Discussion: Symptoms of Posttraumatic Stress Disorder

Studies estimate that between 15% and 43% of girls and 14% and 43% of boys will experience at least one traumatic event. Out of those children who experience trauma, 3%–15% of girls and 1%–6% of boys will develop posttraumatic stress disorder (PTSD) (Erk, 2008, p. 246). Risk factors for the development of PTSD include the severity of the trauma, parental reactions to the trauma, the amount of parental support given to a child or adolescent, and how close the child or adolescent is to the trauma (Prout & Brown, 2007, p. 231). Often, young children show signs of PTSD in their play. For example, children who experienced sexual trauma may act out the trauma by using dolls. Adolescents’ PTSD symptoms often mirror those of adults. There are many treatment options for children and adolescents with PTSD, and no matter the type of treatment you choose, it is important that the child or adolescent you treat feels at ease when working with clinicians.
For this Discussion, select a current traumatic event in the news involving children and/or adolescents. Consider possible PTSD symptoms commonly seen with this type of trauma. Also, consider how you might be affected if you were to work with a child or adolescent who was traumatized by this event.
With these thoughts in mind:
By Day 3
Post a brief description of the traumatic event you selected. Then, describe two symptoms of posttraumatic stress disorder (PTSD) commonly seen with this type of trauma and explain why. Be specific. Finally, explain one way you might be affected when working with children or adolescents who have experienced this traumatic event and why.

Required Readings
Chasser, Y. M. (2016). Profiles of youths with PTSD and addiction. Journal of Child & Adolescent Substance Abuse, 25(5), 448-454.
Herrera, A. V., Benjet, C., Méndez, E., Casanova, L., & Medina- Mora, M. E. (2017). How mental health interviews conducted alone, in the presence of an adult, a child or both affects adolescents’ reporting of psychological symptoms and risky behaviors. Journal of Youth and Adolescence, 46(2), 417-428.
Culver, L.M., McKinney, B., & Paradise, L.V. (2011) Mental health professionals’ experiences of vicarious traumatization in post-hurricane katrina new orleans. Journal of Loss and Trauma, 16, 33-42.
Putman, S. E. (2009). The monsters in my head: Posttraumatic stress disorder and the child survivor of sexual abuse. Journal of Counseling & Development, 87(1), 80–89.
As you review this article, consider PTSD in children and adolescents. Focus on treatment and implications for clinicians.
Document: DSM-5 Bridge Document: Trauma, Stress, and Adjustment (PDF)
Use this document to guide your understanding of trauma, stress, and adjustment for this week’s Discussion.
Stover, C. S., Hahn, H., Im, J. J. Y., & Berkowitz, S. (2010). Agreement of parent and child reports of trauma exposure and symptoms in the early aftermath of a traumatic event. Psychological Trauma: Theory, Research, Practice, and Policy, 2(3), 159–168.
As you review this article, focus on how improving parental understanding of child and/or adolescent trauma might impact treatment outcomes.
Required Media
Laureate Education (Producer). (2014i). Trauma [Video file]. Baltimore, MD: Author.

Note:  The approximate length of this media piece is 31 minutes.

In this media program, Drs. John Sommers-Flanagan and Eliana Gil discuss the difference when working with children and adolescent clients who have experienced trauma. Focus on the techniques used when working with children and adolescent clients.

