One afternoon when 7-year-old Maya and her mother were returning home from a family party, they got into a car accident. A red tractor trailer rear-ended them, trapping Maya in the back seat. Fire trucks raced to the scene, lights flashing and sirens blaring, and emergency workers extracted her from the vehicle. She wasn't seriously injured, nor was her mother. But there was blood and bruising, and Maya was scared. She thought she would die.
After the accident, Maya protested every time her mother put her in her carseat. She begged her mother not to drive past the spot where the crash occurred. Whenever her mother did, Maya seemed to freeze up. She also had nightmares about scary things -- not necessarily the accident. And she no longer wanted to play and sing like she used to. Her parents felt they had lost the child they used to have.
Maya has post-traumatic stress disorder, which affects more than 400,000 children each year. Children must have the ability to remember an event in order to develop PTSD, which means it's usually not diagnosed in children under age 3. Seventy percent of adults and children who are exposed to trauma -- such as an accident, a natural disaster, or violence in the home -- do not develop PTSD. The other 30 percent -- more than 400,000 children under the age of 6 -- do, according to Michael Scheeringa, M.D., who is a professor of child psychiatry at the Tulane University School of Medicine in Louisiana and specializes in the treatment of PTSD.
There are three categories of PTSD symptoms:
In order to develop PTSD, children must have lived through an experience that induces a sudden panic and sense that they could die or someone else might die. "Watching scary things on TV or hearing about them in the news will not give them PTSD," Dr. Scheeringa explains. "It may bother them and distress them, but that's not the same as PTSD. You need to actually be in harm's way or see someone else in harm's way."
Experts aren't sure why some people who experience trauma develop PTSD and others don't. Factors you might think could be accurate predictors (such as the severity of the trauma or age of the child when it occurred) don't pan out in the research. "For every case in which you can find something to blame, you can find other cases where kids in the same circumstance did not develop PTSD," says Dr. Scheeringa. "So it has to be something individual to each person -- possibly genetics."
Cognitive behavioral therapy (CBT) is the first-line treatment for PTSD. "The child systematically goes through education about the trauma and learns new skills in order to cope with her symptoms," explains Dr. Scheeringa. The first CBT session involves talking about what PTSD is. "We give a name to what she has so she can understand what it is and that she's not alone," he says.
In the second weekly session, he works with the child's parents on behavioral issues. "Defiance at home is a common problem after trauma, so we develop discipline plans to reduce oppositional behavior. We do this before we even get into a discussion about the actual trauma," says Dr. Scheeringa.
In subsequent sessions, the child is encouraged to talk about her emotions and where she physically feels them in her body (such as the heart, stomach, or throat). She also learns relaxation skills including muscle relaxation and deep breathing.
Only then does the work of "exposure" begin -- in which the child is slowly guided to revisit the trauma and learn to cope with the resulting anxiety. Maya, for example, may be asked to choose one component of her trauma, like the fact that it was a red truck that hit her family's car. She will then draw the truck, talk about how she feels, and use her relaxation techniques when she gets anxious.
After that, her "homework" will be to go into the community with her mom and find a red truck and look at it for 30 seconds. A week later, she'll be asked to touch it. After that, she and her mother will drive alongside a red truck on the highway. Eventually they will return to the exact spot where the accident occurred. Each step is more difficult, and each time Maya uses her relaxation skills to ease her symptoms.
Throughout treatment, there are many things parents can do to support their children. In Maya's case, her parents can avoid driving by the accident location whenever possible. "It's better to work up to that in a controlled way during therapy," Dr. Scheeringa says. If her carseat was on the right side of the car, something as simple as moving it to the left may also help.
In addition, once the child has finished treatment and her symptoms are manageable, parents can prepare for future relapses. "A year later or five years later, she may be in another accident or her sister may be. We know that can happen, so we prepare for it." He helps the child and parent develop a safety plan. Take a severe storm, for example -- perhaps the child lived through a hurricane and thought she might die. In the future, whenever the severe weather is forecast, the parent and her child can prepare for a possible recurrence by discussing the fact that a storm is coming and acknowledging that the child may feel scared. When the weather hits, the parent can help the child feel secure by spending time with her, distracting her with games or movies, and encouraging her to use her relaxation techniques if she feels anxious. Says Dr. Scheeringa, "This way the child feels, 'Mom's got my back. I'm not in this alone."
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