Contents
In line with its mission, the Editorial Board of MedTvoiLokony makes every effort to provide reliable medical content supported by the latest scientific knowledge. The additional flag “Checked Content” indicates that the article has been reviewed by or written directly by a physician. This two-step verification: a medical journalist and a doctor allows us to provide the highest quality content in line with current medical knowledge.
Our commitment in this area has been appreciated, among others, by by the Association of Journalists for Health, which awarded the Editorial Board of MedTvoiLokony with the honorary title of the Great Educator.
Today Piotrek wetted to bed again. Sometimes he falls asleep with us or comes in the middle of the night … It has been 7 weeks since our accident, and it is still difficult for us to deal with. Once I walked into his room when I thought he was playing and saw a terrible sight. All the cars he had collected and had been given so far were scattered around the room, and Piotrek was sitting in the middle and hitting the next ones with all his might against himself and the floor, throwing them around the room. He destroyed them all. We tried to talk to him, calm down, explain that everything is fine, that we are already together … But he is still scared, as if absent. We don’t know what to do next. We don’t want to wait anymore for the same thing to pass or for Piotrek to forget what happened to us. Because it probably cannot be completely forgotten …
Piotrek, although he is 8 years old, does not leave me alone, as he did when he was still very young. I am still in not the best shape – my leg is in plaster and the collar around my neck – I don’t move much around the house, but as soon as I get up to the bathroom or the kitchen, he is already with me. He stays at home with me often, he doesn’t want to go to school. When he goes, the tutor calls to pick him up earlier because he feels bad or has upset something. The doctor said that after my return from the hospital all these symptoms would disappear because then he would feel safe. However, almost 3 weeks have passed and the problems persist …
What a mother tells about her son is a typical example of symptoms post traumatic stress disorder (PTSD) in a child. Parents, and with time also the boy, while reporting the car accident they experienced, tell about many moments that, apart from the event itself, could have had an impact on their mental state. The son’s strong attachment to his mother may be due to the fact that the boy saw her unconscious in the car, with traces of blood on her body and no reaction to his screaming and crying. He was terrified that mom was dead. Then followed their long separation due to the woman being hospitalized due to numerous injuries. Fortunately, the boy was not seriously injured in the accident. The psychological wound became the most dangerous one. And although it is not visible and as painful as broken bones or abdominal pain, it also requires intensive treatment and providing the child with far-reaching help. Even a shadow of doubts about the child’s mental state and the reasons for the change in behavior should lead to seeking help from a psychologist or specialist doctor – a child and adolescent psychiatrist. Importantly, no referral from a family doctor is required to see a psychiatrist.
The methods of treatment described below apply not only to the diagnosed full-blown post-traumatic stress disorder, but also to all post-traumatic disorders in children. The decision about treatment and its type is made by the doctor, based on the symptoms, their severity and how difficult they are for the normal, daily functioning of the child and the whole family.
Not alone
A very important element of treatment is the participation of parents in the child’s therapy. Common meetings are often held, but also additional separate sessions for parents to help them cope with their own emotions about the child’s trauma and to equip them with appropriate coping guidance. The attitude of parents during this difficult process and skilful support for the child may be crucial for the final effect of the therapy. Positive empowerment, praise, can equip the child with greater amounts of strength and motivation for healing, as well as the self-confidence needed here. Piotrek’s parents tried to spend as much time with him as possible and do many activities together to distract the boy from traumatic memories as often as possible and help him focus on new activities and interests.
In the case of events that involve a group of individuals and the community, group interventions, such as schools, identify children who are developing symptoms of PTSD. Such school peer meetings and group therapies are effective in the event of a shared trauma – for example, a flood experience near the school or an attack of school aggression.
Psychotherapy
Psychotherapy is the cornerstone of treatment of post-traumatic stress disorder in both adults and children. First and foremost, it is cognitive behavioral therapy.
