Post-traumatic Stress Disorder

Definition

Post-traumatic stress disorder (PTSD) is an anxiety disorder some people develop after seeing or living through an event that has caused or threatened serious harm or death.¹

Prevalence

According to a review of the literature, the prevalence of PTSD among child refugees is approximately 11%.² Prevalence estimates have ranged, however, from a low of 5% to a high of 89%.^3,4 The most important reasons for these differences are:

• Differences in the degree of trauma suffered. For example, child and youth refugees from Cambodia have PTSD rates as high as 50%.
• The setting in which studies have been carried out. Refugee children resettled in high-income countries like Canada have lower rates of PTSD than refugee children in medium- and low-income countries, or than children living as displaced persons in or near their country of origin. This is probably because life in a stable, safe country offers children more protection from ongoing trauma than life in more tenuous circumstances.

Differences in rates are also attributable to such factors as:

• Nature of the trauma. ‘Natural’ events such as an automobile accident or a hurricane can trigger PTSD symptoms, but events of human design – distinguished by deliberate, targeted cruelty such as the Cambodian killing fields, Nazi extermination camps or the recruitment of Rwandan child soldiers – are even more likely to create distress and disorders.
• Proximity to the trauma: how close the child was to a combat zone or a scene of mass atrocity.
• Type of trauma experienced, for example, witnessing someone’s death versus being the actual victim of physical abuse, or rape. 

Other factors:

• Head injuries increase the risk for developing prolonged PTSD.
• Gender affects PTSD risk. Most studies report higher rates of PTSD among females than among males.
• PTSD in refugees seems to cluster in families. It is not clear whether this is due to shared experience, compromised parenting resulting from earlier trauma, or a genetic susceptibility to trauma.

Duration

In people who develop PTSD, one-third can remain symptomatic for more than 3 years and are at risk of secondary problems.⁵ The condition can have long-lasting effects on school performance and on later functioning in the workplace or as a parent.

Resilience

Not everyone who experiences catastrophic stress develops PTSD. Although the factors that contribute to resilience in the face of extreme stress are not well understood, stable families and stable resettlement – including a sense of safety and perceived social support in resettlement countries – are particularly important.⁶

Presentation

The underlying pathology of PTSD consists of re-experiencing, avoidance and hyperarousal.¹ PTSD symptoms usually appear within 3 months after a traumatic event but can emerge months or even years later. Table 1 lists commonly occurring symptoms that are thought to manifest the underlying pathology of PTSD.¹

It is important to recognize that while the underlying pathology of PTSD is not affected by language or culture, symptoms can vary according to age and level of maturity. 

Co-morbid psychiatric disorders

Co-morbid psychiatric disorders can occur in children and adolescents with PTSD, including:⁷

• Major depression
• Substance abuse
• Another anxiety disorder (e.g., separation anxiety, panic disorder, generalized anxiety disorder)
• Externalizing disorders (e.g., attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder).

The co-morbidity of depression and PTSD is a particular consideration; PTSD occurs together with a depressive disorder in as many as 50% of cases.

Discussing PTSD with newcomers

Difficulties in recognizing and assessing PTSD

The nature of PTSD and the fact that it often appears in both parents and children can create assessment challenges.

Children are very sensitive to their parents’ reactions – both to an event itself and when talking about it later. It is not uncommon for children to avoid discussing a traumatic event and its consequences as they soon recognize that doing so upsets their parent(s). Children and youth may not be forthcoming about their feelings, particularly if they don’t feel safe.

Some parents have difficulty recognizing PTSD symptoms in their child for a number of reasons. They may:

• Suffer from PTSD themselves, making it difficult for them to relate to or recognize their child’s emotions or to discuss traumatic events.
• Feel guilty about not being able to protect their children from adversity. Guilt can lead parents to overlook or misperceive a child’s symptoms.
• Avoid discussing traumatic events in order to protect their child.
• Avoid discussing traumatic events because of cultural taboos.
• Feel their child is going through a 'phase' that will be soon outgrown.
• Be reluctant to disclose distress in their child or themselves because they fear signs of mental disorder will jeopardize the family’s immigration status.

In the school setting, teachers may fail to recognize disturbing or disturbed behaviour as a symptom of PTSD, instead attributing it to cultural differences, poor parenting or just “being a bad kid”.

It is important to recognize that children and parents or caregivers will have differing interpretations of the significance of symptoms, a different set of explanations for them, and various opinions about what can and should be done.  Read more about these differences in the cultural competency section.

How to discuss PTSD with newcomers

To address some of the difficulties described above, consider using the following strategies when discussing PTSD with newcomers to Canada:

Keep discussion family-centred.

• The best approach is to involve the family as a whole.
• Parents often find it difficult to balance the need to share their own feelings with the risk of upsetting their children.
• Parents require help to deal with their own emotions and symptoms before they can be asked to help their children understand and label feelings.

Encourage parents to create a safe environment for children.

