Psychiatric Annals

CME Article 

Prevention of PTSD in Children and Adolescents

Melissa J. Brymer, PhD, PsyD; Kristine Louie, PhD; Steven J. Berkowitz, MD

Abstract

Employing early intervention to prevent the development of PTSD in youth who have experienced a traumatic event is a significant public health goal and can minimize disruptions to development and the resulting cascade of effects caused by untreated trauma. Because not all youth require treatment, monitoring and identifying those in need of additional services is an important function of early intervention. The length and intensity of early interventions for youth span a continuum, with some emphasizing psychoeducation, safety, basic needs, and social support, whereas more targeted interventions may focus on cognitive appraisals, avoidance, or coping. Given the importance of family functioning to youth outcomes, some early interventions also target parent behavior to bolster the supports available to youth. Increasing access by embedding services in established systems or using web-based technologies is an important area for continued growth. Additional research is needed to understand how timing, development, context, and setting influence outcomes. [Psychiatr Ann. 2019;49(7):320–324.]

Abstract

Employing early intervention to prevent the development of PTSD in youth who have experienced a traumatic event is a significant public health goal and can minimize disruptions to development and the resulting cascade of effects caused by untreated trauma. Because not all youth require treatment, monitoring and identifying those in need of additional services is an important function of early intervention. The length and intensity of early interventions for youth span a continuum, with some emphasizing psychoeducation, safety, basic needs, and social support, whereas more targeted interventions may focus on cognitive appraisals, avoidance, or coping. Given the importance of family functioning to youth outcomes, some early interventions also target parent behavior to bolster the supports available to youth. Increasing access by embedding services in established systems or using web-based technologies is an important area for continued growth. Additional research is needed to understand how timing, development, context, and setting influence outcomes. [Psychiatr Ann. 2019;49(7):320–324.]

Early intervention has multiple meanings and targets in the provision of mental health services. For this article, early intervention refers to interventions implemented soon after a traumatic event and with the aim of preventing psychiatric disorders, such as posttraumatic stress disorder (PTSD). From a public health perspective, early interventions can be universal (interventions appropriate for all people) or targeted (interventions for people with increased risk factors or currently in distress). The study and evaluation of early intervention models for children and adolescents (referred to as youth in this article) exposed to traumatic experience is a limited but a growing area of development and investigation.1

The timing of early interventions is dependent on a number of factors, but most important are context and target population.2 Early interventions generally offer psychoeducation about typical posttraumatic reactions and include elements of promoting safety, attending to basic needs, enhancing effective coping, stabilization, and connecting with healthy social supports.3 The aim is to enhance resiliency, normalize initial reactions, and identify youth who need immediate clinical intervention in a timely manner. Other issues that influence the timing of early interventions are the type of trauma, postsecondary adversities, the setting, and the service provider.4 For example, interventions for youth hospitalized after injury may occur within hours or days depending on the youth's medical status and availability of providers. However, after catastrophic disasters with significant infrastructure damage and large numbers of people affected, the timing will likely be extended.

Immediate Brief Intervention

Children, adolescents, and their families present with diverse needs requiring a range of services and interventions. The most common immediate intervention is psychoeducation about traumatic responses and PTSD. This may be all that is provided, especially for those who are asymptomatic and don't appear to require additional services. The starting point for those who have acute anxiety symptoms may be breathing retraining and grounding. In the case of large-scale events, Psychological First Aid (PFA) is the best practice for initial intervention before providing a trauma-specific intervention or treatment model. It can be delivered in diverse settings and with providers from different service systems. The goals of PFA are to promote safety, attend to practical needs, enhance coping, stabilize, and connect survivors with additional resources.3 Although PFA has not yet been formally studied, reports from its providers have been positive and it appears to have high survivor satisfaction.5

Assessment and Triage

Although the primary aim of early interventions is to promote recovery and build resilience, an additional and important function is identifying youth at increased risk for psychopathological outcomes. Early identification of youth in need of services is critical and can be accomplished by determining the extent of trauma and loss exposure, the degree of current psychosocial difficulties, intensity of distress and functional impairment, and the amount of resource needs. Youth that appear to have risk factors based on the initial assessment can be routinely monitored by providers and family members or, when needed, referred for more specific interventions or treatment. For those youth who present with no symptoms or appear to be coping well on their own, early intervention is not indicated. It is also important to assess parental functioning, family cohesion, and other possible adversities the family may be experiencing (eg, moves, financial hardships, changes in family constellation).6,7

Many risk factors suggest the need for more formal or trauma-focused interventions.6 Referral to more formal interventions may be especially important when a youth reports multiple risk factors. Of these factors, severity of exposure (both direct and indirect) to the event and history of multiple traumatic exposures have been the most robust and consistently predictive factors.4 Of particular relevance are postevent risk factors such as precarious social or family support, higher levels of chronic life stress, lack of or loss of both practical and social resources (most notably the death of a loved one or close friend), use of ineffective coping strategies (eg, self-denial, self-distraction, and self-blame), and negative appraisals about the event and a pessimistic perspective regarding their future.1–10

