The Impact of Violence, Disaster, War,

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The Impact of Violence, Disaster, War,
Terrorism upon Teens

• Dr. Mick Maurer

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PTSD in Children and Adolescents

• The diagnosis of Posttraumatic Stress Disorder
  (PTSD) was formally recognized as a psychiatric
  diagnosis in 1980.
• At that time, little was known about what PTSD
  looked like in children and adolescents.

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Post Traumatic Stress Disorders (PTSD)Type I,
II, III

• - Associated Disorders
• Major Depressive Episode
• Posttraumatic Stress Disorder
• Generalized Anxiety Disorder
• Panic Disorder
• - Associated Complications
• Suicide
• Substance Abuse
• Self-Medication

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Definition

• A diagnosis of PTSD means that an individual
  experienced an event that involved a threat to
  one's own or another's life or physical integrity
  and that this person responded with intense fear,
  helplessness, or horror.

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Children and adolescents may be diagnosed with
PTSD if they have

1. survived natural and man made disasters such as
   floods
2. violent crimes such as kidnapping, rape or murder
   of a parent, sniper fire, and school shootings
3. motor vehicle accidents such as automobile and
   plane crashes
4. severe burns
5. exposure to community violence
6. war
7. peer suicide
8. and sexual and physical abuse.

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PTSD in adolescents may begin to more closely
resemble PTSD in adults.

• However, there are a few features that have been
  shown to differ.
• Children may engage in traumatic play following a
  trauma.
• Adolescents are more likely to engage in
  traumatic reenactment, 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 behaviors.

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Besides PTSD, what are the other effects of
trauma on adolescents?

• problems with fear,
• anxiety,
• depression,
• anger and hostility,
• aggression,
• sexually inappropriate behavior,
• self-destructive behavior,
• feelings of isolation and stigma,
• poor self-esteem,

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Other effects

• difficulty in trusting others,
• and substance abuse,
• also often have relationship problems with peers
  and family members,
• problems with acting out,
• and problems with school performance.

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Psychiatric Disorders that are commonly found in
adolescents who have been traumatized.

• One commonly co-occurring disorder is major
  depression.
• Other disorders include
• substance abuse
• other anxiety disorders such as separation
  anxiety, panic disorder, and generalized anxiety
  disorder
• externalizing disorders such as
  attention-deficit/hyperactivity disorder,
  oppositional defiant disorder, and conduct
  disorder.

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How do children respond to terrorism?

• More severe reactions are associated with
• a higher degree of exposure (i.e., life threat,
  physical injury, witnessing death or injury,
  hearing screams, etc.),
• closer proximity to the disaster,
• a history of prior traumas,
• being female,
• poor parental response,
• and parental mental health problems.

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Research on children from the September 11th,
2001 attacks the Oklahoma City Bombing.

• Two factors related to increased stress symptoms
  were
• 1) amount of television coverage viewed by the
  child,
• 2) parental distress.

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What can parents do?

• Eleven to eighteen years
• Encourage adolescents of all ages to talk about
  the traumatic event with family members.
• Provide opportunities for the young person to
  spend time with friends who are supportive.
• Reassure the young person that strong
  feelings-guilt, shame, embarrassment, or a wish
  for revenge-are normal following a trauma.
• Help the young person find activities that offer
  opportunities to experience mastery, control, and
  self-esteem.
• Encourage pleasurable physical activities such as
  sports and dancing.

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How many children develop PTSD after a terrorist
attack?

• Findings from Oklahoma City indicate that
• Children who lost a friend or relative were more
  likely to report immediate symptoms of PTSD than
  non-bereaved children.
• Arousal and fear presenting seven weeks after the
  bombing were significant predictors of PTSD.
• Two years after the bombing, 16 of children who
  lived approximately 100 miles away from Oklahoma
  City reported significant PTSD symptoms related
  to the event. This is an important finding
  because these youths were not directly exposed to
  the trauma and were not related to people who had
  been killed or injured.

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More findings from Oklahoma City indicate that

• PTSD symptomatology was predicted by media
  exposure and indirect interpersonal exposure,
  such as having a friend who knew someone who was
  killed or injured.
• No study specifically reported on rates of PTSD
  in children following the bombing.
• However, studies have shown that as many as
• - 100 of children who witness a parental
  homicide or sexual assault,
• - 90 of sexually abused children,
• - 77 of children exposed to a school shooting,
  and
• - 35 of urban youth exposed to community
  violence develop PTSD.

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The Effects of Community Violence on Adolescents

• A commonly held belief in the general population
  is that community violence only happens among
  gang members in inner-city neighborhoods.
• Indeed, those of lower socioeconomic status,
• those who are nonwhite,
• and those living in densely populated urban areas
  do appear to bear a disproportionately high
  burden of violence.

