“Susie Ehrens spoke of her daughter who escaped from Sandy Hook with a group of other first graders when the shooter paused. Her daughter, she said, saw her friends and teacher slaughtered before she ran past lifeless bodies and a half a mile down the road”
On December 14th, 2012 the unthinkable happened. A gunman fatally shot twenty children and six adult staff members in a mass murder at Sandy Hook Elementary School in the village of Sandy Hook in Newtown, Connecticut. This incident is the second deadliest school shooting in American History.
Tragically millions of children, all around the world, are frequently exposed to all manner of traumatic experiences. From those of human design such as bearing witness to shootings, inner city violence or the effects of living in a war zone or being the victims of child abuse to enduring the consequences of exposure to natural disasters such as a hurricanes, earthquakes or natural fires.So what is the impact of psychological trauma on children?
To understand more, I recently met with Dr. Victor Carrion, a Professor at the Stanford University School of Medicine and Director of the Stanford Early Life Stress Research Program at the Lucille Packard Children’s Hospital at Stanford. Dr Carrion’s research focuses on the interplay between brain development and stress vulnerability. He has developed treatments that focus on individual and community based interventions for stress related conditions in children and adolescents that experience traumatic stress.
SJ: If we consider the example of a child, of elementary school age, who is exposed to a horrific traumatic event such as Newtown what, as a child psychiatrist, would you expect to see over the coming days and weeks i.e. what would be a normal and expected reaction to such an event in an elementary school child?
VC: The school-aged kid is going to have a difficult time understanding his/her emotional life. So, they may somatise e.g. complain of headaches and stomach aches and they are going to want to not go to school. They may not be psychologically minded enough to verbalize what they are struggling with. Kids sometimes do not have the vocabulary to talk about a traumatic event and sometimes they are still very concrete in their thinking.
Also remember, because of media, even if we are not right where a trauma happened we can still be equally affected. An example would be 9/11, where kids in California were following, minute by minute, everything that was happening in the news and when they started showing those pictures of people jumping from the towers that was traumatic for many kids. Our association, the AACAP (American Academy of Child & Adolescent Psychiatry), actually contacted the networks and they were very responsive and stopped showing those images as soon as we contacted them.
SJ: In your opinion, how best should parents, teachers and caregivers respond to such normal reactions?
VC: It will be important to really encourage discussion after something traumatic happened but not force it. Certainly, not even encourage it in very young kids that may not even know that something happened. Our belief now is that if the kid is 4 and 5 and this is not being discussed at school and they are not watching the news and they do not know that something terrible happened, there is no reason to talk to them about it.
Obviously, if they directly witnessed or experienced something, that is a different story because, as you know, exposure to trauma is one of the strongest predictors of PTSD.
It is important is for caregivers to give children a message of safety and get the message that they are being taking care of and that they will be protected and that nothing will happen to their caregivers. This message of safety is important.
Another piece of this is that children should not be expected to be tough. One of the things that parents can actually model is that it is okay to cry, it is okay to have distress but parents have to be careful in how they balance that with maintaining their safety message and their authority message. They still have to give the message that I am okay enough to take care of you in a good way. But children certainly should be encouraged to express whatever feelings they may have about something that has occurred
Most children, exposed to trauma, are going to have a normal response and be okay with time. With a very small group of these kids, the response is going to continue and is going to become maladaptive and they need extra help. One of the things that is important for caregivers to recognize is when a child’s response becomes maladaptive, chronic or continuous. In that event, they should seek out professional help.
SJ: Let’s consider the more unfortunate scenario, that this child starts to develop signs/symptoms of a prolonged reaction to the trauma/an abnormal reaction: What are the typical manifestations of PTSD (posttraumatic stress disorder) in children of this age?
VC: Kids tend to show their re-experience of trauma through intrusive thoughts. This means thinking or talking about the trauma when they do not want to. So, they are playing basketball with friends and, all of a sudden, the images of the trauma do not let them enjoy the game or even play it. Or, they are doing their homework but they cannot because they are thinking about the traumatic event. Or they re-experience their trauma through what we call traumatic play. Traumatic play is a way for many children to communicate their experience especially if they are not that verbal.
