PTSD PREVENTION. Brooks Keeshin, MD, FAAP Assistant Professor, University of Utah Department of Pediatrics

Transcription

1 PTSD PREVENTION Brooks Keeshin, MD, FAAP Assistant Professor, University of Utah Department of Pediatrics

2 Who is going to get PTSD? Maria 12 years old Fine Abby 10 years old PTSD and GAD Lisa 16 years old Severe PTSD/panic Jim 5 year old Aggression/opposition Donny 15 year old Bereavement Janet 18 years old PTSD with dissociation

3 Objectives Review the diagnostic criteria for PTSD Discuss common reaction patterns to traumatic experiences Explore psychological and biological theories on PTSD and trauma symptom development Identify different patterns of resilience and methods to prevent the development of PTSD and other trauma related sequelae

4 A BRIEF OVERVIEW OF THE DIAGNOSIS OF PTSD IN CHILDREN & ADOLESCENTS IN DSM 5

5 Pediatric PTSD Approximately 5% of children meet criteria for PTSD at some point during childhood Child abuse is highly associated with PTSD Predisposing factor sets up child with subsequent trauma Precipitating factor primary traumatic event Perpetuating factor continued lack of safety PTSD diagnosis in DSM IV is based on adult trauma Challenging to apply to children Challenging for chronically abused DSM 5 revised diagnostic criteria for PTSD New criteria Subtypes

6 Criteria A Threatened death, serious injury or sexual violence 1. Direct experience 2. Witnessing in person 3. Learning event occurred 4. Experiencing repeated/extreme details of event

7 Criteria B Intrusion Symptoms 1. Memories 2. Dreams 3. Flashbacks 4. Psychological distress after exposure to cue 5. Physical distress after exposure to cue

8 Criteria C Avoidance 1. Avoidance of memories, thoughts or feelings 2. Avoidance of external reminders

9 Criteria D Negative alterations in cognition and mood 1. Poor memory of event 2. Negative beliefs towards self 3. Self blame 4. Persistent negative emotional state 5. Loss of interest 6. Detachment 7. Lack of positive emotions

10 Criteria E Increased arousal and reactivity 1. Irritable and angry 2. Reckless and self-destructive behavior 3. Hypervigilance 4. Exaggerated startle 5. Poor concentration 6. Sleep disturbances

11 Dissociation 1. Depersonalization 2. Derealization

12 PTSD under 7 qualifier Criteria A Criteria C + D Criteria E PTSD under 7 symptoms Experiencing repeated/extreme details of event Poor memory of event Negative beliefs towards self Self blame Detachment -> Withdrawn bx Reckless and self-destructive behavior

13 PTSD under 7 qualifier Criteria A Criteria C + D Criteria E PTSD under 7 symptoms Experiencing repeated/extreme details of event Poor memory of event Negative beliefs towards self Self blame Detachment -> Withdrawn bx Reckless and self-destructive behavior

14 Time Course of Trauma

15 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Adapted from Layne et al., 2009

16 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Resistance Adapted from Layne et al., 2009

17 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Decline Adapted from Layne et al., 2009

18 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Resilience Adapted from Layne et al., 2009

19 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Protracted recovery Adapted from Layne et al., 2009

20 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Severe persisting distress Adapted from Layne et al., 2009

21 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Posttraumatic growth Adapted from Layne et al., 2009

22 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Stable maladaptive functioning Adapted from Layne et al., 2009

23 PHYSIOLOGICAL AND PSYCHOLOGICAL PATHWAYS TO TRAUMATIC STRESS

24 Johnson, Riley, Granger & Riis, Pediatrics (2013)

25 Divergence of cortisol and norepinephrine responsible for PTSD maintenance Exposure to traumatic life event PTSD initiation PTSD maintenance Normal cortisol Normal norepinephrine Norepinephrine Cortisol Time (months) Pervanidou. J Neuroendocrinology. 2008

26 Toxic Stress Proposed classification of stress: Positive Tolerable Toxic Toxic stress, like all stress, triggers a neuroendocrine response. Specific neuroendocrine responses to toxic stress may become pathogenic. Effects may be developmentally sensitive. Shonkoffet al, JAMA 2009

27 Felitti, et al. 1998

28 Child Sexual Abuse Accommodation Syndrome Roland Summit's child sexual abuse accommodation syndrome (CSAAS) published in 1983 Describing CSAAS sought to disabuse judges and jurors from commonly held misconceptions about child sexual abuse. CSAAS includes Secrecy Helplessness Entrapment and Accommodation Delayed, inconsistent, and unconvincing disclosure Retraction

