These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.
Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one’s sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible.
This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as young adults and beyond.
There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.
Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.
Exposure therapy also can incorporate gradual steps to help the child overcome their fear. For example, if a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don’t want the brain to go on "red alert" again. In a state of hyperarousal, reliving the trauma may do more harm than good.
The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.
Sometimes vivid, traumatic memories will enter your patient’s mind spontaneously without him knowing why. In other cases, there are triggers. The classic example is the combat veteran who hears a sudden, loud noise and immediately feels in danger. Similarly, someone shouting or crying can trigger a strong flashback for the child exposed to domestic violence.
Sometimes these flashbacks arise shortly following trauma and sometimes they take years. I know of an adult patient for whom painful memories of physical abuse and trauma arose when she became pregnant. When she considered what it would be like to raise her child, it rekindled a lot of memories of her own childhood.
In other cases, consequences are less direct. For example, a woman who was traumatized as a child by witnessing fighting in her home may overreact and try to never fight with her partner. Others might relive the experience by causing a lot of arguments.
We still have much to learn about PTSD. What is the nature of the neurobiology? Why are some children more vulnerable than others? How can medications such as selective serotonin reuptake inhibitors best be used in children and adolescents with persistent PTSD?
Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.
This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. To comment, e-mail him at pdnews@elsevier.com.