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Transcript for the video
Trauma Program Transcript [MUSIC PLAYING] NARRATOR: Trauma is not restricted to age groups or gender. However, helping children and adolescent clients who experience trauma is very different than helping adults. Doctors John Sommers-Flanagan and Eliana Gil explain the difference in working with children and adolescent clients who have experienced trauma, how to assess them, and what techniques they have used to address the trauma. JOHN SOMMERS-FLANAGAN: The Diagnostic and Statistical Manual refers to the core symptoms of PTSD, or post-traumatic stress disorder, as exposure to a traumatic event and intrusive recollection of that event and numbing and avoidance experienced by the individual and kind of a hyper-arousal. And so I’m wondering about that presentation as it initiates the referral process. And in your work, Eliana, because I know you work a lot with traumatic problems in youth, I wonder how you see those symptoms as they present to you within an initial referral. ELIANA GIL: It’s an interesting constellation of symptoms, because often you have the hyper-arousal. Kids are actually having intrusive thoughts or nightmares of very specific pictures of things that have happened to them and scared them. Kids also are able to do, through play, some of the reenactments of things that have occurred. And so looking at it from far way, you look at the play, and you think, wow, what is that about? Is that pretend? Is that fantasy? Or is that something that the child is actually experiencing? But the play is very unusual. So there’s actually a lot of literature on what’s called post-trauma play, which tends to be very different than generic play, in that it’s very literal. It’s very robotic. Kids are really engaged in the play, as they usually are, like with pretend talk or role-play or something like that. And it’s play that’s very repetitive. And as kids do it, their affect is very guarded. And when you encounter post-trauma play, you know that something is very different here and that this is really a way that kids begin to show that they’re living in the climate of the trauma. So definitely we see kids who come in because there’s intrusive thoughts or memories, through nightmares in particular. They’re waking up with night terrors. And we see the post-trauma play that the kids are doing at home or sometimes in a school setting. And then also, there is the child who appears with this very, very 
flat affect, where they’re disengaged, they don’t do the regular things that kids do, they don’t play, they’re not spontaneous, their social interactions are very unusual. I think that one of the insidious lessons of child abuse, talking about interpersonal trauma, is that people who love you hurt you. And so I think that what kids develop is this expectation that the world will not be safe and that this other kid at school is probably going to hurt you, or that adults in your life are going to continue to hurt you. And that produces in them both a feeling of wanting to fight first—so the best defense is offense. But the other possibility is that they just simply withdraw from any kind of interaction, because it’s just not safe enough. And so all of these behaviors can bring kids in or can get kids referred to us. And probably the most typical is after a trauma is disclosed and someone becomes aware that the child has had some traumatic experience. Then we have the referral to really rule out post-traumatic stress disorder. And so that’s a very common presentation as well. JOHN SOMMERS-FLANAGAN: As you were talking, it made me think about the whole process of how often, social, interpersonal interactions will develop into kind of a psychological internal working model. And when you referred to the whole concept of young people then expecting things to not be safe. And so that leads me to ask you, how do you intervene with that? How do you help the children develop new working models so that they might see the world as more safe? ELIANA GIL: And I do think that with internal working models, we can make a contribution in counseling and in therapy. And that process is really important. But even more important is for that to be duplicated outside our weekly psychotherapy, which sometimes really is not sufficient. But as an example, I worked with a little girl who was six years old. And I worked with her for a number of months. And she came in one day, and she brought me a Ping-Pong paddle. And she said to me, “Here, this is for you.” And I said, “Oh, what’s it for?” “For you to hit me.” And I looked at, and I said, “Now, why would I hit you?” And she said, “Well, you like me, don’t you?” And it was clear in her mind that as soon as I liked her or she felt liked by me, the next thing that would happen is that I would injure her. And that’s a very interesting dynamic, because she’s also bringing me something to do it. Now, I look at that, and I say, wow, that’s a child who really has figured out a way to decrease the anticipatory anxiety about getting hurt by just saying, here, here’s the thing, do it, let’s get it over with. And then we can move on. Some people, unfortunately, will look at that, whether it’s a paddle or whether it’s a child that’s being provocative, as a way that the child is saying, basically I deserve this, or do