TRAUMATOLOGYe, 4:2, Article 2, 1998, http://www.fsu.edu/~trauma/

TRAUMA OF CHILDREN IN A RESIDENTIAL WILDERNESS TREATMENT PROGRAM

 
Bonnie C. Bedics, D.S.W.
Paula T. Rappe, L.C.S.W., M.S.W.
Frank Anthony Sansone, Ph.D., M.S.W.

Abstract

This study reports on the results of an exploratory examination of the presenting diagnosis of 48 emotionally disturbed children from 11-16 years old in a residential Wilderness Treatment Program. Researchers explored the presence of symptoms indicative of posttraumatic stress disorder (PTSD). An assessment procedure was developed and applied by clinicians to review residents' case records. The analysis indicated most residents were diagnosed with conduct disorder at or prior to admission to the program. The DSM-IV criteria were used to assess the life events and symptoms reported in those records with psychosocial histories. Of the 43 records with a psychosocial, findings indicated the potential for alternate diagnoses, including events and symptoms suggesting PTSD with chronic traumatic events experienced for a majority and a single traumatic event and/or both types for a few of the children. Implications for assessment are discussed.
 

Department of Social Work
University of West Florida
11000 University Parkway
Pensacola, FL 32514-5751
Phone: (850) 474-2375
Fax: (850) 474-2381
e-mail: bbedics@uwf.edu ,
           prappe@uwf.edu ,
           fsansone@uwf.edu

Trauma of Children
In a Residential Wilderness Treatment Program

Introduction

    The purpose of this study was to explore whether a substantial number of children in residential treatment had experienced traumatic events which may contribute to posttraumatic stress disorder (PTSD). Because of the fairly recent recognition of PTSD among child victims of trauma or traumatic lifestyles, the authors believed that children with long histories in the child welfare system may have experienced a traumatic event or events and exhibit symptoms suggestive of PTSD. To explore this hypothesis, the authors obtained permission to examine the case records of emotionally disturbed children committed to a wilderness program providing long term residential treatment.

Program Description

    The wilderness program provides long term (12-18 months) residential treatment for emotionally disturbed children. The program is an accredited alternative educational program that uses outdoor adventure experiential education as a treatment modality. The first program site opened in 1968 with private funding, and has expanded over time to include 14 program sites in 7 states that now operate with private and state funding.

    According to the program's Annual Report, the typical child entering the program has exhausted all community resources, is fourteen years old, and is two years behind in school with poor academic achievement. The referred children generally have difficulty with anger management, difficulties verbalizing thoughts and feelings, and have a poor self-concept; they display aggressive and sometimes violent behavior and may have been adjudicated delinquent or found dependent due to abuse and/or neglect.

Literature Review

    Posttraumatic stress disorder was first acknowledged and labeled as such in the American Psychiatric Association's Diagnostic and Statistical Manual in 1980 (DSM-III). PTSD among children was not clearly documented and identified until the following decade. It was not until the mid 1980's that a proliferation of studies associating abuse and family violence with PTSD appeared in the literature. As a result, the DSM-IIIR (3rd edition, revised, 1987), included revisions relevant to PTSD criteria and diagnosis.

    Any child who has experienced an abnormal, acutely stressful event or events is at risk for developing posttraumatic stress disorder (PTSD). The Diagnostic and Statistical Manual (DSM-IV, 1994) describes a traumatic event as one that would be markedly distressing to almost anyone. Such events include experiencing serious threat to one's own life or physical integrity, witnessing another person(s) experiencing such an event, or learning about unexpected and violent deaths or harm experienced by a loved one. Trauma is an emotional state of discomfort or stress resulting from memories of the event which shatter the person's sense of invulnerability to harm (Figley, 1986). The traumatic event may have been a natural disaster such as a flood or earthquake, accidents such as train wrecks or plane crashes, or a human act such as murder, assault, or kidnaping. PTSD may be caused by a single traumatic event or by a series of traumatic events, such as a lifestyle of abuse, violence, and severe family dysfunction. Terr (1991) divided the trauma and/or stress conditions of childhood into type I and type II, making it clear that the children differ in certain ways, especially their responses to the trauma(s). Children suffering from type I trauma have experienced a sudden blow from a single event, while those children suffering from type II traumas are the results of long standing and/or repeated ordeals. She also discusses cross-over conditions where childhood traumas fall in between the two.

