Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Children and PTSD

 

Diagnostic Criteria for Children

PTSD is not confined to adults. Children also experience PTSD and manifest symptoms that closely parallel those of adults, with the following notable differences.

The 4th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) did not have specific criteria for diagnosing PTSD in children, and many of DSM-IV PTSD criteria were not age appropriate for children. As a result, it was difficult (if not impossible) to accurately diagnosis PTSD in children. However, the 5th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) now includes specific guidelines for diagnosing PTSD in children under the age of 6. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

A. Children under the age 6 have been exposed to an event involving real or threatened death, serious injury, or sexual violence in at least one of the following ways:

1. The child directly experiences the event.

2. The child witnessed the event (this does not include events that were seen on the television, in movies, or some other form of media).

3. The child learned about a traumatic event that happened to a caregiver.

B. The presence of at least one of the following intrusive symptoms that are associated with the traumatic event and began after the event occurred:

1. Recurring, spontaneous, and intrusive upset- ting memories of the traumatic event.

2. Recurring and upsetting dreams about the event.

3. Flashbacks or some other dissociative response where the child feels or acts as if the event were happening again.

4. Strong and long-lasting emotional distress after being reminded of the event or after encountering trauma-related cues.

5. Strong physical reactions (e.g., increased heart rate, sweating) to trauma-related remind.

 

C. The child exhibits at least one of the following avoidance symptoms or changes in his or her thoughts and mood. These symptoms must begin or worsen after the experience of the traumatic event. 1. Avoidance of or the attempted avoidance of activities, places, or reminders that bring up thoughts about the traumatic event. 2. Avoidance of or the attempted avoidance of people, conversations, or interpersonal situa- tions that serve as reminders of the traumatic event. 3. More frequent negative emotional states, such as fear, shame, or sadness. 4. Increased lack of interest in activities that used to be meaningful or pleasurable. 5. Social withdrawal. 6. Long-standing reduction in the expression of positive emotions. D. The child experiences at least one of the below changes in his or her arousal or reactivity, and these changes began or worsened after the trau- matic event: 1. Increased irritable behavior or angry outbursts. This may include extreme temper tantrums. 2. Hypervigilance. 3. Exaggerated startle response. 4. Difficulties concentrating. 5. Problems with sleeping. In addition to the above criteria, these symptoms need to have lasted at least 1 month and result in con- siderable distress or difficulties in relationships or with school behavior. Finally, the symptoms cannot be better attributed to the use of ingestion of a sub- stance or some other medical condition. In summary, children must experience disorganized or agitated behavior. Children usually do not have a sense they are reliving the past, but rather relive the trauma through repetitive play. Their nightmares of the traumatic event may change to more generalized night- mares of monsters or of rescuing others. A foreshortened future for a child generally involves a belief that they will never reach adulthood. Children may believe they can see into the future and can forecast ominous events. Physical symptoms may appear that include headaches and stomachaches that were not present before the event (American Psychiatric Association, 2000, p. 466). For a long time prevailing wisdom was that young children were not developmentally mature enough to be affected by trauma and as a result couldn’t “catch” PTSD (Bosquet, 2004; Osofsky, 1995). If anything their reaction to disasters would be fleeting. How- ever, with growing research in the field we now know that is anything but true (Devoe et al., 2011; Osofsky et al., 2010). Of the 74 million children in the United States, 30% to 50% will experience at least one trau- matic event by their 18th birthday and will probably comprise a substantial proportion of the 2.5 billion people who have suffered some kind of disaster in the last decade (Kazdin, 2008). Trauma for children is also homegrown, with about 1 million cases of sub- stantiated child abuse in the United States reported yearly (DeAngelis, 2007). Of those who experience at least one trauma, somewhere between 3% and 16% of girls and between 1% and 6% of boys will develop PTSD. What type of trauma children experience makes a big difference. Almost 100% of children will get PTSD if they see a parent killed or sexually assaulted. Approximately 90% of sexually abused children will develop PTSD. Around 77% of children who witness a school shoot- ing experience PTSD, and even witnessing neigh- borhood violence has a “catch” rate of about 35% (National Center for PTSD, 2011). It shouldn’t take a Ph.D. in child psychology to figure out that PTSD and its treatment are differ- ent in children by the mere fact of their developmen- tal levels (Saxe, Ellis, & Kapow, 2007). There is now accumulating evidence, including age of onset, dura- tion, sequence, and co-occurrence of trauma events, which is providing the groundwork for a developmen- tal model that builds on these variables and begins to plot the trauma pathways that are created as the child moves from middle childhood to adolescent to young adulthood (Steinberg et al., 2014). Indeed, PTSD manifests itself very differently in children than in adults in terms of symptoms (DeAngelis, 2007; Terr, 1979, 1981, 1983, 1995) and in how it affects the neu- rodevelopment of children (Saxe, Ellis, & Kaplow, 2007, pp. 23–45; Zilberstein, 2014). Thus, not only because of their age, but also be- cause of how children attempt to cognitively handle trauma, even though TF-CBT is seen as a treatment of choice (Chard & Gilman, 2014; Jensen et al., 2014), PTSD in children calls for treatment strategies that are very different from those used with adults (Clay, 2010; Cohen, Mannarino, & Deblinger, 2006; Ford & Courtois, 2013; Malchiodi, 2008; Saxe, Ellis, & Kaplow, 2007; Webb, 2007). Reactions to violence and trauma in children vary greatly and are dependent on their temperament, chronological age/developmental stage when the traumatic event occurred, whether support systems were and are nurturing or toxic, what the ecosystem of the community was and is like, and the degree, and duration of the trauma (Fairbank et al., 2014), do not make a one-size-fits-all treatment approach. To that end, the National Child Traumatic Stress Network (NCTSN) has been formed (Steinberg et al., 2014) to integrate trauma-informed services and evi- dence- based practices throughout the United States in clinical and community settings. Practitioners can avail themselves of its services at www.nctsn.org. A wide range of training resources may be downloaded at http://learn.nctsn.org, and NCTSN also has an on- line knowledge bank developed by network centers at http://kb.nctsn.org.

