Introduction
For children, as for adults, stress - a tension reaction to a challenge or a threat - is an unavoidable part of life. When short and manageable, stress offers the opportunity to stretch one's potential and adapt to new conditions - preparing for a test, welcoming a new sibling, or meeting a new teacher. When long and unmanageable, adult intervention is needed to help the child cope. Parents should be particularly watchful of two types of situations, chronic stress and posttraumatic stress syndrome (PTSD). In chronic stress the child feels overwhelmed by the tasks ahead - expectations at school, divorce in the family, conflict with peers. The long-term negative consequences on health can be insidious and may include a weakened immune system and higher risk of depression. PTSD occurs as the result of a traumatic experience - threatened death, serious injury or violence - and some children are unable to overcome the initial shock, reliving it with the same emotional intensity months and years later through memory intrusions or nightmares. Symptoms include avoidance of people or things associated with the event, and hyperarousal or increased startle response. Both situations can lead to potentially serious health ailments.
AboutOurKids.org asked Dr. Raul R. Silva, Associate Professor Child Psychiatry and Deputy Director, Division of Child & Adolescent Psychiatry at NYU School of Medicine and author of Posttraumatic Stress Disorders in Children & Adolescents: Handbook, to review the effects of stress on children and outline the latest treatments and coping techniques.
1. Stress
Q: Do children actually experience stress?
A: Yes, children experience stress. For a child, stress is any condition that affects his or her emotional or physical well being. It is not always detrimental though. The excitement of going to summer camp or the pressure of doing schoolwork are both different aspects of stress. It is important to note that the effect any kind of stress has on a kid depends both on the circumstances and the child's personality.
Q: How does the body respond to stress?
A: Under threat or challenge, the mind automatically determines which resources are needed to mount the speediest and best response, and then directs the body to produce the various reactions and chemicals required to meet the demand. This does not occur at the expense of other body functions though; rather the body selects what it needs to mobilize the best response for the current circumstances. The process is totally involuntary and unconscious. The body produces different substances such as hormones - cortisol, adrenaline - and chemicals such as catecholamines. For example if the mind decides your muscles need more energy for running away, it will get this energy from your liver in the form of glucose, and if it decides you need more oxygen, it will accelerate your breathing rate so your body gets more oxygen. There are times when the conscious mind cannot face the worries and anxiety of stress, and instead switches the burden to the body. When that happens, the stress reaction can manifest as headaches.
Q: When does stress become unhealthy? How can parents recognize signs of unhealthy stress in their children?
A: A response to stress is unhealthy when it interferes with everyday normal functioning: for example when the child stops doing his/her homework or when he/she reverts to earlier behaviors that are no longer age-appropriate, such as thumb sucking or bedwetting. Parents must observe carefully their child's behavior, listen and be sensitive to his/her needs. This is how they will be able to notice a negative change - either a worsening of problematic behaviors or a return to previously corrected behaviors. These negative reactions will of course be different with every child.
Q: What can parents do to help their children cope better with stress?
A: You help kids deal with stress mainly by giving them an avenue to discuss their concerns. Kids must trust that their parents will react with understanding and acceptance if they feel like saying "This is too hard, too difficult," or "I am scared, I am worried." You can also help them by modifying their expectations - at school for example - so they are not under undue pressure.
2. Posttraumatic Stress Disorder (PTSD)
Q: How is PTSD different from chronic stress?
A: In chronic stress, a person feels trapped in a lasting difficult situation, such as bleak poverty, an unhappy home, or unrealistic expectations from parents. However chronic stress does not involve the two main characteristics of PTSD: a traumatic experience and persistent emotional distress over time. It's that persistence that makes PTSD difficult.
Q: Why is it so difficult for some individuals to return to the original state?
A: This inability to revert to the original state is true for both chronic stress and PTSD. Some people are less able than others to adapt to a stressful situation, which means it is more difficult for them to get over the experience. Their maladaptive response to stress worsens with time, their sensitivity to stress increases, and their ability to recover decreases. Some studies point out to biological factors to explain this worsening gap. It seems that the overstimulation of the central nervous system may actually cause permanent changes in the brain cells - the neurons. In fact we did a three-year study that suggests that when some people are exposed to more and more stressful experiences, their cognitive attributes - their thinking process - gradually decrease their abilities to recover. However our knowledge of biology in this field is limited. There are no studies of the chemical aspect of PTSD over a long period of time in adults. In addition PTSD in children is probably different because this is a condition that grips their mind when they are developing, disrupting their growth process.
