- [Dr. Jeff] Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on "Healthy Minds".

- This is one of the most devastating aspects of trauma and PTSD, is that it often does make kids and families feel like they are alone.

Or it might make kids feel like they are somehow broken or defective.

Like you said, that this is the only one this has happened to, or that it's such a shameful experience they can't talk about it with anyone.

Those kinds of things are not their fault, and the trauma was not their fault.

The PTSD isn't their fault.

And really helping youth to understand that, and families, can be a bridge to getting that kind of help you talked about.

- That's today on "Healthy Minds".

This program is brought to you in part by the American Psychiatric Association Foundation and the John & Polly Sparks Foundation.

(gentle music) Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

When most of us think of post-traumatic stress, we think of adults who have experienced a trauma.

Often, we think of our service members who have experienced a trauma in service to our nation.

But unfortunately, post-traumatic stress can occur in children and adolescents.

Today, I speak with leading expert, Dr. Ryan Herringa.

Dr. Herringa is the director of the Division of Child and Adolescent Psychiatry, and associate professor at the University of Wisconsin-Madison.

That's today on "Healthy Minds".

Ryan, thank you for joining us today.

- Thank you, Jeff.

It's great to be here.

- I wanna jump in and ask you to tell us about post-traumatic stress in children and adolescents.

What are the symptoms?

What should we look for in children and adolescents?

- So post-traumatic stress disorder in kids can sometimes look like symptoms we might think of from adults with PTSD.

And the way the DSM defines it, which is sort of psychiatry's manual, if you will, for defining mental illness, is a constellation of symptoms that can occur after a trauma or traumatic events.

And we think about looking for certain categories of symptoms.

So there might be re-experiencing of a trauma, such as nightmares or flashbacks.

There also typically would be avoidance of trauma reminders.

And for kids as well as adults, this might look like not wanting to talk about a trauma that happened or not wanting to be near things that remind that child or adolescent that a horrible thing happened.

And then there are also some other red flags or symptoms that we might look for, such as changes in mood, changes in cognition.

So some examples of that could be no longer enjoying things, isolating, staying away from friends, staying away from family when that child might have normally really enjoyed those interactions.

And then what we call hyperarousal symptoms.

And this honestly is the one that probably comes up first for caregivers, for family or teachers, anyone in that child's life who really has knowledge of how they normally are.

All of a sudden that child might become really irritable.

They might get angry easily.

They're not sleeping well and they're getting up at night.

And that of course can often wake up caregivers and family members as well.

Difficulties concentrating, and that can impair schoolwork and other types of academic performance.

So those sort of behavioral signs are often what I see families and teachers recognizing early on for kids.

Now, there's one other thing I should mention that is for younger kids, and particularly maybe early childhood and preschoolers, PTSD, post-traumatic stress disorder, post-traumatic stress symptoms can look quite a bit different.

Those kids might not be able to verbalize that something bad has happened, or they may not be able to recognize the content of their nightmares or bad dreams and even know that that's related to a trauma.

And there can also be other ways that young kids, preschoolers, may express trauma symptoms, such as repetitive play.

So perhaps they're reenacting a trauma with toys or through drawing or other creative ways of doing that.

And then sometimes we also see what we call developmental regression.

Say your 6-year-old who has been potty trained for some time all of a sudden might be bedwetting or having other forms of incontinence.

That sort of regression can also sometimes happen with trauma, and particularly in younger kids.

- Very full description with a lot of information useful for parents, other caregivers, teachers.

How common is post-traumatic stress in youth?

- It's unfortunately quite common.

A lot of people that I talk to think that maybe this only happens in adults and in particular, in combat veterans, which is really where the disorder was first described.

It's quite common in kids.

And by kids, I'm talking about children and adolescents.

And the estimates are that by age 18, 5% of youth will have had post-traumatic stress disorder at one point.

So 1 in every 20 youth, as far as we know, are thought to have the disorder.

- What types of trauma often result in post-traumatic stress?

- The main types of trauma that result in enduring post-traumatic stress are interpersonal types of trauma.