now you should clearly understand that support systems are critical in crisis intervention. Supportive family systems are even more critical for children in their attempts to master a trauma (Cohen, Mannarino, & Deblinger, 2006; Courtois & Ford, 2009; Devoe et al., 2011; Saxe, Ellis, & Kaplow, 2007; Yule, 1998). Family support systems are important in regard to events both external and internal to the family system. Generally in this chapter we are speaking of family support in the context of a traumatic event that occurs external to the family, such as a hurricane or 9/11. We will speak to family support (or lack thereof ) when the trauma is generated within the family, as in child abuse, in Chapter 9, Sexual Assault. Bowlby’s (1982) attachment theory is particularly relevant to traumatized children. In many of the traumas children experience, they are separated from their parents, their homes, and even their com- munities without warning or preparation. It should come as no surprise that such traumatic separation carries with it a smorgasbord of emotional and pe sonality disturbance. Anxiety disorders, physical maladies, depression, panic attacks, rage reactions, and phobic reactions are common comorbid disorders of childhood PTSD. These are magnified even more when families are rent asunder by a traumatic event and support systems literally disappear in front of the child’s eyes (Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Norris et al., 2002) and are even more profound when the young child per- ceives a threat to the caregiver (Devoe et al., 2011). The final ingredient in this witch’s brew of pathology is the unresolved grieving that accompanies loss of loved ones when children do not yet have the cognitive ability to understand and resolve their loss (Cohen, Mannarino, & Deblinger, 2006; Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Yule, 1998). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

 

Support Systems

 

By now you should clearly understand that support systems are critical in crisis intervention. Supportive family systems are even more critical for children in their attempts to master a trauma (Cohen, Mannarino, & Deblinger, 2006; Courtois & Ford, 2009; Devoe et al., 2011; Saxe, Ellis, & Kaplow, 2007; Yule, 1998). Family support systems are important in regard to events both external and internal to the family system. Generally in this chapter we are speak- ing of family support in the context of a traumatic event that occurs external to the family, such as a hurricane or 9/11. We will speak to family support (or lack thereof ) when the trauma is generated within the family, as in child abuse, in Chapter 9, Sexual Assault. Bowlby’s (1982) attachment theory is particu- larly relevant to traumatized children. In many of the traumas children experience, they are separated from their parents, their homes, and even their com- munities without warning or preparation. It should come as no surprise that such traumatic separation carries with it a smorgasbord of emotional and per- sonality disturbance. Anxiety disorders, physical maladies, depression, panic attacks, rage reactions, and phobic reactions are common comorbid disor- ders of childhood PTSD. These are magnified even more when families are rent asunder by a traumatic event and support systems literally disappear in front of the child’s eyes (Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Norris et al., 2002) and are even more profound when the young child per- ceives a threat to the caregiver (Devoe et al., 2011). The final ingredient in this witch’s brew of pathology is the unresolved grieving that accompanies loss of loved ones when children do not yet have the cognitive ability to understand and resolve their loss (Cohen, Mannarino, & Deblinger, 2006; Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007; Yule, 1998).

