I recently had a question from a listener whose child has separation anxiety after the death of a caregiver. I did reach out to this family privately but I wanted to cover this on the podcast as well.
Before the most recent DSM update, PTSD was listed as an anxiety disorder but as the field has become more trauma informed, it is now listed as a trauma and stress-related disorder and anxiety is recognized as one of the symptoms.
This shift recognizes that PTSD is not just a subset of anxiety and in fact anxiety is an adjunct of PTSD. The new diagnosis recognizes that the most pressing concern is to address the trauma. The anxiety may drive the behavior that inspires the intervention, That is, the child may be displaying separation anxiety and that’s the reason the family is seeking help but the underlying reason behind the anxiety is the trauma of losing a family member.
Let’s talk a little bit about trauma. It’s a word we use a lot and not always correctly. The DSM defines trauma as “actual or threatened death, serious injury or sexual violence.” You can see that’s extremely limited and doesn’t include the way we use trauma even in the therapy field. In the therapy field, we include broader upsetting or disturbing events so we might call a divorce a trauma or being fired from a job. Technically, per the DSM diagnosis, these would not be trauma although they would certainly be upsetting and deserve attention and care.
Now I personally have no interest in gatekeeping the word “trauma.” If someone tells me an experience was traumatizing for them, I’m not going to say, “Well, technically I don’t think you can claim that term” instead I’m going to offer support, right? But when it comes to figuring out what to do next and how to treat or address a situation, we do need to be clear about what is traumatic and what is not.
I mention this because I’ve talked to many parents of anxious children who are using the term “traumatized” to describe their child’s experience and this is making it difficult for the parents to address the anxiety. They are understandably concerned that pulling back from the Parenting Pitfalls and exposing their child to the things that make them anxious will further traumatize their child. They are confusing upset with trauma. And I think we need to be very clear that being upset is very different than being traumatized.
Let’s go back to that DSM definition of “actual or threatened death, serious injury or sexual violence.” The key here is threatened, which means that even if we weren’t in danger, we believe we were. Truly believed. This is a big concern about active shooter drills in schools. If children aren’t aware that it’s a drill, this can absolutely be traumatizing.
Now we’ll talk about the symptoms of PTSD — that is, post traumatic stress disorder — in the current DSM for children 6 and under.
For that diagnosis, the child must have been exposed to actual or threatened death, seriously injury or sexual violence either directly experiencing it, witnessing it happening to someone else, or learning that it did happen to a parent or caregiver. The DSM expressly states that this does NOT include media such was watching a violent movie or seeing an upsetting picture. Again, this is the DSM diagnosis and we are not saying that seeing a scary or violent movie would not be upsetting or disturbing.
If the child has this exposure history, then we look at symptoms. These would include intrusive symptoms like:
—Distressing memories that reoccur (sometimes the child won’t seem upset but will play repetitively about the event). When I worked at a shelter, many of the children would act out the police coming to arrest someone in their house over and over again.
—nightmares or dreams about the event. This could be a child who wakes up crying because they’re dreaming about the person who died.
—Dissociative reactions, also called flashbacks, where children act as if the event is happening again, and again this can be expressed through play.
—Distress when exposed to things that remind them of the event, like a child who gets upset driving through the intersection where they were in a car wreck,
And it would include symptoms of avoidance such as:
—Refusing to go into the room where that person died;
—Avoiding conversations about the trauma event.
—Disinterest in play or other activities that used to interest them;
—The presence of negative emotional rates like sadness or confusing or fear;
—not being able to have fun.
Other symptoms might include:
—Irritability or anger so tantrums
—hypervigiliance, which is being super tuned in to the possibility of danger
—exaggerated startle response
You can see how this can be confused with anxiety since anxiety shares many of the symptoms. Sow hat’s the difference? The biggest difference is the presence of the traumatic event.
There are several treatments with a strong evidence base for young children with a PTSD diagnosis. These include Trauma Focused cognitive behavioral therapy or TF-CBT, Parent-Child Interaction Therapy and Child-Parent Psychotherapy. All three of these treatment modalities include the parents. The younger the child is, the more vital it is that parents are included in the therapy. This is because relationships mitigate trauma. EMDR or eye movement desensitization and reprocessing is also a recognized treatment for trauma and if you’re interested in exploring this, I would recommend that you contact EMDRIA at EMDRIA.org. Doing EMDR with children is a specialized skill and EMDRIA has high standards for the people who can be listed in their directory. Sometimes a clinician will take a weekend class and feel like they are ready to go and I just want to caution you about that. EMDRIA can help you screen for a truly qualified therapist.
Children heal best in the context of a loving, supportive, relationship with a caregiver who is dependable and trustworthy. If your child has experienced a traumatic event and you are seeking treatment, make sure that you are included in that treatment, whichever you choose.
Trauma treatment is meant to help the person process the traumatic event so they can move through it. Now I’m going to explain this super simplified but trauma glitches our brains. It gets us stuck. Note that the intrusive symptoms are all about the stickiness — nightmares, memories we can’t shake, being triggered back into our trauma response when confronted by a reminder, avoiding things that make us think of the trauma. Treatment helps us unglitch our brains. Children who may repetitively play out the traumatic event are trying to unglitch. They are trying to play through to understanding so they can let it rest. Sometimes they need help pushing through the stuck place in their play.
It’s important that the therapist a family chooses has specific training in trauma because inappropriate treatment can be retraumatizing. For example, our thinking used to be that people needed to remember the traumatic event. You’ll see that in movies where someone has a blank space in their memory and the big climactic moment in the movie is when they remember what happened. Actually not remembering can be protective and healing doesn’t always require uncovering those distressing memories.
Ok, back to the question that inspired this episode, How do I address anxiety that’s the result of trauma? And the answer is first address the trauma.