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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Welcome to the Nimble Youth Podcast, the show that brings clarity, compassion, and expert insight to the mental health challenges facing today's children and teens. I'm your host, Matt Butterman. Today's episode tackles a topic that too often goes unseen, but leaves a profound impact. Post traumatic stress disorder, PTSD, in children and adolescents. Our guest is Doctor.
Matt (host):Gretchen Hoyle, a pediatrician with over twenty five years of clinical experience and a trusted voice on the front lines of youth mental health. Though PTSD is commonly associated with combat veterans or adults who've experienced extreme trauma, the truth is children are just as vulnerable and sometimes even more so. Consider this: approximately five percent of adolescents meet the criteria for PTSD in any given year and children who have experienced four or more adverse childhood experiences known as ACEs, ACEs, are twelve times more likely to attempt suicide and significantly more likely to struggle with lifelong physical and mental health problems. PTSD in kids and teens is one of the most overlooked and yet most impactful mental health conditions we see and is closely tied to a broader understanding of trauma, especially what we call these adverse childhood experiences or ACEs. We'll explore how PTSD presents differently in kids than in adults, the role of ACEs in shaping long term outcomes, and what steps parents, teachers, and pediatricians can take to intervene early and effectively.
Matt (host):Join us as we shine a light on these invisible wounds and learn to support healing in young people who carry them. Before we get into it, we remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice. While we aim to provide valuable insights on pediatric mental health, it's important to consult with a qualified healthcare professional for any concerns or questions regarding your child's mental well-being. Always seek the advice of your doctor, therapist, or other qualified health provider with any medical or mental health concerns. So Doctor.
Matt (host):Hoyle, let's start with the basics. People often associate PTSD with, as we mentioned, soldiers, combat veterans, or people who have experienced major, natural disasters, but what does PTSD really look like in a young person?
Dr. Hoyle:Sure. Thanks for having me. I'm really glad to be here for this conversation. PTSD in kids and teens is one of the most overlooked and yet most impactful mental health conditions we see. And it is closely tied to what you've talked about with adverse childhood experiences or ACEs.
Dr. Hoyle:The definition of PTSD or post traumatic stress disorder is that it's a psychiatric condition that occurs after someone experiences or witnesses a deeply distressing event. That can be a serious injury or the death of another person, abuse for that person, or even ongoing exposure to violence. For children, it could be something like a single traumatic event, like being in a car accident, or it can be chronic stressors like neglect or living with a parent who struggles with substance use or witnessing domestic violence. And a lot of times the symptoms that kids have don't always look like what we see in adults.
Matt (host):Right. And so what might a parent or teacher notice in a child with PTSD?
Dr. Hoyle:Right. So a lot of times for kids who have experienced a lot of trauma, they may have some even developmental, they're not necessarily meeting their milestones on time. So they may have some developmental slowing. And certainly trauma is not the only reason for that, but it can show up as that. And they can also have what we often call regression, which is they've met certain milestones and then they're kind of going backwards.
Dr. Hoyle:And so things like real, like, difficulty with sleeping or separating from parents and being super clingy, or sometimes it's, you can pick it up on it when a child is acting out their trauma through their play. Sometimes older kids will often have the classic signs like nightmares or even flashbacks that they're able to describe. They can have lots of irritability and they can engage in avoidance behaviors. And that sort of brings me to the four key symptom clusters of PTSD. And so the first of those is intrusion.
Dr. Hoyle:So you have these intrusive thoughts about the trauma that you experienced, and those thoughts can occupy so much of your consciousness that it interferes with other things that you should be doing. The second one is avoidance. And so people will, engage in behaviors to avoid the likelihood of re triggering those thoughts. And that also can interfere with your day to day life. And then you can have negative changes in mood or thinking.
Dr. Hoyle:And then there's this sort of state of it called hyperarousal, which is when you have, if you think about people who have had a lot of trauma, a lot of times their physiology will change to the point where they are in fight or flight so much of the time in their just regular day to day life that it shows up as being, that they're being very jumpy or angry or just feels like they're constantly on alert. And so a history of trauma can show up in those ways in kids and teens.
Matt (host):Absolutely. So we mentioned in the introduction that estimates vary, but somewhere between four and six percent of children and adolescents develop PTSD after a trauma. That number potentially is likely higher when we consider that PTSD is often misdiagnosed, particularly in kids who can't really articulate what they're feeling. Also certain populations are especially at risk, things like children in foster care, refugee families and those who have experienced community violence or chronic chronic stress in their homes which leads us to ACEs which are Adverse Childhood Experiences which run deeply in distressed communities I guess we could call them. So you use a tool called the ACEs questionnaire.
Matt (host):So tell us a little bit about that and how it helps you, make the diagnosis.
