Understanding Child Traumatic Stress
- Responding to Danger
- When Danger Turns Into Trauma
- What a Traumatic Situation is Like for a Young Child
- What a Traumatic Situation is Like for School-age Children
- What a Traumatic Situation is Like for an Adolescent
- Posttraumatic Stress Responses
- How Development Influences Posttraumatic Stress Responses
- The Severity and Duration of Posttraumatic Stress Responses
- Chronic or Repeated Trauma
- Factors in Recovery from Trauma
- Individual Differences
- Posttraumatic Stress Disorder
- The Impact of Traumatic Stress on Development
- The Lessons of Traumatic Experiences
Before we discuss what is meant by a "traumatic experience" or "traumatic stress," let's think about how we recognize and deal with danger. Our minds, our brains, and our bodies are set up to make sure we make danger a priority. Things that are dangerous change over the course of childhood, adolescence, and adulthood. For very young children, swimming pools, electric outlets, poisons, and sharp objects are dangerous. For school-age children, walking to school, riding a bike in the street, or climbing to high places present new dangers. In adolescents, access to automobiles, guns, drugs, and time on their own, especially at night, are new dimensions to danger. Dangers change depending on where children live and on their families' circumstances. Also, dangers change over the history of societies and cultures.
There are three things that happen when we are in a dangerous situation. First, we try to figure out what the danger is and how serious it is. Second, we have strong emotional and physical reactions. These reactions help us to take action, yet they can be very distressing to feel and difficult to handle. Third, we try to come up with what to do that can help us with the danger. We try to prevent it from happening, try to protect ourselves or other people against harm, or try to do something to keep it from getting worse. How we feel about a danger depends on both how serious we think it is and what we think can be done about it.
We live with dangers every day. As children and adolescents grow up, they continually learn about different types of dangers. We are always looking for ways to make our lives safer. However, terrible things sometimes happen within and outside the family. They can happen suddenly without warning. Children may experience different traumas over the course of childhood and adolescence. Some traumas, such as child abuse or witnessing domestic violence, may happen repeatedly over a long period of time.
Dangers can become "traumatic" when they threaten serious injury or death. Traumatic experiences also include physical or sexual violation of the body. The witnessing of violence, serious injury, or grotesque death can be equally traumatic. In traumatic situations, we experience immediate threat to ourselves or to others, often followed by serious injury or harm. We feel terror, helplessness, or horror because of the extreme seriousness of what is happening and the failure of any way to protect against or reverse the harmful outcome. These powerful, distressing emotions go along with strong, even frightening physical reactions, such as rapid heartbeat, trembling, stomach dropping, and a sense of being in a dream.
There are large-scale dangers like disasters, war, and terrorism that threaten large numbers of children and families all at the same time. There are dangers that are particular to a community or neighborhood, like crime, school violence, or traffic accidents. And there are dangers that come from within the family through domestic violence and child abuse. Traumatic experiences fall into a number of categories; click here to read more about different types of traumatic experiences.
Think of what it is like for young children to be in traumatic situations. They can feel totally helpless and passive. They can cry for help or desperately wish for someone to intervene. They can feel deeply threatened by separation from parents or caretakers. Young children rely on a "protective shield" provided by adults and older siblings to judge the seriousness of danger and to ensure their safety and welfare. They often don't recognize a traumatic danger until it happens, for example, in a near drowning, attack by a dog, or accidental scalding. They can be the target of physical and sexual abuse by the very people they rely on for their own protection and safety. Young children can witness violence within the family or be left helpless after a parent or caretaker is injured, as might occur in a serious automobile accident. They have the most difficulty with their intense physical and emotional reactions. They become really upset when they hear cries of distress from a parent or caretaker.
School-age children start to face additional dangers, with more ability to judge the seriousness of a threat and to think about protective actions. They usually do not see themselves as able to counter a serious danger directly, but they imagine actions they wish they could take, like those of their comic strip heroes. So, in traumatic situations when there is violence against family members, they can feel like failures for not having done something helpful. They may also feel very ashamed or guilty. They may be without their parents when something traumatic happens, either on their own or with friends at school or in the neighborhood. Sexual molestation occurs at the highest rate among this age group. School-age children get scared of the speeding up of their emotions and physical reactions, adding new fears to the danger from outside. For example, an 8 year-old child described, "My heart was beating so fast I thought it was going to break."
My heart was beating so fast I thought it was going to break.
With the help of their friends, adolescents begin a shift toward more actively judging and addressing dangers on their own. This is a developing skill, and lots of things can go wrong along the way. With independence, adolescents can be in more situations that can turn from danger to trauma. They can be drivers or passengers in horrible car accidents, be victims of rape, dating violence and criminal assault, be present during school or community violence, and experience the loss of friends under traumatic circumstances. During traumatic situations, adolescents make decisions about whether and how to intervene, and about using violence to counter violence. They can feel guilty, sometimes thinking their actions made matters worse. Adolescents are learning to handle intense physical and emotional reactions in order to take action in the face of danger. They are also learning more about human motivation and intent and struggle over issues of irresponsibility, malevolence, and human accountability.
