Posttraumatic Stress Disorder (PTSD) and Trauma in Children/Youth: Information for Primary Care

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Post-Traumatic Stress Disorder (PTSD) and Trauma in Adults

Do I Have PTSD? Have you been through traumatic events (such as violence, crime, combat or abuse) in the past? If so, then do any of the following apply to you: As a result of that event, do you avoid being reminded of this experience by staying away from certain places, people or activities? Yes/NoDid you lose interest in activities that were once important or enjoyable? Yes/NoDid you begin to feel more isolated or distant from other people? Yes/NoDid you find it hard to have love or affection for other people? Yes/NoDid you begin to feel that there was no point in planning for the future? Yes/NoAfter this experience were you having more ...

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Examples of Common Workplace Accommodations Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations: Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be f...

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Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

If requested, provide supporting documentation or medical certificates.

Meet all relevant job requirements and standards once the accommodation has been provided.

Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp

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Guidance on when to suspect child maltreatment

Published	2009
Produced By	National Institute for Health and Clinical Excellence (NICE)
Ages Served	Up to 18 years
Website	http://guidance.nice.org.uk/cg89

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Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care

Published	2005
Produced By	National Collaborating Centre for Mental Health
Ages Served	All ages
Website	http://guidance.nice.org.uk/CG26/QuickRe...

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Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder

Published	2004
Produced By	American Psychiatric Association (APA)
Ages Served	18 years and up
Website	http://psychiatryonline.org/guidelines.a...

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Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder (PTSD)

Published	2010
Produced By	American Academy of Child and Adolescent Psychiatry (AACAP)
Ages Served	Up to 18 years
Website	https://www.aacap.org/aacap/Resources_fo...

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VA/DoD clinical practice guideline for the management of post-traumatic stress

Published	2004
Produced By	Veterans Health Administration, Department of Defense
Ages Served	All ages
Website	http://guidelines.gov/summary/summary.as...

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Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

If requested, provide supporting documentation or medical certificates.

Meet all relevant job requirements and standards once the accommodation has been provided.

Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp

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Search	Where Locations

depression, psychologists, etc.	city or postal code

Identifying data	To provide culturally appropriate care, consider asking (adults and youth) about: Marital status: “Marital status? Single? LGBT?” Culture: “First nations?” “New to Canada?” Religion/spirituality: “Do you consider yourself religious or spiritual?” Social determinants of health, e.g. poverty: “Any financial stresses?”
Screening question for trauma	For parents ● New patients: “What is the scariest or most upsetting things that has happened in your child’s life?” ● Returning patients: “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” For patients ● For new patients: “What is the scariest or most upsetting things that has happened in your life?” ● For returning patients: “Since the last time I saw you, has anything really scary or upsetting happened to you or anyone in your family?” If the respondent starts providing excessive details, reassure the patient that this is not necessary -- “I just need a rough idea -- you don’t need to go into details, unless you feel it’s necessary.”
Ask about the impact (as opposed to specific details)	“What is your understanding of what’s happened?” “What is worrying you the most about it?” “What do others in the family think about it?”
Ensuring safety	“Do you feel safe right now?” “Are you responsible for any others, e.g. children?” “Are they safe?” “Anything that we can do to help you feel safe?” (e.g. appointments during quieter times) “Anything that triggers you to feel unsafe?” “We can’t always promise, but I want to ask anyways… Do you have any preference about being seen by males or females?”
Family and patient-centred goals	“What are your best hopes from seeing me?” “How can I be helpful?”
Support patient’s strength/resiliency	“With all you’ve been through, what has kept you going?” “Who do you turn to for support?” “Anyone else that could or should be a support?” ”Would you be open to other services and supports?”

Trauma, plus 9 of 14 from 5 clusters
1. Intrusion	Involuntary and recurrent memories, nightmares, flashbacks, distress after exposure to triggers May re-enact trauma in play
2. Avoidance	Avoidance of trauma-related •Internal reminders: Thoughts/feelings •External reminders: People, places, activities, objects, situations
3. Negative Cognitions and Mood	Negative beliefs about self (“I’m bad”) or world (“the world is completely dangerous”) Guilt, shame, fear, horror, emotional numbing May become extremely clingy
4. Arousal and Reactivity	Irritability, aggression, hypervigilance, troubles with focus, exaggerated startle response, sleep problems May regress from being overwhelmed, e.g. bedwetting; stop speaking
5. Dissociation	Altered sense of reality Inability to remember the event

