1

“Child Abuse Victims and Combat Veterans with Post Traumatic Stress

Disorder: Commonalities in Symptoms, Treatment, Effectiveness, and the

Role of New Technologies”

Thomas R. Hoeg

(Cox,

2004)

(Murphy, 2012)

2

Vitae

I was raised in “the projects”, a towering multi apartment dwelling,

that replaced the home of the Major League Baseball National League

Brooklyn Dodgers; Ebbets Field. As a child, I experienced life as a

minority being the only Caucasian child in my elementary school by the

third grade. I experienced a great diversity in culture and many ethnical

flavors. It also resulted in a necessary move out of the neighborhood when

I graduated to the Jackie Robinson Intermediate School then I.S. 320 and

hatred became unbearable. It wasn’t before I experienced personal trauma

to that effect.

I had a decent early academic experience and was able to skip the

eighth grade. However, I found that the repetitive nature of the curriculum

at Midwood High School to be less alluring than spending time at Brooklyn

College, right next door. This led to truancy, early experimentation with

drugs, and an eventual nine month unscheduled vacation that caught up

with me. I elected to attend an alternative High School known as City As,

also attended by Jean-Michel Basquiat the deceased protégé of Andy

Warhol, and Jason Katims, the executive producer of NBC’s “Parenthood”.

The program consisted of working all over New York City and earning

3

credit towards graduation. It was a wonderful experience and I graduated

High School chronologically on time returning my skipped year in

exchange. My parents were separated during this time and there was not

much accountability to guide my executive decisions. I was not without

personal trauma at this juncture either.

I hung around in New York City and worked odd jobs until I

threatened to take my father to court to go to college. I was admitted to the

State University of New Paltz on an interview. I graduated in five years

spending a summer at Ulster County Community College to ward off

academic probation and dismissal. It was at Ulster County Community

College that I decided to pursue a degree in psychology. I met my wife,

Patti, during my time in college and she is my personal savior and mother

of my two children; Brian and Kristin.

I worked as a bartender throughout college and afterwards, 11 years

total, and it amounted to a study in human behavior and a complement to

my academic pursuits and dangerous love affair with alcohol. I applied for

a state job working with delinquent youth at a local facility for the then

Division for Youth and the now New York State Office for Children and

4

Families. I was hired and did not know, at the time, that this would end up

as my career.

I worked in 10 facilities serving in the capacity of direct care staff

up to Acting Director. I also served as the Interim Director of the Bureau

of Counseling Services for the entire state agency. It was during my three

years at Goshen Secure Center, working with youth doing life sentences

that honed my skills and style with youth connecting my past with my

present in order to understand and help youth. I mark my 27th year in the

field this coming March. Currently I serve as a Policy Analyst impacting

policy with my experience and per promulgated law to serve our clients.

I entered the Masters of Arts in Liberal Studies program at Excelsior

College with hopes of being able to teach at the junior college level about

youth, trauma, and juvenile justice. The course work and the writing

proved to be enlightening and an amazing opportunity to grow and relate

my experiences to the diverse and engaging curriculum with the courses

offered in the Issues in Today’s Society track. The experience has

skyrocketed my passion for the underdog and those personally impacted by

trauma.

5

We currently reside outside of Albany, New York and our children

have completed college. We all have pet dogs and enjoy our time together

whenever possible. My Thesis is the one accomplishment, other than my

family, that I can finally hang my cap and gown on. I hope to complete my

goal of walking youth through trauma in their early years of college,

continue writing about attachment and engagement, and walking on a

beach somewhere with my wife and my dog.

6

Thesis Abstract

Abused children are often an invisible population not appearing

anywhere besides a Child Protective Services Investigation or a General

Practitioner’s Office later in life for various maladies. There is a vast

amount of victims of child abuse that end up in the military with studies

done. When there is a diagnoses of PTSD there are physiological and

neurological impacts for both abuse victims and soldiers in combat. There

may be a relation to these changes that results in PTSD sufferers

manifesting symptoms and displaying behaviors in common. Over the

course of time there have been studies, more so with soldiers than children,

describing the symptoms of PTSD and providing other names for the

disorder until 1980. There have been advances in PTSD interventions;

however, the results are less than satisfying in general based on outcomes

and success rates. Some interventions have been provided to both

populations and studied using various control groups but none to a fruitful

conclusion. There are new and novel approaches to treating the disorder

including some technology given the fact that nothing beforehand was

perfected. There is an argument that PTSD in both populations is a wisely

used smoke screen for larger problems and actually migrating towards the

7

horrendous physical injuries of combat and the larger causes of child abuse.

I would agree using my experience with youth and the research on soldiers.

The future path of PTSD and treatment in both populations will be decided

by sheer volume of cases, self-reporting and political manipulation.

8

9

Table of Contents (TOC)

Vitae…………………………………………………………………..2Thesis Abstract...……………………………………………………..5TOC………………………………………………...………………...9INTRODUCTION……………………………………………………8CHAPTER I....................................................................................19

� Child Abuse and PTSD

� PTSD and the Brain

� Combat Soldiers and PTSD

� Combat, PTSD, and Physical Injury

� Commonalities in Symptoms

� Physiological and Neurological Commonalities

CHAPTER II…………………………………………………..……51

� Historical Perspective of Child Abuse, Child Protection, and PTSD

� Historical Perspective of Combat Veterans and PTSD

� Making History

CHAPTER III ………………………………………………………80

� “James”

� 10 PTSD Treatments for Children

� In Closing

CHAPTERIV……………………………………..………………..113

� Clay Hunt

� 10 PTSD Treatments for Combat Veterans

� In Closing

10

CHAPTER V...…………………………..………………..…….….143

� Comparing Treatment Efficacies for Both Populations

� Veterans and CPT/Andrew O’Brien

� CPT Study

� Child Abuse Victims in the Military

� Interview with Dr. Gabor Mate

� In Closing

CHAPTER VI …………………………………………………..175

� Recent Trends in Treatment

� Children

� Veterans

� A Study

� In Closing

Conclusion/Discussion..……………………………………….. 225

Epilogue “Reed”…..………………………………………….…236

References……………………………………………………....244

Appendices…………………………………………………..….319

� Photos

11

Introduction

It is so uncomfortable when it happens. The area, the temperature,

and the smells are always the same. The remnants of events past strewn

about, are evidence of persistent pain and suffering. The air is ripe with

smoke, it is sweaty and hot, and my brothers are licking their wounds,

covering them and embarrassingly moving on day after day. Sudden noises

make my skin crawl and feeling like vomiting. I am watching everything

around me with an impenetrable bull’s-eye focus. Each bang or thud sends

me to a different place, a playground, a movie theater, or grammar school

where I am safe in my mind. It is difficult to tell anyone for fear of being

judged as unable to cope or challenging the people that are supposed to

look out for my well-being. My scars are reminders, my fear is internally

drilling my stomach, and explosive incidents create an indescribable angst

with no resolve. Why won’t it stop? Sleep is impossible; nightmares

suggest fatality, if I could find a hole…

The above paragraph can describe a young person in the throes of

horrible abuse and the heightened memory of the environs featuring

12

horrific beatings or severe neglect to themselves or their siblings. It also

can describe the sensations of being in battle, among your fellow soldiers,

and experiencing the horrors of war. In both cases, the likelihood of being

diagnosed with a form of PTSD increases with the severity of the trauma

experience and becomes a life-long attempt to cope. The traumatic event

or pattern of events that resulted in the diagnosis of PTSD, prove to be

extremely challenging throughout a lifetime. This includes symptomatic

reenactment of the trauma that can be triggered by random or routine

events. Life “altering” or “shattering” are the terms given to the PTSD

experience. In laymen terms, it can be thought of as putting “Humpty

Dumpty” back together again. Soldiers experiencing warfare and children

that have experienced severe forms of abuse, both diagnosed with PTS,

have so much in common.

For 25 years, I have worked with the “most difficult” youth in the

State of New York. I served in the capacity of direct care staff, case

manager, staff manager, and Assistant Director in residential facilities. This

work has been rewarding, harrowing, and heartbreaking. In attempting to

assist young people in untangling their pasts and agreeing on a future plan,

I made many discoveries. It became quite obvious that there were

13

commonalities in reported child abuse in their formative years, significant

history of drug use, and some miraculous compensatory talents. I routinely

delved into the records of each of the admitted youth, which I was fortunate

enough to come in direct contact with, and found a rather alarming

percentage had experienced some form of significant brain injury or

observed acts of violence.

Survivors of the highest order youth utilized skills that were self-

developed to engage in everyday life. Youth without appropriate

nurturance, that could manipulate adults, take advantage of opportunities

when presented and ensure safety by guaranteeing the presence of as many

staff as needed by any means necessary. Their developed skills and talents

were devoted to basic sustenance. I worked directly with youth that relived

previous physical, sexual abuse and various forms of trauma when agency

policy required that staff would use physical restraint to place youth under

control. I witnessed the symptomatic hypervigilence of an abused child or

one that witnessed extreme violence including the murder of family

members. The characteristic disassociation, crippling fear, and sleep

difficulty of youth diagnosed with PTSD were a learning experience for

14

me. At times, the means by which rules were enforced were counter

intuitive to their diagnoses and created situations that became far worse

than the situation assumedly warranting physical intervention. For

example, a young lady was repeatedly raped, as a child, condoned by her

mother. When becoming out of control, and by policy requiring physical

intervention, she dissociated and began fighting with staff intensely, with

eyes closed and thrashing about screaming “get the fuck off me”. “Alice”

was in countless restraints, room confinements and eventually in a cottage

by herself. Without fail her room was filled with cached food, hair gel and

other forbidden items that had to come from staff. She loved to read, I

eventually was able talk to her through her reading. There was a routine of

entering her room standing in a certain place and talking. If I overstepped

she would attack me or anyone else, Alice left eventually after a slew of

attempts at medicating, psychiatric hospitalizations, and several injured

staff.

Despite being outwardly negative and adjudicated by family and

criminal court, self-medicating in the form of drug use and adrenalin

inducing activities and attitudinal misgivings that appeared aggressive,

15

many possessed talents. If appropriate talents were developed in a positive

way, there might be a significant change in their lives. If youth were able

to share their talents in a neutral, initially anonymous and clinically guided

fashion there may be positive results. “Alice” read over 100 books,

articulated fantasies based on content eloquently and there was clearly a

person in there. Many of the talents masked an inability to share their

experiences with trauma. Social networking may be a vehicle to

accomplish this treatment venue.

My interest in trauma has steadily increased as it appears that these

children had adverse experiences that contributed to their difficulty in

competing in mainstream society. This was reinforced by the Adverse

Childhood Effects (ACE) study conducted by Dr. Felitti (1998) that

analyzed the relationship between multiple categories of childhood trauma

(ACEs), and health and behavioral outcomes later in life. (p.248) I have

attended seminars including but not limited to the renowned physician and

author; Dr. Gabor Mate and Dr. Felitti, both advocates of how early

childhood traumas impact future lives. Quoting Dr. Mate: “What

happened to us when we were kids really does affect us dramatically in the

16

here and now, especially if "negative" emotions like anger were repressed

and love was poorly expressed and early trauma leaves an impact like a

wrecking ball hitting delicate crystal” (Gunning, 2003).

My early research in the MALS at Excelsior College provided

increased insight that included combat veterans and PTSD. There appeared

to be a marked similarity in the symptoms and impact of the traumatic

brain injuries and exposure to violence in combat veterans and the

population of abused children. The inability to communicate, isolationism,

self-medication, and the struggle to cope were all similarities experienced

in both populations. The research further revealed that Art Therapy was a

valid means of having combat veterans relate their feelings and emotions. I

worked with countless children that had what appeared to be an innate

talent to draw and relate what had transpired in their lives (Avrahami, D.,

2006 p. 6).

Combat veterans and victims of child abuse require intensive clinical

work to accommodate necessary change to restore quality of life,

somewhat, to an acceptable status. All means of assistance; clinical,

civilian support, and networking must be perpetually evaluated and

17

outcomes viewed critically. Every avenue must be explored for restoration

of a crumpled beginning of either stage of life. Either veterans or child

abuse victims are in formative stages of the remaining portions of their

lives; made fragile by their experiences.

The consequences of the trauma, physiologically and neurologically,

reveal similarities in both populations. For many wars, decades, and years

the lion share of efforts have been geared towards soldiers having

experienced the horrors of war. Children suffering from abuse and

maltreatment were defended by the luck of the draw and professionals

seem to relent and not “reveal” family violence. Treatment options include

but are not limited to therapy and regimens of psychiatric medications

provide an outlook that is far from resolution and require further

exploration. Some treatments are showing signs of increased hope,

understanding and progressing with the times Technology may offer the

ability to share coping mechanisms. Currently we have soldiers returning

from war, children and soldiers involved in community shootings,

abductions and manhunts. The road taken to get to this point and the road

18

ahead are critical in attempts to understand how to protect victims and

society.

19

Chapter I

Child Abuse and PTSD

Overcome by the inability to regulate reaction to stimuli of which

you are hypervigilant about distorts the “normal” characteristics of a child

(Grogan & Murphy, 2011 p.58). The continued exposure to physical and

sexual abuse, extreme acts of violence, and painful neglect tears the

childhood away from an individual. The remaining shell of a human is left

wondering and afraid of what is particularly inane and harmless to the

naked eye of those that are not afflicted with the symptoms of PTSD.

Wethington et al. (2008) identifies the characteristics of PTSD as re-

experiencing the trauma through vivi�� �������� �� ����� ���

nightmares, avoiding anything related to the trauma, numbing of emotions,

and hyperarousal, such as constant scanning for threats and irritability. (as

cited by Grogan & Murphy, 2011, p. 58) I have witnessed this in children

from multi-ethnical cultures. For youth that are adjudicated as juvenile

delinquents, victims or perpetrators of sexual offense and the severely

physical abused individual similarities in symptoms far outweighed

differences in race and creed. The environment, certain cultural

experiences, and wealth versus poverty provided differences in the types of

20

initial trauma inducing PTSD. I have been heartbroken, impressed and

hopeful. In many cases, all three emotions were captured simultaneously

by more than one child. The children that were diagnosed with PTSD and

treated as well as those that were not, were all survivors transitioning back

to the community that precipitated the elements that resulted in the initial

traumatic experiences.

There has been an increase in the reporting and investigating

of child abuse, which includes a review of the history of physical and

sexual abuse, injuries, and exposure to violence of youth that are the

subjects and their families. As reported by the Department of Health and

Human Services (2002, 2010) in 2002 there were 1, 701,780 reports of

child abuse and neglect. In 2010, there were 2, 607,798 reports. These

disturbing results indicate that youth with such histories are likely to be

placed in foster care and some 25-30% becomes exposed to the juvenile

justice system (Courtney et al, 2001 p. 693). PTSD prevalence in the

juvenile justice population range between 3 percent and 50 percent

contingent upon the type of assessment, informant interviewed, and the

time frame between the incident/s and interview. The wide percentage

21

range being attributed to the reliability of the victim in reporting and the

skill of the interviewer, and elapsed time from the initial incident. Referrals

do or do not result in further assessment or clinical diagnoses. (Arroyo,

2001 p.60) The onset of PTSD in children or adolescents may be initiated

through either direct or witnessed exposure to a single or chronic trauma.

These various forms of maltreatment may lead to many physical and

emotional consequences, including posttraumatic stress disorder (PTSD).

(Giardino, Pataki, 2011) This illustrates the onset of PTSD in victims of

child abuse and combat veterans occur similarly in isolated incidents or

repeated incidents of violence.

PTSD and the Brain

In her 2012 article Post Traumatic Stress Disorder, Hornor explains

the susceptibility of children to abuse and trauma: “Young children by

virtue of their developmental stage typically spend more time in the home

with their parents and are unable to separate themselves from a volatile

situation. They are dependent upon their parent or caregiver to protect them

both physically and emotionally.” (p. 2). Brown (2003) reported (as cited

by Shenk, Putnam, & Noll, 2011 p. 118) that physical abuse, sexual abuse,

22

and neglect, are consistent predictors of PTSD symptoms. Copeland et al.,

discussed (as cited by Shenk C., et al., 2011 p. 119) that in both

psychological and emotional circumstances the brains of children subjected

to abuse and neglect may or may not lead to PTSD. There are ongoing

studies as to whether or not the brain is susceptible to PTSD or that PTSD

causes changes in the brain. In cases where there is a diagnosis, research

suggests that there is impact to the brain. The area of the brain that

controls reaction to fear, the hippocampus, shows a significant difference

between PTSD subjects as compared to a brain untouched by trauma.

(Carrion et al., 2001 p. 944)

In an experiment conducted at the Stanford School of Medicine,

scientists were able to conclude that there is direct evidence that children

with symptoms of post-traumatic stress suffer poor function of the

hippocampus, a brain structure that stores and retrieves memories.

Samples of adolescents were given a memory test in conjunction with a

brain scan. It was clear that youth diagnosed with PTSD had several errors

and less hippocampus activity. The study concluded that the impairment of

the hippocampus was connected to symptoms of PTSD including

23

avoidance and numbing, difficulty with trauma recall, isolation and lack of

emotion. (Digitale, 2009)

Physiological symptoms as a result of abuse are manifested in multi-

symptomatic variations. Repeated stressors due to family violence or

sexual abuse have been linked to higher production of hormones such as

norepinephrine, dopamine, epinephrine, and cortisol (De Bellis et al., 1999

p. 1260). Increased production of adrenaline and noradrenaline cue the

body for rapid response via intensified heart rate and blood flow leading to

agitation and attention deficit (Rossman, Hughes & Rosenberg, 2000 p.

73). Over the course of time and continued exposure to maltreatment, the

body changes the regulation of arousal by decreasing the available

receptors for arousal. When discussing a child and their developing brain,

this is critical given their vulnerability and the negative outcomes of

intermittent periods of overactivation and underactivation during their

neurodevelopment (Schwartz & Perry, 1994 p. 4).

Understanding the physiological impact of child abuse and the

potential PTSD diagnoses that may result involves discussing parts of the

human brain; the amygdala and hippocampus and their functions with some

24

detail. Bremner (2003b, as cited in Anda et al., 2006 p. 174) asserted that

the amygdala mediates fear responses, and the prefrontal cortex is involved

in mood as well as emotional and cognitive responses. Smith et al.,

(1997,as cited in Anda et al., 2006 p. 175) identified the important

interaction between development and stress, e. g., young infants do not

have a fully developed glucocorticoid (cortisol in humans) response to

stress, although other markers show that they do respond to stressors.

Nibuya, Duman, and Gould (1995, as cited in Anda et al., 2006 p. 175)

indicate that the hippocampus has the capacity to grow new neurons in

adulthood (neurogenesis) but stress inhibits neurogenesis. Plotsky &,

Meany (1993,as cited in Anda et al., 2006 p. 175) also reported that high

levels of glucocorticoids damage the hippocampus, which can negatively

affect memory and that early stressors cause long-term increases in

glucocorticoid responses to stress. In addition decreased genetic

expression of cortisol receptors in the hippocampus and increased genetic

expression of corticotrophin-releasing factor in the hypothalamus, both of

which may contribute to dysregulation of the hypothalamic-pituitary-

adrenocortical (HPA) system.

25

Bremner (as cited in Anda et al., 2006 p. 182) further reported that

deficits in hippocampal function are linked to deficits in verbal declarative

memory and failure of hippocampal activation with memory tasks in adult

women with early abuse-related PTSD. Children with PTSD have

minimized whole brain and corpus callosum volume as demonstrated in

studies conducted by Carrion, & Steiner and Debellis & Thomas (2000,

2003 as cited in Anda et al., 2006 p.175) Anderson et al., notes alterations

in structure of the cerebellum (2002, as cited in Anda et al., 2006 p. 175)

and Debellis &, Thomas (2003) and Carrion et al., (2001) noted the same in

the frontal cortex (as cited in Anda et al., 2006 p. 175). Teicher, et al.,

(1997, as cited in Anda et al., 2006 p. 175) used electroencephalograms,

(EEG) measuring the electrical activity of the brain to show altered activity

in the frontal cortex of abused children. A child being abused suffers

trauma that impact brain function altering their response to stimuli and

leaving their actions vulnerable to misinterpretation.

Children diagnosed with PTSD due to the impact on critical brain

functions display erratic behavior and varied levels of behavioral

dysfunction largely attributable to the impacted brain function and the over

26

and under production of various hormones. (Perry and Pollard, 1998 p.31)

The deleterious effects of traumatic stress on the developing neural

networks in children and on the hormone producing systems signaled by

the brain have not been obvious, until most recently to researchers and

scientists. Current information, however, presents evidence that leads to

the conclusion that child abuse and children diagnosed with PTSD, due to

the neurological impact of the causal trauma, may also display future

behavioral, health and social problems. (Anda et al., 2006 p. 182)

In my experience with children and adolescents in foster care and

juvenile justice settings that have been abused and later diagnosed with

PTSD, the impact on the production of regulatory hormones and the

ensuing psychological difficulties became obvious. The general recall of

current incidents, the requested rehashing of the suffered trauma, and

retelling of witnessed violence were all marred by vented frustration,

apparent random emotional outbursts, and what appeared to be and may

very well have been reliving the traumatic experiences. In 2010, 408,425

youth were in foster care in the United States ( U.S. Department of Health

and Human Services, 2011) and Oswald(2010) reports (as cited by

27

Greeson, 2011 p. 93) that those who enter foster care have usually

experienced traumatic events at the hands of their guardian resulting in

removal from the home. In the juvenile justice setting the response was to

control such children with traumatic physical intervention: restraints,

medication and privileges lost. This served to magnify the inability to

regulate emotion, violent and disconcerting responses to staff and severe

acting out behavior. These biological diatheses, or a predisposition to

vulnerability, together with stress, set the stage for emotional regulation

���� ���������� ������������ ������� � ��� ����� ��� ������ ��� ������� ��������

such as PTSD, depression, and other emotional problems (van der Kolk,

2005 p.403). Landsverk, et al. (2009), Volpellier (2009), and Morrison &

Anders (2006) (as cited in Grogan and Murphy, 2011p. 60) are credited

with developing the findings associated with the symptoms of PTSD in

children. The findings clearly illustrate the complications that children

suffering from PTSD will experience at all stages of development.

28

Summary of Some Typical Behavioral, History, and Physical Signs and

Symptoms:

History finding Physical Findings Behavioral Findings

� Report of trauma (must be a trauma for diagnosis of PTSD)

� Dysfunctional parent–child interactions

� Dreams of monsters

� Bedwetting, other developmental regression

� Play reenactment of the trauma

� Belief world is an unsafe place

� Upset when thinking about trauma; thoughts or pictures may intrude

� Difficulty going to sleep or waking up multiple times throughout the night

� Avoids reminders of trauma

� Reports feeling lonely, not close to other people

� Generalized fears

� Clinging to caregivers

� Increased startle responses

� Somatic complaints such as stomach aches or headaches, asthma, allergy, gastrointestinal disorders, high healthcare usage

� Suicide attempts

� Unexplained or inconsistent injuries

� Sexually transmitted disease in a young child

� Vaginal bleeding, purulentmalodorous discharge

� Irritability

� Feeling guilty, ineffective

� Impulsive, self-destructive behavior

� Difficulty concentrating

� Unable to feel strong emotions, like love

� Inappropriate response to stressor

� Young children may have new aggression, regression, oppositional behavior, separation anxiety

� School-age children may feel guilt, beaggressive, socially withdrawn, have difficulty concentrating

� Adolescents may become rebellious, have a decline in school performance, delinquency, eating disorders, early sexual activity, substance abuse, increased risk taking

29

"What happens in childhood, like a child's footprint in wet cement,

leaves its mark forever," said Dr. Vincent J. Felitti, the director of the

Adverse Childhood Experiences Study(ACES) at the healthcare provider

Kaiser Permanente's Department of Preventive Medicine in San Diego,

CA. Utilizing the Traumatic Events Inventory, a 14 page instrument for

assessing exposure to traumatic events and the Clinician Administered

PTSD Scale (CAPS) for adult and childhood trauma, a study was

conducted on 245 urban African Americans. The study assessed the

relationship of youth with PTSD and the symptoms associated with

Metabolic Syndrome. Metabolic syndrome manifests itself with elevated

risk for cardiovascular disease and diabetes and has prevalence in low-

income African Americans. Ninety percent of the subjects reported

witnessing traumatic events with a high rate of PTSD diagnoses. Overall

and as a result of the CAPS, 18.8% of the subjects met the DSM-IV

diagnostic criteria for PTSD. Regarding childhood trauma exposure, 43.4%

of subjects reported physical abuse, 34.0% and 44.6% reported emotional

abuse. (Sparks, S.D., 2012) Child abuse victims report and confirm the

ACES study findings and in overwhelming numbers become physically ill;

30

have contributing co-morbid substance abuse problems and impacting

lifespan.

Adolescents that are diagnosed with PTSD also have increased

percentages of suicide. In one study, which assessed co-morbidity patterns

in a large sample of young people (aged 14–24) with a history of previous

suicide attempts, the highest risk for a suicide attempt was found among

those suffering from PTSD, followed by dysthymia and simple phobias”.

(Wunderlich, Bronisch, & Wittchen, 1998 p. 94) Combat veterans and

adolescent youth share characteristics when afflicted with PTSD such as

recurrent reliving the traumatic events, hyperarousal and anxiety and

suicidality. PTSD in both populations, prior to diagnoses, awaits comorbid

conditions to emerge and suicide attempts to happen prior to intervention.

There is evidence that the behavior that requires changing is that of

clinicians. (Couineau & Forbes 2011) Given the PTSD present in both

Combat Veterans and Adolescents, professionals must concur with the best

evidence based treatment and be adept at delivering specific interventions

as close to the traumatic incident as possible.

31

Child abuse resulting in PTSD has lifelong implications pertaining to

physical and mental health. Increased reporting of child abuse is

encouraging and may deter repetitive events. However, the means by

which the traumatic incidents are addressed in an immediate sense such as

the ensuing treatment plan and continued monitoring may or may not

alleviate physical or mental symptoms throughout life. The presented

information validates that abused children are likely to experience a myriad

of problems as adults.

Combat Soldiers and PTSD

Sharpless and Barber (2011) open their article “A Clinician's Guide

to PTSD Treatments for Returning Veterans” with the following statement:

Posttraumatic stress disorder (PTSD) is an all-too-common

consequence of terrifying occurrences, both natural and manmade,

which shock the psychological system and violate core assumptions

that life is predictable, safe, and secure. Such events often reveal the

ultimate fragility of existence, and can eventuate in both immediate

distress and long-term interruptions to normal functioning with far-

32

reaching consequences for oneself, one’s loved ones, and society.

(p.8)

The statement is an accurate depiction of the horrors of war, the jolt to the

psyche and physical health and the resultant diagnoses of PTSD in

returning soldiers. Since 2001, Operation Enduring Freedom (OEF) and

Iraqi Freedom (OIF) resulted in the deployment of more than 2 million

U.S. troops. (Congressional Budget Office (CBO), 2010) These troops

may experience repeated deployments and are likely to return home

whereby 10-20% will experience psychological problems requiring

treatment. That amounts to more than hundreds of thousands of troops

returning with mental health issues including PTSD. (Tuerk, P.,

Steenkamp, M., & Rauch, S.M., 2010 p. 49) Of all 496, 800 deployed

troops receiving treatment stateside, between 2004 and 2009, 103, 500

were diagnosed with PTSD and 26, 600 were diagnosed with PTSD and

traumatic brain injury (TBI). (CBO, p. 24) In September 2011, mental

health diagnoses were the second largest among returning troops receiving

Veterans Health Administration (VHA) services resulting in 52% of all the

soldiers. These statistics are based on those troops that seek VHA

33

assistance. The research was based on registered veterans not accounting

for all veterans returning home. Lapierre et al. (2007, as cited by Fritch,

A.M., Mishkind, M, Reger, M.A., Gahm, G.A., 2010 p.249) reported that

44% of returning troops had depressive symptoms, PTSD or both. In 2006,

30.4% of soldiers and marines returning from OEF had mental health

concerns including PTSD, depression, suicidal ideation and aggression

issues per Hoge and colleagues (Fritch et al. 2011 p.249)

Similar symptoms and diagnoses were reported pertaining to soldiers

returning from Viet Nam. According to a 2003 study conducted by

Schnurr et al. (as cited by COB, 2010 p. 24) 60% of Vietnam veterans were

diagnosed with PTSD within two years after experiencing combat. The

rate drops to ten percent or lower after six years away from combat, and the

trauma experienced. The study by Schnurr et al. (2003) consisted of a

diverse mix of 360 Vietnam theater veterans (p. 546-547). The findings

suggest that delayed onset of PTSD symptoms was not uncommon and that

the chronicity of persistent symptoms was deserving of treatment (p. 551).

The continued return to the U.S. of soldiers from OEF, OIF and combat

theaters in the Middle Eastern Nations assuredly will result in escalated

34

diagnoses of PTSD given the research validating onset delays and

unfortunate cataclysmic TBI.

Combat, PTSD, and Physical Injury

The physiological and neurological consequences in combat soldiers

diagnosed with PTSD are compounded by injuries suffered and traumatic

incident exposure during deployment such as TBI and witnessing death.

Soldiers, regardless of gender and ethnicity and at varying degrees, suffer

from PTSD and Major Depressive Disorder as responses to horrific

violence, or being wounded in combat, or experience physical and sexual

assault or harassment. (Marshall et al., 2005 p. 870) In addition, soldiers

may also experience PTSD from actions they may have taken themselves,

e.g., killing others. (Sharpless & Barber, 2011 p. 9) Regardless of the

varied means of acquiring the diagnoses of PTSD the physiological and

neurological consequences are comparable. Brain abnormalities are

reported in the amygdala or insula responsible for emotion-generation and

the anterior cingulated cortex (ACC) and medial prefrontal cortex (mPFC)

responsible for emotion regulation. There are known correlates with the

roles of the amygdala pertaining to threat detection, fear conditioning and

35

emotional salience and the role of the mPFC connected to basic needs and

emotions and regulation. (Sripada, et al., 2012 p. 241) Magnetic resonance

imaging (MRI) of individuals with PTSD suggest hyper activation

(increased) of the amygdala to emotional stimuli and hypo activation

(decreased) of the prefrontal cortices and were found to generate a lack of

regulatory control over emotion (Sripada, et al., 2012 p. 241). Connections

between the amygdala and the hippocampus were reduced, and the findings

suggest abnormalities in emotion generation and regulation, the failure to

place threats and safety in the proper context and create appropriate

responses to fear all of which are attributable to known PTSD symptoms.

(Sripada, et al., 2012, p. 247)

The neurological impact of PTSD is consistent. However, there may

be additional physical trauma leading to the developmment of PTSD

symptoms such as Traumatic Brain Injury (TBI or mild traumatic brain

injuries (mTBI). When there is a case of TBI or mTBI, and there is a

reported loss of consciousness there is an increase in PTSD. Causation

may be a result of the incident that lead to the loss of consciousness. The

presence of mTBI also may be a cause for the psychological trauma

36

resulting in PTSD.(Ruff, Reichers, Xiao,-Feng, Piero & Ruff. 2012 p.2)

Ruff et al. noted that 44% of the soldiers deployed in Iraq with a history of

loss of consciousness associated with mTBI had PTSD. This is compared

to 16% of soldiers with other injuries and 9% of soldiers with no injuries

with PTSD. The areas of the brain damaged commonly with mTBI mirror

those that are damaged from PTSD.(p. 10 ) Ruff et al contend that there

may be a tendency to attribute physical symptoms to PTSD rather than

mTBI. Futhermore, the authors suggest that further studies should be

conducted that identify symptoms and attribute them to one or the other

and determine the relationship of mTBI and the cumulative effect on the

development of PTSD. (p.11)

Dohrenwend, et al(2006)., Hoge, Auchterlonie, & Milliken (2006),

Hoge et al. (as cited by Gates et al, 2012 p. 361) identify military personnel

and veterans as two highly vulnerable at-risk groups for develoment of

PTSD. (p. 361) The American Psychiatric Association (2000) (as cited by

Gates et al. 2012 p. 361) identifies symptom clusters consisting of re-

experiencing in the form of intrusive thoughts, recurrent dreams,

flashbacks, distress and trauma may cue physiologic reactivity and

37

avoidance and emotional numbing. These symptoms can result in

detachment from others, flat emotional experience, and fatalistic thoughts.

The impact of the hyperarousal symptoms include sleeplessness, irritability

and anger, lack of concentration, hypervigilance and exaggerated startle.

Impact of symptom clusters initially were difficult to interpret due to

the means by which PTSD was to be screened upon return (largely the

same instruments are used to date), the determination of potential

manipulation of reporting soldiers, and the potential of overdiagnoses.

Recent research has illustrated that previous miminization and

underestimation of reported symptoms and diagnoses were inaccurate and

misleading by virtue of the impact and observations of returning troops.

(Gates, et al., 2012 p. 362). The United States Bureau of Justice Statistics

in 2007 (as cited by Elbogen, et al 2012, p. 1097) that over 200,000

veterans were incarcerated at the time of the sample and a large percentage

for violent crimes. This represented 10% of the incarcerated population

and there continues to be a possible underestimation due to how

information is attained from subjects and reported. (Elbogen, et al., 2012

p. 1098). Returning soldiers already emotionally and cognatively

challenged with the symptoms of diagnosed PTSD, are more inclined to

38

experience marital and family problems, job instability, legal difficulties,

and physical health problems (Jordan, Marmar, Fairbank, Schlenger,

Kulka, Hough & Weiss, 1992, Smith, Schnurr, & Rosenbeck, 2005, Kulka,

Schlenger, Fairbank, Hough, Jordan, Marmar, & Weiss, 1990a, Boscarino,

2004; O’Toole, Catts, Outram, Pierse, & Cockburn, 2009)

Several scholars (as cited by Gates 2012 p.362) postulate that

returning veterans face a myriad of ailments that interferes with their return

to society and civilian life. There are documented conditions including

heart disease, respiratory, gastrointestinal, infectious nervous system, and

autoimmune disorders. Soldiers with PTSD commonly exhibit anxiety,

depression, co-morbid alcohol and substance abuse among other mental

health disorders. There are alarming and elevating numbers of suicide

ideation, attempts, and completions to date. In 2012, the number of

suicides, in one month, spiked per New York (NYT) reporter, Timothy

Williams, “eclipsing the number of troops dying in battle”. (NYT, 2012)

Ilgen, Zivin, McCammon & Valenstein in their 2008 article Mental Illness,

Previous Suicidality, and Access to Guns in the United States state that

“Although PTSD symptoms may appear of lesser clinical significance than

the physical impairments that patients often present with in a rehabilitation

39

setting, research indicates that having PTSD doubles the likelihood that a

veteran will die by suicide” (p. 24).

As the evidence suggests, soldiers returning from overseas combat

theater engagements and are increasingly being diagnosed with PTSD.

These men and women have faced enormous personal torment amid deadly

force, violence and the many collateral issues of combat experience. Upon

return home they are faced with continued challenges pertaining to

transitioning to civilian life and lifelong struggles with coping.

Fig. 1.Bremner(2000), in his article The Invisible Epidemic: Post-

Traumatic Stress Disorder, Memory and the Brain used the MRI image

above to illustrate the 8% reduction in right hippocampal volume. The

MRI was conducted on Vietnam veterans reporting memory loss due to

PTSD. The diminished right hippocampus was associated with short term

40

memory loss. Similar results were recognized when the MRIs were

conducted on victims of childhood physical or sexual trauma. (p.4)

Commonalities in Symptoms

Youth removed from their homes via the juvenile justice system, or

placed in foster care after being diagnosed with PTSD, often share similar

symptoms that combat exposed soldiers manifest with the same diagnosis.

One difference in the populations is the difference in age at the time of the

trauma. Abused children are in various stages of development that are

critical without the elements of abuse. The particular stage of development

at the onset of the abuse will determine the extent and severity of the

consequences. Chronic abuse will compound the consequences further.

(Frederico, Jackson, & Black, 2008 p. 344) Inability to regulate emotion,

irritability and difficulty with recall are common place. The behaviors

exhibited provide evidence of commonality with soldiers such as re-

enactment of the trauma; sleep difficulty and nightmare reporting,

hyperarousal and inhibition. In my experiences with youth, some would

overreact to minor incidents, and would often act out to the point of

physical intervention and/or dissociate completely. Youth would begin

41

using names from their past unrelated to the present when physically

engaged with staff. Upon inquiry, the youth could not recall as to why

physical intervention took place at all and felt as if they were yet again

victims with inexplicable passion. This episodic and repetitive behavior has

correlates in research with combat exposed soldiers. However, evidence

suggests childhood abuse manifesting the three characteristics of PTSD

avoidant coping and avoidance symptoms and the ability to maintain social

resources throughout life may impact the means by which adults handle

traumatic experiences such as combat exposure. (Van Voorhees, et al.,

2012 p. 424)

Physiological and Neurological Commonalities

Research suggests commonalities in physiological and psychological

symptoms in the population of children traumatized by a form of abuse and

that of soldiers having experienced combat. Studies further suggest that

there are questions remaining about the level of trauma and the ensuing

diagnoses of PTSD. Information is gleaned from interviewing or screening

soldiers with questions pertaining to their childhood experience and

trauma. The descriptions of what occurs in the human brain during the

42

trauma and the aftermath, the relationship between the traumatic incidents,

the brain, and the diagnosed PTSD and the impact on a life, are uniquely

threaded throughout both populations. The discerning question that is

represented in all the research is the chronological order of events. The

change in volume of specific areas of the human brain may in fact be

genetic and indicate a propensity to handle adversity poorly or the trauma

inducing PTSD may in fact reduce the volume in the brain areas impacted.

