PTSD in Children & Adolescents
Philip A. Saigh, Ph.D. Professor of Psychology & Education Teachers College Columbia University
Behavioral Treatment of Child-Adolescent PTSD
I ascended quite alone to the highest pinnacle of the cathedral spire, where on standing on a platform, without anything particular to hold on to, one sees before one the boundless land. Such anxiety and pain I repeated so often until the impression became quite different to me, and I have therefore derived great advantage from these practices in travels and on great buildings where I have vied with carpenters in running over the beams of buildings (Goethe, 1770, p. 326). Goethe, J. W. Von (1770). Poetry and the truth in my own life. In R. O. Mood (1949)(Translator). Goethe’s autobiography. Washington, DC: Wiley.
The patient was sobbing and tearful, bewailing his fate, terrified of the impending examination and desperate that his condition would stop him from getting there (Malleson, 1959, p. 225).
Malleson, N. (1959). Panic and phobia: A possible method of treatment. Lancet, 1, 225-227.
The patient was advised that whenever he felt a little wave of spontaneous alarm he was not to push it aside but was to enhance it, to augment it, to try to experience it more profoundly and vividly (Malleson, 1959, p. 225). Malleson, N. (1959). Panic and phobia: A possible method of treatment. Lancet, 1, 225-227.
He practiced the exercises methodically and by the time of the examination he reported that he was almost totally unable to feel frightened. He had, as it were, exhausted affect in the whole situation. He passed the examination without apparent difficulty (Malleson, 1959, p. 225).
Malleson, N. (1959). Panic and phobia: A possible method of treatment. Lancet, 1, 225-227.
Imaginal Flooding
“A behavioral treatment based on the principle of extinction and involving prolonged exposures to highly aversive stimuli” (O’Leary & Wilson, 1977, p. 289).
O’Leary, K. D., & Wilson, T. G. (1977). Behavior Therapy: Research and Application. New York: Prentice-Hall.
Flooding vs. Systematic Desensitization “Flooding is at one end of a continuum of approach to distressing situations, at the opposite end of which is desensitization. The difference between the two is largely one of degree. The more sudden the confrontation, the more it is prolonged, and the greater the emotion that accompanies it, the more apt is the label flooding for that procedure” (Marks, 1972, p.154).
Marks, I.A. (1972). Flooding (implosion) and allied treatments. In S. Argas (Ed.), Behavior modification: Principles and clinical applications (pp.151-211). Boston, MA: Little, Brown, & Co.
10
100
Anxiety Rating State Anxiety Hours of Sleep
90 80 Mean anxiety ratings (010) obtained from the selfmonitored data, mean hours of sleep per night (08), and percentiles from the Spielberger State Anxiety Inventory (0-100).
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70
7
60
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50
5
40
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30
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20
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10
1
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0 Baseline
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Blocks of Inpatient Treatment Keane, T. M., & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50 (1), 138-140.
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Beck Depression Inventory
Zung Depression Scale
20
60
16
50 40
12
30 8
20
4
10
0
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Implosive Therapy
Wait List Control
Implosive Therapy
Spielberger Trait Anxiety Inventory
Spielberger State Anxiety Inventory 70
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30
20
Wait List Control
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10
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Implosive Therapy
Wait List Control
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Implosive Therapy
Wait List Control
Follow-Up
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.
In vitro flooding: Emile
Saigh, P. A. (1987). In vitro flooding of childhood posttraumatic stress disorder: A systematic replication. Professional School Psychology, 2, 135-146.
Pre-Treatment, Post-Treatment, and Follow-Up SUDS Ratings 15
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Scene 1 Scene 2 Scene 3 Scene 4
SUDS Rating 5
0 Pre-Treatment
Post-Treatment
Follow-Up
Saigh, P. A. (1998). Effects of flooding on memories of patients with posttraumatic stress disorder. In J. D. Bremner & C. R. Marmar (Eds.), Trauma, memory, and dissociation (pp. 285-320). American Psychiatric Association: Washington, DC.
Child and Adolescent Trauma Survey (CATS) 30 25
Total
20
Reexperiencing Avoidance
15
Hyperarousal
10 5 0
Baseline
Posttreatment
6 Month Follow-up
March, J.S., Amaya-Jackson, L., Murray, M.C., & Schulte, A. (1998). Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 585-593.
• Age range: 8-14 years • 89% met DSM-IV criteria for PTSD
• 9% medicated • 20% received counseling
4.5 4
Pre-Treatment Trauma Focused CBT
3.5 3
Pre-Treatment Child Centered
2.5
Post-Treatment Trauma Focused CBT
2 1.5
Post-Treatment Child Centered
1 0.5 0
Reexperiencing
Avoidance
Hypervigilance
K-SADS Cohen, J., Deblinger, E., Mannarino, A., & Steer, R. (2004). A multi-site randomized controlled trial for children with sexual abuse related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 393-402.
