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Post-traumatic stress disorder in children and adolescents

Child sexual abuse is one of the most devastating forms of traumatization, leaving a severe impact on victim’s mental health. Post-Traumatic Stress Disorder (PTSD) is the most common psychiatric diagnosis associated with exposure to traumatic events in children and adolescents. When it comes to sexual abuse, the prevalence of post-traumatic stress disorder varies between 20% and 70%, and girls are more likely to develop symptoms than boys.

A significant risk factor for the development of PTSD symptoms in adolescents has been found to be the proximity between the victim and the perpetrator. When the latter is a known or close person, the adolescent’s beliefs about trust and intimacy are strongly affected. At the same time, when the abuser is someone known, and especially if they are part of the family, the abuse is less likely to be reported and the adolescent is much less likely to receive the social support they need and to seek specialized help.

PTSD symptomatology also develops according to the age of the child, the severity of the abuse and its duration. Thus, the earlier in the child’s life, the more severe the abuse, and the longer the duration, the higher the chances of developing PTSD-specific symptoms.

Case Study

“C was 10 when she was sexually abused by her uncle. She was playing outside with friends and took a break to go to the toilet at her uncle’s house. The abuse was violent: the man dragged her into the bedroom, pulled down her pants, threw her on the bed, held her by the neck, face down into a pillow and raped her. He threatened to kill her loved ones if she said anything about what happened. Finally, she got dressed and went back to play with her friends. Years later, when she was 15, she confessed that she was in a state of shock and didn’t know what else to do.

The same night that the abuse took place, C. asked her aunt for absorbent pads, an occasion to celebrate her transition from child to woman. Her mother thought it strange, however, when her period stopped returning.

C kept it a secret, but the family began to notice changes in her behavior. Several times a week, she had nightmares from which she woke up screaming. When her mother came into the room to check on her, she would shake and cry. She couldn’t sleep. She said someone was watching her. She began to have unbearable headaches, stopped going out with friends to play, and stopped visiting her uncle. She spent all her time alone in her room. She constantly checked to make sure the doors and windows were closed. She didn’t want to go anywhere. She became violent at home and at school. She couldn’t concentrate in class and refused to sit in the boys’ desks because she said they smelled bad. The family didn’t know what to do. They figured it was either hormones or natural adolescent behavior.

Two weeks after the abuse, C. went to the emergency room because she suddenly lost consciousness and no one understood what had happened. She was sitting with her mother, when her mother grabbed her by the throat while playing. C. screamed, fell down and was unconscious for 3 minutes. The doctors couldn’t find anything wrong with her, so they sent her home. The same thing happened again, shortly after this incident: she was playing with her brothers, one of them grabbed her by the throat, and the girl fainted instantly. Again, the doctors found nothing. On another visit to the emergency room, C. complained that she could not feel her hands, that they were numb, but the check-up found no medical problems.

After 6 months, C. heard that a cousin of hers was going to visit the uncle who had abused her. She was worried that the same thing might happen to her, so she told her grandmother about sexual abuse. The grandmother immediately called the police. Everyone in the family had the same reaction. Things finally made sense: why her period stopped returning and why C. didn’t want to visit her uncle.”

According to the Diagnostic and Statistical Manual of Mental Disorders, Post-Traumatic Stress Disorder (PTSD) can develop when a person is directly exposed to a concrete situation or threat of death, severe injury or sexual violence, when they witness, as a witness such an event experienced by other people (in children, especially close caregivers), when they learn that the traumatic event has affected a close person, or when the person is exposed repeatedly or with extreme intensity to repulsive details of the traumatic event.

