Post-Traumatic Stress Disorder (PTSD) – Pediatrics

Although post-traumatic stress disorder (PTSD) first appeared in the DSM-III in the 1980s from the symptoms displayed by Vietnam veterans in the US, there has been an increased recognition that children can develop PTSD due to trauma. Exposure to traumatic stressors such as violent crime, sexual abuse, natural disasters, and war can cause children to develop PTSD.¹  Most of the time, children generally recover from such events, however, some may experience severe stress that affects them long-term. When children develop long-term symptoms longer than one month from these stressors which interfere with daily activities and relationships, they may be diagnosed with PTSD.²  Around 40% of high school students have experienced domestic or community violence with 3-6% having PTSD.^3 4  The recognition and treatment of PTSD in children and adolescents is important as the symptoms can interfere with physical, cognitive, and emotional development.⁵ 

Causes

• Physical, sexual, and/or emotional abuse
• Being a victim or witness to a violent crime or war
• Serious illness or death of a family member or friend
• Natural or manmade disasters
• Car accidents² 

Symptoms

PTSD symptoms may look different in children than in adults. Children are more likely to show signs of PTSD during play and teenagers may be more impulsive.⁶ 

• Reliving an event over and over
• Nightmares
• Sleep difficulty
• Becoming very upset when something causes memories of the event
• Lack of positive emotions
• Intense ongoing fear or sadness
• Irritability
• Angry outbursts
• Constantly looking for possible threats
• Easily startled
• Acting helpless, hopeless, withdrawn
• Denying that an event happened
• Feeling numb
• Avoiding places or people associated with the event² 
• Diminished interest or participation in play⁷ 

Rule-Out

• Attention-deficit Hyperactivity Disorder (ADHD) – due to symptoms of restlessness, being fidgety or having trouble paying attention² 

Outcome Measures

• Candian Occupational Performance Measure (COPM) ⁸ 
• Sensory Profile – participants with PTS symptoms may have sensory sensitivity with hypersensitivity, be sensation-avoiding, or have low registration.⁹ 

Treatment

• Individual, group, or family
• Medication to deal with agitation, anxiety, or depression¹⁰ 
• Cognitive-Behavioral Therapy (CBT) – most effective approach for treating children. Often involves training and caregivers as well.
  • Trauma-Focused CBT (TF-CBT) – involves talking about the memory of the trauma and includes techniques to help lower worry and stress by becoming more assertive and learning to change thoughts or beliefs bout the trauma not being correct or true.
• Psychological First Aid (PFA) / Crisis Management – used in school-aged children and teens who have been through violence. PFA can be used in schools and traditional settings. PFA involves providing support and letting clients now their reactions are normal. They learn calming and problem-solving skills. Caregivers learn to deal with changes in the client’s feelings and behaviors.
• Play Therapy – used to treat younger children with PTSD who are not able to deal with the trauma directly. Therapists can use games, drawings, and other techniques to help process the traumatic memories.
• Other treatments:
  • Eye movement desensitization and reprocessing (EDMR)
  • Special treatments for sexual behaviors, extreme behavior, or drug and alcohol abuse⁶ 

Occupational Therapy

• Frames of reference:
  • Cognitive-Behavioral FOR¹¹ 
  • Coping FOR¹² 
  • Canadian Model of Occupational Performance and Engagement (CMOP-E) ⁸ 
  • Model of Human Occupation (MOHO) ¹³ 
• Restore habits and engagement in meaningful occupations through mastery and adaptation to life events.¹⁴ 
• In school settings, the OT practitioner consults and collaborates with the multidisciplinary team, analyzes environments, tasks, and routines, and may provide direct occupational therapy with a trauma-informed sensory-based approach.
  • Observe the student for limitations to participation in school.
  • Perform a thorough evaluation of the student – sensory processing, triggers, dysregulation, strengths.
  • Determine participation-based goals.
  • Individualize each plan to the student’s needs and strengths.
  • Work collaboratively with the team to guide a trauma-informed approach.
  • Help provide safety by creating structure.¹⁵ 
  • Modify the environment, e.g., lighting, sound levels, other triggering stimuli.¹⁶ 
  • Use outcome measures or monitor the effectiveness of interventions, e.g., sensory diet.
  • Promote mastery and problem-solving skills.¹⁷ 
  • Promote engagement in occupations, e.g., play.
  • Help to develop a positive self-image.¹⁸ 
• Provide a safe and secure environment for the client.
• Develop a therapeutic relationship with the client, which may be challenging for particular ethnic and racial minority groups due to distrust associated with racism and poverty.
• Address cognitive distortions related to the trauma, e.g., self-blame.
• Help develop an adaptive understanding and perception of the trauma.
• Draw on existing strengths of and resources of the child, their family, and community.
• Address the impact of PTSD symptoms on everyday occupations, e.g., play.
• Provide education about trauma reactions.
• Provide hope for recovery.
• Help children, families, and communities return to or create normal roles and routines.
• Provide care that is consistent with the child’s level of need.
• Follow and respect confidential and privacy issues.
• Prevent and address burnout for the OT/COTA.¹⁹ 
• Develop and promote programs for prevention, e.g., bullying, child maltreatment, youth violence.² 

EBP

• The Alert Program has been found to benefit children with social, emotional, and behavioral difficulties by monitoring, maintaining, and changing alertness level that are appropriate to a situation or task.²⁰ 
• The “use of play and expressive occupational workshops demonstrates the power of occupation and the value of occupational therapy intervention in helping children to successfully express and process traumatic emotions.”²¹ 
• Breathing or relaxation exercises,
• Minimizing hyperarousal from PTSD symptoms with self-regulation, yoga, mindfulness meditation, and aerobic exercise may be helpful¹³ 
• Storytelling using therapeutic stories and children’s stories may be used within group therapy to elicit discussion and possible role play.²² 

Don’ts of Trauma-Informed Care (TIC)

Principles: safety, collaboration, empowerment, trustworthiness, transparency, peer support, culture/historical/gender issues, choice

• Don’t ask “what is wrong with you?”
• Don’t assume pronouns based on name or appearance.
• Don’t assume that clients will be willing to do or say what you ask them to.
• Don’t provide training only for certain staff based on their title or role.
• Don’t ignore the pervasiveness of trauma.
• Don’t ignore trauma-related needs.
• Don’t ignore things that you have no control over.
• Don’t automatically attribute challenging behaviors to static personality traits.
• Don’t diminish historical context.
• Don’t forget that clients may be re-traumatized by telling their story or providing information.
• Don’t assume that clients cannot change.²³ 
• Don’t give false hope.
• Don’t exhibit reactive or escapist behavior.
• Don’t blame the child.
• Don’t close off communication.²⁴ 

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