Although studies of both populations prove difficult, there is a need to

further explore specific relationships between the traumatic event and the

diagnosis of PTSD. Commonalities allow for continued research and may

further impact the means by which victims of child abuse and beleaguered

veterans are provided necessary care.

Most research focuses on combat exposed soldiers with a history of

child abuse. All studies indicate various limitations in the means of

attaining information from children due to the impact of their PTSD and

responses to trauma and screening instruments. Studies further suggest that

PTSD is associated with a lessening of the volume of the amygdala and

hippocampus impacting cognitive function. (See Fig. 1) PTSD in adults

43

with combat exposure, child abuse or some form of trauma when compared

to healthy control groups confirm reduction of the amygdala and

hippocampus and impaired cognition (Weniger, Lange, Sachsse, & Irle,

2008 p. 282) In addition, Iversen et al. (2007), King, King, Foy, &

Gudanowski (1996); Zaidi & Foy (1994) reported that child abuse may

come into play during combat provoking a vulnerability to combat-related

traumatic stress (as cited by Van Voorhees et al., 2012 p. 425).

In their article, Relationships Between Attribution Style, Child Abuse

History, and PTSD Symptom Severity in Vietnam Veterans (2006)

McKeever, McWhirter, & Huff (2006) discuss child abuse and identify that

the trauma and ensuing PTSD are attributed in most cases to external

factors provoking learned helplessness that may actually increase the

abuse. (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993,

Fontana, Schwartz & Rosenheck, 1997) Evidence further supports that the

association between learned helplessness and external attribution and adult

onset PTSD following trauma (combat) exposure may determine the extent

of the PTSD. (Casella & Motta, 1990; McCormick, Taber, & Kruedelbach,

1989; Regehr, Cadell, & Jansen, 1999; Solomon, Mikulincer, & Waysman,

44

1991) (p.124). McKeever, et al. (2006) further contend that learned

helplessness and external loci of control are separate factors having diverse

relationships to abuse history and combat related PTSD severity. Learned

helplessness, self-blame for causing the trauma and the unwillingness to

attempt to resolve subsequent stressors, appears to be the dominant factor.

(p. 131). Furthermore, research suggests that soldiers with a predisposition

to PTSD as a result of child abuse are more likely to be afflicted with

PTSD with exposure to combat than others. In discussing commonalities

between the populations there appears to be a continuous and cyclical pre-

dispositional response to trauma, confounded by learned helplessness and

external attribution. Exposure to violence and trauma in childhood may

impact adult victims that enter the military and face combat exposure.

Thus, it appears that PTSD is a lifetime disorder.

The overall psychological and physiological symptoms of PTSD are

present in both populations, victims of child abuse and combat exposed

soldiers. Children are impacted at various stages of development and have

long term psychological and physiological issues due to PTSD. Combat

exposed soldiers return home and also face psychological issues returning

to what once was home but becomes a different place by virtue of the

45

disorder. Physiological issues also emerge. Soldiers that have been abused

as a child and also have combat exposure, experience PTSD in varying

degrees depending on the level of abuse versus the extent of the combat

(Owens, et al. 2009 p. 115). Studies by Hiley-Young, Blake, Abueg,

Rozynko & Gusman (1995) and Koenen, Stellman, Stellman & Sommer

(2003) (as cited by Owens et al., 2009, p. 115) had findings that

demonstrate that high level combat exposure predicts PTSD severity and as

well as persistence. A 2005 study by Stein et al., on Gulf War veterans

indicated that there has also been evidence that a history of child abuse

appears to be associated with PTSD diagnosed soldiers involved in low

level combat exposure. (as cited by Owens, et al., 2009 p. 115)

In their article Posttraumatic Stress Disorder Symptoms and

Precombat Sexual and Physical Abuse in Desert Storm Veterans, Engel,

Engel, Campbell, McFall, Russo, & Katon (1993) confirm that childhood

trauma strongly influences the development of PTSD particularly in lower

level combat. The findings further support that screening soldiers for level

of child abuse would be as important as assessing combat exposure when

determining treatment for PTSD.(as cited by Owens et al., 2009 p. 122)

46

Based on these findings, it appears that psychological, neurological

and physiological characteristics and symptoms of PTSD diagnoses in both

populations remain related and comparable. The largest common

denominator is the documented long term consequence in psychological

functioning and the impact on physiological well-being. The overarching

theme appears to be exposure to violence representing a multitude of

consequences on the victims, observers and impacted; PTSD being among

them. Brooks, Keeshin, Cronholm and Strawn, (2011) in their article

Physiologic Changes Associated With Violence and Abuse Exposure: An

Examination of Related Medical Conditions reference evidence suggesting

that either severe singular exposure to violence or continual exposure to

violence subjects individuals to health problems and dysfunction. The over

and under production of hormones adds to the likelihood of emotional

problems and physical malady.

The increased secretion of catecholamine in both youth and adults

and the ensuing impact on the amygdala and hippocampus in the brain are

the precursors for PTSD in children which have not been confirmed in

adults. Patients with PTSD have higher concentrations of catecholamine

47

in the central nervous system which often creates physiological conditions.

Catecholamine is also excessively produced by soldiers with PTSD under

stressful situations post combat. Evaluation of urinary norepinephrine in

patients with PTSD has yielded conflicting results. Only a few studies have

examined urinary catecholamine excretion in combat veterans with PTSD,

and one study has examined urinary catecholamines in civilian PTSD. De

Bellis, Lefter, Trickett, & Putnam in their 1994 study found excretion of

catecholamines increased in sexually abused girls compared with a control

cohort. Lemieux and Coe (1995) found that increased norepinephrine

excretion seemingly lasts into adulthood in subjects that are ultimately

diagnosed with PTSD. Kosten et al., (1987) and Yehuda (1992) et al.,

found that epinephrine and norepinephrine excretion in combat-veterans

with PTSD is increased when compared to subjects with multiple

psychological disorders and health control cohorts. (as cited by Strawn &

Geracioti, 2008 p. 263)

Figure 2 indicates the location in the brain impacted by the increased

production of catacholomines:

48

figure 2. These collections of neurons project to a constellation of

structures that are altered or implicated in the pathophysiology of PTSD,

including the prefrontal cortex, amygdala, hippocampus, hypothalamus,

periaqueductal gray matter and the thalamus. (Photograph courtesy of

Patricia Brown, Ph.D., University of Cincinnati, Department of Cell

Biology, Neurobiology and Anatomy.) (As cited by Strawn & Geracioti,

2008 p. 262)

Keeshin et al., (2012 p. 44-49) cite various studies that have

illustrated particular illnesses may have their root in diverse populations

and the prior exposure to violence and abuse.

49

Syndromes including chronic pain and irritable bowel and somatic illnesses

including fibromyalgia and chronic fatigue have been observed.

Respiratory Disorders including COPD and asthma are common as is

obesity, cardio-vascular disease and cancer.

The impenetrable bond shared by childhood victims of abuse and

combat exposed soldiers lies in exposure to violence at any given time in

an individual’s life. Trauma exposure resulting in the diagnosis of PTSD

has been shown to be “enhanced” by previous exposure to violence,

magnified by ensuing stimuli causing neurological over production and at

times the combination of experiencing both abuse and combat perpetuates

and elevates traumatic events throughout life. The neurological and

physiological damage may take a toll in later life in the form of physical

illnesses. Treatment must be provided readily and planned according to the

particular screening of the individual. The research indicates that the

history of combat exposure, child abuse, dysfunction and induced illnesses

were evident with various diagnoses with created names and descriptions.

Given the continued misfortunes of the victims of PTSD, questions remain

50

about the distance our efforts and research have provided, and if we have

actually “come such a long way already”.

51

CHAPTER II

Historical Perspective of Child Abuse, Child Protection, and PTSD

As far as the population of child abuse victims and combat exposed

veterans are concerned, it is mandated to document, despite minimal

understanding of impact to the human psyche, what transpires during the

lifetime of war theaters. As defined by Clausewitz in his book On War

(Graham, 1873) theaters “denote properly such a portion of space over

which war prevails as has its boundaries protected, and thus possesses a

kind of independence”. In order to understand the evolution of PTSD

treatment for children, it is imperative to examine the history of societal

attempts to protect children which provides foundational information.

There is scarcity of research on child abuse, due to the limitations imposed

upon studies pertaining to a child’s ability to relate reality, access to

children being abused and trauma re-enactment. Reported PTSD in

children is factored by a number of variables such as measurement tools,

the severity of the trauma, the personal impact on the child and the time

elapsed since the traumatic event (Cohen, 1998 p. 998). The course of

history regarding child abuse and maltreatment reveals the volume of

52

incidents, attempted prosecution of perpetrators, and attempted legislative

interventions where safety was the priority without consideration to

damages to the psyche. There appeared to be an acknowledgement of

impact without consideration for treatment or follow up for more than

safety, removal from the dangerous environment and halting the violence.

Reporting abuse had a stigmatic element attached to the examining

physician making an allegation. There was disbelief that parents could be

responsible, improper diagnoses of certain fractures that evidenced abuse,

and concern as to the investigative follow up if any if the abuse was

reported (Kempe et al. 1985 p. 149). Entertaining the notion of possible

long term damage to the psyche was not professionally explored, for the

record, until well into the twentieth century (Hollenbeck, 2001 p. 8).

Many child abuse victims have spent the formative years of their lives in

fear due to trauma and the ensuing impact of PTSD likely for centuries.

“It’s a jungle out there” was apropos metaphorically for child abuse victims

in their own home once psychological impact began to be considered.

In his article “A Short History of Child Protection in America”

Myers (2008) divides child protection into three eras: colonial times to

53

1875, 1875 to 1962, and 1962 forward. The first era was pre-organized

child protection; the second era featured the development of non-

governmental child protection societies, the third or modern era was the

onset of child protective services. In 1980, the Public Law 96-272, the

Adoption Assistance and Child Welfare Act, was the first legislation

pertaining to child protection in the modern area. Some 17 years later the

Adoption Safe Families Act was passed clearly illustrating that the plight

of abused children had a place on the “back-burner” (Center for the Study

of Social Policy & the Urban Institute (Urban.org.) 2009). Both laws were

based on the cyclical swaying of legislators between the swift reunification

of families versus the risk of leaving children in dangerous situations or

returning them to the same.

Children never were without some form of protection as there were

inconsistent means of addressing abuse, arrests and removals from home in

the first era. There was no uniform approach and no organizations

advocating or protecting children. Some adults were knowledgeable,

aware and willing to help. It was the responsibility of the local jurisdiction

and judge to stop reported abuse. In New York in 1809 there is a record of

54

arrest of a shop owner for the sadistic attack on a slave and her three

children, a woman murdering her newborn in Schenectady New York in

1810, a father confining his blind son in a cellar in Illinois in 1869 and a

host of removals or arrests for rape, abuse, and “wanton and needless

cruelty”.(Myers, 2008) 1866 legislation from chapter 23 “An Act

Concerning the Care and Education of Neglected Children” (as cited by

Myers, 2008) authorized judges to take action and “intervene in the family

when by reason of orphanage or of the neglect, crime, drunkenness or other

vice of parents," a child was "growing up without education or salutary

control, and in circumstances exposing said child to an idle and dissolute

life." (Myers, 2008) Late in the first era and into the second era Charles

Loring Brace founded the Children’s Aid Society and between 1853 and

1890 relocated 92,000 children to safer places to live from the streets of

New York City via a process called “placing out” (Hollenbeck, 2001 p. 5).

The second era, spanning from 1875 to 1962, as identified by Myers

(2008) was sparked by the 1874 case of Mary Ellen Wilson, a nine year old

orphan severely and repeatedly beaten by her adoptive family; the

Connolly’s. There were no agencies at the time to assist, and concerned

55

parties turned to the American Society for the Prevention of Cruelty to

Animals. Mary Ellen qualified, being mammal, and was ordered removed

from home and punishment was meted to Mrs. Connolly (Hollenbeck, 2001

p. 6). The infamy of the case and the public reaction spurred the creation

of the New York Society for the Prevention of Cruelty to Children in 1874.

Legislation was passed in New York in 1875 authorizing societies to

process violations with the assistance of law enforcement (Meyer, 2008).

The creation of the New York Society for the Prevention of Cruelty

to Children spurred the creation of 400 non-governmental agencies by 1905

(Hollenbeck, 2001 p. 7). Despite the formation of agencies, due to victims

being in remote areas, most support for victims of abuse came from local

persons willing to help and authorities. In conjunction with the formation

of non-governmental agencies juvenile courts emerged and by 1919, most

states had these courts. Juvenile courts were mainly concerned with

delinquent behaviors; however, they had jurisdiction in cases involving

abuse. Federal funding was provided to the non-governmental agencies

largely due to the 1912 formation of the Children’s Bureau. This was

located in the fine print, in the SSA legislation; mandating money is

56

provided for health services for mothers and babies. (2008) The Great

Depression changed the entire tone of the nation and funding was for child

protection was not prioritized. This resulted in agency mergers or

dissolution, child protection coming from the courts and authorities, and

protection efforts ending in some communities. Within the small print of

the Social Security Act (SSA) was an amendment that authorized the

Children’s Bureau: (Myers, 2008)

to cooperate with state public welfare agencies in establishing,

extending, and strengthening, especially in predominantly

rural areas, for the care of homeless, dependent, and neglected

children and children in danger of becoming delinquent. (SSA

1935 521, 49 Stat. 620, 633 as cited by Myers, 2008)

This paved the way for government involvement and the beginning of the

social work field in child welfare as well as the pivotal role of the federal

and state governments in monitoring child abuse (Myers, 2008).

Serious attention to the issue and any attention to the impact on the

child psychologically did not arise until the 1960’s and 70’s (Hollenbeck,

2001 p. 6-7). In 1961, Dr. C. Henry Kempe presented the notion of

57

“battered child syndrome” to the American Academy of Pediatrics. This

presentation and article references for the first time the medical impact of

“trauma” with the physical indications and evidence of abuse and tying

them to psychiatric issues; largely of the abuser (Kempe, et al, 1985 p.

143). References to the status of research into psychiatric knowledge at the

time are “meager” and “non-existent” (Kempe, et al. 1985 p. 144). In

summation, Kempe contends:

Psychiatric factors are probably of prime importance in the

pathogenesis of the disorder, but our knowledge of these factors is

limited. Parents who inflict abuse on their children do not necessarily

have psychopathic or sociopathic personalities or come from

borderline socioeconomic groups, although most published cases

have been in these categories. In most cases, some defect in

character structure is probably present; often parents may be

repeating the type of child care practiced on them in their childhood.

(p. 154)

“Battered Child Syndrome”, amendments to the social security act, and

meetings of the federal children’s bureau made 1962 a landmark year.

58

Kempe recommended that legislation require doctors to report suspicion of

abuse to law enforcement and child welfare. Four states passed such

legislation in 1963. All states had reporting laws by 1967 (Myers, 2008).

In the 1970’s federal legislation mandated the identification and

reporting of child abuse to the appropriate social service agencies. States

established their own laws and identified specifically titled professionals,

clinicians, physicians, social workers, and teachers, for example, as

“mandated reporters” (New York State Office of Children and Family

Service (NYS OCFS), 2011). New York, in 1973, passed the Child

Services Protective Act to enhance reporting of child abuse and

maltreatment in state counties. Each county was deemed responsible for

investigating reports, protecting children from further harm, and providing

rehabilitative services to children and their families. The act provides five

fundamental components:

� detection through third party recognition;

� emergency protective custody;

� State Central Register;

� child protective services;

59

� And, when necessary, court action (which included “treatment”.)

(NYS OCFS, 2011)

This may include referrals to services including casework and psychiatry

aimed at “breaking the cycle of abuse” (Silver and Green, 2001). The act

did not include language as to the trauma of abuse and treating PTSD

symptoms. A population began to evolve that could be subjects for

assessment, intervention and attempts to improve outcomes. Laws were

passed that began to discuss “permanency” and ultimately safe places for a

child following a traumatic experience.

Child welfare provided little change in the eighties. Some concerns

were beginning to emerge about the length of time that youth were

removed from their parents and home, languished in foster care and their

ability to be freed for adoption. Reunification was the priority but not

always a viable solution. In 1997, the Adoption Safe Family Act was

passed, and the focus became permanency. The act attempted to set time

frames for steps in the process for either terminating parental rights and

free for adoption or move to reunification. The law created many variables

relative to case planning. “Reasonable efforts” was the catch phrase as to

60

the energies exerted in the reunification process documenting the path to

termination. This included living with “trusted” relatives, placement in

foster care for a pre-determined time frame, or placement in a residential

facility with varying degrees of security whereby the process for

termination was initiated in the family court system captured the range of

alternatives. The law accounted for special court orders for treatment by the

judge if there were reported mental health issues. Politically, there was an

advantage to addressing the child abuse issues as bi-partisan and carried

public favor (Center for the Study of Social Policy & the Urban Institute

Urban.org, 2009). The political world favors gaining public acceptance,

from “either side of the aisle” and stating compassion and concern for

children never lost votes. Approaches to engaging youth and families

began to include consideration for the experience and trauma.

Brander (1943), Dunsden (1941), and Freud & Burlingham (1943)

discussed children’s reaction to trauma at the time of WWII (as cited by

Salmon and Bryant 2002, p. 166). McNally (1993) reported that most

studies were often conducted following natural disasters, war, criminal

violence, burns, sexual abuse, and accidents (as cited by Salmon and

61

Bryant 2002, p. 166). Early research and studies about trauma and

children that were victims of physical, psychological and sexual abuse

displayed wide ranges of percentages of experience and provocation.

Based on several studies, natural disasters generally run a lower percentage

of PTSD diagnoses in children (5%) than warfare (27%-33%) PTSD has

been reported in all children exposed to maternal rape or parental homicide

in study subjects. The report of PTSD diagnoses following sexual abuse

ascended with time ranging from as little as 0% to 48% in studies

conducted over a decade. (1987-1997) Physical trauma such as motor

vehicle accidents and traumatic brain injury had resultant PTSD diagnoses

at 23%. It appears that brain injury increased the likelihood of diagnosis

(as cited by Salmon & Bryant, 2001, p.167). The research and studies did

not specifically look at victims of physical abuse. However, some child

abuse victims may have fallen in other groups. According to research, the

diagnosis of PTSD is enhanced by brain injury. The diagnoses and impact

to the stage of development is complicated by the poor conceptualization of

the symptoms by virtue of the age of subjects and the prescribed

characteristics of each developmental stage (Salmon & Bryant (2001) p.

62

168). There were incremental injuries taking place before, during or after a

major event that may have enhanced PTSD diagnosis potential.

Acute stress disorder (ASD) was introduced in the DSM-IV as

trauma reactions that occur within one month of the trauma; the rationale

was the provision of a road map to chronic PTSD (Meiser-Stedman et al.,

2007 p. 359). There are few studies on children connecting ASD with

PTSD; however, the inclusion in the DSM-IV and the criteria and

symptoms was based on findings from adult subjects. In addition, further

studies confirmed ASD as a predictor of other psychoses to a greater

degree than PTSD. However, in studies were the assessments of

dissociative characteristics were less rigid and sensitivity increased the

prediction of PTSD was apparent and not dismissed entirely (Bryant,

Creamer, O’Donnell, Silove, & McFarlane 2011 p. 172).

Anthony, Lonigan, and Hecht (1999) reported that the largest

common denominator in children and adults is the presence of the

aforementioned three symptom clusters: Intrusion/Active Avoidance,

Numbing/Passive Avoidance and Arousal. It is interesting to note that

these factors manifested themselves in late childhood, through adolescence

and into adulthood (as cited by Salmon & Bryant, 2001, p. 167). Relative

63

to the comparison of adults/children/child abuse victims/combat exposed

veterans, the difference is discussed using the developmental stage of a

child and the commonalities are the symptoms and the likelihood of

physical malady possibly years after the trauma. Over the course of time

children were thought of as vulnerable to many forms of abuse that had

long term consequences related to well-being. Physicians unwilling to

connect injury to abuse stalled deeper investigation into victims of child

abuse (Kempe et al. 1985 p. 146). The earliest report of a child or infant

having a comprehensive brain scan due to trauma study is related to

contemporary studies within the last 20 years (Richert, Carrion,

Karchemskiy, & Reiss, 2006 p. 18). Many combat veterans were the

subject of studies by virtue of their history of being abused as a child and

being diagnosed with PTSD as a result of their war experience.

Historical Perspective of Combat Veterans and PTSD

Throughout the history of war, there have always been problems

maintaining the troops due to physical injury, mental breakdown and

morale. In war psychiatry, the diagnoses and treatment of disorders

including PTSD and other trauma related psychological problems are

complicated by the variables presented by the afflicted. These disorders

64

have both general and non-specific characteristics rendering treatment

somewhere in the middle of mind and body (Chamberlin, 2012 p. 359).

Further complicating treating victims of “soldier’s heart, “shell shock” and

“combat fatigue”, names given to describe collective symptoms associated

with PTSD, is the lore of the war hero, every bit deserving of recognition

of following orders and holding their ground, they are all truly warriors.

For a soldier to come to terms with compromised ability to maintain

composure and enter into an unknown world of uncontrollable emotion

would be to admit to cowardice and impotence under pressure, contrary to

the soldier in American culture as represented by the bravado of film actors

such as Errol Flynn and John Wayne. The aforementioned lack of specific

disease or symptoms and the image of the war hero created cynicism

among health professionals pertaining to the reality of the soldier’s

complaints of being physically injured or not (Chamberlin, 2012 p. 360).

Early written accounts of soldiers overtaken by an “indescribable

something” first surfaced during the civil war.

65

Errol Flynn John Wayne

Lasiuk and Hegadoren (2006) in their article, Posttraumatic Stress

Disorder Part I: Historical Development of the Concept, discuss the

coining of the terms, “soldiers heart”, “irritable heart”, “nostalgia” and

“effort syndrome” and “DaCosta’s syndrome” by Myers (1870) and

DaCosta(1871) himself. These conditions came with the physical

symptoms of extreme fatigue, dyspnea, palpitations, sweating, tremors, and

fainting spells. The conditions were linked to increased cardiovascular

activity and biological response to the stressors of battle. (p. 17) According

to Bourne, (1970) during the Civil War there were 5,213 cases of this

disorder reported during the first year or 2.34 per 1000. This escalated to

3.3 per 1,000 in the second year of the war (as cited by Chamberlin, 2012

p. 360). The ease of writing these conditions off as combat and war and

biological responses to concussion provided means to preserve the integrity

66

of the soldier. This was despite PTSD symptoms and behavioral

difficulties and therefore served to minimize blame and stigma. Most

believed this medical model explanation while few believed there may be a

psychological origin. In any case, the disorders proved costly and difficult

for the military (Chamberlin, 2012, p, 360). The study of trauma was

largely invisible until the horrors of World War I provoked discussion.

World War I was laden with traumatic environs. Soldiers were

exposed to the constant threats of personal death and the witnessing of the

mutilation and killings of friends (Chamberlin, 2012 p. 360). Asaf and

Powell (1915) penned the lyrics and music to the song “Pack Up Your

Troubles”. The chorus of the song which is repeated twice after every

verse:

Pack up your troubles in your old kit-bag,

And smile, smile, smile

While you’ve a Lucifer to light your fag,

Smile boys that’s the style

What’s the use of worrying

It never was worthwhile so

67

Pack up your trouble in your old kit-bag

And smile, smile, smile

The song soared with popularity as a march and masked the physical and

mental torment of those boys that were destined to be smiling if they made

it home. By the end of the war, there were 80, 000 cases of mental

breakdowns in epidemic proportion (Chamberlain, 2012, p. 360) with “full

kit-bags” if they made it home at all.

The new term given to the symptoms of PTSD exhibited by World

War I soldiers became “shell shock” and “shell concussion” as originated

by Dr. Charles Samuel Myers (1915). Shell shock was associated with

psychological problems. Upon learning that soldiers that were not involved

in combat were manifesting shell shock symptoms he created shell

concussion. Shell concussion was tied to neurological problems attributed

to physical injury (Lamprecht and Sack, 2002 p. 224). Symptoms, as

explained by Herman (1977) were (soldiers) “began to act like hysterical

women. They screamed and wept uncontrollably. They froze and could not

move. They became mute and unresponsive. They lost their memory and

the capacity to feel” (as cited by Lasiuk and Hegadoren, 2006 p. 17).

Chamberlin (2012) argues that the creation of shock concussion was an

68

attempt to justify shell shock symptoms in “good soldiers”. (p. 361)

Victims of shell shock were treated as lesser men (Lamprecht and Sack,

2002 p. 224). Hurst in his book Medical Diseases of War (1918) discusses

the main causes of war neuroses as “congenital nervousness, a previous

mental breakdown, concussion and chronic alcoholism” Hurst further

stated that:

A man with a good family history, who has never suffered

from any nervous disability, only develops war neuroses,

including shell-shock, under exceptional circumstances (as

cited by Chamberlin, 2012 p. 361).

The separation between neurological and psychological causation

eventually drifted away as did the discussions of the PTSD symptoms of

shell shock until World War II provided yet another forum. After digesting

the cost of psychiatric casualties during WWI, attempts were made to

screen prospective soldiers to serve in WWII for units free of the

“psychologically vulnerable” and less likely to “breakdown”.

Assessments were done contemplating those that would become “good

soldiers”. It was learned shortly thereafter that the process was a failure

and that even “good soldiers” were prone to breaking (Chamberlin 2012, p.

69

362, Lasiuk and Hegadoren 2006, p. 18). It was at this time that there was

significant work done pertaining to the symptoms of what was now called

“combat fatigue” or “combat exhaustion” (Lamprecht and Sack, (2002 p.

224).

The continuing casualties of combat fatigue served as the

foundational research on the phenomenon of both biological and

psychological impact of warfare and the general vulnerability of all soldiers

to the symptoms (Chamberlin, 2012 p. 362). Abram Kardiner (1941) in his

book The Traumatic Neuroses of War discusses the term “physioneuroses”

which denotes the involvement of the body from the onset. Kardiner

initiated concepts that have contemporary resonance in PTSD research. He

described “hallucinatory reproductions of sensations in the original

occasion” today known as flashbacks. Kardiner alluded to the “contraction

of the ego” as an inhibitory process. This was tied to amnesia regarding

the traumatic event or blocking out. He went on to associate this with

proneness to motor activity and the arousal to anger. Sleep difficulties and

nightmares were also connected to the inability to deal with external

stimuli. There is a reference to functional sense organs that are modified.

Kardiner discriminated between normal responses and the altered response

70

as a result of trauma. He identified that three interconnected disciplines

were involved: organic neurology, internal medicine and psychiatry

(Lamprecht and Sack, 2002 p. 224). This recalls the earlier discussion of

the impact on the brain, the over and underproduction of catecholamine and

the ensuing difficulty in regulating emotions which are synonymous to

Kardiner’s work.

As the discussion of psychological trauma progressed, Herbert

Spiegel was in Tunisia, in 1947, evaluating soldiers to develop a plan to

reduce psychiatric casualties. Spiegel theorized that the single most

important deterrent in preventing neuroses and returning a soldier to

combat was the strength and unity of the soldier’s platoon. Conversely the

lack of unity and cohesiveness heightened the risk for psychiatric casualty,

and this became even higher if there was mistrust in the leadership (Lasiuk

and Hegadoren, 2006 p. 18). This was reinforced by a collaboration of

Kardiner and Spiegel (1947) and lead to the development of “front line

psychiatry” as described by Van der Kolk et al., 1996 (as cited by Lasiuk

and Hegadorn, 2006 p. 18). The thought of the mobile army hospital, as

popularized by the movie M*A*S*H*(Lardner, 1970) set during the Korean

War, was to maintain proximity to the supportive troop, immediate

71

treatment and expectancy of return. Psychiatrists began to staff these

hospitals; treatment was brief and focused on the immediate and the

anticipated return to the unit (Marlowe, 2000 as cited by Lasiuk and

Hegadorn 2006, p. 18). This also served to return soldiers to battle quickly,

possibly compounding PTSD symptoms, however, meeting the need to

maintain adequate infantry numbers in battle. Between WW II and the

Korean War, the interest in trauma did not wane as before with

consideration being given to civilians victims as well. “Gross stress

reaction” was listed in the Diagnostic Statistical Manual (DSM-1) of the

American Psychiatric Association (2000) in 1952 coinciding with the

Korean War. It was defined as a transient response to severe physical or

emotional stress which could evolve into a chronic neurotic reaction in

accordance with predisposing character traits (Turnbull, 1998 p. 89). The

United States anticipated that combat in the jungles of Viet Nam would

continue the attrition of soldiers with combat fatigue seen in previous wars

(Chamberlin, 2012 p. 362).

In Ted Engelmann’s article “Who Are Our Fathers?”(2007) he

discusses being a combat veteran, a victim of PTSD and his attempts to

reconcile his experiences as a soldier:

72

For several years I was very angry and could not talk to

anyone about my feelings. I was hyper alert, slept with a knife

under my pillow, had loaded weapons in my house, flew into

instant rages, hated just about any bureaucracy, especially the

U.S. government, had nightmares, felt emotionally numb, and

exhibited other behaviors that are attributable to post-

traumatic stress disorder (PTSD). In short, I did not belong

anywhere, and I have been seeking my place—my identity—

for close to forty years. (p. 165)

Engelmann was not alone. Kulka et al. (1990) cited the Congress

mandated National Vietnam Veterans Readjustment Study in 1983. In the

study, 30% of males and 26% of females reported PTSD experiences

during their lives (as cited by Nidiffer & Leach, 2010 p. 12). Soldiers that

returned from Vietnam were labeled as “baby-killers” as societal views of

the war were unfavorable, and this was transferred to the soldiers upon

return. Soldiers experienced a sense of isolation and compounded

emotional difficulties experienced in the field. In a New York Times

article in 1970 by Ralph Blumenthal, the term Post-Vietnam Syndrome was

used to describe the plight of the returning soldiers (Figley 2007, as cited

73

by Nidiffer & Leach, 2010 p. 10-11). As the numbers of soldiers reporting

PTSD symptoms increased upon return and months after, Post Vietnam

Syndrome was the foundation for inclusion of PTSD in the DSM III in

1980. In 1990-1991, studies of Gulf War veterans have represented a large

number of soldiers who continued to report adverse health effects.

Symptoms include headache, joint pain, fatigue, and problems with

memory and concentration (Wolfe, et al.1999, p. 532). There may have

been external factors as well in this particular war. Discussions have taken

place about the possibility of having PTSD and being exposed to another

element, i.e., chemical warfare, which may have compounded the effects of

either. Since 2001, Operation Enduring Freedom (OEF) and Iraqi

Freedom (OIF) resulted in the deployment of more than 2 million U.S.

troops (Congressional Budget Office Pub no. 4097 (CBO), 2010). These

troops may experience repeated deployments and are likely to return home

whereby 10-20% will experience psychological problems requiring

treatment. That amounts to more than hundreds of thousands of troops

returning with mental health issues including PTSD (Tuerk, Steenkamp, &

Rauch, 2010 p. 49). Of all 496,800 deployed troops receiving treatment

stateside, between 2004 and 2009, 103,500 were diagnosed with PTSD and

74

26,600 were diagnosed with PTSD and traumatic brain injury (TBI). (CBO,

p. 24) In comparison to proceeding wars, PTSD has been prioritized

relative to societal awareness and inclusion in the DSM. In a repetitive

manner to earlier history, several studies report that serving in OIF/OEF

has caused veterans to experience anxiety and depression, substance abuse,

physical health problems, aggression, risk taking behavior and suicide

(Tuerk, Steenkamp, & Rauch, 2010 p, 49). The recent initiation of

withdrawal of troops from Iraq and Afghanistan will elevate the numbers

of veterans reporting PTSD and over time will inevitably pose the burden,

feature the same mental and physical characteristics, and require the

equivalent support of troops beforehand( Tuerk, Steenkamp, & Rauch,

2010 p, 50). Smith, Schnurr, & Rosencheck (2005) and Resnick &

Rosencheck (2008) reported that in veteran populations diagnosed with

PTSD the severity of the symptoms incrementally increases the likelihood

of unemployment (as cited by Tuerk, Steenkamp, & Rauch, 2010 p, 50).

All studies are representative of those veterans that report to a VA for

assistance. There is a population of veterans that may have PTSD that have

not registered for services. For example, of the 1.64 million troops

deployed for Operation Enduring Freedom/Operation Iraqi Freedom,

75

300,000 are currently suffering from PTSD. The remaining troops may be

healthy or have not sought assistance.(Chamberlin, 2012 p. 363 )The total

cost of PTSD and increased service utilization is unknown as are the

disability claims with up to 94% of soldiers seeking treatment for service

related PTSD (Beckham et al., 1998; Chan et al., 2009; Deykin et al.,

2001; Hankin et al., 1999; McCrone, Knapp,& Cawkill, 2003, Frueh et al.,

2003; Frueh et al. 2007 as cited by Tuerk, Steenkamp, & Rauch, 2010 p,

50). The discussion of cost is escalated by the “signature injury” of the

current wars; traumatic brain injury (TBI). One third of the soldiers

airlifted from Afghanistan between 2003 and 2006 were victims of TBI.

Victims of TBI are likely to have the secondary psychological disorders

including but not limited to PTSD. The stressors of the injury and the

following hours of flight may, in fact, cause additional neurological

damage (Chestnut, Marshall, & Klauber et al., 1993, Bridges & Evers,

2009 as cited by Dukes, Bridges & Johantgen, 2013 p. 11). No studies

have examined the severity related to travel time of TBI in combat

veterans. Wounded soldiers navigate the spectrum of care from air to land,

hospital to hospital, and services at home (Dukes, Bridges & Johantgen,

2013 p. 12).

76

Making History

On February 23, 2013 in New York periodicals, Albany Times

Union and Newsday, three articles addressed both populations in very

different ways. In her Newsday article “Monitoring Kids After Trauma”

(Ferrete, 2013 pp. 3) Ferrete interviews LIU Post psychologist Thomas

Demaria who contends that children “exposed to threatening events should

be subject to long term monitoring”. Demaria also discusses that

protection from future vulnerability, victimization and mental health

difficulties. Demaria and the LIU Post Clinical Psychology Doctoral

Program commendably counsel community victims post tragedies that

include Hurricane Katrina, the Haiti earthquake and victims of serious

crimes or fatal accidents. The context of the interview was the Sandy Hook

Elementary School shooting. Twenty six individuals lost their life. It is

absolutely impossible to minimize the need to be trauma sensitive when

approaching child witnesses to such a horrible event. However, in New

York State alone in the fiscal year 2012 there were 65, 000 reported cases

of child abuse, 39.6% substantiated, and 5,180 families referred to New

York City Administration for Children Services for court ordered

intervention and supervision (Child Welfare Watch, 2013). It is a man-

77

made disaster when someone hurts a child. The same level of attention is

required for unfortunate, traumatized, and helpless children suffering abuse

and diagnosed with PTSD.

In the Albany Times Union, (2013) there are two articles that pertain

to PTSD and soldiers. One story, “Wrong Way Thruway Crash Kills 2”,

authors Carleo-Evangelist & Brown provide details of the tragic death of

decorated and disabled soldier, Julian F. With, who was 43 years of age

and was killed when driving his vehicle the wrong way on a major

roadway. There were two other victims. With had been arrested just hours

earlier for violating a restraint order based on a domestic dispute and

released on bail. With was an Iraqi War veteran decorated with the

Soldier’s Medal for saving the life of a critically injured sergeant major and

several other soldiers, when their truck overturned and burst into flames.

His diagnosis was PTSD and tinnitus, “ringing in the ears”.

The second story, “Leaving War but Not the Memories”, (Grondahl,

2013 pp. 1A, 8A) from the same issue was about another soldier, Elijah

Willete, an Army Commendation recipient who was diagnosed with PTSD

and committed suicide. “It was the demons of war” was the quote that his

grandfather offered as well as mentioning his grandson’s recurring

78

nightmares of children strapped with explosives approaching American

soldiers. In 2012, there were 349 service members who committed suicide,

exceeding last year’s totals for those lost in combat. Since 2012, there

have been a total of 6,500 suicides of former U.S. Military personnel. The

article cites the Defense Department as indicating there were 50, 000 new

cases of PTSD in 2012 with 16, 531 in the last quarter. This is at an

epidemic rate of 184 cases daily. The article closes with signs and

symptoms of PTSD that applied to shell shock, combat fatigue, and combat

exhaustion (as cited by Grondahl, 2013 pp. 8A).

Adding “insult to injury” is the appropriate and summative statement

considering the historical perspectives of the population of victims of child

abuse, combat soldiers, and PTSD. Although not all inclusive as to the

exhaustive history of both populations and PTSD, studies indicate repeated

trauma throughout the ages. Children have suffered egregious injury left

unexplained and were vulnerable to harm with inconsistent protection in

society. Soldiers were being belittled for not being John Wayne. There

was a significant delay in studying the overall impact of each experience,

preventing it and further damage, and solution focused work. Being in

combat for their country deems the country responsible for aftercare, the

79

quality of which continues to need improvement. Children do not have

voices and require advocates to support their plight to be removed from

volatile situations. A larger concern is due both populations without delay

before violence comes to either population or either population brings

violence to innocent individuals. Treatment considerations must take

priority and services need be consistent and cognizant of the physical and

mental impact and disorders. In both cases, there is ongoing suffering,

difficulties in being in mainstream society, and a life filled with question

marks as to their ability to cope and psychological and physical prognosis.

As history continues to repeat itself, there needs to be acute treatment,

available services and outcomes measured to change the course of the

future.

