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Post-Traumatic Stress Disorder (PTSD) and the Family
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Table of Contents
For Parents with Young Children
Purpose of this Booklet
When someone at home has been diagnosed with post-traumatic stress disorder (PTSD), the whole family will be affected. If you are parents with young children (pre-school to 12 years) and if you or your spouse/partner has PTSD, this booklet is for you. It will provide both of you with information to help you recognize how your children might be affected and what to do about it. It will also alert you to the potential signs of excessive stress in your children and suggest ways you can help to protect your children from disruptions in family life.
How to Use this Book
It is important that you and your partner work together to understand and use the ideas in this booklet depending on your particular family situation. There is no one right way to do this as people learn in different ways. You may wish to read short sections together and talk about how it might apply to your situation; or you may choose to read the booklet from cover to cover separately and then together discuss ways this information can be of help to your family. Do what works for you and proceed at your own pace. As with other family matters, open and respectful communication is the key to success.
As you come to understand the information presented here, you will be able to identify things that you can do to support your children and each other in dealing with the impacts of PTSD on family life. Remember, in taking action, set modest goals to ensure success and avoid disappointments. Treat these action goals as an experiment and learn what works for your family from each goal you set for yourselves. Celebrate your successes! Then build on small successes by returning to the booklet to help decide on another action goal that will benefit your family.
If at any time, you are unable to manage your child's reactions and behaviours, or if you are experiencing intense emotions such as fear, anger, depression, problems at work, intimacy, or substance abuse problems, seek professional help.
What is PTSD?
PTSD is a psychological response to the experience of intense traumatic events, particularly those that threaten life. For military personnel the trauma may relate to direct combat duties, being in a dangerous war zone, or taking part in peacekeeping missions under very difficult and stressful conditions. PTSD can affect people of any age, rank, culture or gender.
PTSD is characterized by three main groups of problems. They can be classified under the headings of intrusive, avoidance and arousal symptoms. These symptoms cause intense distress and can result in other emotions such as guilt, fear or anger. The symptoms affect the person's ability to function in their everyday activities and so will impact on the whole family.
In the majority of people, the symptoms gradually disappear over time; however, for reasons that are not yet clear, for some people the symptoms persist and they can continue to suffer for years. Effective treatments do exist for PTSD. Treatment can significantly reduce symptoms and improve abilities to cope with the illness. If your symptoms persist or worsen take immediate steps to get professional help. Early treatment can help avoid prolonged stress on yourself and your family and usually results in better outcomes for all.
The path to recovery involves education about the illness; adopting coping strategies for the affected individual and the family; use of medications, if required; and counselling to successfully manage symptoms and deal effectively with the traumatic experience. If you are seeking or receiving professional help and are ready to take a problem solving approach to the family issues that arise, you are well on the way to recovery.
Recovery is a shared responsibility of the individual, the family and the community of service providers. It is important to realize that a person with PTSD experiences powerful physical and psychological changes (symptoms) that make return to normal life initially very difficult. The affected person's reactions and attempts to cope with these changes often results in behaviours that are upsetting to family members. It is not their fault that these changes happened and they often express a feeling of loss of control over their emotions and behaviour. It is their responsibility to learn to deal effectively with these changes. Even though they are ill they can still find ways to participate as a spouse and a parent. At the same time, the affected person will need the patience, support and acceptance of family and friends on their road to recovery.
Recognizing the Symptoms
We focus here on a brief explanation of the major symptoms that present themselves in affected persons. It is through these symptoms that family members are directly and indirectly impacted.
Traumatic events or prolonged and severe levels of stress have impacts on the feelings, the thinking and the behaviour of the affected person. You will notice these three levels of impacts in the following description of symptoms.
Intrusive Symptoms
Memories, images, smells, sounds and feelings of the traumatic event can "intrude" into the lives of individuals with PTSD. Sufferers may remain so captured by the memory of past horror that they have difficulty paying attention to the present. People with PTSD report frequent, distressing memories of the event that they wish they did not have. They may have nightmares of the event or other frightening themes; sometimes, even acting out the dream while still asleep. They sometimes feel as though the events were happening again; this is referred to as "flashbacks" or "reliving" the event. This re-experience of events can be accompanied by exaggerated emotional and physical reactions like fear, frustration and anger; sweating, increased heart rate and muscle tension.
- Distressing memories or images of the incident;
- Nightmares of the event or other frightening themes;
- Flashbacks (reliving the event);
- Becoming upset when reminded of the incident; and
- Physical symptoms, such as sweating, increased heart rate, or muscle tension when reminded of the event.
