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From soldiers to children:

developmental sciences transform
the construct of posttraumatic stress
disorder
a
Bridget A. Franks
a
Teacher Education Department, College of Education,
University of Nebraska at Omaha, 6005 Dodge Street, Omaha, NE
68182-0163, USA
Published online: 31 May 2013.

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To cite this article: Bridget A. Franks (2014) From soldiers to children: developmental sciences
transform the construct of posttraumatic stress disorder, Early Child Development and Care, 184:3,
340-353, DOI: 10.1080/03004430.2013.794796

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 Early Child Development and Care, 2014
Vol. 184, No. 3, 340–353, http://dx.doi.org/10.1080/03004430.2013.794796

From soldiers to children: developmental sciences transform the

construct of posttraumatic stress disorder
Bridget A. Franks*

Teacher Education Department, College of Education, University of Nebraska at Omaha,

6005 Dodge Street, Omaha, NE 68182-0163, USA
(Received 5 November 2012; final version received 8 April 2013)
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Posttraumatic stress disorder (PTSD) was first included in the American Psychiatric
Association’s Diagnostic and statistical manual of mental disorders in 1980. Long
used to describe the reactions of soldiers affected by stress in combat situations,
PTSD is now recognised as a disorder affecting abused and neglected infants
and children, survivors of assault and domestic violence, and disaster victims of
all ages. How did a construct so distinctly associated with the experiences of
adult combat veterans come to describe behaviours seen in children, and even
infants? This transformation can be understood by examining the way clinical
researchers have applied the developmental sciences (child and adolescent
development, neuroscience, and cognitive science) to the study of trauma. Each
of the developmental sciences has contributed to our understanding of children’s
reactions to traumatic situations, and each plays an integral part in the effort to
understand PTSD as a disorder of children as well as adults.
Keywords: posttraumatic stress disorder; children; adolescents; developmental
science; brain development

Introduction
When natural or man-made disasters sweep through our communities, children struggle
in the aftermath. Whether the precipitating event is a hurricane, a civil war, or ongoing
child abuse, caregivers and educators now know that among their students who have
experienced traumatic events, some may be suffering from posttraumatic stress disorder
(PTSD). For all these children, schools and preschools have become important places of
refuge, where children find comfort in the security of familiar routines. Teachers’ obser-
vations can serve as a valuable information source in the diagnosis of PTSD in children,
but what does the diagnosis really mean? How do the changes wrought by traumatic
experiences interact with the developmental changes children are also engaged in?
How does PTSD affect children’s developing cognitive and emotional functioning?
Central to answering these questions is research in the developmental sciences,
because these disciplines explore the effects of trauma on children’s brains, minds,
and behaviour. The traumas associated with PTSD do not halt children’s age-typical
developmental trajectories but do affect them. The purpose of this article is to illustrate
the significance of developmental research in applying the PTSD construct, originally
developed with adults, to infants, children, and adolescents.

*Email: bafranks@unomaha.edu

© 2013 Taylor & Francis

 Early Child Development and Care 341

PTSD was first included in the American Psychiatric Association’s Diagnostic and
statistical manual of mental disorders (DSM-III) in 1980. But for many years previously,
military physicians and others had used the concept (sometimes by other names, such as
shellshock or combat fatigue) to describe the reactions of soldiers affected by their experi-
ences of shock, horror, injury, and stress in combat situations. By the time PTSD was
recognised as an anxiety disorder, its symptoms had been documented for years
among combat veterans. The DSM-III recognition helped to remove some of the
stigma from the veterans’ reactions, which were sometimes treated as evidence of cow-
ardice or lack of character. But it also had the effect of expanding the construct of post-
traumatic stress. In the ensuing years, the construct has been applied to women who have
survived rape, assault, and domestic violence, to infants and children who have survived
abuse and neglect, and to people of all ages who have experienced natural disasters.
This expanded use raises the question: how did a construct so distinctly associated
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with the experiences of adult, predominantly male combat veterans become associated
with behaviours seen in children, and even infants? The transformation clearly involves
an interaction between clinical and developmental perspectives, but it is best under-
stood by examining the way clinical researchers have applied the developmental
sciences (child and adolescent development, neuroscience, and cognitive science) to
the study of trauma. While at first glance a diagnosis of PTSD may not seem appropri-
ate for children, this paper will illustrate how the application of the developmental
sciences has allowed psychologists to transform a very adult-oriented construct into
a tool for helping our most vulnerable trauma victims.

