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[Hypnosis as an effective management of a child with posttraumatic stress disorder after perineal trauma.]
Abstract
Children and teenagers may face trauma that threatens their life, but also their psychological integrity. These injuries can lead to posttraumatic stress disorder (PTSD), which is the most common psychopathological consequence after a trauma. Age is not a protective factor and this disorder can be severe and may last over a long-term period. Effective therapies on PTSD are scarce and research on this topic is rare in children. We report a case of a 12-year-old girl affected by PTSD after a carousel accident at the age of 4years. A therapy based on hypnosis and psychological support was rapidly effective. This psychotherapeutic option was chosen on the basis of common features shared by hypnosis and the posttraumatic symptoms. Clinical manifestations of PTSD disappeared after 4weeks of therapy and the patient remained symptom-free during a 1-year follow-up. Our report suggests that hypnosis could be an effective therapy for children with PTSD. Prospective studies on a larger number of patients are needed to validate this hypothesis.
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Des témoignages de réactions psychotraumatiques datent de 2000 ans avant Jésus-Christ et au cours de l’histoire de nombreuses observations de troubles post-traumatiques ont été rapportées. Mais l’intérêt pour ces troubles est bien plus récent. Ce concept, créé pour décrire les troubles dont souffraient des adultes, ne recouvre qu’une partie des aspects des syndromes liés aux traumatismes psychiques chez l’enfant. Les publications scientifiques sur le sujet se sont multipliées ces dernières années mais jusqu’à récemment bien moins de travaux concernaient les sujets jeunes. Avant d’aborder les distinctions entre les notions de traumatisme, d’évènements de vie, de stress, voire de risque, nous nous intéresserons aux spécificités historiques du traumatisme de l’enfant, à sa reconnaissance tardive et aux avancées effectuées. Les spécificités de la nature des traumatismes chez l’enfant, celles de la symptomatologie et de leurs évolutions seront aussi abordées. L’impact et les conséquences du traumatisme sont différents chez un être en devenir, les possibilités d’adaptation le sont aussi.
Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.
To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.
We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.
All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.
Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team. We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.
Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy. Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group. The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified. No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.
There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others. The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses. More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.
Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. The aim of this review was to examine the effectiveness of all psychological therapies for the treatment of PTSD in children and adolescents. We searched for all randomised controlled trials comparing psychological therapies to a control, other psychological therapies or other therapies for the treatment of PTSD in children and adolescents aged 3 to 18 years. We identified 14 studies with a total of 758 participants. The types of trauma related to the PTSD were sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in the included studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most included studies compared a psychological therapy to a control group. No study compared psychological therapies to medications or medications in combination with a psychological therapy. There was fair evidence for the effectiveness of psychological therapies, particularly CBT, for the treatment of PTSD in children and adolescents for up to a month following treatment. More evidence is required for the effectiveness of psychological therapies in the longer term and to be able to compare the effectiveness of one psychological therapy to another. The findings of this review are limited by the potential for bias in the included studies, possible differences between studies which could not be identified, the small number of identified studies and the low number of participants in most studies.
Objective:
DSM-V is on its way and doubts have been raised regarding the validity of pediatric PTSD. It is the goal of the current review to critically review the empirical literature on PTSD in youth.
Method:
A search of PsycINFO, PubMed and reference lists was conducted. Empirical information considered relevant regarding the validity of the criteria was collected.
Results/conclusions:
The validity of the symptom criteria and clusters varies, with the Avoidance/Numbing cluster outperforming the Re-experiencing-and Arousal cluster. Factor analytic findings suggest that Arousal criterion D4 should be placed within the Re-experiencing cluster, and that the Avoidance/Numbing cluster should be split up. Some non-DSM-IV PTSD symptoms, among which guilt, have considerable validity in trauma-exposed youth and their inclusion in DSM-V PTSD should be considered. As for preschool children, alternative criteria are recommended that are more developmentally sensitive.
To find out child-adjusted protocol for eye movement desensitization and reprocessing (EMDR).
Child-adjusted modification were made in the original adult-based protocol, and within-session measurements, when EMDR was used in a randomized controlled trial (RCT) on thirty-three 6-16-year-old children with post-traumatic stress disorder (PTSD).
