Assessment and Treatment of Child Trauma Symptoms in Children and Adolescents

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Assessment and Treatment of Child Trauma
Symptoms in Children and Adolescents

• Ally Burr-Harris, Ph.D.
• Center for Trauma Recovery
• Greater St. Louis Child Traumatic Stress Program
• University of Missouri St. Louis
• Overview
• Revised October 26, 2004

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Greater St. Louis Child Traumatic Stress Program

• Free trauma-related assessment and treatment of
  children
• Cognitive-behavioral, family systems treatment
  orientation
• Consultation/training for professionals
• School-based group therapy for children/adolescent
  s exposed to violence
• National Child Traumatic Stress Network
  (NCTSN) www.nctsnet.org

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Types of Traumas

• Natural disasters
• Kidnapping
• School violence
• Community violence
• Terrorism/war
• Homicide
• Physical abuse

• Sexual abuse
• Domestic violence
• Medical procedures
• Victim of crime
• Accidents
• Suicide
• Extreme neglect or deprivation

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Trauma Rates

• 69 of the general U.S. population report
  exposure to traumatic event(s)
• 14 to 43 of children/adolescents report having
  experienced a trauma
• Up to 91 of African American youth in urban
  settings report violence exposure
• Among refugee children, rates of trauma exposure
  approach 100

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Protective Factors for Post-Trauma Adjustment

• Strong academic and social skills
• Active coping, self-confidence
• Social support
• Family cohesion, adaptability, hardiness
• High neighborhood/school quality
• Strong religious beliefs, cultural identity
• Effective coping and support by parents

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Risk Factors for Post-Trauma Adjustment Problems

• Severity of trauma
• Extent of exposure
• History of other multiple stressors
• Proximity of trauma
• Preexisting psychopathology
• Interpersonal violence
• Personal significance of trauma
• Separation from caregiver
• Extent of disruption in support systems
• Lack of material/social resources
• Parent psychopathology parent distress
• Genetic predisposition

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Spaccarelli (1994)
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Developmental Differences in Trauma Symptoms

• Infants and Toddlers
• (0 to 3)
• Preschool Children
• (4 to 6)
• School-Age Children (7 to 12)
• Adolescents
• (13 to 18)

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Infants and Toddlers

• Pattern A Withdraws, rejects affection, stops
  exploring environment, lacks trust in others,
  appears unattached
• Pattern B Clingy, anxious, sleep disturbances,
  toileting problems, temper tantrums, regressed,
  disorganized, rages/aggression, crying
  irritability

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Preschool Children

• Regressive behaviors
• Separation fears
• Eating and sleeping disturbances
• Physical aches and pains
• Crying/irritability
• Appearing frozen or moving aimlessly
• Perseverative, ritualistic play
• Reenactment of trauma themes
• Fearful avoidance and phobic reactions
• Magical thinking related to trauma

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School-Age Children

• Sadness, crying irritability, aggression
• Nightmares
• Trauma themes in play/art/conversation
• School avoidance, failure
• Physical complaints
• Concentration problems
• Regressive behavior
• Eating/sleeping changes
• Attention-seeking behavior
• Withdrawal

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Adolescents

• Similar to adult response to trauma
• Feelings of shame/guilt
• Increased risk-taking behaviors
• Withdrawal from peers/family
• Pseudomature behaviors
• Substance abuse
• Delinquent behaviors
• Change in school performance
• Self-destructive behaviors

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When Stress Symptoms Become a Disorder

• Acute Stress Disorder (ASD)
• Posttraumatic Stress Disorder (PTSD)
• Depression
• Anxiety
• Attachment Problems
• Behavior Problems

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Diagnosis of PTSD

• Criterion A1 Person experienced, witnessed, or
  was confronted with a traumatic event(s) that
  involved actual or threatened death or serious
  injury, or a threat to the physical integrity of
  self/others.
• Criterion A2 The persons response involved
  intense fear, helplessness, or horror.

