4. Children's Emotional Response to Disaster

4.3. Severe Stress Reaction and Adaptive Disorders (F43), Acute Stress Reaction, and Post-traumatic Stress Disorder (F43.1)

Post-traumatic stress disorder (PTSD) is a clinical entity that commonly occurs after exposure to a traumatic event. A traumatic event threatens the physical or psychological integrity of the affected person, and is associated with feelings of confusion, insecurity, terror, and bewilderment.

Data on the prevalence of PTSD in childhood vary widely, reflecting the individual experience of the children and families as well as the amount of personal and communal loss. However, most children, while emotionally affected by a disaster, do not develop PSTD.

The International Classification of Diseases (ICD-10) defines PTSD as a disorder that “arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.” The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM V-TR). There must be a documented trigger to PTSD involving exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

  • directly experiences the traumatic event; 
  • witnesses the traumatic event in person;
  • learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
  • experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

Younger children may “act out” the traumatic experience in all its intensity or enact the trauma through repetitive play.

Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition.

Symptoms of anxiety may appear at all ages and affect uniformly the adult and childhood population.

Re-experiencing the Traumatic Event

Children may experience recurrent, intrusive, and pervasive thoughts regarding the traumatic event. This occurs as flashbacks or repetitive dreams, or nightmares. These dreams may not necessarily contain images drawn from the traumatic event; in fact, the frightening dreams may have no recognizable content. Younger children may act out what they have witnessed — in all of its intensity— or they may engage in joyless repetitive play in which themes or aspects of the traumatic experience are re-enacted. Other symptoms include emotional and physiological reactivity to certain reminders (cues) of the event such as smells, images, sounds, or similar emotional triggers.

Avoidance and Numbing

Affected individuals frequently avoid passing through places, conversations, or situations that trigger any painful recollection of the traumatic event. Avoidance in children may take the form of closing or covering their eyes when in proximity to the traumatic scene or other reminder. They may also have tantrums prior to returning to a site of traumatization. Numbing behavior is recognized when children often lose interest in activities they used to enjoy. A child, who once had a full range of emotional expression, may look withdrawn, restricted, and indifferent. Affected children may also seem detached from significant emotionally others. Some older children and adolescents may report a sense of not caring or doom about the future. These sorts of reactions (both avoidance and increased arousal) can be barriers to providing help. Well-meaning supporters can mis-interpret people’s changing the subject, saying they don’t care, getting agitated or inappropriate, and various other behaviors during sessions that are intended to address the trauma. It is important to notice and respect these signals and help work on security and control before trying to do more.

Signs of depression such as sadness, hopelessness, and sleep disturbance are common manifestations after a disaster.

Symptoms of Increased Arousal

Hyperarousal is manifested through sleep disturbance that can include nightmares, fear of sleeping alone, or difficulty initiating or staying asleep. Difficulties in concentration make learning difficult. Hypervigilance and an exaggerated startle response may lead to excessive irri­tability or angry outbursts and may make interpersonal relations quite difficult, especially within the family.

It is necessary that children understand that they are not responsible for what happened in order to prevent inappropriate feelings of guilt.

Other Symptoms

Other associated symptoms that frequently co-occur include regressive behaviors, such as thumb-sucking, enuresis, and encopresis, as well as other phobias and anxieties, multiple somatic symptoms (stomachaches and headaches), and disruptive behavior.

PTSD manifestations vary according to the development stage of the affected child, making it possible to describe them in three groups: preschool-age children, school-age children, and adolescents.