Cognitive and Academic Implications of PTSD
Research suggests that children who have experienced traumatic stress may be at-risk for academic problems (Lipschitz et al., 2000). The normal development of neurobiological modulatory systems may be compromised, thereby negatively affecting activity level, capacity for reflection, and focused attention. These variables are crucial for normative academic achievement (Johnson, 1998; Pynoos, Steinberg, & Goenjian, 1996; Siegel, 1999; van der Kolk, 1996). To illustrate, Barnett (1997) indicated that abused, maltreated, or neglected children demonstrated lower scores on cognitive measures and less school achievement than non-abused, matched controls. Schwab-Stone and colleagues (1995) found that trauma exposure and feeling unsafe significantly predicted grade retention and lower child-reported grades. Lipschitz and colleagues (2000) found that girls with PTSD were significantly more likely to fail a course or grade than girls without PTSD. In addition, research conducted by Delamater and Applegate (1999) found preschool children diagnosed with PTSD to be at increased risk for developmental delay.
Long-term (Type II) exposure may be especially damaging in terms of psychoeducational development. To illustrate, Neumberger (1997) suggested that adults who experienced continuous abuse or stress as children experienced shrinkage of the regions of the brain implicated in memory, learning, regulation of affect, and emotional expression. Language processing may be uniquely affected (Pynoos et al., 1999; Siegel, 1999; van der Kolk, 1996) as severe stressors may impair integration of left hemisphere functioning (van der Kolk, 1996). Trauma may interfere with the formation of narrative coherence, essential to competencies in communication, reading, and writing (Pynoos et al., 1999) and some research has pointed to specific effects in reading (Driver & Beltran, 1998; Pynoos et al., 1999; Rynard, Chambers, Klinck, & Gray, 1998; Schwartz, McNally, & Yeh, 1998). It is important to note that some researchers have not observed academic effects (Sack et al., 1999; Wenz-Gross & Siperstein, 1998) and others have associated effects with preexisting difficulties (Pynoos et al., 1996; Yule, 1991). These findings underscore the importance of controlling for pre-trauma functioning.
The school psychologist can play a consequential role in treatment and recovery processes in PTSD. Notwithstanding, therapeutic interventions should be based within the school setting only when: (a) comprehensive assessment has been completed; (b) it is determined that school-based support is the appropriate, least restrictive level of intervention; (c) parents have been informed of all treatment options; (d) the child is experiencing adequate adjustment and academic success with intervention; and (e) consultation, supervision, and referral are readily utilized by the school psychologist (Cook-Cottone, 2000). Of note, as with diagnosis, treatment issues are sometimes complicated by the manifestation of associated psychopathology. Critically, the school psychologist must function within the ethical parameters predicated by training, refer and/or consult when appropriate, and use empirically guided :interventions (Cook-Cottone, 2000).
Cognitive behavioral techniques. Generally, it is believed that effective trauma treatments help to establish desensitization of trauma-reminiscent stimuli, a reduction of avoidance-related symptomatology, and more normative neurological processing (Yule, 2001).
Cognitive behavioral therapy (CBT) currently shows the most promising empirical efficacy data (Goenjian, Karayan, & Pynoos, 1997; March, Amaya-Jackson, Murray, & Schulte, 1998; Perrin et al., 2000; Yule, 2001). It is believed that CBT works by uncoupling the pairing between the traumatic stimuli/cognitive events and the anxiety response and supplants relaxation response and more logical thinking (Basco, Glickman, Weatherford, & Ryser, 2000). The CBT protocol combines stress management and relaxation techniques, cognitive restructuring, and exposure techniques (Cohen et al., 2000; March et al., 1998). Stress management: strategies include breathing techniques, progressive muscle relaxation, thought stopping, and positive imagery (Herman, 1992; King et al., 2000; Najavits, 2002). Mastering anxiety and symptom management techniques are believed to contribute to self-efficacy and confidence, as symptomatic children begin trauma exposure, symptom management, and/or reintegration work (Cohen et: al., 2000; King et al., 2000). Cognitive restructuring is intended to systematically address each cognitive distortion and help the child coconstruct more practical attributions (Cohen et al., 2000; Farrell, Hains, & Davies, 1998; March et al., 1998). Cognitive restructuring is used to address daily coping, risk appraisal, overresponsibility, and negative assumptions regarding the traumatic event (Cohen et al., 2000; March et al., 1998; Najavits, 2002). The restructuring of faulty, posttrauma cognitive systems helps to place the traumatic experience in a more adaptive cognitive context (Farrell et al., 1998).
