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Post-Traumatic Stress Disorder (PTSD) and Trauma in Children and Youth: Information for Families and Caregivers

Summary: Ask any parent, and most likely they'll say they want their children to have a happy childhood. Unfortunately, many children/youth end up being exposed to stressful, traumatic situations. Examples of traumatic experiences for children experiencing child abuse or neglect; loss of a parent; parental separation or divorce; bullying, including from other family members; experiencing natural disasters or accidents. After a trauma, many children/youth will be able to cope and overcome their trauma. However, others may struggle with coping with their trauma, and may have symptoms such as flashbacks, hypervigilance, and avoidance of reminders of their trauma. Some may even develop post-traumatic stress disorder (PTSD). The good news is that there are many things that can be done to support a child/youth who has experienced trauma.
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Introduction

Ask any parent what they want for their children, and most will say that they would like their children to grow up safe and happy.  Unfortunately, many children and youth end up experiencing stressful and traumatic events in their life. 


Examples of trauma include:

  • “Acute”, single incident trauma, such as being in a car accident; being physically assaulted; experiencing a fire, flood, earthquake or other natural disasters; experiencing war, as a soldier or a civilian. 
  • “Chronic”, repeated trauma which happens over and over again, such as: child neglect, physical or sexual abuse, domestic violence; bullying (from peers or siblings); having a chronic medical illness. 

What Happens During a Traumatic Event? 

In order to survive, human beings are wired with an alarm system that becomes triggered when we encounter stressful events. 

Let’s say you encounter a sabre tooth tiger. 

This activates our body’s autonomic nervous system (ANS), also known as our body’s alarm system. This all happens at an unconscious level, automatically. It leads to a ‘fight/flight/freeze’ response, to either 1) fight the danger, 2) take flight and run away from the danger, or simply 3) freeze (e.g. holding your breath when you are overwhelmed; playing dead so that a bear leaves you alone.)  

After the threat passes, our body’s autonomic nervous system returns to a calm state, i.e. our alarm shuts off. Our alarm system is well designed for typical dangers that hunter-gatherers would face, e..g being attacked by wild animals. 

In PTSD however, the person’s nervous system is overwhelmed from the trauma, or from repeated trauma, and their alarm system becomes always on, and easily triggered. 

What Helps Children/Youth Overcome Trauma? 

Many children and youth are able to overcome their traumatic experiences. 

Protective factors that help a person get over trauma include:

  • Feeling connected to loving parents and adults;   
  • Being physically healthy.  

What Makes A Child/Youth Vulnerable? 

On the other hand, some children and youth have more difficulties coping with their trauma. 

They may have “vulnerability factors” such as:  

  • They may have already faced excessive amounts of stresses or trauma in their life (e.g. bullying, stresses at school or home, mental or physical illness in family members; substance use issues in family members).

Signs and Symptoms

When the brain is overwhelmed by stress and trauma, it becomes unable to normally process memories and feelings, and there may be the following symptoms: 

Re-living (aka ‘re-experiencing’) the traumatic event. 

Examples include:

  •  Flashbacks, which is an experience of seeing, hearing and feeling that one is going through the event all over again (more common in teens than young kids)
  • Nightmares of what happened, which makes it very hard to sleep;
  • Re-enact the trauma in their play or in their drawings; 
  • Intrusive memories of the trauma. . 

These symptoms can be triggered by things such as:

  • Seeing or hearing things that remind the person of the trauma
    • E.g. a person who was assaulted sees a news report about someone else being assaulted and the memories come back, or they see the person who assaulted them on a bus
    • E.g. a person who was raped is triggered by a sexual education class 

Avoiding situations and reminders of the traumatic event


The traumatic event is so stressful, that the child tries to avoid situations or reminders of the event such as:  

  • Refusing to talk or think about the event
  • Avoiding people, places or activities that remind the person of the event. This can be a real problem if it’s part of their everyday life, like school or the bus.
  • Keeping busy and distracted in order to avoid having to think or talk about the event.

Feeling negative or numb since the event happened

When trauma happens, it can: 

  • Make people feel that the world is unsafe by activating the brain’s alarm system.
  • Make the child blame him or herself for the event. 
  • Make it harder to feel pleasant emotions such as happiness. 
  • Make it hard to express his/her feelings as a way of avoiding memories. 
  • Be so stressful that the brain forgets about parts of the trauma in order to protect itself.

