Joseph Spinazzola, Ph.D., Margaret Blaustein, Ph.D., Elizabeth Warner, Psy.D., Bessel van der Kolk, M.D., & The JRI Trauma Drama Ensemble

Transcription

1 Developmental Trauma Disorder: Emerging Science & Best Practices 28 th Annual International Trauma Conference Psychological Trauma: Neuroscience, Identity & The Transformation of the Self Boston, MA May 31, 2017 Joseph Spinazzola, Ph.D., Margaret Blaustein, Ph.D., Elizabeth Warner, Psy.D., Bessel van der Kolk, M.D., & The JRI Trauma Drama Ensemble The Trauma Center at Justice Resource Institute A Call To Action Culmination of a process that began in 2005 with creation of joint ISTSS/ISSTD/NCTSN Developmental Trauma Disorder Task Force Phase II DTD Field Trial 100% Supported by grassroots campaign launched HERE in May 2009 What will YOU do NOW with this information to enhance awareness, proper diagnosis, policy, practices, or resources for those impacted by DTD?! Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 1

2 Developmental Trauma Disorder: Let the Data do the Talking 28 th International Trauma Center Conference Boston, MA May 31, 2017 Joseph Spinazzola, Ph.D. The Trauma Center at Justice Resource Institute PTSD does not capture the predominant or prototypical effects of complex trauma for children or adolescents Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 2

3 75% 60% Complex Symptom Profile 45% 30% 15% 0% Affect Dysreg. Attention/Conc. Neg. Self-Image Impulse Control Aggression Somatization Clinginess Conduct/ODD Sexual Problems Reject/Detach Dissociation PTSD Social Anxiety Substance Use Childhood Experiences Matter: But is it a Matter of How Much, When or What? Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 3

4 Percent With Health Problem (%) HOW MUCH Cumulative Trauma, Polyvictimization & ACES (Or, The Backhoe) 35 CDC ACE Study ACE Score or more Considers Self An Alcoholic Ever Attempted Suicide Sexually Assaulted as an Adult (Women) Anda et al: Sample of 17,000 subjects in medical Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 4

5 WHEN Timing of Developmental Onset (Or, the Trowel) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 5

6 WHAT Trauma Typology (Or, the Sieve) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 6

7 Unseen Wounds: The NCTSN Psychological Maltreatment Study: Study Sample: N = 5,616 youth from the NCTSN Core Data Set with exposure to one or more of the following three trauma exposure categories: Psychological Maltreatment (EA) Comprised of Emotional Abuse or Emotional Neglect Sexual Maltreatment (SA) Physical Maltreatment (PA) Frequency or Severity of 30 NCTSN CDS Outcomes Assessed for Psychological Abuse Versus Physical or Sexual Abuse Greater than both X X X X X X X X Greater than one, less than the other X X Greater than one, equal to the other X X X X X X X X X Equal to one, less than the other X X X X X X Equal to both X X X X X Less than both Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 7

8 Indicators: Odds Ratios Severity Indicators Odds Ratio: Psychological Maltreatment (EA) More Severe than Physically Abused (PA) Youth and Sexually Abused Youth (SA) OR: 1.44 ( ) OR: 1.46 ( ) OR: 1.69 ( ) OR: 1.06 ( ) OR: 1.47 ( ) OR: 1.47 ( ) OR: 1.29 ( ) OR: 1.21 ( ) OR: 1.44 ( ) OR: 1.98 ( ) OR: 2.27 ( ) OR: 1.19 ( ) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 8

9 Severity Indicators Odds Ratio: Psych Maltreatment (EA) More Severe than Combined (PA+SA) Youth OR: 1.93 ( ) A Distinct Clinical Profile Psychological Maltreatment: More severe Internalizing Problems than CPA or CSA Higher prevalence of non-suicidal Self-Injury and Attachment Problems than either CSA or CPA Equivalent Externalizing Problems to CPA; > CSA Higher prevalence of Behavioral Problems at Home than either CSA or CPA Equivalent PTSD symptoms to CSA and CPA Equal or Greater Frequency/Severity of 27 of 30 outcomes than combined CSA + CPA Higher prevalence of Depression, Generalized Anxiety, Substance Use, Separation Disorder & Acute Stress Disorder than combined CSA + CPA Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 9

10 Who Really Gets The Short End of the Stick? Back to Those Telomeres Network Analysis of Trauma Hx Profiles in Txt Sample (N = 618 youth aged 4 18) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 10

11 The Four Horsemen of Developmental Trauma Impaired Caregiving Neglect Psychological Maltreatment Domestic Violence PTSD Developmental Trauma Disorder Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 11

