Science Monday: Child PTSD

Today’s psychopathology class focuses on child related problems. Given the societal focus on ADHD and Asperger’s, our class will hang out there. However, I want to bring to your attention some work in the area of family violence and childhood trauma reactions. Gayla Margolin and Katrina Vickerman (of USC) published 2 articles in a 2007 (38:6) issue of Professional Psychology: Research and Practiceon the topic of PTSD in children exposed to family violence.

Article one (pp 613-619) provides an overview. First, they recognize that some kids have PTSD without a single discrete precipitating and/or life-threatening event. It appears that prolonged exposure to violence (e.g., domestic violence, physical abuse, sexual abuse, community violence) likely has a deleterious impact on children. Some 30% of kids living with both parents experience domestic violence. Some 5-10% of kids experience severe physical abuse. One article summarizing a number of studies suggested that somewhere between 13 and 50% of kids exposed to family violence qualify for a PTSD diagnosis. In foster home and clinic studies, the number with PTSD seems higher, especially in girls. Not every child who experiences violence shows signs of PTSD. Severity and frequency of exposure to violence probably matters most. What makes family violence so troubling is that the child is faced with the constant threat of additional episodes.

What are the common domains of impairment related to complex trauma exposure? Affect regulation (inability to modulate anger, chronic flooding of negative affect), information processing (concentration, learning difficulties, missing subtle environmental nuances, overestimation of danger, preoccupied with worry about safety), self-concept (shame, guilt), behavioral control (aggression, proactive defenses, and substance abuse), interpersonal relationships (trust), and biological processes(delayed sensorimotor development (p. 615).

The authors repeat a previous suggestion of a new diagnosis: Developmental Trauma Disorder(DTD) to adequately capture the picture of youth trauma reactions to family violence. Criteria include: repeated exposure to adverse interpersonal trauma, triggered pattern of repeated dysregulation of affect, persistently altered attributions and expectancies about self and other, and evidence of functional impairment.

In their second article (pp. 620-628), the authors summarize typical treatments for children: reexposure interventions(to help the child understand and gain mastery over their past experiences that intrude. This is done primarily by a trauma interview where therapists work directively to bring fragments of the story together into a coherent whole and meaning and safety are explored), cognitive restructuring and education about violence exposure (goal to undo lessons learned, practice thought stopping, and to normalize reactions), emotional recognition and expression (to attend to and understand connections between emotions, thoughts, and behaviors), social problems solving, safety planning for those not able to be out of potentially violent environments, and parenting interventions.

Do any of these treatments work? It appears several do. I’ll mention just one here:Trauma-focused CBT for child abuse victims (by Cohen, Mannarino, and Deblinger. That intervention is published in their 2006 Guilford Press book, Treating trauma and traumatic grief in child and adolescents.   

We should not underestimate the impact of family and community violence on children. There are many kids labeled bi-polar, ADHD, personality disordered, oppositional (and worse) who carry within their body the impact of violence. They might look like a gang-banger or a thug who’d kill you because you scuffed his shoes, but they likely are hypervigilant and only read part of the environmental cues to determine if they are in danger.


Filed under Abuse, Anxiety, counseling science, Post-Traumatic Stress Disorder, Psychology

7 responses to “Science Monday: Child PTSD

  1. Scott Knapp, MS

    Dr. Phil, I work in residential treatment with kids from age 7-21 years, who have displayed emotional and behavioral challenges that preclude inclusion in the general population. Most, if not all, of them have been on the receiving end of, or the direct witnesses of, horrific abuse, neglect and violence at the hands of parents or other caregivers. I was engaged in direct care as a front-line staff member for many years, and only recently returned to the agency to work as a therapist. My agency takes in the “worst of the worst” from many states across the country who have run out of viable options, aside from long-term incarceration. The children and youth I work with have horribly skewed understandings of the role of family and familial relationships; have little to no trust that others will provide for their best interests and are steeled in self-defense; have learned relational techniques that likely were necessary for survival earlier in life, and have little motivation to learn newer, healthier skills…they prefer sometimes to manipulate their surroundings to mirror the chaos they emerged from, so that their present mode of relating and surviving seems more rational and warranted. “Success” in treatment of this population may be defined as when that child or youth can re-engage with “normal” society and choose to behave and cope in such a way that the previous emotional and behavioral issues do not re-emerge to preclude continued liberty and inclusion in society. Successful treatment of these wounded children and youth runs at about 2-3% , at last “educated guess.” “Treatment”, however, is comprehensive in it’s approach. As a residential program, we bring wounded children and youth into a structured environment with very well trained caregivers managing the milieu; other residents with similar issues form a new type of “family,” and treatment is focused not only on addressing individual psychological/psychiatric issues, but on how that resident functions in the milieu as a member of the “family.” Personal issues are addressed primarily within the context of how they affect or undermine inter-relational success. For many of our clients, our treatment program is the first experience of the closest thing to healthy family dynamics they’ve ever had! I’ve long believed that the most powerful elements of this kind of treatment program are the same elements found in healthy families: purposeful structure, strong and stable limits with consistent consequences, demonstrated grace and personal commitment, open conversation (processing), and the public demonstration of character by care-givers. What I do as a therapist simply removes stumbling blocks in the way of seeing and experiencing these things in the milieu, and benefitting from them. The most powerful impact of treatment is still experienced, however, within the context of the “familial” milieu; treatment is most powerful within the context of relationships. I work for a public agency, and am not permitted to overtly include the spiritual dynamic I would otherwise naturally employ as a trained biblical counselor. Still, staff are permitted to candidly talk about their own faith so long as “proselytization” is not taking place. Those who have had the privilege of growing up with spiritually mature parents (sadly, I’m not in that group) often report that it was not so much the overt words their parents uttered that persuaded them to embrace their parents’ faith, but the living out of dynamic faith in the face of problems, disappointments and disillusionment, and proving through visible experience that God was real and “there.” I believe that the disorders and “faith destroyers” children and youth experience as a result of damaging and dysfunctional family life, are treated most impactfully within the context of healthy interrelation.