Examples include: 

  • The child may withdraw from friendships and relationships 
  • The child may lose interest in usual hobbies / activities  
  • The child may be so overwhelmed that s/he refuses to talk about what happened

Feeling keyed up (also called hyperarousal)

Following the trauma, the child continues to feel on alert, and unsafe, which can lead to: 

  • Troubles with sleep
  • Feeling irritable, angry
  • Troubles focusing 
  • Being always on the lookout for danger 
  • Being easily startled by other people 
  • Being reactive to things that don’t make sense to other people, eg being terrified by men with beards, getting mad when they feel someone is being threatening
  • Changes in one’s worldview: It is natural that when bad things have happened to people, or when they have experienced significant loss or stress, they may try to make some meaning out of what has happened. With children and youth, trauma may cause them to feel that
    1) “the world is not a safe place”, “I cannot trust the others”, and
    2) “I’m no good”, “I’m incompetent.” “I can’t keep myself or other people safe”.

Self-Help Strategies for Parents and Caregivers

Do’s

Self-Care for Parents and Caregivers

  • Ensure that as a caregiver or parent, that you have your own support network that you can turn to, such as 1) family and friends, 2) parent and peer support organizations, and 3) your own health professional. 

Physical safety

  • Keep your child safe. Ensure that your child is no longer exposed to people or things that are triggers for them, to whatever extent is reasonable. 

  • Keep the physical environment a soothing, calming environment. After trauma, people’s senses may be more on alert, as it is a way to try to detect threats. Thus, reduce the amount of sensory overload by having less input, or use soothing input: 
    • Visual 
      • Try to reduce visual clutter in the background.
      • When talking with your child, be mindful of your facial expressions -- try to have a calm, warm, relaxed facial expression. Be mindful they may be hypersensitive to interpreting your stressed out face as being angry at them.  
    • Sound: 
      • As a result, try to keep the background quiet, e.g. don’t have TV playing in the background. If you do have background music or sound, consider classical music, nature sounds.  
      • Volume and tone of voice: When talking with someone who has been through traumatic or frightening experiences, use a slow, calm tone of voice, and avoid talking loudly, as well as screaming or yelling. 
    • For more information about using sensory interventions to help calm someone

Have regular routines

  • For key routines like wake up, breakfast, morning activities, afternoon activities, dinner, bedtime routines, try to have a stable set of routines for your weekdays and weekends. Having more stable routines, even on weekends, helps with safety. 

Lifestyle strategies 

  • Getting enough sleep
  • Eating regular, healthy meals
  • Avoid caffeine, or other substances that might ‘rev up’ the nervous system
  • Getting outside time with nature 

Mental wellness  

  • Reconnect the child/youth to people and activities that bring a sense of 
    • Belonging (e.g. spending one on one time with nurturing adults) 
    • Purpose (e.g. meaningful activities) 
    • Hope and meaning (e.g. providing a child with a sense of spirituality) 

Be aware of triggers. 

  • Be aware that certain occasions, events and anniversaries may remind the child of the trauma, which may lead the child to feel unsafe and become upset, even if the child is not able to verbalize this.
  • Are you noticing your child is upset for no obvious reason? Accept that they may have been triggered. If your child is unable to express the trigger, then focus on supporting your child to get calm, rather than trying to figure out the cause. You might gently say, “I notice you’re breathing faster, and your face is red. How about we sit down on the couch, and I’ll make you a tea and we can sit together with the dog.” When your child seems calm enough, you might gently ask about what the trigger might have been.   

Empathy

  • Do see things from your child’s perspective, and how having gone through what s/he has gone through, and how this would make it hard to trust others and/or see that the world is a dangerous place.
  • Do provide unconditional love, validation and acceptance. Children feel emotionally safe when they feel that they are loved and accepted no matter how they are feeling, or how they are behaving. People feel less safe, if they feel that they are only loved conditionally, i.e. they are only loved or accepted as long as they are a certain way.  
  • Empathize with sadness, and promote crying. 
    • Allow your child to feel sad and cry. When someone has had a trauma, there is always something that has been lost.
      • E.g. a child in a car accident loses a parent.
      • E.g. a child who is assaulted loses the concept that the world is a safe place. 
    • Allow and encourage crying, as tears help the brain to process the trauma and the loss. 
      • E.g. Parent: “You’re sad. Its okay, it is a sad situation. Let the tears out… It’s important to let them out… Here’s a kleenex…”
  • Empathize with anxiety 
    • Accept that your child may be feeling scared and anxious. 
    • Example
      • Child: “I don’t want to (insert activity here)... I’m scared.”
      • Parent: “You’re feeling scared… That’s okay… I’m here… Let me give you a hug…” “How can I support you?” “How can I be helpful?”
  • Empathize with frustration and anger
    • Do accept that your child may get frustrated easily, and have more problems with anger and even meltdowns.
    • Accept your child’s feeling of frustration and anger, and search for the feeling beneath the anger, e.g. fear, frustration, sadness, guilt, shame, etc. Then you can support your child with that deeper feeling. 
    • Example 
      • Child: “I’m not going back to school -- its stupid!” 
      • Parent: “I know it’s scary to go back. That’s okay… I’m here to help…”

Validate. 

