The issues surrounding childrens behaviour after a traumatic experience are complex, multifactorial and often hugely controversial. Having considered the literature on the subject, one could be forgiven for believing that there are as many opinions on the issues as there are people considering the issues.
In this review we have attempted to cover as many of the major areas as possible in order to present a reasonably comprehensive overview of the subject.
The definition of a traumatic experience is subjective from both the point of view of the child concerned and also form the observer. Some commentators have suggested that the only workable definition of a traumatic experience is one that, by definition, produces demonstrable psychological sequelae. (Abikoff 1987)
This may be the case, but as other commentators observe, some psychological sequelae may not surface for years, if at all. This does not mean that the original triggering episode was not traumatic. There is also the view that that the worst kind, or most extreme type of trauma may be the most likely to be actively suppressed at either a conscious or subconscious level. (Haddad & Garralda. 1992)
With an area of literature as vast as the one that we are considering here, it is often difficult to find a place to start. In this instance we will consider the paper by Prof. Harry Zetlin (1995) who starts with a short monograph on the screening of a television programme which dealt with arguably the most catastrophic of stresses to befall a child, that of the loss of a parent through murder or violence. He makes several thought provoking comments which are worthy of consideration as they are germinal to the thrust of this article. The first is a plea that the diagnostic label of post-traumatic stress should not be a catch-all basket for all emotional and behavioural problems that can occur after a traumatic experience. (Gorcey et al.1986)
The second is the realisation that in the particular circumstances portrayed on the television where a parent is murdered have two consequences. The first is the obvious catastrophic trauma that the child experiences with the violent loss of a parent, but the second is the much less obvious fact that the child has, at a stroke, also lost a valuable, and normally available resource, of the protective family environment, which is often one of the most useful therapeutic tools available to the therapist. He adds to this two further insights. The first is that the surviving parent has their own trauma to deal with and that is invariably transmitted to the child and that, because such events are mercifully comparatively rare, only a comparatively few professionals are ever able to build up any significant expertise and experience on the subject.
The main issue of the piece is, however, the very relevant point that considering the apparent obsession of the media with intrusive fly-on-the-wall documentaries and the almost equally insatiable public hunger for sensation, the very fact that such a programme is made at all, almost inevitably adds to the trauma felt by the victims. (Koss et al 1989)
One could argue that actually confronting and talking about such issues is part of the healing process. Such considerations may be of value in the adult who is more able to rationalise the concepts involved, but to the child this may be very much more difficult and being forced to relive the episodes in a very public and unfamiliar arena, may do little more than add to the psychological stresses and damage already caused. (Mayall & Gold 1995)
This paper offers a wise and considered plea for sense and moderation, not to mention reservation and decency. It is written in calm and considered moderate tones which makes the impact of its message all the more powerful.
The next few papers that we would like to analyse deal with the thorny issue of Attention deficit hyperactivity disorder (ADHD) in children. It has to be commented that there is a considerable body of literature which argues on both sides of the debate about whether ADHD is the result of childhood trauma. One side is presented, quite forcibly, by Bramble (et al. 1998). The authors cite Kewley (1998) as stating that the prime aetiology of ADHD is a genetic neuro-developmental one. They challenge the expressed views that it is a manifestation of early childhood abuse or trauma which can have occurred at some time previously with the words:
..early abuse and trauma later manifest as symptoms and that the detection of these symptoms in children clearly illustrates early trauma is a prime example of the logical fallacy that underpins all psychoanalytical theory and practice.
The authors argue that to state because psychotherapy is often effective it must reflect the fact that a traumatic episode must have been responsible because it addresses directly the original emotional trauma (Follette et al.1996), is completely unsound. The natural progression of this argument, they assert, is the reason why many parents of children with ADHD have such difficulty in finding child psychiatrists who can actually help them rather than the many who would seek to blame them for the childs behaviour in the first place. (Breire 1992)
The authors take the view that the reason that psychoanalytical practitioners have held so much influence on the profession over the years is that it is only recently that the glare of evidence based medicine has fallen on their discipline.
The authors argue that far from using psychotherapeutic tools to try to achieve resolution, the evidence suggests that psycho-stimulant treatment is far more effective (Abikoff 1987) if only because it enhances the therapeutic effect of other forms of treatment such as family therapy and special educational provision.
