Manuscript Details

Manuscript number ANXDIS_2017_457

Title Strangulated child’s Psychological trauma intervened with Imagery based

Cognitive therapy

Article type Correspondence

Abstract
Post-traumatic stress disorder in children offers a challenge from treatment perspective. Because of developmental
immaturity, protocol and manual based Cognitive interventions does not suit to many children. This report presents
proof of concept of the feasibility and effectiveness of an imagery based cognitive therapy in a young child who faced
life threatening experience. Clinicians need to be aware of the need for greater flexibility in selecting therapy procedure
based on child’s developmental stage.

Keywords Post traumatic stress disorder; Imagery based Cognitive therapy; Childhood
developmental stage

Taxonomy Cognitive Therapy, Childhood Trauma

Corresponding Author JAIGANESH SELVAPANDIYAN

Corresponding Author's Velammal Medical College

Institution

Order of Authors JAIGANESH SELVAPANDIYAN, Suvethaa Vasu, Ramanujam Venkatasamy

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This is a Case report
 COVER LETTER
Title: Strangulated child’s Psychological trauma intervened with Imagery based
Cognitive therapy

Author names & affiliations:

Dr. Jaiganesh Selvapandiyan MD
Assistant professor, Department of Psychiatry
Velammal Medical College
Madurai

Miss Suvethaa Vasu

Clinical Psychologist, Department of Psychiatry
Velammal Medical College
Madurai

Dr Ramanujam Venkatasamy MD
Professor, Department of Psychiatry
Velammal Medical College
Madurai

Corresponding Author:
Dr. Jaiganesh Selvapandiyan
Assistant professor, Department of Psychiatry
Velammal Medical College
Madurai
EMAIL ID: jai8887tkmc@gmail.com
HIGHLIGHTS

1, Developmental age poses a challenge for doing Cognitive therapy with

Traumatized children

2, Age appropriate adaptations to Cognitive therapy program can help children to

learn therapeutic concepts to overcome psychological effects of trauma.

3, Imagery based cognitive therapy is a viable option for young children suffering
from PTSD.
Strangulated child’s Psychological trauma intervened
with Imagery based Cognitive therapy
Jaiganesh Selvapandiyan, Suvethaa vasu, Ramanujam Venkatasamy
Department of Psychiatry, Velammal Medical college hospital, Madurai

INTRODUCTION:

Children can develop posttraumatic stress disorder (PTSD) after getting exposed to a variety of
traumatic events, including motor vehicle accidents, interpersonal violence, and sexual abuse.
The diagnosis of PTSD in children is almost isomorphic to the adult PTSD criteria with matching symptom
profile. There is ample evidence to recommend Cognitive therapy as an effective intervention for PTSD
in children. (Patrick Smith et al 2007, Atle Dyregrov & William Yule 2006, Cohen et al 2002, 2004,
Deblinger et al 1999). Most of these Randomized controlled trials include children and adolescents of
varying age groups, making extrapolation of the results to developmentally lower age group children
difficult (the mean age of children studied was 14 ± 2 years). There are case reports of using Cognitive
therapy for young children with a 12-session manualized program (Michael et al 2007). But there is an
unanswered question whether the same protocol is universally applicable. The Cognitive therapy
delivered to children differs greatly based on child’s level of cognitive maturity and their comprehension
ability. Doing cognitive therapy for younger children is a challenging task. Here we report a successful
Imagery based cognitive therapy outcome in a 6-year-old child who developed PTSD following a fatal
incident.

CASE DESCRIPTION:

6-year-old Male child was referred to psychiatry OPD with history of Physical abuse and a ligature mark
around neck. During the interview, he revealed that one of his relatives tried to strangulate him using a
cord at school. His father reported that he found his son lying on the floor with froth in mouth and
generalized tonic clonic seizures (probably precipitated by hypoxic state resulting from strangulation).
He was then admitted in Pediatric ICU and had good recovery from physical trauma. The child presented
to psychiatry OPD with symptoms of difficulty falling asleep, fear that he may be abused again, fear to
get back to school. At the time of evaluation, the child was intensely anxious, got vivid images of the
traumatic incident flashed before him as he recalled the event. He repeatedly pleaded his father to save
him from future anticipated harm, seeking short term solace. His symptoms qualified for Post-traumatic
stress disorder according to ICD 10 DCR. We planned to intervene his psychological trauma using
Cognitive therapy in an imagery focused method with the aid of Play based techniques. Psychotropic
medications were not prescribed. The child’s pre-therapy score on Child PTSD symptom scale was 26.
The cut-off score of clinical significance is 12. (Foa et al 1997, 2001).