 

Types of Trauma

Childhood trauma is important not only for what it does to children, but also for the after effects that carry into adulthood (Morgan et al., 2003). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Terr (1995, p. 302) likens childhood trauma to rheumatic fever. Although rheumatic fever is a serious disease of childhood, the damage it causes can later be lethal in adults in a variety of ways. Childhood trauma operates in the same way and can lead to character problems, anxiety disorders, psychotic thinking, dis- sociation, eating disorders, increased risk of violence by others and by oneself, suicidal ideation and behavior, drug abuse, self-mutilation, and disastrous interpersonal relationships in adulthood (Pynoos, Steinberg, & Goenjian, 1996, pp. 331–352; Terr, 1995). Terr (1995, p. 303) proposes a division of childhood trauma into two categories: Type I, which is one sudden, distinct traumatic experience; and Type II (analogous to complex PTSD), which is long-standing and comes from repeated traumatic ordeals. Lack of full cognitive and moral development causes distinctive differences in how children react to trauma. It appears that even infants have the capacity to remember traumatic experiences (Courtois & Ford, 2009; Hopkins & King, 1994). Children who suffer from Type I traumas appear to exhibit certain symptoms and signs that differentiate their condition from those that result from more complicated Type II traumas. Type I events are characterized by fully detailed, etched-in memories, omens such as retrospective rumination, cognitive reappraisals, reasons, misperceptions, and mistiming of the event (Terr, 1995, p. 309).

In contrast, Type II traumas result in the psyche’s developing defensive and coping strategies to ward off the repeated assaults on its integrity. Massive denial, psychic numbing, repression, dissociation, self-anesthesia, self-hypnosis, identification with the aggressor, and aggression turned against self are prominent. Emotions generated from Type II traumas are an absence of feeling and a sense of rage and/or unremitting sadness. These symptoms may be diagnosed in childhood as conduct disorders, attention -span deficit disorders, depressive disorders, or dissociative disorders (Terr, 1995, pp. 311–312). As these children move into adolescence, they have poor grades, drug abuse, and a constellation of other behaviors that get them in trouble (Pynoos et al., 2014). It should LO19 LO18 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned ome as no surprise that there is a high correlation with youth in the juvenile justice system and multiple trauma in their background (Dierkhising et al., 2013).

Terr’s (1983) in-depth, 4-year follow-up on children who were Type I victims of the Chowchilla, California, bus kidnapping is the benchmark study in child- hood PTSD. The victims of this trauma were a group of 26 elementary and high school children who were kidnapped together with their school bus driver, were carried about in vans for 11 hours by their kidnappers, and were buried alive in a truck trailer for 18 hours be- fore they dug their way out—a horrific Type I trauma.

 

Etched Memories

Terr (1983) found that the children still had specific feelings of traumatic anxiety over the event after 4 years. When asked to speak about it, children generalized their anxiety from the event to statements like “I’m afraid of the feeling of being afraid.” Unlike com- bat veterans, who might boast about harrowing experiences, the children were profoundly embarrassed by their experience, were unwilling to talk about the event, and shied away from any publicity. They generally voiced feelings of being humiliated and mortified when asked about their experience. Although 8 of 15 children had overcome their fear of vehicles such as vans and buses, they still reported occasional panic attacks triggered by unexpected sudden confrontation with stimuli such as seeing a van parked across the street from their house and vaguely wondering if some of the kidnappers’ friends had come back for them. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Eighteen of the children were found to employ suppression or conscious avoidance of the trauma. Parents often aided them in this endeavor, although the two children whose parents encouraged them to talk about the experience were still not spared its residual effects. Their typical response was that they hated the feeling of helplessness they experienced and needed to feel in control of the situation. All the children could remember almost every second and minute of the event. However, they were able to remember few, if any, of the emotions or behaviors they experienced during the ordeal. This remarkable retrieval of full, precise verbal memories of almost all Type I traumas indicates that these memories are indelibly etched into the psyche, no matter how the child tries to suppress them, and are carried forward into adult- hood (Terr, 1995, p. 309).

Memory etching may also come from vicariously viewing trauma. Saylor and associates (2003) found that children who saw images of death or injury from the attacks of 9/11 reported more PTSD symptoms than children who did not. Interestingly, the Internet had a more profound effect than television or print media. No measurable benefit was reported in seeing positive or heroic images of 9/11.

Developmental Issues

Trauma may have severe repercussions on develop- mental expectations and acquisition of developmental competencies in children (Ford, 2009; Pynoos, Steinberg, & Goenjian, 1996). When traumatic events impact a child in the middle of a developmental stage or in transition from one to the next, regressive behaviors occur (Gordon, Farberow, & Maida, 1999). Eth and Pynoos (1985, p. 44) believe that continuous intrusion of a traumatic event, evolution of a cogni- tive style of forgetting, and interference with mental processes because of depressed affect very definitely influence school achievement. Children who experience trauma are likely to have problems with “narrative coherence”—the ability to organize material into a beginning, a middle, and an end. This inability to organize a linear story has direct repercussions on reading, writing, and communicative ability (Pynoos, Steinberg, & Goenjian, 1996, p. 342).