Notably, stress management and cognitive restructuring techniques are appropriate for use in both the school and clinic settings. During school implementation, careful monitoring of symptomatology and therapeutic response can facilitate any necessary referral. Referrals are warranted when symptoms shift in severity from mild to moderate or severe (i.e., they begin to interfere with social, occupational, or school functioning; APA, 2000). Some specific examples include: (a) alterations in emotional or physiological presentation (e.g., flat or depressed affect, panic attacks, fears of being alone, hyperarousal, and difficulties with emotional regulation); (b) changes in cognitive or learning experience (e.g., frequent intrusive memory experiences, suicidal ideation, and memory disturbances that interfere with learning); and (c) behavioral symptoms (e.g., reenactment behaviors during school, manifestation of traumatic images in play and drawing, behavioral regressions, self-mutilation, and suicide attempts; Osofsky, 1995).
Direct or indirect exposure may be a critical component of successful treatment (Basco et al., 2000; Cohen et al., 2000). It is important to note that during the exposure-based component of the therapeutic protocol, children may manifest symptom exacerbation (Cohen et al., 2000). Consequently, exposure techniques are not considered appropriate for the typical school setting. However, the school psychologist can provide school-based supports for children and adolescents during exposure treatment. For example, school-based supports might include: coordination of communication among school personnel, family members, and the treatment team; assistance with student symptom management and monitoring; and provision of treatment-consistent stress management and cognitive restructuring techniques. Exposure is typically coupled with relaxation techniques to alter the trauma-reminiscent response. In direct exposure, or flooding, the child is exposed to the threatening stimuli (e.g., use of trauma-reminiscent props; Basco et al., 2000; Saigh, 1987). Conversely, indirect exposure involves a systematic, gradual exposure to increasingly arousing or anxiety-producing aspects of the trauma experience (i.e., systematic desensitization; Basco et al., 2000; Cohen et al., 2000; King et al., 2000). Building on the child's initial, typically brief, and general descriptions of the traumatic experience, in each session the child is directed to increase descriptive detail and then recall event-specific thoughts and feelings (Cohen et al., 2000). This process may incorporate varying expressive modalities including drawing, role-playing, mock interviews, and writing (Cohen et al., 2000; King et al., 2000).
The later 1990s showed the emergence of increasingly sound research demonstrating the effectiveness of comprehensive, manualized, cognitive behavioral protocols (Deblinger, Lippmann, & Steer, 1996; Farrell et al., 1998; Goenjian et al., 1997; King et al., 2000; March et al., 1998). These protocols typically incorporate stress management and relaxation techniques, cognitive restructuring, and exposure techniques (Phillips, 2001) and are typically administered by professionals with extensive clinical training, with the school psychologist playing a supportive role. Continued research is needed as it is difficult to ascertain which components of the comprehensive, therapeutic interventions yielded the positive outcomes. In addition, many of these studies had significant methodological limitations (i.e., experimental control, sample size, extended follow-up latency), which affect the internal and external validity of the findings.
Additional interventions in need of research. Currently, CBT protocol remains the most empirically supported model for treating PTSD in children and adolescents. Trauma interventions showing emerging empirical support include play, art, and narrative therapies and psychopharmacology. Because of issues related to language development in children, play and art therapies may have a unique role in the treatment of pediatric PTSD. That is, visually stored trauma memories may be more readily expressed through nonverbal modalities (Kazlowska & Hanney, 2001; Osofsky, 1995; Stronach-Buschel, 1990). Narrative techniques that have shown some positive effects include: journaling, bibliotherapy (i.e., therapy using children's literature), and constructivistic bibliotherapy (i.e., creation of memory or trauma scrapbooks; King & Holden, 1998; Lowenstein, 1995; Pennebaker & Graybeal, 2001). Finally, medication may be proven useful as an augmentative treatment for those children and adolescents not responding to psychological interventions alone (see Phelps, Brown, & Power, 2002). Though efficacy studies are emerging (Phelps et al., 2002), replicated controlled empirical exploration of the aforementioned treatments of PTSD in children are needed (Cohen, Mannarino, & Rogal, 2001; Donnelly, Amaya-Jackson, & March, 1999).
- Cook-Cottone, Catherine; Childhood Posttraumatic Stress Disorder: Diagnosis, Treatment, and School Reintegration; School Psychology Review, 2004, Vol. 33 Issue 1, p127-139
Reflection Exercise #7
The preceding section contained information
regarding intervention strategies for child disaster survivors with PTSD. Write
three case study examples regarding how you might use the content of this section
in your practice.
According to Cook-Cottone, what form of treatment for PTSD currently shows the most promising empirical efficacy data in children? Record the letter of the correct answer