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Posttraumatic Stress Disorder in Elementary School Students Krista Klein Indiana University of Pennsylvania April 11, 2012

Posttraumatic Stress Disorder in Elementary School Students In recent studies, it was estimated that 25% of all children experience a traumatic event in their lives before they reach the age of sixteen. Experiences that may be traumatic to some children may include being victimized or witnessing an assault or physical/sexual abuse, natural disaster or terrorism (Cook-Cottone, 2004). The instance of the individual acquiring PTSD depends on many factors of each different case such as individual and family history, trauma severity, psychological processes of the victim or witness during and after the event, and the social support that person receives. The symptoms and skewed perceptions of those who have experienced ongoing trauma are dramatically worse than those who have experienced an isolated incident in an otherwise normal life. The reason the event is so traumatic to certain individuals is because it shatters their belief that the world they live in is safe and bad things only happen to others. In order to cope with this change and recover, they must make sense of the event and integrate the event into their thinking about the world. Unfortunately, this involves confronting the traumatizing memories, which can bring about symptoms of fear, anxiety, and depression (Ozer, 2004). If a teacher suspects a student may have Posttraumatic Stress Disorder, or PTSD, they can refer the child for a screening (Cook-Cottone, 2004). The diagnosis of PTSD requires that the individual has been exposed to an incident that has caused feelings of extreme horror, fear, or helplessness. This traumatic event sometimes involves death, injury, or threat of death (Ozer, 2004). There are three groups of symptoms needed to diagnose an individual with PTSD. The first symptom is reexperiencing the trauma. Students may experience intrusive thoughts, flashbacks, visual hallucinations, traumatic play/reenacting, or nightmares. The second group of symptoms involve avoidance. These students may avoid all reminders of the incident and withdraw from family, friends, or social activities. Students may also experience a change in

Posttraumatic Stress Disorder in Elementary School Students personality described as numbness, which is characterized by blank stares, an inability to love, and lack of enthusiasm for activities they once enjoyed. The third symptom is increased arousal. School-age children display increased arousal by hypervigilance, exaggerated startle response, and an inability to sleep and concentrate (Ozer, 2004 & Putman 2009). In order to assess the trauma in an individual, it is recommended that interviews as well as trauma-specific measures are administered. The most common test used to assess PTSD is the DSM-IV-TR (CookCottone, 2004). Criterion states that students with PTSD must display three symptoms of avoidance, two symptoms related to hyperarousal, as well as the symptom of reexperiencing the trauma (De Young, 2011). Finalized reports for school-age children include academic functioning, behavior functioning, symptom severity, diagnosis, and developmentally sensitive recommendations including referral and/or in-school supports (Cook-Cottone, 2004). Trauma assessment can be challenging as the individual being tested may feel threatened or experience symptoms for reasons related to the invasive questions about the traumatic event the student experienced. It may be difficult to assess preschool children, or school-age children that are at a low developmental level because they may have trouble expressing themselves verbally, and more than half of the DSM-IV-TR criteria require a verbal response (CookCottone, 2004). For this population, the DSM-IV-TR was modified and adapted for younger children to create the alternative PTSD algorithm (PTSD-AA; De Young, 2011). Criterion was also changed to be more developmentally sensitive and behavior-anchored for younger children. Two symptoms (sense of foreshortened future and inability to recall aspects of the event) were removed because they did not seem to be developmentally appropriate signs of PTSD. Also, criterion was changed so that they only needed to display one symptom of avoidance along with the symptom of reexperiencing and two symptoms of hyperarousal (De Young, 2011).

