Undiagnosed Post Traumatic Stress Disorder

1.0 Introduction

This chapter provides the background to the study. It includes the problem statement, discusses significance of the study, states research objectives and questions, explains rationale for the study, and lastly discusses the scope and limitation of the study.

1.1Background of the Study

Several empirical studies have been conducted to explore post traumatic stress and the effects of trauma on children and adolescents since 1970s. Langmeier & Matejcek started the research on post traumatic stress in 1973, when they identified four main stages of psychological sequelae and stress. These included: empirical stages, the alarm stage, the period of synthesis, and lastly the beginning of systematic research. Later in 1983, Leonore Terr published her book on the “short and long term effects of traumatic stress to children.” The psychiatric community received that information with disbelief, suggesting that there was no evidence that traumatic events can affect the life of a child over years (Bremner, 1999). From there, successive studies on the effect of traumatic stress on the behavior of children and adolescents were initiated. In 1990, post traumatic stress disorder (PTSD) was identified as an entity by the Diagnostics and Statistical Manual of Disorders and American Psychiatric Associations. The disorder was found to have an impact on the behavior of children and later on adolescents. However, this was not substantiated until the DSM-IV-R version was introduced in 1994 (Brunello, Davidson, Deahl, Kessler, Mendlewicz, Racagni, Shalev, & Zohar, 2001).

Psychologists have been advancing research on traumatic stress since 1990s. In recent years, a lot of studies have been conducted on the impacts of trauma on emotional and behavioral characteristics of children and adults. In addition to those, other empirical studies have also been conducted to explore the effects of childhood trauma on current population. Some of the research reports issued include the 1999 report by one of the United States New York based hospital surgeons about the traumatic stress or (Criteria A) and three other symptom clusters of impairments. The report is posted on the current version of the American Diagnostics Manual popularly known as the DSM. The report was a collaborative effort between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Mental Health (NIMH) (Coslello, Erkanli, Fairbank, & Angold, 2002).

This report was the first ever to adequately evaluate mental health data for children, adults, and the elderly. It revealed the connection between physical health of children and various mental health treatments received. In this study, it was found that there are several criteria that substantially identify the post traumatic stress symptoms in children and adolescents. They include criteria A (experience trauma), criteria B (re-experience), criteria C (avoidance and numbing) and lastly, criteria D (hyper arousal). These criteria must be met before the diagnosis process can begin in children and adolescents.

The DSM diagnostics based criteria for the post traumatic stress disorders in children and adolescent was characterized by certain events. Any child or adolescent at criteria A was found to be a person who was affected by traumatic events at some point in their lives (Breslau, Peterson, Kessler, & Schultz, 1999). The person must have experienced or witnessed a threat of or actual death but survived, may have sustained serious injuries of the head due to accidents, or may have been physically molested by other people at some point in their life time. In children, such traumatic events may cause extreme stress, and, as a result, they may show agitation and irresponsible or even disorganized behavior. Whenever, they recall such events, majority will exhibit fear, hopelessness, and, on certain occasions, tearfulness as a result of the remembrance.  Repercussions of these post traumatic stresses are life long, and a child may grow frustrated and totally confused over time. It is, therefore, essential for such children to visit a psychiatrist or mental health professional at some point in their life time to help ameliorate the symptoms of traumatic stress (Bean, White, & Lake, 2005).

DSM diagnostics criteria B included children and adolescent victims of post traumatic stress characterized by continuous distressing dreams of a certain event, which occurred in their recent past. These dreams are frightening and the child tends to exhibit frustration and tearfulness. Moreover, the stress can be re-experienced when children are playing. The distressed child creates perceptions, thoughts, or even images that portray fear or confusion. The child will even express feelings or act as if the traumatic event is reoccurring exhibiting symptoms of illusions, hallucinations, or even some unusual morning awakening characteristics. Lastly, adolescents will also portray some unusual psychological reactivity on exposure to internal or even external activities relating to the traumatizing and stressing event (Fite, 2008).

