Professional Documents
Culture Documents
and Adolescents
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EPIDEMIOLOGY
Epidemiology
• Different studies report varying rates of PTSD in
childhood
• Examples indicating range:
Lifetime prevalence for PTSD in adolescence:
9.2% (Breslau et al., 1991)
1.6% (Essau et al., 2000)
• Studies (McFarlane, 1987 and Scheeringa, et al. 2005)
show that PTSD, once diagnosed, is still present at
18-24 months, if untreated.
• In the U.S. alone 5 million children each year are
victims or witnesses to violent trauma. (Perry, 2001)
• ¼ of all children experience a significant traumatic
event before adulthood (Costello et al., 2002)
Risk factors for PTSD
• Female gender
• Past trauma exposure
• Greater exposure to the index trauma (amount,
proximity)
• The presence of a pre-existing psychiatric disorder,
particularly an anxiety disorder
• Parental psychopathology
• Parental lack of support
(Pine and Cohen, 2002)
• Witnessing threat to caregiver
(Scheeringa et al., 2006)
• Following a disaster:
a) Increased television viewing of the disaster
b) Delayed evacuation of the disaster-area
c) Life or family member’s life in danger
(Pfefferbaum et al., 1991)
Diagnosis of Child and Adolescent
PTSD confers increased risk for:
• Smaller cerebral volume and corpus
colossi
(Debellis et al., 1996)
• Lower academic scores
(Saigh et al., 1997)
• Child sexual abuse is associated with
increased rates of sexual risk-taking,
substance abuse, conduct disorder,
depression and suicide
(Fergusson et al., 1996)
THEORY
Theory
A theoretical understanding of PTSD in
children and adolescents is aided by a
developmentally-informed integrational
approach. Neurobiological information,
cognitive-behavioral knowledge, an
openness to philosophical perspectives
and a dynamic relational understanding
of a child’s life in their family and
cultural community combine to promote
understanding of treatment.
PTSD: Combinations of
Hyperarousal and Dissociation
• Arousal Alarm Fear
• Frontal cortex shuts down and non-
verbal cues are the focus
• Dissociation may involve the child
curling up into a ball, preparing the
body for possible injury. The heart
rate may be decreased and opioids
released
(Perry and Szalavitz, 2006)
Revised theories of PTSD integrate
an understanding of the abnormal
processing of traumatic memories
and poor organization of
autobiographical memories. The
memories are triggered as if they are
happening in the present and not in
the past. From this perspective,
therapy focuses on re-organizing
these memories.
(Ehlers and Clark, 2000)
TREATMENT
Treatment of Children and
Adolescents with PTSD
• First-step management
• Psychotherapy
• Medications
• Eye Movement Desensitization
and Reprocessing (EMDR)
First-step: Identification and
Management of Symptoms
When a child or adolescent has been
exposed to a traumatic incident, (i.e. in an
emergency room or a disaster relief
situation) healthcare professionals
should inform the parents about the risk
for PTSD. This should be accompanied by
a brief description of the most likely
symptoms and an information sheet
about what to expect.
First-step: Identification and
Management of Symptoms
The “Facts for Families”, “Helping
Your Child After a Disaster” and
“Post-Traumatic Stress Disorder”
prepared by the American Academy
of Child and Adolescent Psychiatry
offer this information and can be
disseminated. (Available in several
languages – used worldwide)
Stage-Based Treatment of PTSD
for Children and Adolescents
Traumatic Event: Treatment
• First-Step Management: Evaluation and trauma-
focused support for children and parents
First Hours • Front-Line Education: Hotlines, media, one:one
consultation
• Consider SSRI’s and alpha-adrenergic blockers
for adolescents and parents following early
screening
• Trauma diaries and drawing pictures
---------------------------------------------------------------------------------
• Evaluation and trauma-trauma-focused support for parents
and children
Days •
•
Ongoing education for parents and children
Trauma-
Trauma-focused CBT for children, adolescents and
parents
• Psychiatric Evaluations for Children and Parents
---------------------------------------------------------------------------------
• Trauma-
Trauma-focused group, individual and family
therapy
• Complex medication evaluations considering
• (SSRI’
(SSRI’s and other medications including support for
sleep disturbances)
• Long-
Long-term education efforts regarding long- long-term
Months/Years problems
• Continue to look for co- co-morbid diagnoses
• Individual, family and group psychotherapy
Trauma-focused Cognitive
Behavioral Therapy (a version)
1. Collaboration between parents and therapist and child
therapist – a trusting relationship must be established
2. Psychoeducation: the therapist explains both to child and
parents, in a developmentally appropriate manner, the
etiology, symptoms and treatment
3. Exposure, both imaginal and in vivo, gradually decreasing a
child’s fears
4. Anxiety is graded by a fear thermometer (0-10)
