The Normal Human Response to Trauma

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1 The Normal Human Response to Trauma Alasdair Vance and Jo Winther Academic Child Psychiatry Department of Paediatrics University of Melbourne Royal Children s Hospital

2 Outline of presentation 1. The vast range of human life experiences 2. The definition of trauma 3. Trauma types: initial versus few months later responses 4. Vulnerability-risk and Protective-resilience models 5. Biological factors 6. Psychological factors 7. Social factors 8. Cultural factors 9. Practical tips - Jo Winther 10. Clinical illustrations Jo Winther Prof. A. Vance

3 Person A: 36 man, bankteller, obsessive-compulsive, MVA on the way to work, major depressive episode, 8 months to get better Person B: 26 man, intelligence operative, tortured and escapes, ASD symptoms, 8 weeks to be back at work Person C: 45 man, cleaner, avoidant, told burglar in building afterwards, develops ASD symptoms, receives counselling, develops PTSD, rehabilitation program still going at 12 months Person D: 18 year old girl, released from 6 years imprisonment with a paedophile, countless episodes of rape, physical abuse and neglect, refuses counselling, being a victim, becomes a nurse and marries

4 Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance

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9 2. Definition of Trauma throw out, alter - injury living tissue by an external agent - disordered behavioural and/or psychological state resulting from a severe mental, emotional stress and/or physical injury - initial effect: Acute Stress Disorder - delayed effect: Post Traumatic Stress Disorder Prof. A. Vance

10 2. Acute Stress Disorder - extreme traumatic, terrifying, horrifying event experienced, witnessed, learnt about family/close friend respond with intense fear, horror, helplessness, disengaged/agitated behavior (children) - within one month and symptoms resolve within one month - psychic numbing, dazed/less aware of surroundings, derealisation, depersonalisation, dissociative amnesia Prof. A. Vance

11 2. Acute Stress Disorder - re-experiencing phenomena: recurrent, distressing, memories, dreams, symbols of traumatic event - avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s), decreased future - hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response Prof. A. Vance

12 2. Acute Stress Disorder - duration: 2 days 4 weeks - significant impairment home, family, work, educational life domains - not due to substance abuse/dependence disorder, medical disorder, brief psychotic disorder, pre-existing psychiatric disorder Prof. A. Vance

13 2. Post Traumatic Stress disorder - extreme traumatic, terrifying, horrifying event experienced, witnessed, learnt about family/close friend respond with intense fear, horror, helplessness, disengaged/agitated behavior (children) - lasts more than one month, chronic if more than 3 months, delayed if onset after 6 months from traumatic event(s) Prof. A. Vance

14 2. Post Traumatic Stress disorder - re-experiencing phenomena: recurrent, distressing, memories, dreams, symbols of traumatic event - avoidance phenomena: places, situations, thoughts, feelings, conversations, decreased recall aspects trauma event(s), decreased future - hyperarousal phenomena: sleep change, irritability, decreased concentration, increased vigilance, increased startle response Prof. A. Vance

15 2. Post Traumatic Stress disorder - significant impairment home, family, work, educational life domains - not due to substance abuse/dependence disorder, medical disorder, psychotic disorder, pre-existing psychiatric disorder-especially OCD, malingering Prof. A. Vance

16 3. Trauma types (National Child Traumatic Stress Network) - physical abuse - neglect - sexual abuse - psychological maltreatment - complex trauma: multiple and/or prolonged episodes - refugee and war zone trauma - terrorism - natural disasters Prof. A. Vance

17 3. Trauma types - medical trauma - domestic violence - community school violence - traumatic grief Prof. A. Vance

18 Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance

19 4. Vulnerability-risk model - Zubin and Spring proposed model - interplay between individual and environment crucial; a true interaction effect - biological, temperamental, psychological, social, cultural vulnerability Prof. A. Vance

20 Zubin and Spring, 1977 Prof. A. Vance

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22 4. Protective-resilience model - Seligman developed model as part of positive psychology - interplay between individual and environment crucial; a true interaction effect - biological, temperamental, psychological, social, cultural resilience Prof. A. Vance

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25 4. - for some factors, risk and resilience are opposite ends of the same spectrum (eg empathic relationships) - for other factors, risk and resilience are two separate domains that a person can be high or low on (eg cognitive strategies) Prof. A. Vance

26 Individual: Biological factors Psychological factors Social factors Cultural factors Person Environment Prof. A. Vance

27 Trauma specific factors - living through trauma event(s) - being physically injured - seeing others hurt and/or killed - experiencing intense horror and/or fear - experiencing extra loss after trauma event(s) loss loved ones, pain, injury, loss job, home, etc Prof. A. Vance

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Region of activation BA C (mm) Z Control Group greater than ADHD-CT Group Parieto-Occipital R Precuneus 19 24-70 32 3.53 R Cuneus 19 32-90 28 2.

