© Springer Science+Business Media New York 2015
Rosemary Flanagan, Korrie Allen and Eva Levine (eds.)Cognitive and Behavioral Interventions in the Schools10.1007/978-1-4939-1972-7_44. Trauma, PTSD, and Secondary Trauma in Children and Adolescents
(1)
Department of Psychology, Hofstra University, Hempstead, NY, USA
Description of the Problem
Trauma and posttraumatic stress disorder (PTSD) in children and adolescents refer to reactions to extremely frightening and threatening events. For those who are interested in learning about PTSD and those subclinical trauma reactions referred to as acute stress disorders, there is often a tendency to go to the latest version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5, 2013) where one encounters a list of symptoms such as intrusive thoughts, negative alterations in cognition and mood, and alterations in arousal and reactivity. The DSM-5 introduces a PTSD subtype for children 6 years and younger which requires avoidance or intrusive thoughts, rather than both, and thereby simplifies the diagnosis of young children. The problem with this approach to defining PTSD and trauma reactions is that the DSM provides a skeletal, and in many ways a distorted view, of what PTSD actually is, especially as seen from the viewpoint of practicing school and clinical psychologists. A major issue in trauma reactions, regardless of the age of the trauma victim, is an alteration of one’s self-view and a change in how the environment is perceived. These changes from prior levels of functioning are so profound that they tend to overshadow most of the specific DSM listed symptoms. The alteration in a child’s or adolescent’s perspective of themselves and their environments are characteristically in the more negative and pessimistic direction than they were before being traumatized (e.g., Ellis, 2005).
Children, adolescents, and adults who are traumatized often feel a sense of alienation from themselves and others. In addition, they often develop a fairly negative view of themselves and a wary, suspicious stance toward their environment. For example, the child who has been physically abused will often have a diminished sense of self perhaps brought on by the belief that they have behaved badly in order to have warranted such abuse. This view can transform a child’s perspective into believing that they are a bad person, not just a person who behaves poorly. The declining sense of self-regard will often lead a youngster into asocial and antisocial activities, and the negative feedback that eventuates from these actions perpetuates and validates the negative sense of self (e.g., Evans, Ehlers, Mezey, & Clark, 2007). From this, it should be apparent that PTSD is not simply a disorder characterized by a menu of symptoms but that it is also a pervasive and often persistent alteration of one’s self-view and a wary take on their environment.
A related concept that involves trauma in children and adolescents is the diagnosis of secondary traumatization (e.g., Motta, 2012). Secondary trauma has been given far less attention than has PTSD, and yet it is among the more common problems that can afflict the young. Secondary trauma of childhood typically encompasses negative psychological experiences that are due to a child having a close and extended relationship with someone who has been traumatized. The traumatized individual could be a parent, guardian, relative, or anyone else with whom the child is emotionally close. The prototypical example is presented by Rosenheck and Nathan (1985) and involved the 10-year-old son of a Vietnam veteran. This child had an unusually close relationship with his father and the father’s emotional life. Unfortunately the father was experiencing PTSD as a result of his war experience and the child began to acquire the father’s depressive and anxious affect and moodiness, along with a wariness of others and a tendency toward isolation. In a related investigation, Parsons, Kehle, and Owen (1990) compared childhood social and emotional functioning as viewed by Vietnam era veterans with PTSD to similar veterans without PTSD. Overall, it was found that the children of veterans with PTSD were seen as having substantially more social and emotional difficulties marked by an inability to initiate and maintain relationships and by negative effect. The children of veterans with PTSD were also seen as having a greater lack of self-control and more aggressive, delinquent, and hyperactive behaviors.
While secondary trauma has not been extensively studied in children, there are a number of situations in which it has been found to occur in adult samples. It has been reported to take place in families living with a traumatized family member (Catherall, 1992), in partners of those who have been sexually abused (Nelson & Wampler, 2000), in wives of combat veterans with PTSD (Waysman, Mikulincer, Solomon, & Weisenberg, 1993), in young adult children of Vietnam veterans with PTSD (Suozzi & Motta, 2004), in wives of police officers (Dwyer, 2005), in grandchildren of Holocaust survivors (Kassai & Motta, 2006; Kellerman, 2001; Perlstein & Motta, 2012), and in family members of those with a serious illness (Boyer et al., 2002; Libov, Nevid, Pelcovitz, & Carmony, 2002; Lombardo, 2005).
