Ilana Berman, B.A. Adele M. Hayes, Ph.D. University of Delaware. Charles Webb, Ph.D. Delaware Division of Prevention and Behavioral Health Services

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1 Ilana Berman, B.A. Adele M. Hayes, Ph.D. University of Delaware Charles Webb, Ph.D. Delaware Division of Prevention and Behavioral Health Services Coders: Beth Ready, Sara Danitz, Ashley Kobovitch, Tifani Biro, Janine Mascari

2 NIMH: R01 MH Adele M. Hayes SAMSHA Grant No. SM57145 Delaware Child Traumatic Stress Treatment Center Grant Nancy Widdoes, Charles Webb Delaware Division of Prevention and Behavioral Health Services University of Delaware Undergraduate Research Program University of Delaware Alumni Association

3 Background Thousands of people experience physical, sexual or emotional abuse, or are exposed to domestic or community violence each year Approximately 25-30% of those individuals develop Post Traumatic Stress Disorder (PTSD) Dose-response relationship for intergenerational transmission This project explores the role of a history of trauma on therapy variables

4 What is PTSD? 3 clusters of symptoms - Re-experiencing symptoms - Emotional numbing/avoidance of reminders - Hyperarousal Symptoms must persist for at least one month Must cause significant distress Risk for other difficulties and co-morbidity Early intervention improves trajectory

5 Effects of Trauma Traumatized people suffer damage to the basic structures of the self (Herman, 1997; Horwitz, Spatz-Widom, McLaughlin & Raskin White,2001; McFarlane & Girolamo, 2000; van der Kolk, 2007) Interpersonal traumas are worse (Charuvasta & Cloitre, 2008; Foa, 1997; Hedtke, Ruggerio, Fitzgerald, Saunders & Resnick, 2008; Pine & Cohen, 2002) Disturbed sense of safety (Herman, 1997; Kallstrom-Fuqua, Weston & Marshall, 2004) Perceptions of stigma, guilt, shame, self-blame (Coffey, Leitenberg, Henning, Turner & Bennett, 1996; van der Kolk, 2007)

6 Recovery Process Cognitive and emotional processing is one of the most important variables in facilitating change (Cohen, Mannarino & Deblinger, 2006; Foa & Kozak, 1986; Sobel, Resick & Rabalais, 2009) Avoidance can inhibit change and mediate the relationship between trauma and psychological distress (Foa & Kozak, 1986; Plumb, Orsillo & Luterek, 2004) Social support is an important factor in the recovery process (Charuvastra & Cloitre, 2008; Guay, Billete & Marchand, 2006) Rumination and unproductive processing can inhibit recovery (Ehring, Frank & Ehlers, 2008; Halligan, Clark & Ehlers, 2007)

7 TF- CBT PRE POST Phase I 1-4 Phase II 5-8 Phase III sessions, 90 minutes Child, Caregiver, Conjoint Supported by eight randomized controlled clinical trials with long-term effects 1-2 years (Mannarino, Cohen & Deblinger, 2006; Wethington, Hahn, Fuqua-Whitely, Sipe & Crosby, 2008)

8 Hypothesis Number of trauma types Support Cognitive/Emotional Processing Avoidance Unproductive Processing

9 METHOD Child participants Eligibility Requirements - Ages 8-16 years old - English- speaking - Under- insured - 3+ PTSD symptoms, score (UCLA PTSD Reaction Index for DSM- IV criteria) Mean age: 12.5 years; SD= % female Ethnically diverse 49% White, 32% African American, 14% Latina, 5% Bi- racial

10 METHOD Caregiver participants 37 Non-offending caregivers - Biological parent (50%) - Other relative (17%) - Foster (33%) 91% Female Mean age = 44.7 years (SD=12.67) Education = 13.3 years (SD=2.45) 62.1% at least part-time employed Mean income = $37,085 (SD=$29,716)

11 METHOD - Measures UCLA PTSD Reaction Index Used to assess Child PTSD DSM-IV Child Version (Pynoos, 1998) Child Wellbeing Initiative Caretaker Interview (2007) - Demographic Info - Mental Health: Depression, Anxiety, Substance use - Traumas experienced: Number of Trauma Types (0-3) Physical abuse Sexual abuse Natural disaster

12 METHOD - Measures CHANGE Coding System for Therapy variables (Hayes, Feldman & Goldfried, 2006) Support Cognitive/Emotional Processing Avoidance Unproductive Processing Inter- rater agreement, 3-6 coders: 87 99% Ratings were averages of 2 sessions from Phase 2 Coders were unaware of caregiver trauma history

13 Therapy Variables - Positive Support From Caregiver Audio Sessions Express concern, care, empathy In relation to trauma, responses, and positive gains Working on therapeutic tasks outside of session Praise, positive encouragement I can t believe how much she s been through. She s so strong

14 Therapy Variables - Positive From Caregiver Audio Sessions Cognitive/Emotional Processing Related to trauma or related events Explores, tries to understand, challenge, make meaning Insight or shift in perspective or meaning Ratings reflect level of processing (not frequency) I guess I couldn t have known the danger was in our own home. I have to stop blaming myself.

15 Therapy Variables - Negative Avoidance Not engaging in goals of TF-CBT - Not responding to questions - Avoiding difficult topics - Changing the topic From Caregiver Audio Sessions - Refusing to participate in therapeutic exercises - Expressing negative views of therapy Can occur in-session or throughout the week He seems to be doing better now. I don t know if we need to dig it up again

16 Therapy Variables - Negative From Caregiver Audio Sessions Unproductive Processing Approaches a problem, explores, tries to understand Gets stuck repetitively thinking about/analyzing problem No significant insight Can also occur across time (not just in session) I can t stop thinking about everything I could have done to protect her. I am haunted by knowing that I could have prevented this.

17 RESULTS Caregiver Trauma History Physical abuse = 62.9% Domestic Violence = 48.6% Sexual abuse = 45.7% Natural disaster = 42.9% No traumas = 10.8% One type = 48.6% Two types = 21.6% Three types = 18.9%

18 RESULTS - Intercorrelations Note: *p<0.05 **p<0.01 Analyzed using Pearson Correlations

19 RESULTS - Correlations Number of trauma types 0.340* Support Cognitive/Emotional Processing 0.370* Avoidance ** ** Unproductive Processing

20 DISCUSSION - Conclusions Depression was not associated with a history of trauma Trauma is prevalent in caregivers (of children who experienced trauma) Trauma history is not associated with Support or Cognitive and Emotional Processing Trauma history is associated with Avoidance and Unproductive Processing Avoidance is a frequent response to trauma reminders - Overwhelming physiological and emotional responses Avoidance and Unproductive Processing are associated with the level of Support provided

21 DISCUSSION - Implications Caregivers with unresolved trauma histories have difficulty addressing trauma topics (even child s) Caregivers may need time to process own traumas Important: Children in TF-CBT treatment will most likely become caregivers

22 RESULTS Not correlated Type of trauma, individually Depressive symptoms (self-reported) Relation of caregiver to child - Birth parent or not - Involved at the time of trauma If caregiver trauma history reflected child s trauma Not enough power to assess trauma vs. no trauma

23 Limitations No control condition (caregiver trauma) Caregivers voluntarily participate in treatment Non-clinical depression measure Caregivers are mostly female Sessions audio-taped Underinsured = Usually low socioeconomic status

24 Future Studies Examine therapy variables at Phase 1 for comparison Factors of trauma (age, # of instances, severity) Clinical evaluation of caregivers - PTSD and Psychopathology (depression) Emotional trauma history Other stressful life events

25 Thank you! Questions?