Diagnostic criteria for Post Traumatic Stress Disorder (PTSD)

Intrusive symptoms

(one or more may be present)

  1. Recurrent, involuntary and intrusive unpleasant memories of the traumatic event (in children, the memories may occur in the context of play and may not necessarily seem unpleasant);
  2. Recurrent unpleasant dreams related to the traumatic event (in children, the dreams maybe nightmares with no recognizable content);
  3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event is repeating itself (in children, trauma-specific flashbacks may occur during play);
  4. Intense or prolonged psychological distress in response to exposure to internal or external stimuli that symbolize or resemble an aspect of the traumatic event;
  5. Significant physiological reactions, both in response to exposure to internal or external stimuli that symbolize or resemble an aspect of the traumatic event.

In the present case, C. fulfilled criteria 2-5: she had nightmares several times a week, said that someone was chasing her (reliving the traumatic experience), started screaming (intense psychological distress) and later fainted (physiological reaction) when her throat was touched (stimulus resembling an aspect of the traumatic event).

Persistent avoidance of stimuli associated with the traumatic event

(one or both may be present)

  1. Avoidance or efforts to avoid unpleasant memories, thoughts or feelings about the traumatic event;
  2. Avoidance of or efforts to avoid external elements (people, places, conversations, activities, objects, situations) that would trigger painful memories, thoughts or feelings related to the traumatic event.
  3. met criterion 2: after the abuse, she stopped going outside to play with friends, refused to visit her uncle and did not want to sit on the bench with boys.

Changes in cognition and mood associated with the traumatic event

(two or more may be present)

  1. Inability to remember an important aspect of the traumatic event due to dissociative amnesia;
  2. Persistent and exaggerated negative negative beliefs and expectations about self, others and the world (e.g. “I am a bad person”, “I can’t trust anyone”, “The world is dangerous”);
  3. Persistent, distorted interpretations about the cause or consequences of the traumatic event, which cause the individual to blame self or others;
  4. Persistent negative emotional state (fear, horror, anger, guilt, shame, sadness, confusion);
  5. Marked decrease in interest in or participation in important activities;
  6. Feelings of detachment or alienation from others (in children, social withdrawal behavior);
  7. Persistent inability to experience positive emotions: joy, satisfaction, feelings of love (in children, persistent reduction in expressing positive emotions).
  8. met criteria 4-6: she was often angry or frightened, stopped going out to play with her friends and constantly retreated to her room.

Significant impairment of excitability and reactivity associated with the traumatic event

(two or more may be present)

  1. Irritable behavior and angry outbursts (at minimal or no provocation) expressed by physical or verbal aggression directed at people or objects;
  2. Reckless and self-destructive behavior;
  3. Hypervigilance;
  4. Exaggerated flinching response;
  5. Trouble concentrating;
  6. Sleep disturbances (difficulty falling or staying asleep, or restless sleep).
  7. met criteria 1 and 3-6: her mother had noticed her behavior changes and angry outbursts occurring at home and at school; she flinched at noises that were not disturbing to others, constantly checked to see if doors and windows were closed, had trouble concentrating at school, and her sleep was often disturbed by nightmares from which she woke up.

A psychiatric diagnosis can only be established by a psychiatrist. This article is only intended as information for parents/adults or professionals who come into contact with minors who are suspected of having been exposed to abusive situations and who are observed to show signs that may indicate symptoms of PTSD.

 

Bibliography:

American Psychiatric Association, DSM-5, Manual de Diagnostic și Clasificare Statistică a Tulburărilor Mintale, Text revizuit, Editura Callisto, 2024;

Alves, A. C., Leitão, M., Sani, A. I., & Moreira, D. (2024). Impact of Sexual Abuse on Post-Traumatic Stress Disorder in Children and Adolescents: A Systematic Review. Social Sciences13(4), 189. https://www.mdpi.com/2076-0760/13/4/189

https://www.americanbar.org/groups/public_interest/child_law/resources/child_law_practiceonline/child_law_practice/vol_31/august_2012/using_undiagnosedpost-traumaticstressdisordertoproveyourcaseachi/

 

Article realized by Diana Munteanu, clinical psychologist & psychotherapist, Barnahus Center