Adolescents and Trauma: Origins, Signs, and Treatments

Deborah F. Corkindale

Capella University

Abstract

Clinicians that see clients on any regular basis are only too familiar with the effects of early trauma on individuals at various stages in life. If left untreated, adolescent and childhood trauma can create feelings of loss of safety, can be overwhelming, and can impair functioning, sometimes to the point of psychological disability. There is a sense that there are more chances for traumatizing experiences in our current societal structure – watching the nightly news can be traumatizing in and of itself. Our public schools often have police officers present; some have metal detectors upon entering the school. Any adolescent today is old enough to remember the 9/11 terrorist activities. Visions of collapsing buildings and running, screaming people are etched in their memories. Clinicians should be familiar with the symptoms of trauma, and of the DSM-IV-TR diagnosis of Post Traumatic Stress Disorder, the reaction to historical trauma. They should know the approaches for treating it that have found to be the most efficacious. This document attempts to bring some of that information together for use by the adolescent psychotherapist.

Adolescents and Trauma

For most people, the word "trauma" brings to mind at least two types of injuries. In one sense, there is medical trauma, which is generally defined to be a sudden physical hurt to an organism that requires immediate treatment. The term "blunt trauma" is a term most people in our society know as we soak up crime investigation television shows. The other type of trauma this society understands is psychological trauma. We are just as familiar with the idea of being "traumatized" by car accidents, by bullies, or by hurtful relationships. Those are forms of trauma, certainly, especially if our personal safety is compromised in any way.

Another type of trauma falls into the second category of psychological trauma and unfortunately is only too common. This includes physical, sexual, emotional, and verbal abuse of minors. So often we hear of infants, children, and adolescents hurt by their caregivers, parents, or guardians. The offending adult is brought to justice. The long-range effects of the trauma to the minor are complex and sometimes difficult to diagnose and treat.

It is also safe to say that most people in our society were affected to varying degrees psychologically by the terrorist attack of September 11, 2001 and the subsequent Orwellian "big brother" world in which we live (Orwell, 1949).

This report will focus on the psychological traumas just described, including personal traumas and societal traumas. Symptoms of childhood and adolescent trauma will be discussed. The progression of untreated trauma will be explored. Finally, treatment methods, both for an immediate trauma and for historical trauma will be presented.

Included in any discussion on trauma today must be Post Traumatic Stress Disorder (PTSD) -- its origins, its DSM-IV-TR diagnosis criteria, and its treatment.

Although the trauma that will be considered for this study may have a physical origin, be it physical abuse or terrorist act, and those physical events may cause physical changes within the victim (Bremner, 2000), the psychological effects of those acts will be the center of discussion. Such events include:

• Physical Abuse
• Sexual Abuse
• Sexual Molestation
• Family Violence
• Dating Violence
• Kidnapping
• Serious Accidents
• Natural Disasters
• Assault
• Rape
• Bullying
• School Violence
• Acts of Terrorism

This study will consider trauma to children and adolescents, and the psychological manifestations in adolescents, related to physical abuse, sexual abuse, and emotional and verbal abuse. The individual affected by these occurrences might be the victim or the witness.

There is a sense that trauma is becoming more and more prevalent. Below is information from the National Clearinghouse on Child Abuse and Neglect for rates of child abuse in the U.S. in 2000 (Faulkner, 2004). The National Center for Post-Traumatic Stress Disorder estimates that 15% to 43% of girls and 14% to 43% of boys have experienced at least one traumatic event. Of these, it is estimated that between 3% and 15% of females and 1% to 6% of males meet the full criteria for PTSD. Rates of PTSD for at-risk populations are even higher.

Composition of substantiated child abuse in 2000:

• Neglect -- 63%
• Physical -- 19%
• Sexual -- 10%
• Psychological -- 8%

Victimization rates declined as age increased.

• Birth to 3 years old = 15.7 victims per 1,000.
• Ages 16 and 17 = 5.7 victims per 1,000.

Except for victims of sexual abuse, rates were similar for male and female victimization:

• 11.2 and 12.8 per 1,000 children respectively.

Rate of sexual abuse by gender:

• 1.7 victims per 1,000 female children
• 0.4 victims per 1,000 male children.

Rate of child abuse by race:

• White = 51%
• African American = 25%
• Hispanic = 15%
• American Indian/Alaska Natives = 2%
• Asian/Pacific Islanders = 1%

The comparative annual rate of child victims decreased steadily from 15.3 victims per 1,000 children in 1993 to 11.8 victims per 1,000 children in 1999; then increased to 12.2 per 1,000 children in 2000. Whether this is a trend cannot be determined until additional data are collected.

Source: U.S. Department of Health and Human Services, Administration for Children & Families, National Clearinghouse on Child Abuse and Neglect, 2000.

