Post-Traumatic Stress Disorder

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

Diagnosis 1)After exposure to actual or threatened death or serious injury  fear, helplessness, or horror May also have disorganized / agitated behavior 2)Re-experiencing, repetition, and re-enactments May manifest repetitive behaviors 3)Avoidance of stimuli associated with trauma Seek parent/teacher/observer report about diminished interest in activities and constriction of affect 4)Hyperarousal May exhibit stomachaches and headaches

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

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

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

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

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 statesDSM-IV Children may experience posttraumatic stress symptoms (PSS) but not meet PTSD criteria They often carry dual diagnoses  hard to distinguish overlapping symptoms

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

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

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) Impact of Events Scale – Revised Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI) PTSD Symptom Scale (PSS) PTSD Symptom Scale Trauma Symptoms Checklist for Children (TSCC)

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: 1)Ensure child feels safe and secure 2)Ensure child is provided with info and clarification about the event and the state of family/friends

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

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

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

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 Dyregrov A, Yule W. A review of PTSD in children. Child and adolescent mental health. 2006; 11(4): Hawkins SS, Radcliffe J. Current measures of PTSD for children and adolescents. J Pediatr Psychol May;31(4): Epub 2005 Jun 9.