  • Validation is when we acknowledge and accept how the person is feeling, given what has happened to them. Sometimes we have to see if we can figure out what the underlying feelings are from the behaviour that we see. Validation does not mean approving of behaviour we don’t like - it means accepting the feelings that underlie the behaviour.

Try validating… 

Rather than invalidating...

“You’re feeling scared…”

“There’s nothing to be scared about!”

“You’re feeling sad…”

“You shouldn’t feel sad about this…”

“You feel guilty… What a kind, caring person you are…”

“You shouldn’t feel guilty…” 

Normalizing: “It’s okay to feel (sad, guilty, etc.) -- everyone feels (sad, guilty, etc.) sometimes. Its part of being human.”


Offer support and be respectful of your child/youth. 

  • Offer to do a coping strategy or distraction with your loved one. “Let me give you a hug…” “Let’s go outside…” 
  • Are you unsure, or dealing with a teen? 
    • Ask them: “I’m here for you. How can I support you?” 

Compassion and acceptance. 

  • Many people are self-critical, which is not helpful. It is important to help your child develop self-compassion and self-acceptance, i.e. the ability to accept oneself. 
  • Was your child was thoughtful and nice to his brother? You might say “Thank you so much for being thoughtful and nice to your brother.” (as opposed to just saying, “Good job for being nice!”) 
  • Praise can be difficult for some people. The problem with praise is that it is judgment, though positive judgment. Deep down, children don’t want to be judged -- they want to be loved no matter what.
  • For more information about self-compassion,
    http://www.ementalhealth.ca/index.php?m=article&ID=52807  

Be supportive

  • Ask your child how s/he would like to be supported, “How can I support you?”

Do accept that your child might regress when s/he is overwhelmed. 

  • When overwhelmed, some children/youth may regress and behave like they did when younger (e.g. sleeping with the lights on; needing a stuffed animal to bed; needing more cuddling with a parent). 
  • Do accept that it means your child is overwhelmed, and needs your support more than ever.
  • Don’t criticize or get upset at your child for this behavior.

Do look beneath negative behaviours.

  • Is your child misbehaving? Try to focus not on the behaviour, but on what is underneath. When your child is calm enough to take your feedback, express your frustration or sadness in a calm way. 
    • Validate your child’s feelings. “I know you were frustrated at your sister. It’s okay to feel frustrated. 
    • Problem-solve: “When you get frustrated, you can let me know.” 
    • Teach emotional intelligence: “How do you think your sister felt when you hit her? When you hit your sister, it made her really sad and hurt.” 
    • Take a parent time out if you need. Are you feeling so angry and frustrated that you can’t stay calm? If so, go take a time out until you are feeling calmer.

Coping with Stresses 

  • What other stresses is your child under? 
  • Are there any expectations / demands that can be reduced? E.g. "picking your battles"   
  • What can be done to address the stress, or help the child cope better? 

Peer support: 

  • Consider connecting with peer / support groups for survivors of trauma, as well as family members and parents (if available). 

Don’ts 

Don’t give advice unless people are ready for it

  • When supporting a loved one, be careful about giving unsolicited advice or suggestions.

Don’t force your child to talk if s/he doesn’t want to. 

  • Talking about trauma can be overwhelming, and/or your child may not feel safe enough to talk about it.

Self-Help: Coping with Flashbacks

 Is your child having problems with flashbacks or dissociation?

  • Between flashbacks or dissociation, talk with your child about trying a strategy such as the following during an actual flashback or dissociative episode. You might say, “I’d like to talk to you about some things that we could try during a flashback, or when you space out. What do you think about trying the following?” 
  • Orient your loved one. 
    • You might say: “Hi ___... It’s me, mom… It’s Saturday… We’re at home….”

