Post-traumatic stress disorder in children and adolescents

Post -traumatic stress disorder (PTSD) is a syndrome defined by the intrusive re-experiencing of trauma, avoidance of reminders of the trauma and increased hyperarousal. Although the condition is well established in adults, there is little research into PTSD in children and adolescents. The available research shows that young people experience similar symptoms to adults. Risk factors include family dysfunction, peer problems, greater exposure to the trauma and the presence of pre-existing psychiatric disorder such as anxiety. Protective factors include good coping skills, good relationship with a parent and support from others in the community. This article reviews treatment approaches to PTSD in young people in particular the use of cognitive behavioural therapy (CBT). Key words. PTSD, hyperarousa!, avoidance, CBT.






Publication: Community Practitioner
Author: Chowdhury, Uttom
Date published: December 1, 2011

Introduction

Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur following the experiencing or witnessing of a traumatic event. The event is usually life threatening or perceived to be likely to cause serious injury to self or others. Young people may react with a number of symptoms such as intense fear, helplessness and nightmares. Usually the change in affect and behaviour is short lived and may fade over a few days or weeks as the threat is removed. Sometimes the young person may respond positively having survived a difficult experience and learn new coping skills. However some young people continue to have acute symptoms months after the event. The continuing presence of a range of symptoms related to anxiety after a traumatic event is called post-traumatic stress disorder (American Psychiatric Association, 1994). See Table 1 for diagnostic criteria.

Clinical features

There are three main groups of symptoms (Scheeringaetal, 2003):

* Re-experiencing of the trauma

* Avoidance of trauma reminders and emotional numbing

* Symptoms of hyperarousal.

Re-experiencing

Re-experiencing can involve:

* Post-traumatic play

* Play re-enactment

* Recurrent recollections

* Nightmares

* Flashbacks

* Distress at exposure to reminders of the traumatic event.

Avoidance and emotional numbing

Symptoms ot avoidance or numbing include:

* Constriction of play

* Relative social withdrawal

* Restricted range of affect

* Decreased interest in activities that were previously enjoyed

* Loss of acquired developmental skills

* Inability to recall an important aspect of the trauma.

Hyperarousal

Hyperarousal can involve:

* Night terrors

* Difficulty going to sleep (not related to fear of having nightmares or of the dark)

* Night waking that is not related to nightmares or night terrors

* Decreased concentration

* Hypervigilance

* Exaggerated startle response

* Angry outbursts.

Some children experience 'dissociation', which is the emotional numbing that may result from repeated trauma in order to block or dull the pain and trauma [Perry and Pollard, 1998). In the dissociative state, the child responds to internal body sensations, such as thoughts, and is less responsive to the external world. The child may present with distraction, avoidance, numbing, daydreaming or wandering off without realising it (fugue), and some may create a fantasy world.

Presentation varies with age. Children may lose interest in things they used to enjoy. They may find it hard to believe that they will live long enough to grow up. They often complain of stomach aches and headaches.

School-aged children (five to 15 years)

Can experience:

* 'Time skew' - mis-sequencing traumarelated events

* Omen formation' - belief that there were warning signs that predicted the trauma

* Post-traumatic play - a literal representation of the trauma, which involves compulsively repeating some aspect of the trauma and does not tend to relieve anxiety, for example an increase in shooting games after exposure to a school shooting

* Re-enactment of the trauma in play, drawings or verbalisations - involves behaviourally recreating aspects of the trauma (eg, carrying a weapon after exposure to violence).

Adolescenrs and teenagers

Adolescents and teenagers are more likely ?? engage in traumatic re-enactment, in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviours. Unlike adults, children have a reduced ability to express verbally feelings of numbness and withdrawai so behaviour report and observation is important.

Other effects of trauma

Sexually abused children often have problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate and self- destructive behaviour, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others and substance abuse. Children often have problems with relationships with peers and family members, with acting out and with school performance.

