Jessica Winkles, Ph.D. - PowerPoint Presentation

Slide1

Jessica Winkles, Ph.D.Laurel Kiser, Ph.D., M. B. A.Department of Psychiatry, University of Maryland BaltimoreMarch 30, 2014

Trauma in AdolescenceSlide2

AgendaReview: adolescent development, defining traumaScope of the problemAdolescent responses to traumaTrauma-informed care

Interventions for adolescent traumatic stress disordersSlide3

Review: Adolescent DevelopmentPhysical CognitiveSocial

Emotional

Identity Development

Time of Enormous

Change

Source: American Psychological Association (APA). (2002).

Developing Adolescents: A Reference for Professionals, 11

.Slide4

Review: Defining Traumatic Stressors in DSM5A new chapter includes disorders that are preceded by a traumatic or distressing eventPTSDAcute Stress Disorder Adjustment Disorders

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

Other Specified Trauma- and Stressor-Related Disorder

Unspecified Trauma- and Stressor-Related DisorderSlide5

Review: Defining Traumatic Stressors in DSM5The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence

Exposure

may occur in many forms:

Direct

Witnessing

Indirectly

Repeated or extreme indirect exposure to aversive details of the event(s) Slide6

Scope of the ProblemSlide7

Scope Specific to AdolescentsGeneral population study found more than 68% of children and adolescents had experienced a potentially traumatic event by the age of 16 Source: Copeland, W.E., Keeler, G.,

Angold

, A., Costello, E.J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64 (5): 577-584.

In

a nationally representative survey of

12-17 year-olds, 8%

reported a lifetime prevalence of sexual assault, 17% reported physical assault, and

39%

reported witnessing violence. 

Source:

Kilpatrick

DG, Saunders BE. (1997). Prevalence and Consequences of Child Victimization: Results from the National Survey of Adolescents. National Crime Victims Research and Treatment Center, Medical University of South

Carolina

Adolescents are twice as likely as adults to become victims of violent crime (completed violence, sexual assault, robbery, assault)

Source:

Bureau of Justice Statistics. (2008).

T

able 3,

Criminal Victimization in the United States 2008: Statistical

Tables

. Slide8

Most Commonly Reported Trauma Types

Not mutually exclusive

There are 20 trauma types

# of Trauma Types M= 3.7, SD= 2.4Slide9

Prevalence of Multiple TraumasNCTSN Core Data Set 2009 (Briggs, 2009)Slide10

Responses to TraumaSlide11

Continuum of Responses

adapted from

Bonanno

2004

Slide12

Traumatic Stress ReactionsMost youth exposed to extreme events are remarkably resilient, which can explain the success of the human species despite the violence of our history

In a community sample of older adolescents,

14.5%

of those who had experienced a serious trauma developed PTSD. 

Source:

Giaconia, R., Reinherz, H., Silverman, A., Bilge, P., Frost, A. & Cohen, E. (1995) Traumas and posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 34: 1369-1380

.Slide13

Response to TraumaWe may all experience reactions when frightening things happen, emotional and physical reactions are normal during trauma: they protect our bodies.

Adolescents with posttraumatic distress and symptoms:

Experience problems in their daily life and ability to interact with others.

Develop reactions that are long-lasting even after the traumas have ended.

Feel differently about themselves, other people and the future after they have experienced trauma.Slide14

Trauma can impact all areas of adolescent developmentPhysicalCognitive

Increased feelings of physical awkwardness

Associate victimization with changes in their bodies

Question sexual preference

Early adolescents may believe their current reality will be permanent

C

ritical thinking points back to adolescent- “What did I do to deserve this?”

May effect development of executive functioningSlide15

Trauma can impact all areas of adolescent developmentSocialEmotional

F

eel unsupported by peers

I

solate from peer group

Increased aggression or risk-taking

“Moody” teen may develop “dark cloud”

Unsure how to manage fear, anxiety, or self-doubt

May want to try managing alone

Identity Development

Incorporate weakness or vulnerability as major element of identity.

