Jurnal : Konseling Traumatik

Erfort, T. 2004. Professional School Counseling : a Handbook of Theories, Program & Pracices. Texas : CAPS Press. (Halaman 562-568)

Clinical presentation

According to the DSM-IV-TR (American Psychiatric Association, 2000) in order for a person (child, adolescent or adult) to meet the criteria for PTSD, symptoms must follow exposure to an extreme traumatic stressor. the person must have experienced, witnessed, or been confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response must have involved fear, helplessness or horror and this may have been expressed by disorganized or agitated behavior. Table 1 includes diagnostic criteria for PTSD from the DSM-IV-TR (APA 2000). The way that a student re-experiences the trauma and manifest distress is likely to change with age and matury, becoming more adult like and closer to the DSM-IV-TR description of the disorder.

Students will often exhibit irritability, anger, and aggression, or may be quite verbal about the trauma and their ensuing feelings, while others do not wish to discuss the incident or how they are feeling. Very young children who have experienced trauma may present with few symptoms listed in the DSM-IV-TR. This may be in part because they do not have the necessary verbal or cognitive skills to communicate their symptoms. Therefore, infants, toddlers, and preschoolers may present with anxiety symptoms such as fears of monsters, animals, separation anxiety, and fear of strangers. These children may avoid situations or circumstances that may or may not have a link with the trauma, have sleep disturbances, and have preoccupations with symbols or words that may or may not have a certain link with the traumatic event (Drell, Siegel & Geansbauer, 1993 : Scheeringa, Zeanah, Drell & Larriey, 1995). The student (like an adult) must express his/her symptoms for longer that one month to meet the criteria for PTSD. The disturbance must also cause clinically significant distress or impairment in social or academic functioning.

Epidemiology

The students subjective appraisal of the situation appears to be an important factor in explaining why some are significantly affected by a traumatic event while others are not (Joseph, Williams, & Yule, 1997). A review of 25 studies indicated that three factors have consistently been found in the development of PTSD in students : 1) the severity of the trauma exposure, 2) trauma-related parental distress, and 3) temporal proximity to the traumatic event  (Foy, Maduiq, Pynoos, & Camilleri, 1996). Prevalence rates varied from 3%-100% depending on the assessor, assessment measures used, type and degree of exposure to the traumatic event, and gender.

Parental reaction to the traumatic event is another factor that has been found to influence the students PTSD symptomology. Numerous studies have reported the impact of familial support and parental emotional reaction to the trauma on the students PTSD symptoms. These studies indicated that familial support across a broad range of different traumas mitigated the development of PTSD in students. Parental distress about the trauma and/or the presence of parental psychiatric disorders also predicted higher levels of PTSD in the student. A study of Holocaust survivors and their offspring found that the offspring were more likely to respond to trauma with PTSD if their parents had PTSD (Yehuda, Scmeidler, Giller, Siever, Binder-Brynes, 1998). Lyons (1987) postulated that the best predictor of outcome for students was the ability of parents and other significant adults to cope with the trauma. Another predictor for positive outcome was intelligence (IQ): higher IQ appears to protect people from developing PTSD and is a strong predictor of resiliency (Silva et al.,2000).

The traumatic event is persistently re-experienced in one or more of the following ways :

1. Recurrent and intrusive distressing recollections of the event (in young children repetitive play may occur)
2. Recurrent distressing dreams of the event (in children there may be frightening dreams without recognizable content)
3. Acting or feeling as if the traumatic event were recurring (in young children, trauma specific reenactment may occur, there is often vivid reenactment of the trauma in drawings, stories, and play)
4. Intense psychological distress at exposure to internal or external cues that remind the person of the traumatic event.
5. Psysiological reactivity on exposure to internal or external cues that remind the person of the event.

