When The Past Won't Go Away

Neel G. Karnani, M.D., Editor-in-chief

On the one-year anniversary of the tragic events of September 11, 2001, the nation commemorated that day in memory of those who are no longer with us.

Earlier this year we dedicated an issue of Jacksonville Medicine to Mental Health. Inadvertently, we left out an article by Dr. Kaplan on Post-traumatic Stress Disorder in the younger population. It only seems fitting to include it at this time.
 

Post-Traumatic Stress Disorder In Children
And Adolescents: A Clinical Overview

Sheldon J. Kaplan, Ph.D.
Sheldon J. Kaplan, Ph.D., is a psychologist in private practice in Jacksonville.

Terrorist acts of September 11, 2001, have prompted physicians, mental health professionals, educators, and parents, to examine the effects of these tragedies on children and adolescents for whom they provide care. Media broadcast of the collapse of the World Trade Center towers was repeated frequently throughout the week of September 11, on network and cable channel news programs. Thus, children and adolescents were exposed and re-exposed to the trauma and fear created by this disaster.

Children have experienced a wide range of other traumatic events, as well, which affect their psychological, emotional, social, behavioral, and academic functioning. In addition to experiencing and/or witnessing terrorist acts, these events include kidnapping, physical assaults, child physical, emotional, and sexual abuse, and severe traffic accidents.

In the DSM-IV,1 Post-Traumatic Stress Disorder (PTSD), is defined by four variables: (1) exposure by personal experience or by witnessing an event which threatened or caused death and severe injury to self or others and was accompanied by a response from the victim of fear and helplessness; (2) a consistent re-experiencing of the traumatic event through flashbacks, nightmares or episodes of intense distress to events of any similarity to the original trauma; (3) persistent avoidance of all stimuli related to the original event to include an avoidance of thoughts, feelings, conversations, or other situations that have similarity to the trauma, a detachment from others, and a numbing of affect; and (4) ongoing symptoms of increased arousal as a result of the trauma to include sleep difficulties, irritability, concentration difficulties, hypervigilance, and an exaggerated startle response. In addition, the duration of these symptoms is at least for one month and PTSD must cause significant clinical impairment in social, occupational, or other important areas of functioning.

Epidemiology

Prevalence rates of PTSD in adults are much different than those for children and adolescents. Epidemiological rates in adults for current and lifetime PTSD are 0.4 and 1.3%.2 An additional 15% of adults are said to have many of the symptoms of PTSD but do not meet the full criteria. Though few studies have been conducted on PTSD rates in children, the National Center for Post-Traumatic Stress Disorder3 estimates that 15 to 43% of girls and 14 to 43% of boys have experienced at least one traumatic event. Of these children, it is estimated that between 3 and 15% of girls and 1 to 6% of boys meet the full criteria for PTSD.

When rates of PTSD are drawn from at-risk populations, prevalence can vary from 3 to 100%. As many as 100% of children who witness a parental homicide or rape, 90% of victims of sexual abuse, 77% of kids involved in a school shooting, and 35% exposed in some way to violence in their communities meet the requirements for PTSD.

Perry and Azad4 estimate that greater than five million youngsters experience PTSD.

Risk Factors and Clinical Considerations

There are a variety of factors which contribute to the development of PTSD in children and adolescents. Three most important factors are 1) severity of the trauma, 2) parental reaction to the trauma, and 3) the temporal proximity of the trauma. Of course, the more severe the trauma (rape, physical assault, life-threatening accidents, and death of a parent), the greater the likelihood of PTSD. Also, the trauma severity can either be based on a single event (Type I) or prolonged exposure to trauma (Type II) such as is the case with protracted physical or sexual abuse that can occur over a period of years. Repeated exposure to trauma is a significant predictor to PTSD.

