Psych class: Chapter 16

Nursing outcome for child with a trauma-related disorder

An overall attachment outcome would be for the parent and infant/child to demonstrate an enduring affectionate bond. In regard to development, general outcomes would pertain to meeting age-appropriate milestones.

What type of care can reduce or imrpove the effects of trauma and prevent the pervasive and damaging psychological and physical consequences of trauma?

Truma-informed care in both behavioral and medical settings can help

Statistical relationships with PTSD in children

those who see parent's murder, those who see parent sexually abused, those sexually asbused themselves, those exposed toa shooting ast school, and those who see community violence in urban settings

BOX 16-1 TRAUMA INTERVENTIONS FOR A CHILD WITH PTSD

*Establish trust and safety in the therapeutic relationship. *Use developmentally appropriate language to explore feelings. *Teach relaxation techniques before trauma exploration to restore a sense of control over thoughts and feelings. *Help the child to identify and cope with feelings through the use of art and play to promote expression. *Involve the parents or appropriate caretakers in 1:1s unless they are the cause of the trauma. *Educate the child and parents about the grief process and response to the trauma. *Assist parents in resolving their own emotional distress about the trauma. *Coordinate with social work for protections as indicated.

The major features of PTSD include the following 4:

1) Re-experiencing of the trauma through recurrent intrusive recollections of the event, DREAMS about the event, and FLASHBACKS—dissociative experiences during which the event is relived, and the person behaves as though he or she is EXPERIENCING THE EVENT at that time. (2) AVOIDANCE of stimuli associated with the trauma, causing the individual to avoid talking about the event or avoid activities, people, or places that arouse memories of the trauma, accompanied by feelings of detachment, emptiness, and numbing (3) Persistent symptoms of increased arousal, as evidenced by IRRITABILITY, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated STARTLE response (4) Alterations in mood, such as chronic DEPRESSION.

After a comprehensive trauma assessment, 2 priority nursing diagnoses are applicable:

1. Risk for impaired parent/child attachment 2. Risk of delayed development

Treatment for the traumatized child is effective when:

1.The child's safety has been maintained. 2.Anxiety has been reduced, and stress is handled adaptively. 3.Emotions and behavior are appropriate for the situation. 4.The child achieves normal developmental milestones for his or her chronological age. 5.The child is able to seek out adults for nurturance and help when needed.

When you know PTSD treatment is effective:

1.The patient recognizes symptoms as related to the trauma. 2.The patient is able to use newly learned strategies to manage anxiety. 3.The patient experiences no flashbacks or intrusive thoughts about the traumatic event. 4.The patient is able to sleep adequately without nightmares. 5.The patient can assume usual roles and maintains satisfying interpersonal relationships.

Outcomes for trauma-related disorders for adults include the following:

1.The person is able to manage anxiety as demonstrated by use of relaxation techniques, adequate sleep, and ability to maintain role or work requirements. 2.Enhanced self-esteem as demonstrated by maintenance of grooming/hygiene, maintenance of eye contact, positive statements about self, and acceptance of self-limitations. 3.Enhanced ability to cope as demonstrated by decrease in physical symptoms, ability to ask for help, and seeks information about treatment.

Nearly ____% of children who witness their parent's murder or sexual assault will develop PTSD.

100

Following a traumatic event, nearly __% of people will develop PTSD.

8%

Posttraumatic stress disorder definition from glossary

An anxiety disorder characterized by persistent reexperiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness, or horror.

How might PTSD manifest in children?

A reduction in play, repetitive play that includes aspects of the traumeatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. May says things like "I am a bad person."

List some specific assessment tools for trauma and stress in children

Child Dissociative Checklist (Putnam, Helmers, & Trickett, 1993), Trauma Symptoms Checklist for Children (Briere, 1996), and the Child Sexual Behavior Inventory (Friedrich et al., 2010). Disturbances of Attachment interview may be administered (Smyke & Zeanah, 1999) for attachment disorder.

Risk factors for diagnosis of risk for impaired parent/child attachment

Anxiety associated with the parent role •Ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization •Inability of parents to meet personal needs •Parental conflict due to altered behavior •Substance abuse •Separation

Trauma-informed care, glossary definition:

Based on an understanding of the vulnerabilities and triggers in psychiatric patients who have histories that include violence and victimization.

What is dissociation?

Dissociation is a disconnection of thoughts, emotions, sensations, and behaviors connected with a memory, with some dissociation considered a normal experience for most people, such as when we "space out" during a movie or when driving; however, severe dissociation or "mindflight" occurs for those who have suffered significant trauma

Describe eye movement desensitization and reporfessining (EMDR)

EMDR is an innovative evidence-based therapy used to treat children and adults (Fleming, 2012). EMDR processes traumatic memories though a specific eight-phase protocol that allows the person to think about the traumatic event while attending to other stimulation, such as eye movements, audio tones, or tapping. Some believe that it works by causing neurological and physiological changes that help to process and integrate traumatic memories.