The person persistently avoids stimuli associated with the trauma and there is often a numbing of general responsiveness, as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that remind them of the trauma
3. Inability to remember some aspects of the trauma
4. Diminished interest or participation in significant activities
5. Feelings of detachment or estrangement from others
6. Restricted range of emotions
7. Sense of foreshortened future

A person who has PTSD will also have symptoms of increased arousal as indicated by two (or more) of the following :

1. Difficulty staying or falling asleep (fears of the dark, bad dreams, nightmares and wakening are common in young children)
2. Irritability or outbursts of anger
3. Difficulty concentrating (especially relating to school work for children and adolescents)
4. Hypervigilence (children may become alert to danger in their environment and become anxious about other related traumatic events)
5. Exaggerated startle response

The literature has differed on gender differences in the development of PTSD. Some researchers have found no gander differences in the development of PTSD. Others have indicated that girls develop more severe and long-lasting PTSD symptoms when exposed to traumatic events, but boys are more likely to be exposed to such events (Helzer, Robins & McEvoy, 1987). Some studies have found age of the student at the time of exposure to significantly mediate the development of PTSD symptoms. These findings have not been consistent and are more likely a reflection of developmental differences in clinical manifestations of PTSD rather that age mediated differences in prevalence (AACAP,1998). Many studies have evaluated students of diverse ethnic backgrounds and have documented that PTSD occurs across numerous cultural and ethnic groups.

Traumatized students often exhibit symptoms of co-occurring disorders in addition to PTSD. It is not always easy to diagnose PTSD as both the students and parents may minimize symptoms. For young children who do not have the cognitive or verbal skills to accurately self-report their symptoms it is often difficult to get a clear diagnostic picture. Relying on parental report can also be problematic as parents may be dealing with their own trauma as well as trying to support their child. Parents may also not be aware of the existence or severity of their child’s symptoms.

Students who present with PTSD may also exhibit symptoms of depression. Brent et al (1995) reported a large overlap in symptom criteria between PTSD and Major Depressive Disorder (MDD). MDD sometimes precedes and predisposes students to the onset of PTSD. The comorbidity of students with PTSD and other anxiety disorders is also not uncommon. Given the many manifestations of traumatization, it is not surprising that rates of comorbidity with PTSD are high. Many students develop fears associated with specific aspects of the trauma, which can eventually become phobic in nature. Others find themselves extremely anxious much of the time and have difficulty controlling their worries. Panic disorder is not uncommon as children react to their own internal state of anxiety with physical symptoms. Some children experience “survivor guilt” and ruminate over cognitions that they should have done more to help others. Increased alcohol use by adolescents exposed to a traumatic event has been documented as has comorbidity to a host of other psychiatric disorders.

Assessment

PTSD is often a difficult to diagnose. While the professional school counselor may not be directly involved in the diagnosis of PTSD, the following assessment procedures are helpful in understanding the diagnostic process. According to the DSM-IV-TR (APA,2000), symptoms usually begin within 3 months after the trauma, although there may be a delay of months, or even years, before symptoms appear. The symptoms of the disorder and the relative predominance or re-experiencing, avoidance, and hyperarousal symptoms may vary with time. Duration of the symptoms varies, with complete recovery occurring within 3 months in approximately 50% of cases, with many others having persisting symptoms for longer than 12 months after the trauma. In some cases, the course is characterized by a waxing and waning of symptoms. Symptoms reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events.

A thorough and proper assessment requires a face to face interview with the student in which she is directly asked questions about the traumatic symptoms experienced. It is important to also interview the parents so as to gather as much information as possible. The use of empathy, establishment of rapport, and a safe environment where the student can discuss painful and angry feelings are very important to acquiring accurate information. Particular attention should be given to using developmentally appropriate language when assessing the student.

Both the parents and the student should be asked directly about the traumatic event and about PTSD symptoms in detail. Specific questions related to re-experiencing, avoidant, and hyperarousal symptoms as described in DSM-IV-TR should be asked. Other symptoms that often present comorbidly with PTSD should be assessed, such as symptoms of depression, anxiety, substance abuse, and acting out behaviors. Obtain reports of any preceding, concurrent, or more recent stressors in the student’s life as well. Some examples of stressors may be child abuse, significant conflict within the family, requent moves, death in the family, and exposure to community violence (AACAP,1998).