• This partly involves parents’ sharing their feelings as well as demonstrating that they have been able to cope with difficulties and that family members can help each other through difficult times.

Communicate the importance of confidentiality.

• Based on their experiences of being mistreated by people in authority, children and youth with PTSD may  mistrust teachers and health care professionals.
• Care providers must reinforce the message that every effort is made to keep personal  information and exchanges confidential.

Develop a trusting therapeutic relationship.

• This is particularly important for children and parents from ethnic and racial minority groups.⁸
• Culturally responsive efforts to engage families in treatment should be used.
• Having an interpreter and or cultural representative present may be important at times, but they must be used appropriately.

Using a fact sheet as a starting point can facilitate discussion of PTSD with children and families new to Canada. B.C.’s HeretoHelp website has a freely downloadable fact sheet on PTSD for patients in several languages.

Screening and diagnosis

Screening tools

A review by Rousseau et al⁵ notes that while there is not enough evidence to support the routine use of screening tools for PTSD, such tools may be useful for assessing symptoms as part of a comprehensive evaluation in some patients.

The U.S. National Center for PTSD provides a number of PTSD measures on their website, including tools for use in children and adolescents.

Diagnosis

The American Psychiatric Association (APA) diagnostic criteria for PTSD in adults and children are summarized in Table 3 below.⁹ Given the evidence for generational transmission, parents as well as children should be assessed for PTSD.

Table 3: Diagnostic criteria for PTSD in adults and children

Criterion A: Stressor
The person has been exposed to a traumatic event in which both of the following have been present:

1. The person has experienced, witnessed or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of the person or others.
2. The person’s response involved intense fear, helplessness or horror. Note: In children, these feelings may be expressed instead by disorganized or agitated behaviour.

Criterion B: Intrusive recollection
The traumatic event is persistently re-experienced in at least 1 of the following ways:

1. Recurrent, intrusive and distressing recollections of the event, including images, thoughts or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including images that occur upon waking from sleep or when intoxicated). Note: In children, trauma-specific re-enactment may occur.
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5. Physiological reactivity when exposed to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Criterion C: Avoidance or numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least 3 of the following:

1. Efforts to avoid thoughts, feelings or conversations associated with the trauma.
2. Efforts to avoid activities, places or people that arouse recollections of the trauma.
3. Inability to recall an important aspect of the trauma.
4. Markedly diminished interest or participation in significant activities.
5. Feelings of detachment or estrangement from others.
6. Restricted range of affect (e.g., being unable to have loving feelings).
7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children or a normal lifespan).

Criterion D: hyperarousal
Persistent symptoms of increasing arousal (not present before the trauma), as indicated by at least 2 of the following:

1. Difficulty falling or staying asleep.
2. Irritability or outbursts of anger.
3. Difficulty concentrating.
4. Hypervigilance.
5. Exaggerated startle response.

Criterion E: Duration
Duration of the disturbance (symptoms in B, C and D) is more than 1 month.

Criterion F: Functional significance
The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Specify if:
Acute: If duration of symptoms is less than 3 months.
Chronic: If duration of symptoms is 3 months or more.

Specify if:
With or without delay onset: Onset of symptoms at least 6 months after the stressor.

Recognize that single-session psychological “debriefings” are ineffective, despite their popularity, and may even cause harm.

Treatment

Assessment and treatment of PTSD call for a combined approach involving the whole family, the child’s or youth’s school, as well as more specialized services.

• “Do no harm” must always be the guiding principle in treatment. Recognize that single-session psychological “debriefings” are ineffective, despite their popularity, and may even cause harm. Evidence even suggests that such encounters may increase the risk of PTSD and depression.¹⁰  
• Support for caregivers: The health care provider can support the family by helping the child’s caregivers or teachers to recognize that troubling behaviours may be symptomatic of PTSD.  Patience, support and understanding are important.   
• Identify comorbidities: Other conditions, such as substance abuse or depression, may co-exist with PTSD. Detecting and treating comorbid illness help to decrease distress and improve overall functioning. 
• Social support is an important aspect of rehabilitation for people with PTSD and their families. A number of services to help victims of torture and trauma are available in major Canadian cities and are listed on the website of the Canadian Centre for International Justice.
• Specialized care: If symptoms seem to be intractable or extremely disabling, and if a trusting relationship with the family has been established, the health care provider may consider referral for specialized service. According to Rousseau et al,⁵ treatment approaches for PTSD with demonstrated positive results include the following:
  • Individual or group trauma-focused cognitive behaviour therapy (CBT)
  • Eye movement desensitization and reprocessing (EMDR)
  • Narrative exposure therapy (NET) and the version for children, KIDDIENET¹¹
  • Pharmacotherapy. To date, the largest drug trials demonstrating short- and long-term efficacy involved selective serotonin reuptake inhibitors (SSRIs)¹²
  • Stress management

Self-care for the care provider

Refugee experiences are often horrible. Health care professionals may find it difficult to listen to narratives of suffering and be tempted to cope by withdrawing emotionally from the clinical encounter (e.g., feeling disbelief or cynicism).