EMDR was applicable after certain modifications adjusted to the age and developmental level of the child. The average treatment effect size was largest on re-experiencing, and smallest on hyperarousal scale. The age of the child yielded no significant effects on the dependent variables in the study.
A child-adjusted protocol for EMDR is suggested after being applied in a RCT for PTSD among traumatized and psychosocially exposed children.
This study evaluated an early intervention for children and their parents following pediatric accidental injury.
Information booklets provided to participants within 72 h of the initial trauma detailed common responses to trauma, the common time course of symptoms, and suggestions for minimizing any post-trauma distress. Following admission for traumatic injuries sustained in motor vehicle accidents, falls and sporting injuries a total of 103 children (aged 7-15) and their parents were evaluated at pre-intervention, 1 month, and 6 months post-trauma. The intervention (N = 33) was delivered to one of two hospitals, the second hospital was the control (N = 70).
Analyses indicated that the intervention reduced child anxiety symptoms at 1-month follow-up and parental posttraumatic intrusion symptoms and overall posttraumatic symptoms at the 6-month follow-up. No other differences between the intervention and control groups were found.
Overall, the information-based early intervention is simple, cost-effective method of reducing child and parent distress post-trauma.
We review recent evidence regarding risk factors for childhood posttraumatic stress disorder (PTSD) and treatment outcome studies from 2010 to 2012 including dissemination studies, early intervention studies and studies involving preschool children.
Recent large-scale epidemiological surveys confirm that PTSD occurs in a minority of children and young people exposed to trauma. Detailed follow-up studies of trauma-exposed young people have investigated factors that distinguish those who develop a chronic PTSD from those who do not, with recent studies highlighting the importance of cognitive (thoughts, beliefs and memories) and social factors. Such findings are informative in developing treatments for young people with PTSD. Recent randomized controlled trials (RCTs) confirm that trauma-focused cognitive behaviour therapy (TF-CBT) is a highly efficacious treatment for PTSD, although questions remain about effective treatment components. A small number of dissemination studies indicate that TF-CBT can be effective when delivered in school and community settings. One recent RCT shows that TF-CBT is feasible and highly beneficial for very young preschool children. Studies of early intervention show mixed findings.
Various forms of theory-based TF-CBT are highly effective in the treatment of children and adolescents with PTSD. Further work is needed to replicate and extend initial promising outcomes of TF-CBT for very young children. Dissemination studies and early intervention studies show mixed findings and further work is needed.
In line with the heightened interest in child hypnotherapy, we discuss three broad topics in this book. First, we review the early history of therapeutic hypnosis with children, emphasizing the 19th-century literature so as to collect in one place those intriguing reports that predated modern scientific method. Second, we discuss issues related to child hypnosis, by which we mean a child can enter that altered state of consciousness that most people define as hypnosis. . . . Third, we review the broad topic of hypnotherapy with children, with chapters devoted to the treatment of psychological, medical, and surgical problems. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Post-traumatic stress disorder (PTSD) is a complex and chronic disorder that causes substantial distress and interferes with social and educational functioning. Consequently, identifying the risk factors that make a child more likely to experience traumatic distress is of academic, clinical and social importance. This meta-analysis estimated the population effect sizes of 25 potential risk factors for PTSD in children and adolescents aged 6-18 years across 64 studies (N=32,238). Medium to large effect sizes were shown for many factors relating to subjective experience of the event and post-trauma variables (low social support, peri-trauma fear, perceived life threat, social withdrawal, comorbid psychological problem, poor family functioning, distraction, PTSD at time 1, and thought suppression); whereas pre-trauma variables and more objective measures of the assumed severity of the event generated small to medium effect sizes. This indicates that subjective peri-trauma factors and post-event factors are likely to have a major role in determining whether a child develops PTSD following exposure to a traumatic event. Such factors could potentially be assessed following a potentially traumatic event in order to screen for those most vulnerable to developing PTSD and target treatment efforts accordingly. The findings support the cognitive model of PTSD as a way of understanding its development and guiding interventions to reduce symptoms.