31 Region of activation BA C (mm) Z Control Group greater than ADHD-CT Group Parieto-Occipital R Precuneus R Cuneus Posterior Parietal R Inf. Parietal Frontal/Subcortical R Caudate Nucleus, Body Vance et al, Mol Psych 2007 N=24, CBCL inattention subscale T score: (9.43)

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34 5. Biological factors: Irritability, Mood lability Mood Euthymia Time Prof. A. Vance

35 5. Biological factors Arousal dysregulation: impaired physiological arousal decreased habituation Mood dysregulation: increased irritability decreased emotional salience Prof. A. Vance

36 5. Biological factors - Executive functioning deficits Response disinhibition: motor and cognition suboptimal response speed and accuracy Working memory deficits: verbal and visuospatial decreased span and strategy Prof. A. Vance

37 6. Psychological factors - dissociation: helpful initially, longer duration=increased risk - helplessness - coping strategy - able to get through trauma event(s) - able to learn from it - able to respond effectively despite fear - feel good about one s actions - good cognitive skills attention, problem solving - temperament; adaptive, good self-regulation-impulses/emotions - positive self-perceptions Prof. A. Vance

38 7. Social factors - degree of social support after trauma - ability to seek, find and maintain social support - warmth of relationships: empathy, attunement - family structure, expectations and monitoring - low parental discord - prosocial, competent, supportive family/peer group - collective efficacy school, neighbourhood environment Prof. A. Vance

39 8. Cultural factors - individual versus group cultural focus Prof. A. Vance

40 Young people exposed to trauma may react in a variety of ways : Aggressive behaviour Staring episodes Eating and sleep disturbances Difficulty concentrating Exaggerated startle response Irritability and outbursts of anger Hypervigilance jumpy or fidgety or having trouble staying in their seat Restricted range of emotions Guilt Clinginess and fear of separation Crying or giggling without obvious reason

41 Developmentally specific responses to disasters and trauma vary in children of different ages: Younger children commonly express new fears, separation anxiety, clinginess and show regressive behaviours School age children describe difficulty concentrating or having fun. Learning and behavioural problems, aggressive behaviours and withdrawal Adolescents are at particularly high risk as their reactions can include increased risk-taking behaviours including fighting, substance and alcohol abuse, heightened sexual activity and suicidal thoughts

42 Practical tips when working with the young person Ensure people closest to the young person provide information and support Protect the young person from public curiosity Provide reassurance (the world has not completely changed) Don t be afraid to talk about the events using factual information When discussing the event with the young person keep it simple and be honest Find out what they think and feel allow them to guide the discussion, give them time to ask questions, discuss their feelings and emotions, and correct misperceptions with accurate but age appropriate explanations

43 Practical tips when working with the young person Reassure the young person by verbally acknowledging and normalising their experiences. Listen to what they say and acknowledge with them the awfulness of their experience Inform them that what they are feeling is very normal for someone who has been through a traumatic event and to give themselves time to adjust Sometimes stories about other young people in a similar situation can help them feel more in control Take the young person s lead on when, what and how much to say Accept that some young people do not want to talk (they might express themselves through writing or drawing)

44 Practical tips when working with the young person Assess the situation and gather information Seek crisis intervention if required Include young people in mourning rituals and processes Keep memories alive (mementos, photographs, a keepsake) Ensure that they are spending some time doing nice things (going for walks, seeing friends, doing fun things) Help the young person find a legitimate course of action if they wish (donate pocket money, send some toys or clothes) Don t over focus on the event resume normal patterns of activity as soon as possible

45 Practical tips when working with the young person Allow re-emergence of grief Assist the young person to manage difficulties with concentration (time management skills, study skills and relaxation skills) Anticipate increased behavioural and emotional problems and decreased capacity to learn - but don t let the behaviour get out of hand before treating it as you would at any other time

46 Tips for working with families If parents are not doing well young people may experience increased distress and symptoms Discuss with them that it is OK to share their own grief not to hide their sadness. This will help young people to feel more normal about their feelings. However if they are really distressed it may not be helpful to share feelings because it is important that young people know that parents are in control and can keep them safe Provide practical support as required Problem solve for individuals and families (housing, basic life issues)