Epidemiology
The vast majority of epidemiological studies on PTSD have been done with adult samples; however, there are available studies referring to PTSD rates in children and adolescents. For example, terrorized communities in Cambodia during the era of the Khmer Rouge atrocities and rampages revealed that virtually 100 % of children and adolescents displayed symptoms similar to those seen in PTSD. After 3 years the rate was down to still troubling 50 % (Kinzie, Sack, Angell, Mason, & Ben, 1986). A study of sexually abused foster care children and adolescents revealed PTSD rates of 60 % (Dubner & Motta, 1999). These rates are remarkably high especially in light of the fact that fewer than 10 % of adults who have been traumatized meet the criteria for PTSD as described in the DSM.
Given that traumatized parents negatively impact children, it is important to examine adult PTSD rates. Nearly one in four (24.5 %) of Iraq and Afghanistan war veterans have received a PTSD diagnosis by the Veterans Health Administration. A commonly reported statistic is that approximately 7 % of individuals have PTSD in the general population and 19 % of Vietnam War veterans are current PTSD cases (Dohrenwend et al., 2006). Females generally develop PTSD at a higher rate than males. In addition to younger age increasing one’s vulnerability, the existence of preexisting psychological problems also predicts an increased probability of developing PTSD (Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1996). Female children who have witnessed serious interpersonal conflict among adults in the home and those from abusive and emotionally non-supportive home environments are seriously at risk for developing secondary trauma and PTSD reactions. What follows below are typical cases of secondary trauma and PTSD.
Case Examples
Case #1
The first case highlights the symptoms and behavioral characteristics that are commonly seen in cases of childhood secondary traumatization. At the time of this event, Larry was 5 years old and had five siblings. His intact family was sitting at home when approximately 50 bullets hit the house. A number of police officers had cornered a deranged man who had threatened them with a shotgun, which turned out to be empty. The fusillade of bullets from the police officers killed the man but also hit the house behind him and thoroughly traumatized the parents and the older children who were sitting at home watching television. Larry really did not know what to make of what was happening. He interpreted the events as rocks being thrown against the house. He did not grasp that there were bullets hitting the house or that he and his family members were lucky to be alive. As a result, he did not have the intense fear that typically precipitates PTSD. His parents and the older teenage siblings, however, were horrified and fully realized that luck was the only factor that prevented them from being injured or killed.
He witnessed extreme upset among his family members, their sleeplessness, their anxiety, their depression, and their growing distrust and insecurities, and he began to react. He started having nightmares about being attacked by monsters and was unable to sleep. He became sullen, moody, withdrawn, and irascible. He developed nocturnal enuresis and began failing at school. His teachers described an increasing tendency to isolate himself from others, a general moodiness and withdrawal, and difficulties with concentration. Nothing seemed to console Larry. He was reacting not to a traumatic event, but to his family’s responses, to their upset, and to the overall disruption in the home. He cried in response to his mother’s unhappiness and to his father’s now frequent emotional outbursts. Larry was traumatized by the emotional reaction of those with whom he was emotionally bonded and upon whom he relied for guidance and support. He was showing classic symptoms of secondary traumatization.
Larry entered into counseling and made significant progress. Given that a major issue for him was that of secondary trauma , i.e., the emotional upset of his family, parental counseling significantly benefitted him. Overall, his therapy followed a CBT and exposure framework. For example, Larry was often asked to recount the events that took place, in detail. This form of exposure through imagery was supplemented with efforts to reframe his thinking from seeing the shooting event as a common occurrence to a highly unusual one. Attempts were also made to reframe his thoughts in the direction of positive changes and adjustments being made by his family. It was clear that this child’s emotional adjustment was directly tied to that of his parents and siblings. Stability and relative normalcy eventually returned to the home and Larry continued to improve and eventually reverted to his old spontaneous and fun loving self. In school his grades began to improve and he showed a notable improvement in the quality of his social interactions. While he continues to have occasional nightmares and startle reactions, overall he is markedly improved.
Case #2
Case 2 is a more typical PTSD case that occurred in response to a rape which took place in the first year of college but is unfortunately typical of such events seen in high schools. Janet was a highly athletic, academically talented, and extroverted teen who was accepted to a fairly selective university in California. She had also been accepted by the Naval Academy but chose this particular private university because it had a renowned swimming program and swimming was the area in which she excelled. One night she accepted an invitation to a fraternity house Halloween party where the alcohol was flowing heavily. At some point during the revelry, she was pulled into a room and raped by two competitive swimmers from her school.
