• The rescue of 12 Thai boys from the flooded cave complex has led to questions about post-traumatic stress disorder.
  • Children who experience trauma are at risk of many health factors throughout their childhood and life if they do not receive effective psychological or psychiatric treatment.
  • Too often children do not receive the mental health care they need and lack strong family and friend support networks, which are key to recovery.

The 12 Thai boys rescued from the flooded Tham Luang cave complex in Thailand have survived the extreme physical duress, but now they may face a daunting mental challenge: post-traumatic stress disorder.

While officials have said the boys’ overall health is fine, health-care experts are concerned for the boys’ long-term mental health. Pediatric clinicians believe the boys are at severe risk for developing mental illnesses, such as PTSD, after more than two weeks of captivity in dark, claustrophobic conditions.

Three of the Thai soccer players wave from their hospital beds after being rescued.

“There’s no way that these people were not impacted by what happened to them. And they’re going to need a lot of support. At the very minimum, they’re going to experience acute stress disorder,” said Adam Brown, director of the department of child and adolescent psychiatry at NYU Langone.

The rescue story that captivated the world earlier this week also raises the question: Do children suffer PTSD in ways that differ from the experience, and potential health consequences, of adults?

How children are changed by stress

Researchers have long concluded that exposure to trauma can result in severe mental illnesses such as anxiety, depression, borderline personality disorder, schizophrenia and PTSD. Furthermore, mental health experts have concluded that individuals who have experienced trauma during their childhood — including physical, sexual or emotional abuse, neglect, natural disasters or divorce — are more vulnerable to develop mental health disorders.

“Kids are at a higher risk because they are still developing a sense of who they are, what their relationship is to the world and to others, their worthiness. And so a traumatic event happening in childhood can alter their development of their sense of themselves in the world,” Brown said.

In addition to the risk of mental illness, there is also growing evidence that children who are exposed to adverse experiences are at increased risk for learning difficulties and behavioral issues.

“Individuals who are highly exposed to highly traumatic experiences are more likely to do poorly in school. It lessens kids' ability to concentrate, process information and, consequently, lessens their ability to get along with other kids,” said professor of psychology Russell Jones of Virginia Tech, who specializes in trauma research.

A study performed at Rutgers Robert Wood Johnson Medical School found an inverse relationship between adverse childhood experiences, and performance in school and social behavior. Specifically, the study showed that language and literacy skills were below average, and attention deficit and aggression were increased in a cohort of kindergartners who had experienced childhood trauma.

Two decades ago, researchers from the Centers of Disease Control and Prevention concluded that the greater number and severity of traumatic experiences a person suffers throughout his or her childhood, the more likely he or she is also at risk for developing several of the leading causes of death in adults such as heart disease, cancer, and chronic lung disease. More recent studies show that exposure to large amounts of stress during childhood, can permanently alter a child’s biology.

Psychological trauma can alter genetics

Childhood trauma can leave what scientists refer to as “epigenetic marks” on a child’s genes. The marks alter gene expression, by activating or silencing certain genes. To put it simply, the marks can either turn “on” or “off” certain heritable traits in children since birth. Although scientists have not been able to determine how all of these differences affect long-term health, they have been able to pinpoint how epigenetic changes, following childhood trauma, can alter the expression of cortisol — the neurochemical that is released to trigger the fight or flight response, and to cope with stress.

In individuals with PTSD or acute stress disorder, Brown said that the stress response either doesn’t shut off when the danger is gone, when it’s supposed to, or it gets quickly turned on. Even when the danger is over, small things that remind the person of the danger can trigger cortisol to be released.

Cortisol is also heavily linked to the function of the body’s immune system. Adverse changes in the expression of cortisol can weaken the body’s ability to fight off infection and disease, which may contribute to the increased risk of severe illnesses commonly found in adults who’ve experienced childhood trauma.

There are some individuals who will do better after a traumatic event, but many more will do worse.
Russell Jones
Virginia Tech professor of psychology and trauma researcher

Not all individuals who experience childhood trauma are at risk for long-term health consequences, and in addition to proper psychological care, a big part of a successful recovery process will depend on the strength of a personal support network.

Jones said an individual’s support system, prior to and following an adverse experience, can ultimately change the projected negative health outcome. If an individual has close ties to family, friends, community, or a religion, Jones said the patient is less likely to suffer long-term health consequences. In the case of the Thai cave rescue, the group’s coach, who’s spent the last decade as a Buddhist monk, reportedly taught the 12 boys to meditate to help them through the 17-day ordeal. CNBC previously reported that meditation experts from Stanford University, contributed this tactic to their survival.

“We have a deep understanding of who will do well during a traumatic event of this nature,” Jones said. “We’re able to determine who is going to do great, who is going to do okay, and who will do poorly, based on a number of protective and resilience factors,” he said.

Some individuals will develop strong coping mechanisms following traumatic experiences, possibly protecting them from breaking under future traumatic events. But these are more likely to be the exceptions.

“There are some individuals who will do better after a traumatic event, but many more will do worse,” Jones said.

Research shows that treatment methods for PTSD — cognitive-behavioral therapy (CBT) and psychopharmacology — in children and adults is somewhat similar. Clinical psychologists will use CBT to train patients to re-evaluate their thinking patterns and assumptions in order to identify unhelpful patterns and replace them with healthy and effective thought processes. This form of psychotherapy is intended to help patients conceptualize their trauma and develop effective coping skills. It has been clinically proven to work on both children and adults.

Brown said the key distinction with children is their dependence on others. “The main difference is that for treatment of children you need to involve the caregiver of the families.” Brown said caregivers of children with PTSD are often vulnerable to suffering themselves, due to guilt. As a result, parents also need to be treated in order to recover from their child’s trauma.

“All the literature says the effective treatments include that of the caregivers,” Brown said.

Researchers say that one of the main challenges in overcoming PTSD in children is getting kids into treatment. Some of the most severely traumatized children with never seek treatment. The Centers for Disease Control and Prevention found that 13 to 20 percent of children living in the US experience a mental health disorder each year — a trend that is growing. However, only 22 percent of those who would benefit from treatment are receiving it, according to Mental Health America. Both studies suggest that a lack of access to healthcare and a lack of a collaborative family unit, are the main reasons children go untreated. And getting children into treatment sooner rather than later is critical. “The earlier you intervene, the more helpful it is. The longer it goes untreated, the longer the pattern goes on.”