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What Are the Symptoms, Causes, and Treatments of Childhood Post-Traumatic Stress Disorder?

By Richard Famularo, M.D.
The Harvard Mental Health Letter, January 1997

We asked Richard Famularo, M.D., Associate Professor of Pediatrics and Child Psychiatry, Boston University School of Medicine.

The causes and symptoms of post-traumatic stress disorder (PTSD) are generally similar in children and adults. The traumatic experience is followed by recurrent or intrusive recollections, including repetitive play, frightening dreams, reenactment of the trauma, and intense reactions to symbolic reminders of the trauma. The child tries to avoid thoughts, feelings, people, and places associated with the traumatic event and may be unable to recall important aspects of it. There may also be signs of general emotional numbing, a diminished interest in life, and a foreshortened sense of the future. Other symptoms are insomnia, irritability, difficulty in concentrating, outbursts of rage, and jumpiness (an exaggerated startle response).

Like adult PTSD, the childhood form is a severe and debilitating mental illness, not just the extreme of a continuum of responses to distressing situations. It is also a chronic disorder: in our research we have found that more than 40% of maltreated children are still suffering from PTSD a year after they were first diagnosed. Despite these resemblances to adult PTSD, the childhood type has certain special features involving the nature of the trauma, the particular forms taken by the symptoms, the frequency of the individual symptoms, and the course and duration of the disorder.

The traumatic experiences of children often involve maltreatment by parents or other caregivers. The resulting loss of protection, sense of betrayal, daily fear, and overwhelming sense of helplessness may color all the child's later personal relations. Adults often have the strength to cope with traumas that are devastating for children, leaving them cognitively and emotionally disorganized, helpless, and hopeless. Maltreated children often fail to develop social skills and have serious difficulties with their families and others. Many adults with personality disorders and almost all those with multiple personality were seriously maltreated as children.

Maltreated children with PTSD are often angry and aggressive. They may develop psychotic symptoms and suicidal thoughts, and they have a high rate of psychiatric hospitalization. Sexually inappropriate behavior and conduct disorders (lying, stealing, truancy) are common. Traumatized children are more likely than others to need remedial classes and more likely to be suspended from school. The symptoms are so varied that children with PTSD are often misdiagnosed as hyperactive, depressed, or suffering from bipolar disorder, a personality disorder, overanxious disorder, or avoidant disorders.

Not all children exposed to extreme conditions develop PTSD. Developmental and biological predispositions are also important. Some relevant factors are the child's age and developmental level when the trauma occurs, the kind, duration, and severity of the trauma, the level of parental support, and the psychiatric condition of the parents or other caregivers. Although the identical twin of a child with PTSD is more likely than average to develop PTSD, there is no evidence of a direct biological predisposition and no compelling evidence that the typical symptoms can occur without exposure to trauma.

There are few well-controlled studies of treatment for PTSD in children. In the most severe cases they are removed from abusive homes, in other cases efforts are made to preserve the family. Therapists who treat these children must maintain a careful balance, confronting the effects of the trauma while exercising restraint to avoid re traumatizing the child. Potentially useful medications are beta adrenergic blockers such as propranolol (Inderal), alpha2-adrenergic agonists such as clonidine, antidepressants, valproic acid (an anticonvulsant and mood stabilizer), and benzodiazepines (sedatives and anti-anxiety drugs). No medicine has proven consistently effective in controlled studies.

© President and Fellows of Harvard College, 1997.
Reprinted with permission.

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