PTSD in Children
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Transcript PTSD in Children
PART 3
Interventions
INTERVENTIONS
Approach should be individualized for:
1) Exposure level of the population
directly exposed
bereaved
eyewitnesses
indirectly exposed
through others
remotely affected
2) Needs of individual children
building resilience and coping skills
treatment of psychiatric illness
3) Timing: disaster phase
DISASTER PHASE
PRE-DISASTER
To be most effective, disaster mental health planning
for children must begin well before the disaster occurs
Pre-disaster relationships promote effective postdisaster response:
among mental health professionals
in organizational settings such as schools, daycare
centers, churches, community centers, health care
facilities, and other places that serve children
DISASTER PHASE
ACUTE IMPACT
Supportive efforts during and immediately after
the disaster:
Child safety and assurance
Shielding children from horror
Providing accurate information
Reunification with families
DISASTER PHASE
EARLY POST IMPACT
Focus on immediate needs of:
Directly exposed children and families
At-risk children
Community children
Interventions:
Crisis debriefing
Individual, family, and group interventions
Community interventions
DISASTER PHASE
LONG TERM
Individual, family, group, school,
and community interventions
Evolve from disaster response to
new disaster preparedness
PULSED INTERVENTIONS
Planned interventions at strategic points:
For managing secondary sequelae of disaster
For transitions to other disaster stages
Anticipate and address critical moments
Reduce potential for emotional arousal by
managing the child's exposure to reminders
ANNIVERSARIES AND MEMORIALS
Time for commemoration
Time for reflection
Review event and progress
Set goals for the future
Anticipate emotional arousal
Include children in planning
COMMON ELEMENTS OF INTERVENTION
Restore sense of safety and security
Validate experiences and feelings
Protect children from excessive exposure to other
frightening situations and reminders of the event
Restore equilibrium
Attend to lines of communication
REINFORCE SENSE OF SAFETY AND SECURITY
First priority: establish physical safety and meet
physical needs
Reinforce sense of safety and security
Different age groups need different approaches
Preschool - the world is black & white
Latency age - shades of gray
Adolescence - more detail
VALIDATE EXPERIENCES AND FEELINGS
Listening validates the child's experience and feelings
Hear their stories and answer their questions
(sometimes the same ones repeatedly)
Be calm and provide simple, direct answers
Gain information about the child's fears and concerns
Manage anger, bitterness, and hate
Listen; redirect anger and defuse hatred with information
Correct underlying misconceptions and misattributions
PROTECT FROM EXCESSIVE EXPOSURE
Be judicious in re-exposing children
to the site of the incident
Assist with processing media material
Managing common reminders
RESTORING EQUILIBRIUM
Maintain a predictable schedule and rules
Encourage school attendance and
extracurricular activities
Don't panic over a brief decline in school
performance
Encourage healthy habits
COMMUNICATION
Maintain regular communication with
others involved in the child’s life
Be aware how you convey your own
observations to the child, and how they
might influence the child
TYPES OF INTERVENTIONS
Supportive interventions & support services
Formal evaluations & needs assessments
Crisis intervention & debriefing
Formal mental health assessment & treatment
DEVELOPING SOCIAL SUPPORT
Social support can come in many forms:
Extended families
Neighborhood or community activities
Religious organizations
Consider cultural fit
COMMUNITY INTERVENTIONS
Family
Small group
School-based
FAMILY INTERVENTIONS
Family work should:
Educate parents about children’s reactions in
general and about their own child’s experiences
and responses
Help families rebuild the child's sense of security
Assist families with secondary stressors
Anticipate needs of the children in the family
FAMILY SAFETY PLANNING
Identify safe people and places
Develop plans for self and family
Learn, review, and practice plans
ASSIST PARENTS
Allow parents to process their own
thoughts and feelings about the event
Discuss how parents’ distress and
behaviors can adversely affect their
children
THE MEDIA
Children, parents, and other adults should
be educated about media issues
The association between posttraumatic
stress reactions and media exposure does
NOT establish cause and effect
Children who are distressed may be drawn to
media coverage
MANAGING MEDIA IN THE HOME
Parents should monitor media exposure at home
- especially TV and Internet
Limit media contact that becomes excessive or overstimulating
Parents may need to work through their own reactions to media
Discuss media coverage with children:
Address reactions and concerns
Clarify misperceptions
Help process emotions stimulated by media coverage
Validate feelings
Observe and reflect, but do not reinforce, hostile feelings
SMALL GROUP INTERVENTIONS
Large numbers of children accommodated
Safe setting facilitates sharing
Children educated about traumatic responses
and develop new coping skills
Expedient case finding
SCHOOL SETTINGS
Schools are developmentally appropriate settings
School settings provide opportunities to:
conduct screenings and needs assessments
facilitate disclosure, discussion, and correction of
misperceptions
utilize curricular approaches, small group
activities, and projective techniques
SCHOOL-BASED APPROACHES
Advantages:
Access to large numbers
Safe and secure environment
Encourage normalcy
Minimize stigma
Accessible opportunities to screen and refer
FORMAL TREATMENT
General therapeutic principles
Common elements across interventions
Specific therapies and techniques
GENERAL THERAPEUTIC PRINCIPLES
Heightened arousal and discomfort may arise in treatment
