“The Drama of Trauma: Post Traumatic Stress Disorder in Children”

1. “The Drama of Trauma: Post Traumatic Stress Disorder in Children” presented by: Theodora Phea Pinnock, M.D., Developmental and Behavioral Pediatrician theodorapinnock@att.net November 19, 2010

2. Movies wirh Themes of PTSD • Born on the Fourth of July (1989) • Taxi Driver (1976) • Coming Home (1978) • Apocalypse Now (1979) • The Deer Hunter (1979) • Return of the Soldier (1982) • Birdy (1984) • Heaven and Earth (1993) • Fearless (1993) • The Fisher King (1991) • Ordinary People (1980)

3. The Movie Board • Born on the Fourth of July (1989) • Goals • Pretest • Ordinary People (1980) • Statistics • History of PTSD • Definition • Signs & symptoms • Fearless (1993) • Why some children & not others? (Risk Factors) • Impact of Foster Care

4. The Movie Board • Taxi Driver (1976) • Some evidenced–based treatments • Coming Home (1978) • Prevention of PTSD in children • Recommendations for clients with PTSD • The Fisher King (1991) • Posttest • Questions • Birdy (1984) • Credits (References)

5. “Born on the Fourth of July”

6. Goals • The participant will learn the DSM-IV definition of Post Traumatic Stress Disorder and common signs and symptoms. • The participant will discover that although children experience adverse events, they may or may not develop PTSD. • The participant will gain knowledge about some current evidenced-based treatments. • The participant will find out ways to assist clients in obtaining treatments.

7. Pretest • 1. Post Traumatic Stress Disorder (PTSD) is a diagnosis that : • A. Has been included in the Diagnostic & Statistical Manual of Mental Disorders (DSM) since 1946. • B. Has been included in the DSM since 1965. • C. Has been included in the DSM since 1980. • 2. PTSD usually occurs after: • A. An unusual and terrifying event (war, act of terrorism, natural disaster, etc.) • B . A usual but terrifying event ( car accident, witness a murder, abuse, etc. ) • C. Neither of two descriptions • D. Both of the two descriptions

8. Pretest • 3. Ways to prevent PTSD in children : • A. Provide a strong supportive presence • B. Establishing routines with flexibility • C. Accept children’s regressed behaviors while encouraging and supporting a return to age-appropriate activity • D. Neither of the above. • E. All of the above.

9. Pretest • 4. Evidenced-based treatments for PTSD in children include: • A. Cognitive behavior al therapy. • B . Eye Desensitization • C. Neither of two treatments • D. Both of the two treatments

10. Pretest • 5. Diagnosis of PTSD in children: • A. Must be made at least 30 days after the event • B . Must be made at least 2 weeks after the event • C. Must be made at least 90 days after the event.

11. “Ordinary People”

12. Statistics • Exposure: • Girls: 15 -43 % have experienced at least one traumatic event in their lifetime. • Boys: 14-43% have experienced at least one traumatic event in their lifetime. • Incidence of PTSD- Of those children and adolescents who have experienced at least one traumatic event • Girls: 3 to 15 % • Boys: 1 to 6 %

13. Statistics • Incidence in specific populations of at-risk adolescents and children: • Children who witness the murder of a parent: 100% • Children who witness sexual assault : 100% • Children who are sexually abused : 90 % • Children exposed to a school shooting: 77% • Urban youth exposed to community violence: 35%.

14. History of PTSD • People have been experiencing extremely stressful, potentially life-threatening events for centuries, clearly PTSD is a condition that has plagued humans for quite some time before the American Psychiatric Association officially recognized it as an emotional disorder.