47 Tips for working with families Be aware of the other losses associated with the major loss or death (loss of income, family networks, household and security) Family and marital problems can occur (crowded living conditions, loss of employment, forced separations) Connect them with the limited resources that are available Help them build resilience by developing a sense of routine and normality in their lives, reestablishing safety

48 Tips for working with families Remind parents to let the young person s teacher or child care worker know what has happened so that they can be ready to support the young person Ensure that they are restricting the young person s availability to media Provide awareness training about the effects of trauma and where they can get help from if they need it

49 Tips for you as a worker Work out your own needs first think about what this disaster means for you before working with young people Your reactions will influence the young person s Don t feel that you have to have all the answers Don t take it personally if they want to be alone sometimes Don t take their anger or other problems personally they are part of the normal response to trauma

50 Tips for you as a worker The job is to evaluate if a person is able to be resilient and recover or if a referral for treatment is needed Don t hesitate to get more advice and help Vicarious traumatisation take time out, participate in other professional activities that are not disaster related to achieve continuing balance and resilience for this difficult work

51 Key elements of a safe healing environment (Perry & Dobson, 2009) Information Predictability Structure Patience Compassion Physical activity Productivity Hope

52 When to refer? If the young person is experiencing: Re-experiencing the traumatic event / flashbacks / images Severe and continued sleep disturbance / nightmares Severe anxiety when separated from loved ones Withdrawing from their friends and/or family Avoiding thoughts, feelings or things that remind them of the event A depressed or irritable mood (and getting angry easily) Behavioural problems at home or school Self-doubt or other significant changes in emotions or personality Difficulty concentrating on and remembering other things Substance use, dangerous behaviours, or unhealthy sexual activity among adolescents

53 PTSD is not the only issue: Symptoms of depression were more prevalent than posttraumatic stress symptoms (Hurricane Katrina) loneliness, sadness and anger Substance abuse (self medicating)

54 Individual Case Leigh 10 year old, boy Referred as his mother had been murdered He was removed from his father s care as he was suspected of murdering his mother Child protection and his aunty were concerned for his mental state One month into seeing Leigh his father suicided

55 Completed a clinical assessment to: Find out what Leigh was like prior to the incident (baseline behaviour) Find out how he was coping after the incident (including risk assessment) To assess what protective factors were present in Leigh s life (caring school who were monitoring him closely, supportive and very loving aunty, uncle and cousin who had taken him in and reported that they would be involved in his long term care)

56 Intervention provided: Psycho-education with aunt/uncle and the school staff regarding what symptoms to look for For the first two months weekly sessions with aunt to discuss general parenting/caregiver issues and check in regarding Leigh s behaviour/mental state Aunt could phone me at anytime (working hours) for a consultation if required Fortnightly sessions with Leigh to find out how his week had gone, build rapport, check risk factors no therapy! Weekly phone calls to the school to check Leigh s behaviour/mental state Then monthly for six months Then closed the case ensuring that the family knew what to look for and how to re-refer

Whole school response after the bushfires Formed a mini team (CAMHS and School Support Services) First day of school, before school meeting with the teachers

clinical staff Provided consultation to the Principal regarding how to structure the school week and provided assurance that they were doing the right thing

57 Whole school response after the bushfires Formed a mini team (CAMHS and School Support Services) First day of school, before school meeting with the teachers to provide psycho-education about normal responses to trauma Start of the school day met with students to discuss normal responses to trauma and introduce clinical staff Provided consultation to the Principal regarding how to structure the school week and provided assurance that they were doing the right thing Hung out in the staff room before school, lunch time and after school Hung out in the school yard during recess and lunch and engaged in general chat with students

58 Whole school response after the bushfires Provided individual session times for students that teachers were concerned about filtered by the school nurse (psycho-education regarding normal reactions, risk assessments and discussion regarding strategies to manage these reactions) For the next month provided clinicians two days a week to touch base with the school and at risk students Ensured staff knew what to look for and how and where to make referrals if required in the future

MODULE IX. The Emotional Impact of Disasters on Children and their Families

MODULE IX. The Emotional Impact of Disasters on Children and their Families MODULE IX The Emotional Impact of Disasters on Children and their Families Outline of presentation Psychological first aid in the aftermath of a disaster Common reactions to disaster Risk factors for difficulty