Low Income Children with PTSD: Effects and Coping Mechanisms

Almost all of us are familiar with newscasts and newspaper reports showing returning US war veterans from Iraq and Afghanistan and the difficulties they face returning to civilian life. Many have lost limbs and are adjusting to a lifetime of physical limitations. Others saw unspeakable events while on duty: children blown up by enemy fire, entire villages wiped out, or their unit buddies taken out by a bullet to the face. These news reports, while difficult to watch, have an unintended benefit. We get the message that witnessing or being a part of horrible events such as war, mutilation, and unnecessary death can cause an inability to function as healthy human beings. Life is distorted and flashbacks to the traumatic event itself are frequent. Reliving the event can easily cause the victim to be immobile and unable to perform even the simplest of life’s functions, such as showering or eating regularly. The more complex aspects of modern life such as finding and keeping a job or relating well to a spouse and other close relatives are often totally out of reach.

Post-Traumatic Stress Disorder (more commonly known as PTSD) is known to us. Our attention to our returning veterans gives us a seemingly tacit understanding of this mental disorder and how it manifests in our military members. But, other horrific events in a non-military environment can cause the disorder to appear as well. Witnessing a murder; living in violent neighborhoods; or being a victim of physical, mental, or sexual abuse can easily result in PTSD. This paper specifically addresses one such population: children living in poverty who might routinely face the aforementioned life events. Specifically, the paper will explore the learning and social effects of the disorder and highlight coping strategies that work among this group of vulnerable children. While no therapies were specifically designed for low income children and teens, some work better than others against this group.

PTSD Background

PTSD is a mental health condition that is triggered by witnessing (vicarious trauma) or being a part of a ghastly event. Symptoms include, but are not restricted to, flashbacks to the event itself, nightmares, anxiety, and uncontrollable thoughts about the event. If the patient receives treatment as soon as possible post event, treatment modalities will generally work faster and better. The disorder can, however, last for weeks or months, or perhaps even years. With proper intervention by mental health providers, the disorder can be alleviated or entirely cured (Mayo Clinic.org). In the US, about 5.6 million adults suffer from PTSD each year, or about 3.6 percent of the adult population. Among veterans returning from war the figure rises to an astonishing 30 percent (Right Diagnosis.com).

In 2013, the World Health Organization (WHO) published guidelines for the treatment of people who developed adverse symptoms as a result of witnessing or being a part of a traumatic event. The WHO encouraged mental health professionals and nurses to offer basic psychological support, psychological first aid, stress management, and to help patients identify and strengthen positive coping methods and social supports. The WHO also advised these professionals to refer people who did not respond to front-line treatment to therapists with a specialty in treating PTSD. Those therapists are able to offer advanced behavioral therapy and special types of coping treatments that the front-line professionals probably are not trained to administer.

WHO also specifically stated there was no essential difference in the specific therapies for children as opposed to other groups? Therapies developed for adults are appropriate for children as well. Those specific therapies, however, need to be adjusted and tailored to take into account the mental age of children and their cognitive ability. For example, it would be inappropriate to use vocabulary beyond the grade level of a low-income child with PTSD. Instead, the counselor could use children’s books to illustrate what the counselor wants the patient to do in the therapeutic session. (Pulse International, August 2013).

PTSD Effects on Children

While there are many studies of adults with PTSD and the disorder’s effect on memory and cognitive ability, there are few studies concerning children. And, what few there are mostly do not specifically address the disorder as it affects low income children. An exception is a 2013 study summarized in the American Journal of Occupational Therapy. The study showed that people who experienced the toxic stress of recurrent traumas such as physical or sexual abuse in childhood are prone to develop an increased risk of physical and mental problems later in life. (Journal of Occupational Therapy 2013). The American Psychological Association summarized other research that speaks to the effects of trauma on children in poverty. Unsafe neighborhoods can expose these children to increased violence which can cause psychosocial problems in the future. Behavioral problems can include impulsiveness, aggression, Attention deficit Hyperactivity Disorder (ADHD), and impaired ability to relate well with peers. (apa.org.)

