The child exhibits at least one of the following avoidance symptoms or changes in his or her thoughts and mood. These symptoms must begin or worsen after the experience of the traumatic event. 1. Avoidance of or the attempted avoidance of activities, places, or reminders that bring up thoughts about the traumatic event. 2. Avoidance of or the attempted avoidance of people, conversations, or interpersonal situa- tions that serve as reminders of the traumatic event. 3. More frequent negative emotional states, such as fear, shame, or sadness. 4. Increased lack of interest in activities that used to be meaningful or pleasurable. 5. Social withdrawal. 6. Long-standing reduction in the expression of positive emotions. D. The child experiences at least one of the below changes in his or her arousal or reactivity, and these changes began or worsened after the trau- matic event: 1. Increased irritable behavior or angry outbursts. This may include extreme temper tantrums. 2. Hypervigilance. 3. Exaggerated startle response. 4. Difficulties concentrating. 5. Problems with sleeping. In addition to the above criteria, these symptoms need to have lasted at least 1 month and result in con- siderable distress or difficulties in relationships or with school behavior. Finally, the symptoms cannot be better attributed to the use of ingestion of a sub- stance or some other medical condition. In summary, children must experience disorganized or agitated behavior. Children usually do not have a sense they are reliving the past, but rather relive the trauma through repetitive play. Their nightmares of the traumatic event may change to more generalized night- mares of monsters or of rescuing others. A foreshortened future for a child generally involves a belief that they will never reach adulthood. Children may believe they can see into the future and can forecast ominous events. Physical symptoms may appear that include headaches and stomachaches that were not present before the event (American Psychiatric Association, 2000, p. 466). For a long time prevailing wisdom was that young children were not developmentally mature enough to be affected by trauma and as a result couldn’t “catch” PTSD (Bosquet, 2004; Osofsky, 1995). If anything their reaction to disasters would be fleeting. How- ever, with growing research in the field we now know that is anything but true (Devoe et al., 2011; Osofsky et al., 2010). Of the 74 million children in the United States, 30% to 50% will experience at least one trau- matic event by their 18th birthday and will probably comprise a substantial proportion of the 2.5 billion people who have suffered some kind of disaster in the last decade (Kazdin, 2008). Trauma for children is also homegrown, with about 1 million cases of sub- stantiated child abuse in the United States reported yearly (DeAngelis, 2007). Of those who experience at least one trauma, somewhere between 3% and 16% of girls and between 1% and 6% of boys will develop PTSD. What type of trauma children experience makes a big difference. Almost 100% of children will get PTSD if they see a parent killed or sexually assaulted. Approximately 90% of sexually abused children will develop PTSD. Around 77% of children who witness a school shoot- ing experience PTSD, and even witnessing neigh- borhood violence has a “catch” rate of about 35% (National Center for PTSD, 2011). It shouldn’t take a Ph.D. in child psychology to figure out that PTSD and its treatment are differ- ent in children by the mere fact of their developmen- tal levels (Saxe, Ellis, & Kapow, 2007). There is now accumulating evidence, including age of onset, dura- tion, sequence, and co-occurrence of trauma events, which is providing the groundwork for a developmen- tal model that builds on these variables and begins to plot the trauma pathways that are created as the child moves from middle childhood to adolescent to young adulthood (Steinberg et al., 2014). Indeed, PTSD manifests itself very differently in children than in adults in terms of symptoms (DeAngelis, 2007; Terr, 1979, 1981, 1983, 1995) and in how it affects the neu- rodevelopment of children (Saxe, Ellis, & Kaplow, 2007, pp. 23–45; Zilberstein, 2014). Thus, not only because of their age, but also be- cause of how children attempt to cognitively handle trauma, even though TF-CBT is seen as a treatment of choice (Chard & Gilman, 2014; Jensen et al., 2014), PTSD in children calls for treatment strategies that are very different from those used with adults (Clay, 2010; Cohen, Mannarino, & Deblinger, 2006; Ford & Courtois, 2013; Malchiodi, 2008; Saxe, Ellis, & Kaplow, 2007; Webb, 2007). Reactions to violence and trauma in children vary greatly and are dependent on their temperament, chronological age/developmental stage when the traumatic event occurred, whether support systems were and are nurturing or toxic, what the ecosystem of the community was and is like, and the degree, and duration of the trauma (Fairbank et al., 2014), do not make a one-size-fits-all treatment approach. To that end, the National Child Traumatic Stress Network (NCTSN) has been formed (Steinberg et al., 2014) to integrate trauma-informed services and evi- dence- based practices throughout the United States in clinical and community settings. Practitioners can avail themselves of its services at www.nctsn.org. A wide range of training resources may be downloaded at http://learn.nctsn.org, and NCTSN also has an on- line knowledge bank developed by network centers at http://kb.nctsn.org.
now you should clearly understand that support systems are critical in crisis intervention. Supportive family systems are even more critical for children in their attempts to master a trauma (Cohen, Mannarino, & Deblinger, 2006; Courtois & Ford, 2009; Devoe et al., 2011; Saxe, Ellis, & Kaplow, 2007; Yule, 1998). Family support systems are important in regard to events both external and internal to the family system. Generally in this chapter we are speaking of family support in the context of a traumatic event that occurs external to the family, such as a hurricane or 9/11. We will speak to family support (or lack thereof ) when the trauma is generated within the family, as in child abuse, in Chapter 9, Sexual Assault. Bowlby’s (1982) attachment theory is particularly relevant to traumatized children. In many of the traumas children experience, they are separated from their parents, their homes, and even their com- munities without warning or preparation. It should come as no surprise that such traumatic separation carries with it a smorgasbord of emotional and pe sonality disturbance. Anxiety disorders, physical maladies, depression, panic attacks, rage reactions, and phobic reactions are common comorbid disorders of childhood PTSD. These are magnified even more when families are rent asunder by a traumatic event and support systems literally disappear in front of the child’s eyes (Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Norris et al., 2002) and are even more profound when the young child per- ceives a threat to the caregiver (Devoe et al., 2011). The final ingredient in this witch’s brew of pathology is the unresolved grieving that accompanies loss of loved ones when children do not yet have the cognitive ability to understand and resolve their loss (Cohen, Mannarino, & Deblinger, 2006; Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Yule, 1998).