What are the developmental sciences?

In policy recommendations prepared by a panel of experts for the National Council for
Accreditation of Teacher Education, the term ‘developmental science’ is used to
describe the sciences of child and adolescent development, neuroscience, and cognitive
science (Snyder & Lit, 2010). Research in child and adolescent development examines
change processes in various domains (e.g. physical, emotional, cognitive, or social) that
occur in humans during approximately the first two decades of life (Steinberg, 2011).
Neuroscience is the study of functions that are linked to neural processes; it emphasises
the anatomical structures and physiological functions of the brain (Banich, 2004). Cog-
nitive science is an interdisciplinary field that embraces such disciplines as cognitive
psychology, computer science, philosophy, and linguistics, among others. It examines
cognition at the level of representation of information, incorporating such concepts as
symbols, rules, and images (Galotti, 2004). To put it another way, neuroscientists study
the activity of neurons, axons, and synapses, while cognitive science explores the
products of that activity, such as learning, memory, and attention. Each of these
areas has contributed to our understanding of children’s reactions to traumatic situ-
ations, and each plays an integral part in the effort to understand PTSD as a disorder
of children as well as adults.

What is PTSD?
In the DSM-III (1980), diagnostic criteria for PTSD fell into four basic categories. The
first was the existence of a recognisable stressor: an uncommon, extremely stressful
event such as a military combat experience, a natural disaster such as a flood or earth-
quake, a rape or other assault, a car accident, or a head trauma. The second was the
 342 B.A. Franks

re-experiencing of the event through recurrent and intrusive memories, anxiety dreams,
or nightmares. The third was a diminished responsiveness or ‘numbing’ of responses to
people or significant activities, and the fourth included various signs of hyperarousal,
such as an exaggerated startle reflex, sleep disturbance, memory impairment, or
trouble concentrating, as well as avoidance of reminders of the traumatic event (Eth
& Pynoos, 1985). In an interesting historical note, Eth and Pynoos (1985) described
Freud’s (1939) distinction between ‘positive’ and ‘negative’ effects of trauma. ‘Posi-
tive’ effects were attempts by trauma victims to bring the trauma into operation
again by remembering, repeating, and re-experiencing. ‘Negative’ effects were the
opposite – attempts to keep the event from being repeated through avoidance, inhi-
bition, and phobia. Both of these ideas are reflected in the DSM-III symptom categories.

PTSD and child/adolescent development

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The diagnostic criteria in the DSM-III were validated for adults, but some researchers
suggested the construct could be directly applied to children who experienced traumatic
events such as abuse, kidnapping, and dog bites (Gislason & Call, 1982; Green, 1983;
Senior, Gladstone, & Nurcombe, 1982). Eth and Pynoos (1985), then working with
children who had witnessed the murders of their parents, disagreed. While not minimis-
ing the severity of the traumas children may experience, they reported many age-depen-
dent differences between children and adults in reactions to trauma, especially in very
young children. Some effects of trauma were demonstrated by children but not by
adults, such as misperception of time and sequence of events, and unknowing perform-
ance of acts similar to the traumatic event. Using semi-structured interview techniques,
Eth and Pynoos (1985) identified different reactions to traumatic situations in
preschool, school-aged, and adolescent survivors of trauma. These reactions are sum-
marised below, along with more recent evidence for similar age-related reactions.

Preschool-aged children
The young children described by Eth and Pynoos (1985) showed initial withdrawal fol-
lowing a traumatic event, with talk about the event following later. They reenacted the
event in the form of non-enjoyable play with traumatic themes. They showed anxious
attachment behaviour, such as clinging, crying, or tantrums, and regressive loss of pre-
viously attained skills, such as toilet training. Nightmares and other sleep disturbances,
higher anxiety, new fears, and avoidance behaviour also characterised young children
following trauma, as did denial in fantasy (e.g. thinking a parent who has been killed
might return). Osofsky and Osofsky (2006) reported very similar reactions among
young children who experienced Hurricane Katrina (e.g. new fears, separation
anxiety, clinginess and regression).

