Post Traumatic Stress Disorder

What is Post-Traumatic Stress Disorder (PTSD)?

Definition of PTSD:

A common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Family members of victims also can develop the disorder. PTSD can occur in people of any age, including children and adolescents. More than twice as many women as men experience PTSD following exposure to trauma. Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur with PTSD.

http://www.medterms.com/script/main/art.asp?articlekey=18779

What is Child Traumatic Stress (CTS)?

Definition of CTS:

Child traumatic stress occurs when children and adolescents are exposed to traumatic events or traumatic situations, and when this exposure overwhelms their ability to cope with what they have experienced. Depending on their age, children respond to traumatic stress in different ways. Many children show signs of intense distress—disturbed sleep, difficulty paying attention and concentrating, anger and irritability, withdrawal, repeated and intrusive thoughts, and extreme distress—when confronted by anything that reminds them of their traumatic experiences. Some children develop psychiatric conditions such as posttraumatic stress disorder, depression, anxiety, and a variety of behavioral disorders.

http://www.nctsn.org/nccts/nav.do?pid=faq_def

Children and adolescents experience trauma under two different sets of circumstances.

Some types of traumatic events involve (1) experiencing a serious injury to yourself or witnessing a serious injury to or the death of someone else, (2) facing imminent threats of serious injury or death to yourself or others, or (3) experiencing a violation of personal physical integrity. These experiences usually call forth overwhelming feelings of terror, horror, or helplessness. Because these events occur at a particular time and place and are usually short-lived, we refer to them as acute traumatic events. These kinds of traumatic events include the following:

• School shootings
• Gang-related violence in the community
• Terrorist attacks
• Natural disasters (for example, earthquakes, floods, or hurricanes)
• Serious accidents (for example, car or motorcycle crashes)
• Sudden or violent loss of a loved one
• Physical or sexual assault (for example, being beaten, shot, or raped)

In other cases, exposure to trauma can occur repeatedly over long periods of time. These experiences call forth a range of responses, including intense feelings of fear, loss of trust in others, decreased sense of personal safety, guilt, and shame. We call these kinds of trauma chronic traumatic situations. These kinds of traumatic situations include the following:

• Some forms of physical abuse
• Long-standing sexual abuse
• Domestic violence
• Wars and other forms of political violence

http://www.nctsn.org/nccts/nav.do?pid=faq_def

Symptoms:

The diagnosis of PTSD requires that one or more symptoms from each of the following categories be present for at least a month and that symptom or symptoms must seriously interfere with leading a normal life:

• Re-experiencing the traumatic event:

 * Post-traumatic play: play that represents a reenactment of some aspects of trauma
 * Traumatic event outside play such as drawing pictures related to the event.
 * Repeated nightmare. 
 * Distress at exposure to reminders of the trauma. 
 * Episodes with objective features of a flashback or dissociation: a child makes dolls fight after hearing a siren because it reminds
   the child of the ambulance that arrived after the argument between the child’s parents.

• Numbing of responsiveness

 * Increased social withdrawal.
 * Restricted range of affect.
 * Temporary loss of previously acquired developmental skills.
 * A decrease or constriction in play compared to the child’s pattern before the traumatic event. 

• Increased Arousal

 * Night terrors: child starts from sleep with a panicky scream and shows some signs such as rapid breathing, racing pulse, and sweating. 
 * Difficulty going to sleep.
 * Hypervigilance.
 * Exaggerated startle response.

• Symptoms not present before the traumatic event

 * Aggression toward peers, adults or animals.
 * Separation anxiety.
 * Fear of toileting alone. 
 * Fear of the dark.
 * Other new fears.
 * Pessimism or self-defeating behavior. 
 * Sexual and aggressive behaviors inappropriate for a child’s age.
 * Other new symptoms.

Zero to Three: National Center for Infants, Toddlers, and Families. (1999).

Physical symptoms such as headaches, gastrointestinal distress, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common in people with PTSD. Often, these symptoms may be treated without the recognition that they stem from an anxiety disorder.

Assessment:

Diagnosis tools that have been used for evaluation are:

• Clinician-administered Post-traumatic Stress Scale (CAPS) for adults
• Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3) for children

Treatment:

• Cognitive-Behavioral Therapy (CBT) is the most effective approach. The process of CBT 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. There are a number of approaches to Cognitive-Behavior Therapy including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy, however all share some common traits and beliefs:

    Thoughts cause feelings and behavior
    Both client and therapist use questioning techniques
    CBT is inductive (based on facts)
    Many CBT approaches help clients meet a new situation calmly, thus 
      better able to think through the situation and respond positively
    CBT is structured and goal oriented
    Success is dependent upon the client completing homework
    Therapy is a collaborative effort between the client and the therapist
    Results from therapy are relatively quick
    CBT has long term results because clients learn how to feel better 
      and why that happens
    CBT teaches rational self-counseling (people learn to think differently
      and act on those thoughts)

• Psycho-education and parental involvement: Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. It is believed that the better parents cope with the trauma, and the more they support their children, the better their children will function.
• Several other types of therapy have been suggested for PTSD in children and adolescents include play therapy, psychological first aid, eye Movement desensitization and reprocessing (EMDR), medications, and specialized interventions

How to Help Children with PTSD in the Classroom and Other Setting?