80

Chapter III

“James”

David Opont testified that on March 7th 1990 an older boy stopped

him, took his belongings and then set something on fire in a shovel and

held it against his chest (Fried 1990). “James” told me he threw David

down the basement stairs, set him on fire and put a door on top of him.

James was 14 at the time and was at an Upstate NY Secure Facility. I was

his Case Manager. James knew institutions and manipulation. He would

get thrown in the County Jail for assault, his motive being so he could

smoke cigarettes. He would get admitted to the County Psychiatric Center,

where he was able to have sex. Cyclically, he would be returned to my

unit. James would commit planned egregious assaults after being held

accountable for a minor misbehavior. A serious restraint and room

confinement would take place immediately after the assault, where he

would begin to eat and throw feces and urine, threaten and gesture suicide

and create chaos. In James’ official record abuse was recorded and he was

removed from his home. Aided by some research and inquiry, it was found

that during his formative years, James was routinely burned by his

biological mother with a cigarette dropped in the middle of his held

81

forearms for punishment. David Opont had numerous health issues

associated with serious burns. I recall seeing him throw out the first ball at

a Major League All Star game that year. The level of trauma David

experienced from the assault certainly warranted an assessment for PTSD.

I am quite sure that James had PTSD. The appalling things are the crimes

committed on both youth. The attention paid to both children did not enter

into the realm of PTSD and the symptoms. The entire unfortunate event

may have been avoided with screening, assessment, and

intervention/treatment. David Opont was determined to be angry and

lonely (Fried, 1999).

Former V.P. Quayle and ASA President Lou Schwartz present the ASA “Hero of the Year”

award to David Opont who was almost burned to death because he refused to take drugs.

Master of ceremonies Larry King looks on. (American Sportscasters online, 2012).

82

10 PTSD Treatments for Children

Studies with children that have been abused are often complicated by

circumstance, lack of a valid caregiver, and the multiple traumas associated

with removal from family. These difficulties also apply to effective

treatment planning, implementation and stymie research. In my experience

with parents and children there is a certain air of indifference and “blaming

the system”. According to Sheeringa, Wright, Hunt, & Zeanah, (2006)

children and parents both have a way of minimizing PTSD

symptomatology (as cited by Loeb, Stettler, Gavila, Stein, & Chinitz, 2011

p. 440). Shemesh et al., (2005) indicated that parents that have been

traumatized or are the perpetrators of the abuse typically are unclear when

reporting their child’s behavior (as cited by Loeb et al., 2011). Oswald,

Heil, & Goldbeck, (2010) state that children that have been placed in the

Child Welfare system have nomadic backgrounds, multiple foster care

parents and settings, and trauma histories that are difficult to track (as cited

by Loeb et al., 2011 p. 440). Over the course of twenty four years, I would

routinely be presented with a child with unspecific indications, history and

omitted facts that would inform treatment. These factors render children

83

that have been traumatized by abuse, difficult to engage. Further

complications are effective screening instruments and the skill level of the

interviewer, proximity to the traumatic event/s and the stage of

development of the child. Most psychiatric medications are not Food and

Drug Administration (FDA) approved for children and the disorder being

treated. The “off-label” usage of such medications can only be considered

experimental, feature inconsistent dosage and combinations, and there is

minimal evidence to support utilization (Irwin, 2008). However, there is

significant evidence that promotes the use of psychiatric medications in

concert with forms of therapy. There are many options to choose from

including combinations of different types of therapies, therapy combined

with psychiatric medications, and alternative treatments. Unfortunately

there is a modicum of success for an often complex disorder for children

that desperately need consistent monitoring quite possibly well into

adulthood. The initial screening and assessment of a child is essential, and

the presence of the DSM-IV triad of intrusive thought, avoidance, and

arousal must be present and for 30 days beyond the last or a single incident.

84

Screening

Screening for trauma impact, considerate of the variables mentioned

above, relies on various instruments to assess levels of trauma. Screening

children for trauma is critical in assessing immediate dangers, behaviors

that “erupt”, and the measurement of symptoms treatment and response

that may indicate the presence of PTSD. It is important to understand that

screening is not diagnosing. In the not so distant past a commonly used

instrument was the Child Behavior Checklist List (CBCL) which has been

modified to reflect a sub-set of questions pertaining to trauma. In their

1989 study Wolfe, Gentile, & Wolfe compared the CBCL-PTSD subscale

with the children Impact of Traumatic Events Scale-Revised and found a

high level of correlation in scores. There have been studies questioning the

validity of the CBCL-PTSD subscale trauma relative to recognizing trauma

symptoms in sexually abused children or preschool age children witnessing

domestic violence (Ruggiero & McLeer, 2000; Sim et al., 2005,

Levendosky, Hutch-Bocks, Semel & Shapiro, 2002 as cited by Loeb et al.

2011 p. 431). Loeb, et al.(2011) conducted a study to determine the

validity of the CBCL-PTSD subscale versus parent reports in a Diagnostic

85

and Statistical Manual of Mental Disorders(DSM-IV) based measure of

PTSD and the Diagnostic Classification of Mental Health and

Developmental Disorders of Infancy and Early Childhood(DC:0-3). The

CBCL-PTSD subscale proved to be unable to discriminate between

children that were sexually abused versus those that were not. In addition,

there was a 10 percent difference in indications of PTSD symptoms

between the CBCL-PTSD subscale and the DC.0-3. The CBCL also relies

on parent response, which is not reliable. The DSM-IV also is based on

adult diagnoses. (Loeb et al., 2011 p. 433) Initial assessments are generally

done by a case worker/administrator when a child initially is reported as

being a victim of abuse. Referrals are made to a clinician, in the event that

there is a reportable issue by observation, record review, or court order. A

scheduled evaluation by a clinician takes place within an allotted time

frame not to exceed a prescribed number of days.

According to Steinberg et al., (2013) the most comprehensive

screening instrument over the last two decades is the UCLA PTSD

Reaction Index (PTSD-RI). The comprehensive PTSD-RI has been used

nationally and internationally for screening, needs assessment, surveillance

86

and treatment outcome evaluation after major disasters and catastrophic

violence (p. 2). The screen for exposure to traumatic events and PTSD

symptoms for the last 30 days maps directly onto the DSM IV criterion of

intrusion, avoidance, and arousal criteria of PTSD. Part I consists of a

Trauma History Profile with three categories. They are Chronic/Repeated

(maltreatment and neglect, sexual abuse, etc.), Circumscribed (motor

vehicle accident, sexual assault/rape, etc.) and Loss/Separation (traumatic

bereavement, divorce and extended separation displacement)

Part II is a self-report screener done verbally or in writing conducted

by a clinician with yes or no questions related to the objective and

subjective experiences and memories of the traumatic event. Then there is

a frequency rating sheet which puts a time frame on the PTSD symptoms

exhibited. Multiple traumas are captured in the history portion, has been

used for individuals and groups, and there is an effort to use an electronic

administration for children. In terms of engaging children, it is very

helpful to ask for explanatory examples providing both the child and the

clinician an opportunity to understand each other (Steinberg & Vivrette,

2013). The PTSD-RI is validated in terms of the DSM-III-R diagnoses

87

criterion, scoring high on sensitivity and specificity. The current study, 6

years in the making, featured 6, 291 children ranging in age from 7-18,

who had experienced at least one trauma and were racially diverse

(Steinberg et al. 2013 p. 1-2). The instrument is a continuous scale with

increased psychometrics. The sensitivity is high in that some children may

meet some criterion and not others. The fact that the children most

exposed to trauma score the highest continues to validate the instrument.

The finding of the study also demonstrated consistency and reliability with

regards to sex, age range and racial ethnic groups (Steinberg et al., 2013, p.

1-2). Following the use of screening instruments and identification of a

child with PTSD potential a diagnosis is made by a clinician who begins to

plan a course of treatment. If all the variables are present, the information

and history are available, and the information is reliable there is strong

support for the instrument and the development of treatment.

The National Child Traumatic Stress Network (NCTSN, 2012) lists

interventions pertaining to PTSD from trauma for a variety of traumatic

incidents. NCTSN has been developing and disseminating evidence based

treatments (EBT) commencing in 2002. Following screening with allotted

88

time frames to comply with DSM-IV diagnostic criteria, interventions may

be clinically indicated. The following 10 interventions, from the NCTSN

list, are utilized for sexual and physical abuse and maltreatment and

neglect.

Alternatives for Families-A Cognitive Behavioral Therapy (AF-CBT)

AF-CBT is an evidenced base treatment (EBT) for physical abuse

and family violence. The child directed components for AF-CBT are

engagement and goal-setting, psycho-education about abuse and disclosure

of incidents involving hostility and physical force. These components are

important to have the child investment and understanding the context under

which the event/s took place. There is also a cognitive processing of

automatic thoughts that could maintain aggressive behavior or family

conflict. Training takes place in the form of affect identification,

expression and management skills such as relaxation training and anger

control. Social competence is enhanced by the development of

interpersonal skills and social support plans are developed. There is

imaginal exposure and making means from the disclosure of traumatic

events related to physical abuse/discipline as needed (NCTSN, 2012 p. 2).

89

Caregiver/Parent-directed and Parent-Child or Family-System

directed are provided equivalent components. Kolko, Iselin, & Gully

(2011) in their article “Evaluation of Sustainability and Clinical Outcome

of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in

a Child Protection Center” examined AF-CBT versus four other EBT’s in a

community-based child protection program. 52 families with an abused

child and recipients of AF-CBT were assessed between 2 and 5 years post

treatment (p. 105). The results were that there were limited findings

specifically crediting AF-CBT and that there were different combinations

of a number of EBT’s delivered in conjunction with each other by virtue of

clinical perception. The study calls for evaluating treatment choices of

clinicians and production of outcomes from a specific EBT (p. 115). The

art of engagement with a child is extremely critical and requires skills

beyond academia/licensure. In my experience, securing the investment of

the child creates a world of opportunity in assessment and treatment.

90

Child and Family Traumatic Stress Intervention (CFTSI)

Strengthening families and reducing early post-traumatic stress

symptoms and decreasing traumatized children from developing long term

post-traumatic psychiatric disorders are the goals of CFTSI. CFTSI also

identifies children that require longer term mental health care. The

intervention is intended for 7-18 year old youth having experienced or

revealed traumatic incidents (Marans, Hahn, & Arnow, 2012 p. 3).

According to NCTSN (2012) the key components of CFSTI are to improve

screening and identification of children impacted by traumatic stress,

reducing traumatic syndromes and increasing communication between

caregiver and child about the child’s traumatic stress reactions. In addition,

providing skills and reducing concrete external stressors complete the

components (p. 2). There remains a period of time that adult interactions

are born of mistrust from the trauma of abuse. So the reductions of

concrete external stressors may include the persons that are attempting to

assess the child.

The Yale Childhood Violent Trauma Center conducted a randomized

control trial. Children who received CFTSI were 65% less likely to meet

91

the criteria for full PTSD and 73% less likely to meet the criteria for full or

partial PTSD at the three month follow up compared to youth in the control

group. Children, post CFSTI scored significantly lower on posttraumatic

and anxiety measures suggesting that this occurs quicker than in a control

group (Berkowitz, Stover, & Marans, 2011 p. 682). The collaboration

between Safe Horizon (CTFSI provider) and Yale’s Childhood Violent

Trauma Center continues to provide the intervention and measures in a

model approach in order for children in New York City to recover from

trauma (Marans. Hahn, & Arnow, 2012 p. 3). Notable limitations to the

study included attrition between phone contact and attending sessions

(Berkowitz, Stover, & Marans, 2011 p. 683). This issue is an indicator of

the difficulty of dealing with children and caregivers with trauma history.

Contact after the initial meeting as always proved to be difficult.

Commonly families move, communication resources are cut off, and

family dynamics change.

Trauma Focused-Cognitive Behavioral Therapy (TF-CBT)

Individual sessions with the child and the non-offending parent and

sessions with both parents are the approaches applied in the cognitive

92

behavioral, family and empowerment based TF-CBT; the most commonly

investigated treatment. In several studies, there is substantial support for

TF-CBT to be designated as the only “well-established treatment for

children exposed to traumatic events” (Silverman, et al., 2008 p. 162).

NCTSN (2012) identifies the key components of TF-CBT as establishing a

therapeutic relationship with youth and parent and the use of gradual

exposure throughout treatment. The components consist of psycho-

education and information about child trauma, parenting skills, and

relaxation skills for both child and parent. TF-CBT considers the child,

family and their culture and provides tailored affect modulation skills and

coping mechanisms which connect thoughts feelings and behaviors. A

trauma narrative is developed and there is in vivo mastery of trauma

reminders. The concepts enhance safety and promote future development

and a place to “restart” from. This is complimented by traumatic grief

components as emotional and quite often literal loss is part of the process.

TF-CBT was determined to be “well established” because the

treatment was found to be superior to placebo treatment or to another

treatment in at least two research settings by two different research groups

(Silverman et al., 2008 p. 160) In a more recent study that investigated TF-

93

CBT, with and without the trauma narrative and processing component, the

results remain strong. In four groups, the pre to post treatment changes

were rated “moderate to large” (Deblinger, Mannarino, Cohen, Runyon, &

Steer, 2011 p. 71). TF-CBT provides a safe exploration into the trauma,

education, and critical skill development. The main ingredient in providing

TF-CBT is the environment in which it is presented. If the norm of the

environment is one of safety and processing trauma, narratives can be

powerful and have a tremendous calming effect by virtue of sharing.

Combined TF-CBT and SSRI Treatment

This treatment combines TF-CBT with psychiatric medications

specifically Selective Serotonin Reuptake Inhibitors (SSRI). Serotonin is a

neurotransmitter that may be associated with the PTSD symptoms of

aggression, obsession/intrusive thoughts, substance abuse and suicidal

behavior. Two FDA approved medications for adults with PTSD are

sertraline (Zoloft) and paroxetine (Prozac), neither of which has been

approved for children with PTSD (Foa, Keane, Freidman, & Cohen, 2009

p. 273). Cohen et al., (2007) conducted a pilot study with 24 children and

adolescents, females 10-17 and their primary caretakers, in two groups.

94

One group was given sertraline and provided TF-CBT, the other given a

placebo and TF-CBT. Both groups were of Caucasian origin, under

treatment for twelve weeks, and showed improvements. Only a non-

significant difference, in the Child Global Assessment Scale between

groups favored TF-CBT plus Zoloft (as cited by Huemer, Erhart, & Steiner,

2010 p. 628). Medication requires astute observation to determine effect.

The observers are generally “line staff” or direct care workers that are not

trained to understand side effects and the overall goals of medicines that as

previously mentioned are not FDA approved for children.

Combined Parent Child Cognitive Behavioral Approach for Children

and Families at Risk for Physical Abuse (CPC-CBT)

CPC-CBT is a 16 session treatment designed to empower parents to

be better parents, improve parent-child relationships, assist children to heal

from traumatic experiences and maintain safety for family members. The

structured sessions feature engagement strategies, educating parents on the

impact of corporal punishment, education on childhood development,

providing children with coping skills, and the development of family safety

plans. The sessions conclude with practicing communication, behavior

95

management skills and developing the safety plan together. The last phase

is reserved for the child to prepare a trauma narrative and for the parents to

write a letter taking full ownership of the abuse. The parent has the

opportunity to address the child’s fear directly (NTCSN, 2012 p. 2). CPC-

CBT demonstrates an ability to be implemented easily, measuring

outcomes via pre and post treatment indicators and producing change in

emotional and behavioral function (Runyon, Deblinger, & Schroder, 2009

p. 115). In their study, Runyon, Deblinger, & Schroder (2009) reported

that there were significant reduction in children in PTSD symptoms and

medium to large changes in parenting skills. There were no significant

changes in the depression level of children and parents compared to a

control group. The pre and post treatment assessment also indicated

significant change in Problem and Anger Intensity subscales. (p. 114-115)

Identified barriers to this treatment are logistical in nature, i.e.,

transportation and childcare. In addition, the social stigma of therapy may

limit participation. Further studies of this model, which despite limited

studies and offering promising results, need to include barrier statistics.

96

Child physical abuse is intergenerational, and this particular treatment

could be a cycle breaker (Runyon, Deblinger, & Schroder, 2009 p. 116).

Culturally Modified Trauma Focused Treatment (CM-TFT)

There are many ways to discuss the issue of racial disparity in the

United States. The ethnical breakdown of the incarcerated, the availability

and quality of mental and physical health services for minorities and

lacking education are all connected to disparity and require addressing.

Bernal, Bonilla & Bellido, (1995) and Bernal & Scharron-Del-Rio (2001)

found that there is an absence of efficacious treatments for minority youth

and that data cannot be generalized beyond European American samples

(as cited by Huey and Polo, 2008, p. 263). Griner and Smith (2006) in

their article “Culturally Adapted Mental Health Interventions: A Meta-

analytic Review”, determined that more attention is being given to adapting

psychotherapy to cultural values and contexts. Their findings, after

evaluating 76 culturally adapted interventions, reinforce the effectiveness

of conducting therapy in one’s native language with respect to cultural

differences. They conclude that there needs to be more outcome research

done to advance the adaptations of specific interventions (p. 543). There

97

are a myriad of traumatic experiences that minorities are exposed to, in

deference to the traumatic experiences that are mainstream to all cultures.

The study, however, was not trauma specific, had a broad inclusion and

adapted treatment had higher effect sizes (deArellano & Danielson, 2005).

CM-TFT, developed for Latino children and families, features a

culturally modified assessment considering a broader range of traumatic

events, immigration and migration history and is completed in the preferred

language. The cultural beliefs about mental health and mental health

treatment are considered. The “cultural constructs” are integrated as part of

therapy and consist of the change in gender roles, the importance of

spirituality and established folklore. Other constructs include the

glorification of a leader, (“personalismo”) belief in destiny, (“fatalismo”)

and a family focus (“familsmo”).

In a pilot study of CM-TFT, UCLA-PTSD-RI scores were found to

be decreased pre to post treatment and, 100% of the participants met the

criteria for PTSD at the onset being treatment failures in the traditional

setting. Upon discharge, only 9.4% still met the diagnostic criteria

(deArellano & Danielson, 2005). This study indicates that meeting clients

98

“where they are at” is critical and must include familiarity and appreciation

pertaining to cultural differences.

Adapted Dialectical Behavior Therapy for Special Populations

(DBT-SP)

Developed by Marsha Linehan (1993), DBT is a comprehensive

treatment program addressing deficits in emotion regulation, distress

tolerance, and interpersonal relationships. DBT was intended for the

treatment of individuals diagnosed with borderline personality disorder

(BPD). A number of studies since that time have indicated DBT

effectiveness with a large variety of different disorders, age ranges and

including suicidal adolescents and clients with binge eating disorders (as

cited by Charlton, 2006). DBT is now best described as being designed

for the chronic, multi-diagnostic, difficult to treat a client with both Axis I

and Axis II disorders including PTSD provided that the provider is fully

trained in the intervention.

In terms of utilizing DBT for the treatment of PTSD, there has been

no study examining the intervention alone (Lanius & Tuhan, 2003 as cited

by Mulik, Landes & Kanter, p. 27). There is a high rate of children

99

diagnosed with BPD that have suffered abuse and exhibit suicidal

tendencies. DBT can be used to stabilize the symptoms of BPD

treating PTSD symptoms using another intervention. In conjunction with

exposure treatment, DBT can prove effective to introduce the concept of

exposure and work behaviorally to be prepared for exposure to treat PTSD

(Chu & Dill, 1990, Zlotnick et al, 1994 as cited by Mulik, Landes &

Kanter, 2013 p. 27). Dissociative behavior, which may be determined to be

avoidance behavior, and therefore a symptom or characteristic of PTSD,

may be treated with DBT. A “behavior chain analysis” is conducted to

assess the chronological steps that transpired resulting in the dissociative

state. Then behavioral changes are made by interjecting alternative

appropriate behaviors at key points en route to a dissociative state. The

therapist can use emotion regulation skills, cognitive restructuring or

exposure to aversive emotions. DBT first targets reducing cues that may

trigger a traumatic experience/memory which elicits dissociative

behavior and includes avoidance behaviors of the threatening stimuli. The

second phase is to teach mindfulness and emotion regulation skills and

exposure to present emotions and traumatic experiences. The third phase is

to change the value of the cue that is connected to traumatic experiences

100

(Wagner & Linehan, 1998 as cited by Mulik, Landes & Kanter, 2013 p.

27). DBT is relatively new for children and the notion of behavior chain

analysis followed by assignments to correct behaviors is not always easy

for traumatized children who have affect issues.

There needs to be studies conducted that utilize the stabilizing and

cue reducing factors of DBT as the foundation for introducing other

interventions for PTSD. DBT provides the flexibility of targeting

behavioral symptoms that allow clinicians to target specific PTSD

symptoms.

Real Life Heroes (RLH)

RLH is an integrated attachment and trauma therapy for child and

family service program and utilizes an activity based workbook and

manualized protocols to help children deal with the symptoms of PTSD.

Children are assisted in skill building and developing internal resources to

re-integrate painful memories, reducing affect dysregulation following

traumatic experiences. The workbook and protocols are specifically

designed to provide a structured and safe curriculum for creative arts and

life story activities to engage children and the caring adults working with

101

them. For children that lack parents or guardians, RLH can be used to

search and build attachments to safe and caring adults committed to raising

children to maturity. (Kagan, Douglas, Hornik, & Kratz, 2008 p. 6) Using

a child’s imagination to release feelings allows for immediate engagement

and investment. This approach with appropriate clinical guidance allows

for different level staff caretakers to be involved and report out.

RLH incorporates CBT modalities for treating PTSD that include

safety planning, trauma Psycho-education adapted from Trauma Adaptive

Recovery Group Education and Therapy (T.A.R.G.E.T.) (Ford, Mahoney,

& Russo 2003, Ford & Russo, 2006 as cited by Kagan et al., 2008 p. 6)

skill building in affect regulation, and problem solving. In addition, RLH

utilizes cognitive restructuring of beliefs, nonverbal processing of results

and enhanced social support. The workbook includes a Pledge that initiates

an adventure and a contract to find a caring adult that will validate and

protect the child. The eight chapters are:

1. A Little About Me-biographical exploration and safe

expression of feelings

102

2. Heroes and Heroines-assists children to identify individuals

from family and community that embody strength

development, overcome adversity, and modeled mastery over

trauma. Encourages helping others to define a hero

3. Looking Back-chronicling both the good and bad moments in

life in a timeline, family tree, and learning about those that

helped, how one helped oneself, and overcoming problems

4. People in My Life-assists in remembering who cared for them

in sickness and health, expanding an awareness of people who

actually helped and exploring their own talents in this area.

5. Good Times-assists in remembering the skills, beliefs, and

supportive relationships involved in the good times

remembered

6. Making Things Better-assists a child to move from fantasy and

magical wishes and developing skills the child needs to

improve life. Children explore the “ABC’s of trauma and the

Hero’s Challenge” Helps the child replace dysfunctional beliefs

with positive self-statements via Psycho education and CBT.

103

7. Through the Tough Times-encourages children to remember

the skills employed to get them through tough times and

desensitize a series of progressively more difficult times,

Children write a short story about a time that they label the

“toughest time ever”

8. Into the Future-creating a successful image of oneself in the

future to instill planning for all variables.

Each session is preceded by a “check in” about the current mood, provisos

about being able to stop at any time, and a magical moment where the child

is asked to put their thoughts to music with instruments like a xylophone.

This is followed by a review of the self-assessment discussed earlier which

validates the child’s feelings. (Kagan et al., 2008, p. 8)

Kagan et al. (2008) concluded that there are benefits of RLH when

“doing with” an adult begins trust development for a child that has been

abused. There is a marked difference when the child experiences

desensitization in this fashion with the symptoms associated with PTSD.

However, there were no differences in social supports, possibly due to staff

turnover during the study. The study also took a long time to get started

104

due to funding discrepancies. This resulted in the subjects receiving

concurrent interventions of a different nature possibly enhancing RLH.

More research is needed in this type of intervention as strength

identification and building are critical in developing needed resilience (p.

19-20).

Safety, Mentoring, Advocacy, Recovery and Treatment (SMART)

Several studies, over the past two decades, have confirmed that child

sex abuse victims are likely candidates to develop PTSD symptoms (as

cited by Offerman, Johnson, Johnson-Brooks & Belcher, 2008 p. 179). In

1998, SMART was created by the Kennedy Krieger Family Center to

address problem sexual behavior of child sex abuse victims. This model

uses a phase-based, abuse-focused approach. The treatment consists of

safety and stability issues, effect and behavior regulation, formation of a

meaningful trauma narrative and the acquisition of new skills. The

intentional development of a narrative helps the child see both roles in the

situation; that of the victim and the offensive problem sexual behavior.

The study of 67 children with a history of sexual abuse focused on the

hypothesis that children who were treated with SMART would show

105

reduced problem sexual behavior and improved life skills and placement

stability (Offerman, 2008 p. 181).

There are supportive data in this study for the effectiveness of the

SMART model in reducing problem sexual behavior in young children.

The reductions increased throughout a year in follow up. SMART can be

adapted to various cultural beliefs pertaining to sexuality which enhances

treatment and engagement in the process. Cohen & Mannarino (1998,

2000) cited more evidence in the literature that supported increased

effectiveness for symptoms of PTSD rather than the problem sexual

behaviors. Putnam (2003) reported that problem sexual behaviors prove to

be difficult to treat than other behaviors associated with sexual abuse (as

cited by Offerman et al., 2008 p. 180). Future research, according to

Offerman et al., (2008) needs to include a comparison group and

randomized design to further support the efficacy of the model. The model

should also be explored for efficacy with other symptoms of child abuse.

106

Assessment-Based Treatment for Traumatized Children: Trauma

Assessment Pathway-child maltreatment (TAP)

A time limited manualized treatment is appropriate for some of the

population of traumatized children. At times, a child may need an effective

individualized treatment plan and a specific form of treatment meeting their

needs. This is the basis for TAP. Utilizing a sequence of assessment,

triage, and decisions or clinical pathways, TAP, developed by Taylor,

Gilbert, Mann & Ryan (2005 as cited by Conradi, Kletzka & Oliver, 2010

p. 40), provides a process of pinpointing appropriate interventions and

creating the best practice. TAP provides mental health agencies with the

ability to sustain an assessment based trauma program. There are a myriad

of interventions available. TAP enables a program to incorporate and

integrate existing evidence-based treatment into their program and prove

appropriate services to a wide age ranged and diversified population in

terms of severity (Conradi, Kletzka & Oliver, 2010 p. 40).

Most treatment planning revolves around standardized measures of

assessment, observation and clinical judgment. In the TAP model, there

are presented strategies to help the clinician understand the “bigger picture”

107

with a youth. The gathered information is divided into four

quadrants/domains. The domains are trauma history (specific trauma and

duration), symptom presentation (internal or external behaviors), relevant

contextual history (family dynamics, structure and culture) and

developmental history (age, developmental and attachment issues). The

information is gathered using observation, caregiver report, collateral

report and standardized measures. The domains are combined to present

the youth for ideal treatment planning and the parties necessary to be

involved and the most appropriate intervention (Conradi, Kletzka & Oliver,

2010 p. 43). “Triage trees” are designed based on evidence-based

resources and the clinician can utilize the tree to make decisions on

treatment resource provided to the child and family. Agencies are

encouraged to update their triage trees as information and evidence become

available on interventions. For difficult cases, TAP utilizes a “trauma

wheel”. The foundations of the wheel are developmental, relational, and

cultural dynamics. All of the required elements of treatment are the spokes

of the wheel. The child’s developmental functioning moves the youth

through treatment. (Conradi, Kletzka & Oliver, 2010 p. 44)

108

Trauma Wheel (Chadwick Center for Children and Families. (2009)

TAP is a tool for clinicians and staff in an organization to become trauma

focused. The study conducted on three children did provide promising

evidence that the selected interventions were chosen effectively, and there

were positive results. The advantages of TAP are clearly the ability to use

the tool to make decisions and land firmly on an intervention. This allows

for fidelity to the chosen model, the ability to monitor and track progress

and outcomes, and effectively treat children and families with investment

having gone through the TAP process. Disadvantages include not having a

109

number of interventions to choose from, the ambiguity of the trauma wheel

relative to specific difficulties of a child in the middle of treatment and the

incorporation of new language and structure into an existing framework.

The model must also be supervised succinctly as adherence is critical to

success (Conradi, Kletzka & Oliver, 2010 p. 54-56).

In Closing

There is no one size fits all pertaining to a trauma focused delivery

of services for victims of child abuse. However, there cannot be stronger

support for evidence based assessment and screening than presented by any

of the aforementioned intervention/treatment. There is also a large

population of victims that go unreported. Currently in the system of

reporting child abuse there are no plans for immediate comprehensive

trauma evaluation, including physical and mental health. TAP provides an

option and framework but must be built around a wide array of resources.

There are proposed changes to the system to include child sensitive arrest

(when parents are placed in custody, and the children are present) or

removal from home, considering trauma being a part of any case and

trauma focused treatment. Research on the human brain and impact on the

110

amygdala/hippocampus pertaining to early assessment in the identification

of an abused child should be part of the treatment plan. It is time to

evaluate and research a consistent screening instrument and treatment plans

including specific interventions based on fact and professional opinion and

data gathering and analysis. Medications that are not approved for a child

should only be used in extreme cases and studies must be acute in terms of

side effects and overall effectiveness. In the event that a child is the victim

of abuse and any risk of PTSD, treatment should begin in the form of

engaging and intense triage and assessment, tailoring plans developed and

implemented with acute follow up, and the necessity to listen to the child

prioritized. These children are commonly in a world where adults are

perceived as untrustworthy. This has to be considered in every aspect of

their experience with caretakers charged with making changes.

There are efforts taking place to find evidence based treatment and

deal with a very difficult population in terms of transience. Caregivers not

aware of the impact to their children by virtue of their lacking observations

to professionals, harmful behaviors, and the lack of awareness of resources

confound treatment and research. In the long term, consistency throughout

111

the system in terms of triage and effective treatment may be the answer to

many societal issues. Children continue to suffer unheard. There must be a

call to arms that hug children. When there is awareness of abuse,

incarcerated parents, removal from home, sexual abuse, neglect and

maltreatment there can’t be enough care taken to change a life so young

and so impacted. Services cannot be associated with any stigma and may

be too late.

For every child who cries at night

Alone with shame and pain and fright

For every child who wants so much

To only feel a gentle touch

For the beaten child, who cries in painWhose tears run silent, like the rain

For the child used to satisfy lustWho never learns to love or trust

For the child taken from her homeAnd made to feel so all alone

For the child whose home is just a shellWhere life becomes a living hell

For the child who smiles but cannot feelBecause of scars too deep to heal

112

For every child who yearns for love

I hope and pray to God above

To hear your cries and heal your pain

And give you back your life again (Williams, 1995)

Kathy Williams was a survivor of abuse and a champion for child

victims and is a testimony to Adverse Childhood Experiences, passing

away at the age of 36. The immediate reaction would be to inquire as to

the cause of her death. I would counter that inquiry with sentiment

regarding how very little difference that makes.

113

Chapter IV

Clay Hunt

On the CBS news program, 60 Minutes, a recent segment featured

combat veterans, PTSD and suicide entitled: The life and death of Clay

Hunt (Schneider, 2013). Clay Hunt was awarded a Purple Heart when he

was wounded in Iraq recovered and was redeployed to Afghanistan. Hunt

witnessed the death of fellow soldiers, was shot twice and was sent to his

base in California. Being sent away from his troop did more harm than

good. Hunt was diagnosed with PTSD, medicated, and he continued to

struggle with depression, panic attacks, and sleeplessness. Despite his

continuing struggles, engaging in helping earthquake victims, and speaking

publicly about his state, there were delays in VA benefits adding financial

woes. Hunt joined Ride2Recovery, a cycle outing group of veterans. Hunt

had a new truck, new girlfriend after his divorce and remained haunted. He

went home to his apartment one day and shot himself in the head at 28

years of age (Schneider, 2013). Clay Hunt provides a microcosm of a

much larger dilemma. The Unites States is facing an epidemic rate of

PTSD, suicide and physiological and psychological injury among military

114

service men and women. Assessment, treatment plan and follow up are

suspect on behalf of Clay’s brothers in warfare. There are treatment

options that are available to explore and cannot be quelled as a “resource

issue” when the lives of those willing to die for our country are doing so by

their own hand.

10 PTSD Treatments for Combat Veterans

Screening

The rates of PTSD in combat veterans, and the potential

psychological and physical injury, indicate the need for immediate and

accurate screening, assessment and referral and treatment planning. A

number of studies indicate that screening provides an opportunity to

identify veterans with PTSD symptoms or the potential to develop

symptoms and provide interventions and reduce negative outcomes (as

cited by Gates et al., 2012 p. 367). According to Gates et al. (2012 p. 367)

screening also allows for tracking of groups of soldiers over time,

recording outcomes and the ability to enhance services (Hoge et al., 2006

as cited by Gates et al., 2012 p. 368). In 2003, the Department of Defense

(DoD) implemented the Post-Deployment Health Assessment (PDHA), an

instrument used to assess soldier’s physical and mental health after

115

deployment. Depression, suicidal ideation, aggression and PTSD, are

mental health areas that are assessed. The format is a self-report

questionnaire followed up by a brief interview with a health care

professional who documents any concerns. This screening determines the

need for further evaluation and begins to establish resources for post-

deployment. Upon return from deployment to Iraq and Afghanistan, after

the first year of the PDHA, 9.8% and 4.7% respectively were screened as

positive for probable PTSD. The increase of soldiers returning with PTSD

symptoms and some developing the symptoms months beyond the initial

assessment resulted in the DoD ordering additional screenings after a 3-6

month period. This resulted in a much higher percentage of PTSD

probability, 16.7% of active soldiers and 24.5% National Guard and

Reserve soldiers screened positive for PTSD (Milliken et al., 2007 as cited

by Gates, 2012 p. 368). Another study conducted by Bliese, Wright, Adler,

Thomas & Hoge (2007), found that the delay in screening revealed a higher

number of soldiers with PTSD and that screening immediately upon

returning home may result in missing and not referring many soldiers for

services (as cited by Gates et al., 2012, p. 368).

116

As cited by Gates et al., (2012) PTSD screening tools, in regards to

PTSD symptomology, should have a high degree of sensitivity and at least

modest specificity, when compared with expert diagnosis. Cut off points

indicate the score that requires clinical follow up (p. 73). The following

chart (p. 370-371) represents a number of studies of screening assessments

including the number of items used for inquiry and their psychometric

rating including sensitivity, specificity and efficiency and cut off scores:

PTSD SCREENING INSTRUMENTS FOR SOLDIERS

Psychometrics

Name No. of

Items

Sensitivity Specificity Efficiency Item structure

and

description

Cutoff

Score

PTSD Checklist (PCL) (Blanchard et al.,1996; Weathers et al., 1993)

17 0.78-0.94 0.83-0.86 0.83-0.90 Rate how much specific problems havebothered patient in the past monthranging from 1(not at all) to 5(extremely)

Varies

Primary Care Posttraumatic Stress DisorderScreen (PC-PTSD) (Prins et al., 2003)

4 .78 .87 .85 Indicate presence/absence ofnightmares, avoidance,hypervigilance, and numbness in the past month resulting from atraumatic event

3

Davidson Trauma Scale (DTS) (Davidson et

17 .69 .95 .60 Rate frequency/severity of eachsymptom in the past week from

40

117

al., 1997) 0 _ not at all to 4 _ every day/extremely distressing.Re-experiencing symptoms are tied toa specific event.

Startle, Physiological arousal, Anger, andNumbness (SPAN) (Meltzer-Brody et al.,1999)

4 .84 .91 .88 Rate frequency/severity of symptomsfrom 0–4

5

Impact of Event Scale (IES) (Horowitz etal., 1979; Neal et al., 1994)

15 .89 .88 .88 Rate frequency of symptoms in past week (not at all, rarely, sometimes,and often) in response to a specificlife event

35

Psychometrics

Name No. of

Items

Sensitivity Specificity Eff. Item structure

and

description

Cutoff

Score

Single Item PTSD Screen (SIPS) (Gore etal., 2008)

1 .76 .79 “Not bothered at all,” “bothered alittle,” or “bothered a lot” by a pasttraumatic experience

“Bothered a little”

War-Zone Related PTSD Scale (WZ-PTSD)(Brewin, 2005; Weathers et al., 1996)

25 0.87-0.98 0.65-0.72 0.81-0.82

Rate current PTSD symptoms(occurring in the past 7 days) on afive-point scale

1.3

PTSD Statistical Prediction Instrument(PSPI) (Marx et

12 0.86-0.99 0.36-0.8 0.75-0.87

Twelve items that significantly predict

Optimally efficient at 6, optimally

118

al., 2008) PTSD diagnostic status

sensitive at 3

Posttraumatic Adjustment Scale (PAS-P)(O’Donnell, Creamer et al., 2008)

10 .82 .84 Five-item severity-based Likert scaleranging from “Not at all” to“Totally”

16

Self-Rating Inventory for PTSD (SRIP)(Hovens et al., 2002)

22 .86 .71 .78 4 scaled sentences measuring presence/absence of PTSD symptoms, alongwith degree, frequency, or intensityof symptoms.

52

Penn Inventory for PTSD (Hammarberg,1992)

26 0.90-0.98 0.94-1.00 0.94-0.97

4 scaled sentences measuring presence/absence of PTSD symptoms, alongwith degree, frequency, or intensityof symptoms.

