**8.3.2 Direct exploration/discussion of the traumatic experience**

There is a strong clinical consensus that addressing the traumatic experience, regardless of the specific methodology, is the core ingredient of effective treatment for PTSD in children. Exposure to the traumatic memories and feared reminders under safe circumstances serves to decondition these associations and reduce the use of avoidance coping. Safety does not just mean that the child has developed trust in the therapy environment. Most important is that the child is in a safe and supportive living situation. It is inappropriate and possibly dangerous to encourage children to engage in trauma-focused therapy when they are still at risk.

#### **1. Exposure techniques**

For children, gradual exposure techniques are recommended. These techniques gradually expose a child to thoughts, memories and other cues or reminders of the traumatic experience. When children can tolerate the memories without significant emotional distress they are less likely to resort to avoidant behaviors. The goal is that when children face trauma-related memories or cues, more adaptive responses like feelings of control, mastery, pride and courage will gradually replace fearful/anxious responses. There are a variety of different exposure techniques used to elicit children's participation and provide them with a sense of control. It is important, regardless of the exposure technique used, that a therapist clearly presents to the child the rationale behind exposure. No matter how well a therapist prefaces the exposure procedure, resistance by children may be an initial reaction to this therapeutic approach because significant emotional and physical discomfort may be experienced. For this reason it is important to inform caregivers and children that some increased symptoms are common responses at first. In order to attain relief in the long run, some level of anxiety or distress may need to be endured while confronting fears. Preparing caregivers for children's possible negative reactions to therapy will increase cooperation and compliance.

Gradual exposure techniques are primarily designed to be useful when post-traumatic stress symptoms are present. Children who do not exhibit fear or anxiety may not need extensive focus on the traumatic experience itself. Emotions such as embarrassment, shame, or sadness associated with recalling the event may be reasonable reactions or may be better addressed through a focus on attributions and perceptions about the event. A child's symptoms may worsen if a therapist insists upon constantly talking about the traumatic memories or events. There is currently no evidence that talking about the details of what happened is necessary to recovery in children.

In sum, a child's capacity to talk about the trauma without experiencing significant distress or use of avoidance coping is an indication of successful emotional processing. However, a child's unwillingness to talk about it may not be because of post-traumatic stress reaction but instead a legitimate response( e.g., tired of talking about it, embarrassed). In these situations, various indirect methods of addressing trauma-related issues like art, book making and play techniques may be more useful. Mediums such as clay or PLAY-DOH can also facilitate children in depicting different aspects of the traumatic event.

#### **2. Strategies for gradual exposure**

16 Post Traumatic Stress Disorders in a Global Context

reassuring thoughts (e.g., I am strong, I can handle this situation, I am not really in danger

There is a strong clinical consensus that addressing the traumatic experience, regardless of the specific methodology, is the core ingredient of effective treatment for PTSD in children. Exposure to the traumatic memories and feared reminders under safe circumstances serves to decondition these associations and reduce the use of avoidance coping. Safety does not just mean that the child has developed trust in the therapy environment. Most important is that the child is in a safe and supportive living situation. It is inappropriate and possibly dangerous to encourage children to engage in trauma-focused therapy when they are still at

For children, gradual exposure techniques are recommended. These techniques gradually expose a child to thoughts, memories and other cues or reminders of the traumatic experience. When children can tolerate the memories without significant emotional distress they are less likely to resort to avoidant behaviors. The goal is that when children face trauma-related memories or cues, more adaptive responses like feelings of control, mastery, pride and courage will gradually replace fearful/anxious responses. There are a variety of different exposure techniques used to elicit children's participation and provide them with a sense of control. It is important, regardless of the exposure technique used, that a therapist clearly presents to the child the rationale behind exposure. No matter how well a therapist prefaces the exposure procedure, resistance by children may be an initial reaction to this therapeutic approach because significant emotional and physical discomfort may be experienced. For this reason it is important to inform caregivers and children that some increased symptoms are common responses at first. In order to attain relief in the long run, some level of anxiety or distress may need to be endured while confronting fears. Preparing caregivers for children's possible negative reactions to therapy will increase cooperation and