Early childhood PTSD is marked by general personality traits that include mood instability, difficulty delaying gratification, withdrawal from or obsessive attention seeking, attention deficit and task completion problems, and oppositional defiance (Manly et al., 2001). Toddlers specifically demonstrate nonverbal attempts to communicate fears and anxiety: continuous crying, screaming tantrums, excessive clinging, immobility with trembling, frightened expressions, and either running toward the adult or aimless motion. Regression to thumb sucking, bed wetting, loss of bowel and bladder control, a variety of fears, night terrors, sleeping with a light on or an adult present, marked sensitivity to loud noises, speech difficulties, and eating problems may occur (Gordon, Farberow, & Maida, 1999). These symptoms are indicative of the effect survival-threatening stresSors can have in rupturing the early attachment bonds that are so critical to development (Ford, 2009, p. 47). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Fears and anxiety continue to predominate in elementary school children, as do the previously mentioned regressive behaviors. School problems also emerge and range from outright refusal to go to school to poor academic performance, fighting, and loss of ability to concentrate (Gordon, Fa Maida, 1999). Trauma may cause anxious attach- ment to caretakers and separation anxiety. The child regresses socially, which can result in poor affiliation with peers, social isolation, and avoidance of school. Parents may exacerbate this behavior because of their own unresolved fears of the traumatic event, and may become overprotective of the child. Conversely, mem- ories in which the primary caretaker was either unable or unwilling to provide help and succor during the traumatic event do severe harm to the developmen- tal expectation that the caregiver is capable of pro- viding nurturance and security (Pynoos, Steinberg, & Goenjian, 1996, pp. 340–345). A constellation of behavioral problems may appear, such as depression, panic and anxiety attacks, conduct and impulse con- trol disorders, eating and sleep disorders, and sexual identity issues (Cook et al., 2005).

Adolescents who experience trauma invariably find disruption in their peer relationships and their school life. Peers who were not traumatized may shun them because of their “weird” behavior and not know how to offer support. Any outward physical problems may ex- acerbate their fragile self-concept and ability to fit into the peer group. Behavioral trouble signs include with drawal and isolation, antisocial behavior, awareness of their own mortality, suicidal ideation, academic fail ure, alcohol and drug abuse, sleep disturbance, night terrors, depression, mental confusion, school failure, truancy, problems with the legal system, gang involvement, teen pregnancy, and various physical com- plaints (Ford et al., 2008; Gordon, Farberow, & Maida, 1999; Halpern & Tramontin, 2007).

 

Other Responses to Type I Trauma

Sense of a Foreshortened Future. Terr (1983) found that intrusive thoughts did not repeatedly enter the children’s conscious thoughts; however, sleep brought very different problems. Whereas a few reported day- dreams, more children had nightmares through which ran many repetitious themes of death. The children believed these dreams to be highly predic ive of the future and made comments such as “I’m 11 now, but I don’t think I’ll live very long, maybe 12, ’cause somebody will come along and shoot me.” Adolescents in particular are brought face to face with their own vulnerability and, in the case of those who have experienced the murder of a parent, report that they will never marry or have children because they fear history will be repeated (Cohen, Mannarino, & Deblinger, 2006, p. 9; Eth & Pynoos, 1985, p. 48; Terr, 1995, p. 308).

Reenactment.

In an attempt to gain mastery over a Type I trauma, children replay the event and develop a reason or purpose for it. Once the reason is found, children often feel intensely guilty about it. “I should have listened to what Mom said and come home right after school!” In Type I traumas the question is, “How could I have avoided that?” as opposed to the question of Type II traumas, “How will I avoid it the next time?” (Terr, 1995, p. 310). The play of children with PTSD is very distinctive because of its thematic quality, longevity, dangerous- ness, intensity, contagiousness for siblings, and un- conscious linkage to the traumatic event (Maclean, 1977; Terr, 1981). The clearly prevalent dynamic is a continuing reenactment of the children’s plight dur- ing the trauma (Eth & Pynoos, 1985, p. 42). This thematic play can be characterized as burdened, constricted, and joyless (Wallerstein & Kelly, 1975). Traumatic play is also problematic because it replaces normal developmental play that is a vital component in childhood maturation (Parker & Gottman, 1989). For adolescents, reenactment may take the form of delinquent behavior (Eth & Pynoos, 1985, p. 47), ranging from truancy, sexual activity, and theft to reckless driving, drug abuse, and obtaining weapons (Newman, 1976). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Physical Responses.

Approximately half the children in the Chowchilla kidnapping manifested physical problems that could be construed to be related to the trauma of being held prisoner without food, water, or bathroom access (Terr, 1983). In young children suf fering from PTSD, regression may occur and previ ously learned skills such as toilet training may have to be retaught (Bloch, Silber, & Perry, 1956). Sleep disturbances and severe startle responses can cause a variety of educational and social problems in school (Pynoos, Steinberg, & Goenjian, 1996, p. 350). Displacement.