this, or provokes them, because I think that sometimes kids who are pushing a lot and push our buttons, as it were, sometimes as those working with children, we do have these responses that they’re pulling for. So in terms of helping that particular child, first and foremost, patience, and secondly, consistency, and third, really trying to up the therapy experience for her so that it wasn’t just a weekly situation, but I could see here two or three times a week, and then the engagement of her foster care system, in this case, to provide the same kinds of messages and responses that I was doing. What I found, very interesting, that initially I would try to be very supportive and warm. That scared kids. And so I found them actually withdrawing. So my fantasies—this was when I was very young and first starting out in this work—my fantasy was, I would sit and rock these children who had been injured in a chair or do something affectionate and warm. And when I came to find was that that actually increased their anxiety so much, because it was so unfamiliar. And somehow the familiar interaction, the, you’re going to hurt me, was the one they expected, felt more comfortable with in a way, tolerated better, and definitely pulled for. So I had to go into neutral mode. And so when I work with kids, often it’s the neutral, non-directive play therapy approach, where you basically are doing empathic listening. And you’re giving them feedback from time to time about what you notice them to be doing, but not a lot of positive validation or my intuitive responses about trying to be warm and much more positive in terms of validation with them, because they need to develop, stretch their comfort zone around these new behaviors that they’ve never encountered, and get past the anxiety that that provokes, and then also keep testing it constantly, because that little girl, I think I worked with her for another year before she really believed that I would not hurt her. It took that long. And so one of the things that I always keep in mind is, repetition is so valuable and so critical that it’s not enough to do it once. It’s not enough to do it 100 times. You just have to be really patient, not allow for the pulling of the children to guide responses that are impatient, perhaps harsh, or anything like that that we just have to be so careful. And the relationship gets built up, I think, in a very careful way, because it’s a fragile system at that particular juncture. But again, I emphasize that without an external caretaker, someone who’s invested in the child, a relationship I can promote outside the therapy, I think that again, these efforts in our therapy would not be sufficient. JOHN SOMMERS-FLANAGAN: When I here you use the “patience,” I think you’re also talking about for us, as counselors, our expectations. I know we live in a culture that expects quick change. But I remember just reading recently a research study by Michael Lambert, where he said that, contrary to the short term four to eight session EAP model, in order for individuals to experience— 50% percent of clients who come to counseling to experience significant benefits, we need a model that is 20 to 25 sessions. And although I know a lot of times, we can’t work within that bigger, more expanded model, I think it’s really important for us to keep our expectations in check so that we’re not thinking, oh, yes, I can just create that safe environment, and that young traumatized person will experience it. Of course, as you’re saying, it’s not just the office safe environment. You need to start building safe environment outside of the office. Otherwise you will be really confusing the child in terms of whether things are safe and not safe. ELIANA GIL: I think one of the most optimistic movements has been the movement towards the understanding of the development of the brain and the neuroscience of interpersonal trauma and how that affects the child at different developmental junctures. And what’s so optimistic about that is, thinking about perhaps the brain having more plasticity that there is no quick fix, but that also at the basic premise of all this is the relationship and how important the relationship is to the establishment of these interventions that are designed to do some good and to stimulate parts of the brain and the child that may be haven’t had an opportunity to grow. So I feel good about that, and I think it also challenges a little bit this model of, let’s do this in four to six sessions. I get concerned that we get economically driven sometimes and that when we’re talking about kids who’ve had histories of trauma, severe neglect, severe sexual abuse, physical abuse, just general maltreatment, that what they come in with is really a distrust of adults and caretaking of them, kind of a lack of grounding and anchoring in possibilities around the development of relationships and that there are often hyper-aroused by things that we’re not even aware of it. So I can wear, for example, a particular color, and that could trigger a child who’s been traumatized to have a very active re-experiencing of fear and anxiety that I may not even understand. Sometimes I’m talking to schoolteachers, and they say, well, I was talking loudly, but I wasn’t yelling. And I don’t understand why that child would suddenly have to leave the room. And they don’t understand that it’s possible that that cues the child that we’re about to have a violent episode here. I better get out of here, because I need to stay safe. JOHN SOMMERS-FLANAGAN: What’s coming next? ELIANA GIL: What’s coming next? So we just have to be so careful to understand that this process takes time. At least for the people that I’ve worked with, it’s never a quick fix. Now, within the whole context of trauma, yes, there are some kids who fare better than others. Trauma, I think is very phenomenological.  