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PTSD in Children

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Title: PTSD in Children

1
PART 3
Interventions
2
INTERVENTIONS

Approach should be individualized for

1) Exposure level of the population
?directly exposed ?bereaved ?eyewitnesses
?indirectly exposed through others ?remotely
affected
2) Needs of individual children ?building
resilience and coping skills ?treatment of
psychiatric illness
3) Timing disaster phase
3
DISASTER PHASEPRE-DISASTER

? To be most effective, disaster mental health
planning for children must begin well before the
disaster occurs
? Pre-disaster relationships promote effective
post-disaster response
?among mental health professionals
?in organizational settings such as schools,
daycare centers, churches, community centers,
health care facilities, and other places that
serve children

4
DISASTER PHASEACUTE IMPACT

Supportive efforts during and immediately after
the disaster
? Child safety and assurance
? Shielding children from horror
? Providing accurate information
? Reunification with families

5
DISASTER PHASEEARLY POST IMPACT

? Focus on immediate needs of
?Directly exposed children and families
?At-risk children
?Community children

? Interventions ?Crisis debriefing ?Individual,
family, and group interventions ?Community
interventions
6
DISASTER PHASELONG TERM

? Individual, family, group, school, and
community interventions
? Evolve from disaster response to new disaster
preparedness

7
PULSED INTERVENTIONS

? Planned interventions at strategic points
?For managing secondary sequelae of disaster
?For transitions to other disaster stages

? Anticipate and address critical moments ?Reduce
potential for emotional arousal by managing the
child's exposure to reminders
8
ANNIVERSARIES AND MEMORIALS

? Time for commemoration
? Time for reflection
? Review event and progress
? Set goals for the future
? Anticipate emotional arousal
? Include children in planning

9
COMMON ELEMENTS OF INTERVENTION

? Restore sense of safety and security
? Validate experiences and feelings
? Protect children from excessive exposure to
other frightening situations and reminders of the
event
? Restore equilibrium
? Attend to lines of communication

10
REINFORCE SENSE OF SAFETY AND SECURITY
? First priority establish physical safety and
meet physical needs ? Reinforce sense of safety
and security ? Different age groups need
different approaches ?Preschool - the world is
black white ?Latency age - shades of
gray ?Adolescence - more detail
11
VALIDATE EXPERIENCES AND FEELINGS
? Listening validates the child's experience and
feelings ? Hear their stories and answer their
questions (sometimes the same ones
repeatedly) ?Be calm and provide simple, direct
answers ? Gain information about the child's
fears and concerns ? Manage anger, bitterness,
and hate ?Listen redirect anger and defuse
hatred with information ?Correct underlying
misconceptions and misattributions
12
PROTECT FROM EXCESSIVE EXPOSURE
? Be judicious in re-exposing children to the
site of the incident ? Assist with processing
media material ? Managing common reminders
13
RESTORING EQUILIBRIUM

? Maintain a predictable schedule and rules
? Encourage school attendance and extracurricular
activities
? Don't panic over a brief decline in school
performance
? Encourage healthy habits

14
COMMUNICATION

? Maintain regular communication with others
involved in the childs life
? Be aware how you convey your own observations
to the child, and how they might influence the
child

15
TYPES OF INTERVENTIONS

? Supportive interventions support services
? Formal evaluations needs assessments
? Crisis intervention debriefing
? Formal mental health assessment treatment

16
DEVELOPING SOCIAL SUPPORT
? Social support can come in many
forms ?Extended families ?Neighborhood or
community activities ?Religious organizations ?
Consider cultural fit
17
COMMUNITY INTERVENTIONS

? Family
? Small group
? School-based

18
FAMILY INTERVENTIONS

Family work should
? Educate parents about childrens reactions in
general and about their own childs experiences
and responses
? Help families rebuild the child's sense of
security
? Assist families with secondary stressors
? Anticipate needs of the children in the family

19
FAMILY SAFETY PLANNING

? Identify safe people and places
? Develop plans for self and family
? Learn, review, and practice plans

20
ASSIST PARENTS

? Allow parents to process their own thoughts and
feelings about the event
? Discuss how parents distress and behaviors can
adversely affect their children

21
THE MEDIA

? Children, parents, and other adults should be
educated about media issues
? The association between posttraumatic stress
reactions and media exposure does NOT establish
cause and effect
?Children who are distressed may be drawn to
media coverage

22
MANAGING MEDIA IN THE HOME

? Parents should monitor media exposure at home
- especially TV and Internet
?Limit media contact that becomes excessive or
overstimulating
?Parents may need to work through their own
reactions to media

? Discuss media coverage with children ?Address
reactions and concerns ?Clarify
misperceptions ?Help process emotions stimulated
by media coverage ?Validate feelings ?Observe
and reflect, but do not reinforce, hostile
feelings
23
SMALL GROUP INTERVENTIONS

? Large numbers of children accommodated
? Safe setting facilitates sharing
? Children educated about traumatic responses and
develop new coping skills
? Expedient case finding

24
SCHOOL SETTINGS

? Schools are developmentally appropriate
settings
? School settings provide opportunities to
?conduct screenings and needs assessments
?facilitate disclosure, discussion, and
correction of misperceptions
?utilize curricular approaches, small group
activities, and projective techniques

25
Advantages
SCHOOL-BASED APPROACHES

? Access to large numbers
? Safe and secure environment
? Encourage normalcy
? Minimize stigma
? Accessible opportunities to screen and refer