The degree of parent and family support can influence the occurrence of PTSD. A strong parental and family support system can reduce the onset or severity of PTSD symptoms.5 Foa 6 suggests that parents tend to minimize PTSD symptoms in their children. However, when the parent is also traumatized by the same event or by the child's exposure, the degree of their own traumatization will further impact the PTSD in their children. Ladakakos7 found that parental traumatization was moderately related to their recognition of their child's behavioral and emotional difficulties, thus suggesting that the more traumatized the parent, the less sensitive they are to the needs of their affected child. Further, Vila, Witowski, Tondini, et al. 8 found that there was a significant impact on the child's development and severity of PTSD as a result of the parental disorders pre-morbidly or as a result of the trauma upon the child. Should the child suffer the loss of a parent as part of the traumatic event, PTSD has an even greater likelihood.

The proximity of the child to the event is an additional risk factor. There is a greater likelihood of PTSD if the child directly experiences the trauma rather than witnessing the event. It is known, however, that children do not have to directly experience a traumatic event for PTSD to develop. Rather, witnessing domestic violence, observing assault or murder that occur while living in high crime areas 9 watching traumatic events on television;10, 11 and living in war torn nations such as Croatia12 and Israel13 can trigger the development of PTSD.

There are other risk factors to consider in the development of PTSD. These include demographic characteristics such as gender, age, developmental level,14 psychiatric co-morbidity of both the child and the parent,15 cognitive style16 and family functioning and integrity.17 Young children may not manifest PTSD symptoms in the same manner as adolescents, and some research indicates that PTSD is more likely in girls than boys.18,19 McCloskey and Walker20 found that a background of abuse in the family is a risk factor to the development of PTSD from non-family based traumatic events. Finally, Silva, Alpert, Munoz, et. al.21 conclude that traumatic experiences interact with multiple factors in the child, parent, and family in the development of PTSD.

Symptoms of PTSD vary widely depending on the age of the child.3 In fact, the presentation of PTSD symptoms in children often does not resemble those of traumatized adults. Very young children may appear to have few symptoms, yet they may experience more co-morbidity of anxiety and depressive disorders. Some very young traumatized children will engage in play or behavioral re-enactment that will resemble the original trauma. A child being involved in a traffic collision in which the car he was riding in was engulfed in flames may want to play with fire or light his toy cars on fire.

Elementary age children with PTSD, unlike adults, may not have flashbacks but may have memory deficits and poor recall of the original trauma. These students may also believe they should have had forewarning of the disaster and that they can avoid other traumas if they become hypervigilant. They may also replay the trauma through posttraumatic play or through drawings. It is also known that the child of greatest risk for development of PTSD is the vulnerable anxious child who has been exposed to violence, especially violence in the immediate family.

Adolescents' PTSD reactions most closely resemble adult PTSD. They may incorporate events of the trauma into their daily lives. For example, a teenager who has been viciously attacked by a group of other adolescents may become a student of the martial arts in anticipation of further trouble with the gang of students. There is a greater likelihood of impulsive and aggressive behavior in PTSD adolescents, as well. Eth22 and King23 observe the high rates of youth in the juvenile justice system who have been directly exposed to or witnessed traumatic events in their lives and who have developed PTSD and other mental disorders and substance abuse. King23 theorizes that though these adolescents have been diagnosed with Oppositional Defiant Disorders and Conduct Disorders, many of these youngsters could be diagnosed with PTSD. Overlooking this diagnosis could well lead to inappropriate treatment.

When adolescents are chemically dependent, they are at greater risk for PTSD.24 A group of 297 chemically dependent adolescents ages 15-19 were evaluated for PTSD in seven Massachusetts treatment facilities. Higher lifetime prevalence rates were noted (29.6%). These extremely high lifetime rates were five times the rate reported for a typical community sample of adolescents. There were almost twice as many females than males identified (24.3% for males and 45.3% for females) and the current prevalence rates averaged 15.2%. Current rates were more than triple for females than males (12.2% for males versus 40.0% for females) and the higher rates were due to a greater risk for rape.