    Common trauma responses such as nightmares, anxieties, and intrusive recollections are common and normal. When the responses do not subside after a prolonged period of time, with PTSD. For a list of symptoms of PTSD, please see Table 1.

    PTSD and single event trauma. Those who have studied children after a catastrophic event seem to agree that children do suffer from PTSD, but their behavioral responses may differ from those of adults because of the developmental stage at the time of the trauma (Ayalon, 1982; Benedek, 1985; Malmquist, 1986; Pynoos & Eth, 1985; Terr, 1983a&b; Yule & Williams, 1990). Children who were very young at the time of the trauma may demonstrate symptoms of PTSD years later. Some of the more commonly noted behaviors are: repetitive play, time distortion, a journalistic or bland affect, clear recall, and repetition of details. Daydreaming and nightmares are more common than developmentally regressive behavior. Development of phobias, psychosomatic problems, either acting out or withdrawn behavior, and a lack of a sense of future, as well as anxiety, ego constriction, lack of trust and low self-esteem have been noted.

    Malmquist (1986) studied sixteen children who witnessed a parental murder. Of these, 10 were survivors of familicide. All of these children met the diagnostic criteria for PTSD. All had recurrent dreams of the event and 14 had phobias about going to sleep or going into rooms after dark. Rather than the psychic numbing seen in adult trauma victims, these survivors were anxious, restless, hyperalert, and vigilant. He noted vivid recall of details of the event, psychosomatic complaints, a blandness in expression, and a lack of enthusiasm for life. Contrary to other research focused on children, he found that all but one child showed a significant decline in school performance (comparable to adults showing a decline in work performance) one year after the incident. Pynoos and Eth (1985) studied children who witnessed a broader spectrum of violence against their parents including murder, rape, suicide, and violent injury. They found that the closer the relationship with the victim, the more traumatic the event was to the child. They found that in play or in retelling the story, that the children reversed the outcome of the event (denial). A dominant theme was that a third party (self, police, paramedic) would intervene and change the outcome. They, too, found victims exhibited blandness or a journalistic affect. These children also had fantasies of future harm or terrors. They tried to avoid reminders of the event and had persistent problems such as night terrors, somnambulism, and startle reactions to reminders of the event. Aggressive, reckless, self destructive behavior or inhibitions often appeared.

    Terr and Ayalon (1983a; 1985a) studied children who were held captive in terrifying situations. Terr studied Chowchilla, California children who were abducted on their school bus and then buried. Two of the boys dug out from the pit and effected the rescue of the others. Four years after the event, Terr interviewed the survivors and found PTSD symptoms lingering. Of the children interviewed, 18 were still engaged in repetitive posttraumatic games and 8 others repetitively reenacted the event. Twelve had lingering reexperiences of the sensations felt during the kidnaping. The children remembered details of the event but tried to suppress their thoughts of it, and they repressed their feelings. Like many Vietnam veterans, these children preferred that others did not know they were involved in the incident. In retrospect, they tended to see omens of the event, and they often saw omens of future disaster. The children tended to see a short life for themselves, and therefore, had difficulty predicting career, marriage, and children. Nineteen (19) had personality shifts, but only 4 suffered a decline in school performance. She found regressive developmental behavior immediately after the trauma.

    Ayalon (1982), who studied Israeli children who were held hostage, also found developmental regression. In some hostage incidences, these children experienced the added trauma of seeing their adult protectors in a helpless situation; in some instances they witnessed their murder. They, too, experienced nightmares and engaged in compulsive repetitive play. As with the Chowchilla children, they suffered from time distortions. Unlike the children studied by Pynoos and Eth (1985), these children's fantasies centered on revenge or retaliative outcomes rather than on reversing the outcomes. This may be because, in many of these instances, the parents of the children were not murdered or seriously injured.