Janet hid this horrific event from her parents because she was ashamed and felt that she displayed bad judgment in going to the party. However, her parents saw an inexplicable and dramatic change in her. She began transforming from an exuberant, athletic, honors student into a depressed, angry, rebellious, substance-abusing teen that her parents no longer recognized. Rather than being proud of her accomplishments she now felt sullied, diminished, and undesirable. Her primary emotional states were anger, depression, and anxiety. She developed a pervasive sense that the world is a dangerous place where one’s safety and security are never assured. Janet had changed in profound ways. She now had a critical and negative view of herself and the motivations of others. She felt intensely threatened and vulnerable. Janet’s radically negative transformation of her self-view and her equally pessimistic views of the environment are common outcomes of those suffering from PTSD.
Janet refused to take court action because the process of reliving what happened was too much for her to manage. She did identify the two rapists to the administration of her school and they were dismissed from that university, but without her testimony, no further action could be taken. Janet pursued psychotherapy and drug abuse counseling. The cognitive-behavioral focus of her therapy was aimed at altering her self-blaming thoughts and negative self-evaluations. She has made tremendous strides and is now a more mature person who gives rape-counseling seminars at local high schools. Overall, Janet has made a good recovery. She is a serious and focused individual and seems more emotionally seasoned than her years would dictate.
Case #3
This is not the case of an individual, but rather, a case of group trauma . The current author and his assistant recently held a meeting of Long Island, New York, residents who endured the ravages of Hurricane Sandy, which struck in October 2012. This hurricane devastated numerous seaside homes and did extensive damage to many other residences. What is of particular interest about this affected group of individuals was the variation in response to the trauma. The majority of those present at the meeting were seriously traumatized and spoke of the nightmarish experience of being in a home without lights and without heat or drinking water, often in subfreezing temperatures, for periods of weeks. As might be expected, there were many reports of nightmares, intrusive images during waking hours, and a profound suspiciousness of community and state leaders who promised relief. Little relief came, even after 3 months. Many reported that they had changed from a religious, community oriented individual to something of a wary, suspicious survivor. However, there were a few in the group of 25 who reported no PTSD symptoms and, in fact, had a relatively positive stance of having the opportunity to build a new home. This highlights the fact that adults and children differ significantly in their ability to cope with trauma.
Many of the participants observed that their children seemed far more troubled by their parents’ besieged responses to the hurricane, than to the hurricane itself. Some even reported that the children enjoyed the storm! From this one might surmise that the children were suffering from secondary trauma in that their exposure to the emotional upset of their parents had a more negative emotional impact than the storm itself. While systematic studies have not been carried out with groups within the schools, it seems reasonable to assume that getting children together to discuss their experiences would be a form of graded exposure and could lessen the anxiety and emotional upset that many of the children feel. It is important to assure children that normalcy and balance will return to their households and that their family can and will cope with this natural disaster. School psychologists and other mental health personnel can play an important role in facilitating such discussions.
Historical Roots
Reactions to trauma situations have been known and described for centuries. They have been alluded to as far back as Homer’s Iliad and noted in literary heroes and heroines, including Shakespeare’s Henry IV (Trimble, 1985). Samuel Pepys diary in 1666 contains quotations of sleeping difficulty and night terrors in response to the Great Fire of London (Daly, 1983). During the American Civil War (1861–1865), trauma reactions were noted to occur in the absence of physical injury, and these reactions included irritability, rapid heart rate, and increased arousal. The condition became known as Da Costa’s Syndrome, named after the American physician who described them. The condition was also referred to as Soldiers’ Irritable Heart or Irritable Heart Syndrome, perhaps in reference to the fact that the heart rate was elevated and the condition seemed to have more of an emotional than physiological etiology. Similar emotional reactions have occurred as a result of railway accidents during the uncertain development of our rail system. These responses became known as “railway spine” due to a belief that the trauma reactions had a neurological basis (Trimble, 1981).
Terms such as “shell shock ” and “rape trauma syndrome ” also appear to be descriptive of the symptoms of PTSD. However, it was not until the publication of the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM III; American Psychiatric Association (APA), 1980) that PTSD became an officially recognized disorder. The DSM III alluded to traumatic events that were “beyond the range of normal human experience.” The Vietnam War was a driving force in the inclusion of PTSD in the DSM. The criterion that the trauma experience should be beyond the range of normal human encounters was subsequently dropped when it was found that relatively common stressors such as car accidents, life threatening illness, and child abuse could also precipitate PTSD.