The experience of the child and how that child experiences power and control, if any, during a traumatic event or what defenses they use, this will set the stage for basically how receptive they may be to interventions that come along. But it also is in an important precursor to what kind of symptoms they’re going to develop and how they’re going to fare. So I always think it’s really important to look at assessing the traumatic impact, because we can’t just assume that every child is going to react the same. And honestly, some of them have internal resources that they use. Some of them have even things like having a pet that they can really talk with, that they can hold, and that they sleep under the covers with. That can make a huge difference in their perception of how safe or how nurtured or how connected they are to something else that then impacts their other responses to these events that are happening that may be obviously serious stressors and traumatic stressors. So I find this assessment piece a very important piece of the puzzle in terms of trying to understand how we approach children. I’m amazed at natural reparative healing systems and how some kids can engage, even in post-trauma play, and be able to, in some ways, do their own gradual exposure. We talk a lot about cognitive behavioral therapy, this desensitization that often is provided as a therapeutic intervention. This is what I think children do in post-trauma play. When they’re repeating the trauma externally, they’re exposing themselves to this play, and they’re interacting with it. And they’re in some ways managing it and resolving things and answering their own questions. And it’s a beautiful thing to watch when it works towards its proposed goal. Every now and then, I encounter kids who do that, and they get stuck in it. And so the actual gradual exposure isn’t as effective, because they just keep reexperiencing the traumatic memory the same way, and nothing changes. And in those cases, I have to be more actively involved. JOHN SOMMERS-FLANAGAN: I’m thinking of the desensitization model. And that’s going to link us to evidence-based treatments. But I’m also reminded of a case I’m supervising of a graduate student, who’s working with a 17-year-old young man. The young man just can’t even talk in this session. And so I said, “Lower your expectations,” to the graduate student. “Just bring some games.” And so he took in backgammon. They had contracted to three sessions, where they would just work together. And then the young man, the client could decide whether he wanted to continue. And they mostly played backgammon for three sessions but talked a little bit while they’re playing. In the third session, the young man says to the therapist, to the counselor, well, this is our third session. I guess we have to decide whether we’re going to continue working together. And the counselor said, “Yeah, what do you think?” And the client said—who had been completely opposed to this process, but after three sessions of playing backgammon, he says, “Well, whatever you think,” kind of giving over the choice, which I saw as a very clever way to avoid rejection. He doesn’t have to say, “Yes, I want counseling,” and then have the counselor reject him. And so the counselor said, “Well, how about if we keep meeting then?” And session after session, just like in a desensitization model, this 17-year-old who couldn’t speak about his own personal experiences with another person gets better and better and more and more able to speak. And I found that process to be just very, very kind of joyful for me to watch the development of that relationship and the trust build. ELIANA GIL: It’s interesting when you say that example, because sometimes people look at that and they say, well, they just played. There’s nothing going on. Or someone, a graduate student, might say, well, how do I document that in my notes? And is that legitimate? Can I do this and call it therapy? And I think there’s so much to playing a game together; because it is something you do with another. And it has rules, and it has a structure, and you get to experience this person without any demands. There’s so much going on when kids are playing games. But especially the older kids really seem to enjoy it. And it’s a way to begin to get their feet wet into this new kind of environment, where they don’t have a lot of control. So I think it’s a beautiful example of how valuable that can be and how much we have to take our time. JOHN SOMMERS-FLANAGAN: And I would say we could document that as desensitization and social skills, training, and there’s all that going on in addition to just the building of trust in the relationship. So let’s talk for a moment about evidence-based strategies. I know with PTSD, post-traumatic stress disorder, there are a number of evidence-based strategies. One