School-age children
Eth and Pynoos (1985) found a decline in school performance, apparently due to a
decreasing ability to concentrate in class to be a common reaction among traumatised
children during the school years. They suggested a possible cause to be the intrusion of
memories and thoughts connected to the traumatic event (murder of a parent) and the
evolution of a cognitive style of forgetting to dispel reminders of the event. The school-
aged children they studied imagined ways to alter a fatal outcome through denial in
 Early Child Development and Care 343

fantasy, and fixated on the trauma, talking about it excessively. Some remained in a
state of anxious arousal, or hypervigilant alertness, as if to prepare for further
danger. Reenactment of the trauma also occurred, but in more sophisticated and elab-
orate ways than with preschoolers, because of the older children’s greater facility with
words. Children in this age group were especially susceptible to psychosomatic com-
plaints such as headaches and stomach pains as well as behaviour problems in
school. Osofsky and Osofsky (2006) also reported difficulty concentrating on academic
tasks among school-age children who survived Hurricane Katrina, and observed that
these children found it difficult to have fun, as well.

Adolescents
Eth and Pynoos (1985) noted that because their adolescent clients were too old for play
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reenactments and denial in fantasy, they used directly self-destructive behaviour to dis-
tract themselves from anxiety and painful memories, and to expiate their guilt in the
event of the loss of a family member. This survival guilt is one of the ways in which
adolescent posttraumatic stress begins to resemble adult PTSD. Post-traumatic acting
out, such as school truancy, precocious sexual activity, substance abuse, and delin-
quency all characterised the trauma reactions of adolescents. As Eth and Pynoos
(1985) observed, adolescents have the capacity for an abstract understanding of motiv-
ation, alternative action, and the sequencing of events. Thus, they are capable of antici-
pating how a trauma will personally affect their lives. They may accurately identify
how their own actions figured in the traumatic event, but may also inflate their own feel-
ings of guilt about those actions. Osofsky and Osofsky (2006) observed very similar
behaviour among adolescent Hurricane Katrina survivors, including high-risk reactions
such as fighting, substance abuse, heightened sexual activity, and suicidal thoughts.
The developmental observations made by Eth and Pynoos (1985) showed that,
unlike adults’ responses to trauma, children’s reactions are associated with specific
ages that are commonly identified as qualitatively distinct in the study of child and ado-
lescent development. This is important because the trauma victim’s age is seen as
shaping or at least strongly influencing the way trauma is experienced and the kinds
of symptoms that may indicate PTSD. Eth and Pynoos (1985) also noted that children’s
early efforts to cope with traumatic anxiety and helplessness are a function of their
maturity, and that developmental influences can enhance or impede trauma resolution,
because children are susceptible to different influences at different ages. Interplay
between the processes of trauma resolution and other childhood tasks will have an
effect on recovery as well. For example, continued reworking of traumatic memories
may cause enduring effects on cognition and learning, and changes in affective life
can alter children’s perceptions of the nature and stability of human relationships.
What can explain such persistent effects of trauma in developing children? To under-
stand these effects, we must look to structures in the brain and the course of their devel-
opment; both are concerns of another of the developmental sciences, neuroscience.

PTSD and neuroscience

Several important processes in early brain development are at risk in children who
suffer from traumatic events, especially if those events are prolonged, as in the case
of child maltreatment. Two of these, synaptogenesis and myelination, will be described
here.
 344 B.A. Franks

Synaptogenesis and myelination

In brief, neurons, the specialised nerve cells that transmit electrical and chemical signals
to one another, comprise the brain’s communication system. Each neuron has both long
fibres called axons and shorter fibres called dendrites. Axons extend from neurons and
carry messages to other cells. Dendrites receive incoming messages (in the form of
chemicals called neurotransmitters) across a small space between cells, called a
synapse, and pass the signal to the cell body; the message is then transmitted via the
axon to the next neuron. This establishment of ongoing connections among neurons
is called synaptogenesis, and it is especially rapid during prenatal development and
the first few years of life. Eventually, the brain has more neurons and synapses than
it needs, and a process of selective cell death, or pruning, begins. By middle to late ado-
lescence, teenagers have fewer, but stronger and more effective neural connections than
they did as children (Bjorklund, 2012).
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Myelination, a developmental process critical to normal brain functioning, greatly

improves the quality of the signals between neurons. In this process, supportive brain
cells called glial cells produce a fatty substance called myelin, which covers, protects,
and insulates axons. Myelination speeds the rate at which nervous impulses can be
sent and reduces interference from other neurons. Sensory and motor areas receive
myelin in infancy, so children’s abilities in those areas develop rapidly. But myelination
of the frontal cortex, the ‘thinking’ area of the brain, is not complete until early adulthood
(Banich, 2004; Sowell, Thompson, Holmes, Jernigan, & Toga, 1999).