Psychiatric disorders

A number of common co-occurring psychiatric disorders have been found to be associated with PTSD. These conditions are as a result of the spécifie trauma and in some cases, a behavioural response to the trauma. Substance abuse and anxiety disorders such as separation anxiety, panic disorder and generalised anxiety disorder and depression have increased prevalence in children with PTSD (American Academy of Child and Adolescent Psychiatry, 1998).

Bereavement

It is worth noting that traumatic experience may be accompanied by bereavement and other significant losses (Tufnell and Defong, 2009). There are usually three main stages of grief in children: initial crisis response; emotional disorganisation; adjustment.

First there is an initial crisis response. This involves shock, denial and disbelief. There may be emotional numbness, and thoughts and behaviour are directed toward the lost person.

Then comes emotional disorganisation. This includes sadness, crying, anger and resentment. Sometimes there may be feelings of despair and hopelessness or guilt. These may be accompanied by poor sleep, poor appetite and self-blame.

Adjustment takes place eventually with increased participation in life and everyday activities and formation of new attachments.

The child moves from stage to siage and may sometimes temporarily go back to the previous stage. The rate of progress through the stages also varies.

Epidemiology

The British National Survey of Menta! Health of over 10,000 children [Meltzer et al, 2000J reported that 0.4% of children aged 11- 15 years were diagnosed with PTSD, with girls showing twice the rate of boys.

Risk factors and protective factors

Risk factors include family dysfunction, peer problems, female gender, sexual victimisation past trauma exposure, greater exposure to the trauma and the presence of a preexisting psychiatric disorder such as anxiety. Protective factors include good coping skills, a good relationship with a parent, supportive family and support from others such as friends, teachers and the community.

Management

For a detailed review, please see the National Institute for Health and Clinical Excellence guidelines (NICE, 2005). Treatment involves assisting children in overcoming avoidance of innocuous trauma reminders, such as people, places, situations that are inherently safe. However, it is essential to protect children from realistic on-going threats or danger wherever possible. The main aspects of management include:

* Helping the child gain a sense of control over the trauma and a feeling of safety and security. Controlling the trauma includes the ability to recall, relate, narrate, and reconsider the trauma without feeling overwhelmed and without dissociating

* De-stigmatise the child's symptoms in the eyes of the child and the parents as they are natural responses to a traumatic event.

Parents should not be critical of the child and should support them. Children should participate in normal social activities as much as possible.

Some children show a natural remission in PTSD symptoms over a period of a few months (Bryant et al, 2004). However, a significant number of children continue to exhibit symptoms sometimes for years if untreated. There is good evidence to show that trauma focussed cognitivebehavioural psychotherapy can be effective for treatment of PTSD in children and young people who have been sexually abused. The research evidence for other interventions, however, is sparse. Currently NICE recommends CBT for PTSD symptoms in children. If other therapies are used then parents and families should be informed that the evidence for efficacy is not established. Current treatment options available via the child and adolescent mental health service (CAMHS) include:

* CBT

* Play therapy

* Psychological first-aid

* Eye movement desensitisation and reprocessing (EMDR)

* Medication

* Specialised interventions

CBT

Research studies show that CBT is the most effective approach for treating children and that it is safe. One of the best- researched types is trauma -focused CBT (TF-CBT). This usually involves thechild directly discussing the traumatic event, anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories. CBT also involves challenging children's false beliefs, such as 'the world is totally unsafe.'

CBT is often accompanied by psychoeducation and parental involvement. Psychoeducation involves educating the child about the symptoms of PTSD and their effects. It is equally important for parents and caregivers to understand the effects of PTSD, as studies show that the better parents cope with the trauma, and the more they support their children, then the better their children will function.

Play therapy

Play therapy can be used to treat young children with PTSD who are not able to deal with the trauma more directJy. The therapist uses games, drawings, and other techniques to help the children process their traumatic memories.

