Background

We know that a person who has gone through a traumatic experience is at higher risk for developing a mental health concern, like post-traumatic stress disorder. The risk of developing an anxiety or depressive disorder is higher than for developing PTSD. Studies have shown that 80-90% of individuals who have experienced a traumatic event will go back to their normal functioning over time. The amount of time can vary, based on their functioning before the event, whether the trauma was human-caused or a natural disaster and whether harm was intended. Some can go back to their normal functioning after 2-4 weeks and, for others, it can take much longer. Some people are even able to make meaning or create purpose from a trauma they experienced.

The basic premise of Psychological First Aid is to use a non-pathologizing stance with the assumption of adaption and not of disease development. The goal is for crisis support to help survivors move to the adaptive side. There are 8 basic core actions that focus first on providing safety and comfort followed by coping skills and resources. The foundation is making sure people who have gone through a trauma have access to social support.

Reg Flags

There are certain “red flags” to be aware of as concerns that something else might be going on and further assessment and intervention could be helpful. These include social isolation and withdrawal, extreme avoidance of thinking/talking about the event, feeling numb or not feeling at all, intrusive images/flashbacks, nightmares and poor sleep, anger or violence, and excessive use of alcohol and drugs.

Core Action Steps:

1. Contact and Engagement

In the immediate aftermath of a trauma, people first need their basic needs met. Introducing yourself can help a person feel better connected.

2. Safety and Comfort

After letting someone know you are there to help, it can be nice to offer basic comforts like water and food, a blanket, etc. If there are children in the group, toys and plushies can be additional comforts.

3. Stabilization

People are understandably dysregulated after a trauma. There are some simple things that you can encourage someone to do to help him feel calmer and more regulated – deep breathing exercises, stretching and body movement. It can also help to validate how they are feeling and provide a quiet space.

4. Information Gathering

It is important to keep in mind that you don’t need to know details of a traumatic experience in order to help reduce symptoms and provide comfort and coping skills. It is better to not prompt for details. This is especially true for children. Some children play out their feelings about a traumatic experience and others use play as distraction to not think about the trauma. Research has shown that talking repeatedly about a traumatic experience does not necessarily help with recovery and can actually cause unintended consequences.

5. Practical Assistance

The next step is to help with basic needs including shelter, meals, etc.

6. Connection with Social Supports

PFA focuses on establishing social supports based on a homogenous experience. With mass disasters, not everyone experiences the same thing.  It is important to limit exposure to details of a traumatic event for those who hadn’t experienced those details to begin with. So groups should be put together keeping these factors in mind. It can be helpful to train someone within a particular culture on the PFA principles so that they can overlap their understanding of cultural factors and the PFA response to trauma.

7. Information on Coping

Basic CBT principles like reframing thoughts, focusing on doing enjoyable activities that bring happiness, and mindfulness practices can be useful coping strategies. Again one does not need to know the details of the trauma in order to be able to provide coping strategies.

8. Linkage with Collaborative Services

It is important to be aware of local resources, like SmartCare BHCS here in San Diego,  for when someone could benefit from further assessment or intervention after a trauma.

Further Resources

If interested in learning more, the National Center of Trauma and Stress Network offers a 6 hour course on PFA:

https://www.nctsn.org/resources/psychological-first-aid-pfa-online

There are also wonderful resources about school based PFA on their website:

https://www.nctsn.org/resources/psychological-first-aid-schools

Here is another resource on PFA for healthcare workers:

https://www.ptsd.va.gov/professional/treat/type/SFA/docs/SFA_HCW_Manual_508.pdf

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Co-Medical Director, Vista Hill Foundation

Health Science Clinical Professor, UCSD Department of Psychiatry

President, San Diego Academy of Child and Adolescent Psychiatry

Recent attention to ACEs screenings for children is an important step in identifying families at risk and presents an opportunity for providers to initiate discussion with parents as to their own past trauma exposure— this potentially an opportunity to recommend referral of the parent for either a psychotherapy intervention and/or to offer them an opportunity to learn about resilience interventions that may help reframe the parent-child interaction in a more positive manner.

SmartCare can be a referral resource that primary care providers can offer to parents who wish to obtain support for themselves and for their children.