12 DTD Field Trial Phase I: International Clinician Survey S = 303 International, 1018 United States Child-Serving Clinicians view Attachment Trauma & DTD Symptom Domains to be: 1. Clinically Significant 2. Discriminable from PTSD, Anxiety/Affective Disorders, and Externalizing Disorders 3. Often not responsive to existing EBTs Developmental Trauma Disorder Field Trial Clinician Survey DTD symptoms most discriminable from PTSD (95% CI > 4.0) N = Excessive Intimacy Seeking ( ) Impaired Emotional Boundaries ( ) Somatic Dysregulation ( ) Risk-taking Behavior ( ) Self-Harm ( ) Maladaptive Self-Soothing ( ) Affect Dysregulation ( ) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 12

13 Developmental Trauma Disorder Criterion A A1. Attachment Disruption + A2. Traumatic victimization Criterion B Affective/Physiological Dysregulation Criterion C Attentional/Behavioral Dysregulation Criterion D Self/Relational Dysregulation DTD Field Trial Phase II: National Diagnostic & Comorbidity Study COHORT 1: SIX NATIONAL FIELD TRIAL SITES N = 236 ages 7-18 years old; 50% female 30% African American/Biracial, 17% Hispanic, 3% Asian American, 50% White NonHispanic 38% PTSD (23% with comorbid DTD) 41% DTD (24% with comorbid PTSD) Treatment Seeking Sample (4% no trauma history) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 13

14 DTD Field Trial Phase II: Criterion A Logistic Regression A1 & A1+A2 but not A2 more likely than No A1 or A2 DTD Diagnosis (OR A1 = 12.8, 95% CI = ) (OR A1+A2 =26.1, CI = ) DTD Criterion B (OR A1 = 11.2, 95% CI = ) (OR A1+A2 =20.9, CI = ) DTD Field Trial Phase II: Criterion A Logistic Regression A1, A2 & A1+A2 all more likely than No A1/A2 DTD Criterion C (OR = , CI = ) DTD Criterion D (OR = , CI = ) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 14

15 DTD Field Trial Phase II: Criterion A Exposure Type Positive DTD Diagnostic Presence (within Criterion A subgroup) Positive DTD Subscale B Positive DTD Subscale C Positive DTD Subscale D No A1/A2 3.3% 6.7% 13.3% 16.7% A1 only 30.6% 44.4% 55.6% 72.2% A2 only 22.2% 27.8% 55.6% 61.1% A1 + A2 47.4% 59.9% 65.8% 77.0% Total 37.3% 48.3% 56.8% 67.4% DTD Field Trial Phase II: Criterion A Multivariate Logistic Regression Neither PTSD nor DTD were associated with: Age Gender White vs. Minority Ethnicity Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 15

16 DTD v. PTSD: Shared and Differential Trauma Antecedents Unique to PTSD: Physical violence / victimization Traumatic arrest of family member Shared: Traumatic separation from caregiver Unique to DTD: When Nowhere is Safe Witnessing family or community violence DTD Criterion B: Affective/Physiological Dysregulation B. 1. Inability to modulate or tolerate extreme affect states B. 2. Inability to modulate/recover from extreme bodily states: aversion to (a) touch, (b) sound; (c) unexplained bodily problems B. 3. Diminished awareness/dissociation of emotional or bodily feelings B. 4. Impaired capacity to describe emotions or bodily states Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 16

17 DTD Criterion C: Attentional/Behavioral Dysregulation C. 1. Attention bias toward or away from potential threats C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking C. 3. Maladaptive self-soothing C. 4. Habitual or reactive self-harm C. 5 Inability to initiate or sustain goal-directed behavior DTD Criterion D: Self and Relational Dysregulation D. 1. Persistent extreme negative selfperception D. 2. Attachment insecurity: attempt to care for caregivers, or difficulty tolerating reunion after separation from primary caregiver(s) D. 3. Extreme persistent distrust, defiance or lack of reciprocal behavior in close relationships Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 17

18 DTD Criterion D: Self and Relational Dysregulation D. 4. Reactive physical/verbal aggression D. 5. Psychological boundary deficits (excessive seeking of intimate contact or reliance on peers/adults for safety/reassurance) D. 6. Dysregulated empathic arousal (intolerant/indifferent or overly reactive to others distress) Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 18

19 Frequency (%) Figure 1. Significant, Large Symptom Endorsement Difference B1 B3 B3a B4 B4b C5 D5 D5b DTD Control Symptoms OR > 10.0; p <.00 Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 19

20 Frequency (%) Figure 2. Significant Age Epoch by Symptom Differences * 3.24* -4.61* C3 Symptoms D5 *p <.05 Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 20

21 Frequency (%) Figure 3. Significant Age Epoch by Subsymptom Differences ** -3.33* * 2.74* -3.02** * ** B2a C2a D2b D3b D5b Subsymptoms *p <.10, **p <.05 Kristine Kinniburgh, LICSW, Margaret E. Blaustein, Ph.D. The Trauma Center at JRI 21