Making the diagnosis of PTSD requires evaluation by a trained mental health professional. However, regular classroom teachers have a major role in the identification and referral process. Children often express themselves through play. Because the teacher sees the child for many hours of the day including play time, the teacher may be the first to suspect all is not well. Where the traumatic event is known, caregivers can watch for PTSD symptoms. However, traumatic events can involve secrets. Sexual abuse, for example, may take place privately. Sensitive teachers should monitor all children for changes in behavior that may signal a traumatic experience or a flashback to a prior traumatic experience.

Teachers can help a child suspected of post traumatic stress disorder by:

• Gently discouraging reliance on avoidance; letting the child know it is all right to discuss the incident;

• Talking understandingly with the child about their feelings;

• Understanding that children react differently according to age - young children tend to cling, adolescents withdraw;

• Encouraging a return to normal activities;

• Helping restore the child's sense of control of his or her life; and

• Seeking professional help.

Professional assistance is most important since PTSD can have a lifelong impact on a child. Symptoms can lie dormant for decades and resurface many years later during exposure to a similar circumstance. It is only by recognition and treatment of PTSD that trauma victims can hope to move past the impact of the trauma and lead healthy lives. Thus, referral to trained mental health professionals is critical. The school psychologist is a vital resource, and guidance counselors can be an important link in the mental health resource chain.

Although professional assistance is ultimately essential in cases of PTSD, classroom teachers must deal with the immediate daily impact. Becoming an informed teacher isthe first step in helping traumatized children avoid the life long consequences of PTSD.

Core Principles for Practice

• Healing begins with relationships.

No matter what your role is, you have a relationship with the child and the family that becomes the foundation for helping them. Some professionals —police officers, for example—are not usually trained to think in relationship terms. Our research findings, which document children’s positive feelings about police officers and their readiness to turn to them for help, provide a useful beginning for a discussion of non-threatening ways in which police officers can talk to young children about frightening events.

• Stabilize environments for children and families and to provide safety and security for them.

This principle has different implications for a mental health clinician than a health provider or a teacher. The mental health clinician can begin to think about the therapeutic space as a safe haven. Teachers can strive to make their classrooms havens of predictability and routine, thereby helping children to feel safer and calmer.

• Helping their parents.

This principle leads us to look carefully at how easy it is to blame parents for their failure to protect their children. This stance of blame or anger at parents leads us act in ways that undermine, criticize, or de-value them. This ultimately will not help children.

• Comforting with the limits of our professions.

In learning what we can do to help children affected by violence, we must also be reminded of what we are not able to do. Child care providers, for example, cannot intervene directly with families, but they can and should learn where to go for consultation and guidance if they are concerned that a child might be living with domestic violence.

• Good supervising, peer supporting, and self care are essential for workers in this field.

We have learned in working with young children and families exposed to violence that any act of violence has a ripple effect on the caregiving system of a child—child care providers, other professionals who work with the family, and the community. All agencies—including law enforcement agencies— whose staff work to any extent with young children and families exposed to violence must be attuned to the stresses of this work and responsive to the needs of staff for a safe place to talk about the meaning of violence and about difficult feelings of anger and vulnerability. Exceptionally strong support for staff is essential to the success of programs that serve young children and families who have been traumatized by violence.

• Looking at our own attitudes toward violence as we seek to understand and inform the attitudes of others.

Many of us began our work with young children exposed to violence with a focus on violence in the community. As we have learned more about how children are exposed to violence and where this violence happens, we have learned about the prevalence of domestic violence, which is even more difficult and complex to talk about than violence “out there” in the street. We must be prepared to confront our own stereotypes and prejudices in order to join families and colleagues in addressing the wrenching dilemmas presented by domestic violence.

Betsy McAlister Groves, Alicia Lieberman, Joy D. Osofsky, and Emily Fenichel. (2000).

