PTSD in children and adolescents

1. PTSD in children and adolescents Katy Coonan M. Psych. (Clin.) Program Student Phone: 07 4923 2233 Fax: 07 4930 6999 Website: www.cqu.edu.au/wellnesscentre Ground Level, Building 32 at CQUniversity Rockhampton.

2. Purpose and overview of this resource The focus is on Posttraumatic Stress Disorder in children and adolescents. Criticism for the DSM-IV; may not be developmentally sensitive in criteria for PTSD in children and adolescents. Family systems and PTSD in children; The role of attachment The impact of trauma, particularly interpersonal trauma, in children and adolescents; Building therapeutic relationship Role of therapeutic relationship Posttraumatic Growth and Trauma-Informed Resilience

3. Posttraumatic Stress Disorder PTSD is a mental disorder involving symptoms and dysfunction arising in the wake of trauma.

4. Criterion A: DSM-IV • Direct personal experience of an event that involves actual or threatened death or serious injury • Witnessing an events that involves threat to the physical integrity of another person • Learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate • The person’s response to the trauma must have involved intense fear, helplessness, or horror

5. Criterion B: Re-experiencing Symptoms • Distressing recollections of trauma. In young children, repetitive play involving aspects of the trauma. • Distressing dreams of the trauma. In children, nightmares. • Reliving the trauma, including; illusions, hallucinations, and dissociative flashback. In young children, trauma-specific re-enactment. • Intense psychological distress at reminders to the trauma. • Physiological reactivity on exposure to reminders of the trauma.

6. Criterion C: Avoidance Symptoms • Efforts to avoid thoughts, feelings or conversations associated with the trauma • Efforts to avoid activities, places, or people that remind them of the trauma • Inability to recall an important aspect of the trauma • Diminished interest or participation in significant activities • Feeling detached from others • Restricted range of affect • Sense of a foreshortened future

7. Criterion D: Increased Arousal Symptoms • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

8. Limitations of the DSM-IV in diagnosing children and adolescents • Based on the experiences of symptoms and dysfunction arising after military combat and rape in adults (Herman, 1992). • Questionable generalizability for other types of trauma and diagnosis of children and adolescents (Herman, 1992) • Several researchers have argued that PTSD symptoms may differ substantially between children and adults (e.g., Scheeringa, et. al., 2012)

9. Revisions to DSM-IV • The traumatic experience was modified to include a subjective component (fear, helplessness, horror) • This may be seen as disorganised behaviour or agitation in children • Repetitive play, frightening dreams, and re-enactment were included as indicators of re-experiencing in children • Criterion C and D do not describe behaviours that may be indicative of avoidance or increased arousal unique to children

10. Developmental Sensitivity • DSM-IV may not be developmentally sensitive enough to effectively diagnose PTSD in children and adolescents • Infancy and childhood involve rapid developmental change. Symptoms vary depending on capacities of infants and children in areas of perception, memory, behaviour, affect and cognition • Verbal capacity to describe symptoms is limited • Behavioural symptoms may manifest differently e.g., loss of interest in play

11. Developmental Sensitivity • Loss of previously acquired skills • Difficulty toileting • Development of new fears • Less avoidance in preschool and school aged children has been found, in comparison to their adult counterparts • ‘Intense psychological distress’ and ‘feeling detached or estranged from others’ may be difficult to assess in children

12. Family Systems • Complex factors relating to family systems must be considered in children with PTSD • Parent’s reports of their child’s experience of symptoms following trauma generally minimise the level of distress as described by the child • Secondary stressors are often involved in cases of childhood or adolescent trauma (relocation, changing schools, separation from family members, financial difficulties of the family)

13. Family Systems • Threat to caregiver is a strong predictor of the development of PTSD in infants and young children • Parents experiences of trauma may precipitate PTSD in their children • Children’s experiences of trauma may precipitate PTSD in their parents • Parents may inflict trauma onto their children (in cases of physical or sexual abuse)

14. Attachment and trauma • Infant and child attachment to a caregiver provides the infant/child with a context through which to organise emotional, cognitive and behavioural interactions (Finziet. al., 2001). • Three attachment styles; secure, avoidant/ambivalent, and avoidant.

