Working With Teens Who Have Experienced Trauma. Gloria Castro Larrazabal, Psy.D. Infant-Parent Program UCSF/SFGH

Transcription

1 Working With Teens Who Have Experienced Trauma Gloria Castro Larrazabal, Psy.D. Infant-Parent Program UCSF/SFGH

2 Trauma Principles It is the child s experience of the event, not the event itself, that is traumatizing. If we do not look for or acknowledge trauma in the lives of children and adolescents, we end up chasing behaviors and limiting the possibilities for change.

3 Trauma The behavioral and emotional adaptations that maltreated children and adolescents make in order to survive are brilliant, creative solutions, and are personally costly. If you do not ask, they will not tell your. Since Trauma = Chaos Structure = Healing

4 Children and Adolescents are Exposed to Traumatic Life Events Traumatic Event: is one that threatens injury, death, or the physical integrity of self and others. It causes horror, terror, or helplessness at the time it occurs.

5 Traumatic Events Sexual, physical, and emotional abuse. Domestic, school and community violence Medical trauma. Motor vehicle accidents. Acts of terrorism and war experiences. Natural and human-made disasters. Suicide and/or loss of a loved one.

6 In community samples more than two thirds of children report experiencing a traumatic event by age 16. Witnessing community violence: the range goes from 36% to 85% and estimated rates of victimization go up to 66% Exposure to sexual abuse: the estimated rates go from 25% to 44%

7 Reactions Displayed by Children and Adolescents The development of new fears Separation anxiety (particularly in young children Sleep disturbances, nightmares Sadness, anger, irritability Loss of interest in normal activities Reduced concentration Declined in schoolwork Somatic complaints

8 TRAUMA SCHOOL COMMUNITY ADOLESCENT FAMILY PEERS RESILIENCE moderates risk factors on outcomes at the level of neighborhood, family, and child.

9 Complex Trauma in Adolescents Complex Trauma describes the dual problem of adolescent s exposure to multiple traumatic events and the impact of this exposure on immediate and long-term outcomes. Complex Trauma results when a child is abused or neglected.

10 Impact of Complex Trauma Normative development Psychiatric and addictive disorders Chronic medical illness Legal, vocational, and family problems These difficulties may extend from childhood through adolescence and into adulthood

11 Impact of Complex Trauma on Development Attachment Neurobiology and neurophysiology Affect regulation Dissociation Behavioral regulation Cognition Self-Concept

12 Attachment Secure Attachment: children learn about themselves, their emotions, and their relationships with others within the relationship of the caregiver. Secure Attachment: supports a child s development in areas, including his capacity for regulating physical and emotional states, his sense of safety (this allows him to explore the world), his early knowledge about how he can have an impact on his environment, and his early capacity for communication.

13 How Trauma Impacts Attachment Disconnecting from social relationships Acting coercively towards others Due to the unpredictable violence or repeated abandonment, they tend to cope by restricting their processing of what is happening around them When they are confront with a challenging situation, they cannot formulate a coherent, organized response

14 Neurobiology Toddlers and preschool age children: they are at risk for failing to develop brain capacities necessary for regulating emotions in response to stress. Trauma interferes with the integration of left and right hemisphere brain functioning. The child cannot access rational thought in the face of overwhelming emotions. They tend to react with extreme helplessness, confusion, withdrawal, or rage when stressed.

15 In middle childhood and adolescence, the most rapidly developing brain areas are those that are crucial for success in forming interpersonal relationships and solvingproblems. Traumatic stressors can lead to difficulties in emotional and behavioral regulation, consciousness, cognition, and identity formation.

16 Neurobiology of Adolescents Expose to Trauma Substance abuse to cope with hypersrousal, numbness, and reexperiencing the event Indiscriminant sexual behavior Cutting and suicidal gestures Continued contact with the abuser The freeze response Engaging in high risk behaviors

17 Conceptual Framework Trauma is a neurophysiologic state stemming from neurobiological injury. The brain is plastic and has the ability to change its structure and function in response to experience.

18 Sympathic Nervous System Response Catecholamine are increased: damage to memory, rational thought, hypervigilance, inability to distinguish danger signals Corticosteroids are low: reduced immune functioning Opioids levels increase: flat affect (equivalent of 8 mg of morphine)

19 Other Neurotransmitters Serotonin: inhibitory; involved in emotion and mood. Low levels of serotonin lead to depression, problems with anger control, obsessive-compulsive disorder, and suicide. Dopamine: inhibitory; controls arousal, alertness, attention; gives motivation (drugs like cocaine, opium, heroin, alcohol and nicotine increase the levels of dopamine). GABA: inhibitory; acts like a brake to the excitatory neurotransmitters that lead to anxiety.

20 Supportive relationships with adults and peers can protect children and adolescents from many of the consequences of traumatic stress. The role adults play in the life of adolescents is crucial.

21 Affect Regulation The identification of internal emotional experiences. It requires the ability to discriminate among states of arousal, interpret these states, and apply appropriate labels (e.g. happy, frightened ). Able to express emotions safely and to adjust or regulate internal experience.

