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 Did not think it would occur in children Revised as DSM-III-R in 1987
Herald of Free Enterprise Cross channel ferry Capsized on 6 March 1987 400 passengers Half survived Including around 30 children Asked to see survivors to see if I could help
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
2 other shipping disasters 1: Ferry approaching Piraeus harbour when attacked by terrorists Results of positive outreach 2: Sinking of the Jupiter October 1988 400 teenagers being educated!
The Jupiter Screened most of those on board for the lawyers Arranged clinical assessments as soon as possible Arranged treatment for those who needed
State of the Art in late 1980s In 1980, Jack Rachman had published his seminal paper on Emotional Processing That guided our thinking Prolonged exposure treatment was treatment of choice
Exposure Therapy 16 year old boy 70 60 50 40 30 IES 20 10 0 Mar- 89 Jul- 89 Mar- 91 May July Oct Jan- 92
Meanwhile Increasing dissatisfaction with both DSM and ICD for describing children s reactions Lack of natural history in children Developmental aspects insufficiently acknowledged Paucity of good intervention studies
ICD vs DSM Both are adult-o-centric Still need more child oriented descriptive studies ICD emphasizes Intrusive phenomena, downplays avoidance and arousal
Developmental Aspects Younger children show repetitive play Also repetitive drawing Increase in aggression Increase in destructiveness Is immaturity a protective factor?
Scheeringa et al 1995 Suggested criteria Re-experiencing (one of:-) Posttraumatic play Play re-enactment Other recurrent recollections Nightmares Flashbacks or dissociations
Criteria for numbing (one item needed) Constriction of play Socially more withdrawn Restricted range of affect Loss of acquired developmental skills NB drops most avoidance
Criteria for arousal (one item needed) Night terrors Difficulty going to sleep Night waking Decreased concentration span Hypervigilance Exaggerated startle response
Role of Parental Distress Children very sensitive to parental reactions McFarlane claimed child distress fully accounted for by maternal distress But mothers rated both Mostar study found direct exposure more predictive of child distress
Natural History of PTSD Jupiter follow-up 60 50 40 30 20 %PTSD 10 0 Year 1 Year 5-7
Aberfan 33 years later 50 45 40 35 30 25 20 15 10 5 0 PTSD ever Currently Survivors Controls
PTSD and RTAs Incidence 50 45 40 35 30 25 20 15 10 5 0 Canterbury DiGallo Ellis %
Treatment of PTSD in children Crisis Intervention Critical Incident Stress Debriefing Group Treatment Individual Treatment Trauma Focused CBT EMDR KidNET
Is it always good to talk? When to talk, when not to? Talking seen as upsetting children? Children do not want to upset adults Stallard: Those who talked did better
Crisis Interventions Make contact initially Survivors probably not able to benefit for first few days
Critical Incident Stress Debriefing (Dyregrov) Introduction rules of group Facts - what happened Thoughts Reactions Sensory, delayed Information and Advice Conclusion
Stallard et al RCT of single session early intervention Children after RTAs Active discussion vs general one No difference at follow-up Both groups improved All appreciated being able to discuss the accident?? Is systematic assessment therapeutic
Contingency Planning in schools Risk analysis Contingency plan Pre-assign responsibilities Immediate tasks Longer term planning
Group Treatments Yule & Williams Herald of Free Enterprise Gillis - 1993 Pragmatic - not evidence based March - staggered groups
Child PTSD Outcome March et al
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
CBT - new protocol Smith, Perrin, Yule & Clark Flexible, 10 session manualised treatment for child PTSD RCT recently published
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)
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
Elements of treatment Education/normalisation Reclaiming life Relaxation Imaginal reliving Cognitive restructuring In vivo exposure Image work Sleep Hygiene Parent sessions
Reliving Prepare child, relax, take at own pace,may be hard to start with SUDS ratings Tell all that see, hear, feel, smell, think Run through unprompted First person, present tense Revisit hot spots
Participants N = 38 (23 boys, 15 girls) mean age = 13 years old (8 to 17) Traumatic event: Assault 12 Road traffic accident 21 Witnessing violence 5 24 attended hospital (10 admitted overnight) 11 previous traumatic event 10 previous psychiatric history
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
Response to diaries Children who responded to symptom monitoring: - had lower initial PTSD Sx scores (PDS) (mean=19.5 (sd 8.2); mean=27.1 (10.2); t=1.9; p=.07) - had lower initial depression Sx scores (DSRS) (mean=10.3 (sd 4.8); mean=16.4 (6.9); t=2.0; p=.05) were more recently exposed (9 months vs 15 months) less likely to have co-morbid diagnosis (2/8 vs 14/20; χ 2 = 4.7, p =.03)
CPSS (PTSD) 30 25 20 15 10 WAIT CBT 5 0 pre post 6/12 FU
CAPS (clinician PTSD) 70 60 50 40 30 WAIT CBT 20 10 0 pre post 6/12 FU
DSRS (Depression) 20 18 16 14 12 10 8 6 4 2 0 pre post 6/12/FU WAIT CBT
RCMAS (Anxiety) 25 20 15 10 WAIT CBT 5 0 pre post 6/12/ FU
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
Mechanism of change? Cognitive model predicts: outcome (PTSD Sx) should be related to changes in maladaptive appraisals Pre-post changes in PTCI scores correlate with changes in CAPS (r=.86, p <.005)
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
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
Clinical Measures: PTSD, Depression and Anxiety 25 20 15 10 PTSD Depression Anxiety 5 0 Screening Pre-Tx Post-Tx Follow_up