35

Posttraumatic Diagnostic Scale (PTDS)(Foa et al., 1997)

49 .89 .75 Symptom frequency in the past monthrated on a 4-point scale from0_”not at all” to 3_”five or moretimes a week”

Numerous checklists and self-administered questionnaires have been

developed, and not one has proven to be more effective than others. The

psychometric properties have proved beneficial in the successful screening

119

of PTSD symptoms. Brevity does not preclude efficiency and is favorable

when assessing soldiers as long as follow up is given a priority. The

current study calls for continued research and development of screening

instruments (p.374)

Psychological Debriefing

There is not an abundance of studies done on debriefing and early

interventions for combat veterans. Interventions that include ”Battlemind

Debriefing” and “Battle Mind Training”, consisting of describing

emotional reactions, normalizing reactions, and PTSD preparedness as

presented in the Adler, McGurk, Bliese & Hoge (2011) study have varied

results contingent upon group member characteristics (p. 66). Raphael and

Wilson (2000) describe military and civilian models of debriefing to

consist of phase, topics, and structure yet vary in the facilitation.

Generally, and in a group fashion, it is a guided intervention (as cited by

Adler et al., 2011 p. 67). The results for individual victims of PTSD versus

professional teams hired to do the same work were markedly different.

Studies are not clear as to the impact on individual PTSD victims versus

military groups because there is not an educational component making

comparison impossible (Rose, Bisson, & Wessely, 2001 as cited by Adler

120

et al. 2011 p. 67). Weisaeth (2000) noted that conversely the studies for

individual victims do not consider the relevance of intra-group dynamic in

the military style of debriefing (as cited by Adler et al. p. 79). Battlemind

debriefing and training have a high success rate for manifesting

fewer symptoms of PTSD 3 to 4 months after combat with a noticeable

benefit to those with a high level of exposure to combat (Resnick et al,

2005 as cited by Adler et al., 2011 p. 79). As aforementioned this

reinforces the strength of dealing with symptoms in a homogenous group

such as combat veterans and the nature of soldiers wanting to go back to

their unit as soon as possible.

Psychopharmacology

Pharmacotherapy can be administered in a generic manner by a

qualified health professional swiftly. It also provides a quick return to

active duty. The National Center for PTSD (2009) guidelines encourages

the use of pharmacotherapy concurrent with psychotherapy for better

outcomes (p. 9). According to Martenyi & Soldatenkova (2006), studies of

psychopharmacology use for treatment of PTSD have been focusing

largely on anti-depressants. This includes monoamine oxidase inhibitors

(MAO) and selective serotonin re-uptake inhibitors (SSRI) (p. 341).

121

Several studies with anti-depressants have proven effective with

improvements in all three main DSM-IV criteria for PTSD; intrusive

thoughts, avoidance, and hyperarousal symptoms. Some medications

showed little to no improvement or addressing only some of the symptoms

(as cited by Martenyi & Soldatenkova, 2006 p. 341).

In their study, “Fluoxetine in the Acute Treatment and Relapse

Prevention of Combat-Related Post-Traumatic Stress Disorder: Analysis of

the Veteran Group of a Placebo-Controlled, Randomized Clinical Trial”,

Martenyi & Soldatenkova(2006) discuss the use of fluoxetine (Prozac) and

sertraline (Zoloft) when treating soldiers for the cluster of symptoms of

PTSD as well-tolerated and efficacious when compared to placebo control

groups. Prozac and Zoloft proved more efficient in all three cluster

symptoms than the tricyclic antidepressants, imipramine (Deprimine) and

amitriptyline (Ellaville) and monoamine oxidase inhibitors (MAO)

phenelzine (Nardil) and imipramine (Deprimin.) The MAO inhibitors

showed strengths in one or two areas of the cluster symptoms neither

addressing hyperarousal symptoms. Limitations may have been imposed

122

on the studies by insufficient doses and a non-compliant and resistant

population (p. 341).

Prolonged Exposure (PE)

PE is an approach intended to reduce PTSD symptoms by addressing

the underlying emotions through a modification of memory structures (e.g.,

Foa & Kozak, 1986 as cited by Sharpless and Barber p. 10). PE is a

systematic desensitization to the traumatic incident/s resulting in PTSD and

safe exposure to fear causing stimuli that the clients fear and avoid. This is

done by a retelling of the initial trauma/s and discussing the feelings

associated with doing so immediately afterwards. This is called

“processing” and done “in vivo” or “live” involving the client in real time.

PE is a manualized treatment that consists of 8-15 weekly 90 minute

sessions and also includes psycho education, and training in slowed

breathing techniques (Sharpless and Barber p. 10).

PE has been characterized as a "well-established", and several

randomized controlled trials have recently been conducted examining the

efficiency of the intervention (Aderka et al., 2011, Schnurr et al., 2007 as

123

cited by Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010 p. 636).

Powers, et al. (2010), indicate that PE was associated with better outcomes

both at post treatment and follow up. The results indicate that PE is a

highly effective treatment. However, there was no significant difference

between PE and other psychotherapeutic approaches i.e., Cognitive

Processing Therapy (CPT), Eye Movement Desensitization and

Reprocessing (EMDR), Cognitive Therapy (CT) and Stress Inoculation

Therapy (SIT). PE results feature better outcomes than up to 86% of the

patients in control conditions (p. 640)

Exposure Therapy Using Virtual Reality (VR)

It is possible to expose PTSD clients to traumatic situations via VR.

VR may include graphic visual stimuli, surround sound, scents, and the

feeling of being amidst traumatic scenarios (Sharpless & Barber, 2011 p.

10-11). VR creates an environment via technology. The client adorns a

headset that provides a 3D view sensitive to head motion thereby moving

the client about the virtual environment in accord with the head movement,

and at times providing a sense of the smell in the environment. There are

also vibrations and the ability to isolate sounds adding to the sense of being

in the middle of a traumatic event. Currently there are three environments

124

for combat veterans and terrorism survivors. They are Virtual Viet Nam,

Virtual Iraq and Virtual World Trade Center. Clients report that the critical

element of “being there” that is essential in exposure therapy is captured in

the technologically created environment. The traumatic memory is

generated in a safe environment for the client, and ideally there is

emotional engagement, fear elicited, and the ability to assist the client in

the emotional processing of fears (Rothbaum, Rizzo, & Difede, 2010 p.

127).

Clinically driven, the VR experience can be somewhat tailored to the

client’s exposure needs per treatment planning and screen scores. Virtual

Viet Nam, with all the sensory and olfactory components, was tested with

16 clients. Evaluations were performed incrementally in 4-7 weeks post

treatment, three months and six months and veterans self-reported having

significant decreased symptoms of PTSD in all three cluster areas.

Preliminary evidence suggested that VR could prove an effective

intervention for veterans with PTSD. Virtual Iraq, which was developed

with feedback from soldiers having served there, was also tested using

twenty veterans with PTSD. Sixteen of twenty veterans, that completed the

125

treatment, no longer met DSM criteria for PTSD on a self-report measure.

Other studies are being conducted, and there have been promising results

(Rothbaum, Rizzo, & Difede, 2010 p. 130).

Advantages of VR include a certain familiarity with virtual

environments through video games and training equipment, the soldiers

being able to “walk through” the traumatic environment with their

clinicians, and use for simulation of other events to work through the PTSD

symptoms associated with them e.g., airplane flight. Another advantage is

the ability to control the degree of exposure and the accuracy this adds to

research. The disadvantages may be the client feigning disinterest in the

modality due to an unwillingness to face the trauma, the cost and expense

of training and equipment and the inherent difficulties and malfunctions

with technology. Clinicians have to be able to use the technology and

conduct the treatment without stops and starts. In addition, the

technologically created an environment despite being tailored for the

reality of War Theater, specific memories of a soldier may be omitted and

produce an effect of not being able to achieve the level of exposure

126

necessary to conduct treatment (Rothbaum, Rizzo, & Difede, 2010 p. 130-

131).

Cognitive Processing Therapy (CPT)

CPT shares many of the components of CBT (e.g., challenging

automatic thoughts) and features a 12-session format. CPT also contains

an exposure component, but one quite different from PE. Specifically,

clients are instructed to write about their traumatic events in descriptive

fashion utilizing all sensory perceptions. CPT is a three stage manualized

intervention. Sessions are one hour in duration. The three stages consist

of:

� the initial phase- exploring the impact of the trauma, the connection

between thoughts and emotions, and the initial identification of

“stuck points”

� the second stage- entails writing the traumatic event and initial

incident

127

� the final phase of CPT involves replacing what is referred to as

“stuck points” identified in the prior stage and replacing them with

more balanced thoughts.

This allows for the client to identify and examine their stuck points on

particular topics such as safety, trust, power/control, esteem and intimacy.

There are specific strategies in each presentation that includes cognitive

techniques, challenging inquiries, pattern identification and facilitating

worksheets on beliefs. Clients are asked to process the event and see

definitive change in their thought process at the completion of treatment

(Davis, Walter, Chard, Parkinson & Houston, 2013 p. 38, 39).

A study of CPT was conducted that examined efficacy with PTSD

veterans with mild traumatic brain injury (mTBI) and adherence rates.

The study, consisting of PTSD groups with and without mTBI, was

conducted because of a concern that patients with mTBI would be difficult

to treat with cognitive behavioral interventions. Davis et al. (2013) noted

the dropout rate was higher for the mTBI group by the fourth session.

However, there was no marked difference in adherence rates in both

groups, and that lessened the validity of the hypothesis. Future studies may

128

want to measure outcomes with consideration of neuropsychological data

to assess progress of those with mTBI (p. 40).

Eye Movement and Desensitization and Reprocessing (EMDR)

EMDR is a structured and manualized treatment that combines parts

of CBT with mindfulness, body-based approaches and person-centered

therapies (Sharpless and Barber, 2011 p. 10). It is clinically guided by the

Adaptive Information Processing Model (AIP) which has proven to have

positive treatment results. Clinicians use AIP to look at the “whole

picture” of a client’s response to trauma. This includes the past trauma that

contributes to present difficulties, current events that promote negative

responses and the development of adaptive neural networks of memories to

elicit appropriate responses in the future. EMDR is based on the concept

that psychopathology is based on traumatic memories that remain

incompletely processed by the brain’s information processing symptom.

The traumatic experience remains as the moment it transpired including the

emotions, physical reactions and beliefs which are static. The brain is

conditioned to respond to new stimuli similar to the traumatic experience

as if nothing has changed from the traumatic event. Where EMDR

separates from traditional psychodynamic therapy, despite fundamental

129

concepts being very similar, is focusing on the physiologically stored

memory as the primary source of pathology and the use of specific

information processing as the agent of change (Shapiro & Laliotis, 2011 p.

191)

Another unique component of EMDR is the use of bilateral

stimulation, such as eye movements, physical tapping, or auditory tones.

Despite some controversy, tests have been conducted on eye movement

alone that had the desired results of memory retrieval, decreased negative

emotions, and less irritability (Shapiro & Laliotis, 2011 p. 192). The

desensitization and reprocessing stage of EMDR, which includes the

bilateral stimulation, essentially is the therapist uninstalling unprocessed

negative memories and installing new and complete memories. This is

done while the patient tracks the bilateral movements fostered by the

therapist (Sharpless & Barber 2011, p. 8). There are eight phases in the

EMDR/AIP treatment process; the following chart illustrates the phases,

purpose of each and the procedures:

130

Overview of EMDR treatment (Shapiro, 2005 as cited by Shapiro and Laliotis, 2011, p 194)

Phases Purpose Procedures

Client History Obtain background information

Identify suitability for EMDR

treatment

history-taking questionnaires and

diagnostic psychometrics

Preparation Prepare appropriate clients for

EMDR processing of targets

Stabilize and increase access to

positive effects

Education regarding the symptom

picture

Metaphors and techniques that

foster stabilization and a sense of

self-mastery and control

Assessment Access the target for EMDR

processing by stimulating primary

aspects of the memory

Elicit the image, negative belief

currently held, desired positive

belief, current emotion, and

physical sensation, and baseline

measures

Desensitization Process experiences and triggers

toward adaptive resolution

Fully process all channels to allow

a complete assimilation of

memories

Incorporate templates for positive

experiences

Process past, present, future

Standardized EMDR processes

that allow the spontaneous

emergence of insights, emotions,

physical sensations and other

memories

“Cognitive Interweave” to open

blocked processing by elicitation

of more adaptive information

Installation Increase connections to positive

cognitive networks

Increase generalization effects

within associated memories

Identify the best positive cognition

(initial or emergent)

Enhance the validity of the desired

positive belief to a 7 VOC

Body Scan Complete processing of any

residual disturbance associated

with the target

Concentration on and processing

of any residual physical sensations

Closure Ensure client stability at the

completion of an EMDR session

and between sessions

Use of guided imagery or self-

control techniques if needed

Briefing regarding expectations

and behavioral reports between

sessions

Reevaluation Evaluation of treatment effects

Ensure comprehensive processing

over time

Explore what has emerged since

the last session

Re-access memory from last

session

Evaluation of integration within

larger social system

131

Van der Kolk et al. (2007) observed that in approximately 20 controlled

studies, comparing to both pharmacological and various psychotherapies,

EMDR has proved to be effective in the treatment of trauma. As a result of

the studies, EMDR has been recommended as a preferred treatment in

several guidelines, including those of the American Psychiatric Association

(2004 as cited by Shapiro & Laliotis, 2011 p. 192).

Stress Inoculation Training (SIT)

Sharpless & Barber (2011) identify SIT as a number of techniques

such as relaxation, thought stopping and in vivo exposure. The intervention

was developed to combat anxious symptoms and has been adapted to

PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991 as cited by Sharpless and

Barber, 2011 p. 10). Stress management programs such as SIT are

difficult to substantiate as effective for the long term. Questions arise as to

the setting and the level of delivery in terms of education and the skill of

the facilitator. All results that are captured are “in-house” in terms of how

they are obtained. The intervention at the street level may be wholly

different resulting in different outcomes. SIT consists of three phases:

132

1. The conceptualization or education phase- educating the client

in stress and stressors

2. Coping skill acquisition and rehearsal-developing and

practicing a repertoire of appropriate responses to stress

3. Application and Follow Through-incorporation of the acquired

coping skills in environments that replicate the stressors with

general negative responses

(Saunders, Driskell, Johnston & Salas, 1996 p. 171).

Study results provide support for the efficacy of SIT as a stress

training intervention. SIT has been shown to reduce anxiety and enhance

performance under stress. However, prolonged exposure (PE) has proven

to have longer sustained behavioral changes than SIT suggesting that the

intervention may be an effective relief for immediate symptoms en route to

another treatment. There are considerable variables that include setting,

clients, provider skills that impact effectiveness. SIT has been used for

couples with returning veterans that will face PTSD symptoms or other

traumatic responses to events. Stress inoculation is used to set the stage for

Structured Approach Therapy and to assist couples in the application of

133

skills acquired during inoculation. (Sautter, Armelie, Glynn, & Wielt,

2011, p.65) The hypodermic reference is analogous to the effect. It is

literally a dose of education and developing and acquiring coping

mechanisms to stabilize and lay the framework for some intense work

utilizing another intervention.

Cognitive Behavioral Group Therapies (CBT)

CBT Group Therapies consist of manualized sessions including but

not limited to psycho-education on PTSD, cognitive therapy, relaxation and

distraction techniques and imaginal and in vivo exposure. Psycho-

education also includes PTSD prevalence, symptoms, and management,

post trauma reactions, survival guilt, addictive behaviors, medications and

physical wellbeing. Sessions are also dedicated to basic problem solving,

goal setting, and communication and social skills training. Group

Therapies are ideally run by psychiatrists, psychologists, social workers

and medical staff or a combination thereof. Guest speakers are not

uncommon (Khoo, Dent, & Oei, 2011 p. 666).

Ready et al. (2012) conducted a study of 30 combat veterans that

were involved in Group based exposure therapy (GBET). GBET was

134

developed over a 9 year period utilizing clinical experience and adapting

techniques from other interventions. The trauma narrative is read and re-

read outside of the group, similar to Prolonged Exposure, and then shared

with the group. The advantage being that peers may empathize with the

reaction to the trauma. GBET is comprised of three phases (p. 85).

The phases are:

� Build the Group: activities to instill trust in the group, sharing

combat experience, coping skills and grounding techniques

� Exposure: group members do a 2.5 hour presentation on their

combat days and their most traumatic moment, a non-presenter is

asked to provide a meal, peer assistance during the daunting

presentation, leading to a polished one hour presentation.

Throughout the phase, there are re-reads of the presentations,

feedback and discussion

� Close the Wound: encourages and acknowledges the importance of

continued support system and social networking, discussion of

returning home, grieving lost friends in combat, imagery of a

135

stateside funeral for a lost friend. There is a presentation of an

Auschwitz survivor and recorded feedback to each of the group

members by all other participants and staff. Certificate of

completion and a gold pin distributed (Ready et al., 2012 p. 88).

During the first two phases members are encouraged to call each

other as a means of stressing the importance of the bonds formed in the

group. There seems to be a natural hesitance and a certain level of

stress when the notion of calling each other is initiated. Participants

were sent home with a rather inane conversation starter (where did you

buy your first car?) to break the ice. In a short period of time hour long

calls were more than common (Ready et al., 2012 p. 87).

The results from this study provided support for the efficacy of the

intervention in abating or reducing symptoms of PTSD with treatment

compliance. A majority of the participants reported reductions in PTSD

symptoms and 36% no longer met the criteria for PTSD at the 7-11

month post treatment assessment. In the same assessment, 73% of the

participants indicated that there were reductions in PTSD, depressive

symptoms or both. There was a low dropout rate attributed to cohesion

136

of the group members. Limitations of this study were that there is no

valid comparison group, clients were taking medications for up to a year

before participation and results were gleaned from self-report rather

than measurable instruments. There is hope that more studies follow

with measurable instruments and outcomes (Ready et al., 2012, p. 91).

Psychodynamic Psychotherapy

According to Parry, Roth, & Fonagy (2005 as cited by Town et al.,

2012 p. 277) psychotherapists have an indifferent attitude toward scientific

research. The means by which data is collected over simplifies the

complexities of the mental activity within the therapy and the client and

clinician relationship. The process of taping and recording sessions,

thereby creating data also is seen to confound treatment, increase

resistance, and alter the relationship of the client and therapist. The

argument presented includes the notion of worsening symptoms and

progress impediment occurs when treatment includes manuals and fidelity

checks. It is likely that psychodynamic means of providing services will be

exposed to traditional means of research. However, there is increasing

support in the recording of sessions, so therapists are able to analyze

themselves and can be training tools (p. 277-78). Town et al. (2012)

137

contend that there are a number of studies that support efficacy, improving

and sustained change following psychodynamic psychotherapy which

supports foregoing resistance to research methodology. The benefits

appear to outweigh the reluctance of therapists due to perceived progress

interference (p. 277).

The main difference between Cognitive Behavioral Therapy (CBT)

and Psychodynamic Psychotherapy (PP) is that CBT deals with cognition

or thought where PP deals with feelings. The goal of PP is to change

behavior by increasing the client’s ability for feeling and their response to

those feelings. Therapists use psychodynamic, interpersonal and

experiential concepts and focus on the client relationship as the basis for

disclosure of and resolution to interpersonal difficulties. The difficulties

are viewed as a result of symptoms of PTSD or other disorders (Stiles,

Agnew-Davies, Hardy, Barkham, & Shapiro 1998, p. 792). The therapist

maintains an active role in the relationship and develops a focus via the

current problem, past difficulties and the transferential relationship with the

client (Mitra, Basu, & Sanyal, 2013 p. 43) Sessions include but are not

limited to:

138

� Entering the session/s, orientation of client (post psychological

assessment)

� Emergence and resolution of resistance

� Exploration of inner dynamics to achieve change

� Planning and handling termination(of behavior)

The therapist has a number of psychodynamic options in terms of guiding

the client to change and within the stages above. (Mitra, Basu, & Sanyal,

2013 p. 44-45)

In general, psychotherapy provides a sense of being uncomfortable

through thought processing, discussing, and instilling change. As

compared to cognitive behavioral treatment where safety and comfort are

assured, concepts are introduced and taught that provoke discussion about

painful feelings, coping skills are developed, and change takes place. In

terms of the group members, there is a comfort level in the group

pertaining to cohesiveness, and there is acceptance of both milieus (Lanza

et al., 2002 p. 95).

139

In their study, “Assaultive Behavior Intervention in the Veterans

Administration: Psychodynamic Group Psychotherapy Compared to

Cognitive Behavioral Therapy”, Lanza et. al., (2002) found that the two

treatment modalities have differences, similarities and positive outcomes.

In a three month follow up of clients, the psychotherapy group members

reported that they were helped and learned to recognize problems and deal

with them in a healthy way. The clients reported that they felt able to

interact with others. The cognitive behavioral group reported learning to

appreciate the views of others. They also discussed the feeling of needing

more tools and situational assistance indicating that learning had taken

place. The study was relatively small (p. 95).

In Closing

The authors indicate that both treatments were effective for

aggression, more comparison studies should be conducted, and incentives

are needed to have attendance be consistent (p. 96-97). Town et al, (2012)

found that psychodynamic psychotherapy can have outcomes that improve

over time and using research-specific treatment is not specifically

associated with better or worse outcomes. The research indicated that

140

additional research into psychodynamic psychotherapeutic treatment

incorporating research specific procedures that outweigh the perceived

limitations is warranted (p. 277).

The statistics are alarming: “We are losing about 22 veterans every

single day as a result of suicide,” said Sen. Bernard Sanders, I-Vt.,

chairman of the Senate Veterans Affairs Committee. That’s more than

8,000 veterans every year” (Donga, 2013). Suicides of veterans (349) at

one point in 2012, exceeded mortalities in combat (295) (Chappell, 2013).

Veterans are returning home with TBI, PTSD and challenges that

compound their traumatic experiences in war. Screening takes longer than

warranted, and disability benefits are denied. DoD is making an effort by

hiring clinicians yet this may prove to be too late. To date, 47 of the

authorized 1700 clinicians have been hired (Donga, 2013) Interventions are

provided for those that return and seek VA assistance. Stigma continues to

surround those that “lost it” or seek clinical help. “Outpatient mental

health visits have increased to over 17 million in 2012, up from 14 million

in 2009,” said Petzel. “The number of veterans receiving specialized

mental health treatment rose to 1.3 million in 2012.”(Donga, 2013) A

141

striking similarity of the veterans that did report for assistance is survival

guilt, and the need to return to their unit.

The camaraderie developed in the battle zone provided a sense of

normalcy to what is anti-humanity. This reality needs to be considered for

returning veterans. Comprehensive battlefield debriefing followed by

screening and assessment should include a breakdown of unit members and

their locations. Being aware of their unit members and their status would

be helpful as would indirect or direct contact. As a country, we need to

develop and research a thorough screening instrument that is trauma

sensitive and inclusive of minute detail and then evaluate it thoroughly.

Limitations imposed by physical injury also should be an intricate part of

treatment planning. There appears to be a number of

treatments/interventions that are excellent in providing a foundation for

additional and specific intervention. DBT has been consistent in this vein.

Perhaps as a pre-requisite, to return, all veterans need to be exposed to such

a curriculum which would raise awareness to existing issues and establish

the framework for continued and prescribed treatment.

Psychopharmacology may be required in certain cases, and if that is

142

warranted, acute follow through is necessary as is pairing the medication

with an appropriate CBT. It is essential that the veterans have the

resources to sustain treatment inclusive of prescription medication.

Veterans are isolated upon return, large proportions seek assistance

and their feelings are enflamed. The false promises disrupted by combat,

injury and then PTSD. Emotions are accompanied by survivor’s guilt and

contemplating suicide leaving their ended lives in others hands. There

needs to be a definitive and consistent means to help the men and women

of the military and meet them on the ground floor, have an awareness of

the basement and stop at a designated floor to get the appropriately and

carefully planned treatment. Returning soldiers require the embrace of a

child. Their experiences are beyond the capacity of understanding.

143

Chapter V

Comparing Treatment Efficacies for Both Populations

I immediately removed handcuffs and offered the hospitality of

“home”. When a child reported to my 25 bed facility, which was nested in

the top of the Hilltowns of Albany County, I always met them at the door.

In Rensselaerville, New York, a town with noted residents such as Andy

Rooney (60 minutes, CBS TV curmudgeon; RIP) and Molly O" Neill

(Yankee slugger Paul’s sister and New York Times author), there always

seemed to be snow under rich enormous pine trees until June. The 15-17

year old child would be introduced to countless staff, other “ranking”

officials and then eventually peers. The initial discussion is quite simply

“Restroom?”, “Shower?” (voluntary, a discreet staff outside), “Food?”,

“Phone”?”, and inquiring as to any issues that need to be addressed

immediately.

In our environment, everything began and ended in group.

Recognition, problems in the dorm, individuals acting up and annoying

others, curriculum and manualized treatment were all dealt with in a group

setting (“circle up”). It was a 25 bed dormitory style camp. Dormitory

living was an unintended intervention. There was 100% interaction,

144

always a peer or staff to bounce something off of, and many youth would

ask if they could go “back to their unit” after hearing bad news or needing

an out. There is an astounding similarity with soldiers. Oddly enough, an

unusual amount of youth appeared with head injury, which was also found

by Ahrens & Rexford in their study (2002, p. 207). Each staff had personal

investment in every child using amazing skills including constructive

means to maintain the environment by taking the unit to a group session to

discuss without personalizing behaviors. Staff routinely incorporated the

children into their personal interests indoors and out. There was an effort

to form relationships and attachments that had escaped the youth. There

was a core group of youth that never fell apart as individuals replaced

departing core group members naturally. The core group always set the

tone, explained the environment and mastered facilitation skills, anger

management and the ability to express oneself. We had 37 restraints in 6

years; one child being restrained nine times. Other 25 bed facilities in New

York State were averaging over 100 a month. After a period of time, any

child will speak in a group, which can be heart wrenching, alarming and

extremely deep. When you are an adolescent in this mode, you can learn

145

how to present with passion and emotion. That is when the term “drill

down” applies, and you have layers upon layers to “un peel”.

Screening

PTSD, in terms of DSM IV criteria for diagnosis, has three main

symptoms: intrusive thoughts, avoidance behaviors and hyperarousal.

The nature of exposure to extreme violence resulting in being wounded and

feeling vulnerable and helpless manifests itself in both populations with

only a contextual difference. The means by which symptoms are reported

to service providers is by seeking help in the case of veterans or being the

subject of an abuse allegation and investigation in the case of a child.

There is a stigmatic issue for both populations in working with

professionals in either scenario. The amassed experience of world wars has

not changed the negative connotation to seeking assistance. For whatever

reason, 49, 425 newly diagnosed veterans of the Iraq and Afghan wars are

completing recommended treatment at a rate of less than one in 10 from

facilities run by the Department of Veteran Affairs (Seal et al., 2009). The

numbers of individuals with PTSD continues to increase at an alarming

rate.

146

In 2010, 408, 425 children were in foster care in the U.S. (U.S.

Department of Health and Human Services, 2011 as cited by Greeson et al.,

2011 p. 93). Children are thrust into the world of authority figures, face

emotional turmoil, and are probed by the parties that compounded the

trauma by removing them from their homes resulting in loss and separation

(Greeson et al., 2011 p. 93). Child Welfare has the daunting task of

handling various reactions following traumatic events and developing a

better understanding of characteristic behaviors associated with complex

trauma histories and what they actually represent (Kisiel, Fehrenbach,

Small, & Lyons, 2009 as cited by Greeson, et al., 2011 p. 93). The trauma

suffered by both populations is the cause of the array of problems that

follow. The process, by which assistance is provided, at times, exacerbates

the trauma and reinforces hopelessness. According to Brown et al.(2010)

and Vogel, Wade, & Hackler (2007), individuals new to treatment may

experience barriers pertaining to misperception, internal sentiment, or

misinformation about available treatment options(as cited by Pruitt et al.,

2012 p. 811). The reception for those that have experienced trauma and the

potential for PTSD is marred by such barriers, obstacles, and

misperceptions.

147

From screening to diagnosis to treatment planning and choice,

engagement is critical and outcomes rely on the strength and fidelity of the

treatment choice and “getting to the trauma”. Both populations have been

studied, veterans identifiably more than children, and the results are not

promising for a troubled population with alarming impact beyond the initial

trauma. Screening is an early stage that needs to be repeated in three

month intervals due to delayed onset, worsening or improvement of

symptoms. Outcomes are extremely difficult to measure. Treatment

selection must be based on a consideration of all presented factors and in

evidence based milieus.

Cognitive Behavioral Treatments

In both PTSD populations, there are similar characteristics that

support utilizing a number of cognitive behavioral individual and group

treatments. PTSD symptoms include social isolation and trust issues

(avoidance). Group treatment offers safety, social connectedness and the

ability to develop trust. In addition, PTSD victims feel as if they are alone

relative to symptomatology and not respond initially to a clinician

pertaining to direct testimony or confrontation. In a group setting, where

148

members all have been diagnosed with similar trauma resulting in the

PTSD diagnosis, peer interaction presents an advantage that contradicts

myths and encourages open dialogue. There is also the issue of cost

reduction of seeing patients in a group setting compared to individual and

may maximize limited staff resources (Sloan, Bovin, & Schnurr, 2012 p.

690). The difference in the ages of the clients, child abuse victims and

combat veterans, would change the nature and slightly modify content of

the group. In any case, there is a paucity of research on group

interventions as compared to individual and there is great difficulty in

establishing a control group outside of “wait listers”(Sloan, Bovin &

Schnurr, 2012 p. 697).

In a comparison of treatments for both populations there is a

continued dearth of research pertaining to child abuse victims. There are

studies of veterans, sexual assault victims, natural and community disasters

and adults that were victims of child or sexual abuse (Ahrens & Rexford,

2002 p. 212, Black, Woodworth, Tremblay & Carpenter, 2012 p. 194).

Continued research for children with PTSD is warranted, and the benefits

extend beyond their affliction relative to generational repetition of

149

exposure to trauma. Cognitive Processing Therapy (CPT) has been utilized

with some success with children and veterans. Comparing two studies

provides insight to the common efforts and results of a specific

intervention; Cognitive Processing Therapy (CPT).

CPT

Chapter IV included CPT as a treatment for Combat Veterans with

PTSD. Resick & Schnike (1992) created CPT based on the social

cognitive theory of PTSD. The focus is on the traumatic event and how it

is construed or misconstrued by an individual that is attempting to regain

an internal locus of control (Monson et al. 2006 p. 901). CPT provides an

avenue to appropriately address thoughts. Misinterpretation must be

cleared up, and certain myths be dispelled. Attribution and guilt, cessation

of matching prior beliefs to new stimuli and minimizing inappropriate gut

wrenching reactions are the goals through education, discussion and

narrative writing. Inappropriate behaviors dissipate over the course of

treatment.

In the studies that follow, CPT is used as a 12 week model with

combat veterans and an 8 week model with youth in family court facility

150

residential placement. In reviewing the studies, the format of therapy is

adapted from the Cognitive Processing Therapy Veteran/Military Version:

Therapist’s Manual (Resick & Schnicke, 1992 as cited by Ahrens and

Rexford, 2002 p. 208). CPT begins with a PTSD education component.

This is followed by the creation of an Impact Statement/Narrative allowing

a window into belief systems and challenging faulty beliefs. Ensuing

sessions deal with self-blame, hindsight bias, and other guilt thoughts. The

client begins to learn skills and how to focus on issues pertaining to safety,

trust, power/control, and esteem to counter act the triad of PTSD

symptoms. There are modified versions of CPT that disallow the narrative

and some that add a component for co-morbid issues such as substance

abuse. There are homework and practice assignments, handouts, and it is

not uncommon to address issues that arise that are equally informative and

insightful (Resick, Monson & Chard, 2007 p. 6). Ahrens and Rexford’s

study (2002) involved 38 adolescent males, ages 15-18, ethnically mixed,

in a youth facility. All youth were assessed using clinical interview and

checklist and diagnosed with PTSD per the DSM-IV (APA, 1994) criteria.

Youth were randomly assigned to two groups; treatment and wait list

(control). Youth were placed due to assault charges, burglary, theft, and

151

drug charges. Many had witnessed death. There were also a high

percentage of youth that had a diagnosis of ADD or ADHD (p. 207).

Sessions were done in increments of 60 minutes over the course of 8

sessions as described above (p. 209).

Means and Standard Deviations for PSS-SR by Treatment Group

Pre Test Follow up

X SD X SD

CPT 16.89 10.49 7.82 10.00

Control 19.36 10.12 20.8 10.46

Means and Standard Deviations for IES by Treatment Group

Pre Test Follow up

CPT 35.52 11.80 23.41 6.88

Control 33.42 8.70 33.50 6.29

Means and Standard Deviations for BDI by Treatment Group

Pre Test Follow up

X SD X SD

CPT 15.26 12.10 23.41 6.88

Control 18.52 9.97 17.94 8.22

152

The above chart represents the PTSD Symptom Scale Self-Report

(PSS-SR), the Impact of Events Scale (IES) and the Beck Depression

Inventory (BDI) scores from validated instruments. The CPT group shows

a significant change between pretest and one month follow-ups whereas the

control group remained the same. Measures of trauma symptoms and

depression decreased significantly over time (as cited by Ahrens and

Rexford, 2002 p. 211).

Youth expressed an interest in continuing group being aware that

other desirable activities were scheduled at the same time. This is

indicative of my experience in Rensselaerville lacking a detailed approach

to treatment. There was much less licensed staff than afforded to the

aforementioned study which was facilitated by a female doctorate

candidate and a female psychologist with 15 years collective experience

complimented by direct care staff with experience. The common threads

with my experience with a similar population were the head injuries, the

ability to grasp group processing and the lack of resistance resorting to the

group to process and learn skills. It was obvious that attitudes changed as

beliefs were altered about violence as the only answer, that authority can be

153

helpful and a resource, and that parents and guardians are not necessarily

acting in your best interest. The toughest groups that I ever ran were those

where a youth reveals that s/he couldn’t go home and succeed. My

experience is confirmed by the Ahrens and Rexford’s 2002 study.

The 2002 study denotes limitations such as the size of the group and

the findings translating to similar groups. The presence of co-morbid

conditions, such as substance abuse, may have changed the dynamic which

might have altered outcomes, in addition to the study being conducted by

the primary researcher, potentially resulting in experimental bias. Outcome

measures that utilized adult scales may not have been sensitive enough to

measure treatment effect (p. 212). CPT reduced self-reported levels of

depression and PTSD symptoms of intrusion, avoidance and

hypervigilance four months after the treatment. The authors state that the

power of the study could be increased by incorporating non-specific

treatment condition to test against results, assessing in-program behaviors,

length of stay and recidivism rate. This would provide measurements

illustrating the effectiveness of CPT (p. 212).

154

Children are susceptible to structured and safe treatment models.

Ahrens and Rexford’s 2002 study, despite small group size, is an indicator

of the potential of empowered youth beginning to feel a change in their

ability to demonstrate control. It is a powerful feeling to see a youth

blossom in the group and begin to return to a child, and exhibit once lost

wonderment in a science class. According to Resick, Nishith & Griffin

(2003), CTP has an exposure narrative component, but a large portion of

the treatment is devoted to breaking down the traumatic event challenging

the client to meet erratic beliefs through questioning and assignments (p.

2). Youth experienced growth similar to combat veterans in the reduction

of PTSD symptoms and the ability participate in an interactive healing

process.

Veterans and CPT

Andrew O’Brien

Andrew O’Brien came home from Iraq with nightmares, suffered in

silence and isolation, and survived a suicide attempt. Andrew was 19 when

he followed his older brother’s footsteps and joined the military. At the

time, the U.S. troops were surging to the highest level of the Iraqi war. At

155

the bleak outpost in Baghdad, he was a truck driver and then a lead gunner.

His responsibilities as lead gunner included riding shotgun and scouting for

Improvised Explosive Devices (IED). He disobeyed a direct order to

refrain from looking under a tarp covering a truck that had been ravaged by

an IED. The bodies had been removed, but the remnants of the tragedy

remained. It became imprinted on his brain. Andrew became paranoid;

stopping his truck every 10 yards for any debris. The dreams of his men in

the detonated vehicle commenced. Upon return to his base in Honolulu,

what started out as ceremonious partying, turned into numbing self-

medicating alcohol dependency. Flashbacks came as Andrew began to

train troops heading for the front line. Sounds and smells triggered painful

thoughts and images. Andrew received the required mental health

screening when he landed on U.S. soil. Andrew describes the scenario as

“Soldiers being herded into a large room and asked in plain view of other

waiting soldiers if they needed mental health help”. Most soldiers in that

environment are not going to admit personal defeat. An individual

counselor was assigned, and those visits ended abruptly as the counselor

questioned the validity of his account of combat. He was also publicly

156

humiliated for seeking assistance by his superior by rank. He decided to

“go it alone”.

Andrew had a negative experience with an old army buddy, went

home and explained his mind going a “hundred miles an hour”. He was

contemplating the morbid truck, missing his comrades, and suicide. He

saw pills for sleep, anxiety, and anti-depressants. He took them all and

chased them with beer and in a flash thought that it was a mistake. He had

no recollection of calling 911. He awoke in a hospital. The very first time

he shared his feelings with anyone were with his brother on the phone in

his hospital bed. They both had symptoms of PTSD and now were each

other’s resource. They did their own peer-to-peer counseling.

Andrew requested to share his story with other soldiers and was

denied. The dreams lessened, and he was able to wake himself when they

started. Andrew struggled to get work, continue his education and couch

surfed with old friends. He landed in Austin, TX and found out that

statistics of suicide had risen to 22 suicide deaths of soldiers on a daily

basis. The only difference that he felt was that he “woke up the next

morning”. He wrote a 32 page guide book for families with returning

157

veterans. He established a web site and a Twitter account and made a now

viral You Tube video. There was no turning back, and he was beginning to

share his world markedly different from others.

