Transcript Debbie Kaminer - Vula - University of Cape Town

THE ROLE OF PEDIATRICIANS IN
THE MANAGEMENT OF
TRAUMATISED CHILDREN
Debra Kaminer
Department of Psychology / Child Guidance Clinic
University of Cape Town
NORMAL RESPONSES TO TRAUMA
 For both adults and children, some posttraumatic responses are
normal and expectable in the days and even weeks after a
traumatic event – part of the natural process of adapting to
extreme experiences and re-establishing a state of equilibrium
 The need for intervention depends on the DURATION of the
symptoms and their IMPACT on the child’s school, home and
social functioning
 If symptoms continue for longer than 4 weeks post-trauma, and
cause significant impairments in the child or family’s daily
functioning, a referral to a mental health professional should be
made
POSTTRAUMATIC STRESS DISORDER
(PTSD)
 In adults, symptoms of:
 Re-experiencing the trauma (flashbacks, intrusive
images, nightmares, physiological reactivity to
reminders)
 Avoidance of traumatic reminders (behavioural;
cognitive; emotional)
 Hyperarousal (poor concentration, disturbed sleep,
hypervigilance to danger, startle response, aggression
or irritability)
lasting more than 4 weeks and causing serious
impairments in functioning
 Co-morbid depression, panic disorder and substance
abuse are common
POSTTRAUMATIC STRESS DISORDER
(PTSD)
 PTSD does not manifest the same way in children as
it does in adults
 Manifestations of posttraumatic stress vary according
to the developmental stage of the child
COMMON PSYCHOLOGICAL RESPONSES
TO TRAUMA IN CHILDREN
CHILDREN UP TO SIX YEARS:
 Physical manifestations:


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Sleep disturbance: night terrors and nightmares,
fear of going to sleep, fear of sleeping alone, fear
of dark)
Eating disturbance
Somatic complaints
COMMON PSYCHOLOGICAL RESPONSES
TO TRAUMA IN CHILDREN
CHILDREN UP TO SIX YEARS:
 Emotional regression:


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Anxious attachment (clinging, separation anxiety,
worry about something happening to caregivers)
Fearful (fears may be old or new, specific or
generalised)
Increase in dependent behaviours re. dressing,
eating etc.
COMMON PSYCHOLOGICAL RESPONSES
TO TRAUMA IN CHILDREN
CHILDREN UP TO SIX YEARS:
 Repetitive play with traumatic themes
 Do not understand that danger is over
 Limited verbalisation resulting in difficulty identifying
source of distress / anxiety
COMMON PSYCHOLOGICAL RESPONSES
TO TRAUMA IN CHILDREN
CHILDREN AGE 7 – 12 YEARS
 Sleep disturbance
 Somatic complaints
 Repetitive play about the trauma
 Re-tellings of the traumatic event
 A sense of guilt or responsibility for the traumatic
event
 Impaired concentration and learning
 Concern about own and other’s safety
 Unusually aggressive or irritable
COMMON PSYCHOLOGICAL RESPONSES
TO TRAUMA IN CHILDREN
ADOLESCENTS:
 May become withdrawn, uncommunicative and ‘shut
down’
 May become defiant, oppositional or aggressive
 Possible increase in risk-taking behaviours (alcohol
or substance abuse, risky sexual behaviours,
reckless behaviour)
These are easily mistaken for “typical adolescent”
behaviours rather than symptoms of trauma – need to
compare with pre-trauma personality / behaviour
MANAGEMENT GUIDELINES
In acute stages (first 72 hours):
 Calm and comfort
 Normalise any ‘symptoms’
 Assist family to activate existing support networks
 Encourage return to normal routines
 No debriefing – allow parents or child to talk about traumatic
event if they volunteer information, but do not push them to
do so if they are reluctant
 Make a referral to a counsellor / psychologist only if family
requests it
 Liaise with child’s school / teacher where necessary
MANAGEMENT GUIDELINES
Monitor child and family functioning for first four weeks after
traumatic event
With parents’ permission, getting collateral from child’s teacher may
be helpful in monitoring child’s posttrauma adjustment
NB to assess and monitor distress levels of parents and functioning
of family system – levels of family support and parental coping are
strong predictors of whether the child will have ongoing symptoms
If children and / or parents remain highly symptomatic, and the
functioning of the child or caregivers does not stabilise and return
to pre-trauma levels within a month, a referral to a mental health
professional should be discussed with the family
TYPES OF INTERVENTION
Psychotherapy:
 Parent counselling
 Family therapy
 Play therapy (symbolic exploration of traumatic experience)
 Cognitive-behavioural therapy (for children who are able to talk
more directly about the trauma)
 Depending on the child and family’s pre-trauma functioning,
psychotherapy after a traumatic event can last from a few
sessions to a few months
 Long-term psychotherapy more indicated in cases of child
abuse / maltreatment or severe family dysfunction
TYPES OF INTERVENTION
Medication:
 Research evidence for medication treatments for childhood
PTSD lags behind adults, few controlled trials
 In highly symptomatic children, SSRI’s (citalopram, sertraline)
are first choice - many posttraumatic symptoms in children are
associated with serotonergic dysregulation
 SSRI’s generally safe and well-tolerated but some concerns
about increased suicidal ideation and behaviour
 Criteria to consider:
 Is medication acceptable to child and caregivers?
 Are symptoms severe enough to interfere with
psychotherapy?
 Are there comorbid psychiatric conditions that also
respond well to medications used for PTSD?