The links below provide discussion about the psychodynamic understanding of how childhood trauma can impact parenting behaviors.

This first YouTube is a brief discussion of the topic “Ghosts in the Nursery”:

https://www.youtube.com/watch?v=e7HxuTZ7A_E&t=1s

A more detailed and lengthy discussion of the topic “Ghosts & Angels in the Nursery”  is presented at the following link:

https://www.youtube.com/watch?v=hHrR3kJoOg0

Prazosin (minipress) is a centrally acting alpha 1 antagonist, decreasing sympathetic tone.  It is an FDA approved ant-hypertensive. It is a well-tolerated as an off-label treatment for PTSD-associated nightmares, with a small but significant improvement in sleep and decrease in nightmare frequency (Kung et al. 2012).  In 2018, Raskind and others published findings from the PACT study, a randomized control trial which called into question the effectiveness of prazosin for PTSD associated nightmares in combat veterans (Raskind 2018). There were some limitations to the generalizability of this study, such as no non-combatants in the sample. Overall, when evaluating the cumulative research data, there is still a consensus that there is a role prazosin as a therapeutic for trauma-related sleep disturbance (Kendrick et al, 2021).

Alpha agonists, such a clonidine and guanfacine, have been safely used for the treatment of ADHD in youth and adults.  While there is some evidence for the role of these agents in PTSD associated nightmares, given the paucity of studies, prazosin would likely by the first agent of choice.

• Prazosin is well a tolerated treatment for PTSD-associated nightmares with a small but significant improvement in sleep and decrease in nightmares
  • Adolescents – 1 – 4 mg
    • No FDA indication
    • No RCTs, but systematic review is positive (Akinsanya et al. 2017)
  • Adult doses vary but generally 1 – 10 mg, with higher doses for men.
    • No FDA indication
    • Varying evidence, still
• Clonidine has been used to treat PTSD (Aloa et al. 2021)
  • No FDA indication
  • Dosing less well studied and Limited studies in adolescents

References:

AcesAware.org

Akinsanya A, Marwaha R, Tampi RR. Prazosin in Children and Adolescents With Posttraumatic Stress Disorder Who Have Nightmares: A Systematic Review. J Clin Psychopharmacol. 2017 Feb;37(1):84-88. doi: 10.1097/JCP.0000000000000638. PMID: 27930498.

Alao A, Selvarajah J, Razi S. The use of clonidine in the treatment of nightmares among patients with co-morbid PTSD and traumatic brain injury. Int J Psychiatry Med. 2012;44(2):165-9. doi: 10.2190/PM.44.2.g. PMID: 23413663.

Kendrick, J, Adamczyk, R, Thomas, C, 2021. “Prazosin Prazosin for PTSD: Sorting out the evidence Current Psychiatry. 2021 April;20(4):39-41 | doi:10.12788/cp.011

Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic Proceedings, 87(9), 890–900. https://doi.org/10.1016/j.mayocp.2012.05.015

Raskind MA, Peskind ER, Chow B, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-517.

The seminal Adverse Childhood Experiences study demonstrated the strong correlation between the number of adverse events experienced in childhood and the risks for negative health and social outcomes in adult life.  A recent paper in the Archives of Psychiatric Nursing (Hambrick, Brawner, Perry, et al)¹ examines the timing of experienced adversity as a factor negatively impacting overall developmental outcomes. It demonstrates that disruptive and adverse experiences in the early years have significantly more troubling and pervasive consequences than the still harmful disruptions that occur later in childhood.   The study further identified that the presence of positive parent-child inter-relatedness is an important protective factor in the face of such early ACEs, and that the absence of positive relatedness is a damaging one, most particularly for infants and younger children.

This finding suggests that, while current efforts to identify all children and families with ACEs are important throughout childhood and adolescents, efforts to identify parents/families struggling with their own lives during the post-partum and their earliest years of their children’s lives can potentially mitigate some of the long-term risks to these children’s health and well-being.  This may be from current or future ACEs or from experiencing interpersonal and emotional neglect.

