Conference Coverage

AAP: Creating safe environment aids recovery from trauma disorders


 

EXPERT ANALYSIS FROM THE AAP NATIONAL CONFERENCE

References

WASHINGTON – Maintaining safety and helping to ensure caregiver well-being are critical interventions for children with posttraumatic stress disorder (PTSD) and other trauma syndromes, Dr. Mary Margaret Gleason said at the annual meeting of the American Academy of Pediatrics.

“Talk a lot [with caregivers] about safety, meaning the [importance of a] lack of violence in the home and the lack of corporal punishment,” said Dr. Gleason, a pediatrician and child and adolescent psychiatrist at Tulane University in New Orleans. “And equally important, make sure that parents are taking care of themselves and are getting treatment [if they’ve also experienced trauma].”

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PTSD must be treated with evidence-based therapy or it will become more entrenched with time, she said. Both child-parent psychotherapy in toddlers and preschool-aged children, and cognitive behavioral therapy (CBT) in children of preschool age and up, lead to short-term and sustained reductions in children’s symptoms.

In communities without treatment specialists and resources, stressing safety becomes even more important. Help children with PTSD and other trauma disorders to learn to recognize and label their feelings, manage emotional dysregulation, learn the principles of CBT, and achieve deep relaxation. “You can put a pulse oximeter on a child and teach them how to do deep relaxation,” she said. “You can challenge them to bring down the numbers.”

Books on CBT for general anxiety – and, increasingly, online CBT tools – can be helpful for some families, as can the National Child Traumatic Stress Network’s online resources (www.nctsn.org).

Dr. Gleason advised looking for a broad range of disorders in children who have experienced trauma – whether the trauma is acute or chronic, and whether it involves personal or community events. “You need to be thinking about PTSD, certainly, but also attention-deficit/hyperactivity disorder (ADHD), disruptive behaviors, mood disorders, separation anxiety disorders, and sleep disorders,” she said. Conversely, “if a child develops another disorder after a traumatic event, look for signs of PTSD.”

A study of children living in and around New Orleans when Hurricane Katrina struck in 2005 found a wide range of disorders as well as high prevalence of PTSD. “There were [few] children who developed new diagnoses who didn’t also have some symptoms of PTSD,” Dr. Gleason said.

The Diagnostic and Statistical Manual of Mental Disorders–5 placed PTSD in the diagnostic category of trauma- and stressor-related disorders and included separate criteria for PTSD in preschool children. PTSD broadly involves symptoms of at least 1-month duration from four symptom clusters: Intrusive thoughts (e.g. distressing dreams), avoidance, negative alterations in cognition and mood, and changed arousal and reactivity.

Preschool PTSD applies to children ages 6 years and younger, and requires fewer symptoms to be present. The arousal/reactivity symptoms cluster includes irritability and extreme tantrums, she noted.

For children of any age, it is important to note that distressing dreams do not have to involve content specific to the traumatic event to meet diagnostic criteria, Dr. Gleason said.

Compared with PTSD, less is known about the presentation in school-age children and adolescents of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) – two other trauma-related disorders in DSM-5. Both are related to the attachment system and require a developmental age of at least 9 months, and both involve “pathogenic care,” which can mean emotional neglect and/or persistent disregard of the child’s basic physical needs.

The child with RAD “rarely seeks comfort” when distressed, has a limited response to comfort, and has limited positive affect, Dr. Gleason explained.

“When they fall and hurt their knee, or when they build a tower and it falls over, they don’t look for anyone to help them organize their feelings. And when someone tries to help them, this doesn’t reduce their distress,” she said.

There is some overlap with the clinical presentation of autism spectrum disorder, so it is important to rule out ASD in diagnosing RAD.

Treatment, she said, entails placement in an adequate caregiving environment. “What’s really important to know about RAD is that it’s really a reflection of the current caregiving environment,” Dr. Gleason said. “It’s not about the history. It’s about the [trauma] of what’s happening now.”

DSED is quite different in its clinical construct and course. “These children are indiscriminately social,” she said. “They’ll go off with a stranger … off into new situations without ever looking back to see if their caregiver is there.”

Unlike RAD, this disorder is not associated with current caregiving quality. “It’s important for caregivers to know that this syndrome is a reflection of what happened earlier and not what’s happening now,” Dr. Gleason said. “And it does respond to quality caregiving, but very, very slowly. It can take years.”

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