In addition to the symptoms outlined above, those adolescents and children meeting criteria C of the DSM for post traumatic stress disorder meet specific characteristics outlined below in their life time. First, they will persistently be noted to avoid stimuli that are associated with the trauma or stressful event. They will, for instance, avoid all thoughts, conversations, or feelings associated with the trauma, which may include fear to visit places or people associated with the trauma. Lastly, they may demonstrate a feeling of being detached from other children or family members. Moreover, adolescents may portray other unusual characteristics such as having no feelings of love, lacking expectations to marry and have children or be in long-term intimate relationships. They may seem to seek out life paths that are considered to be socially abnormal or at least different from those of other people in their peer group.

Lastly, those children and adolescents classified to be in criteria D portrayed certain characteristics such as difficulty sleeping, becoming easily angered or irritated, having difficulty concentrating and/or listening to others, hyper vigilance, and exaggerated responses to situations or life events. Additionally, in most cases, they develop poor health and experience loss of appetite. They may attempt to commit suicide (may even be successful in their attempts) or, in some cases, they may even injure other children or family members around them.

It has been suggested that screening of children and adolescents routinely can help parents and guardians identify those affected by post traumatic stress. Screening needs to be trauma-based only. It should not be complex or threatening because this will undermine the process of determining how stress impacts the behavior of these children. It should convey to trauma victims that all histories of suffering and victimization are over and healing can begin. The ultimate goal is to perform screening of every child or adolescent for the post traumatic stress before they are sent for a formal referral therapy process. If the case is more complicated, then it is recommended to prescribe medical treatment to the victim. Psychologists and counselors have to to identify characteristics of stress victims before coordinating with psychiatrists for medication.

Recently, several studies have been conducted about screening and treatment of trauma.  For instance, in March, 2010 Family Resources Inc. joined the network of Midwest Trauma Services Network (MTSN) founded and directed by Dr. Robert Macy and co-directed by Frank Grijalva MSPH.  MTSN was founded with assistance of a 3-year federal grant awarded to the Office of Juvenile Justice & Delinquency Prevention (OJJDP) project/earmark partnering with Iowa Kidsnet and Lutheran Social Services, Boys & Girls Home & Family Service, Inc., Boston Children Foundation, and international Center for Disaster Resilience (Atkins, McKay, Talbot, & Arvanitis, 2010). This grant allows MTSN to conduct research on post traumatic effects among children and adolescents. Secondly, the partners were to provide training and capacity building, support, and ongoing consultation for systems and agencies working with children and adolescents across the states of Nebraska and Iowa. Emergence of trauma informed Evidence Based Practices (EBP’s) for traumatized children and recognition that the majority of people who request help from social service agencies demonstrate complex trauma histories has prompted the organization to access, modify, and develop programming and vision to meet the needs of the client, agency, and direct care staff. As the mission statement of Midwest Trauma Services Network states, the goal is “to provide integrated, community-based psychosocial stabilization initiatives utilizing state-of-the-art, trauma-specific intervention strategies to reduce the negative effects of maltreatment and exposure from traumatic incidents and disasters on children, youth, and their adult caregivers.” 

Social service agencies are exposed to a variety of external stressors. Federal and state requirements, provider requirements, fiscal constraints, and client family requirements all are typically present and often in conflict. In addition, the complexity of adolescence is compounded by incomplete and/or dangerous family dynamics, medications, forced transitions, and exposure to multiple traumatic events. This in many occasions can result in a behavioral picture that is difficult to make sense of from all sides. The response of MTSN program to the overall picture of organizational stress is the Sanctuary Model developed by Sandra Bloom. This model has demonstrated a deep understanding of the interaction of the traumatized client, the agency, and the community (Bremner, 1999). The Sanctuary model was selected to develop an overarching philosophy of care to be introduced throughout the state and to specifically increase the understanding of client-caregiver interaction.

In October 2011, Family Resources Inc. began the implementation of the Universal Screening for Trauma.  In early 2011, the Health History Questionnaire (HHQ), which is the structured clinical interview that the agency used, was revised to provide more thorough and trauma-sensitive information while gathering information from clients served by the agency.  The HHQ was divided into three parts to make administration easier with resource coordinators (case managers), nursing and licensed practitioners of the Healing Arts (LPHA), each performing their respective tasks with the client. In addition to the revision of the HHQ, the Life Events Checklist taken from the Clinician Administered PTSD Scale for children and adolescents (CAPS-CA) was added to the HHQ to facilitate screening for traumatic events immediately following the admission. In August 2011, the Trauma Symptom Checklist for Children began to be administered following admission as well. The Family Resources Inc. clinical team has also approved the CAPS-CA to be used in identifying the level of PTSD and helping develop treatment for clients who endorse Trauma and PTSD symptoms (Aaron, Ziegenhorn, & Brown, 2011).