So these are instances like child abuse, sexual abuse or physical abuse.

It might be witnessing domestic violence in the home.

It might be witnessing violence in the community or at school.

So these types of traumas I think are some of the most severe or potent in terms of risk for PTSD.

But youth can also get PTSD from a single type of trauma, like a car accident, losing a loved one very suddenly, oftentimes traumatically.

So really whenever there's this threat, if you will, to either the child or losing someone who's close to them can result in PTSD.

- The risk of having a trauma, such as the ones that you described, are unfortunately, tragically, fairly high and not uncommon.

Tell us a little bit about that.

- Yeah, so there are data suggesting that two out of every three youth experience a potentially traumatic event by the age of 18.

And that is not the same across age or the same across racial and ethnic groups.

So those numbers are much higher actually for Black and Hispanic and Native American youth.

It also differs by age, and the types of traumas we're talking about really increase markedly in adolescence, mid to late adolescence, so that there's a much higher risk of being exposed to a traumatic event as kids get older.

- So is there something that puts somebody at greater risk of developing post-traumatic stress after one of these traumas, since unfortunately, the traumas are so common?

Fortunately, although common, much less common is the development of post-traumatic stress.

- That's a great way to say it, Jeff.

The good news is that despite there being so much trauma in life that most kids in fact are quite resilient and don't necessarily develop PTSD.

So I do think that's some good news folks can take away.

With that said, there are risk factors, known risk factors for developing PTSD in kids.

And these include things like being female.

So females are at higher risk for developing PTSD than males, particularly after puberty as far as we know.

Also, having a prior internalizing disorder, and by that I mean having a history of depression or anxiety or even having PTSD in the past puts a child at greater risk for developing it again.

And then there are factors around the time of the trauma that matter.

So how much social support does that child have?

How are their caregivers or parents doing?

Are they coping well or okay with that stress and trauma?

And then going onwards, we also know after the trauma that factors such as feelings of guilt or shame can put someone at much higher risk for developing PTSD.

So those are some of the big risk factors that come up.

- So when you look at those risk factors, it may point towards steps that could be taken to prevent or at least decrease the severity of PTSD after a trauma.

What should a family do if a child, adolescent, experiences a trauma of the likes that you already described, what should that family do to help their child?

- There's a number of things that family can do, and I think it's also important to recognize that oftentimes in these situations, the whole family is traumatized to a certain degree.

So really wanna make sure the whole family system is getting the help that they need.

And when there has been a trauma, certainly if there's a crime to be reported or a safety issue involving child protective services or the police can be an important part of that.

Outside of the criminal or legal system, though, we're really thinking about what kind of supports can the family engage for recovery and psychological wellbeing.

In those instances, families might start with their pediatrician, for example, and letting their doctor know about the trauma or traumas that have happened and what kind of help or resources they can provide.

It might be a school counselor.

Schools can often be very helpful in these types of situations and connecting the family with other forms of care that they may need.

And then certainly thinking about if symptoms are quite severe after a trauma, reaching out for professional mental health services such as a therapist or a psychiatrist can be really important as well.

Other families may have strong sources of support in spiritual or religious areas, and so perhaps they might go to their church or mosque or temple and think about what sorts of supports that they might have there.

So I do think it's important to mold that around the family's context and what's gonna be most helpful for them.

But building in that social support is really, really important.

- Before we get to some of the details about treatment, I'd like you to describe some of the co-occurring or what we often call comorbid types of symptoms that may occur along with post-traumatic stress in some people.

- It's a really important question because PTSD unfortunately does not travel alone or seldom does it travel alone.

So there are other comorbid symptoms or illnesses, Jeff, as you're talking about.

Some of the most common ones are ADHD, and kids with ADHD are at higher risk for developing PTSD as well after a trauma.

Also quite common though are other anxiety disorders, whether it's social anxiety, panic disorder, depression also can be quite common with post-traumatic stress disorder in youth.

And there's another area of symptoms that I do wanna mention as well, which we call dissociation or dissociative symptoms in youth.

