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!