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B. Re-experiencing Symptoms

• Recurrent, intrusive, distressing memories
• Recurrent, distressing dreams
• Acting or feeling as if trauma is recurring
• Intense distress at exposure to trauma cues
• Physiological reactivity upon cue exposure
• Need 1 Criterion B symptom for diagnosis

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C. Avoidance Symptoms

• Efforts to avoid thoughts, feelings, or
  conversations associated with trauma
• Efforts to avoid reminders of trauma (activities,
  places or people)
• Inability to recall important aspects of trauma
• Diminished interest/participation in activities
• Feeling detached or estranged from others
• Restricted range of affect
• Sense of foreshortened future
• Need 3 Criterion C symptoms for diagnosis

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D. Arousal Symptoms

• Sleep difficulties
• Irritability
• Angry outbursts
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
• Need 2 Criterion D symptoms for diagnosis

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Other Diagnostic Requirements

• Criterion E. Symptoms must be present for at
  least one month since the event.
• Criterion F. Disturbance causes clinically
  significant distress or impairment in social,
  occupational or other areas of functioning.
• Subtypes Acute (lt3 months) Chronic
  (gt3 months) Delayed (onset post 6 months)
  

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Prevalence of PTSD

• Lifetime prevalence for PTSD 1 to 14 (APA,
  1994)
• Approximately 25 of individuals exposed to acute
  trauma will develop symptoms of PTSD (Pine
  Cohen, 2002).
• 3 to 15 of girls and 1 to 6 of boys exposed to
  trauma could be diagnosed with PTSD
• 6 to 8 of children in U.S. will develop PTSD
  during childhood.
• For severe, chronic, or interpersonal traumas,
  rates of PTSD are as high as 90 (Hamblen, 2002).
• Underdiagnosed in young children

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Natural Course of PTSD

• Complete recovery in 50 of PTSD cases after
  three months
• Between 25 and 50 of PTSD cases are likely to
  have chronic PTSD without intervention.
• Chronic PTSD predictors Severe acute trauma,
  high trauma exposure, repeated abuse, and
  interpersonal violent trauma

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Other Stress-Related Disorders

• 80 of people with PTSD also meet criteria for
  another mental disorder
• Other disorders include adjustment disorder,
  depression, separation anxiety, general anxiety,
  attachment disorders, ADHD, and other behavior
  disorders.

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Differential Diagnosis andComorbidity with PTSD

• Differential Diagnoses
• Adjustment Disorder, Acute Stress Disorder,
  psychotic disorders, OCD, ADHD, BPD, Bipolar
  Disorder
• High Comorbidity Diagnoses
• Mood Disorders (MDD, Dysthymic Disorder)
• Substance Abuse
• Anxiety Disorders (Panic Disorder, GAD, OCD)
• Behavior Disorders (ADHD, ODD, CD)
• Personality Disorders (particularly BPD)

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Attachment Explanation

• Innate drive to survive
• Baby seeks closeness to caregiver for safety and
  comforting
• When caregiver responsive and attuned, child is
  secure and caregiver becomes secure base
• When caregiver inconsistent, unresponsive, or
  dangerous... child adapts

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Insecure Attachment Adaptations

• Inconsistent caregiver
• whiney, clingy, demanding, angry
• Unresponsive caregiver
• aloof, distant, unaffectionate, indiscriminately
  friendly
• Dangerous caregiver
• manipulative, sneaky, lying, superficial
  emotionality

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When Trauma Interferes with Attachment

• Pervasive Neglect and Persistent Disruption in
  Caregiving
• Chronic institutionalization and/or neglect
• RAD, Inhibited Type
• Doesnt attach withdraws
• Multiple placements
• RAD, Disinhibited Type
• Attaches indiscriminantly/superficially

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When Trauma Interferes with Attachment

• Fear Related to the Caregiver
• Frightening caregiver (child abuse)
• Hypercompliant, frozen watchfulness
• Frightened caregiver (domestic violence)
• Dysfunctional/erratic attention-seeking (not
  comfort-seeking) from distressed, unreliable
  caregiver

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When Trauma Interferes with Attachment