Reaction Time Emotional Stroop: Changes following Treatment Latency 1040 1020 1000 980 960 Pre-Tx Post-Tx 940 920 900 Neutral Happy Sad Threat PTSD
Hensel 2009 36 children: Single incident trauma 30 25 20 15 10 PROPS 5 0 T1 T2 T3 T4
Narrative Exposure Therapy (NET) (Schauer, Neuner, Elbert; 2005) field-oriented culturally sensitive science-based short-term (based on CBT and Testimony Therapy): psycho-education exposure autobiographic approach human rights focus
Narrative Exposure Therapy (NET) narration of the refugee s whole life focus on the detailed report of traumatic experiences: sensory information, emotions, thoughts, physical reactions and spatiotemporal aspects reintegration into / reconstruction of the autobiographic narrative report of traumatic event until experience of relief repeated reading of the narration for habituation
Efficacy of Narrative Exposure Therapy in field studies 40 35 30 25 20 15 Pre Post 10 5 0 NET Relax
Large Scale interventions After wars Natural disasters e.g. Turkish Earthquake 1999 Asian Tsunami 2004
Levels of psychosocial intervention 1. Psychological first aid 2. Multi-professional psychosocial support and services 3. Special expertise in crisis, trauma and disaster psychology
What is psycho-social? Psychological first aid Volunteers? Mental health professionals? Need to develop interventions that can be directed at total communities, but also that help rather than do damage
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
To talk or not to talk? Disagreement between many NGOs, WHO and the evidence base Cognitive psychology stresses the need to clarify distortions in autobiographical memory Need to help construct a verbal narrative
Different from mindless debriefing The debriefing debacle has hindered consideration of improving early responses, by both lay and professional responders Evidence is that it is usually good to talk But people should not be forced to do so in early stages
The Challenge How to deliver high quality, effective treatment for those who need it Issues about screening Too many short workshops and not enough follow-on supervision Increase local capacity in a sustainable way
No country was known to have been so prepared! Iran, after the Bam earthquake of precisely one year earlier was prepared
Bam Dr M T Yasamy, Director of Mental Health in Iran had prepared and started training mental health personnel Screened and treated over 55,000 adults and children in first 7 months Used the Children and War Foundation s Recovery Manual as a basis (see www.childrenandwar.org)
Built on prior training First workshop held on day 5 Nightly debriefing of trainers 17,127 tents visited 67,108 got initial support 85% reported as improved
Teaching Recovery Techniques 1: Intrusion 2: Arousal 3: Avoidance 4: Bereavement Parent s Group Children and War Foundation
Greek earthquake results (Giannopolou, 2000) 30 25 20 15 10 Pre Post 5 0 IES8 Depression IES8 Depression
Aims of early psychosocial crisis and trauma intervention Lower arousal Verbal representation of the experience, help transfer the experience into a narrative and organise it along a time line Build structure and coherence in the story of the event to create more cognitive clarity and elaboration Counteract or question retrospective negative interpretation of own behaviour and challenge perception of self-blame and guilt
Aims of early psychosocial crisis and trauma intervention Stimulate adaptive functioning, stimulate selfempowerment; facilitate adaptive coping Help to secure social support (reinitiate, reactivate the victim s social network) Build or expand a person s or family s coping repertoire Screen for highly traumatized people and give them appropriate care If necessary, facilitate access to next level of care
What to do in immediate intervention First priority: help affected person to access important information Important to convey information in a sensitive, caring way
Bring down arousal by helper s behaviour Be calm Be direct Use tone of voice and calm appearance to control the situation and lower arousal Be proactive but not invading Establishing a caring climate in the midst of chaos can prevent secondary trauma
To talk or not to talk? Let the person talk freely notice their focus of attention Ask what happened and what they thought as events unfolded Notice degree of distress or tension and screen for highly traumatized people and give them appropriate care Map strong sensory impressions
Normalize reactions they bring up Make a plan for what they need to do help them if necessary Provide support and advice on important questions ritual participation use of medication return to work. etc.
Check on degree of social support they have available Help person achieve a first- hand understanding of what took place Help in establishing good strategies for self-care, self-soothing and family support
All this is a far cry from the arid debate on debriefing With children and adolescents we have to involve families and schools You cannot say to them that you must not talk about what happened because a Mr Cochrane said it was wrong to talk!!
Implications for mental health professions Every National Association should have a structure to deal with trauma All MH professional should have a minimum training in Disaster, Crisis and Trauma Psychology in their introductory years Some should have specialist training
Standards Standards should be developed for professional mental health responders, first responders, volunteers and NGOs involved in psychosocial care Responses to major disasters should be properly evaluated so that feed-back can improve interventions
References mentioned in this plenary talk can be accessed at: www.childrenandwar.org 2 other relevant sites www.uksrilankatrauma.org.uk www.vivo.org