Physical abuse means hitting or harming a minor child, usually by someone that has that child’s trust or has been entrusted to care for that child. If a child is hit by a neighbor and the parent takes action to prevent it from occurring again, the child may not experience traumatic reactions to such a great degree, if at all. This would be true especially if it occurred only once. Certainly this is suggested by one study of an earthquake in Turkey that found that parents imprint their reactions on their children (Kilic, Ozguven, & Savil, 2003). This study suggests that children often react in the same manner as their parents. If their parents stand up to the abuser, blows to self-esteem and feelings of loss of safety may not manifest in the minor and trauma may not result. Therefore, if the parent does not try to protect that child from harm, and it happens again and again, that child may begin to feel unsafe and display symptoms of trauma. His personal safety feels compromised. If a child is hit or physically harmed by a parent, even if the other parent takes steps to protect that child, there may still be trauma. Certainly trauma can originate from someone other than a guardian or parent, but harm from the person that is supposed to protect you can be especially traumatizing.

Studies have been done to assess why certain individuals experience greater degrees of PTSD than others do. Children that have prior trauma experiences or pre-existing mental health concerns are more at risk for PTSD as a result of adolescent or childhood trauma (About, Inc., 2004).

Sexual abuse can originate in a parent, or a relative, or a neighbor, or a friend. It is tempting to say that abuse from a parent is more traumatizing, but certainly any sexual abuse is scary. Most often, the abuser, with an accompanying threat, instructs children not to tell anyone. And most often, the minor does as told. So often there are stories of victims of sexual abuse not reporting the abuse to the non-perpetrating parent, to authorities, or to school officials (Brooke, 2004).

This sexual abuse is loosely defined as any improper action or words or suggestions against children and adolescents (Genesis Consultants, 2004). It can be intercourse, non-intercourse sexual acts, improper touching, watching sexual acts, listening to certain things, or really anything that has sexual overtones into which the victim is somehow coerced into participating.

The familiar expression "Sticks and stones will break my bones but names will never hurt me," is not entirely true. Emotional and verbal abuse can rip apart a person’s self esteem very quickly. This type of abuse includes terrorizing, bullying, degrading, and isolating (Izquierdo, 2004). Neglect is also considered abuse. Terrorizing is actions against a person with the intent of invoking fear. Degrading is making a person feel badly about themselves and not worthy. It is aimed at destroying self-esteem. Isolating is keeping an individual from participation in the world around. This can occur at various levels, all the way from total isolation to limiting whom the person may see. Neglect is often cited in child abuse cases. This means not taking physical and emotional care of a minor, and can include physical neglect, i.e., lack of providing food and shelter, or not being present to care for the minor. It can also include emotional neglect, although that is not so easily identified. A parent that works all day and then is busy all night at home may be neglecting his or her child, even though the child is well fed, well clothed, and lives in a fine house. Those persons may show signs of trauma if the isolation continues for any length of time. Bullying most often refers to peer bullying, i.e., a child or group of children bullies a classmate. It can include terrorizing, degrading, and isolating. Bullying can be considered a form of childhood and adolescent abuse, especially when parents and schools ignore it.

Adolescents and children may be the victims of abuse, but many times they are the witnesses. Quite often, adolescents and children may see their parents being physically and emotionally abusive to each other. Sometimes, they may see parents abuse siblings. These adolescents may be observers of community violence. These witnesses can exhibit the same symptoms as victims.

PTSD is a DSM-IV-TR diagnosis (DSM-IV-TR, p.218) that specifies that the individual "experienced, witnessed, or was confronted" with a life threatening or serious event and that the reaction was "fear, helplessness, or horror" and in children it might display as "disorganized or agitated behavior." Adolescents generally respond like adults, and the reactions will include recollections of the event, dreams of the event, a sense of reliving of the event, intense psychological distress, and reactions to things that symbolize the event

It was added to the DSM-III in 1980. It seems that the timing has something to do with Vietnam Era Veterans, although there are not clear references to adding PTSD because of veterans’ experiences and reactions. Certainly the term "shell shocked" which is still in use but originated in World War I (Parrish, 2001), is a pre-cursor term for PTSD. Originally PTSD was used in reference to veterans’ experiences. Over time it came and is currently being used to describe the symptoms of reaction to trauma. It is similar to Acute Stress Disorder (DSM-IV-TR, p.221), which symptoms tend to be somewhat more current, more intrusive, and more acute than PTSD. ASD can be the result of certain traumas to adolescents and children, but it tends to be diagnosed closer to the actual trauma. PTSD refers to the delayed reaction to traumas.

