Herbert A. Schreier

The Effectiveness of Art Therapy Interventions in Reducing Post Traumatic Stress Disorder (PTSD) Symptoms in Pediatric Trauma Patients

Although post traumatic stress disorder (PTSD) in children has been extensively studied during the past 15 years, little research exists regarding the efficacy of treatment interventions. This report describes an outcome-based art therapy research project currently conducted at a large urban hospital trauma center. Included are the theoretical rationale and overview of an art therapy treatment intervention called the Chapman Art Therapy Treatment Intervention (CATTI) designed to reduce PTSD symptoms in pediatric trauma patients. Used in this study, the CATTI was evaluated for efficacy in measuring the reduction of PTSD symptoms at intervals of 1 week, 1 month, and 6 months after discharge from the hospital. An early analysis of the data does not indicate statistically significant differences in the reduction of PTSD symptoms between the experimental and control groups. However, there is evidence that the children receiving the art therapy intervention did show a reduction in acute stress symptoms.

Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: a longitudinal examination of symptom prevalence, correlates, and parent-child symptom reporting

BACKGROUND Full recovery from injury may be hindered by both physical ailments and psychologic distress. Little information is available on the psychologic response of children to physical trauma, although long-term dysfunction may result if psychologic needs are not identified and addressed. This study examined the prevalence and correlates of posttraumatic stress disorder (PTSD) symptoms in children and adolescents after an acute traumatic event resulting in mild to moderate physical injury. We were also interested in analyzing the discrepancies between parent/child reporting of the childs PTSD symptomatology. Because of the paucity of research evaluating interventions for pediatric PTSD, and as a secondary objective for this study, we collected preliminary data on the effectiveness of a single-session art therapy intervention designed to reduce PTSD symptoms. METHOD From July 1998 through October 2000, 83 children/adolescents between the ages of 7 and 17 and their caregivers were interviewed within 24 hours of hospital admission and assessed for PTSD symptomatology, trauma history, and other measures of child and family functioning. Interviews were repeated at 1 month, 6 months, and 18 months after the initial hospitalization. Patients with at least mild symptomatology at the initial interview were randomized to receive either an art therapy intervention or standard hospital services alone. RESULTS A total of 69% of children were found to have at least mild PTSD symptoms at baseline, 57% at 1 month, 59% at 6 months, and 38% at 18 months postinjury. Younger age and the severity of parental PTSD symptoms were correlated with symptom presence in children. Parents initially underreported their childs symptom severity when compared with the childs report, but assessments converged over time. The art therapy intervention showed no sustained effects on the reduction of PTSD symptoms. CONCLUSION The presence of PTSD symptoms in children after traumatic injury is very high. Parental distress and characteristics of the family environment appear to be more relevant to the presence of child symptoms than the family make-up, course of hospitalization, or extent of the childs injuries. Parents may not initially recognize the degree to which their children experience such symptoms. The high presence of symptoms in this population underscores the need for treatment efficacy studies and parent/medical staff education in identification of PTSD.

Position Paper: Definitional Issues in Munchausen by Proxy

In 1996, a multidisciplinary task force of experts was created to develop working definitions for the constellation of behaviors currently described as Munchausen by proxy (MBP). The aim of the task force was to develop a synthesis of the most current thinking in pediatrics, psychiatry, psychology, child protection, and law and to articulate the current consensus among professionals to facilitate the identification and treatment of this complex clinical problem. The term Munchausen by proxy was first used by Roy Meadow (1977), a British pediatrician, to describe illness-producing behavior reminiscent of adult Munchausen syndrome but using the child as a proxy. Adult Munchausen syndrome, described in 1951 by Asher, is a psychiatric disorder in which an adult intentionally induces or feigns symptoms of physical or psychiatric illness to assume the sick role. MBP was initially described as “the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care for the purpose of indirectly assuming the sick role” (American Psychiatric Association, 1994, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV], p. 475). The fact that Munchausen syndrome and MBP share the same name has resulted in considerable confusion. Although once thought to be quite rare, most experts now believe that MBP is fairly common. Using the results of a careful but conservative British study (McClure, Davis, Meadow, & Sibert, 1996), we estimate that a minimum of 600 new cases of just two forms of MBP (suffocation and nonaccidental poisoning) will present in the United States each year. Given the wide spectrum of pediatric conditions that have been known to be feigned, the problem is far from trivial. Furthermore, experts now agree that MBP

Gender identity disorder in children and adolescents.