Psychological first-aid

Psychological first-aid has been used for school-age children and adolescents exposed to disasters and community violence, and can be used in schools and traditional settings.

Psychological first-aid involves providing co mfortandsupport.normalisingthe children's reactions, helping caregivers deal with changes in the child's emotions and behaviour, teaching calming and problem-solving skills, and referring the most symptomatic children for additional treatment. Interventions undertaken soon after the event should be low-key and care must be taken to avoid re-traumatising the child through vivid discussions or re-enactments of the events.

EMDR

EM DR combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and adults with PTSD, studies indicate that it is the cognitive intervention radier than the eye movements that accounts for the change.

Medication

Some evidence exists to show that selective serotonin re-uptake inhibitors (SSRJs) may help young people with anxiety1. Some dopamineblocking agents such as the neuroleptics may help symptoms. Alpha and beta-blockers have also helped, including clonidine and propranolol.

Specialised interventions

Specialised interventions may be necessary for children exhibiting particularly problematic symptoms or behaviours, such as inappropriate sexual behaviours, extreme behavioural problems or substance abuse.

It is worth noting that help in school is important. Group-based therapy has been shown to be effective for school children following specific trauma (Stein et al, 2003).

Prognosis

PTSD symptoms may last from several months to many years. The best approach is trauma prevention. However, once trauma has occurred, early intervention is essential:

* Support from parents, school and peers is important

* Emphasis needs to be placed upon establishing a feeling of safety

* Psychotherapy (individual, group or family) that allows the child to speak, draw, play or write about the event is helpful

* Behaviour modification techniques and cognitive therapy may help reduce fears and worries

* Medication may also be useful to deal with agitation, anxiety or depression.

Summary

Children and young people cope with trauma in different ways. Many get brief symptoms of anxiety lasting a few days. In some cases, the anxiety symptoms include nightmares, flashbacks and inability to cope with daily activities such as school work and general social functioning. Some children will develop symptoms of PTSD including hypervigilance, experiencing flashbacks and loss of enjoyment in usual pleasure activities with numbing of affect. It is important that clinicians recognise the symptoms in order to assess whether further intervention is needed. If symptoms persist for more than a month then a referral to the GP may be required. In turn he or she may refer to the local CAMHS if specific intervention is required.

References

American Academy of Child and Adolescent Psychiatry. (1998) Practice parameters for the assessment and treatment of children and adolescents with PTSD. Journal of the American Academy of Child and Adolescent Psychiatry 37 (suppl) 4s-26s.

American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders (4th ed.) (DSM-IV). Washington DC: APA.

Bryant B, Mayou R, Wiggs L et aL (2004) Psychological consequences of road traffic accidents for children and their mothers. Psycho] Med 34(2): 335-46.

Meltzer H et al. (2000) The mental health of children and adolescents in Great Britain: summary report. London: The Stationery Office.

National Institute for Health and Clinical Excellence (NICE). (2005) Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. London: NICE.

Perry BD, Pollard R. Í1998) Homeostasis, stress, trauma and adaptation. A neurodevebpmentai view of childhood trauma. Child Adolesc Psychiatr Clin N Am 7(1): 33-51, viii.

Scheeringa MS, Zeanah CH, Myers L et al. (2003) New findings on alternative criteria for PTSD in preschool children. ) Am Acad Child Adolesc Psychiatry 42(5): 561-70.

Stein B, laycox L, Kataoka S et al. (2003). A mental health intervention for schoolchildren exposed to violence. IMlA 290: 603-611.

Tufnell G, Dejong M. (2009) Stress and post-traumatic stress disorder. Paediatr Child Health 19(2): 79-83.

Author affiliation:

Uttom Chowdhury MRCPsych, MBChB

Consultant in child and adolescent psychiatry, Bedfordshire Child and Adolescent Mental Health Services

Amit Pancha

Medical student, Lancaster University

Correspondence: uttom.chowdhury@sept.nhs.uk

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