Avoidance and Numbing Symptoms
Memories and reminders of traumatic events are very unpleasant and usually lead to considerable distress. Therefore, people with PTSD often avoid situations, people, or events that may remind them of the trauma. They often try not to think about, or talk about, what happened, and attempt to cut themselves off from the painful feelings associated with the memories.
In their attempts to do this, they often withdraw from family, friends and society and no longer take part in activities they used to enjoy. In this way they can become "numb" to their surroundings and do not experience normal everyday emotions such as love and joy, even toward those close to them. Such reactions can lead to depression and feelings of isolation. They can also lead to problems with motivation. People with PTSD often find it hard to make decisions and get themselves going.
In addition to these symptoms, use of alcohol or drugs may be used as a coping strategy.
- Trying to avoid any reminders of the trauma, such as thoughts, feelings, conversations, activities, places and people;
- Gaps in memory — forgetting parts of the experience;
- Losing interest in normal activities;
- Feeling cut-off or detached from loved ones;
- Feeling flat or numb; and
- Difficulty imagining a future.
Environmental reminders (triggers) play a part in raising these intrusive memories by recalling an image, sound, smell or feeling that is associated with the original events (e.g. a loud noise may be experienced as gunfire or a bomb blast).
Arousal Symptoms
Often people who have experienced trauma have been confronted with their own mortality and realize they could have been seriously injured or died. Their assumptions and beliefs that the world is safe and fair, that other people are basically good, and that "it won't happen to me," may be shattered by the experience. After the event, these people often see danger everywhere and become "tuned in" to threat. As a consequence, they may become jumpy, on edge, and feel constantly on guard. They may be overly alert or watchful and have problems concentrating. Disturbed sleep is very common.
Anger is often a central feature in PTSD, with sufferers feeling irritable and prone to angry outbursts with themselves, others around them, and the world in general. Many Veterans feel let down, abandoned, and judged by others. They may have a sense of betrayal about the way they were treated by a range of people upon their return home. Some people express their anger verbally and others become physically aggressive and violent to property or people. These symptoms can cause major problems at work and with family and friends.
- Sleep disturbance;
- Anger and irritability;
- Concentration problems;
- Constantly on the look-out for signs of danger; and
- Jumpy, easily startled.
How Does PTSD Affect Family Life?
As indicated in the previous section, a person with PTSD will have symptoms that will affect the whole family. The ability of the affected person to function as a parent, partner, employee and community member is undermined by these symptoms. Changes in their functioning can lead to unmet family needs and increased levels of stress for the family.
You and other family members may find it difficult to adjust to these changes and to communicate or discuss family problems together. You may feel frustrated, hurt, angry, rejected, and become distant toward each other which could lead to feelings of guilt and self-blame. As a result, relationships within the immediate and extended family can be seriously strained and involvement in work, social and community activities will likely become restricted. Here are some real life examples of how an affected person's role in the family can change:
"The younger children just don't understand why their father doesn't like to play with them anymore. For example, when they had a lot of their toys and belongings lying around, (he) used to make a game of it and help them clean up. Now he is short with them and orders them around. They come to me for help and comfort. Sometimes I feel like I have an extra kid around the house that I need to look after."
"I had to encourage him to interact with our seven-month-old son, who was only two weeks old when he left. I noticed a difference, our families noticed a difference and our friends noticed a difference."
Affected families also report a variety of other impacts on their lives as a result of the symptoms of the affected person. You may recognize some of these impacts happening in your situation. Take note of the things that apply to you and think about how you could put into practice the suggested actions.
- Intrusive symptoms such as vivid memories or strong belief that the trauma is recurring can cause families to feel worried about the sufferer or perplexed by the behaviour. Others may feel embarrassed (if it occurs in a social situation) or uncertain of how to respond and begin to withdraw from your life.
Action: Learn about the symptoms yourself; talk to others about them; and have information that friends and family members can read to help reduce the discomfort and maintain important connections
- There is a need in all of us to confide in others about the stresses and difficulties we are having. However, because of particular attitudes or beliefs, some people have difficulty understanding and accepting psychological problems. It is important to choose people who do not judge others and can keep a confidence.
Action: Use discretion when confiding in others. Think in advance about who, in your circle of family and friends can provide this support in a respectful manner.
- The discomfort of others combined with the avoidance behaviours of the affected person tend to isolate the family socially. Some families find that their social and recreational activities are significantly reduced.
Action: Gradually re-introduce spouse/partner and family, social and recreational activities as symptoms improve.