C 1 c w t t T f d d d w c a t G ender identity disorder (GID) has increasingly garnered media attention over the past several years: Ma Vie en Rose (“My Life in Pink,” 997), a sympathetic but realistic story about the ribulations and triumphs of a young transgender child, nd “Boys Don’t Cry” (1999), based on a true story in hich a girl passing as a boy meets a tragic end, ocused on this subject. News articles regarding this opic have appeared in Time, the New York Times, nd Newsweek; ABC’s 20/20 has featured several ransgendered children and their families that can be atched on YouTube. The Atlantic ran a piece on ransgender children, and on May 7-8, 2008 in a wo-part series, National Public Radio also explored he complex issue of the various therapeutic aproaches to GID, including the controversial topic of uberty-delaying therapy for preteens struggling with ID. As a result of this increasing media coverage and esearch indicating that cross-gender interests and ehavior are not rare (see below), families who have oncerns about a child’s gender identity development re increasingly likely to bring their child to the ttention of the pediatrician or others taking care of hildren. Pediatricians may be the first to be called on when arents have concerns about their child’s atypical ender behaviors. These are often not the chief comlaint for the encounter but are brought up toward the nd of an office visit, or the so-called “out-the-door” uestion. Alternatively the parent may wait to see if

Auditory Hallucinations in Nonpsychotic Children With Affective Syndromes and Migraines: Report of 13 Cases

This report describes the discovery of a possible association between auditory hallucinations, migraine, and affective/anx iety disorders in nonpsychotic children. The cases were culled by a review of all consultations in an outpatient practice in an 8-month period. Thirteen cases of nonpsychotic children who experienced hallucinations (auditory in 12) were found. All but one suffered from a variety of major affective or anxiety/panic disorders and migraine headaches. The family histories were strongly positive for affective/anxiety disorders and migraine, and four of the parents also had a history of hearing voices. The age of onset of the auditory hallucinations, where known (8 cases), was between 4 and 8 years. In only two cases did the voices accompany the migraine attacks, and these two children also heard voices at other times. Although a strong association between migraine and anxiety, panic, and affective syndromes in adults has been repeatedly found in epidemiologic study, no such association has been studied in children, and this is the first known report of a possible association between migraine, affective/anxiety disorders, and auditory hallucinations in nonpsychotic children. It suggests the need for epidemiologic study. (J Child Neurol 1998; 13:377-382).

Repeated false allegations of sexual abuse presenting to sheriffs: when is it Munchausen by proxy?

Abstract Munchausen by proxy syndrome, wherein a caretaker (most often a mother) simulates or fabricates illness in a child in order to assume the sick role through another, has now been described involving a variety of psychiatric problems and false allegations of sexual abuse. Given that a proposed dynamic appears to be a need in a dependent and/or hostile relationship with powerful transferential people from the past, it was expected that professionals (school psychologists, social workers, lawyers) other than doctors would be involved. A case involving law enforcement agents as a primary “target” is described and its significance discussed.

On the importance of motivation in Munchausen by Proxy: the case of Kathy Bush.

The recent trial and conviction of Kathy Bush for abusing her daughter is used to illustrate (1) the nature of the motivation, in at least some cases of MBP, and (2) the importance of distinguishing the motivation found in MBP from that found in other forms of child abuse and other conditions involving factitious illness production.

Munchausen by Proxy: Presentations in Special Education:

Munchausen by proxy is a disorder in which a child is victimized through a formof child abuse called pediatric condition falsification (PCF). PCF has been documented for psychological and psychiatric conditions including one such formpresented here in which educational disabilities are the focus of falsification. Parents meet their own self-serving needs through “impostering” as good mothers. This maternal mental disorder is called factitious disorder by proxy. This article presents a series of cases in which children have PCF that primarily consists of educational disabilities. Characteristics of the children, their mothers, and their families are outlined and outcomes for the 9 children in the sample are discussed. Guidelines for identification of children with PCF in educational settings are provided, and special guidance is offered in differential diagnosis.

Acute Phobic Hallucinations in Very Young Children

Acute hallucinations in children aged 2–6 is not a rare occurrence. Emerging at times of stress, they are associated with severe anxiety and phobic behavior. The hallucinations are almost always visual and/or tactile. Contrary to reports of hallucinations at other ages, they tend to occur in bright, independent children. They are self-limited, with the acute hallucinatory phase over in a matter of several days and a subacute phobic phase which may last from weeks to months. In all of our cases there was a return to normal functioning. Hallucinations in this age group appear to be a different phenomenon from those occurring in older children, which are more frequently associated with more serious illnesses. These need to be understood in a developmental framework, but current knowledge does not permit a thorough explanation.

Further Thoughts on “Beyond Munchausen by Proxy: Identification and Treatment of Child Abuse in a Medical Setting”

To the Editor .— This letter is in response to an article by Dr Stirling and the American Academy of Pediatrics Committee on Child Abuse and Neglect titled “Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting.”1 We were pleased to see the article published to remind pediatricians of this unusual but potentially fatal form of child abuse. We are writing today with 2 comments. First, the authors indicated that the motivation of the suspected parent is unimportant when evaluating for possible illness falsification and, later in the article, that treatment options vary depending on the motivation of the parent. We can see how this might be confusing to readers (see ref 2). We agree that abusive illness falsification must be …