Q: Are there biological similarities between PTSD and other anxiety disorders?
A: I think it is fair to say that PTSD shows some physiological similarities with other anxiety states. Healthy stress responses include the release of catecholamines - chemicals that help mobilize energy for the fight-or-flight responses - and of cortisol - a hormone that contributes to the cessation of the emergency response.
Studies have shown that in PTSD sufferers, the level of cortisol diminishes instead of increasing; they exhibit what is called a "blunted cortisol response." Other anxiety disorders also include that blunted cortisol response. However we cannot generalize. There are many different anxiety states, and the similarities among them are limited.
Q: Only a small percentage of the people who witness a traumatic event will develop PTSD. Which child is more at risk to develop PTSD?
A: The child most at risk is the vulnerable anxious child exposed to violence, especially violence in the family. Studies show that personality plays an important role in the response to extreme stressors. The child with an anxious personality will react much more intensely than the child who does not worry easily. If an anxious kid is physically abused, his reaction may be very different from the response of another kid who goes through the same trauma but does not have an anxious personality to start with. I believe that the development of PTSD is also associated with the deprivation of an instrumental response - when an individual cannot think of any action on his part that would produce positive results. An individual who cannot mount a regular response to the stress and instead reacts by falling into an anxiety or a depressive state is more susceptible to develop Posttraumatic Stress Disorder (PTSD).
Q: Do genes influence the way we respond to stress?
A: Current research does not fully answer this question. It seems that a child's reaction to a stressor shows similarities with a parent's. So the way we deal with stress is probably not entirely dictated by our genes, but they may play a role in the type of reaction we exhibit.
Q: Are there other factors that raise the risk of a child developing PTSD?
A: A lot of factors interact, making the situation very complex. The effect of external events on a child depends on his prior experiences and on his personality. Studies show that the following circumstances may amplify the response to a traumatic event:
- Domestic violence
- Physical abuse
- Emotional and mainly physical proximity to a traumatic event
- Viewing of the traumatic event in the media
Q: Are there factors that lower that risk?
A: Studies demonstrate that participating in a support network contributes to reduce the risk. Some research findings suggest that a higher IQ may also provide some protection. More research is needed though. Other studies have found that a higher IQ may in fact be associated with more severe PTSD. Personally I think that children with higher cognitive abilities may be able to deal better with traumatic situations because of their capacity to reason, to consider different options, etc. Curiously enough, children with conduct disorder (CD) - aggressive children who do not respect authority, trample the basic rights of others and defy societal rules - seem protected from developing signs and symptoms of PTSD. These findings may simply be due to the fact that stress reactions of CD children may not fit the classical PTSD characteristics. Symptoms of conduct disorders are external, while symptoms of PTSD are internal.
Q: How can parents help a child to cope with traumatic events?
A: If you know that your child responds anxiously to stressful events, avoid exposure as much as possible, because he will be more affected than a child with a calmer disposition. The study we did on PTSD and the viewing of the 9/11 event on television confirms this: the amount of TV exposure is directly linked to more severe forms of PTSD, but so is the anxious personality.
Q: What should parents do when they suspect their child may be suffering from PTSD?
A: The best thing to do is to have the child evaluated ASAP by a mental health professional.
Q: What are the treatments available for PTSD?
A: Treatments include medications and cognitive behavioral therapy. Medications for PTSD are mainly regular antidepressants and SSRIs - Selective serotonin reuptake inhibitors (SSRIs). Current studies on these medications show very promising results but we need more research to definitively say they can help PTSD sufferers. Some cognitive behavioral treatment modalities have been shown to be very effective. Two of them are being developed here at NYU: PARTNERS by Dr. Elissa Brown and STAIRS MPE by Dr. Marylene Cloitre. "PARTNERS" is a parent-child intervention designed to decrease children's mental problems, improve parenting practices and enhance parent-child communication. "STAIRS MPE," a treatment for adults who experienced chronic trauma in childhood, focuses on helping improve skills and emotion management and interpersonal relationships.
Q: Can meditation, massage, yoga, or other alternative treatments change the way the brain deals with fear?
A: Any success with these therapies may have something to do with how the patient feels about the treatment. Alternative treatments must be subjected to rigorous scientific research.
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Stress in Children: What It Is, How Parents Can Help
About the NYU Child Study Center
The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at www.aboutourkids.org.
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