In the Chowchilla survivors, a great deal of displacement of affect occurred, with emotions about the event being shifted to a related time, an associated idea, or another person—particularly the interviewing psychiatrist. Prior to the follow-up inter- views, children displayed a variety of displaced behav iors, including the belief by one of the children that the psychiatrist had placed notes posing questions about the kidnapping in her school locker (Terr, 1983). Transposition.

Misperceptions, visual hallucinations, and peculiar time distortions often occur in child who have experienced Type I traumas—as opposed to Type II traumas, in which the perpetrators and events have a long history with the children and are rarely misperceived once the events are brought to aware- ness (Terr, 1995, p. 311). In the Chowchilla survivors, one of the most profound changes occurred in trans- position of events surrounding the trauma. Events that happened after the trauma were remembered as having happened before the trauma (Terr, 1983). Also, there was a general belief that the traumatic events were predictive of what was about to happen to them. Ayalon (1983), in a study of victims of ter- rorism, found a similar effect in children. Children attempted to resolve their vulnerability and lack of control by saying they should have listened to the omens and “shouldn’t have stepped in the bad luck square.” In PTSD, such distortions of time become part of the child’s developing personality and are at- tempts to take personal responsibility and even feel guilty for events over which they had no control. Terr’s (1983) study indicates that whereas children behave differently from adults in their attempt to re- solve the traumatic event, they are no more flexible or adaptable than adults after a trauma, and it would be erroneous to assume that they “just grow out of the event.” Furthermore, these children did not become toughened by their experience, but simply narrowed their sphere of influence in very restrictive ways to control their environment better. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Type II Traumas

Children who have suffered continued physical and sexual abuse and refugee children from war-torn countries are typical victims of Type II traumas. They are poster children for the affective dysregulation that goes with complex PTSD. Massive denial and psychic numbing are primarily associated with Type II trau- mas. These children avoid talking about themselves, go years without talking about their ordeals, and try to look as normal as they can. If they do tell their sto- ries, they may later deny they did. This aspect is quite different from Type I children, who tell their stories over and over again. Denial may become so com- plete that Type II children will forget whole spans of their childhood (Terr, 1995, p. 312). Type II children are indifferent to pain, lack empathy, fail to define or acknowledge feelings, and absolutely avoid psycholog- ical intimacy. In adulthood, this massive denial cuts across narcissistic, antisocial, borderline, and avoid- ant personality disorders (Terr, 1995, p. 313). Although self-hypnosis and dissociation in Type II children may take the form of dissociation identity disorders (formerly known as multiple personality disorder) in adulthood, such children most often develop anesthe- sia to pain and to sex and emotionally distance them- selves in the extreme (Terr, 1995, p. 314). That does not mean the rage at what happened to them is not there. Rage includes anger turned inward against the self and outward toward others and can range from self-mutilation to murder. Reenactments of anger oc- cur so frequently in Type II traumas that habitual pat- terns of aggression are formed, and the seething anger is probably as debilitating as the chronic numbing. Paradoxically, defenses may be formed, whereby the child becomes completely passive or identifies with the aggressor (Terr, 1995, p. 315). At times crossover changes from Type I to Type II traumas may occur, as when a single event such as an accident that requires long-term hospitalization and many painful operations turns into a Type II trauma. Children who come out of Type I traumas with permanent physical handicaps, disfigurement, long-term pain, or loss of significant others may be forced into adaptational techniques of Type II trau- mas but still retain clear and vivid memories of the event. Children who are physically injured or disfig- ured and suffer psychic trauma tend to perpetually mourn their old selves and may employ regression, denial, guilt, shame, and rage over their disabilities (Terr, 1995, p. 316). When traumatic shock interferes with the normal course of bereavement, unresolved grief continues, and the child becomes a candidate for a major depressive disorder (Terr, 1995, pp. 316–317).

A variety of problems that have to do with how a traumatized child looks, acts, feels, and thinks may promote secondary stressors in his or her social milieu (Pynoos, Steinberg, & Goenjian, 1996, p. 341). Communicable disease, altered physical appearance, social distancing, memory impairment, decreased in- tellectual functioning, guilt, and shame are a few of the problems that can follow in the wake of a trauma. All these problems may present very different before- and-after pictures of the child and alter perceptions by family, peers, and teachers to the detriment of the child. These negative response patterns are then ad- ditive to the initial trauma and present additional psychological burdens to adaptation. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Intervention Strategies

The methods of assessment and therapy used with children are different from those used for adults.

