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Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 37-40

Post Traumatic Stress Disorder (PTSD) in children of Kashmir and role of nurse

MSc Pediatric nursing Ist year student, MMINSR SKIMS SOURA

Date of Web Publication9-Jul-2019

Correspondence Address:
Ulfat Amin
MSc Pediatric nursing Ist year student, MMINSR SKIMS SOURA

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-1505.262422

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In Kashmir perpetual turmoil has taken a heavy toll on the people living over here, by destabilizing their physical, social, mental and spiritual health. The impact of this unrest has affected lives of all, irrespective of gender, age, occupation and religion. This paper is written with an objective of, giving description of present mental health scenario and associated behaviour of people of Kashmir especially children.

Keywords: Crackdown, Scapegoat, Nightmare, Extremists, Psychopathology, PTSD

How to cite this article:
Amin U. Post Traumatic Stress Disorder (PTSD) in children of Kashmir and role of nurse. Indian J Psy Nsg 2017;14:37-40

How to cite this URL:
Amin U. Post Traumatic Stress Disorder (PTSD) in children of Kashmir and role of nurse. Indian J Psy Nsg [serial online] 2017 [cited 2023 Jun 1];14:37-40. Available from: https://www.ijpn.in/text.asp?2017/14/1/37/262422

  Introduction Top

Kashmir the paradise on earth has became a scapegoat due to socio-political unrest from last 2½ decades. This altercation has outrageously affected different aspects of Kashmir’s society. Undoubtedly there has been an immense damage to infrastructure; however its wallop can be felt and seen nowhere more than on the mental health of people of Kashmir. In other words, mental health has emerged as one of the most distressing public health concerns in present day Kashmir. The long standing controversy has caused Post Traumatic Stress Disorder (PTSD) among up to 90% people of the valley. And the worst part of this conflict is that it equally affected the psyche of children which are considered to be the future of every society. Study conducted by Khan and Margoob (2006) found, that the most common horrifying events experienced by children are witnessing the killing of a close relative (49%), followed by witnessing the arrest and torture of a close relative (15%). Loss of parents, frequent dislocation and exposure to violence has led to an increase in pediatric psychopathology. As the children lack the cognitive capacities than that of adults and find it difficult to talk upon their traumatic experiences. They are unable to transform their internal conflicts and feelings into words, they are expressed in repetitive reduplications, interfering visual images, trauma specific fears, aggressive and regressive activities, and other behavioral states[1].

Post Traumatic Stress Disorder (PTSD), also called as a railway spine, nightmare, stress syndrome, shell shock, and battle of fatigue and traumatic war that can develop after a person has sustained a traumatic event or has been subjected to or threatened by some serious physical harm[2].

Children could be victim of PTSD if they have lived through an event that could have caused them or someone else to be killed or badly hurt. Such events include assault, physical abuse, disasters such as floods, school shootings, car crashes, fires, a friend’s suicide, violence or crimes in the area they live.

PTSD also characterized by hyper-arousal re-experiencing images of the past stress full events and avoidance of reminders. About 1-14% develops post traumatic stress disorders after few weeks to months following the event and rest exceeds even after years together. This disorder is commonly present in the population of Kashmir region, in varying levels of severity. Dr Margoob et al study reported significant increase in number of individuals seeking treatment in psychiatric OPD of lone Psychiatric hospital in Srinagar, from 1200 in 1989 to 100,000 in 2011.

This is strongly linked to the presence of severe political and military turmoil in Kashmir, which is a major factor for PTSD[1]. In India intra state conflicts have been frequent in the event of terrorism, prototype of modernization and globalization. The major states involved in internal conflicts are northeast regions like Assam, Nagaland, Mizoram and Manipur. Punjab, West Bengal and Jammu & Kashmir have also been known to suffer from internal conflicts. From last many years, sovereignty struggle between Kashmiri extremists and India has led to around 20,000 deaths and 4,000 disappearances in Kashmir. Due to this continuous unrest, traumatic events and political insurgency, Kashmiri Population, especially children have been affected harshly. Its contribution towards PTSD in Kashmir community is 58.69%[3].

Childhood in Kashmir is not like that of in other areas of the world, secure, safe, full of enjoyment, recreational and pleasurable activities. It is like a small strip of land interceding between innocence and bitter experiences. Protests and revenge is not new, nor the presence of paramilitary forces in the valley that interrupt the daily life of the children living here. One of the teenagers words during recent unrest, Respect the existence or expect the resistance, when oppression “becomes a fact, revolution becomes a right”. This statement reveals the anger, frustration and anxiety in children of Kashmir. There is no doubt that the recent turmoil in Kashmir has affected the psychological and sociological makeshift of the children in the valley and leads long run into many problems, among which PTSD is the commonest one[4].