Researches of PTSD in Young Children

Study 1

Adolescents who witness interparental violence (IPV) are at increased risk for perpetrating aggressive acts. They are also at risk for post-traumatic stress disorder (PTSD). In this study, the researchers examined the relation between exposure to maternal vs. paternal physical IPV and adolescent girls' and boys' aggressive behavior toward mothers, fathers, friends, and romantic partners. The researchers also assessed the influence of PTSD (as assessed by the Diagnostic Interview for Children and Adolescents-IV (DICA-IV)) on the relation between exposure to IPV and aggressive behavior.

Methodology: Participants were 63 girls and 49 boys, ages 13–18, consecutively admitted to a youth correctional facility or assessment facility designated to serve aggressive and delinquent youth. Structural equation modeling was used to estimate unique relations between exposure to maternal vs. paternal IPV and youth aggression in relationships.

Results: Girls who observed their mothers' aggressive behavior toward partners were significantly more aggressive toward friends. Similarly, boys who witnessed their fathers' aggression were significantly more aggressive toward friends. Adolescent girls and boys who observed aggression by mothers toward partners reported significantly higher levels of aggression toward their romantic partners. Approximately one third of our sample met PTSD criteria; the relation between exposure to parental IPV and aggression was stronger for individuals who met criteria for PTSD.

Conclusion: The implications of understanding the relations between parents' and their daughters' and sons' use of aggression are discussed within the context of providing support for families in breaking intergenerational patterns of violence and aggression.

Moretti, Mariene M., Obsuth, Ingrid, Odgers, Candice,and Reebye, Pratibhe. (2006).

Study 2

Three studies on children have shown that females are more symptomatic than males following trauma. Kiser et al.(1988) showed that following sexual abuse, males were initially more symptomatic, but females were more symptomatic at 1-year follow up. Wolfe, Sas, and Wekerle (1994)examined children following sexual abuse, and found that females met the diagnosis of PTSD more often than males. Finally, in Green et al.'s (1991) study of flood victims, gials were more symptomatic than boys.

Michael S. Scheeringa and Charles H.Zeanah. (1995).

Study 3

To determine whether infants have a traumatic response to intimate partner violence (male violence toward their female partner; IPV) experienced by their mothers, two questions were explored: (1) Is the number of infant trauma symptoms related to the infant's temperament and the mother's mental health? (2) Does severity of violence moderate those relationships?

Methodology: Forty-eight mothers reported whether their 1-year-old infants experienced trauma symptoms as a result of witnessing episodes of IPV during their first year of life. Mothers also reported on their own trauma symptoms that resulted from experiences of IPV.

Results: For those infants experiencing severe IPV and whose mothers exhibit trauma symptoms, we were able to predict whether infants exhibited trauma symptoms (b =.53, p <.01). This was not true for children who witnessed less severe IPV (b =-.14, ns). Maternal depressive symptoms and difficult infant temperament did not predict infant trauma symptoms for either group of infants.

Conclusion: Mothers report that infants as young as 1-year-old can experience trauma symptoms as a result of hearing or witnessing IPV. The significant relationship between infant and maternal trauma symptoms, especially among those infants experiencing severe IPV, are consistent with the theory of relational PTSD. Findings suggest that interventions for mothers and families need to consider the influence of the severity of IPV on very young children

Bogat, G. Anne, DeJonghe, Erika, Levendosky, Alytia A., Davidson, William S., and von Eye, Alexander. (2006).

Critics and Rationale of PTSD

Scheeringa, Zeanah, Drell, and Larrieu (1995)found that the DSM-IV criteria for PTSD were inadequate for diagnosing a post traumatic stress disorder in very young children. The reason is that the DSM-IV criteria did not adequately take into account the preverbal or barely verbal capacities of such young children which rendered then unable to report their subjective ewperience as required chilnicians to make inferences about the children's thoughts and feelings, which left much room for clinician bias, error, and unreliability. They also demonstrated that an alternative set of criteria for infants and young children was more reliable and more valid that the DSM-IV criteria.

Michael S. Scheeringa and Charles H.Zeanah. (1995).

Considerations of PTSD and CTS

The United States is the most violent developed country in the world. Children are its youngest victims. Violence has reached down to our very youngest children and even shaken the cradle. Parents, justifiably, are concerned with their children's physical and psychological safety.

Unfortunately, today's infants are in double jeopardy. On the one hand, they are in danger of becoming the victims of violence. And on the other hand, they can become accustomed to violence, losing the ability to empathize with its victims, and taking on the role of the aggressor. The fact is: violence is learned.

