Assessment
PTSD is often a difficult disorder to diagnose. While the professional school counselor may not be directly involved in the diagnosis of PTSD, the following assessment procedures are helpful in understanding the diagnostic process. According to the DSM-IV-TR (APA, 2000X symptoms usually begin within 3 months after the trauma, although there may be a delay off months, or even years, before symptoms appear. The symptoms of the disorder and the relative predominance or re-experiencing, avoidance, and hyperarousal symptoms may vary with time. Duration of the symptoms varies, with complete recovery occurring within 3 months in approximately 50% of cases, with many others having persisting symptoms for longer than 12 months after the trauma. In some cases, the course is characterized by a waxing and waning of symptoms. Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events.
A thorough and proper assessment requires a face-to-face interview with the student in which she is directly asked questions about the traumatic symptoms experienced. It is important to also interview the parents so as to gather as much information as possible. The use of empathy, establishment of rapport, and a safe environment where the student can discuss painful and angry feelings are very important to acquiring accurate information. Particular attention should be given to using developmental^ appropriate language when assessing the student.
Both the parents and the student should be asked directly about the traumatic event and about PTSD symptoms in detail. Specific questions related to re-experiencing, avoidant, and hyperarousal symptoms as described in DSM-IV-TR should be asked. Other symptoms that often present comorbidly with PTSD should be assessed, such as symptoms of depression* anxiety, substance abuse, and acting out behaviors. Obtain reports of any preceding, concurrent, or more recent stressors in the student’s life as well. Some examples of stressors may be child abuse, significant conflict within the family, frequent moves, death in the family, and exposure to community violence (AACAP, 1998).
The professional school counselor should be aware of developmental variations in the presentation of PTSD symptoms, especially with young children. For an accurate assessment ask about developmentally specific symptoms when interviewing young children. AACAP (1989) reports there are a few published semi-stnictured assessments available such as the Structured Clinical Interview for DSM-111-R, and the Diagnostic Interview Schedule Clinician-Administered PTSD Scale for Children and Adolescents. AACAP also reported that the following child/parent
rating forms may be clinically useful for following the course of PTSD symptoms in children: (1) PTSD Reaction Index; (2) Trauma Symptom Checklist for Children; (3) Checklist of Child Distress Symptoms-Child and Parent Report Versions; (4) Children ’j Impact of Traumatic Events Schedule; (5) Child PTSD Symptom Scale; and (6) Impact of Events Scale. However, there is no single instrument that is considered optimal. Using a single instrument limits the type of information needed to make a PTSD diagnosis, as a student must have a certain number of symptoms from each of three different categories to meet DSM-IV-TR criteria. It is difficult for any single instrument to assess for all of these criteria. Therefore, there is no good substitute for a good, thorough and direct interview with both the student and parents. It is also sometimes useful to speak with the student’s teacher(s) to get a history of symptomology manifested at school with a particular emphasis on changes in school behavior, interaction with peers, concentration, activity level, and academic performance since the traumatic stressor.
In addition, it is a good idea to initially meet with the parents separately from the student. When interviewing parents, the goal is to gather as much information as possible so that an understanding of the parents’ perspective on the trauma and relationship with the child can be determined. It is also important to assess information on: (1) family psychiatric and medical history; (2) marital conflict, separation, divorce, abuse; (3) developmental history, including the student’s temperament and mood; (4) academic history and performance in school prior to and after the trauma; (5) student’s current functioning; (6) impact of the trauma on the family and parent(s); (7) presence of parental PTSD symptoms; and (8) the perception of how much support is available to the child from the family (Perrin, Smith, & Yule, 2000).
When interviewing the student, have the student recall as much of the trauma as possible. After die student has told her story, go back and clarify or prompt with additional questions. Tracking the time line of the trauma and subsequent symptoms is useful in making a diagnosis of PTSD. If unsure about the sequence of events or a particular symptom, ask about it directly. As much as possible try to obtain the student’s report of trauma-related attributions and perceptions. Query beliefs about the event, how the student feels subsequent to being exposed to the stressor, level of responsibility, and perception of family support (AACAP, 1998). The student’s feelings, thoughts, and behaviors related to the event should be queried, as well as their thoughts and feelings about the future. With very young children who find it difficult to developmentally discuss the trauma and their thoughts, feelings, and behaviors related to it, it is often useful to use other methods of gathering information. According to Perrin et al. (2000), giving the student pencil and paper and encouraging him to draw something about which he can tell a story is useful in gathering information and helps the student feel comfortable enough to disclose. Encourage the student to elaborate on his story and then try to link the story with some part of the traumatic event in order to facilitate emotional release. After the student has become more comfortable, ask him to draw the traumatic event. Discuss the picture with the student and ask him to describe the sensory components, feelings, thoughts, and coping strategies used during and since the trauma. It is also important to help normalize the student’s reactions to the traumatic event as well as positively reinforce the student for having courage to draw about and discuss the traumatic event.