• General Acute Trauma
• Disrupted attachment is usually temporary and
  responsive to treatment
• Possible behaviors Clingy, whining, separation
  anxiety, stranger anxiety, hypervigilance, frozen
  watchfulness, excessive worry about well-being of
  others, resists leaving secure places

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Assessment Protocol forChildren and Adolescents

• Assess for trauma symptoms, behavior problems,
  cognitive distortions, functional impairment,
  attachment to caregiver, family functioning,
  strengths, and resources
• Direct clinical interview with child and
  non-offending parent/caretaker
• Behavioral observation (child play, parent-child
  interaction, parenting skills)
• Direct questioning about trauma exposure
• Consider including self/other-report measures to
  assess for trauma symptoms, behavior problems,
  depression, and cognitions

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Assessment of Attachment Problems in Preschoolers

• Caregiver - emotional availability,
  nurturance-warmth-sensitivity, protection,
  provision of comfort
• Child - emotional regulation, trust-security,
  vigilance-self protection, comfort-seeking,
  showing affection, cooperation, exploratory
  behavior, controlling behavior, ability to
  separate, reunion responses
• Need to assess in natural and clinical settings
  across each major attachment figure

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Assessment of PTSD in Preschoolers

• Observation during free play with parent,
  compliance situation, therapist-guided play with
  trauma themes
• Measures of PTSD
• Trauma Symptom Checklist for Young Children
  (TSC/YC) - ages 3 to 12
• Levonn - preschoolers
• Checklist for PTSD Symptoms in Infants and Young
  Children - ages 0 to 3
• PTS Inventory for Children - ages 4 to 8

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Screening for PTSD in Children and Adolescents

• UCLA PTSD Index, Revision I (Pynoos, Rodriguez,
  Steinberg, et al., 1998) Parent/child report
  measure, school-age
• Child PTSD Symptom Scale (CPSS Foa, Treadwell,
  Johnson et al., 2001) 17-item child interview or
  self-report measure for school-age
• Trauma Symptom Checklist for Children (TSCC,
  Briere, 1995) 44-item self-report for school-age
• Trauma Symptom Checklist for Young Children
  (TSC/YCBriere et al., 2001) 90-item
  parent-report for ages 3 to 12

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Trauma Exposure Measuresfor Children and
Adolescents

• Traumatic Event Screening Inventory (TESI Ford,
  1996) Child/parent interview or checklist
• TESI - Parent Report Revised (Ghosh Ippen et al.,
  2002) Brief parent-report or interview format
• UCLA PTSD Index, Revision I (Pynoos, Rodriguez,
  Steinberg, et al., 1998) Parent/child report
  measure, school-age

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Evidence-Based Treatments for Child Trauma

• Trauma-Focused Cognitive Behavioral Therapy
  (TF-CBT)
• Parent-child
• Group
• Family
• Parent Child Interaction Therapy (PCIT)
• Multisystemic Therapy (MST)

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TF-CBT Treatment Objectives

• Break associations between negative feelings and
  trauma cues
• Increase tolerance of trauma thoughts and
  memories
• Decrease reliance on maladaptive coping
• Facilitate processing of trauma
• Correct trauma-related distortions
• Model (therapist, parent) effective coping
• Reinforce (therapist, parent) positive coping and
  respond effectively to behavior problems

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Trauma-Focused CBTAdvantages of Model

• Applicable to wide array of symptoms
• Flexible (cognitive, behavioral,
  emotional-processing techniques)
• Approach made explicit to client
• Collaborative, empowering
• Coping skills can be applied to non-trauma
  difficulties
• Active, directive, structured approach is
  effective and preferred by minority groups
• Empirically supported

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Appropriate TFCBT Clients

• Functioning at 3 years or higher
• PTSD symptoms
• Trauma-related confusion or misconceptions
• Best for ages 3 to 13 - need to adapt for
  adolescents and for preschoolers
• Substantiated abuse/trauma
• Parents (nonoffending) able to participate

