Introduction
Modern families face numerous challenges during the development phase of their children, and they must take appropriate measures to address these issues. Secondary Post Traumatic Stress Disorder (PTSD) is a topical problem in children that has been thoroughly researched over the past decades. According to research, secondary traumatic stress can be described as stress resulting from the obtaining of information on the traumatic experience of other people (Ogińska-Bulik et al., 2021). Such a condition is commonly suffered by people who stay in close contact with individuals who encountered stressful life situations in the past. Nevertheless, the issue of secondary posttraumatic stress disorder can also affect people who are exposed to graphic content on television or social media. Children also may become victims of the condition in question in various ways, which can eventually negatively impact their entire lives. Therefore, it is essential to have a full understanding of all aspects of secondary posttraumatic stress disorder to prevent it from progressing. As demonstrated by the research, secondary PTSD is a condition that often occurs in children as a result of interactions with traumatized relatives, yet the issue can be treated.
Origins and Causes of Secondary Post-traumatic Stress Disorder in Children
As mentioned above, the condition of secondary posttraumatic disorder often affects people who interact with individuals with a history of stressful experiences. Military service is a significant factor contributing to the development of PTSD. Subsequently, family members and especially children of people who participated in military operations and were exposed to traumatic experiences, become particularly susceptible to the condition. There is evidence that parents with PTSD, which emerged as a result of military service, tend to cause their children to develop behavior problems (Monson et al., 2009). Essentially, PTSD can be viewed as a transgenerational issue capable of affecting relatives of people suffering from the disorder. Avoidance is one of the key symptoms in PTSD patients, which was found to be related to dissatisfaction with parenting (Monson et al., 2009). In other words, people with PTSD do not experience any joy in parenting due to being preoccupied with their condition. Research also shows that veterans with PTSD often engage in physical and verbal aggression against their family members (Monson et al., 2009). Under such conditions, there is a substantial probability that children will develop secondary PTSD or other behavioral issues.
It is clear PTSD in parents is a considerable factor contributing to the emergence of secondary traumatization in children. At the same time, it is important to establish the role of spouses of people with PTSD in the development of the condition in children. Dekel and Goldblatt (2008) conducted a literature review of the studies on the topic of secondary PTSD and children and discovered important evidence on mothers’ impact on secondary traumatization in children. The research demonstrated that the wives of male veterans suffering from PTSD could also experience distress which may lead to vicarious traumatization of children (Dekel & Goldblatt, 2008). In families where the father is often absent because of military service, the mother can become the central figure for the child. Thus, when the woman starts having stress due to being concerned over the health issues of her husband, the increased burden, and growing responsibilities, her parental functioning can be undermined (Dekel & Goldblatt, 2008). Thus, the mother can become a person who will indirectly pass the PTSD of the father to the child, subjecting them to secondary traumatization and causing behavioral problems in them.
The relationship with parents is an important factor that directly affects the healthy development of the child. Research shows that difficult relations of a child with their parents can lead to psychopathology later in their life (Dinshtein et al., 2011). Thus, the role of parents is extremely important in the health of each child. Einstein et al. (2011) conducted a study that assessed the rate of secondary traumatization in families of veterans with PTDS. The findings indicated that even adult children exposed on a regular basis to the posttraumatic symptoms of their fathers were more likely to have higher levels of distress (Dinshtein et al., 2011). Therefore, it is possible to assume that living in a family with a PTSD veteran contributes to a higher possibility of secondary traumatization of children. At the same, the researchers discovered that mothers could minimize the negative impact of PTSD fathers on their children by reducing the likelihood of them being traumatized (Dinshtein et al., 2011). Thus, mothers can act both as facilitators of secondary PTSD in children and moderators of the condition preventing it from progressing or emerging in the first place.
At the same time, family relations cannot be considered the only factor capable of causing secondary trauma and children. There are several other important environments where children can experience events that can ultimately lead to their vicarious PTSD. Research by Howard (2021) indicated that community trauma, unlike family one, was a better predictor of secondary PTSD in children. For instance, a child who discovered that their friend was subject to kidnapping can develop symptoms of vicarious traumatization and face behavioral issues as a result. The study also discovered that certain groups of children were more likely to suffer from community trauma and subsequent secondary PTSD. Adolescents were found to be at a higher risk of being exposed to vicarious community trauma than children from other age groups (Howard, 2021). Such information shows that older children, despite being more emotionally and physically mature, in fact, can suffer from secondary PTSD more often than younger children. The aforementioned study also has certain limitations, including the lack of measurements on the severity of secondary trauma at the moment when the child received it.
