Post-Traumatic Stress Disorder in Children

Post-Traumatic Stress Disorder in Children

University’s Name

Submitted by Names:

Tutor:

Date

Post-Traumatic Stress Disorder in Children

The society today needs to acknowledge that sexual abuse happens to children today as well as in the past generation and many women have grown with the abuse to date, as they search for answers to help them deal with the situation. Due to the underreporting of this trauma, the actual number of children who are sexually abused still remains an estimate and the agencies that keep current numbers on child sexual abuse reports did not necessarily keep statistics when most of the women today were children, (Duncan, 2004, p. 67). Research conducted in the 1970s and 1980s indicate that between 15 per cent and 45 per cent of children were abused during this period and are now fully grown women but still have the sexual trauma from the vents that happened to them as they were children . Today, these numbers are thought to be even higher due to the improvement in the reporting mechanisms and the willingness of these women to speak out about their ordeals, (Cohen, 2003, p. 176). Population surveys that assess the childhood sexual abuse experiences indicate that approximately one in four children are reported to be abused hence the need to come up with the necessary measures to reduce this a well as deal with childhood trauma caused by sexual abuse, (Duncan, 2004, p. 17 ).

Child sexual abuse is a leading cause in the development of post-traumatic stress disorder as citing previsous researches indicates that in the United States at least 15 per cent of the population is reported to have been molested, physically assaulted, raped or involved in combat. Women report higher rates of sexual assaults than men do 7.3 per cent of women versus 1.3 per cent for men and while strangers perpetrate 22 per cent of the reported rapes committed towards women, husbands and boyfriends are responsible for 19 per cent and other relatives account for 38 per cent, (Foa, Keane et al., 2000, p. 14). Trauma that results from violence within intimate relationships is more prevalent for women and children as four out of five assaults on children are at the hands of their own parents. The glaring realizations from this information are that it is a family member, not a stranger who is most likely to cause the trauma of sexual abuse; that sexual assault occur more often to women than to men; and that the child molestation and other types of abuses to children continue to be wide spread problems in the society today, (Silverman, 2001, p. 171)

According to Foa, Keane et al. (2000, p. 19), given the prevalence of sexual trauma and the increased risk of prolonged problems, the availability of information to women and children about treatment and recovery from sexual abuse trauma is of utmost importance since sexual abuse is traumatic mentally, physically and emotionally to children and it continues to affect them as they grow into adulthood hence the need to deal with such trauma from an early age. As a national health problem, sexual abuse affects millions of children every year and the long term health problems can include depression, anxiety, chemical dependency and addiction, and the perpetuation of maltreatment of children into the next generation. The safety of our children warrants societal commitment and resources to intervene and prevent the effects of this trauma from occurring in order to protect the future generations. Too often, the embarrassment from this trauma will cause the victims not seek help as some might blame themselves or feel shame for such problems as sexual disinterest, lack of sexual desire or the physical pain that results from the abuse, (Foa, Keane et al., 2000, p. 21). Victims can blame themselves for recurring symptoms of depression and anxiety or for problems of self-harm such as eating disorders or addictions that develop from abuse but they may not understand that these emotional states and behaviors are often reenactment of the trauma experience, expression of emotional pain, or chronic shocks from the abuse. The victims are not responsible for how the abuse affected her, just as they are not responsible for the perpetrator abusing them but they can take responsibility for their own healing, (Yehuda, 2002, p. 35).

Psychological interventions

Benedek, & Wynn, (2011, p. 299) asserts that successful treatment of post-traumatic stress disorder should improve the quality of life in multiple domains, such that the patient experience improved functional status, decreased symptom severity and reduced vulnerability to subsequent stress. Certain psychological modalities may be used in clinical practice e.g. although play therapy is often used in the treatment of childhood trauma, no empirical evidence supports its independent use. At times paly techniques are incorporated in many evidence-based interventions as a means of enhancing communication (Cohen, Berliner & Mannarino, 2003, p. 51).