Or may decide to be “tough”

Regression- pull back from autonomySlide16

Most Commonly Reported Functional Impairments

Problems in the Home/Community

Behavior Problems at Home

Attachment Problems

Criminal Activity

Social and School Functioning

Academic Problems

Behavior Problems in School

Problems Skipping School

Risk Taking Behaviors

Self injury

Suicidality

Inappropriate sexual behaviors

Substance abuse

Alcohol use

Running away

54%

40.7%

14.1%

59.9%

44.0%

21.7%

14.6%

21%

12.3%

15.3%

12.5%

12.5%

I

mpairments in multiple domainsSlide17

Review: Criteria for Post-traumatic Stress Disorder (PTSD) in DSM-5Exposure to trauma, previously describedOne or two symptoms in each of these four categories:

Intrusion:

recurrent intrusive memories; nightmares; dissociative reactions (e.g., flashbacks); distress and physiological reactivity after exposure to reminders

Avoidance:

effortful avoidance of trauma-related thoughts, feelings, or reminders

Negative alterations in cognitions and mood:

Negative beliefs about oneself or the world; persistent negative emotions; constricted affect; feel alone;

anhedonia

;

distorted blame of self or others

Changes in arousal and reactivity:

Irritable or aggressive; reckless;

hypervigilance

; exaggerated startle; sleep disturbance; problems with concentration or attention

Greater than one month duration

Significant functional impairmentSlide18

Negative alterations in cognitions and mood Inability to remember an important aspect of the traumatic event(s)(not related to alcohol, drugs or head injury).Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.

Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themself or others.

Persistent negative emotional state.

Markedly diminished interest or participation in significant activities.

Feelings of detachment or estrangement from others.

Persistent inability to experience positive emotions.Slide19

Complex Stress Disorder Events accompanied by chronic coercionChanges in affect regulationChanges in consciousness (depersonalization)

Changes in self-perception

Cognitive distortions regarding trauma and perpetrator

Changes in relationships

Changes in systems of personal meaning

Herman, 1992Slide20

Developmental Trauma Disorder (DTD)Exposure + disruptions in protective caregivingAffective and Physiological Dysregulation

Attentional and Behavioral Dysregulation

Self and Relational Dysregulation

Posttraumatic Spectrum Symptoms

Duration of disturbance

Functional Impairment

van

der

Kolk

, 2005Slide21

Trauma-Informed CareSlide22

Core Components of Effective Trauma-Informed PracticeUnderstand Trauma

Identify Trauma Exposures and Responses

Safely intervene

From: Modified National Child Traumatic Stress NetworkSlide23

Identify Trauma ExposureSlide24

Identify Trauma Exposure: Adolescents’ Obstacles to ReportingCompared to other age groups, teens are least likely to report victimization

Lack of understanding

Fear they will not be believed

Fear of blame or punishment

Feeling shame or guilt

Fear of retaliation

Mistrust of adults

Belief that nothing will be done

Lack of knowledge about available services

Perceived and real limits of confidentiality

Source:

National Crime Prevention Council and The National Center for Victims for Crime. (2005).

Reaching and Serving Teen Victims: A Practical Handbook.Slide25

Identify Trauma ExposureOpen-Ended QuestionsWhat is the most upsetting or overwhelming event that has ever occurred in your life?..

After a very upsetting event we sometimes feel and act differently. Can you tell me whether you have experienced any of these changes since that most overwhelming or very upsetting event in his or her life, …if so did it last for more than one month?

(

Graham-

Bremann

, 2008; Cohen, Kellener

, &

Mannarino

, 2008

)

Self-report Screeners

UCLA PTSD Index for DSM-5

Traumatic Events Screening Inventory (TESI)Slide26

Identify Trauma Symptoms: Standardized AssessmentTrauma Questionnaire for Adolescents-Revised

Copied with permission from J.

Benamati

, 2002

I avoid thinking about bad things that happened to me.

I have trouble concentrating on things.

I have dreams about the bad things that happened to me.

I feel afraid whenever I think about the bad things that happened to me.

When I have thoughts about these things I cannot control how my feelings are expressed.

I feel like the same bad things are happening all over again.

I get jumpy when I hear loud noises or when there is unexpected activity around me.

I feel alone even when I am with my family and friends.

I feel I will not have a normal life.

I feel my life is in danger. Slide27

Identify Trauma Symptoms: Standardized AssessmentUCLA PTSD Index for DSM-5Pynoos, R., & Steinberg, A. (2013). UCLA PTSD Index for DSM-5.

Child/adolescent

(ages 7 older) and parent-report of

youth symptoms

Most commonly used measure in the field

The score sheet provides instructions for calculating a total PTSD severity score, and severity subscale scores for each of the DSM symptom categories.

Ratings can be used to calculate whether partial or full criteria are met for PTSD diagnosisSlide28

Safely InterveneManaging your client’s trauma responseSlide29

Pediatric PTSD treatment From AACAP Practice Parameter for the Assessment andTreatment of Children and AdolescentsWith Posttraumatic Stress Disorder, 2010

Treatment

planning should incorporate appropriate

interventions

for

comorbid

psychiatric disorders.Trauma-focused psychotherapies

should be considered

first-line treatments

for

adolescents with PTSD.

