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Glenn N. Saxe, MD, FRCP |
Abuse, neglect, war, disease, natural disasters, accidents and violence all have the potential to lead to post-traumatic stress disorder (PTSD), according to Glenn N. Saxe, MD, FRCP, director of Children’s Hospital Center for Refugee Trauma and Resilience. Here, he discusses the condition.
Interpersonal trauma, particularly sexual trauma, has higher rates of PTSD. But the trauma itself is a weak predictor. Only 20 to 30 percent of kids who are traumatized will develop PTSD. There are factors besides the trauma, such as living in an unsupportive family or one that’s not attuned to the child’s emotional needs, and children who grow up with ongoing stresses are more likely to have PTSD. There are also biological factors.
Adults are more likely to be able to tell you what they’re feeling, whereas younger children aren’t. One of the primary features of PTSD is intrusive memories: Patients feel the sensations of the event in their body, get disoriented and feel like it’s happening again. Younger children and some adults outwardly react to these intrusive memories. They’re behaviorally out of control because they’re fighting for their life, and they’re not able to describe it. All you see is the aggressive behavior.
In general it’s important to screen for exposure to trauma. Ask several non-leading questions, then follow up based on the responses: “Has anything very scary ever happened to you? Have you ever been hurt physically by someone else?” Follow-up questions should be asked about the child’s and parents’ thoughts about the impact of the event on the child and family. It is best to begin with non-leading questions, then get more specific depending on the child’s or parents’ responses: “How do you think what happened affected you/your child?” This question could be followed up with questions about common reactions to trauma such as, “Do you ever have frightening memories or dreams about what happened? Does it ever seem like it is happening again? Do you stay away from people, places, or things that remind you about what happened? Do you ever get really jumpy when you hear loud or sudden noises?”
The degree of trauma, as measured by the injury severity score, does not have a direct relationship to PTSD. It only exerts its effect via other variables. An important group of symptoms is called dissociative symptoms—a patient’s memory is fragmented, she has a poor sense of time, experiences being separate from her body—if children have these symptoms shortly after a trauma, they are at higher risk. One of the genes we found called FKBP5 is strongly related to these dissociative symptoms in the wake of a trauma.
There’s literature showing that some medications, administered shortly after a traumatic event, may prevent PTSD. Our group showed that the more morphine children hospitalized with burns received in the hospital, the more their symptoms of PTSD diminished over 10 months after hospital discharge (when the children were no longer treated with opiates). Our group replicated this finding with children hospitalized with non-burn injuries, and a group in Australia replicated this finding with adults. There are also promising findings with a drug called propranolol on preventing PTSD. Importantly, morphine also blocks the activity of the norepinepherine system.
One must be cautious, but clearly, there are important implications for the treatment of injured children in pain. Pain is usually the main target for opiate treatment. We may need to consider symptoms that may develop down the road as a possible target of opiate treatment. There are obvious clinical and ethical complexities that must first be wrestled with before opiates are routinely used in this way.
We’ve developed a treatment called Trauma Systems Therapy. Traumatic stress boils down to two things: One is a child that is not able to regulate emotional or behavioral states. The second is that the child lives within a social environment that isn’t able to help them regulate those emotional states. When we train agencies and clinicians, we train them to recognize when kids are shifting into these extreme states and to look at specific things in the environment that keep triggering them. If clinicians can recognize those things, then strategies can be developed to diminish them. The other part of treatment is when a child is confronted with a stressful stimulus; you can help her develop skills to not lose control. Within Trauma Systems Therapy, we also include pharmacology, when necessary, which sometimes works together with emotional regulation skills and legal advocacy.
I think it’s important to refer for full evaluation with a mental health specialist when children report a trauma for which they are developing some symptoms and dysfunction. About 20 to 30 percent of children exposed to a trauma will develop PTSD, so we should not expect that all traumatized children will be symptomatic. Kids are, in general, pretty resilient. However, there is evidence that chronic childhood trauma may actually have an impact on brain development. If you have a child who has been traumatized, and is developing PTSD, and it’s unrecognized and untreated, it may have a lifelong consequence related to brain development.
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