DSM-V Update on Child Trauma-Related Diagnoses

Transcription

1 DSM-V Update on Child Trauma-Related Diagnoses Susan R. Schmidt, PhD Center on Child Abuse and Neglect OU Health Sciences Center Training materials may not be reproduced without permission of the material developers. Training materials may not be reproduced without permission of the material developers. 1

2 Developmental Impacts Of Childhood Trauma 2 Training materials may not be reproduced without permission of the material developers. 2

3 Child/Individual Stressors Parental/Family Stressors Sources of Resilience Physiological Stress Other Vulnerabilities Positive Brief & mild elevations in heart rate and stress hormone Tolerable Serious, temporary stress responses buffered by supportive relationships Toxic Prolonged activation of stress response system Traumatic Alterations From Helping Foster and Adoptive Families Cope with Trauma. American Academy of Pediatrics, 2013, & Training materials may not be reproduced without permission of the material developers. 3

4 Trauma and Children Trauma Exposure PTSD Significant Factors Impacting Long Term Response: Exposure Frequency & Severity Number of Direct Losses Time Since Trauma Parent Distress and Overall Functioning Social Supports Training materials may not be reproduced without permission of the material developers. 4

5 Trauma inhibits development of the hippocampus and prefrontal cortex areas managing executive functioning: -Working Memory -Inhibitory Control -Cognitive Flexibility 5 Training materials may not be reproduced without permission of the material developers. 5

6 DSM IV Version Re-Experiencing Recurrent/intrusive thoughts and images Flashbacks Nightmares about trauma (any nightmares in kids) Traumatic play Reactivity to cues Avoidance Numbing Detachment Avoiding reminders Difficulty recalling events of trauma Diminished activity interest Foreshortened future Hyperarousal Jumpy Hypervigilant Startle Response Difficulty Concentrating Sleep trouble Irritable Training materials may not be reproduced without permission of the material developers. 6

7 DSM 5 Revision Tightening A1 criterion Eliminating A2 criterion 3 new symptoms clarification of others 4 symptom clusters Special criteria for preschoolers Dissociative subtype Training materials may not be reproduced without permission of the material developers. 7

8 DSM 5 Revision A: Trauma Exposure Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders) NOTE: A4 Doesn t apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Training materials may not be reproduced without permission of the material developers. 8

9 DSM 5 Revision B: Re-Experiencing 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). NOTE: May be non-specific nightmares in children. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Symptoms may occur on a continuum. NOTE: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Training materials may not be reproduced without permission of the material developers. 9

10 DSM 5 Revision C: Avoidance 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Training materials may not be reproduced without permission of the material developers. 10

11 After a while you begin to almost lose the physical capacity for fear. Explosions go off. You cease to jump or flinch This is not to say the terror goes away. It simply moves out from the twitching muscles and nerves in your body and takes up residence in your mind. If you feed it with morbid thoughts of all the terrible ways you could be maimed or die, it gets worse. It also gets worse if you think about pleasant things. Good memories or plans for the future just remind you how much you don't want to die or get hurt. It's best to shut down, to block everything out. But to reach that state, you almost have to give up being yourself. -- Evan Wright, Generation Kill: Devil Dogs, Iceman, Captain America and the New Face of American War Training materials may not be reproduced without permission of the material developers. 11

12 DSM 5 Revision D: Negative alterations in cognitions and mood that are associated with the traumatic event 1. Inability to remember an important aspect of the traumatic event(s) 2. Persistent & exaggerated negative beliefs or expectations about one s self, others or the world (e.g., I am bad, no one can be trusted, my whole nervous system is permanently ruined ). 3. Persistent distorted blame of self or others about the cause or consequences of the traumatic event (e.g., selfblame). 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., happiness, satisfaction, love). Training materials may not be reproduced without permission of the material developers. 12

13 DSM 5 Revision E: Alterations in Arousal & Reactivity 1. Irritable or aggressive behavior (e.g., yelling at other people, getting into fights or destroying things). 2. Reckless or self-destructive behavior (e.g., driving too fast or while intoxicated, heavy substance use, risky sexual behavior, or attempted self harm). 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Training materials may not be reproduced without permission of the material developers. 13

14 DSM 5 Revision F. Disturbance is over 1 month in duration. G. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. Disturbance is not attributable to physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Training materials may not be reproduced without permission of the material developers. 14

15 DSM 5 Revision Specify if: 1. With dissociative symptoms: Depersonalization Feeling detached from one s mental processes or body(e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). 2. With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). Training materials may not be reproduced without permission of the material developers. 15

16 DSM 5 Revision For children 6 and under Training materials may not be reproduced without permission of the material developers. 16

17 DSM 5 Revision For children 6 and under A: Trauma Exposure Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure. NOTE: Witnessing doesn t apply to exposure through electronic media, television, movies, or pictures. Training materials may not be reproduced without permission of the material developers. 17