There is a certain sense that PTSD is a somewhat more quantitative than qualitative diagnosis. That is, in order for PTSD to exist, there must have been an event in the past that caused trauma to the individual. PTSD cannot exist without that traumatizing event and does not rely only on symptoms for diagnosis. Additionally, the symptoms of it can also be symptoms of various depression type diagnoses. Therefore, unless a full history can be obtained, this diagnosis might not be used in favor of a more symptom driven diagnosis, such as Major Depressive Disorder.

Adolescents’ responses to trauma may be similar to those of adults, including: flashbacks, nightmares, emotional numbing, avoiding reminders of the traumatic event, depression, substance abuse, problems with peers, and anti-social behavior. Teenagers may also withdraw and isolate themselves, may have some physical complaints, may have suicidal thoughts, will avoid school, will have poor academic performance, may have sleep disturbances, and may display general confusion. Guilt may be present, whether there was loss or not – the adolescent may take some of the blame on his or herself. Thoughts of revenge may also be present (About, Inc., 2004). Adolescents, in particular, may begin to exhibit more aggressive or impulsive actions after a traumatizing event (Hamblen, 2003). It is safe to say that any change in behavior or academic performance or life patterns in adolescents is suspect and should be reviewed with an eye to trauma. An additional hallmark of trauma is a tendency to not tell about the incident. Below is a list of adolescent symptoms of abuse.

PTSD

• Nightmares
• Flashbacks
• Memory and concentration problems
• Hyper-arousal
• Hyper-vigilance
• Intrusive memories
• Avoidance
• Abnormal startle responses
• Feeling worse when reminded of trauma
• Eating disturbances, i.e., more or less than usual
• Sleep disturbances, i.e., more or less than usual
• Compulsive Behavior
• Difficulty making decisions

Dissociative

• Out-of-body experiences
• Amnesia
• Fragmented sense of self and identity

Anxiety

• Panic attacks
• Claustrophobia
• Fearfulness

Substance Abuse

• Alcoholism
• Drug addiction

There is some evidence that there are physical changes within the brain that occur at the moment of trauma (Perry & Azid, 1999). The brain can return to homeostasis after the traumatizing event, but it does not always. Evidence suggests that continued exposure to trauma can alter the brain’s response systems so that they do not return to the pre-stress state. There is also information that adults who were victims of adolescent and childhood sexual abuse may encounter difficulty in childbirth, gastrointestinal disorders, gynecological problems, chronic pain, headaches and fatigue (Perry & Azid, 1999). This certainly speaks to the importance of early intervention, when possible, to forestall further trauma.

The results of an English study present the following findings (Calam, Horne, Glasgow, & Cox, 1998). This listing is a fairly complete enumeration of the different problems associated with reaction to trauma in adolescents. It is especially interesting because for each of the selected disturbances, prevalence increases rather than abates as time goes on for most of the items.

Most people look at September 11, 2001, as a line drawn in the sand. Everything changed on that date. Physically we have the presence of Transportation Security Administration (TSA) officers at airports, the establishment of a Homeland Security Agency. Emotionally, every little package left at a public place causes concern and just generally, most people feel a little more vulnerable. It is difficult to find a current assessment of American attitudes as a result of or subsequent to 9/11. One would expect that it is still in process, i.e., attitudes are still shifting. So much has changed since that day, including the addition of the current war in which we are involved. It is relatively safe to say that we have not still as a nation had a chance to take a deep breath and exhale since that date. Perhaps the recent Reagan funeral offered one small respite from the constant news of war and allowed us to breathe.

Whether today’s adolescents, who were roughly 10-15 years old when that happened, are showing any symptoms of PTSD or not, they will carry that scar forward with them. As children, boomers were the generation that had bomb drills at school as a result of the Cold War. These involved going to as safe a place as possible, such as a school basement, bending down, hugging the wall, and covering their heads (CBC, 2004). Some boomers remember the fear of being away from their parents during this cold war time. The attacks on 9/11 made those memories and fears surge to the surface for some of that generation.

Others in the previous generation were reminded of World War II and the air raid drills, or blackouts, that they had. They had to either turn off all lights or shut the shades tight and stay indoors (CPTV, 2003). The Terror Alert code we now have in place in the United States echoes those drills of other years, but it does not seem to be so invasive.

One might expect that perhaps this current generation of adolescents will be spared the "run and hide" mentality of prior generations, however, television seems to be replacing the air raid drill siren. During the recent television coverage of former President Reagan’s funeral, Dan Rather and Bob Schieffer were discussing the impact of televising the funeral and mentioned that President Kennedy’s funeral in 1963 was the first time that a state funeral was broadcast. Television has become the warning system for our lives. And this has generated its own set of problems. As adults were glued to their television sets after the 9/11 attacks, and after the U.S. attack on Iraq, adolescents were tuned in also. The fear that gripped the adults of this nation and of the world was felt by our teens also.