In several prospective studies, level of symptoms in the early phases post-trauma were predictors of symptom levels in later phases of recovery and is probably the most expeditious marker for the consideration of trauma-focused intervention. Although not every youth with early posttraumatic symptoms will require early interventions, there is no other current algorithm for predicting with whom to intervene early.8

Internet-Based Early Interventions

To increase access to interventions for a larger number of trauma-exposed youth, there has been a growth in development of digital technologies such as smart phone apps and Internet-based platforms. These have the promise of increasing access in a cost-effective manner. One such intervention, Coping Coach, offers an innovative Internet-based game for school-age children who experience a severe pediatric illness or injury. Coping Coach provides psychoeducation, helps children identify emotions, teaches strategies for modifying maladaptive appraisals, encourages reduced avoidance, and models accessing social support through interactions with in-game characters.11 A second web-based intervention, Bounce Back Now, targets adolescents exposed to disasters and includes separate modules for parents.12 Bounce Back Now offers four modules addressing PTSD symptoms, cigarette use, alcohol use, and symptoms of depression. Both Coping Coach and Bounce Back Now have demonstrated feasibility and have shown promising results for preventing PTSD.12,13 Such interventions can provide coping support to those youth not in the clinical range and identify those who require more formalized treatment.

Youth and Family Focused Interventions

Most youth and family focused early interventions include age-appropriate psychoeducation, education and practice of adaptive coping skills, and the engagement of parents/caregivers.14 Although a few interventions incorporate variations of a trauma narrative, this component in early intervention still needs further research.15 Across interventions, there is evidence that more than one session is recommended.16

The early intervention with the most evidence supporting its efficacy in reducing the potential of PTSD in children exposed to various traumas is the Child and Family Traumatic Stress Intervention (CFTSI).17 CFTSI uses a 5- to 8-session model to prevent PTSD by increasing family communication and facilitating parents' coping skills to support their children who have been exposed to trauma. CFTSI is based on the findings that familial support and the capacity to cope are key protective factors after exposure to trauma. A randomized pilot study of CFTSI compared 112 youth age 7 to 17 years who were assigned to either CFTSI or a supportive psychoeducational intervention within 30 days of exposure to a trauma. The CFTSI group was significantly less likely to develop partial or full PTSD at follow-up, with a reduced odds ratio of 73%.16 A chart review at a Child Advocacy Center of 114 completed cases of CFTSI after sexual abuse also found that CFTSI was effective in reducing PTSD.17,18 This further highlights how bringing evidence-based practices into child-serving systems, increases the early identification and intervention for youth experiencing trauma reactions, thereby minimizing the potential impact on development and other known adversities that youth experience when trauma goes untreated.

Another intervention that is increasingly in use after trauma exposure is Eye Movement Desensitization and Reprocessing (EMDR). EMDR is designed to help youth process distressing memories or reduce their effects by having them focus simultaneously on the disturbing memory and on a therapist-directed attention stimulus (eg, hand tapping, eye movement, auditory tones). Although studies have found that EMDR may be effective at reducing PTSD symptoms in youth and is comparable to other types of CBT in this goal,19 it is not yet clear how efficacious EMDR is at preventing PTSD or the appropriateness of implementing EMDR soon after a trauma. Additional research is needed with larger sample sizes, standardized protocols, and tests of proposed mechanisms to evaluate this therapy as an early intervention.

Intervention Programs Embedded in Child-Serving Systems

Trauma-focused programs that are embedded in child-serving systems increase access for youth who are exposed to traumatic stress but are not necessarily implemented within a given timeframe after a posttraumatic event. However, these programs have evidence of reducing posttraumatic stress symptoms in youth.

There is vast research demonstrating that schools are one of the best settings to provide mental health services for children and adolescents.20 Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is an evidence-based group intervention for middle and high school students that has been shown to reduce PTSD in multicultural and multidiverse youth exposed to multiple traumas.21 CBITS includes psychoeducation, relaxation, cognitive restructuring, exposure, and social problem-solving, in addition to parent and teacher education sessions. Bounce Back, a similar intervention but for elementary school students, also showed a reduction in posttraumatic stress reactions in diverse students that completed the intervention compared to those randomized to a 3-month waitlist.22

Children of active-duty military personnel and veterans face unique stresses including multiple parental deployments; combat-related parental injury, illness, or death; and numerous family hardships (eg, frequent moves, financial difficulties, separations). One promising intervention for this population is Families OverComing Under Stress (FOCUS), which is a skills-building intervention for youth and their parents that provides psychoeducation, training on trauma-informed coping skills, and strategies to strengthen parent and youth social, behavioral, and emotional adjustment.23 It also includes a narrative timeline to help families identify key family transitions to strengthen family members' ability to communicate, be supportive of each other, and be empathic to their unique experiences. This family-centered program has been successfully implemented in more than a dozen US military installations. Initial evaluation data from 2,615 families shows that both youth and parents showed improvements in psychological health outcomes and enhancements in family adjustments.23