18 DSM 5 Revision For children 6 and under B: Re-Experiencing 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). NOTE: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). NOTE: May be non-specific nightmares in children. 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. Symptoms may occur on a continuum. NOTE: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). Training materials may not be reproduced without permission of the material developers. 18

19 DSM 5 Revision For children 6 and under C: Avoidance or Negative Cognitions and Mood Persistent Avoidance of Stimuli: 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Negative Alterations in Cognitions: 1. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 2. Markedly diminished interest or participation in significant activities. 3. Socially withdrawn behavior. 4. Persistent reduction in expression of positive emotions. Training materials may not be reproduced without permission of the material developers. 19

20 DSM 5 Revision For children 6 and under D: Alterations in arousal and reactivity 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). 2. Hypervigilance. 3. Exaggerated startle response. 4. Problems with concentration. 5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Training materials may not be reproduced without permission of the material developers. 20

21 Training materials may not be reproduced without permission of the material developers. 21

22 DSM 5 Revision For children 6 and under Specify if: 1. With dissociative symptoms: Depersonalization Feeling detached from one s mental processes or body(e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). 2. With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate. Training materials may not be reproduced without permission of the material developers. 22

23 DSM 5 Revision Acute Stress Disorder PTSD A Criterion No mandatory symptoms from any cluster 9 or more of the following: -Intrusion (4) -Negative mood (1) -Dissociative (2) -Avoidance (2) -Arousal (5) Training materials may not be reproduced without permission of the material developers. 23

24 DSM 5 Revision Trauma-Related Diagnoses Reactive Attachment Disorder Highly uncommon diagnosis 10% prevalence in severely neglected young children A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, including both: 1. The child rarely or minimally seeks comfort when distressed. 2. The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: 1. Minimal social and emotional responsiveness to others. 2. Limited positive affect 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident during nonthreatening interactions with adult caregivers. Training materials may not be reproduced without permission of the material developers. 24

25 DSM 5 Revision Trauma-Related Diagnoses Reactive Attachment Disorder C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation of basic emotional needs for comfort, stimulation, and affection by caregivers. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments 3. Rearing in unusual settings that severely limit opportunities to form attachments (e.g., institutions with high child-to-caregiver ratios) D. Care is presumed to be responsible for behavior. E. Criteria aren t met for autism spectrum disorder. F. Disturbance is evident before age 5 G. Child has developmental age of at least 9 months Training materials may not be reproduced without permission of the material developers. 25

26 DSM 5 Revision Trauma-Related Diagnoses Disinhibited Social Engagement Disorder Highly uncommon diagnosis 20% prevalence in severely neglected young children Diagnosed in children from age 2 through adolescence. A. A consistent pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. 2. Overly familiar verbal or physical behavior (that is inconsistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. Training materials may not be reproduced without permission of the material developers. 26

27 DSM 5 Revision Trauma-Related Diagnoses Disinhibited Social Engagement Disorder B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but include socially disinhibited behavior. C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation of basic emotional needs for comfort, stimulation, and affection by caregivers. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments 3. Rearing in unusual settings that severely limit opportunities to form attachments (e.g., institutions with high child-to-caregiver ratios) D. Care is presumed to be responsible for behavior. E. Child has developmental age of at least 9 months Training materials may not be reproduced without permission of the material developers. 27

28 DSM 5 Revision Trauma-Related Diagnoses Dissociative Identity Disorder Highly uncommon diagnosis; 1.5% prevalence in adults May manifest from childhood to late life. A. Disruption of identity characterized by 2 or more distinct personality states. B. Recurrent gaps in the recall of traumatic and everyday events. C. Symptoms cause clinically significant distress or impairment. D. Disturbance isn t part of a broadly accepted cultural or religious practice. E. Symptoms aren t attributable to substance use or a medical condition. Training materials may not be reproduced without permission of the material developers. 28

29 DSM 5 Revision Trauma-Related Diagnoses Dissociative Amnesia Highly uncommon diagnosis; 1% prevalence for males 2% for females. May manifest from childhood to late life. A. An inability to recall personal information, usually trauma-related, that is inconsistent with ordinary forgetting. B. Symptoms cause clinically significant distress or impairment. C. Disturbance not attributable to substance use, or a neurological or medical condition. D. Disturbance not better explained by dissociative identity disorder, PTSD, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder. Training materials may not be reproduced without permission of the material developers. 29

