Focus on the One Interview with Dr. Daniel Hoover

Focus on the One Interview with Dr. Daniel Hoover

August 5, 2021

At EverDriven, every single one of the students we transport to and from school are individually unique and special in their own way. That's why we've dedicated ourselves to consistently focus on the one to help every child have an equal opportunity to learn, grow, and succeed.

However, many might not realize that the most vulnerable of children are more susceptible to experiencing harrowing events that could potentially result in post traumatic stress disorder (PTSD). Dr. Daniel Hoover, Board Certified Clinical Child and Adolescent Psychologist, joins us for our second Focus On The One interview dispelling misconceptions about PTSD in children and educating us on its significance in those who suffer from it specifically.

Interview Transcription

Abi Studer (AS): Thank you for joining us in our next episode in our focus on the one interview series today. As always, our goal is to bring you insights from subject matter experts on topics that are beneficial to your districts. I'm Abi Studer representing ALC Schools. And today I have with me Dr. Daniel Hoover. Dr. Hoover is the director of psychology training and a Board Certified Clinical Child and Adolescent psychologist at the Center for Child and Family Traumatic stress at the Kennedy Krieger Institute, as well as an assistant professor at Johns Hopkins School of Medicine in the Department of Psychiatry and Behavioral Sciences. So thank you, Dr. Hoover, for joining us today.

Dr. Hoover (DH): Glad to be here.

AS: So today we're going talk about PTSD, specifically as it relates to children. Let's just go ahead and jump right in if that's okay?

DH: Sure.

Causes of PTSD

AS: Alright, so when people think of or hear of PTSD, they don't usually associate it with kids. What types of things cause or can cause PTSD in children?

DH: Well, you're right off Abby. Often we think about Post Traumatic Stress Disorder as coming with things like combat or war, that war veterans have PTSD because they've witnessed terrible things or had terrible things happen to them. With children, it may be some are faced with war, in this world, unfortunately. But more more often, it has to do with exposure to witnessing or experiencing things happen to them which are number one, maybe life threatening and terribly dangerous and scary, or threatening to shake up their well being. For example, their security in a parent or somebody who's taking care of them, or shaking up the world as being a safe place. And it can include a variety of specific violence types, including physical abuse, sexual abuse, bullying, other kinds of tragic losses of parents, witnessing accidents, natural disasters, being removed from family removed from homes for neglect, or other things. So lots of things can cause Post Traumatic Stress Disorder symptoms in children.

Signs to Watch

AS: Okay. And so for those of us who work with children every day, from teachers, to the people that drive them to school every day, what are some of the signs that they can watch for that children may exhibit when they're suffering from post traumatic stress disorder?

DH: Well, there are two things to look at the very first thing to be aware of, if possible, is whether the child has been exposed to anything that might result in post traumatic stress disorder. So a large proportion of kids have experiences that could potentially cause PTSD. Some research lately has been showing that upwards of 60% of kids in the United States witness things or have things happen to them that could potentially cause PTSD, but surprisingly, and maybe fortunately, only a pretty small proportion of those kids actually develop Post Traumatic Stress Disorder symptoms as a result. So you can have exposures and bad things happen, but it doesn't mean you have PTSD. Having PTSD is kind of a syndrome that some people get when they've been exposed to terrible things. And you would look for a variety of symptoms that the person might be displaying, after already knowing they had some sort of traumatic event. So knowing that they've had trauma, potentially traumatic events, doesn't mean they have PTSD. And knowing and seeing them have some of these symptoms, I'm going to say, doesn't mean they had an event, because you can have some of these symptoms without being traumatized.

So you need to have the full picture, first of all. So I also want to say that here's some of the things if you already know a child has been exposed to some traumatic things, then you want to look for the following. One some evidence that the child is re-experiencing or struggling with having memories, repeated memories of what happened, and those can be in the form of talking about it a lot. Or seeming to be focusing on it, or having bad dreams related to it, things like that. So that's one thing is re experiencing. Another one is kind of mood issues or negative thoughts. So feelings of sadness, anxiety, feeling like they're to blame for bad things that have happened, or feeling like the world is a hopelessly dangerous and scary place to be in. So that's the mood part of it. Number three, you might look for avoidance.

So adults and kids, when we have something bad happened to us someplace, what's the first thing we do, we try not to go back there. Right? So that can be a helpful coping response. But sometimes, kids can generalize that so that anything that looks like that thing becomes avoided. And I actually have an example recently of a child that I've evaluated who was physically assaulted on a school bus, and has a fear of buses. So she avoids those buses for all she's worth, and we're trying to help work with work with her about that. So that's avoidance. Another one is hyper arousal. So kids will become overactive, over talkative, risk taking. Surprisingly enough, sometimes kids who have been exposed to traumas or have PTSD actually throw themselves into dangerous situations repeatedly, almost as a way of maybe mastering it, you know.