Risk Factors of PTSD in Children from Kashmir

The major risk factors of PTSD in children of Kashmir valley include;

  • Violent traumatic events due to continuous turmoil
  • Lower Literacy rate (54.4%)
  • Lower IQ
  • Weak social support
  • Male gender
  • Lower socioeconomic status
  • Family history of psychiatric illness,
  • Presence of neurotic or extroverted personality
  • Many natural disasters like earth quakes, floods and avalanches.
  • Multiple traumatic events like killing of a close relative, witnessing arrest, torture of a close relative, caught up in cross firing, beaten up, torture etc[5].


  1. Biological causes

    • Constitutional factor- body physique (thin people)
    • Genes- Monozygotic twins more prone than Di-zygotic twins

  2. Psychosocial causes

    • Maternal/ Parental Deprivation
    • Pathogenic home environment
    • Childhood traumatic experience

  3. Socio cultural causes

    • War and Violence
    • Disaster like floods, earthquakes.
    • Migration, crack downs, unrest etc.

  4. Physiological causes

    • Following the war or any trauma, studies have showed that there is a low secretion of cortisols levels and high secretion of catecholamine and nor epinephrine[6].

    Clinical Features of PTSD Children from Kashmir

    Clinical features can vary based on the intensity of PTSD. The most common ones are as;

    • Intense feeling or fear following traumatic event.
    • Inability to experience pleasure
    • Emotional numbness
    • Outbursts or aggressive behaviour.
    • Insomnia due to reoccurring distressing dreams
    • Hyper vigilant or watchfulness
    • Pre-occupied with past events
    • Hopelessness
    • Not able to maintain close relationships or socially isolated.
    • Feeling of guilt and shame
    • Trouble in concentrating.
    • Easily startled or frightened.
    • Susceptibility of self harm
    • Mistrust
    • Suicidal and unwanted thoughts.[2],[5],[7]


Management for PTSD usually begins with a detailed evaluation, and treatment plan is then tailored as per individual needs. The various medications used to treat pediatric PTSD include;

  1. Antidepressants: Helps to relieve symptoms like depression, anxiety. It also improves sleep and concentration. Common drugs used are Amiprimine and Amitrytyline.
  2. Mood stabilizers: These are helpful in dealing with increased arousal and impulsivity. Common drug used is Lithium Corbonate.
  3. Anti-anxiety medications: These drugs improve feeling of anxiety and stress. Common drug given is Alprazolum[2],[8].

Role of Nurse

Nursing management plays vital role in management of PTSD. Parents or guardians can seek the help of mental health professionals like psychiatric nurse, psychiatrist, psychologist etc who are specialized in management of such disorders. Nurse is the backup of health care team, she teaches self-soothing techniques and coping skills to assist the child and their parents in reviewing the traumatic incident. Nurse has following role in the management of PTSD children.

  1. Establish trusting relationship with the child and show empathic approach and confidence towards the parents or guardian of the child.
  2. Encourage the child to express his/her distressing event. As it is important that nurse should detect an ongoing grieving process and help the child to find conclusion.
  3. Use crises intervention techniques for management of outbursts of anger by identifying how anger escalates.
  4. Assist client in using displacement whenever he is angry by providing things he can manipulate or destroy such as clay, pillow, balloons etc.
  5. Desensitize the child with his/her memories of traumatic event.
  6. Administer prescribed medications as needed. Evaluate the child’s response to the medications.
  7. Encourage client to accept forgiveness from him/her and for others.
  8. Educate parents/ guardians about the importance of strict adherence to medications.
  9. Refer clients to other sources of support such as community, organizations and support groups.
  10. Encourage child to express the anger verbally rather than physically.
  11. Teach parents about the side effects of medications and not to discontinue without doctors consultation.
  12. Nurses can also act as advocates for unsafe situations and practices, such as corporal punishment. She acts as a counselor for the client and his/her family[2],[9].

The nurse can prevent and treat the child with various interventional therapies; like Cognitive behavioral therapy (CBT), Eye movement desensitization and reprocessing (EMDR), play therapy (PT), Image Rehearsal Therapy (IRT) and Intensive Trauma Therapy (ITT). She can assist the counselor or sometimes practice these therapies independently, provided she is well off with knowledge about the therapy.