Clinicians involved in the care of children exposed to trauma should:⁸

• Engage in self-care: emotional, physical and spiritual.
• Know their limits.
• Watch for signs of secondary stress or burnout (e.g., exhaustion, numbing, distancing, over-involvement).
• Enlist consultation or supervision as needed.

Selected resources

• American Psychological Association. Children and trauma: Report of the Task Force on Post-traumatic Stress Disorder and Trauma in Children and Adolescents.
• Bronstein I, Montgomery P. Psychological distress in refugee children: A systematic review. Clin Child Fam Psychol Rev 2011;14(1):44-56.
• Cukor J, Spitalnick J, Difede J, et al. Emerging treatments for PTSD. Clin Psychol Rev 2009;29(8):715-26.
• National Child Traumatic Stress Network (NCTSN), Refugee Trauma Task Force. Mental health interventions for refugee children in resettlement: White paper II. Los Angeles, CA and Durham, NC: NCTSN, 2005.
• Te Pou o te Whakaaro Nui. Te Pou works to support and develop the mental health, addiction and disability workforces in New Zealand. Therapies for refugees, asylum seekers and new migrants, 2010.
• U.S. Department of Veterans Affairs, National Center for PTSD. PTSD Research Quarterly.
• Wilson JP, So-kum Tang C, eds. Cross-cultural Assessment of Psychological Trauma and PTSD: International and cultural psychology series. New York, NY: Springer Science and Business Media, 2007.

References

1. National Institute of Mental Health. Post-traumatic stress disorder (PTSD).
2. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. Lancet 2005;365(9467):1309-14.
3. Attanayakea V, McKay R, Joffres M, et al. Prevalence of mental disorders among children exposed to war: A systematic review of 7,920 children. Med Confl Surviv 2009;25(1):4-19.
4. Bronstein I, Montgomery P. Psychological distress in refugee children: A systematic review. Clin Child Fam Psychol Rev 2011;14(1):44-56.
5. Rousseau C, Pottie K, Thombs BD, et al. Appendix 11: Post traumatic stress disorder: Evidence review for newly arriving immigrants and refugees. In: Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011;183(12):1-11.
6. Fazel M, Reed RV, Painter-Brick C, et al. Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. Lancet 2012;379(9812):266-82.
7. U.S. Department of Veterans Affairs, National Center for PTSD. PTSD in children and adolescents. [Fact sheet by J Hamblen, E Barnett E, 2009]
8. American Psychiatric Association. Children and trauma: Update for mental health professionals. Washington, DC: APA, 2008.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM-IV-TR). Washington, DC: APA, 2000.
10. Rose SC, Bisson J, Churchill R, et al. Psychological debriefing for preventing post-traumatic stress disorder (PTSD) (Review). Cochrane Database of Systematic Reviews 2009;1:CD000560.
11. Ruf M, Schauer M, Neuner F, et al. Narrative exposure therapy for 7‐ to 16‐year‐olds: A randomized controlled trial with traumatized refugee children. J Trauma Stress 2010;23(4):437-45.
12. Stein DJ, lpser J, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Syst Rev 2006;(1):CD002795.

Other works consulted 

• American Psychological Association. Presidential Task Force on Posttraumatic Stress Disorder and Trauma in Children and Adolescents. Washington, DC: American Psychological Association, 2009.
• Beiser M, Simich L, Pandalangat N, et al. Stresses of passage, balms of resettlement, and posttraumatic stress disorder among Sri Lankan Tamils in Canada. Can J Psychiatry 2011;56(6):333-40.
• Cukor J, Spitalnick J, Difede J, et al. Emerging treatments for PTSD. Clin Psychol Rev 2009;29(8):715-26.
• Hinton DE, Pich V, Hofmann SG, et al. Acceptance and mindfulness techniques as applied to refugee and ethnic minority populations with PTSD: Examples from culturally adapted CBT. Cogn Behav Pract 2011;DOI:10.1016/j.cbpra.2011.09.001.
• McPherson J. Does narrative exposure therapy reduce PTSD in survivors of mass violence? Res Soc Work Pract 2012;22(1):29-42.
• Rousseau C, Singh A, Lacroix L, et al. Creative expression workshops for immigrant and refugee children. J Am Acad Child Adolesc Psychiatry 2004;43(2):235-8.
• Shalev AY, Bonne O, Eth S. Treatment of posttraumatic stress disorder: A review. Psychosom Med 1996;58(2):165-82.
• Steckler T, Risbrough V. Pharmacological treatment of PTSD—established and new approaches. Neuropharmacology 2012;62(2):617-27.
• Wilson JP, So-kum Tang C, eds. Cross-cultural Assessment of Psychological Trauma and PTSD: International and cultural psychology series. New York, NY: Springer Science and Business Media, 2007.
• Wilson JP, Thomas RB. Empathy in the Treatment of Trauma and PTSD. New York, NY: Brunner-Routledge, 2004.