Childhood Trauma: Risk Factors

Case Study: Sandra
	About six months ago, 13-year-old Sandra was in a car with her mother when "out of the blue," another vehicle veered out of control and crashed into them. Sandra responded with intense fear and feelings of helplessness, despite the fact that her injuries were minor. She was unable to soothe herself and would not allow her mother to comfort her. She was convinced that she and her mother were going to die and that the car accident was just the first in a series of "bad" things that were going to happen to her. Currently, Sandra is having difficulty falling asleep because she is afraid of having nightmares. She can't stop thinking about the event; she is cranky, and spends a lot of time worrying that she might be in another car accident. She refuses to travel by car, and becomes jumpy when she is near traffic. She doesn't tell her parents about her fears because she feels they wouldn't understand. Prior to the accident, Sandra was a friendly and outgoing adolescent; she was an excellent student, was upbeat, and had many friends. Since the accident, her eighth-grade teacher has noticed that Sandra is having trouble concentrating and focusing on her schoolwork. She finds that at times Sandra is unusually withdrawn, while at other times her aggressive and irritable behavior disrupts the class and alienates her classmates. She shows no interest in being with her friends and refuses to participate in activities such as sports, birthday parties, or sleepovers. At a parent-teacher conference, Sandra's parents complained that their daughter's behavior had drastically changed at home. She was no longer the sweet child they knew, now spending most of her time alone in her room watching television or moping around the house. They were frustrated by their inability to "handle" her, and attributed her behavior to adolescent instability.

Victims of an automobile accident may suffer long-term physical as well as psychological damage.
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A good indication that Sandra is struggling with the effects of trauma is that her post-trauma symptoms are intense and have persisted beyond three months. Other factors to consider when evaluating whether Sandra is at risk for developing the severe and long-lasting psychological effects of her experience are those that existed prior, during and after the event. From Sandra's case study , we already have some important information. We know that Sandra's exposure to the accident was direct. Despite the fact that neither she nor her mother sustained serious injuries, she reacted with acute stress and intense fear. We also know that she believes the accident was a foreboding of a catastrophic future. However, we don't yet know if, after the trauma, Sandra was exposed to excessive media coverage, other traumatic reminders, or any adverse environmental conditions resulting from the event. Any of these factors can trigger severe traumatic reactions.

View "Trauma Risk-Factors Chart."

During the school counselor's meetings with Sandra and her parents—both separately and together—it was discovered that family violence had placed Sandra at risk to develop the long-term and damaging effects of trauma after the accident. Throughout Sandra's life she had regularly witnessed her father's sudden and violent temper and his physical assaults on her mother. Her mother's concern for herself and for Sandra's safety, combined with attempts to pacify her husband, made it difficult, if not impossible, for her to provide consistent emotional support to her daughter. In order to protect her mother, Sandra never talked about the fear and desperation she felt during the violent episodes.

	Immediate concern for the physical trauma of an accident should be followed by a an assessment of the psychological impact.
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Prior to the accident, Sandra was able to function on a high level both academically and socially, despite her unstable home life. However, the accident seemed to intensify Sandra's feelings of fear and desperation. Not surprisingly, her usual coping mechanisms failed her. Her irrational belief that she and her mother would die suggest that the crash, occurring without warning, may, at some level, have felt like a replay of her father's erratic and violent behavior.

In the first three months following the accident, it would be reasonable to consider Sandra's symptoms as a normal response to an abnormal event. However, not only do her symptoms persist, they are intense. They are interfering with her functioning at home and at school. She remains preoccupied with the accident and avoids any reminders of the trauma. Her crankiness, irritability, and withdrawal suggest that, in addition to her posttraumatic symptoms, she may be suffering from depression.

Professor Jackson discusses Sandra's case.

We have learned that the effects of risk factors tend to be cumulative.4 Thus, those like Sandra, who have multiple risk factors, require special attention and monitoring, and should be brought to the attention of their parents and the school counselor for evaluation. If ignored or left untreated, students like Sandra are in danger of developing chronic posttraumatic stress disorder (PTSD) and other emotional disturbances such as depression, obsessive-compulsive disorder, panic, conduct, and substance-abuse disorders.

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