He was contacted by a Louisiana group called NOLA Patriots who

explained their recent rash of suicides. He and his roommate, Tana, with

whom he finally established a home, excitedly took off for New Orleans.

He stood in front of a crowd that included a mother of a soldier that had

taken his life. He was nervous at first, accepted a tissue to dab tears and

eventually found his niche in story-telling and talking to people. A mother

of a young soldier that had been deployed four times called Andrew “a

resource” following a meeting scheduled at Andrew's house and that he

was “what we are looking for” (Schwartz, 2013). Andrew would like to

speak to soldiers prior to their returning home with hopes of saving lives.

Experts comment that there is a dire need to commence discussions early

and raise awareness that nightmares can be faced. There is gaining

momentum towards reducing the stigma in seeking assistance (Schwartz,

2013).

158

Our military is being forced to recognize soldier demise through the

unavoidable truth of men taking their lives as the easier alternative to living

with the three symptoms of PTSD. Our reach has to become more

personable, maintain the alliances formed in the services and use treatment

to re-establish lives. Andrew O’Brien is fortunate in that he called 911.

Other veterans need to know that there are support systems, there is no

stigma, and that talking amongst peers provides hope and skills.

CPT Study

Hoge, Auchterlonie, & Milliken (2006, as cited by Monson et al.,

2006 p. 898) indicated that the growing populations of veterans are

experiencing high levels of PTSD and other mental health symptoms. The

authors also note a sense of urgency in developing effective means of

treatment. Monson et al. (2006) also contend that there is validation of the

efficacy of cognitive based therapy (CBT) and prolonged exposure (PE),

for PTSD, quite possibly without the use of psychiatric medications. CPT

is a treatment that combines both CBT and PE (Resick & Schnurr, 1992 as

cited by Monson et al., 2006).

159

Monson et al. (2006) conducted a controlled study whereby the

hypothesis was that the CPT cohort would show lessened clinician rated

PTSD symptoms than the wait list cohort during and after treatment. The

second hypothesis was that the subjects in the CPT cohort self-report

reduced PTSD symptoms during and after treatment as compared to the

wait list cohort. This study consisted of 60 veterans with chronic PTSD.

Participants had to be diagnosed with PTSD as a result of military

stressors. Participants were randomly assigned to the CPT group and the

wait list group. If participants were receiving treatment that included

psychiatric drugs or psychotherapy not related to PTSD, they had to be on a

consistent dosage for at least two months, and the therapy could continue.

Exclusionary criteria included substance abuse dependency, current

suicidal or homicidal thoughts and significant cognitive impairment.

Sessions were run twice weekly and whenever possible. All the sessions

were taped, and a clinician expert in CPT, not connected with the study,

rated 10% of the sessions. The sessions followed the manual in steps and

content. This included the psycho education, creating the trauma narrative

and the beliefs therein, problematic beliefs and cognitions and “stuck

points” were discussed, and homework was assigned. Another written

160

exercise capturing the “worst experience” was completed and processed,

and this creates a focus on the traumatic event leading to the diagnosis and

creating the intrusive symptoms (Monson et al. 2006 p. 901).

The study provided encouraging results in treating veterans with

PTSD. There were improvements seen in both clinician interpreted results

of instruments and self-reported. 40% of the participants did not meet

criteria for PTSD, and 50% of the participants had a change in their

symptoms at post treatment assessment. CPT also had a long lasting effect

on other mental health symptoms such as depression, anxiety, affect, guilt

and social adjustment. Limitations to the study include the possibility of

failing to generalize to all veterans, the ethical reservations of maintaining

a group on a wait list shortening the length of a control capability, the lack

of measurements that captured the effects of the individual psychotherapy

(Monson et al. 2006 p. 903). There is a dire need for follow up research

on this intervention to determine the validity of CPT with all factors

mitigated and outcome measures to determine consistency.

161

Cognitive Processing Therapy (n=30) Waiting List (n=30)

Baseline Mid trtmt, Post trtmt 1 MONTH

FOLLOW UP

Baseline Mid trtmt Post trtmt 1 MONT

FOLLOW UP

Measures M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) M (SE)

CAPS total 76.73 (2.6 67.69 (3.4) 52.14 (3.4) 58.13 (4.5) 79.10 (3.5) 75.56 (3.2) 76.03 (3.7) 74.37 (4.3)

CAPS Re-

experiencing

23.00 (1.2) 19.93 (1.5) 14.70 (1.7) 13.52 (1.7) 20.70 (1.5) 19.24 (1.4) 19.55 (1.6) 19.92 (1.6)

CAPS

Numbing

18.13 (1.2) 14.55 (1.5) 11.06 (0.8) 13.63 (1.7) 20.93 (1.2) 21.86 (1.6) 22.28 (1.6) 20.61 (1.7)

CAPS

Avoidance

10.57 (0.6) 9.79 (0.8) 7.07 (0.8) 8.15 (0.9) 11.77 (0,6) 9.81 (0,8) 10.23 (0.8) 10.61 (0.8)

CAPS

Hyperarousal

25.03 25.03 24.10 (0.8) 19,27 (1.3) 22.99 (1.3) 25.70 (1.0) 24.44 (0.8) 23.80 (1.2) 23.24 (1.3)

PCL 60.66 60.66 49.58 (2.1) 44.62 (2.2) 45.55 (2.4) 61.50 (1.8) 57.91 (2.0) 56.38 (2.0) 57.23 (2.3)

BDI 25.39 25.39 20.15 (1.6) 17.42 (1.6) 18.75 (1.9) 28.53 (1.6) 27.08 (1.4) 27.06 (1.4) 23.92 (1.8)

STAI 54.38 54.38 47.28 (2,2) 46.92 (2,1) 47.51 (2.4) 55.62 (1.8) 58.23 (2.1) 58.16 (2.0) 56.98 (2.3)

The chart above indicates that positive values favor CPT over the

wait list. The Clinician Administered PTSD scale (CAPS), the PTSD

checklist (PCL) and the Beck Depression Inventory (BDI) were

instruments utilized for measurements at indicated intervals. In addition,

the State-Trait Anxiety Inventory-State scale instrument was utilized. In

the study, re-experiencing and emotional numbing symptoms showed

improvement in the CPT group as compared to the wait list. However,

behavioral avoidance and hyperarousal did not show a significant

162

difference in improvement between the groups. This was possibly

attributed to actual improvements in the wait list group, and inadequate

strength in the study to find the interaction effect in the small numbers of

participants. The authors called for additional studies with larger samples

(Monson et al. 2006 p. 904). The avoidance and hyperarousal may be

directly attributed to the drop out factor as either symptom may result in

the inability to attend.

There was a 16% drop out rate and measurements were taken on the

“intent to treat group” and the “completers”. Even those that dropped out

showed improvement which indicates that incomplete treatment does not

translate to the inability to tolerate treatment. The authors suggest that the

sessions may have needed to be more prescriptive to individuals to reduce

the dropout rate (Monson et al., 2006 p. 905). The results appear to

indicate that there are lessened symptoms with some longevity. This is

encouraging. However, there seems to be a disconnect in engagement of

military personnel in getting to treatment and completing the process.

163

Child Abuse Victims in the Military

The lack of studies and research on childhood victims of abuse may

be attributable to the difficulty in dealing with a youthful distraught

population with severe “acting out” behaviors. As adults are expected to

manage their behavior, youth are challenged with remaining neutral and

dealing with their own issues. The same difficulties exist with veterans

that manifest itself in the form of substance abuse, resistance to treatment,

and isolation among other characteristic destructive “behaviors”. There are

studies, however, supporting the notion that many childhood victims of

abuse show up in our military population. PTSD is a common thread in

both populations and there are compelling statistics pertaining to victims

enlisting perhaps related to attachment, normalcy, and structure. The

thought process is subject to extreme backfire.

There is support that connects childhood trauma from various forms

of abuse to PTSD symptoms in veterans despite combat exposure. In a

study that controlled for combat exposure, veterans that had PTSD

symptoms from childhood trauma had considerably relevant issues in

attaining support as an adult (Van Voorhees et al. 2012 p. 424). Gillespie,

164

Phifer, Bradley, & Ressler, (2009) and Koenen (2006) have theorized that

childhood abuse hypothalamic-pituitary-adrenal axis (HPA-axis) associated

HPA-axis dysregulation may hinder emotional learning and the maturation

of emotional regulations, making ensuing traumatic

experiences challenging to absorb and process. (as cited by Van Voorhees

et al. 2012 p. 424) The study, in agreement with others, concluded that

child abuse and combat exposure did not necessarily translate to increased

PTSD symptomology.

It appears that disruption to key developmental stages of early life

increased the likelihood of being able to proceed without difficulty in

stressful experiences and in garnering adult and social support (as cited by

Van Voorhees et al. 2012 p. 429). There is vast agreement that childhood

abuse and PTSD diagnoses foster severe reactions later in life, particularly

in the case of military experiences. As aforementioned, studies call for

continued research be done on the connections between childhood abuse,

combat trauma, and psychiatric issues to determine the sequence with

which the trauma results in PTSD diagnosis. Many studies are

recommending that childhood abuse be examined thoroughly to determine

165

the length of abuse and to what extreme (Fritsch, Mishkind, Reger, &

Gahm, 2010 p. 252). This confirms the lack of research done on this

population and how critical the issue is for the child to grow without being

prone to PTSD symptoms increasing in severity.

As indicated above, there are supportive studies that indicate that

child abuse and combat correlate to increased PTSD symptoms. There is

no specific rationale as to why there is a prevalence of child abuse victims

in the military. Soldiers with suicidal behavior had a history of child abuse

(61.2%), service members experienced abuse in childhood (35%), and a

general population of soldiers reported a childhood history of abuse for

males (48%) and females (51%) as concluded by Perales, Gallaway, Forys-

Donahue, Piess & Milliken (2010) in their analysis of current research

(p.1037). Marie, Fergusson and Boden, (2008, as cited by Skopp, Luxton,

Bush & Sirotin, 2011 p. 363) discussed the significance of belonging to a

group in dealing with childhood adversity on mental health conditions and

suicide ideation. Both populations have a desire to be included and the

ability to form meaningful attachments.

McLaren & Challis (2009) and Werner & Smith (2001) surmise that:

166

The social acceptance associated with such camaraderie and feelings

of belongingness associated with military service may be very potent

for someone who experienced minimal feelings of belongingness for

much of their life. Belonging to a defined group with a defined

identity, emotional bonding, purpose, and strong leadership may

potentially confer a salutary effect that reduces the suicide risk

associated with childhood adversity (as cited by Skopp, Luxton,

Bush, & Sirotin (2011 p. 372).

The desire for soldiers to return to their unit, and enlisting in the first place,

may have a background in attachment and wanting to be a part of

something.

Interview with Dr. Gabor Maté

I had the good fortune to interview Dr. Maté following his

presentation at the 18th Annual New York State Child Abuse Prevention

Conference, “Many Voices One Vision”. Dr. Maté is a well-known expert

on topics including addiction, attention deficit disorder, mind body

wellness, adolescent mental health and parenting. His best-selling books

Scattered Minds, Hold onto Your Kids and In the Realm of Hungry Ghosts

167

outlines the mental implications of early childhood emotional loss due to

abuse. The following is excerpted from Dr. Maté’s presentation and my

interviewing him personally. (G. Maté, personal communication, April

16th, 2013)

Dr. Maté compared the population of child abuse victims and

combat veterans with PTSD as “one and the same”’. Dr. Maté explained

that many veterans are victims of child abuse and they are “sitting ducks”

for PTSD and substance abuse issues later in life as a coping mechanism.

In his argument that attributes attachment issues to this topic he argues that

this is why many abuse victims enlist in the armed forces. They are

attempting to attach where attachment has failed them as children. Dr.

Maté added that “all addicts that I work with have been exposed to or are

victims of childhood abuse or neglect and many of them have had military

experience”. In reference to child abuse victims, Dr. Maté contends that as

a society we have taken youth that are “acting out” and labeling them either

as behavioral problems or diagnose pathology. “We all have the primary

attachment which means the drive for closeness and proximity to be close

to another human being to be taken care of or take care of someone”,

168

explained Dr. Maté. The pursuit of behavioral rational or diagnosed

pathology never inquires as to how the youth feels internally in his mind,

hear, or gut.

“We have entered into experimentation with psychiatric medications

with children. We use anti-psychotics for children that are not

psychotic. The term “acting out” actually means portraying

something that you don’t have. A youth that is “acting out” is

merely attempting to communicate something where they do not

have language to express. It is our job as professionals to assess

what the children are trying to communicate not punish or diagnose a

behavior.” (G. Maté, personal communication, April 16th, 2013)

Children attach with their parents and other caring adults in an ideal world.

This is part of survival in the event parents die and they eventually do. If

primary attachment is distorted or impaired, the child will act out due to not

having appropriate attachments and the ability to effectively

communicate”. Dr. Maté is absolute in his theories of attachment and the

lack of the same contributing to adverse effects of childhood impacting

well-being for life.

169

Dr. Maté discussed the fact that trauma and abuse, as defined by

society are sources of loss but not the only loss experienced. The

vulnerability of infants and toddlers with emotional stressors during rearing

has the potential to scar the psyche later in life. Such people may try to

soothe this with addictive behaviors. Any perpetual sense of emotional

disconnect, either abuse or neglect, from a parent figure has the capacity to

have the same effect. Many people acutely traumatized or not, have these

lingering challenges. “We can be grateful things weren’t worse but we

can’t minimize the pain we carry form childhood even if it were not due to

severe neglect or abuse”, Dr. Maté continued to explain.

In reference to his theories of attachment gaining ground in the

field, Dr. Maté said the public is definitely very hungry for a different,

broader perspective. The current school of thought, according to Dr. Maté,

does not answer to the entire experience of either population. Dr. Maté has

hopes that the momentum is building and that it will flood the professional

field in order to properly train health professionals in society to respond as

they should”.

170

Dr. Maté clearly has some valid issues pertaining to child abuse and

later in life implications and both populations in some shape or form

reinforce his theories of faulty attachments throughout life leading to

adverse effects. There is a longing to be part of something, good, bad, or

indifferent that is dictated by experience and response to trauma and

negative stimuli. Attachments formed as a child, and their strengths,

equate to the ability to handle incidents that are attributable to the onset of

PTSD.

In Closing

In comparing victims of childhood abuse and combat veterans with

PTSD, there are many factors that serve as connections. The commonality

in PTSD symptoms experienced by both groups, such as being wounded or

exposed to extreme violent acts or repetitious exposure to violence are

common place for an abused child and a veteran returning from combat

(Gates et al. 2012 p. 361).

Children are particularly susceptible to obvious attachment issues

when the perpetrator of abuse is a relative or an adult, and this may be an

inter-generational phenomenon (Rodriguez & Tucker, 2012 p. 246). This

171

leads to continual exposure to negative elements to supplant the inability to

attach to a trusted adult such as joining a gang or a peer group and the

inability to trust (Rodriguez & Turner, 2012 p. 253). This comes across as

defiant, anti-authority and “acting out” behavior. In helpful nurturing

environments, children adapt and begin to learn differences in their

experience with adults and new strangers. It is essential that attachment

and relationships are established as individual contact with professionals

and fellow group members hopefully interfaces with a group therapy

experience, and there may be gain, learning and acquisition of skills (Sloan,

Bovin, & Schnurr 2012, p. 691). Group members identify with the subject

matter and find discussions productive, in my experience. However, there

are some conformists that do the bare minimum in all program areas and

really navigate through programs unwilling to explore their trauma and

resistance comes in the form of silence. When one of the silent youth takes

off “the armor” it is powerful, physically displayed in aggression and self-

destruction and the process of individual and group therapy takes longer.

Those that “made it through unscathed” and did not address their trauma

were doomed to maintain their diagnosis in an exponential manner with

increased exposure to trauma.

172

The presentation by clinicians and their support may be a

curriculum or manualized treatment or consistent groups that address and

challenge visible behaviors that are deemed inappropriate both allow for

growth. Clinicians and those exposed to these youth must be encouraged

to “look behind the behavior” as there is invariably a rationale or a reason

for behaviors labeled wrongly as oppositional defiance. The dearth of

research on children and treatment is a testimony to the lack of change in

the means by which we address “acting out” behaviors. We resort to

medication, control and punitive measures which serve to confuse and

exacerbate the children’s symptoms and is the opposite of meeting the

child’s needs.

Veterans that are exposed to combat and return state side have also

experienced loss and attachment issues. The values imposed during

childhood and in society are depleted as acts of violence destroy more than

lives. Being in combat is the equivalent of being a child in a new world as

boot camp cannot prepare one for the earth shattering direct observations of

death and destruction. There are several studies that indicate that soldiers

that were victims of child abuse are likely, in greater percentages, to

173

develop PTSD symptoms, in addition to what was already present from

childhood. The story of Andrew O’Brien and his experiences in his short

life are indicative of a needed change in the way returning veterans are

assessed as needing help. It appears that once attention is paid, and the

environment is therapeutic there is some success in reducing PTSD

symptoms as exhibited by improvement in both the “intend to treat” groups

and the wait list in several studies (Monson et al., 2006 p. 904). There is

no indication of abating symptoms just reduction. The search for normalcy

should not be kicked off by a disability assessment and struggles to locate

benefits and the appropriate milieu for help.

The similarity in both populations of success in reduction of

symptoms once arriving at the appropriate individual or group treatment

milieu is indicative of the need for funding research that allows for control

groups, intervention and treatment from a consistent delivery of services.

This would include everything from a uniform battlefield debriefing to post

treatment measures. For a child, this would mean at the point of abuse and

removal from home (battlefield debriefing) to successful return to a

trustworthy adult be it a retrained parent or a foster home. Both

174

populations are in dire need of an engaging form of stigma free triage that

enables the victim of PTSD to feel as if they are normal and their reactions

to stimuli are within the realm of the three main symptoms of PTSD.

Complete histories should be available to further identify the potential of

previous head injury and traumatic brain injury. Scans should be taken to

determine hippocampus and amygdala size and recognize that you may be

dealing with difficult to control emotions. The trauma needs to be

discussed as soon as the victim is ready not when the manual says to do so.

The advantage of the manualized treatment is for the facilitator’s road map.

The skill of knowing when to leap to a traumatic event revelation or

discussion in a group therapy environment takes a well-trained and

educated clinician specializing in each of the populations.

175

Chapter 6

Recent Trends in Treatment

Given the volume of PTSD diagnoses and the harsh reactions to

stimuli, continuing efforts to assist veterans with improved treatment and

new approaches continues. The population of those diagnosed with PTSD

continues to grow and the barriers to treatment selection remain constant.

The clinical focus needs to be on effectively delivering evidenced base

therapies (Foa, Gillihan, and Bryant, 2013 p.99). Child abuse victims, who

must feel safe before treatment to begin and be absorbed, are screened and

treated with newer psychotherapies, unique therapeutic approaches, and

polypsychopharmacology. Treatments have been developed and tested

using medical marijuana and MDMA, also known as “ecstasy” for

veterans, (Mashiash, 2012, Oehen, Traber, Widmer & Schnyder, 2013 p.

41) in addition to other nascent approaches. Social networking and the

internet has shown to have some benefits similar to exposure and

discussion with similar groups. The cost to society in terms of providing

services and sustaining productivity from damaged populations would be

supported by consistent choice in best practices, allowing for study control,

and effectively measuring for outcomes. Recent treatment trends that have

176

been studied with little or no comparison to accepted treatments, yet show

promising results, can best be described as complements to standard

treatment plans as a relief for PTSD symptoms and for continuity

(Feinstein, 2012 p. 371).

Children

Eye Movement Desensitization and Reprocessing (EMDR)

In Chapter IV EMDR was introduced as a treatment for combat

veterans with PTSD. EMDR is a relatively new treatment for children and

its appeal for use with children may be related to its simplicity and

structure (Tinker, 2002 as cited by Field & Cotrell, 2011 p. 375). There are

skeptics and those that label this unorthodox treatment as “pseudoscience”

(Fletcher, 1996; Herbert et al. 2000; Metter and Michelson, 1993 as cited

by Field & Cotrell, 2011 p. 386) However, in their systematic analysis of

EMDR, Field & Cotrell (2011) did not prove or disprove the effectiveness

of EMDR (p. 386). Research on EMDR appears to be gaining momentum

as an effective intervention with children and as a studied comparison or

complement to other interventions (Rodenburg, Benjamin, de Roos, Meijer

& Stams, 2009 p. 605).

177

EMDR was the discovery of Francine Shapiro in 1987. It has

evolved over the years to provide sustained relief of PTSD symptoms in

adults in several studies (Ahmad, Larsson & Sundelin-Wahlstein, 2007 p.

349). The “skeptics” raise many issues; however, there are more

supporters and a growing use of this intervention for children. When a

child undergoes EMDR, they are often asked to recall the most troubling

memory of a traumatic incident (internal). The trained clinician than guides

the child through structured rapid eye movements by having the child

follow their fast moving finger (external). Then the therapist inquires as to

what came up in terms of images, thoughts or emotions during the 30

second eye movement “set”. These internal negative thoughts are changed

to positive thoughts with the continued use of the external stimuli until the

positive internal thoughts are adopted (Fletcher, 1996, Field & Cotrell,

2011 p. 375). The request to recall the traumatic incident matched with

structured instructions to “follow my finger” and other rhythmic tapping

appears to be a natural way of breaking down thoughts for children and

building new and encouraging beliefs. Ricky Greenwald is a leading

therapist in the use of EMDR with children. He reports that children take

178

to the treatment quicker and results indicate a better resolution for trauma

victims than in Cognitive Behavioral Therapy (Huso, 2010).

Ahmad, Larsson & Sundelin-Wahlstein (2007) conducted a

randomized controlled study of EMDR treatment for children with PTSD.

33 children were chosen to participate based on the study criteria. Children

were entered either in an 8 week session of EMDR or placed on a waiting

list used in the form of a control group. EMDR was present in the adult

protocol with modifications considering the ages of children in the study

(6-16). The results of the study indicated that children in the EMDR scored

significantly lower than the control group in the symptom of re-

experiencing but little difference in that of hyperarousal. The study

indicated that EMDR has potential with the symptom of re-experiencing

symptoms for both adults and children. Despite the critics of EMDR, the

results of this study are positive and cite the need for further research with

larger samples of children with PTSD (Ahmad, Larsson & Sundelin-

Wahlstein, 2007 p. 353). The chart that follows (Ahmad, Larsson &

Sundelin-Wahlstein, 2008 p. 129) indicates the modifications to EMDR for

children.

179

The original adult-focused EMDR protocol and the child-adjusted

modifications:

Original adult-focused EMDR protocol Child-adjusted modifications

1. The first session starts with informing

the patient about the treatment

procedure, the technique used and the

possible benefit and side effects

1. If the child demands, the caregiver

can attend but without commenting on

the session. The child is asked to

confirm that she/he understands the

information given by the therapist

2. A relaxation technique is used to

assist the patient getting relaxed

2. The relaxation technique is adjusted

to the child’s age and the surrounding

circumstances during the session

3. The patient is asked to tell the most

enjoyed memory. This is considered as a

‘‘safe place”

3. The therapist assists the child by

asking questions that make the child

describe the contents of a chosen

enjoyed memory in details. This is

considered as ‘‘safe place’’

4. By following the therapist’s finger

moving horizontally 10–12 times in

front of the eyes of the patient, the

patient is asked to keep thinking of that

pleasant event which is called ‘‘safe

place’’

4. The child is asked if she/he could

think of the memory while following the

fingers with her/his eyes. If not, the eye

movements are replaced by tapping on

hands or thighs or by clicking with

fingers in front of the child’s ears

5. The patient is inquired to recall a

most terrifying memory. This is

considered as the traumatic event

5.Whatever the child reports is to be

registered as a traumatic memory, even

if it seems banal for the therapist

6,The patient is encouraged to find out

the most relevant negative emotion

when thinking of the traumatic event

and where in her/his body it is mostly

felt

6. Ask the child what she/he is feeling

while relating the traumatic event. If

difficulties arise, face-pictures

expressing various emotions are shown

to the child to point out the most

relevant feeling

7.To determine the severity of the

negative emotion, the patient is asked to

estimate the subjective units of distress

(SUD) on a scale ranging between ‘‘0’’

and ‘‘10’’, where ‘‘0’’ means ‘‘not at

all’’ and ‘‘10’’ means ‘‘all the time’’ or

7. The adult scaling form of the SUD is

attempted first. If the child is unable to

record with numbers, the scaling has to

be adjusted to the child’s age by

pointing out on a line from the least to

the maximum. For small children, a

180

‘‘very much’’ ranging of ‘‘not at all—little—often—all

the time’’ might be more applicable

8. The patient is asked about trauma-

related thoughts. This is considered as

‘‘negative cognition’’

8. The face-pictures are used whenever

the child has difficulties in estimating

thoughts and emotion

9. The patient is asked about what

she/he wants to think instead. This is

called ‘‘positive cognition’’

9. Whenever the child shows difficulties

in finding out alternative cognition, ask

about how it could be instead

10. The validity of the positive cognition

(VOC) is estimated by the patient

determining how true it is between ‘‘0’’

and ‘‘7’’, where ‘‘0’’ means ‘‘not at

all’’ and ‘‘7’’ means ‘‘all the time’’ or

‘‘very much

10. The estimation of the VOC has to be

attempted first in the same way as for

the adults. If it does not succeed,

modifications have to be applied

according to the estimation of the SUD

for children as described in 7

11.The patient is asked to recall the

traumatic memory

together with the negative emotion and

the negative cognition while following

the therapist’s finger through the same

movements as before

11.The EMDR processing is performed

in similar way as in the installation of

the ‘‘safe place’’, while encouraging the

child to remain thinking of the negative

emotion and the negative cognition

associated to the traumatic memory

12.After every 10–12 finger movements,

the patient is asked to take a deep

breath, to think free, and to talk about

what is coming up

12.The relaxation after each EMDR is to

be accomplished as it is described for

the ‘‘safe place’’, while letting the child

freely associate by telling what she/he

wants to tell

13. Same procedure is repeated until the

patient reports

no further comment

13. The EMDR processing is repeated

until the child has nothing more to

report

14. Then, both the SUD and the VOC

are re-assessed

14. Then, the traumatic memory is

recalled again, and the SUD and the

VOC are re-estimated

15.The procedure is repeated until the

SUD diminishes to ‘‘0’’, and the VOC

increases to ‘‘7’’

15. The child is asked to repeat the

procedure until satisfactory results are

obtained on the SUD and VOC

16. Before leaving the session, the ‘‘safe

place’’ is installed

again as in the beginning

16. The ‘‘safe place’’ is re-installed as at t

beginning of the session

181

In the event that the stated efficacy of EMDR is accurate there is

room for inclusion in treatment plans of children with PTSD as a result of

abuse. If a child shows incremental improvement over time with

professional and clinically guided EMDR replacing the symptomatic re-

experiencing of the traumatic event with positive thoughts cannot hurt

children that need resilience.

Art and Poetry Therapy

According to Brillantes-Evangelista (2012) in her article “An

evaluation of visual arts and poetry as therapeutic interventions with

abused adolescents”, children and adolescents that are the victims of

physical and sexual abuse have low self-esteem, feel worthless and

damaged. They also potentially manifest developmental disorders and

psychopathologies including depression, PTSD, and uncommon psychotic

behaviors (p.72). Adolescent victims often have trouble expressing the

emotions associated with the abuse particularly when the perpetrator is a

family member or relative, exacerbating the pain suffered at the hands of

those that you must trust. This creates the unfortunate circumstance where

every adult is suspect (p. 72). The non-threatening use of arts

182

psychotherapy provides children a means to express their emotions, with

clinical guidance, through their production in an art form that includes

visual arts and poetry. (p. 72)

Brillantes-Evangelista (2012) conducted her evaluation on

adolescent children in the Philippines utilizing a control group of

traditional therapy. There may be a cultural difference regarding the use of

art in communities, however, visual arts and poetry created by victims in

any society provide a clinical perspective and insight difficult to achieve

from talk therapy (p. 72). Several studies regarding the use of arts therapy

for various disorders such as depression, schizophrenia, and abuse (as cited

by Brillantes-Evangelista, 2012 p. 73) show efficacy in creating the

language needed to conduct productive therapy. The following drawings

indicate the artwork of eight session art psychotherapy and a breakdown of

the eight week session that accompanied the art (Brillantes-Evangelist

2012,p.189).

183

� The first session included a still life drawing of preferred

objects on display. While drawing, clients were asked to

remember their experiences and significant people in their life.

184

� The next session enabled the client to draw, using a Chinese

brush and India ink, a portrait of each group member asked to

pose for the drawing. This session was “getting to know you”

for group members and allowed for humor and established a

comfort level within the group.

� The third session was a self-portrait with a request to enhance

the most important body part. This session provides personal

insight to an individual‘s self, personality, sexuality, and may

allude to the experienced trauma.

� In the fourth session a life box was created and it represented a

container for memories one chooses to forget, important things

to maintain, and metaphorical gift for future desires. This

becomes a biographical tool. A client is described as placing a

black rock in the box signifying her anger. Through

conversation she realized that she was projecting her anger

onto others. The client’s aggressive behavior was reduced

significantly.

185

� In session five the clients would produce clay pots. The use of

clay initially created a display of emotion with throwing clay,

forceful kneading, and seemed to represent outbursts of anger.

Once the clients began to mold the clay into prescribed shapes

the other behaviors ceased.

� Session six allowed for clients to express fear in the form of

both concrete and abstract drawings. Clients made both

abstract and concrete paintings which had them face their

fears, using the description of the abstract and the reality of

the concrete drawing. A child drew a beautiful waterfall

stating that he was not afraid of anything and realized his

talent in art.

� The seventh session features a life story in book form. This

allows clients to tell their story, include family and friends and

hopes for the future. All of the life stories had happy endings

featuring improved lives. Increased internal processing was

the goal.

186

� Monster masks were the final session, similar to the clay pot

activity. The masks were to be of people hated or produced

fear. The hostile feelings were transferred to the clay, the

masks were poked and distorted and became effigies of the

represented people. Clients expressed an ability to release

their emotions and felt relieved. (Brillantes-Evangelista, 2012

p. 80-81)

There is a similar breakdown utilizing poetry and the writing of the

client as it pertains to the various themes similar to the sessions described

above. The final session on creating poetry signifies hope for a future

following their traumatic event and the possibilities. A limitation of this

evaluation of art/poetry therapy was the lack of professional clinicians in

guiding the groups. The groups were run by artists with experience in

doing this therapy and there was clinical assistance in developing the

content only. However, the evaluation demonstrated a positive impact on

PTSD symptoms, scoring lower in symptoms than the control group and

the need for development of this intervention/treatment and skilled

professional level clinicians/facilitators.

187

In the evaluation of visual arts and poetry as therapeutic

interventions with children, there were initial increases on PTSD symptoms

possibly elicited by the recall of the traumatic experiences and the

provocation of the symptoms. In addition where there was increased

symptomologies, the involved children discussed a coming to terms with

what happened and different thoughts for the future emerged. The

evaluation included the need for psychotherapists for “damage control” and

to assist in the various forms of developing new thoughts about the past

and the future. (p. 84).

My experience with having youth develop their artistic talents in a

residential facility revealed several talented young people that admitted to

drawing when “things were bad” and could reproduce these drawings upon

request. The conversations that followed inevitably included descriptions

of the “bad times”, abuse/neglect and familial relationships. There also

seemed to be an appreciation for praise that overshadowed disclosure

issues and reduced inhibition to discuss very personal background

information. At one point in my role as Assistant Director, I was gravely ill

and hospitalized for radical surgery. I received a two pound envelope of

188

get well cards with well-intentioned feelings, that revealed certain values

and familial relationships that allowed the youth to emote in a neutral way.

This type of contact always included critical information not available in

the child’s records. Art therapy promotes expression of emotional, physical

and mental states allowing clients to piece together and finds meaning

pertaining to the traumatic experience and prevents the symptoms

associated with PTSD (Rankin & Taucher, 2003 as cited by Kaiser et al.,

2005). Future studies are imperative as utilizing arts can become a clinical

gamble and psychotherapeutic resources should be available when the

youth begin to explore their lives via their products. Raw emotions are

expressed quite possibly for the first time and sessions should continue as

needed beyond eight weeks.

Game Based CBT (GB-CBT)

To just about any child, being paid attention to and the notion of

“games” are both appealing. In many cases where children are the

unfortunate victims of abuse, the interests of the child become distorted,

survival oriented, and the ability to trust and love are compromised. There

are resultant emotional difficulties for the child and their family (Zielinski,

189

2009 as cited by Springer and Misurell, 2012 p. 199). Child victims of

sexual abuse via traditional means of therapy are expected to discuss

painful and harsh memories of the initial trauma. Springer and Misurell

(2010) developed Game Based Cognitive Behavioral Therapy (GB-CBT)

as a means of creating psychological treatment that was appealing to

children and families (as cited by Springer and Misurell, 2012 p. 189).

Research has shown that manual driven inflexible treatment may be less

effective than treatment that is creative and responsive to children

(Chorpita, Taylor, Francis, Moffitt, & Austin, 2004; Weisz et al., 2012 as

cited by Springer and Misurell, 2012 p. 189). The authors sought to create

a treatment milieu that was engaging to caregivers and children that

encouraged involvement and dealt with the many issues of abuse in a way

that maintained the client and caregiver attention. GB-CBT was developed

as a combination of two interventions with a solid track record; CBT and

Play Therapy (PT). The components of CBT as previously discussed, uses

gradual exposure, behavioral modification and relaxation techniques, skill

development, and psycho-education is coupled with developmentally

appropriate games (DAGs), a play therapy technique.

190

The DAGs are designed to teach social and emotional skills via

experiential learning with a structured, goal-oriented and rule-based format.

DAGs are a vehicle for recounting personal trauma via gradual exposure

and limiting experiential avoidance. The DAGs are client driven and

dictated by the clinician based on assessed needs of the client/caregiver.

The DAGs are played in various modules and the client/caregivers can play

one or all the games in the module. The DAG’s are based on the

developmental level of the child, language capacity and by the judgment of

the clinician. GB-CBT is designed for children ages 4-17 and families

which are screened extensively, all records are reviewed and an

individualized treatment plan is developed noting the needs of the

client/caregiver relative to the components of GB-CBT (Springer and

Misurell, 2012 p. 192).

The two main components of GB-CBT are social and emotional

skills training and childhood sexual abuse (CSA) education and treatment.

The first component consists of learning social skills and developing a

relationship with the therapist. The second component deals with CSA in a

comprehensive manner. This includes psychoeducation, healthy sexuality,

191

gradual exposure for trauma and anxiety and the development of personal

safety and coping skills. GB-CBT is designed to improve self-esteem,

expression of emotions, appropriate assertiveness and anger management.

GB-CBT is strength based and also deals with cognitive distortions based

on the trauma. Children are provided with consistent positive feedback and

correction verbally and through the DAGs. The interactions, in turn,

identify areas that require further attention (Springer and Misurell, 2012

p.190). The DAGs played in the modules foster the therapeutic efforts in a

neutral, non-threatening and engaging manner in a number of sessions that

are determined by need.

The sessions consist of a caregiver only meeting, a child only

meeting, and a caregiver and child meeting (after the DAGs). In the

caregiver and child meetings, questions are posed and assessments of

critical issues pertaining to the trauma and the content of the specific

module. The DAGs are taught, played and processed. The caregiver and

child participate in role plays in addition to playing the DAGs and process

module related materials together. Homework assignments are given

weekly with the expectation of rehearsing acquired skills, playing DAGs,

192

and add to the clinician’s assessment tools by client/caregiver report out.

An age appropriate token economy is used for participation incentive and

maintaining the experience as a “game” (Springer and Misurell, 2012, p.

193).

The modules and associated games are as follows: (Springer &

Misurell, 2012 pps. 194-197)

193

MODULE DAG DESCRIPTION

Rapport Building Getting to Know You Stack points awarded for level of disclosure for all players initiated by the subject expressed on each card

Personal Space and

Boundaries

Personal Space-O-Meter a game of making an “arm-length chain” with pipe cleaners in 30 seconds for elementary school children. Cultural differences relative to personal space are taught and the game “Out of Bounds” is played where children hunt in magazines for people engaging and dressing in appropriate and inappropriate ways

Emotional Identification

and Expression

Feeling Fast points are awarded for the correct identification of the emotion displayed on flash cards of faces

Linking Feelings to

Experiences

Cup of Feelings Cups are placed in various locations in the room and labeled with feelings. All parties attempt to toss ping pong balls into the cups and when successful must disclose a time they experienced the feeling.

Coping with Difficult

Emotions and Social

Problem Solving

Thought Stopping Game Identification of emotional triggers and negative thoughts and emotional regulation techniques. the players read a list of self-talk statements and clap hands when a negative statement is read. Children and caregivers learn to identify dysfunctional thoughts and beliefs. Alternative means of responding to situations and thoughts are reviewed.

194

Relaxation Training and

Self-Control

Relaxation Competition learning the body’s response to stress and techniques when stressed. where the participants try to distract someone that is using the relaxation techniques.

Psychoeducation about

Touches, Child Abuse,

and Healthy Sexuality

Life Size Wheel of Knowledge

children learn anatomical names of private parts, appropriate and inappropriate touching, and child physical and sexual abuse. Beliefs, myths and misconceptions are addressed. In the Trivial Pursuit fashion wedges fill a “block of cheese” to win by answering questions.

Passive Disclosure How Did it Happen Verbal and non-verbal games to begin to construct the abuse narrative. Assisting children in understanding that it is appropriate to be uncomfortable and sharing. Points are rewarded for level of disclosure of and the expectations are that the children will share in the “hypothetical” sense.