And this can happen oftentimes when a trauma is so severe or it's been so repeated over time that the brain effectively shuts off the memory or thinking about that trauma and it's doing this in a way to try to protect that child.

What can happen though is it becomes very difficult for us as clinicians or perhaps for families or teachers to know that something is wrong, where in fact the PTSD, sort of classic PTSD symptoms we think about are suppressed because of all of these dissociative symptoms.

But that's very taxing for a child and for the brain to be able to do that for a long time.

So that's an important aspect to look for as well.

- Now I'm gonna ask you, tell us a little bit more about dissociative symptoms.

What is that, so that people get a better sense of that?

- Yeah, what is dissociation, it's an important question to answer first.

So dissociation is when the way the mind functions, it might be our emotions, it can be our cognition or way of thinking, when that becomes separate from our conscious experience or control of it.

And I like to think of it as the brain's way of compartmentalizing really horrible and bad things.

So all those emotions and negative feelings I might have about a trauma that happened to me, I'm gonna put in this box and I'm gonna lock that away.

So that can be a sign of dissociation.

And the way that might come up is kids might tell us, oh, that never happened to me, or it happened, but that doesn't bother me at all.

Even in instances that would seem pretty horrific, like abuse.

Kids might also say, well, I have a safe place that I go to, that's that box over here where I know I'm safe and I know no one's going to hurt me.

So it can also look like a retreat of a sort.

Now the other thing that can happen though with dissociative symptoms, this sort of compartmentalizing of the trauma and all the emotions and feelings associated with it is sometimes that can't be contained.

So if the trauma reminders become so strong or there's another trauma that happens, that box or that lock on that box can actually break.

And so then the symptoms, reactivity, aggression, difficulty sleeping, you know, all those PTSD symptoms can become much worse.

- In some ways, the dissociative process is sort of on the one hand maybe helpful in the short term, holding back uncomfortable, terrible feelings, but on the other hand, sitting there waiting to get out and maybe blocking the person from getting the help that they need.

- That's really well said, Jeff.

It is the brain's best attempt to try to protect that child from really horrific memories oftentimes.

And it's so taxing.

It takes so much energy for the brain to be able to do that.

And you're right, it doesn't work for the long term.

It can be helpful in the short term, but eventually other stressors, other things come up and out of exhaustion sometimes that simply can't be held in place any longer.

- I'd like you to tell us about some of the treatments that are available for post-traumatic stress in youth.

So jump right in with the treatments.

- Yeah, so the great news is we have some really good treatments for PTSD in youth, and the mainstay of these treatments are really psychotherapy or talk therapy based.

And the common themes around these, whether we look at trauma-focused cognitive behavioral therapy, or EMDR, which is eye movement desensitization and reprocessing, your viewers may hear about terms like those.

What they seem to have in common is recounting a trauma narrative.

So helping the child in a safe space to be able to tell their narrative, tell the story of what happened to them and how that impacted them and their family, what emotions they've had and so forth.

And so with that story and unveiling some of the thoughts and the feelings around that, a trained therapist can help that child really begin to dismantle some of the cognitions or thoughts that may come up.

Common ones being, oh, it was my fault, I should have told somebody.

So they can help them to correct that sort of skewed thought to something that's really more compassionate and more realistic.

Also, as part of these therapies, there's a lot of psychoeducation, so educating people on what common responses to trauma are, how that may differ in kids, how families are affected by trauma.

And I think an important piece of therapies, like trauma-focused cognitive behavioral therapy is it brings in a safe and supportive caregiver as well that's doing a lot of these therapy steps in parallel with their child and then coming together with their child as part of some of the healing sessions as well.

- It's not just treatment while in the therapy room, also by engaging family members, the treatment is ongoing even at home.

- Absolutely.

Yeah.

And the caregivers, parents, family are really critical in this process because they need to be able to understand why their child might be behaving the way they do, putting that through what we call a trauma lens, that their anger or their impulsivity is actually related to trauma triggers.

They're not trying to be a bad kid, right?

