benefit if the interviewer acknowledges the child’s courage and the privilege of having shared the experience with them.
Differential diagnosis Stressful experience can provoke a range of possible responses, both normal stress responses and a variety of PTSDs.14 A single, brief, unexpected stressor (e.g. an accident) is likely to produce a very different response from traumatic experience that is repeated, prolonged, and expected (e.g. sexual abuse). 301
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debriefing remains controversial owing to conflicting reports about its efficacy. It is a skilled procedure that should be carried out by a trained clinician and is most likely to be effective when used as part of a comprehensive stress management programme rather than as a stand-alone treatment.16
Trauma interview for older children and adolescents 1 Ask the patient: • ‘Have you ever [for example] been in a car accident… or a house fire… or thought you might get hurt or die?’ • ‘Have you ever seen someone else get hurt badly?’ • ‘Did someone important to you ever die, such as someone in your family or a good friend?’ 2 Having identified traumatic event/s, ask the child to tell their own story about it/them. Use free recall as much as possible • Assist recall with questions about context of the traumatic event (e.g. when/where/who; the child’s physical/ psychological responses at the time) 3 Track the course of symptoms from immediately after trauma to the present • Ask about attributions: the child’s feelings of guilt and being different, damaged, or isolated; reactions of others 4 Ask the child to describe their thoughts/plans about the future 5 ‘Wind down’ (see text)
Cognitive–behavioural therapy (CBT) can be very helpful for many types of PTSD. This approach essentially relies on helping the child to recall the distressing events (imaginal exposure) in such a way as to reduce distress (desensitization) and enable symptoms to be mastered (cognitive restructuring). Prerequisites for success include: • the establishment of a safe and supportive environment • a trusting and cooperative relationship with the therapist • ensuring that the child is not retraumatized as a result of the treatment. A number of studies have reported gains made during treatment which are well maintained at follow-up.8 Very young children, however, are unlikely to be able to make use of formal CBT, but can benefit from similar therapeutic approaches using play, drawing, and narrative techniques.
Table 3
Eye movement desensitization and reprocessing (EMDR) is a relatively new technique that has shown promising results so far in research with traumatized adults.17,18 To date, controlled trials with children are few. Symptom improvement is rapid and well maintained, even in very young children. EMDR uses many of the same elements as CBT but relies less on homework and verbal competency, and is particularly helpful with avoidant or very young children.
epending on the circumstances, a child may develop the sympD toms of a disorder (e.g. PTSD) but fall short of meeting the full criteria. The most common disorders are listed in Table 1. Comorbidity is common following severe trauma. Careful history-taking and clinical examination are crucial for accurate diagnosis. Traumatized children are often withdrawn, avoidant, or dissociative. This affects their ability to communicate, so that definitive diagnosis is likely to take time. Standard questionnaires can be helpful adjuncts to the detailed clinical interview.15
Medication is increasingly used as an adjunct to multidimensional psychological therapy packages for post-traumatic disorders.19 However, few studies have looked specifically at children.8 Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are effective, at least in the short term, in treating symptoms of hyperarousal, such as irritability and sleep disturbance, as well as those of depression. Night terrors, startle responses, avoidance reactions, and overactivity may respond to propranolol (a β-blocker) or clonidine (an α2-noradrenergic agonist).20 ◆
Effective management and treatment Management will depend on the specific circumstances and needs of the individual child and family. A broad, multisystemic approach may be needed in order to identify and address all of the child’s needs, especially following chronic or complex trauma.11 Situational factors such as family adjustment problems, school difficulties, or complex legal processes could cause significant ongoing stress and require practical help or advice. Clearly, given the range of possible stress-related disorders, a number of treatment approaches may be needed. What follows is just a brief outline of what may help a child to recover from severe stress.
References 1 Ledoux J. The emotional brain. New York: Simon & Schuster, 1996. 2 Porges SW. The polyvagal theory: phylogenetic contributions to social behavior. Physiol Behav 2003; 79: 503–13. 3 Morgan L, Scourfield J, Williams D, et al. The Aberfan disaster: 33- year follow-up of survivors. Br J Psychiatry 2003; 182: 532–6. 4 Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14: 245–58. 5 Glaser D. Child abuse and neglect and the brain – a review. J Child Psychol Psychiatry 2000; 41: 97–116. 6 Bradley SJ. Stress, trauma and abuse. In: Affect regulation and the development of psychopathology. New York: Guilford Press, 2000.
Immediate measures: for any child who has been exposed to life-threatening danger, the most immediate requirements are safety and security. Much distress in the immediate aftermath can be alleviated by providing information and practical help. Later, screening to identify those at risk of developing mental health problems can also be valuable. Psychological first aid is an early intervention that aims to promote healthy recovery from traumatic stress by ensuring that support can be accessed, thus optimizing the ability to cope and enhancing resilience. An approach known as psychological
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7 Lauterbach D, Koch EI, Porter K. The relationship between childhood support and later emergence of PTSD. J Trauma Stress 2007; 20: 857–67. 8 National Institute for Clinical Excellence. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London: NICE, 2005. 9 Yehuda R, Engel SM, Brand SR, et al. Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. J Clin Endocrinol Metab 2005; 90: 4115–18. 10 Bonanno GA, Galea S, Bucciarelli A, Vlahov D. What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. J Consult Clin Psychol 2007; 75: 671–82. 11 Cook A, Spinazzola J, Ford J, et al. Complex trauma in children and adolescents. Psychiatr Ann 2005; 35: 390–8. 12 van der Kolk BA. Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories. Psychiatr Ann 2005; 35: 401–8. 13 Pynoos R, Eth S. Witness to violence: the child interview. In: Chess S, Thomas S, Hertzig M, eds. Annual progress in child psychiatry and child development 1987. Philadelphia: Brunner/Mazel, 1987. 14 Yule W, Perrin S, Smith P. Post-traumatic stress disorders in children and adolescents. In: Yule W, ed. Post-traumatic stress disorders: concepts and therapy. London: Wiley, 1999. 15 Perrin S, Smith P, Yule W. The assessment and treatment of post-traumatic stress disorder in children and adolescents. J Child Psychol Psychiatry 2000; 41: 277–89. 16 Bisson JI, MacFarlane AC, Rose S. Psychological debriefing. In: Foa EB, Keane TM, Friedman MJ, eds. Effective treatment for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press, 2000. 17 Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols, and procedures, 2nd edn. New York: Guilford Press, 2001.
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18 Spector J, Read J. The current status of eye movement desensitisation and reprocessing (EMDR). Clin Psychol Psychother 1999; 6: 165–74. 19 Stein DJ, Zungu-Dirwayi N, van der Linden GJ, Seedat S. Pharmacotherapy for posttraumatic stress disorder. Cochrane Database Syst Rev 2000; (4): CD002795. 20 Donnelly CL. Post-traumatic stress disorder. In: Martin A, Scahill L, Charney DS, Leckman JF, eds. Pediatric psychopharmacology: principles and practice. New York: Oxford University Press, 2003. 21 Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 2004; 59: 20–8. 22 van der Kolk BA, Spinazzola J, Blaustein ME, et al. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. J Clin Psychiatry 2007; 68: 37–46.
Further reading Black D, Newman M, Harris Hendricks J, Mezey G, eds. Psychological trauma: a developmental approach. London: Gaskell, 1997.
Practice points • Traumatic experiences are common and can have long-lasting psychological effects • Children are especially vulnerable to the effects of extreme stress • Parental accounts are unreliable – it is therefore important to interview the child • Specific treatments work best as part of a multimodal intervention
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