  • 5-4-3-2-1 exercise
    • You: “Let’s think about 5 things that we can see…” 
E.g. other people, things in the room or outside 
    • You: “Let’s think about 4 things we can touch and feel…”
E.g. E.g. stomp the ground, rub or clap your hands together, feel your pulse
    • You: “Let’s think about 3 things we can hear…”
E.g. sing a song, talk to yourself, turn on the radio, the sound of the wind or birds  (i.e. turn on music, sing out loud etc.)”
    • You: “Let’s think about 2 things you can smell (put lotion on your hands etc.)”
E.g. lotion on your hands, lip balm, chewing gum, sucking on ice chips, popsicle, mints, perfume   
    • You: “Let’s think about 1 thing that we are grateful for….” / “Or one thing positive…”

Learn more about grounding strategies 

Bilateral brain stimulation. 

Therapies such as eye movement desensitization and reprocessing (EMDR) and brainspotting (BSP) use techniques that stimulate alternating sides of the brain. 

Ways that you can do some of this on your own include:

  • Listen to biolateral music. Whereas most standard music involves the left and right channels, biolateral music is designed to alternate between the left and right channels. Biolateral music can be online from various places including Youtube,  iTunes, Android store, and websites such as www.biolateral.com, www.bodhitreebilateral.com.  

  • Practice alternate nostril breathing. Alternate nostril breathing (aka “nadi shodhana”) is a form of breathing in yoga. It involves alternating one’s breathing between one’s left nostril, then the right nostril, and doing this for several minutes. Learn more from any yoga instructor, or online  
https://www.artofliving.org/yo...
  • Do butterfly hugs. There are many videos showing how to do this, such as 

When and Where to Find Help 

Has your child/youth had a traumatic event? 

  • If so, start by re-establishing normal life routines, and supporting them with the strategies described above. 

Is your child still struggling with problems coping, and/or with symptoms with PTSD?

  • If so, consider seeing a health professional.  

What Types of Professional Treatment Are Available?

Many treatments are available such as counseling/therapy and medications.

1. Counseling / therapy 

What types of treatments exist for trauma?

Depending on the therapist, there might be different types of trauma treatment such as:  

  • Trauma-focused cognitive-behavioral therapy (CBT): Looks at negative, unhelpful thoughts and replaces them with more helpful, positive thoughts. Behavioral strategies can be used at a child's own pace to help desensitize the child to the traumatic parts of what happened so he or she doesn't feel so afraid of them. Therapy can be 1:1 (where a therapist meets individually with the child/youth), or it may be in a group format with 1-2 therapists with 5-10 children/youth.  
  • EMDR and related ‘sub-cortical’ treatments such as brainspotting and progressive counting): These are types of therapies designed to help the brain cope with trauma without needing to talk about the trauma in the way that classic talking therapies require. 

Professionals (such as psychotherapists, psychologists, and social workers) will typically use a “sequenced” approach with 3 phases: 

Phase I (Early Phase) 

Involves getting to know and trust the therapist; 

Learning about self-care, how to cope with symptoms, and learning about self-regulation. 

Phase II (Middle Phase)

Exploring the trauma in greater detail, in order to help the patient process, work through and make sense of what happened. 

For example, rather than believing that “it happened because I am a weak person”, the person might see that “it happened and it wasn’t my fault, and I can move on from this…”

Phase III (Late Phase) 

Working on strategies to help the patient get back into their life such as school, work, home and relationships.

It is usually recommended to start with counseling/therapy. However, sometimes people are so distressed, that counseling/therapy is not possible.  

2. Medications

Have non-medication strategies, such as counseling, have already been tried, but not been helpful? 

  • If so, medications might be helpful. Talk to a physician (such as a family physician, paediatrician or psychiatrist) to ask about medications. 
  • Medications are not meant to be used alone as the sole treatment. Rather, medications can help reduce a person’s distress and anxiety, to the point that then the person is able to benefit from other treatments (such as counseling/therapy). 

3. Peer Support 

Interested in working together with others going through the same thing? 

  • If so, then peer support can be very powerful. Peer supports may include support for parents/caregivers, as well as children/youth affected by trauma.. 

For More Information 

AnxietyBC

Home management strategies for PTSD

https://www.anxietybc.com/parenting/home-management-strategies-ptsd 

PTSD in Children/Adolescents from KidsHealth

http://kidshealth.org/en/parents/ptsd.html#

Authors

Written by the members of the Mental Health Promotion Committee at the Children’s Hospital of Eastern Ontario (CHEO). Special thanks to Yehudis Stokes (RN, trauma-informed care). 

References

Au et al: Compassion-Based Therapy for Trauma-Related Shame and Posttraumatic Stress: Initial Evaluation Using a Multiple Baseline Design, Behaviour Therapy, 48(2): Mar 2017, 207-221.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Date Posted: Apr 27, 2018
Date of Last Revision: Dec 14, 2020