Kelsey Ragsdale
March 18, 2013
Research Paper
Advanced Writing in the Disciplines
Childhood Trauma and Treating PTSD
There are many works that look into trauma and children. It is a popular subject, but a wide one as well. ‘Trauma’ is defined by the American Psychological Association as an “emotional response to a terrible event like an accident, rape or natural disaster,” (APA). Unfortunately, there are a variety of reasons why children can suffer psychological trauma, some of which can cause very compounded and complex situations for the child. For this reason, and many others, creating effective treatment for the children who need it most can be a challenge. In addition, children’s minds are constantly undergoing growth and change, and as a result their thoughts and behaviors do not match up with what a therapist might expect from an adult. Children also all develop at their own rate, so one therapy technique may not work for all children of that age range. To summarize; how does trauma in children differ from trauma in adults, and how is that reflected in therapy strategies?
Trauma that results in lasting emotional damage is categorized as Post-Traumatic Stress Disorder (PTSD). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) defines PTSD as the development of characteristic symptoms following a traumatic event. These responses must involve intense fear, helplessness, or horror, and in children, the response must involve agitated or disorganized behavior. Symptoms include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, a numbing of general responsiveness, and persistent symptoms of increased arousal (arousal meaning, in this context, heightened awareness and sensory sensitivity). In children, sexually traumatic events are typically defined as developmentally inappropriate sexual experiences without need of threatened or actual violence or injury (DSM-IV). Common symptoms include distressing dreams concerning the trauma, heightened arousal, avoidance of triggering stimulus, diminished responsiveness, emotional numbing, and in some cases “flashbacks,” or intrusive thoughts of the traumatic event with a strong and persistent dissociative effect.
Very young children display PTSD differently than adults or even adolescents. Distressing dreams of the event may turn into generalized nightmares of monsters, rescuing others, or threats to themself or others. They often do not experience the trauma as reliving the past. Instead, they engage in repetitive play that reenacts or signifies the event (e.g., a young girl who was molested may mutilate dolls). Sometimes, they have a sense of “foreshortened future” where they image their lives as too short to include growing into an adult. They may also experience physical pains as an expression of their stress or anxiety (DSM-IV). The current DSM’s diagnosis criteria for PTSD in children is, in fact, based off a diagnosis for an adult, and there has been some concern over whether this diagnostic method is appropriately accurate. Philip Saigh’s Children’s PTSD Inventory was designed with the express purpose of correcting this oversight, taking into account the developmental complexities of children and adolescents as well as the concerns about the applicability of current diagnostic systems to youth.
One reason why diagnostic models and treatments originally designed for adults would not be appropriate for a child is that due to their differing levels of mental development, they understand the world different, and in a constantly changing way. As Bridget Franks states in the introduction to her paper, “Children are all still developing, the disasters that strike them hit moving targets” (Franks). In this case, “disasters” can be read as “traumatic events,” the cause for the development of PTSD in children. She makes the point that children are not only at different developmental stages than adults, but constantly changing and growing as well, and that a traumatic event effects not only how they are in that moment, but alters their continued development in the future. A number of variables, including their level of psychological development, social environment, pre-existing conditions, coping mechanisms and emotional support, all contribute to how a child reacts to trauma. Some children may adapt with surprising emotional competence, or in pathological “stage-specific” ways (Franks). Not taking such developmental conditions into account severely handicaps a clinician trying to diagnose or treat a child’s PTSD. A better understanding of the child’s psychological state is reached when the clinician views the child in the context of developmental movement as opposed to the stable and well-studied mind of an adult.
The most widely studied and accepted theories on how PTSD is formed (in both children and adults) are cognitive theories based on information processing. Those theories relate how emotions are stores in memory networks that contain stimuli, responses and meaning related to emotional events– in the case of PTSD, a fear network forms after the traumatic event, storing information about stimulus related to the threat. These networks are characterized by low thresholds for interpreting stimuli as threatening, and have many closely related representations of the trauma due to its strong association with fear. A bias is created in assessing threats, and is readily activated by both internal and external cues. Proposed theories on creating a ‘resolution’ of the fear network require two conditions; first, prolonged activation of the memory network to weaken associations with threat and to permit the familiarization of anxiety (or in other words, desensitizing them to triggers) and new, corrective networks form based around reasonable reactions towards threats (Salmon & Bryant).