Therapy must provide a safe and comfortable environment
to process painful and overwhelming experiences
Avoidance is a core aspect of posttraumatic stress and may
prevent the initiation of therapy or impede its progress
Treatment involves transforming the child’s self concept from
victim to survivor
COMMON ELEMENTS OF INTERVENTIONS
Educate both child and family
Directly address the incident
Correct inaccurate and maladaptive attributions
Teach anxiety management
Teach coping skills
Provide parallel components for parents/caregivers
INDIVIDUAL TREATMENT
Formal clinical assessment and individual treatment
For children exposed directly or indirectly through the experience
of loved ones
For those showing high levels of distress or impaired functioning
Modalities of individual treatment:
Supportive psychodynamic approaches
Play therapy
Cognitive-behavioral approaches
Adjunctive medication (rarely needed)
ADVANTAGES OF INDIVIDUAL THERAPY
Focuses attention on the child
Allows intensive treatment
Addresses comorbid conditions and
issues not directly related to the disaster
Can supplement other approaches
INITIAL CLINICAL INTERVIEW
Parent report needed to obtain objective
aspects of the child’s experience and
reactions
The child must be interviewed directly
Projective techniques may be useful
INDIVIDUAL APPROACHES
Psychodynamic
Cognitive-behavioral
Play
Medication
PSYCHODYNAMIC APPROACH
Support for this approach is
anecdotal
rather than empirical
COGNITIVE-BEHAVIORAL APPROACH
Supported by empirical research
Utilizes a variety of techniques
Can be incorporated into various activities
PLAY THERAPY
Part of a more comprehensive approach
Directed rather than free play
Not perseveration in repetitive re-enactment of some
aspect of the event, but rather moves the child
forward to productive activity
PHARMACOTHERAPY
Medication is rarely needed
Adjunctive to other modalities
Refer children with persistent or disabling symptoms
First-line agents: SSRIs
FAMILY THERAPY
Family plays a major role in the child's recovery
Multiple family members may be traumatized
Traumatized parents may overlook their
children's needs
Parents can be helped to help their children by
attending to the parental distress and educating
them about their children's needs
ADVANTAGES OF FAMILY THERAPY
Children see they are not alone in their distress
Children gain support and feel accepted
Children can have safe and open discussions
of the event
Children can model reactions and coping strategies
Family can address dynamics affecting the child's
adjustment
FAMILY AND GROUP THERAPY
STRUCTURE AND CONTENT
Type and amount of structure vary
Appropriate topics
Normal reactions to traumatic events
Reminders and anniversaries
Coping strategies
Parallel parent groups
ADVANTAGES OF GROUP THERAPY
Accommodates larger numbers
Provides opportunity to share and reassure
Allows children to observe how others cope
and to practice new skills with peers
Provides reinforcement
DISADVANTAGES OF GROUP THERAPY
Some are uncomfortable in groups
Some need more individual work
Groups may retraumatize some
Children may prematurely adopt the
coping strategies of others
SPECIFIC THERAPEUTIC TECHNIQUES
Opening discussion
Identifying and expressing feelings
Relaxation exercises
Modifying thoughts & behaviors (cognitive-behavioral)
Planning for the future
Reviewing progress
OPENING DISCUSSION
Raise the issue of the traumatic event and the child’s experiences
and reactions early in the course of treatment
Provide assurance that the therapeutic environment is a safe
place to discuss these issues
Cover all senses in the child’s experience
Encourage repeated review of the experience
Use “real” words (avoid euphemisms)
IDENTIFYING AND EXPRESSING FEELINGS
Feelings vocabulary
Faces
Identifying feelings in self and others
Non-verbal expressions of feelings
Drawing Music Writing
RELAXATION EXERCISES
Deep breathing
Scripted imagery
Muscle relaxation
For older children: yoga, meditation
MODIFYING THOUGHTS AND BEHAVIORS
Challenge thoughts
Redirect thoughts and activities
Thought-stopping
Create positive coping statements
Generate a list of positive thoughts and behaviors
Focused thinking time
Generate alternative explanations
Correct misconceptions and misattributions
Create positive reinforcements
Encourage sharing ideas with others (particularly family)
PLANNING FOR THE FUTURE
Discuss the future
Identify triggers or possible reminders
Plan anniversaries and other activities related to
the traumatic event
Practice learned skills on a regular basis
Maintain a supportive and caring environment
SAFETY PLANNING
Develop a plan for family safety
Include children in the development of the plan
Practice the plan
Review the plan on a regular basis
Revise the plan as needed
REVIEWING PROGRESS
Encourage and reinforce successes
in integration of thoughts, feelings,
and memories of the event
LONG-TERM AND LATE TREATMENT
Some children with intense reactions or other
problems may need long-term treatment
Later interventions may be needed at key
points, including:
During transitions to subsequent disaster stages
Anniversaries and marker events
LOOKING AHEAD
Ongoing threat of new attacks
War on terrorism and war with Iraq
Threat of other types of terrorist attacks
Preparedness:
Readiness Response Recovery
RESILIENCE
DEFINITION: ability to recover from or
adjust easily to misfortune or change
Does everyone have this ability?
Can we increase this ability?
BUILDING RESILIENCE
Practice skills learned after trauma
Keep things in perspective
Set realistic goals
Seek out support
Take care of yourself
COORDINATION AND COLLABORATION
Government leaders
Federal agencies
State agencies
Community agencies
Non-profit agencies
Law enforcement
First responders
Media
Education
Mental health
Medicine
Public health
Clergy
Parents and caregivers
Children and Adolescents
Private Sector
QUESTIONS
QUESTIONS & ANSWERS
SREWSNA & SNOITSEUQ
QUESTIONS & ANSWERS
QUESTIONS & ANSWERS
ANSWERS!