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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


BEST PRACTICES IN MANAGING PSHYCHOTRAUMAS IN CHILDREN AND ADOLESCENTS

Autor: Bogdan Fițiu Georgiana Golea Iuliana Jucuți
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In the past 20 years there has been a constant attention to psychical and emotional maltreatment of children but the problem still needs ongoing supervision from mental health professionals around the world.

In this paper we analyzed international guidelines and scientific articles about the management of the psychotraumatic events that children and adolescents suffer in order to identify the clinical practices with the most promising result in the care of those exposed to trauma.

We observed that the exposure to a traumatic event is generally accompanied by short term emotional distress followed by possible long term damage, and that because of the highly heterogeneous cultural environments and the individual’s perspective over the traumatic experience a multilevel system of therapy is needed.

These therapies include: trauma focused cognitive behavioral therapy, pharmacologic therapies, social services involvement, eye movement desensitization and reprocessing therapy

These therapies are proposed to the patients in individual settings and the quality of the psychiatric care depends on the relationship between the patient, its family and the therapist, this being the starting point for a successful recovery.

Introduction

One of the earliest researches on the traumatic effects of the war on children was coordinated by Anna Freud who observed the way children dealt with the war experiences during the Second World War. Her team found that being closed to a stabilizing paternal figure made the war experience less traumatic than simply offering the child a secure environment without the comfort and care of a parent, and it was amplified when the child suffered from separation anxiety or a shocking separation from the parent.

Psychotrauma is described as natural reaction to an extreme event. It is important to underline that the event alone is not responsible for the trauma but rather the thoughts, feelings and convictions the individual has about the event itself. (Boscarino J, 2004) The impact of the traumatic event over an individual differs on the basis of the duration of the exposure, the intensity of the event, the past experiences he had, the individual’s social support networks, and the cultural environment in which the child lived making it almost impossible to predict if a mental health problem will arise. (Eckes&Radunovich, 2012)
In the USA by the time children reach 16 years if age two thirds of them report suffering from a traumatic event. (Presidential Task Force on Posttraumatic Stress Disorder and Trauma in Children and Adolescents, APA, 2008) However the rates of exposure vary according to the population, the testing tools and other factors including cultural ones.

 

Aim of the study

To identify the best practices a mental health professional should currently use to promote the wellbeing, the autonomy and the dignity of those exposed to a traumatic experience.

 

Material and Method

We analyzed international guidelines and articles published during 2003-2013 regarding the management of trauma related problems.

Results

Following the exposure to a traumatic event short term emotional distress is universal. Almost all children and adolescents experience behavioral problems in the early stages of trauma, but not all of these responses are problematic, some reflect copping mechanisms to the event. Other problems may arise regarding anxiety symptoms, sleep problems and nightmares, anger, lack of interest for daily activities, attention deficits, irritability, and somatic symptoms.
Some children and adolescents develop resilience in the face of trauma (especially those who suffered a single traumatic event). Regarding the risk of poor psychiatric outcomes those who live in aversive families and those that had prior mental health problems tend to have a higher risk of mental health problems.

Trauma focused therapy systems should include:  (Ellis et al, 2011)

A mental health professional that is a vital part in the recovery from a traumatic experience. The mental health professional has the responsibility to know and apply the best current practices and to offer the patients a gold standard therapy and to aid the adjacent professional that work with the children (school teachers, medical doctors, social services workers). These information are best given in the educational form as a preventive step. It is also important that the terms used by the mental health professional should be adapted to the developmental level of all those involved in the therapeutic process and to insure the child’s caregiver that the current behavior is a normal response to an abnormal event.(Moroz, 2009).

A key priority in the recovery of children suffering from traumatic experiences is instructing the caregivers to maintain the routine the child new before like regular meals, keeping in touch with peers that help the child to restore its feeling of safety.  (Packard, 2008)

One of the challenges that mental heath professionals may encounter refer to the family’s wish to accept or deny therapy, in these cases “open door policy” should be applied meaning that the therapist will stand by until parents have a proper understating of the children’s need for therapy.

Another challenge is dealing with children that come from different ethnic and cultural groups that may have limited access to mental health services due to their economic status or beliefs. In these cases the therapist must focus its therapeutic efforts keeping in mind the different cultural, political and demographical origin of the child. (American Psychiatric Association,  2011).

Trauma focused Cognitive – Behavioral Therapy (TF-CBT):

 
In a meta-analysis of evidence based psychosocial treatments TF-CBT was the only form of treatment to meet Silverman’s Criteria of therapeutic efficacy (Silverman et al, 2008) and also Kauffman’s Best Practices Project (2004) criteria which were used in these two separate studies that evaluated the best course of treatment in post-traumatic exposure, and also obtain a number one scientific rating (an evidence based therapeutic approach; Child Welfare System Relevance Level: High).

