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PTS3398 - SECTION 4: PTSD IN CHILDREN

 

PTSD Scenario: Childhood Trauma and Symptom Development

Janet is a 17 year old Caucasian female with a history of anxiety and intrusive worries about her physical attractiveness. She grew up with a very dominating mother who was obsessed with physical appearance, modeling and inculcating in her children an extremely strong linkage between one’s outward presentation to the world and one’s worth, and combining this with serious corporal punishment if her children would not obey her or challenge her in any way. While Janet understands cognitively that she is a relatively good looking person, at a very deep level she cannot help but scrutinize her appearance, looking for any signs of fault or imperfection. As a result, she is self-conscious to the point of paralysis, leading to a somewhat severe withdrawal from social interactions.

This avoidance of facing her worries about her appearance has magnified the problem, leading to a self-propagating cycle of withdrawal, increased anxiety, and increased focus on imperfections related to her appearance. She has attempted several courses of psychotherapy, but neither CBT nor psychodynamically driven therapy seem to be able to break the cycle of her withdrawal-anxiety-preoccupation. She has begun to give up hope on the process of controlling her anxiety, and lately in her therapy sessions she has been spending the last fifteen minutes of each session looking at the time with increasingly growing anxiety. 

 

PTSD In Children and Adolescents

The National Institute of Mental Health (NIMH) reports that in the United States there are a substantial number of children and adolescents who experience trauma in any given year. “Twenty million (or more) children with PTSD are among the least understood and inconsistently served [people] in the United States.” (National Institute for Mental Health, n.d.)

In addition, according to National Center for PTSD, a small number of studies of the general population have been conducted that examine rates of exposure and PTSD in children and adolescents.

Results of these studies indicate that up to 43% of girls and boys have experienced at least one traumatic event in their lifetime. Limited studies have shown that the prevalence of PTSD is much higher in children and adolescents who are already are considered at-risk. (Hamblen, n.d)

STATISTICS

The rates of a PTSD diagnosis for these at-risk children and adolescents varied from 3-100%.

“For example, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault develops PTSD. Similarly, 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.” (Hamblen, n.d.)

Traumatic events can be the same for adults and children, but for children and adolescents, trauma can be caused by a parent or caregiver’s physical or emotional abuse or by a physical or emotional assault by anyone else, including neighborhood or school bullies.

Scary movies and real-life tragedies aired by the media and viewed by millions, including children, can also be considered traumatic events.

In the U.S., recent examples of mass media exposure include the media footage of the tragedies at numerous schools and universities, the media footage of the war in Ukraine, media footage of the political unrest, and living through or watching video footage of natural or manmade disasters.

When children develop severe symptoms and remain untreated or undiagnosed, they may be misdiagnosed with:

- Attention deficit disorder
- Attention deficit hyperactive disorder
- Oppositional defiant disorder

The Cyclic Effect

As stated earlier, the symptoms of PTSD in one family can span generations. We call it the cyclic effect, because the learned patterns of behavior can cycle from one generation to the next. Children may experience secondary trauma because of the actions or inactions of a caregiver who has untreated or ill-managed PTSD symptoms.

Dysfunctional family environments may occur when one or both of the parents display chronic or ongoing symptoms of PTSD. There have been several studies that have shown that parents with a history of PTSD can have a negative impact on the child-parent relationship. (Lauterbach et al., 2007)

Additionally, these studies documented the association between individuals with PTSD and marital discord. (Lauterbach, et al, 2007) With this information, one might conclude that these issues will likely have at least some impact on the wellness of family functioning and successful childrearing.

Children also can have learn from their environment that trauma may emerge at any time, and from this they can develop PTSD symptoms in response. For example, a parent whose mood is constantly changing due to alcohol or substance abuse may leave the children guarded. That is, they may feel like they are “walking on eggshells,” not sure when the “angry parent” will appear, or what will trigger the “angry parent” to emerge.

These children are also at elevated risk for dropping out of school and failing to maintain meaningful employment. They can end up relying on the welfare system. If their PTSD arose from childhood abuse, they are likely to also abuse their children, and the cycle continues as they become adults who are predisposed to anti-social or criminal behavior.



Case Scenario

Consider the following abbreviated scenario:

A mother returns from serving in the military. While she was away, the father remained at home with their five-year-old daughter. The girl was doing very well in school until her mother returned from her tour of duty. The mother witnessed several traumatic events while she was on tour, and she recounted these experiences almost daily to her family and friends.

According to family members, the mother has not been the same since she came back two years ago. Family members describe her as depressed and angry; she often throw fits, hits her husband, screams at her child, drinks heavily, and no longer engages in family or other social functions. In addition, the mother has not been able to maintain employment because she frequently calls in sick.