    Frederick (1985), who studied child victims of a wide spectrum of disastrous events, concluded that children are more traumatized when their parents are in a situation over which they have no control. Through his study of children who experienced natural disasters, terror imposed by humans, or sexual molestation, he concluded that their PTSD symptoms were similar to adults. He suggested the following signs of PTSD: conduct problems, sleep disorders at home and apathy, weariness, lack of concentration, and irritability at school. In order to detect the signs of PTSD in children, parents and teachers can observe play disturbances, contents of drawings, and subjects or themes of drawings [Ayalon, 1982; Malmquist, 1986; Terr, 1983].

    PTSD and chronic trauma Previously, there had been disagreement among researchers about the appropriateness of a diagnosis of PTSD for child victims. Terr (1985b) had objected to the use of the diagnosis on two bases. Because the trauma is chronic, it lacks the surprise element of human and natural disasters. The behavioral symptoms of either withdrawal or indiscriminate relatedness to others, rage, denial, and unremitting sadness, were viewed as different from the behavioral symptoms of child victims of other traumatic events. She does agree that other PTSD symptoms are found in many child abuse victims. As discussed earlier, Terr (1991) has modified her prior stance and "broadened the concept of trauma to include not only those conditions marked by intense surprise but also those marked by prolonged and sickening anticipation (p.11)." She proposed a dual typology of trauma for children with crossover features which addresses her previous objections and incorporates recent research results on single event (type 1) and chronic trauma (type 2), including different responses patterns for children and adults and for each type of childhood trauma. Important to her definition is that all childhood traumas come from the outside, i.e., the trauma begins with external events.

    Saigh (1991), however, found that the level of psychopathology did not differ for children diagnosed with PTSD no matter how they experienced the trauma, i.e., through the major DSM types of traumatization: direct experience, observation or witness, verbal mediation or confrontation, and/or combinations of. This is an important finding that has implications for the diagnosis and treatment of children with PTSD. Indeed the incidence of physical abuse as chronic trauma should alert clinical staff to the potential for PTSD, and especially when the history includes sexual abuse (Armsworth & Holaday, 1993; Havilland et al., 1995; McLeer et al., 1994; Pelcovitz et al., 1994; Terr, 1991; Finkelhor, 1987). Pelcovitz et al. (1994) report that physically abused adolescents showed higher rates of depression, conduct disorder, internalizing and externalizing behaviors, and social deficits; while Havilland et al. (1995) found abused children exhibit classic PTSD symptoms and sexually abused children have more severe symptoms.

    Finkelhor (1987) agreed with Terr's (1985) earlier statement regarding other PTSD symptoms being found in child abuse victims, and went further by stating the PTSD framework was beneficial for an understanding of the traumatic aspects of sexual abuse. He contended, however, that at that time PTSD was limited as a diagnostic tool because it did not account for all of the symptoms associated with sexual abuse. Self-blame and sexual dysfunction problems were not explained by PTSD and the DSM, either then or in its recent revisions. Those problems are located in the cognitive realm whereas the PTSD framework locates problems in the affective realm. He too addressed the chronicity of abuse as different than the trauma of a single overwhelming event. However, there is growing evidence to suggest that both prolonged trauma and later problems of adjustment result from childhood sexual abuse (Finkelhor, 1984; MacFarlane & Waterman, 1986; Havilland et al., 1995; Kiser et al., 1991; Livingston et al., 1993; McLeer, 1994; Pelcovitz, 1994; Terr, 1991; ).

    A number of studies (Frederick, 1985; Goodwin, 1985; Green [1985], Kiser, 1988; Kiser et al., 1991; Wolfe, 1989) posited the diagnosis of PTSD as appropriate for some victims of child abuse. Frederick (1985) stated that among the 3090 cases of child molestation he studied, he's "never seen any case beyond the age of six where PTSD was not in evidence (p.82)." Goodwin (1985) agreed that "most incest victims who request treatment meet the criteria for posttraumatic stress disorder although this can be difficult to recognize either due to the victim's young age, the severity of symptoms, or the victim's tendency to conceal both symptoms and the extent of the prior sexual abuse ( p.158)."