29 Traumagenic Dynamics A frequently cited conceptual model for organizing the various effects observed in studies of sexually abused children was proposed by Finkelhor and Browne. It describes four traumagenic dynamics as the core psychological injuries associated with child sexual victimization Traumatic Sexualization Betrayal Stigmatization Powerlessness Anticipate and understand the psychological reactions Reaction is affected by child's own psychological predispositions environment type of trauma

30 Traumatic Sexualization Process Rewarded Taught misconceptions about sexual behavior Conditioned to perceive sexual activity with negative emotions or memories Psychological Outcome Increased knowledge of sexual issues Premature and distorted sexualization Increased sexual behaviors and interest or Avoidance and sexual inhibition.

31 Betrayal Process Perpetrator, when a caregiver causes direct harm to the child Nonoffending caregivers n Don t believe the child n Change their attitude toward the child Psychological Outcome Lack of trust in the caregiver Depression Extreme dependency or mistrust Anger Inability to judge trustworthiness in others.

32 Stigmatization Process Blamed for the abuse Told to keep the abuse secret n Abuser n Nonoffending caregivers Victims are given the impression that they are damaged goods Psychological Outcome Feelings of shame and guilt as a result of the abuse Views self as different from others n Isolation or n Maladaptive behaviors that originate from an increased need for acceptance n Self-mutilation or suicidal behavior

33 Powerlessness Process Child's inability to prevent the invasion of his or her body, Lack of efficacy in stopping the abuse, Continual fear. Exacerbated when attempts to disclose are not believed. Psychological Outcome Anxiety Fear Lower self-esteem Increased need for control Identification with the aggressor

34 Felitti, et al. 1998

35 Tipping the Scale

36 BREAK

37 Tipping the Scale

38 Resilience Resilience is the ability to recover from or adjust easily to adversity or change. Resilience allows children to overcome negative experiences. Resilience develops through childhood.

39 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Resistance Adapted from Layne et al., 2009

40 Good Level of adaptation Poor Pre-trauma Peri-trauma Post-trauma Resilience Adapted from Layne et al., 2009

41 Borrow from 3 evidence based models Child Parent Psychotherapy Attachment Parent Child Interaction Therapy Behaviors Trauma Focused Cognitive Behavioral Therapy/Child Family Traumatic Stress Intervention Distress

42 Enhancing Attachment

43 Attachment Behaviors in the young child designed to achieve proximity to a preferred attachment figure when the child needs comfort, support, nurturance, or protection. In response, the caregiver provides comfort for distress, emotional availability for support, warmth and care for nurturance, and protection from danger.

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45 Child Parent Psychotherapy Two main principles: Exposure to violence/adversity impact young child s expectation of parent as protector. n Loss of secure base Imitation is a primary form of learning. Intervention guided by child parent interactions and child s play to elicit trauma play and foster interaction. Intervention improves maladaptive behaviors, supports parent-child interactions and guides the dyad in creating a joint narrative.

46 CPP outcomes Significantly improved trauma-related symptoms and overall behavior problems as well as maternal avoidance symptoms. A 6-month follow-up study observed continued improvement in children s behavior problems and maternal distress in dyads who received CPP. Lieberman et al., 2005, 2006 JAACAP

47 Strengthen the Base Play Rhyme and sing Read Reach Out and Read Draw and color Warm contact Comfort when upset

48 Addressing Behaviors

49 What is PCIT? Parent Child Interaction Therapy Highly specific, step-by-step, live-coached behavioral parenting model. Provides immediate prompts to parents while they are interacting with their child, using bug in the ear system. Combines elements of attachment and learning theory, systems theory, and behavior modification. Short-term: sessions. Empirically validated in >100 studies. Gives parents responsibility, not blame.

50 PCIT Helps Parents Focus on Positive Experiences with Their Children

51 CDI PRIDE Skills - Do s Labeled Praise: Nice job picking up the blocks Reflect: child- It s a blue doggy parent- The dog is blue Imitate: Parent closely follows child s actions Describe Behavior: You re building a tall tower Enthusiasm: Voice tone, eye contact, etc.

52 Parent Directed Interaction (PDI) Dealing with Challenging Behaviors Key features of the discipline phase of PCIT: n Consistency n Predictability n Follow-through

53 PCIT Outcomes Improved parenting skills. Decreased child behavior problems. Improvement in the quality of the parent-child relationship. Gains are maintained over time. Parenting skills learned will generalize to other children and situations.