An issue with these cognitive theories and their subsequent suggested correction methods is that young children do not have fully developed threat-assessment facilities, and their cognitive networks are extremely placid and malleable at this stage. Theories based off adult models are not easily applied to a child’s brain. Adult theories rely heavily on processes such as the disparity between trauma-related information and existing cognitive schemata, which isn’t as developed in a child’s mind. Cognitive theory of childhood PTSD must acknowledge the differences that regulate the encoding of the traumatic event. Many cognitive theories rely on the ability of the subject to employ emotional coping mechanisms, or the ability to understand one’s own emotions and thinking. These theories could not apply to a child too young to engage in that level of cognitive awareness. For some children, emotional coping and mental self-awareness don’t fully develop until late adolescence. Also, children rely heavily on adult caretakers when dealing with difficult emotions, and therefore the social context and situation of a child has an enormous effect on their ability to cope with trauma (Salmon & Bryant). Current cognitive theories on childhood PTSD do not give adequate attention to the role that familial and social influences play in a child’s response to trauma.
Other areas in which children have developmental differences in coping with trauma include danger appraisal, magical beliefs, emotion regulation, memory representations, and understandings of the mind. Changes in thinking are slow moving and continuous, and as such are at differently levels of functioning at different ages. Trauma interacts with these factors as opposed to merely affecting them. It has been suggested that comparisons between children who have and have not experienced disasters, but are in comparably similar developmental stages, would be highly useful in understanding what ways disasters affect and interact with these half-formed mental states (Franks). Very young children may rely almost completely on external sources (e.g. parents) to help regulate emotions, but by the age of 8 children have some ability to manage their thinking in relation to a traumatic experience. Their strategies range from thinking pleasant thoughts, reappraising difficult situations, shifting and refocusing attention, and cognitive avoidance (Salmon & Bryant). Children develop at different rates in different ways, however, and a child may use all or none of these strategies when faced with traumatic events.
A phenomenon found specific to children recovering from PTSD is their ability to undergo sudden gains during treatment and follow up sessions. It was found that around 42% of the children in a study experienced sudden gains between 3 to 12 months after the traumatic event, accounting for 48.6% of the total reduction in PTSD symptoms. The proposed explanations for these sudden gains vary with no consensus on a single answer. This is due to the fact that these sudden gains occur in a diverse amount of treatments including pharmacotherapy and even pill placebo. In this study, as in others, pretreatment clinical measures did not predict the occurrence of these sudden gains (Aderka, et. al.). Since this phenomenon is specific to children as opposed to adults, I would suspect a connection could be made to their more adaptable minds, as well as a child’s enhanced ability to learn, creating a better environment for a clinician to assist a child with PTSD. This theory is supported by data that reports such sudden gains occur over multiple types of disorders and treatments in children. Whether children do or do not experience sudden gains should be taken into account when considering treatment, and clinicians should be open to adjusting their treatment timeline in response to these gains or lack of gains.
There have been various models proposed for treating children with PTSD, many of which are extensions of adult treatment plans. As discussed, treatment plans based off adult models do not take into account developmental contexts and coping methods. Eye Movement Desensitization and Reprocessing (EMDR), is a therapy that combines cognitive therapy with directed eye movements. While EMDR has had success in treating both adults and children with PTSD, studies indicate that it may be due to the cognitive intervention rather than the eye movements that account for the change (Abdulbaghi, et. al.). Play therapy is also a commonly used treatment for especially young children who are not able to deal with the trauma more directly. Through the use of games, drawings, and other such techniques, a therapist helps a child process their traumatic memories. This also surveys as a good method of observing and understanding the child’s level of trauma, as children often reenact their trauma through play.
A more controversial method of treatment, as is always the case in regards to children, is the use of medication. This is a treatment more commonly used for adult than for children, and since there is relatively little research into the effects of such drugs on such young and developmentally fluid minds, it is often discouraged. Research by Strawn indicates that the effectiveness of numerous medications in treating PTSD in adults have not been duplicated in child studies. There are a few agents that have “shown promise in case reports,” but the risk factors involved with such medications typically outweigh the uncertain benefits of such treatment (Strawn & DelBello). The success shown in even preliminary work done to incorporate developmental psychology into the PTSD treatment with children indicates that the focus of treatment would be better directed towards incorporating family methods of therapy as opposed to medication.
