Stress and reactions to stress in children
If the consequences of the event are manageable
and disruption is minimal, the child’s distress and
upset may resolve within a few days or weeks.
The ability of parents (who may themselves be
distressed and traumatized) to provide adequate
care, and the presence of a stable caring system
around the child, is crucial in promoting recovery.
When these are absent, significant mental health
problems can develop. And of course, if traumatic
experience is repeated there is a risk that chronic
and complex responses will develop [16].
PSYCHOPATHOLOGY
Following a traumatically stressful experience,
repetitive and intrusive memories of the event
are common. A chance noise or other stimulus
may trigger a flashback. Disturbing images may
also occur at quiet moments such as bedtime,
making it difficult for the child to settle to sleep.
In very young children, sleep disturbances such as
night terrors and night waking are common. Older
children often report that their sleep is disturbed
by bad dreams and nightmares. Children who
are too young to be able to understand what has
happened to them or to express their thoughts and
feelings in words are likely to re-enact a traumatic
event in their play or drawings. They often develop
symptoms of hyperarousal, such as overactivity,
irritability, difficulty concentrating and hyper-
vigilance. Signs of generalized anxiety are also
common, including clinginess and fears of the dark.
Language, toilet-training and other developmental
skills may regress or even be lost altogether. The
child may become withdrawn or unresponsive and
try to avoid situations, objects or even words that
remind them of the traumatic experience.
When children are exposed to chronic and
repeated stress such as abuse or domestic violence,
many domains of development may be affected
[17]. Such children present a diagnostic challenge
to the clinician, not uncommonly presenting with
complex disorders of arousal, mood and conduct.
When trauma is not identified, such children may
be misdiagnosed as suffering from attention deficit
hyperactivity disorder (ADHD), conduct disorder
or psychosis.
As children get older, their reactions to
extreme stress become more like those of adults.
Adolescents may meet DSM or ICD criteria for
PTSD and other disorders. Those exposed to
prolonged or repeated stress may also present
with dissociative symptoms, angry outbursts,
self-injury and substance abuse [16]. Memory and
concentration difficulties are common and can
affect school work and grades. Moodiness, anxiety,
depression and irritability can put pressure on
peer and family relationships.
ASSESSMENT
When asked to assess a child following a major
stressful event, it may be helpful, before arrang-
ing to meet the child, to have a planning meeting
with the parents/carers. Interviewing parents and
child together about the child’s current circum-
stances and functioning is often a good place to
start the assessment. Parents can provide useful
background information such as family history, and
the child’s developmental history. It is often help-
ful to see parents separately to obtain information
about the parental developmental history (includ-
ing trauma and attachments), marital relationship,
and life experience of separations, abuse, illness
and other stressors or life events. The parental
account of any traumatic events should include
their own and the child’s reactions to the trauma,
and how these have been managed.
Interviewing the child individually is especially
important following traumatic experience. Parents
often lack crucial detailed information about their
child’s experience and may therefore be unable to
provide all the information needed. Children often
communicate more freely about their experiences
when not afraid of causing distress to carers. It is
usually necessary to ask the child direct questions
about their experience of traumatic events and
their symptoms. Asking the child about what has
helped them to cope is also important. A semi-
structured interview can be helpful [18] (Box 18.3).
Young children respond best to an approach
using play and drawing to help them to express
themselves. At the end of any interview about
trauma, the interviewer needs to help the child
‘wind down’, to review and summarize the ses-
sion, and to discuss anything that was particularly
disturbing or helpful. Providing information about
traumatic experience and its consequences helps to
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