So I remember one particular patient told me, I keep doing this over and over, because I want to be in control of it, I don't want it to happen to me when I'm not expecting it. So there's this over arousal and over activity and impulsivity that can happen. And then finally, dissociation. And dissociation has to do with a mental tendency to sort of check out and do some numbing. And you might see that most commonly on school transportation, as a kid who tends to sort of stare off a lot and be hard to hard to get their attention. Of course, other things can do that too. But it can be a result of traumas. So you're looking for re-experiencing negative emotions and mood avoidance, hyper arousal, and dissociation - those are the five Cardinal things. And if you're seeing some or most of those in a kid, you know, have had some hard experiences that could be having PTSD.

How to Help

AS: Hmm, that's interesting. So for many of the people that work with the children - their teachers or their drivers in our case - many of those people won't know what the problem is. And obviously, they're not professionally trained or equipped to help a student work through PTSD. So instead, what can they or what can we do to help children cope without knowing what the problem is?

DH: Well, I think one major thing is you're not going to know what the problem is, in fact, sometimes mental health experts who are working with the child don't know what the problem is. It's sometimes fairly hard to figure out and pin it to trauma. You know, it's hard to figure that out. But, you know, I think one thing that the employees and folks might want to be aware of is to have kind of a trauma informed environment and kind of keep it in the back of your mind about the things that can cause trauma, and to maybe try to prevent it from happening - which I'm sure you do in your efforts to keep kids safe.

But kids with vulnerabilities, kids who have disabilities especially, have been shown to be much more likely to get traumatic things happen to them, you know, they get victimized more often. Why is that? A lot of times they're, they're picked up pretty quickly as being vulnerable and not able to really communicate very well about what happened to them. So little things can happen to them. They get bullied in a way much more often than typically developing kids do. So we know that in the US we have this large proportion of kids who get bullied, but kids who have vulnerabilities, they get bullied like twice as much. So keeping an eye out for signs of somebody getting bullied, victimized, hit, punched, kicked, or even seriously teased, can be for a vulnerable student can surprisingly cause PTSD and wouldn't happen in other students but it might happen in a kid.

Here's another example, I had a child I worked with, who had autism and he was a pretty smart kid. So he was what we call higher functioning with autism, or Asperger's Syndrome we call it, and he had this kid who would tease him by saying his name wrong over and over. He was really interested and loved the New England Patriots. And they would say deflate gate. I don't know if you guys know about deflate gate. But you know, there's a whole thing about deflating the ball so Tom Brady could win more and all that. And so this kid would say deflate gate to him over and over. And most kids won't be bothered by that, but this kid, for him, the Patriots he worshiped them, they were this whole life. And so he would actually melt down, want to kill himself, and not go to school because of those things which would seem kind of minor to us but they were huge to him. So I guess one thing to be aware of is, relatively surprisingly little things for kids who are vulnerable, can set off trauma reactions and trying to prevent those and be really vigilant about that is really good. And taking it seriously, even though you think, "Oh yeah bullying, everybody talks about bullying, is it that big a deal, everybody gets bullied," but for some kids it's actually a pretty big deal. So that's one thing I'd want to be aware of.

Another thing is maybe if you can, and I'm sure you probably do this, is to be kind of watchful, and keep an eye on kids who are the quieter ones who may look scared. The ones who are more rambunctious and loud and doing behaviors that require managing, those are the ones that it's easy for us to focus on. But, it's the quieter ones who are nervous and startle easily, those are the ones that we we find develop the symptoms of PTSD more often. So kind of keeping an eye on them still staying close to them and making sure that they're being attended to. So those are some thoughts. I don't know if that leaves more questions and answers for you. But that's what I thought.

Signs of Bullying

AS: I have a follow up question for that. You mentioned bullying. What are what are some of the signs that kids with vulnerabilities might be exhibiting if they are being bullied?

DH: Great, great question. Well, sometimes you can't tell. A lot of times if you think back to your own childhood when you were bullied, did you go around telling everybody? I didn't, I tried to fight back or whatever, you know. So there's a kind of a shame associated with it. You don't really don't want people to know it. And so they might not tell you. And sometimes teachers, parents, and employees will think, "Well, they're not saying anything about it so it must not be so bad," but that may be not that meaningful. Another thing is you can tell if you're attending carefully to a kid's reactions. I think most of us can kind of tell whether they're starting to struggle, if they get tearful, if they start to act out more, or they show a classic sign is avoidance. So a tendency to step back to try to stay out of situations to try to walk around the kid who keeps victimizing them. But, those are subtle signs. And you have to kind of keep your eyes wide open for those. Because they won't necessarily tell you, and even if you say, "Make sure to tell us, make sure to come to someone you know," my experience with my patients and our patients they don't usually.