In summary, the successive empirical and theoretical studies carried out from 18th century to 21st century targeted the causes, symptoms, impacts on the society, and behaviors of the post traumatic effects among children, adolescents, and adults. Today, there are several undiagnosed and untreated post traumatic stress disorders reported in certain parts of the world, especially in Asia and Africa. Most of the researchers have identified this gap, though no research work has been conducted to fill it. Thus, the main aim of this dissertation paper is to explore how undiagnosed and untreated post traumatic stress impacts the development of behavior disorders in later childhood and adolescence. Children are the future generation and it is important to protect them from traumatic stress, which affects their daily chores such as learning, playing, and even sleeping. It has often been stated that healthy children create the healthy future of a nation. Hence the study fits the expectations of the society, government, and individuals.

1.2 Statement of the Problem

Since 1980s, various traumatic events such as child abuse, community violence, war trauma, accidents, and other disasters have been studied and found to have great post traumatic stress effects on children and adolescents. The studies were completed in areas noted to be significantly impacted by traumatic events, such as in developing countries involved in wars. Studies found that these events are noted to contain stressor characteristics found to cause post traumatic stress implications in children and adolescents (Angold et al, 2002). Various reports published related to post traumatic stress disorders revealed that the impact of traumatic events varies across populations. Several factors were found to explain this diversity, which include measurement tools, chronic and severity of trauma, proximity of the affected child to the scene of trauma occurrence, and lastly, time passed from the moment the traumatic event occurred. Children were found to vividly remember horrific events, which occurred in their lives. Some recalled death incidences during which they lost their parents, friends, and neighbors. Some had frightening dreams. They have changed behavior from courageous to frighten and became fearful. Whenever they were reminded of the scenes of traumatic events, some were found to keep silent, run away from researchers, or even cry. This revealed that experienced traumatic events had great psychological influence on the life of these children (Breslau, Peterson, Kessler, & Schultz, 1999).

According to a meta-analysis study conducted by Fletcher in 1996 among 2697 children from the warring countries such as Bosnia and Israel among others, 36% of them met the post traumatic stress disorders criteria. This study revealed that children's behavior changed since they experienced traumatic events (Fite, 2008). Some reported to have been sexually abused, seriously injured in the war or in other accidents, or having experienced community violence such as stabbing, shooting, mugging, beatings, and homicide. This research sought to address the problem of behavior disorders in later childhood and adolescence caused by undiagnosed and untreated post traumatic stress disorders (PTSDs). Children and adolescents portrayed some unusual behaviors such as inability to learn, sleep, and converse with others. They also were not interested in intimate relationships or becoming married (for adolescents) among other behaviors.

1.3: Theoretical basis of PTSD on behavior of childhood and adolescence

This study is built based on the diathesis stress model of the PTSD. According to this theory, the PTSD results from diatheses, premorbid biological and ecological factors and stress (Billick & Mark, 2005). Thus in our study, theoretical  model will have dependent variable which will be the behavior of the children and adolescent  while the independent variables will involve; personal development history, coping based skills, social supports, genetics, neurological differences, role models and other aspects of trauma on the childhood and adolescence and found to be key factors cause the PTSD.

Given the stressor, such acute medical trauma requires emergency brain attention as the premorbid and the event based factors can weaken the child or adolescent ability to respond and learn healthily though the factors are unbalanced across individuals (Aarons,2003). Research is essential in determining the undiagnosed and untreated PTSD influences the behavior of the childhood and adolescents in the society and hence answer the research questions stated below.

1.4 Research Questions

 i. How do undiagnosed and untreated post traumatic stress disorders affect the development of behavior disorders in later childhood and adolescence?

 ii.  Which programs should the governments and other stakeholders adopt to combat PTSD?