While the professional school counselor is assessing the student for PTSD symptoms and the associated sequelae symptoms, she should also be asking the student about, and noting, other symptoms often associated with PTSD such as depressive symptoms, suicidal ideations, anxiety symptoms, substance abuse, and conduct disorder behavior.
Treatment
To dale there is limited empirical outcome research on the treatment of students with
PTSD. Direct exploration of the event is likely to be more efficacious the older and more mature the student is. For younger children, more indirect methods of addressing traumatic issues, such as art and play therapy (use of drawings, puppets, dolls, etc.) may be indicated. The use of multiple informant assessment, especially with young children, is likely to elicit more information about the traumatic event and the manifestation of symptoms. For this reason, information collected from young children should be supplemented by parent reports.
A treatment plan should be based on the clinical presentation of the child and should address PTSD symptoms as well as other emotional/behavioral symptoms the student may be experiencing. Each student’s course of PTSD and associated symptoms will be variable and may be extremely idiosyncratic in the nature, intensity and length of symptoms. Therefore, different treatment modalities may be needed depending on the student and the nature of the presenting symptoms and problems. Some will require short-term, long-term or intermittent treatment. Others may require different levels of care, e.g., outpatient care, partial hospitalization, or inpatient hospitalization. The professional school counselor may also need to decide which treatment modality will be the most efficacious for the student - individual, family, or group therapy (AACAP, 1998).
There are quite a few authors who advocate for psychoeducation for parents, teachers, and family members in order to help normalize PTSD symptoms and enlist their help in treating the student who has PTSD (Gallant & Foa, 1986; Molta, 1995). Education about the traumatic experience and subsequent symptoms may also be helpful to the student who has been exposed to a stressor. The student often has perceptions, feelings, and symptoms about the stressor that can be normalized in order to help increase self-efficacy and, thereby, decrease anxiety.
Individual therapy is another modality that can be extremely helpful to students who have been exposed to a stressor. There are many different theoretical orientations that are used by professional school counselors in order to help students with PTSD. Psychoanalytic/ psychodynamic approaches are sometimes used and often help expose defense mechanisms that are being utilized and also help to redefine current significant relationships in the student’s life. Play and art therapy are also often used to accommodate students who are developmentally incapable of benefiting from a direct verbal exchange with a professional school counselor. These indirect methods of addressing traumatic issues may be helpful to students so as not to retraumatize them as they think about and talk about the traumatic event.
There is also significant empirical support for cognitive-behavioral therapy (CBT) in the present literature for the treatment for PTSD. The goals of CBT treatment are the reduction of PTSD symptoms, the development of positive coping skills, and an increase in the individual’s sense of well-being. It is helpful to provide both the parents and student with education and information on PTSD and its effects on all levels of functioning. Normalizing the student’s, parents’, and family’s feelings and responses also may help to lessen anxiety and alleviate the severity of symptoms. This form of psychotherapy also focuses on the teaching of progressive muscle relaxation, thought-stopping, positive imagery, and deep breathing prior to having the student discuss the traumatic event. Mastering these skills gives the student a sense of control over thoughts and feelings rather than being overwhelmed by them, aj\d will help the student approach the discussion of the traumatic event with confidence, thereby reducing uncontrollable re-experiencing of fears and symptoms. At the center of CBT is also the use of imaginai or in vivo exposure to help the emotional processing of traumatic memories. This process is done in such a way as to help the child process his or her emotional reactions to the event in a safe and trusting way to master and lessen feelings about the traumatic event.
Pynoos and Nader (1988) described a “psychological first aid” approach for students exposed to community violence which may be offered in schools as well as traditional treatment settings. This model emphasized clarifying the facts about the traumatic event, normalizing
student’s PTSD reactions, encouraging expression of feelings, teaching problem-solving techniques, and referring the most symptomatic children for ongoing treatment.
Family therapy is a way to integrate the whole family into the student’s treatment. Parental support and reaction to the child/adolescent are likely to affect the child/adolescent’s symptomology. Most experts assert that inclusion of the parents and/or supportive others in treatment is important for resolution of PTSD symptoms for children and adolescents. Including parents in treatment helps them monitor their child’s progress and symptomology and also helps the parents resolve their emotional distress related to the trauma (AACAP, 1998; Cohen, Berliner, & March, 2000).
Trauma-focused groups for children/adolescents, as well as parents, can lead to beneficial and encouraging open discussions of perceptions, attributions, and feelings about the traumatic event. Group therapy is often used after major traumas and disasters as a way to help debrief and normalize the event for the child/adolescent. School-based group crisis intervention may be particularly useful after trauma and disaster situations.
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