15. Secure attachment • Securely attached children are confident in the availability of their caregiver • Securely attached children love and value their caregiver; they are also more inclined to love and value themselves • They have a mental representation of the caregiver as being responsive in times of trouble; primary defence against trauma-induced psychopathology • Through secure attachment, children learn to understand the mental state of others; further protection against traumatisation (de Zulueta, 2009)

16. Insecure attachment • Child does not see their caregiver as being responsive in times of need • Caregivers may induce traumatic states in their children (e.g., abuse) • Caregivers tend not to interactively repair their child’s negative affective states • Children of abusive caregivers may react with fight-or-flight responses, develop ‘freezing’ responses, or enter a state of ‘fear without solution’ which can result in early dissociative states • Children of abusive caregivers are still dependent on their caregiver; dissociation may allow maintenance of attachment whilst ‘escaping’ harm

17. Risk factors for trauma from caregivers • Caregiver is aggressive, punitive, domineering and inconsistent • Unemployment, job dissatisfaction, single parent families and low income may increase risk of abuse • Premature birth, disability, and having a difficult temperament may increase a child’s risk of experiencing trauma at the hands of a caregiver

18. Attachment, trauma and PTSD • Secure attachments are protective as well as predictive of better outcomes following trauma • When parents are the source of trauma, negative outcomes in terms of attachment, emotional, behavioural, and cognitive transactions are observed

19. Implications for therapeutic alliance • Children who have experienced abuse may apply coping strategies informed by early insecure attachment to future relationships • Children may expect similar maltreatment in future relationships • Clinicians need to be mindful of this phenomena when treating traumatised children

20. Shattered Assumptions Shattered assumptions about safety and control can be considered as part of the ‘meaning making’ process that occurs following significant trauma. Prior to a traumatic event; My parents are in control My parents will keep me safe Bad things happen to other people, not me I am worthy and life has meaning

21. Shattered Assumptions Trauma can alter children’s core beliefs about their sense of self and the world. The basic assumptions listed previously can be shattered and reconstituted in forms such as; I am not in control and neither are my parents I am not safe and my parents are unable to keep me safe Bad things can happen to me If bad things happen to me I must deserve it I am not worthy of safety

22. Shattered Assumptions The story of Sarah from Lenore Terr (1990) ‘Too Scared to Cry.’

23. Building relationships with traumatised children and adolescents • Relationships with therapists may be especially important for traumatised populations • Building relationships with traumatised young people can be challenging for therapists • Therapists should foster predictability, consistency and safety in the relationship and in sessions • Use ritual greetings, session format, taking things out and putting away, goodbye

24. Building relationships with traumatised children and adolescents • Traumatised children and young people may test out the limits of the relationship with their therapist • Rule breaking • Dangerous behaviour • Physical aggression • Inappropriate sexual behaviour Therapists must set limits on behaviour whilst maintaining relationship; the young person needs to know that their behaviour does not change the therapists view of them as a person.

25. Treatment of PTSD in children and adolescents Treatments that have been found to effectively treat PTSD in children and adolescents include; • Trauma-focused Cognitive Behaviour Therapy • Systemic family systems approaches • Eye Movement Desensitisation and Reprocessing

26. Posttraumatic Growth and Trauma-Informed Resilience. • Positive change arising from a persons’ recovery from trauma, through the effective use of coping skills following exposure to trauma • Trauma-informed resilience is a similar concept whereby a person’s ability to ‘bounce back’ from adversity is strengthened following successful recovery from trauma (Steele & Kuban, 2011).

27. Posttraumatic Growth and Trauma-Informed Resilience Trauma informed therapy will foster; • physical and emotional safety of the child • self-regulation • sensory cognitive integration • trauma-informed relationships and environments • trauma integration.

