1. Treating Children and Adolescents with PTSD William Yule Prague March 2014

2. In the beginning…. When DSM III first identified PTSD, it was thought that children would rarely show it Why did professionals come to such a wrong conclusion?

3. Simply, they had not asked the children themselves how they were reaction to major stressors. They had asked parents and teachers who greatly underestimated the reactions children had

4. Adults, even today, are scared to talk to children about how they are feeling after a bad experience in case they make things worse. In case by asking, they traumatise the child!

5. Faced with child survivors of a big shipping disaster, I did what I was trained to do – I asked the children themselves. This what they told me:

6. Stress Reactions in Children Sleep Disturbance Separation Difficulties Concentration Difficulties Memory Problems Intrusive thoughts Talking with parents Talking with friends Heightened alertness to danger Premature awareness of mortality Fears Irritability Anxiety and Panic Depression Bereavement

7. ICD vs DSM Both are “adult-o-centric” Still need more child oriented descriptive studies ICD emphasizes Intrusive phenomena, downplays avoidance and arousal

8. Recent changes Both DSM5 and forthcoming ICD10 have refined their rules for making a diagnosis of PTSD But the essential features remain with ICD placing more emphasis on re-experiencing

9. Post Traumatic Stress Disorder Intrusive recollections, nightmares, “flashbacks” Avoidance of remembering and reminders Over-arousal (sleep, concentration, anger, jumpiness)

10. Developmental Aspects Pre-school children Alternative diagnostic criteria developed by Scheeringa et al (2011) http://www.infantinstitute.com/measures.htm Checklists & questionnaires Diagnostic interview schedules Treatment manual Available from Michael Scheeringa’s website

11. Incidence of PTSD after assaults & RTAs

12. Mental Health Effects of the Jupiter Sinking Any DSM-IV Diagnosis

13. Natural History of PTSD Jupiter follow-up

14. Aberfan

15. Aberfan – 33 years later

16. Emerging Theoretical Models 1980 – Rachman: Emotional Processing 1987 et seq: Keane, Foa – Anxiety and Habituation 1996 – Brewin: Dual Representation 2000: Ehlers and Clark: Memory

17. Emotional Processing Rachman 1980 Distress usually wanes when realize threat no longer remains If overwhelmed, no habituation and so avoid Stress symptoms indicate that emotional processing is incomplete

18. Treatment of PTSD in children Crisis Intervention –Critical Incident Stress Debriefing Group Treatment Individual Treatment –CBT - Prolonged Exposure –EMDR –KidNET

19. Crisis Interventions Make contact initially Survivors probably not able to benefit for first few days

20. Critical Incident Stress Debriefing (Dyregrov) Introduction –rules of group Facts - what happened Thoughts Reactions –Sensory, delayed Information and Advice Conclusion

21. Contingency Planning in schools Risk analysis Contingency plan Pre-assign responsibilities Immediate tasks Longer term planning

23. Review of early intervention 4 RCTs + 3 others found Small to large beneficial effect sizes Early intervention should include: –Psycho-education –Individual coping skills –Some trauma exposure Early intervention may be helpful

24. Cognitive models of PTSD Seek to explain a why minority of trauma-exposed individuals develop chronic PTSD Foa, Steketee, & Routhbaum 1989 Brewin, Dalgleish, & Joseph 1996 Ehlers & Clark 2000 sense of “current threat” from idiosyncratic appraisals disjointed memory unhelpful coping

25. Characteristics of Trauma/ Sequelae Prior Experiences/ Beliefs/ Coping State of Individual Cognitive Processing during Trauma Nature of Trauma MemoryNegative Appraisal of Trauma and/ or its Sequelae Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/ Symptoms leads to influences prevents change in PERSISTENT PTSD Ehlers & Clark’s Cognitive Model of PTSD (2000)

26. Cognitive factors in children Nature of the trauma memory laid down Attributions & misappraisals about the event (eg Joseph et al, 1991) Appraisals of symptoms (Ehlers et al, 2004; Meiser-Stedman et al) Thought control strategies (eg Ehlers et al 2004; Aaron et al 1999)

27. Treatment Targets Reduce fragmentation of trauma memory Modify misappraisals of the trauma and PTSD symptoms Reduce dysfunctional coping strategies (cognitive and behavioural avoidance) Modify maladaptive beliefs of parents (re trauma and sequelae), recruit parents as co- therapists

28. Elements of treatment Education/normalisation Reclaiming life Relaxation Imaginal reliving Cognitive restructuring In vivo exposure Image work Sleep Hygiene Parent sessions

29. Patient flow N = 38 27/36 retain diagnosis 9/36 lose diagnosis 3 decline Rx before randomisation CBT = 12 WL = 12 Diary monitoring 4 weeks

30. CAPS (clinician PTSD)

31. PTSD diagnosis Semi-structured interview by clinician blind to group status, post CBT/WAIT CBT group11/12 (92%) free of PTSD diagnosis WAIT group5/12 (42%) free of PTSD diagnosis

32. Summary Substantial proportion of children respond well to symptom monitoring Significant effect of CBT on PTSD and associated problems Improvement maintained at 6 month follow up Symptom improvement accompanied by changes in mis-appraisals

33. Eye Movement Desensitization and Re-processing (EMDR) Construct a “Safe Place” Picture Worst Memory Negative Cognition (Rate 1-7) Positive Cognition (Rate 1-7) Feelings (Rate SUDS 1-10) Body Sensation “Desensitization” - eye movements Repeat cycle

34. EMDR & PTSD 1

35. EMDR & PTSD 2

36. Narrative Exposure Therapy Kid NET

38. KidNET timeline

39. Efficacy of Narrative Exposure Therapy in field studies

40. Mental health in complex emergencies Lancet article in early December 2004 Stressed need for each country to develop a plan to screen for adverse reactions after a disaster and then provide effective treatment Need to develop appropriate measures Need to develop treatment to be delivered on a large scale

41. Teaching Recovery Techniques 1: Intrusion 2: Arousal 3: Avoidance 4: Bereavement Parent’s Group

42. TRT RCT Barron et al (in press) significant difference at post-test, controlling for initial symptom severity p<.005

43. CHILDREN and WAR Writing for Recovery Aimed at Adolescents Builds on Jamie Pennebaker’s work 2 x 15 minute sessions on 3 days

44. PTSD before and after writing manual

45. Writing and Grief Afghani adolescents (Kalantari et al, 2012)

46. Education for war affected children School as a focus for intervention and support Need to emphasize continuing education Skills can be taken anywhere But stress reactions such as attention, memory problems etc interfere with learning So Stress reactions need to be targetted

47. References mentioned in this workshop can be accessed at: www.childrenandwar.org www.childrenandwar.org