And then also helping the caregivers and family to really better be able to manage their child's behaviors and the situations and context they're in.

Absolutely.

- I want you to tell us a little bit about EMDR, because to some people, many people may not have heard of it, others who have, sort of moving the eyes around, why does that work?

Tell us about it.

- Yeah, there's still a lot I think we need to learn about EMDR, or eye movement desensitization and reprocessing.

That's a mouthful, which is why we say EMDR.

But for families who are looking into this, it might seem a bit odd at first.

Jeff, like you said, it does involve some sort of visual or tactile distraction.

It might be a light going from left to right, back and forth.

Might also be having buzzers in each hand going back and forth.

And it's during that distraction that the therapist is working with a child to recall images, smells, or other sensory ways that a trauma may come up for them.

And then helping them to process some of the thoughts around that.

Now, I suspect, and I think the research, we still need more research really to figure out exactly why this is working and for whom.

But my sense clinically is that EMDR does use that distraction in a very therapeutic way.

In other words, for some kids, many kids, in fact, it can be really difficult to talk directly about a trauma and horrible things that have happened in their lives.

What EMDR may offer is some additional distraction that then allows the brain to more easily tap into some of those memories in a less direct way, in a less confrontational way, that's still allowing processing of those trauma memories, but doing it in a way that perhaps is a bit more gradual.

- How about medication?

Talk about the use of medicine for post-traumatic stress or for the co-occurring conditions that may happen with post-traumatic stress.

- So medications can be helpful in certain instances, and let me just first say, for kids, there are no approved medications for PTSD, whereas in adults we do have some options for PTSD, like SSRIs, serotonin reuptake inhibitors.

Now with that said, you mentioned the comorbidities and that can be a case where treating comorbidities with medications can be very effective and very helpful for helping that child to recover.

And we have medications for anxiety and depression that do work for kids.

The SSRIs I just mentioned are one example of that.

And then also making sure ADHD, if that child has it, is well treated.

And we have very effective medications for ADHD.

Sometimes called stimulant medications, there are also non-stimulant medications for ADHD that can be very helpful.

Another aspect of that is by helping to get some of those comorbid illnesses or conditions under better control, that can allow youth to make better use of the skills and therapy and to be able to better tolerate the talk therapy experience.

So that can be really important.

I will finally mention there are some instances where we may try off-label use of medications for PTSD symptoms in youth.

Most often these come up for sleep disturbances and nightmares.

So there are some medications that can be helpful for youth where there are significant sleep problems or aggression, irritability that tie into that.

- I want to ask you about the important topic of suicide prevention and risk of suicide in youth with post-traumatic stress and what can be done about that.

- Suicide is a very big problem and a big concern in youth who have been through trauma first off.

And in particular the risk of suicide after sexual abuse is extremely high, even higher than some of the other types of trauma that we might think about.

- I think an important thing for parents is to help their child know that they're not alone and if they are having thoughts of hurting themselves, they should seek help from their family and/or professionals that they may be working with.

- Yeah, that's a really important part of this, Jeff, and this is one of the most devastating aspects of trauma and PTSD is that it often does make kids and families feel like they are alone or it might make kids feel like they are somehow broken or defective.

Like you said, that this is the only one this has happened to or that it's such a shameful experience they can't talk about it with anyone.

So that those kinds of things are not their fault and the trauma was not their fault.

The PTSD isn't their fault.

And really helping youth to understand that, and families, can be a bridge to getting that kind of help you talked about, seeing a therapist, psychiatrist, or other mental health professional.

- Ryan, I want to thank you for joining us today and more importantly for all of the people that you've helped, the youth, the family, and for the research that you're doing to develop better treatments, better understanding of post-traumatic stress in young people.

Thank you.

- Thank you so much, Jeff.

It's really been an honor to be here with you.

- If your child has experienced a traumatic event, don't let him or her suffer in silence.

Get the help that he or she needs.

Remember, with help, there is hope.

(gentle music) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation and the John & Polly Sparks Foundation.

(gentle music continues) (gentle music continues)