Examples of situations that may cause PTSD:

Examples are military combat; detention as a prisoner of war; natural disasters, such as floods, tornadoes, and earthquakes; human disasters, such as plane and train accidents; crime-related events, such as bombing, assault, mugging, rape, and being taken hostage; or diagnosis of a life-threatening illness.

What initial education should you do with PTSD?

Initial education should include reassurance that reactions to trauma are common and that these reactions do not indicate personal failure or weakness.

What makes a child likely to develop PTSD?

It is thought that the younger the child, the more seriously ill, and the more invasive the procedure, the more likely the child will deelop PTSD. (example research shows children who survived cancer to have 4 times the amount of PTSD than their siblings)

Initial medication for PTSD

May include a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft), or a serotonin norepinephrine reuptake inhibitor (SNRI) such as venlafaxine (Effexor) to decrease anxiety and depressive symptoms. Tricyclic antidepressants (TCAs) or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. Clonidine (Catapress) and prazosin (Minipress) are centrally acting alpha agonists used for the hyperarousal and intrusive symptoms; propranolol (Inderol), a beta-blocker, is used for hyperarousal and panic.

Posttraumatic stress disorder (PTSD) in adults is characterized by:

Persistent re-experiencing of a highly traumatic event that involves actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness, or horror.

The staged model of treatment for trauma includes the following 3 stages:

Stage 1: Providing safety and stabilization through creating a safe, predictable environment; stopping self-destructive behaviors; providing education about trauma and its effects. Stage 2: Reducing arousal and regulating emotion through symptom reduction and memory work through reducing arousal; finding comfort from others; tolerating affect; integrating disavowed emotions and accepting ambivalence; overcoming avoidance; improving attention and decreasing dissociation; working with memories; and transforming memories. Stage 3: Developmental skills catch up through enhancing problem-solving skills; nurturing self-awareness; social skills training; and developing a value system. Interventions in this phase should focus on teaching coping skills to deal with trauma, supporting efforts to achieve socially appropriate goals, and facilitating development of and integration into healthy social support systems.

Why is it thought that there is a higher incidence of PTSD in women?

This is thought to be due to the greater incidence of sexual assault on women and also the higher likelihood for women to have a past mental health problem such as anxiety and depression, which may make them more vulnerable to response to a traumatic event.

Describe attachment theory

This theory describes the importance and dynamics of the early relationship between the infant and the caretaker based on the early work of Bowlby

How can one be diagnosed with acute stress disorder?

To be diagnosed with acute stress disorder, the individual must display eight out of the following 14 symptoms either during or after the traumatic event, including a subjective sense of numbing; derealization (a sense of unreality related to the environment); inability to remember at least one important aspect of the event; intrusive distressing memories of the event; recurrent distressing dreams; feeling as if the event is recurring; intense prolonged distress or physiological reactivity; avoidance of thoughts or feelings about the event; sleep disturbances; hypervigilance; irritable, angry or aggressive behavior; exaggerated startle response; and agitation or restlessness. ASD is diagnosed from 3 days to 1 month after the traumatic event.

Popular developmental assessment tool for children

The Denver II Developmental Screening Test for infants and children up to 6 years of age

Screening tools for PTSD in adults include:

The Primary Care PTSD Screen (PC-PTSD) (Prins et al., 2010) and the PTSD Checklist (PCL) (Lang & Stein, 2005).

Average age of onset for PTSD

The average age of onset is 23 years old, with women more than twice as likely as men (10% vs. 4%) to develop PTSD.

What does resilience mean?

The term resilience refers to positive adaptation, or the ability to maintain or regain mental health despite adversity.

What does the "window of tolerance" mean?

The window of tolerance is a term that means a balance between sympathetic and parasympathetic arousal. Often traumatized children may alternate between hyperarousal, which includes anxiety, fear, hyperactivity, aggression, and hypoarousal, which includes withdrawal, isolation, numbness.

Describe children with disinhibited social engagement disorder

These children demonstrate no normal fear of strangers, seem unfazed in response to separation from a primary caregiver, and are usually willing to go off with people who are unknown to them.

Describe children with reactive attachment disorder

These children have a consistent pattern of inhibited, emotionally withdrawn behavior, and the child rarely directs attachment behaviors toward any adult caregivers.

Characteristics of someone with PTSD:

They are sad, anhedonic (unable to feel pleasure), aggressive, angry, guilty, dissociative, and abuse substances. Difficulty with interpersonal, social, or occupational relationships nearly always accompanies PTSD, and trust is a common issue of concern.