Early assessment is critical in determining the poten- tial for trauma (Terr, 1979, 1981, 1983) and should happen as soon as possible after the event (Mowbray, 1988, p. 206). Generally, assessment needs to occur in two complementary areas: trauma-specific issues and generic behavioral issues. While we are interested in isolating specific traumatic events and their effects, focusing on them may miss more general issues of depression or behavior problems. Interviewing.

There is some evidence that allowing children to talk about their experience in an inter- view format also helps in reducing long-term symp- toms of PTSD (Nader, 1997, p. 293). However, parent resistance may be severe, and interviewers should care- fully explain to both the parents and the child what the purpose of the interview is and how it is going to be done. Interviewing should involve determining the degree and severity of exposure to trauma and assess- ing the child’s response as it relates to the degree of exposure (Pynoos & Nader, 1988). Pynoos, Steinberg, and Goenjian (1996, pp. 336–337) suggest that more precise rather than gen- eral features of the traumatic experience be elicited, such as hearing unanswered screams for assistance, smelling bad odors, being close to the threat, being trapped, witnessing atrocities, and remembering the degree of brutality and other specific traumatic con- ditions. Given the targeting of what will probably be very traumatizing material, the crisis worker needs to proceed in as patient, caring, and empathic a way as possible. Because children’s reports may be affected by fear of disclosure, shame, guilt, and other negative attributions, it is also important to get corroboration from parents or other significant adults about the trauma. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Instruments.

Because of the need to systematically measure the response of children to trauma, a num- ber of instruments specifically designed for children have been developed. The Trauma Symptom Check- list for Young Children is a caregiver rating for chil- dren ages 3–12. It has validity scales and measures a variety of posttraumatic responses plus sexual con- cerns, anxiety, depression, dissociation, and anger/ aggression (Briere, 2005). The Clinician-Administered PTSD Scale for Children (CAPS-C) (Nader et al., 1994) is a comprehensive children’s version of the adult CAPS. It measures standard PTSD symptoms plus symptoms of childhood PTSD. It further determines social and scholastic functioning, along with how well the child is coping with the event. The Di- agnostic Interview for Children and Adolescents– Revised (DICA-R; Reich, Shayka, & Taibleson, 1991) is a widely used semistructured interview to assess common psychiatric diagnoses and includes a PTSD subscale. Briere (1996) has also developed a self-report checklist for children, which covers anxiety, depres- sion, anger, posttraumatic stress, sexual concerns, and dissociation. It has an alternate form that leaves out sexual concerns. The Trauma Symptom Inven- tory (Briere, 1995) is useful for older adolescents who tend to act out their distress. It also has two validity scales that assess under- and overendorsement in rating items. The Child PTSD Symptom Scale has been developed to assess the severity of PTSD in chil- dren exposed to trauma (Foa et al., 2001). The Child Behavior Checklist is a widely used scale that has par- ents, teacher, and youth self-report forms. This test looks at both external issues such as behavior prob- lems and internal issues such as anxiety and depres- sion, as well as how resilient children are at adapting to stressors (Achenbach, 1991). Finally the University of California Los Angeles Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004) is particularly note- worthy because it has reliability and validity across age, sex, race/ethnicity, and trauma variety (Steinberg et al., 2013 ).

Projective Techniques .

Because children submerge their affect and parents are loath to deal with the trauma until it causes severe repercussions in their lives, children are rarely brought in for counseling un- til behavior has reached crisis proportions (Mowbray, 1988, p. 206). Triage assessment at this time may not reveal that trauma is the underlying agent. In that regard, the crisis worker who works with children should have a good knowledge of both projective and question-and-answer personality inventories that will ferret out the trauma. A classic example is the artwork of sexually abused children whose drawings are replete with exaggerated genitalia (Kaufman & Wohl, 1992). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Therapy

Treatment of PTSD directed specifically to children falls into two main categories: cognitive-behavioral therapy and play therapy. EMDR may also be used in combination with or exclusive of cognitive-behavioral or play therapy. Also of critical importance is building a caring and supportive social context (Saxe, Ellis, & Kaplow, 2007), as discussed in Chapter 9, Sexual Assault.

Cognitive-Behavioral Therapy.

There is a great deal of support for cognitive-behavioral therapy as the treatment of choice for children (Cohen, Mannarino, & Deblinger, 2006; de Arellano et al., 2014; Herpertz-Dahlmann, Hahn, & Hempt, 2005; Neubauer, Deblinger, & Sieger, 2007; Webb et al., 2014). Although Saigh (1987) has reported suc- cess using flooding techniques with school-age chil- dren, it should be strongly emphasized that this is a hazardous procedure for children and may exacer- bate symptoms. A more benign and controlled ap- proach is the use of desensitization procedures that alternate between relaxing the child and presenting scenes of the trauma that are progressively enhanced to their full florid detail. This is a stepwise procedure that makes small approximations toward exposing the child to the total traumatic event. The key to this approach is that the child can be immediately removed from the noxious image and transferred to a safe, calm, tranquil scene. Any cognitive-behavioral therapy should give the child a sense of empowerment and control. Relax- ation techniques, cognitive restructuring, stress inoc- ulation, anger management, desensitization, and any other behavioral or cognitive-behavioral techniques should be paced at the child’s speed. A good deal of dis- cussion with the child and the caretakers about what is going to occur, how the child has the power and control over what will be included, and providing ad- equate time for processing, debriefing, and follow- up should all be a part of the therapeutic regimen (Cohen, Mannarino, & Deblinger, 2006; deArellano et al., 2014; Gordon, Farberow, & Maida, 1999). Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

Play Therapy.

