Presentation on theme: "PTSD in children and adolescents"— Presentation transcript:
1PTSD in children and adolescents Katy CoonanM. Psych. (Clin.) Program StudentPhone: Fax: Website: Ground Level, Building 32 at CQUniversity Rockhampton.
2Purpose and overview of this resource The focus is on Posttraumatic Stress Disorder in children and adolescents. Criticism for the DSM-IV; may not be developmentally sensitive in criteria for PTSD in children and adolescents. Family systems and PTSD in children; The role of attachment The impact of trauma, particularly interpersonal trauma, in children and adolescents; Building therapeutic relationship Role of therapeutic relationship Posttraumatic Growth and Trauma-Informed Resilience
3Posttraumatic Stress Disorder PTSD is a mental disorder involving symptoms and dysfunction arising in the wake of trauma.
4Criterion A: DSM-IVDirect personal experience of an event that involves actual or threatened death or serious injuryWitnessing an events that involves threat to the physical integrity of another personLearning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associateThe person’s response to the trauma must have involved intense fear, helplessness, or horror
5Criterion B: Re-experiencing Symptoms Distressing recollections of trauma. In young children, repetitive play involving aspects of the trauma.Distressing dreams of the trauma. In children, nightmares.Reliving the trauma, including; illusions, hallucinations, and dissociative flashback. In young children, trauma-specific re-enactment.Intense psychological distress at reminders to the trauma.Physiological reactivity on exposure to reminders of the trauma.
6Criterion C: Avoidance Symptoms Efforts to avoid thoughts, feelings or conversations associated with the traumaEfforts to avoid activities, places, or people that remind them of the traumaInability to recall an important aspect of the traumaDiminished interest or participation in significant activitiesFeeling detached from othersRestricted range of affectSense of a foreshortened future
7Criterion D: Increased Arousal Symptoms Difficulty falling or staying asleepIrritability or outbursts of angerDifficulty concentratingHypervigilanceExaggerated startle response
8Limitations of the DSM-IV in diagnosing children and adolescents Based on the experiences of symptoms and dysfunction arising after military combat and rape in adults (Herman, 1992).Questionable generalizability for other types of trauma and diagnosis of children and adolescents (Herman, 1992)Several researchers have argued that PTSD symptoms may differ substantially between children and adults (e.g., Scheeringa, et. al., 2012)
9Revisions to DSM-IVThe traumatic experience was modified to include a subjective component (fear, helplessness, horror)This may be seen as disorganised behaviour or agitation in childrenRepetitive play, frightening dreams, and re-enactment were included as indicators of re-experiencing in childrenCriterion C and D do not describe behaviours that may be indicative of avoidance or increased arousal unique to children
10Developmental Sensitivity DSM-IV may not be developmentally sensitive enough to effectively diagnose PTSD in children and adolescentsInfancy and childhood involve rapid developmental change. Symptoms vary depending on capacities of infants and children in areas of perception, memory, behaviour, affect and cognitionVerbal capacity to describe symptoms is limitedBehavioural symptoms may manifest differently e.g., loss of interest in play
11Developmental Sensitivity Loss of previously acquired skillsDifficulty toiletingDevelopment of new fearsLess avoidance in preschool and school aged children has been found, in comparison to their adult counterparts‘Intense psychological distress’ and ‘feeling detached or estranged from others’ may be difficult to assess in children
12Family SystemsComplex factors relating to family systems must be considered in children with PTSDParent’s reports of their child’s experience of symptoms following trauma generally minimise the level of distress as described by the childSecondary stressors are often involved in cases of childhood or adolescent trauma (relocation, changing schools, separation from family members, financial difficulties of the family)
13Family SystemsThreat to caregiver is a strong predictor of the development of PTSD in infants and young childrenParents experiences of trauma may precipitate PTSD in their childrenChildren’s experiences of trauma may precipitate PTSD in their parentsParents may inflict trauma onto their children (in cases of physical or sexual abuse)
14Attachment and traumaInfant and child attachment to a caregiver provides the infant/child with a context through which to organise emotional, cognitive and behavioural interactions (Finzi et. al., 2001).Three attachment styles; secure, avoidant/ambivalent, and avoidant.
15Secure attachmentSecurely attached children are confident in the availability of their caregiverSecurely attached children love and value their caregiver; they are also more inclined to love and value themselvesThey have a mental representation of the caregiver as being responsive in times of trouble; primary defence against trauma-induced psychopathologyThrough secure attachment, children learn to understand the mental state of others; further protection against traumatisation (de Zulueta, 2009)
16Insecure attachmentChild does not see their caregiver as being responsive in times of needCaregivers may induce traumatic states in their children (e.g., abuse)Caregivers tend not to interactively repair their child’s negative affective statesChildren of abusive caregivers may react with fight-or-flight responses, develop ‘freezing’ responses, or enter a state of ‘fear without solution’ which can result in early dissociative statesChildren of abusive caregivers are still dependent on their caregiver; dissociation may allow maintenance of attachment whilst ‘escaping’ harm
17Risk factors for trauma from caregivers Caregiver is aggressive, punitive, domineering and inconsistentUnemployment, job dissatisfaction, single parent families and low income may increase risk of abusePremature birth, disability, and having a difficult temperament may increase a child’s risk of experiencing trauma at the hands of a caregiver
18Attachment, trauma and PTSD Secure attachments are protective as well as predictive of better outcomes following traumaWhen parents are the source of trauma, negative outcomes in terms of attachment, emotional, behavioural, and cognitive transactions are observed
19Implications for therapeutic alliance Children who have experienced abuse may apply coping strategies informed by early insecure attachment to future relationshipsChildren may expect similar maltreatment in future relationshipsClinicians need to be mindful of this phenomena when treating traumatised children
20Shattered Assumptions Shattered assumptions about safety and control can be considered as part of the ‘meaning making’ process that occurs following significant trauma. Prior to a traumatic event; My parents are in control My parents will keep me safe Bad things happen to other people, not me I am worthy and life has meaning
21Shattered Assumptions Trauma can alter children’s core beliefs about their sense of self and the world. The basic assumptions listed previously can be shattered and reconstituted in forms such as; I am not in control and neither are my parents I am not safe and my parents are unable to keep me safe Bad things can happen to me If bad things happen to me I must deserve it I am not worthy of safety
22Shattered Assumptions The story of Sarah from Lenore Terr (1990) ‘Too Scared to Cry.’