There are several adaptations of cognitive-behavioral therapy for trauma, referred to as trauma specific cognitive-behavioral therapy. Core components of trauma specific cognitive-behavioral therapy include psychoeducation, relaxation training, coping skill development, exposure and cognitive reconstructing (Cohen, Berliner & Mannarino, 2003, p. 77; Taylor and Chermtob 2004, p. 787). Several trauma specific Cognitive-Behavioral Therapy interventions have been tested and these interventions differ mostly in the balance between and emphasis on cognitive and behavioral components, (Stallard, 2006, p. 906). Compared with other trauma interventions, trauma specific Cognitive-Behavioral Therapy has the most evidence for efficacy in treating Post-Traumatic Stress Disorder and has also been shown to be superior to wait-list conditions and other treatment in preschoolers, children and adolescents, (Silverman, Ortiz and Viswesvaran, 2008, p. 182). In addition the treatment studies supporting trauma specific Cognitive-Behavioral Therapy have included a wide range of ethnicities, greater effect size and greater effect on comorbid conditions compared with other treatments and this treatment has had success in many instances that has led to complete recovery of the children involved in the therapy.

Trauma focused Cognitive-Behavioral Therapy was originally developed for use with sexually abused children, but has been adapted for children with other behavioral issues. This standard treatment has been used with children aged 3 – 17 years from multiple ethnic backgrounds. It uses cognitive-behavioral, interpersonal and family therapy principles to address trauma related symptoms, including Post-Traumatic Stress Disorder, depression, trauma related shame and trauma related cognitions, (Taylor and Chermtob 2004, p. 786). It incorporates a non-offending caregiver component that is designed to enhance caregiver support of the child, decreases caregiver distress related to the child’s trauma and increase positive parenting behaviors as the treatment components include parenting skills, psycho-education, relaxing skills training, affective modulation skills training, cognitive processing, trauma narration, in vivo desensitization and other incorporative therapies.

According to Cohen, Berliner, & Mannarino (2003, p. 6), the core values in Trauma focused Cognitive Behavioural Therapy applying to all cases regardless of the community or setting reflects a universality of the human condition in terms of essential therapy ingredients. They contribute to the overall healing of the children and their families in respect to the community, cultural and religious traditions that are adaptable to individualised needs and circumstances as well as leaving the focus on the family as the basis is on a strong therapeutic relationship that encourages self-efficiency. These core values involve component based such that it incorporates knowledge, skills and processes that build on one another and are reintegrated in a way that it best suits the needs of the particular client and family. The other core component of the approach if respect of individual family, community, culture and religious practises, in terms of understanding the impact of the traumatic experiences and optimally supporting the child’s and family’s healing in the context of their family, culture and community, (Cohen, Berliner, & Mannarino, 2003, p. 6)

The other core principle is the adaptable and flexible ways that the therapists optimally motivate clients and implement the treatment components for inverse population and settings while maintaining fidelity to the model. The family focused approach in every aspect is there to include the efforts of the supportive family members. The therapists take the extra mile to involve parents and other care givers in the treatment process whenever possible as it is appropriate to involve the siblings when feasible and clinically possible since it is a therapeutic relationship cantered such that much attention should be given to creating a therapeutic relationship that allows parents and children to feel safe, accepted and validated. Such relationship helps the clients to feel trusting and confident to share their traumatic experiences as well as their most distressing fears, thoughts and developing beliefs while also taking the risks necessary to learn and utilise new skills that will produce significant positive change in their lives.

The last principle if the self efficacy in that Cohen, Berliner, & Mannarino (2003, p. 7) assert that Trauma focused Cognitive Behavioural Therapy is a short term, strengths based model designed to have long-term benefits. In the contexts, therapists encourage self-efficacy and feelings of mastery by actively collaborating with clients and planning therapy, motivating clients to follow through on assignments between sessions, acknowledging therapy success, encouraging and recognising the on-going of Trauma focused Cognitive Behavioural Therapy skills and enhancing the client’s feelings of preparedness for trauma reminders and other life stressors that they may encounter long after therapy has ended.

According to Stallard (2006, p. 901), another form of Cognitive-Behavioural Therapy is the multimodality Trauma Treatment which is an intervention based on the learning theory that is designed to address Post-Traumatic Stress Disorder symptoms related to single incidence trauma. The intervention uses storybooks, narrative exposures, cognitive games and peer modeling to teach anxiety management training, promote interpersonal problem solving for anger control, induce gradual exposure, replace maladaptive trauma related cognitive schemas with more helpful thought patterns, improve coping skills and reduce concurrent depression and grief. The treatment is delivered in 11-13 group sessions, with one mid-treatment individual session to introduce narrative exposure and correct trauma-related misattribution and distortions, (Lieberman & Van Horn, 2005, p.9). Observations in the examination of this treatment revealed that general anxiety, depression and trait anger significantly reduced from pretreatment to post treatment in children aged 10 – 15 years and this pattern of symptom reduction was consistent across both the early and late start groups as well as across elementary and middle school groups and treatment was maintained at 6 months post-treatment.