- Persons with PTSD often report being unable to feel emotions. Family members may feel rebuffed by a sufferer who is unable to show appropriate involvement, emotion and affection. This can be particularly hard on children.
Action: Understand that this is part of the emotional response to the disorder and not a true reflection of how the person feels about their family and friends. Talk openly with your family and friends about this and reassure them that you do care.
- Anxiety experienced by the person with PTSD may lead to overprotective behaviour that creates conflict in the family.
Action: Separate the feelings from the facts by "reality testing"; talk about what risks the overprotective behaviour is trying to prevent and whether they fit with the current situation.
- Inappropriate expression of anger and irritability can begin to harm family relationships and cause anxiety and upset within your children.
Action: Acknowledge and take responsibility for your anger. Learn about and use anger management techniques. Let family members know they are not to blame.
- Sometimes anger is expressed in abusive behaviour toward a spouse or a child. This is a signal that attempts at coping have broken down. Verbal or physical abuse of family members is never acceptable.
Action: If abuse occurs in your family take immediate steps to ensure that it is stopped and not repeated. Seek outside help and follow through on the treatment recommended. It takes courage to take this step but it is the most important gift you can give to your family.
- Sufferers may abuse alcohol or other drugs in a attempt to blunt memory or relieve symptoms of anxiety or depression. Family members may respond with embarrassment, anger, fear for the health and safety of the affected person. This can be very difficult for families to cope with.
Action: Understand that abuse of alcohol and drugs is not a solution to symptom management. Seek addictions treatment and practice alternate ways of managing your symptoms.
How May Your Children Be Affected?
As a result of the symptoms of the affected parent and the increased parental stress of coping with them, your ability as parents to meet your child's needs may also be impacted. What follows is a way of thinking of your child's basic needs in a structured fashion. As you read through each one, ask yourself if there are examples in your family when the child's needs are being affected. Make a list of these examples and talk about them with your partner. Evaluate if action is needed by noting how often similar things happen and how your child reacts. If action is needed, make a plan to change the situation. Check the ideas that follow in the "What Can You Do?" section to help you in making a plan.
Some disruptions of household routines that address the child's physical needs may include:
- meal schedules and school lunches;
- opportunities for physical activity; and
- regular sleep routines.
Some psychological/emotional needs affected by changes in your situation may include:
- expressing closeness/affection;
- open communication;
- structure and routines in the home;
- trust/safety; and
- fun/leisure/relaxation.
Ways in which family traditions and community involvement are affected may include:
- having the child's friends over to play, watch movies, etc.;
- family social activities like birthdays, outings, holiday rituals; and
- community participation like scouts/guides, choir, youth clubs.
Some opportunities for intellectual support and stimulation that may be affected include:
- attendance at kindergarten and school;
- reading to children;
- help with homework;
- board games and hobbies; and
- visits to the library, museums.
Important family values that may be sidelined include:
- sharing, cooperation, fairness, in the family;
- participation in Sunday school and religious services; and
- helping others in need.
No family is perfect. Celebrate the things you have been able to achieve despite the stress and disruption in your family life. Also, remember that children can be quite resilient and adaptable to change and that they feel most secure when it is clear to them that Mom and Dad are "in charge," that you talk and work together to solve daily problems.
What Can You Do?
Parents play the lead role in meeting their child's needs and helping children manage stress in their lives by providing a supportive physical and emotional environment. First, here are some ideas for creating a supportive environment.
- Give your children regular undivided attention and time even if this time cannot be for a very long period. Play with them, read to them, go for walks or do other enjoyable activities together. Ask how things are going for them.
- Seek out support of family and friends. Address some of your child's needs by "sharing the care" through using the positive relations the child has with relatives, family, friends and neighbours.
- Maintain a calm atmosphere in the home when your children are present to enhance their feelings of security.
- Provide a comfortable and familiar environment by keeping to daily routines as much as possible.
- To the extent possible, try to restore family traditions that existed before the events that led to PTSD (i.e. before becoming ill, did he/she routinely make a special pancake breakfast on Sunday; read bedtime stories, help with homework, etc.).
- Encourage kids to focus on things they enjoy and get involved in extra-curricular and community activities.
- As parents, talk together to identify how your children may innocently trigger intrusive memories (i.e. slamming doors, shouting, etc.). Discuss ways to reduce these events. Try different approaches, talk about them and make changes if necessary.
- Take care of yourself. Practice positive thinking and self-talk, learn muscle relaxation and breathing exercises, and other techniques that can help you cope. Lower your expectations. Find sources of support, take breaks, exercise, eat a healthy diet and maintain good general health. Keep up medical check-ups. Contact your local public health or mental health office to find out more about reducing stress. By taking care of yourself you will be better able to support your children.