Then there is avoidance. But with kids is it really avoiding or is it that the kid does not have the words to talk about what happened? There might be a cognitive inability to really talk about what happened but certainly we also see an avoidance of trauma related triggers. For example, if something traumatic happened and it was a rainy day then the next rainy day they may be particularly sensitive or nervous that day.
We see emotional numbing quite often also: kids say that they can no longer feel sad when something bad happens. They feel happy when something good happens but not as good as they used to feel. They may go to a birthday and it is okay but they used to love birthdays before.
The other type of symptom is the physiological hyperarousability. That is what leads many kids to receive a misdiagnosis (especially kids that live in environments where they are surrounded by violence) of ADHD. Now, this gets very complicated, clinically, because kids that truly have ADHD are at increased risk of experiencing traumatic events. For example, they may not see the car coming and they go and cross the street. The kid that has ADHD is at increased risk of experiencing traumatic events which means they may end up with PTSD also.
Then, another thing as I said is that traumas are stressors to the system and you develop whatever you are vulnerable to. It may be that you do not develop PTSD but you develop OCD/a phobia as a consequence of experiencing a traumatic event.
We have always known that having anxiety puts you at risk for developing PTSD but what we have also seen in our data is that developing PTSD is a good predictor of developing other anxiety disorders after having PTSD.
What we also see is that children tend to be egocentric and naturally narcissistic. In kids it is a helpful drive because they get the necessary attention and all that but that also means that if something bad happens, children take excessive responsibility for it and it creates this sense of guilt and guilt is a very good predictor of developing PTSD. This is not survivor’s guilt. This is guilt over an act. For example, “there was a fire and I could have prevented it and I did not”.” I was abused and that is because I provoked it or I made it happen”. Whenever there is that sense of guilt after a kid experiences a traumatic experience it is good to start some clinical remediation to correct those cognitive distortions.
SJ: How does this differ from PTSD in adults?
VC: Immediately, when we look at the first criterion for diagnosing PTSD, we already have an issue when it comes to kids. Criterion A requires that the traumatic event make you feel as though your life is in danger/threatened. But if you are younger than 7 or 8, you may not understand death as something that is universal and something that is irreversible.
One of the studies that we did is that we looked at children who had experienced separation or loss and were in that age group and compared them with kids that had experienced physical abuse, sexual abuse, and also had functional impairment. They really did not differ in terms of the amount of functional impairment that they had in their lives, in their personal relationships, and the amount of distress and so forth. So for children younger than 8, what I am saying is that separation or loss is considered a traumatic event. even if they might not have a full understanding of death or loss.
The symptoms of PTSD, in children as well as in adults, are mostly on and off. They are not there all the time and they tend to be triggered by cues. When those cues or triggers are there, that is when you see the symptoms. This becomes problematic if you are conducting a trial and at the end of the trial this group looks like it is doing well, it may be the case that the treatment worked but it might also be the case that there were no triggers/cues around those kids at that time. That is one of the reasons why we need to know about the neurofunctionality or the neuroscience of how traumatic stress impacts development.
For kids it is still a balance between internal and external resources, and it is like a mathematical equation. So you may have a lot of coping and strength and that may be able to help you overcome the lack of support you have in your life or you may have total perfect support but you have so many risk factors to begin with like a previous history of trauma exposure or family history of anxiety disorder that you are more likely to have a post traumatic reaction. I am calling it a post traumatic reaction not necessarily PTSD because some of the work that we have done and also work done by Dr. Michael Scheeringa at Tulane University shows that children do not have to have all the criteria for PTSD listed in the DSM to experience functional impairment. For example, we showed that kids that have PTSD compared to kids that have a history of trauma and symptoms in 2 of the clusters are equally impaired. We still have work to do in terms of how we develop this diagnostic criterion for children. That is one of the things that Michael has done. He has proposed a number of criteria that has less symptoms and also that some symptoms might be somewhat different in children compared to adults
SJ: In terms of the neuroscience of PTSD, how might this look in terms of impact on child development from a psychophysiological, neuroimaging or neuroendocrinological point of view?