Gradual exposure techniques are primarily designed to be useful when post-traumatic stress symptoms are present. Children who do not exhibit fear or anxiety may not need extensive focus on the traumatic experience itself. Emotions such as embarrassment, shame, or sadness associated with recalling the event may be reasonable reactions or may be better addressed through a focus on attributions and perceptions about the event. A child's symptoms may worsen if a therapist insists upon constantly talking about the traumatic memories or events. There is currently no evidence that talking about the details of what

In sum, a child's capacity to talk about the trauma without experiencing significant distress or use of avoidance coping is an indication of successful emotional processing. However, a child's unwillingness to talk about it may not be because of post-traumatic stress reaction but instead a legitimate response( e.g., tired of talking about it, embarrassed). In these situations, various indirect methods of addressing trauma-related issues like art, book making and play techniques may be more useful. Mediums such as clay or PLAY-DOH can also facilitate children in depicting different aspects of the

**8.3.2 Direct exploration/discussion of the traumatic experience** 

now).

risk.

compliance.

traumatic event.

happened is necessary to recovery in children.

**1. Exposure techniques** 

The process of gradual exposure begins by confronting the least anxiety provoking stimuli first and works its way through more distressing stimuli (e.g. the child might identify hearing the word "rape" as upsetting, but less so than remembering what actually happened). Talking, writing, speaking into a tape-recorder, responding to "mock interview," or drawing a picture with explanation can be used to accomplish exposure. Role-playing, puppet play, and doll-play can be helpful especially with young children. Some children may choose to create books, poems or songs about their traumatic experiences.

**Direct Exposure:** This method is appropriate for an older child with good visualization skills. The child is asked to recall specific sensory details of traumatic event, focusing on visual memories. Fantasy is discouraged when recalling the account. This approach should not be confused with hypnotic suggestion or guided imagery. For example, a therapist asks the child to close her eyes (if comfortable) and recall a scene of the traumatic event as if she were there. The therapist poses some specific questions to help the child stay focused like, "describe the room you were in, the time of day, or what the child smells, hears, feels, and thinks at the time." Too many questions may interfere with the child's visualization. The therapist should only ask as many questions as they feel necessary to help the child visualize the scene. The session should not end until the child's anxiety level has decreased or coping techniques have been used to help the child regain a sense of calmness.

**In Vivo Exposure**: this technique is most used in the later stages of the exposure therapy. The child is helped to identify situations for in vivo practice of exposure to fear inducing stimuli. This should occur in a situation where there is no actual danger or risk thus enabling the child to experience mastery and competence (e.g., confronting fear of the dark by turning off the light during the session, sleeping alone in her room, walking to school).

### **8.3.3 Exploring and correcting inaccuate attributions**

Most interventions for traumatized children also involve the evaluation of cognitive assumptions children may have made relating the traumatic experience. Children make sense of their experiences in the world by developing belief systems. Like adults, most children have a generally positive view of themselves, other people and the world. Being the victim of a traumatic stress situation can conflict with those beliefs. In order to resolve the conflict, children may change their ideas and thoughts about themselves and others or develop inaccurate, distorted and confused beliefs about the trauma[]. Examples of faulty attributions are "Nothing is safe anymore", "It was all my fault", "I must be a bad person for this to have happened." For some children, unfortunately, a traumatic event can serve to confirm already existing negative perceptions. When treating children with PTSD, it is important to explore and correct these distorted thought patterns related to the trauma. The maladaptive assumptions or beliefs must first be identified. This means it is important initially to allow children to express beliefs even though they may be inaccurate (e.g. self blame-"I asked for it because I went to his house" – or thinking that drinking caused the offender to abuse). Then through various therapeutic exercised, like role playing, telling stories, and providing corrective feedback, these negative or inaccurate thoughts can be disputed. The therapist helps the child generate positive thoughts to replace negative distorted ones instead of just telling children what they should think. With younger children, play therapy using toys and dolls, art materials, and games may be a more effective approach to explore their inaccurate attributions.

