Anxiety disorders: PTSD

1. Anxiety disorders: PTSD Child’s drawing of plane dropping bombs on his village

2. READINGS Book of readings: • Armsworth, M. & Holaday, M. (1993).The effects of psychological trauma on children and adolescents (p.164). Closed Reserve readings: • Wenar, C. & Kerig, P. (2000)“Middle childhood: The anxiety disorders in Developmental Psychopathology (pp. 169-73, 185-188). Singapore: McGraw-Hill

3. Lecture Questions • What is trauma? • What happened in Chowchilla and why is it significant? • What are the key features of PTSD in children? • What are the effects of PTSD at different ages? • Why is it that not all children develop PTSD in response to experience a traumatic event?

4. Post traumatic Stress “Psychological trauma is an affliction of the powerless. At the moment of trauma the victim is rendered helpless by overwhelming force. When the force is that of nature we speak of disasters. When the force is that of other human beings we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection and meaning” Judith Herman: ‘Trauma and Recovery’

5. What defines a traumatic event? • Life-threatening, injurious or integrity threatening for self or others • Individual responds with intense fear, helplessness or horror • Violates safety assumptions objectively & subjectively Source: APA Bosnia Refugee Children

6. Recurrent traumatic events • Witnessing community violence • Witnessing domestic violence • Physical, emotional and sexual abuse Once Were Warriors

7. History of trauma research • Wars from C19th on- “shell shock” ,“battle fatigue”- WWII- behaviours in children documented • Post Vietnam war ‘birth’ of PTSD in DSM III (1980) • 1970- slag avalanche in Aberfan, Wales killing 116 children – psychiatrist’s study of 56 young people over 5 years, ‘odd’ behaviours, traumatic play • 1972- Buffalo Creek dam burst- 125 deaths- Newman interviewed 11 children, identified traumatic responses- perpetual mourning, gloominess and daydreams of death

8. Lenore Terr (Too scared to cry) • Chowchilla kidnapping, 1976 • First controlled study on childhood trauma- Chowchilla children compared with control groups- “normal” and those with other trauma experiences • Prospective study- followed children through • Interviews with children 5 months later, four years later • Findings opened up research on child witnesses, concurrent trauma, abuse victimisation, child refugees • Implications for those indirectly involved e.g. siblings

9. How common is PTSD in children? • Refugees- 8.3% to 70% • Child witnesses to violence- 13% (Graham-Berman) • Child sexual abuse- 10-35% • Physical abuse 5 to 15% • Witnesses to shooting- 38% (Pynoos & Eth) • Perry- 15 million children in US at risk when look at estimates for child abuse, child witnessing violence, plus surviving natural disasters

10. DSM Criteria • experience of event that poses serious threat to which individual responds with helplessness, fear, or horror • three sets of symptoms: re-experiencing, avoidance and increased autonomic arousal • duration of symptoms for at least one month following the traumatic event • Note: the same criteria is given for children & youth as for adults

11. Re-experiencing the trauma Repetitive, intrusive thoughts: • Going to sleep • Environmental reminders (e.g. objects, places, noises) • Nightmares (actual event, modified event, disguised, terror dreams ) Fears- intensity (Terr) • Traumatic play (play that acts out traumatic event over and over again)

12. Avoidance • Not thinking about the traumatic event/s • Avoidance of trauma related stimuli and reminders • Psychic numbing (shut off the feelings, denial of event/s happening) • Dissociation (in children may be seen as daydreaming, removing self from reality)

13. Hyperarousal • sleep problems- waking, trouble going to sleep • hypervigilance- watchfulness, on alert • concentration problems • aggression

14. Problems with DSM-IV • Co-morbidity - major depression - anxiety - conduct disorder - adhd • Overlapping because behavioural symptoms of PTSD mirror those in other disorders e.g acting out, self-destructive & suicidal behaviour, regressive behaviours, withdrawal, disruptive • Perry- 85% of children at trauma centre had comorbid DSM classification

15. Developmental effects • Toddlers- changes in autonomy such as regression in feeding/toileting, motor activity e.g. more passive, aggression e.g. hitting, destroying objects • Pre-schoolers- somatisation (e.g. tummy aches, headaaches), repetitive play, avoidance, fears sadness, clinginess, delays in language, aggression

16. Developmental effects • School age- • guilt, anxious, depressed, inhibited (withdrawn), hypervigilant, change in play, school performance (profound effect) • Sleep disorders • Impaired concentration, functioning, initiative

17. Developmental effects • Adolescents- • depression & suicidality • substance abuse • truancy • delinquency • self mutilation • hypersexuality

18. Why do some children/youth develop PTSD and not others? • Degree of subjective/objective threat to safety (> threat, > distress) • Nature of trauma (ongoing vs single event) • Proximity (nearer > severe) • Expectancy (> unexpected, > severity) • Family support (< , > severity, Eth & Pynoos) • Age (> severity if < 4 (Perry)

19. Why do some children/youth develop PTSD and not others? Factors in the child: • Previous psychological difficulties e.g., separation anxiety, severe grief reaction • Gender- greater vulnerability for girls • Low self-esteem • Tendency to be withdrawn or inhibited • Protective: high ability and good problem-solving skills

20. Why do some children/youth develop PTSD and not others? Factors in the family • Parent al PTSD- but if coping well, can help child to manage emotional effects • Parental psychological problems (especially anxiety or depression) • Parental support (e.g. not blaming the child, listening to the child, getting help for the child, assuring the child) • Inverse of these are protective factors- buffer risk of developing PTSD in face of traumatic event/s

21. Why do some children/youth develop PTSD and not others? Factors in school/wider community • If community trauma, responses within and to the community • In school, absence of problems such as victimisation • In school, way in which child treated after traumatic event (with understanding & support)

22. Checkpoint