TRAUMA AND PTSD ASSESSMENT AND INTERVENTION Brooks Keeshin, MD University of Utah
Disclosures I receive funding from SAMHSA and Utah Department of Health, Uppsala University and Hunter College. I receive royalties from UpToDate. I have no other potential conflicts.
DEFINING TRAUMA
Definition of Child Abuse CDC Words or overt actions that cause harm, potential harm, or threat of harm to a child WHO all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child s health, survival, development or dignity in the context of a relationship of responsibility, trust or power. Harm - not objectively reported - requires interpretation
Sexual Abuse Sexual abuse occurs when a child is engaged in sexual activities that the child cannot comprehend the child/adolescent is developmentally unprepared and cannot consent and/or that violate the law or social taboos of society.
Age of Consent *Image source: Wikimedia
Gershoff, 2008, Report on Physical Punishment in the United States
Standardized Measures ACES questionnaire(s) UCLA PTSD Reaction Index Childhood Trauma Questionnaire (CTQ) Lifetime Incidence of Traumatic Events (LITE) Traumatic Events Screening Inventory (TESI) Childhood Trust Events Survey (CTES) Conflict Tactics Scale Parent Child Version (CTSPC) DSM V Criteria for PTSD Threatened death, serious injury or sexual violence 1. Direct experience 2. Witnessing in person 3. Learning event occurred 4. Experiencing repeated or extreme details of event
Post Trauma Experience Additional Experiences and Adversities Suicidality Traumatic Stress Symptoms Intrusive Symptoms Avoidance Negative Thoughts and Mood Hyperarousal +/- Dissociation
How do we know about symptoms? Ask about symptoms Sleep Standardized screens: UCLA PTSD RI CPSS Trauma Symptom Checklist for Children Trauma Symptom Checklist for Young Children
IF IT IS TRAUMA, WHAT NOW?
Trauma-focused psychotherapies should be considered first-line treatments for children and adolescents with PTSD. Cohen et al. J. Am. Acad. Child Adolesc.Psychiatry, 2010;49(4):414 430.
Efficacy for Youth with PTSD Symptoms Trauma Focused CBT Child Parent Psychotherapy Prolonged Exposure (A) EMDR CBT for PTSD KIDNET Cue-Centered Treatment CFTSI (prevention) Keeshin and Strawn. Child and Adol Psych Clinics of NA 2014
Trauma-Focused Cognitive Behavioral Therapy Prepare and Cope Exposure and Process Safety and Stability 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
Effect Sizes Wait list PTSD 0.83 Exposure based 1.44 Active control PTSD treatment 0.41 Exposure based 0.56 Depression 0.3 Exposure based 0.59 Depression 0.32 Exposure based 0.48 Morina 2016
Relative Effectiveness of Psychotherapy & SSRI treatment PTSD Anxiety Depression TF-CBT effect size CAMS effect size TADS effect size Combo -0.53 Sertraline -1.42 CBT 1.44/0.56 Combo 0.86 Sertraline 0.45 CBT 0.31 Combo 0.98 Fluoxetine 0.68 CBT -0.03 Cohen 2007; Robb 2010; Morina 2016
Sleep Pre Sleep Difficulties Volitional vs. Avolitional Volitional Anticipatory anxiety Feeling unsafe Avolitional Difficulty going to sleep Persistent hyperarousal Within Sleep Difficulties Ineffective vs. Disrupted Ineffective Increased motoric activity Easily awakening Disrupted Nightmares Night Terrors
Sleep Interventions for Traumatized Children Parent proximity/support Coping skills Sleep routine/negotiation Hygiene Trauma therapy referral Temporary use of medications: Melatonin Prazosin (in PTSD) or Clonidine
Potential Red Flags Benzodiazepine use No efficacy Second generation antipsychotic use for PTSD High risk of obesity No efficacy Exacerbation of dissociation Lack of referral for psychotherapy Trauma or Behavioral
BEFORE COMPREHENSIVE TRAUMA TREATMENT
Child and Family Traumatic Stress Intervention 4-8 Session Family Based model 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!
Non-Trauma Focused Psychotherapies Dialectical Behavior Therapy (DBT) Parent Child Interaction Therapy (PCIT) Effective treatment for specific conditions often found among those who experience trauma Do not necessarily treat PTSD/trauma symptoms
Traumatic Stress Clinical Decision Tree Children with known trauma exposure and current trauma symptoms Recent trauma Brief Intervention and follow Behaviors > Trauma specific symptoms Address behaviors first Younger children - PCIT Adolescents DBT Ongoing PTSD or increased PTSD risk Exposure based trauma treatment
Traumatic Stress Medication Decision Tree Benzos Children with current trauma symptoms SGAs Sleep Problems Melatonin/Prazosin Anxiety and Depression Sx Address sleep first Consider SSRI for clearly independent anxiety/depression ADHD and or increased reactivity symptoms EBT first Re-evaluate Consider Alpha 2 Agonists
CARE PROCESS MODEL FOR PEDIATRIC TRAUMATIC STRESS
Determine if reportable event Assess suicide risk Assess for trauma treatment
SAFETY Address Ongoing Risk & Suicide 1 st
Low Risk Follow up or MHI
Mod Risk MHI or Trauma Tx
High Risk Trauma Informed Eval
Focus on Sleep
Focus on Coping with Distress
Focus on Activation
Resources PTSD Coach
Follow Up Repeat PRN
Discussion Brooks.Keeshin@hsc.utah.edu
Example Screener Primary Care setting Recent Trauma Low Risk PTSD Suicide Not Endorsed
Example Screener Primary Care setting Recent & Past Trauma Moderate Risk PTSD Suicide Endorsed Trauma-EBT Referral
Example Screener Primary Care setting Depression sx Suicide Endorsed Fluoxetine and MH referral Recent & Past Sexual Abuse High Risk PTSD Trauma-EBT Referral & MHI