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55 Decreasing Distress

56 Trauma Focused - CBT TF-CBT is a manualized week individual treatment for children Stepwise approach for the treatment of individuals who have been traumatized, either acutely or chronically, and suffer psychiatric and/or behavioral complications from their trauma. Potential patients include those with PTSD, anxiety, depression, behavior and self-image changes as a result of a traumatic event or series of traumas. Cohen et al., 2006

57 TF-CBT TF-CBT uses a combination psycho-education, relaxation, didactic and narrative techniques. Empower the child to better cope with remembering the trauma. Help the child process the trauma(s) Become desensitized to memories Therapist works with both the patient and parents. Well replicated in numerous studies in different trauma exposed populations Cohen et al., 2006

58 TF-CBT Psychoeducation and parenting skills Relaxation Affective expression & modulation Cognitive coping Trauma narrative processing In vivo mastery of trauma Conjoint parent-child sessions Enhancing safety and future development Cohen et al., 2006

59 WHAT CAN WE USE BEFORE TF-CBT? Child Family Traumatic Stress Intervention

60 Trauma Assessment Trauma Treatment EBT CFTSI Trauma Screening Recent trauma exposed families

61 Trauma Assessment Trauma Treatment EBT CFTSI Trauma Screening Recent trauma exposed families

62 TF-CBT Psychoeducation and parenting skills Relaxation Affective expression & modulation Cognitive coping Trauma narrative processing In vivo mastery of trauma Conjoint parent-child sessions Enhancing safety and future development Communication and Case Management = CFTSI Cohen et al., 2006

63 CFTSI Child and Family Traumatic Stress Intervention. 4-6 session brief intervention/prevention model for 7-17 year olds. Evidence based treatment for trauma exposed youth and their families.

64 CFTSI Components Assessment of both child and caregiver(s) Current distress Risk factors for distress Targeted case management Focus of treatment Symptom identification Improved communication within the family Enhancement of coping strategies No Trauma Narrative!

65 CFTSI Sessions Session 1 parent(s) only Parents symptoms and case management Child s history and symptoms Session 2a child only Child s history and symptoms Session 2b parent and child together Compare symptoms Decide on treatment focus n Limit to 1 or 2 symptoms and 1 or 2 skills Session 3, 4, etc parent and child together Evaluate symptoms and skills

66 CFTSI Clinical Goals Symptom Reduction Additional goals Anxiety Depression/Withdrawal Intrusive Thoughts/Traumatic Reminders Sleep Disturbances Tantrums/Oppositional Behavior Sexualized Behaviors Improved communication Improved awareness of distress and skills Generalization Within child Other children Increased access to other systems Empowerment Awareness

67 Randomized Control Trial: Results CFTSI versus 4-session psychoeducation/supportive comparison intervention Sample size = 112 Participants recruited from: Forensic Sexual Abuse Program Pediatric Emergency Department New Haven Department of Police Service

68 Nature of Trauma Injury 8% Animal Bite 5% Sexual Abuse 21% WV/Threats 22% Assault 20% MVA 24%

69 Outcomes at 3 months After intervention, CFTSI participants were 65% less likely to develop PTSD at 3 months Risk of either significant PTSS or PTSD was reduced by 73% at 3 months Overall symptom burden as measured by UCLA PTSD RI was significantly less in CFTSI participants at 3 months (8.7 versus 14.7) Berkowitz et al., 2011 J Child Psychol Psychiatry

70 Children who Received CFTSI Were 65% Less Likely to Meet Full Criteria for PTSD Percent of Youth * 17 * Comparison (N=53) CFTSI (N=53) 10 0 Baseline 3-Month FU *p<.01

71 Safe and Healthy Families Providing CFTSI since August, providers (MD and LCSW) 54 patients scheduled for visits, 48 showed for at least one appointment

72 SHF CFTSI outcomes Families that made at least one appointment (n=150): 83% completed CFTSI (at least 3 sessions) 33% continued with EBT after CFTSI TF-CBT, EMDR, DBT and PCIT 45% had no need for additional treatment at time of completion 5% were referred for non-trauma therapy *prior to CFTSI, all would have been assessed and enrolled in an EBT

73 Elmo Belly Breathing

74 Healthy Children (AAP)

75 Zero to Three

76 American Psychological Association

77 Wrap Up Points Resiliency and PTSD develops over time. Understanding the wiring of the child. (temperament) and the parent child relationship (attachment) provides clues as to how to build resiliency. EBT provide techniques applicable within and outside of traditional therapies When in doubt refer!

78 Comments and Questions