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Inappropriate TFCBT Clients

• Psychotic symptoms
• Substance dependence/abuse
• Suicidal intent, high self-harm risk
• Questionable validity of abuse/trauma

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Course of Treatment

• Short-term (Averageassessment phase plus 12
  treatment sessions)
• Divided individual sessions for child and parent
  initially
• Joint sessions begin once parents symptoms have
  decreased and coping skills are improved

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Trauma-Focused CBT Components

• Psychoeducation
• Ensuring Environmental Safety
• Stress Inoculation Training (coping skills)
• Gradual Exposure
• Affective and Cognitive Processing
• Safety Skills
• Parental Involvement
• Behavior Management Skills Training
• Family Sessions

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Psychoeducation

• Common reactions to trauma (parent, child)
• PTSD in children
• Accurate trauma-related information
• Self-care after trauma supporting child
• Purpose, rationale, estimated length, typical
  course of treatment
• Ensuring safety
• Healthy discipline Healthy sexuality
• Appropriate developmental expectations

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Stress Inoculation Training (SIT)

• Goal Reduce physiological stress reactions to
  trauma reminders
• Techniques
• Deep breathing
• Mindfulness, visual imagery
• Progressive muscle relaxation
• Thought-stopping/replacement
• Cognitive coping skills (positive focus)

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Gradual Exposure (GE)

• Goal Increase tolerance for upsetting memories
  and decrease avoidance of nonharmful trauma cues
• Techniques
• Hierarchical exposure starting from moderate
  distress and working toward extreme distress
• Modalities play, art, visualization, narratives,
  drama, in vivo exposure if appropriate
• Reduce arousal through reprocessing and
  elaboration across sessions
• SIT skills as needed during GE

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Affective and Cognitive Processing (CP)

• Goal Increase ability to identify thoughts,
  feelings, behaviors Challenge distorted or
  hurtful thoughts
• Techniques
• Feeling Identification and Expression
• Cognitive Triangle
• Practice generating helpful thoughts
• Identify trauma-related inaccurate or unhelpful
  thoughts
• Model helpful trauma-related thoughts
• Correct distortions

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Common Trauma-Related Cognitive Distortions

• Self-blame
• Guilt, survivor guilt
• Shame/embarrassment b/c of trauma or symptoms
• Hero fantasies related to trauma
• Overgeneralization of danger/risk
• Minimization of trauma
• Omen formation
• Foreshortened future
• Magical thinking

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Safety Skills

• Recognize dangerous situations
• Good touch/bad touch (SA cases)
• Problem-solving skills
• Support-seeking skills
• Calming skills if risk of self-injury
• Present carefully so as not to blame
• Develop safety plan

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Parental Involvement in Treatment

• Assessment feedback
• Psychoeducation
• Parallel work in areas of SIT, GE, and CP
• Parenting Skills Building, Behavior Mgmt.
• Joint parent-child sessions
• Continuation of GE and CP jointly
• Parent models positive coping with trauma
• Parent assumes role of therapist as childs
  supporter related to trauma

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Behavior Management

• Caregiver interventions
• Anger control skills with child
• Skills training (problem-solving, social skills,
  communication)
• Specific behavior plans (sleep problems, sexual
  behavior problems)
• Intervene in relevant systems

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Traumatic Bereavement

• PTSD in the case of traumatic loss often impedes
  the grieving process. The person focuses on the
  traumatic death rather than the loss.
• After exposure, additional treatment components
  include recognition/acceptance of the loss,
  positive reminiscing, coping with future loss
  reminders, and addressing conflicting thoughts
  about the deceased.