  1. Cognitive-Behavioral Therapy (CBT)

  2. It is the most competent of the all available treatments. This therapy is highly structured and consists of 10-18 sessions lasting for 1 hour each. This therapy focuses on stress management, education about the symptoms and exposure to traumatic events narrated by client. Nurse helps the child to recognize his own thoughts and identify where and when those patterns help and where they hurt. Nurse, parents and the child, work together to change dysfunctional thoughts and replace them with more enthusiastic thoughts by using problem solving strategies. CBT is used for children with both chronic and acute PTSD symptoms.
  3. Eye movement desensitization and reprocessing (EMDR): EMDR helps the child to have more positive emotions, behaviour and thoughts. It does not rely on talk therapy by therapist/nurse; rather it uses child’s own rapid, rhythmic eye movements. This therapy uses the approach that helps the child to recall long lasting distressing images or events while receiving side to side eye movements.
  4. Play Therapy: Most commonly used therapy for children from 3–8 years of age. In this technique child’s natural means of expression, is used as a therapeutic method to assist him/her in coping with emotional stress or trauma. Childs experiences and knowledge are often communicated through play; it is an important vehicle through which they express themselves. Sessions usually last about 45 minutes a week for several months. Nurse working with child should be trained in play therapy.
  5. Image Rehearsal Therapy (IRT) :In this therapy nurse asks the child to write down everything they remember about the dream, including what they see, smell, hear, feel and whatever happens in the dream. The main goal of nurse is to help child overcome the feeling of helplessness. This therapy does not remove the traumatic memory, it only eliminate dream related to the trauma.
  6. Intensive Trauma Therapy (ITT): In this therapy nurse/therapist uses art therapy, play therapy, hypnosis, guided imagery and video therapy to help children process trauma without reliving it. Depending on the magnitude and frequency of trauma experienced by children, as well as their ages, nurses/therapists work with them individually for 3-6 hours for a period of 1–2 weeks[10].

  Conclusion Top

Post Traumatic Stress Disorder is a widespread mental disorder all over the world, remarkably in children of Kashmir due to it being a conflict zone. It has increased over here from last two decades and is associated with increased risk factors and psychiatric co-morbidity. Psychological response of children reverberates with the parental response as they have less cognitive capacity to independently evaluate the dangers. If preventive measures, like basic counseling of children about safety and support, will be taken that will help them to overcome such situations.

  References Top

Cited from Firdous, Kashmir Conflict: Alarming Mental Health Consequences, The International Journal of Indian Psychology ISSN 2348-5396 (e)|ISSN: 2349-3429 (p) Volume 3, Issue 1, DIP: C00224V3I12015 http://www.ijip.in|October–December, 2015.  Back to cited text no. 1
Santosh Kour, Post Traumatic Stress Disorder, journal of nursing practice & research; issue 2012. No;8, vol 1&2. P-16.  Back to cited text no. 2
Cited from Mushtaq, Shah, Mushtaq; PTSD in children of conflict region in Kashmir; 7860/JCDR/2016/11766-7152; vol-10(1) :v201-v203.  Back to cited text no. 3
Umar Farooq Veeri. “Psychosocial implication on Kashmir children, Kashmir moniter-sep 29/2016”  Back to cited text no. 4
Cited from Khan AY, Margoob MA. Paediatric PTSD: Clinical presentation, traumatic events and socio-demographic variables - experience from a chronic conflict situation JK-Practitioner. 2006;13(Suppl1):S40-44.  Back to cited text no. 5
Cited from Margoob MA, AY Khan MBBS, H Mushtaq. PTSD symptoms among children and adolescents as a result of mass trauma in south Asian region: experience from Kashmir. JK- Practitioner. 2006;13(Suppl 1):S45-48.  Back to cited text no. 6
Cited from Vieweg WV, Julius DA, Fernandez A, Brooks MB, Hettema JM, Pandurangi AK. Treatment W. Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment. American Journal of Medicine. 2006;119(5):383-90.  Back to cited text no. 7
Margoob MA, Ali Z, Andrade C. Efficacy of ECT in chronic, severe, antidepressant–and CBT-refractory PTSD: an open, prospective study. Brain Stimul. 2010; 3(1): 28-35.  Back to cited text no. 8
Keltner, N., Bostrom, C., McGuiness, T. Psychiatric Nursing 6th Edition. 2012  Back to cited text no. 9
Jolene Philo, Post Traumatic Stress Disorder therapies, 4 treatment options for children with PTSD, 2013/10/25.  Back to cited text no. 10

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