AS: So how do you usually find out? How do they become your patients?

DH: They tell somebody later, or sometimes what we see is they start to have behavior problems or anxiety problems in their lives at home or at school. For example, become too scared to go to school, or they start to get inattentive and not doing their work, or they are not sleeping well. And you start asking the questions and you say, "Oh, that's what happened, that happened a while ago, but you never told us and now we realize all these problems you're having, or at least in some degree, are related to the bullying that you had." So we often get it after the fact. But another way we find out is that parents or others are watching and they're noticing, "He's not quite right, that's not what he's usually like."

Those of us who work with people with disabilities, sounds like you guys do, we can do this thing that's often called diagnostic overshadowing, and what that means is that you can get kind of caught up in a kid's disability and you start explaining everything based on their disability, "Well, he's slow, or he does these repetitive behaviors, and his behavior is hard to deal with," so if he shows something new you think, "Well, that must be part of the autism or it must be part of the disability." But we have to be careful about that diagnostic, overshadowing that is attributing everything to the disability, a lot of times it's not all the disability and if we see new problems arise, or we see regressions in they used to be able to do a thing and now they can't even do it for themselves anymore. They're wetting themselves and they didn't used to, or they keep repeating this thing over and over they weren't doing, then you kind of start, you have to tune in and say, "What's going on here? There's probably something happening." But I know that's hard. I'm not saying that's an easy task. But that's, that's how you do it is you have to keep an eye on the ones who are vulnerable.

AS: Focus on the one.

DH: Yeah.

3 Things to Remember

AS: Awesome. Thank you. So in your highly educated professional opinion, what would you say are the top three things to know about children with PTSD?

DH: Okay, top three things. One is it has ripple effects. So it tends to impact a lot of things in their lives. You know, you might see it on the school transportation, but you're often going to see it at home, at school with peers in the neighborhood. That's ripple effects. Okay.

Number two, I guess that's important to know is that sometimes it happens in the people you'd least expect. We even as scientists don't have much way of predicting who's going to get it and who's not. But it seems like the kids who have some vulnerabilities already mental health difficulties or disabilities, they're more likely to get it.

And I guess a third big thing, big takeaway message for PTSD is it's treatable. People can get better. Actually, there's, there's a lot of really good treatment, like evidence based therapies that we use now for kids with trauma. And they can get quite a bit better with that. I mean, we're showing success rates of 80 to 90% of kids exposed to trauma get better when they have the right kind of therapies. So there is hope for that. It's probably easier to get them better than adult combat victims, because you know they're kids and they tend to be a little more resilient maybe and they do get better.

Consistency is Key

AS: Consistency, you mentioned a ripple effect, how PTSD can have an effect on not just this one little aspect of their life, but it ripples out from there. How important would consistency be to a child who is affected by PTSD having the same people involved in their life everyday? Routine? What what part does that play, or does it play a part in their everyday life?

: Well, as long as the routine and the structure are safe and the child experiences them are safe, then the routine can be massively comforting because you don't have to constantly be watching out for what could happen to you. And you're not going to be surprised by unpredictable things that could scare you. A child who has PTSD often lives in a world where just about anything can happen at any time and they're constantly on their guard for something bad to happen. And to have a repeated routine and structure and people in their lives who are regular and they trust, it puts to rest some of that and makes it a lot more comfortable. Having said that, I said in the beginning as long as it's safe, you know. The opposite is true if they have consistency but with people and events that are scary, then that can actually be more traumatizing so, structure and routine that are safe, predictable and supportive makes a huge difference.


: Awesome. Well, Dr. Hoover, you've given us a lot to think about today and we appreciate so much the time that you've taken to help us learn and focus more on the one. Is there anything else that you'd like to leave us with before we close up?

DH: No, I just want to say I appreciate the work that you all do. It is super hard work. And you've got so many balls to juggle while you're trying to take care of everything that's going on. But I really liked what you said Abi, that taking care of the one is really important to prevent trauma and prevent PTSD. So thanks. Glad to be here to talk to you.

AS: Awesome. Well, thank you so much again, and to everybody who is listening. If you have any questions, you can email us at and enjoy the rest of your day.

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