Terr, Bloch, Michel, et al.25 found that latency-age children were significantly more symptomatic than adolescents during the witnessing of the Challenger disaster in Concord, New Hampshire, the home of Astronaut Christa McAuliffe. It is hypothesized these latency-age children operate more from unfettered emotion, mental confusion, and, at times, regression characteristic of their developmental level. Adolescents, however, are well into abstract thought, and may be able to think contextually, avoiding the overwhelming emotion surrounding tragedy and thinking more rationally about such traumatic events.

Pfefferbaum26 reviewed research on PTSD in children over the previous 10 years. Prevalence estimates for children suggest that by 18 years of age, more that two fifths of youths in a community experienced at least one trauma and 6% met the full PTSD criteria. There are indications that neurophysiological and neurobiological changes occur in response to trauma and that children are less able to adapt via the fight or flight response. According to Pfefferbaum, when young children are exposed repeatedly to a trauma, they will freeze emotionally and then begin to dissociate. Further, there is a loss of the inhibitory function of the startle response27 and Perry28 suggests that protracted stress in children causes large increases in neurotransmitter activity which can affect brain development and placing children at risk for developmental disorders. Southwick and Friedman29 discuss two major neurobiological systems implicit in the coping mechanism of individuals, the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. These and other systems are involved in coping with acute and chronic stress. De Bellis, Keshavan, Clark, et al.30 studied the biological stress systems in 44 maltreated children and adolescents utilizing psychiatric, neuropsychological, and MRI brain scan. Results of this investigation found that PTSD children had smaller intracranial and cerebral volume than matched control subjects. Brain volume was also correlated positively with age of onset of PTSD trauma and negatively correlated with duration of abuse. Further, symptoms of intrusive thoughts, avoidance, hyperarousal and dissociation were correlated with ventrical volume. Overall, results suggested severe stress in childhood is associated with deficits in brain development.

Pfefferbaum31 cites a variety of predictors of trauma. Included are proximity to the event, prolonged exposure to descriptions and images of the disasters through the media (e.g. repeated replay of the collapse of the World Trade Center and tearful interviews with families of those lost), gender, age and developmental level. In addition, other predictors include previous exposure to trauma, family support and influences, socioeconomic factors, and "symptom contagion" from other traumatized members of a family, association with those also affected, social, cultural, and community influences, media exposure, and ensuing legal proceedings. Terr, Bloch, Michel, et. al.32 documented the degree of community exposure, intensity of immediate fear and arousal as well as chronic symptoms of stress following the bombing of the Murrah Federal Building in Oklahoma City. These researchers hypothesize that the more members of the community were involved or that knew someone who had been injured or killed in the bombing, the more affected was the community, and the increased risk of PTSD to its inhabitants. Pfefferbaum found while studying 3,217 Oklahoma City adolescents that, following the bombing, there were high rates of PTSD symptomatology exacerbated by many weeks of prolonged television viewing of bomb-related programming. Unfortunately, there were also low rates noted of students receiving therapy. It is suggested that regardless of adolescents' avoidance of discussing trauma, immediate therapeutic intervention is necessary.

March, Amaya-Jackson, Terry, and Costanzo33 studied children and adolescents following an industrial fire at the Imperial Foods chicken-processing plant in Hamlet, North Carolina, in which there was an excessive loss of life. Findings suggested that co-morbid internalizing and externalizing behaviors (depression and anxiety, anger and defiant behaviors) increased in frequently directly in proportion with the degree of exposure of the child to the trauma. These co-morbid symptoms are strongly correlated with PTSD.

Cognitive, emotional, social, and educational functioning are impacted by the development of PTSD. Acosta34 analyzed the verbal and non-verbal memory functions of twenty inpatient adolescents diagnosed with PTSD compared to twenty students randomly selected from a nearby school district. Despite small sample size, results indicated that those students with PTSD performed significantly more poorly than their controls on tasks requiring delayed recall, free recall, sequential and associative recall. Memory bias was also studied.35 In this study, PTSD participants showed overall poorer memory that their controls on a task requiring recall after a short period of retention for negative, positive, and neutral words. Also, these participants showed bias in their memory for threat-related information.

