2005 Jordan Institute
10, No. 3
PTSD and Children in the Child Welfare System
A trauma is a psychologically distressing event that is outside the range of usual human experience, one that induces an abnormally intense and prolonged stress response (Child Trauma Academy, 2002).
Despite the fact that they are outside the range of usual human experience, traumatic events are fairly common, even among children. In their study of children and adolescents (9-16 years old) in Western North Carolina, Costello et al. (2002) found that 25% had experienced at least one potentially traumatic event. In her review of the literature, Solomon (2005) found 90% of people surveyed experience at least one traumatic event during their lifetimes.
Events that can induce trauma include the sudden death of a loved one, assaultive violence (combat, domestic violence, rape, torture, mugging), serious accidents, natural disasters, witnessing someone being injured or killed, or discovering a dead body.
In child welfare, physical and sexual abuse are common sources of trauma in children. Other causes of childhood trauma can include animal attacks (dog bite), life-threatening illnesses, and prolonged separation from caretakers.
The intensity of a person’s reaction immediately after a traumatic event is not predictive of that person’s chances of developing PTSD. The most important indicator of subsequent risk of chronic PTSD seems to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (McNally et al., 2003). Adversities experienced for an extended period after the trauma (such as a series of different placements or separation from a caregiver) and the supports available to children also influence their risk for more serious posttraumatic stress reactions.
With informal support, the majority of trauma survivors recover on their own within a few weeks (NIMH, 2001), though some need longer to heal. For a small minority, however, traumatic events trigger various mental disorders, including PTSD.
The symptoms must cause distress or impair functioning (APA, 1994).
It is important to note that many children experience great distress from traumatic events but do not, for one reason or another, qualify for a diagnosis of PTSD. However, these children should also be screened and, if appropriate, treated by a qualified mental health professional.
Rates of PTSD are higher in children and adolescents recruited from at-risk samples than they are for the general population (Hamblen, 1999). In their study of PTSD in children in foster care, Dubner and Motta (1999) found PTSD was diagnosed for 60% of sexually abused children and 42% of physically abused children. Dubner and Motta also found 18% of the foster children who had experienced neither physical nor sexual abuse also had PTSD. These children may have developed PTSD due to exposure to domestic violence, community violence, or other events (Marsenich, 2002).
Another study examining children entering foster care aged six to eight found that one out of three met criteria for PTSD (Dale et al., 1999).
It has also been suggested that the incidence of PTSD may be higher in individuals with developmental disabilities (Pitonyak, 2005). This may have serious implications for child welfare work, since according to CWLA (1998) 20% of the children in foster care have some form of developmental disability.
About half of those with PTSD recover completely within three months, but others suffer chronically. If a person has symptoms for more than a year, it will usually be a lifelong condition if not treated (APA, 1994). Even if PTSD does become chronic, treatment can alleviate many symptoms.
It is important to have children assessed by mental health practitioners who have training and experience with PTSD and child trauma. A therapist we spoke to said she often sees traumatized children who have been misdiagnosed as having attention problems or oppositional defiant disorder (ODD). Misdiagnosis can subject children to inappropriate, ineffective interventions while depriving them of the treatment they need.
Risk and Protective Factors
Goodman (2002) states that trauma-exposed children are most at risk if they have:
PTSD may be especially severe or long lasting when the stressor is of human design, as in cases of sexual abuse (Flick & Woodcock, 2002a).
Gender also appears to be a risk factor. Several studies suggest girls are more likely than boys to develop PTSD (Hamblen, 1999).
Factors that reduce a person’s chances of developing PTSD include: higher cognitive ability; strong social supports; having a happy, safe childhood in a stable family; and an overall positive outlook/personality (McNally et al., 2003).
Multiple Diagnoses. PTSD frequently occurs in conjunction with disorders such as depression, problems of memory and cognition (APA, 1994; Harney, 2000), anxiety disorders such as separation anxiety and panic disorder, and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder (Hamblen, 1999). Substance abuse is also a problem; the National Child Traumatic Stress Network (2003) cites a study that found 25% of children with PTSD became substance abusers, compared with 3.7% of non-traumatized children.
Relationships and Behavior. Children who have experienced traumas often have relationship problems with peers and family members and problems with acting out (Hamblen, 1999). Exposure to trauma, especially community violence, has been linked to aggressive and anti-social behavior (NIMH, 2001). Adults with posttraumatic stress symptoms are more likely to report marital problems (Solomon, 2005).
Physical Health. Solomon (2005) found in her research review that PTSD increases a person’s risk for serious and chronic disease, including circulatory, digestive, musculoskeletal, endocrine, respiratory, and infectious diseases. She also notes that trauma victims are less likely than others to take steps to protect their health (e.g., fewer preventive healthcare visits, exercising and using seatbelts less). Child maltreatment in general is linked to a long list of later adult health problems (Felitti et al., 1998).
School Performance. Because it contributes to difficulties with behavior, relationships, mental health, attention, concentration, and memory tasks, PTSD has also been linked to school failure (Goodman, 2002).
Finances and Employment. Amaya-Jackson (cited in Solomon, 2005) found that adults with posttraumatic stress symptoms were much more likely to miss work, to experience insufficient income, and to be receiving public assistance (food stamps, Medicaid, TANF) than people without symptoms.