The treating psychologist hands you a diagnosis: Post Traumatic Stress Disorder. Now what? Most clinicians will begin to take a closer look at the child’s behaviors. What does the parent or foster parent say the child is doing? What treatment has been tried in the recent past? What worked, what did not?

In many cases, clinicians inherit PTSD cases from other clinicians. The sad fact is there are not enough well-trained clinicians who understand stress disorders, let alone stress disorders in children. I have received cases that have been in services for years and years, having had many therapists, and yet made no real discernable progress.

In review of the case file and past treatment plans, I often find that the clinician attacked the behavior problems in what might be termed a very generic fashion. The goals often center on “ending tantrums”, “learning anger management techniques”, or “gaining better social skills.” While all of these areas may be important and valid, they often are not a sharp enough focus for children with a PTSD diagnosis. These areas are what I call “wide brushstrokes” of behaviors. The stress-disordered child needs a finer and more precise brush stroke in their treatment approach.

In a later chapter, I will outline a sample treatment plan. But for now, it is important to lay the groundwork for that plan. As alluded to earlier, each person has his or her own unique and subjective experience of a traumatic event. So too, each person has more or less a very individualized demonstration of their distress. While we can certainly make generalizations of signs and symptoms common to most victims, each victim will have a personal profile of signs and symptoms. This information has very important implications in treatment for several reasons.

First, when the clinician can accurately assess which behavioral signs and symptoms the victim has, a baseline view of behaviors develops that can be used later for comparison to determine what improvements have been made in treatment. Secondly, this data can help to focus the areas of treatment, and create a protocol of what behavioral areas to treat first, second, and so on. Next, this information can be used directly with the victim to help sensitize them to the processes that go on inside their body and the behaviors that they engage in.

In many cases, children have lived so long with their stress behaviors; they do not even realize that they are abnormal. In addition, this list of signs and symptoms can be used to educate all of the adults in the child’s life, such as parents, foster parents, teachers, therapeutic support staff, guidance counselors, ministers, lawyers, and judges. In cases where legal issues related to abuse are present, such clinical behavioral data becomes very important in demonstrating if and when the child is ready to return to their biological family.

A Child Stress Profile

In my clinical experience, I have noticed that children, while having many of the behavioral signs well-documented in adult PTSD victims, have either different expressions of these signs, or have unique signs only seen in children. Behavioral stress signs in children can range from quite dramatic to very subtle. A Stress Profile can help the clinician recognize some of these unique expressions as sourced in stress and not some other area. A brief example of this would be the common assessment that a child is behaving in an oppositional manner, when in fact they may be expressing defensive behaviors related to a trauma memory.

Gaining the ability to differentiate when a set of behaviors has its source in a traumatic event in history rather than a child simply misbehaving or demonstrating a “tantrum” is important in the daily care of the child. When pressure is applied to the (apparently oppositional) child with PTSD, the child’s difficult behaviors often increase rather than decrease. Truly oppositional children, who are not acting in reaction to traumatic stress, will comply with pressure at some point. It is also important to the long term goal of easing the behavioral effects of PTSD, because when a child is given ordinary discipline to control PTSD behaviors, the PTSD behaviors are driven deeper, making them harder to treat.

The taking of a Child Stress Profile (CSP) should not be confused with an “assessment”. An assessment leads to a diagnosis, and is completed by a psychologist. The CSP is a tool that a clinician uses following the diagnosis to begin to gain a clear picture of the child’s stress related behaviors.

This becomes particularly important if the child has other issues that affect their behaviors, such a co-morbid mental health condition, or have lived in a household with inadequate discipline. Lots of children have had their stress symptoms confused with their lack of discipline. When the former is treated as if it were the latter, neither condition improves.

I developed the Child Stress Profile out of my desire to better understand, organize, and measure children’s stress behaviors and treatment outcomes. After having used it for two years, I was pleased to see that it demonstrated clear progress in the children I was treating. The CSP uses six sub-scales (or categories) of signs and symptoms, including the three classic symptom areas drawn from the DSM-IV: re-experiencing, avoidance-numbing-detachment, and psychobiological alterations.

The other three categories: personal relationships, psychological alterations, and self structure, have been taken from Treating Psychological Trauma & PTSD (Wilson, Friedman, and Lindy, 2001). Specific signs and symptoms were gleaned both from the DSM-IV and the work of Wilson, Freidman, and Lindy. I have placed a “spin” on many items so that they more accurately reflect what I have seen in children. Some items are the result of my own clinical experience of signs and symptoms common to children with stress disorders.

The resulting Child Stress Profile (CSP) tool has just over 100 items contained in six different sub-scales. The tool is designed for the clinician to conduct an interview with significant adults in the child’s life, preferably caretakers. If more than one person is being interviewed at the same time, I use a consensus method to determine the most accurate response. The interviewing clinician may need to give some further explanation for some of the items by giving examples. When completed, the clinician scores the responses.

Please turn to Appendix A of this book to review the actual questions contained in the CSP. The scoring block is reproduced below:

SCORING: Indicate the number of each response in each grouping

Scoring the CSP is not difficult. The abbreviations may be decoded as:

• “D” is used to indicate that the symptom “does not appear”.
• “FN” is used to indicate that the symptom is “frequent, but not intense”.
• “NI” is used to indicate that the symptom is “not frequent but intense”.
• “FI” is used to indicate that the symptom is “frequent and intense”.

The number of each response for each symptom grouping is tallied and recorded. The balance or percentage of items in the “Intense” (I) range then can be discerned, along with the balance between “not frequent, but intense”(NI) and “frequent and intense”(FI).

Interpreting results is also quite simple; in most cases where the child has a PTSD diagnosis the initial Profile scores for each area will have above or about 50% of the responses in the Intense range. For example, if the child has a PTSD diagnosis, then sum of NI and FI marked questions in through items 45-60, then he or she will probably score 9 or higher (above 50%).

It is important to note that the Child Stress Profile is not intended to be a scientific/statistical instrument, but a practical, clinical profile, a description of the individual’s unique symptom status; a snapshot in time. It is not intended to compare one survivor to another (or a group of others), but a tool for understanding the individual. The idea is that the clinician uses the tool as an outcomes measure to keep track of the lowering of symptoms from “frequent and intense”(FI) to “not frequent, but intense”(NI), to “frequent, but not intense”(FN) to near cessation of negative impact on the individual.

Generally, stress disordered children score in the mid 50-60% in the “intense” range (total score) then drop below the 50% and lower as treatment progresses. The Profile is repeated approximately every three to four months in treatment to test outcomes and direct treatment focus. If a child scores well below 50% in the allostatic process and load category (for example, having only six items in the ‘intense’ range), then consideration of a different diagnosis would be in order.

Adaptations must be made when using the CSP for very small children under the age of five. They, of course will not be able to give any accurate indications on items such as self-esteem or guilt expressions, though these may be somewhat apparent to the observer being interviewed through the child’s behaviors and expressions. In cases where an opinion of the observer cannot be formed, I simply score...