Treatment Recommendations for Children and Adolescents Suffering from Posttraumatic Stress

The past two or three decades have seen us make great strides in our ability to recognize and diagnose PTSD in children. Unfortunately, we have not as yet had as much success developing methods for treating children's posttraumatic distress once we ha ve identified it. It is now time to begin exploring the effectiveness of various interventions that might be used in the treatment of childhood PTSD. In order to help promote this next phase of research in childhood PTSD, I propose to summarize what li ttle is currently known about the treatment of childhood PTSD. In a future article I may add a few recommendations of my own. I would like to encourage others to send me comments or articles or suggestions on this matter as well.

I had the good fortune to attend a symposium at the ISTSS conference in Montreal last November, and again this November in Washington, D.C., wherein Judy Cohen and Tony Mannarino summarized their understanding of both the methods currently available fo r assessing PTSD in children and what is currently known about the effectiveness of different treatment interventions. An expanded version of their presentation has just been published as practice parameters in a supplement to the October issue of The J ournal of American Academy of Child and Adolescent Psychiatry. I base my summary on their two presentations, as well as on another paper that has come out this past year.

Only four controlled studies had investigated treatment of childhood PTSD by the end of 1997. Two of these examined the effectiveness of cognitive behavioral therapy (CBT) on sexually abused children (Cohen & Mannarino, 1996; Deblinger et al., 1996). CBT was effective in both studies. Goenjian et al. (1997) demonstrated that a school-based grief-and-trauma-focused CBT effectively decreased symptoms of depression in teens following the earthquake in Armenia. And, finally, Field et al. (1996) demonst rated that massage therapy can help alleviate symptoms of PTSD among children exposed to a disaster such as Hurricane Andrew.

At least one more study has since demonstrated the effectiveness of CBT with children exposed to a single-incident stressor. March et al. (1998) have provided what may be one of the most rigorous tests to date of CBT as a treatment for children and ad olescents with PTSD. The authors report that, "Fourteen of 17 subjects completed treatment. Of these, 8 (57%) no longer met DSM-IV criteria for PTSD immediately after treatment, 12 (86%) of 14 were free of PTSD at 6-month follow-up" (p. 585).

So there is good preliminary evidence that at least some of the elements of CBT can be effective in treating PTSD symptomatology. These elements include direct discussion of the trauma, desensitization and relaxation techniques, cognitive reframing, a nd contingency reinforcement programs for problematic behaviors (Cohen & Mannarino, 1993; Deblinger & Heflin, 1996).

Although some therapists may be inclined to avoid directly discussing the trauma with the child, it actually appears to be an important part of therapy. Simply asking children about the experience and their reactions to it can have a beneficial effect for the child. Some therapists have suggested gradual exposure to increasingly upsetting aspects of the traumatic experience can be helpful in desensitizing the child to the traumatic event(s). There is no clear evidence that exposure per se is necessa ry for treatment. No studies have separated this component from other CBT interventions. A combination of asking the child to describe the traumatic events and discussing the child's thoughts and feelings at the time appears to be helpful, however.

Direct exposure and other desensitization techniques might be more effectively accomplished in some cases in conjunction with relaxation and stress management techniques. These include such things as progressive muscle relaxation, deep breathing, thou ght stopping, positive imagery, etc. Learning such techniques also may be one avenue of helping the child gain a sense of mastery over her or his thoughts and feelings, an important consideration when unavoidable reexperiencing of the trauma may be the p rimary symptom of posttraumatic stress.

Directly addressing the trauma is not indicated for all children, however. Insistent focus on talking about the trauma may have adverse consequences for some children, especially those who are asymptomatic in the first place, or who are embarrassed by the circumstances or in some other way are resistant to discussing the event(s). In this case, more indirect methods of discovering and addressing relevant issues may be more helpful. These include techniques such as art and play therapy, or creative w riting of stories, poems, or songs.

It is essential that the therapist learn how the child interprets his or her adverse experience. This is because children are inclined to make misattributions and incorrect assumptions when placed in adversity. Once the child's interpretation of the event(s) is better understood, helping him or her to correct any misunderstandings and misattributions can frequently alleviate much suffering and symptomatology. It can help the child to "normalize" his or her reactions to the event; that is, help him o r her understand that his or her thoughts and feelings are pretty much what any kid in the same situation would be likely to think and feel. There is nothing "crazy" or "weird" about his or her reactions. It also helps to try to find out what the child believes others think about his or her experience.