The context for the “Beyond the ACE Score” study referenced herein entailed awareness that social, emotional, cognitive, and physiological functioning of a child is impacted by a multiplicity of inputs, amongst which both overt trauma incidents (ACEs) and impairment in parent-child relatedness (relational poverty) are pivotal issues negatively impacting developmental outcomes.   The absence of a strong positive caregiver-child relationship in early childhood is in itself a challenge to healthy development, but its absence in the face of other stressors and adversity, magnifies the trauma load by removing from the equation the resiliency benefits that supportive caregiving, interpersonal engagement and responsive attention can provide to the traumatized child.

The importance of strong, and very importantly, early positive interactions between infants and their caregivers as a positive force in the child’s developing the core building blocks of social-emotional health (engagement, reciprocity, etc.) as well as in enhancing future cognitive and behavioral competency, is clearly supported by the study’s findings.

While adverse incidents and the lack of interpersonal support are problematic at any stage in childhood, the study clearly indicates that the earlier in time that exposure to these two negative factors (trauma and relational poverty) occurs, the higher the predictive risk for negative outcomes.   Conversely, but in no way surprising, the study indicated that greater levels of relational health were associated with better outcomes, even in the face of adverse events and challenges.

These findings provide strong support for providing screening and early intervention in support of parents and families (and their children) to mitigate the likelihood of harm and disruption in children’s overall development. Screening for maternal depression is one form of intervention that many primary care providers already do that are congruent with this goal.  Inquiries about the potential presence of other concerns such as food or housing insecurity, substance abuse in the home and community, and the presence of domestic conflict or domestic violence are other opportunities identify potential children and families at risk.

Making these inquiries can be awkward at times, but just as inquiries of youth and parents about ACEs and just as inquiries of teens about self-harm, substance use and sexuality can be challenging, framing the questions as a routine matter of health promotion can minimize discomfort on both sides of the interchange.    Asking about these risk factors in a calm and non-judgmental manner can open the door to discovery: “I hope this is not uncomfortable for you, but part of our work as healthcare providers is to ask all our patients’ parents about potential challenges that can have impact on health and well-being.  If you are OK with this, I’ve got a few personal questions.  Is this OK for you?  [If ‘No’, end of inquiry, but if ‘Yes’, proceed]   Is your family having challenges with: food insecurity; …..housing; …. substance use; ….interpersonal conflicts?”

If any replies are affirmative, an empathic and support comment (e.g., “That sounds tough” would be appropriate) followed by a recommendation about potential resources.  Responsive options could include the County’s 211 information line or referring to SmartCare’s Parent Line [868 956-5900] for further follow up and services.

Reference:

Hambrick, Brawner, Perry, et al; “Beyond the ACE score:  Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children; in Archives of Psychiatric Nursing 33 (2019) 238-247

When assessing inattention, it is important to consider all possible causes, including: depression, anxiety, reaction to trauma, family or psychosocial stressor, a learning disability, a sensory processing issue, mental retardation, poor educational fit, brain injury, substance abuse, and rarely psychosis. If these other causes have been considered and ruled out, the inattention symptoms are impairing in both the home and school settings and the symptoms began before age 7, then a diagnosis of ADHD is likely. A treatment course involving a stimulant medication will likely be helpful. Likewise if a diagnosis of ADHD has been made but a child does not respond to multiple medication trials including stimulants and non-stimulants, then the treating clinician should reconsider the diagnosis.

Here are two case examples to illustrate the point:

1. 14yo female presents with a chief complaint of “trouble focusing”. She previously maintained good grades and did not have concerns of inattention, hyperactivity or impulsivity in early childhood. She now has failing grades. Associated symptoms include: irritability, poor sleep, isolation including from friends and non-suicidal self-injury for the last 2 months. She has a family history of depression in her mother and maternal GM and older sister.

-This presentation is more consistent with a diagnosis of Major Depression than ADHD. Patients with depression commonly report poor concentration and trouble with attention. A diagnosis of ADHD would not be consistent with this presentation because the patient did not have symptoms begin before age 7. A good treatment plan would be to consider an SSRI and individual therapy. While a stimulant may have helped with her inattention, it would not have helped with her other depressive symptoms.

2. 6yo boy presents with a chief complaint of  “inattention and impulsivity” primarily in the school setting. This child is in protective custody after being removed from bio parents because of physical abuse and neglect. He was not in school prior to the removal and was mostly isolated at home. He also presents with delays in speech and cognitive development as well as anxiety and aggression.

