Baby Li, four years old, was playing in the living room when there was a loud and aggressive knock on the door. The mother opened the door — it was their neighbor, and he had a child the same age as Baby Xiaoli, who stood up to see if the children were also at the door. The neighbors started shouting. Mom shouted back and tried to close the front door. The neighbor was still yelling and forcibly opening the door, which hit Mom in the face and her nose began to bleed. When blood was pouring down Mom's face and she was visibly upset, the neighbor left. Will this event have a lasting negative impact on young children – what would it look like if that happened?
After a stressful or traumatic event, both children and adults can find themselves thinking about the event more often than they expected, feeling stressed, anxious, or depressed, or having trouble falling asleep. Usually, this is a normal response to what the brain perceives as a dangerous condition, and for most people, this reaction subsides within a month of the event.
Post-traumatic stress disorder (PTSD) is a debilitating mental condition that occurs after a perceived threat to life, safety, or personal integrity. For the diagnosis of PTSD, the current Diagnostic and Statistical Manual for Mental Illness (DSM-5) lists key issues that must last at least a month after a traumatic event, including unconsciously reliving the trauma (e.g., through invasive thoughts and images); avoidance of people, events, or places that remind people of the trauma; negative changes in thoughts and feelings; and higher arousal.
Young children may also develop PTSD after various events that cause PTSD in adults, such as abuse or assault, war, car accidents, or witnessing major acts of violence against others. However, threatening or harmful experiences that may not produce PTSD symptoms in adults (e.g., being attacked by a dog) sometimes develop these symptoms in children. What matters is the perception of the threat – young children may not understand the cause of the event or the intent behind someone's actions, and often cannot actively control what is happening. As a result, symptoms of PTSD sometimes appear in young children, and these events occur after events such as aggressive or harmful behavior towards caregivers or invasive medical procedures.
Psychologists and other health professionals have recognized that young children (3 to 6 years old) tend to exhibit different symptoms of PTSD after experiencing trauma.
In the case of Baby Xiaoli (which is fictional, but based on real cases), it is understandable that she felt uneasy and scared immediately after the incident. But a month later, Xiaoli's baby is still clinging to her mother's side, and she doesn't like her mother to go out without her. She began to refuse to sleep in her own bed as before. When taken to a dance class she usually likes, she loses her temper. She no longer plays in the living room or in the garden. When the doorbell rings, Baby Li is visibly stiff or becomes upset, which may also be expected by adults with PTSD. But Baby Xiaoli's other behaviors don't seem to fit the traditional description of the disease. Does this mean that Baby Li is experiencing a normal reaction, or that her difficulties are not related to the event? Will she benefit from the support of health professionals?
The standard outlines symptoms specific to young children, such as reenacting trauma while playing, having terrible dreams that are difficult to describe, and tantrums.
Researchers around the world have been working to improve the identification of young children who are experiencing PTSD — and crucially, develop psychotherapies that can help them.
Addressing this challenge requires rethinking how PTSD is diagnosed in young children. A series of studies in the early 2000s showed that standard diagnostic criteria for PTSD failed to identify a large number of young children in need of support. Therefore, the researchers proposed an alternative, developmentally sensitive diagnostic algorithm for young children. After minor improvements to this alternative algorithm, the latest version of the DSM includes new diagnostic criteria for subtypes of PTSD for children 6 years of age and younger.
The core features of the PTSD (PTSD-YC) subtype in young children are the same as those in adults. However, there are some important differences. For example, criteria suitable for development reduce the degree of certain symptoms required for diagnosis, such as avoidance symptoms. (Younger children are less in control of where they go: for example, even if a young child wants to avoid a trauma scene, a caregiver can pick them up and take them there.) The criteria outline possible changes in symptoms specific to young children, such as recreating trauma during play, having terrible dreams that are difficult for them to describe, and tantrums. As in adults, diagnosis requires multiple symptoms to appear simultaneously to ensure that normal behavior does not morbidize, and that these symptoms must severely disrupt daily functioning. Behavior must have started or deteriorated since the traumatic event, which is also at the heart of the diagnosis.
