Theodora Phea Pinnock, M.D.,

1
The Drama of Trauma Post Traumatic Stress
Disorder in Children

• 
  
• 
  
• 
  
• presented by
• 
  Theodora Phea Pinnock, M.D.,
• Developmental and Behavioral Pediatrician
  
• theodorapinnock_at_att.net
• November 19, 2010

2
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)

3
The Movie Board

• Born on the Fourth of July (1989)
• Goals
• Pretest
• Ordinary People (1980)
• Statistics
• History of PTSD
• Definition
• Signs symptoms
• Fearless (1993)
• Why some children not others? (Risk Factors)
• Impact of Foster Care

4
The Movie Board

• Taxi Driver (1976)
• Some evidencedbased treatments
• Coming Home (1978)
• Prevention of PTSD in children
• Recommendations for clients with PTSD
• The Fisher King (1991)
• Posttest
• Questions
• Birdy (1984)
• Credits (References)

5

• Born on the Fourth of July

6
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.

7
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

8
Pretest

• 3. Ways to prevent PTSD in children
• A. Provide a strong supportive presence
• B. Establishing routines with flexibility
• C. Accept childrens regressed behaviors while
  encouraging and supporting a return to
  age-appropriate activity
• D. Neither of the above.
• E. All of the above.

9
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

10
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.

11

• Ordinary People

12
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

13
Statistics

• 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.
•  

14
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.
•  

15
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
•  

16
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

17
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.

18
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).

19
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).

20
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).

21
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

22
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.

23
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
  trauma-related 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.
•  

24
Signs and Symptoms of PTSD

• Symptoms in Elementary School Children
• School-aged children also reportedly exhibit
  post-traumatic 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).

25
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.

26

• Fearless

27
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.

28
Other Risk Factors for PTSD

• Interpersonal Trauma- Rape and assault
• Experienced a number of traumatic events
• Gender Girls versus boys 

29
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

30
Children Who Experience Maltreatment

• Substance abuse
• Depression
• Anxiety Disorders
• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Conduct Disorder

31

• Taxi Driver

32
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.

33
Trauma Focused-CBT Components

• APRACTICE
• Assessment
• Psychoeducation and Parenting Skills
• Relaxation
• Affective Modulation
• Cognitive Coping
• Trauma Narrative and Processing
• In Vivo Desensitization
• Conjoint parent-child sessions
• Enhancing safety

About Anxiety About Trauma
Imaginal Exposure
In Vivo Exposure
34
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.

35
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

36
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.

37
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.

38
Treatment

• Family TherapyWith 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

39
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
  parent-child 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.

40

• Coming Home

41
Prevention of PTSD

• Screenings-Screening Tool for Early Predictors of
  PTSD (STEPP)

42
Recommendations

• Support
• Parents or Caregivers
• School
• Peers
• Therapists in Tennessee
• Cities Counties in Tennessee
  http//therapists.psychologytoday.com/rms/prof_res
  ults.php?stateTNspec19

43

• The Fisher King

44
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

45
Posttest

• 3. Ways to prevent PTSD in children
• A. Provide a strong supportive presence
• B. Establishing routines with flexibility
• C. Accept childrens regressed behaviors while
  encouraging and supporting a return to
  age-appropriate activity
• D. Neither of the above.
• E. All of the above.

46
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

47
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
Questions
49

• Birdy

50
References

• WEBSITES
• http//www.aacap.org
• http//www.mental-health-today.com/ptsd/dsm.htm
• http//ncmbts.blogspot.com/2010/01/post-traumatic-
  stress-disorder.html
• http//www.practicenotes.org/vol10_no3.htm
• http//www.iom.edu/Activities/MentalHealth/PTSDTre
  atment.aspx
• http//www.jaacap.com/article/S0890-8567(09)62235-
  8/abstract

51
References

• WEBSITES
• http//emedicine.medscape.com/article/918844-overv
  iew
• http//www.governorsinstitute.org/index.php?option
  com_docmantaskdoc_viewgid197
• http//www.culturallycompetentmentalhealthnj.org/d
  ocs/Sept07Workshops/evidence-based-practices/Evide
  nce-Based-Practices.pdf
• http//www.agpa.org/pubs/5-children-adolescents-eb
  t.pdf
• http//www.dartmouth.edu/admsep/resources/cinema.
  html

52
References

• WEBSITES
• http//www.abct.org/sccap/?msProfapro_ESToption
  ssec3
• http//bjp.rcpsych.org/cgi/content/abstract/160/3/
  30
• http//www.brighthub.com/mental-health/anxiety-pa
  nic/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/290/5/6
  43
• http//www.brighthub.com/mental-health/anxiety-pa
  nic/articles/90489.aspx

53
References

• WEBSITES
• http//anxiety.emedtv.com/ptsd/ptsd-in-children-p5
  .html
• http//www.ptsd.va.gov/public/pages/ptsd-children
  -adolescents.asp
• http//anxiety.emedtv.com/ptsd/ptsd-in-children.ht
  ml
• http//userwww.service.emory.edu/jdbremn/instrume
  nts/ETISR-SF.pdf

54
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 AssociationWashington, DC,
  2000.