How to spot and address PTSD in children

A school shooting. Car accident. Violence. Assault. Traumatic events that children experience can leave a lasting impact and result in a range of mental and behavioral health issues, including Post-Traumatic Stress Disorder (PTSD). PTSD can be considered a “normal” reaction to an abnormal event. If there is to be one silver lining associated with the COVID-19 pandemic, it’s that it has raised awareness about what trauma and PTSD can look like in children, reducing the stigma that often exists when it comes to seeking mental health treatment after a trauma.

Defining PTSD and trauma

Trauma and PTSD are terms that are often confused. Trauma is an event that happens to someone while PTSD is the psychological experience resulting from experiencing a traumatic event. Post-traumatic stress is the psychological or behavioral reaction to a trauma. To be diagnosed with PTSD, the individual must have experienced a life-threatening or very frightening event or heard about this type of event happening to a close loved one. What may be “traumatic” to one person may not be perceived as traumatic to another, so two people who experienced the same event may have very different reactions. For example, one person may develop PTSD while the other may not.

It is important to note that trauma or post-traumatic stress is very different than bereavement or grief. This is why we need both trauma-focused and grief-focused interventions to better address the needs of children and adolescents in our community, especially in the context of COVID.

How to know whether a child has PTSD

Sadly, many children seeking treatment at the Trauma and Grief (TAG) Center at Children’s Hospital New Orleans (CHNOLA) have experienced deaths of loved ones due to COVID-19, reflecting the high number of COVID-related losses that we’re seeing across the country. Many of these children have also experienced prior traumas and losses, making them even more vulnerable to developing PTSD.

What is often confusing about PTSD in children is that it can look like other psychological or behavioral problems. For example, children with PTSD may look like they have Attention Deficit Hyperactivity Disorder (ADHD) because PTSD symptoms such as hyperarousal (being jumpy) or hypervigilance (being on edge) resemble attention and hyperactivity problems. For this reason, our TAG Center’s trainings with teachers and school personnel focus on recognizing how PTSD can manifest in students of different ages, shifting their line of questioning from “what’s wrong with that child” to “what happened to that child?” Shifting this mindset is the first step to truly understanding the impact of trauma on children's behaviors and what that can look like in the classroom.

Symptoms of PTSD in children can look like:

• Re-experiencing the event, which can involve nightmares or feeling like the event is happening all over again, even during the day.
• Avoidance - not wanting to talk about or think about the event. For example, children may walk out of the room if they hear people talking about a loved one who died.
• Feeling numb. Sometimes children with PTSD report that they feel like they don't have any feelings at all. This can often be confusing to parents, especially if a child is not showing much emotion after someone has died.
• Hypervigilant – appearing to be very jumpy or highly attuned to what's happening in the environment at all times.
• Negative beliefs about the world – children with PTSD may believe that the world is a dangerous and unpredictable place after experiencing a trauma.

Risk factors for PTSD

There are several factors that make it more likely that a child will experience PTSD after a traumatic event.

Some of these include:

• Proximity – the closer they were to the event, the more likely they are to develop PTSD (e.g., those who were closest to a school shooting are more likely to develop symptoms).
• History of prior traumas and losses
• Pre-existing mental health issues (e.g., depression or anxiety)
• Lack of social support

Core treatment elements for PTSD

There are a number of trauma-focused treatments for children that share some common elements. First, most trauma-focused treatments include emotion regulation and cognitive coping. Emotion regulation skills are used to help children cope with their strong feelings related to the trauma. Cognitive coping skills help children to generate more “helpful” thoughts that can help them to feel better, such as “I know I’m safe now” or “I’m stronger than I thought I was.”

Many trauma-focused treatments also include “trauma processing” which involves helping children to talk about and make sense of the traumatic event itself. The more children are able to talk about and describe the trauma in a safe, supportive environment, the less powerful and scary those traumatic memories are. Finally, many trauma-focused treatments include a caregiver component, where children share the skills they’re learning with the caregiver. We find that if the caregivers can provide ongoing support, both in therapy and at home, the more effective the treatment is. This often requires that the caregiver receive his or her own therapy, especially if they have experienced their own traumas or losses, in order to be able to fully support their child.

What happens if PTSD goes untreated?

Left untreated, PTSD can lead to long-term problematic outcomes, even into adulthood. These can include depression, suicide risk, substance abuse, relationship problems or violent behavior. In fact, the majority of our society's most significant problems, including sex trafficking, domestic violence and community violence, stem from unresolved childhood trauma. This speaks to the need to identify “at-risk” youth and intervene as early as possible to help them lead healthy, happy and productive lives.

To learn more about the signs and symptoms of PTSD or to explore treatment options with the Trauma and Grief Center at Children’s Hospital New Orleans, please visit our website at www.chnola.org. If you would like to refer a child to the Trauma and Grief Center, please call 504-896-7797.

Julie Kaplow, Ph.D., ABPP, is executive director of The Trauma and Grief Center (TAG) Center at Children’s Hospital New Orleans and executive director of The TAG Center at The Hackett Center for Mental Health in Houston, TX. The overarching mission of each of the TAG Centers is to raise the standard of care and increase access to best practice care among youth who have experienced trauma and bereavement.