Dr. Hoyle:Right, so I do use the ACES questionnaire. There's some specific, scenarios in which I will use this. First of all, ACES stands for Adverse Adverse Childhood Experiences. It's typically a 10 questionnaire or ten ten question screener, that looks at early life stressors. And so the context in which I use this is when I am meeting or talking with, say, a teenager, and there are some indicators that that teenager experienced developmental trauma as a child.
Dr. Hoyle:So I'm not necessarily talking to young children about these questions. It's more of a retrospective view with the teenager that I'm working with. Okay. So that's typically how I use it. And I and, I would say that of these this work on adverse childhood experiences, we've learned a lot about these from the groundbreaking work of Doctor.
Dr. Hoyle:Nadine Burke Harris. And in her book, The Deep As Well, she, describes ACEs and she also describes that it's not just like mental health challenges that folks with who have accumulated a lot of ACEs in their childhood, face, but that those are associated with physical health challenges. Moving forward into adulthood. So you'll have folks who have experienced a lot of developmental trauma in childhood, and it will affect their blood pressure and their cardiac risk factors up in their 50s and 60s. And so there is really, good evidence of that sort of impact that you can have from developmental trauma that stays with you.
Dr. Hoyle:And so her book, The Deepest Well, I highly recommend. There's another one called The Body Keeps the Score, which, also reflects the idea that somewhere in ourselves, in our physical and psychological selves, we have stored these events that have happened and that it is important for us to to recognize the impact of that. And so as far as, like, what these questions look like, I do this questionnaire a little differently from the way that I do other questionnaires. And I do this one on paper. So when I'm with a teen, I will print out this, adverse childhood experiences questionnaire, and and then I will hand them the questionnaire.
Dr. Hoyle:And I will say, I want you to read over these and I don't need you to elaborate and specify which of these apply to you, but I would like for you to tell me the number that apply to you. Does that make sense?
Matt (host):Yeah.
Dr. Hoyle:Okay. So, so I'm just gonna run down a few of these so that it makes sense from the, from the perspective of the, of the listener. One of the questions that we would ask is that at any point since birth, have you lived in a household with a member who subsequently served time in jail or prison? Have you lived in a household with a person who was mentally ill or attempted suicide? Prior to your eighteenth birthday, did you see or hear household members hurt or threaten each other?
Dr. Hoyle:Was there a person in your household who swore at, insulted, humiliated, or put you down in a way that scared you that made you feel afraid that you might be physically hurt? Did you struggle with lack of food, clothing, a safe place to live, or felt that you had no one to protect you? Have you been pushed, grabbed, slapped, or threw, or something being thrown at you or hit so hard that you were injured or had marks? Have you lived with someone who had a problem with drinking or using drugs? And then have, has someone touched you in a sexual manner or touched your private parts in a way that was unwanted against your will or made you feel uncomfortable?
Dr. Hoyle:So those are on that questions list. And so I will ask them to look at that list and tell me the number that apply to them. And we'd love it if all if everyone was a zero, but but we do know that as those as that total goes up, especially once we hit around four, that there is some pretty statistically important correlation with mental health concerns that we should be aware of.
Matt (host):Right. Yeah. And so, we know from the work of, of Doctor. Nadine Burke Harris and others that these ACEs, they really impact our physical development as well as our brain, is an important insight I think. We talk about the brain being pliable when young and susceptible to injury but so are our bodies as well.
Matt (host):And as with every condition that we seem to talk about on this podcast, the earlier you get treatment, the less damage lasting damage there will be. And so how do you treat PTSD in children and adolescents?
Dr. Hoyle:Right, so there are some really helpful like therapeutic modalities. So SPONS specific is trauma focused cognitive behavioral therapy, or sometimes it's, abbreviated as TFCBT. And in order for like the therapist to, help address the specific needs of that patient, they'll often do, and sometimes I will do this questionnaire as well, which is the one that's called the PCL five. And so this is specifically to see about symptoms of PTSD. And so there's sort of, we wanna sort of separate these into two different things.
Dr. Hoyle:The ACEs tell us what the experience was, and then the PCL five can help us as clinicians understand the impact of that experience on that person. So there can be people who have, accumulated a lot of ACEs and yet their symptoms may not be as intrusive or problematic as someone who has maybe accumulated fewer ACEs, but they're having a whole lot of trouble with dealing with that. And so we do, and when we're trying to address their symptoms, we want to understand kind of the nature of those. And so the PCL-five is a questionnaire that we'll use. It's on a scale of zero to four, meaning the replies to each statement can either be not at all, a little bit, moderately, quite a bit, extremely.
Dr. Hoyle:And so the questions on there are things like, in the past month, how much were you bothered by repeated, disturbing, and unwanted memories of the stressful experience. In the second question, repeated disturbing dreams of the stressful experience. Suddenly feeling or acting as if the stressful experience were actually happening again, as if you were actually back and there and reliving it. Feeling very upset when something reminded you of the stressful experience. Having strong physical reactions when something reminded you of the stressful such as heart pounding, trouble breathing, sweating, so sort of that fight or flight panicky physical response.