Some attention has been paid to how 9/11 affected adolescents. The National Association of School Psychologists (NASP) notes that 9/11 might cause reactions similar to those of reactions to trauma. They add the following emotions that adolescents might feel after a traumatic event (NASP, 2003):

• Shock/disbelief
• Fear
• Guilt
• Grief
• Confusion
• Shame/loss
• Anger

This organization stresses the importance of what parents and adults model. That is, how an adolescent’s parents react to a traumatic event will affect how their children react and process the event. It is important to allow adolescents to see real feelings, but it is also important for the parents to remain in control of their emotions and not let their children know if they are having their own reaction to trauma.

The types of trauma listed above can be especially difficult for the individual to cope with as the years go on. Treatment has historically been difficult, especially if left untreated for a long period. Early intervention, often thought to be important in overcoming certain PTSD symptoms, has recently been found to be fairly ineffective in the treatment of that diagnosis (Litz & Gray, 2003). Although certainly initial treatment will not hurt the victim, it is ongoing and fairly constant interventions that have the most efficacy.

At a very general level, there are a number of attitudes and techniques that individuals working with adolescents that are traumatized via either personal or societal injuries can exhibit. After a trauma, individuals are looking to get back to how life was before the crisis. Crisis workers can (NASP, 2003):

• Be honestly concerned about the victim.
• Listen to the victim.
• Allow people to talk but also let them just listen.
• Encourage sharing of both information and experiences.
• Accept all feelings and reactions as valid.

Psychotherapy techniques that have found to be effective with trauma and PTSD aim to bring the individual from victim, through survivor, and all the way to be one that thrives. Honesty and openness, as always, are especially important with trauma victims. Some points to cover are:

• Reactions to trauma are normal and can be far reaching and may surprise the victim.
• Although the victim may not want to re-experience the event, it is important to do so, especially in a safe environment.
• Feelings of guilt, anger, and shame are common and should be confronted.
• Finally, the symptoms of trauma may not be dispelled, but may need to be managed only.

Some therapeutic models that have been used to treat reactions to trauma are Cognitive Behavior Therapy (CBT), medication, group therapy, and Eye Movement Desensitization and Reprocessing (EMDR). These models appear most often in the literature and seem to provide the most consistent, effective results. Of course, many other therapies are being used to treat trauma and PTSD in adolescents. Additionally, specific reactions might suggest specific therapies.

CBT has been found to be an effective approach for treating PTSD in adolescents (Hamblen, 2003). CBT therapy will allow the teen to discuss and confront the situation. There may be anxiety management techniques used, the teen may be taught to meditate to produce relaxation. It is important to teach the adolescent methods of coping and dealing with the symptoms of trauma. The symptoms may linger indefinitely, but the adolescent must continue to live, so the teen could benefit from coping techniques.

EMDR is a relatively new therapy accidentally discovered by Dr. Francine Shapiro in 1987, and then subjected to controlled research by her in order to develop an effective use and treatment (EMDR, 2004). It is a rather exact process, but essentially it uses the technique of eye movements across an image of the trauma or one that suggests the trauma as a means to desensitize. A number of studies have shown that this is very effective treatment for PTSD and all reactions to trauma (EMDR, 2004). Specialized training is necessary for correct application of this method.

Group therapy provides a safe situation for the victim to share the trauma and share subsequent experiences and feelings. This could be used in conjunction with individual therapy to assist the adolescent. Certainly a group is a logical situation for teens that are usually quite social. A group of peers that has had the same experience will be helpful to teens. It is especially important for this age group to not feel alone.

Medication has proven to be very effective for adult sufferers of PTSD, but it may not be appropriate for adolescents. More research needs to be done before medication’s effectiveness on teens is known. Currently Zoloft is the only medication approved by the FDA to treat PTSD. Zoloft is prescribed to adolescents, so it may be a viable form of treatment.

Trauma is an only too common element of our society, and television brings it into our homes on an almost daily basis. Since there have been studies that show that multiple traumas can have the most devastating effect on adolescents, as well as adults and children, it is important to take steps to minimize the effects of each trauma that may present itself. Therapists working with adolescents must be knowledgeable of how trauma manifests in teens. They must be able to spot the signs. They must have a good knowledge of how the events of September 11, 2001, and the subsequent anti-terror activities and the attack on Iraq have affected our youth. Knowing what therapeutic methods have worked well in the past is an important part of the therapist’s toolbox. Finally, maintaining a positive but open attitude as we work with adolescents will go far. Any reaction to trauma is valid. Knowing how to cope with those reactions is the help we can give our adolescent clients.

References