In my own experience working with young children and toddlers, I have noticed how different the mind of a child is from a grown adult’s, or even an older adolescent. Even among child peers, the developmental scope is wide and varied, and no two children grow at the same pace. This understanding reinforces the idea that specific and personalized treatment is imperative for children with trauma and coping difficulties. Research has shown that current therapeutic methods, though moving towards child-specific practices, are still lacking in that area. More incorporating techniques could be utilized, with an understanding of developmental psychology in a combined textbook and real-world way. The reliance on and importance of the mother (or central caretaker) is paramount and cannot be understated, especially for very young children. Treating the parent directly for anxiety disorders such as PTSD would indirectly affect the child’s recovery; therefore, including the caretaker in any and all treatment methods would be most beneficial for the child.
Bibliography:
American Psychological Association. (2013). Trauma.
Retrieved from website: http://www.apa.org/topics/trauma/index.aspx
First, Michael B. (2000). Diagnostic and Statistical Manual of Mental Disorders – 4th Edition
(DSM-IV-TR), American Psychiatric Association. Washington, DC.
Saigh, Philip A. (2004). Children’s PTSD Inventory: A Structured Interview for Diagnosing
Posttraumatic Stress Disorder. The Psychological Corporation, San Antonio, TX.
Franks, Bridget A. (2010) Moving targets: A developmental framework for understanding
children’s changes following disasters. Journal of Applied Developmental Psychology,
32(2):58-69.
Salmon, Karen. & Bryant, Richard A. (2002). Posstraumatic stress disorder in children: The
influence of developmental factors. Clinical Psychology Review, Vol22.2, pages 163-188.
Aderka, Idan M., Appelbaum-Namdar, Edna., Shafran, Naama., Gilboa-Schechtman, Eva.
(2011). Sudden Gains in Prolonged Exposure for Children and Adolescents With
Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, Vol79.4,
pages 441-446.
Ahmad, Abdulbaghi., Larsson, Bo., Sundelin-Wahlsten, Viveka. (2007). EMDR treatment for
children with PTSD: Results of a randomized controlled trail. Nordic Journal of
Psychiatry, Vol61.5, pages 349-354.
Strawn, Jeffery R., DelBello, Melissa P. (2010). Evidence base limited for medications in
treatment of PTSD in children. Brown University Child & Adolescent
Psychopharmacology Update, Vol12.9 pages 1-3.
March 18, 2013
Research Paper
Advanced Writing in the Disciplines
Childhood Trauma and Treating PTSD
There are many works that look into trauma and children. It is a popular subject, but a wide one as well. ‘Trauma’ is defined by the American Psychological Association as an “emotional response to a terrible event like an accident, rape or natural disaster,” (APA). Unfortunately, there are a variety of reasons why children can suffer psychological trauma, some of which can cause very compounded and complex situations for the child. For this reason, and many others, creating effective treatment for the children who need it most can be a challenge. In addition, children’s minds are constantly undergoing growth and change, and as a result their thoughts and behaviors do not match up with what a therapist might expect from an adult. Children also all develop at their own rate, so one therapy technique may not work for all children of that age range. To summarize; how does trauma in children differ from trauma in adults, and how is that reflected in therapy strategies?
Trauma that results in lasting emotional damage is categorized as Post-Traumatic Stress Disorder (PTSD). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) defines PTSD as the development of characteristic symptoms following a traumatic event. These responses must involve intense fear, helplessness, or horror, and in children, the response must involve agitated or disorganized behavior. Symptoms include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, a numbing of general responsiveness, and persistent symptoms of increased arousal (arousal meaning, in this context, heightened awareness and sensory sensitivity). In children, sexually traumatic events are typically defined as developmentally inappropriate sexual experiences without need of threatened or actual violence or injury (DSM-IV). Common symptoms include distressing dreams concerning the trauma, heightened arousal, avoidance of triggering stimulus, diminished responsiveness, emotional numbing, and in some cases “flashbacks,” or intrusive thoughts of the traumatic event with a strong and persistent dissociative effect.
Very young children display PTSD differently than adults or even adolescents. Distressing dreams of the event may turn into generalized nightmares of monsters, rescuing others, or threats to themself or others. They often do not experience the trauma as reliving the past. Instead, they engage in repetitive play that reenacts or signifies the event (e.g., a young girl who was molested may mutilate dolls). Sometimes, they have a sense of “foreshortened future” where they image their lives as too short to include growing into an adult. They may also experience physical pains as an expression of their stress or anxiety (DSM-IV). The current DSM’s diagnosis criteria for PTSD in children is, in fact, based off a diagnosis for an adult, and there has been some concern over whether this diagnostic method is appropriately accurate. Philip Saigh’s Children’s PTSD Inventory was designed with the express purpose of correcting this oversight, taking into account the developmental complexities of children and adolescents as well as the concerns about the applicability of current diagnostic systems to youth.