As a result of his wife’s behavior, the husband feels stressed and unable to cope. He begins drinking heavily; they yell at each other constantly and physically fight, and neither of them spends any significant family time with their now seven-year-old daughter.

The seven-year-old child’s grades fall significantly; she reports to the nurse almost daily for a stomach ache and/or headache and stays home from school on many occasions for such psychosomatic pains.

She becomes withdrawn and no longer engages with her classmates, except to occasionally belittle and berate another classmate. The child is counseled about her poor academic performance, offered a tutor, and is even been suspended for a belittling/bullying incident.

The parents are also counseled, and they assure school officials that their child would be punished at home. Yet their daughter’s grades, mood, and behavior continue to deteriorate. Neither parent nor child has been diagnosed or treated for any mental health condition.

The parents take their child to their family pediatrician, but he cannot find any physical etiology that would account for the child’s physical complaints. No follow-ups are provided.

In this scenario, once the family history was known, one might conclude that all three members of this family suffer from some degree of PTSD. Clinicians might agree that at least a portion of the child’s recent behavior was learned by observing her parents’ behavior.

However, questions remain regarding the child: her bullying, her poor performance in school, her avoidance of school, and her lack of socialization. Is she merely exhibiting bad and/or learned behavior, or is the child suffering from PTSD due to the neglect and abusive behavior of her parents or from secondary PTSD due to exposure to her mother's experiences?

Related Stress and Trauma Based Disorders

There are two diagnoses found in the DSM-5 in the same section as Posttraumatic Stress Disorder that are particularly relevant to work with children. These are Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. The etiology of both of these disorders can be seen as very similar to that of PTSD, and it can be a difficult decision to determine whether the appropriate diagnosis should be PTSD or one of these other two disorders. 

Both of these disorders may be viewed as arising from problems with the creation of secure attachments during the early childhood years. From an etiological perspective, disruptions to the development of secure attachments can certainly be viewed as a form of trauma, whereby the trauma is early, ongoing and profound enough to create the signs and symptoms seen in both of these diagnoses. The process that leads to the signs and symptoms, however, may be viewed as an inability to develop a typical capacity for attachment, rather than a regression from a more evolved state to a less evolved state that is typically the hallmark of PTSD pursuant to a specified traumatic incident or incidents. 

Only a very thorough assessment process will allow the clinician to distinguish between a diagnosis of PTSD or a diagnosis of Reactive Attachment Disorder or Disinhibited Social Engagement Disorder. In order to help the trainee make these determinations, summary sheets for these two other disorders may be found below. 

 

                       Reactive Attachment Disorder Summary Page

DSM-5 Code:       F94.1 Reactive Attachment Disorder

Common Specifiers:
• Persistent

Etiology of Reactive Attachment Disorder: This disorder is created when a person experiences profound deficiencies in early childhood bonding experiences, where primitive needs for comfort, support, nurturance, stimulation, emotional attunement, and safety/security are not available at the critical times when bonding experiences are essential for healthy development. There appear to be important differences in the capacity for resiliency from child to child based upon factors that have not fully been determined, and the interplay between intrinsic resiliency and sub-optimal caretaking environments determine whether RAD will develop and the degree to which it is relatively intractable.

Prevalence: Prevalence rates for Reactive Attachment Disorder have not been accurately determined. However, some studies report a prevalence rate of up to 38% for maltreated foster children in the US foster care system.

Clinical Manifestations: People with Reactive Attachment Disorder will present with a variety of symptoms related to poor interactivity with others, including minimal social and emotional responsiveness, limited positive affect, disinclination to seek out or accept comfort when distressed, and episodes of irritability, sadness or fearfulness even in non-threatening situations.

Best Practices Diagnostic Approaches: An accurate diagnosis of Reactive Attachment Disorder will involve gathering a thorough history of the client and his/her early caretaking experiences, including disruptions to bonding and early caring experiences, as well as an inventory of signs and symptoms of social and relationship disruptions and dysfunctions. Signs and symptoms may be present in children who are not capable of verbalization of their emotional state, so observation of the child in interaction with family caretakers and other caretaking figures would be diagnostically useful, particularly if the caretaking figures continue to demonstrate deficiencies in bonding and attunement capabilities.

Best Practices Treatment Approaches: Best practices treatment approaches for Reactive Attachment Disorder include intervention in the child’s milieu to encourage development of the caretaking and attunement capacities of the child’s care givers to create an environment which allows for healthier and more positive interactions and which fosters the child’s inherent capacities for forming emotionally stable and healthy relationships. The earlier in the child’s development that corrective interventions can be applied, the more likely the therapeutic approach will be to create durable changes to this disorder. Intervention in the child’s milieu can include family and individual therapy, psychoeducation to the care givers about the disorder, and parenting skills classes to improve the quality of the interactions between the care giver and the child.

