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 D. Richard Martini, MD
If you have questions about the diagnosis and treatment of a disorder or are interested in case consultation, please contact us. No physician or patient names will be used in the articles. Responses will be written by selected members of the Department of Child and Adolescent Psychiatry. |
The Doctor is in— Questions and answers about behavioral and D. RICHARD MARTINI, MD aFall 1997 Psychiatric risk factors following violent injury My practice is in an area of Chicago that is increasingly affected by gang violence and seemingly senseless trauma to children and adolescents. I recently saw a 13-year-old boy who was wounded in the cross fire of a gang incident. He stated over and over that he is not involved with gangs and that he was simply in the wrong place at the wrong time. Fortunately, his injuries were superficial. The bullet grazed his right arm causing a wound that required several stitches to close. He was treated in Children's emergency room and released. I saw him after this incident and cared for his injury. He and his mother complained that he was having difficulty sleeping and that he seemed anxious and irritable much of the time. In addition, the patient said that he was avoiding the area where the shooting took place, even though it was within four blocks of his house. I told them that this was an expected response to a traumatic event and that it would probably resolve within days. The mother called me three weeks later saying that her son continued to have sleep difficulties, appeared distracted and edgy, and remained at home after school despite requests from peers. Is he suffering from post-traumatic stress disorder and if so, how does it present in children? Dr. Richard Martini responds: Children have been exposed to violence with increasing frequency, and there is a growing concern that these events have emotional consequences. Children may not only be affected immediately after the trauma, but may also be emotionally scarred by the events and experience long-term changes in behavior. Problems develop in the formulation of research in this area due to several factors:
Epidemiology Violent injury and death occur at an alarming rate in the United States. In fact, the homicide rate in the U.S. is four times that of the country with the next highest rate. Two thousand children between the ages of 0 and 19 die of violence each year. With this, the rates of violence within American communities has also increased. During the 1980s the murder rate increased in almost every major city, and one out of five teenage and young-adult deaths is gun-related. By 1988, gun-related deaths exceeded death by natural causes in this population.1 Violent crime against children and adolescents usually results in minor injury; however, in 20% of older adolescents (between the ages of 16 and 19 years) the injuries are more serious. They include broken bones, internal injuries, loss of consciousness and lengthy hospital stays. African-American males are particularly at risk; their murder rate is nearly seven times that of white victims. Exposure to violence is not limited to victimization. In fact, most children are witnesses to violence rather than participants or victims, ranging in ratios from 2:1 to 4:1. Studies of inner-city youth have revealed alarming rates of violence exposure. In a survey of 1,000 Chicago teenagers, 23% said that they saw someone murdered. Of these teens, 40% knew the victims as family members, friends, neighbors or fellow students. Among 539 Chicago elementary school children, 17% witnessed fights among family members, 33% saw a shooting, 31% saw a stabbing, and 84% witnessed a beating.2,3 Children who were exposed to violence had higher levels of psychiatric disturbance when compared to control groups. The risk was not associated with gender, family structure or the involvement of parents. Stress in children The NIMH community violence project by Martinez and Richters examined the impact of violence on children, particularly long-term sequelae, while examining environmental factors that may affect their immediate and long-term response and the impact of the violence on overall social and emotional functioning. Subjects were between the ages of six and ten years; parents described them according to the Checklist of Child Distress Symptoms and the Childhood Behavioral Check List, and the youngsters themselves used a self-report measure with illustrations that described psychiatric symptoms.4 Youngsters' overall self-ratings of distress were strongly related to levels of victimization and reports of witnessing violence. In addition, children with the highest levels of distress were more likely to have witnessed stabbings and were aware of drug use in the home. Children experiencing distress were more likely to have parents who did not complete high school. Typically, these are families of lower socioeconomic standing, with higher levels of unemployment and prolonged periods of parental absence. There was a large discrepancy between parent and child report on a number of variables. Fifty percent of parents believed that their children never worried about safety, while none of the children said that they never worried. Sixteen percent of parents thought that their children worried a great deal about safety, a figure that climbed to 50% when the children responded to the question. The parents' inability to recognize these symptoms in their children may lead to maladaptive coping strategies in the absence of parental support. In addition, the parents lose opportunities to help their children protect themselves and avoid violent situations in the future. These results also reemphasize the need to interview the child directly. Children as young as six years of age were able to acknowledge psychiatric symptoms on a self-report measure of distress. Surprisingly, the level of distress or depression in children was not related to victimization by strangers but rather by the extent of violence in the home. Children with high levels of distress were more likely to have witnessed drug deals, to have seen someone arrested, to have witnessed family violence and to have seen someone carrying an illegal weapon. Violence that affected family members or individuals known to them had the greatest impact on children; the youngsters demonstrated the classic signs of distress typically noted in adults. Parents from the most violent homes were less likely to agree with their children on the presence of distress symptoms. This indicates a lack of sensitivity that places the child at greater risk. The long-term sequelae of these symptoms is not known. Children may become more vigilant and therefore safer as a result of fear and anxiety. However, normal social, educational and emotional development may be adversely affected by overly cautions and reticent behaviors. In addition, exposure to violence may change the nature of relationships between the child and family or friends. Children may begin to steel themselves against the possibility of loss, and the value of human life may change in the process. Development of Post-Traumatic Stress Disorder PTSD in children following single, intense, traumatic events has been well documented. This is particularly true of single incidents