Dr. Hoyle:Avoiding memories, thoughts, or feelings related to the stressful experience. Avoiding external reminders of the stressful experience. For example, people, places, conversations, activities, objects, or situations. So there's where the avoidance is coming in. Trouble remembering important parts of what happened, having strong negative beliefs about yourself or other people or the world.
Dr. Hoyle:For example, having thoughts such as, I am bad. There is something seriously wrong with me. No one can be trusted. The world is completely dangerous. Blaming yourself or someone else for the stressful experience or what happened after it, having strong negative feelings such as fear, horror, anger, guilt, or shame, loss of interest in activities you used to enjoy, feeling distant or cut off from other people, irritable behavior, taking too many risks, and being super alert or watchful or always on guard.
Dr. Hoyle:And so we can take the responses from that patient and get a score and then be able to recognize how symptomatic that person is. And that will help us then measure as we are engaging in different therapeutic options, whether or not we're having an impact on their symptoms. So certainly the trauma focused cognitive behavioral therapy is important for younger kids. A lot of times we're just mostly doing play therapy if we're able to identify that. There are some other emerging technologies and therapies such as EMDR and then art or narrative therapy.
Dr. Hoyle:Occasionally, we'll have folks, you can imagine that folks who meet the criteria for, PTSD will often have overlapping anxiety diagnoses or depression diagnoses. Sometimes that warrants treatment with, an SSRI antidepressant medication. And then there are even further emerging therapies that are on the horizon that are sort of built around the idea that if we can engage brain in neuroplasticity, so making new connections so that, we're not sort of stuck in a ruminating pattern around the traumatizing events that we can improve symptoms. And so some of those are gonna be substances such as psychedelic substances that look promising in studies that have been done, like specifically with combat veterans, where it helps harness the potential neuroplasticity in the brain to make new connections and therefore not get stuck in that rumination pattern.
Matt (host):Right. So sometimes the medications are prescribed, but, it seems like the constant, in treating PTSD is some form of therapy, right?
Dr. Hoyle:Correct. Yes. Yep.
Matt (host):So, let's talk a little bit about, how pediatricians and schools can help. You've said that there's a method that should be used, should be embraced called trauma informed care. Can you describe what that is?
Dr. Hoyle:Trauma informed care, there are ways to train folks who work, especially with kids or with young people, in being able to recognize behaviors that are likely being driven by trauma. And sometimes, I guess the classic story that I hear is, you know, that you have a kid in high school and their teacher asks them to take out their ear pods for class and then they stand up and like punch the wall. Well, that's like a completely out of bounds type of out of proportion response to a pretty simple request. But for whatever reason, that response happened, a lot of times what's driving that is some sort of traumatic past experience. And so for folks to be aware that those kinds of responses can happen and to make sure that kids who are at risk for having responses.
Dr. Hoyle:We want to be able to have systems in place that can understand who what's happening to them and help support them as opposed to it being entirely punitive. We definitely want to hold people accountable for their actions, but a lot of kids who react in ways that surprise us, are doing so from a place that is much deeper in their psyche than just oppositional behavior. And so trauma informed care, training folks in that can be helpful in making the environment for kids who have had a lot of trauma more hospitable.
Matt (host):Right.
Dr. Hoyle:Yeah.
Matt (host):And you said resilience can grow in the presence of a safe, stable, and nurturing relationships in Absolutely. Their lives, So what's one message you hope that listeners take away from this?
Dr. Hoyle:Right, well, and I think it kind of echoes what our messages often are, which is that if there is a concern that a parent or caregiver has about a patient or a child, whether it's related to trauma or whatever behavior it is that they're concerned that could be related to that. The sooner that we get the chance to make an evaluation or do an evaluation and start getting involved, certainly the better. A lot of times with trauma, especially the full impact of that is not, really understood until the patient reaches like teenager years and they are able to look back and process what happened. But even at that point, it's not too late. It's definitely the kind of thing that we want to be able to provide support, and we want to do it in a way that is appropriate for that patient.
Dr. Hoyle:We're not wanting to necessarily push them into a place to try to describe everything that happened to them in a quick visit or something. But it often takes time to sort of build that rapport, build that relationship. And over that time, a lot of times we can, help reframe what happened so that it doesn't take over their present conscious experience in life and then therefore make their future brighter.
Matt (host):Absolutely. Well, thanks again, Doctor. Hoyle, for your insights on this important topic and relevant topic to many of those listening. And for you listeners, please do check out resources like the National Child Traumatic Stress Network, ACEs Aware, and Doctor. Burke Harris's book, mentioned called The Deepest Well.
Matt (host):And we'll have links to all of those in the show notes, which you can find at our website podcast. Also please follow us and, like us, on Facebook and Instagram at nimble youth podcast. Until next time, please take care of each other and especially the kids in your world.