These behavioral problems resemble some of those that are associated with PTSD and may, in fact, be the symptoms of a mild form of the disorder. But, whether it is PTSD, depression, conduct disorder, or some other mental health issue, too many children escape treatment while they are young (apa.org). These childhood behavioral problems can lead to low self esteem and a reduced ability to relate well with peers and family..

We can surmise that the effect of being PTSD-positive among children in poverty would be the same or more severe compared to the average for all children. One study summarized in the journal Biological Psychiatry investigated three groups of children. One group was PTSD-positive, that is, it conformed to the definition of PTSD’s symptoms. Another group was trauma-exposed but did not meet the rigorous definition of PTSD’s symptoms. The third group was PTSD-negative. The study showed there were significant memory impairments among those children exposed to trauma or who were PTSD-positive using standard psychological memory tests (Yasik, 2007)

When we consider what the studies mean in terms of a child’s ability to learn and absorb lessons through elementary and high school, we can understand the true toll of PTSD, and other mental disorders caused by trauma, takes on children and adolescents. Compared to the rest of their friends and classmates, they will not read at grade level. They will not know how to do simple arithmetic. They will be severely limited in their ability to find a future job that pays beyond minimum wage. They will drop out of school before graduation. Unless mental health professionals intervene, these children might be lost to us, their potential severely limited by untreated PTSD.

Coping Mechanisms for the PTSD Child and Adolescent

If children are able to access mental health facilities and professionals with some measure of frequency, there is a high likelihood that the youth will be able to deal with his PTSD and establish normal and healthy responses to actual and imagined trauma. As stated previously, there is little difference in treatment protocols for children and adolescents compared to adults. However, the protocols may need to be adjusted so that they are age-appropriate. Professionals administering treatment also need to be attuned to the child or adolescent to ensure the youth is not scared of the treatment. Several coping mechanisms are outlined next.

Prolonged Exposure Therapy

Prolonged exposure therapy (PE) and exposure therapy (ET) are methods mental health professionals often use with patients with PTSD, depression, and other conditions. The patient is taken back through the traumatic event that has caused his distress so that he can gradually see that his fear and anxiety are unfounded because the event is in the past and can not hurt him anymore. PE is administered over several or more sessions depending on how well the patient does confronting the event in question. PE differs from ET in the amount of exposure is undertaken by the patient and the mental health professional, with ET the shorter of the two.

In a 2010 review of literature by the Department of Veterans Affairs and the Department of Defense, exposure therapy (ET) was rated as the most effective first line defense for PTSD. The review found that this was true even if co-morbidities were present and regardless of the type of trauma the patient had experienced. While the review was intended for use in treating returning vets with PTSD, the review was thorough enough that it has meaning for other non-military groups afflicted with PTSD (Rauch 2012).

PE is also successful in reducing other negative emotions that alienate the patient from his own feelings and from significant family members and friends. These negative feelings include anger, guilt, negative self-health perceptions, and depression. The VA/DOD review of the literature on PE’s role in PTSD and other mental disorders was not expected to reveal such a positive outcome for PE. But, as a result the VA has trained an additional 1,300 health professionals in how to administer PE methods (Rauch 2012).

Surely this is a lesson for health professionals outside of the military. School counselors could be taught the techniques so that they could work with children and adolescents afflicted with PTSD or related mental disorders.

PE Sessions

Wide variability exists in how exposure sessions are handled. They can be done individually or in groups, and some therapists will take patients through a set number of sessions, while others conduct sessions until no more can be usefully gained from them.

In one study cited in the literature concerning PE and its use with PTSD patients, a group of patients were taken through a total of 12 sessions. The treatment sessions allowed each patient to come to a candid rationale for the exposure to his own trauma, a recounting of the traumatic event by each patient in the study, learning breathing exercises to help each patient deal with the fear of recounting the event, and homework for the next session. Homework consisted of trying to recount the event without signs of anxiety. Patients were also given a final project to complete, the preparation of a booklet cataloging what was helpful about the therapy experience and how it has helped the patient regain healthy coping mechanisms. Patients were noticeably better adjusted post-treatment according to the patients themselves. The study also showed that the treatment sessions could be administered by medical professionals such as nurses trained in PE methods and practice (Otto 2014 4).

