Presented by: Glenn Saxe,MD. Chair, Department of Child and Adolescent Psychiatry at the NYU School of Medicine and Director, NYU Child Study Center.

Transcription

1 Presented by: Glenn Saxe,MD Chair, Department of Child and Adolescent Psychiatry at the NYU School of Medicine and Director, NYU Child Study Center.

2 What is Traumatic Stress?

3 Denise Denise is a 13 year old girl with history of sexual abuse; Seen in an emergency room following episode of self mutilation after male peer commented on her breasts; Lives with mother, three siblings in two bedroom apartment; Substandard housing conditions. No bedroom door, older brother leers at her; Sometimes hears (and sees) violent fights between mother and mother s boyfriend; Failing at school related to school avoidance and truancy

4 What do you do??

5 Bottom line

6 It s about a trauma system 1) A traumatized child who is unable to regulate emotional states, 2) A social-environment/system-of-care that cannot help contain this dysregulation.

7 Dysregulation of Emotional States

8 Survival-in-the-Moment The amygdala leads a hostile takeover of consciousness by emotion (Joseph LeDoux, The Emotional Brain)

9 Survival Circuits Amygdala Broca s area Rauch, S., Van der Kolk, B., Fisler, R., Alpert, N. (1996). A symptom provocation study of Posttraumatic Stress Disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53(5) pp

10 What Regulates the Survival Circuit? Kirsch, P., Esslinger, C., Chen, O., Mier, D., Lis, S., Siddhanti, S., et al. (2005). Oxytocin modulates neural circuitry for social cognition and fear in humans. Journal of Neuroscience, 25,

11 Denise: 13 yearold girl who cut her arms after boy commented on her body. Denise s Moments

12 Michael: 15 year-old boy who assaulted classmate on basketball court and was restrained by school monitors.. Michael s Moments

13 Patterns of links between emotional/behavioral dysregulation, and the stimuli that provoke it. The role of members of the child s social environment in helping or hindering regulation during these patterns of links. The functional implications for these patterns of links.

14 Social Environment

15 Playing Rats In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions, Oxford, New York

16 Where is the cat hair? In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions, Oxford, New York

17 1. Fix a broken system 2. Safety first 3. Plans are clear, focused, and based on facts 4. Don t Go before you are Ready 5. Put scarce resources where they ll work 6. Insist on accountability, particularly your own 7. Align with reality 8. Take care of yourself, and your team 9. Build from strength 10. Leave a better system

18 1. Fix a broken system 1. Fix a broken system

19 It s about a trauma system 1) A traumatized child who is unable to regulate emotional states, 2) A social-environment/system-of-care that cannot help contain this dysregulation.

20 Culture Neighborhood School/ Peer group Family Child Brain Molecule and cell

21 2. Safety first 2. Safety first

22 Where is the cat? How much do you know about the location of the cat hair and the cat in the individuals whom you treat? How important is this knowledge for understanding their main emotional & behavioral problems? What tools do you use for locating the cat hair and the cat; and doing something about it?

23 3. Plans are clear, focused, and based on facts 3. Plans are clear, focused, and based on facts

24 Just the facts, Ma am

25 Patterns of links between emotional/behavioral dysregulation, and the stimuli that provoke it. The role of members of the child s social environment in helping or hindering regulation during these patterns of links. The functional implications for these patterns of links.

26 Examples of TST Priority Problems Physically abused child repeatedly enters dissociative states when parent or teacher speaks with him harshly; Sexually abused child repeatedly cuts arms after mother comes home intoxicated; Refugee child repeatedly runs away after conflict with teacher about math, Child who witnessed family violence repeatedly assaults classmates who expresses disrespect.

27 4. Don t Go before you are Ready 4. Don t Go before you are Ready

28 Do you know the answer to the following questions? What is the priority problem? What does the child/family see as the priority problem? What is most important to the child/family? How much does the way you see the priority problem address what is most important to the child/family? What are you asking the child/family to do in order to address the priority problem? Why should they do it? What practical barriers may get in the way?

29 5. Put scarce resources where they ll work

30 Denise s Problems history of sexual abuse, engages in self mutilation, has inappropriate peers she associates with, crowded housing, no bedroom door, exposed to domestic violence, failing at school, is truant, hates social studies, doesn t clean her room, Mom has trouble enforcing limits, swears too much, teachers say she seems tired at school, family doesn t have money for new clothes she wants, family doesn t have money for summer camp for her, brother is involved in gang, doesn t have contact with her bio father, overweight, has trouble falling asleep, possibly inappropriate school placement, family doesn t know how to initiate an IEP, Denise and Mom fight over how Denise dresses, has trouble paying attention during class, seems socially isolated, possibly exposed to inappropriate content on television, Denise s grandmother moved away recently and Denise s Mom has lost social support, ipod was stolen, has tried alcohol, neighbor plays music loudly at night, family car broke down, favorite teacher is transferring schools, didn t show up for appointment, feels anxious when speaking in front of the class, dog died, loses things, has contemplated suicide

31 6. Insist on accountability, particularly your own 6. Insist on accountability, particularly your own

32 7. Align with reality 7. Align with reality

33 8. Take care of yourself, and your team 8. Take care of yourself, and your team

34 9. Build from strength 9. Build from strength

35 10. Leave a better system 10. Leave a better system

36 What about Denise??

37 Denise s TST Priority Problems 1) Sexualized comments from peers at school and older brother (who stares at her) leads to self mutilation; 2) Witnessing violence at home leads to dysphoric/suicidal states; 3) School failure and consequential disappointment expressed by mother lead to school avoidance

38 Denise s TST Priority Problems: Interventions 1) Sexualized comments from peers at school and older brother (who stares at her) leads to self mutilation; Advocacy Bedroom door, then standard housing SOS Work with school about peer comments 2) Witnessing violence at home leads to dysphoric/suicidal states; Advocacy Domestic violence protection & services SOS Work with mother in home to better help and protect Denise. Treat mother s depression. Psychopharm SSRI s to help manage dysphoric/suicidal states 3) School failure and consequential disappointment expressed by mother lead to school avoidance Advocacy Work with school to integrate trauma related problems into IEP SOS Home-based family work with mother and Denise to help mother respond in more effective way and to help Denise get to school safely.

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40 1. Treatment must directly address the core developmental problem of traumatic stress; the dysregulation of emotional states when confronted with a stressor. 2. Treatment must directly address the social ecology. 3. Treatment must be compatible with systemsof-care. 4. Treatment must be disseminate-able and sustainable. 5. Treatment must engage and generate value to users

41 TST is both a Clinical model for the efficient and effective treatment of traumatized children; Organizational model for the integration of services for agencies that provide treatment for traumatized children.

42 The 4 Service Elements Psychiatry/ Psychopharmacology Skill-based Psychotherapy Community- Based/Milieu Based Legal advocacy

43 Define group of organizational leaders and create plan that aligns with the top priorities of the organization and is specific enough about operations and finances to generate confidence that this can work and be sustained -Organizations most important priorities - Vision for how TST will help organization achieve these priorities - Decisions on how programs and partnerships will be identified, integrated, and operate - Decisions on how staff will be identified, trained, and supervised - Decisions on how the program will be financed - Decisions on start up and scale - Decisions on the organization s most important goals for the TST program and how the program will be evaluated based on the evidence of helping the organization reach these goals.

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45 Glenn N. Saxe, MD Arnold Simon Professor and Chair Department of Child and Adolescent Psychiatry Director NYU Child Study Center NYU Langone Medical Center One Park Avenue, 7th Floor, New York NY Tel: Fax:

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