15. History of PTSD • PTSD has been called a number of other different names, including: • “Soldier’ s heart” - soldiers who experienced PTSD symptoms after the Civil War • “Combat fatigue or shell shock ”- for soldiers who experienced PTSD symptoms after World War I • “Battle fatigue or gross stress reaction”- for soldiers who came down with PTSD after World War II

16. History of PTSD • The symptoms used be thought of as a sign of weakness • Korean War • Vietnam War • Post traumatic stress disorder was first classified as a disorder in 1980 in the Diagnostic and Statistical Manual of Mental Disorders

17. History of PTSD • In the DSM-III, trauma was seen as an event beyond the range of normal that would be distressing for anyone who experienced it. In the DSM-IV, trauma is viewed as an event that can cause serious injury, harm or death but not necessarily beyond the range of normal. • The DSM-IV was revised in 2000 and redefined trauma to include events that cause intense fear, helplessness and horror. The revision also states that exposure to a traumatic event can also cause post traumatic stress disorder.

18. Definition (DSM-IV) • The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1).

19. Definition (continued) • The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D).

20. Definition (continued) • The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

21. Signs and Symptoms of PTSD • Researchers and clinicians recognize that PTSD may not present itself in children the same way it does in adults. Criteria for diagnosis now include age-specific features for some symptoms. • Symptoms in Very Young Children (not as verbal) • Stranger or separation anxiety • Avoidance of situations that may or may not be related to the trauma

22. Signs and Symptoms of PTSD • Symptoms in Very Young Children (not as verbal) • Sleep disturbances • A preoccupation with words or symbols that may or may not be related to the trauma. • These children also may display post-traumatic play in which they repeat themes of the trauma. In addition, children may lose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event.

23. Signs and Symptoms of PTSD • Symptoms in Elementary School Children • May or may not experience visual flashbacks or amnesia for aspects of the trauma. • Do experience "time skew" and "omen formation," which are not typically seen in adults.   • Time skew refers to a child missequencing trauma-related events when recalling the memory. Omen formation is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas.

24. Signs and Symptoms of PTSD • Symptoms in Elementary School Children • School-aged children also reportedly exhibit post-traumatic play or reenactment of the trauma in play, drawings, or verbalizations. . • Example of post-traumatic play: Increase in shooting games after exposure to a school shooting. • Example of post-traumatic reenactment: Behaviorally re-creating aspects of the trauma (for example, carrying a weapon after exposure to violence).

25. Signs and Symptoms of PTSD • Symptoms in Adolescents • May begin to more closely resemble the condition in adults. • Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives. • Adolescents are more likely to exhibit impulsive, aggressive behaviors.

26. “Fearless”

27. Risk Factors for PTSD • The three following risk factors determine whether a child develops PTSD: • 1) The severity of the traumatic event. • 2) The parental reaction to the traumatic event. • 3) The physical proximity to the traumatic event.

28. Other Risk Factors for PTSD • Interpersonal Trauma- Rape and assault • Experienced a number of traumatic events • Gender: Girls versus boys 

29. Children Who Experience Maltreatment • Sexual Abuse: • Fear • Anxiety • Depression • Anger and hostility • Aggression • Sexually inappropriate behavior • Self-destructive behavior • Feelings of isolation and stigma • Poor self-esteem • Difficulty in trusting others • Substance abuse

30. Children Who Experience Maltreatment • Substance abuse • Depression • Anxiety Disorders • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Conduct Disorder

31. “Taxi Driver “

32. Treatment • Cognitive Behavioral Therapy (CBT)- the most effective approach. For children, this generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques (such as relaxation and assertiveness training), and correction of inaccurate or distorted trauma-related thoughts.

33. Trauma Focused-CBT Components A…PRACTICE Assessment Psychoeducation and Parenting Skills Relaxation Affective Modulation Cognitive Coping Trauma Narrative and Processing In Vivo Desensitization Conjoint parent-child sessions Enhancing safety About Anxiety; About Trauma Imaginal Exposure In Vivo Exposure

34. Treatment • Eye Movement Desensitization & Reprocessing (EMDR) - incorporates some elements of cognitive behavioral therapy, • Focuses on the distressing memories of begin by identifying trauma-related images and sensations, as well as negative self-beliefs associated with these memories.

