“Sandy,” a 3-year-old girl, is at home with her mother. The doorbell rings, and a friend of her mother arrives. But during this visit something goes awry and the visitor attacks her mother. Sandy’s mother is raped before being sliced and stabbed to death. “Mama was yelling, the bad guy was hurting her,” Sandy says. She tries to get him to stop, but to no avail. She helplessly looks on as her mother is murdered.

The attacker then turns his attention to the little girl. He slices her throat, twice, saying, “It’s for you own good, dude.” She collapses and loses consciousness, and the visitor leaves her for dead.

Sandy survives, and eventually regains consciousness. She spends the next 11 hours alone and in pain with her dead mother’s body in his apartment. During this time, she tries to rouse her mother, but nothing seems to work, and mom doesn’t wake up. She fetches her mother some milk. After all, milk is good for you, best for building strong bones and muscles. But milk isn’t powerful enough for wounds like these, and her mother won’t drink anyway. When she gets thirsty, she attempts to drink some milk herself, only to have it gag her and spill out through the wound in her neck. Eventually a friend of her mother, concerned that she can’t get a hold of her, stops by the apartment and discovers the grisly scene. Sandy is taken to the hospital for treatment before being placed in a foster home.

Fast forward a year, and Sandy is now four. At first glance she seems just like any other little girl. But she suffers from behaviors that baffle her foster parents, who have largely been kept in the dark about her background, since the little girl is in witness protection, hiding from the gang members who have put out a contract on her life to keep her from testifying.

She’s constantly anxious, and suffers from profound sleep problems. She startles easily, jumping at the slightest unexpected noise. She hides whenever the doorbell rings, often disappearing so good it takes her foster parents some 20 minutes to find her again. She won’t drink milk and is afraid of silverware. Kitchen knives are especially terrifying (I can’t imagine why). She seems to zone out from time to time, becoming so lost in her own world that it’s difficult to rouse her out of it. An outsider might assume she was stricken with some form of rare seizure disorder. In her play she regularly repeats the phrase, “It’s for your own good, dude.” And her caretakers sometimes come across her hiding behind furniture or in some other nook and cranny, rocking back and forth while crying. (Perry & Szalavitz, 2017)

Sandy’s case is what we’d refer to as a classic or “true” case of PTSD. It was triggered by a legitimately traumatic experience and was followed by all of the classic symptoms. I can only hope that whatever child you’re working with hasn’t suffered anything near this extreme.

Fortunately, most childhood trauma isn’t as severe as what Sandy endured, and there’s a lot of confusion out there about exactly what type of experiences have the potential to cause PTSD. Under the true definition of the diagnosis, PTSD is caused by an extremely scary or life-threatening event, such as…

• Witnessing a murder or extreme violence

• Being witness to domestic violence

• Being physically attacked

• Violent sexual abuse

• A severe car accident

• Removal from the home and placement into foster care

• Surviving a tornado or other severe natural disaster

• Terrorist attacks

• War exposure.

This doesn’t mean a child who experiences these things WILL develop PTSD. Fewer than 1 in 10 who experience such traumas will go on to develop persistent traumatic stress symptoms. It just means that these are the type of experiences that are so intense they might reasonably be expected to overwhelm a child’s ability to cope with the situation.

Things unlikely to cause PTSD

PTSD is massively over diagnosed, and often incorrectly applied to situations that don’t fit the standard definition of trauma, which is to disregard the entire premise of the disorder. Here are some things unlikely to cause PTSD in children:

• Typical, non-violent child molestation

• Verbal and emotional abuse

• Common accidents & injuries

• Bullying

• Garden variety physical abuse

These things may lead to psychological turmoil or create problems in their own right. Verbal and emotional abuse, for example, tends to be the most destructive form of child abuse, resulting in more long-term harm than either physical or sexual abuse. (Ney et al., 1994) But they are not “traumatic” events in the traditional sense, and therefore any diagnosis of PTSD in response to such experiences is highly suspect.