23Building relationships with traumatised children and adolescents Relationships with therapists may be especially important for traumatised populationsBuilding relationships with traumatised young people can be challenging for therapistsTherapists should foster predictability, consistency and safety in the relationship and in sessionsUse ritual greetings, session format, taking things out and putting away, goodbye
24Building relationships with traumatised children and adolescents Traumatised children and young people may test out the limits of the relationship with their therapistRule breakingDangerous behaviourPhysical aggressionInappropriate sexual behaviourTherapists must set limits on behaviour whilst maintaining relationship; the young person needs to know that their behaviour does not change the therapists view of them as a person.
25Treatment of PTSD in children and adolescents Treatments that have been found to effectively treat PTSD in children and adolescents include;Trauma-focused Cognitive Behaviour TherapySystemic family systems approachesEye Movement Desensitisation and Reprocessing
26Posttraumatic Growth and Trauma-Informed Resilience. Positive change arising from a persons’ recovery from trauma, through the effective use of coping skills following exposure to traumaTrauma-informed resilience is a similar concept whereby a person’s ability to ‘bounce back’ from adversity is strengthened following successful recovery from trauma (Steele & Kuban, 2011).
27Posttraumatic Growth and Trauma-Informed Resilience Trauma informed therapy will foster;physical and emotional safety of the childself-regulationsensory cognitive integrationtrauma-informed relationships and environmentstrauma integration.
28Posttraumatic Growth and Trauma-Informed Resilience By using strategies to enhance these components of therapy, posttraumatic growth outcomes can include;Increased compassion and empathy for othersGreater psychological and emotional maturityIncreased resilience and ability to flourishA greater appreciation for life and othersA deeper purpose and meaning in lifeA deeper spiritual focus that values others and community
29Useful resources for families and schools The KidsMatter website has some great resources. The website is Here are just a few resources that can be given to families;
30Useful resources for teachers The Australian Childhood Foundation offers ‘SMART’ training free online. This training is tailored to teachers, to help them to understand the challenges facing children who have experienced trauma in the classroom. It provides information on how to accommodate these children in classrooms and schools. The information is also useful for clinicians and mental health workers who want to gain an understanding of the effects of trauma on children and adolescents. Visit
31ReferencesAmerican Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision). Washington, DC: APA.Brewer, J. & Sparkes, A. (2011). Parentally bereaved children and posttraumatic growth: Insights from an ethnographic study of a UK childhood bereavement service. Mortality, 16,Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002). Toward an empirical definition of pediatric PTSD: The phenomenology of PTSD symptoms in youth. Journal of the American Academy of Child and Adolescent Psychiatry, 41,Critendon, P. M. & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory. In Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect by Cicchetti, D. & Carlson, V. Cambridge University Press: United Kingdom.De Zulueta, F. (2009). Post-traumatic stress disorder and attachment: possible links with borderline personality disorder. Advances In Psychiatric Treatment, 15,Dyb, G., Jensen, T. K., & Nygaard, E. (2011). Children’s and Parents’ posttraumatic stress reactions after the 2004 Tsumani. Clinical Child Psychology and Psychiatry, 16,Fernandez, S., Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A case series: Cognitive-behavioural treatment (exposure, relaxation, and rescripting therapy) of trauma-related nightmares experienced by children. Clinical Case Studies, 12,
32ReferencesFinzi, R., Ram, A., Har-Evan, D., Shnit, D. & Weizman, A. (2001). Attachment styles and aggression in physically abused and neglected children. Journal of Youth and Adolescents, 30,Graham-Bermann, S. A., Castor, L. E., Miller, L. E., & Howell, K. H. (2012). The impact of intimate partner violence and additional traumatic events on trauma symptoms and PTSD in preschool-aged children. Journal of Traumatic Stress, 25,Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5,Lemma, A. (2010). The power of relationship: A study of key working as an intervention with traumatised young people. Journal of Social Work Practice, 24,Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002). Trauma symptoms in preschool aged children exposed to domestic violence. Journal of Interpersonal Violence, 17,Ostrowski, S. A. (2010). Development of child posttraumatic stress disorder in pediatric trauma victims: The impact of initial child and caregiver PTSD symptoms on the development of subsequent child PTSD. Dissertation Abstracts International: Section B: The Sciences and Engineering, 70, 5838.
33ReferencesPearce, J. W. & Pezzot-Pearce, T. D. (2007). The Therapeutic Relationship in Psychotherapy of Abused and Neglected Children (2nd Ed.). The Guilford Press: New York.Roth S. & Friedman M. J. (1998): Childhood Trauma Remembered: A Report on the Current Scientific Knowledge Base and Its Applications, Journal of Child Sexual Abuse, 7,Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012). Diagnosing PTSD in early childhood: An empirical assessment of four approaches. Journal of Traumatic Stress, 25,Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioural therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52,Stafford, B., Zeanah, C. H., & Scheeringa, M. (2003). Exploring psychopathology in early childhood: PTSD and attachment disorders in DC: 0-3 and DSM-IV. Infant Mental Health Journal, 24,