-This case example is more complicated because there are factors related to trauma, as well as developmental and educational delays. It would be important to fully evaluate those delays (including a speech evaluation and cognitive evaluation) and to ensure that he is in an appropriate educational placement prior to considering a diagnosis of ADHD. Also because of the co-morbid anxiety, a stimulant may not be the best medication choice as stimulants can make anxiety worse. Other options might be atomoxetine or guanfacine. Until a more thorough assessment can be completed, a more appropriate diagnosis might be Adjustment Disorder with Disturbance of Conduct and Emotion.

Hopefully this discussion and these case examples help illustrate the importance of a thorough assessment when a child presents with a chief complaint of “trouble focusing”, prior to beginning treatment. Since most patients will first present to their primary care provider with this concern, it is important for primary care providers to be comfortable beginning that assessment process .

Anxiety is a universal and highly adaptive experience, as it keeps us alert to real life dangers. Excessive and/or chronic anxiety, however, can be problematic as it reduces a person’s ability to function. Timely and effective intervention for anxiety disorders can have a dramatic positive impact on a patient’s life.

Core symptoms: The central psychological features of the anxious patient are feelings of nervousness and thinking that is constricted and dominated by worry. Other features may include ruminations, poor concentration, racing thoughts, panic and feelings of exhaustion. Physical features may include signs of over-arousal such as restlessness, muscle tension, sweating, tremor, pain, dizziness, and others. Some patients present with concern about psychological and emotional symptoms; others may present with predominantly with physical health complaints. Many suffer quietly. Acute and chronic anxiety can have significant negative impact on health conditions.

Multiple Subtypes: Anxiety disorders have many faces and it can be helpful to differentiate among the types.

Social Anxiety Disorder: shyness, embarrassment, physical distress associated with exposure

Obsessive Compulsive Disorder: thinking and action constricted, with distress and impaired functioning

Post-Traumatic Stress Disorder: past trauma exposure with ongoing distress, remembering, distress, arousal

Acute Stress Disorder: recent trauma–distress, arousal

Generalized Anxiety Disorder: pervasive and excessive worrying, typically without clear precipitant or trigger

Panic Disorder: florid episodes of intense anxiety with inter-episode apprehensiveness and anticipation

Adjustment Disorder: anxiety experienced in context of acute stressor which resolves as patient adapts or stressor abates.

Important Questions:

1) Simply asking a patient about their level of emotional distress is an important first step in reaching a diagnosis and developing a collaborative treatment relationship.

2) Is the anxiety acute or is it chronic? Most patients report lifelong challenges with their anxiety symptoms.

3) Are there current life stressors—relationships, job, financial, other? Does the patient have natural supports or others (counselors, clergy, etc.) who can help?

4) Was there prior trauma or abuse? It is best to ask this question openly and directly to see if it could be a factor in the patient’s current symptom profile.

5) Is there a family history of similar problems? If so, what helped them?

6) Is there an underlying medical problem? The list is long but endocrine and other conditions may be of note.

7) Are symptoms being triggered by a medication given for a medical or another psychiatric illness?

8) Is substance abuse a contributing factor or a risk factor?

9) Are there other psychiatric issues—depression, mood problems, personality difficulties, etc.?

Treatment: Optimal treatment often entails a combination of education, psychotherapy and/or medication intervention. Psychotherapy alone can be highly beneficial with a focus on faulty thinking patterns, self-calming strategies, social engagement and other activities. Educational resources may prove useful even without formal therapy referral.

Psychopharmacology: SSRIs and SNRIs are the first line of long term medication treatment for most of the anxiety disorders– use with a low starting dose and slow gradual up-titration, as needed and tolerated. Monitoring symptom progression and side effects is necessary early on, but if treatment is effective, routine follow ups for refills can be done more episodically.

Judicious use of anxiolytic agents such as the benzodiazepines can be an important element in psychopharm management— occasional use of low dose, short acting agents is often quite helpful, but ongoing and increased use of these medications can lead to dependence and other problems. A patient needing to take multiple daily doses of a short acting agent for a sustained period needs attention. In some cases, routine use of longer acting agents may be appropriate, with periodic trials of dose reduction planned.