It consists of several basic elements:
– psychoeducation of the child and parents about the post-traumatic stress disorder itself, its causes and symptoms; it is important to understand the causal link between the child’s injury, event and complaints,
– strengthening parental skills and their relationship with the child, using praise, positive empowerment, etc.,
– learning relaxation, breathing and muscle relaxation skills that help to reduce symptoms resulting from stress and increasing agitation,
– learning to identify emotions, especially negative ones, and strengthening the sense of security,
– learning to recognize, combine emotions and behaviors with events that precede them, and strengthen the ability to control this relationship,
– telling about the trauma, the experience that caused it, along with a description of the emotions that arose at that time, correcting their impact on the rest of the child’s life,
– depending on the cause of post-traumatic stress disorder, an element of treatment is also exposure therapy based on gradual re-familiarization with the factor involved in the traumatic event,
– strengthening further proper development,
– joint therapy sessions for the whole family.
Depending on the type of trauma, the severity of symptoms and the child’s dysfunction and age, individual elements of therapy are used with different intensity and in appropriate proportions adapted to the patient’s needs.
Cognitive behavioral therapy also corrects the patient’s incorrect identification with the causes of the event. Blaming yourself for what happened is a very common symptom of post-traumatic stress disorder. It is not uncommon for rape victims who believe that the incident was the fault of their behavior or allegedly defiant dress or appearance.
Piotrek also blamed himself – because he was rude in the morning, because he wanted to go to his grandparents that day …
A very important stage of treatment is to understand that what happened was mostly beyond our control and could not be prevented.
Sometimes psychodynamic therapy is also used in the treatment of dysfunction related to trauma and stress, but this applies to events that are not individual, but chronic, stretched over time or repeated. It can be effective in children who witness domestic violence that creates an environment that prevents the proper development of the child, or where proper development cannot be ensured by the parents-guardians who are themselves victims of violence. In older children, psychodynamic therapy can help e.g. in developing more mature forms of coping with emotions, objectifying them and perceiving cause-effect relationships. The decision on the type of therapy should be made by a physician, taking into account the entire picture of posttraumatic disorders in the child.
Pills will help you forget?
Pharmacological treatment is used in the case of severe symptoms and acute post-traumatic syndrome. It helps in dealing with the worst moments, when, among others, strong anxiety and anxiety “paralyze” each day, and sleep disturbances, insomnia, changes in appetite and other such symptoms lead to the exhaustion of the child’s body. Pharmacotherapy is also recommended when post-traumatic symptoms are accompanied by other disorders and diseases, and when psychotherapy itself produces incomplete or unsatisfactory results. Importantly, it should be remembered that drug treatment is not used in place of psychotherapy, nor is it an alternative, but it can only be an additional element to psychotherapy, which is the basis here.
The group of drugs used in the treatment of PTSD are selective serotonin reuptake inhibitors, i.e. SSRI. However, compared to the treatment of adults, where the choice of these preparations is very large, only those SSRIs that can be taken in people under 18 can be used in children. At the moment, these are only preparations of sertraline and fluvoxamine. Children with coexisting symptoms of other disorders, e.g. depressive or obsessive-compulsive disorders, benefit from the additional use of pharmacotherapy. You should also be careful about the potential side effects of drugs, such as gastrointestinal problems or sleep disorders.
Other drugs used primarily to control acute symptoms of PTSD, such as severe anxiety, tachycardia, rapid breathing, are drugs that inhibit the activity of the sympathetic nervous system responsible for preparing the body for “fight and flight”. The most common are propranolol and clonidine. Benzodiazepines can also be used on an ad hoc basis, but it must be remembered that these drugs do not cure PTSD, but only reduce symptoms caused by anxiety. Due to their strong addictive potential, they can only be taken for a short time (up to approx. 3 weeks) and under medical supervision. When the child suffers from ADHD at the same time, additional treatment is used that is appropriate for this disorder.