Active Disclosure Multi-Modal Games means of expression including writing, discussion, drawing and acting. The abuse narrative is developed. Cognitive distortions are addressed as they emerge. Caretakers and children are encouraged to participate due to the importance of discussing the abuse together.

195

Despite being developed for CSA, a modified version is available if

a parent/guardian is the perpetrator of abuse; GB-CBT has merit in

addressing physical abuse as well. Results of studies from a recent meta-

analysis of GB-CBT, which combines two identified best practices, (CBT

and Play Therapy) are positive (Sanchez-Meca et al., 2011, as cited by

Springer & Misurell, 2012, p. 199) In working with adolescent children, I

would invent games and have experiential learning taking place whenever

possible. A favorite game would be “Have You Ever”. In the tradition of

Personal Safety Skills

Training

What If….Board Game assisting children in developing personal safety plans. The games require a high level of exposure and promotes healing through safely confronting andmastering the abuse experience. Players answer scenario questions in which personal safety is compromised. Correct answers earn a roll of the dice and players advance on the game board.

Skills Review and

Termination Processing

Moving On helping clients to process termination, gain appropriate closure with the therapeutic process, and develop post treatment goals. Players write and illustrates goodbye letters and posters, compose poetry and songs and are awarded points.

196

musical chairs, using pieces of paper as the “chairs” with enough for all but

one child and the facilitator to stand on, a volunteer would stand in the

center to start and say something that they have done that is “out of the

ordinary” e.g., “Have you ever snuck on the subway” Everyone that has

done such a thing would have to move to another spot causing a flurry of

movement. The person left in the middle, who could not find a “chair”,

would have to reinitiate by revealing something they had done. This would

be debriefed afterwards and there was always fun, disclosure, and the

gamut of emotions related to their chosen reveal. Youth would talk about

offending the law, others, and invariably would evolve into things that

happened to them. A hidden part of the game is the integrity lesson. There

is an extraordinary sense of truth and it is part of the game. Children that

have been abused are removed from childhood that comes back quickly

when there is trust, a game to be played and the ability to disclose and

normalize circumstance in a group.

197

Veterans

Voices of Valor

Samantha Henry’s article (2012), “Program helps veterans

reintegrate through music”, includes soldiers who turned to music like

Vivaldi, country, and mixed artists during times where deployment was

stressful. All soldiers indicate that music helped them weather the fierce

storms of battle. The soldiers providing the testimony are currently

enrolled in a program called “Voices of Valor”.

The Voices of Valor program takes veterans through a musical

journey of their experiences that proved difficult to express verbally and in

traditional therapy. The founders of the program, Rena Fruchter and Brain

Dallow, and a psychologist mentor work with veterans to produce a CD.

Fruchter and Dallow began the program working with children at shelters

for victims of domestic violence. They noted that traumatized individuals

may be hesitant to disclose but were willing to tinker with instruments to

release their feelings on sheet music and eventually in a recording.

Research has shown that music can rewire parts of the brain. Music

stimulates the brain and influences emotions and an action, reduces stress,

198

is relaxing and provides an avenue to express emotion (Music for all

seasons, 2010)

We’ve had situations in which veterans have been carrying

their burdens deep inside for such a long time, and they come

into this group and they begin to talk about things that they’ve

never talked about before. They really open up, and it

translates into some music that is really amazing and

incredible and powerful (Henry, 2012).

Some of the songs produced have been entitled “Tired of being

angry”, “Easier not to move on” and “The war at home”. These songs were

made by taking these phrases and placing them on newsprint and the

musicians start playing instruments and saying the phrases. Then lyrics

come naturally, “Sometimes I wish the past is where I stayed” as an

example, and the tempo and pace are dictated by the group process and the

group is on their way to production. This particular class assembled at a

professional recording studio to record their first tune “Freedom”. On a

regular basis the founders report observing participants arriving at the

program wearing their PTSD in their demeanor, posture and expression.

199

The healing properties of music convert them to productive group

members, sensing freedom and “ready to belt out a tune”. The website

features a sampling of their music. You can feel the emotions associated

with their experience and the need to belong in every tune (Henry, 2012).

On Monday May 13, 2013 the Voice of Valor program was featured

at the famous Russian Tea Room in New York City. The evening was a

benefit for Music for All Seasons’ Voices of Valor program, launched in

2011 with a major grant from the Robert Wood Johnson Foundation

(Music for all seasons, 2013). This is a special showcase for the veterans

involved.

Service Dogs

Unconditional love, perked ears and loving wide eyes can never hurt

a veteran reeling with symptoms of PTSD. Thompson (2010) in his article,

“Bringing Dogs to Heal”, discusses the merit of using “man’s best friend”

as a support for these individuals that are wracked with physical and mental

pain, frightening memories and nightmares, and are basically existing with

their “tail between their legs”. There are no better creatures on this earth to

understand this feeling.

200

The article tells the story of staff sergeant Brad Fasnacht, who was

clearing mines in Afghanistan, when an IED blast broke his spine and both

ankles. He recalls waking up in the Walter Reed Army Medical Center in

Washington. His physical injuries increased the severity of PTSD. His

ability to walk was restored but the rest was left to a four legged expert;

Sapper, an Australian cattle dog mix ready and eager to help with PTSD.

Fasnacht had sequestered himself to his apartment being wary of snipers in

suburban areas based on his experiences and the hypervigilence associated

with PTSD. Sapper goes with Fasnacht everywhere now and eases him

prior to anxiety attacks, alerting him to the presence of people and their

location, and will wake him from a nightmare by licking his face.

Minnesota Senator, Al Franken, authored a law ordering the

Veteran’s Administration (VA) to study dogs’ effects on PTSD sufferers.

Franken is quoted in the article as saying: “The whole point of

this is to measure in a scientifically valid way what the

benefits are of service dogs to vets with psychological injuries

and make a better life for these guys and women who have put

everything on the line for us.(Thompson, 2010)

201

In the last few decades, studies have indicated anxiety levels drop in half

the time using music and art as a control group. Other studies found after

spending only 15 minutes with dogs that there was a reported “significant

reduction” in fear in patients awaiting electroconvulsive therapy. Another

study detailed the “buffering effect” dogs have on the stress experienced by

their owners measured by cortisol levels, heart rate and blood pressure. At

the 2009 VA National Mental Health Conference and the Annual

Conference for the International Society for Traumatic Stress Studies,

reports were gathered form clinicians and program instructors indicating

that Veterans that engage in training service dogs manifest the following:

� Increase in patience, impulse control, emotional regulation

� Improved ability to display affect, decrease in emotional numbness

� Improved sleep

� Decreased depression, increase in positive sense of purpose

� Decrease in startle response

� Increased sense of belonging/acceptance

202

� Increase in assertiveness skills

� Improved parenting skills and family dynamics

� Fewer war stories and more in the moment thinking

� Lowered stress levels and increased sense of calm (Yount, Olmert &

Lee, 2012 p. 65)

The issue becomes cost and the degree of training working with

PTSD patients for service dogs with this specialty. The VA commenced a

program that will provide $10,000 each for 200 suffering vets urged by

Franken. One lucky recipient, “Sam,” was given “Gillian,” a black lab.

Sam had his left hand amputated due to complications from combat

wounds. Gillian is able to open doors and turns lights on and will be side

by side with Sam when she feels his anxiety growing. Sam reported still

having PTSD but credits Gillian with being able to handle it better. Dogs

are now being trained with PTSD specific tasks such as blind spot

awareness, providing safety checks and room inspections, and being there

for people with PTSD. The article closes with the possible images of these

four legged experts in airports, restaurants and ball games. A trainer of

203

these dogs and former deployed soldier with PTSD claims that the pets for

vets forces engagement and discussion that would never take place

otherwise. I assume there are many treats provided.

MDMA (Ecstasy) and Marijuana

The need for treatment for veterans with chronic PTSD symptoms

has the research world reaching out for all possible treatments. In recent

studies have been conducted featuring the use of MDMA, popularly known

as “Ecstasy” and Marijuana. Given the legally controlled status of both

drugs, there is natural cynicism towards utilizing the substances to treat the

veterans that have not taken to other therapies. There are supportive

studies, however, that indicate the reduction of PTSD symptoms for

extended periods of time with both MDMA and Marijuana. The hypothesis

being that the drugs work on the brain in making the unfathomable

thoughts bearable for the moment and through exposure.

Many soldiers have reached out to Michael and Ann Milhoefer, a

psychiatrist and a nurse, who are evaluating, MDMA as an aid to

psychotherapy. The “party drug” was criminalized in 1985; however, there

has been limited licensure granted for researching the drug for the benefits

204

it provides for therapy (Carey, 2012). In the first randomized controlled

study the authors hypothesized that MDMA may reduce the symptoms of

PTSD enough to begin to be comfortable with therapy and increase

effectiveness. In other therapies the issue of resistance and the inability to

cope with exposure therapy due to PTSD symptoms fosters a need for an

intervention and the study has positive evidence for MDMA as a potential

catalyst. (Mithoefer, Wagner, Milhoefer, Jerome & Doblin, 2011 p.440)

The authors explain that where selective serotonin reuptake

inhibitors (SSRI) sertraline (Zoloft) and paroxetine (Prozac) have displayed

a 20-22% greater than response to placebo and 30% of the subjects can

achieve remission at 12 weeks in trials, all studies remain consistent in

recommending further research in more effective agents (Milhoefer et al.,

2010 p. 440). In addition, according to Milhoefer et al., the combination of

evidence based therapies combined with the use of SSRI’s, has shown that

there is a 25% to 50% rate of ineffectiveness for patients that enroll in

clinical trials and that an effective treatment for PTSD that reduces failure

rates is needed. The physiological impact of MDMA may provide an

opportunity during therapy that minimizes the overreaction or under

205

reaction to stimuli associated with PTSD thereby increasing the

effectiveness of exposure therapy (2010 p. 440). MDMA

pharmacologically releases serotonin, receptor stimulation and increases in

levels of neurohormones oxytocin, prolactin, and cortisol (Dumont et al.,

2009, Grob et al., 1996; Harris et al,. 2002; Mas et al., 1999; Thompson et

al., 2007; Wolff et al., 2006 as cited by Milhoefer, et al., 2010 p. 441).

Serotonin release contributes to the subjective effects of MDMA and lends

to the elevation of oxytocin which has been recently tied to affiliation,

trust, and accurate perception of emotion (Domes et al., 2007; Kirsch et al.,

2005; Zak et al., 2005 as cited by Milhoefer, 2010 p.441). This is seen as a

potential aid in therapy as is the prolactin release which creates a sense of

relaxation and receptivity (Passie et al., 2005 as cited by Milhoefer et al.,

2010 p. 441). There is a sense of speculation pertaining to these effects of

MDMA. MDMA, through these changes in brain activity may reverse

some of the impact to the brain of PTSD (Milhoefer, 2010 p. 441).

Participants of the study were screened and selected via a telephone

interview, were further evaluated in an outpatient office, and 20 were

finally selected for the study. Subjects were randomized in double blind

206

method to receive two sessions of either psychotherapy with MDMA

administration or the same therapy with a placebo. Participants were asked

to abstain from any prescribed psychiatric medications less “rescue

medications” (sedative hypnotics or anti-anxiety) to be used as needed

between MDMA administrations. Standard assessments for trauma were

used, before and after treatment, such as CAPS for its psychometric

measures quantifying PTSD symptoms. The treatments included non-drug

psychotherapy sessions for preparation and integration of MDMA or

placebo. Sessions were held in two stages with integration and the

administration of MDMA defining the two stages (Milhoefer et al., 2010,

p. 443-444).

The group that had treatment inclusive of MDMA administration as

compared to that of the placebo group produced significant improvement in

the reduction of PTSD symptoms. The strength of the study was the use of

randomized control, the use of CAPS, the subjects being resistant to

treatment and a blind rater. The limitations were the small sample size,

mostly female and Caucasian, and the variant treatment history of both

groups. Another weakness was the transparency of the placebo has the

207

effects of MDMA were not subtle. The study cites the effectiveness of the

reduction of PTSD symptoms as meriting further evaluation of MDMA

(Milhoefer et al., 2010 p. 450).

One of the subjects stated: “The feeling I got was

nothing at all for 45 minutes, then really bad anxiety,

and I was fighting it at first,” said Anthony, the Iraq

veteran, who patrolled southwest of Baghdad in 2006

and 2007 amid relentless insurgent harassment and

attacks with improvised explosive devices. “And then

— I don’t know how to put it, exactly — I felt O.K. and

messed up at the same time. Clear. It was almost like I

could go into any thought I wanted and fix it (Carey,

2012).

Anthony may have suppressed these feelings for years and was able to

discuss them after the MDMA treatment. There certainly appears to be a

relocation of anxiety and a replacement with the ability to have controlled

response.

208

There have been studies pertaining to marijuana abuse by

traumatized soldiers upon their return home. Bonn-Miller, Harris, &

Trafton (2012), in their study “Prevalence of cannabis use disorder

diagnoses among veterans in 2002, 2008, and 2009”, discussed that there

has been a 50% increase in cannabis use disorder (CUD) diagnoses (p.

411). There are many variables that factor into this increase including the

increased sensitivity of any substance abuse by veterans and veterans self-

reporting cannabis use indicating a need to address the habit (p. 411).

Recognizing that many veterans attempt to cope with the symptoms of

PTSD by using marijuana provided the impetus for a case study of the

evidence to support medical use of cannabis resin to treat PTSD symptoms

(Passie, Emrich, Karst, Brandt, & Halpern, 2012 p. 649).

Passie et al., (2012) also reference the use of marijuana self-

medication to alleviate symptoms of PTSD in adolescents, veterans, and

other sufferers (p. 649). There has been recent evidence that cannabis is

implicated in homeostatic cortical excitation and inhibition as well as

emotional homeostasis. In addition, there is growing evidence that there

are antidepressant and anxiolytic effects of the ingredients in cannabis

209

(Marco & Viveros, 2009; Marco et al., 2011 as cited by Passie et al., 2012

p. 650). Research has shown that the ingredient THC in marijuana acts as a

dimmer switch pertaining to excitability, inhibition, and the receptors in the

brain that control response to stimuli (Wilson & Nicoli, 2002; Leweke &

Koethe, 2008 as cited by Passie et al., 2012, p. 651).

The case study concludes that the individual with grave PTSD

symptoms had relief from the use of marijuana. In addition the authors

state that conditioned fear altering, memory systems, general central

nervous system arousal, mood and sleep impacted by the chemical

properties of marijuana may hold potential treatment for the complex

pathogenesis of PTSD Parolaro, Realini, Vigano, Guidadi, & Rubino,

2010; as cited by Passie et al., 2012).

At the Patients Out of Time conference in 2012, Mordechai

Mashiash presented his study: “Medical Cannabis as Treatment for Chronic

Combat PTSD”. Mashiash stated that out of 8,000 patients with PTSD,

currently there are 200 receiving cannabis as treatment. Mashiash

performed a study of 29 soldier subjects diagnosed with PTSD by virtue of

standard assessments including the CAPS interview. Subjects were

210

directed to smoke marijuana daily during treatment at an undesignated

amount “until they felt comfortable”. The 29 subjects started the study, 26

completed the second CAPS, 25 completed the third CAPS and 10

completed the final CAPS. Mashiash presented that the medical use of

marijuana, as indicated by the second CAPS interview, was associated with

reduction of PTSD symptoms in his open-label pilot study, larger

controlled studies are warranted, and that after varying intervals of time

after the study patients still had moderate to severe PTSD. Mashiash

contends that marijuana can be an effective part of holistic care treatment

in clinics (Mashiash, 2012)

The use of MDMA and marijuana as either an aide to therapy or as a

means to alleviate the symptoms of PTSD in combat exposed veterans

seems antithetical to offering assistance to treat the often comorbid

appearance of substance abuse in PTSD sufferers. In our desperation to

assist the unfortunate service members, we are turning to mind altering

chemicals that are controlled and providing licensure for experimentation.

In the support of the use of MDMA, the study cites the failure of at least

25-50% of those veterans involved in traditional SSRI and therapy

211

(Milhoefer et al., 2010 p. 440). That also translates to an arguably

significant success rate. The resurgence of the possible benefits of

“psychedelics” to therapy is a hindrance on continuing research to

formalize healthy approaches to alleviate the symptoms of PTSD and

smoking marijuana appears to dull just about everything for the user. I do

not believe we would suggest having a strong drink to a veteran struggling

with PTSD symptoms. If there are chemicals that are available in MDMA

and marijuana that may provide assistance in therapy, use technology to

separate them out, thoroughly research the physical and mental deleterious

effects and rename the product to remove the thought of using the

properties of illegal drugs to remedy PTSD.

Social Networking/Internet

The age of the internet has provided means of communication that

never existed before. If our culture, traditions, and communities were

about compassion, the internet would have been developed with the

thought of helping others. There are an excessive amount of interests,

prurient and otherwise, that prove the opposite to be true. The symptoms

of PTSD, hyperarousal, avoidance and isolation are not readily responded

212

to by the use of social networking and the internet or may be the ideal

condition to utilize the internet if the appropriate security measures are

taken. (Knaevelsrud & Maercker, 2007 p. 2) In fact, there may be a great

deal of skepticism in trusting “Big Brother”. The internet is also a breeding

ground for addiction and a sense of paranoia largely generated by the

media hype. However, studies have been conducted with favorable results

in the treatment of PTSD and as a valid predictor of face to face therapy

(Knaevelsrud & Maercker, 2007 p.9). Prior to investing in internet options

there should be extensive planning and developing fool proof methods of

appropriate access involved governance and clinical participation.

In terms of the population of victims of child abuse, technological

advancements appear to be improving how we address potential child

abuse cases and ensuing removals from home. For veterans with PTSD,

there appears to be numerous resources available to address PTSD. Both

populations have extreme vulnerability and will seek assistance by any

means that appear safe, stable and that create a sense of belonging.

However, in this day and age there is also a population of exploiters ready

to take advantage. In an ideal environment this may be a tool that can

213

assist a veteran in “getting to therapy”. You cannot replace the human

contact of therapy and skill building towards rewarding friendships

considerate of attachment issues and reestablishment.

One example that illustrates this point is Restore Warriors, a website

for soldiers living with the complications of PTSD and depression. There

are tools and strategies to develop coping skills through exposure, peer

interaction and attempt to self-assess. Restore Warriors has licensed

videotapes of soldiers offering their experiences. The Warriors currently

on the website are struggling with PTSD and other problems. There are

highly charged personal disclosures and this is viewed as therapeutic for

the subject and the audience (Wounded Warrior Project; Restore Warriors,

2013).

The Navy as also introduced a program for PTSD. The Office of

Naval Research (ONR) has developed a website application that educates a

marine or sailor with the Stress Resilience Training System (SRTS).

According to Military.com (2013), the system that is set up as a game to

assist in developing appropriate response to stimuli via biofeedback and

your physiological and mental status. This is being piloted at the Combat

214

and Operational Stress Control (NCCOSC) currently. “Fit for Duty” and

“prepare, perform and recover” are the slogans used on the SRTS site

seemed to get you back on duty.

� Know How: wealth of information about stress and resilience.

� Techniques: introduces the coherence advantage training

program and producing best physiological mental state for

building resilience and performing your best.

� Immersions: games that are driven by the coherence of your

own physiology.

� Review: observe progress and understand areas for needed

improvement.

Physiological measurements are taken and a plan is generated to improve

both mental and physiological states and master the ability to succeed.

The presentation of the components is harsh and direct. There is no

mention, other than the reference to video games, about how this will be

provided (Military.Com, 2013).

215

There are resources available and centralized by the Veterans

Administration which maintains a directory of services and information.

The National Center for PTSD is promoted as the “center of excellence for

research and education on the prevention, understanding and treatment of

PTDS” (Department of Veterans Affairs, 2013). There is no direct clinical

care; however, the mission is stated as the health and well-being of trauma

victims; particularly veterans. The website is featuring June as PTSD

Awareness Month as designated by an act of Congress. The National

Center does have a page that has many resources that appear neutral. There

is a menu of information, publications for printing, education and

miscellaneous offerings. There is an opportunity for veterans to share

stories, solicit media and public support and belong. (Department of

Veterans Affairs, 2013)

When it comes to discussing social networking, the internet and

assisting victims of child abuse, today’s technology lays claim to the dearth

of values in society rather than helping the vulnerable. It appears that the

internet is a breeding ground for exploitation of children and other

populations rather than using a powerful communication tool for the

216

prevention of child abuse and the benefit of child abuse victims. In their

article, Internet-Facilitated Commercial Sexual Exploitation of Children:

Findings From a National Representative Sample of Law Enforcement

Agencies in the United States, Mitchell, Jones, Finklehor & Wolak (2011)

cite many studies in listing the main types of internet cries as offenders

meeting victims on line, technology-facilitated child sexual exploitation, by

family members and acquaintances of victims, child pornography

production, possession and distribution. (Wolak, Finkelhor, & Mitchell,

2004, 2005,a, b, 2009, a, b Wolak, Finkelhor, Mitchell, & Ybarra, 2008 as

cited by Mitchell, Jones, Finkelhor, & Wolak, 2011 p. 46)There are several

agencies not for profit and for profit that promotes child safety and

advocacy. There is difficulty in trusting the media hype for families that

must answer to investigating entities that utilize the equipment to file

reports, access is difficult to come by virtue of cost of personal equipment,

and there is a certain amount of wherewithal that comes with the use of

technology and being “tech savvy”. The hope for this area of proactive and

preventive measures against child abuse is for the computer systems

involved in child welfare and involved in the continuity of care for children

217

and families use an “interface” to communicate and share valuable

information.

Cases involving child abuse and removal to foster care take on a

naturally nomadic tendency and the ability to have information follows the

child pertaining to their specific needs and plans is critical. In New York

State there are emerging examples of these systems. One example is

“Justice for Children”, an advocacy website that provides services such as

pro-bono legal advocacy and public policy monitoring. There is guidance

offered through the complexities of Child Protective Services, professional

referrals, mental health services, court watch, research, education and

emotional support (Justice for Children, 2013) there is also “The Innocent

Justice Foundation”, (IJF) a 501(c) (3) charitable organization that boasts

of technology solutions able to attempt to rescue millions of sexually

abused children circumventing future abuse. IJF takes referrals from law

enforcement waging battles “the front lines” pledging to protect innocents,

give justice to the abused, and removes predators from the street. IJF also

educates communities as a means of protecting children from predators. It

has partnered with the Department of Justice’s Office of Juvenile Justice

218

and Delinquency Prevention (OJJDP) five Internet Crimes Against

Children (ICAC) task force commanders and a mental health expert to

establish a training program. The training is entitled Supporting Heroes in

Mental Health Foundational Training (SHIFT). There are many

components ranging from handling the disturbing imagery to finding

clinical resources. (Innocent Justice, 2013)

Currently in New York State there are many changes underway to

provide and share information on specific cases relative to potential and

active child abuse cases. The informational system of Child Welfare in the

Office of Children and Family Services is called Connections (CONNX).

Information and Technology are attempting to create interfaces that would

allow case planners to see the all-inclusive history of the child from

medical visits, medications (Child’s Passport), and child protective services

involvement. Family Assessment Response (FAR) is an alternative

response to reports of child maltreatment by engaging families in an

assessment of child safety. Healthy Families New York is modeled after

Healthy Families America and is a community-based prevention program

seeking to improve the health and well-being of children by providing in

219

home visits and necessary services. HFNY produced sustained effects on

harmful parenting practices. Based on mothers’ reports of parenting

practices, HFNY generated... an 88% reduction in the average # of acts of

very serious physical abuse - Age 1, a 75% reduction in the average # of

acts of serious physical abuse - Age 2, an 80% reduction in the average # of

acts of serious physical abuse - Age 7. (Office of Children and Family

Services, 2013)

A Study

In terms of a study pertaining to the use of the internet to conduct

therapy or “interapy” on line, Knaevelsrud & Maercker (2007) examined

ninety-six patients with PTSD. Patients were randomly assigned to internet

based sessions of cognitive behavioral therapy (CBT) over a five week

period. The remainder was placed in a wait list control group.

Measurements were taken on severity of PTSD, level of depression,

anxiety, dissociation, and physical health immediately following the

treatment. Three months following the completion of the therapy

measurements were taken again. The authors contended that PTSD

sufferers would welcome treatment on line due to the three main symptoms

220

of PTSD in addition to, the shame and guilt, and self-imposed isolation.

The internet potentially provided an environment where there are internal

controls for level of involvement and degree of sharing (p. 2). Patients

were assigned to two weekly 45 minute writing assignments over a five

week period. The three treatment phases conducted on-line were: 1) Self

confrontation, 2) Cognitive restructuring, and 3) Social Sharing and a

farewell ritual. (p. 3) Patients, upon completion of the interapy, largely

reported that the treatment was comfortable, and also reported positive

attitudes to receiving interapy as opposed to traditional in office therapy.

Patients also reported not missing the face to face communication with a

therapist. There were positive results pertaining to the reduction of the

symptoms of PTSD and mental health improved. There were similar

results in the control group. These improvements were noted again at the 3

month mark after treatment (Knaevelsrud & Maercker 2007 p. 8). The

authors of the study compared these results with a different study of the

same nature from another country and found results to be the same (Lange

et al., 2003 as cited by Knaevelsrud & Maercker 2007 p. 8). The overall

results were positive regarding the symptom reduction and the working

relationship (“alliance”) between the therapist and the client. There were

221

limitations of the study including, strict exclusionary criteria limiting

generability, questionnaires used to assess factors were not developed for

an internet experience, and the lack of a placebo control group allowing for

a comparison at three months after treatment due to the unethical practice

of withholding treatment from the control group (Knaevelsrud & Maercker

2007 p. 9). The authors support additional research on interapy due to the

cost savings in provision of the service of the milieu, despite the question

that remains about the development of the therapeutic relationship. In

addition, the means of integrating the interapy with face to face counseling

merits further study for effectiveness. (Knaevelsrud & Maercker 2007 p. 9)

Psychopharmacology

Currently the FDA approves sertraline and paroxetine (Zoloft and

Prozac) as prescribed drugs for treatment of PTSD for adults. Studies

indicate that the psychiatric drugs are best to be used in conjunction with

therapy. The combination of CBT and either psychiatric drug appear to be

the choice of prescribing psychotherapists. The effectiveness of the

medications is only as strong as the psychotherapy protocols and delivery

(Steckler and Risbrough, 2012 p. 623). This requires follow up, planning

222

and continuity of care relative to cost management of the prescriptions and

provision of therapy. The use of stimulants for the treatment of ADHD

prescribed drugs approved for children. The annual rate of psychiatric

medication for children in the U.S. is 6.7 % compared to 2% in Germany

(Zito et al., 2008 as cited by Alavi & Calleja 2012 p. 78). The FDA (2009

as cited by Alavi & Calleja 2012 p. 78) reported that more than 500,000

children and adolescents are taking antipsychotic drugs.

This is an alarming practice with undesirable side effects that may be

creating unwarranted issues with children e.g., obesity. (Alavi & Calleja p.

85) Prior to initiating any such treatment of children or adults, for behavior

management especially, all means of therapy and intervention should be

exhausted. There are going to be cases that merit adventuring into various

classes of psychiatric drugs. They should be the minority and working

towards a goal of not needing medication. Unfortunately they are

becoming the norm and the market is not being driven by patient need.

Controls need to be in place on pharmaceutical companies, the FDA, and

physicians to assure that the patient is the priority not the pills.

223

In Closing

Innovation and inventiveness breeds investment with both populations and

can produce a sense of optimism and success. Newer interventions, despite

lacking thorough examination, are creating opportunities for those with

PTSD to experience reduction in symptoms, being part of something, and

success. EMDR with children seems effective and creative and is rerouting

memory. Creative means of self-expression in the form of art and music

both allow for dialogue that manifests comfort levels by virtue of the

products and generated discussion. Gamesmanship also fosters an air of

“we are all in this together” and leads to productive interaction which in

and of itself is a positive outcome. Canine companions arguably fill many

voids created by the symptoms for PTSD. Study limitations and resource

availability make the reality of innovation very difficult considering the

large populations of victims. However, the expenses currently being

generated by the inconsistent means of providing desperately needed

assistance is an argument for the continued funding of novel approaches.

The ideal situation appears to be to land on an individual and group

interventions by treatment plan, deliver that intervention consistently, and

224

measure for effectiveness, outcomes, and the homogenous groupings of

those deemed to attend specific interventions. For follow up and continued

engagement the innovative ideas would serve as ideal complements to the

therapy chosen by plan and as a choice for the patient. The need to be part

of something should be reinforced by any means necessary for extended

time frames and potentially lifelong.

225

Conclusion/Discussion

According to U.S. Department of Health and Human Services

Administration for Children and Families (2011, 2012), child maltreatment

is a global public health problem. In the United States alone,

approximately 6.2 million children were involved in 3.4 million referrals to

Child Protective Services (CPS) in Fiscal Year 2011. It is not clear how

many of the substantiated cases resulted in a diagnosis of PTSD. In

Science Daily(2013), it was noted that approximately 20% of the 1.7

million men and women who have served in the wars in Iraq and

Afghanistan, have PTSD. That equates to over 340,000 soldiers. The

estimated cost of treating these veterans in the US, considering the fact that

there is no civilian national health service for veterans, is between $600

billion and $1 trillion (Blimes, 2011 as cited by Howell, 2012 p. 221). The

costs are overwhelming, matching defense budgets, and both populations,

veterans and children subjected to abuse, equaling small countries in

numbers.

The daunting volume and potential diagnoses outweigh the resources

available to accurately provide services and current services do leave

something to be desired. Engagement, fruitful assessment, and consistent

226

treatment of traumatized individuals, proceeded by getting them to a safe

place physically and mentally, prior to initiating any treatment is key.

Van der Kolk (2013), authority on PTSD and treatment, in an interview

stated:

I have been surprised that something that is not central

to our pursuit of effective treatments: learning to

regulate your autonomic arousal system is maybe the

single most important prerequisite to dealing with

PTSD (p. 520)

As a society, there have been an abundance of studies and intense

explorations of how to manage the behavior and the pathology of those

afflicted with PTSD. There seems to be a trend in moving to trials with no

concern for other trials and largely focusing on perceived specialties.

Currently the limitations of studies are consistently single trials, testing

unique therapies that mimic other interventions in some ways. There are

wait-list and consequential control groups, as opposed to comparison of

evidence based interventions. There is poor reporting of the drop-out

rationale and follow through, diverse diagnoses within the treatment group

227

and inconsistent metrics for outcome measurements. There is not enough

consistency to make a sound judgment (Goldman et al., 2013 p. 148).

There is no doubt that the efforts of countless mental health

professionals are valid, strenuous and matched with an equally strong

population of sufferers. Discussing the plight of veterans and the

unmanageable children reeling from a single traumatic incident or series of

incidents does provide a mask for the horrors of war and the perpetrated

abuse. The question of “now what do we do?” creates discussion and

advocacy with an intentional misaligned focus steering away from causal

relationships. That does not minimize complex PTSD, the symptoms, and

the comorbid conditions associated with it. The smokescreen of mental

health conditions that require treatment or “fixing” does not hide the fact,

for example, that victims of child abuse migrate to the military.

In her article “The Demise of PTSD: From Governing to Resilience”

Howell (2012) argues that the PTSD diagnoses has worn out its welcome

and utility in disguising reality and is trending towards the notion of

resilience. Howell contends that:

228

Treating trauma as a medical problem has meant that it is

approached as something to be cured, safely sequestering the

experiences of, for example, war, in the private realm, and

removing them from political scrutiny and action. The

diagnosis became a way of managing traumatic memory,

rendering it pathological and subject to cure and demanding

that those diagnosed with the disorder seek the assistance of

therapeutic interventions in order to govern their interior lives,

and their behavior. All this has been explored in a number of

excellent works on the topic (p. 216).

She goes on to reference several examples of military programs that are

being initiated to instill resilience such as the Australian Defense Forces

“Project Laser” (a longitudinal study evaluating resilience),

“BattleSMART”(self-management and resilience training) both aimed at

improving the resilience of their personnel (p. 218). Howell also mentions

the evolving terms that accompany the atrocities of war and how it is

straying from PTSD. The Canadians use “Operational Stress Injuries” the

British:”Combat Stress Injuries”; and the Americans: “Psychological

229

injuries” and the issue of traumatic brain injuries increase the sway towards

physical and away from psychological (p. 222). Apparently, according to

Howell, the political edge of using a PTSD diagnoses as a subterfuge for

most wars and somewhat for child abuse is succumbing to developing

resilience as a response or new veil for the masses (p. 224).

The notion of “marketing” mental health issues to distract from war

and from child abuse is particularly nauseating given my experience with

the diverse adolescent product reeling with fear, avoiding new experiences,

and watching every single move of everyone around them. Many of these

marketable youth had seen egregious acts of violence, forced to commit

acts of violence or sex to be included in gangs, and often times beaten by

their caregivers. By the time they arrived at my door, they had been

indoctrinated into the juvenile justice system and re-traumatized by staff

and other youth. The struggle becomes behavior management leading to

medication for some, eventual placement outside of the home if necessary,

and trying to recoup a fractured education. We seldom discuss the causes,

the disproportionate representation of minorities, and poverty, and on a

larger scale the issue is “what do we do now?” Again the parallels for

230

child abuse victims and combat veterans are blatantly obvious and a “bill of

goods” for politicians, health care professionals and institutions.

There may be some truth to Howell’s assertion of moving away from

the diagnoses of PTSD, however, it may be based upon cost, the inability to

provide services that work, and the overall confounding generational

impact on society. Sadly, and in the political scheme of things we delve

into a “soup du jour” means of presenting interventions or add new

programming in the mix. Van der Kolk (2013) sums up the PTSD

treatment efforts as follows:

When you look at the data, they are by and large,

disappointing. There typically is a 25%-30% drop in

symptoms, maybe slightly better than � ��� ��� ����

when we give people placebo pills. The question is: Are

our patients really getting better, or do they just meet

the statistical cutoff for improvement? Until your

patient says to you, “It’s over and I feel fully alive now”

and is joyously engaged in the present, nobody should

claim victory. (p. 521)

231

All variables considered in today’s world most thinking is backward

and archaic. The war to be fought begins with an impossible task of ending

inhumane war, taking the “combat” to the streets to educate youth and their

families, and provide proactive services to deter violence and minimize

trauma. Marketing health and well-being in a real sense would pay

dividends relative to what is being paid now in social services to establish

sustenance resulting in dependence. Legislation is necessary that would

govern funding, requests for proposals to develop programs, and minimum

expectations of research and studies that have strength, consistent control

groups, and measurable outcomes. Included in the language of drafted bills

must be for acute follow through, continuity of care, and “after care”. At

the projected cost of treatment, there could be investments made in the

future of children and soldiers by developing skills and furthering

education.

There is a host of interventions, and it appears that TF CBT is

garnering the most support. There is an opportunity at triage of any case, be

it the returning soldier or the child that has been abused, that safety can be

the mandatory message and treatment will begin in slow measured steps.

232

Individual counseling can be used to assess and establish a plan that

includes being prepared for group. The instrument used for assessment

must be consistent with clear evidential support. Given the status of

today’s disasters both manmade and natural, violent confrontation in many

nations, and the continued violation of children, there is room for a global

approach to PTSD and identified treatment appropriate to the diagnoses

and valid instruments to measure outcomes. The information gathered

must be accurate and entered in a system that travels with the individual,

family and friends must be identified and incorporated in the treatment plan

and as a major support for an individual that is drained by their affliction

caused at the hands of another.

Both populations have so much in common that it is extremely sad to

think that they are the underbelly of society. This image represents a

vulnerable population with a distorted view of life removed so far from

“how it ought to be”. Soldiers are ordered to perform unconscionable acts

of torturous harm and fatalities to another human being or stand by and be

directly responsible for protecting others from random explosive devices or

be traumatically injured trying to do so. A child can look up from the floor

233

from where he or she had been knocked down countless times, raped, or

ignored by someone that is around for family gatherings or a complete

stranger. We have all the advances of science and technology, the latest in

medical treatments with appreciated results in that form of combat, and a

sports and entertainment world where a million dollars is minimum wage.

How can we stand by as a country where we send men and women to die

for that country and if they make it back allow their experience to get to the

point where 22 a day take their life anyway because it is just that much

easier to die?

Children that are abused want so much to be included that they join

the military service in high percentages only to place their traumatized life

back in harm’s way just to create a sense of belonging. The armor that

goes on starts with the initial trauma and ensuing PTSD diagnoses. The

screaming child and the destitute veteran are silent and perhaps the same

person; however, the President, First Lady, and Second Lady have all

voiced support for our troops. We stand ashamed at what is allowed to

happen to children time and time again and expect to not mar the future of

this nation. The notion of political camouflage applied to both populations

234

does not disprove anything but the lack of compassion for survivors that

need resources.

There needs to be a sense of compassion and love that welcomes

soldiers and damaged children and begin their life anew with hope,

understanding and a chance to breathe. Years are deducted from these

lives based on their trauma, emerging co-morbid issues, and the stressors of

the three symptoms mentioned time and again in this Thesis. There is

strong support that once there is engagement there is always a percentage

of success. Creating attachment where these vulnerable populations have

experienced the opposite in turns creates the means by which we heed these

needs and simply provide services for the rest of their lives.