Other Conditions to Rule Out: This disorder must be distinguished from Autism Spectrum Disorder in which the disruption to the bonding experience is attributable to cognitive-affective problems at the neurological level. Other kinds of neurodevelopmental and neurocognitive disorders must also be ruled out to assure that disruptions to the ability to engage in emotionally healthy relationships is not due to some sort of neurological impairment that affects areas of the brain necessary for successful social and emotional interaction.

Comments: Due to the difficulties posed by ruling out many of the other diagnoses that may show signs and symptoms similar to Reactive Attachment Disorder, it is not generally recommended that this diagnosis be utilized by a Master’s level clinician without substantiation and validation from referral for a psychiatric and/or psychological assessment. The importance of early intervention cannot be understated, as there are critical developmental periods for the formation of secure attachment to care givers, and treatment protocols become more complicated and generally less successful if this disorder remains undiagnosed and untreated past early childhood periods. There is a subset of children who present with signs and symptoms of both Reactive Attachment Disorder and Disinhibited Social Engagement Disorder, since the etiological factors are very much the same.

 

                       Disinhibited Social Engagement Disorder Summary Page

DSM-5 Code:       F94.2 Disinhibited Social Engagement Disorder

Common Specifiers:
• Persistent
• Severe

Etiology of Disinhibited Social Engagement Disorder: This disorder is created when a person experiences profound deficiencies in early childhood bonding experiences, where primitive needs for comfort, support, nurturance, stimulation, emotional attunement, and safety/security are not available at the critical times when bonding experiences are essential for healthy development. As a result, children with this disorder will present with indiscriminate friendliness to any available caretaking figure, showing no preference for primary caretakers over complete strangers.

Prevalence: Prevalence rates for Reactive Attachment Disorder have not been accurately determined. However, some studies have reported a prevalence rate of up to 22% for maltreated foster children in the US foster care system.

Clinical Manifestations: People with Disinhibited Social Engagement Disorder will present with an age-inappropriate inclination to seek out interactions with unfamiliar adults and disinclination to check back in with adult caretakers even in unfamiliar settings. Children with this disorder are at risk for going off with strangers and engaging in overtly familiar physical behaviors with adults they do not know.

Best Practices Diagnostic Approaches: An accurate diagnosis of Disinhibited Social Attachment Disorder will involve gathering a thorough history of the client and his/her early caretaking experiences, including disruptions to bonding and early caring experiences, as well as an inventory of signs and symptoms of socially and age-inappropriate behaviors with regard to social interactions with strangers. Signs and symptoms may be present in children who are not capable of verbalization of their emotional state, so observation of the child in interaction with family caretakers, other caretaking figures, and strangers (including the clinician) would be diagnostically useful, particularly if the caretaking figures continue to demonstrate deficiencies in bonding and attunement capabilities. Older children may be assessed utilizing the Disturbances of Attachment Interview or the attachment disorder scale of the Development and Well Being Assessment (DAWBA).

Best Practices Treatment Approaches: Best practices treatment approaches for Disinhibited Social Engagement Disorder include intervention in the child’s milieu to encourage development of the caretaking and attunement capacities of the child’s care givers to create an environment which allows for healthier and more positive interactions, and which fosters the child’s inherent capacities for forming emotionally stable and healthy relationships and encourages the development of socially appropriate inhibitions in interactions with strangers. The earlier in the child’s development that corrective interventions can be applied, the more likely the therapeutic approach will be to create durable changes to this disorder. Intervention in the child’s milieu can include family and individual therapy, psychoeducation to the care givers about the disorder, and parenting skills classes to improve the quality of the interactions between the care giver and the child.

Other Conditions to Rule Out: This disorder must be distinguished from Autism Spectrum Disorder in which the disruption to the bonding experience is attributable to cognitive-affective problems at the neurological level. Other kinds of neurodevelopmental and neurocognitive disorders must also be ruled out to assure that disruptions to the ability to engage in emotionally healthy relationships is not due to some sort of neurological impairment that affects areas of the brain necessary for successful social and emotional interaction. Reduced inhibition due to Attention Deficit Disorder and disorders of impulse control must also be ruled out.

Comments: Due to the difficulties posed by ruling out many of the other diagnoses that may show signs and symptoms similar to Disinhibited Social Engagement Disorder, and the advantages of utilizing psychological measures to arrive at this diagnosis, it is not generally recommended that this diagnosis be utilized by a Master’s level clinician without substantiation and validation from referral for a psychiatric and/or psychological assessment. The importance of early intervention cannot be understated, as there are critical developmental periods for the formation of secure attachment to care givers, and treatment protocols become more complicated and generally less successful if this disorder remains undiagnosed and untreated past early childhood periods. There is a subset of children who present with signs and symptoms of both Reactive Attachment Disorder and Disinhibited Social Engagement Disorder, since the etiological factors are very much the same.

 

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