Play is the child’s work. Being able to play is at the central core of positive child develop- ment. However, the ability to do that must invariably have the support of reliable and nontoxic caregiving and parenting for that to occur. When children suffer chronic deprivation, abuse, or neglect with little posi- tive parental support there is no space, time, or per- mission to engage in curiosity and discovery through positive play (Tuber et al., 2014). When traumatized children play it is not about the joy of social relation- ships or discovery of new and wonderful things, but rather a reflection of the toxic trauma they have expe- rienced. We believe therefore that play therapy is a pri- mary therapeutic vehicle for removing that toxicity. Creative arts and play therapy have considerable merit and can be efficacious with PTSD in children (Gordon, Farberow, & Maida, 1999; Johnson, 2000b; Malchiodi, 2008; Webb, 2007). Play therapy generally falls into two distinct categories: directive, which is collaborative and interactive between the child and the interventionist; and nondirective, which is child centered and interventionist passive. However, nondirective play therapy may be ill advised because restitutive play (attempting to reenact the trauma through play and somehow resolve it) becomes increas- ingly destructive and serves only to increase anxieties that are allowed to go ungoverned (Terr, 1979). We believe a safer approach to reenacting the trauma is to involve the interventionist collaboratively using a va- riety of play therapy techniques (Gordon, Farberow, & Maida, 1999; Landreth, 1987; Malchiodi, 2008) that include artwork (Drucker, 2001; Loumeau-May, 2008), puppets (Carter, 1987; James & Myer, 1987), sand play (Allan & Berry, 1987; Bethel & Oates, 2007; Vinturella & James, 1987; Zarzaur, 2005), dance (Johnson, 2000a), poetry (Gladding, 1987), writ- ing (Brand, 1987), music (Bowman, 1987; Hilliard, 2008), bibliotherapy (Malchiodi & Ginns-Gruenberg, 2008), computer art (Johnson, 1987), storytelling (White, 2005), and drama (Haen, 2008; Irwin, 1987), as well as drawing the traumatic event and telling a story about it (Chapman et al., 2001; Eth & Pynoos, 1985, p. 37; James, 2003; Schreier et al., 2005). Play therapy is also a nonthreatening way to involve par- ents in the therapeutic intervention with children who have had trauma exposure (Cattanach, 2008; Haen, 2008; Echterling & Stewart, 2008; Steele & Malchiodi, 2008). All these techniques may be controlled and paced by the therapist in consideration of the psycho- logical safety of the child. The overarching reason for any of the foregoing techniques is to take the global, nebulous, uncon- trollable chaos of the crisis event and make it into a concrete, real object that the child can gain a sense of control over. Play therapy would seem efficacious because it enables the therapist to enter the trauma on the child’s cognitive terms, reduce the threat of the trauma, establish trust, and determine the child’s current means of coping and ways of defending against the trauma (Gumaer, 1984). Play therapy is a safe exposure technique that allows clients (including adults) to integrate their traumatic memories into ac- tive consciousness without the fear of reactivating the sensory trauma demons they are so afraid of letting resurface (Steele & Raider, 2001). Furthermore, as thematic trauma-related play subsides and more so- cially appropriate play reappears, this is an excellent assessment device for determining how well treat ment is proceeding. We will examine three very dif- ferent cases of how play therapy is used with children in Chapter 9, Sexual Assault; Chapter 13, Crises in Schools; and Chapter 17, Disaster Response.

EMDR.