Assessment: Role of Clinical Observation
Assessment is commonly accepted to mean the use of measures, usually paper and pencil measures, to evaluate a particular psychological characteristic. There are no measures specifically designed to measure secondary trauma in childhood, although measures of secondary trauma do exist for adults (e.g., Motta, Hafeez, Sciancalepore, & Diaz, 2001). There are also a number of measures of PTSD in children and adolescents and these will be described below. An important point to consider is that PTSD is most often assessed not by scales, but by a clear-eyed process of clinical observation of PTSD characteristics. These characteristics include a falling off from a previous level of functioning; a tendency toward sullenness, isolation, anhedonia, irritability, sleeplessness and nightmares; and a tendency for these symptoms to persist for an extended time.
Among the more important characteristics of PTSD, which are included in the DSM-5 is the previously mentioned alteration in the sense of self and in the perception of one’s environment. Perhaps the simplest way of encapsulating the change is to state that a child, an adolescent, or an adult who has been traumatized is far more pessimistic than they were before the trauma. Traumatized children come across as sullen, moody, and withdrawn. They show a lack of interest in many of the activities they once enjoyed, they tend to avoid close friendships and contacts, and they seem to be preoccupied. Herman (1992), in a classic examination of traumatized children who had been buried underground inside a school bus, noted many of the above characteristics in addition to what she referred to as “foreshortened future.” By this she meant that many of the children could not view their future selves. They had no expectation of leading a long life. The lack of expectancy of continued living and the negative view of themselves and their world all reflect a pessimism that typically was not previously there.
Those who are traumatized, regardless of the nature of the trauma, see their world as lacking in possibilities they might desire. In fact, they often have few desires per se (e.g., Terr, 1983). The traumatized person sees their world as a negative place that is not only devoid of possibilities, but even if there were incentives in the world, there would be a lack of interest in them. This bleak stance reflects the negative view of the future, the self, and the world as initially descried in the CBT model of depression by Beck, Shaw, Rush, and Emery (1979). In the previous examples, the rape victim transformed from an exuberant, enthusiastic student, into a depressed, acting out, substance abuser. The young boy whose house had been hit by bullets became withdrawn, angry, and moody. People traumatized by Hurricane Sandy see themselves as having changed in a negative way. These outcomes are very common in trauma. Rape victims, torture victims, traumatized war veterans, natural disaster survivors, and many other survivors of varied traumas have a negative sense of self and a philosophically somber view of the world and any future that might be out there.
One of the particular problems in dealing with traumatized children is that PTSD and secondary traumatization can often mimic depressive and anxiety reactions. From a differential diagnosis perspective, the difference between common anxiety reactions, depression, and PTSD is that PTSD often is characterized by an identifiable event that caused extreme fear, startle reactions, threatening nightmares, prolonged sleeplessness, and avoidance of any stimuli that remind the traumatized individual of the traumatic event. Anxiety and depressive reactions are usually not associated with sudden fear-producing and life-threatening events.
Assessment Measures: Secondary Trauma
As noted above, diagnosis of secondary trauma is usually through clinical observation. The secondary trauma measures that do exist are usually designed to assess secondary trauma in therapists. One such scale is the Secondary Trauma Stress Scale (STSS: Bride, Robinson, Yegidis, & Figley, 2004). The scale shows good psychometric characteristics but has two relative weaknesses. First, it is designed specifically for therapists and therefore does not have defensible application to other populations, particularly children. The second problem is that it lacks empirically derived cutoff scores that are based on standardized measures. The same strengths and weakness are revealed in the Traumatic Stress Institute Belief Scale (TSI; Pearlman, 1996), the Compassion Satisfaction and Fatigue Test (CSFT, Figley & Stamm, 1996), and the Compassion Fatigue Scale-Revised (CFS-R; Adams, Boscarino, & Figley, 2006). The Professional Quality of Life (ProQOL; Stamm, 2010) has been used with varied populations but it is not specifically a measure of secondary trauma and, again, lacks empirically based cutoff scores. These issues are addressed by the Secondary Trauma Scale (STS; Motta et al., 2001) in that the measure is applicable across a wide range of populations including community samples, therapists, students, etc. It is designed specifically to assess secondary trauma and also has cutoff scores such that a given score on the STS is associated with levels of anxiety and depression. Like the scales mentioned above, however, it is not applicable to children.
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Depression
Using CBT to Assist Children with Autism Spectrum Disorders/Pervasive Developmental Disorders in the School Setting
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