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

“The Drama of Trauma:
Post Traumatic Stress
Disorder in Children”
presented by:
Theodora Phea Pinnock, M.D.,
Developmental and Behavioral Pediatrician
[email protected]
November 19, 2010
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)

The Movie Board

Born on the Fourth of July (1989)
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
Ordinary People (1980)
Statistics
 History of PTSD
 Definition
 Signs & symptoms
Fearless (1993)
 Why some children & not others? (Risk Factors)
 Impact of Foster Care


Goals
Pretest
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)
“Born on the
Fourth of July”
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.

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
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.
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
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.
“Ordinary
People”
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 %

Statistics
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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%.
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.
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
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

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.

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).
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).
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).
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
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.
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 traumarelated 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.
Signs and Symptoms of
PTSD

Symptoms in Elementary School Children
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
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School-aged children also reportedly exhibit posttraumatic 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).
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.
“Fearless”
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.

Other Risk Factors for PTSD
Interpersonal Trauma- Rape and assault
 Experienced a number of traumatic events
 Gender: Girls versus boys

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
Children Who Experience
Maltreatment
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Substance abuse
Depression
Anxiety Disorders
Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Conduct Disorder
“Taxi Driver “
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.
Trauma Focused-CBT
Components
A…PRACTICE
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About Anxiety; About Trauma
Assessment
Psychoeducation and Parenting Skills
Relaxation
Imaginal
Affective Modulation
Exposure
Cognitive Coping
Trauma Narrative and Processing
In Vivo Exposure
In Vivo Desensitization
Conjoint parent-child sessions
Enhancing safety
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.
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
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.
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.
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Treatment
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Family Therapy
With 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
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 parentchild 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.

“Coming Home“
Prevention of PTSD

Screenings-Screening Tool for Early Predictors of
PTSD (STEPP)
Recommendations

Support:
 Parents
or Caregivers
 School
 Peers

Therapists in Tennessee:
Cities & Counties in Tennessee:
http://therapists.psychologytoday.com/rm
s/prof_results.php?state=TN&spec=19
“The Fisher King”
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
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.
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
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
“Birdy “
References
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WEBSITES:
http://www.aacap.org
http://www.mental-health-today.com/ptsd/dsm.htm
http://ncmbts.blogspot.com/2010/01/post-traumatic-stressdisorder.html
http://www.practicenotes.org/vol10_no3.htm
http://www.iom.edu/Activities/MentalHealth/PTSDTreatment
.aspx
http://www.jaacap.com/article/S0890-8567(09)622358/abstract
References

WEBSITES:
http://emedicine.medscape.com/article/918844-overview
 http://www.governorsinstitute.org/index.php?option=com_do
cman&task=doc_view&gid=197
 http://www.culturallycompetentmentalhealthnj.org/docs/Sept
07Workshops/evidence-based-practices/Evidence-BasedPractices.pdf
 http://www.agpa.org/pubs/5-children-adolescents-ebt.pdf
 http://www.dartmouth.edu/~admsep/resources/cinema.html

References
 WEBSITES:

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
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http://www.abct.org/sccap/?m=sPro&fa=pro_ESToptions#s
ec3
http://bjp.rcpsych.org/cgi/content/abstract/160/3/30
http://www.brighthub.com/mental-health/anxietypanic/articles/77851.aspx
http://www.foh.dhhs.gov/NYCU/afteremergency.pdf
http://jcem.endojournals.org/cgi/content/full/90/7/4115
http://jama.ama-assn.org/cgi/content/full/290/5/643
http://www.brighthub.com/mental-health/anxietypanic/articles/90489.aspx
References
 WEBSITES:
http://anxiety.emedtv.com/ptsd/ptsd-in-children-p5.html
 http://www.ptsd.va.gov/public/pages/ptsd-childrenadolescents.asp
 http://anxiety.emedtv.com/ptsd/ptsd-in-children.html
 http://userwww.service.emory.edu/~jdbremn/instruments/E
TISR-SF.pdf

References

Books:
Children and Trauma: A Guide For Parents and Professionals
by Cynthia Monahon, Jossey-Bass Publishers; San Francisco;
1997.
 The Scared Child: Helping Kids Overcome Traumatic
Events by Barbara Brooks, Ph.D., and Paula M. Siegel;
John Wiley & Sons, In.; New York; 1996.
 A Terrible Thing Happened by Margaret M. Holmes;
illustrated by Cary Pillo; Magination Press; American

Psychological Association;Washington,
DC, 2000.