EMDR seems to be effective with children in symptom reduction of PTSD (Adúriz Bluthgen, & Knopfler, 2011; Chemtob, Nakashima, & Carlson, 2002; Oras, de Ezpeleta, & Ahmad, 2004; Sharpiro & Laliotis, 2015; Tufnell, 2005). Shapiro (1995, pp. 276–281) in- dicates a number of special considerations for using EMDR, especially with young children. First, the worker must give special consideration to safety concerns. Although Shapiro does not believe parents should at- tend the session with the child, she does believe parents should brief the worker with the child present. Then the parent should leave and allow the child to present his or her version. This two-step sequence allows the parents’ authority to be transferred to the worker and also gives the child a sense of being special when the worker’s at- tention is focused exclusively on him or her. For children, average EMDR sessions should be no longer than 45 minutes, with eye movements in- terspersed with other activities. Because children do not have the cognitive ability to conceptualize SUDs units, more concrete representations of the degree of discomfort need to be devised. Holding a hand close to the floor can represent a “little” hurt, while holding a hand at shoulder height can represent a much “big- ger” hurt. Because most children are familiar with the workings of a body thermometer, we have used picto- rial representations of a thermometer to let children indicate how much discomfort they are feeling. Because play is such an integral part of a child’s world, eye exercises can be accomplished more easily by drawing puppets on the worker’s fingers or using finger puppets to perform the saccades. Creativity in helping the child “bring up the picture” is important, so sound effects such as starting an engine or “blowing up the picture” with a loud explosion can involve the children at their experiential level. Installing new, positive cog- nitions needs to be simplified. “I’m fine” or “I’m safe” may be highly appropriate because of their simplicity and straightforwardness for young children. Artwork may also be effective in helping to con- cretize the memory. Having the child draw the event and then hold the picture in his or her mind while eye exercises are conducted gives the child a concrete way of visualizing the memory. Shapiro (1995) reports that (much as in Gumaer’s [1984] method of serial drawing to determine if treatment is effective) when the child is asked to redraw the event after successive eye movements, the intensity of the event as depicted in the drawings is likely to diminish. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)

SUMMARY

 

Posttraumatic stress disorder (PTSD) has probably been in existence as long as humankind has been rational enough to personalize the disasters that assail us. However, it was the debacle of the Vietnam War that brought PTSD enough publicity to become a classifiable malady. The psychologically virulent milieu that was the Vietnam War became a breeding ground for trauma, which found its way back to the United States in an estimated 960,000 service person- nel who have PTSD or related disorders. PTSD has multiple symptoms and for that reason is often confused with a variety of other disorders. Its basis is maladaptive adjustment to a traumatic event. The disorder is both acute and chronic. In its chronic form it is insidious and may take months or years to appear. Its symptoms include, but are not limited to, anxiety, depression, substance abuse, hypervigilance, eating disorders, intrusive-repetitive thoughts, sleep disturbance, somatic problems, poor social relation- ships, suicidal ideation, and denial and affective numbing of the traumatic event. Both natural and human-made disasters may be responsible for PTSD, but it is far more likely to occur in individuals who have been exposed to some human-made disaster that should have been prevented and is beyond ac- cepted moral and societal bounds. Slow to recognize the disorder, human ser- vices professionals did little to ameliorate problems returning Vietnam veterans suffered. Self-help groups were started by veterans when they had no other place to turn. Through lobbying efforts by such men, Vietnam Veterans Centers were set up through- out the United States. Along with other mental health professionals who had been grappling with the prob- lems of veterans and other victims of trauma, staffers at the centers began doing research and developing treatment approaches for PTSD. Those research and treatment approaches have spread out to civilian ar- eas of trauma, and much common ground is being found between war-related and civilian-related trau- matic events. Recent research on the psychobiologi- cal aspects of PTSD is uncovering a great deal of the intricate interplay between traumatic events and the brain’s physiological responses to them. Contempo- rary treatment includes both group and individual intervention that is multimodal and considers psy- chological, biological, and social bases as equally im- portant. The United States Army is currently putting in place a comprehensive program that attempts to provide psychological fitness to soldiers to inoculate them against PTSD and other emotional disorders that go with combat. Children are not immune to PTSD, and they do not just “grow out of it.” If PTSD has taught the hu- man services one thing, it is that no traumatic expe- rience should ever be dismissed in a cursory manner and that any initial assessment of a crisis client should investigate the possibility of a traumatic event buriedsomewhereintheclient’spast.Assessmentand intervention are particularly difficult when the traumatic event is of a familial or sexual nature. A great deal of finesse and skill is necessary to uncover and treat such problems because of clients’ reluctance to talk about socially taboo subjects or the feeling that a person should have the intestinal fortitude to bear up under the trauma. From what we now know, the latter assumption is patently false; under the right circum- stances, anyone can fall victim to PTSD. There are three books that we think can be help- ful to you if you are going to get into or are already in the PTSD business. They are both focused on the military, but could surely be adapted for civilian use, and are as follows: Clinician’s Guide to Treating Stress After War: Education and Coping Interventions for Veterans (Whealin, DeCarvalho, & Vega, 2008), The Veterans and Active Duty Military Psychotherapy Treatment Planner (Moore & Jongsma, 2009), and Curran’s (2013) 101 Trauma-Informed Interventions. These books have lots of useful tips and worksheets that can be adapted for use with most anyone who has PTSD. Visit CengageBrain.com for a variety. Psychiatry -Topic Posttraumatic Stress Disorder (PTSD)