The Impact of Violence, Disaster, War, &

Terrorism upon Teens Dr. Mick Maurer

PTSD in Children and Adolescents

• The diagnosis of Posttraumatic Stress Disorder (PTSD) was formally recognized as a psychiatric diagnosis in 1980.

• At that time, little was known about what PTSD looked like in children and adolescents.

Post Traumatic Stress Disorders (PTSD)

Type I, II, III - Associated Disorders • Major Depressive Episode• Posttraumatic Stress Disorder• Generalized Anxiety Disorder• Panic Disorder

- Associated Complications• Suicide• Substance Abuse• Self-Medication

Definition:

• A diagnosis of PTSD means that an individual experienced an event that involved a threat to one's own or another's life or physical integrity and that this person responded with intense fear, helplessness, or horror.

Children and adolescents may be diagnosed with PTSD if they have:

1. survived natural and man made disasters such as floods;

2. violent crimes such as kidnapping, rape or murder of a parent, sniper fire, and school shootings;

3. motor vehicle accidents such as automobile and plane crashes;

4. severe burns; 5. exposure to community violence; 6. war; 7. peer suicide; 8. and sexual and physical abuse.

PTSD in adolescents may begin to more closely resemble PTSD in adults.

However, there are a few features that have been shown to differ.

• Children may engage in traumatic play following a trauma.

• Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives.

• In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.

Besides PTSD, what are the other effects of trauma on adolescents?

• problems with fear, • anxiety, • depression, • anger and hostility, • aggression, • sexually inappropriate behavior, • self-destructive behavior, • feelings of isolation and stigma, • poor self-esteem,

Other effects:

• difficulty in trusting others,

• and substance abuse,

• also often have relationship problems with peers and family members,

• problems with acting out,

• and problems with school performance.

Psychiatric Disorders that are commonly found in adolescents who have been traumatized.

• One commonly co-occurring disorder is major depression.

• Other disorders include:

- substance abuse; - other anxiety disorders such as separation

anxiety, panic disorder, and generalized anxiety disorder;

- externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

How do children respond to terrorism?

More severe reactions are associated with:• a higher degree of exposure (i.e., life threat,

physical injury, witnessing death or injury, hearing screams, etc.),

• closer proximity to the disaster, • a history of prior traumas, • being female, • poor parental response, • and parental mental health problems.

Research on children from the September 11th, 2001 attacks & the

Oklahoma City Bombing.

• Two factors related to increased stress symptoms were:

1) amount of television coverage viewed by the child,

2) parental distress.

What can parents do?

Eleven to eighteen years:• Encourage adolescents of all ages to talk about the

traumatic event with family members. • Provide opportunities for the young person to spend time

with friends who are supportive. • Reassure the young person that strong feelings-guilt,

shame, embarrassment, or a wish for revenge-are normal following a trauma.

• Help the young person find activities that offer opportunities to experience mastery, control, and self-esteem.

• Encourage pleasurable physical activities such as sports and dancing.

How many children develop PTSD after a terrorist attack?

Findings from Oklahoma City indicate that: • Children who lost a friend or relative were more likely to

report immediate symptoms of PTSD than non-bereaved children.

• Arousal and fear presenting seven weeks after the bombing were significant predictors of PTSD.

• Two years after the bombing, 16% of children who lived approximately 100 miles away from Oklahoma City reported significant PTSD symptoms related to the event. This is an important finding because these youths were not directly exposed to the trauma and were not related to people who had been killed or injured.

More findings from Oklahoma City

indicate that: • PTSD symptomatology was predicted by media

exposure and indirect interpersonal exposure, such as having a friend who knew someone who was killed or injured.

• No study specifically reported on rates of PTSD in children following the bombing.

• However, studies have shown that as many as:- 100% of children who witness a parental homicide or

sexual assault, - 90% of sexually abused children, - 77% of children exposed to a school shooting, and - 35% of urban youth exposed to community violence

develop PTSD.

The Effects of Community Violence on Adolescents

• A commonly held belief in the general population is that community violence only happens among gang members in inner-city neighborhoods.

• Indeed, those of lower socioeconomic status, • those who are nonwhite, • and those living in densely populated urban

areas do appear to bear a disproportionately high burden of violence.

Are some youths at greater risk for exposure to community violence?

Factors that may increase a child's risk for exposure to community violence:

• Living in poor, inner-city areas and being a minority appears to increase the risk for community violence exposure.