Many times, PTSD may not be evaluated for very young children who have experienced a traumatic event because these symptoms may be seen as separate, unrelated behavioral problems rather than representatives of underlying mental health problems. As a result, these children often do not receive any trauma-centered treatment. This is a problem for children – if left untreated, PTSD can last for years and even into adulthood and can seriously affect continued development, including the child's ability to learn, build healthy relationships, and enjoy life. But we do have PTSD treatments designed specifically for adults that are also effective in treating young children, and international health guidelines now recommend these treatments for children.
One of the most effective ways to treat PTSD in adults and older children is trauma-centered cognitive behavioral therapy (CBT). A core feature of trauma-centric CBT is the processing of individual memories of trauma — which is often disjointed and lacking in coherence — to identify and adjust their unhelpful beliefs about events (e.g., it's my fault; the world is insecure; bad things happen to people I love).
Like all of us, young children may also need to remind them of the good things they do in terrible situations (e.g., trying to protect siblings).
Although younger children are still developing their language skills and may have difficulty describing their memories and abstract concepts, many clinical trials now show that trauma-focused CBT can be adapted to successfully treat PTSD in these children. One treatment regimen, CBT-3M, focuses on changing three key factors that contribute to PTSD: traumatic memory, the child's significance to the event, and the maladaptive coping strategies that children use to manage the effects of trauma.
A structured and coherent memory of a traumatic event helps to recover from PTSD because it helps individuals understand why the event occurred and limits the meaning of the event to the appropriate context. For example, updating intermittent memories of a traumatic car accident to include details you didn't pay attention to at the time (e.g., you kept following the rules of the road) or details you didn't know at the time (e.g., another driver was drunk) can help adjust the unhelpful meaning you made from the incident (driving is always dangerous; if I'm in the car, I'll hurt someone else) to something more adaptable and representative (a car is only dangerous if it's driven irresponsibly)). Maladaptive coping strategies that make symptoms long-standing must also be addressed. For example, avoiding reminding trauma may reduce pain in the short term, but it also reinforces the notion that you can't deal with what you're avoiding when in fact you can.
To help your child improve each of these factors, the therapist will complete the treatment activities alone with the child or with a caregiver. Therapeutic tasks may involve the use of dolls, plush toys, or toys (e.g., cars, ambulances) to recreate traumatic events and help children organize their memories to accurately describe what happened. Your child may be guided to draw a picture or choose a card with different emotional faces to show how your child feels and reacts to traumatic reminders. This helps them relate their feelings to traumatic events and understand why these feelings suddenly appear and seem to come from nowhere. Cartoons or short videos can also be used to explain how and why the brain produces the symptoms that children are experiencing. I'm going crazy; I'm sad) by teaching children that their symptoms are an understandable response to trauma and showing them that other children have the same problem after the traumatic event.
Therapists can work with their child's caregiver to develop routines for their children to make their world more predictable and therefore feel safer. Caregivers can also provide additional information to help children better understand traumatic events. For example, a child may feel that no one is coming to help them, when in fact an observer has called an ambulance or a lifeguard is quickly swimming toward them. Like all of us, young children may also need to remind them of the good things they do in terrible situations (such as trying to protect their siblings).
For Xiaoli baby, the mother may be able to explain that the neighbor did not intend to hurt her, and although she shed a lot of blood, it was not as painful as Xiaoli baby feared. A recent trial even trained parents on how to provide trauma-focused CBT lessons to their children at home with promising results. However, a child's caregiver often shows up during a child's traumatic period, so they themselves may need support.
Research is steadily improving our understanding of how best to support young children with PTSD. But it's clear that very young children do experience PTSD, and we have psychotherapy to help them overcome it. This support allows children to get rid of the trauma they are constantly reliving, take better control of their emotions, and re-engage with activities they enjoy – minimizing the risk of the trauma having a lasting impact on their future.