The use of other medical professionals such as nurses and guidance counselors as substitutes for higher-paid psychiatrists is one sound method to make PTSD treatment more readily available to poor children and youth. It is important for PTSD patients to confront the trauma that has caused them so much malaise. Providing counselors or social workers are empathetic to the particular needs of PTSD stricken youth, and putting them through ET session training first, could mean additional resources for poor youth.

Pills Versus CBT for PTSD

A review of the literature shows that forms of cognitive behavior therapy (CBT) such as ET and PE have a noticeable and significant positive impact on those afflicted with PTSD. It is the acknowledged front-line therapy for this mental disorder whether the patient is a returning veteran, an adolescent, or a child. While the treatment sessions need to be appropriate for different age groups, with illustrations and other support material for a five-year-old much different from what would be used with a teenaged patient.

Still, the PE method is in competition with the drug industry for patients. In 2012, Dr. Robert T. London, a psychiatrist practicing in New York, questioned the use of drugs as the first line of defense when psychiatrists treat PTSD. In 2012, the Food and Drug Administration approved paroxetine and sertraline for use in treatment of the disorder. Dr. London’s point is Americans typically look to the drug industry for solutions to health issues without first looking at what non-drug solutions have worked in the past. The issue is of particular importance to those treating children and teens. If PTSD can best be addressed with PE therapy, why would anyone want to prescribe drugs as part of the treatment regimen? And, consider low income children: Would their families be able to afford new prescription drugs? To Dr. London, PTSD treatment professionals need to carefully consider the risks of prescribing drugs when non-drug treatment programs already work well without them (London 2012 37). And, certainly when special consideration is given to PTSD children and teens in poverty we should not add an extra burden of affording a drug regimen.

Future PTSD Treatment Strategies

While PE and ET are established treatment modalities for PTSD and are in heavy use today, other treatments are beginning to come on stream as well. Some patients do not respond well to PE and ET even though they are established cognitive behavioral treatments that have stood up to rigorous testing. And, some newer therapies may be more appropriate for lower income children and teens.

Stress inoculation therapy is one such protocol. It involves a series of exercises that are easily taught and easily assimilated by lower income children and teens. No drug regimen is required, and the therapist administering the therapy does not have to have any specialized psychological training. Patients are taught controlled breathing exercises to use when memories of the trauma seem too hard to bear. Muscle relaxation, guided positive imagery, thought stopping, and cognitive restructuring are also a part of this newer therapy.

For lower income children and teens, this therapy is an inexpensive way to bring needed help to those living in poverty and suffering from PTSD. Families of PTSD youth can more easily afford this type of treatment. Expensive drugs and therapists are not an issue (Cahill 2007, 32).

Cognitive restructuring was first used to treat depression, but today it is used more and more to treat PTSD. This is again a treatment modality that can gain acceptance in the treatment of low-income children and teens. As the basis for the therapy, cognitive restructuring recognizes that it is not the actual event that causes problematic emotional reactions, but the interpretation of that event that count. Patients are encouraged to identify and challenge inaccurate cognitions they may have about a trauma and replace those with more realistic and helpful ones. This therapy can be administered by a nurse, a parent, or anyone else trained in how the therapy works; it does not have to be administered by a more expensive psychotherapist. It, again, is cost effective, making it an attractive therapy for low income youth (Cahill 2007 32).

Eye movement desensitization and reprocessing (EMDR) is another emergent therapy to treat PTSD. In this therapy, patients are shown a series of rapid images about the trauma that are flashed quickly before the patient’s eyes. The therapy is designed to enhance the patient’s ability to build on his information processing skills and thereby reduce the likelihood of being affected by the trauma. This therapy is probably not appropriate for children and teens as it requires an ability to follow directions closely and to buy into what the therapy hopes to accomplish. Both might well be beyond the capabilities of youth who are already emotionally at risk and unable to grasp the intent and the steps required of this therapy (Cahill 2007 32).