Veterans are not the only group of people who are at high risk of having PTSD; there are also prisoners of war (POWs). As a result, it is important to assess the mental health outcomes of children of people who, at some point in their life, were prisoners of war. Zerach and Aloni (2015) conducted research on the issue of secondary traumatization in children of former World War II POWs and discovered information relevant to the current literature review. The results show that children of people who were prisoners of war during World War II were more likely to have secondary trauma symptoms than those in the control group (Zerach & Aloni, 2015). At the same time, parental care was an effective way of reducing the effect of being exposed to the unstable behavior of a former POW parent. POWs often suffer from PTSD and other mental problems, which translates into avoidance or aggressive conduct within the family, undermining the psychological health of children. The primary limitation of the study in question concerns the lack of information on children of POWs of other wars.
As mentioned above, children can experience secondary trauma also in cases involving media and exposure to sensitive content. In other words, having a parent or friend who had stressful and traumatic events in the past is not the only factor that can cause vicarious traumatization. Comstock and Platania (2017) conducted a study on the role of media in the development of secondary trauma, and their evidence is exceptionally relevant to the current review. For instance, they discovered that subjecting children to watching terrorism on TV may contribute to them becoming emotionally reactive (Comstock & Platania, 2017). Essentially, children are extremely vulnerable to any content which can be considered sensitive or graphic and may suffer from mental problems because of it. Moreover, children who watched terrorist events on television also experienced sleep problems and exhibited aggressive behavior. The study did not offer any evidence of the effect of social media on the development of secondary PTSD in children. It is clear that modern children are more likely to consume content on the Internet and therefore have a considerable chance of viewing sensitive content online.
Symptoms of Secondary Post-traumatic Stress Disorder in Children
Children who have secondary PTSD or general trauma experience numerous symptoms which may vary from one child to another. Kelly and Paul (2017) studied children of military veterans and their behavior in response to the conduct of their traumatized parents. The research indicated that during the period of childhood, people develop their abilities to tolerate frustration and adapt to external circumstances in an effective manner. The person who was subject to secondary traumatization through living in close proximity to a parent with PTSD may fail to develop their ego properly. As a result, the child suffering from the condition can experience various symptoms, including anxiety, educational withdrawal, memory loss, and poor concentration (Kelly & Paul, 2017). Such symptoms may remain present in children for a substantial period of time and even continue to affect them in adulthood. The limitation of the study is the fact that it only proposes a conceptual framework. Currently, the framework on the loss of ego among children of former servicemen has not been tested, and it would be interesting to assess the prevalence of the aforementioned symptoms in children with secondary PTSD.
The number of studies exploring the issue of symptoms among children living with PTSD relatives is high, and their evidence allows doctors to be more adept at detecting secondary traumatization. Klarić et al. (2008) conducted extensive research among veterans in Bosnia and offered them a questionnaire asking them about the behavioral problems of their children. Compared to the control group, PTSD veterans were substantially more likely to report feeding difficulties, night fears, speech disorders, and aggressive behavior in their children (Klarić et al., 2008). The study did not state that the children of the PTSD veterans who participated in the research had secondary traumatization. Nevertheless, it is still possible to say that there are apparent differences between children of parents who had and did not have PTSD. The study once again stresses the role of the military action of parents in the development of behavioral problems in children. The primary limitation of the study in question is the fact that the evidence on the health of children was not collected by researchers. It would be interesting to see the results of a professional analysis of children’s health.
There are also studies involving answers to questionnaires provided by the children of parents with PTSD themselves. For instance, Selimbasic et al. (2016) once again studied the children of the people who participated in a military conflict in Bosnia and were diagnosed with PTSD. The questionnaires were distributed to the children, who had to answer different questions on their mental state. As a result, the evidence showed that, on average, children of PTSD veterans demonstrated higher levels of emotional externalizing and internalizing, as well as depressive symptoms (Selimbasic et al., 2016). Moreover, such children also experienced anxiety which was at the border limit, according to the researchers (Selimbasic et al., 2016). The study once again proved that the passing of PTSD symptoms from a parent to a child was a significant issue. Nevertheless, since the study relied on a questionnaire, it was impossible to determine whether the children had secondary PTSD. At the same time, considering the previously mentioned study involving asking PTSD fathers about their children’s behavioral problems, it now can be concluded that the problem of vicarious traumatization is real.