One reason why diagnostic models and treatments originally designed for adults would not be appropriate for a child is that due to their differing levels of mental development, they understand the world different, and in a constantly changing way. As Bridget Franks states in the introduction to her paper, “Children are all still developing, the disasters that strike them hit moving targets” (Franks). In this case, “disasters” can be read as “traumatic events,” the cause for the development of PTSD in children. She makes the point that children are not only at different developmental stages than adults, but constantly changing and growing as well, and that a traumatic event effects not only how they are in that moment, but alters their continued development in the future. A number of variables, including their level of psychological development, social environment, pre-existing conditions, coping mechanisms and emotional support, all contribute to how a child reacts to trauma. Some children may adapt with surprising emotional competence, or in pathological “stage-specific” ways (Franks). Not taking such developmental conditions into account severely handicaps a clinician trying to diagnose or treat a child’s PTSD. A better understanding of the child’s psychological state is reached when the clinician views the child in the context of developmental movement as opposed to the stable and well-studied mind of an adult.
The most widely studied and accepted theories on how PTSD is formed (in both children and adults) are cognitive theories based on information processing. Those theories relate how emotions are stores in memory networks that contain stimuli, responses and meaning related to emotional events– in the case of PTSD, a fear network forms after the traumatic event, storing information about stimulus related to the threat. These networks are characterized by low thresholds for interpreting stimuli as threatening, and have many closely related representations of the trauma due to its strong association with fear. A bias is created in assessing threats, and is readily activated by both internal and external cues. Proposed theories on creating a ‘resolution’ of the fear network require two conditions; first, prolonged activation of the memory network to weaken associations with threat and to permit the familiarization of anxiety (or in other words, desensitizing them to triggers) and new, corrective networks form based around reasonable reactions towards threats (Salmon & Bryant).
An issue with these cognitive theories and their subsequent suggested correction methods is that young children do not have fully developed threat-assessment facilities, and their cognitive networks are extremely placid and malleable at this stage. Theories based off adult models are not easily applied to a child’s brain. Adult theories rely heavily on processes such as the disparity between trauma-related information and existing cognitive schemata, which isn’t as developed in a child’s mind. Cognitive theory of childhood PTSD must acknowledge the differences that regulate the encoding of the traumatic event. Many cognitive theories rely on the ability of the subject to employ emotional coping mechanisms, or the ability to understand one’s own emotions and thinking. These theories could not apply to a child too young to engage in that level of cognitive awareness. For some children, emotional coping and mental self-awareness don’t fully develop until late adolescence. Also, children rely heavily on adult caretakers when dealing with difficult emotions, and therefore the social context and situation of a child has an enormous effect on their ability to cope with trauma (Salmon & Bryant). Current cognitive theories on childhood PTSD do not give adequate attention to the role that familial and social influences play in a child’s response to trauma.
Other areas in which children have developmental differences in coping with trauma include danger appraisal, magical beliefs, emotion regulation, memory representations, and understandings of the mind. Changes in thinking are slow moving and continuous, and as such are at differently levels of functioning at different ages. Trauma interacts with these factors as opposed to merely affecting them. It has been suggested that comparisons between children who have and have not experienced disasters, but are in comparably similar developmental stages, would be highly useful in understanding what ways disasters affect and interact with these half-formed mental states (Franks). Very young children may rely almost completely on external sources (e.g. parents) to help regulate emotions, but by the age of 8 children have some ability to manage their thinking in relation to a traumatic experience. Their strategies range from thinking pleasant thoughts, reappraising difficult situations, shifting and refocusing attention, and cognitive avoidance (Salmon & Bryant). Children develop at different rates in different ways, however, and a child may use all or none of these strategies when faced with traumatic events.