    Among the victims of sexual abuse studied by Frederick (1985) and Godwin (1985), common PTSD symptoms were identified as follows: intrusive thoughts and dreams or nightmares, phobias or fears related to reminders of the abuse, daydreaming, repetitive play, regressive behavior or developmental delay, generalized fears and anxiety, hypervigilance, psychosomatic complaints, and avoidance of activities or situations which might result in retraumatization. They further believed that for child sexual abuse victims, the stressful repeated events of abuse meet the criteria for PTSD because there is a threat or fear or anticipation of bodily harm to self or to a loved adult, the child is isolated in these fears because of the secretness surrounding the act, the victim is brainwashed or misinformed about his or her situation, and there is a threat to the child's self-image (Ayalon, 1982; Goodwin, 1985; Kiser et al., 1988; Terr, 1991). Some victims have adopted an identification with their aggressor-abuser (the Stockholm syndrome), not report the abuse, and adopt other defenses in response to abuse.

    The purpose of this study was to explore whether a substantial number of children in this residential treatment program had experienced traumatic event(s) which may have contributed to unresolved trauma reaction symptoms. For the purposes of this study, both chronic traumatic events (such as from repeated physical and sexual abuse, neglect, frequent separation, family violence) and a single traumatic event (such as from witnessing a murder or suicide, experiencing a disaster), and their combinations were noted. The traumatic events and symptoms of the children as found in their case records and psychosocial histories were charted and compared to the DSM diagnostic criteria.

Method

    Sample. Residents of the program were 48 emotionally disturbed children whose case records were reviewed for this study. The ages of the residents at intake ranged from 11.5 to 16.6 years, with an average age of the purposive sample of 14.5 years (M=14.54). The mean age of males was slightly older at 14.68 years with a range of 12.6 to 16.6 years compared to females who were slightly younger, M=14.29, with a range of 11.5 years to 16.4 years. The population of 48 residents consisted of 13 females (27%) and 35 males (73%), with 23 (47.9%) being African American or black and 25 (52.1%) white. Of the 13 female residents, 11 (84.6%) were white and 2 (14.4%) were African American or black. Of the 35 male residents, 23 (66.7%) were white and 12 (34.3%) were African American and over represented for the region served. The emotionally disturbed children were diagnosed at admission with the following: conduct disorders, depression, learning disabilities, attention deficit hyperactivity disorder (ADHD), PTSD, and borderline intelligence.

    Procedure. The researchers obtained permission to examine the case records of the residents of a regional wilderness treatment program. An assessment protocol was developed to record the information in the records. The records of the children were examined for the following information: characteristics such as age at intake, race, gender, diagnosis, social histories at admission, progress notes, and all documents such as previous psychosocial histories, medical and school records, court documents, and parent reports. The data were reviewed, recorded, and charted .

    The researchers examined the charted material and determined if the child had experienced trauma, the nature of the trauma (chronic or single event), the symptoms and behaviors noted, if a trauma reaction or PTSD diagnosis had been made, and if the child had been treated for trauma. The researchers also examined the data collected to determine if other patterns were present.

Findings

    Most of the 48 emotionally disturbed children in the residential program had numerous psychological evaluations; however, at admission, the diagnosis for the majority of clients, 34 (70.8%), was conduct disorder. Of those diagnosed as conduct disorder, 9 (26.5%) were female and 25 (73.5%) were male. Of the 13 female clients, 3 (23.1%) were diagnosed with depression but only one of the male clients was so diagnosed. At admission, only 9 (18.8%) children were diagnosed as having a learning disability, including a specific learning disability, attention deficit hyperactivity disorder (ADHD), and borderline intelligence.

    Patterns emerging from the records revealed that school performance problems were universal for this population. School problems were described as poor performance, decreased performance, failed grades, and inability to concentrate at school. The records also revealed 30 (62.5%) of the children had at some time in the past been diagnosed with a learning disability, even though this was not noted as an admitting diagnosis. Substance abuse, not including tobacco, was a problem for twenty-two (45.8%) residents. Including 3 clients who used tobacco and 2 who associated with drug dealers, 27 (56.3%) of the residents used or were associated with a substance that was illegal for the child's age.

    Of the 48 residents, 5 new admissions had case records with no psychosocial history at the time of the study. These 5 records were the only ones with no record of family dysfunction. Of the 43 children with documented psychosocial histories, severe family dysfunction was observed, including: abandonment, substance abuse by parent(s), parental incarceration, family violence, parental mental illness, and parental suicide. Among the family dysfunctions found, the incidence of substance abuse was the prevailing problem noted among the 43 family histories. Twenty-one (48.8%) children had parents with documented addiction problems and 11 children (25.6%) were parented by adult children of alcoholics (ACOAs).