VC: One of the things that have been studied for a long time is the autonomic nervous system in children as well as in adults. It seems that those who have PTSD are actually a heterogeneous group and that physiology may help us differentiate between kids that dissociate versus all the kids that might display symptoms of aggression. For example, the kids that dissociate seem to have a lower heart rate when narrating a stressful event or a stressful story. Whereas, those that do not dissociate seem to have increased heart rate but increased heart rate does not seem to be a good marker because it depends where your baseline is. What seems to be a good marker is how long is the latency? i.e. how long it takes you to return to your baseline heart rate after a stressor. So, if the stressor increases your heart rate, kids that are vulnerable or have PTSD will take longer in coming back to a baseline heart rate.
We concentrated on looking at cortisol and identifying what would be a good cortisol marker for this kids. What we find is that these kids have the normal circadian rhythmicity that you would expect (i.e. higher at the beginning of the day and going down at the end of the day) but then at the end of the day it seems to be elevated so these kids have high levels of cortisol. That is what we found about 10 years ago but what we found out years later is that that variable of” time since trauma” is very important.
What we did is we looked at a big sample of kids and we looked at those that had had trauma during the past year and those that had trauma prior to that year. We hypothesized that our theory of increased cortisol was going to hold true for the kids that had it in the past year but not for the others. What we actually found was exactly that and we found 2 reverse correlations where if you had events in the past year, the higher your cortisol, the higher your symptoms of PTSD. Whereas, for the other individuals that had experienced trauma from a long time ago and were still with symptoms of PTSD, the more symptoms, the lower the level of cortisol.
But in general, I would say, that high pre-bedtime (before you go to bed) cortisol in kids, I am starting to think of that as a marker of pediatric PTSD.
Now, if you have these high levels of cortisol, the next normal question was to see what is going on in the brain because of the potential neurotoxicity of cortisol at high levels every day, right? So, we looked at kids who were experiencing chronic trauma i.e. physical abuse, sexual abuse and witnessing a lot of violence.
Cross sectionally there were no significant findings. But in 2007, we followed 15 kids for 1-1 ½ years and we saw that there was a correlation between high cortisol, (pre bedtime) cortisol, and decreased volume from time1 to time 2 of the hippocampus.
Of course, the hippocampus is important for memory storage and retrieval so we did a task in functional MRI, a verbal declarative memory task, to look at encoding and retrieval in kids. We saw that in the control/healthy group, with no history of trauma and no PTSD symptoms, was activating significantly more hippocampus than the PTSD kids were. So we were not seeing the volume differences but, functionally, you can see that the hippocampus really does not work as well in kids with PTSD.
We then decided to look at emotional regulation. We did the faces task and saw that kids that have PTSD activate their amygdala significantly earlier when viewing an angry face. When viewing a fearful face, there was a trend for their pre-frontal cortex to not be as activated as it was in the healthy controls. But the interesting thing about the amygdala activation is that, potentially, what we are talking about is a neuro functional marker of hyperarousability for these kids who have a history of exposure to interpersonal violence. For these kids, the face of someone angry is a cue/trigger and we here see the amygdala getting activated.
So then, we started thinking that treatments that treat these kids better pay attention to emotional regulation, memory processing, and executive function. The other thing we realized is that we could increase the empirical validity of some treatment interventions by demonstrating that they can lower cortisol or decrease amygdala function on this task and so forth.
SJ: What are the most common misperceptions/misunderstandings regarding the impact of traumatic stress on child development?
VC: There used to be this idea that children were resilient just by virtue of being children but there is no literature to really back that up. In fact, we know the opposite. We know that you are more vulnerable when you are younger, when you do not have defensive styles, when your brain is still developing, when your physiology is still developing. It affects you more.
SJ: What are effective treatments for children with PTSD? (psychological therapies and pharmacotherapies)
VC: Trauma focus cognitive behavioral therapy is the treatment of choice. It is a treatment that was developed to treat children who have experienced sexual abuse but it has now been adapted to be used in different settings including for children who have witnessed domestic violence.
One of the things that Judith Cohen (the developer of trauma focused CBT) and I are talking about is the need to develop algorithms for treatment. So, the age of the kids, the type of trauma and duration of the trauma would determine which specific treatment a child would get.
