Treating Children and Adolescents with PTSD. William Yule Prague March 2014

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1 Treating Children and Adolescents with PTSD William Yule Prague March 2014

2 In the beginning. When DSM III first identified PTSD, it was thought that children would rarely show it Why did professionals come to such a wrong conclusion?

3 Simply, they had not asked the children themselves how they were reaction to major stressors. They had asked parents and teachers who greatly underestimated the reactions children had

4 Adults, even today, are scared to talk to children about how they are feeling after a bad experience in case they make things worse. In case by asking, they traumatise the child!

5 Faced with child survivors of a big shipping disaster, I did what I was trained to do I asked the children themselves. This what they told me:

6 Stress Reactions in Children Sleep Disturbance Separation Difficulties Concentration Difficulties Memory Problems Intrusive thoughts Talking with parents Talking with friends Heightened alertness to danger Premature awareness of mortality Fears Irritability Anxiety and Panic Depression Bereavement

7 ICD vs DSM Both are adult-o-centric Still need more child oriented descriptive studies ICD emphasizes Intrusive phenomena, downplays avoidance and arousal

8 Recent changes Both DSM5 and forthcoming ICD10 have refined their rules for making a diagnosis of PTSD But the essential features remain with ICD placing more emphasis on re-experiencing

9 Post Traumatic Stress Disorder Intrusive recollections, nightmares, flashbacks Avoidance of remembering and reminders Over-arousal (sleep, concentration, anger, jumpiness)

10 Developmental Aspects Pre-school children Alternative diagnostic criteria developed by Scheeringa et al (2011) Checklists & questionnaires Diagnostic interview schedules Treatment manual Available from Michael Scheeringa s website

11 Incidence of PTSD after assaults & RTAs 14 % PTSD Meiser-Stedman yrs DSM Meiser-Stedman 2-6 yrs DSM Meiser-Stedman 2-6 yrs DSM-AA

12 Mental Health Effects of the 70 Jupiter Sinking Any DSM-IV Diagnosis Since trauma Currently 10 0 Survivors Controls

13 Natural History of PTSD Jupiter follow-up %PTSD 10 0 Year 1 Year 5-7

14 Aberfan

15 Aberfan 33 years later PTSD ever Currently Survivors Controls

16 Emerging Theoretical Models 1980 Rachman: Emotional Processing 1987 et seq: Keane, Foa Anxiety and Habituation 1996 Brewin: Dual Representation 2000: Ehlers and Clark: Memory

17 Emotional Processing Rachman 1980 Distress usually wanes when realize threat no longer remains If overwhelmed, no habituation and so avoid Stress symptoms indicate that emotional processing is incomplete

18 Treatment of PTSD in children Crisis Intervention Critical Incident Stress Debriefing Group Treatment Individual Treatment CBT - Prolonged Exposure EMDR KidNET

19 Crisis Interventions Make contact initially Survivors probably not able to benefit for first few days

20 Critical Incident Stress Debriefing (Dyregrov) Introduction rules of group Facts - what happened Thoughts Reactions Sensory, delayed Information and Advice Conclusion

21 Contingency Planning in schools Risk analysis Contingency plan Pre-assign responsibilities Immediate tasks Longer term planning

23 Review of early intervention 4 RCTs + 3 others found Small to large beneficial effect sizes Early intervention should include: Psycho-education Individual coping skills Some trauma exposure Early intervention may be helpful

24 Cognitive models of PTSD Seek to explain a why minority of trauma-exposed individuals develop chronic PTSD Foa, Steketee, & Routhbaum 1989 Brewin, Dalgleish, & Joseph 1996 Ehlers & Clark 2000 sense of current threat from idiosyncratic appraisals disjointed memory unhelpful coping

25 Ehlers & Clark s Cognitive Model of PTSD (2000) Characteristics of Trauma/ Sequelae Prior Experiences/ Beliefs/ Coping State of Individual Cognitive Processing during Trauma leads to influences prevents change in Nature of Trauma Memory Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Negative Appraisal of Trauma and/ or its Sequelae PERSISTENT PTSD Strategies Intended to Control Threat/ Symptoms

26 Cognitive factors in children Nature of the trauma memory laid down Attributions & misappraisals about the event (eg Joseph et al, 1991) Appraisals of symptoms (Ehlers et al, 2004; Meiser-Stedman et al) Thought control strategies (eg Ehlers et al 2004; Aaron et al 1999)

27 Treatment Targets Reduce fragmentation of trauma memory Modify misappraisals of the trauma and PTSD symptoms Reduce dysfunctional coping strategies (cognitive and behavioural avoidance) Modify maladaptive beliefs of parents (re trauma and sequelae), recruit parents as cotherapists

28 Elements of treatment Education/normalisation Reclaiming life Relaxation Imaginal reliving Cognitive restructuring In vivo exposure Image work Sleep Hygiene Parent sessions

29 Patient flow 9/36 lose diagnosis CBT = 12 N = 38 Diary monitoring 4 weeks 27/36 retain diagnosis 3 decline Rx before randomisation WL = 12

30 CAPS (clinician PTSD) WAIT CBT pre post 6/12 FU

31 PTSD diagnosis Semi-structured interview by clinician blind to group status, post CBT/WAIT CBT group 11/12 (92%) free of PTSD diagnosis WAIT group 5/12 (42%) free of PTSD diagnosis

32 Summary Substantial proportion of children respond well to symptom monitoring Significant effect of CBT on PTSD and associated problems Improvement maintained at 6 month follow up Symptom improvement accompanied by changes in mis-appraisals

33 Eye Movement Desensitization and Re-processing (EMDR) Construct a Safe Place Picture Worst Memory Negative Cognition (Rate 1-7) Positive Cognition (Rate 1-7) Feelings (Rate SUDS 1-10) Body Sensation Desensitization - eye movements Repeat cycle

34 EMDR & PTSD Anxiety IES-13 Feb-99 Jul-99

35 EMDR & PTSD Anxiety IES-13 Jan '00 Aug '00

36 Narrative Exposure Therapy Kid NET

38 KidNET timeline

39 Efficacy of Narrative Exposure Therapy in field studies Pre Post NET Relax

40 Mental health in complex emergencies Lancet article in early December 2004 Stressed need for each country to develop a plan to screen for adverse reactions after a disaster and then provide effective treatment Need to develop appropriate measures Need to develop treatment to be delivered on a large scale

41 Teaching Recovery Techniques 1: Intrusion 2: Arousal 3: Avoidance 4: Bereavement Parent s Group

42 TRT RCT Barron et al (in press) significant difference at post-test, controlling for initial symptom severity p<.005

43 CHILDREN and WAR Writing for Recovery Aimed at Adolescents Builds on Jamie Pennebaker s work 2 x 15 minute sessions on 3 days

44 PTSD before and after writing manual Control Group B Group C PTSD 1 PTSD 2

45 Writing and Grief Afghani adolescents (Kalantari et al, 2012) Cont Exp Pre Post

46 Education for war affected children School as a focus for intervention and support Need to emphasize continuing education Skills can be taken anywhere But stress reactions such as attention, memory problems etc interfere with learning So Stress reactions need to be targetted

47 References mentioned in this workshop can be accessed at:

The Science and Art of Treating PTSD in Children: Reflections on 20 years practice

The Science and Art of Treating PTSD in Children: Reflections on 20 years practice William Yule UKPTS Oxford 2011 APA DSM III First described PTSD in 1980 Based mainly on observations of Vietnam Veterans