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Group TF-CBT

• Same components as Individual CBT
• Members need to have similar level/type of trauma
  exposure
• Provides opportunity for social skills-building,
  peer feedback, and stigma reduction
• Advantageous if large-scale trauma or school
  setting with high violence rate
• Modules include traumatic bereavement
• Example CBITS (Jaycox, 2004)

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Trauma-Focused (TFCBT)Family Therapy

• Goal Facilitate family members ability to
  support one another in trauma recovery
• Advantageous when trauma affects entire family or
  when trauma cues are brought on by family members
• Need to consider how family members symptoms
  affect one another (reexperiencers vs. avoiders)
  in designing interventions
• FT-for externalizing symptoms
• IT-for internalizing symptoms
• TF-CBT criticism - lacks family systems focus

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Empirical support for TF-CBT

• TF-CBT (individual, group) - 13 randomized
  trials, mostly with SA samples - treatment
  effects for PTSD symptoms, depression, behavior
  problems, social competence, parental distress,
  and parental support
• TF-CBT effects gt nondirective play therapy,
  supportive therapy, child-centered therapy
  effects
• Parent involvement improved childs symptoms
  (depression, ext. behavior), even when child not
  involved in tx
• School-based groups- treatment effects for PTSD,
  grades, classroom behavior
• SIT, GE alone also effective
• Family and individual modalities both effective

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Parent-Child Interaction Therapy (PCIT)

• Goal Parent-child relationship enhancement
  increase childs compliance increase positive
  parenting skills decrease parents abuse risk
• For children ages 2-12
• Short-term (12 to 14 sessions)
• Involves active live coaching of parent and
  overlearning of positive parenting behaviors
• Integrates play therapy techniques and operant
  conditioning

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PCIT Components

• Child Directed Interaction (CDI)
• Praise, Reflect, Imitate, Describe, Enthusiasm
  (PRIDE) skills
• Parent Directed Interaction (PDI)
• Behavior management-reward praise, clear
  directions, time outs for noncompliance

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Empirical support for PCIT

• PCIT lowered parent abuse potential more than
  parenting group intervention
• Treatment effects for child compliance, decreased
  opposition, improved parenting skills (up to 6
  years follow-up)
• Improved attachment between parent and child
• Criticism no trauma resolution

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Multisystemic Therapy (MST)

• Intensive, in-home family therapy that focuses on
  solving problems within multiple systems
• Cognitive behavioral, behavioral, and pragmatic
  family therapy interventions
• Goals include improving caregiver discipline
  practices, enhancing family affective relations,
  decreasing youth antisocial behavior, improving
  prosocial involvement, and development of social
  support for family
• Used in abuse populations, but target population
  is antisocial, violent adolescents

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Empirical support for MST

• Reduced antisocial behavior, improved family
  cohesion, decreased aggression with peers,
  decreased out-of-home placements across multiple
  research sites
• Criticism No trauma resolution

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Other Treatments for PTSD

• Group therapy (supportive, psychoeducational)
• Psychodynamic therapy
• Eye Movement Desensitization and Reprocessing
  (EMDR)
• Pharmacotherapy (SSRIs)
• Psychological Debriefing
• Play therapy
• Creative therapies (art, drama, music)
• Hypnosis

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Empirical Support for other PTSD Treatments

• EMDR research inconclusive treatment effects may
  be due to cognitive processing component
• Holding therapy not empirically supported
• Massage therapy after acute trauma resulted in
  lower PTSD symptoms in one controlled study
• Therapeutic preschool for abused children
  resulted in improved social skills and
  developmental gains
• Addition of grief resolution component enhances
  TFCBT effects in cases of traumatic bereavement
• Critical Incident Stress Debriefing does not
  lower post-traumatic stress symptoms
• Limited research on other interventions

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TF-CBT References

• Deblinger, E., Heflin, A. H. (1996). Treating
  Sexually Abused Children and Their Nonoffending
  Parents A cognitive Behavioral Approach. Sage
  Publications, Inc. Thousand Oaks, CA.
• Cohen, J. A., Mannarino, A. P., Deblinger, E.
  (2001). Child and Parent Trauma-Focused Cognitive
  Behavioral Therapy Treatment Manual. Allegheny
  General Hospital, Center for Traumatic Stress in
  Children and Adolescents.

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PCIT and MST References

• www.pcit.org
• www.mstservices.com

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Were Done!

• For additional questions, references, or
  referrals, contact Ally Burr-Harris, Ph.D.
• Phone [phone]
• Email Burrharrisa_at_msx.umsl.edu