But certainly, the first line of intervention for children that have PTSD is psychosocial interventions and it is not medication. Now, do I use medication? Yes. I use medication in 2 scenarios. One, when there is comorbidity and the comorbidity in PTSD is high, it is 80%. So if the child has major depression, in addition to the PTSD, I would want to treat that. That is one scenario. The other scenario is when the severity is so high that this individual may have difficulties engaging in their psychosocial treatment.
But the reality is that we have no pharmacological agent that would target all the neurotransmitter systems that traumatic stress impacts.
We actually developed a manual to treat kids called the Cue-Centred Treatment Protocol. The whole idea here is that it is a hybrid. It has different components that we know help kids, it has: CBT, exposure and psycho education and insight orientated therapy. But the main thing that it does is that it empowers children to be their own agent of change. It is not so much about processing a narrative as teaching you how important a narrative is because the chances that these kids will continue to have traumas after we finish treatment is still pretty high and we want these kids to be equipped in knowing what to do.
We did a randomized controlled trial in East Palo Alto and Hunters Point in Bayview at some schools there and the treatment has shown efficacy to decrease PTSD symptoms and anxiety symptoms when compared to kids put on a wait list.
There are some family interventions too. One is called parent-child psychotherapy. This is worked by Alicia Lieberman at UCSF
where she helps children age zero to 5. It gives treatment to both the parent and the child, it is more about their dyad, their relationship and that has also been shown to be effective.
SJ: What are the factors that determine how children, with PTSD, will respond to treatment?
VC: With children, there are 3 factors that we think are very important to the outcome of the psychosocial intervention: Intelligence, motivation, and psychological mindedness. If a child is motivated and they can talk about feelings and they are smart, then the treatments will likely work. For some special populations, like children with mental retardation that get traumatized or children in the juvenile justice system we still need more effective treatments.
SJ: What types of preventative interventions/public health measures do you think are key to reducing the amount of violence children in our society are exposed too?
VC: One of the things that I have done for the past 3 years is that I have been part of this coalition in San Francisco where we have built an ecological approach to the problem of trauma. Rather than just concentrating on models or treatments for the individual, we think of the whole system. We think about their school, we think about their family and how can we, in one place, do preventive work or treatment. We have developed this Centre for Youth Wellness (CYW) which is a place that integrates paediatric care with mental health. So, every time they come for their paediatric checks, they get additional screenings for trauma. In that way, we know very early if they had traumatic events or not and then we start working with them, but not only with them, with their families and with the primary care team that is taking care of them in the same place.
The CYW is also co-located with the CAC i.e. the Child Advocacy Centre. The CAC is the place that, when something traumatic happens, the child will come here get their forensic evaluations and physical exams etc. So, if that family shows up with kids to the CAC, the other siblings can be enrolled right away in the Centre for Youth Wellness. So, we are concentrating a lot on prevention, on interdisciplinary work and concentrating on developing new treatment methods that are empirically validated.
At Ravenswood Family Health Centre, here in East Palo Alto, we have this model where we have a behavioral health worker working with the pediatricians. We looked at referrals and found that when we did a “warm hand off” (between psychiatry and the behavioural health person) there was significantly more follow through and less no shows for treatment.
SJ: What do you envision will be key obstacles to progression in this field? Or what are the major controversies in this field that need to be resolved?
VC: The way that ground mechanisms work in terms of funding for 3 or 5 years or maybe even less than that. This makes follow up research very difficult. We need longitudinal studies to advance our knowledge of what goes on in PTSD.
SJ: What do you envision will be key advances in the treatment/understanding/prevention of traumatic stress in children in the next 10-20 years?
VC: I think working with mathematicians will advance our field, because I think that mathematical formulas are going to help us understand how these variables interact with each other e.g. like genetics and severity of the traumatic event.
I get excited about treatment interventions that can demonstrate that they can actually alter the physiology of someone who struggles with PTSD.
I am excited to know more about how stressors and traumatic events impact the physical health of the individual, for example, through atherosclerosis or pro-inflammation and things like that. This will inform not only our psychiatric practice but I think medicine in general and the role of environment in medicine.