Post-Traumatic Stress Disorder

1. Post-Traumatic Stress Disorder

2. Numbers • Many children suffer from PTSD resulting from an array of different events • Sexual abuse • Witnessing family violence • Suffering physical violence • Peer victimization • Community violence • Warfare

3. Diagnosis • After exposure to actual or threatened death or serious injury  fear, helplessness, or horror • May also have disorganized / agitated behavior • Re-experiencing, repetition, and re-enactments • May manifest repetitive behaviors • Avoidance of stimuli associated with trauma • Seek parent/teacher/observer report about diminished interest in activities and constriction of affect • Hyperarousal • May exhibit stomachaches and headaches

4. Diagnosis • PTSD is difficult to assess because it occurs as a mixture of internalizing and externalizing symptoms • Internalizing symptoms • Social withdrawal • Somatic complaints • Anxiety • Depression • Externalizing symptoms • Delinquent behavior • Aggressive behavior

5. Predictors of PTSD Following Trauma • Level of exposure • Lack of social support • Problems in family cohesion • Female gender • Prior exposure to trauma • Prior psychiatric problems • Strong acute response • Less clear relationship: age, ethnicity

6. Stress Reactions by Age • Pre-school children • Reactions determined by parental reactions • If parents are calm, child feeds protected/secure • >Age 8-10 years • Reactions more similar to adults’ • The more they understand, the more they can reflect on their role in what happened • More girls than boys qualify for diagnosis • Adolescence • Sense of foreshortened future

7. Stress Reactions by Age • Younger children • More overt aggression and destructiveness • More repetitive play/drawing • Behavioral re-enactments • Regardless of age, if exposed to chronic and repeated stressors, child may develop: • Self-injurious & suicidal behaviors • Depression or other psychiatric disturbances • Altered maturation of CNS and neuroendocrine systems

8. Why PTSD is Difficult to Diagnose in Children • Different symptom manifestation than adults • In DSM-IV, 8 criteria require verbal descriptions of experiences and emotional states • Children may experience posttraumatic stress symptoms (PSS) but not meet PTSD criteria • They often carry dual diagnoses  hard to distinguish overlapping symptoms

9. PTSD / PSS Measures • Youth reports more reliable for internalizing symptoms • Parent reports used to assess externalizing symptoms • More known about screening, assessment, and diagnosis in children >7 years • Can read • Can complete self-rating scale

10. PTSD / PSS Measures • Child interview with companion parent interview • Diagnostic Interview for Children and Adolescents – Revised (DICA) • Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version

11. PTSD / PSS Measures • Child/Adolescent interview only • Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) • Child/Adolescent self-report • Impact of Events Scale – Revised (IES-R) • Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI) • PTSD Symptom Scale (PSS) • Trauma Symptoms Checklist for Children (TSCC)

12. Early Intervention • Clinical experience shows that by intervening early it is possible to stimulate early family communication around traumatic events  • Clarify misunderstandings • Prevent family secrets • Foster good recovery environment for children • Principles: • Ensure child feels safe and secure • Ensure child is provided with info and clarification about the event and the state of family/friends

13. Discussion After Trauma • Parental climate of communication may be instrumental in helping child cope • When adults talk with children, it can: • Reinstate the experience in memory and prevent forgetting • Help child to appraise & interpret the event • Correct misconceptions • Help the child manage and regulate emotions • Provide info about coping strategies and facilitate their enactment

14. Drawing as a communication tool • Children 3-9 years give more detailed verbal reports if allowed to draw about an emotionally laden event than if required to give an account without drawing • Benefits: • May reduce perceived social demands of the situation  children feel more comfortable • May facilitate memory retrieval • May help them organize their narrative, allowing for better storytelling

15. Treatment • Cognitive behavioral therapy (CBT) is effective with children with PTSD • In all studies, trauma-focused CBT (TF-CBT) showed the best results • Reduced depression, PTSD, # of behavioral problems • Results from individual and group therapy domain should lead clinicians to choose CB-based methods to help traumatized children • Use extreme caution in using psycho-pharmacological agents for children

16. References • "Child Behavior Checklist/4-18." Child Behavior Checklist/4-18. National Archive of Criminal Justice Data (NACJD) at the University of Michigan's Inter-university Consortium for Political and Social Research (ICPSR), n.d. Web. 14 May 2013. <http://www.iprc.unc.edu/longscan/pages/measures/Age16/writeups/Age%2016%20Child%20Behavior%20Checklist%20EXTERNAL%20%20SITE%20MM%20FINAL.pdf>. • Dyregrov A, Yule W. A review of PTSD in children. Child and adolescent mental health. 2006; 11(4):176-184. • Hawkins SS, Radcliffe J. Current measures of PTSD for children and adolescents. J Pediatr Psychol. 2006 May;31(4):420-30. Epub 2005 Jun 9.