Seek professional help if you have concerns or feel that you are unable to manage your child's reactions and behaviours, or if you are experiencing intense emotions such as fear, anger, depression, problems at work, intimacy, or substance abuse problems.
Remember, regardless of what has happened, it is never too late to seek help for yourself and for your children.
Understanding and Meeting Your Child's Psychological/Emotional Needs
We will now focus on the psychological/emotional needs of your children because in families under stress this is the area where children may experience the most immediate impact. It is also the area where families are most likely to be asking for information and assistance. We try to look at things from the child's point of view and encourage you to take this perspective when considering how to help your child.
When a parent has been diagnosed with PTSD and things at home have been changing, children feel the impacts. Children always know when something serious happens in a family. They are quick to notice physical and emotional changes in their parents and they will attempt to come up with an explanation for why this is happening and what to do about it. At the same time, depending on age, they may lack the information, thinking skills and language in order to come up with an accurate understanding of what is happening and why. It is not surprising then that they will often come to wrong conclusions like:
- "I'm bad - this is punishment for something I did."
- "I'm responsible - if I am extra good Mom or Dad will get better."
- "I'm scared - Dad or Mom might die."
- "I'm worried - I will catch this illness... like a flu."
- "I'm confused - will I inherit this illness?"
- "I'm stuck - asking about what is happening will upset my parent(s) - make it worse."
- "I'm afraid - to ask for attention, support, affection. Can I still be a kid?"
- "I'm angry - no one pays attention to me any more."
As you can see, their attempts to understand the situation and what it means for them, without adult help, can lead to a lot of unnecessary negative emotions and confusion.
Talk, Talk, Talk!
The most important lesson we can take from this example is that communication with your children is the key to helping them adapt successfully to changes. Honest and open communication about what is happening, why it is happening, what is being done about it, and what it means for them is a very important way to help your children cope and limit their distress and worry. This is an ongoing process; you will need to create regular opportunities to talk about their questions and concerns and you may need to repeat basic information and reassurances. This will give the child an opportunity to correct misunderstandings that lead to unnecessary negative emotions.
- Use language that is appropriate to your child's age. With younger children whose verbal skills are not yet developed to the point that they can understand what is happening in the family, use actions to reinforce your messages of support and reassurance (i.e. touch, hugging, playing with the child, maintaining routines). Older children should have the verbal skills to understand your explanations but be prepared to repeat them over time. Also, check out how they understand what you are saying by asking them directly how they have understood what you have been talking about.
- Use body language that shows you are paying attention. This can include touching your child, keeping good eye contact, nodding your head, and acknowledging what your child said by repeating it back to them in similar words.
- Be calm and "matter of fact" in your communication; your openness, comfort and confidence is as reassuring as your actual words.
- Use the child's experiences to explain the feelings of others where possible. Pick experiences that have a similar emotional meaning (fear, sadness, anger, etc.). For example: "Remember the movie that gave you bad dreams? Well, Daddy saw some bad things happen at work and now he has upsetting dreams about it."
What Your Children Need to Know
In talking to your children, keep in mind these key messages to help them with their psychological/emotional needs.
- Children need permission to express their feelings and concerns. Let them know that what they think and feel is important to you. Don't assume they know this. Say it simply and directly — "It is important to me that you let me know what you are feeling so we can talk about it. Sometimes just talking helps us both feel better." or "When you have questions that are bothering you, I want to hear them. If we can't talk right away, I will make time to talk with you as soon as we can."
- Let your children know that you value what they think and that you would like to hear any ideas they have about solving problems that directly involve them. Tell them they may be able to play a very important role in helping you find a solution to a problem but they do not have to solve the problem. Problem solving is an adult responsibility. Try asking "What do you think we could do about this?"
- Protection from negative feelings (worry, fear, guilt) is an important way of caring for your child's emotional health. In talking to your children explore how they feel about things; help them find words to express their feelings by using and explaining feeling words. — "I guess you were pretty angry about not being able to go to the movie." This helps them move beyond the negative feeling by recognizing and accepting their feelings. You then can redirect their focus by offering alternatives; "Maybe you could come with me to pick out a rental movie and we can make popcorn and watch it tomorrow night." Also giving direct messages like; "I don't want you to worry about your Dad. We are getting help and he is going to get better." can also help your child manage their concerns about the affected parent.