1.5 Objectives of the Study

1.4.1 General objective

The general objective of this research paper is to explore how undiagnosed and untreated post traumatic stress disorder impacts the development of behavior disorders in later childhood and adolescence.

1.4.2 Specific objectives

 i. To explore how undiagnosed and untreated post traumatic stress disorders affect the development of behaviors disorders in later childhood and adolescence;

ii. To determine the programs that the government and other stakeholders should adopted to combat PTSD.

1.6 Significance of the Study

The study is geared towards exploring how undiagnosed and untreated post traumatic stress disorder impacts the development of behavior disorders in later childhood and adolescence. Various stakeholders all over the globe are expected to benefit from this study. Some of them include: governments, private institutions dealing with guidance and counseling of children and youths among others, children homes, medical practitioners, sociologists, psychiatrists, psychologists, and upcoming psychology and medical researchers (Greenwald, 2008).

The outcome of this study may significantly help the government understand other undiagnosed and untreated post traumatic stress disorders and their effects on young citizens. Secondly, it is expected to help community agencies and governments understand the main causes of traumatic events such as community violence, war, and accidents. Possible recommendations on how to combat traumatic events are also expected to be important to the government. In most cases, resources in any country are efficiently allocated with a help of conscious people, who function well cognitively and intellectually. This can be attained through improving health of all citizens, and thus all community agencies and governments may use the information gathered from this study to facilitate improvements in traumatic community and familial traumas.

Moreover, the empirical study is expected to assist private institutions, particularly those interested in addressing children's needs as well as in adolescents’ guidance and counseling. Some of the institutions include residential treatment programs and group foster care, which are flooded with children driven from homes by war, community violence, poverty, parental substance abuse, physical abuse, parental neglect, and even sexual abuse. The post traumatic stress affecting them can have a negative impact on behavior, and thus this study is expected to guide social workers, therapists, counselors, and other mental health professionals towards understanding these children and adolescents impacted by traumatic events. The researcher is also optimistic that this study will influence the minds of medical practitioners, psychologists, and sociologists by helping them understand behavior disorders of children and adolescents well (Bean et al, 2002).

Lastly, it is expected that upcoming medical and psychological researchers will benefit from the study by identifying various research gaps that need to be addressed in this psychological field.

1.7 Scope and Limitations of the Study

The study expects to generate debates among other researchers about the impact of undiagnosed and untreated post traumatic stress disorders. They may relate them to the DSM criteria and question the relationship existing between the scope of the study and the behavior developed in later childhood and adolescence. There are other factors that may also contribute to the development of behavior disorders in the life of these young men and women, and these factors may be mentioned as having equal or bigger impact on the development of behaviors identified.

Collection and data analysis processes were very complex as the data had to be collected from various samples of children and adolescents from various communities with different cultures and education levels (Atkins et al, 1998). Secondly, inquiries related to traumatic events experienced by children, such as community violence and sexual abuses they have experienced in their life time, are very sensitive and thus require sensitivity and empathy while obtaining the necessary information to provide treatment.  In fact, some of these questions could create a lot of tension causing some of children to cry, run away, or keep silent. Secondly, it is difficult to question children and adolescents about the severity, frequency, or the duration of the occurrence of sexual abuse and other significant traumas. Lastly, the interviewer must be aware of the associated somatic and psychological health implications that can develop later in their life.

Another challenge that may occur during the study are subjective perceptions, such as life threats, that may be found to play an essential role in development of post traumatic stress disorders in the life of children, especially those who suffered in road traffic accidents. Other researchers had initially disclosed that objective features, such as type of accidents or even physical injuries, had no impact on the associated level of post traumatic stress and behavioral disorders in children. Thus challenging these research outcomes may be difficult given that a lot of research works have already been accredited and published.

Moreover, systematic designing of the sample size to use in the data collection process may be a challenge. Some of the selected sample participants may provide biased and un-analyzable data. Yet the researcher cannot adjust the data. This is caused by the facts that the sample used for this study is smaller than sample sizes of many research projects. Secondly, the selection criteria of the sample size may also be challenged by uneven distribution of respondents within the population. Other challenges faced include negative attitudes from uncooperative respondents and inadequate information collected among others (Greenwald, 2008).

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