There are three core groups of posttraumatic stress reactions.
- First, there are the different ways these types of experiences stay on our minds. We continue to have upsetting images of what happened. We may keep having upsetting thoughts about our experience or the harm that resulted. We can also have nightmares. We have strong physical and emotional reactions to reminders that are often part of our daily life. We may have a hard time distinguishing new, safer situations from the traumatic situation we already went through. We may overreact to other things that happen, as if the danger were about to happen again.
- Second, we may try our best to avoid any situation, person, or place that reminds us of what happened, fighting hard to keep the thoughts, feelings, and images from coming back. We may even "forget" some of the worst parts of the experience, while continuing to react to reminders of those moments.
- Third, our bodies may continue to stay "on alert." We may have trouble sleeping, become irritable or easily angered, startle or jump at noises more than before, have trouble concentrating or paying attention, and have recurring physical symptoms, like headaches or stomachaches.
We may try our best to avoid any situation, person, or place that reminds us of what happened.
Age, developmental maturity, and experience can influence posttraumatic stress reactions. More than twenty years of studies have confirmed that school-age children and adolescents can experience the full range of posttraumatic stress reactions that are seen in adults. We might wish to believe that children under five years of age are too young to know what was happening and whatever impression was left would be forgotten soon. However, recent studies show that traumatic experiences affect the brains, minds, and behavior of even very young children, causing similar types of reactions as seen in older children and adults.
Young Children. It is extremely difficult for very young children to experience the failure of being protected when something traumatic happens. In response, they may become passive and quiet, easily alarmed, and less secure about being provided with protection. Their minds may stay on a central action, like being hit or seeing someone fall to the floor. They may have simple thoughts about protection, for example, "Daddy hit mommy, mommy call police." They can become more generally fearful, especially in regard to separations and new situations. In circumstances of abuse by a parent or caretaker, the young child may act confused as to where to find protection and where there is threat. A child may respond to very general reminders, like the color red or the sounds of another child crying. The effects of fear can quickly get in the way of recent learning. For example, a child may start wetting the bed again or go back to baby-talk. Because a child's brain does not yet have the ability to quiet down fears, the preschool child may have very strong startle reactions, night terrors, and aggressive outbursts.
Traumatic experiences affect the brains, minds, and behavior of even very young children.
School-age Children. The post-trauma responses of school-age children include a wider range of intrusive images and thoughts. School-age children think about lots of frightening moments during their traumatic experiences. They also go over what could have stopped it from happening and what could have made it turn out differently. These thoughts can show up in what is called, "traumatic play". Sidebar: Traumatic Play
School-age children respond to very concrete reminders: someone with the same hairstyle as an abuser; the monkey bars on a playground where a child got shot; feeling alone inside like they did when one parent attacked the other. They are likely to develop intense specific new fears that link back to the original danger. They can easily have "fears of recurrence," that result in their avoiding even enjoyable things they would like to do. More than any other group, school-age children may go back and forth between shy or withdrawn behavior and unusually aggressive behavior. They can have thoughts of revenge that they cannot resolve. Normal sleep patterns can be easily disturbed. They can move around restlessly in their sleep, vocalize, and wake up tired. Their lack of restful sleep can interfere with their daytime concentration and attention. It can then be more difficult for them to study because they remain on alert for things happening around them.
Adolescents. Adolescents are particularly challenged by posttraumatic stress reactions. They can easily interpret many of these reactions as regressive or childlike. They may interpret their reactions as signs of "going crazy," of being weak, or of being different from everyone else. They may be embarrassed by bouts of fear and exaggerated physiological responses. They may harbor the belief that they are unique in their pain and suffering. These reactions may result in a sense of personal isolation. Grief reactions, however painful, are often easier for them to understand and accept than posttraumatic stress reactions.
In their post-trauma thoughts, adolescents think about behavior and choices that go back to well before a traumatic situation. They are also very sensitive to the failure of family, school, or community to protect or carry out justice. Afterwards they may turn even more to peers to judge risks and to take protective action. They may be especially "grossed out" or fascinated by grotesque injury or death and remain very focused on their own scars that serve as daily trauma reminders.
Adolescents may respond to their experience through dangerous reenactment behavior.
