Post Traumatic Stress Disorder, PTSD, is an ongoing reaction to an unusual and traumatic situation; wherein, you feel your health and safety or the health and safety of a loved one is threatened. Although this diagnosis was originally developed in relationship to Vietnam War veterans, it is now used to include situation of abuse, rape, kidnapping, torture, near fatal accidents, violent attacks and damaging acts of nature.  Symptoms may include sleep disturbances, appetite disturbance, haunting vision at day or night of reliving the event, emotional numbness, detachment, depression, anger or rage, avoidance of triggers related to the event and the interference of these symptoms in your everyday life.  It is important to know that PTSD can be very effectively treated with therapy, sometimes, in effective combination with medication.  You can get your life back and regain a sense of emotional stability that you had before the event. Please read the following information from the National Institute for Mental Health.  It is a great government resource and note the telephone number at the end highlighted in red for support.

PTSD and KIDS

In children, Post Traumatic Stress Disorder looks very much the same as in adults with few age related exceptions. "Moving in the rhythm of the Child" allows you to access  the world of your child.  (This title comes from a wonderful video available atwww.giftfromwithin.org )  Listen to their words and concerns and understand how the move through the world. Children express themselves through play and metaphor.  The greater your understanding of these languages and rhythms, the greater the likelihood for successful resolution.  The stress in children may be expressed in disorganized behavior that appears regressive and unusual for the child such as clinging, separation anxieties or bed wetting.  If the parent is unaware of a preceding traumatic event, it may be through play therapy that the trauma is uncovered or expressed.   In addition to facilitating healing, these modalities, play therapy, art therapy, sandplay, drama or music therapy, may be the first place where the nature of problems such as abuse or family violence is expressed.   If your child is experiencing severe physical symptoms, such as rage, anxiety, sleep disturbance, depression ,etc. medication may be a valuable tool in their recovery.  Please work with a physician. If the trauma is a large scale disaster, relief for some concerns may come from government agencies or the Red Cross.  There are often additional nonprofit agencies in place to help with many of the concerns facing our clients. 

Children tend to be quite resilient and often work through issues related to  PTSD catalysts like terrorism and disasters relatively quickly.   With this in mind stay away from any tendency to overreact.  Children are often quite eager to express themselves through art, acting out, role playing or any variety of letting us know that they have been affected and want to "get it out."  For a single occurrence of traumatic stress, it may only take a few days for some kids to rebound to their more typical selves.   With ongoing family violence, intervention will be more complex and of greater length. Recognize once again that what may seem like "abnormal" behavior may be a "normal response to an abnormal situation."  The longer duration of symptoms and interference with daily life, the more likely there is may  a need for clinical intervention.  Many people looked to the news and the internet for information on how to talk with children following the events of Columbine and 9/11. Nickelodeon and the Today show both hosted shows for children to talk about their reactions and solutions.  Not meeting violence with violence emerged as the theme.  The younger Nick group aged 9-12 was more committed to this idea than the older adolescent group, but there was a voice in opposition to a violent response and that is important. 
 
Terrorism and Children A National Center for PTSD Fact Sheet 
On Tuesday, September 11, 2001 the nation was shocked by the news of a terrorist attack on the United States. Two airliners crashed into the World Trade Center and one struck the Pentagon. There were reports of people seen jumping out of the World Trade Center to their death.  As adults, many of us gathered around televisions and radio seeking as much information as we could find and discussing the tragedy among our friends, family, and co-workers. But, how should we speak to our children about this event? Should we shield them from such horrors or talk openly  about it? How can we help children make sense of a tragedy that we ourselves cannot understand? How will children react? How can we help our children? Fortunately, there have been few terrorist attacks on the United States. One consequence, however, is that there is little empirical research to help us answer the above questions. Instead, information from related events will be used to best try and answer the above questions.