Since children do experience violence, do try to understand it, and do remember it, we must pay attention to their experience. We must learn to comprehend the meaning of violence for infants and toddlers, especially since they don't yet have language to help organize their experience and express their feelings.

http://www.zerotothree.org/Search/index2.cfm

Case Study of Children with PTSD

Case 1

Jessica, a 7-year-old girl, was withdrawn and quiet in the classroom and somewhat distant from her peers. Although she had previously been a top student, Jessica's academic performance was faltering. On several occasions, the teacher had observed her masturbating while she was working at her desk. Jessica then began to refuse to go to gym class because she said she was afraid of the teacher, a male. She also complained frequently that she was tired, but she had trouble falling asleep at night and was often awakened by nightmares about strange men. When the school psychologist spoke with Jessica, she learned that her mother had recently remarried and on weekends Jessica was left in the care of her stepfather while her mother was at work. Jessica also stated that when her stepfather had a "funny smell on his breath" he would engage Jessica in mutual genital stimulation.

Case 2

Larry is 40-months-old. Almost a year ago, when he was 29 months old, Larry saw his father shoot himself, fatally, in the head. Now, Larry's mother has brought him to an infant mental health clinic because Larry won't stop talking about his father shooting himself. During the initial evaluation session with his mother and a male examiner, Larry picks up a toy gun that is in the playroom, examines the trigger, walks over to the examiner and shoots him in the head, saying "I'll shoot you!" Then Larry says, "I'll shoot Mommy!" He walks over to his mother and shoots her in the head. Later in the session, he picks up the daddy doll, shoots it in the head with the gun, and he says, "He is dead." Then he shoots the mother doll in the head...

http://www.zerotothree.org/Search/index2.cfm

Case 3

This story is about 22-month-old boy and his paternal grandmother. The child had witnessed his mother murder his father; the next day, the mother kills herself. The grandmother decided to assume responsibility for the boy and brought him to the mental health clinic for evaluation. She was grief-stricken at her son’s death and not too familiar with her grandson (she had 12 children and 23 grandchildren at the time). Treatment included sessions with the boy and grandmother together and occasional sessions with the grandmother alone. Work involved both helping to resolve the boy’s post-traumatic symptoms and building a relationship between the boy and his grandmother. A central part of this process was being available to the grandmother so that she could become aware of and address her own feelings of grief about son’s murder. She also needed to recognize her fears about losing this child, as she had lost his father. When she was able to bring these fears to conscious awareness, she became better able to make an explicit commitment to her grandson.

Charles H.Zeanah. (1994).

References and other links of interest

References:

Betsy M. Groves, Alicia Lieberman, Joy D. Osofsky, and Emily Fenichel. (2000). Protecting Young Children in Violent Environments, April/May 2000 (Vol 20:5).

Bogat, G. Anne, DeJonghe, Erika, Levendosky, Alytia A., Davidson, William S., and von Eye, Alexander. (2006). Trauma symptoms among infants exposed to intimate partner violence. Chid Abuse & Neglect; Feb 2006, Vol. 30 Issue 2, p109-125, 17p.

Charles H.Zeanah. (1994). The assessment and treatment of infants and toddlers exposed to violence. In J.D. Osofsky & E. Fenichel (Eds.), Caring for infants and toddlers in violent environments: Hurt, healing and hope (pp. 29-37). Arlington, VA: Zero to Three.

Defining trauma and child traumatic stress. Retrieved July 6, 2006 from http://www.nctsn.org/nccts/nav.do?pid=faq_def.

Definition of post-traumatic stress disorder. (2003). Retrieved July 6, 2006 from http://www.medterms.com/script/main/art.asp?articlekey=18779.

Michael S. Scheeringa and Charles H.Zeanah. (1995). Symptom expression and trauma variables in children under 48 months of age. Infant Mental Health Journal, Vol.16, No.4, Winter 1995

Moretti, Mariene M., Obsuth, Ingrid, Odgers, Candice,and Reebye, Pratibhe. (2006). Exposure to maternal vs. paternal partmer violence, PTSD, and aggression in adolecent girls and boys. Aggressive Behavior; Aug 2006, Vol.32, Issue 4, p385-395, 11p.

Zero to Three: National Center for Infants, Toddlers, and Families. (1999). Diagnostic classification: 0-3: Diagnostic classification of mental health and development disorders of infancy and early childhood. (5th ed., pp. 75-76). DC: Zero to Three.

Zero to Three Home. (N.A.). Young children and violence. Retrieved July 6, 2006 from http://www.zerotothree.org/Search/index2.cfm.

Links:

The National Child Traumatic Stress Network. URL: http://www.nctsn.org/nccts/nav.do?pid=faq_def

Zero to Three URL: http://www.zerotothree.org/

United State Department of Veterans Affairs URL: http://www.ncptsd.va.gov/

Cognitive Behavior Therapy - National Association of Cognitive-Behavioral Therapists URL: http://www.nacbt.org/whatiscbt.htm