Moreover, it is also important to assess the outcomes of children living with PTSD parents in terms of their communication and interactions with people from their social network. Selimbasic et al. (2009) conducted another study on the children of PTSD veterans in Bosnia, which focused on satisfaction with contacts. The results demonstrated that children of PTSD veterans were more likely to have communication problems with their fathers and, in general, with males. Such evidence indicated that children subject to PTSD symptoms by their fathers developed a complex relationship with other men in their life. Moreover, the researchers discovered that the children of PTSD parents were more unsatisfied with their contact in general with other different groups, including relatives and family members (Selimbasic et al., 2009). Thus, it can be concluded that children with prior experience of living with PTSD parents tend to face more communication challenges than their ordinary peers. The limitation of the study in question is the lack of information about the communication experiences of children with PTSD parents later in their life, especially during adulthood.
There is also evidence in support of the idea that children with secondary PTSD tend to exhibit symptoms characteristic of PTSD experienced by their parents. Kaminer et al. (2005) published an article that provided an extensive account of all the behavioral aspects of children diagnosed with secondary PTSD. According to the research, such children may face the emergence of new fears, loss of previously acquired skills, and even psychosomatic pains such as headaches (Kaminer et al., 2005). All of these symptoms are also relevant for PTSD found in adults, for instance, in parents of secondly traumatized children. There is also evidence showing that such children may exhibit hyperactivity due to anxiety and increased impulsivity (Kaminer et al., 2005). Such symptoms are also inherent to hyperactivity disorder which may cause confusion for doctors attempting to provide their diagnosis. The article by Kaminer et al. (2005) is a source of reliable information on the topic of secondary PTSD in children since it is based on data gathered from numerous resources. Thus, the article should be a part of the current literature review since it supplies vital evidence which makes the research more complete.
Secondary traumatization is a complex issue that may also arise in adults working with children who have PTSD or behavioral problems. A study by Motta (2012) describes the effects of working with traumatized children on school personnel and their health. Although the main subject of the research is not relevant to the current literature review, it contains important information on symptoms related to secondary PTSD. Motta lists several symptoms which already were mentioned, as well as new ones. For instance, in line with the previously presented sources, Motta (2012) highlights that anxiety, concentration difficulty, depression, and body aches can be common issues experienced by people with secondary PTSD, including children. At the same time, Motta (2012) writes that low self-esteem is also a possible symptom of the condition. The main limitation of the study is the lack of statistics on the prevalence of each symptom among people with secondary PTSD. There is also a lack of information on the symptoms which are relevant to certain age groups, such as children, which would be relevant for the current literature review.
Prevention
As it has become clear from the previously described sources, the condition of secondary PTSD has the same symptoms as standard PTSD, and they are the same both in children and adults. As a result, it is reasonable to utilize the traditional methods for preventing the development of PTSD in cases involving secondary traumatization. Moreover, there is a lack of sources containing information on viable preventive measures for the condition of secondary PTSD.
Additionally, the majority of studies focus on interventions rather than prevention measures. Nevertheless, there are articles that extensively document existing ways to reduce the possible onset of PTSD in children. Research conducted by Hanratty et al. (2019) is one of the most in-depth ones since it describes several key methods for preventing PTSD. One of the main prevention techniques involves community resiliency programs which seek to provide the child at risk of developing secondary PTSD with community support. The goal of such programs is to enable children to face the experiences related to trauma in an environment where they can get assistance and support. Discussions and reflections on the difficult topic are among the primary measures used as part of the aforementioned programs. Research shows that such a preventive technique contributes to the improvement of community connectedness and offers a child a resource necessary for overcoming potential negative outcomes (Hanratty et al., 2019). It is clear that community resiliency programs are effective for children who both have not yet had any traumatic experience and those who were subject to it to a certain extent.