Post Traumatic Stress Disorder – An Overview 19

and effectiveness in treating both depressive and anxiety disorders, serotonin reuptake inhibitors (SSRIs) are often he first psychotropic medications selected for treating pediatric PTSD. Imipramine also is often chosen to treat children suffering from co-morbid panic

After any disaster, children are most afraid that the event will recur, that they or someone they love will be hurt or killed, and that they may be separated from those they love and will be left alone. Suggested strategies for helping children cope with trauma include the

 Children younger than 6 years of age should not be exposed to TV videotape coverage of the attacks (or any television coverage of war or prolonged violence), and the

 Encourage children to express their feelings about what has happened. Parents should share their feelings with them. Regressive behaviors (e.g., thumb sucking, night awakenings, and bed-wetting) may occur in response to traumatic events. Parents should know not to punish or scold their child for these types of behaviors, but instead

 Children need to be frequently reassured that they are safe and that they are loved. Parents should be encouraged to be honest with their children about what has occurred and to provide facts about what has happened. Children usually know when something

Encourage parents to try to return the child and the family to a normal routine as soon

Encourage parents to spend extra time with the child, especially doing something fun

 Encourage parents to talk with teachers, baby-sitters, and day care providers and others who may be with the child so that they will understand how the child has been affected. Watch for signs of repetitive play in which children re-enact all or part of the disaster. Although excessive reenactment of a traumatic experience may be a warning sign, this

Encourage children who are not able to articulate their feelings to express themselves

Remind parents to praise and recognize responsible behavior and reassure children that

Events that are threatening to life or bodily integrity will produce traumatic stress in its victim. This is a normal, adaptive response of the mind and body to protect the individual by preparing him to respond to the the threat by fighting or fleeing. If the fight or flight is successful, the traumatic stress will usually be released or dissipated allowing the victim to return to a normal level of functioning. PTSD develops: when fight or flight is not possible;

 Remember the importance of touch. A hug can reassure children that they are loved. Each family should review safety procedures so children will be prepared the next time

viewing time allowed for older children should be limited.

as possible. This will help provide a sense of security and safety.

behavior is an appropriate form of expression of emotions.

their feelings are normal in response to an abnormal situation.

to try to help the child put their feelings into words.

symptoms.

following[]:

**Helping Children Cope With Trauma** 

is being "sugar-coated."

or relaxing for both of them.

an emergency situation occurs.

**9. Conclusion** 

through coloring, drawing, and painting.

#### **1. Strategies for correcting cognitive distortions**

**Cognitive coping triangle:** The therapist facilitates discussion with the child about the interrelationship among thoughts, feelings, and behavior starting with a general discussion and moving toward trauma-specific examples. Using examples from every-day life is a useful way of conveying these connections and then relating them to post-traumatic symptoms. For example, the child is presented with a negative and a positive scenario involving peers. For each situation, the child is asked what his/her thoughts, feelings and behaviors would be. The child practices identifying the emotions generated by different thoughts and then identifying thoughts underlying emotions. The therapist helps the child work through examples modeling the process and pointing out how different thoughts about the same situation can result in very different feelings and behaviors. This process may be difficult. Visual aids like pencil and paper, a chalkboard, or a dry-erase board are used to help work through fictitious examples until the child understands the problem triangle concept.

**Disputing negative/unproductive-thoughts:** The therapist explains that changing distressing thoughts and emotions is a skill that can be gradually acquired through practice. The therapist stresses that negative thoughts are not necessarily valid or permanent. The therapist presents fictitious examples through storytelling in which the child practices substituting positive replacement thoughts for negative unhealthy ones. For example, the therapist may use the "Best Friend Role Play" in which the child role plays with the therapist, (or puppet, empty chair, etc.) imagining that their best friend is having negative thoughts and their job is to convince the best friend that these thoughts are NOT true. It is important to distinguish between the personal thoughts and feelings of the therapist and the role that they are playing during these exercises. For younger children, the use of a puppet reinforces the idea that they are engaged in a game and distinguishes the character's beliefs in the role-play from the therapist's beliefs.

**Generating positive self statements:** The therapist teaches the child a series of positive selfstatements that can replace negative dysfunctional thoughts. Children's self-statements are made to fit their individual difficulties. For example, a child with low self esteem and poor self-image may be encouraged to say, "I am just as good as other kids" or generate reasons why they are special. A withdrawn and/or fearful child may be taught to say, "It's fun trying new things or I am very brave sometimes."

