This guest post is by Dr. Alexandra De Young. Alexandra is a clinical psychologist and research fellow. Her expertise lies in the impact of burns trauma on very young children and their parents.  She currently works at the Centre of National Research on Disability and Rehabilitation Medicine (CONROD), University of Queensland, where she conducts research on the assessment, diagnosis and treatment of accidental trauma in children. 

Five key considerations for working with young traumatized children:

1. Young children are a high risk group for exposure to traumatic events

Infants, toddlers, and preschoolers are particularly vulnerable to trauma exposure due to their stage of development.  Young children interact with their environment before they become aware of potential dangers and threat, are strongly reliant on adults to keep them safe and have limited skills to protect themselves. As a result, young children typically fall within the highest risk category for exposure to sexual and physical abuse, unintentional injury and witnessing domestic violence.  Other potentially traumatic events for young children include natural disasters, war, terrorism, painful medical procedures and witnessing a threat to their parent/caregiver.

It is important to be aware that what a young child perceives to be threatening may be different to adults.  Additionally, young children are at risk of making false assumptions or drawing the wrong conclusions which can compound the negative impact of the trauma (e.g. “The burn happened because I was bad”).  Further, due to their limited verbal skills, it may not always be obvious that a young child has experienced a traumatic event.

2. Young children can develop posttraumatic stress disorder (PTSD)

There is a common misconception that young children (< 6 years) are not affected by trauma. Due to their limited developmental capacities there has been scepticism about the ability to diagnose PTSD or other anxiety and mood disorders during early childhood. However, there is now a strong empirical data base that indicates that young children do indeed develop PTSD. Young children also present with many of the same PTSD symptoms as older children, adolescents and adults (i.e. reexperiencing, avoidance and hyperarousal). However, due to unique developmental differences, trauma symptoms can manifest differently in this age group.  In response to concerns raised about the appropriateness of the DSM-IV PTSD criteria for preschool children, the DSM-V Task Force have proposed an age-related subtype of PTSD for preschool children.

3. Comorbidity with PTSD is common

Recent research has reported that there is a high rate of comorbidity with PTSD during early childhood. Separation anxiety disorder and oppositional defiant disorder are the most common disorders that follow or emerge concurrently with the onset of PTSD. It also appears that new onset non-PTSD disorders that develop following a traumatic event usually occur in the presence of posttraumatic stress symptoms.

Parents are typically poor reporters of child internalizing difficulties and this is particularly the case for parents of pre-verbal or barely verbal children. There is therefore the risk that the common and more easily observable disruptive trauma-related symptoms (e.g. tantrums, irritability, aggression, poor concentration) are mistaken for the “terrible twos” or misdiagnosed and mistreated as a behavioral disorder (e.g. ADHD or ODD). Accurate diagnosis, formulation and treatment planning will be greatly improved by good history-taking about exposure to potentially traumatic events, the timing of symptom onset and knowledge that PTSD may be the underlying basis of new disorders following trauma exposure.

4. PTSD during early childhood can follow a chronic and debilitating course

Thankfully, most young children are resilient or only experience transient distress following exposure to a traumatic event. However, studies with injured preschool children have shown that approximately 10% are at risk of a chronic PTSD symptom trajectory. Further, a 2-year longitudinal study has demonstrated that PTSD symptoms did not remit over time or from community treatment in preschool children with mixed traumatic experiences.

These findings are particularly concerning given that young children’s neurophysiological systems are still in the process of rapid development. Additionally, trauma during childhood has been associated with permanent structural and functional brain impairment as well as the onset of psychiatric disorders, health risk behaviors and physical health conditions in adulthood. Thus trauma that occurs during early childhood may have even greater ramifications for developmental trajectories than traumas that occur at a later stage of development. Early intervention is therefore essential!

5. The impact of trauma should be considered within the context of the parent-child relationship

It is widely recognized that the quality of the parent-child attachment, parental mental health and parenting behaviors are crucial factors that influence a child’s adjustment following trauma. For young children, the parent-child relationship is particularly important as they need a sensitive and emotionally available caregiver to cope with strong emotions during times of distress. Additionally, young children often look to their parents to determine how to interpret or respond to an event and may therefore model their parent’s fear responses and maladaptive coping responses. Parents can also influence their child’s recovery from trauma by accommodating avoidance behaviors or allowing their child to be repeatedly exposed to trauma reminders. Interventions that target child distress, parent distress and the parent-child relationship are likely to be beneficial in reducing the subsequent development of parent and child posttraumatic stress reactions.

Useful websites:

• Tulane Institute of Infant and Early Childhood Mental Health: Measures & Manuals
• US National Child Traumatic Stress Network
• Zero to Three: US National Center for Infants, Toddlers, and Families

References:

Young, A., Kenardy, J., & Cobham, V. (2011). Trauma in Early Childhood: A Neglected Population Clinical Child and Family Psychology Review, 14 (3), 231-250 DOI: 10.1007/s10567-011-0094-3
De Young, A., Kenardy, J., & Cobham, V. (2011). Diagnosis of Posttraumatic Stress Disorder in Preschool Children Journal of Clinical Child & Adolescent Psychology, 40 (3), 375-384 DOI: 10.1080/15374416.2011.563474
De Young, A., Kenardy, J., Cobham, V., & Kimble, R. (2012). Prevalence, comorbidity and course of trauma reactions in young burn-injured children Journal of Child Psychology and Psychiatry, 53 (1), 56-63 DOI: 10.1111/j.1469-7610.2011.02431.x