- Children are keenly aware that they are just "a little person in a great big world," that they are dependent on adults for their safety and security. In times of family distress they can become worried about losing that protection and support. Give your child direct messages like: "Even though things are a bit upset at the moment, we are still going to take care of you."
- Children need to know that "adult problems" are for adults to solve. Let them know that they are not responsible for solving these problems and that you are taking steps to improve the situation. "Your mom's upset at the moment but she and I will talk about it and decide what to do."
- Changes in your family may leave children wondering what this means for their responsibility and role in the family. Identify with them age appropriate things that they can do to help the family run more smoothly. Having them take action restores a sense of control that may have been undermined by changes in their situation that were beyond their control. "Illness can have a big impact on a family, there will be changes for everyone but we will all work together to make things better over time. If you can help with this chore, it will help the whole family."
- When children see that their parents are under stress they may need to know that they can still be a kid. "Since, Mom or Dad, has been ill things have changed for you ... give recent examples ... we want you to know that your most important job in this family is still being a kid; we want to see you play and have fun, learn at school and let us know when you need our help because that is what kids do."
- Children may feel rejected by an affected parent who withdraws from normal activities with them. Let them know that this is because of the illness and not because of them. "Since I have been ill I am often very tired and don't feel like doing things like I used to. I am not upset with you and still love you very much. Perhaps we could ..." Pick an activity that you feel you can do comfortably with your child. If the affected parent is unable to respond at the time, communicate this message on behalf of the affected parent and later talk with your spouse/partner about how to get re-involved with the child. Remember that even small events or activities can make a big difference to your child.
Critical Events
From time to time your child will be unintentionally exposed to an occurrence of one of the symptoms we discussed earlier in the "Recognizing the Symptoms" section. Families report a variety of circumstances in which their child may be affected. For example:
- The affected parent has had a disturbing nightmare and the child has been awakened and frightened by yelling or the crash of furniture.
- The affected parent has a flashback and tries to protect the child from a danger which the child cannot see or understand.
- The child approaches the affected parent from behind and touches them to ask for some help. This results in a startle response and an angry outburst directed at the child.
There will of course be other examples that you can identify in your particular circumstances but in each instance the general pattern of response to support your child(ren) is the same. Where possible talk about these possibilities in advance and agree that the non-affected parent or other adult in the home can assume a leadership role in these situations. Here are suggested steps for the non-affected parent to follow.
- Protect your child from further distress by removing him/her from the situation and helping to stop the reaction that is taking place. Help the affected parent to re-establish their orientation to reality and their sense of safety.
- Reassure your child that he/she is safe and the affected parent is going to be fine. Talk calmly to your child about what just happened and help them express their feelings about the event.
- Talk to your child about how and why this happened to help give an explanation to the events that they can understand.
- Where the child was the trigger/target of the event, let them know that it was not their fault and that the reaction was not appropriate. As soon as possible, have the affected parent talk to the child and take responsibility for the event, apologize for the upset and reinforce the message that it was not their fault. If the affected parent is still too upset to do this, speak on his or her behalf and try to have the conversation later when things are more settled.
- When things are settled down, set a time for the family to talk about what to do if this kind of thing happens again. In particular, give the child permission to say stop, move away from the situation and call for your help.
How Do You Know if Your Child is Under Too Much Stress?
Everyone experiences stress, including your children. It is a very important and natural part of life. It is important to remember that some stress is good because it helps us learn to cope with the tasks of everyday life. Stress becomes harmful to the physical and emotional health of your child when it is constant, unrelieved and overwhelming.
There is a broad range of physical and behavioural symptoms that you may notice in a child experiencing too much stress. The younger the child is, the less likely he or she is able to tell you about what is bothering them. Signs of stress are more likely to show up in a child's actions, such as in play or interactions with others. The key is to look for long term changes in your child's normal behaviours.
The following is a list of potential symptoms that may be exhibited by children under too much stress.
- frequent crying;
- fear of being alone;
- drop in school performance;
- inappropriate attention-seeking behaviour, temper tantrums;
- headaches, body aches, pains;
- regression to behaviour of younger child (e.g.) wetting the bed;
- worry and concern for others;
- speech problems;
- inability to concentrate;
- fear of strangers;
- nightmares or other sleep disturbances; and
- increased aggressive behaviours, angry outbursts.
If your child is exhibiting one of these symptoms, it does not necessarily mean they are under too much stress. However, if they are exhibiting several of these symptoms, and they continue over a long period of time; or they are exhibiting extremes of one or more symptoms, they are likely having difficulty coping with stress. If so, seek professional help to assess the situation and decide what to do.