Posttraumatic Stress Disorder in Elementary School Students An elementary school student diagnosed with PTSD may display symptoms that interfere with the learning process. Because of the constant changing and developing of children, elementary school students may display PTSD symptoms found in the preschool, school-age, or preadolescent stages, depending on the individuals developmental level. Preschoolers or students at a low developmental level my display symptoms that include acting out, developmental regression, clinging behavior, threats to themselves or others, and traumatic play. School-age children may also experience regression in addition to fighting with peers, withdrawal from friends, poor attention and concentration, and declining academic performance. These students may experience anxiety-like symptoms and describe these incidences as physical pain, such as stomach aches and headaches (Cook-Cottone, 2004). A student with PTSD may also struggle with the concept of appropriate interpersonal relationships with peers and teachers and have trouble making friends (Putman, 2009). Symptoms in preadolescents and students at a higher developmental level may encompass skewed perceptions of identity, future, safety, and connection. For example, students may have a sense of a foreshortened future and lose expectations of getting married and having a career. Students with these abstract conceptions and chronic PTSD may have suicidal thoughts, display conduct problems, exhibit self-injurious or dissociative behaviors, or participate in substance abuse (Cook-Cottone, 2004). Interventions that may be effective include group therapy. Students who have PTSD benefit from communicating their experiences with others who can sympathize with them and form trusting relationships with group members. Together they share common fears, mutual concerns, and similar avoidant behaviors. This helps them deal with their emotions and find normality in their reactions to the traumatizing event. Family therapy can also be a helpful way of having the child maintain family connections as well as facilitating an open relationship

Posttraumatic Stress Disorder in Elementary School Students between family members to express feelings about what has happened and generate an understanding of what the child is going through. Other interventions may include teaching the student how to be safe, avoid traumatic events, and what they should do if they find themselves in a dangerous situation in the future. In some cases, medication may be helpful if the individual displays PTSD symptoms that interfere with other areas of functioning such as arousal symptoms, sleep disturbances, and altered self-concept/personality (Putman, 2009). Cognitive-Behavior Therapy (CBT) protocol is the most effective intervention in children with PTSD because the students visually stored trauma memories are more easily expressed by CBTs combination of play, art, and narrative therapies. Narrative therapies include journaling, therapy using childrens literature, and creation of memory or trauma scrapbooks. Also included as an aspect of CBT is medication, which is used when the individual is not responding to psychological interventions alone (Cook-Cottone, 2004). After a traumatic event occurs, it may be appropriate to implement early-intervention models for prevention of PTSD (Ozer, 2004). In recent studies, after a traumatic event occurring, 63 students who showed PTSD symptoms underwent a 10 session classroom-based Cognitive Behavior Therapy program, after the sessions, students were reassessed and those still showing symptoms then went through individual interventions. It was found that, at post-treatment, 57% of students no longer met the criteria for PTSD and after a 6-month follow-up, 86% of students no longer met the criteria for PTSD (Brown, 2006). The school psychologist can be very helpful to the treatment and recovery process, but interventions based in a school should only be done after the following steps have been taken:

Posttraumatic Stress Disorder in Elementary School Students comprehensive assessment has been completed, it is determined that schoolbased support is the appropriate and least restrictive level of intervention, the parents have been informed of all treatment options, the child is experiencing adequate adjustment and academic success with intervention, and consultation, supervision, and referral are readily utilized by the school psychologist (CookCottone, 2004). A successful treatment may involve exposure of the traumatic event to the patient. This part of the therapy may bring about the worst of the students PTSD symptoms and is not recommended to be completed in the school setting. In a clinical setting, exposure can be accomplished in two ways. Direct exposure, or flooding, involves exposing the child to stimuli that they respond to as threatening (Cook-Cotton, 2004). When appropriate, in a safe setting with a trained professional, the individual may look at a picture of their attacker or hold the clothes that they were wearing when the incident occurred. A form of indirect exposure would be imaginal reliving in which students in a therapy session may start with a general description of the traumatic incident and gradually, with each new session, add more details until they can relive the incident and recall their thoughts and feelings during the event. This therapy with combinations of relaxing techniques and stress management therapy will help to empower the victims and allow them to be able to successfully confront the memory of the traumatic event (Cook-Cottone, 2004 & Jaycox, 2002). School reintegration may be necessary if the traumatic experience and symptomatic expression that follows has kept the student absent from school. The reintegration should be carefully planned with the student in mind, then slowly implemented. The first step that needs to be taken is for the school psychologist to establish a relationship with the student, family,

