Identification and management of children with post-traumatic stress disorder (PTSD)
Michelle Bosquet Enlow, PhD, is a developmental and clinical psychologist in the Department of Psychiatry at Boston Children’s Hospital and assistant professor in the Department of Psychiatry at Harvard Medical School.
When should a pediatrician consider the possibility a patient has PTSD?
Trauma is quite prevalent in our society and can happen to anyone. Children with PTSD don’t necessarily present with classic symptoms, such as flashbacks. In fact, their symptoms often look like attention deficit hyperactivity disorder (ADHD): difficulty concentrating, acting out, not attending to directions, outbursts, hyperactivity, agitation, irritability and sleep problems. When you see such symptoms, PTSD is a diagnosis to keep in mind, especially if the child has experienced some kind of trauma or major stressor.
In taking a history, question caregivers about whether the child has experienced something stressful, whether the symptoms have come on suddenly and whether certain places, people or situations seem to trigger symptoms. Triggers can include driving by the location of a car accident, an ambulance going by, or something more subtle, such as a certain smell or the feeling of one’s heart racing. You can ask the family whether symptoms worsen at certain times of year, at a change of season or around certain anniversaries.
Is there a ‘good’ way to ask about traumatic events?
Asking about trauma can be tricky; sometimes the trauma is happening at home, and the caregiver might not want to report it, and may herself have a history of trauma. In other situations, the traumatic event could be something that happened long ago and may be hard to connect to the present. Sometimes the caregiver might not know that the child has experienced a trauma that happened, for example, at school or in the neighborhood.
Getting a timeline of when the symptoms have occurred can often provide insight. Talk to as many people involved with the child as possible, asking questions that sound non-accusatory. You could start by saying, “Sometimes children have this kind of behavior because something has happened that has made them feel particularly frightened or stressed.” You may need to offer specific prompts:
- “Has your child witnessed anything frightening in his neighborhood or at school?”
- “Does he ever hear anyone fighting or yelling in the home?”
- “Has anyone ever hurt your child?”
- “Is something happening to you or someone else that might be frightening to your child?”
If possible, interview the child alone. You can do this with children as young as 5 unless they have separation anxiety, telling parents, “We sometimes find it helpful to interview children alone; sometimes they don’t want to scare their parents or hurt their parents’ feelings.” If the parents refuse, this can be a red flag, but it can also be a natural desire to protect the child.
In speaking to the child, you can ask, “Tell me more about what was happening, what you were feeling” during, for example, an outburst at school. Older children can fill out questionnaires. As you know, if the traumatic events involve abuse, you are legally mandated to report this to child protection authorities.
What can a PCP do to manage PTSD?
The first thing would be to get a thorough psychiatric evaluation for the child. If he is diagnosed with PTSD, medication can be helpful, but that is only one piece of managing the condition. A bigger piece is identifying what is setting off the child’s symptoms, and learning how to manage and minimize exposure to those triggers. A good behavioral therapist can teach the child some emotion regulation skills, so that the child can identify when he is becoming aroused and learn how to calm himself.
What kinds of therapy are helpful?
Trauma Systems Therapy (TST), co-developed by the Department of Psychiatry's Heidi Ellis, PhD, is a mental health treatment designed to engage families and help traumatized children by stabilizing the social environment and working to reduce emotional dysregulation. TST also has an advocacy and a psychopharmacology component, and has been implemented in a variety of service settings including schools, foster care, residential and outpatient settings.
Cognitive Behavioral Therapy that is trauma-focused can be helpful for older children; for younger patients, we find play therapy helpful. For children age 6 and younger, parent-child psychotherapy uses the relationship between the primary caregiver and child to help both heal from trauma. It was developed initially for situations in which the mother was experiencing domestic violence.
When should patients be referred for specialty care?
If your practice does not have a mental health practitioner, referral for mental health evaluation is warranted if the child is distressed and if family concern is high, prior to trying medication. The practitioner can be a psychiatrist, psychologist or social worker, but should have background in treating children with a history of trauma.
While psychiatric medications are being used in PTSD, we like to avoid unnecessary use of psychotropic drugs in children because their brains are still developing. Medications are sometimes an important part of the treatment plan but need to be carefully monitored.
Can children get better after suffering or witnessing trauma?
Yes. The sooner you can identify PTSD and refer children for intervention, the easier it is to treat. Conversely, the longer PTSD has gone untreated, the more challenging it can be to treat; it is not a phase or something a child will simply outgrow. Furthermore, without treatment, exposure to additional traumas, which unfortunately happens often, can magnify the severity of symptoms.