By the age of 16 years more than two-thirds of children will have been exposed to at least one traumatic event. Jane Nursey, Senior Clinical Specialist with the Australian Centre for Posttraumatic Mental Health (ACPMH), explains how children are affected by – and treated for – acute stress disorder (ASD) and post-traumatic stress disorder (PTSD).
Why specify different treatment guidelines for children and adolescents?
People often assume that children are little adults when it comes to psychological treatment and that what works for adults should work for children as well. This is far from the truth, especially in the case of trauma. The level of emotional, cognitive, social and personality development that the child has achieved at the time of trauma exposure, together with the nature of the relationship with their primary caregiver, can influence the trauma’s impact, as well as the child’s response to treatment. It is therefore important that treatment for children and adolescents be tailored to their developmental needs and trauma-specific symptoms.
Therapists working with children must ensure that they use language appropriate to the developmental level of the child and present information through a range of sensory channels using multiple media and practical activities to engage them in the therapeutic process. It is also important that treatment protocols for children and adolescents actively incorporate the system that surrounds and supports the child through their recovery – particularly parents, but potentially also teachers, other community groups, service providers or carers that may be connected to the child.
How frequently are children exposed to traumatic events?
By the age of 16 years more than two-thirds of children will have been exposed to at least one traumatic event. While we know that the majority of children will recover naturally with the help of a supportive family, a minority will go onto develop a psychological disorder such as depression, an anxiety disorder, or ASD and PTSD.
What proportion of children are diagnosed with ASD and PTSD?
Rates of ASD and PTSD in children can vary depending on the type of trauma they are exposed to and the level of support they have around them. The formal diagnoses of ASD and PTSD had not been developed specifically for children and adolescents prior to the release of DSM-5 [The Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition] in May 2013. This limited the usefulness of the diagnosis in these age groups and made it difficult to know how common these disorders are in children.
From the few prevalence studies for ASD in children that have been published, rates vary between eight per cent and 19 per cent depending on the type of trauma. In terms of PTSD, the prevalence rates vary significantly depending on the sample under study, the type of trauma experienced, and the methodology used to make the diagnosis. Published lifetime prevalence rates have varied between a low of 1.6 per cent to a high of six per cent. However, a meta-analysis of primary school aged children and adolescents exposed to a range of trauma events found that, overall, 36 per cent of participants were diagnosed with PTSD. This can be even higher for specific types of trauma.
What does the research suggest for treating children with ASD and PTSD?
PTSD in very young children tends to persist over time and be associated with a range of poor developmental outcomes. Among older children and adolescents, approximately one-third will recover without treatment within the first 12 months. Another third will respond well to treatment, and the remainder may develop a chronic course and suffer for many years. Unfortunately, there are few studies that have looked at the long-term impact of PTSD treatment in children and adolescents and, in reality, only a minority of children and adolescents with PTSD receive treatment.
Not enough research has been done on treating ASD in children and adolescents to determine a best practice approach. For PTSD, the treatment approach with the strongest evidence base for children of school age and above is Trauma Focused Cognitive Behavioural Therapy (TF-CBT). TF-CBT includes elements of psycho-education and symptom management, but emphasis is placed on the two core elements of exposure therapy and cognitive restructuring. In children, the implementation of this therapy will vary according to the child’s age.
How do interventions differ between developmental ages (under six years versus seven to 13 years) set out in the revised guidelines?
Trauma-focused work with children and adolescents would generally proceed at a gentler pace than it would with adults, and primary caregiver involvement will be central. Skills training in emotional regulation appropriate to the child’s developmental level would be a core component.
With a child aged under six, a therapist might use drawing and play to engage the child in therapy and assist them to engage with and talk about their traumatic memories. This is done in order to minimise the impact of the traumatic memory, and help the child to dispel myths and develop a new understanding about the concerns that trouble them the most. For these very young children, the parent may sit in on some sessions, but they and the child may also have individual sessions. The parent will be an integral part of the therapy and be responsible for reinforcing key messages and skills learned in therapy as well as modelling appropriate behaviour for the child.
For children aged seven to 13 years, parents and children may have parallel individual sessions so that the parent is informed and empowered to support the child through their therapy and to reinforce at-home skills learned in the session. Rather than using play and drawing, children in middle childhood will be encouraged to engage in therapy through writing and talking about their traumatic memories. Real-life exposure to activities or places they avoid or that cause them distress would also be used where indicated. Cognitive behavioral techniques aimed at challenging some of the child’s misconceptions or distorted beliefs about the trauma would be matched to the developmental age of the child.
With community-wide traumas, what can professionals encourage families, schools and early childhood services to do to support children in the aftermath and at each stage of recovery?
Based on the premise that most children will recover naturally, the best thing parents and educators can do is to help children feel safe. Children will pick up on adults’ distress, so it is very important that caregivers identify and manage their own distress in productive and helpful ways and model effective coping skills to children. The following list can assist both adults and children affected by trauma:
Keep to fixed routines as much as possible.
Use simple calming and relaxation techniques, such as calm breathing, muscle relaxation, self-talk, grounding and mindfulness techniques or activities that you would normally do to relax.
Ensure healthy eating and get plenty of sleep.
Provide opportunities for the child or adolescent to talk about the traumatic event and their feelings about it when they are ready to do so. Encourage children to play, draw or use other creative activities to help express themselves.
Keep socially connected. Being surrounded by supportive friends and family is the strongest protective factor, while social isolation and lack of support is a strong risk factor for poor recovery.
Avoid engaging in unhelpful activities, such as heavy alcohol or substance abuse, and high-risk activities.
Minimise ongoing stress as much as possible.
Be patient and tolerant of your own and others’ reactions. Expect that feelings of distress may linger for a number of weeks following a traumatic event, but that they will eventually pass. If children become aggressive or develop other challenging behaviours, parents should set limits as normal, but also help the child to talk about what is going on for them.
Seek help early. If parents are concerned about their own or their child’s recovery, they should seek support from a GP or a mental health professional. A professional can provide reassurance or offer treatment if required.
Access the guidelines, resources and information for practitioners and the community.