### **2. Pharmacotherapy**

Preliminary studies have shown that some children with PTSD present with physiologic abnormalities much like those seen in adults with PTSD. Even though randomized trials have not yet been conducted, preliminary reports have prompted clinicians to sue a variety of medication with children suffering from PTSD symptoms and associated symptoms of depression or panic. The psychopharmacological agents that have been recommended include propranol, carbamazapine, clonidine, and antidepressants. Most often these medications are not considered the primary intervention but prescribed in conjunction with psychotherapy. Research on psychopharmacological treatments for children with PTSD have revealed that certain psychotropic medications have significantly reduced reexperiencing symptoms like nightmares and other PTSD related symptoms in uncontrolled clinical trials[]. As a general practice, "medication should be selected on the basis of established practice in treating the co-morbid condition (e.g., antidepressants for children with prominent depressive symptoms)". Due to their favorable side effect profile

**Cognitive coping triangle:** The therapist facilitates discussion with the child about the interrelationship among thoughts, feelings, and behavior starting with a general discussion and moving toward trauma-specific examples. Using examples from every-day life is a useful way of conveying these connections and then relating them to post-traumatic symptoms. For example, the child is presented with a negative and a positive scenario involving peers. For each situation, the child is asked what his/her thoughts, feelings and behaviors would be. The child practices identifying the emotions generated by different thoughts and then identifying thoughts underlying emotions. The therapist helps the child work through examples modeling the process and pointing out how different thoughts about the same situation can result in very different feelings and behaviors. This process may be difficult. Visual aids like pencil and paper, a chalkboard, or a dry-erase board are used to help work through fictitious examples until the child understands the problem

**Disputing negative/unproductive-thoughts:** The therapist explains that changing distressing thoughts and emotions is a skill that can be gradually acquired through practice. The therapist stresses that negative thoughts are not necessarily valid or permanent. The therapist presents fictitious examples through storytelling in which the child practices substituting positive replacement thoughts for negative unhealthy ones. For example, the therapist may use the "Best Friend Role Play" in which the child role plays with the therapist, (or puppet, empty chair, etc.) imagining that their best friend is having negative thoughts and their job is to convince the best friend that these thoughts are NOT true. It is important to distinguish between the personal thoughts and feelings of the therapist and the role that they are playing during these exercises. For younger children, the use of a puppet reinforces the idea that they are engaged in a game and distinguishes the character's beliefs

**Generating positive self statements:** The therapist teaches the child a series of positive selfstatements that can replace negative dysfunctional thoughts. Children's self-statements are made to fit their individual difficulties. For example, a child with low self esteem and poor self-image may be encouraged to say, "I am just as good as other kids" or generate reasons why they are special. A withdrawn and/or fearful child may be taught to say, "It's fun

Preliminary studies have shown that some children with PTSD present with physiologic abnormalities much like those seen in adults with PTSD. Even though randomized trials have not yet been conducted, preliminary reports have prompted clinicians to sue a variety of medication with children suffering from PTSD symptoms and associated symptoms of depression or panic. The psychopharmacological agents that have been recommended include propranol, carbamazapine, clonidine, and antidepressants. Most often these medications are not considered the primary intervention but prescribed in conjunction with psychotherapy. Research on psychopharmacological treatments for children with PTSD have revealed that certain psychotropic medications have significantly reduced reexperiencing symptoms like nightmares and other PTSD related symptoms in uncontrolled clinical trials[]. As a general practice, "medication should be selected on the basis of established practice in treating the co-morbid condition (e.g., antidepressants for children with prominent depressive symptoms)". Due to their favorable side effect profile

**1. Strategies for correcting cognitive distortions** 

in the role-play from the therapist's beliefs.

trying new things or I am very brave sometimes."

triangle concept.

**2. Pharmacotherapy** 

and effectiveness in treating both depressive and anxiety disorders, serotonin reuptake inhibitors (SSRIs) are often he first psychotropic medications selected for treating pediatric PTSD. Imipramine also is often chosen to treat children suffering from co-morbid panic symptoms.
