Helping children and adolescents cope with violence and disasters      

Part 5: Post-traumatic stress disorder

[April 28, 2007]  The National Institute of Mental Health has brought forth information to assist the nation as we recover from the shock and distress created by the recent Virginia Tech shootings. This information is particularly designed to help in times of unanticipated, great or violent loss, but the underlying principles are useful for any level of grief and healing.

(Part 1: Introduction)

(Part 2: Trauma -- What is it?)

(Part 3: How children and adolescents react to trauma)

(Part 4: Helping the child or adolescent trauma survivor)

Part 5:

POST-TRAUMATIC STRESS DISORDER

As mentioned earlier, some children and adolescents will have prolonged problems after a traumatic event. These potentially chronic conditions include depression and prolonged grief. Another serious and potentially long-lasting problem is post-traumatic stress disorder (PTSD). This condition is diagnosed when the following symptoms have been present for longer than one month:

• Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma.

• Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future).

• Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behavior.

Rates of PTSD identified in child and adult survivors of violence and disasters vary widely. For example, estimates range from 2 percent after a natural disaster (tornado), 28 percent after an episode of terrorism (mass shooting), and 29 percent after a plane crash.¹³

The disorder may arise weeks or months after the traumatic event. PTSD may resolve without treatment, but some form of therapy by a mental health professional is often required in order for healing to occur. Fortunately, it is more common for traumatized individuals to have some of the symptoms of PTSD than to develop the full-blown disorder.¹⁴

As noted above, people differ in their vulnerability to PTSD, and the source of this difference is not known in its entirety. Researchers have identified factors that interact to influence vulnerability to developing PTSD. These factors include:

• characteristics of the trauma exposure itself (e.g., proximity to trauma, severity, and duration),

• characteristics of the individual (e.g., prior trauma exposures, family history/prior psychiatric illness, gender
  -- women are at greatest risk for many of the most common assaultive traumas), and

• post-trauma factors (e.g., availability of social support, emergence of avoidance/numbing, hyperarousal and re-experiencing symptoms).

Research has shown that PTSD clearly alters a number of fundamental brain mechanisms. Abnormal levels of brain chemicals that affect coping behavior, learning, and memory have been detected among people with the disorder. In addition, recent imaging studies have discovered altered metabolism and blood flow in the brain as well as structural brain changes in people with PTSD.^15-19

TREATMENT OF PTSD

People with PTSD are treated with specialized forms of psychotherapy and sometimes with medications or a combination of the two. One of the forms of psychotherapy shown to be effective is cognitive behavioral therapy, or CBT. In CBT, the patient is taught methods of overcoming anxiety or depression and modifying undesirable behaviors, such as avoidance of reminders of the traumatic event. The therapist helps the patient examine and re-evaluate beliefs that are interfering with healing, such as the belief that the traumatic event will happen again. Children who undergo CBT are taught to avoid "catastrophizing." For example, they are reassured that dark clouds do not necessarily mean another hurricane, that the fact that someone is angry doesn't necessarily mean that another shooting is imminent, etc. Play therapy and art therapy also can help younger children to remember the traumatic event safely and express their feelings about it. Other forms of psychotherapy that have been found to help persons with PTSD include group and exposure therapy. A reasonable period of time for treatment of PTSD is 6 to 12 weeks with occasional follow-up sessions, but treatment may be longer depending on a patient's particular circumstances. Research has shown that support from family and friends can be an important part of recovery.

There has been a good deal of research on the use of medications for adults with PTSD, including research on the formation of emotionally charged memories and medications that may help block the development of symptoms.^20-22 Medications appear to be useful in reducing overwhelming symptoms of arousal (such as sleep disturbances and an exaggerated startle reflex), intrusive thoughts, and avoidance; reducing accompanying conditions such as depression and panic; and improving impulse control and related behavioral problems. Research is just beginning on the use of medications to treat PTSD in children and adolescents.

There is accumulating empirical evidence that trauma/grief-focused psychotherapy and selected pharmacologic interventions can be effective in alleviating PTSD symptoms and in addressing co-occurring depression.^23-26 However, more medication treatment research is needed.

A mental health professional with special expertise in the area of child and adolescent trauma is the best person to help a youngster with PTSD. Organizations on the accompanying resource list may help you to find such a specialist in your geographical area. (Resources)

References:

¹³Smith EM, North CS, Spitznagel EL. Post-traumatic stress in survivors of three disasters. Journal of Social Behavior and Personality, 1993; 8(5): 353-68.

¹⁴Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 1998; 55(7): 626-32.

¹⁵Bremner JD, Randall P, Scott TM, Bronen RA, Seibyl JP, Southwick SM, Delaney RC, McCarthy G, Charney DS, Innis RB. MRI-based measurement of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 1995; 152(7): 973-81.

¹⁶Stein MB, Hanna C, Koverola C, Torchia M, McClarty B. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 76-82.

¹⁷Rauch SL, Shin LM. Functional neuroimaging studies in posttraumatic stress disorder. In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 83-98.

¹⁸De Bellis MD, Baum AS, Birmaher B, Keshavan MS, Eccard CH, Boring AM, Jenkins FJ, Ryan ND. Developmental traumatology part I: biological stress systems. Biological Psychiatry, 1999; 45(10): 1259-70.

¹⁹De Bellis MD, Keshavan MS, Clark DB, Casey BJ, Giedd JN, Boring AM, Frustaci K, Ryan ND. Developmental traumatology part II: brain development. Biological Psychiatry, 1999; 45(10): 1271-84.

²⁰Golier JA, Yehuda R. Neuroendocrine activity and memory-related impairments in posttraumatic stress disorder. Development and Psychopathology, 1998; 10(4): 857-69.

²¹Cahill L. The neurobiology of emotionally influenced memory: implications for understanding traumatic memory. In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, vol. 821. New York: The New York Academy of Sciences, 1997; 238-46.

²²Gold PE, McCarty RC. Stress regulation of memory processes: role of peripheral catecholamines and glucose. In: Friedman MJ, Charney DS, Deutch AY, eds. Neurobiological and clinical consequences of stress: from normal adaptation to post-traumatic stress disorder. Philadelphia: Lippincott-Raven, 1995; 151-62.

²³Yule W, Canterbury R. The treatment of post traumatic stress disorder in children and adolescents. International Review of Psychiatry, 1994; 6(2-3): 141-51.

²⁴Goenjian AK, Karayan I, Pynoos RS, Minassian D, Najarian LM, Steinberg AM, Fairbanks LA. Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 1997; 154(4): 536-42.

²⁵March JS, Amaya-Jackson L, Pynoos RS. Pediatric posttraumatic stress disorder. In: Weiner JM, ed. Textbook of child and adolescent psychiatry, 2nd edition. Washington, DC: American Psychiatric Press, 1997; 507-24.

²⁶Murphy L, Pynoos RS, James CB. The trauma/grief-focused group psychotherapy module of an elementary school-based violence prevention/intervention program. In: Osofsky JD, et al., eds. Children in a violent society. New York: Guilford Press, 1997; 223-55.

The information in this series has been made available through the National Institute of Mental Health.

Article to come:

Monday, April 30

• Helping children and adolescents cope with violence and disasters
  Part 6: What are scientists learning about trauma in children and adolescents?

[Text copied from National Institute of Mental Health]