A phenomenon found specific to children recovering from PTSD is their ability to undergo sudden gains during treatment and follow up sessions. It was found that around 42% of the children in a study experienced sudden gains between 3 to 12 months after the traumatic event, accounting for 48.6% of the total reduction in PTSD symptoms. The proposed explanations for these sudden gains vary with no consensus on a single answer. This is due to the fact that these sudden gains occur in a diverse amount of treatments including pharmacotherapy and even pill placebo. In this study, as in others, pretreatment clinical measures did not predict the occurrence of these sudden gains (Aderka, et. al.). Since this phenomenon is specific to children as opposed to adults, I would suspect a connection could be made to their more adaptable minds, as well as a child’s enhanced ability to learn, creating a better environment for a clinician to assist a child with PTSD. This theory is supported by data that reports such sudden gains occur over multiple types of disorders and treatments in children. Whether children do or do not experience sudden gains should be taken into account when considering treatment, and clinicians should be open to adjusting their treatment timeline in response to these gains or lack of gains.
There have been various models proposed for treating children with PTSD, many of which are extensions of adult treatment plans. As discussed, treatment plans based off adult models do not take into account developmental contexts and coping methods. Eye Movement Desensitization and Reprocessing (EMDR), is a therapy that combines cognitive therapy with directed eye movements. While EMDR has had success in treating both adults and children with PTSD, studies indicate that it may be due to the cognitive intervention rather than the eye movements that account for the change (Abdulbaghi, et. al.). Play therapy is also a commonly used treatment for especially young children who are not able to deal with the trauma more directly. Through the use of games, drawings, and other such techniques, a therapist helps a child process their traumatic memories. This also surveys as a good method of observing and understanding the child’s level of trauma, as children often reenact their trauma through play.
A more controversial method of treatment, as is always the case in regards to children, is the use of medication. This is a treatment more commonly used for adult than for children, and since there is relatively little research into the effects of such drugs on such young and developmentally fluid minds, it is often discouraged. Research by Strawn indicates that the effectiveness of numerous medications in treating PTSD in adults have not been duplicated in child studies. There are a few agents that have “shown promise in case reports,” but the risk factors involved with such medications typically outweigh the uncertain benefits of such treatment (Strawn & DelBello). The success shown in even preliminary work done to incorporate developmental psychology into the PTSD treatment with children indicates that the focus of treatment would be better directed towards incorporating family methods of therapy as opposed to medication.
In my own experience working with young children and toddlers, I have noticed how different the mind of a child is from a grown adult’s, or even an older adolescent. Even among child peers, the developmental scope is wide and varied, and no two children grow at the same pace. This understanding reinforces the idea that specific and personalized treatment is imperative for children with trauma and coping difficulties. Research has shown that current therapeutic methods, though moving towards child-specific practices, are still lacking in that area. More incorporating techniques could be utilized, with an understanding of developmental psychology in a combined textbook and real-world way. The reliance on and importance of the mother (or central caretaker) is paramount and cannot be understated, especially for very young children. Treating the parent directly for anxiety disorders such as PTSD would indirectly affect the child’s recovery; therefore, including the caretaker in any and all treatment methods would be most beneficial for the child.
Bibliography:
American Psychological Association. (2013). Trauma.
Retrieved from website: http://www.apa.org/topics/trauma/index.aspx
First, Michael B. (2000). Diagnostic and Statistical Manual of Mental Disorders – 4th Edition
(DSM-IV-TR), American Psychiatric Association. Washington, DC.
Saigh, Philip A. (2004). Children’s PTSD Inventory: A Structured Interview for Diagnosing
Posttraumatic Stress Disorder. The Psychological Corporation, San Antonio, TX.
Franks, Bridget A. (2010) Moving targets: A developmental framework for understanding
children’s changes following disasters. Journal of Applied Developmental Psychology,
32(2):58-69.
Salmon, Karen. & Bryant, Richard A. (2002). Posstraumatic stress disorder in children: The
influence of developmental factors. Clinical Psychology Review, Vol22.2, pages 163-188.
Aderka, Idan M., Appelbaum-Namdar, Edna., Shafran, Naama., Gilboa-Schechtman, Eva.
(2011). Sudden Gains in Prolonged Exposure for Children and Adolescents With
Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, Vol79.4,
pages 441-446.
Ahmad, Abdulbaghi., Larsson, Bo., Sundelin-Wahlsten, Viveka. (2007). EMDR treatment for
children with PTSD: Results of a randomized controlled trail. Nordic Journal of
Psychiatry, Vol61.5, pages 349-354.
Strawn, Jeffery R., DelBello, Melissa P. (2010). Evidence base limited for medications in
treatment of PTSD in children. Brown University Child & Adolescent
Psychopharmacology Update, Vol12.9 pages 1-3.