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2005 Jordan Institute
for Families

Vol. 10, No. 3
June 2005

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.

Typical Reactions
Normal, immediate reactions to trauma cover a wide range and can include overwhelming feelings of helplessness, fear, withdrawal, depression, and anger. Reactions may last for weeks or months but more commonly show a swift decrease after the direct impact subsides (Goodman, 2002). Child welfare workers should look for and be able to spot the age-specific reactions to trauma described in the related article "How Children and Teens React to Trauma." Know that children are less likely to exhibit some of the well-known adult symptoms of PTSD (e.g., flashbacks).

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.

PTSD
PTSD may arise weeks, months, or even years after the traumatic event (NIMH, 2001). Formal diagnosis of the disorder may be made only by a qualified professional. A person can be diagnosed with posttraumatic stress disorder only when all three of the following conditions are met: (1) the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others; (2) the person’s response involved intense fear, helplessness, or horror (in children, this may be expressed by disorganized or agitated behavior); and (3) he or she exhibits at least one of the following symptoms for longer than one month:

  • Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma
  • Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future)
  • Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behavior

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.

What Does It Feel Like to Have PTSD?

Symptoms vary. One person described it this way: “At first it didn’t seem to bother me, but now I have terrifying dreams about it and can’t seem to get it out of my mind. All I want is to be left alone. My family and friends want me to be the way I used to be, to forget it, but I’m not the same person . . . . If I don’t have a couple of drinks I can’t get to sleep, and now I’m drinking more. The kids bother me a lot, and I’m pretty irritable and snap at everybody for nothing.” (Williams, 1995)

Risk and Protective Factors
PTSD can develop in individuals without any predisposing conditions, especially if the traumatic event is extreme. However, research has identified factors influencing an individual’s likelihood of experiencing PTSD.

Goodman (2002) states that trauma-exposed children are most at risk if they have:

  • Physical injuries as a result of the event (e.g., physical abuse)
  • Personally witnessed the event (e.g., domestic violence, abuse of a sibling, community violence)
  • Pre-existing mental health issues or learning difficulties
  • A limited support network
  • Someone close to them who is missing, hurt, or dead
  • Caregivers who are experiencing emotional difficulty
  • Pre-existing or consequent family life stressors (e.g., divorce, job loss)
  • Previous loss or trauma experiences (may include multiple placements in foster care)

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).

Impact
Research has shown that if it goes untreated, PTSD affects children, teens, and adults in various ways:

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.

Conclusion
PTSD represents a special threat to children involved with the child welfare system. The potential costs of PTSD—for these children and for society—are significant. This issue of Practice Notes suggests ways that workers and agencies can respond to children and families affected by traumatic events.

References for this and other articles in this issue