Conclusions

PTSD is a confounding mental illness. It can manifest itself as one thing on one day such as depression, and be something else entirely on another day, such as forgetfulness or general apathy about life. This is not stated to minimize its consequences. PTSD is a serious mental illness that needs careful diagnosis and treatment. Not doing so can result in patients perhaps harboring suicidal tendencies and acting on those tendencies. Or, patients are generally fine, with only occasional bouts of flashing back or becoming overly anxious. The point is patients exist on all points along the spectrum of disease characteristics. We serve them better with complete knowledge of the disease and matching knowledge of available treatments.

Much of the work in understanding PTSD has been done on returning war veterans. That population of PTSD sufferers is one of the largest and easiest to keep track of. Little work, by comparison, has been done on children or teens as PTSD test subjects, meaning we have to extrapolate findings on other groups to make assumptions about diagnosis and treatment among youth, and especially low-income youth. But, those extrapolations do not seem overly far-fetched and low-income children treated with the usual treatment modalities seem to recover at least as well as our war vets.

Cognitive behavioral therapy (CBT) and its various offshoots such as ET and PE are the usual modes of treatment for those afflicted with PTSD, whether veterans, children, or teens, or those in low income households. It may take some time for any of these therapies to work, but over time, they tend to help patients live fulfilling lives. These therapies tend to be on the expensive side as they are usually administered by trained psychologists. And, they may not be immediately available to lower income patients. .Still, mechanisms are being developed to make CBT easier for less well-educated or credentialed medical professional to administer these therapies. One possible outcome is that new CBT sessions will be developed that cater specifically to the needs of low-income youth.

While CBT continues to be the go-to therapy of choice for PTSD today, there are additional therapies coming online that may broaden the treatment protocols among low income children and teens suffering from PTSD. These alternative therapies promise to provide more choice, be less expensive and more readily available in low income neighborhoods. They include cognitive restructuring, stress inoculation therapy, and eye movement desensitization therapy. These therapies are relatively quick to administer and can be accomplished by someone who is not a psychologist (a nurse, for example). They can also be made available in low income neighborhoods, or even schools, where they are good candidates to use with youth. They provide quick and appropriate relief for those who are suffering mightily.

The PTSD patient may be on the cusp of being able to benefit from additional treatments that are in testing today. Ten years ago, or even five years ago, few new treatments were on the horizon. Given the number of returning war vets the US has seen over the last 15 years, it is gratifying to know that other treatments may soon be in the mainstream of treatment protocols. And, poverty-stricken children and teens, who bore witness to a traumatic event that triggers extreme emotional distress, will also get the help they need.

Works Cited

American Psychological Association (2014). “Effects of poverty, Hunger, and Homelessness on Children and Youth”. Retrieved from http://apa.org.March 28, 2014.

Cahill, Shawn P. "PTSD: Treatment Efficacy and Future Directions." Psychiatric Times (1 Mar. 2007: 32).

Gronski, Meredith P., et al. "Childhood toxic stress: a community role in health promotion for occupational therapists." AJOT: American Journal of Occupational Therapy. 67.6 (2013):

London, Robert T. "PTSD patients deserve first-line treatment." Clinical Psychiatry News (Jan. 2012)

Mayo Clinic. (2014). Diseases and Conditions. “Post Traumatic Stress Disorder”. Retrieved from mayoclinic.org/diseases and conditions/ptsd.

Otto, M. Alexander. "Exposure therapy beats counseling for adolescent PTSD” Clinical Psychiatry News. ( Jan. 2014).

Pulse International. (August 31, 2013) “New clinical protocol and guidelines to enable effective mental health care for adults and children exposed to trauma and loss”

Rauch, Sheila A. M., Eftekhari Afsoon, and Ruzek, Josef I. “Review of exposure therapy: a gold standard for PTSD treatment:.. Journal of Rehabilitation Research & Development. 49.5 (May 012) p679.

Right Diagnosis.com. (2014) “Prevalence and Incidence of Post Traumatic Stress Disorder”. Retrieved from http://rightdiagnosis .com.

Yasik, Anastasia E.’ Saigh, Philip A., Oberfield, Richard A., Halmandaris, Phill v., Biological Psychiatry. (Feb. 2007). “Posttraumatic Stress Disorder: Memory and Learning Performance in Children and Adolescents"