Hypervigilance for threatening versus depressive stimuli was also studied by Dalgleish, Moradi, Taghavi, et al.36 Results showed that children and adolescents paid more attention to socially threatening stimuli than depression-related material. Thus, in information processing, there is more attentional bias to anxiety, fear, arousal, and worry rather than depression as part of the emotional disorders of young PTSD children.37

Moral development and conscience functioning is directly impacted in the face of catastrophic disasters. Goenjian, Stilwell, Steinberg, et al.38 compared moral development and psychopathological interference with the functioning of conscience in adolescents exposed to earthquake trauma. Adolescents living nearest the epicenter of the earthquake, and therefore, more directly affected, showed advances in moral development. Levels of conscience were significantly related to the severity of PTSD symptomatology. It was concluded that traumatized children assume greater life responsibilities and confront greater moral dilemmas regarding their own lives than their controls. Further, these children are more apt to evaluate themselves negatively as they try to integrate their frightening experiences into a view of the positive and negative features of their lives and of the world. In support of this negative attributional style, Saigh, Mroueh, Zimmerman, and Fairbanks39 found in a comparison of traumatized versus non-traumatized adolescents, that those who experienced PTSD had significantly lower ratings of their self-efficacy on Bandura's Multidimensional Scales of Perceived Self-Efficacy than their controls. These authors attribute these lower self-efficacy scores to PTSD-related difficulties and interpersonal problems.

Psychosocial functioning among older PTSD adolescents was studied in a community environment. Using a variety of rating scales and assessment methods, Giaconia, Reinherz, Silverman, et. al.40 examined 384 - 18-year-old adolescents. Findings indicated that by age 18, more than 40% experienced at least one traumatic event in which PTSD symptoms developed in 14.5% of the sample. Results of the comprehensive assessment of these students found widespread deficits to include behavioral and emotional difficulties, interpersonal problems, academic failure, suicidal behavior, and health problems.

PTSD has long lasting effects also on the educational success of students in high school and as they attend college. Duncan41 followed 210 freshmen through their four years in college. Students who were multiply abused and those who were sexually abused only were less likely to be enrolled by their second semester than non-victims. In fact, enrollment continued to drop at each subsequent semester until, by their senior year, only 35% of multiply abused students and 50% of students sexually abused only were in attendance. Scholastic impairment in PTSD adolescents was studied by Saigh, Mroueh and Bremmer.42 Adolescents with PTSD had significantly lower scores on standardized achievement tests than did their controls, confirming the impact PTSD has on academic performance in traumatized adolescents.

Assessment Methods and Treatment Strategies

Assessment

Cohen43 summarized practice parameters in the assessment and treatment of PTSD in children and adolescents. In this article, the controversy surrounding the assessment of child and adolescent PTSD is cited as the reason for the need to develop such guidelines. Though there are many standardized rating scales to measure anxiety in children and adolescents, Cohen indicates that assessment issues involve determining the severity of the trauma, and how many symptoms from each of the three broad categories: re-experiencing, avoidance/numbing, and increased arousal are needed to make a diagnosis. The assessment of these symptoms must occur not just from a rating scale, as no single scale or test can confirm PTSD. Rather, careful and direct clinical interviews with thorough history-taking are needed. According to Cohen, children should be asked directly about the traumatic event and about the ensuing symptoms in clear detail, though some clinicians have concern about re-traumatizing the child. Pynoos and Eth indicate that thorough questioning and assessment of the traumatic event and its effects is key to the initial interview and subsequent treatment. The clinician must be aware of the developmental level of the child or adolescent and of any pre-existing or complex psychiatric disorder that may be part of the clinical picture as an additional factor in or as a result of PTSD. Overall, the diagnosis and assessment of PTSD relies primarily on the clinical interview of the child and parent.