The initial session was initiated by introducing different toys and games to establish rapport and engage
the child in therapeutic process. Second session was directed towards establishing base line character
description for imagery based therapy. The therapy was directed towards character stabilization and to
target hotspots of traumatic memories that infuse strong distress. In this session, super hero "bheem"
was chosen for role play (child could easily relate with the character). The role play consisted of
different characters - strong and brave person, wise person (adult figure), negative character and
supportive roles. Situations relevant to the child's milieu were chosen for the role play.

In the subsequent session, the therapist followed the child's lead during the role play and focused
on creating resilience and adopting a winning role. The session also focused on the activity “party hat on
the monster” in which he was asked to draw a nice and scary figure and turn the scary art into fun art. In
the next session, he was asked to draw his favorite person which helped in establishing nurturer image.
In pretend play, he took the role of a strong person and a safe place was created for him.

The closing session was used for transition from traumatic victimized stage to a healthy survivor
stage. He was initially asked to pictorially represent the trauma. Then the same situation was enacted in
the role play. Few hotspots were observed. In vivo exposure was attempted by adding new events and
aspects in the memory of the trauma. Then imagery was used to relive and alter the experience. He was
asked to use the techniques learned to apply for the problems as and when they occur.

At the end of the therapy 'blue print' was developed for the child. Set of strategies like bubble
breathing, imagery technique, support from nurturer and focusing on inner strength were framed.
Parents were educated on using the technique to deal with possible setbacks.

The final score on Child PTSD symptom scale (post therapy) is 6 and total number of sessions
offered was 5. The child remains symptom free during follow up evaluation (over a period of 2 months)
attends school regularly and performs adequately in academics.

10
9
8
7
6
5
4 pre
3 post
2
1
0
re avoidance hyper
experiencing arousal
symptoms

Graphical representation of Pre and Post therapy assessment

DISCUSSION:

Clinical presentation of Single incident traumas differs from experience of repeated traumas. Hence,
they can be managed with brief therapeutic programs instead of highly specialized CBT protocols.
(Feeny et al 2004) In the various studies involving Cognitive therapy for childhood PTSD, a variety of
different methods within the realm of CBT have been used, and the critical elements within the
treatment remains elusive because children occupy a distinct position in tailor made therapy by virtue of
highly variable and developing cognitive structures. Imagery based cognitive therapy offers simple ways
of handling the cognitive disturbances of PTSD that is comprehensible by a child who is so young to
understand other cognition based interventions. Four groups of factors are considered to moderate a
child’s short-term reaction to a trauma. These include a) Proximal trauma reminders (e.g internal and
external cues, physiological excitability), b) proximal secondary stresses (e.g changes in family dynamics
and societal approach following the incident), c) the “ecology” of child (parental, peer group and school
factors), d) factors intrinsic to child’s psychological makeup (genetic vulnerability and developmental
acquisitions). The therapy specifically addressed the proximal trauma reminders and the child was
equipped to handle the “Hot spots” (memories that elicit strong emotions). (Richard Meiser-Stedman et
al 2002, Anke Ehlers & David M. Clark 2000). Of late Piaget’s childhood psychological developmental
concepts were revised. A derivation of the revision states that if a child can’t learn a particular cognitive
task in therapy session it does not mean that the child has not acquired that specific cognitive skill in a
concrete fashion rather he/she can do the same task if presented in a developmentally matching
method. (Philip J. Graham 2005) This report demonstrates that child’s developmental age is an
important factor that decides the selection of appropriate Cognitive technique and means of delivering
it for optimum response.

Sources of Funding: None

Conflicts of Interest: None

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