In terms of technology and the use of the internet for a resource for

these populations, we must address the shortcomings of the face to face

approach to claim valid expertise to do so at a distance. There is a great

potential for continued victimization to populations that are traumatized

and victimized already. There must be support for safety and security of

these individuals, when technology is considered. There is tremendous

potential of using technology for neutral image creation that sparks

235

memories and conversation, a network of like victims to get through tough

times, and clinically guided interventions as a preparatory for live face to

face individual and group therapy. As a society, we will not prioritize this

effort instead opting for YouTube coverage of zoo animal’s doing weird

things at zoos. The media covers homecomings of soldiers that is joyous

and ends at the airport where they step on the ground. We can use our

current technology for these soldiers, children and their families to create a

new and exciting environment that allows for interaction, creativity, and is

solely for the diagnosed and as continuing treatment.

We have come so far in so many things. There are two constants

that have sustained over time and progress is not accurately measured.

Dating back from Society for the Prevention of Cruelty to Children to

Child Protective Services to PTSD Soldier’s heart to Combat Fatigue to

Shell Shock to PTSD and we have ongoing populations with potential

diagnoses of PTSD and quite possibly a means of keeping our mind off

things. In any case, I have returned to the beginning and there is little hope

of an end.

236

EPILOGUE

Reed: A Case Study

Reed was born in 1931 in Kew Garden, Queens, New York. His

parents were Reed Sr. and Gladys. Reed recounted his earliest memory

seeing three maternal generations; great grandmother, grandmother, and

mother in the Memorial Day parade. His recall of the memory included the

fact that all three were stumbling drunk; the eldest being in a wheelchair.

Reed Sr. spent an inordinate amount of time on the road with work. Gladys

came from a long line of wealth and alcoholics and she was not about to

stop the trend. Her drinking became an issue to the point where all alcohol

and money were removed from the home when Reed Sr. was away on

business. Reed had a younger sibling; Barton. Not much is known about

Barton other than the fact that he was also alcoholic. When Reed Sr. left

on business Gladys took to prostitution and various “Johns” to supply

money and alcohol.

It was during these times that Reed Jr., approximately at age 6, was

chained to a table to view his mother’s exchanges with various men, would

be beaten when making a sound, and would be inappropriately exposed to

sexual acts and contact. It was not easy for Reed Jr. to recount these

237

incidents and there were some he would not dare discuss particularly when

it came to Barton. This went on until Gladys was removed entirely from

the home some years later. Gladys was excommunicated from the family,

allegedly dying in the street and buried in an unmarked grave. One

Christmas Eve, Reed witnessed his father, at the age of 47, die of a massive

coronary. Reed explained that his father worked himself to death. The

then 17 year old Reed, graduated from Roosevelt High School with a letter

in baseball and basketball; and an orphan. Reed was able to move in with a

couple which was close to the family.

Reed had a stint as a semi-pro baseball player, attempted to attend

New York University, and worked at a Chess Magazine and Club in the

popular Village in New York City. No longer able to afford tuition, Reed

drifted towards the military. He enlisted in the Navy just in time for the

Korean War. In the Navy, he became a teletype operator on the U.S.S.

Oklahoma. Reed told horrible stories of the Korean War, going through

villages where there were piles of corpses being burned, homes destroyed,

and brutal combat. In an exchange of artillery and mortar and advancing

from one trench to the next; Reed was seriously wounded. He was hit with

238

shrapnel in the neck and wrist and remembers losing consciousness but not

before being hit with the organs of his friend, dating back from semi-pro

baseball, and he had literally been blown to bits. Reed spent the next year

of his life in the hospital. He blatantly refused any VA benefits, swore off

religion, and participated in anti-war protests during Viet Nam.

Reed returned home following the war and rehabilitation to reside

with his deceased father’s paramour and initially worked for ITT as a

teletype operator. He was estranged from his brother, expressing

resentment over bearing most of the responsibility of raising him and his

brother returned the resentment. Both had wicked stories they never

wanted to share which seemed to be the bigger issue. Reed later married

and had a son and nine years later a daughter.

I am Reed Hoeg’s son.

Reed Hoeg was the kind of father a young boy adored. He was

shockingly athletic with high expectations, loved adventure and risk taking,

and would often be whistling and singing. He had a joie de vivre that was

unbelievable. I remember watching him disappear into the ocean

swimming in rough water before a raging storm only to return as if it were

239

nothing. He was a functional alcoholic and did the best he could to be the

opposite of what he experienced. This did not always work out quite that

well. Reed liked to share alcohol with his 6 year old son, laughing at the

results, and when I was 12 years of age we brown bagged canned cocktails

in the park.

My father walked everywhere and rarely slept. He would walk to

work from Brooklyn to Manhattan, approximately 4 miles, leaving home at

3AM in the morning. On weekends there was no time to rest as we rode

bikes all over the place, attended street fairs and carnivals, and went to

every revival of old movies offered. I do not remember down time and I

loved the films. One of his favorite walks would include a stop at a police

precinct in Manhattan when the “ladies of the evening” would be released

having been arrested from the night before. I just thought they were nice

and didn’t belong in jail. At least that was what I was told. He routinely

would take me to movies that were “R” rated and elbow me during

lovemaking scenes and joke that “they were wrestling”. Reed broke a

man’s wrist in Times Square when he attempted to pick his pocket and was

sore with me for not being cognizant of the fact. He would say “… a

240

drama unfolds at every corner…..pay attention”. In terms of discipline

there was not much and he never lifted a hand to me. If he talked to you in

a low serious tone you could literally relieve yourself, hope for a beating,

feeling that would be better. I made the mistake, only once, of telling him

“not to worry”. He scared me to death and told me to never tell him that.

”Never!” Apparently that was all he ever did. He never once ever said that

he loved me.

His attitude towards sex was strange. In addition to his “impromptu”

visits to the hooker release show, he had an affinity for pornography, took

photographs of his family nude once, and was quick to point out naked men

sun bathing in Coney Island visible from the famous Ferris Wheel; the

Wonder Wheel. He urinated on me once in the shower area at a public

beach thinking it was funny. This all was presented as normal to a child

that worshipped the ground he walked on.

Our family fell apart when I was 15. This served as devastation in

Reed’s life, shattering his attempt at raising a family and being loved. He

left for Connecticut with his job and my sister and I saw him on Sundays.

I really never lived at home again consistently. I couch surfed, shacked up

241

with girlfriends, and stayed away from my home. My mother is an entirely

different story. I felt horrible about my sister, who lived a life of neglect

and maltreatment. Reed eventually met a woman that was divorced and

wealthy and lived in a virtual castle relative to the squalor his children were

expected to live. This really did not speak well to his qualities of being a

father.

Years later when I began a family of my own we reconnected. He

was a proud Dad as far as my achievements; including my wonderful wife

and children. His health was catching up with him as was his love of

scotch, and his paramour began to deteriorate due to Alzheimer’s. As he

took care of his partner he would discuss devotion as the reason to keep on.

I asked if he would like me to find Barton; his brother. He said yes behind

tears. I found Barton to be deceased and never told him. As we were about

to visit him one weekend we received a call that at age 71 he was receiving

CPR and ultimately passed. We were heading his way to have him sign

papers relative to his marital situation having never divorced my mother

and his paramour was about to be put in an institution. He bailed. He was

242

never afraid to die instead spending his time worrying about everything but

his health.

There are more stories, good and bad. I certainly have my demons,

none of them exorcised completely. Reed had PTSD; self-medicated with

alcohol, and created his own therapy in his love of reading, theater, film,

and song. Reed never missed a day’s work in 40 years. He imparted a huge

passion for sports, the same love of entertainment to his son and a durable

work ethic. I am hyperaware of all things and I have never struck my

children or peed on them. I am a cancer survivor, possibly due to possible

exposure to HPV earlier in life, largely due to alcoholism, and have a

tremendous gift with children. I know where they come from. I was

traumatized terribly when Reed left my life and that gave me the ability to

incorporate that memory and think like that 15 year old boy when I needed

to reach a child that was frightened.

My father’s experience generated my passion for this thesis. With

all of his faults and terribly inappropriate eccentricities he desperately

sought to belong to something; a family. He was afraid of loss and had

everything taken from him more than twice. I wonder what he wanted to

243

tell Barton, and I could not tell him he had died four years earlier from

cirrhosis. He took me and three of my friends on a 300 mile round trip

bike ride with the consent and trust of their parents. It was on that bike trip

that we observed him place a man in the dumpster of a hotel for slapping

his daughter for playing in a puddle. I was in awe of this man and my

friends thought he was a super hero. He provided as much as he could and

when my mother called it quits, he was devastated. He was not off the

hook as a parent but he threw in the towel. I was pleased to have time with

him later in life, enjoy many gifts that he provided to me, and I dedicate

this effort to him. Reed Hoeg would have scoffed at the notion of needing

assistance and intervention, instead noting the problems of minorities and

the poor. He sorely needed to know he was not alone and would have

benefited from sharing with peers. He was a victim of severe child abuse, a

wounded combat veteran that had PTSD and he died too young.

“Don’t worry Dad”…….I loved you!

244

References

20th Century Fox (Producer), Altman, R. (Director). (1970)

M*A*S*H* (Motion Picture) USA: 20th Century Fox

Aderka, I. M., Appelbaum-Namdar, E., Shafran, N., & Gilboa-

Schechtman, E. (2011). Sudden gains in prolonged

exposure for children and adolescents with

posttraumatic stress disorder. Journal Of Consulting

And Clinical Psychology, 79(4), 441-446.

doi:10.1037/a0024112

Adler, A. B., Bliese, P. D., McGurk, D., Hoge, C. W., &

Castro, C. (2011). Battlemind debriefing and battlemind

training as early interventions with soldiers returning

from Iraq: Randomization by platoon. Sport, Exercise,

And Performance Psychology, 1(S), 66-83.

doi:10.1037/2157-3905.1.S.66

Ahmad, A. & Sundelin-Wahlsten, V. (2008). Applying EMDR

on children with PTSD. European Child & Adolescent

Psychiatry, 17(3), 127-132.

245

Ahrens, J. & Rexford, L. (2002). Cognitive processing therapy

for incarcerated adolescents with PTSD. Journal of

Aggression, Maltreatment & Trauma,6(1)201-216

American Psychiatric Association. (2000). Diagnosticand

statistical manual of mental disorders (Revised4th ed.).

Washington, DC: American Psychiatric

Association

American Psychiatric Association. (2004). Practice guideline

for the treatment of patients with acute stress disorder

and posttraumatic stress disorder. Arlington, VA:

American Psychiatric Association Practice Guidelines

Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D.,

Whitfield, C., Perry, B. D., et al. (2006). The enduring

effects of abuse and related adverse experiences in

childhood: A convergence of evidence from

neurobiology and epidemiology. European Archives of

Psychiatry and Clinical Neuroscience, 256(3), 174-186.

246

Anderson, C.M., Teicher, M.H., Polcari, A, Renshaw, P.I.

(2002) Abnormal T2 relaxation time in the cerebellar

vermis of adults sexually abused in childhood: potential

role of the vermis in stress-enhanced risk for drug

abuse. Psychoneuroendocrinology 27:231–244

Anthony, J. L., Lonigan, C. J., & Hecht, S. A. (1999).

Dimensionality of posttraumatic stress disorder

symptoms in children exposed to disaster: results from

confirmatory factor analyses. Journal of Abnormal

Psychology, 108, 326 – 336.

Arroyo, W. (2001). PTSD in Children and Adolescents in the

Juvenile Justice System Eth S (editor): PTSD in

Children and Adolescents (Review of Psychiatry Series,

Volume 20, Number 1; Oldham JM and Riba MB,

series editors). Washington, DC, American Psychiatric

Publishing, 2001

Asaf, G. & Powell, F., (1915) Pack up your troubles in your

old kit bag (Sheet Music). New York: Chappell & Co.

247

Avrahami, D. (2006) ‘Visual art therapy’s unique contribution

in the treatment of posttraumatic stress disorders’.

Journal of Trauma and Dissociation 6(4): 5–38.

Beckham, J. C., Moore, S. D., Feldman, M. E., Hertzberg, M.

A., Kirby, A. C., & Fairbank, J. A. (1998). Health

status, somatization, and severity of posttraumatic stress

disorder in Vietnam combat veterans with posttraumatic

stress disorder. American Journal of Psychiatry, 155,

1565-1569

Berkowitz, S. J., Stover, C., & Marans, S. R. (2011). The

Child and Family Traumatic Stress Intervention:

Secondary prevention for youth at risk of developing

PTSD. Journal Of Child Psychology &

Psychiatry, 52(6), 676-685. doi:10.1111/j.1469-

7610.2010.02321.x

248

Bernal & Scharron-Del-Rio(2001) Are empirically supported

treatmentsvalid for ethnic minorities? Toward an

alternative approach for treatment research. Cultural

Diversity and Ethnic Minority Psychology

Vol. 7, No. 4, 328–342

Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological

validity and cultural sensitivity for outcome research:

Issues for cultural adaptation and development of

psychosocial treatments with Hispanics. Journal of

Abnormal Child Psychology, 2367-82.

Black, P.J., Woodworth, M., Tremblay, M. & Carpenter, T.

(2012). A review of trauma informed treatment for

adolescents. Canadian Psychology/Psychologie

Canadienne, 53(3), 192-203. Doi:10.1037/a0028441

Bliese, P. D., Wright, K. M., Adler, A. B., Thomas, J. L., &

Hoge, C. W. (2007). Timing of postcombat mental

health assessments. Psychological Services,4, 141–148.

doi:10.1037/1541-1559.4.3.141

249

Blimes, L. (2011).Current and Projected Future Costs of

Caring for Veterans of the Iraq and Afghanistan Wars.

The Costs of War Report (Watson Institute for

International Studies, Brown University),

http://costsofwar.org/sites/default/files/articles/52/attach

ments/Bilmes%20Veterans%20Costs.pdf

Bonn-Miller, M. O., Harris, A. S., & Trafton, J. A. (2012).

Prevalence of cannabis use disorder diagnoses among

veterans in 2002, 2008, and 2009. Psychological

Services, 9(4), 404-416. doi:10.1037/a0027622

Bourne, Peter G. (1970) Men, Stress, and Vietnam. Boston:

Little, Brown,

Bremner JD (2003b) Does Stress Damage the Brain?

Understanding trauma-based disorders from a

neurological perspective. New York: Norton

250

Bremner JD, Southwick M, Darnell MA, Charney DS (1996b)

Chronic PTSD in Vietnam combat veterans: Course of

illness and substance abuse. American Journal of

Psychiatry 153:369–375

Bridges E., & Evers K (2009) Wartime critical care air

transport. Military Medicine 174(4): 370-5

Brillantes-Evangelista, G. (2013). An evaluation of visual arts

and poetry as therapeutic interventions with abused

adolescents. Arts in Psychotherapy, 40(1), 71-84.

doi:10.1016/j.aip.2012.11.005

Brown, C., Conner, K. O., Copeland, V. C., Grote, N., Beach,

S., Battista, D., & Reynolds, C. F., III. (2010).

Depression stigma, race, and treatment seeking behavior

and attitudes. Journal of Community Psychology,38,

350 –368. doi:10.1002/jcop.20368

Brown, E.J., (2003) Child physical abuse: Risk for

psychopathology and efficacy of interventions Current

Psychiatry Reports, 5 (2) (2003), pp. 87–94

251

Bryant, R.A., Creamer, M., O’Donell, M.,Silove, D.,

McFarlane, A. (2011).The capacity of acute stress

disorder to predict posttraumatic psychiatric disorders.

Journal Of Psychiatric Research, 46168-173.

Carey, B. (2012) A ‘party drug’ may help the brain cope with

trauma. New York Times. Retrieved at:

http://www.nytimes.com/2012/11/20/health/ecstasy-

treatment-for-post-traumatic-stress-shows-

promise.html?pagewanted=all&_r=0

Carleo-Evangeliste, J. & Brown, K. V. (2013, February 23)

Wrong Way Thruway Crash Kills 2. Albany New York

Times Union pp 1A, 8A.

Carrion VG, Steiner H (2000) Trauma and dissociation in

delinquent adolescents. Journal of American Academy

of Child Adolescent Psychiatry 39:

353–359

252

Carrion, V.G., Weems,S.E., Eliez, S., Patwardhan, A., Brown,

W., Ray R.D., Reiss A.L., (2001) Attenuation of frontal

asymmetry in pediatric posttraumatic stress disorder.

Society of Biological Psychiatry 50: 943-951

Casella, L. & Motta, R.W. (1990). Comparison of

characteristics of Vietnam veterans with and without

posttraumatic stress disorder. Psychological Reports,

67, 595-605.

Center for the Study of Social Policy & the Urban Institute.

(2009). Intentions and results: A look back at the

Adoption and Safe Families Act. Retrieved

from http://www.urban.org/UploadedPDF/1001351_saf

e_families_act.pdf (671 KB)

Chamberlin, S. M. E. (2012). Emasculated by trauma: A social

history of post-traumatic stress disorder, stigma, and

masculinity. Journal Of American Culture, 35(4), 358-

365. doi:10.1111/jacc.12005

253

Chan, D., Cheadle, A. D., Reiber, G., Unutzer, J., & Chaney,

E. F. (2009). Health care utilization and its costs for

depressed veterans with and without comorbid PTSD

symptoms. Psychiatric Services, 60, 1612-161

Chappell, B. (2013 January 14) U.S. Military's Suicide Rate

Surpassed Combat Deaths In 2012. the two way;

Breaking news from NPR. National Public Radio,

retrieved from:

http://www.npr.org/blogs/thetwo-

way/2013/01/14/169364733/u-s-militarys-suicide-rate-

surpassed-combat-deaths-in-2012

Charlton, M. (2006a). Dialectical behavior therapy for

children with developmental disabilities. National

Association for the Dually Diagnosed Bulletin, 9(5), 90-

93.

254

Chesnut RM, Marshall LF, Klauber MR, et a (1993) The role

of secondary brain injury in determining outcome from

severe head injury. Journal of Trauma 34(2): 216-22.

Child Welfare Watch (2013) Brushes with the law: Young

new yorkers and the criminal justice system. Volume 22

Winter/2012/2013

Chorpita, B. F., Taylor, A. A., Francis, S. E., Moffitt, C., &

Austin, A. A. (2004). Efficacy of modular cognitive

behavior therapy for childhood anxiety disorder.

Behavior Therapy, 35, 263–287. doi:10.1016/S0005-

7894(04)80039-X

Chu, J. A., & Dill, D. L. (1990). Dissociative symptoms in

relation to childhood physical and sexual abuse.

American Journal of Psychiatry, 147, 887-892.

Clausewitz, C., & Graham, J. J. (n.d). On War. Champaign,

Ill. [P.O. Box 2782, Champaign 61825]: Project

Gutenberg.

255

Cohen, J.A., Mannarino A.P. , Perel, J.M., Staron, V.,

(2007) A pilot randomized controlled trial of combined

trauma-focused CBT and sertraline for childhood PTSD

symptoms. Journal of the American Academy of Child

& Adolescent Psychiatry. Vol. 46, Issue 7, Pages 811-

819, DOI: 10.1097/chi.0b013e3180547105)

Cohen, J. A., & Mannarino, A. P. (1998). Factors that mediate

treatment outcome of sexually abused preschool

children: Six and 12 month follow-up. Journal of the

American Academy of Child and Adolescent Psychiatry,

37(1), 44–51.

Cohen, J. A., & Mannarino, A. P. (2000). Predictors of

treatment outcome in sexually abused children. Child

Abuse Neglect, 24(7), 983–994.

Cohen, J. A., and the American Academy of Child and

Adolescent Psychiatry Work Group on Quality Issues

(1998). Practice parameters for the assessment and

treatment of children and adolescents with

posttraumatic stress disorder. Journal of the American

256

Academy of Child and Adolescent Psychiatry, 37 (10

Supplement), 4S–26S.

The Congress of the United States (2010) The veterans health

administration’s treatment of PTSD and traumatic brain

injury among recent combat veterans. (Congressional

Budget Office Publication No. 4097) Washington, DC:

U.S. Government Printing Office.

Conradi, L., Kletzka, N. T., & Oliver T. (2010). A clinician’s

perspective on the trauma assessment pathway (TAP)

model: A case study of one clinician’s use of the TAP

model. Journal of Child & Adolescent Trauma, 3, 40-

57. doi: 10.1080/19361520903520450

Copeland, W., Keeler, G., Angold, A., & Costello, E. (2007).

Traumatic events and posttraumatic stress in childhood.

Archives of General Psychiatry, 64, 577-584

Couineau, A.-L., & Forbes, D. (2011, August 29). Using

Predictive Models of Behavior Change to Promote

Evidence-Based Treatment for PTSD. Psychological

257

Trauma: Theory, Research, Practice, and Policy.

Advance online publication. doi: 10.1037/a0024980

Courtney, M., Piliavin, I., Grogan–Kaylor, A., & Nesmith, A.

“Foster youth transitions to adulthood: A longitudinal

view of youth leaving care.” Child Welfare, vol. 80, no.

6, 2001, pp.685-715.

Cox, Lee (2004). Raised on Fear (Book) Retrieved October,

21, 2012 from:

http://www.amazon.com/Raised-Fear-Lee-

Cox/dp/0976613506

Crosby, A. E., Johnson, R. L.,... Chattopadhyay, S. K. (2008).

The effectiveness of interventions to reduce

psychological harm from traumatic events among

children and adolescents: A systematic review.

American Journal of Preventive Medicine, 35(3), 287–

313

258

Davis, J. J., Walter, K. H., Chard, K. M., Parkinson, R., &

Houston, W. S. (2013). Treatment adherence in

cognitive processing therapy for combat-related PTSD

with history of mild TBI. Rehabilitation

Psychology, 58(1), 36-42. doi:10.1037/a0031525

deArellano, M. A. & Danielson, C. K. (2005). Culturally-

Modified Trauma Focused Treatment. Unpublished

Manuscript, Medical University of South Carolina

De Bellis, M.D., Baum, A.S., Birmaher, B., Keshavan M.S.,

Eccard,C.H., Boring A.M., et al (1999): Developmental

traumatology: I. Biological Stress Systems. Biological

Psychiatry 45:1259–1270.

De Bellis MD, Lefter L, Trickett PK, Putnam FW Jr. 1994.

Urinary catecholamine excretion in sexually abused

girls. Journal of American Academy of Childhood and

Adolescent Psychiatry 33:320–327.

259

De Bellis M, D., & Thomas L (2003) Biologic findings of

post-traumatic stress disorder and child maltreatment.

Current Psychiatry Reports 5:108–117

Deblinger, E, Mannarino, AP, Cohen, JA, Runyon, M & Steer,

R (2011). Trauma-focused CBT for children: Impact of

the trauma narrative and treatment length. Depression

and Anxiety, 28, 67-75.

Department of Veterans Affairs (2013) National Center for

PTSD. Retrieved from http://www.ptsd.va.gov/

Deykin, E. Y., Keane, T. M., Kaloupek, D., Fincke, G.,

Rothendler, J., Siegfried, M., & Creamer, K. (2001).

Posttraumatic stress disorder and the use of health

services. Psychosomatic Medicine, 63, 835-841

260

Digitale, E., (2009), Brain imaging shows kids’ PTSD

symptoms linked to poor hippocampus function in

Stanford/Packard study. Retrieved from:

http://med.stanford.edu/ism/2009/december/carrion.html

Domes G, Heinrichs M, Michel A, Berger C and Herpertz SC

(2007) Oxytocin improves ‘‘mind-reading’’ in humans.

Biological Psychiatry 61: 731–733

Donga, E. (March 21, 2013) Advocates offer solutions to

combat veterans suicide. Rutland Herald .Retrieved

from

http://www.rutlandherald.com/article/20130321/NEWS

01/703219862

Dohrenwend, B. P., Turner, J. B., Turse, N. A.,Adams, B. G.,

Koenen, K. C., & Marshall, R. (2006). The

psychological risks of Vietnam for U.S. veterans: A

revisit with new data and methods. Science, 313, 979–

982. doi:10.1126/science .1128944

261

Dukes, S., Bridges, E., & Johantgen, M. (2013). Occurrence of

secondary insults of traumatic brain injury in patients

transported by critical care air transport teams from

Iraq/Afghanistan: 2003-2006. Military Medicine,

178(1), 11-17. doi:10.7205/MILMED-D-12-00177

Dumont, G., Sweep, F.C., van der Steen, R., Hermsen, R,

Donders, A.R., Touw, D.J. et al. (2009) Increased

oxytocin concentrations and prosocial feelings in

humans after ecstasy (3, 4-

methylenedioxymethamphetamine) administration.

Society for Neuroscience 4: 359–366

Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster,

K., Vasterling, J. J., Wagner, H., & Beckham, J. C.

(2012). Criminal justice involvement, trauma, and

negative affect in Iraq and Afghanistan war era

veterans. Journal Of Consulting And Clinical

Psychology, 80(6), 1097-1102. doi:10.1037/a0029967

262

Engel, C. C., Engle, A. L., Campbell, S. J., McFall, M. E.,

Russo, J., & Katon, W. (1993). Posttraumatic stress

disorder symptoms and precombat sexual and physical

abuse in Desert Storm veterans. Journal of Nervous and

Mental Disease, 181, 683–688

Englemann, T. (2007). Who are our fathers? Journal of

American History, 94 163-171

Feinstein, D. (2012). Acupoint stimulation in treating

psychological disorders: Evidence of efficacy. Review

Of General Psychology, 16(4), 364-380.

doi:10.1037/a0028602

Felitti V..J. Anda, R.F., Nordenberg, D., Williamson, D.F.,

Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S. The

relationship of adult health status to childhood abuse

and household dysfunction. American Journal of

Preventive Medicine, 14 (1998), pp. 245–258

Ferrete, C. (2013, February 23). Monitoring kids after trauma.

New York Newsday pp. 3

263

Field, A., & Cottrell, D. (2011). Eye movement

desensitization and reprocessing as a therapeutic

intervention for traumatized children and adolescents: a

systematic review of the evidence for family therapists.

Journal Of Family Therapy, 33(4), 374-388.

doi:10.1111/j.1467-6427.2011.00548.x

Figley, C. R. (2007, June 18). From Post Vietnam Syndrome

to Combat Stress Injuries: An historical overview of the

medicalization of combat stress reactions. Featured

presentation at the First Marine Corps

Combat/Operational Stress Control Conference,

Arlington, VA

Fletcher, K. (1996) Pro and con-EMDR for traumatized

children. Retrieved 24 February 2011 from

http://users.umassmed.edu/Kenneth.Fletcher/emdr.html

264

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of

fear: Exposure to corrective information. Psychological

Bulletin, 99, 20–35.

Foa, E. B., Rothbaum, B. O., Riggs, D., & Murdock, T.

(1991). Treatment of posttraumatic stress disorder in

rape victims: A comparison between cognitive-

behavioral procedures and counseling. Journal of

Consulting and Clinical Psychology, 59, 715–723.

Foa, E. Keane T.M, Friedman, M.J., Cohen, J (2009) Effective

Treatments for PTSD: Practice Guidelines from the

International Society for Traumatic Stress Studies The

Guilford Press New York, NY

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges

and Successes in Dissemination of Evidence-Based

Treatments for Posttraumatic Stress: Lessons Learned

From Prolonged Exposure Therapy for PTSD.

Psychological Science In The Public Interest (Sage

265

Publications Inc.), 14(2), 65-111.

Doi:10.1177/1529100612468841

Fontana, A., Spoonster-Schwartz, L., Rosenheck, R., (1997)

Posttraumatic Stress Disorder among Female Vietnam

Veterans: A Causal Model of Etiology American

Journal of Health, Vol. 87, No. 2 169-175

Ford, J. D., Mahoney, K., & Russo, E. (2003). Trauma

Adaptive Recovery Group Educationand Therapy (9

Session Version) Leader Guide and Participant

Handouts. Farmington, CT: Real Life Heroes Pilot

Study 21

University of Connecticut Health Center.

Ford, J. D., & Russo, E. (2006). A trauma-focused, present-

centered, emotional self-regulation approach to

integrated treatment for post-traumatic stress and

addiction: Trauma Adaptive Recovery Group Education

and Therapy (TARGET). American Journal of

Psychotherapy, 60(4), 335–355.

266

Frederico, M.M., Jackson A. L., & Black C. M. (2008).

Understanding the impact of abuse and neglect on

children and young people referred to a

therapeutic program. Journal Of Family Studies,

14(2/3), 342-361.

Fried, J.P. (1990 August 17) 5 Months Later, Youth Set Afire

Returns Home. New York Times

Fritch A.M., Mishkind M., Regerm M.A., Gahm G.A. (2010)

The impact of childhood abuse and combat-related

trauma on post deployment adjustment. Journal of

Traumatic Stress. 2010;23:248–254.

Frueh, B. C., Elhai, J. D., Gold, P. B., Monnier, J., Magruder,

K. M., Keane, T. M., & Arana, G. W. (2003). Disability

compensation seeking among veterans evaluated for

posttraumatic stress disorder. Psychiatric Services, 54,

84-91

267

Frueh, B. C., Grubaugh, A. L., Elhai, J. D., & Buckley, T. C.

(2007). US Department of Veterans Affairs disability

policies for posttraumatic stress disorder:

Administrative trends and implications for treatment,

rehabilitation, and research. American Journal of Public

Health, 97, 2143-2145

Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M.,

Marx, B. P., & Rosen, R. C. (2012). Posttraumatic

stress disorder in veterans and military personnel:

Epidemiology, screening, and case

recognition. Psychological Services, 9(4), 361-382.

doi:10.1037/a0027649

Giardino, A.P., Pataki, C., Harris, T.B.,Giardino, E.R.,

Berkowitz, C.D.,Windle, M.L.,Sylvester, C.(23 Aug

2011) Posttraumatic Stress Disorder due to child Abuse

and neglect. Medscape Reference Drugs, Diseases &

Procedures. Retrieved from:

http://emedicine.medscape.com/article/916007-clinical

268

Gillespie,C.F., Phifer,J., Bradley, B., &

Ressler,K.J. (2009).Risk and resilience:

�������������������������������������������������

of the stress response. Depression and Anxiety, 26.,

984–992.

Goldman Fraser J, Lloyd SW, Murphy RA, Crowson MM,

Casanueva C, Zolotor A, Coker-Schwimmer M,

Letourneau K, Gilbert A, Swinson Evans T, Crotty K,

Viswanathan M. Child Exposure to Trauma:

Comparative Effectiveness of Interventions Addressing

Maltreatment. Comparative Effectiveness Review No.

89. (Prepared by the RTIUNC Evidence-based Practice

Center under Contract No. 290-2007-10056-I.) AHRQ

Publication No. 13-EHC002-EF. Rockville, MD:

Agency for Healthcare Research and Quality. April

2013.

www.effectivehealthcare.ahrq.gov/reports/final.cfm.

269

Greeson, J. A. (2011). Complex Trauma and Mental Health in

Children and Adolescents Placed in Foster Care:

Findings from the National Child Traumatic Stress

Network. Child Welfare, 90(6), 91-108

Greeson, J. P., Briggs, E. C., Kisiel, C. L., Layne, C. M., Ake

III, G. S., Ko, S. J., & ... Fairbank, J. A. (2011).

Complex trauma and mental health in children and adolescents

placed in foster care: Findings from the national child

traumatic stress network. Child Welfare, 90(6), 91-108.

Griner, D., & Smith, T. B. (2006). Culturally adapted mental

health intervention: A meta-analytic review.

Psychotherapy: Theory, Research, Practice,

Training, 43(4), 531-548. doi:10.1037/0033-

3204.43.4.531

Grogan, S., & Murphy, K. (2011). Anticipatory Stress

Response in PTSD: Extreme Stress in Children. Journal

Of Child & Adolescent Psychiatric Nursing, 24(1), 58-

71. doi:10.1111/j.1744-6171.2010.00266.x

270

Grob C.S., Poland R.E., Chang, L. & Ernst, T. (1996)

Psychobiologic effects of 3,4-

methylenedioxymethamphetamine in humans:

methodological considerations and preliminary

observations. Behavioural Brain Research 73: 103–107

Grondahl, P.(2013 February 23) Leaving War but Not the

Memories. Albany New York Times Union pps. 1A, 8A

Gunning, M., (2003, April). Gabor Maté. January Magazine,

Retrieved from http://januarymagazine.com/index.html

Hankin, C. S., Spiro, A., Miller, D. R., & Kazis, L. (1999).

Mental disorders and mental health treatment among

U.S. Department of Veterans Affairs outpatients:

The Veterans Health Study. American Journal

of Psychiatry, 156, 1924-1930.

271

Harris D.S., Baggott, M., Mendelson, J. H, Mendelson, J.E. &

Jones R.T.(2002) Subjective and hormonal effects of

3,4-methylenedioxymethamphetamine (MDMA) in

humans. Psychopharmacology (Berlin) 162: 396–405

Hegadoren, K.M., & Lasiuk, G.C (2006). T

Posttraumatic Stress Disorder Part I:

Historical Development of the Concept. Perspectives in

Psychiatric Care Vol. 42, No. 1

Henry, S. (2012) Program helps veterans reintegrate through

music. Associated Press. Retrieved from:

http://bigstory.ap.org/article/program-helps-veterans-

reintegrate-through-music

Herbert, J., Lilienfeld, S. and Lohr, J. (2000) Science and

pseudoscience in the development of eye movement

desensitization and reprocessing: implications

for clinical psychology. Clinical Psychology Review,

20: 945–971

272

Hiley-Young, B., Blake, D. D., Abueg, F. R., Rozynko, V., &

Gusman, F. D. (1995). Warzone violence in Vietnam:

An examination of premilitary, military, and

postmilitary factors in PTSD in-patients. Journal of

Traumatic Stress, 8, 125–141

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D.,

Cotting, D. I., & Koffman, R. L. (2004). Combatduty in

Iraq and Afghanistan, mental health problems, and

barriers to care. New England Journal of Medicine, 351,

13–22. doi:10.1056/NEJMoa040603

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S.(2006).

Mental health problems, use of mental health services,

and attrition from military service after returning from

deployment to Iraq or Afghanistan. Journal of the

American Medical Association,295, 1023–1032.

doi:10.1001/jama.295.9.1023

Hollenbeck, K. (2001). Between a Rock and a Hard Place:

Child Abuse Registries at the Intersection of Child

273

Protection, Due Process, and Equal Protection. Texas

Journal Of Women & The Law, 11

Hornor, G., (2012). Original Articles: Post-traumatic Stress

Disorder. Journal Of Pediatric Health Care,

doi:10.1016/j.pedhc.2012.07.020

Howell, A. (2012). The demise of PTSD: From governing

through trauma to governing resilience. Alternatives,

Global, Local, Political 37(3) 24-226 DOI:

10.1177/0304375412450842

Huemer, J., Erhart, F., & Steiner, H. (2010). Posttraumatic

stress disorder in children and adolescents: A review of

psychopharmacological treatment. Child Psychiatry and

Human Development , 624-640. DOI: 10.1007/s10578-

010-0192-3

274

Huey, S. J., & Polo, A. J. (2008). Evidence-based

psychosocial treatments for ethnic minority

youth. Journal Of Clinical Child & Adolescent

Psychology, 37(1),262-301.

doi:10.1080/15374410701820174

Hurst, Arthur F. (1918) Medical Diseases of the War. London:

Arnold,Huso, D.R., (2010) Treating child abuse with

emdr, Social Work Today Vol. 10 No. 2 P.

20.Retrieved05/10/2012from:

http://www.socialworktoday.com/archive/032210p20.sh

tml

Innocent Justice Foundation (2013). Helping Rescue Children

from Abuse. Retrieved from http://innocentjustice.org/

Irwin, M. (2013) Understanding the Use of Psychiatric

Medication for Children in Foster Care and Residential

Treatment -Part 1 & Part 2. The New York Public

Welfare Association 144th Annual Winter Conference;

Albany, NY

275

Iversen, A.C ., Fear N.T.,. Simonoff, E, Hull L. l, O. Horn, N.

Greenberg, M. Hotopf, R. Rona, S. Wessely Influence

of childhood adversity on health among male UK

military personnel The British Journal of Psychiatry,

191 (2007), pp. 506–511

Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W.

E., Kulka, R. A., Hough, R. L., et al. (1992). Problems

in families of male Vietnam Veterans with

posttraumatic stress disorder. Journal of Consulting and

Clinical Psychology, 60,916-926.

Justice for Children (2013) The current cost of Child Abuse in

the US. Retrieved from

http://justiceforchildren.org/

Kagan, R., Douglas, A., Hornik, J. & Kratz, S. (2008). Real

life heroes pilot study: Evaluation of a treatment model

for children with traumatic stress. Journal of Child &

Adolescent Trauma, 1(1),

5-22. doi: 10.1080/19361520801929845

276

Kaiser, D., Dunne, M., Malchiodi, C., Feen, H., Howie, P.,

Cutcher, D., Ault, R., (2005) A call for art therapy

research on treatment of ptsd. American Art Therapy

Association.

Kardiner A. The traumatic neuroses of war. Psychosomatic

Medicine Monograph II III. Menasha, Wis: George

Banta Publishing Company. 1941

Kardiner, A. & Spiegel, H. (1947) War, stress and neurotic

illness (Rev. ed.) New York: Hoeber

Keeshin, B. R., Cronholm, P. F., & Strawn, J. R. (2012).

Physiologic Changes Associated With Violence and

Abuse Exposure: An Examination of Related Medical

Conditions. Trauma, Violence & Abuse, 13(1), 41-56.

doi:10.1177/1524838011426152

Kempe, C., Silverman, F. N., Steele, B. F., Droegemueller,

W., & Silver, H. K. (1985). The battered-child

syndrome. Child Abuse & Neglect, 9(2), 143-

154.