The professional school counselor should be aware of developmental variations in the presentation of PTSD symptoms, especially with young children. For an accurate assessment ask about developmentally specific symptoms when interviewing young children. AACAP (1989) reports there are a few published semi-structured assessments available such as the Structured Clinical Interview for DSM-III-R and the Diagnostic Interview Schedule Clinician-Administered PTSD Scale for Children and Adolescents. AACAP also reported that the following child/parent rating forms may be clinically useful for following the course of PTSD symptoms in children : (1) PTSD Reaction Index : (2) Trauma Symptom Checklist for Children (3) Checklist of Child Distress Symptoms-Child and Parent Report Versions (4) Children’s impact of Traumatic Events Schedule (5) Child PTSD Symptom Scale and (6) Impact of Events Scale. However, there is no single instrument that is considered optimal. Using a single instrument limits the type of information needed to make a PTSD diagnosis, as a student must have a certain number of symptoms from each of three different categories to meet DSM-IV-TR criteria. It is difficult for any single instrument to assess for all of these criteria. Therefore, there is no good substitute for a good, thorough and direct interview with both the student and parents. It is also sometimes useful to speak with the student’s teacher to get a history of symptomology manifested at school with a particular emphasis on changes in school behavior, interaction with peers, concentration, activity level, and academic performance since the traumatic stressor.

In addition, it is a good idea to initially meet with the parents separately from the student. When interviewing parents, the goal is to gather as much information as possible so that an understanding of the parents perspective on the trauma and relationship with the child can be determined. It is also important to assess information on (1) family psychiatric and medical history (2) marital conflict, separation, divorce, abuse (3) developmental history, including the student’s temperament and mood (4) academic history and performance in school prior to and after the trauma (5) student’s current functioning (6) impact of the trauma on the family and parent (7) presence of parental PTSD symptoms and (8) the perception of how much support is available to the child from the family (Perrin, Smith & Yule 2000).

When interviewing the student, have the student recall as much of the trauma as possible. After the student has told her story, go back and clarify or prompt with additional questions. Tracking the time line of the trauma and subsequent symptoms is useful in making a diagnosis of PTSD. If unsure about the sequence of events or a particular symptom, ask about it directly. As much as possible try to obtain the student’s report of trauma-related attributions and perceptions. Query beliefs about the event, how the student feels subsequent to being exposed to the stressor, level of responsibility, and perception of family support (AACAP,1998). The student’s feelings, thoughts, and behaviors related to the event should be queried, as well as their thoughts and feelings about the future. With very young children who find it difficult to developmentally discuss the trauma and their thoughts, feelings, and behaviors related to it, it is often useful to use other methods of gathering information. According to Perrin et al. (2000), giving the student pencil and paper and encouraging him to draw something about which he can tell a story is useful in gathering information and helps the student feel comfortable enough to disclose. Encourage the student to elaborate on his story and then try to link the story with some part of the traumatic event in order to facilitate emotional release. After the student has become more comfortable, ask him to draw the traumatic event. Discuss the picture with the student and ask him to describe the sensory components, feelings, thoughts, and coping strategies used during and since the trauma. It is also important to help normalize the student’s reactions to the traumatic event as well as positively reinforce the student for having courage to draw about and discuss the traumatic event.

While the professional school counselor is assessing the student for PTSD symptoms and the associated sequelae symptoms, she should also be asking the student about, and noting other symptoms often associated with PTSD such as depressive symptoms, suicidal ideations, anxiety symptoms, substance abuse, and conduct disorder behavior.

Treatment

To date there is limited empirical outcome research on the treatment of students with PTSD. Direct exploration of the event is likely to be more efficacious the older and mire mature the student is. For younger children, more indirect methods of addressing traumatic issues, such as art and play therapy (use of drawings, puppets, dolls,etc) may be indicated. The use of multiple informant assessment, especially with young children, is likely to elicit more information collected from young children should be supplemented by parent reports.