5. Relaxation techniques may be used to decrease anxiety
6. The therapist helps the child to tell and re-organize their
trauma narrative, modifying negative thoughts and reducing
avoidance
7. The meaning that the traumatic memory has for them is
understood and dysfunctional beliefs are modified
(Vickers B et al., 2005)
An Integrated Treatment Model
Child-Parent Psychotherapy with Young
Children Exposed to Violence
(Liberman A, 2006)
Violence in domestic situations with
younger children results in loss of security
for the child and the parent alike, doubles
the rate of psychiatric problems and
negatively changes the parent-child
relationship. Following violence, the parent
and child may act as traumatic reminders to
each other with mutual negative attributions
and impaired affect regulation
Multi-Theoretical/Integrational
• Developmentally Informed
• Attachment
• Psychoanalytic
• Social Learning
• Cognitive-Behavioral
(Lieberman A, 2006)
Child-parent Psychotherapy
Intervention Modalities
1. Promote developmental progress through
play, physical contact, and language
2. Unstructured/reflective developmental
guidance
3. Modeling protective behaviors
4. Interpretation: linking past and present
5. Emotional support
6. Concrete assistance, case management,
crisis intervention
(Lieberman A, 2006)
Child-Parent Psychotherapy Goals
• Encouraging normal development:
engagement with present activities and
future goals
• Maintaining regular levels of affective
arousal
• Establishing a trust in bodily
sensations
• Achieving reciprocity in intimate
relationships
(Lieberman A, 2006)
Child-Parent Psychotherapy
Trauma-Related Goals
• Increased capacity to respond to threat
• Differentiation between reliving and
remembering
• Normalization of the traumatic
response
• Placing the traumatic experience in
perspective
(Lieberman A, 2006)
Treatment of Child and Adolescent
PTSD with Medications
Key Points
1. There are few randomized controlled trials, but several clinical trials have
been completed
2. Early treatment of anxious arousal with Beta-blockers (10-100 mg PO
daily) may decrease acute symptoms of anxiety and/or prevent the
development of the disorder (Off-label-prescribing)
3. Treatment of symptoms at any point with Selective Serotonin Reuptake
Inhibitors (low-full dose). These medications also treat associated
depression, panic attacks and sleep disturbance. (Sertraline (12.5-200
mg) and paroxetine (5-50 mg) are FDA-approved with adults for treating
PTSD and other symptoms).
If children and adolescents are treated with SSRI’s it is important to be aware of:
Black Box Data: A recent meta-analysis of suicidal ideation and behavior
in placebo-controlled clinical trials of paroxetine in adult patients with
Major Depressive Disorder and other psychiatric disorders showed a
higher frequency of suicidal behavior in young adults treated with
paroxetine as compared with placebo. It is vital to carefully monitor
young adult patients treated with paroxetine and other SSRI’s. “Start low
and go slow” in both directions to avoid increased arousal and unwanted
side effects.
Treatment of Child and Adolescent
PTSD with Medications
4. Antiseizure medications such as carbamazepine
(200-800 mg daily) may be used to treat anger and
behavioral problems associated with PTSD.
5. Benzodiazepines such as clonazepam (.25-2 mg
daily) can be used on a temporary basis to treat
associated anxiety, but pose several problems.
Withdrawal and aggravation of symptoms in
adolescents are serious concerns.
6. Major tranquilizers such as risperidone (.25-1 mg
daily) can be used to reduce associated anxiety,
disorganization and psychotic features
7. Buspirone (a 5-HT receptor agonist) has
successfully treated anxiety in adolescents (5-60
mg). There are no trials with PTSD.
Treatment of Child and Adolescent
PTSD with Medications
8. Clinical Studies of PTSD Symptoms in Children and
Adolescents with Atypical Antipsychotics (off-label uses)
• Stathis et al, 2005 – 6 week open label study of
quetiapine (50-200 mg). Six adolescents with PTSD
showed decreased symptoms of dissociation, anxiety,
depression and anger. No side effects noted.
• Kant et al, 2004. Nineteen adolescents with refractory
PTSD were treated with clozapine (mean dose 102
mg/day). Symptom reduction but many side effects
among them weight gain, agranulocytosis, neutropenia
and sedation.
• Harrigan and Barnhill (1999) – 15 of 18 children with
PTSD and co-morbid bipolar disease or ADHD showed
large decreases in symptoms with risperidone (mean
dose 1.37 mg/day) No side effects noted.
Treatment of PTSD in children and
adolescents:
Eye Movement Desensitization and
Reprocessing (EMDR)
• Based on theoretical model – dysfunctional
intrusions, emotions and physical sensations are
due to improper storage of traumatic events in
implicit memory.
• Treatment consists of eliciting specific targets to
represent the traumatic events, triggers and
future templates for better function.
(Shapiro, 2001)
Question: Is it the cognitive therapy component
that is helpful?
