October 1st, 2014

PTSD in children disrupts development, relationships

Many people associate posttraumatic stress disorder with veterans returning from war, victims of violent crime or individuals who’ve been involved in natural disasters. However, adults are not the only ones subject to developing this disorder. The National Institute of Mental Health reports that four percent of adolescents between the ages of 13 and 18 have a lifetime prevalence for PTSD.

Wellspring and the Arch Bridge School in Bethlehem, Conn., treats adolescent girls and young women with PTSD at two outpatient clinics and residential treatment facilities, according to Daniel Murray, Psy.D., CEO. “Private schools offer the benefit of clinical treatment and an environment where we’d put our own kids,” he says. “When they get to residential treatment, the child has already been through all other therapies, so our approach is highly nurturing, highly structured.”

Much like adults with PTSD, children and adolescents present with symptoms that range from intrusive thoughts, flashbacks and nightmares to depression, panic attacks and anxiety. “You rarely see PTSD in isolation. We see the worst of it in residential care,” says Murray, adding that family substance abuse issues, personality disorders and every type of relational disorder may also be present. “Research indicates that PTSD co morbidity rates range between 40 and 95 percent. It swings back and forth with other psychological problems.”

Appropriate treatment for PTSD depends on the family and parents for its foundation. “The entire model is relationship-based. We try to figure out how to restore relationships with family and peers and get them stronger to be in school,” Murray says. The adolescent program at Wellspring involves weekly family therapy and a multi-family group every other week for three hours. “Our goal is to not be in your life. The parents have to be on board. We are teaching parents to receive kids.”

Murray notes that in some cases, trauma could have occurred during the preverbal time of life. These children have no way of communicating what happened to them. To help instill confidence and trust in these youngsters, Wellspring encourages them to engage with farm animals at the school and participate in outdoor activities, such as horseback riding, playing in the gardens, running and jumping. “For the young ones, their confidence grows, especially for kids whose trauma is preverbal,” says Murray, adding that Wellspring also teaches coping and relaxation skills and mindfulness. “So many kids don’t know how to do this.”

If left untreated, PTSD disrupts brain development, says Murray, citing social and cognitive deficits, family behavioral problems, anger management issues, substance abuse and suicidal ideation as potential repercussions.

Kim T. Mueser, Ph.D., executive director for the Center for Psychiatric Rehabilitation at Boston University, co-created a treatment model called Cognitive Restructuring (CR) for PTSD, which involves establishing the understanding that thoughts and beliefs about a situation are filtered through upbringing and experience and may not always be interpreted accurately. “Cognitive restructuring is the core element of CBT and helps you understand how thinking relates to behavior,” he says. “We help the patient examine critical thoughts and modify reaction.”

“This is part of the broad clinical picture of PTSD. We spend time talking and exploring ways in which PTSD affects lives and the most important ways patients want their lives to be different. We identify at least one goal to have as a result of participating in the program,” Muesur explains. If, after talking about the trauma, the evidence doesn’t support the thought, then the client is taught to change the thought. If the thoughts are accurate, then have an action plan, he says.

The treatment has proved to be successful with adolescents since it avoids some dynamics with clients who are reactive to others’ efforts to change them. “The tendency for some patients is to resist another’s efforts to control them,” says Mueser. “CR involves self-management. [The clinician] is no longer directly trying to change the patient. It can be empowering. Adolescents are at a developmental stage where they are psychologically reactive and defiant with parents and authority.”

To be successful, a patient does need to be somewhat motivated, according to Mueser. “In my experience, most people living in a relatively stable situation and who are not actively re-traumatized are motivated,” he says.

Mueser and colleagues conducted a study using CR with nine girls and three boys with a mean age of 16 who were diagnosed with PTSD. After between 12 to 16 weeks of individual treatment, the researchers noted significant improvements in PTSD and depression from baseline to post treatment. Moreover, the treatment gains were maintained at three-month follow up.

The Bridge of Central Massachusetts is an evidence-based and best practice human services provider that operates 46 programs throughout Central and Eastern Massachusetts to individuals in residential and community programs. It provides special education to youths between the ages of eight and 13, has used CR for PTSD for the last 4-1/2 years, according to Barent Walsh, Ph.D., executive director. “We’ve implemented this treatment with some adolescents and kids with developmental disabilities,” he says, noting that exposure therapy is too intense for youths. “Adolescents can’t do systematic prolonged exposure. In residential programs and outreach, it’s too daunting for the kids.” To date, The Bridge has successfully used CR for PTSD with 80 adolescents.

CR for PTSD comprises three main components: breathing retraining to help with relaxation and stress reduction, education and cognitive restructuring, Walsh explains. During the education phase, individuals learn that re-experiencing the trauma, nightmares, flashbacks, avoidance and hyper-arousal are common reactions that can be unlearned. He emphasizes that homework is an essential part of the therapy and says that assignments foster better retention of the material and help the individual generalize the situation to the real world.

“I’ve been at The Bridge for 40 years and this is a promising development. It’s no longer unspeakable that it’s a crime to have been abused. Individuals receive compassion, support and recognition of the problem,” says Walsh. “The process of dissolution and seeing an individual progress to a normative life is meaningful for the clinician.”

By Phyllis Hanlon

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