HOW DO CHILDREN RESPOND TO TRAUMA? 
There is a wide range of emotional and physiological reactions that children may display following disaster. Based on previous research we know that more severe reactions are associated with a higher degree of exposure (i.e. life threat, physical injury, witnessing death or injury, hearing screams, etc.), closer proximity to the disaster, history of prior traumas, female gender, and poor parental response and parental psychopathology.  Findings from a study following the Oklahoma City bombing indicate that more severe reactions were related to female gender, exposure through knowing someone injured or killed, and bomb-related television viewing/media exposure (Pfefferbaum et al., 1999; Pfefferbaum et al., 2000). 
       Below are some common reactions that children and adolescents may 
                       display (Dewolfe, 2001; Pynoos & Nader, 1993). 
       Young Children (1-6) 
                                 Helplessness and passivity; lack of usual responsiveness 
                                 Generalized fear 
                                 Heightened arousal and confusion 
                                 Cognitive confusion 
                                 Difficulty talking about event; lack of verbalization 
                                 Difficulty identifying feelings 
                                 Sleep disturbances, nightmares 
                                 Separation fears and clinging to caregivers 
                                 Regressive symptoms (e.g. bedwetting, loss of acquired 
                                 speech and motor skills) 
                                 Unable to understand death as permanent 
                                Anxieties about death 
                                 Grief related to abandonment of caregiver 
                                 Somatic symptoms (e.g. stomach aches, headaches) 
                                 Startle response to loud/unusual noises 
                                 "Freezing" (sudden immobility of body) 
                                 Fussiness, uncharacteristic crying, and neediness 
                                 Avoidance of or alarm response to specific trauma-related 
                                 reminders involving sights and physical sensations 
                       School-aged Children (6-11 years) 
                                 Responsibility and guilt 
                                 Repetitious traumatic play and retelling 
                                 Reminders trigger disturbing feelings 
                                 Sleep disturbances, nightmares 
                                 Safety concerns, preoccupation with danger 
                                 Aggressive behavior, angry outbursts 
                                 Fear of feelings and trauma reactions 
                                 Close attention to parents' anxieties 
                                 School avoidance 
                                 Worry and concern for others 
                                 Changes in behavior, mood, and personality 
                                 Somatic symptoms (Complaints about bodily aches, pains) 
                                 Obvious anxiety and fearfulness. 
                                 Withdrawal and quieting 
                                 Specific, trauma-related fears; general fearfulness. 
                                 Regression to behavior of younger child. 
                                 Separation anxiety with primary caretakers. 
                                 Loss of interest in activities. 
                                 Confusion and inadequate understanding of traumatic events 
                                 most evident in play rather than discussion. 
                                 Unclear understanding of death and the causes of "bad" 
                                 events. 
                                 Magical explanations to fill in gaps in understanding. 
                                 Loss of ability to concentrate and attend at school, with 
                                 lowering of performance. 
                                 "Spacey" or distractible behavior. 
                       Pre-adolesents and Adolescents (12-18 years) 
                                 Self-consciousness 
                                 Life-threatening reenactment 
                                 Rebellion at home or school 
                                 Abrupt shift in relationships 
                                Depression, social withdrawal 
                                 Decline in school performance 
                                 Trauma-driven acting-out behavior: sexual acting out or 
                                 reckless, risk-taking behavior. 
                                 Effort to distance from feelings of shame, guilt, and 
                                 humiliation. 
                                 Flight into driven activity and involvement with others or 
                                 retreat from others in order to manage their inner turmoil. 
                                 Accident proneness. 
                                 Wish for revenge and action-oriented responses to trauma. 
                                 Increased self-focusing and withdrawal. 
                                 Sleep and eating disturbances; nightmares. 
                    

HOW TO TALK TO YOUR CHILD
                                

Create a safe environment. One of the most important steps you can take is making children feel safe. If possible, children should be in a familiar environment with people that they feel close to.

Keep your child's routine as similar as possible. There is comfort in having things be consistent and familiar.                                  

Provide reassurance to children and extra emotional support. Adults need to create an environment in which children feel 
safe enough to ask questions, express feelings, or just be by themselves. Let your children know they can ask questions. 
Ask your children what they have heard and how they feel about it. Reassure your child that they are safe and that youwill not abandon them. 
                                
Be honest with children about what happened.

Provide accurate information, but make sure it is appropriate to their developmental level. Very young children may be protected because they are not old enough to be aware that    something bad has happened. School age children will need help understanding what has happened. You might want to tell them that there has been a terrible accident and that many people have been hurt or killed. Adolescents will have a  better idea of what has happened. Talk to them about terrorism and how the United States responds to terrorism. It may be appropriate to watch selected news coverage with your adolescent and then discuss it. 

Tell children what the government is doing.

Reassure children that the state and federal government, the police, firemen, and the hospitals are doing everything possible. Explain that people from all over the country and from other countries offering their services. 