22 How Trauma Impacts Affect Regulation Dissociation Chronic numbing of emotional experience Dysphoria Avoidance of emotional situations (including positive experiences) Maladaptive coping strategies ( substance abuse)

23 Dissociation It is the failure to integrate information and experiences Thoughts and emotions are disconnected Physical sensations are outside conscious awareness Repetitive behaviors take place without conscious choice, planning, or selfawareness

24 Behavioral Regulation Behavioral patterns that represent adolescents defensive adaptations to overwhelming stress. They may reenact behavioral aspects of their trauma (e.g., through aggression, selfinjurious, or sexualized behaviors). They can be attempts to gain mastery or control over their experiences.

25 Behavioral Regulation They may use alcohol or drugs to avoid experiencing intolerable levels of arousal. They may engage in sexual behaviors in order to achieve acceptance and intimacy.

26 Cognition Attention. Abstract reasoning. Problem solving. They have three times the drop out rate of the general population.

27 Self-Concept If adolescents perceive themselves as powerless or incompetent and expect others to reject or despise them are likely to: A) Blame themselves for negative experiences. B) Have problems eliciting and responding to social support.

28 Family s Contribution to Healing Process Believing and validating the adolescent s experience. Tolerating the adolescent s affect. Managing the caregiver s own emotional response.

29 ASSESSMENT AND TREATMENT

30 ASSESSMENT The adolescent s own disclosures Collateral reports from caregivers and other providers The therapist s observations Standardized assessment measures that have been completed by the adolescent, parents, and by the teachers Assessments need to be cultural sensitive

31 The Adolescent Sexual Behavior Inventory (ACSBI) It is used to assess sex-related behaviors that might suggest a need for intervention. It assess: sexual risk taking, nonconforming sexual behaviors, sexual interest, and sexual avoidance/discomfort. It is used for children age range from 12 to 18. There are two versions, a parent report version (ASBI-P)

32 TREATMENT The Complex Trauma Workgroup NCTSN 1. Safety: Creating a safe home, school, and community environment. 2. Self-regulation: enhancing his/her capacity to modulate arousal and restore equilibrium following disregulation of affect, behavior, physiology, cognition, interpersonal relatedness and self-attributions.

33 3. Self-reflective information processing: consists in helping the adolescent to construct selfnarratives, reflect on past and present experiences, and develop skills in planning and decision-making. 4. Traumatic experience integration: enabling the adolescent to transform or resolve traumatic memories or reminders. It can be done by using techniques as meaning making, traumatic memory containment or processing, mourning of the traumatic loss, managing symptoms, developing coping skills, and cultivation of present-oriented thinking and behavior.

34 5. Relational engagement: helping the adolescent to form appropriate attachment and to apply this experience to current interpersonal relationships. 6. Positive affective enhancement: enhancing the adolescent sense of self-worth, esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery, communitybuilding and the capacity to experience pleasure.

35 A Phase-Based Approach Treatment proceeds through a series of phases that focus on different goals. This avoids overloading the adolescent with too much information at one time. This approach begins with providing safety followed by teaching self-regulation Gradually incorporates self-reflective information processing, relational engagement, and positive affect enhancement

36 Establish a substantial period of stabilization in which internal and external resources have been established. Foster integration of traumatic experiences by identifying and coping with present triggers. Interventions should build strengths and decrease symptoms.

37 Compassion Fatigue Secondary Traumatization Compassion: feeling of deep sympathy for another s suffering. Compassion Stress: is the feeling of tension or demand associated with feelings of compassion. Compassion Fatigue: progresses from Compassion Stress and is an overwhelming state of tension and preoccupation with the cumulative trauma experienced and reported by clients.

38 Compassion Fatigue Internal images are created within the professional s mind and can stimulate intense feelings of compassion which can result in vicarious experiences of the actual trauma.

39 Risk Factors to develop Compassion Fatigue Professionals who have poor boundaries Have unresolved traumatic experiences in their own lives May be exhausted from the demands of their work Professionals who are driven to rescue clients or whose self-worth is tied to being liked by their clients

40 Coping With and Managing Compassion Fatigue Develop self-care behaviors. Examine within themselves any unresolved trauma issues of their own. Be alert of the symptoms of compassion fatigue. Be aware of their feelings and mood states. Recognize when additional support is needed. Talk to fellow professionals. Set realistic goals and boundaries in your work. Additional training and education about trauma.

41 References Cook, A., Blaustein, M., Spinazzola, J., van der Kolk, B. (Eds.). Complex Trauma in Children and Adolescents. National Child Traumatic Stress Network. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.,Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). Complex Trauma in Children and Adolescents. Psychiatric Annals, 35, Frederick, W.N., Lysne, M., Sim, L., & Shamos, S. (2004). Assessing sexual behavior in high-risk adolescents with the Adolescent Clinical Sexual Behavior Inventory. Child Maltreatment, 9(3), Wilgocki, J. (2008). The Effects of Trauma on Children and Adolescents. Mental Health Center of Dane County. The National Child Traumatic Stress Network.