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Casualties of war: Canadian children and vicarious PTSD

The image of the soldier returning home from war with mental health problems is not new. During World War I, soldiers became "shell-shocked" and often did not manage to overcome what they had seen and done in the trenches. A few decades later, so many soldiers returned from Vietnam 'changed' that the figure of the unstable Vietnam vet became a stereotype.

Over the years, as medicine's understanding of mental illness improved, so too did its understanding of how trauma can injure the psyche. Following the Vietnam War, post-traumatic stress disorder (PTSD) was described and defined by psychiatrists. Stress, a reliving of traumatic events, and difficulty coping with ordinary life are among the symptoms of the condition.

More recently, medicine has come to realize that trauma can have grave psychological effects on families, even on members of the family who were not direct participants or witnesses to the traumatic event.

"Many children were presenting with anxiety, depression, and sleep disorders. Some of them were acting out and engaging in substance abuse," says Dr. Tatyana Barankin, staff psychiatrist at SickKids, describing her experiences working with staff who assist families from Canadian Forces Base Petawawa. In the last few years, hundreds of Petawawa-based soldiers, many of whom have families, have been deployed to Afghanistan. "It's a close knit community, every child knows another child whose father did not come back or came back injured. They watch the news about the war and they feel worried. These kids are highly sensitized and tend to have an uncertainty about the future."

Dr. Barankin is no stranger to the trauma war can inflict on children. At her practice in Toronto, she helps children with PTSD and other mental conditions who have lived through war and have come to Canada as refugees. Because of this expertise, Dr. Barankin was asked to help set up monthly telepsychiatry consultations for the staff at the Phoenix Child and Family Centre in Pembroke, Ontario, near Petawawa. Established in March of 2007, the Phoenix centre is a mental health facility that helps children and spouses of military members.

"This is a bit of a different situation from refugee children. [The children at Petawawa] have had indirect experiences through the media or through one of their parents who returns from overseas with PTSD," says Dr. Barankin. Perhaps not surprisingly, the amount of trauma a child is subjected to is one of the factors that determine whether the child goes on to develop PTSD or other psychological conditions such as depression.

Contradictory symptoms, multiple sources

PTSD is a very severe form of anxiety. Often, this anxiety turns into a kind of hyper-arousal. "You can call their name and they jump," says Dr. Barankin. "But if the child has been exposed to multiple events, they may develop a dis-associative numbing, a desensitization and withdrawal." Children often demonstrate this by joylessly re-enacting a traumatic event over and over again.

While this type of injury and behaviour is not uncommon in refugee children, these symptoms are seen less frequently in the children of Canadian soldiers or indeed in children in developed nations who are less likely to be exposed to war. However, horrific events perpetuated during war are not the only things that can cause PTSD or related psychological effects such as depression.

A recent study has looked at children who attended day cares or preschools in lower Manhattan during 9/11 who directly witnessed some aspect of the attack. The study found that children who had witnessed a high-intensity event associated with 9/11 were more likely to suffer PTSD if they had also been exposed to some other unrelated trauma. Examples of high-intensity events during 9/11 were such things as seeing people jumping out of the towers, seeing the towers falling, or seeing dead or injured people on the street. Examples of unrelated trauma were severe illness, animal attacks, a death in the family, and exposure to suicide or attempted suicide, among others.

The study implies that witnessing trauma can have a cumulative effect. It also suggests there are limits to a child's resiliency, the word psychologists use to describe a child's ability to overcome negative experiences.

Identifying and treating PTSD

As with many illnesses, whether physical or mental in nature, early treatment of PTSD increases the chances that a sufferer can get better. However, because of the stigma attached to mental illnesses, coming forward and admitting that you have a problem and need help is not easy. For PTSD, especially in a military context, this may be even more difficult than normal.

"I didn't know there was anything really wrong, though I always suspected it," says 'Jim,' who spent 32 years in the Canadian military. Stepfather to two teenage girls, Jim was recently diagnosed with PTSD after years of ignoring his symptoms. He believes his problems started during the 1970s while on a peacekeeping mission in the Middle East. "A [foreign soldier] put an AK-47 to my nose. It bothered me for about four months, but I got over it."

At least on the outside.

Perhaps not surprisingly, being threatened at very close range with an assault rifle by an angry soldier is not easily overcome. "Even now, years later, I could pick that guy's face out of a line up. I can still smell him." During a subsequent mission to Bosnia, Jim, like many other soldiers, was witness to ethnic cleansing and other atrocities. His claustrophobia, extreme irritability, insomnia, and nightmares got worse - though Jim stayed quiet until he voluntarily left the military a few years ago.

"I thought I had sleep apnea," he says. However, Jim was also acutely aware that a diagnosis of PTSD was, at the time, virtual career suicide in the military. By chance, Jim couldn't find a family doctor and accessed medical services available to veterans. After describing some of his symptoms, it was suggested he be assessed for PTSD.

"When I was told I had PTSD, I said 'no I don't.' The psychiatrist told me my denial was a typical response." Jim is now in counselling and has been prescribed medications. Family relations have improved. "Initially, I wrote off the kids' bad behaviour to 'stepdad syndrome.' My wife has noticed a major difference. People think I am ten times calmer than before." Jim understands the road to recovery is long and will involve the whole family. His spouse and kids have been referred to peer support programs set up by the military.

A newly enlightened military

One the individuals responsible for setting up peer support and other programs for Canadian soldiers and their family members is Lieutenant Colonel Stephane Grenier. "The approach used used to be to 'get over it. Suck it up and keep going'," says Grenier, on how the military formerly expected its troops to deal with what the Forces now call "operational stress injuries." Over the last decade, with an increased combat role for Canada's military and a new awareness of PTSD due to the highly publicized story of General Romeo Dallaire's mental health issues following the Rwandan genocide, the Canadian military has changed its stand on PTSD. In an effort to prevent what they term secondary wounding, the Forces have implemented a number of programs to educate members before and after deployment, identify those at risk, and provide treatment for anyone who needs it, including family members.

"We now have a countrywide peer support program dedicated to supporting the military and their families. This is something that doesn't exist anywhere else in the world," says Grenier. "The tendency is that soldiers say 'I can get over this myself.' Trained mentors who are also peers help make the patient more treatment compliant." Grenier admits the military still has a way to go in terms of both improving services and changing attitudes about PTSD and mental illness in general. This effort mirrors Canadian society as a whole, he notes.

The good news

With comprehensive treatment, the effects of PTSD can be reduced if not eliminated. With the Canadian Forces on the lookout for new cases in its soldiers, and family member who may also be affected are now also more likely to be treated. A higher awareness of PTSD may also benefit Canadians not connected to the military.

"Statistics show more than 50% of all people will experience a traumatic event in their lives, though that doesn't mean they will develop PTSD," says Dr. Barankin. For those who do, research suggests that when evidence-based practices are used, complete remission is achieved in 30% to 50% of cases, and partial improvement can be expected with most patients.

Jonathan Link
Medical Writer
AboutKidsHealth

6/10/2010

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