277

Khoo, A., Dent M.T, & Oei, T.P.S., (2011) Group cognitive

behaviour therapy for military service-related post-

traumatic stress disorder: effectiveness,

sustainability and repeatability. Australian and New

Zealand Journal of Psychiatry 2011; 45:663 –672

DOI:10.3109/00048674.2011.590464

King, D. W., King, L. A., Foy, D. W., & Gudanowski, D. M.

(1996). Prewar factors in combat-related posttraumatic

stress disorder: Structural equation modeling with a

national sample of female and male Vietnam Veterans.

Journal of Consulting and Clinical Psychology, 64,

520-531.

Kirsch P, Esslinger C, Chen Q, Mier D, Lis S, Siddhanti S, et

al., (2005) Oxytocin modulates neural circuitry for

social cognition and fear in humans. Journal of

Neuroscience 25: 11489–11493

278

Kisiel, C.L., Fehrenbach,T., Small,L., & Lyons,J.(2009).

Assessment of complex Trauma exposure, responses

and service needs among children and adolescents in

child welfare. Journal of Child and Adolescent

Trauma, 2, 143–160.

Koenen, K. C., Stellman, J. M., Stellman, S. D., & Sommer, J.

F. (2003). Risk factors for course of posttraumatic stress

disorder among Vietnam veterans: A 14-year follow-up

of American Legionnaires. Journal of Consulting and

Clinical Psychology, 71, 980–986

Koenen,K.C.(2006). Developmental epidemiology of PTSD:

Self-regulation as a central mechanism. Annals of New

York Academy of Science, 1071, 255–266.

Kolko, D. J., Iselin, A. R., & Gully, K. J. (2011). Evaluation

of the Sustainability and Clinical Outcome of

Alternatives for Families: A Cognitive-Behavioral

Therapy (AF-CBT) in a Child Protection Center. Child

Abuse & Neglect: The International Journal, 35(2),

105-116.

279

Kosten TR, Mason JW, Giller EL, Ostroff RB, Harkness L.

(1987). Sustained urinary norepinephrin and

epinephrine elevation in posttraumatic stresss disorder.

Psychoneuroendocrinology 12:13–20.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L.,

Jordan, B. K., Marmar, C. R., Weiss, D. S., Grady, D.

A., & Cranston, A. (1990a). Trauma and the Vietnam

War generation: Report of findings from the National

Vietnam Veterans Readjustment Study. New York:

Brunner/Mazel.

Lange A, Rietdijk D, Hudcovicova M, Van de Ven JP,

Schrieken S,Emmelkamp PMG: Interapy. A controlled

randomized trial of the standardized treatment of

posttraumatic stress through the Internet. Journal of

Consulting and Clinical Psychology 2003, 71:901-909.

280

Lanius, R. A., & Tuhan, I. (2003). Letters to the editor: Stage

Oriented trauma treatment using Dialectical Behaviour

Therapy. Canadian Journal of Psychiatry, 48, 126-127.

Lamprecht, Friedhelm, and Martin Sack. (2002)“Posttraumatic

Stress Disorder Revisited.” Psychosomatic Medicine

64.2: 222–37.

Landsverk, J. A., Burns, B. J., Stambaugh, L. F.,& Reutz, J. A.

(2009). Psychosocial interventions for children and

adolescents in foster care: Review of research literature.

Child Welfare, 88(1), 49–69.

Lanza, M., Anderson, J., Boisvert, C., LeBlanc, A., Fardy, M.,

& Steel, B. (2002). Assaultive behavior intervention in

the Veterans Administration: psychodynamic group

psychotherapy compared to cognitive behavior

therapy. Perspectives In Psychiatric Care, 38(3), 89-97.

LPTSD: Historical Development of the Concept

281

Lapierre, C. B., Schwegler, A. F., & LaBauve, B. J. (2007).

Posttraumatic stress and depression symptoms in

soldiers returning from combat operations in Iraq and

Afghanistan. Journal of Traumatic Stress, 20, 933–943.

Lemieux AM, Coe CL. 1995. Abuse-related posttraumatic

stress disorder: Evidence for chronic neuroendocrine

activation in women. Psychosomatic Medicine 57:105–

115

Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., &

Shapiro, D. L. (2002). Trauma symptoms in preschool

age children exposed to domestic violence. Journal of

Interpersonal Violence, 17, 150–164.

doi:10.1177/0886260502017002003

Leweke, F.M., Koethe, D. (2008) Cannabis and psychiatric

disorders: It is not only addiction. Addiction Biology.

2008, 13, 264

282

Loeb, J., Stettler, E.M., Gavila, T., Stein, A., & Chinitz S.

(2011). The child behavior checklist PTSD scale:

Screening for PTSD in young children with high

exposure to trauma. Journal Of Traumatic Stress, 24(4)

430-434 doi:10.1002/jts.20658

Marans, S., Hahn, H, Epstein, C and Arnow, N. (2012). The

Safe Horizon-Yale Child Study Center Partnership:

Offering Hope for Abused Children. [White

Paper].Retrieved from

http://www.safehorizon.org/images/uploads/misc/13334

60124-ChildAbuse_CFTSI_WhitePaper_Final.pdf

Marco, E.M., Viveros, M.P. (2009). The critical role of the

endocannabinoid system in emotional homeostasis:

��������� ����� ���� ������������ Mini Reviews in

Medicinal Chemistry. 2009, 9, 1407.

Marco, E.M. García-Gutiérrez, M.S. Bermúdez-Silva, F.J. ,

Moreira, F.A. , Guimarães, F. Manzanares, J. et al.

(2011) Endocannabinoid system and psychiatry: In

283

search of a neurobiological basis for detrimental and

potential therapeutic effects. Frontiers in Behavioral.

Neuroscience., 5, DOI: 10.3389/fnbeh.2011.00063

Marie, D., Fergusson, D. M., & Boden, J. M. (2008). Ethnic

identification, social disadvantage, and mental health in

adolescence/young adulthood: Results of a 25-year

longitudinal study. The Australian and New Zealand

Journal of Psychiatry, 42, 293–300

Marlowe, D.H. (2000). Psychological and psychosocial

consequences of combat and deployment with special

emphasis on the Gulf War. Retrieved January 27, 2006,

from

http://www.gulflink.osd.mil/library/randrep/Marlowepa

per/index.html

Marshall, A. D., Panuzio, J., & Taft, C. T. (2005).Intimate

partner violence among military veterans and active

duty servicemen. Clinical Psychology

Review, 25, 862–876

284

Martenyi, F.., & Soldatenkova, V., (2006) Fluoxetine in the

acute treatment and relapse prevention of combat-

related post-traumatic stress disorder: Analysis of the

veteran group of a placebo-controlled, randomized

clinical trial. European Neuropsychopharmacology, 16

340-349. doi:10.1016/j.euroneuro.2005.10.007

Mas, M., Farre, M., de la Torre, R., Roset, P.N., Ortuno J,

Segura J, et al. (1999) Cardiovascular and

neuroendocrine effects and pharmacokinetics of 3, 4-

methylenedioxymethamphetamine in humans. Journal

of Pharmacology and Experimental Therapeutics. 290:

136–145

Mashiash, Mordechai (2012) Medical cannabis as treatment

for chronic combat PTSD: Promising results in an open

pilot study (PowerPoint Slides). Retrieved from:

http://fourfreedoms.co/wp-content/uploads/2012/06/ed-

Packet1.1-of-3.pdf

285

McNally, R. J. (1993). Stressors that produce posttraumatic

stress disorder in children. In: J. R. T. Davidson, & E.B.

Foa (Eds.), Posttraumatic stress disorder: DSM-IV and

beyond (pp. 57 – 74). Washington: American

Psychiatric Press

McCormick, R. A., Taber, J. I., & Kruedelbach, N. (1989).

The Relationship Between Attributional Style and Post-

Traumatic Stress Disorder in Addicted Patients. Journal

Of Traumatic Stress, 2(4), 477-487.

McCrone, P., Knapp, M., & Cawkill, P. (2003).Posttraumatic

stress disorder (PTSD) in the Armed Forces: Health

economic considerations. Journal of Traumatic Stress,

16, 519-552.

McKeever, V. M., McWhirter, B. T., & Huff, M. E. (2006).

Relationships Between Attribution Style, Child Abuse

History, and PTSD Symptom Severity in Vietnam

Veterans. Cognitive Therapy & Research, 30(2), 123-

133. doi:10.1007/s10608-006-9018-9

286

Meiser-Stedman, R., Dalgleish, T., Smith, P., Yule, W.,

Bryant, B., Ehlers, A., & Winston, F. (2007).

Dissociative symptoms and the acute stress disorder

diagnosis in children and adolescents: A replication of

the Harvey and Bryant (1999) study. Journal of

Traumatic Stress, 20(3), 359-364. doi:10.1002/jts.20211

Metter, J. and Michelson, L. (1993) Theoretical, clinical,

research and ethical constraints of the eye movement

desensitization reprocessing technique.

Journal of Traumatic Stress, 6: 413–415.

Military.Com (2013) Navy Creates PTSD App. Retrieved

from:

http://www.military.com/military-report/navy-creates-

ptsd-app?ESRC=miltrep.nl

287

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W.(2007).

Longitudinal assessment of mental health problems

among active and reserve component soldiers returning

from the Iraq war. Journal of the American Medical

Association, 298, 2141–2148.

doi:10.1001/jama.298.18.2141

Mitchell, K.J., Jones, L.M., Finkelhoer, D., Wolak, J. (2011).

Internet-facilitated commercial sexual exploitation of

children: Findings from a nationally representative

sample of law enforcement agencies in the United

States. Sexual Abuse: A Journal of Research and

Treatment 23(1) 43-71

288

Mithoefer, M., Wagner, M., Mithoefer, A., Jerome, L., &

Doblin, R. (2011). The safety and efficacy of {+/-} 3,4-

methylenedioxymethamphetamine-assisted

psychotherapy in subjects with chronic, treatment-

resistant posttraumatic stress disorder: the first

randomized controlled pilot study. Journal Of

Psychopharmacology, 25(4), 439-452.

doi:10.1177/0269881110378371

Mitra, S., Basu, S., & Sanyal, N. (2013). Unravelling the

Roots of Personality Disorganization through

Psychodynamic Lens: A Case Study. SIS Journal Of

Projective Psychology & Mental Health, 20(1), 42-48.

Molnar, B. E., Berkman, L. F., & Buka, S. L. (2001).

Psychopathology, childhood sexual abuse and other

childhood adversities: Relative links to subsequent

suicidal behaviour in the US. Psychological Medicine,

31, 965–977.

289

Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J.,

Young-Xu, Y., & Stevens, S. P. (2006). Cognitive

processing therapy for veterans with military-related

posttraumatic stress disorder Journal of Consulting and

Clinical Psychology, 74(5) 898-907 doi:10.1037/0022-

006X.74.5.898

Mulick, P.S., Landes, S.J., Kanter, J.W., (2011) Contextual

Behavior Therapies in the Treatment of PTSD: A

Review. The International Journal of Behavioral

Consultation and Therapy 2011, Vol. 7, No. 1, 23–31

Murphy, H. (2012). Marines' Faces Before, During, and

After Serving in Afghanistan. BEHOLD, the photo

blog Retrieved October 17th 2012, from

http://www.slate.com/blogs/behold/2012/10/17/claire.fe

licies.photographs

marines_faces_before_during_and_after_afghanistan.html

290

Music for All Seasons (2010) Voices of valor: A new program

for veterans taps into the healing power of music.

Retrieved from:

http://musicforallseasons.org/vvnews.html

Music for All Seasons (2013) Voices of valor at the Russian

tea room: Groundbreaking music program debuts new

works. Retrieved from:

http://musicforallseasons.org/Press%20Release.pdf

Myers, J. B. (2008). A Short History of Child Protection in

America. Family Law Quarterly, 42(3), 449-463.

The National Child Traumatic Stress Network (2012). CFTSI:

Child and family traumatic stress interventions.

Retrieved from http://www.NCTSN.org

New York State Office of Children and Family Services.

(Revised, 2011). Summary Guide for Mandated

Reporters in New York State. Albany, NY:

The Author. Retrieved June 2012 from

http://www.ocfs.state.ny.us/main/publications/pub1159.

pdf

291

New York State Office of Children and Family Services

(2013). Family Assessment Response/Healthy Families

New York. Retrieved from:

http://www.ocfs.state.ny.us/main/

Nibuya M, Morinobu S, Duman RS (1995) Regulation of

BDNF and trkB mRNA in rat brain by chronic

electroconvulsive seizure and antidepressant drug

treatments. Journal of Neuroscience 15:7539–7547

Nidiffer, F., & Leach, S. (2010). To Hell and Back: Evolution

of Combat-Related Post Traumatic Stress Disorder.

(Cover story). Developments In Mental Health

Law, 29(1-2), 1-22.

NYU Langone Medical Center (2013). For combat veterans

suffering post-traumatic stress disorder, ‘fear circuitry’

in the brain never rests. Science Daily. Retrieved May

20, 2013, from http://www.sciencedaily.com-

releases/2013/05/130518153257.htm

292

Oehen, P., Traber, R., Widmer, V., & Schnyder, U. (2013). A

randomized, controlled pilot study of MDMA (±3,4-

Methylenedioxymethamphetamine)-assisted

psychotherapy for treatment of resistant, chronic Post-

Traumatic Stress Disorder (PTSD). Journal Of

Psychopharmacology, 27 (1), 40

doi:10.1177/0269881112464827

Offerman, B.J., Johnson, E., Johnson-Brooks, S.T., & Belcher,

H.M.E., (2008) Get SMART: Effective treatment for

sexually abused children with problematic sexual

behavior. Journal of Child & Adolescent Trauma,

1:179–191

Oswald, S. H., Heil, K., & Goldbeck, L. (2010). History of

maltreatment and mental health problems in foster

children: A review of the literature. Journal of Pediatric

Psychology, 35, 462–472. doi:10.1093/jpepsy/jsp114

293

O’Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J

(2009)The physical and mental health of Australian

Vietnam veterans 3decades after the war and its relation

to military service, combat,and post-traumatic stress

disorder. American Journal of Epidemiology 170:318–

330

Owens, G., Dashevsky, B., Chard, K., Mohamed, S., Haji, U.,

Heppner, P., & Baker, D. (2009). The relationship

between childhood trauma, combat exposure, and

posttraumatic stress disorder in male veterans Military

Psychology, 21(1), 114-125

Parry, G., Roth, T., & Fonagy, P. (2005). Psychotherapy

research, health policy, and service provision. In A.

Roth & P. Fonagy (Eds.), What works for whom: A

critical review of psychotherapy research (2nd ed.,

pp. 43– 65). London: The Guilford Press.

294

Passie, T., Emrich, H.M., Karst, M., Brandt, S.D., Halpern,

J.H. (2012) Mitigation of post-traumatic stress

symptoms by cannabis resin: A review of the clinical

and neurobiological evidence. Drug and Testing

Analysis, 4 649-659

Perales, R., Gallaway, M., Forys-Donohue, K., Spiess, A.,

Millikan, A. (2012). Prevalence of childhood trauma

among U.S. army soldiers with suicidal behavior.

Military Medecine, 177(9), 1034-1040

Plotsky P.M., Meaney M.J., (1993) Early postnatal experience

alters hypothalamic-corticotropin-releasing factor

(CRF) mRNA, median eminence CRF content and

stress-induced releasing in adult rats. Molecular Brain

Research 18:195–200

Perry, B.D., & Pollard R. (1998) Homeostasis, stress, trauma,

and adaptation. A neurodevelopmental view of

childhood trauma. Child Adolescent Psychiatry Clinical

North America 7:33–51,vii

295

Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S.

J., & Foa, E. B. (2010). A meta-analytic review of

prolonged exposure for posttraumatic stress disorder.

Clinical Psychology Review, 30, 635–646.

Pruitt, L., Zoellner, L.A., Feeney, C.A., Caldwell, D., Hanson,

R. (2012). The effects of positive patient testimonials

on PTSD treatment choice. Behaviour Research And

Therapy, 50 805-813, doi:10.1016/j.brat.2012.09.07

Putnam, F. W. (2003). Ten-year research updates review:

Child sexual abuse. Journal of the American Academy

of Child & Adolescent Psychiatry, 42(3), 269–278.

Rankin, A. B., & Taucher, L. C. (2003). A task-oriented

approach to art therapy in trauma treatment. Art

Therapy: Journal of the American Art Therapy

Association, 20, 138-147.

Raphael, B., & Wilson, J. P. (2000). Introduction and

overview: Key issues in the conceptualization of

�����������*��<��>�� ����@�\��^��`�����|~���

296

^�� ��������� ���������� |���� �–14). New

York:Cambridge University Press.

Ready, D.J., Sylvers, P., Worley, V., Butt, J. ,Mascaro, N., &

Bradley, B. 2012 The impact of group-based exposure

therapy on the PTSD and

depression of 30 combat veterans. Psychological

Trauma: Theory,

Research, Practice, and Policy, Vol. 4, No. 1, 84–93

DOI: 10.1037/a0021997

Regehr, C., Cadell, S., Jansen, K., (1999) Perceptions of

control and long-term recovery from rape. American

Journal of Orthopsychiatry Volume 69, Issue 1 pages

110-115.

Resick, P. A., Monson, C. M., & Chard, K. M. (2007).

Cognitive Processing Therapy: Veteran/military

version. Washington, DC: U.S. Department of Veterans

Affairs

297

Resick, P.A., Nisith, P., Griffin, M.(2003) How well does

cognitive behavior therapy treat symptoms of complex

PTSD? An examination of child sexual abuse survivors

within a clinical trial. CNS Spectrums. 2003 May ; 8(5):

340–355.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing

therapy for sexual assault victims. Journal of

Consulting and Clinical Psychology, 60, 748 –756.

Resnick, H., Acierno, R., Kilpatrick, D. G., & Holmes, M.

(2005). Description of an early intervention to prevent

substance abuse and psychopathology in recent rape

victims. Behavior Modification, 29, 156–188

Resnick, S. G., & Rosenheck, R. A. (2008). Posttraumatic

stress disorder and employment in veterans participating

in Veterans Health Administration

Compensated Work Therapy. Journal of Rehabilitation

Research & Development, 45, 427-435

298

Richert, K. A., Carrion, V. G., Karchemskiy, A., & Reiss, A.

L. (2006). Regional differences of the prefrontal cortex

in pediatric PTSD: an MRI study. Depression & Anxiety

(1091-4269), 23(1), 17-25. doi:10.1002/da.20131

Rodenburg, Benjamin, de Roos, Mejias & Stams. (2009).

Efficacy of EMDR in children: A meta-

analysis. Clinical Psychology Review, 29599-606.

doi:10.1016/j.cpr.2009.06.008

Rodriguez, C.M. & Tucker, M.C.(2011) Behind the cycle of

violence, beyond abuse history: A brief report on the

association of parental attachment to physical child

abuse potential. Violence & Victims, 26(2), 246-256

doi: 10.1891/0886-6708.26.2.246

Rose, S., Bisson, J., & Wessely, S. (2001). Psychological

debriefing for preventing post traumatic stress disorder

(PTSD) [Article. No. CD000560]. Cochrane Database

of Systematic Reviews, 4. doi:

10.1002/14651858.CD000560

299

Rossman, B. B. R., Hughes, H. M., & Rosenberg, M. S.

(2000). Children and interparental violence: the impact

of exposure. Philadelphia: Taylor and Francis.

Rothbaum, B. O., Rizzo, A., & Difede, J. (2010). Virtual

reality exposure therapy for combat-related

posttraumatic stress disorder Rothbaum et al. Virtual

reality exposure therapy for PTSD. Annals Of The New

York Academy Of Sciences, 1208(1), 126-132.

doi:10.1111/j.1749-6632.2010.05691.x

Ruff, R., Riechers, R., Wang, X., Piero, T., & Ruff, S. (2012).

A case-control study examining whether neurological

deficits and PTSD in combat veterans are related to

episodes of mild TBI. BMJ Open, 2(2), e000312.

doi:10.1136/bmjopen-2011-000312

Ruggiero, K. J., & McLeer, S. V. (2000). PTSD scale of the

child behavior checklist: Concurrent and discriminant

validity with non-clinic referred sexually abused

children. Journal of Traumatic Stress, 13, 287–299.

doi:10.1023/A:1007710828777

300

Runyon, M.K., Deblinger, E. & Schroder, C. (2009) Pilot

evaluation of outcomes of combined parent-child

cognitive-behavioral therapy group for families at risk

for child physical abuse. Cognitive and Behavioral

Practice, 16, 101-118

Salmon, K., & Bryant, R. (2002). Posttraumatic stress disorder

in children. The influence of developmental factors.

Clinical Psychology Review, 22(2), 163-188.

Sánchez-Meca, J., Rosa-Alcázar, A. I., & López-Soler, C.

(2011). The psychological treatment of sexual abuse in

children and adolescents: A meta-analysis. International

Journal of Clinical and Health Psychology, 11, 67–93.

Saunders, T., Driskell, J. E., Johnston, J., & Salas, E. (1996).

The effect of stress inoculation training on anxiety and

performance. Journal Of Occupational Health

Psychology, 1(2), 170-186. doi:10.1037/1076-

8998.1.2.170

301

Sautter, F. J., Armelie, A. P., Glynn, S. M., & Wielt, D. B.

(2011). The development of a couple-based treatment

for PTSD in returning veterans. Professional

Psychology: Research And Practice, 42(1), 63-69.

doi:10.1037/a0022323.

Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F.

(2003). New findings on alternative criteria for PTSD in

preschool children. Journal of the American Academy of

Child and Adolescent Psychiatry, 40, 561–

570.doi:10.1097/01.CHI.0000046822.95464.14

Shenk, C/E., Putnam, R.W. Noll, J.G.,(2001) Experiential

avoidance and the relationship between child

maltreatment and PTSD symptoms: Preliminary

evidence Child Abuse & Neglect, Volume 36, Issue 2,

February2012,Pages118–126

Schneider (Producer), Pitts (Correspondent) (2013). The life

and death of Clay Hunt (60 Minutes). New York:

Columbia Broadcasting System

302

Schnurr, P. P., Lunney, C. A., Sengupta, A., & Waelde, L. C.

(2003). A Descriptive Analysis of PTSD Chronicity in

Vietnam Veterans. Journal Of Traumatic Stress, 16(6),

545-553.

Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea,

M. T., Resick, P. A., Bernardy, N. (2007). Cognitive

behavioral therapy for posttraumatic stress disorder in

women: A randomized controlled trial.

Journal of the America Medical Association, 297, 820–

830.

Schwartz, E. D., & Perry, B. D. (1994). The post-traumatic

response in children and adolescents. Psychiatric

Clinics of North America, 17(2), 311-326.

Schwartz, J. (2013) After suicide attempt, combat veteran

finds his voice Statesman.com. 04/13/2013 Retrieved

from:

http://www.statesman.com/news/news/local/after-

suicide-attempt-combat-veteran- finds-his-voice/nXFPH/

303

Seal, K.H.; Metzler, T.J.; Gima, K.S.,Bertenthal, D., Maquen,

S., Marmar, C.R. (2009) Trends and risk factors for

mental health diagnoses among Iraq and Afghanistan

veterans using Department of Veterans Affairs health

care, 2002–2008. American Journal of Public

Health 99(9):1651–1658, PMID: 19608954

Shapiro, F. (2005). Eye movement desensitization and

reprocessing (EMDR) training manual. Watsonville,

CA: EMDR Institute

Shapiro, F., & Laliotis, D. (2011). EMDR and the Adaptive

Information Processing Model: Integrative Treatment

and Case Conceptualization.Clinical Social Work

Journal, 39(2), 191-200. doi:10.1007/s10615-010-

Sharpless, B. A., & Barber, J. P. (2011). A clinician's guide to

PTSD treatments for returning veterans. Professional

Psychology: Research And Practice, 42(1), 8-15.

doi:10.1037/a0022351

304

Shemesh, E.,Newcorn, J.H., Rockmore, L., Shneider, B. L.,

Emre, S., Gelb, B.D., Yehuda, R. (2005). Comparisons

of parent and child reports of emotional trauma

symptoms in pediatric outpatient settings. Pediatrics,

115, 582–589.doi:10.1542/peds.2004-221

Shenk , C.S., Putnam, F.W., & Noll, J.G.,(2011) Experiential

avoidance and the relationship between child

maltreatment and PTSD symptoms: Preliminary

evidence. Child Abuse & Neglect, 36 118-126.

doi:10.1016/j.chiabu.2011.09.012

Skopp, N. A., Luxton , D. D., Bush, N., & Sirotin, A.

(2011). Childhood adversity and suicidal ideation in a

clinical military sample: Military unit cohesion and

intiMaté relationships as protective factors. Journal Of

Social & Clinical Psychology, 30(4), 361-377.

doi:10.1521/jscp.2011.30.4.361

305

Silver, S. & Green, R (2001 revised edition) A Guide to New

York's Child Protective Services System Retrieved

from:

http://assembly.state.ny.us/comm/Children/20011016/

Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J.,

Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L.

(2008). Evidence-based psychosocial treatments for

children and adolescents exposed to traumatic

events. Journal Of Clinical Child & Adolescent

Psychology, 37(1),156-183.

doi:10.1080/15374410701818293

Sim, L., Friedrich,W. N.,Hobart Davies,W., Trentham, B.,

Lengua, L.,&Pithers, W. (2005). The child behavior

checklist as an indicator of posttraumatic stress disorder

and dissociation in normative, psychiatric, and sexually

abused children. Journal of Traumatic Stress, 18, 697–

705. doi:10.1002/jts.20078

306

Sloan, D.M., Bovin, M. J. & Schnurr, P.P.(2012). Review of

group treatment for PTSD. Journal of

Rehabilitation Research and Development, 49(6) 689-

701. doi:10.1682/JRRD.2011.07.0122

Smith, M.A., Kim, S.Y., van Oers, H.J., Levine, S. (1997)

Maternal deprivation and stress induce immediate early

genes in the infant rat brain. Endocrinology 138:4622–

4628

Smith, M. W., Schnurr, P. P., & Rosenheck, R. A. (2005).

Employment outcomes and PTSD severity. Mental

Health Services Research, 7, 89-101.

307

Solomon, Z . Mikulincer, M., & Waysman, W. (1991).

Delayed and immediate onset post traumatic stress

disorder: The role of life events and social resources.

Journal Of Community Psychology, 19(3), 231-236.

Sparks, S.D., (2013 June 1), Research traces impacts of

childhood adversity. Education Week. Retrieved from:

http://www.edweek.org/ew/articles/2012/11/07/11pover

ty_ep.h32.html

Springer, C., & Misurell, J. R. (2012). Game-based cognitive-

behavioral therapy individual model for child sexual

abuse. International Journal of Play Therapy, 21(4),

188-201. doi:10.1037/a0030197

Sripada, R. K., King, A. P., Garfinkel, S. N., Xin, W., Sripada,

C. S., Welsh, R. C., & Liberzon, I. (2012). Altered

resting-state amygdala functional connectivity in men

with posttraumatic stress disorder. Journal Of

308

Psychiatry & Neuroscience, 37(4), 241-249.

doi:10.1503/jpn.110069

Steckler, T., & Risbrough, V. (2012). Pharmacological

treatment of PTSD - established and new

approaches. Neuropharmacology, 62(2), 617-627.

doi:10.1016/j.neuropharm.2011.06.012

Stein, A. L., Tran, G. Q., Lund, L. M., Haji, U., Dashevsky, B.

A., & Baker, D. G. (2005). Correlates for posttraumatic

stress disorder in Gulf War veterans: A retrospective

study of main and moderating effects. Journal of

Anxiety Disorders, 19, 861–876.

Steinberg, A.M., Vivrette, R., (2013), Administration and

scoring of the UCLA PTSD Reaction Index for DSM-IV

(Power Point Slides). Retrieved from

http://mediasite.nctsn.org/NCTSN/Viewer/?peid=96c76

814bfb74853aa49be35e9eaca78

309

Steinberg, A.M., Brymer, M.J., Kim, S., Briggs, E.C., Ippen,

C.G., Gully, K.J., Pynoos, R.S.., (2013). Psychometric

properties of the UCLA PTSD reaction index: part I.

Journal of Traumatic Stress. 2013 Feb;26 (1):1-9. doi:

10.1002/jts.21780.

Stiles, W. B., Agnew-Davies, R., Hardy, G. E., Barkham, M.,

& Shapiro, D. A. (1998). Relations of the alliance with

psychotherapy outcome: Findings in the second

Sheffield Psychotherapy Project. Journal Of Consulting

And Clinical Psychology, 66(5), 791-802.

doi:10.1037/0022-006X.66.5.791

Strawn, J. R., & Geracioti, T. D. (2008). Noradrenergic

dysfunction and the psychopharmacology of

posttraumatic stress disorder. Depression & Anxiety

(1091-4269), 25(3), 260-271. doi:10.1002/da.20292

Tinker, R. (2002) EMDR for traumatised children around the

world. ACPP Occasional Papers, 19: 9–14. Thompson,

M. (2010). Bringing Dogs to Heal. Time, 176(21), 54-

57.

310

Thompson, M.R., Callaghan, P.D., Hunt, G.E., Cornish, J.L.,

& McGregor, I.S. (2007) A role for oxytocin and 5-HT

(1A) receptors in the pro-social effects of 3,4-

methylenedioxymethamphetamine(‘‘ecstasy’’).

Neuroscience 146: 509–514

Town, J., Diener, M., Abbass, A., Leichsenring, F., Driessen,

E., & Rabung, S. (2012). A meta-analysis of

psychodynamic psychotherapy outcomes: Evaluating

the effects of research-specific procedures.

Psychotherapy, 49(3), 276-290.

Tuerk, P.W., Steenkamp, M., & Rauch, S.M. (2010) Combat-

related PTSD: Scope of the current problem,

understanding effective treatment, and barriers to care.

Developments in Mental Health Law, 29 (1-2), 49-58.

(v)

311

United States Bureau of Justice Statistics. (2007). Veterans in

state and federal prison, 2004. Washington, DC: United

States Department of Justice.

U.S. Department of Health and Human Services,

Administration for Children and Families,

Administration on Children, Youth and Families,

Children’s Bureau. Child Maltreatment 2011. 2012.

www.acf.hhs.gov/programs/cb/researchdata-

technology/statistics-research/childmaltreatment

van der Kolk, B. A. (2005). Developmental trauma disorder:

Toward a rational diagnosis for children with complex

trauma histories. Psychiatric Annals, 35, 401–408

van der Kolk, B., Spinazzola, J., Blaustein, M., Hopper, J.,

Hopper, E., Korn, D., et al. (2007). A randomized

clinical trial of EMDR, fluoxetine and pill placebo in

the treatment of PTSD: Treatment effects and long-term

maintenance. Journal of Clinical Psychiatry,

68, 37–46.

312

Van Voorhees, E. E., Dedert, E. A., Calhoun, P. S., Brancu,

M., Runnals, J., & Beckham, J. C. (2012). Childhood

Trauma Exposure in Iraq and Afghanistan War Era

Veterans: Implications for Posttraumatic Stress

Disorder Symptoms and Adult Functional Social

Support. Child Abuse & Neglect: The International

Journal, 36(5), 423-432.

Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007).

Perceived public stigma and the willingness to seek

counseling: The mediating roles of self –stigma

and attitudes toward counseling. Journal of Counseling

Psychology, 54, 40-50. doi: 10.1037/0022-0167.54.1.40

Wagner, A. W., & Linehan, M. M. (1998). Dissociative

behavior. In V. M. Follette, J. I. Ruzek, & F. R. Abueg

(Eds.), Cognitive behavioral therapies for trauma (pp.

191-225). New York: Guilford

313

`����� � ��� |������� <������� ���� ����������� ������

psychological interventions in acute stressor situations.

In B. Raphael & J. P. Wilson (Eds.), Psychological

����������� � ����� ��������� ���� ��������� |���� ��–57).

Cambridge, England: Cambridge University Press

Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S.

K., Miranda, J., Bearman, S. K., the Research Network

on Youth Mental Health (2012). Testing standard and

modular designs for psychotherapy treating depression,

anxiety, and conduct problems in youth: A randomized

effectiveness trial. Archives of General Psychiatry, 69,

274–282. doi10.1001/archgenpsychiatry.2011.147

Weniger, G. G., Lange, C. C., Sachsse, U. U., & Irle, E.

(2008). Amygdala and hippocampal volumes and

cognition in adult survivors of childhood abuse with

dissociative disorders. Acta Psychiatrica

Scandinavica, 118(4), 281-290. doi:10.1111/j.1600-

0447.2008.01246.x

314

Wethington, H. R., Hahn, R. A., Fuqua-Whitley, D. S., Sipe,

T. A., Wolfe, J., Proctor, S. P., Erickson, D.J., Heeren,

T., Friedman, M. J., Huang M.T., Sutker,

P.B., Vasterling J.J., White R.F. (1999) Relationship of

psychiatric status to Gulf War veterans' health

problems. Psychosomatic Medicine July-August 61(4)

532-540

Wilson, R.I., Nicoll R.A. (2002) Endocannabinoid signaling in

the brain. Science, 296, 678.

Wolfe, V. V., Gentile, C., & Wolfe, D. A. (1989). The impact

of sexual abuse on children: A PTSD formulation.

Behavior Therapy, 20, 215–228.

doi:10.1016/S0005-7894(89)80070-X

Wolak, J., Finkelhor, D., & Mitchell, K. (2004). Internet-

initiated sex crimes against minors: Implications for

prevention based on findings from a national study.

Journal of Adolescent Health, 35, 424-433.

315

Wolak, J., Finkelhor, D., & Mitchell, K. J. (2005a). Child

pornography possessors arrested in Internet-related

crimes: Findings from the National Juvenile Online

Victimization Study. Alexandria, VA: National Center

for Missing and Exploited Children.

Wolak, J., Finkelhor, D., & Mitchell, K. J. (2005b). The

varieties of child pornography production. In E. Quayle

& M. Taylor (Eds.), Viewing child pornography on the

Internet: Understanding the offense, managing the

offender, helping the victims (pp. 31-48). Dorset, UK:

Russell House Publishing.

Wolak, J., Finkelhor, D., Mitchell, K. J., & Ybarra, M. L.

(2008). Online “predators” and their victims: Myths,

realities, and implications for prevention treatment.

American Psychologist, 63, 111-128

316

Wolak, J., Finkelhor, D., & Mitchell, K. J. (2009a). Law

enforcement responses to online child sexual

exploitation crimes: The national juvenile online

victimization study, 2000 & 2006. Available from

http://unh.edu/ccrc/pdf/LE_Bulletin_final_Dec_09.pdf

Wolak, J., Finkelhor, D., & Mitchell, K. J. (2009b). Trends in

arrests of “online predators” [Electronic Version].

Crimes against Children Research Center, University of

New Hampshire, 1-10. Retrieved May 29, 2009, from

http://unh.edu/ccrc/pdf/CV194.pdf

Wounded Warrior Project (2013) Restore Warriors. Retrieved

from

http://www.woundedwarriorproject.org/programs/comb

at-stress-recovery-program/restore-warriors.aspx

Wunderlich, U., Bronisch, T., & Wittchen, H. (1998).

Comorbidity patterns in adolescents and young adults

with suicide attempts. European Archives Of Psychiatry

And Clinical Neuroscience, 248(2), 87-95.

317

Yehuda R, Southwick S, Giller EL, Ma X, Mason JW. (1992(.

Urinary

catecholamine excretion and severity of PTSD

symptoms in

Vietnam combat veterans. Journal of Nervous and

Mental Disease 180:321–325

Yount, R. A., Olmert, M. D., & Lee, M. R. (2012). Service

Dog Training Program for Treatment of Posttraumatic

Stress in Service Members. U.S. Army Medical

Department Journal, 63-69.

Zaidi, L. Y., & Foy, D. W. (1994). Childhood Abuse

Experiences and Combat-Related PTSD. Journal Of

Traumatic Stress, 7(1), 33-42.

Zak, P.J., Kurzban, R. & Matzner, W.T. (2005) Oxytocin is

associated with human trustworthiness. Hormones and

Behavior. 48: 522–527.

318

Zielinski, D. S. (2009). Child maltreatment and adult

socioeconomic well-being. Child Abuse & Neglect, 33,

666–678. doi:10.1016/j.chiabu.2009.09.001

Zito, J.M., Safer, D.J., de Jong- vandenBerg Janhsen, K.,

Fegert, J.M., Gardner, J.F., Glaeske, G. & Valluri, S.C.

(2008) .A three-country comparison of psychotropic

medication prevalence in youth. Child and Adolescent

Psychiatry and Mental Health, 2, Journal of the

American Academy of Child & Adolescent Psychiatry,

48,961–973

Zlotnick, C., Begin, A., Shea, T. M., Pearlstein, T., Simpson,

E., & Costello, E. (1994). The relationship between

characteristics of sexual abuse and dissociative

experiences. Comprehensive Psychiatry,

35, 465-470.

319

APPENDICES

Reed Hoeg "Part of Something" Photo restored by Kristin Hoeg (www.khoeg.us)

320

Dr. Gabor Mate and Tom Hoeg

Buy your books fast and straightforward online - at one of world’s

fastest growing online book stores! Environmentally sound due to

Print-on-Demand technologies.

Buy your books online at

www.get-morebooks.com

Kaufen Sie Ihre Bücher schnell und unkompliziert online – auf einer

der am schnellsten wachsenden Buchhandelsplattformen weltweit!

Dank Print-On-Demand umwelt- und ressourcenschonend produzi-

ert.

Bücher schneller online kaufen

www.morebooks.deVDM Verlagsservicegesellschaft mbH

Heinrich-Böcking-Str. 6-8 Telefon: +49 681 3720 174 info@vdm-vsg.deD - 66121 Saarbrücken Telefax: +49 681 3720 1749 www.vdm-vsg.de