Trauma and brain development

In their developmental model of trauma, Robert Pynoos and his colleagues (Pynoos,
Steinberg, & Piacentini, 1999) described many connections between these normal pro-
cesses of brain maturation and children’s reactions to trauma. They noted the signifi-
cance of three reactions to threatening situations: estimating the nature and
magnitude of dangers, regulating one’s emotional and physiological reactions to
danger, and identifying the forms of protection available (in other words, appraising
danger, reacting to danger, and securing safety). These operations, they observed, are
strongly rooted in neurobiological development in infancy. For example, the early
stages of danger appraisal rely on social referencing to attachment figures; the capacity
for recognising facial expressions of emotion in caregivers is related to the amygdala, a
part of the brain’s limbic system that plays a role in memory and the processing of
emotions. Pynoos, Steinberg, Ornitz, and Goenjian (1997) identified four periods in
which major structural changes in brain development (including brain growth and cor-
tical reorganisation) occur: early childhood (15 months to 4 years), late childhood
(6–10 years), puberty, and mid-adolescence. These periods correspond to a progression
in children’s ability to estimate external danger and to consider protective actions,
either by themselves or by others.
Pynoos et al. (2009) noted that many of the symptoms of PTSD in children reflect
disturbances in the balance, normally driven by maturation, between the need for pro-
tection by others and increasing self-efficacy in facing danger. Trauma may interrupt
this maturational process, causing young children to reduce exploration or play to
stay close to caregivers, whether for protection, social referencing, or monitoring the
safety of the caregiver, since trauma experiences for children may involve death or
injury to parents or other relatives. School-age children may show new fears related
 Early Child Development and Care 345

to the trauma incident, and may regress to relying on others for protection at a time
when they would normally be showing more independence. Adolescents may propel
themselves into greater independence, making misjudgments about danger and enga-
ging in high-risk behaviour. This latter effect is a risk because the neural signature
of achieving safety engages the reward centres of the brain that are also involved in sub-
stance abuse and thrill-seeking behaviour (Pynoos et al., 2009).
How does trauma interrupt these important maturational processes in the brain?
Research in neuroscience suggests that traumatic experiences in childhood can alter
structures in the brain while they are developing. In their discussion of the developmen-
tal neurobiology of traumatic stress, Pynoos et al. (1997) observed that trauma can
affect structures in the limbic system of the brain, which are involved in emotions
related to survival, such as fear and anger. Other limbic system structures such as the
amygdala and the hippocampus play important roles in memory, especially in the
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storage and retrieval of significant events.

With normal brain maturation, children gradually learn how to manage their
emotional reactions to experiences that may evoke fear or anxiety. Learning to do
this depends on interactions between the emotional centres of the brain (limbic
system) and the cortex, which interprets input from the senses and maintains cognition.
Perry, Pollard, Blakley, Baker, and Vigilante (1995) argued that trauma in early child-
hood can alter structures in the limbic system, mid-brain, and brain stem, producing
prolonged alarm reactions. In children who also experience deprivation and neglect,
development of the cortex can be impeded, affecting its ability to modulate limbic
system responses to danger and fear. The combination of increased reactivity by the
limbic system and decreased modulation by the cortex can result in impaired cognition,
poor impulse control, and deficits in emotional regulation. A likely outcome, Perry et al.
(1995) note, is an increase in aggressive behaviour.