Who is more likely to develop PTSD?

Women are more than twice as likely as men (10% vs. 4%) to develop PTSD.

Reactive attachment disorder is caused by:

a lack of bonding experiences with a primary caregiver by the age of 8 months.

Examples of traumatizing incidents

abuse, interpersonal violence, automobile accidents, natural disasters, war medical procedures, and illnesses

What does ACE stand for?

adverse childhood experiences

Nurses and other licensed health care providers are mandated by law to report:

all instances of suspected abuse of a minor child to the local child protective services.

What should those with PTSD avoid?

caffeine and alcohol

Common presenting symptoms with PTSD:

chronic pain, migraines, vague somatic complaints, intoxications, anxiety or depression, irritability, avoidance, anger or nonadherence, self-risk behavior, threatening or aggressive behavior, dissociative symptoms, or a change in functioning. Spousal abuse may be associated with hypervigilance and irritability, and chemical abuse may begin as an attempt to self-medicate to relieve anxiety.

Advanced practice interventions for the traumatized child:

cognitive-behavioral therapy: psychoeducation, behavior modification, cognitive therapy, exposure therapy, and stress manageent eye movement desensitization and reprocessing: evidence-based therapy for children and adults.

Techniques to teach children

deep breathing techniques mindfulness techniques

Comorbidities for adults with PTSD include:

depression, anxiety disorders, sleep disorders, and dissociative disorders

Witnessing violence is traumatizing and a well-documented risk factor for many mental health problems, including:

depression, anxiety, PTSD, agressive and delinquent behavior, drug use, academic failure, and low self-esteem

Signs of PTSD in kids

diminished interest or participatin in significant activities irriability agressive or self-destructive bhehavior sleep distrubances prblems concentrating hypervigilance

Adjunctive therapies for traumatized children include:

family therapy, group therapy, play therapy, mutual storytelling, therapeutic games, bibliotherapy, therapeutic drawing, and mindfulness exercises.

A person is particularly vulnerable to adverse events during these years:

first 5 years of life

Most-difficult side effect of PTSD medications:

hypotension

Interventions for the traumatized child are used in a variety of settings:

inpatient, residential, outpatient, day treatment, outreach programs in schools, and home visits.

Methods for assessment for trauma or stressor-related disorder

inter iewing, screening, testing (neurologica, intelligence), observing, and interacting with the child or adolescent.

Significant comorbitities with PTSD for children

learning and attention problems behavioral problems sleep disorders depression suicide attempts dissociation substance--abuse problems

How do most children who suffer a trauma or stressful event event develop?

most develop normally

_______ is the most prevalent form of child abuse in the United States

neglect

Consequences of ACE (adverse childhood experiences) include:

obesity, sexually transmitted diseases, alcoholism, severe and persistent mental illness, psychosis, substance abuse, eating disorders, sleep disorders, dissociative disorders, anxiety and depression.

Victims who suffer from PTSD begin to feel:

permanently damaged and often hate themselves for feeling so needy and helpless.

According to the American Psychiatric Association, disorders included under the truma umbrella include:

posttraumatic stress disorder, reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders.

The overall treatment plan for trauma includes:

psychobiological, psychological and family goals within a staged treatment protocol.

Broad categories to assess mental status of children

safety, general appearnace, socialization, activity level, speech, coordination and momtor function, affect, manner of relating, intellectual function, thought processes and content, and characteristics of play.

Name the 4 different attachment styles described in attachment theory

secure avoidant, ambivalent, and disorganized

Essential symptom assessment data includes:

sudden state changes such as uncontrollable rage, somatic symptoms, post-traumatic symptoms such as nightmares, night terrors, disturbing hallucinations intrusive traumatic thoughts and memories, re-experiencing or flashbacks, traumatic re-enactments, and self injurious behaviors, and negative symptoms such as numbing and avoidance. Somatic symptoms may manifest as headaches, stomachaches or pain; memory problems include amnesia, forgetfullness, difficulty oncentrating, or trance states.

Since the child with trauma has suffered significant disconnection and fragmentation of relationships with self and others, the most important healing ingredient is:

that of relationship and connection to others.

Studies have shown that factors that enhance resilience include:

the presence of supportive relationships and attachments as well as the avoidance of frequent and prolonged stress

Soothing strategies to redirect behavior might include:

warm baths, singing, distraction, listening to music, guided imagery, and using a low, calming voice.

Nursing diagnoses include the following for PTSD:

•Anxiety (moderate, severe, panic) •Ineffective coping •Social isolation •Insomnia •Sleep deprivation •Hopelessness •Chronic low self-esteem •Self-care deficit

Risk factors for diagnosis of risk of delayed development

•Substance abuse •Failure to thrive Unstable home •Unwanted pregnancy •Poverty