Post-traumatic stress disorder and childhood maltreatment

Dr John Devaney and Dr Michael Duffy consider how cognitive therapy could help children suffering from PTSD after experiencing abuse

Children looking over climbing frameWe’ve recently received funding from the NSPCC and the Economic and Social Research Council (ESRC) to carry out research into post-traumatic stress disorder (PTSD) and child abuse. We aim to find out whether it’s possible for practitioners to screen children who have been abused for PTSD and if trauma focused cognitive behavioural therapy can effectively treat PTSD linked to neglect and abuse.

Here we’re providing a background to our research by summarising what is already known about PTSD and childhood maltreatment.


What is PTSD?

The American Psychiatric Association defines a ‘traumatic event’ as fulfilling one of the following criteria:

  • exposure to actual or threat of death, serious injury or sexual violence directly or as a witness
  • learning of a violent or accidental death of a family member or friend
  • experiencing repeated or extreme exposure to aversive details of the traumatic event (American Psychiatric Association, 2013).

Some research explores the link between isolated traumatic incidents and their impact on children. But fewer high quality studies have explored the impact of experiencing multiple adversities in childhood. These are likely to affect a child’s emotional and psychological wellbeing.

Symptoms of PTSD

The core symptoms of PTSD are:

  • recurrent, involuntary and intrusive distressing memories of the traumatic event: for example, a child may exhibit themes of the trauma in repetitive play
  • re-experiencing the event in the form of nightmares: in children, it may be difficult to link the content of a nightmare with the trauma
  • flashbacks or dissociative reactions: a child may feel and re-experience the trauma as if it’s happening again
  • intense or prolonged psychological distress in response to triggers that symbolise or resemble an aspect of the trauma, such as witnessing an accident, hearing a loud noise or seeing something emotive on television
  • persistent avoidance of stimuli associated with the trauma: for example, a child may avoid situations that trigger bad memories, including places or people. They may try to suppress memories, or avoid talking about the trauma - and avoid seeking help because they’re frightened of re-experiencing the symptoms. This can lead to a child becoming isolated and withdrawn
  • changes in cognition and mood: a child may appear more depressed or less happy, and respond to daily occurrences differently
  • changes in the way children engage with and respond to the world around them.

A child or young person with PTSD may be anxious, constantly on the lookout for threats, and have trouble sleeping.

Their symptoms may include:

  • irritability
  • angry outbursts
  • a lack of concentration
  • reckless or self-destructive behaviour.

Young children (under 8) may not complain directly of experiencing the symptoms of PTSD, but they may complain of sleep disturbance, nightmares, difficulty concentrating and irritability.

So, unlike the physical injuries from traumatic events or physical abuse, PTSD arising from severe neglect or emotional abuse can often be missed.

Existing studies on PTSD and children

It’s common for children and adolescents to experience some form of trauma and a significant number of these children (15.9%) will develop PTSD (Alisic et al, 2014). Children in care experience substantially higher levels of psychological distress than children in the general population (Burns et al, 2004; Ford et al, 2007) but PTSD is often missed when professionals assess children: there are no separate criteria for diagnosing PTSD in adults and children over 6.

If left untreated, PTSD can become chronic, having a significant impact on a child’s academic and social functioning, and their mental health in adulthood.

Many existing studies look at the impact of a wide range of traumatic events on children:

Ford et al (2007) found that PTSD was 19 times more prevalent in children in care than in the general population. A greater understanding of trauma that’s specifically linked to child abuse and neglect is important to help such children who are suffering from PTSD to get back on track.

PTSD interventions

The majority of child-focused research to date has concentrated on the extent and nature of post-traumatic symptoms, documenting the way symptoms change over time.

Some psychological interventions have reported favourable results in the treatment of chronic post-traumatic symptoms. However, there is comparatively little published evidence available on methodologically robust treatment trials.

A relatively new therapy has shown encouraging results: cognitive therapy for PTSD (Smith et al, 2007).

Cognitive therapy for PTSD addresses the core mechanisms within our brains that affect our ability to deal with trauma in the long term, including coping strategies we may have adopted that inadvertently maintain PTSD symptoms (Ehlers and Clark, 2000).

    The Ehlers and Clark model

The Ehlers and Clark model of cognitive therapy for PTSD has proven very effective for treating PTSD in adults (Ehlers and Clark, 2000).

The approach has 3 treatment targets:

  • the person’s memories of their trauma are elaborated and developed into a coherent account
  • the way a person judges the consequences of the trauma are identified and updated, for example the idea that “nowhere is safe anymore”
  • any cognitive and behavioural coping strategies which are actually unhelpful in the long term are ‘reprogrammed’.

