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Pediatric Update

 
Summer 2007

Children and Traumatic Stress

Treating Traumatic Stress in Children

Children may suffer from traumatic stress when exposed to a life-threatening or otherwise earth-shattering traumatic event— serious injuries from accidents or dog bites; physical or sexual abuse or assault; natural and man-made disasters; chronic, domestic, school or community violence; loss of family members or friends—that terrorizes them and overwhelms their ability to cope. A medical condition, invasive procedure or hospitalization also can provoke a traumatic-stress response.

“With advances in medical treatment, more children are undergoing procedures like liver, kidney and heart transplants, and other highly intrusive procedures that can be associated with traumatic-stress reactions. However, we have observed traumatic-stress symptoms even among children after minor procedures like a tonsillectomy, which nobody would consider to be particularly lifethreatening,” says Margaret L. Stuber, M.D., the Jane and Marc Nathanson Professor of Psychiatry at UCLA. “Also, when experiencing danger, separation from parents can in itself be extremely frightening for children, and lead to later stress reactions.”

Depending on their age, children react to traumatic stress in different ways, and the severity of stress reactions can vary greatly. While some children and adolescents cope effectively with the after-effects of a painful event through their own resilience and with support from family and friends, others face chronic difficulties that impede normal social and psychological development. Many show signs of intense distress that may include regressive behaviors, disturbed sleep, difficulty with paying attention and concentration, hypervigilance, exaggerated startle reactions, anger and irritability, withdrawal, and repeated intrusive upsetting thoughts and images of what happened, explains Alan M. Steinberg, Ph.D., a researcher at UCLA’s Semel Neuropsychiatric Institute and an associate director of the National Center for Child Traumatic Stress (NCCTS).

“If a child is having trouble sleeping because of nightmares or other reasons, he or she may be irritable during the daytime and may have trouble getting along with friends and family or have difficulty in school. For kids, these negative experiences have a very overwhelming effect over and above the distress they may be undergoing,” Dr. Steinberg says. In addition, some children develop psychiatric conditions such as post-traumatic stress disorder, depression, anxiety and a variety of behavioral disorders.

When traumatic-stress reactions become particularly severe or do not begin to resolve over the first few weeks following an event, or when a child’s ability to function in school and relationships is impaired, it is important to seek consultation from a mentalhealth professional with experience in child trauma. Pediatricians should be aware that such symptoms, particularly if there is an abrupt onset, could be signs of a traumatic-stress response and may warrant a referral.

“The impact of traumatic events on our children reaches deep into the fabric of everyday life,” says UCLA Professor of Psychiatry Robert Pynoos, M.D., national co-director of the NCCTS, which is jointly led by UCLA and Duke University. “Traumatic experiences can result in a significant disruption of child or adolescent development and have profound longterm consequences. Parents can help by taking a child’s traumatic experience seriously and by letting a child know that it is okay to talk about their feelings and ways they are reminded of what happened.

”The center coordinates the work of the National Child Traumatic Stress Network (www.nctsnet.org), a collaboration involving some 70 member centers across the country “to raise the standard of care and improve access to services for traumatized children and their families and communities.” The network, which offers a wealth of educational materials and toolkits for medical professionals as well as parents and caregivers, is funded through the Center for Mental Health Services, which is part of the U.S. Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services.

Repeated exposure to traumatic events can affect the child’s brain and nervous system and increase the risk of low academic performance, engagement in high-risk behaviors, and difficulties in peer and family relationships. “Traumatic stress can cause increased use of health and mental-health services and increased involvement with the child-welfare and juvenile-justice systems. Adult survivors of traumatic events may have difficulty in establishing fulfilling relationships, holding steady jobs and becoming productive members of our society,” Dr. Pynoos says.

Fortunately, clinically sound and effective treatments are available for child traumatic stress. Cognitive behavioral therapies are a good place to start, says Dr. Stuber. Teaching children stress management and relaxation skills can help them cope with unpleasant feelings and physical sensations about the trauma. Skills to help families handle reminders of trauma and loss are also important.

Talking about the traumatic event and feelings also can be helpful. In addition, employing strategies to correct untrue or distorted ideas about what happened can help children deal with the event and lessen stress.“Children sometimes think something they did or didn’t do may have caused the trauma, or that if only they had acted a certain way a traumatic experience might have turned out differently,” Dr. Stuber says. “This is rarely true, and getting the story right helps a child stop prolonging the traumatic stress by punishing himor herself.”

Medication also can help in some cases to lessen symptoms such as nightmares or to help with sleep and anxiety. “But it is important for parents to understand that the research on using these medications with young people lags behind the research on adults,” Dr. Stuber says. “Medications may be helpful for treating specific symptoms, but there is no definitive medication treatment to ‘cure’ children’s traumatic stress.”

he also cautions that each child has different needs, and treatment must be individualized. “Some children may not be ready immediately to talk about their trauma, and therapists must move at a speed that a child can tolerate,” Dr. Stuber says. “One size does not fit all.”

A pediatric medical-traumatic-stress toolkit for healthcare providers is available at http://www.nctsnet.org/nccts/nav.do?pid=typ_mt_ptlkt

Recommended Reading

Stuber ML, Shemesh E. Post-traumatic stress response to life-threatening illnesses in children and their parents. Child Adolesc Psychiatr Clin N Am. 2006 July; 15(3); 597-609.

Pynoos RS, Steinberg AM: (2006) Recovery of children and adolescents after exposure to violence: developmental ecological framework. In A.F. Lieberman and R. DeMartino (Eds.) Interventions for Children Exposed to Violence, Johnson & Johnson Pediatric Institute, 17-43.

Stoddard FJ, Ronfeldt H, Kagan J, Drake JE, Snidman N, Murphy JM, Saxe G, Burns J, Sheridan RL. Young burned children: the course of acute stress and physiological and behavioral responses. Am J Psychiatry. 2006 June; 163(6); 1084-90.

Kazak AE, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer MA, Rourke M. An integrative model of pediatric medical traumatic stress. J Pediatr Psychol. 2006 May; 31(4); 343-55.





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