Stress and the structure of the brain

What actually causes these changes in the structure of the brain? Hormones released in
the body in response to prolonged stress appear to be major factors (De Bellis, 2001).
Catecholamines, for example, are hormones produced by the adrenal glands and
released into the blood when we experience physical or emotional stress. They cause
physiological changes that prepare the body for fight or flight, such as increased
heart rate and blood pressure. High catecholamine levels in the blood are associated
with stress, and can have many negative effects on the developing brain. Studies in
humans and primates have shown that elevated levels of catecholamines and cortisol,
another stress-related hormone, can impair brain development by causing accelerated
loss of neurons, delays in myelination, and abnormalities in the developmentally appro-
priate pruning of neurons (De Bellis, 2001).
Using MRI technology to examine changes in brain development in maltreated chil-
dren, De Bellis et al. (1999) observed that maltreated children and adolescents with PTSD
had smaller measures of intracranial volumes (ICVs), cerebral volumes, and corpus cal-
losum areas, as well as larger lateral ventricles than controls. They found ICVs to be posi-
tively correlated with age of onset of abuse, meaning that the lower the age of onset of
abuse, the lower the ICV of the child’s brain. This suggests that traumatic stress is associ-
ated with disproportionately negative consequences if it occurs during early childhood.
ICVs also correlated negatively with abuse duration and PTSD symptoms, meaning
that the longer the duration of the abuse, the lower the child’s ICV. Both of these findings
 346 B.A. Franks

suggest there may be both critical periods and dose effects for stress-related alterations in
brain development. Another investigation (De Bellis, Keshavan, Spencer, & Hall, 2000)
found evidence in maltreated children and adolescents of neuronal loss in the anterior cin-
gulate regions of the prefrontal cortex, which are involved in the extinction of con-
ditioned fear responses. De Bellis (2001) argued that all of these stress-induced
neuronal losses may combine to produce the compromised cognitive and psychosocial
outcomes observed in maltreated children and adolescents who have PTSD.
In summary, neuroscientific research has shown us that traumatic experience,
especially if prolonged, may not only result in loss of brain cells, but may also derail
some of the most important processes in the development of the brain, myelination
and developmental pruning. Evidence based on children who are persistently maltreated
suggests that stress interferes with synapse formation and myelination, two processes
critical to the development of a normally functioning brain. Neuroscientific research
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with children diagnosed with PTSD provides us with important information about
developing brains and minds, suggesting that this construct is useful for identifying chil-
dren when they are very vulnerable and when early intervention, especially rescue from
abuse, could prevent long-term cognitive deficits. Adult trauma affects brains that are
already formed, but trauma in children can create lifelong limitations in their cognitive
functioning by interfering with crucial aspects of brain development.
Recognising that children with PTSD may have suffered actual damage to their
brains is important; however, teachers and caregivers are interacting not with trauma-
tised brains, but with traumatised children, who are still developing in their own edu-
cational and family contexts. In our efforts to help these children, it is their actual
cognitive and social abilities that we need to assess. What do we know about these abil-
ities? To understand how trauma interacts with children’s thinking, we turn to the third
member of the developmental science trio: cognitive science.

PTSD and cognitive science

Neuroscience provides us with an understanding of the brain: how it is structured, how
it works, and how its functions change over time with maturation. But cognitive
science, and in particular cognitive psychology, is the discipline that provides us
with models of the mind – that is, what we actually do with our brain activity. Neuro-
science is about neurons, synapses, and myelination, while cognitive psychology is
about learning, memory, and problem solving. Without normal brain development,
such activities would be impossible, and recent developments in neuroscience have
given us much more information about how the brain affects specific cognitive
processes. But neuroscience does not map brain activity directly onto thinking; it is
to cognitive psychology that we turn for models of how learning, memory, and other
cognitive activities take place. Research in neuroscience has revealed how the
brain’s structures can be altered by trauma. Research in cognitive psychology helps
us to understand how trauma comes to be represented in the minds of children, and
how that representation may interfere with other important cognitive tasks, and there-
fore with children’s learning and development.

PTSD and cognitive psychology

In their discussion of a more developmental approach to understanding PTSD in chil-
dren, Salmon and Bryant (2002) focused on children’s developing information-
 Early Child Development and Care 347

processing capacities and how they differ from those of adults. Processing information,
they noted, begins with encoding, which involves attending to particular cues and not
others, appraising an event or other stimulus, and attributing meaning. Danger apprai-
sal, for example, occurs during encoding. Encoding of a traumatic event creates a rep-
resentation that can be stored in and retrieved from long-term memory. In explaining
how such events are processed, Salmon and Bryant (2002) drew upon models of
semantic networks that encode and store emotions along with information (Bower &
Sivers, 1998; Lang, 1977) as well as an adaptation of these models by Foa, Steketee,
and Rothbaum (1989). Foa et al. (1989) proposed that people who experience
trauma form a ‘fear network’ that stores information about sources of threat. Because
these trauma-related representations are easily activated by internal or external cues,
people with PTSD may have a low threshold for interpreting stimuli as dangerous.
Studies with adults point to an attentional bias towards looking for and identifying
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threatening information (McNally, 1998).

