Review Article

POST TRAUMATIC STRESS DISORDER IN CHILDREN FOLLOWING DISASTER

Nilamadhab Kar, Jagadisha. N. Murali..

Department of psychiatry

Kasturba Medical College, Manipal - 576119

Introduction
 Disasters are ubiquitous. The psychological consequences of disasters especially post traumatic stress disorder (PTSD) cause considerable distress and disability following disasters. Children seem to be at considerable risk for developing PTSD. Considering the fact that about 40% of Indian general population are constituted by children between the ages 0-15 years the magnitude of the problem following disasters may assume a public health importance. There is a need for the community to be prepared to handle the consequences of disasters, including the psychological ones.
 There are differences between PTSD experienced by children and adults. Compared to that in adults, literature on PTSD in children is sparse, and one cannot generalize the adult findings to children. Studies have noted that parents, teachers and even mental health professionals significantly underestimate both the intensity and the duration of the stress reactions in children. The reason can be denial, rationalization that children are too young to remember the trauma and reassuring themselves that the children are not 'damaged' (American Academy of Child and Adolescent Psychiatry [AACAP] 1998; Amaya -Jackson 2000)
 Age at the exposure to the traumatic event mediates the prevalence of PTSD (Davidson and Smith 1990; Hoffman and Bizzman 1996). However, this may be the reflection of developmental differences in the manifestation of PTSD and not the actual difference in prevalence. Thus prevalence difference from that of adults may be because of use of criteria which is less sensitive to detect PTSD in children and an indication that PTSD can be missed in children unless age appropriate criteria are not used. Studying PTSD in children exposed to disasters, as a distinct entity is hence relevant. this article reviews the various aspects of PTSD in children following disasters.
 Epidemiology
 The core symptoms of posttraumatic stress disorder were not actually applied to children until 1987, in the revised third edition of DSM (DSM- !!! - R, APA 1987). Research then confirmed that children's exposure across a wide range of traumatic life events could result in posttraumatic stress disorder. The general population prevalence of PTSD is about 1-14% (APA 1994). There are only a few report of prevalence of PTSD in children exposed to disasters. Earls et al (1988) studied 32 children one year after flood that resulted in evacuations and property damage. A number of children displayed symptoms of PTSD but none met diagnostic criteria for the DSM lll diagnosis. More than 5% of the children affected by Hurricane Hugo reported sufficient symptoms to be classified as PTSD after three months of the incident (Shannon et al 1994). Asarnow at al 1999 found that 28.6% of children reported mild to moderate PTSD symptoms one year after Northridge Earthquake. We had screened 447 children affected by the super cyclone of 1999 Orissa and found that 48 (10.73 %) had PTSD after one year of the incidence using ICD-10 checklist (Kar et al unpublished data). McFarlane (1987) found that parents reported that 13% of their children had dreams or nightmares and played games of the fire, 35% were upset about at reminders of the fire, and 43% talked about fire. At 26 months the prevalence of  these symptoms had not decreased and were more common in children defined as causes on the basis of a teacher completed behaviour questionnaire. This suggests that while PTSD symptoms are more common, syndromal PTSD may be seen in only a few children.
 Terr described posttraumatic stress symptoms in all the children involved, regardless of their developmental, psychiatric, or prior trauma histories following a school bus kidnapping. Pynooset al noted higher than 90 percent incidence of posttraumatic stress. Disorder in child victims of a school yard sniper attack, and nearly 60% of exposed children continued to meet full criteria 1 year later. Other investigators studying disaster, community violence and post war adolescent refugee populations have reported posttraumatic stress disorder prevalence rates of 30 to 70 percent (Amaya - Jackson 2000). Schwartz and Perry(1994) quote 27 to 100% prevalence rates of PTSD in children especially those exposed to sudden, unexpected man-made violence. In summery man made disasters seems to have higher prevalence of PTSD than those following natural disasters.
Nature of trauma that affect children