When working with children and young people, cognitive therapy for PTSD could include work with parents or caregivers, recruited as co-therapists.

Helping to modify any unhelpful parental beliefs around the trauma and its effect may also be helpful to the child’s long-term wellbeing.

A new study

There is strong preliminary evidence from randomised control trials (RCTs) that using trauma-focused cognitive behavioural therapy can help support children experiencing PTSD following sexual abuse.

But there are no published RCTs of trauma-focused cognitive behavioural therapy for PTSD in adolescents following other forms of traumatic experience. This could include domestic/community violence, emotional maltreatment or complex and life-threatening health difficulties.

Our new study, funded by the NSPCC and the Economic and Social Research Council (ESRC) has two main elements:

  • to find out whether a short mental health and PTSD awareness training programme helps frontline staff in a voluntary organisation working with children who have experienced child neglect or abuse to screen for depression, anxiety and (specifically) PTSD
  • to determine whether cognitive therapy for PTSD is an effective therapeutic intervention for adolescents with PTSD.

This study coincides with the DECRYPT study being carried out by the University of East Anglia. This aims to evaluate the effectiveness of trauma-focused cognitive behavioural therapy for PTSD in young people exposed to multiple traumas, compared to treatment as usual. It is being delivered by clinicians in Child and Adolescent Mental Health Service (CAMHS) teams.

We’re considering the potential for collaborating with DECRYPT, within agreed ethical and trial boundaries.

We hope these studies will add to our knowledge about how to identify and respond appropriately to children experiencing trauma as a result of childhood maltreatment.

Research to help children

Dr John Devaney and Dr Michael Duffy are leading one of 4 new research projects we are funding in partnership with the Economic and Social Research Council (ESRC) to find out what works to help children get back on track after abuse. Find out more about the £1.7 million to fund new research into what works for children after abuse.

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References

  1. Alisic, E. et al (2014)  Rates of post traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. British Journal of Psychiatry, 204 (5): 335–340

  2. American Psychiatric Association (2013) The diagnostic and statistical manual of mental disorders, 5th edition. [Virginia]: American Psychiatric Association.

  3. Bryant, B. et al (2004) Psychological consequences of road traffic accidents for children and their mothers. Psychological Medicine, 34 (2): 335−346.

  4. Burns, B.J. et al (2004) Mental health need and access to mental health services by youths involved with child welfare: a national survey. Journal of the American Academy of Child and Adolescent Psychology, 43 (4): 960-70.

  5. Cohen, J. A., Mannarino, A. P., and Knudsen, K. (2004) Treating childhood traumatic grief: a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 43 (10): 1225−1233.

  6. Ehlers, A. and Clark, D.M. (2000) A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38 (4): 319–345.

  7. Green B.L., Korol M., and Grace M.C. (1991) Children and disaster: age, gender and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry 30 (6): 945–951

  8. Keppel-Benson, J. M., Ollendick, T. H., and Benson, M. J. (2001) Post traumatic stress in children following motor vehicle accidents. Journal of Child Psychology and Psychiatry, 43(2): 203−212.

  9. McFarlane, A. (1987) Family functioning and overprotection following a natural disaster; the longitudinal effect of post-traumatic morbidity. Australian and New Zealand Journal of Psychiatry, 21, 210−218.

  10. Pynoos R.S. et al (1993) Post-traumatic stress reaction in children following the 1988 Armenian earthquake. British Journal of Psychiatry 163 (2): 239-247.

  11. Smith P. et al (2007) Cognitive-behavioural therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46 (8): 1051-1061.

  12. Stallard P., Salter E., and Velleman R. (2004) Post traumatic stress disorder following road traffic accidents: a second prospective study. European Child and Adolescent Psychiatry  13: 172–178. 

  13. Stein, B. et al (1999) Prospective study of displaced children's symptoms in wartime Bosnia. Social Psychiatry and Psychiatric Epidemiology, 34 (9): 464−469.

  14. Terr, L. C. (1983) Chowchilla revisited: the effect of psychic trauma four years after a school bus kidnapping. American Journal of Psychiatry, 140 (12) 1543−1550.

  15. Thabet  A. A. M., Vostanis P. V. (1999) Post traumatic stress disorder reactions in children of war. Journal of Child Psychological Psychiatry 40 (3): 385-391.

  16. Vila, G., Porche, L. M., and Mouren-Simeoni, M. C. (1999) An 18-month longitudinal study of post-traumatic disorders in children who were taken hostage in their school. Psychosomatic Medicine, 61 (6): 746−754.