It is important to understand that community-based preventive measures are also exceptionally effective in cases when the source of the traumatic experience is family. At the same time, as evinced by the research discussed earlier, children also can experience secondary PTSD or be at risk of it as a result of interactions with friends and other members of their community. Therefore, it becomes important to devise a prevention method set in the family environment. Hanratty et al. (2019) proposed several family-related methods, including increasing parental involvement and reducing the level of stress of parents. Secondary PTSD is a condition that is transgenerational, meaning that it is acquired by children as a result of their parent’s trauma. The stressful behavior of parents with PTSD can impact the child. Therefore, families must create a calm environment at home to prevent imposing any harm to their children. Improving the relationship between parents and children is another viable strategy for preventing the onset of secondary PTSD (Hanratty et al., 2019). Essentially, parents must ensure that their child is always able to get their help and support.
Apart from the community and family-based methods, there are general ones that focus on the prevention of secondary PTSD in children. One of them is emotional regulation which involves preparing a child for potentially traumatizing events. Emotional regulation techniques are different, but they include breathing exercises, positive self-talk, and help-seeking. Such measures must enable the child to develop appropriate coping skills, which will be necessary for them to avoid becoming traumatized by stressful events. Although such techniques are commonly used for the prevention of PTSD, they also can be utilized in cases involving the risk of subjecting a child to secondary traumatization. Overall, the article of Hanratty et al. (2019) constitutes an invaluable source of information for the current literature review. Nevertheless, the main limitation concerning the article is the lack of evidence on the use of preventive measures which are specific to cases of secondary traumatization.
Since children spend a substantial amount of their time outside of the home environment, preventive measures also can be introduced in schools. For instance, Frydman and Mayor (2017) described the process of utilization of the ALIVE program intended for the prevention of trauma in school children. ALIVE involves practitioners who conduct weekly dialogues with students on the topic of trauma in order to normalize the conversations on the issue. The ALIVE program is intended to enable children facing adverse situations in the community or at home to be able to speak about their problems. The desired outcome of the program is the provision of basic skills to children that are necessary for them to be open about stress in their lives. In order to avoid directly talking about adverse experiences, ALIVE practitioners use parables that help them to detect children with problems. The article by Frydman and Mayor (2017) presents evidence on the use of special school-based preventive methods for protecting children from experiencing adverse outcomes related to their secondary traumatization.
Psychoeducation, as the main way of addressing the prevention of PTSD symptoms in children, can be implemented in different ways and using various techniques. Skeffington et al. (2013) described another school-based intervention that involved exposing 700 primary school students from Israel to resilience training before rocket attacks on the country. The program included conducting sessions on the topics of working with negative experiences, managing emotions, and balancing body tension. The results show that children who underwent the rain demonstrated fewer PTSD symptoms than those who did not partake in the sessions (Skeffington et al., 2013). Thus, it is possible to assume that such an intervention would also be effective with children who are at risk of facing secondary PTSD, for instance, those living in the families of PTSD veterans. Skeffington et al. (2013) is a quality source of information on viable preventive strategies for the reduction of PTSD symptoms in children. Nevertheless, the limitation of the article is the small sample size of the study involving children in Israel. The data would be more accurate if more children participated in the program.
Treatment
The situation with treatment for secondary PTSD is similar to that of the prevention of PTSD symptoms. In other words, treatment for PTSD can also be effectively used as an intervention for reducing the effects of secondary traumatization. Galovski and Lyons (2004) studied the topic of the existing interventions to decrease the impact of PTSD parents on children and discovered several effective techniques. One of them involves family therapy sessions which should be used in addition to the actual treatment for the PTSD of the parent. Such intervention must focus on developing a consensus in the family in terms of the core problem associated with the parent’s mental issues. Moreover, family therapy must also enhance communication among relatives and contribute to the establishment of a supportive environment at home. Although the article of Galovski and Lyons (2004) provides a relevant overview of the existing interventions, it has certain limitations. For instance, the aforementioned treatment can be effectively used only in families where children were not several traumatized by the PTSD symptoms of their parents.