    Through examination of the children's records, the researchers determined that a total of 36 or 83.7% of the children with a psychosocial history had experienced traumatic events, as follows: 32 residents (74.4%) had endured chronic traumatic events, 2 (4.7%) had experienced both chronic and single traumatic events, and two children (4.7%) had reported a single traumatic event. Of the 34 children who were determined to have experienced chronic or both chronic and single traumatic events, 33 had documented histories of child abuse. The one client determined to have had a history of chronic traumatic events but with no documented child abuse, had lived, by the age of twelve, with the mother and her 7 husbands and then with the father and stepmother after the natural mother was incarcerated. Both natural parents were ACOAs. Of the 4 children who experienced single traumatic events, 2 experienced parental or close relative suicide, one experienced a fatal accident of both parents, and one a house fire that killed family pets. Of the 36 children with known traumatic events, PTSD was diagnosed for only one child (parental suicide), however, there was no indication in the case record that the child was ever treated for PTSD.

    The DSM-IV (1994) diagnostic criteria were then compared to the children's records containing a psychosocial history. The criteria for PTSD include that the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious physical injury, or a threat to physical integrity of self or others; e.g., a close friend, relative or family member (Morrison, 1995). In children, the response to the traumatic event(s) differs from that of adults and may include agitated or disorganized behavior.

    Chronic traumatic events from abuse and severe family dysfunction were noted in 100% of the children in this study with completed psychosocial histories (43 of 48 residents). The records indicated 36 (75%) of the 48 children in residential care, or 83.7% of those with a psychosocial history, had experienced a single traumatic event, chronic traumatic events, or both. The following specific categorical results were found for the study sample: 31 had experienced actual or threatened death, serious injury, or threat to physical integrity; 8 had witnessed such events; and 6 had learned about unexpected and violent deaths or harm experienced by a loved one, with some children in more than one category. The literature supports recognition of the presence of PTSD among child victims of single event and chronic trauma (Terr, 1991). The case records reviewed for this study clearly document the experience of traumatic events by a majority of the residents.

    Table 1 compares those symptoms listed in the DSM-IV for PTSD, those in the studies cited in the literature review, and those noted by clinicians in the records of the study population. Clearly the largest category of symptoms exhibited by the children in the sample and most frequently noted can be subsumed under the general heading of conduct problems. This supports the most frequently assigned diagnosis for the study population, conduct disorder. At the same time, the array of problems described in the records of the children in the residential treatment program fit comfortably within the framework described by researchers who have studied trauma reactions of children.

    The review of the literature, particularly the early research, revealed an emphasis on studies of children who have experienced single event trauma rather than chronic trauma, the focus of current research. Table 1 shows that psychosomatic symptoms, play, time distortion, clear recall of the event, and repetition of details of the event were not among the behaviors of the children in care who had predominantly experienced chronic traumatic events. An interesting observation was that for the children who had no recorded history of traumatic events, those without a psychosocial, there was no distinguishable difference in recorded symptoms compared to those attributed to children who were victims of documented traumatic events. The research (Terr, 1991; Figley, 1989) recognizes the presence of PTSD among child victims of single and chronic traumatic events. The psychosocial histories and case records evaluated for this study clearly document the experience of traumatic events and the resultant symptoms of a majority of the residents.

Discussion

    Evidence of PTSD symptomology was found, mostly from long term abuse and severe family dysfunction, in 100% of the children's case records that contained completed histories (43 of 48 admitted children). Additional data indicated that 36 or 83.7% of the 43 children with psychosocial histories had recorded incidents of traumatic events. Although no claim can be made that all of these children were suffering from PTSD, the documented behaviors exhibited by the children do suggest that child welfare service providers should explore the possibility that PTSD may be present in children from severely dysfunctional families. Given the overwhelming use of conduct disorder as the presenting diagnosis for the sample, results of recent research (Clark, Pollock, Bukstein, Mezzich, Bromberger, & Donovan, 1997; Riggs et al., 1995; Atlas et al., 1992; Terr, 1991) indicated the potential of comorbidity of PTSD with conduct disorder, depression, and other disorders.