It is based on the premise that mental health concerns in young children can be best addressed thought the child’s relationship with the primary caregiver. It works within the context of free play during joint parent-child sessions and incorporates parent-only sessions as indicated. During joint sessions, the child is provided with developmentally appropriate toys selected to elicit trauma play and foster social interaction as well as the application of specific interventions directed at child maladaptive behaviors by supporting developmentally appropriate interactions and creating a joint child-parent trauma narrative, (Stallard, 2006, p. 906).

Psychoeducation of the child and parent involved the two receiving information about the types of trauma experienced that could be in the form of sexual violence against the child and may take the form of how many children experienced this type of trauma, the fact that it impacts many children, not just themselves, education about typical reactions to traumatic experiences including what Post-Traumatic Stress Disorder is, normalizing the child’s parent’s reaction to the traumatic experience and providing ongoing information to correct cognitive distortions through the course of the treatment,(Foa, Keane, Friedman, & International Society for Traumatic Stress Studies, 2000, p. 227), thus psychoeducation continues throughout trauma-specific Cognitive Behavioral Therapy.

Other skills such as relaxation skills are provided in a variety of different ways in different trauma specific Cognitive Behavioral Therapy models. Most include individualized interventions, whereby children and parents are encouraged to develop ways of self-monitoring and regulating physiological. The goal of all these skills is to enhance children’s ability to recognize their own physical tension, stress or anxiety, and to take active productive steps to reduce these. Parents are also encouraged to learn and practice these skills between treatment sessions both personal and with their children.

Affective modulation skills in addition to relaxation skills are other ways of modulating distressing affective states such as anxiety, anger, sadness and emptiness are addressed in trauma specific Cognitive Behavior Therapy and therapist use games and therapeutic activities to encourage the child’s affective expression skills. The therapist then assists the child in developing an individualized plan to identify the most difficult feeling and how to cope with situations in which these arise. Some children may need to learn to disengage from activities that lead to negative affective states, learn how to make friends and to find activities they enjoy etc. many children need to learn all of these coping strategies a well as how to choose selectively which skill to use in a given situation. For children who are severely affectively deregulated, the affective modulation component may take many sessions and parents are encouraged to learn affective modulation skills, both themselves and to assist and encourage their children to use these skills between treatment sessions, (Foa, Keane, Friedman, & International Society for Traumatic Stress Studies, 2000, p. 229).

When children experience a distressing feeling or engages in a dysfunctional behavior, the therapist encourages them to learn to identify the thought that preceded the feeling or behavior. By changing to more accurate and/helpful thought, children develop more soothing feelings and more positive behaviors especially in the early stages of treatment and cognitive copings is used as a general stress management tool used to assist children in managing generally upsetting affective states rather than to change trauma specific cognitive distortions. Later in therapy, after children have developed a narrative of their trauma experiences, these same strategies are used to explore and to reframe inaccurate and unhelpful cognitions related to children’s traumatic experiences and the therapist might ask a child about any upsetting feelings he or she had during the past week in relation to the sexual abuse that the child encountered. He would then ask the child of another encounter that mad the child feel better about himself an, the therapist might then help the child explore how each of these thoughts would make him or her feel and understand that he or she can choose among all these thoughts in the situation. Parents are also encouraged to learn cognitive coping skills, both for their personal use and to encourage their child to use them between the sessions, (Seligman, Reivich, Jaycox & Gillham, 1995, p.55).

Recommendations for the interventions

According to Yehuda (2002, p. 99), researchers studying sexually abused children and physically abused children have found Post-Traumatic Stress Disorder prevalence rates to vary across studies, yet the prevalence rates in cases of sexual abuse tend to be higher than cases relating to physical abuse. In studies of sexually abused children, researchers have reported Post-Traumatic Stress Disorder prevalence rates ranging from 20.7% to 90%. Study estimates of the Post-Traumatic Stress Disorder in physical abused children range from none, to 6.9%, to 23% and to 33% in other studies, (Yehuda, 2002, p. 101). Studies of child physical and sexual abuse have not differentiated the rates of Post-Traumatic Stress Disorder associated with each type of abuse report prevalence ranging from 35% to 39% to 50% in others and combining these rates appear to result in understanding the effects of sexual abuse and inflating the effects of physical abuse (Yehuda, 2002, p. 102).

