Academic journal article Journal of Cognitive Psychotherapy

Developmental Considerations in the Use of Cognitive Therapy for Posttraumtic Stress Disorder

Academic journal article Journal of Cognitive Psychotherapy

Developmental Considerations in the Use of Cognitive Therapy for Posttraumtic Stress Disorder

Article excerpt

This article discusses empirical support for cognitive behavioral therapy with children and adolescents experiencing posttraumatic stress disorder (PTSD) symptoms. Developmental features influencing the presentation of PTSD symptoms include age-related differences in arousal modulation, cause and effect reasoning, language and conceptual skills, and social information processing. Basic cognitive behavioral procedures for treating PTSD in children and adolescents include coping skills training, exposure to traumarelated stimuli, cognitive restructuring, and education and information giving. These procedures must be adapted to match developmental capabilities in language and conceptual skills, emotion regulation and coping skills, and memory. Family, contextual influences, and comorbidity should be evaluated and included in treatment planning. When indicated, treatment of PTSD should be imbedded in a broader conceptualization of the child or adolescent's adaptive functioning, comorbid conditions, and caretaking environment.

Cognitive symptoms feature prominently in Posttraumatic Stress Disorder (PTSD). These include positive symptoms, such as recurrent, intrusive trauma-related memories or dreams, but also negative symptoms indicating a numbing of general responsiveness (e.g., feelings of detachment, selective amnesia for trauma events) and cognitive symptoms related to overarousal (e.g., hypervigilance, poor concentration) (American Psychiatric Association, 1994). There is ample evidence that many children and adolescents develop significant symptoms of PTSD following severely traumatic events, although debate remains over age-related manifestations of the disorder (American Academy of Child and Adolescent Psychiatry, 1998; Vernberg & Varela, 2001; Vogel & Vernberg, 1993). Recent reviews argue that cognitive behavioral treatments for PTSD have garnered the greatest research support as an evidence-based approach, although the need remains for further study via randomized, controlled trials (Cohen, Mannarino, Berliner, & Deblinger, 2000; Saywitz, Mannarino, Berliner, & Cohen, 2000; Smith, Perrin, & Yule, 1999). Developmental considerations in the use of cognitive behavioral approaches for PTSD continue to be important issues to be articulated and evaluated systematically.

Developmental Issues and Posttraumatic Stress Disorder Symptoms

To summarize developmental issues, it may be helpful to consider the major elements of PTSD in order. The first element involves exposure to a traumatic event involving actual or threatened death, serious injury, or violation of bodily integrity. To meet diagnostic criteria, the person's response to exposure must include intense, overwhelming emotions (e.g., fear, horror) or thoughts (e.g., helplessness). For children, these intense emotions or thoughts may be inferred through disorganized or agitated behavior. Several developmental considerations influence children's encoding and interpretation of traumatic exposure. The threshold and tolerance for arousal increases gradually with age. Control over the startle reflex matures gradually during childhood. Thus, younger children may experience overwhelming emotions or thoughts more readily, especially when the traumatic event involves pain or startle-producing stimuli such as loud noises (Cole & Putnam, 1992). Age influences the ability to attend to multiple dimensions of experience and to understand accurately cause and effect relationships. Children tend to attend idiosyncratically or selectively to signals of threat during trauma exposure, and to attach causal significance to temporally related but incidental stimuli. Children also depend heavily on attachment figures for emotion regulation and interpretations of potential danger cues (Bowlby, 1979). The reactions of caregivers at the time of exposure likely influence children's interpretations of trauma experiences, or, in the event of a caregiver's extreme reactions to threat, may be the most salient aspect of a child's traumatic exposure (Scheeringa, Zeanah, Drell, & Larrieu, 1995). …

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