 Disasters can be natural (earthquakes, cyclones, hurricanes, etc.) or man-made (Major traffic accidents, fires, terrosist attacks, kidnapping etc.). Cognitive immaturity may protect the child from appreciating the implications of the disaster (Hoare 1993). In spite of this, a considerable proportion of children does experience severe psychological consequences after trauma. Disasters can not only have a direct acute psychological impact on the children, but they may change significantly change the social milieu. Both of these can influence the manifestation of PTSD differentially. Terr(1991) has delineated two classes of trauma that may lead to development of PTSD in children. Type l trauma involves single traumatic events that are sudden and unexpected for example disasters like fires, hurricanes, floods, and industrial accidents. Type ll trauma entails the repeated occurrence of a traumatic event and the traumatic event may often the expected and predictable. Examples of type ll trauma include many cases of sexual abuse, ritualistic abuse or repetitive physical abuse of the child. Type ll trauma in a disaster situation can be thought of as being homeless, being exposed to repeated physical illness and hospitalizations in the aftermath  of the disaster, being brought up in relief camps with unknown adults and possibly being physically and sexually abused because of the vulnerable situation. 
Phenomenology 
 The phenomena of re-experiencing, numbering and avoidance and hyper- arousal in children are comparable to that in adults. However there can be major differences in which these manifesting themselves. For example, in young children, repetitive play may occur in which thems or aspects of the trauma are expressed; the dreams may not have any specific trauma related contents and the children may actually re-enact the trauma instead of re-experiencing it. Numbing or avoidance may take the form of restlessness, hyper-alertness, poor concentration and behavioural problems (Malmquist, 1986).
 The chronicity and the type of trauma can influence the manifestation of PTSD. Acute PTSD presents more with typical physiological hyper-arousal and$n re-experiencing and sleep problems, the chronic variety presents with dissociation, restricted affect, sadness and detachments (Famularo et al 1996).
 Terr (1991) described that type l trauma results in re-experiencing, avoidance and increased arousal and type ll results in denial, numbing, dissociation and rage. Children may have periods during which they have inly re-experiencing, or only avoidance and numbing, which alternate between each other, rather than exhibiting both groups of symptoms simultaneously (Regamer 1986; Schwartz and Kowalski 1991). Spiegel (1984) also stressed on the presence of dissociative symptoms in children with PTSD. The dissociative symptoms may take the form of hallucinations or disorganized thinking and behaviour.
 Developmental perspective is important in understanding the diversity of presentation of PTSD. Very young children may present with few DSM lV symptoms. Preschool children can present with features of seperation anxiety, stranger anxiety, fears of monsters or animals, avoidance of situations or preoccupied with certain words or symbols that may or may not have connection to the event (Drell et al 1993). There can be compulsively repetitive play, which represents part of the trauma but fails to relieve anxiety (post trauma play) or play, which represents part of the trauma but which is less repetitive and more like normal play (play reenactment), both of which can be representative of re-experiencing. In the place of avoidance/numbing, only construction of play, social withdrawal, restricted range of affect or loss of acquired developmental skills can be present. Another interesting manifestation is "omen formation" (Terr 1983). Children start believing that there are certain signs, which predict a traumatic event and if they are alert, they can detect these signs (omens). A clinician should be sensitive to these varied manifastations of PTSD in children to avoid misdiagnosis and inappropriate treatment.
Clinical Assessment