Trauma specific Cognitive-Behavioral Therapy is applicable to children aged 3 – 17 years who have undergone both single and multiple traumas and may as well work with children from diverse backgrounds culturally and ethically. It is also efficient in individual, family and group modalities as well as in school and office setting as it is structured to be flexible and can be considered a first line treatment in most cases of children and adolescent Post-Traumatic Stress Disorder. According to Benedek, & Wynn, (2011, p. 316) key points to note is that children and adolescents can develop symptoms consistent with Post-Traumatic Stress Disorder and providers should be aware of the unique aspects of Post-Traumatic Stress Disorder within this population.

Young children are less likely to have emotional numbing or avoidance symptoms and often present with a wider range of behavioral disturbances compared with other children, teens and adults. Children and adolescents with posttraumatic symptoms often do not meet the current full criteria for Post-Traumatic Stress Disorder and frequently they have comorbid disorder, including developmental problems, attention-deficit hyperactivity disorder, anxiety and depression. Complex trauma, occurring when a child is exposed to multiple traumatic stressors can have a severe impact on multiple domains of function and as well trauma specific cognitive behavioral therapies such as Trauma Focused -Cognitive-Behavioral Therapy and Multi-Modal Trauma Treatment are best supported by evidence for efficacy in treating Post-Traumatic Stress Disorder in pre-schoolers, children and adolescents, (Benedek, & Wynn, 2011, p. 316)

Child-parent psychotherapy, a trauma specific relationship intervention developed for young children exposed to interpersonal violence has shown efficacy in children up to the age of 6 years in reducing trauma symptoms and behavioral problems. Other forms of intervention such as Eye Movement Desensitization and Processing appear to be an effective intervention among children and adolescents, though the standard protocol may have to get altered depending on the age of the child.

Although a few studies of pharmacological treatment for children and adolescents with Post-Traumatic Stress Disorder have been completed, clear scientific evidence of benefiting from such interventions is lacking, pharmacotherapy for Post-Traumatic Stress Disorder should be considered in children and adolescents only when psychological interventions have been ineffective and when used should be integrated into a multimodal treatment plan. As in all diagnoses, particular caution should be exercises in using medication with preschool-aged children, (Greenwald, 1933, p. 43; Shapiro, 2001, p. 108). It is critically important to assess parent’s overall functioning as well as given that they are often directly and indirectly affected by the traumas their children experienced as this assessment may also help determine the need for separate therapy referral if the parents’ emotional difficulties are of an individual nature, require immediate attention or are likely to interfere with their ability to participate in the treatment on behalf of their child.

Bibliography

Benedek, D. M., & Wynn, G. H. (2011). Clinical manual for management of PTSD. Washington

D.C: American Psychiatric Pub

Cohen J, A, Berliner L, & Mannarino A.P. (2003) Psychological and Pharmacological interventions for child crime victims. J Trauma Stress 16: 175-186

Cohen J.A., (2001). Pharmacologic treatment of trumatised children. Trauma violence abuse 2:

155-171

Duncan, K. A. (2004). Healing from the trauma of childhood sexual abuse: The journey for

women. Westport, Conn: Praeger.

Foa, E. B., Keane, T. M., Friedman, M. J., & International Society for Traumatic Stress Studies.

(2000). Effective treatments for PTSD: Practice guidelines from the International

Society for Traumatic Stress Studies. New York: Guilford Press

Greenwald, R. (1993). Using EMDR with children. Pacific Grove, CA, EMDR institute

Lieberman, A.F., Van Horn, P. (2005). Don’t hit my mommy. A manual for child-parent

psychotherapy with young witnesses of family violence. Washington DC, zero to three

press.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: basic principles, protocols

and procedures, 2nd edition. New York, Guilford.

Silverman, W.K., Ortiz C.D., & Viswesvaran, C. (2008). Evidence based psychosocial

treatment for children and adolescents exposed to traumatic events. J Clin Child Adolesc

Psychil 37: 156-183

Stallard, P. (2006). Psychosocial interventions for post-traumatic reactions in children and

young people: A review of randomized controlled trials. Clin Psychol Rev 26: 895 – 911

Seligman, M.E. P., Reivich, K., Jaycox, L., & Gillham, J. (1995). The optimistic child. Boston:

Houghton Mifflin.

Taylor, T. L., & Chemtob C. M., (2004). Efficacy of treatment for child and adolescent traumatic stress. Arch Pediatr Adolesc Med 158: 786 – 791.

Yehuda, R. (2002). Treating trauma survivors with PTSD. Washington, DC: American Psychiatric Pub.