Three significant elements affect children’s representations of trauma: their knowl-
edge base, their ability to regulate thoughts and feelings, and their memory skills. All
three are influenced by interactions with adults, and all develop over the course of child-
hood, so the extent of their development at a given time will likely influence reactions
to trauma.

Children’s knowledge base

Encoding an event as dangerous is influenced by children’s knowledge of the world,
but that knowledge is limited. With less knowledge, children may not initially appraise
dangerous situations as traumatic and may therefore experience less stress. On the other
hand, they may appraise some situations as very dangerous when they are not, creating
unnecessary fearful associations. In either case, their knowledge base influences their
appraisal of the event, which in turn influences their emotional reaction to it (Vogel
& Vernberg, 1993). This interaction of knowledge with the ability to regulate one’s
thoughts and feelings illustrates why a developmental approach is helpful in predicting
children’s reactions to stressful events.

Regulating thoughts and feelings

Notable age-related changes in both thought and emotion regulation have been
observed. Preschool children, for example, can use some attention management strat-
egies, such as covering their ears, but typically need adult help to manage their
emotions under stress (Cicchetti & Lynch, 1995). By age 8, however, children report
a variety of cognitive strategies to manage their thinking after traumatic experiences,
such as thinking pleasant thoughts, reappraising a difficult situation, shifting and refo-
cusing attention, and cognitive avoidance; effective use of these strategies helps chil-
dren to manage their overt responses as well as their thoughts (Eisenberg, 1998).
Another skill that develops over time in childhood is cognitive inhibition – the
ability to suppress the intrusion of unwanted or irrelevant information from conscious-
ness. Up to about 10 years of age, children find it difficult to forget unwanted infor-
mation intentionally (Harnishfeger & Pope, 1996) which may intensify the
difficulties they experience with intrusive thoughts after traumatic experiences.
Developmental differences in awareness and control of one’s own cognitions illus-
trate an aspect of typical development (theory of mind) that is highly relevant to an
 348 B.A. Franks

aspect of PTSD (intrusive thoughts). Sprung (2008) explored this relation by integrat-
ing clinical studies of children’s intrusive re-experiencing of disaster with developmen-
tal research on children’s theory of mind, that is, their developing concepts of mental
activity. Developmental research suggests that children are somewhere between five
and eight when they fully realise the existence of thought in themselves and others,
and understand that thoughts can occupy one’s mind even when they are not wanted
(Flavell, Green, & Flavell, 1998, 2000), and disruptive (Duke, 2006). This suggests
that younger elementary-school children may have difficulty monitoring and reporting
intrusions of thought, even though they may suffer from them.
Working with children five to eight years old who either had or did not have direct
experience of Hurricane Katrina, Sprung (2008) assessed several aspects of the chil-
dren’s theory of mind, such as knowledge of their own thoughts and understanding
of intrusive thoughts. He also recorded children’s self-reports of unwanted intrusive
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thoughts, including thoughts about Hurricane Katrina. Finally, he assessed the actual
cognitive interference of unwanted intrusive thoughts, using a visual attention task,
interrupted by loud recorded wind and rain sounds from Hurricane Katrina. Children
with direct experience of the hurricane showed more off-task behaviour when inter-
rupted by the loud sound than children without such experience, suggesting the pres-
ence of more intrusive, hurricane-related cognition. Children who experienced major
loss or disruption from the hurricane indeed reported more negative intrusive thoughts
than children who did not. More significantly, however, children who reported having
negative intrusive thoughts had more advanced theory of mind scores than children
who did not report such thoughts. The potential for receiving and benefiting from
help with intrusive thoughts, such as cognitive strategy training, is more likely for chil-
dren who are aware of their intrusive thoughts and report them; when children cannot
report such thoughts, determining their needs is more difficult.