Meta-analysis of Psychotherapy
with PTSD in Adults
• Brief psychotherapies for PTSD produce
substantial improvement. Of patients who
complete treatment, 67% no longer meet
criteria for PTSD.
• Of those who enter treatment (whether or
not they complete), the recovery rate is
56%.
• Most studies do follow-up only through 6
months. Studies are planned with children
and adolescents.
(Bradley et al., 2005)
High Risk Situations for
Child and Adolescent PTSD
1. Pediatric Intensive Care Unit and
serious medical illnesses
2. Having a Developmental Disability
3. Physical and sexual abuse plus
witnessing violence at home and in
communities
4. Exposure to man-made and natural
disasters
5. War, terrorism and refugee status
PTSD in the Pediatric ICU
• Children, adolescents and their
parents in ICU settings are at
increased risk for PTSD during and
after their stay
• Injury, illness, treatment and
separation from family all contribute
to PTSD in the ICU setting
(Ward-Begnoche, 2007)
PTSD in the Pediatric ICU
Symptoms persist after discharge
• In one study, 75% of children and
adolescents presented with PTSD
symptoms on admission
• 50% had depressive or anxiety
disorders
• 17% had symptoms three months later
Consult questions:
• Is he depressed?
• Does he need medications?
• Can you help him talk?
Assessment and Diagnosis
• Phone interview with parents who reveal details
about the car accident and earlier history of
Benjie’s life.
• In-person interview with aunt, uncle and a 14 year-
old sister who were not in the accident.
• Check adequacy of pain medications.
• Review diagnostic criteria for ASD, PTSD,
bereavement, selective mutism, separation anxiety
disorder, communication disorders and major
depressive disorder.
• Symptom checklist filled out by Benjie’s primary
nurse
• Medical tests have ruled out medical etiologies for
Benjie’s silence.
Early Interventions and
Continued Assessment
• An initial phone call is arranged with
Benjie and his mother. Their primary
nurses and Benjie’s therapist are
present. Benjie cries, but does not
speak. Daily calls are begun.
• Benjie’s symptoms fit selective mutism
and major depressive disorder and he is
also grieving, although has not yet been
told about his two siblings.
In addition, Benjie meets the
following criteria for PTSD:
A. Witnessed the death of his two siblings and experienced fear
and helplessness, verified by parents.
B. Re-experiencing symptoms
Intense psychological distress at cues that remind him of
trauma.
C. Avoidance
1. Efforts to avoid thoughts, feelings and conversations about
trauma
2. Inability to recall events related to trauma
3. Decreased interest in significant activities
4. Restricted range of affect
D. Symptoms of Arousal
1. Difficulty falling asleep
2. Difficulty concentrating
3. Hypervigilence
4. Exaggerated startle response
Continued Interventions
1. Low doses of an SSRI are added and within 4-5 days
his hypervigilence and exaggerated startle are
decreased.
2. Benjie develops sign language with his therapist and
begins to hum in sessions.
3. Following a session where he draws a picture of the
accident, he says a few words.
4. Several days later, his parents are able to visit him
for the first time. They tell him his two siblings are
dead.
5. Family sessions are held with Benjie, his grieving
parents and their parist priest.
6. Benjie leaves the hospital with two casts, but
speaking and continues treatment outside of the
hospital.
PREVENTION
PREVENTION
PRIMARY Efforts which decrease
(universal) PTSD by decreasing its
incidence
SECONDARY Efforts to reduce the
(selective) prevalence of the disorder,
treats the population at
highest risk
TERTIARY Efforts to minimize the
(indicated) sequelae of PTSD
Prevention Efforts with PTSD
and Children
PRIMARY Gun-control efforts, post-
(universal) disaster media effort, seat
belts
SECONDARY School and community
(selective) based intervention
programs, post-disaster
intervention efforts
TERTIARY Most treatment efforts
(indicated)
Mental Health Intervention for
Children Exposed to Violence
in Los Angeles Schools
• Context: First randomized controlled study
conducted on 6th graders who reported symptoms
of PTSD.
• Design: Randomized control – two schools used
with a 10-session module
• Pre-assessment and 3 and 6 month post-
assessment
• Results: At 3 months, significant difference in
reported PTSD and depression symptoms. At 6
months, no significant difference noted.
(Stein et al., 2003)
Cognitive Behavioral Intervention in
Los Angeles Schools (10 sessions)
SESSION PROGRESSION
1 Introduction, explanation of trauma and treatment
2 Relaxation training, education about common reactions
to trauma
3,4 Fear thermometer, combat negative thoughts, links
between thoughts and feelings.
5 Alternative coping strategies
6,7 Exposure to trauma memories through drawing.
8 Introduction to social problem-solving
9 Practice with problem-solving and hot-seat
10 Graduation
(Stein et al., 2003)
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