 Children present unique challenge to the clinician assessing the PTSD symptoms. They may not report their psychological reactions to the trauma unless they are specially asked about aspects of trauma (Wolfa et al 1994). Hence, expert believe that directly asking the child about PTSD symptoms as they relate to the stressor is always required (AACAP, 1998). Cognitive immaturity of the children mar also be disadvantageous, as the child may not be given the opportunities to talk about the event (Hoare 1993). Since DSM IV requires verbal descriptions from patients of their experiences of and internal status, there limited cognitive and expressive language skills make inferring their thoughts and feelings difficult (Scheeringa et al 1995). Eliciting symptoms of avoidance and linking them with trauma is very difficult in children, and hence the stress on these symptoms in the diagnosis systems is less applicable to the children (Green 1991). To add to the problems, parents and teachers have been shown to be poor repoters of PTSD symptoms in children (Sack et al 1986; Rigamer 1986 Malmquist 1986). Formal and objective assessments of play can also aid in diagnosing PTSD in children. (Almqvist and Brandell-Forsberg, 1997).
 From the above, it is clear that clinicians should spend a considerable amount of time with children to elicit symptoms of PTSD. This posses a special problem in assessing children for PTSD in disasters. There will always be shortage of time and staff for detailed assessment of children for PTSD in disasters. There will always be shortage of time and staff for detailed assessment of children for PTSD in a post-disaster situation. One may like to use either semi structured interview schedules or self/ parent report instruments. Though several of them are available for use in different age groups, none of them deemed optimal (reviewed by  AACAP, 1998). Development of an instrument to tap PTSD in children of all age groups especially in the Indian setting is therefore very much a felt need, considering the cultural difference which is known to influence the manifestation. 
 Differential diagnosis and co-morbidity:
 Many symptoms of PTSD overlap with other childhood disorders namely, ADHD, depression, conduct disorder, oppositional defiant disorder and substance use (AACAP 1998). Moreover, PTSD is highly co-morbid with these conditions. Differentiation of PTSD from other co-morbid conditions if therefore very difficult, but is very important to accomplish, as the treatment can vary. 
 For example, young victims of trauma, like adult victims, make the conscious attempt not to think about the event. Children not only cognitively suppress but also make conscious attempts to distract themselves via motor restlessness or impulsive behaviour. This combined hyperarousal symptoms (criterion D of DSM IV, (APA 1994) makes differentiation from attention-deficit disorder difficult. It may also be because those who have pre-existing ADHD are possibly more vulnerable to develop PTSD. Similar mechanisms hold good for other co-morbid disorders also. In post-disaster situations, other factors like complicated grief reactions survivor guilt and trauma-induced demoralization may occur.
  Etiology
 There are not enough studies looking at etiological factors for PTSD children make any definitive conclusions. The finding of studies of adult PTSD have generally been extrapolated to children. Abnormalities in the noradrenergic and sertonergic systems have been implicated in the development of PTSD in adults. The concepts of classical conditioning, instrumental conditioning and two-factor models have been implicated as behavioural mechanisms of PTSD in adults. The information-processing model explains PTSD on the basis of "malignant memories". These are patterned dysfunctional contents of neural network activities, which integrates perception memory, arousal, cognition, affect somatic and psychological stat, and behaviour. Malignant memories can be triggered by sensory, cognitive, affective or somatic cues and can lead to cognitive distortions, memory changes, dissociative and somatic states and behavioural and affective over activity or numbness and avoidance (Schwarz E 1994 PCNA). Since children are not miniature adults, the extrapolation of adult findings to children needs to be seen with caution.
 Vulnerability factors/predictors
 Not all children exposed to disasters develop PTSD. Certain vulnerability factors, which predispose some children to develop PTSD, hava been noted in the literature (table I). The most consistent factors found to be predictive of development of PTSD are: severity of trauma exposure, trauma related parental distress and the time of assessment.
 Table I. Vulnerability factors for children to develop PTSD
 Vulnerability factor  Author
 Female gender  Goenjian et al 1997
 Degree of exposure, extent of loss of family members and separation anxiety Amaya-jackson 2000
 Severity of trauma exposure, trauma related parental distress, and temporal proximity to traumatic events Foy et al 1996
 Accumulation of multiple stressors  Rutter (1987)
 Previous experience of stressful events and their outcome, successful or otherwise and coexisting adverse circumstances  Hoare, 1993