28. Posttraumatic Growth and Trauma-Informed Resilience By using strategies to enhance these components of therapy, posttraumatic growth outcomes can include; • Increased compassion and empathy for others • Greater psychological and emotional maturity • Increased resilience and ability to flourish • A greater appreciation for life and others • A deeper purpose and meaning in life • A deeper spiritual focus that values others and community

29. Useful resources for families and schools The KidsMatter website has some great resources. The website is www.kidsmatter.edu.au. Here are just a few resources that can be given to families; • http://www.kidsmatter.edu.au/sites/default/files/public/03_Managing%20trauma%20and%20ways%20to%20recover.pdf • http://www.kidsmatter.edu.au/sites/default/files/public/05_Getting%20through%20tough%20times_Resources%20for%20families%20and%20staff.pdf • http://www.kidsmatter.edu.au/sites/default/files/public/02_When%20times%20get%20tough.pdf

30. Useful resources for teachers The Australian Childhood Foundation offers ‘SMART’ training free online. This training is tailored to teachers, to help them to understand the challenges facing children who have experienced trauma in the classroom. It provides information on how to accommodate these children in classrooms and schools. The information is also useful for clinicians and mental health workers who want to gain an understanding of the effects of trauma on children and adolescents. Visit www.childhood.org.au

31. References • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4thEd., Text Revision). Washington, DC: APA. • Brewer, J. & Sparkes, A. (2011). Parentally bereaved children and posttraumatic growth: Insights from an ethnographic study of a UK childhood bereavement service. Mortality, 16, 204-222. • Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002). Toward an empirical definition of pediatricPTSD: The phenomenology of PTSD symptoms in youth. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 166-173. • Critendon, P. M. & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory. In Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglectby Cicchetti, D. & Carlson, V. Cambridge University Press: United Kingdom. • De Zulueta, F. (2009). Post-traumatic stress disorder and attachment: possible links with borderline personality disorder. Advances In Psychiatric Treatment, 15, 172-180. • Dyb, G., Jensen, T. K., & Nygaard, E. (2011). Children’s and Parents’ posttraumatic stress reactions after the 2004 Tsumani. Clinical Child Psychology and Psychiatry, 16, 621-634. • Fernandez, S., Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A case series: Cognitive-behavioural treatment (exposure, relaxation, and rescripting therapy) of trauma-related nightmares experienced by children. Clinical Case Studies, 12, 39-59.

32. References • Finzi, R., Ram, A., Har-Evan, D., Shnit, D. & Weizman, A. (2001). Attachment styles and aggression in physically abused and neglected children. Journal of Youth and Adolescents, 30, 769-786. • Graham-Bermann, S. A., Castor, L. E., Miller, L. E., & Howell, K. H. (2012). The impact of intimate partner violence and additional traumatic events on trauma symptoms and PTSD in preschool-aged children. Journal of Traumatic Stress, 25, 393-400. • Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391. • Lemma, A. (2010). The power of relationship: A study of key working as an intervention with traumatised young people. Journal of Social Work Practice, 24, 409-427. • Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002). Trauma symptoms in preschool aged children exposed to domestic violence. Journal of Interpersonal Violence, 17, 150-164. • Ostrowski, S. A. (2010). Development of child posttraumatic stress disorder in pediatric trauma victims: The impact of initial child and caregiver PTSD symptoms on the development of subsequent child PTSD. Dissertation Abstracts International: Section B: The Sciences and Engineering, 70, 5838.

33. References • Pearce, J. W. & Pezzot-Pearce, T. D. (2007). The Therapeutic Relationship in Psychotherapy of Abused and Neglected Children (2nd Ed.). The Guilford Press: New York. • Roth S. & Friedman M. J. (1998): Childhood Trauma Remembered: A Report on the Current Scientific Knowledge Base and Its Applications, Journal of Child Sexual Abuse, 7, 83-109. • Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012). Diagnosing PTSD in early childhood: An empirical assessment of four approaches. Journal of Traumatic Stress, 25,359-367. • Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioural therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52,853-860. • Stafford, B., Zeanah, C. H., & Scheeringa, M. (2003). Exploring psychopathology in early childhood: PTSD and attachment disorders in DC: 0-3 and DSM-IV. Infant Mental Health Journal, 24, 398-409.