Treating Children and Adolescents with PTSD William Yule Prague March 2014

In the beginning…. When DSM III first identified PTSD, it was thought that children would rarely show it Why did professionals come to such a wrong conclusion?

Simply, they had not asked the children themselves how they were reaction to major stressors. They had asked parents and teachers who greatly underestimated the reactions children had

Adults, even today, are scared to talk to children about how they are feeling after a bad experience in case they make things worse. In case by asking, they traumatise the child!

Faced with child survivors of a big shipping disaster, I did what I was trained to do – I asked the children themselves. This what they told me:

Stress Reactions in Children Sleep Disturbance Separation Difficulties Concentration Difficulties Memory Problems Intrusive thoughts Talking with parents Talking with friends Heightened alertness to danger Premature awareness of mortality Fears Irritability Anxiety and Panic Depression Bereavement

ICD vs DSM Both are “adult-o-centric” Still need more child oriented descriptive studies ICD emphasizes Intrusive phenomena, downplays avoidance and arousal

Recent changes Both DSM5 and forthcoming ICD10 have refined their rules for making a diagnosis of PTSD But the essential features remain with ICD placing more emphasis on re-experiencing

Post Traumatic Stress Disorder Intrusive recollections, nightmares, “flashbacks” Avoidance of remembering and reminders Over-arousal (sleep, concentration, anger, jumpiness)

Developmental Aspects Pre-school children Alternative diagnostic criteria developed by Scheeringa et al (2011) Checklists & questionnaires Diagnostic interview schedules Treatment manual Available from Michael Scheeringa’s website

Incidence of PTSD after assaults & RTAs

Mental Health Effects of the Jupiter Sinking Any DSM-IV Diagnosis

Natural History of PTSD Jupiter follow-up

Aberfan

Aberfan – 33 years later

Emerging Theoretical Models 1980 – Rachman: Emotional Processing 1987 et seq: Keane, Foa – Anxiety and Habituation 1996 – Brewin: Dual Representation 2000: Ehlers and Clark: Memory

Emotional Processing Rachman 1980 Distress usually wanes when realize threat no longer remains If overwhelmed, no habituation and so avoid Stress symptoms indicate that emotional processing is incomplete

Treatment of PTSD in children Crisis Intervention –Critical Incident Stress Debriefing Group Treatment Individual Treatment –CBT - Prolonged Exposure –EMDR –KidNET

Crisis Interventions Make contact initially Survivors probably not able to benefit for first few days

Critical Incident Stress Debriefing (Dyregrov) Introduction –rules of group Facts - what happened Thoughts Reactions –Sensory, delayed Information and Advice Conclusion

Contingency Planning in schools Risk analysis Contingency plan Pre-assign responsibilities Immediate tasks Longer term planning

Review of early intervention 4 RCTs + 3 others found Small to large beneficial effect sizes Early intervention should include: –Psycho-education –Individual coping skills –Some trauma exposure Early intervention may be helpful

Cognitive models of PTSD Seek to explain a why minority of trauma-exposed individuals develop chronic PTSD Foa, Steketee, & Routhbaum 1989 Brewin, Dalgleish, & Joseph 1996 Ehlers & Clark 2000 sense of “current threat” from idiosyncratic appraisals disjointed memory unhelpful coping

Characteristics of Trauma/ Sequelae Prior Experiences/ Beliefs/ Coping State of Individual Cognitive Processing during Trauma Nature of Trauma MemoryNegative Appraisal of Trauma and/ or its Sequelae Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/ Symptoms leads to influences prevents change in PERSISTENT PTSD Ehlers & Clark’s Cognitive Model of PTSD (2000)

Cognitive factors in children Nature of the trauma memory laid down Attributions & misappraisals about the event (eg Joseph et al, 1991) Appraisals of symptoms (Ehlers et al, 2004; Meiser-Stedman et al) Thought control strategies (eg Ehlers et al 2004; Aaron et al 1999)

Treatment Targets Reduce fragmentation of trauma memory Modify misappraisals of the trauma and PTSD symptoms Reduce dysfunctional coping strategies (cognitive and behavioural avoidance) Modify maladaptive beliefs of parents (re trauma and sequelae), recruit parents as co- therapists

Elements of treatment Education/normalisation Reclaiming life Relaxation Imaginal reliving Cognitive restructuring In vivo exposure Image work Sleep Hygiene Parent sessions

Patient flow N = 38 27/36 retain diagnosis 9/36 lose diagnosis 3 decline Rx before randomisation CBT = 12 WL = 12 Diary monitoring 4 weeks

CAPS (clinician PTSD)

PTSD diagnosis Semi-structured interview by clinician blind to group status, post CBT/WAIT CBT group11/12 (92%) free of PTSD diagnosis WAIT group5/12 (42%) free of PTSD diagnosis

Summary Substantial proportion of children respond well to symptom monitoring Significant effect of CBT on PTSD and associated problems Improvement maintained at 6 month follow up Symptom improvement accompanied by changes in mis-appraisals

Eye Movement Desensitization and Re-processing (EMDR) Construct a “Safe Place” Picture Worst Memory Negative Cognition (Rate 1-7) Positive Cognition (Rate 1-7) Feelings (Rate SUDS 1-10) Body Sensation “Desensitization” - eye movements Repeat cycle

EMDR & PTSD 1

EMDR & PTSD 2

Narrative Exposure Therapy Kid NET

KidNET timeline

Efficacy of Narrative Exposure Therapy in field studies

Mental health in complex emergencies Lancet article in early December 2004 Stressed need for each country to develop a plan to screen for adverse reactions after a disaster and then provide effective treatment Need to develop appropriate measures Need to develop treatment to be delivered on a large scale

Teaching Recovery Techniques 1: Intrusion 2: Arousal 3: Avoidance 4: Bereavement Parent’s Group

TRT RCT Barron et al (in press) significant difference at post-test, controlling for initial symptom severity p<.005

CHILDREN and WAR Writing for Recovery Aimed at Adolescents Builds on Jamie Pennebaker’s work 2 x 15 minute sessions on 3 days

PTSD before and after writing manual

Writing and Grief Afghani adolescents (Kalantari et al, 2012)

Education for war affected children School as a focus for intervention and support Need to emphasize continuing education Skills can be taken anywhere But stress reactions such as attention, memory problems etc interfere with learning So Stress reactions need to be targetted

References mentioned in this workshop can be accessed at: