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The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
Development and interventions
among trauma-affected children and
families
Raija-Leena Punamäki, Kirsi Peltonen & Esa Palosaari
University of Tampere
Prevalence of childhood trauma
Children < 16 years 1 or more trauma
 13-43% Europe
 68-71% USA
Prevalence of childhood PTSD
Meta-analysis (34 samples,2697 children)
 36% of children exposed to trauma suffered PTSD
 24% among trauma exposed adults
 No differences in PTSD according to age
Prevalence of childhood
PTSD Nature of trauma
Natural disasters
 30-50% moderate to severe symptoms
 5% -10% criteria for a full diagnosis
War and military violence
 17-80% Severe personal atrocities ->dose-effect
Accidents
 25-50% E.g. vehicle, boat and traffic, fires
Sexual or physical abuse, family violence
 3-90%, sexual trauma with high rate rates
Screening for PTSD
and other post-trauma responses
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Reliable results in using DSM-IV diagnosis
Important to get information:
Current symptoms and concerns
Attempts to managege and cope with trauma
Timing and course of symptoms
Developmental and family history
Information from both the parent/guardian and
directly children themselves
Screening for PTSD II
 A brief PTSD assessment at 1 months
after trauma among survivor families
 Parental and/or self-reports (e.g. IES-R,
CPSD-RI)
 Interviews (The Child PTSD Interview)
Comprehensive assessment
of trauma responses
 Depressive symptoms (CDI)
 Bereavement: absence and overhelming grief
(PGI)
 Excessive and generalized fears
 Increased life threat; separation anxiety, worry
about safety of family, shortened views of
future
 Somatic symptoms: headaches, stomach
aches, disturbances and changes in sleeping
patterns
PTSD in toddlers (2- 4 year olds)
 One symptom per Intrusive, Avoidance & Arousal
category of PTSD may count for clinical diagnosis
 Changes in behavior
 Repeated and ritualistic play (flashback)
 Developmental delays (language, sensomotor)
 Loss of acquired skills (language, toileting)
 New symptoms: aggression to others, separation
anxiety, fear of dark and dark of being alone
Compex & comprehensive nature of
childhood traumatization
Experiences
Neurofysiology
Sensomotor
Cognitive
•Coordination
•Timing
•Attention
•Complexity
Emotional
•Language
•Speed
•Memory
Maturation
•Problem
solving
•Attachment
Social
•Empathy
•Friendship
•Attachment
Why children differ in their
reaction to traumatic stress?
From
birth
Before
trauma
During
Trauma
After
trauma
Later
reactions
High symptom
group
Population
Traumatic
event
Low symptom
group
Protective
Vulnerability
and
and
modifying factors
risk factors
By Helen Christie
Developmental aspects I
 Children of all age are vulnerable, but react in
age-specific ways
 Each developmental stage provides both
protective self-healing processes and
vulnerabilities
 Traumatic experience may slow down or
expedite developmental transition
 The target of worries and threats age-specific
 Families respond as a system
Developmental aspects II
Uniqueness of children in traumatization :
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Personality: temperament
Age
Family relations
meanings of trauma
Cognitive capacity
Developmental concerns
New diagnosis: Developmental Trauma Disorder (DTD)
Affect regulation – emotions
 Biased; either numbing or escalating of
feelings
 Lack of synchrony between levels
(psychological/physiological)
 Fear dominates
Trauma and memory
 Traumatic
 Neutral
 Sensory & emotional
 Visual, auditory,
kinesthetic, smell, taste
 Memories unchanged
 Sensory memory easily
recalled : flashbacks
 Multiple cues for evoke
memories
 Involuntary &
uncontrollable
 The meaning is
constructed
 Can be verbalized and
presented in symbols
 Memories fade &
disappear with time
 Conscious links between
cues & memory
 Voluntary control
Symbolic processes
Traumatized play interfers recovery
 Narrow and lacks repertoire – trauma focused
 Concrete and low symbolic activity
 Themes, roles and plots are repetitious and
unchanging
 Compulsive, ritualistic features
 Lack joy and progres
 Lack of narratives and fantasy
 Absense of play is the most worrying
Social relations
 Negative interactions: scapecoting, rigid &
reversed roles
 Family secrets and silence: every
members protects the other
 Communication fragmented: ”knowing-notknowing”
 Vicious circle: good peer relations protect
mental health, but trauma exposure
deprives children from friendships
Family approach to trauma
 Family roles crystallize in the face of
danger and trauma
 Distinct roles in emotional, cognitive and
behavioral ‘share of work’
 Serves family’s survival and adaptation
 If flexible and short-living
 Prevent child development and effective
coping
 If ‘cemented’, rigid and permanent
Importance of attachment I
The first relationship with caregiver creates inner
models of:
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Whether safe place is available
How to avoid rejection
Whether to trust others and oneself
How to express distress
Whether to dare explore
Importance of attachment II
 In the first year of life: Sensory integration of
eye, movement and brain connections
 Emotional attunement and arousal
 Re-establish the circadian rythm
Main early risks:
1) Fear in mother’s eyes
2) Maternal PSTD-intrusive and dissociative
states of mind
Importance of attachment III
Attachment is a condition to survival; 4
types
 Secure: access to safe base, rich emotions and
cognitive framing
 Insecure-avoidant: Thrusts oneself, numbing
emotions and self-soothing
 Insecure-ambivalent: Clinging to adults,
overwhelming emotions, difficult to calm
 Disorganized: not clear attachment behavior
 Attachment behavior activates in face of danger
and threat
Interventions
RESILIENCEbased
preventive
interventions:
By enhancing
A the B is
avoided
B
Mental Health Problems
-maladaptive processes
SYMPTOMbased
interventions:
By beating B
the A is
achieved
A
Optimal Development
-basic processes
Preventive interventions
in war & military violence
Intervention & Treatment
Acute symptoms of depression,
aggression, PTSD & dissociation
•CBT, EMDR, Family therapy
Prevention
•Resiliency groups
•Psychoeducational
•Family involvement
Children at risk: wounded, homeless, poor,
earlier trauma, family problems,
low threshold temperement, poor coping
Mental Health Promotion
•Knowledge, agency & child rights
•School, healthcare, civic participation
•National politics, strategies, rights
(WHO, 2001,Jordans, 2010)
Trauma-exposed children &
families with no high risk
factors & vulnerabilities
Interventions
Intervention packages such as
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CBT/ TF-CBT
EMDR
Interpersonal group psychotherapy
Teaching Recovery Tecniques
Health to Peace Initiatives
Critical Incident Stress Management
Narrative Exposure Therapy
The components/modules/elements/
tools based on knowledge of risk and protective factors
Teaching Recovery Techniques as
an example of GBT approach
Arousal
 Own experiences and learning about
own body responses
 Muscular relaxation and breathing tension and release, inhaling - exhaling
 Guided imagery to safe place
 Self statements to reduce helplessness
 Explanation of events > control arousal
Intrusive symptoms
 Positive feedback frame, positive counterimages, lock away,
 Corresponding techniques for
auditory,olfactory (smell), kinesthetic (body),
touching
 Dreamwork
 Introduce a protector whom child trusts (helper
both real & fantasy)
 Change dreamer position: victim – hero, active passive, helped-helpe
Avoidance symptoms
 Graded exposure – until habituation
 use the same tools as with intrusion
 imaginal
 drawing, writing, talking
 Safety creation and self-regulation training
 Psychoeducative: give information &
normalize & educate
 Parallell story (indirect) & description of PTSD
(direct)
 Own unique experiences
Guidelines including children I
 National Institute for Clinical Excellence
(NICE) 2005
 American Academy of Child and
Adolescent Psychiatry, 2003
 Psychological First Aid: field operation
Guide. National Child Traumatic Stress
Network,NCPTSD
(www.ncptsd.va.gov/pfa/PFA_V2.pdf)
Guidelines including children II
 AAP-disaster-prepadness Web
www.aapp.org/terrorism
 National Centre for Children Exposed to
Violence Yale Child Study Center
www.nccev.org
 IASC Guidelines on Mental Health and
Psychosocial Support in Emergency
Settings
 IMPACT The Netherland
Evidence base for treatment of
PTSD
I Single-incident trauma
 The most common treatments: CBT,
EMDR,and play therapy
 CBT use manualized, reproducible treatment,
group and individual, school-based & clinical
 EMDR treatments typically short &individual
 Most studies show statistically significant
improvement but lack methodological rigor
II Sexual abuse
 10 studies on efficacy of group therapy for
sexually abused girls
 Treatment types: CBT, psychoeducational,
psychodrama, eclectic, humanistic
 Only 4 utilized comparison or control groups
 Psychodrama groups: decrease in depressive
symptoms,
 CBT & eclectic groups (with graduated
exposure): decrease in PTSD
III War- and military trauma
 16 effectiveness studies
 Only 4 randomized control studies (RCT)
 Common treatment: CBT, focusing on
biased cognitive processes and
negative emotions
 Self-reported results: PTSD and
depression decreased
Key guidelines
 All structured therapy more effective
than non-therapy with children with
PTSD
 Scientific evidence available on Trauma
Focused CBT and EMDR
 No evidence on other systematic
treatments e.g. play therapy, dynamic
therapies (no comparison studies
available)
Conclusions
 Developmental science: sensitive &
transition periods
 Intervention & Prevention science: tailored
& evidence based interventions with
specific focus