This Practice Parameter reviews the evidence from research and clinical experience and highlights significant advances in the assessment and treatment of posttraumatic stress disorder since the previous Parameter was published in 1998. It highlights the importance of early identification of posttraumatic stress disorder, the importance of gathering information from parents and children, and the assessment and treatment of comorbid disorders. It presents evidence to support trauma-focused psychotherapy, medications, and a combination of interventions in a multimodal approach.
The aim of this study was to assess the effectiveness of a spiritual-hypnosis assisted therapy (SHAT) for treatment of posttraumatic stress disorder (PTSD) in children. All children, age 6-12 years (N=226; 52.7% females), who experienced the terrorist bomb blasts in Bali in 2002, and subsequently were diagnosed with PTSD were studied, through a longitudinal, quasi-experimental (pre-post test), single-blind, randomized control design. Of them, 48 received group SHAT (treatment group), and 178 did not receive any therapy (control group). Statistically significant results showed that SHAT produced a 77.1% improvement rate, at a two-year follow up, compared to 24% in the control group, while at the same time, the mean PTSD symptom score differences were significantly lower in the former group. We conclude that the method of spiritual-hypnosis is highly effective, economic, and easily implemented, and has a potential for therapy of PTSD in other cultures or other catastrophic life-threatening events.
Childhood psychic trauma appears to be a crucial etiological factor in the development of a number of serious disorders both in childhood and in adulthood. Like childhood rheumatic fever, psychic trauma sets a number of different problems into motion, any of which may lead to a definable mental condition. The author suggests four characteristics related to childhood trauma that appear to last for long periods of life, no matter what diagnosis the patient eventually receives. These are visualized or otherwise repeatedly perceived memories of the traumatic event, repetitive behaviors, trauma-specific fears, and changed attitudes about people, life, and the future. She divides childhood trauma into two basic types and defines the findings that can be used to characterize each of these types. Type I trauma includes full, detailed memories, "omens," and misperceptions. Type II trauma includes denial and numbing, self-hypnosis and dissociation, and rage. Crossover conditions often occur after sudden, shocking deaths or accidents that leave children handicapped. In these instances, characteristics of both type I and type II childhood traumas exist side by side. There may be considerable sadness. Each finding of childhood trauma discussed by the author is illustrated with one or two case examples.
The psychological impact of trauma can include cognitive, affective, and behavioral components. The degree to which a child is either overwhelmed by or unable to access the traumatic event can make the working through of the event in therapy difficult. Hypnotherapy is a useful modality not only for alleviating symptoms but also for uncovering the traumatic event(s) with associated affects, integrating and making sense of the experience. 4 case studies are reported to illustrate the utility of hypnotherapy with young, traumatized children.
Twenty-three children involved in a school-bus kidnapping were studied from 5 to 13 months following the event. Each child suffered posttraumatic emotional sequelae. The author found that the children suffered from initial misperceptions, early fears of further trauma, hallucinations, and "omen" formation. Later they experienced posttraumatic symptoms consisting of posttraumatic play, reenactment, personality change, repeated dreams (including predictive dreams and those in which they died), fears of being kidnapped again, and "fear of the mundane." Differences between child and adult response to psychic trauma are discussed.
Although conceptualized as a normal reaction to loss and not classified as a mental disorder, grief can be considered a focus of treatment. When grief complicates and becomes pathological by virtue of its duration, intensity, and absence or by bizarre or somatic manifestation, a psychiatric diagnosis is in order. Childhood PTSD in Complicated Bereavement is a condition derived from the loss of a loved one when the nature of death is occasioned through traumatic means. The traumatic nature of the loss engenders trauma symptoms, which impinge on the child's normal grieving process and his/ her ability to negotiate the normal grieving system. The 2 cases presented herein constitute single session treatment with clinical hypnosis of PTSD, a result of the traumatic loss of the paternal figures. The setting in which these cases took place was rural Guatemala. Treatment consisted of single session hypnosis with the Hypnotic Trauma Narrative, a tool designed to address the symptomatology of PTSD. Follow-up a week later and telephone follow-up 2 months later demonstrated the resolution of traumatic manifestations and the spontaneous beginning of the normal grief process.
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