The child's understanding of the experience can helpfully be explored and reframed through detailed discussion. One way to help reframe the child's understanding of the events is to use third person examples. Such as, "What would you think if your br other thought or did this?" Children may be thinking in extremes about their experience, and one way to help correct this is to exaggerate the tendency and use global generalizations or exaggerations that are very extreme in order to help the child see t he absurdity of that way of thinking. For example, "So when you trip and fall everybody in the world, everybody in the whole universe in fact, is laughing at you for being so silly!" (to give a silly example). It can also be help to use pictorial aids t o measure or assign responsibility for the events that took place. For example, you might have the child use a "responsibility ruler" to mark how much of what happen what the child's responsibility, how much was the responsibility of the driver of the ot her car who hit the car the child was riding in, etc.

Other issues may need to be addressed in therapy, too. Grief and bereavement might be an issue for the child. Even the loss of personal belongings, such as dolls or pets, can be very disorienting. It may be particularly important to help children un derstand major losses. Children can quickly change their beliefs, and after tragic experiences, they may suddenly begin to believe that life really does not follow rules after all. They may be inclined to no longer belief that life is safe or fair, for example, or that it pays to be good. It is important to identify these maladaptive changes in World Views.

Anger management is another area that may need to be dealt with after traumatic experience. Survivor's guilt, too, may lead to troublesome behaviors. As a consequence of such guilt, some children may attempt to be perfect children. Other may begin t o misbehave in order to call down punishment upon themselves.

It is also important to include parents and/or guardians in treatment, whenever possible. The response of parents to the child's traumatization can play an important role in the child's own response. The more extreme or intense parents' responses are to the child's experience, the worse the child's symptomatology. The more supportive parents are of the child, the less the child's symptomatology. Parents need to be educated about PTSD and the kinds of behaviors they might expect to see in their chil dren as a result of posttraumatic stress. Such responses easily can be confused with other things, such as ADHD, for example, or aggressiveness or depression. Parents can be taught appropriate management techniques, too. Parents themselves may have iss ues related to the traumatic event(s), or their child's reactions to it, that need to be addressed. Sometimes a child's trauma can trigger a parent's memories of their own earlier traumatic experiences, too. In some cases, similar interventions with tea chers may be helpful as well, especially if they were involved in the traumatic event in some way.

Parental self-blame for the child's traumatization is very common. This may model self-blame for the child. Parental blame of the child may be unrealistic or exaggerated, too. Sometimes this is inadvertently expressed after first disclosure of abuse , for example. The therapist needs to help parents identify, exame, and reframe inaccurate cognitions about the trauma.

It is important to enhance parental support of the child. Offer support for the parents, so they can work through their own issues. Give them the opportunity to share their feelings about everything related to the consequences of the trauma. Teach t hem how to provide support to their child, emphasizing the importance of offering direct support, expressing love and telling the child the parents do not believe the child did anything wrong.

Behavioral management training for the parents will probably be helpful too. Sometimes parents don't follow through on normal limit-setting and guidance because they feel so badly about what the child went through. Parent may need to be reminded that the child is still going through the same developmental tasks as nontraumatized children. The trauma is important, but it is not the only important thing in the child's life. Parents should also be sure to deal with behaviors that are out of the ordina ry, such as sexually inappropriate behaviors. Parents need to show the child that certain behaviors are inappropriate. The bottom line, however, is that parent need to try not to exaggerate the impact of the trauma on the child.

There is not yet much evidence concerning the relative effectiveness of group versus individual therapy. Group interventions may have some utility when the group has experienced a common trauma or disaster.

As for psychopharmocology, it appears that medicating children suffering from posttraumatic stress may be at best mildly effective (March et al., 1996).

References

Cohen, J.A., & Mannarino, A.P. (1993). A treatment model for sexually abused preschoolers. Journal of Interpersonal Violence, 8, 115-131.

Cohen, J.A., & Mannarino, A.Pl (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 42-50.

Cohen, J.A. et al. (1998). Practice parameters for the assessment and treatment of children and adolescents with Posttraumatic Stress Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 4S-26S.

Deblinger, E., & Heflin, A.H. (1996). Cognitive behavioral interventions for treating sexually abused children. Thousand Oaks, CA: Sage Publications.

Deblinger, E., Lippman, J. & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310-321.

Field, T., Seligman, S., Scafedi, F., Schanberg, S. (1996). Alleviating posttraumatic stress in children following Hurricane Andrew. Journal of Applied Developmental Psychology, 17, 133-145.

Goenjian, A.K., Karayan, J., Pynoos, R.S., Minassian, D., Najarian, L.M., Steinberg, A.M., Fairbanks, L.A. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154, 536-542.

March, J.S., Amaya-Jackson, L., Murray, M.C., & Schulte, A. (1996). Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder: A controlled trial of a new protocol-driven treatment package. Norbert and Charlot te Rieger Award Lecture, AACAP Annual Meeting, Philadelphia, PA.

March, J.S., Amaya-Jackson, L., Murray, M.C., & Schulte, A. (1998). Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor. Journal of the American Academy of Child and Adol escent Psychiatry, 37, 585-593.

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