Posttraumatic Stress Disorder in Elementary School Students classroom teacher, and any other professional who works with the child. The school transition can be made easier with shared literature, professional-to-professional consultation, school personnel visits to the hospital, cross disciplinary workshops, and multispecialty child conferences. The next step is to educate the child, family, and school personnel about the recovery process, the stresses the child may face during reintegration, coping and relaxation skills, and relapse prevention. It is also important to educate the student about self-monitoring skills and what to do when certain symptoms arise in the classroom. After this is complete, it is now time to identify the students needs, goals, and treatment guidelines to develop an individualized plan for the student. This plan should include a calendar of appointments and schedules, a list of names and phone numbers of professionals involved, and a plan for meetings and conferences. It may also be necessary to create a goal for appropriate behaviors and boundaries within the context of relationships with peers, school staff, and professionals of whom they come into contact. Now it is time to implement the integration plan, keeping in mind that you are working toward the students independence and ability to attend the entire school day. This may involve adapting the length of the initial school visit and gradually lengthening their school day until they reach full school attendance. The last step is focusing the students attention on self-monitoring so that they can function independently. The school psychologist can now fade supports and allow monitoring to be done by parent contacts or perhaps a child study team (Cook-Cottone, 2004). When a child experiences traumatic stress, the development of neurobiological modulatory systems may be compromised, and the student may be at risk for academic problems. Long-term exposure to trauma can be especially damaging to the students psychoeducational development (Cook-Cottone, 2004). In the classroom, it would be crucial to establish a safe,

Posttraumatic Stress Disorder in Elementary School Students trusting atmosphere for students with PTSD (Jaycox, 2002). The teacher should model appropriate interactions between teacher/student relationships as well as instruct appropriate classmate relations and provide examples in the form of students role-playing different situations. The teacher should remember to then generate opportunities for the student to build relationships with others and practice interpersonal skills. As students with PTSD often have trouble sleeping and display hypervigilance, which can lead to exhaustion, teachers should allow students with PTSD to rest if needed, as they will have great difficulty concentrating or completing tasks when fatigued (Putman, 2009). In case of relapse, prevention efforts may be implemented in the classroom for students with PTSD. As always, teachers should be prepared and have a plan. The classroom teacher should collaborate with the school psychologist about what to do if there is an emergency related to the childs PTSD. The classroom teacher should also be trained in relaxation and coping techniques that the student may use if he finds that he is experiencing symptoms. These efforts would benefit at-risk students as well as any other students who have been traumatized but have delayed onset (Cook-Cottone, 2004). In conclusion, the key to working with students who have Posttraumatic Stress Disorder is to show understanding. Parents, school psychologists, teachers, and other professionals have a responsibility to work together to make sure the student has had appropriate and successful identification, treatment, and reintegration into the school and to create a safe, trusting environment where students will feel comfortable spending their day. These students need to know that they had no control over what happened to them; but they can control how to deal with the traumatic event, and how they let it influence their lives.

Posttraumatic Stress Disorder in Elementary School Students

Posttraumatic Stress Disorder in Elementary School Students References Brown, E. J., McQuaid, J., & Farina, L. (2006). Matching Interventions to Children's Mental Health Needs: Feasibility and Acceptability of a Pilot School-Based Trauma Intervention Program. Education & Treatment Of Children (ETC), 29(2), 257-286. Cook-Cottone, C. (2004). Childhood Posttraumatic Stress Disorder: Diagnosis, Treatment, and School Reintegration. School Psychology Review, 33(1), 127-139. De Young, A., Kenardy, J. A., & Cobham, V. E. (2011). Diagnosis of Posttraumatic Stress Disorder in Preschool Children. Journal Of Clinical Child & Adolescent Psychology, 40(3), 375-384. Jaycox, L. H., Zoellner, L., & Foa, E. B. (2002). Cognitive-Behavior Therapy for PTSD in Rape Survivors. Journal Of Clinical Psychology, 58(8), 891-906. Ozer, E.J., & Weiss D.S. (2004). Who Develops Posttraumatic Stress Disorder? Current Directions in Psychological Science, 13(4), 169-172. Putman, S. E. (2009). The Monsters in My Head: Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse. Journal Of Counseling And Development, 87(1), 80-89.