Trauma focused cognitive behavioral therapy is sustained by a number of researches that allowed it to be validated as a treatment plan is cases that required post-trauma care except in cases that involved post-traumatic depression, suicidal ideation, or substance abuse. (National Child Traumatic Stress Network – NCTSN 2004, 2008)
TF-CBT is a united therapeutic model approach between the parent, child that is offered to children presenting with significant behavioral and emotional problems connected with the traumatic experience. This therapy system brings together trauma-related interventions with behavioral and specific family therapy sessions offered in individual settings and adapted to each individual patient and its family. Although initially it was developed to help victims of sexual abuse, recent changes made it possible to adapt this therapeutic system to meet the needs of children subjects to a wide range of traumatic experience. (NCTSN 2004, 2008)

In order to establish a better cooperation between the therapist, the child and its family TF-CBT implementation guidelines recommend that those participating should be informed that trauma focused cognitive behavioral therapy is an evidence based method of treatment, that it usually requires between 6-12 therapy sessions, that it will be offered individually to each child, individual (Villalba J. A., Lewis L., 2007), and that discussing about the traumatic event- although painful- is a key part of the therapeutic process.

TF-CBT is efficient primarily in reducing trauma related symptoms such as post-traumatic reactions (intrusive thoughts, upsetting memories, physical hyper arousal, attention and irritability) and also depressive symptoms, anxiety, conduct disorders, shame related to trauma (especially when sexual abuse is the case), trust issues and post-traumatic social functioning. The implementation manuals for TF-CBT recommend that the parent or caregiver should be included in the therapeutic approach but if this is not possible children should not be denied treatment with this form of therapy. (NCTSN 2004, 2008) However TF-CBT is not the only treatment approach, and for it to be used clear evidence is needed that the mental health problems experienced at the start of the therapy are related to a traumatic event and that any other psychiatric disorder that was present prior to the start of the treatment is being well managed so that constant problems are avoided in the course of the therapy.

 

Components of the trauma focused cognitive behavioral model: (Cohen&Mannarino, 2008)

 

  1. Psychoeducation – is an essential part of the therapeutic alliance between the child, the therapist and the family. To start the therapist explains the importance of the problems the child may experience and that the behavioral changes that occur are transient thus offering a message of hope in the face of the unknown. These facts help to reduce stigma and decrease the anxiety the parent and the child feel. Psychoeducation is the first key component and should start from the initial contact with the therapist and it will be offered at any stage during therapy based on the needs of the parent, child or its extended family.
  2. Parenting – the second component that has a major role in therapy is offering the parents parallel sessions and interventions that optimize their parenting skills that they need in to cope with the symptoms that may arise:  aggression, enurezis or sudden mood changes. Parents may be advised to not become overprotective or alternatively to accept disruptive behaviors in an effort to further protect their children. Therapists must collaborate with parents to individualize the treatment plan and are attentive to the individual needs and more importantly to the cultural background of the family.
  3. Relaxation skills – these set of skills are aimed at reversing any psychological changes that may have resulted from the traumatic experience. These tools are effective in the situation that stressful triggers appear in different settings: at school, home or during peer to peer interactions, providing the child with a sense of control and calm that was deprived after the traumatic event. These skills may include deep breathing, yoga, mindfulness exercises (for adolescents), progressive muscle relaxation, listening to music or doing sports. Therapists then work with the child and its family in order to fine tune the practices that help the most in bringing psychical or psychological comfort and that the child can practice regardless of the setting.
  4. Affective modulation skills – are used between therapeutic sessions in order to help the child face the negative or positive events that may arise after the traumatic experience. After trauma some children become hyper aroused so that even a minor distress can trigger a major response while others seem unresponsive to positive events. These set of tools help the child to improve its social skills and also improve the family interactions.
  5. Cognitive coping skills – allow the child and the parents to recognize the connection among thoughts, feelings and behaviors as they relate to everyday situations and to the traumatic event. Therapists allow children and their parents to identify the thoughts, feeling and behaviors they associated with the thoughts and to evaluated if these are helpful or not.  Then children and parents are encouraged to think of alternative thoughts for each of the problematic situation and to explore the new feeling and behaviors, and to identify if these new sets of feeling and behaviors would be more pro-social than before. Also the child obtains a feeling of control over its thoughts, feelings and behaviors and the consequences they generate.
  6. Trauma narrative and cognitive reprocessing – after all the sets that help the child and parent in building the skills set have been completed, work can begin on the traumatic event and its specific components. Children should be encouraged to develop a trauma narrative by gradually telling the story of what happened by writing or singing about it (books, poems, songs). Thus the child can overcome the avoidance of the traumatic memories and identifies the cognitive distortions that were associated and helps the child to contextualize the traumatic experience into the larger framework of his or hers life. Therapists should share the narrative process with the parents to prepare them for the following parent-child sessions. After the child creates the narrative task, the therapist assists the child in cognitively reprocessing distortions that contribute to the negative states such as shame, self-blame and low self esteem.
  7. Child-parent sessions – conjoined parent-child sessions are an important part of the TF-CBT model, and children experience added benefits when parents participate. During these sessions children are encouraged to share the traumatic experience directly with the parent aiding further in the recovering from cognitive distortions the child may have such as feeling of guilt that the parents may be upset or have a negative opinion of the child.