of the challenges in counseling is, how do we transform or translate the information from the scientific research into our clinical practice? And so I’m wondering how you do that, what kinds of evidence-based information you find useful in your practice. ELIANA GIL: I welcome the evidence-based practices, and I’ve been very interested in learning whatever I can. What I think of now is integrating evidence based principles and practices into my clinical practice, often because now, there’s a movement towards, we have to do this in order to get reimbursed. So   there’s a movement towards, you won’t get paid if you’re not doing some evidence-based practices. This is a starting in California and certainly moving all the way across the country. And that’s good. It’s an accountability. I think that that’s an important piece. Where I end up a little bit concerned is the model of one size fits all. And that’s where I have the concern. I value what people do in research. And I value some of the outcomes, but I also understand that because one particular method is proven, someone’s had the money and the environment in which to conduct research, it doesn’t mean that what other people are doing isn’t equally valuable. It just hasn’t been proven yet. So in the area that I work in, which has to do really, with children who have been abused, the evidence-based model is traumafocused cognitive behavioral therapy. And it is a model that I’ve obviously taken a lot of training in. And it’s a model that we’ve implemented. We actually even did a small research study comparing TFCBT to what we do, which is trauma-focused integrated play therapy. And my feeling is that they’re both effective. I think that the rigid application of anything is problematic, and with TFCBT, really, there isn’t a demand for fidelity. So the original research was done quite a while ago now. I think it’s been at least 10 years. And now where we are is that there’s a hybrid model. And I went to a recent training by a certified TFCBT trainer, and that’s what she said. So this new hybrid model, even though it’s evidence-based, is really a new development of incorporating the feedback from the world out there as people began to present this to their clients. And what they found is that it didn’t fit everybody. Children are children. And sometimes the cognitive behavioral strategies are not as inviting to them. It may feel more like school to them, and if we’re talking about four and five and sixyear-olds, it kind of falls flat. Now, some other people have started looking at CBT in a playful way. So they’ve actually combined the two and started saying, we can teach this in this kind of fun way. And that engages the kids a little bit more. So we may not do TFCBT in terms of the actual way it was designed way back in the research, where you do this in the first few sessions, and then you move to this and you move to this. But obviously we incorporate the basic principles of it, which is a real focus on a direct movement of understanding of the trauma and that the narratives are important. And the narrative we do may not be verbal. But we may have the kids draw things out or play things out or do things in the sand tray. And that all works, as long as for that person there’s an understanding of what was, what this trauma was. Some of the compartmentalized feelings and thoughts and reactions are explored. They feel a restoration of power and control. And they have had the opportunity to release affect. And they have a good support system. And as long as all of that is happening, I think the incorporation of the evidencebased principles might be the most effective way to go. There are also some other evidence-based practices. One of them is called parent-child psychotherapy, which was done by Lieberman and Van Horn in San Francisco, with children who witness domestic violence. That’s an interesting program, because that has the parents and the kids doing play therapy together. But in addition to that, there’s a co-construction of a narrative between a parent and a child. Again, the focus is the restoration of power and the perception of each other in a different way. Especially in domestic violence, the kids perceive their parents as having not a lot of power and being helpless or something like that—so the restoration of a different perception of that parent. And there’s also PCIT, parent child interaction therapy. That model is probably, of all of them, the least accessible right now, because it’s a very expensive training program. And then there’s a lot of fidelity requirements that a lot of agencies will have trouble implementing. I understand from some of the people who work with that that they’re looking to soften the guidelines a little bit so that more programs can implement it. And that’s a good model. And then we have something called child-parent relationship therapy, which is a play therapy base model based on filial therapy, which has been very well researched. So it’s kind of like an explosion of these models that are appearing on the scene. And I think there’s a common ground among all of us who have been doing trauma work for a while. And I like right now to call what I do evidence informed and continue to have a model that’s integrated so that whenever possible, we will utilize the evidencebased models. And again, in your private