The converse argument, or perhaps an extension of the argument, is presented by Thambirajah (1998) who takes the view that many papers on ADHD (and by inference he is referring to the one reviewed above), regard the syndrome as being a diagnosis made simply by checking an appropriate number of boxes on a check-list. He asserts that factors such as biopsychological circumstances should be weighed equally strongly as the symptom cluster of impulsivity, inattention or hyperactivity. (Tannock 1998)
In direct contrast to the preceding paper he states that early traumatic experiences, current abuse or even depression of the mother may all be contributory factors in the aetiology of the condition. He argues that taking no account of these factors is to ignore much of the accumulated evidence and wisdom on the subject.
He also makes a very valid point that to ignore these factors and only to use the check-list approach means that here is an over-reliance on the significance of these symptoms and, as a direct result, this leads to an overestimation of prevalence. He points to the obviously erroneous estimate of a study that was based exclusively on check list symptomatology, of 15% (although the study is not quoted).
The author makes the very valid point that most psychiatrists would agree that the hyperkinetic disorder is a small sub-group within the ADHD syndrome and that these children may need treatment with stimulants but only after other aetiologies have been excluded. He makes the rather apt comparison of treating all children with ADHD the same way as calling all four legged animals with a tail donkeys.
There are a great many more papers on this issue which we could usefully review but we must explore other areas of trauma in a childs life in order to try to give a representative overview.
With the possible exception of the situation outlined in the first paper reviewed, there can be few experiences more traumatising to a child than to me made homeless as a refugee in a time of war. The paper by Hodes (et al. 2001) is both heart rending and informative as it explores the health needs of refugees arriving in the UK. Although the paper catalogues all of the health needs (that need not concern us in this article) of the refugees, it does not overlook the psychosocial trauma aspects of the childrens plight. They point to the fact that one way that a childs psychological trauma can be minimised is by being accepted into a peer group such as a school. While this may indeed be true, the problem is that refugee children are seldom seen by their peers as belonging and are therefore seldom completely accepted. (Lewis 1998)
This is either aggravated or caused by the fact that they already have twice the rate of psychiatric disorder as found in control groups of children. (Tousignant et al. 1999). It is therefore important to be aware of these problems as they are often very amenable to psychiatric intervention (OShea et al. 2000).
The authors quote a paper by Burnett and Peel (2001) who appear to be particularly pessimistic about making a diagnosis of post-traumatic stress disorder in children from a fundamentally different culture, as their recovery is thought to be secondary to the reconstruction of their support networks, which may prove particularly difficult in a different or even alien, cultural environment. They point to studies of the children who fled to the USA to escape the Pol Pot regime, who had post-traumatic stress in childhood, and even when followed up 12 years later they quote 35% as still having post traumatic stress and 14% had active depression. (Sack et al. 1999).
This may be a reflection of the difficulty in getting appropriate treatment for a condition in a different culture. But, in distinct relevance to our considerations here, the authors comment that even exposure to a single stressor may result in a surprisingly persistent post traumatic stress reaction. (Richards & Lovell 1999)
The last article that we are going to consider here is a paper by Papineni (2003). This paper has been selected partly because of its direct relevance to our consideration, but also because on a human level, it is a riveting piece of writing. It is entitled Children of bad memories and opens with the quote Every time there is a war there is a rape (Stiglmayer 1994).
The whole article is a collection of war-related rape stories and the resultant psychopathology that ensued. The author specifically explores the issues relating to childhood rape and its aftermath. She also considers a related issue and that is how the effect of maternal shame shapes a childs perception of themselves (with heartrending consequences), how the shame felt by the mother is often externalised to affect the child who is the visible symbol of the physical act. (Carpenter 2000)
The catalogue of emotion and reaction described in this article by some of the subjects, would almost make an authoritative text book on the consequences of a traumatic experience in childhood. It would be almost impossible to quantify a single negative emotion that was neither articulated nor experienced by the victims, not only of the act of rape, but also of the stigma and aftermath of the act which was often described as the worst aspect of the whole thing.
A constant theme that runs trough the paper is the realisation that the presence of a child conceived by a rape is a potent reminder of the trauma and therefore is, in itself a bar to psychological healing. The author also points to the fact that another, almost inevitable consequence of forcible rape, is difficulty with relationships and intimacy which can devastate a childs social development. (Human Rights Watch.1996). Such a child may not only have this burden to bear for its life, but the stigma forced upon it by society may also have untold consequences. The author quotes a child born from the Rwandan conflict, describing itself by different names which bear witness to societys perception, and more accurately and inevitably, the childs perception of itself:
children of hate, enfants non-desirés (unwanted children), or enfants mauvais souvenir (children of bad memories)
The author describes how such psychological trauma may never be successfully treated and ends with the very perceptive comment
There cannot be peace without justice, and unless the international community recognises all rape in conflict situations as crimes against humanity, there will be no peace for the victims of such atrocities.