There is also information about the effectiveness of the method called EMDR therapy (eye movement desensitization and reprocessing), i.e. desensitization through eye movements. In simple terms, this method is supposed to “block” certain regions of the brain to prevent the expression of fear related to the event. This, in turn, is to allow you to reach emotions and memories that were previously unavailable, and at the same time resulted in symptoms of post-traumatic stress disorder. However, at the moment these reports mainly concern the treatment of PTSD in adults.
When trauma is not everything …
It happens that post-traumatic stress disorder is not the only mental disorder that affects a young patient. At the same time, they often show symptoms of depression, anxiety disorders, eating disorders, ADHD or addiction to psychoactive substances. Stress and trauma can also be triggers for these disorders and their symptoms can be at the fore of a child’s illness.
There may be a situation when, for example, a girl suffering from anorexia is referred to a psychiatrist, and only during treatment and therapy it turns out that one of the many triggers of the disease was a rape. Losing weight was supposed to help in getting rid of all features of the female body, reducing breasts or narrowing the hips. This was supposed to make the girl, in her opinion, “invisible” to male attention and protect her from further such attacks. Such situations require the doctor to be very careful and careful in making a diagnosis, and treatment is then carried out with attention to all comorbid disorders. It is also important which of these diseases was the first (primary), because it itself could predispose to a stronger stress response.
Piotrek’s behavior and the possibility of collecting objective information about the accident made it easier to diagnose post-traumatic stress disorder and its treatment. It is different when the child denies and the parents do not talk about any traumatic event. Such a situation may arise when the parents are the perpetrators of the trauma. They may also not know what happened to the child or downplay their behavior and the fears thus expressed. It hampers the treatment process, but it certainly never prevents it … And then the trauma stops hurting and ceases to be a heavy burden for life …
The boy’s mom is eager to talk about what happened next in their lives:
After consulting a doctor, we decided to start post-traumatic stress treatment with Piotrek. It turned out that he needed drugs first to reduce the most severe symptoms. We were afraid of it, we did not know how it would react to such substances and whether it was too small for them. However, the doctor reassured us that it is safe and that we do not have to worry about anything.
Piotrek quickly began meetings with a child psychologist. It was a very important time for our family. We also often talked to the doctor and the psychologist. They told us what happened to our son, why he was behaving this way, how to support him, not to leave him. Importantly, it turned out that my husband and I also needed such talks to discuss everything that had happened in us since the accident and so that we could also deal with our own wounds. The psychologist first tried to evoke a sense of security in Piotrek. Gradually, also with the help of toys, illustrations and drawings, they tried to face what had happened together and tame and banish all fears. The doctor warned us that we must be patient, because we will have to wait for any results. He was right. But we knew it made sense and we knew we would make it… We were together and that was the most important thing. With time, Piotrek less and less, and then he stopped coming to us at night. He started playing with his friends again. He was calmer. All such small steps were great joy and success for us.
Of course, it wasn’t always so “rosy”. Sometimes we took two steps forward and one step back. Piotrek sometimes gave up, he did not want to come to these meetings. We tried to be patient and we knew it was also some kind of manifestation of his pain. We understood how horrible this accident was for him and what happened to him when he saw me unconscious. It is hard for me to imagine how terrible it was for such a little child. We are still seeing the psychologist. We regularly, though less frequently, see a child psychiatrist who continues to prescribe the boy the medications he started taking at the beginning of treatment. Tolerates them well all this time. And the doctor reassures us that it must be a long-term therapy. We try to be vigilant and observe whether this trauma will have an impact on Piotr’s further development, but we do not keep him secret. He would have opposed it himself. He is curious about everything. I think we’ll all come out stronger …
Text: lek. Anna Zielińska
Literature:
Amercian Academy of Child and Adolescent Psychiatry: „Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder” J. Am. Acad. Child Adolesc. Psychiatry, 2010;49(4):414 – 430.