Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.
Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.
If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.
Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?
If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.
Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.
However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.
If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.
Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.
Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.
School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.
Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.
Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.