March45 advocates a multi-dimensional evaluation of PTSD. Not only should interviews be conducted with the child and parent, but also with teachers and significant others. Rating scales such as the Child Behavior Checklist,46 the Conner's Rating Scale,47 the State-Trait Anxiety Scale,48 the Children's Depression Inventory,49 the Multidimensional Anxiety Scale for Children,50 the Child version of the Anxiety Disorders Interview Schedule for DSM-IV51 and the Clinician-Administered PTSD Scale-Child and Adolescent Version52 can be used along with semistructured clinical interviews to assess the nature and extent of the PTSD symptoms. Eth53 also suggests that the assessment of PTSD should be multidimensional and comprehensive. Cognitive, emotional/behavioral, personality, developmental, social-adaptive, and academic functioning should be included and thoroughly studied. There is some evidence that gains are being made in the psychophysiological assessment of PTSD. Orr and Roth54 indicate that some advances have been made toward predicting and assessing treatment response via physiological tests which can predict the development and persistence of PTSD.

Treatment Strategies

There have not been extensive empirical studies of the various methods of treating child and adolescent PTSD. The treatment of children with PTSD varies depending on the clinician training, perspective, and experience. In addition, children and adolescents react idiosyncratically to the variety and severity of their symptoms which requires individualized treatment planning. Treatments may differ relative to single event stressors versus prolonged traumatic experiences. Therefore, there are a variety of approaches to treatment, some which are very promising, and which are briefly reviewed here.

Debriefing and psychoeducation

Immediately following the traumatic event, it is crucial to diminish acute stress as in improves treatment outcomes. Debriefing involves interviewing those involved regarding their knowledge of the event, proximity to the trauma, and their emotional and physical reactions. Assisting those children in normalizing their reactions (a normal response to an abnormal event) and immediately intervening with crisis intervention strategies is a part of this debriefing approach. Especially in the case of individually experienced trauma, parents and children are involved in psychoeducational sessions to learn about the course of trauma, coping mechanisms, and to develop a support system early in the treatment regimen. Informing the family and the child what to expect regarding the symptoms to follow can ease anxiety, improve confidence through therapy, and help the family through the intense moments of this disorder.

Individual therapy

The core symptoms of PTSD, re-experiencing the trauma, avoidance/numbing, and hyperarousal, cause the child or adolescent to have a variety of social, emotional, academic, and behavioral difficulties. Individual therapy, therefore, has to be multi-faceted in attempting to resolve problems in each of these areas. The therapeutic regimen may involve relaxation and imagery training, anxiety management training, and desensitization and exposure therapy. Cognitive therapy to correct cognitive distortions and negative attributions, social skills training, consultation with school personnel and modification of curriculum, as well as behavioral intervention strategies for parents and teachers may also be needed to deal with the manifestations of anxiety, anger, and aggression. For very young children, play therapy may be a useful modality in treatment. Young PTSD children may benefit through projective drawings and storytelling, role-playing, and interpretation of trauma re-enactment.

Family therapy

As cited previously, the family plays a major role in the child's or adolescent's progress and outcome of therapy5, 6, 7, 8 since more than one family member is usually affected and parents tend to deny or diminish their child's symptoms. Family therapy can help the child feel more secure, validate emotions, and develop an environment of support through the course of therapy.

Group therapy

This approach is commonly used when many children are exposed to a traumatic event (hostage-taking at schools, natural disasters, terrorist acts). The benefits of group therapy are many and include psychoeducation regarding the trauma, exploring loss and normalizing reactions by sharing experiences, learning a variety of coping mechanisms used by others, and developing a sense of competence in collectively assisting others. Groups should routinely deal with common trauma responses, how to deal with re-experiencing of traumatic events, and a variety of coping strategies.26 Group therapy for parents may also be a suitable adjunct to child/adolescent therapy, so that parents can resolve their own emotional difficulties, their own trauma, and learn self- and child-management methods. Not all children or adolescents are comfortable in groups, however. Also, groups can vary regarding their structure. Cohen43 indicates that there are few studies comparing group versus individual therapy and that as long as treatment is trauma focused, this approach may be more salient than which treatment modality to use (individual, group, or family).

