Childhood

Childhood is a time of significant development. Children’s language skills, executive functioning, and self-regulation are developed actively through positive interactions (Center on the Developing Child, 2007). The associated skills that they develop contribute to academic, social, and emotional functioning. Delayed or disrupted development can result in difficulty sustaining attention, following instructions, retaining new information, and establishing positive relationships with peers. As development progresses, evidence of neurodiversity may become apparent. For example, inability to maintain focus, careless behaviour, and excessive talking may be indicators of Attention-Deficit Hyperactivity Disorder (ADHD) and delayed language and communication skills, challenges with social interactions and sensory difficulties are some indicators of Autism Spectrum Disorder (ASD; Wicks-Nelson & Israel, 2015). As they develop, children also experience significant integration of neurological and physical skills through proprioception development; this is interconnected with cognitive development and affects areas like handwriting, gross motor skills, and self-regulation (Raising Children Network, 2022).

Children are vulnerable and dependant on their parents/caregivers. The relationship that children experience with their parents is a central component of their development (Center on the Developing Child, 2015). It is a source of protection but can be also a major risk factor. This relationship, known as attachment, is established in a child’s formative years and can be classified as either secure, ambivalent, avoidant or disorganised (Cherry, 2019). The patterns of attachment formed with parents also affects the attachment style the child may use in other relationships thus contributing either to positive development or developmental challenges (Bowlby, 1982). Ambivalent, avoidant, and disorganised attachment styles are indicators of possible exposure to neglect, abuse and/or trauma. These suboptimal attachment styles then further increase a child’s vulnerability to abuse and trauma, both of which have a major impact on all areas of their development (Bowlby, 1982; Cherry, 2019; Davidson & Davidson, 2007).

Posttraumatic Stress Disorder

Both the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013b) and the International Classification of Diseases 11th Revision (ICD-11; World Health Organisation, 2019a) recognise Posttraumatic stress disorder (PTSD) as a psychiatric disorder that develops in response to the person experiencing or witnessing a stressful or traumatic event or events. Examples of stressful or traumatic events include war, natural disaster, terrorism, serious accident, personal attack (including rape or sexual violence), and bereavement (The National Child Traumatic Stress Network, n.d.). There are some variations though between definitions and related conditions. This Mental Health Case Report will be referring to the DSM-5 definition of PTSD that applies to adults, adolescents, and children as young as six years old.

While data relating to incidence of trauma in Australia is limited, international research estimates between 62 to 68% of young people have had exposure to at least one traumatic event by 17 years of age (Australian Institute of Health and Welfare, 2020e). PTSD is experienced by up to 16% of children (Phoenix Australia, 2021). Symptoms of PTSD are organised into four categories and can vary in severity (Wicks-Nelson & Israel, 2015). These categories are intrusion, avoidance, alterations in cognition and mood, and alterations in arousal and reactivity. Intrusion can be explained as re-experiencing the event with intrusive thoughts, and avoidance includes conscious and unconscious efforts to evade association with the event. Alterations in cognition and mood are characterised by negative thoughts and negative emotional state, including distorted thinking. Altered arousal and reactivity is typified by anger, irritability, and variation in engagement from hypervigilance to poor concentration (Rothbaum, 2021).  Experiencing these symptoms is a normal response to trauma. Symptoms become a sign of PTSD when they are present for more than a month and affect daily functioning.  Three months post-experience is when many develop symptoms but in some instances it is later. The duration of PTSD can also vary, from months to years, and be experienced in conjunction with other psychopathology and disorders including depression, anxiety, behavioural, substance abuse, and developmental delays (APA, 2020b; Wicks-Nelson & Israel, 2015). Related conditions include acute stress disorder, adjustment disorder, disinhibited social engagement disorder, and reactive attachment disorder.

Evidence of symptoms

Symptoms that are the observable behaviours and experiences of a person with PTSD can be classified in the four categories of avoidance, intrusion, negative cognitions and mood, and alterations in arousal (Phoenix Australia, 2021; Wicks-Nelson & Israel, 2015). Observable behaviours and experiences associated with intrusion include recurring nightmares, vivid memories, flashbacks, intense emotional distress, and physiological reactions (Rothbaum, 2021). In children this may present as sleep problems resulting in fatigue and affecting their ability to engage in learning when at school (Phoenix Australia, 2021). Children may recreate their experiences of trauma in their play or repeatedly retell the story and events associated with their traumatic event. Children may experience a racing heartbeat or trouble breathing when reminded of the trauma.

Experiences in the category of avoidance include avoiding discussing or thinking about the trauma, and avoiding external reminders including people, places, and activities (Phoenix Australia, 2021). Depending on where the trauma was experienced will impact on a child’s ability to feel safe. Avoidance may result in school or activity refusal, or difficulty being with certain peers or school staff.  Children may also experience increased separation anxiety.