 

Trauma focused cognitive behavioral therapy is a flexible therapeutic model allowing it to be applied in various traumatic events having a background of almost 70 meta-analysis studies that certifies the short and long terms benefits in reducing the post-traumatic symptoms and lowers the risk of comorbid psychiatric disorders.(Bisson, 2013)

Social services A vast majority of children and adolescents suffering from traumatic events are not identified and therefore do not receive adequate psychiatric care. Even when these types of situation are identified some still do not receive help from mental health professionals (this is true especially for ethnic groups and those experiencing poor social conditions that have a lower access to health services). The high number of children that are not receiving proper care may be lowered by an efficient team of social workers specialized and trained in recognizing and intervening in case of children exposed to traumatic experiences.

Pharmacologyc management The psychopharmacologic treatment of traumatized patients is a challenge for any psychiatrist as there are few drugs available that target this complex problem. Kaplan & Sadock wrote about the use of Selective Serotonine Reuptake Inibitors (fluoxtine and paroxetine) as the most efficient molecules in treating the vast symptomatology of the post-traumatic disorder not limiting it to treating only depressive disorder. Thomas in an article from 2014 (Thomas, 2014) bring to discussion the use of Prazosin as treatment for nightmares and flash-backs using a one time administration before bedtime (18 mg for women and 25 mg for men). Intrusive PTSD symptoms may respond well to the use of a low dosage of atypical antipsychotic medication and for extreme agitation or aggressive behavior Haldol should be taken into consideration (Lowenstein et all, 2005). Propranolol may be effective in diminishing hyper arousal symptoms when external triggers are at fault, which may be experienced at enhanced intensity due to the recent traumatic event (Vaiva et al, 2012). Benzodiazepines, usually lorazepam or clonazepam, may be used to treat panic attacks and anxiety however the physician should take into consideration that typically PTSD gives rise to terror not anxiety, and the situations must be evaluated rigorously (Foa, 2009).

Rapid eye movement desensitization and reprocessing therapy is a technique discovered since 1987 targets the link between traumatic images and cognitive effects and emotions that they associate when they arise. (Korn and Leeds, 2010) The purpose of this treatment method is todesensitize and to help the individual reprocess the negative images using bilateral stimuli that cause the patient to integrate the experience in a more adaptive way. This process is repeated again and again until symptoms of physical and emotional distress no longer appear. The effect is similar to that of REM sleep, as it is known that during REM phase the integration of episodic memories into the memory and as a therapy it serves to integrate these distressing memories into the sematic memory, without them further inducing hippocampic activation that has negative consequences over the amigdala. A number of studies, including Van der Kolk et, 2007 shows that the clinical efficiency of the EMDR therapy when compared to the administration of fluoxetine for 8 weeks, has a responsive rate for the EMDR group of clos to 81 %. However the International Society for Traumatic Stress Studies Guideline (Foa, 2009) warns that the use of EMDR therapy on patients that exhibit dissociative disorders is dangerous and can cause significant adverse psychiatric outcomes. Van der Hart et al, 2006 bring into light the same problem stating that the use of MDR on chronically traumatized patients can cause it to bring up “too many traumatic memories too soon”. Although it has been established as a safe and useful clinical tool a study by Sondergaardet from 2008 shows that only 50% of the patients treated with this type of therapy are helped.

Adherence to strict psychiatric interview protocols ensures that a traumatizing event can be accurately discovered. For example, Child behavior Checklist (CBCL) an age appropriate interview method for parents or teachers analyses the child’s aggression, hyperactivity or shifts in behavior associated with violence, and Child & Adolescent Functional Assessment Scale (CAFAS) asses clusters of symptoms regarding behavioral issues, social interactions, substance abuse and negative affect are some of the most used tools for screening and diagnosis.

 

Conclusions

  • In order to help the child process the traumatic event to which he has been exposed and to help him gain previous functionality guidelines and gold standard practices have been developed worldwide
  • Adherence to these relevant standards in psychiatric care ensures uniformity in the treatment of trauma related symptoms, lowers the risk of adverse outcomes, and ensures that the therapist is protected against malpraxis
  • Appropriate partnerships must be established within relevant institutions for the screening and identification of those children and adolescent that have been exposed to traumatic events and need help in the form of therapy
  • The trauma focused cognitive behavioral therapy system brings together an integrated approach in the treatment of post traumatic symptoms. These therapeutic model is offered individually and in child-parent sessions, with a constant watch over the needs of the patient and it cultural beliefs
  • The need for psychopharmacological treatment should be carefully assessed at all times
  • Therapist need to incorporate a developmental and a holistic body-mind-spirit approach to ensure adequate care for the child and its family
  • Investments in programs to educate, prevent and to intervene when necessary should be enforced. These programs would not only improve quality of life for those exposed to trauma, but also lower the costs of care.

 

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