Pharmacological therapy

Very few studies have documented the effectiveness of pharmacotherapy for children and adolescents with PTSD. However, the use of medication as adjunctive therapy when symptoms of anxiety, panic, and/or depression are present may be necessary if these symptoms are debilitating. Essentially, the clinician must be guided by clinical judgement in the selection of psychotropic medication. Pfefferbaum26 and Perry and Azad4 suggest that Clonidine may help decrease physiologic hyperreactivity associated with sleep problems, generalized anxiety, impulsive behavior, and hyperreactivity of the sympathetic nervous system. Further, anti-anxiety and antidepressants medications may also be helpful. Unfortunately, the state of psychopharmacology for PTSD in children and adolescents is in its infancy with few controlled studies. Psychotropic medication may provide only symptom relief.55

Cognitive-behavior therapy is the most studied of the therapeutic approaches to PTSD. This methodology appears to be the most effective and the few empirical studies conducted in this treatment approach are very promising.56, 57, 58, 59, 4 In these studies, cognitive-behavior therapy was found to have greater clinical effectiveness than nondirective supportive therapy for sexually abused preschool children. This and similar literature does suggest that desensitization, relaxation, and cognitive restructuring and other behavioral methods are beneficial in treating PTSD in children and adolescents.59 Two such studies have demonstrated the effectiveness utilizing a manual-based group cognitive-behavior approach to PTSD children following a single-incident stressor60 and for children who had experienced multi-episode sexual assaults.61 Both studies utilized an 18-20 week format in which various cognitive-behavior strategies were taught via a manual. Psychoeducation, group processing, anxiety management training, cue-controlled relaxation training, assertive training and problem-solving, graded exposure techniques following individualized planning sessions, and relapse prevention to promote generalization of effects were components of each program. Results of each controlled study showed a significant reduction in PTSD symptoms of re-experiencing, avoidance, and hyperarousal.

In addition and most important was the resulting shift from participants' external locus of control, a possible factor in the maintenance of PTSD in children, to one based on an internal locus of control suggesting greater internalized coping ability and self-efficacy. Despite their small sample size, these controlled studies do demonstrate the effectiveness of a manual-based cognitive-behavior approach which integrates a wide array of treatment procedures into an effective treatment protocol.

Summary and Future Directions

A great deal of research on PTSD in children and adolescents has accumulated over the past 15 years. Though the knowledge base has grown significantly, more research and applied clinical studies are needed to solidify the field. Future research should focus on the developmental aspects of this disorder as well as the efficacy of some treatment procedures over others. Different treatment strategies need to be developed to address single-incident PTSD versus the more complex cases involving prolonged and multiple types of trauma. Replication of clinical studies utilizing existing treatment manuals must validate the effectiveness of such multimodal approaches toward treatment standardization. Psychopharmacology research should continue to examine which psychotropic agents are most successful in treating children and adolescents so as to integrate the treatment modality into a broad spectrum approach.

Early identification of PTSD by primary care physicians is needed62 and efforts should be undertaken to broaden the diagnosis of PTSD to include those individuals who do not meet full criteria. A diagnostic category of PTSD Spectrum Disorders may be appropriate and inclusive. Broadening the diagnostic classification may assist in better identification. Finally, there are a growing number of children and adolescents who are traumatized each year. Recent figures estimate that five million children and adolescents experience trauma, and of those, 1.5 million are diagnosed with PTSD.4 Therefore, there must be a greater focus on violence prevention programs, education to reduce "symptom contagion," and psychoeducational programs to physicians, clergy, parents, teachers and other caregivers.

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Jacksonville Medicine / August-September 2002

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