Trauma, plus
1. Intrusion	Involuntary and recurrent memories, nightmares, flashbacks, dissociation, distress after exposure to triggers May re-enact trauma in play
2. Avoidance	Avoidance of trauma-related •Internal reminders: Thoughts/feelings •External reminders: People, places, activities, objects, situations
3. Negative Cognitions and Mood	Can’t remember key features of trauma Negative beliefs about self (“I’m bad”) or world (“the world is completely dangerous”) Guilt, shame, fear, horror, emotional numbing May become extremely clingy
4. Arousal and Reactivity	Irritability, aggression, hypervigilance, troubles with focus, exaggerated startle response, sleep problems May regress from being overwhelmed, e.g. bedwetting; stop speaking

Criteria	Possible questions
T)raumatic event	What is the scariest or most upsetting thing that has happened in your life?
R)e-experiences of trauma by intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images.	Do you find that you get nightmares about the trauma? Or that you can’t stop thinking about it?
A)voidance and emotional numbing	Have you found yourself avoiding things that remind you of the trauma?
U)nable to function, due to symptoms causing impairment in social, occupational, and interpersonal functioning	Have you had troubles functioning since the trauma?
M)onth: i.e. symptoms last more than one month for PTSD; or less than one month for ASD	Have your symptoms lasted more than a month?
A)rousal: Increased Arousal, usually manifested by startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance	Ever since the trauma, have you found yourself more nervous or on edge? Getting scared easily? Troubles focusing? More irritable? Troubles sleeping? Feeling more stressed out?

Posttraumatic Stress Disorder (PTSD) and Trauma in Children/Youth: Information for Primary Care

Case

Epidemiology

Screening

Screening Tools

History

Diagnosis of PTSD and Related Conditions

Mnemonic (“Trauma)

Diagnostic Tools

Differential Diagnosis (DDx) of Trauma / PTSD

Physical Exam

Investigations

Management of PTSD: Psychotherapy

Management of PTSD: Medications

Management of PTSD: What if standard talking therapy hasn’t worked?

Clinical Practice Guidelines

References

Authors and Disclosures

Acknowledgements

Related Info Sheets

Patient Handouts

External Links

Counselling and Therapy

Day treatment programs

Drop-in centres

Walk-In Counselling

Housing and Home Supports

Assertive Community Treatment (ACT) teams

Self-help, Mutual Aid and Support Groups

Finances and Money

Community Health and Resource Centres

General Community Mental Health Services

Other

Care Plan

Screening Tools on eMentalHealth.ca

Condition	Questions
Major depressive disorder	Any problems with depressed mood?
Adjustment disorder	Any big stresses lately? Any troubles coping or adjusting to the stress?
Anxiety disorders such as generalized anxiety, panic disorder, phobias, etc.	Is your child a big worrier? What sorts of worries?
Attention deficit hyperactivity disorder (ADHD)	Any troubles focusing or paying attention? Any hyperactivity, such as troubles sitting still, or constantly moving?
Attachment problems (e.g. Reactive attachment disorder of childhood)	Did ___ have any troubles connecting or attaching to caregivers? Avoidant? Or clingy?
Substance and alcohol use	Screeners include AUDIT CRAAFT
Psychosis	Hearing things that others do not? Seeing things that others do not? Are there any people out to harm you?

Condition	Questions
Thyroid Hyperthyroidism can lead to restlness, insomnia, autonomic hyperactivity, which are also seen in PTSD	Any complaints of being much hotter than others? Any complaints of being much colder than others
Neurologic If the trauma was physical (e.g. motor vehicle accident, physical assault), , there may be traumatic brain injuries such as concussion	After the trauma, any problems with: * Memory? * Concentration? * Headaches? * Fatigue?
Sleep disorder	Problems with sleeping? Did these problems exist prior to the trauma?

Condition	Investigations
Thyroid ● Hyperthyroidism can lead to restlessness, insomnia, autonomic hyperactivity, which are also seen in PTSD	Thyroid indices such as ● TSH ● Free T4
Neurologic ● If the trauma was physical (e.g. motor vehicle accident, physical assault), , there may be traumatic brain injuries such as concussion	Brain imaging
● Sleep disorder	Sleep studies
Substance use	Urine screening