Transcript PTSD in Children

P-FLASH with Kids:
PRACTICAL FRONT LINE
ASSISTANCE
& SUPPORT FOR HEALING
Betty Pfefferbaum, MD, JD1
Carol S. North, MD2
Robin H. Gurwitch, PhD1
Barry Hong, PhD2
University of Oklahoma Health Sciences Center1
Washington University School of Medicine2
INTRODUCING...
YOUR PRESENTERS
PURPOSE
To provide a tool kit for practical,
front line postdisaster mental
health interventions with children
following the 9/11 terrorist attacks
GOALS OF THE TRAINING
1) Differentiate normative and
pathological responses
2) Review disaster responses,
assessment, and treatment
3) Provide disaster mental health
education and skill-building
INTRODUCTIONS
Please introduce yourself
to the group
What issues do you face?
TOPICS
Part 1: Reactions to disaster
Part 2: Assessment
Part 3: Intervention
PART 1
Reactions
REACTIONS
 Posttraumatic stress disorder
 Other disorders
 Reactions
 Factors affecting response
DISASTERS
 Overwhelming events
 Affect many individuals and entire
communities
 Result in:
Property damage
Disruption of daily life
Human suffering, injury, and/or loss of life
TERRORISM AS UNIQUE TRAUMA
 Intentional human design
- to undermine sense of safety and trust in
government and social institutions
 Innocent people targeted
 Unpredictable
TIMING: PHASES OF DISASTER
Disaster phases:
 Pre-disaster
 Acute impact
 Early post-disaster
 Long-term post-disaster
REACTIONS TO DISASTER
Normal reactions
 Most children significantly exposed to a disaster
will manifest some distress, but most do not
develop psychiatric illness
Pathological reactions
 Some children will develop a diagnosable mental
disorder after a disaster
DIAGNOSIS VS. DISTRESS
Psychiatric diagnosis: not just a label
- Need for professional evaluation and treatment
- Has implications for prognosis
- Used to select appropriate interventions
Subdiagnostic distress:
- Deserves recognition and intervention
(just because it is not PTSD does not
mean it is not significant)
PTSD DOESN'T CAPTURE IT ALL
Comorbidity with PTSD in adolescents
 Population adolescents: 6% PTSD (lifetime)
- 80% of those with PTSD had another disorder
 Adolescents in cruise ship sinking: 52% PTSD
- Few or no delayed-onset cases
- 1/3 of those with PTSD recovered within 1 year
and another 1/3 recovered by 5-8 years
COMMON NORMAL REACTIONS
PTSD FEATURES:
Group B Intrusive re-experience
 Re-enactment in play
Group C
Emotional constriction
Group D
Heightened arousal
 Increased sensitivity to sounds
 Increased activity
 Irritability
 Concentration problems
 Sleep disturbance
COMMON NORMAL REACTIONS
Fear and anxiety
 Disaster-specific fears
 Fear of recurrence
 Concerns about safety
 Separation anxiety
COMMON NORMAL REACTIONS
Depressive symptoms are common. They may:
Pre-date the trauma exposure
Occur in the context of:
 PTSD and other disorders
 Intervening stressors
 Bereavement
INFANTS
 Sleeping problems
 Feeding problems
 Irritability
 Failure to meet
developmental milestones
PRESCHOOL CHILDREN
 Behavioral regression
 Separation anxiety, clinging, and dependence
 Irritability, temper tantrums, and behavior problems
 Sleep disturbance; nightmares
 Repetitive play re-enactment
 Withdrawal: subdued or even mute
SCHOOL CHILDREN
 Excessive questions or discussion
about the incident
 Irritability
 Increased negative behaviors
 Somatic complaints
 Changes in school performance
ADOLESCENTS
 Irritability
 Isolation and withdrawal
 Guilt and self-blame
 Anger and hate
 Anxiety about the world and their future
 Fascination with death and dying
 Absenteeism
 Risk for substance abuse/alcohol use
 Poor impulse control and high-risk behaviors
BEREAVEMENT AND TRAUMATIC GRIEF
 Bereavement is a normal process that may be a focus
of clinical attention; traumatic grief is complicated
 Bereavement may complicate recovery from traumatic
events, and traumatic circumstances may complicate
the grief process
 Bereavement and traumatic grief are distinct from, but
share common features with, psychiatric disorders,
most notably major depression and PTSD
FACTORS AFFECTING RESPONSE
 Disaster characteristics
 Exposure
 Child factors
 Family factors
 Community factors
CHARACTERISTICS OF THE DISASTER
Man-made disasters may be more
traumatizing than natural disasters
because:
they are intentional
their purpose is to create fear,
mistrust, and societal disruption
TYPE OF EXPOSURE
 Physical presence and witnessing
Proximity
Subjective experience
 Interpersonal relationship with
those directly exposed
ELEMENTS OF EXPOSURE
 Separation
 Property damage
 Secondary adversities
 Traumatic reminders
MEDIA COVERAGE
 Exposure to media coverage absent other
means of exposure does not meet the
PTSD stressor criterion
 Research connecting media exposure and
PTSD symptoms does not imply causality
 Cognitive processing of media coverage
depends on the child's developmental level
CHILD FACTORS
 Age and development
 Gender
 Ethnicity
 Pre-existing conditions and prior trauma
FAMILY FACTORS
 Association between child and parent reactions
 Risk:
Disruption of routine
Parent symptoms
Family stressors
Impaired family functioning
Strained parent-child relationship
 Interpersonal awareness
COMMUNITY FACTORS
 Pre-disaster characteristics
of communities
 Post-disaster changes
Property damage
Community disruption
Competition for resources
Community response