30 DSM 5 Revision Trauma-Related Diagnoses Depersonalization/Derealization Disorder Common experience, with up to ½ of adults having at least one episode. But, only around 2% of adults meet full criteria. Mean age of onset is 16, but can start in early or middle childhood. A. Presence of persistent or recurrent experiences of depersonalization, derealization, or both: A. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one s thoughts, feelings, sensations, body, or actions. B. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., unreal, dreamlike, foggy, lifeless, or visually distorted). B. During the experiences, reality testing remains intact. C. Symptoms cause clinically significant distress or impairment. D. Not attributable to substance use or a medical condition. E. Disturbance isn t better explained by schizophrenia, panic disorder, major depressive disorder, acute stress disorder, PTSD, or another dissociative disorder. Training materials may not be reproduced without permission of the material developers. 30

31 Training materials may not be reproduced without permission of the material developers

32 Child Trauma Screening and Assessment 32 Training materials may not be reproduced without permission of the material developers. 32

33 Be sure to screen for trauma exposure and assess for trauma-related symptoms before diagnosing: Bipolar Disorder Attention Deficit Hyperactivity Disorder Reactive Attachment Disorder Oppositional Defiant Disorder How do these diagnoses impact: Adults perceptions of children s: Behavioral motives? Developmental potential? Placement decisions? Treatment decisions (including medication referrals)? Training materials may not be reproduced without permission of the material developers. 33

34 Useful Internet Sites on Child Trauma Screening and Assessment NCTSN Database of information on instruments for use with children and adolescents California Evidence Based Clearinghouse for Child Welfare: Screening and Assessment Tools for Child Welfare tools/ The Chadwick Center Downloadable manual: Assessment based Treatment for Traumatized Children: A Trauma Assessment Pathway Training materials may not be reproduced without permission of the material developers. 34

35 Trauma Assessment Considerations Overall Child Functioning Internalizing & Externalizing Symptom Overview Examples: CBCL BASC Pediatric Symptom Checklist (free) Trauma Exposure Examples: UCLA PTSD Symptom Scale, Part 1 Life Events Checklist (free) Training materials may not be reproduced without permission of the material developers. 35

36 Trauma Assessment Considerations Posttraumatic Stress Symptoms Examples: UCLA PTSD Symptom Scale, Part 2 Trauma Symptom Checklist for Children (Briere) Trauma Symptom Checklist for Young Children (Briere) Child PTSD Symptom Scale (Foa; free) Clinician Administered PTSD Scale (CAPS CA; free) Specialized Measures Examples: Child Dissociation Checklist (free) Child Sexual Behavior Inventory Parent functioning and PTS exposure/symptoms (see Center for PTSD for free measure) Cognitive functioning/development Training materials may not be reproduced without permission of the material developers. 36

37 Treating Child Trauma Training materials may not be reproduced without permission of the material developers. 37

38 MISSION: Building resilience and facilitating recovery. Training materials may not be reproduced without permission of the material developers. 38

39 Mission: To raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. Training materials may not be reproduced without permission of the material developers. 39

40 40 Training materials may not be reproduced without permission of the material developers. 40

41 Trauma Focused Cognitive Behavioral Therapy Judith A. Cohen, M.D. Anthony P. Mannarino, Ph.D. Allegheny General Hospital, Pittsburgh, PA Center for Traumatic Stress in Children and Adolescents Esther Deblinger Ph.D. New Jersey Child Abuse Research Education and Services Institute Training materials may not be reproduced without permission of the material developers. 41

42 Trauma-Focused CBT Target symptoms: PTSD, depression, anxiety, and behavioral symptoms secondary to trauma. TF-CBT treats: Children ages 3-18 All types of traumas With or without parental participation In schools, group home, foster home and in-home settings. Most commonly provided to child and parent in clinical settings. 42 Training materials may not be reproduced without permission of the material developers. 42

43 TF CBT Treatment Elements Teaching children emotional expression, relaxation and stress management skills Creating a coherent narrative or story of what happened Correcting untrue or distorted ideas about what happened and why Changing unhealthy and wrong views that have resulted from the trauma Involving parents in creating optimal recovery environments Training materials may not be reproduced without permission of the material developers. 43

44 TF-CBT Resources TF-CBT Consult A consultation tool for Trauma-Focused Cognitive-Behavioral Therapy cbt consult/index.php CTG Web A web-based learning course for Using TF-CBT with Child Traumatic Grief CPT Web A web-based learning course for Using Cognitive Processing Therapy Training materials may not be reproduced without permission of the material developers. 44

45 Over 80% of children in TF-CBT show significant PTSD symptom improvement within 12 to 16 weekly 60- to 90- minute sessions. Significant TF-CBT Child Outcomes Reductions in: 1: Child behavior problems 2: Child symptoms of PTSD 3: Child depression 4: Child feelings of shame Training materials may not be reproduced without permission of the material developers. 45

46 Training materials may not be reproduced without permission of the material developers. 46

47 "The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen. Elisabeth Kübler Ross, M.D. Training materials may not be reproduced without permission of the material developers. 47

48 Contact Information Center on Child Abuse and Neglect University of Oklahoma Health Sciences Center Susan Training materials may not be reproduced without permission of the material developers. 48