 Treatment

 Psychological intervention
 Though there is a lot of literature about treatment of PTSD in adults, very few controlled studies are available regarding the treatment of PTSD in children. Many of them address PTSD of other kinds, e.g., secondary to sexual abuse (Deblinger et al 1996; Cohen and Mannario 1996). Few have examined the treatment for PTSD in children faced with disaster in a controlled fashion. Geojian et al (1997) have shown the efficacy of a school-based short-term group and individual trauma/ grief-focused therapy in adolescents exposed to  disaster. Their module addressed five major areas. 1. Trauma, 2. Traumatic reminders, 3. Post-disaster stresses and adversities, 4. Bereavement and interplay of trauma and grief and 5. Developmental impact. Their module consisted of 4 half-hour group sessions and an average of 21 hour individual  sessions conducted over a 3-week period after 1 11/2 years of disaster. They showed that such an intervention not only prevents worsening of symptoms but also reduces the severity of all PTSD symptom categories. Un-treated adolescents would worsen gradually. Fifty two percent of adolescents had PTSD after 1-1/2 years after an earthquake. The number rose to 69% by the end of 3years. In contrast, the intervened group's prevalence of PTSD came down from 60% at the end of 11/2 years to 28% at the end of 3 years (Geonjian, 1997).
 Field et al (1996) used message therapy, which included muscle relaxation for children exposed to Hurricane Andrew and compared it with video attention-control condition. The message therapy group experienced significantly more improvement than the control group. Taking cluse from treatment studies in the non-disaster related PTSD in children, it seems that cognitive behavioural interventions that include direct discussion of the trauma, desensitization and relaxational techniques, cognitive reframing and contingency reinforcement programmes for problematic behaviors are useful in treating children with PTSD. Despite controversies, it seems that trauma focused interventions have strong clinical and limited empirical support. The components of such interventions generally include techniques of stress management (relaxation, thought-stopping, positive imagery, deep breathing, etc.) evaluation and reconsideration of cognitive assumptions the child would have had the trauma (e.g., "nothing is safe anymore") and inclusion of parents and supportive others in treatment. Pynoos and Nader (1988) have used "emotional First Aid" techniques to deal with PTSD in disaster situations. Their therapeutic tools included clarification of facts about the trauma, normalizing children's PTSD reactions, encouragement of expression of feelings and teaching problem-solving techniques.
 In disasters, there is scarcity of experts to impart psychotherapy for a large number of children affected. This stresses the need for an effective group intervention to deal with the situation. though from adult literature individual therapy seems to be better than group therapy, some authors believe that trauma focused approach that treats child's specific symptoms is more important than the treatment modality used (Friedrich 1996). Many authors have focused on the efficacy of group therapy (Blom 1986; Galante and Foa, 1986; Goenjian et al 1997; La Greca et al 1996; Pynoos and Nader 1988; Rigamer 1986; Stallard and law 1993; Stoddard 1996; Sullivan and Evans, 1994; yule and Udwin 1991). They have all intervened the child population affected in a common traumatic event; They have used schools, hospitals and other community settings for this purpose. This kind of approach seems to be the best way of dealing with the problem of a number of children being affected in a typical disaster. Education of the family members and the children involved in the disaster about the manifestations of PTSD will go a long way in the treatment of the condition.
Pharmacological
 To data there are no controlled studies about the efficacy of any medication in PTSD in children. Various medications like the TCA's SSRI's, clonidine, propranolol have been used individual cases or a small series of cases. Though in a disaster situation it is tempting to treat children with medications because of lack of expertise to conduct psychological interventions, one should be extra careful about the use of medications, as their safety and efficacy have not been well studies. Moreover, in such a situation, monitoring of side effects also becomes difficult. A very judicious used of drugs is therefore advocates, taking into consideration the amount of distress, co-morbid conditions, sleep problem, etc. SSRIs seem to be the drugs of choice because of their safety and there is some support for their use from the adult literature
Course and outcome :
 The results of follow-up studies of children with PTSD are unclear and contradictory. There are reports of the prevalence/ symptom severity decreasing (Famularo et al 1996; Laor et al 1997) remaining the same (Shaw et al 1995; Mc Farland 1987) or increasing (Nader et al 1990; Goenjian et al 1997) during the follow-ups. The knowledge regarding the PTSD symptoms in children over time and their associated outcomes are not et clearly known (La Greca et al 1996).
Management Strategies in community
 Considering recent Indian experience in Orisa cyclone and Gujarat earthquake (Kar and Jagadisha, unpublished data) PTSD and other anxiety disorders can be easily detectable and are seen in substantial proportion of children. During such disasters so many children are affected that it would be difficult for any existing health care system to handle. Moreover, specific training in handling children with psychiatric problems in poet disaster situations is lacking in our country. This call for through preparedness on the part of the community to handle the situation in the light of current knowledge about the problem, using the local resources. Volunteers from various walks of life in the community are likely to be actively involved in relief measures. They need to be trained well in advance in the concepts of emotional first aid and basics communication skills in dealing with traumatized children. They need to be sensitized about the importance of talking to children about the trauma and about prevention of abuse and neglect of children in such situations. In this context, training the medical personnel in the primary level of health care system in principles of crisis intervention may go a long way in handling the psychological impact of the young victims of disasters.
Acknowledgement : This work was supported in part by Quality of Life research and Development Foundation.
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 Nilamadhab Kar*, MD, DPM, DKB, Jagadisha, MD, N Murali, DPM, DNB, Assistant professors, Department of Psychiatry, Kasturba Medical College, Manipal, 576119, Email: nmadhab @yahoo.com. *Corresponding author.