Memory skills
Finally, children’s developing memory capacities are among the most significant
factors in their responses to disasters, since they must use what they remember to
make meaning of their traumatic experiences. Robin Fivush and her colleagues
explored young children’s traumatic memories of a storm shortly after Hurricane
Andrew in 1992 (Bahrick, Parker, Fivush, & Levitt, 1998) and again six years later
(Fivush, McDermott Sales, Goldberg, Bahrick, & Parker, 2004), in the context of auto-
biographical memory. This kind of memory is a complex interweaving of what children
experience and how these events are discussed and thought about over the years
(Fivush et al., 2004).
In both the abovementioned studies, children were grouped into low-, moderate-,
and high-stress groups based on the severity of their personal experiences with the
storm, and were interviewed at ages 3–4 and again at ages 9–10. In the first study, chil-
dren in the high-stress group reported less information than children in the moderate-
stress group. Six years later, children in all stress groups reported similar amounts of
information, but children in the high-stress group needed more questions and cues to
recall the information, suggesting that verbally reporting their memories remained dif-
ficult for them. Encoding was not the issue, since they recalled as much information as
the other groups; instead, Fivush et al. (2004) suggested that remembering highly
stressful experiences may continue to create negative emotions for children even
years after the event. Age was also an important factor in the two studies, with the
 Early Child Development and Care 349

children reporting twice as much information at ages 9–10 as they had reported at ages
3–4. As Fivush et al. (2004) noted, differences in memory between preschool and
school-age children reflect developing organisational and retrieval skills as much as
they do the initial encoding processes.
Children’s event memories, like those of adults, are naturally affected by shared dis-
cussions with others. Hurricane Andrew was both talked about and viewed on televi-
sion by most Floridians. This high level of ‘rehearsal’ of the event likely influenced
what children recalled. Also, because children’s general world knowledge is limited,
they rely heavily on the reactions of significant people around them. Interactions
with adults can compensate for their limited knowledge and provide a framework for
interpreting events (Salmon & Bryant, 2002). This may distort children’s memories
for events (Tessler & Nelson, 1994), but it also helps them to regulate their emotional
responses (Eisenberg, 1998). Pynoos et al. (1999) proposed that post-trauma appraisals
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of danger by children may rely on co-construction of the event with family or friends.
The importance of safe adults with whom children can process trauma cannot be under-
estimated. Especially in the case of maltreatment, but in all types of trauma, teachers,
counsellors, and caregivers can play a significant role in children’s trauma recovery
simply by talking with them about their experiences.

Alternative criteria for PTSD in young children

The influence of the developmental sciences is nowhere more clearly demonstrated
than in the efforts mental-health practitioners have made to identify more suitable
criteria for identifying PTSD in children. Developmentally appropriate assessment is
important, Scheeringa (2008) notes, because of the uniquely rapid brain development
in the first two years of life, with the possibility of permanent alterations in the devel-
oping brain due to early trauma. Scheeringa and Zeanah (1995) also stressed the impor-
tance of developmental transitions, noting that the capacity for storing and expressing
memories of traumatic events, and therefore re-experiencing them, may be very differ-
ent before and after the development of symbolic representation.
Modifications were made to diagnostic criteria in the DSM III-R (1987) as well as in
the DSM-IV (2000), revising the pattern of symptoms for PTSD into four clusters: (A)
Exposure, (B) Reexperiencing, (C) Avoidance/Numbing, and (D) Hyperarousal (See
Appendix for a full version of DSM-IV criteria). The criteria still required that children
be able to report on, and label, their emotional reactions to the traumatic event (A2), and
to show awareness of their own thoughts and efforts to avoid reminders of the traumatic
event (C1, 2, 3). Since this kind of metacognition (thinking about one’s own thinking)
typically develops between ages 5 and 8 (Flavell et al., 1998, 2000), diagnosis in
preverbal infants and young children remained difficult. Several researchers have
suggested that further modification in the upcoming DSM-V is needed to develop criteria
for children that are truly developmentally appropriate. Michael Scheeringa and his col-
leagues (Cohen & Scheeringa, 2009; Scheeringa, Zeanah, Drell, & Larrieu, 1995;
Scheeringa, Zeanah, Myers, & Putnam, 2003; Scheeringa, Zeanah, & Cohen, 2011) pro-
posed that alternative criteria for PTSD in preschool-age children should depend more on
behavioural observations (such as reenacting trauma in play) and less on verbalisations
or abstract thought, which are not well developed in young children.
Pynoos et al. (2009) also offered many recommendations for developmental modifi-
cations to the DSM-V criteria for PTSD, stressing the compounding effect of trauma and
loss as particularly important with maltreated children. In the case of a child who is
 350 B.A. Franks