26
FORMAL TREATMENT

? General therapeutic principles
? Common elements across interventions
? Specific therapies and techniques

27
GENERAL THERAPEUTIC PRINCIPLES

? Heightened arousal and discomfort may arise in
treatment
? Therapy must provide a safe and comfortable
environment to process painful and overwhelming
experiences
? Avoidance is a core aspect of posttraumatic
stress and may prevent the initiation of therapy
or impede its progress
? Treatment involves transforming the childs
self concept from victim to survivor

28
COMMON ELEMENTS OF INTERVENTIONS

? Educate both child and family
? Directly address the incident
? Correct inaccurate and maladaptive attributions
? Teach anxiety management
? Teach coping skills
? Provide parallel components for
parents/caregivers

29
INDIVIDUAL TREATMENT

? Formal clinical assessment and individual
treatment
?For children exposed directly or indirectly
through the experience of loved ones
?For those showing high levels of distress or
impaired functioning

? Modalities of individual treatment
?Supportive psychodynamic approaches ?Play
therapy ?Cognitive-behavioral approaches ?Adjuncti
ve medication (rarely needed)
30
ADVANTAGES OF INDIVIDUAL THERAPY

? Focuses attention on the child
? Allows intensive treatment
? Addresses comorbid conditions and issues not
directly related to the disaster
? Can supplement other approaches

31
INITIAL CLINICAL INTERVIEW

? Parent report needed to obtain objective
aspects of the childs experience and reactions
? The child must be interviewed directly
? Projective techniques may be useful

32
INDIVIDUAL APPROACHES

? Psychodynamic
? Cognitive-behavioral
? Play
? Medication

33
PSYCHODYNAMIC APPROACH

Support for this approach is
anecdotal
rather than empirical

34
COGNITIVE-BEHAVIORAL APPROACH

? Supported by empirical research
? Utilizes a variety of techniques
? Can be incorporated into various activities

35
PLAY THERAPY

? Part of a more comprehensive approach
? Directed rather than free play
? Not perseveration in repetitive re-enactment of
some aspect of the event, but rather moves the
child forward to productive activity

36
PHARMACOTHERAPY

? Medication is rarely needed
? Adjunctive to other modalities
? Refer children with persistent or disabling
symptoms
? First-line agents SSRIs

37
FAMILY THERAPY
? Family plays a major role in the child's
recovery ? Multiple family members may be
traumatized ? Traumatized parents may overlook
their children's needs ? Parents can be helped to
help their children by attending to the parental
distress and educating them about their
children's needs
38
ADVANTAGES OF FAMILY THERAPY

? Children see they are not alone in their
distress
? Children gain support and feel accepted
? Children can have safe and open discussions
of the event
? Children can model reactions and coping
strategies
? Family can address dynamics affecting the
child's adjustment

39
FAMILY AND GROUP THERAPYSTRUCTURE AND CONTENT

? Type and amount of structure vary
? Appropriate topics
?Normal reactions to traumatic events
?Reminders and anniversaries
?Coping strategies
? Parallel parent groups

40
ADVANTAGES OF GROUP THERAPY

? Accommodates larger numbers
? Provides opportunity to share and reassure
? Allows children to observe how others cope and
to practice new skills with peers
? Provides reinforcement

41
DISADVANTAGES OF GROUP THERAPY

? Some are uncomfortable in groups
? Some need more individual work
? Groups may retraumatize some
? Children may prematurely adopt the coping
strategies of others

42
SPECIFIC THERAPEUTIC TECHNIQUES

? Opening discussion
? Identifying and expressing feelings
? Relaxation exercises
? Modifying thoughts behaviors
(cognitive-behavioral)
? Planning for the future
? Reviewing progress

43
OPENING DISCUSSION

? Raise the issue of the traumatic event and the
childs experiences and reactions early in the
course of treatment
? Provide assurance that the therapeutic
environment is a safe place to discuss these
issues
? Cover all senses in the childs experience
? Encourage repeated review of the experience
? Use real words (avoid euphemisms)

44
IDENTIFYING AND EXPRESSING FEELINGS

? Feelings vocabulary
? Faces
? Identifying feelings in self and others
? Non-verbal expressions of feelings
?Drawing ?Music ?Writing

45
RELAXATION EXERCISES

? Deep breathing
? Scripted imagery
? Muscle relaxation
? For older children yoga, meditation

46
MODIFYING THOUGHTS AND BEHAVIORS

? Challenge thoughts
? Redirect thoughts and activities
?Thought-stopping
?Create positive coping statements
?Generate a list of positive thoughts and
behaviors
? Focused thinking time
? Generate alternative explanations
? Correct misconceptions and misattributions
? Create positive reinforcements
? Encourage sharing ideas with others
(particularly family)

47
PLANNING FOR THE FUTURE

? Discuss the future
? Identify triggers or possible reminders
? Plan anniversaries and other activities related
to the traumatic event
? Practice learned skills on a regular basis
? Maintain a supportive and caring environment

48
SAFETY PLANNING

? Develop a plan for family safety
? Include children in the development of the plan
? Practice the plan
? Review the plan on a regular basis
? Revise the plan as needed

49
REVIEWING PROGRESS

Encourage and reinforce successes in integration
of thoughts, feelings, and memories of the event

50
LONG-TERM AND LATE TREATMENT

? Some children with intense reactions or other
problems may need long-term treatment
? Later interventions may be needed at key
points, including
?During transitions to subsequent disaster stages
?Anniversaries and marker events

51
LOOKING AHEAD