Be aware that children will often take on the anxiety of the adults around them. Parents have a difficult job of finding a balance between sharing their own feelings with their children while at the same time not placing their anxiety on their  children. For many, the attack on the United States was inconceivable. Our sense of safety and freedom was  shattered. Many parents may feel scared and fearful of another attack. Others may be angry and revengeful. Parents  must deal with their own emotional reactions before being able to help children understand and label their feelings. If you are frightened, tell your child, but also talk about your ability to cope and how you as a family can help each other.  Try and place the attack in perspective. Although you  yourself may be anxious or scared, children need to know  that what they witnessed or heard about regarding the attack is a rare event. Most people will never be attacked by terrorists and the world is generally a safe place. When healing from a traumatic event learn all you can about the nature of PTSD, education and normalization are part of the healing process. Try to make time to engage in normal pleasurable activities. Do not push yourself too fast or too soon,  Things have happened that were outside of your control, give yourself permission to regain some control, take small steps and regain your trust.

When should you seek professional help for your self or your child?  Parents of children with prolonged reactions or more severe reactions may want to seek the assistance of a mental health counselor. It is important to find a counselor who has experience working with children as well as with trauma. Referrals can be obtained though the American Psychological Association at 1-800-964-2000.  You may also access referrals through National Association of Social Workers    California Association of Marriage and Family Therapists   National Board of Certified Counselors
  
 

                       References:

                       DeWolfe, D. (2001). Mental Health Response to Mass Violence and 
                       Terrorism: A Training Manual for Mental Health Workers and Human 
                       Service Workers.

                       Monahan, C. (1993). Children and Trauma: A Parent's Guide to Helping 
                       Children Heal. Lexington Books, New York, NY.

                       Pfefferbaum , B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, 
                       R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in 
                       bereaved children after Oklahoma City bombing. Journal of the American 
                       Academy of Child and Adolescent Psychiatry, 38, 1372-1379.

                       Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., 
                       Maynard, B., Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress 
                       two years after the Oklahoma City bombing in youths geographically 
                       distant from the explosion. Psychiatry, 63, 358-370.

                       Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic 
                       stress in children and adolescents. In J.P. Wilson and B. Rapheal (Eds.), 
                       International Handbook of Traumatic Stress Syndromes (pp. 535-549). 
                       New York: Plenum. 
       The information on this Web site is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider. 
 

THE BEST RESOURCE I HAVE FOUND FOR UNDERSTANDING PTSD AND RECEIVING SUPPORT FROM A COMMUNITY OF SURVIVORS IS GIFT FROM WITHIN. PLEASE VISIT THIS VALUABLE RESOURCE.

We gratefully acknowledge the following authors and sources for permission to link and download.

The National Center for Post traumatic StressPrins, A., Kimerling, R., Cameron, R., Oumiette, P.C., Shaw, J., Thrailkill, A., Sheikh, J. & Gusman, F. 
                       (1999). The Primary Care PTSD Screen (PC-PTSD). Paper presented at the 15th annual meeting of the 
                       International Society for Traumatic Stress Studies, Miami, FL.

National Clearinghouse for Child Abuse and Neglect at http://calib.com/nccanch

 Richard Leslie, The California Therapist January/February 1990 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, San Diego, California.)

A National Center for PTSD Fact Sheet 
  References:

                       DeWolfe, D. (2001). Mental Health Response to Mass Violence and 
                       Terrorism: A Training Manual for Mental Health Workers and Human 
                       Service Workers.

                       Monahan, C. (1993). Children and Trauma: A Parent's Guide to Helping 
                       Children Heal. Lexington Books, New York, NY.

                       Pfefferbaum , B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, 
                       R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in 
                       bereaved children after Oklahoma City bombing. Journal of the American 
                       Academy of Child and Adolescent Psychiatry, 38, 1372-1379.

                       Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., 
                       Maynard, B., Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress 
                       two years after the Oklahoma City bombing in youths geographically 
                       distant from the explosion. Psychiatry, 63, 358-370.

                       Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic 
                       stress in children and adolescents. In J.P. Wilson and B. Rapheal (Eds.), 
                       International Handbook of Traumatic Stress Syndromes (pp. 535-549). 
                       New York: Plenum.    http://playtherapycentral.com/ideas.html

Moving in The Rhythm of the Child video, Gift From Within