Negative alterations in mood and cognition include memory lapses of the event, and pervasive negative thoughts and feelings leading to distorted beliefs about themselves or others (APA, 2020b; Phoenix Australia, 2021). Mood and cognition alterations may also include inaccurate thoughts about the cause and consequences of the event and associated feelings of guilt and shame, inability to experience positive emotions, and withdrawal from regular activities where enjoyment had previously been experienced. Children may experience a new realisation of their own mortality, feel anxious or depressed, and have difficulty concentrating and remembering.

Alterations in arousal and reactivity may result in feelings of anger and irritability, or uncontrolled behaviour (Phoenix Australia, 2021). Children may exhibit tantrums, oppositional behaviour, show skill regression in previous areas of mastery and may also develop new fears. Feelings of hypervigilance may also be present affecting a child’s ability to feel safe and engage in learning.

Impact on the Individual and Interactions

A sentiment felt by those who have experience PTSD, is that rather than focusing on what is wrong with them and trying to fix it, they want those around them to acknowledge and understand what they have experienced (Ford, 2015; Llewellyn, 2015). PTSD can range in intensity and duration with one third of children with PTSD experiencing natural recovery with a year, one third achieving positive outcomes from direct interventions, although the remainder of children experience prolonged effects (Phoenix Australia, 2021). A major consideration is the vulnerability of children and their reliance on parents/caregivers. It is essential for adults who are in a support role to children, to receive assistance with their experiences of trauma first or concurrently as their experiences of PTSD can affect the parent-child attachment relationship (Phoenix Australia, 2013).

After incidents like the recent flooding, pandemic, drought, and bushfire events whole communities may be experiencing symptoms of PTSD. Coordinated responses of support may be required between schools and multiple government or other external agencies. Triggers may be readily experienced with seemingly simple events like rain and schools need to have response plans in place to minimise the recurrence of stress, especially if children are in a hypervigilant state. Peer interaction may increase anxiety and further traumatisation if left unchecked and a formal strategy is not in place. Recommendations for responses include information dissemination, emotional support, and assistance of a practical nature, but avoiding psychological debriefing (Phoenix Australia, 2021).

Suggested Interventions

It is important that treatment is provided as soon as possible by a skilled counsellor who specialises in trauma and PTSD (Geldard et al., 2019) to avoid grave consequences. Guidance officers (GO) may play a significant role in identifying initial symptoms and then refer a student on to receive the appropriate treatment.  In the instance of counselling and psychological intervention being required, the Australian guidelines for the prevention and treatment of acute stress disorder, posttraumatic stress disorder and Complex PTSD (Phoenix Australia, 2021) recommends trauma-focussed Cognitive Behaviour Therapy (TF-CBT) for both the child, and the child and caregiver together, post incidents of trauma. TF-CBT is effective and strongly recommended because it supports individuals to develop skills to process memories and come to terms with their trauma experience (Phoenix Australia, 2021). Delivered by a skilled professional, TF-CBT generally involves 6 to 12 sessions, or more if required. It is tailored to the individual according to their age and parental/caregiver involvement is encouraged to support skill and strategy mastery. TF-CBT is a psychoeducational approach that aims to develop conscious understanding of cognitions, reactions and emotions, and skills to process these including self-regulation strategies.

Research has also identified that children who have experienced trauma benefit from sand play and play-based therapy with other media as it is developmentally appropriate and fosters feelings of safety (Geldard et al., 2019). Geldard et al. (2019) cite multiple studies to illustrate that therapies using media and play-based approaches have a vastly positive effect on children who have experienced abuse, neglect, and/or witnessed domestic violence. These positive results not only include reduced negative symptoms of anxiety, depression and anger but increased positive results, including collaboration and self-regulation.

There is consensus across treatment guides that family and relational involvement in treatment is important (Barrett & Ollendick, 2003; Ford, 2015; Phoenix Australia, 2021). What does this mean though for the intervention or support strategies a GO might apply? The GO plays a key role in providing not only onsite support to students individually or in group sessions but also educating staff in how to best create an environment that is supportive and promotes recovery. A key intervention for a GO is the provision of professional development about trauma-informed and resilience promoting practices. Building staff understanding of the significance of their relationship with children and their caregivers and how this contributes to children feeling safe is paramount. Staff must be cognisant that for a child to be able to engage in learning, they must first feel safe. When students do not feel safe, negative behaviours that are detrimental to the student’s learning, social connections, and overall safety emerge (Delahooke, 2019). Examples of these behaviours include refusal to participate, avoidance, or aggression.  Some simple and practical steps staff can take to support students to feel safe include establishing strong relationships with the student and their family, considerations to the classroom’s physical environment, awareness of proximity, conscious use of an even facial expression, using a prosodic vocal tone, and calming music (Phoenix Australia, 2021).