practices or in your agencies, there’s going to have to be an implementation process. So in the agencies that we work, there’s going to have to be the implementation of and adaptation of these models so that it makes sense to the people providing the services. And then there’s, of course, the whole other issue of education and training. So we’re telling counselors and therapists, you need these basic things to graduate. And then suddenly, what happens is that they are told, well, actually, no, you’re going to have to go get some certifications now. TFCBT is about to launch a certification process. So it’s going to require people to go back and take training and then consult and so forth and so on. So I think it’s interesting. And I think for all of us, it’s a challenge to figure out how much of it we can integrate and in what ways and what fits best for the families that we’re working with. JOHN SOMMERS-FLANAGAN: I love the integration of the play with the CBT, because I think they fit well together. A couple specific questions—what are your thoughts on EMDR and/or medications in the treatment of children and adolescents with trauma ELIANA GIL: I think over the last 20 years or so, what we’ve seen the emergence of the MDR for the treatment of PTSD. And I think that anyone doing any trauma work needs to be trained in it, to be honest. And it’s a very powerful training. I think it gives you another set of tools that I think can be used in the treatment process that you have. The evidence is pretty clear that it works. The evidence on it working as well with children is now growing. So I think again, if you’re working with kids and/or adults and there’s PTSD trauma backgrounds, you have to be able to know that and be conversant with it and use it. I’ve taken the training. There are some clients who respond very well to it. It’s again, one of those questions that you ask yourself about, does it lead the way in the practice that you do? Like, there are some people who say, I do EMDR and a therapist might refer to that clinician to do 10 or 12 sessions of EMDR. Or do you incorporate it into your practice and use it as you believe it’s indicated? So I tend to do it in that way rather than referring out for it. And I think it’s a very valuable tool. And again, that’s evidence-based. And also, we can’t ignore it. It’s been shown over and over and over again to work. Nobody seems to quite understand why. JOHN SOMMERS-FLANAGAN: It’s a little mystical. ELIANA GIL: A little mystical, but that’s fine. And things like that, I’m really very well oriented towards, if there’s something that really would help me and that I can learn from. That’s why the neuroscience, for example, the work of Bruce Perry and his neuro-sequential model of therapy, these are really important things for us to be aware. They are sort of on the horizon. People are really trying to standardize some tools. And I think we’re going to be practicing with a broader lens from this point on. JOHN SOMMERS-FLANAGAN: How about medications? ELIANA GIL: In terms of medication, I have always felt that it’s very useful to be aware of the new medications and how they work and how they can be effective and to have a very good psychiatric consultant. I’ve been lucky in my lifetime that I’ve worked with people who have had the point of view that medication is really something you go to after you try more of the traditional therapies and that you refer, consult, and then sometimes it’s a really good adjunct to the psychotherapy experience with children. So meds can definitely be a big part of helping the child regulate emotions, stabilize, so we can do the work that they need to do. And again, my only concern is having that as the first response, and some people do that, and that’s just a different approach. But I think from my point of view, we try other things and try to get a contextual understanding of the problem first. And then if we see a continuation of symptoms that are not relieved, then we have things that are very dangerous for kids to be experiencing that at some point we do the consultation. And I have some very good working relationships. And when the kids are on medications, that’s great. One of the problems that I see sometimes is, the kids will go into a hospital setting. And they get put on a cocktail of medications. Then they’re released, and there’s not a lot of follow-up. So the parents are withdrawing the medications, or they say they didn’t like that one. I thought I’d give them this. And that gets really tricky, very problematic, and potentially dangerous as well. JOHN SOMMERS-FLANAGAN: It seems to me that the medication cocktails, there’s really no evidence to predict how individual children and adolescents are going to respond to these mixes of different, very potent medications. And that, to me, is a bit frightening. One pet peeve of mine is the whole idea that medications are going to somehow restore balance in some chemicals in the brain, when, in fact, there’s no good empirical evidence for a chemical imbalance in the first place. And so I think to myself, well, a pill is not a skill, although it may be, as you’re saying, a kind of a supplementary, may be helpful in some ways. But what we really need to work on is to help the individual through some human experiences to develop the skills to function more effectively in the world