Exposure Therapy Procedures I. II. III. IV. V.
Assessment Education Intervention Debrief Re-evaluate
FLOODING SEQUENCE Phase I: Assessment Goals • Identify pathological behaviors • Identify the specific trauma-specific etiological variables • Establish baseline data to determine treatment efficacy over time Recommendation • Multiaxel- use of different sources of information (e.g., structured interviews, unstructured interviews, norm referenced self-report tests, norm referenced parent/teacher ratings, or psychophysiological reactivity) • Multimodal – Based on Lang’s tripartite model that regards anxiety as a combination of three response parameters (behavior, self-report, and psychophysiological).
Chronological Description of Trauma-Specific Events Clinical Example Involving Abducted and Tortured Boy Scene Number 1
Content
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Walking into a building while blindfolded, being questioned, accused, and listening to kidnappers argue over the merits of his execution
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Being interrogated, responding, receiving repeated blows to the head and body, and experiencing intermittent periods of isolation
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Learning that he was going to be released and not trusting the kidnappers to keep their word
Approaching the place where the abduction occurred, being stopped, forced into a car a gun point, blindfolded, and driven away
Saigh, P. A. (1987). In vitro flooding of a childhood posttraumatic stress disorder. School Psychology Review, 16, 203-211.
Phase II: Education A) State and write out treatment goals. B) Inform youth and families about all the procedures that will be used. C) Advise youth and parents that exposure is aversive and PTSD symptoms may initially increase. D) Advise that exposure therapy for child PTSD has met with positive outcomes in majority of published articles. E) Make sure that the youth and parents understand goals and procedures by asking them to paraphrase and/or write out goals and treatment description. F) Make sure that youth and parent agree to treatment. G) Inure that child participation is voluntary.
Phase III: Intervention A) Train child to identify feelings of distress and selfmonitor feelings using a subjective units of distress scale (SUDs). B) Train child to establish and maintain relaxing images. Recommend using Endemic Image Questionnaire to identify most preferred image. Hand Out C) Present an aversive (but not PTSD related) scene and ask child if he/she is able to visualize the scene.
Phase III: Intervention (cont) D) Recommend use of armchair with headrest. E) Present relaxation directions with very specific instructions involving the contraction and relaxation of different muscles. F) After 20-25 minutes assess degree of arousal (1-10 with 1 = very calm and 1 = very tense). Note: Relaxation facilitates the ability to imagine scenes (Borkovec & Sides, 1979) Borkovec, T. D., & Sides, J. (1979). The contribution of relaxation and expectance to fear reduction via graded imaginal exposure to feared stimuli. Behaviour Reaserch & Therapy, 17, 529-540.
Phase III: Intervention (cont) G) Present aversive images as based on information compiled during the Assessment Phase. 1) Start by asking youth to imagine that he/she is at the location of the traumatic event shortly before trauma occurred. 2) Ask youth to imagine the specific setting, conversation, and behaviors that occurred. 3) Present each traumatic scene is a slow and calm way. 4) Monitor SUDS every 3-5 minutes. 5) Repeat until 0 SUDs are reported on 3 consecutive occasions. 6) After 30-50 minutes of exposure, induce relaxation for 10 minutes followed by 5 minutes of endemic images.
Example of the In Vitro Imaginal Exposure Procedure with Adolescent Child Sniper Victim Therapist:
Tony: Therapist: Tony:
“Imagine that you and Robert are walking in the direction of the video store.” (15-second pause) “Imagine the cars going by.” (15-second pause) “The summer heat.” (15 second pause). “Can you do this?” “Yes.” “According to the scale that we talked about, how much does it bother you?” “A lot. I don’t like it. A 10.”
Saigh, P. A. (1989b). The use of in vitro flooding in the treatment of traumatized adolescents. Journal of Behavioral and Developmental Pediatrics, 10, 17-21.
Phase IV: Debrief 1) Ask child about cognitive and physical reactions. 2) Ask child to speak about any new material that he/she recalled. 3) Therapist and parents must be exceptionally supportive. 4) Remind parents and child that short term reactivity is normal and that the treatment works over time
Phase V: Re-evaluate • Structured and unstructured DSM interviews • Self-reports • Behavioral Avoidance Tests (BATs) • Parent/Teacher Ratings
Limitations • Aversive • Time Intensive Therapist Training Required • Not Appropriate for All Participants
Ethical Safeguards Therapist should educate traumatized youth and their parents about the actual procedures. The informed consent of children-adolescents and their parents or guardians should be obtained. Therapists should ensure that a youth’s participation is voluntary.