While younger children may use play, adolescents may respond to their experience through dangerous reenactment behavior, that is, by reacting with too much "protective" aggression for a situation at hand. Their behavior in response to reminders can go to either of two extremes: reckless behavior that endangers themselves and others, or extreme avoidant behavior that can derail their adolescent years. The avoidant life of an adolescent may go unnoticed. Adolescents can try to get rid of post-trauma emotions and physical responses through the use of alcohol and drugs. Their sleep disturbance can remain hidden in late night studying, television watching, and partying. It is a dangerous mix when adolescent thoughts of revenge are added to their usual feelings of invulnerability.
The posttraumatic stress reactions of children and adolescents can fall on a scale from mild to severe, last for a short time or for many years, and get better only to get worse at different times in the child's life. In order to understand these differences, the starting point is the seriousness of the child's experience. There are two ways to judge the degree of seriousness.
First, it is important to keep in mind the details of what a child went through. Consider a child who is trapped in a seat belt after a serious automobile accident, parent unconscious, and the car on fire; a child on a playground being shot at by someone with a semiautomatic rifle; a child injured and trapped during an earthquake; a child who witnesses a parent take a knife to the other parent and then is left to try to stop the bleeding before help arrives; a child who must endure repeated and increasingly violent abuse by a parent or caretaker; a child who sees a friend killed in a hit and run accident; or an adolescent who is gang-raped. In general, the more violence, the more life threat and injury, the more witnessing of grotesque injury and death, the more severe and, potentially long-lasting the posttraumatic stress responses. A single traumatic experience can contain many traumatic threats and losses, making the recovery more complicated.
Second, the child's subjective experience of what happened also helps to explain the severity and duration of his or her posttraumatic stress reactions. It is important to understand how terrified, horrified, or helpless the child felt, including the degree to which the child feared being seriously hurt or killed or having loved ones hurt or killed. In addition, the experience of physical violation of the body or betrayal by a parent or caretaker can lead to more severe reactions. Heightened physical feelings or a sense of unreality at the time may also add to the severity and duration of post-trauma reactions. Feeling that something a child did or did not do made things worse can also increase the severity of reactions.
A single traumatic experience can contain many traumatic threats and losses
What happens if the violence, molestation, or trauma occurs repeatedly, or several different types of traumas happen over a child's years of growing up? Children and adolescents may never have the time or support to recover from one set of posttraumatic stress reactions before new ones add to them. Young children who are abused commonly also witness domestic violence. A teenager may have been the victim of a criminal assault or rape and, at another time, have witnessed a friend being shot. Experiencing a prior traumatic event does not toughen up a child. Instead, the effects can add up, with each successive experience leading to more severe and chronic posttraumatic stress reactions and other developmental consequences. In fact, a child who has suffered from prior traumatic experiences may be apt to have more intense reactions to another trauma.
Experiencing a prior traumatic event does not toughen up a child. Instead, the effects can add up.
How children or adolescents recover from trauma depends a lot on the different ways that their lives are changed by what happened. There may be a dramatic change because of the loss of a family member or friend during the traumatic situation. Dealing with both posttraumatic and grief reactions can make recovery much more difficult. Sidebar: Traumatic Loss and Bereavement
A cascade of additional stresses and adversities often follow trauma and loss experiences. These can seriously reduce the emotional comfort and practical help that children and adolescents can get from their family, friends, school, or community. As hardships increase, children and adolescents often have behavioral problems and depression. The experience of another trauma or loss can make recovery all the more difficult. In the middle of all these changes, the up and down course of trauma reactions can also depend on how often a child faces trauma and loss reminders. Sidebar: Trauma and Loss Reminders.
Children are different in their temperaments, in their worries and fears, in their personal strengths, and in the ways they go about handling problems. These differences can influence recovery from trauma. For example, anxious children respond with more fear, may respond to trauma reminders with greater fears of recurrence, and have a lot more trouble calming down or being reassured. They may have more difficulty determining the danger of a later situation.
It is important to understand that situations of danger and trauma can cause types of responses other than posttraumatic stress reactions.
From twenty years of studies, we now know that children and adolescents can develop Posttraumatic Stress Disorder. The diagnosis of Posttraumatic Stress Disorder (PTSD) is used when posttraumatic stress reactions are serious, continue, and interfere with the daily functioning of children and adolescents. Traumatized and bereaved children and adolescents may also develop symptoms of Depression and Separation Anxiety Disorder.
Traumatic experiences have effects on children's development that are not simply posttraumatic stress reactions or PTSD. Children and adolescents are going through many developmental changes. Their brains and bodies are maturing. They are gaining more ability to understand and be in charge of their emotions. They are learning from experiences and becoming better at using their thoughts to govern their behavior and plans for the future. Traumatic stress can lead to many changes in these areas of development. It is not uncommon for parents to say that, because of traumatic experiences, their child "grew up too fast," or for children and adolescents to complain that they missed out, in important ways, on being kids or teenagers.