• Gang affiliation appears to be a key risk factor,

• as is involvement in substance abuse,

• and exposure to domestic violence.

• Gender is another risk factor;

- males witness more community violence and are at higher risk for physical assault and other direct forms of community violence,

- females are at higher risk for community-violence related sexual assault.

What are the effects of community violence?

• Adolescents with PTSD also experience nightmares and intrusive thoughts about the trauma.

• They may be easily startled and avoid reminders of the trauma.

• They can become depressed, angry, distrustful, fearful, and alienated, and they may feel betrayed.

• Many do not feel they have a future and believe that they will not reach adulthood. This is especially common among adolescents who are chronically exposed to community violence.

Other trauma-related reactions can include:

impaired self-esteem and body image,

• learning difficulties,

• and acting out or risk taking behaviors

- such as running away,

- drug or alcohol use,

- suicide attempts,

- and inappropriate sexual activities.

How is PTSD treated in children and adolescents?

Cognitive-Behavioral Therapy (CBT) generally includes:• the child directly discussing the traumatic

event (exposure), • anxiety management techniques such as

relaxation and assertiveness training, • and correction of inaccurate or distorted

trauma related thoughts.

• Through this procedure, they learn that they do not have to be afraid of their memories.

• CBT also involves challenging children's false beliefs such as, "the world is totally unsafe."

• The majority of studies have found that it is safe and effective to use CBT for children with PTSD.

CBT is often accompanied by psycho-

education and parental involvement.

• psycho-education is education about PTSD symptoms and their effects.

• parental involvement Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function.

Several other types of therapy have been suggested for PTSD in children and

adolescents.

• Play therapy The therapist uses games, drawings, and other techniques to help the children process their traumatic memories.

• Eye Movement Desensitization and Reprocessing (EMDR), combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and adults with PTSD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change.

Treatments continued:

Psychological first aid has been prescribed for children exposed to community violence and can be used in schools and traditional settings.

• involves clarifying trauma related facts,• normalizing the children's PTSD reactions, • encouraging the expression of feelings, • teaching problem solving skills, • and referring the most symptomatic children for

additional treatment.

Other treatments:

• Twelve Step approaches have been prescribed for adolescents with substance abuse problems and PTSD.

• Medications have also been prescribed for some children with PTSD. However, due to the lack of research in this area, it is too early to evaluate the effectiveness of medication therapy.

Further Treatment Options:

• specialized interventions may be necessary for children exhibiting particularly problematic behaviors or PTSD symptoms. For example, a specialized intervention might be required for inappropriate sexual behavior or extreme behavioral problems

The Effect of Combat-Related PTSD on Children

• Transgenerational effects of combat-related PTSD have critical implications for a veteran’s interpersonal and family life

• Children of combat veterans with PTSD generally exhibit one of three response patterns.

The “over-identified” child.

• Through a process Rosenheck and Nathan (1985) has termed secondary traumatization, children come to experience an emotional disequilibrium similar to the veteran with PTSD.

• Children with secondary traumatization are often their father’s closest companion and are at risk for "reliving" their father’s trauma, experiencing his flashbacks, and sharing his nightmares.

• These children fail to develop their own friendships because their lives revolve around their father.

• In school, they often have difficulty with concentration because they are distracted by their concern for their father’s well-being.

The "rescuers"

• Whereby they take on parental roles and responsibilities.

• They often feel guilty about trouble at home and blame themselves.

• They assume that if they are good, life at home will go well.

• They believe it is their responsibility to keep their parents happy and to insure nothing goes wrong.

• These children often lose spontaneity and interest in daily activities.

• Similar to children of alcoholics, these children are at risk for continuing this pattern into adult life.

Third pattern

• Children who are emotionally uninvolved in family life.

• They often know about their father's war experience and need for support, but generally receive little emotional support themselves from their parents.

• In an effort to gain recognition, they are apt to perform well academically,

• Their emotional and social constriction may cause symptoms of depression and anxiety,

• and later cause problems in their adulthood efforts to form intimate relationships.

Treatment of Combat-Related PTSD on

Children The focus of children’s treatment is the:• strengthening of ego functions (i.e. reality

testing, frustration tolerance, and verbalization).

• children are encouraged to recognize their separateness,

• address their own developmental needs,• and not assume responsibility for their

parents’ behavior and pain.