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Are some youths at greater risk for exposure to
community violence?

• Factors that may increase a child's risk for
  exposure to community violence
• Living in poor, inner-city areas and being a
  minority appears to increase the risk for
  community violence exposure.
• Gang affiliation appears to be a key risk factor,
  
• as is involvement in substance abuse,
• and exposure to domestic violence.
• Gender is another risk factor
• - males witness more community violence and are
  at higher risk for physical assault and other
  direct forms of community violence,
• - females are at higher risk for
  community-violence related sexual assault.

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What are the effects of community violence?

• Adolescents with PTSD also experience nightmares
  and intrusive thoughts about the trauma.
• They may be easily startled and avoid reminders
  of the trauma.
• They can become depressed, angry, distrustful,
  fearful, and alienated, and they may feel
  betrayed.
• Many do not feel they have a future and believe
  that they will not reach adulthood. This is
  especially common among adolescents who are
  chronically exposed to community violence.

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Other trauma-related reactions can include

• impaired self-esteem and body image,
• learning difficulties,
• and acting out or risk taking behaviors
• such as running away,
• drug or alcohol use,
• suicide attempts,
• and inappropriate sexual activities.

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How is PTSD treated in children and adolescents?

• Cognitive-Behavioral Therapy (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.

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• 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."
• The majority of studies have found that it is
  safe and effective to use CBT for children with
  PTSD.

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CBT is often accompanied by psycho-education and
parental involvement.

• psycho-education is education about PTSD
  symptoms and their effects.
• parental involvement Research shows that the
  better parents cope with the trauma, and the more
  they support their children, the better their
  children will function.

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Several other types of therapy have been
suggested for PTSD in children and adolescents.

• Play therapy The therapist uses games, drawings,
  and other techniques to help the children process
  their traumatic memories.
• Eye Movement Desensitization and Reprocessing
  (EMDR), 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 rather than the eye
  movements that accounts for the change.

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Treatments continued

• Psychological first aid has been prescribed for
  children exposed to community violence and can be
  used in schools and traditional settings.
• involves clarifying trauma related facts,
• normalizing the children's PTSD reactions,
• encouraging the expression of feelings,
• teaching problem solving skills,
• and referring the most symptomatic children for
  additional treatment.

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Other treatments

• Twelve Step approaches have been prescribed for
  adolescents with substance abuse problems and
  PTSD.
• Medications have also been prescribed for some
  children with PTSD. However, due to the lack of
  research in this area, it is too early to
  evaluate the effectiveness of medication therapy.

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Further Treatment Options

• specialized interventions may be necessary for
  children exhibiting particularly problematic
  behaviors or PTSD symptoms. For example, a
  specialized intervention might be required for
  inappropriate sexual behavior or extreme
  behavioral problems

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The Effect of Combat-Related PTSD on Children

• Transgenerational effects of combat-related PTSD
  have critical implications for a veterans
  interpersonal and family life
• Children of combat veterans with PTSD generally
  exhibit one of three response patterns.

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The over-identified child.

• Through a process Rosenheck and Nathan (1985) has
  termed secondary traumatization, children come to
  experience an emotional disequilibrium similar to
  the veteran with PTSD.
• Children with secondary traumatization are often
  their fathers closest companion and are at risk
  for "reliving" their fathers trauma,
  experiencing his flashbacks, and sharing his
  nightmares.
• These children fail to develop their own
  friendships because their lives revolve around
  their father.
• In school, they often have difficulty with
  concentration because they are distracted by
  their concern for their fathers well-being.

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The "rescuers"

• Whereby they take on parental roles and
  responsibilities.
• They often feel guilty about trouble at home and
  blame themselves.
• They assume that if they are good, life at home
  will go well.
• They believe it is their responsibility to keep
  their parents happy and to insure nothing goes
  wrong.
• These children often lose spontaneity and
  interest in daily activities.
• Similar to children of alcoholics, these children
  are at risk for continuing this pattern into
  adult life.

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Third pattern

• Children who are emotionally uninvolved in family
  life.
• They often know about their father's war
  experience and need for support, but generally
  receive little emotional support themselves from
  their parents.
• In an effort to gain recognition, they are apt to
  perform well academically,
• Their emotional and social constriction may cause
  symptoms of depression and anxiety,
• and later cause problems in their adulthood
  efforts to form intimate relationships.

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Treatment of Combat-Related PTSD on Children

• The focus of childrens treatment is the
• strengthening of ego functions (i.e. reality
  testing, frustration tolerance, and
  verbalization).
• children are encouraged to recognize their
  separateness,
• address their own developmental needs,
• and not assume responsibility for their parents
  behavior and pain.

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