THE ROLE OF PEDIATRICIANS IN THE MANAGEMENT OF TRAUMATISED CHILDREN

1. THE ROLE OF PEDIATRICIANS IN THE MANAGEMENT OF TRAUMATISED CHILDREN Debra Kaminer Department of Psychology / Child Guidance Clinic University of Cape Town

2. 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

3. 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

4. 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

5. COMMON PSYCHOLOGICAL RESPONSES TO TRAUMA IN CHILDREN CHILDREN UP TO SIX YEARS: • Physical manifestations: • Sleep disturbance: night terrors and nightmares, fear of going to sleep, fear of sleeping alone, fear of dark) • Eating disturbance • Somatic complaints

6. COMMON PSYCHOLOGICAL RESPONSES TO TRAUMA IN CHILDREN CHILDREN UP TO SIX YEARS: • Emotional regression: • 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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?