A treatment plan should be based on the clinical presentation of the child and should address PTSD symptoms as well as other emotional/behavioral symptoms the student may be experiencing. Each student’s course of PTSD and associated symptoms will be variable and may be extremely idiosyncratic in the nature, intensity and length of symptoms. Therefore, different treatment modalities may be needed depending on the student and the nature of the presenting symptoms and problems. Some will require short-term, long-term or intermittent treatment. Others may require different levels of care, e.g., outpatient care, partial hospitalization, or inpatient hospitalization. The professional school counselor may also need decide which treatment modality will be the most efficacious for the student-individual, family, or group therapy (AACAP,1998).

There are quite a few authors who advocate for psychoeducation for parents, teachers, and family members in order to help normalize PTSD symptoms and enlist help in treating the student who has PTSD (Gallant & Foa, 1986: Molta 1995). Education about the traumatic experience and subsequent symptoms may also be helpful to the student who has been exposed to a stressor. The student often has perceptions, feelings, and symptoms about the stressor that can be normalized in order to help increase self-efficacy and, thereby, decrease anxiety.

Individual therapy is another modality that can extremely helpful to students who have been exposed to a stressor. There are many different theoretical orientations that are used by professional school counselors in order to help students with PTSD. Psychoanalytic/psychodynamic approaches are sometimes used and often help expose defense mechanism that are being utilized and also help to redefine current significant relationships in the student’s life. Play and art therapy are also often used to accommodate students who are developmentally incapable of benefiting from a direct verbal exchange with a professional school counselor. These indirect methods of addressing traumatic issues may be helpful to students so as not to retraumatize them as they think about and talk about the traumatic event.

There is also significant empirical support for cognitive-behavioral therapy (CBT) in the present literature for the treatment for PTSD. The goals of CBT treatment are the reduction of PTSD symptoms, the development of positive coping skills, and an increase in the individual’s sense of well-being. It is helpful to provide both the parents and student with education and information on PTSD and its effects on all levels of functioning. Normalizing the student’s parents, and family’s feelings and responses also may help to lessen anxiety and alleviate the severity of symptoms. This form of psychotherapy also focuses on the teaching of progressive muscle relaxation, thought-stopping, positive imagery, and deep breathing prior to having the student discuss the traumatic event. Mastering these skills gives the student a sense of control over thoughts and feelings rather that being overwhelmed by them, and will help the student approach the discussion of the traumatic event with confidence, thereby reducing uncontrollable re-experiencing of fears and symptoms. At the center of CBT is also the use of imaginal or in vivo exposure to help the emotional processing of traumatic memories. This process is done in such a way as to help the child process his or her emotional reactions to the event in a safe and trusting way to master and lessen feelings about the traumatic event.

Pynoos and Nader (1988) describe a “psychological first aid” approach for students exposed to community violence which may be offered in schools as well as traditional treatment setting. This model emphasized clarifying the facts about the traumatic event, normalizing student’s PTSD reactions, encouraging expression of feelings, teaching problem-solving techniques, and referring the most symptomatic children for ongoing treatment.

Family therapy is a way to integrate the whole family into the student’s treatment. Parental support and reaction to the child/adolescent are likely to effect the child/adolescent’s symptomology. Most experts assert that inclusion of the parents and/or supportive others in treatment is important for resolution of PTSD symptoms for children and adolescents. Including parents in treatment helps them monitor their child’s progress and symptomology and also helps the parents resolve their emotional distress related to the trauma (AACAP, 1998: Cohen, Berliner, & March 2000).

Trauma-focused groups for children/adolescents, as well as parents, can lead to beneficial and encouraging open discussions of perceptions, attributions, and feelings about the traumatic event. Group therapy is often used after major traumas and disasters as a way to help debrief and normalize the event for the children/adolescent. School-based group crisis intervention may be particularly useful after trauma and disaster situations.

Summary/Conclusion

As Students are increasingly exposed traumatic stressors and events it is likely that the professional school counselor will be called upon to assess and intervene with a student with PTSD or PTSD-like symptoms. Familiarity and knowledge of DSM-IV-TR criteria for PTSD is essential for the professional school counselor to understand the complexity of this disorder. With a comprehensive assessment and proper treatment most students will typically improve within three to six months, while others may need longer term treatment.