35. Treatment • Eye Movement Desensitization & Reprocessing (EMDR) - • Next, clients are exposed to feared sensations by concentrating on various details surrounding these memories while tracking therapists' hand movements with their eyes. • During the "reprocessing" stages, clients are told to focus on positive thoughts regarding the memory during further sets of eye movements

36. Treatment • Resilient Peer Treatment (RPT) • A classroom-based intervention that pairs a traumatized or maltreated child with resilient peers or "play buddies." Under the supervision of a trained parent assistant, a target child develops social competency in a natural classroom environment through a series of unstructured play activities.

37. Treatment • Child-Centered Therapy (CCT) • Based on research evidence suggesting that traumatized children and their parents often develop difficulties because they both experience a violation of trust and disempowerment. • Focuses on the relationship between parents/caregivers and the effected child or adolescent, aims to reverse these difficulties by (re)establishing a therapeutic parent-child relationship. • Importantly, children and parents are encouraged to determine their own structure, content, and pace of treatment.

38. Treatment • Family TherapyWith the understanding that families may play a vital role in the treatment of maltreated or otherwise traumatized children and adolescents, Family Therapy for PTSD is designed to optimize overall family functioning, as well as enhance relationships between individuals. • Family clinic sessions are combined with periodic home visits as treatment progresses through phases which include engagement, assessment, education, skill building, application, and termination

39. Treatment • Child-Parent Psychotherapy • A major premise behind Child-Parent Psychotherapy (CPP) is that a child's attachment to his/her caregivers serves as the main root from which he/she organizes responses to danger and safety during the first years of life. As such, when a young person develops extreme and maladaptive responses to perceived danger in the wake of trauma, CPP interventions utilize the parent-child relationship as the agent of change. • Therapists guide parent-child pairs to develop supportive interactions as they co-construct the "story" of traumatic events and move towards their resolution.

40. “Coming Home“

41. Prevention of PTSD • Screenings-Screening Tool for Early Predictors of PTSD (STEPP)

42. Recommendations • Support: • Parents or Caregivers • School • Peers • Therapists in Tennessee: Cities & Counties in Tennessee: http://therapists.psychologytoday.com/rms/prof_results.php?state=TN&spec=19

43. “The Fisher King”

44. Posttest • 1. Post Traumatic Stress Disorder (PTSD) is a diagnosis that : • A. Has been included in the Diagnostic & Statistical Manual of Mental Disorders (DSM) since 1946. • B. Has been included in the DSM since 1965. • C. Has been included in the DSM since 1980. • 2. PTSD usually occurs after: • A. An unusual and terrifying event (war, act of terrorism, natural disaster, etc.) • B . A usual but terrifying event ( car accident, witness a murder, abuse, etc. ) • C. Neither of two descriptions • D. Both of the two descriptions

45. Posttest • 3. Ways to prevent PTSD in children : • A. Provide a strong supportive presence • B. Establishing routines with flexibility • C. Accept children’s regressed behaviors while encouraging and supporting a return to age-appropriate activity • D. Neither of the above. • E. All of the above.

46. Posttest • 4. Evidenced-based treatments for PTSD in children include: • A. Cognitive behavior al therapy. • B . Eye Desensitization • C. Neither of two treatments • D. Both of the two treatments

47. Posttest • 5. Diagnosis of PTSD in children: • A. Must be made at least 30 days after the event • B . Must be made at least 2 weeks after the event • C. Must be made at least 90 days after the event.

48. Questions

49. “Birdy “

50. References • WEBSITES: • http://www.aacap.org • http://www.mental-health-today.com/ptsd/dsm.htm • http://ncmbts.blogspot.com/2010/01/post-traumatic-stress-disorder.html • http://www.practicenotes.org/vol10_no3.htm • http://www.iom.edu/Activities/MentalHealth/PTSDTreatment.aspx • http://www.jaacap.com/article/S0890-8567(09)62235-8/abstract