of urban violence. In such cases, there is a relatively high rate of exposure to violent events that are close to home and involve individuals well known to the child. These youngsters are psychiatrically distressed by the events and tend to report more symptoms of disorder than their parents. In addition, the violence has different age and gender repercussions; it appears to impair younger females the most. The degree of exposure to the violence was directly correlated to PTSD symptoms, and the disorder may develop as a result of direct, witnessed, or verbal exposure.5 Studies of homicide victims have identified risk factors for the development of psychiatric disorder among the surviving family members. Survivors of criminal homicide or vehicular homicide were equally likely to suffer from PTSD. In addition, the age of the survivor did not predict prevalence of PTSD. PTSD frequently follows violent crime regardless of its nature; rates are as high as 50% when the fear of death is involved and injury results.6 Prior criminal history is an important factor in the development of PTSD because the patient is not only at risk for further exposure, but is more likely to suffer from psychiatric distress when exposed. This scenario is becoming more common, particularly in inner-city neighborhoods. Fitzpatrick and Boldizar collected data related to the exposure to violence from 221 low-income African-American adolescents between the ages of 15 and 19. The incidence was remarkably high; 70% were the victims of at least one violent attack, and 85% witnessed at least one violent episode. Twenty-seven percent of this population met criteria for PTSD in all three categories. An additional 61% met criteria in at least one category. The degree of violence exposure predicted the rates of PTSD. Males were not only victimized by violence more frequently, but were also more likely to witness violent acts. A stable female presence in the family reduced levels of both violence and PTSD symptomatology. The authors recommended education among all members of the community coming in contact with the child to not only recognize the symptoms but to begin appropriate interventions in much the same way that ADHD and learning disabilities are now recognized in the classroom.7 Burton et al. studied the relationships between traumatic exposure, family dysfunction and post-traumatic stress symptoms in male juvenile offenders. They defined exposure to violence by the following criteria: 1) Perpetration of gang violence involving physical harm; 2) Victimization by gang violence; 3) Death of a family member or close friend; 4) Death of a bystander or of an enemy; 5) Violent deaths not related to gang violence and; 6) Physical or sexual abuse. Participants were incarcerated juvenile delinquents between the ages of 13 and 18, with more than 80% reporting involvement in gang activities. Attempts were made to characterize the family environments through the family environmental scale because family support has consistently been an important factor in the development of PTSD. Twenty-four percent met diagnostic criteria for PTSD, and the number of symptoms increased with the level of violence exposure. Family conflict predicted PTSD severity, while a higher level of family cohesion prevented symptoms.8 PTSD frequently occurs in the context of other psychiatric disorders, and the overlap occasionally confounds the diagnosis. PTSD may also lead to the development of additional psychiatric disorders including anxiety disorders, affective disorders and disruptive behavioral problems. The long-term consequences of PTSD on behavior and further exposure to violence has not yet been carefully studied in prospective protocols. A study considered the development of PTSD in survivors of the Brooklyn Bridge shooting. Victims in the Crown Heights community of New York were interviewed for the presence of PTSD along with symptoms of anxiety disorder and depression. Four of 11 participants had PTSD and also suffered from concurrent major depression. Ten months after the shooting, these 11 individuals were again assessed, and those with anxiety and mood disorder demonstrated some remission of symptoms. The four with PTSD, however, continued to meet diagnostic criteria for the disorder. This suggests that PTSD has a chronic course and that initial presentation as acute stress disorder may persist in the development of PTSD.9 Treatment for PTSD Children require three principle supports in order to better tolerate exposure to violence. The first is the availability of a principle caretaker who loves the child unconditionally. The second is the availability of a safe place to which the child can retreat in case of threat. The final factor is the ability of the child to develop several coping strategies, and this is usually dependent upon intelligence, experience and temperament. Violence in the community also takes a toll on the parents. They become frustrated with the neighborhood and lose faith in its ability to change. This feeling is easily communicated to the child. The treatment of PTSD in children has not been well-described in the literature and is primarily limited to case reports. The treatment of choice seems to be cognitive-behavioral therapy although most therapeutic interventions involve support and strengthening coping skills. In addition, therapists treat or triage patients suffering from additional psychiatric disorders that result from the traumatic experience. Most forms of therapy involve reviewing the trauma and correcting misperceptions and and allowing the patient to master elements of the event in a safe and non-threatening environment. Along with an understanding of the trauma, therapy should also focus on the child's current level of functioning and the impact that feelings of guilt, depression, anxiety and grief have made on the patient. REFERENCES 1. Richters J, Martinez P: The NIMH Community Violence Project: I. Children as victims of and witness to violence. Psychiatry 1993;56:7–21. 2. Shakoor B, Chalmers D: Co-victimization of African-American children who witness violence and the theoretical implcations of its effect on their cognitive, emotional, and behavioral development. J Nat Med Assoc 1989;81:93–98. 3. Dyson JL: The effect of family violence on children's academic performance and behavior. J Nat Med Assoc 1990; 82:17–22. 4. Martinez P, Richters JE: The NIMH community violence project: II. Children's distress symptoms associated with violence exposure. Psychiatry 1993;56:22–35. 5. Pynoos R, Frederick C, Nader K, Arroyo W, Steinberg D, Eth S, Nunez F, Fairbanks L: Life-threating and post-traumatic stress in school age children. Arch Gen Psych 1987;44:1057–1063. 6. Resnick HS, Kilpatrick DG. Crime-related PTSD: Emphasis on adult general population samples. PTSD Res Quarterly 1994;5(3):1–4. 7. Fitzpatrick KM, Boldizar JP. The prevalence and consequences of exposure to violence among African-American youth. J Am Acad Child Adolesc Psychiatry, 1993;32(2):424–430. 8. Burton D, Foy D, Bwanausi C, Johnson J, Moore L: The relationship between traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders. J Traumatic Stress 1994;7(1):83–93. 9. Trappler B, Friedman S: Post-traumatic stress disorder in survivors of the Brooklyn Bridge shooting. Am J Psychiatry 1996; 53:705–707. |