Be Proactive in Preschool PTSD

Article excerpt

NEW ORLEANS -- Preschool children with posttraumatic stress disorder can be diagnosed effectively when treated with trauma-focused cognitive-behavioral therapy, according to preliminary study results.

It is important to take a proactive approach when treating young children with PTSD, Dr. Michael S. Scheeringa said a conference on posttraumatic stress in preschool children sponsored by Tulane University.

"Preschool children with PTSD do not improve naturalistically or 'grow out of it,'" said Dr. Scheeringa of the department of psychiatry and neurology at Tulane in New Orleans. Nor do these children respond to unstructured community treatment-as-usual.

However, a manualized assessment and 12-session CBT program developed by Dr. Scheeringa and his colleagues appears to be effective, a preliminary analysis shows.

Because the program is based in New Orleans, a large proportion of the cohort suffered PTSD as a result of Hurricane Katrina, but the program was started be fore the hurricane and includes individuals with PTSD from any stimulus. The program includes about 75 children aged 3-6 years.

In addition to developing PTSD in response to natural and man-made disasters, children often develop PTSD after vehicular accidents, attacks by animals, sexual or physical abuse, accidental burning, near-drowning, and medical procedures, and after witnessing violence.

The general principle is to diagnose PTSD through interviews with the primary caregiver (usually the mother), and to treat the child in 12 structured sessions that ultimately desensitize the child to trauma reminders. The interviewer (who may or may not be the therapist) uses a structured form to elicit information about the event and the child's key symptoms.

If PTSD is diagnosed, the child begins 12 sessions of weekly CBT treatments lasting 45-90 minutes. During most sessions, the therapist works first with the child (while the mother observes the session on closed-circuit television), and then with the mother. The mother provides feedback and interpretation as needed, is given instructions for "homework" with her child, and provides a weekly evaluation of behavior changes since the last visit.

Using Caregiver Interviews

The diagnosis of PTSD in children is made using a modified version of the DSM-IV criteria for PTSD in adults. The modified version, based on observable behaviors, is sensitive to developmental differences in young children, Dr. Sheeringa said.

"A problem in trying to diagnose young children is that they are barely verbal. The DSM-IV criteria contain many items that concern subjective experiences, which preschool children cannot really articulate," he explained. "We made the items more behaviorally anchored and objective."

A scoring algorithm is used to make the diagnosis. While a variety of symptoms are possible, the most frequent are the occurrence of psychological distress reminders, physiological distress reminders, intrusive recollections, and new aggressive behaviors.

"We must be able to read nonverbal cues and to have the mother's interpretation," he added. "Many anxiety reactions are subtle, but mothers can usually tell."

Trauma-Focused CBT

The idea behind trauma-focused CBT is to help children produce a narrative of the traumatic experience, identify their fears, learn to relax in the face of them, and become desensitized to distress reminders. …