Another secondary prevention program is Skills for Psychological Recovery (SPR). This program was created for the Federal Emergency Management Agency-funded Crisis Counseling Assistance and Training Program, which is launched after the President declares a national disaster. SPR is a modularized intervention that teaches a range of skills including problem-solving, positive activity scheduling, managing reactions, promoting helpful thinking, and rebuilding healthy social connections. SPR can be implemented in various settings or can be implemented in one session, but multiple sessions are encouraged. SPR has not been formally evaluated but evaluations from its use in Australia report that SPR was found to be helpful by providers and that survivors reported a reduction of distress.24

Pharmacological Interventions

Currently, there are no effective or replicated studies of early psychopharmacological interventions for youth. The most effective preventive interventions for youth are talk therapies, which should be the first-line treatment. Unfortunately, there is limited access to these modalities, making pharmacological interventions a needed resource. Studies of acute administration of hydrocortisone after a potentially traumatic experience have shown some promise in adults but have not been studied in youth.25 Other medications, such as propranolol, have demonstrated efficacy in an initial study but have not been replicated.26 In general, pharmacological interventions have suffered from difficulties in identifying timing of administration, dosage, and length of administration (eg, single, several days, weeks).27,28 Further complicating the use and research of preventive pharmacological interventions for youth is the gap of understanding of the neurobiological factors in development of PTSD in this population, which should inform areas such as timing and dosage. Further clinical research must consider these issues.

Key Clinical Points

  • Early and timely identification of youth through screening and assessment is the most cost-effective and critical element of early interventions. For youth who present with no symptoms or appear to be coping well on their own, psychoeducation is beneficial but more formal early intervention is not indicated.7
  • Routinely monitor youth and their family members for escalating trauma reactions or functional impairment that warrant more formal treatment.
  • Incorporate parents in both screening and treatment. Supporting parental roles and family recovery can enhance a youth's overall recovery. Early interventions need to extend to those parents who are experiencing distress. By supporting the family structure and the parental role, each member of the family can have a better understanding of how the traumatic event has affected other family members. This provides the basis for parents' ability to offer support to their children.
  • Address developmental issues, including any developmental disruptions, previous trauma history, and pre-event level of maturity and functioning.6
  • Identify and coordinate resources in the community to maximize the effectiveness of an early-intervention program. Many families may require basic needs (eg, housing, medical care, legal services) after a traumatic event occurs. For most people, these services are both sufficient and preventive.
  • Coordinate among child-serving systems within a community to ensure early identification and access to services. For example, a partnership between mental health providers and police officers helps to ensure that youth exposed to trauma receive early intervention.
  • Foster social connections within communities by engaging with natural support networks and build bridges between community groups to foster tolerance and support for one another. Reach out to other providers (primary care, schools, religious institutions) who may know of families in need but may be hesitant to seek services.29
  • Provide a continuum of services to ensure that youth and their families get the appropriate intervention based on their level of distress and symptoms.
  • Recognize the cultural norms of the families you are serving, including preferred language, understanding of the concept of recovery for this culture, the type and role of spirituality, and specific culturally related barriers to accessing care.

Conclusions

The need for more sophisticated evaluation of early intervention models for all ages and for all interventions is unquestionable; however, the timing and range of traumatic experiences has proven to be a formidable obstacle. In addition, there is a need to evaluate and understand what models are most effective for different ages, familial context, and setting (eg, disaster versus sexual abuse). For instance, do injured youth require different interventions when the injury is accidental or intentional? Interventions embedded in child-serving systems are increasing the early identification of youth needing services and increasing the access to such services. Further exploration is needed on which components of early intervention can be conducted by less clinically trained providers, freeing up those who are formally trained to treat more serious at-risk youth. Finally, more attention is needed for how to adapt these early interventions for different developmental levels, especially young children, adolescents, and youth with special needs.

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Authors

Melissa J. Brymer, PhD, PsyD, is the Director, Terrorism & Disaster Program, University of California, Los Angeles (UCLA)/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, UCLA. Kristine Louie, PhD, is the Assistant Director, UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, UCLA. Steven J. Berkowitz, MD, is a Professor and the Driector, Stress, Trauma, Adversity Research and Treatment (START) Center, Department of Psychiatry, University of Colorado, School of Medicine.

Address correspondence to Melissa J. Brymer, PhD, PsyD, UCLA/Duke University National Center for Child Traumatic Stress, 11150 West Olympic Boulevard, Suite 650, Los Angeles, CA 90064; email: mbrymer@mednet.ucla.edu.

Disclosure: Melissa J. Brymer reports royalties from QuickSeries Psychological First Aid manuals. Steven J. Berkowitz is on the speakers' bureau for Sage Therapeutics and has been a consultant for Sage Therapeutics. The remaining author has no relevant financial relationships to disclose.

10.3928/00485713-20190603-01

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