Treatment

planning should consider a

comprehensive

treatment approach which includes consideration

of the

severity

and

degree of impairment

of the youth’s PTSD symptoms.Medications may be considered for adolescents with PTSD, however there is limited evidence-base to guide medication treatment (Mostly open label and case studies, unclear differences in efficacy of agents for acute/single episode vs. chronic/recurrent trauma, evidence extrapolated from the adult literature).Slide30

Psychotherapy TechniquesSlide31

Trauma Informed PsychotherapyRecognizing and understanding emotionsManaging anxiety, fear and anger

Correcting thinking

Communicating and problem solving

-

Mahoney, Ford,

Ko

, Siegfried, 2004

http://www.nctsnet.org/nctsn_assets/pdfs/edu_materials/trauma_focused_interventions_youth_jjsys.pdfSlide32

First Step to Re-Setting the Brain’s Alarm: SOS (Mental Focusing)Source: Ford, J.D. (2013). The Impact of Trauma on Adolescents: Understanding Survival Mode. Presentation given at the Ohio Family and Domestic Court Judges Annual Training.

Step I: Stop, Slow Down, Sweep Your Mind Clear

Notice how your body feels as you breathe in and out

Let your mind be a river that carries every thought away

Step II: Orient Yourself

Focus your mind on just one thought that you choose

The hope, goal, or relationship that you value most in your life

Step III: Self Check Your Level of Alarm and Focus

How Much Stress? How Much Focused Personal Control?Slide33

7 Steps to Re-Setting Adolescents’ Alarms After Trauma Source: Ford, J.D. (2013). The Impact of Trauma on Adolescents: Understanding Survival Mode.

Presentation

given

at the Ohio

Family and Domestic Court Judges Annual

Training.Slide34

Safety MappingAdolescents draw maps of their neighborhoodsLabel areas where they feel most and least safeMake safety plans based on perceptions of safety in different areas Slide35

Trauma-Focused Psychotherapy for AdolescentsTrauma-Focused Cognitive Behavioral Therapy (TF-CBT)Prolonged Exposure Therapy for Adolescents (PE)Trauma Affect Regulation: Guide for Education and Therapy (TARGET)Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS; adolescent group intervention)Strengthening Families Coping Resources (SFCR; family group intervention)Slide36

PharmacotherapySlide37

WHEN SHOULD MEDICATIONS BE CONSIDERED?Severe symptoms causing impaired functioning Prolonged symptoms (> 1m)Along with TF-CBT to help control symptoms that therapy will evoke or to allow child to access treatmentPatient/family unable or unwilling to participate in psychological and social treatments

Failure of psychological, supportive and family

interventions

Co-morbidity

Slide38

Pharmacotherapy Targets Two Central Roles in PTSD TreatmentTargets disabling symptoms so the child may pursue normal growth and developmental trajectory: Anxiety (separation, fears, hypervigilance, etc…)

Behavior problems (aggression,

etc

…)

Depression,

negative

cognitions, irritability

Impulse control

Sleep problems

Thought irregularities

Concentration/attention

Self-injury

Somatic problems (GI, neuropathic

)

Helps child tolerate emotionally distressing material and enables them to work through their distress in therapy, as well as improving their functionality.Slide39

Approach to Medication Treatment

Literature

extremely limited, few controlled

trials.

No

specific agent

for Pediatric PTSD

Inventory all

symptoms; focus

initial therapy on one or two most distressing

symptoms

Treat

comorbidity

When medications are used, adjunctive psychotherapy is critical to adequately address trauma

experience

39Slide40

Serotonergic AgentsSSRI’s generally considered first line medication intervention because of their broad spectrum of activity.May benefit irritability/mood, anxiety, compulsive & impulsive behaviors.BUT, SSRIs may be overly activating

in some

youth and

lead to

irritability, poor

sleep, or inattention; because these

are symptoms of PTSD hyperarousal, SSRIs may not be optimal medications for these

youth.

P

aroxetine and sertraline have FDA indication for treatment of PTSD

in adults

, none for PTSD in pediatrics.

Slide41

SummaryMost adolescents have experienced a traumatic event; many have experienced multiple traumas. Screening for trauma exposure is recommended for every patient

Wide range of adolescent

responses to

trauma, which can potentially impact every domain of adolescent development

Psychotherapy is first line treatment

Pharmacotherapy literature is limited, but may improve functionality and help adolescents work through their distress in therapySlide42

Questions???