  2. Scott, Here’s the best line you said and it bears being repeated:

    I’ve long believed that the most powerful elements of this kind of treatment program are the same elements found in healthy families: purposeful structure, strong and stable limits with consistent consequences, demonstrated grace and personal commitment, open conversation (processing), and the public demonstration of character by care-givers. What I do as a therapist simply removes stumbling blocks in the way of seeing and experiencing these things in the milieu, and benefitting from them. The most powerful impact of treatment is still experienced, however, within the context of the “familial” milieu; treatment is most powerful with in the context of relationships

  3. bellabpd

    This article interests me as someone who has experienced childhood abuse and violence. I was never violent myself, but had a very disturbed affect throughout my life. I am now 24 and have been diagnosed with Borderline Personality disorder just four months ago. I have been diagnosed with Post Traumatic Stress Disorder for many years, but no mental health professional has ever suggested my childhood to be considered a trauma worthy of PTSD.

    Your discription of Developmental Trauma Disorder explains my childhood better than I could have imagined. My conclusion is that all cases of BPD result from childhood PTSD, and therefore BPD can be equated with DTD (my apologies for the heavy acronyms). When I suggest this relationship between BPD and PTSD to professionals at my university, many are without comment. What is your reaction?

  4. The connection between childhood trauma and PTSD and BPD is pretty clear. I do think the new proposed diagnosis helps clarify matters here since adult onset of PTSD is quite different from childhood onset in scope.

    In theory, BPD results for some when a person has a predisposition to emotional lability and intensity PLUS is raised in an invalidating environment (e.g., sexual abuse, not allowed to express or have own feelings, etc.). The person then learns to invalidate themself and does not form a proper sense of self. You can see similarities with PTSD (loss of sense of self) but differences as well.

  5. There are 2 points that come to mind:

    1) this is the key to the juvenile justice system. Unless we get at the core of their neurological disturbances resulting from the abuse they’ve witnessed and experienced, no counseling or punitive measure will do them good.

    2) This is directly applicable to our adopted children in what we see resulting from transfer to multiple caregivers. I love the term DTD. As an infant or young toddler, having “mom” disappear once, twice, three times is tantamount to abandonment. The adoption community hates, rabidly, the term Reactive Attachment Disorder, think that it only applies to the severely negleted who set things on fire. In truth, we are experiencing – living with – children who have much less violent but nonetheless socially isolating and malevolent symptoms, all the ones you list above: hypervigilence, lack of trust, avoidance, affect regulation, etc.

    The general TRA community REFUSES

    I, along with many of my TRA friends have children with all of the symptoms you list, even though they were not classically in “abusive” situations. But everything you list rings true for us. My son has experienced every single one of those symptoms. It is through 4+ years of “attachment parenting,” attachment therapy, reading websites, books, having many painful conversations with friends, and neurological reorganization that our son is now reaching the realm of health.

    Do you know Cheryl Nitz? She heads up Attachment and Bonding Center of PA, and is a member of Glenside PCA.

    Thank you for this post and your blog.

  6. bruce

    i was recently hospitialized a year after returning from my deployment to kosovo i am 31 years old and was diagnosed with bipolar nos disorder about a week ago i asked for a second opinoin because being bipolar and in the military dont mix. the doctor said i have severe depression with childhood ptsd steming from the 13 years of emotional physical and sexual abuse i encountered from my father, the abuse is still going on today from my mother well emotional anyway. this disorder has really screwed up my marriage and family life to the point to where if i walked out today i wouldnt care. every morning is a strugle to get out of bed and in all honesty i look at myself in the mirrior and ask myself why am i still alive. i dont know if i will ever recover from it i know my sister found her peace with god and has a good husband and 7 childern. i have a wife and 3 kids and she dont seem to understand me neither does my own mother i just dont know what the hell to do.

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