The improvement of the relationship between PTSD parents and traumatized children is essential for effective treatment and healing. Therefore, researchers designed several programs which are based on the facilitation of positive interactions between parents and children. Lucio and Nelson (2016) conducted an overview of the existing research and discovered that child-parent psychotherapy was one of the most popular ways of resolving trauma in children. Such psychotherapy focuses on modeling positive behaviors in children and their parents, providing them with knowledge on how to communicate correctly, and erasing cognitive distortions. The ultimate goal of parent-child psychotherapy is the development of a new family narrative that is free from previous problems and conducive to trust and support. The psychotherapist can act as a facilitator of the communication between the child and the parent since, in a usual setting, they may not talk much. The lack of communication is a considerable factor contributing to the worsening of trauma symptoms; therefore, when treating secondary PTSD in children, the bond between the parent and child should always be prioritized.
There are other effective treatments explored by Lucio and Nelson in their article, including trauma-focused cognitive behavioral therapy. Such therapy is considered to have the most beneficial impact on children suffering from trauma, including secondary ones (Lucio & Nelson, 2016). The therapy implies providing skills to children and youth, helping them to cope with their problems as well as their reactions to them. Parents also receive important information on how to correctly address the trauma symptoms of their children and manage them. Research shows that a 12-session program can significantly improve the situation and reduce trauma symptoms in children (Lucio & Nelson, 2016). The key to trauma-focused cognitive behavioral therapy is, once again, the involvement of parents. Essentially, the majority of treatments designed for traumatized children will require the presence and interference on the part of parents. The research by Lucio and Nelson is a source of invaluable data on the use of the most common treatments for decreasing the trauma effects. Nevertheless, the article has a small sample size of the previously published studies, which constitutes its main limitation.
Another potential treatment procedure is eye movement desensitization and reprocessing (EMDR), which has been extensively studied by numerous scientists. For instance, Yurtsever et al. (2018) conducted research involving refugees experiencing symptoms of PTSD and discovered multiple pieces of evidence proving the effectiveness of EMDR. The therapy is used to facilitate the accessing of traumatic memory, thus improving information processing and establishing new associations between traumatic and more adaptive memories. The study shows that EMDR was an extremely successful intervention for the treatment of PTSD symptoms, as well as an inexpensive one. At the same time, the main limitation of the study is the lack of any results on the use of EMDR on children. The research by Yurtsever et al. (2018) focused only on adults. Therefore it is possible that the intervention may not be as effective when used on traumatized children. Nevertheless, EMDR still can be viewed as a potential treatment for children who were traumatized as a result of their parent’s mental problems. It is necessary to conduct additional studies using the intervention in question in the future and to utilize a large sample of people from different age groups.
While all of the aforementioned sources explored psychological treatments used for managing PTSD and trauma symptoms, there are also pharmacological ones. Coventry et al. (2020) conducted a meta-analysis on the use of various interventions and discovered that Prazosin and antipsychotics such as Sertraline were the medicine capable of alleviating symptoms of PTSD. For instance, Prazosin was particularly effective in improving the sleep quality of people suffering from PTSD. As it is clear from the research, sleep problems are also experienced by children who have secondary PTSD, therefore such pharmacological interventions may be relevant for them. The study also revealed that pharmacological and psychological treatments could be sued together to achieve better results. For example, fluoxetine and tianeptine used with group therapy led o substantial improvements in the health of PTSD patients and minimized their symptoms (Coventry et al., 2020). The primary limitation of the meta-analysis is the lack of data on the use of pharmacological interventions in children with PTSD symptoms. At the same time, parents may refuse to allow children to take medicine and such experiments are difficult to conduct.
Conclusion
Secondary PTSD is a condition that is common among children and has been thoroughly studied by researchers. Secondary PTSD may arise as a result of obtaining information on the traumatic experience of other people. PTSD often affects children who live together or in close proximity to relatives suffering from trauma and stress. Numerous studies show that children of veterans to have PTSD symptoms are likely to become traumatized by the behavior of their parents. In other words, children living in families with veterans were at greater risk of getting secondary PTSD. The symptoms of secondary traumatization are similar to those of PTSD and involve sleep problems, low self-esteem, depression, anxiety, and aggression. Behavioral issues suffered by such children can interfere with their school performance and ability to communicate with their peers as well as parents. There are many interventions both for the prevention and treatment of the condition. Resiliency programs and emotional regulation are methods commonly used by practitioners in order to reduce the probability of the onset of secondary PTSD. In terms of future research, it would be interesting to study the pharmacological treatment of secondary PTSD in children.
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