removed from an abusive and/or neglectful environment, for example, traumatic grief reac-
tions can accompany PTSD when the traumatic event includes loss of a caregiver. They also
noted that Cluster A of the DSM-IV criteria begins with the child being exposed to ‘a trau-
matic event’, but in the case of maltreatment, it is challenging to identify one precipitating
event because young children may have multiple, and co-occurring trauma exposures.
Pynoos et al. (2009) argued that the accompanying text in the DSM-V should alert clini-
cians to these compounding effects, because they are associated with both PTSD symptoms
and disturbances in developmental competencies (Cloitre et al., 2009).

Conclusion
When clinical researchers began to take a developmental approach to the PTSD
construct, one of their most significant findings was that with children, the experience
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of repeated, consistent, ongoing negative events (such as domestic violence and child
maltreatment) can result in the same symptoms of posttraumatic stress as the experience
of one significant, horrific event, as originally proposed in the DSM-III. The important
difference, however, is that when repeated trauma happens to children, it interferes with
ongoing developmental processes in the brain. Traumatic events are even more likely to
be repeated with children than with adults, because children cannot independently
remove themselves from the situations that are causing the trauma. Whether maltreat-
ment occurs at home, at school, or in a daycare setting, children, especially when they
are very young, may not have the language skills, assertiveness, or awareness to solicit
help. Thus, trauma may continue for significant periods of time.
Children do, of course, experience single traumatic events such as natural disasters,
fires, and terrorist attacks, and may show PTSD symptoms as a result (La Greca, Silver-
man, Vernberg, & Roberts, 2002). But when their post-event experience is supportive
and they are able to return to familiar routines soon after the traumatic event, the most
damaging effects can be avoided. It is the experience of prolonged trauma, especially
violent and/or sexual trauma, that has the most serious educational implications (Cope-
land, Keeler, Angold, & Costello, 2007).
What can teachers, caregivers, and other educators expect when dealing with trau-
matised children? Research in the developmental sciences suggests that difficulties in
both academic and behavioural areas are possible, because prolonged trauma can
affect the developing brain in permanent ways, resulting in lower cognitive functioning
as well as emotional problems. When compared with a matched control group, Beers
and De Bellis (2002) found that children with maltreatment-related PTSD demonstrated
deficits in sustained attention, abstract reasoning, and executive functions, and were
more easily distracted and more impulsive than control-group children. As the research
in developmental neuroscience has demonstrated, cognitive problems that may affect
school functioning are not simply the result of distraction due to emotional stress,
but may reflect actual damage to brain structures and interference with brain growth.
The study of PTSD in children illustrates well the benefits of a developmental
sciences approach, that is, one that integrates findings from research in child and
adolescent development, neuroscience, and cognitive science. In bringing all these dis-
ciplines to bear on the PTSD construct, researchers have not simply applied adult-
related criteria for PTSD to children. Nor is their work only a matter of reducing or
rewriting diagnostic criteria. Rather, our current understanding of PTSD in children
is based on knowledge of their typical development, understanding of their neurologi-
cal growth, and exploration of the cognitive processes by which they represent and deal
 Early Child Development and Care 351

with traumatic experiences. This multi-layered approach not only demonstrates that the
PTSD construct is appropriately applied to children as well as adults, but also offers
great promise for interventions on their behalf.

Notes on contributor
Bridget A. Franks, PhD is a faculty member in the teacher education department at the
University of Nebraska at Omaha, USA. She is interested in the integration of developmental
perspectives with the study of children’s welfare in a variety of contexts, including poverty,
institutionalization, and exposure to disasters.

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Appendix. 309.81 DSM-IV criteria for PTSD

A. The person has been exposed to a traumatic event in which both of the following have
been present:
(1) the person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others.
(2) the person’s response involved intense fear, helplessness, or horror. Note: In chil-
dren, this may be expressed instead by disorganised or agitated behaviour.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions. Note: In young children, repetitive play may occur in
which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening
dreams without recognisable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving
the experience, illusions, hallucinations, and dissociative flashback episodes,
including those that occur upon awakening or when intoxicated). Note: In young
children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolise
or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolise or
resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general respon-
siveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g. unable to have loving feelings)
(7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, chil-
dren, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by
two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response