Brain and Hormones. In early childhood, the brain is growing. During these early years, neglect, physical, sexual, and emotional abuse can affect the normal development of the brain, including the size of parts of the brain that help us, as we grow up, to control our responses to danger. In school-age children, the brain is not growing as much, but is gaining more ability to manage automatic reactions to danger, like the startle reflex. During these years, trauma can delay this ability, leaving children overly tuned into noises or other stimuli from the outside world. These traumatized children will then find it harder to concentrate and study and to control their everyday behavior.
Abuse can affect the normal development of the brain.
The brain also controls hormones in the body. The brain starts major hormonal changes in puberty. Some of these changes may begin early in children who are sexually abused during pre-adolescence. An important set of hormones helps us deal with danger and stress. In a way, the brain and the body "talk with each other" through these hormones to help prepare us to act in the face of danger and to return to normal behavior when the danger is over. Children who have gone through terrible disasters and lots of post-disaster adversities may, by adolescence, show changes in the levels of these stress hormones, like those changes found among combat veterans. A concern is that these changes from normal development may affect the way traumatized children and adolescents respond to danger and future stresses in their lives and influence long-term health. Because children and adolescents may experience traumatic stress across several developmental stages, they may have a combination of these biological changes.
Emotional Maturity. Another major goal of development is emotional maturity. Traumatic stress can interfere with this growth. Very young children are learning to name emotions and handle them with the help of their parents and caretakers. During a trauma, intense fear easily overwhelms young children's beginning efforts to manage emotions. In situations of family violence, the person the child might turn to for protection, security, and help with calming down, may also be the very person the child fears. A traumatized parent may also find it difficult to provide a child with much needed emotional support. Child abuse and domestic violence may affect the entire preschool years of a child, making it very difficult to gain this type of emotional ability which is so important to a child's personal and social growth.
Traumatic situations create a different emotional challenge for school-age children. They are learning to differentiate and manage difficult emotions. For example, they are learning to distinguish being a little scared from a lot scared, or a little angry from a lot angry. The intensity and speeding up of emotions during traumas blur these differences and take them to the extreme. Afterwards, school age children can clamp down on their emotional life, fearing that everyday emotions will get the best of them. They may become much more aware of the difference between what they feel inside and what they feel they can say to others. Shame and guilt can lead them to be secretive about their feelings. Feelings of revenge can also interfere with their efforts to manage aggressive feelings in a more constructive, rule abiding way.
School-age children can clamp down on their emotional life, fearing that everyday emotions will get the best of them.
Adolescent Development. Trauma-related emotions create additional problems for adolescents. They are gaining a more mature understanding of the origins and consequences of strong emotions as part of a growing capacity for entering a wider social world and achieving an intimate personal life with others. Imagine the challenge their greater emotional awareness causes them in a traumatic situation. Adolescents can appreciate the malevolence of a rapist. They can feel the painful dilemma over self-protection and heroic action to help others in the midst of catastrophic danger. They can have enormous guilt after taking an action that injures or kills a friend. Adolescents can be quick to dismiss even close friends who do not respond in what they feel is an appropriate way to what they have gone through. They also can be very aware of the social stigma attached to their experience. Adolescents can thrust themselves into altruistic activities, draw back into an emotional shell, or sometimes do both.
Adolescents can thrust themselves into altruistic activities, draw back into an emotional shell, or sometimes do both.
As children grow up, they learn from their experiences and form a picture of what the world is like. What is it that they learn from traumatic experiences? They may learn positive things about how they conduct themselves in the midst of danger, of the heroic efforts of others to protect or rescue , and of the helpful support trauma survivors may receive afterwards. However, children may also take on "traumatic expectations." Their view of the world, its safety and stability, help govern how they behave. Children and adolescents are forming a world view that is constantly changing. Trauma experiences can create the sense that things can go horribly wrong at a moment's notice, that no one can really provide protection, and that laws don't really work. Adolescents can then think it is not worth working toward a better future or that it is better not to get close to others just to lose them in a tragic way.
Children and adolescents are building up confidence in the "social contract," a trust that the rules of a family, community, or society are fair and look after the best interests and welfare of its members. After family violence, young children may learn that feelings of love can be betrayed through abuse. If abuse occurs in the larger community, they may conclude that children can be taken advantage of by adults in positions of authority. It is more difficult to teach a school-age child that rules count when no one has been arrested for murdering a parent.
Many refugee children and adolescents lived through horrible violence in another country before moving to the United States. They may know first hand through civil war or ethnic violence how ruthlessly governments can act, how they can destroy families and communities. With great hopes for security in the United States, they can feel extremely disillusioned if they then experience violence in their new communities and schools.
There may be positive lessons as well.
But there may be positive lessons as well. Most important, traumatic experiences can lead children and adolescents to be more compassionate, to work harder to make the world better and safer, and to do something valuable with their lives.