Opinion | Assume Every Child Has PTSD These Days Until Proven Otherwise

We are only halfway into 2022 and there have already been 214 mass shooting events in America, several of which have been in schools. It goes without saying that even one life lost to senseless violence is too many, but this week on May 24, the lives of 19 innocent fourth graders and two of their teachers were taken by an 18-year-old gunman who purchased two assault rifles legally. This gruesome carnage adds burden to a society already wrecked by the COVID-19 pandemic, international wars and armed conflicts, natural disasters, legislation limiting the freedoms of marginalized groups, political partisanship, racially motivated assaults on minorities, outrageous costs of education and basic healthcare, and countless other perils of contemporary life.

It is said that each generation has its unique set of challenges to overcome, but this constellation of complex societal problems is unprecedented and much too heavy for any generation to bear. Compounding these macro-level stresses are adverse childhood experiences (ACEs) that a majority of children (61%) experience at least one of in their lifetimes. ACEs of a potentially traumatic nature include exposure to or witness of violence in the home or community, abuse, or neglect, mental health or substance use problems in the household, and a family member attempting or completing suicide. These toxic stresses contribute to chronic mental and physical health problems in adolescence and adulthood. Consequently, we, as professional helpers, need to be as proactive as possible to support our children, particularly survivors of mass shootings and violent atrocities like that at Robb Elementary School in Uvalde, Texas.

As a general rule of thumb, clinicians should assume that the child you are treating today has PTSD until otherwise ruled out.

Posttraumatic stress disorder (PTSD) is a serious diagnosis that should not be given lightly, but erring on the side of inclusion will allow the clinician to be as sensitive as possible in the assessment of symptoms of trauma, and its subsequent referral and/or treatment. Additionally, a presumption of PTSD provides clinicians a trauma-informed treatment framework to contribute to a child’s felt sense of safety and trust in helpers, which is vital for a child survivor’s recovery. Oftentimes, survivors of trauma may not disclose their experiences or symptoms of acute stress disorder or PTSD because their clinician does not show openness or competency to listen to their stories of horror. However, when a clinician genuinely shows empathic regard and concern for the child and what they have gone through, the child is often more willing to entrust the clinician with their vulnerabilities and hopefully begin to heal emotionally from the trauma.

How to assess for the immediate impact of trauma

• Clinicians should bravely inquire directly about how a recent trauma exposure has impacted the child
• If you are seeing the child within a month of the event, look for acute traumatic stress reactions such as avoidance of places, thoughts, or feelings involving the traumatic experience, dissociation from reality (e.g., blank stares into space or being lost in thought), or intrusive distressing memories of the event
• Children will have increased likelihood of impairments in their functioning if they have multiple acute stress reactions
• When there are noted impairments in a child’s functioning, clinicians should refer the child for additional psychological assessment, treatment, or follow-up to monitor their progress towards recovery

Long-term implications of trauma

In addition to the acute stress responses noted above, a child survivor may experience the following long-term symptoms, which then warrants a PTSD diagnosis and psychological treatment by a trained practitioner:

• Denial or numbness to all or parts of the event
• Repeated flashbacks to the event and enactment of their experiences in play or thoughts (children with prolonged exposure to significant amounts of media coverage of the event are at risk of re-traumatization)
• Inability to feel well rested due to bothersome nightmares or interruptions to sleep
• Changes in mood, such as increased irritability, anger, sadness, helplessness, hopelessness, and tearfulness
• Withdrawal and isolation from others and meaningful activities
• Self-medication, self-injurious behaviors, and/or engagement in alcohol or illegal substances
• Hypervigilance to potential threats and being easily startled by what seem to be innocuous stimuli; be aware that these symptoms may disguise as symptoms of attention deficit/hyperactivity disorder (ADHD), so do not stop at a diagnosis of ADHD

While not every child who has experienced ACEs or every child survivor of trauma will develop PTSD, we cannot afford to let any child survivor of mass shootings or other forms of violence slip through our hands when providing care. We know that untreated PTSD can contribute to a lifetime of pain and suffering not only for the child, but also their families and communities. In addition to our clinical responsibilities, our work needs to extend into advocacy for tighter gun control laws and prevention of interpersonal and community violence. Consider contacting your local elected officials and demanding that they impose a trauma-informed approach to legislative work, too. All our children are carrying too much unnecessary weight on their small shoulders, and we cannot just stand by and see what will become of them.

Kathy Wu, PhD, is a licensed psychologist with a background in treating child survivors of trauma.