    Terr (1991) has stated, in regard to the diagnosis of children exposed to horrible external events, the manifestations of trauma in a traumatized child on any given day could result in a diagnosis of any of the following disorders: conduct, borderline personality, major affective, ADHD, phobic, dissociative, obsessive-compulsive, panic, and adjustment disorder, plus conditions not yet officially recognized, and not be wrong. As reported here, some of those disorders were found in this study's children.

    Riggs et al. (1995) report that in youths with conduct disorder comorbid conditions may tend to be overlooked or not adequately assessed. The tendency is for the management of conduct problems to dominate other considerations, with the result that the assessment or treatment of other coexisting disorders become unlikely. A recent study (Clark et al.,1997) found that alcohol dependent adolescents as compared to controls had higher rates of disruptive behavior disorders, especially conduct disorder, major depressive disorder and PTSD and related symptoms, with females having reported twice as many depression and PTSD symptoms as males. It should be noted that PTSD may well be the underlying cause of the behavioral and emotional disorders.

    The increase in severity of problems documented in these records indicate that the array of home based services provided prior to admission were not effective. Perhaps the primary diagnosis of conduct disorder may have masked PTSD and resulted in inappropriate treatment approaches for these children. The researchers are knowledgeable about the treatment programs in which these children were receiving services prior to referral to long term residential treatment. The treatment approach of these programs was primarily reality based as was that of the treatment facility studied. For children who may be suffering from PTSD and comorbid conditions, one or a combination of the following modalities could be implemented: pharmacotherapy, cognitive-behaviorial therapy, and psychosocial interventions such as individual, group, and family counseling.

Recommendations and Conclusions

    In order to adequately assess and develop an appropriate treatment plan for a child, casework staff must be able to fully document the child's medical and social history. Such a basic procedure will assist greatly in a more complete and accurate assessment of PTSD for children who come to the attention of the child welfare system. To assist in this process, we believe consideration should be given to designing and implementing a comprehensive case record procedure. Complete histories are needed when working with children and their families. Life experiences and reactions need to be explored to better serve our clients. Less emphasis on symptomologies and more on experiences and reactions to experiences are needed. For effective treatment, an accurate assessment is essential.

    To this end, practitioners should also use an assessment scale designed to assess for PTSD when the history indicates that traumatic events have occurred. Sauter and Franklin (1998) reviewed and critiqued available instruments for assessing school age children and teens for PTSD. They found some utility for the PTSD Reaction Index to assess school age children. They state that it is easy to administer, that it provides reliable assessment unaffected by age, sex or ethnicity of the child, and that it is available in several languages. The limitation of this instrument is that it does not assess criterion E in the DSM IV. They also state that the easy to use Child Behavior Checklist (CBCL) is useful if it is used with another PTSD measure. The Trauma Symptom Checklist for Children (TSCC) seems to be the most useful instrument for children in the age group of 7-16. It is easy to administer and score, and in addition to assessing symptoms of PTSD, it also provides information about the type of trauma experienced.

    More research is also needed to fully understand the different ways that children respond to traumatic events and stress in order to be able to diagnose and apply the most appropriate treatment for a particular child. Once the research knowledge and resulting recommendations have been incorporated into practice, the capability of clinical staff to diagnose PTSD will be improved and lead to appropriate treatment strategies for children and adolescents.

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    Zilbert, N., Weiss, D., & Horowitz, M. (1982). Impact of event scale: A cross validation study and some empirical evidence supporting a conceptual model of stress response syndrome. Journal of Consulting and Clinical Psychology, 50, 407- 414.

REFERRALS: CAICA is not a referral agency. CAICA does not refer to or promote facilities or transport companies for children or teens. CAICA warns parents that the parent pay / parent choice programs ie. Residential Treatment Centers, Therapeutic Boarding Schools, Behavior Modification Programs, Christian Programs, Positive Peer Culture Programs, etc., are not regulated by the Federal Government and that it is a "Buyer Beware" industry. CAICA provides the following for parents: Message to Parents, Help for Distraught and Desperate Parents, and Questions to Ask and Warning Signs.

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