Jessica Winkles, Ph.D.Laurel Kiser, Ph.D., M. B. A.

Department of Psychiatry, University of Maryland Baltimore

March 30, 2014

Trauma in Adolescence

AgendaReview: adolescent development, defining

traumaScope of the problemAdolescent responses to traumaTrauma-informed careInterventions for adolescent traumatic

stress disorders

Review: Adolescent Development

Physical CognitiveSocial EmotionalIdentity

Development

Time of Enormous ChangeSource: American Psychological Association (APA). (2002). Developing

Adolescents: A Reference for Professionals, 11.

Review: Defining Traumatic Stressors in DSM5

A new chapter includes disorders that are preceded by a traumatic or distressing eventPTSDAcute Stress Disorder Adjustment Disorders Reactive Attachment DisorderDisinhibited Social Engagement DisorderOther Specified Trauma- and Stressor-Related

DisorderUnspecified Trauma- and Stressor-Related

Disorder

Review: Defining Traumatic Stressors in DSM5The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence

Exposure may occur in many forms:oDirectoWitnessingo IndirectlyoRepeated or

extreme indirect exposure to aversive details of the event(s)

Scope of the Problem

Scope Specific to AdolescentsGeneral population study found more than 68% of

children and adolescents had experienced a potentially traumatic event by the age of 16  Source: Copeland, W.E., Keeler, G., Angold, A., Costello, E.J. (2007). Traumatic events and

posttraumatic stress in childhood. Archives of General Psychiatry, 64 (5): 577-584.

In a nationally representative survey of 12-17 year-olds, 8% reported a lifetime prevalence of sexual assault, 17% reported physical assault, and 39% reported witnessing violence.  Source: Kilpatrick DG, Saunders BE. (1997). Prevalence and Consequences of Child

Victimization: Results from the National Survey of Adolescents. National Crime Victims Research and Treatment Center, Medical University of South Carolina

Adolescents are twice as likely as adults to become victims of violent crime (completed violence, sexual assault, robbery, assault) Source: Bureau of Justice Statistics. (2008). Table 3, Criminal Victimization in the United States 2008:

Statistical Tables.

21.9%

22.7%

29.5%

35.6%

36.4%

42.8%

54.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

Sexual abuse

Neglect

Physical abuse

Emotional abuse

Impaired caregiver

DV

Loss/Separation

Percentage of Children & Adolescents

Most Commonly Reported Trauma Types

• Not mutually exclusive

• There are 20 trauma types

# of Trauma Types M= 3.7, SD= 2.4

Prevalence of Multiple TraumasNCTSN Core Data Set 2009 (Briggs, 2009)

24.4

75.6

0

10

20

30

40

50

60

70

80

90

100

Single Trauma

Multiple Traumas

Responses to Trauma

Continuum of Responses

Event 1 month 6 months 12 months 24 months

Fu

nc

tio

nin

g

Time

Thriving

Resilent

Acute Stress

Disorder

Delayed

Chronic

Normal

adapted from Bonanno 2004

Traumatic Stress ReactionsMost youth exposed to extreme events are

remarkably resilient, which can explain the success of the human species despite the violence of our history

In a community sample of older adolescents, 14.5% of those who had experienced a serious trauma developed PTSD. Source: Giaconia, R., Reinherz, H., Silverman, A., Bilge, P., Frost,

A. & Cohen, E. (1995) Traumas and posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 34: 1369-1380.

Response to TraumaWe may all experience reactions when frightening

things happen, emotional and physical reactions are normal during trauma: they protect our bodies.

Adolescents with posttraumatic distress and symptoms:o Experience problems in their daily life and ability to

interact with others. o Develop reactions that are long-lasting even after

the traumas have ended.o Feel differently about themselves, other people and

the future after they have experienced trauma.

Trauma can impact all areas of adolescent development

Physical CognitiveIncreased feelings

of physical awkwardness

Associate victimization with changes in their bodies

Question sexual preference

Early adolescents may believe their current reality will be permanent

Critical thinking points back to adolescent- “What did I do to deserve this?”

May effect development of executive functioning

Trauma can impact all areas of adolescent developmentSocial EmotionalFeel unsupported by

peersIsolate from peer groupIncreased aggression

or risk-taking

“Moody” teen may develop “dark cloud”

Unsure how to manage fear, anxiety, or self-doubt

May want to try managing alone

Identity DevelopmentIncorporate weakness or

vulnerability as major element of identity.

Or may decide to be “tough”

Regression- pull back from autonomy

Most Commonly Reported Functional Impairments

Problems in the Home/Community Behavior Problems at

Home Attachment Problems

Criminal ActivitySocial and School Functioning Academic Problems

Behavior Problems in School

Problems Skipping School

Risk Taking Behaviors Self injury Suicidality

Inappropriate sexual behaviors

Substance abuse Alcohol use

Running away

54%40.7%14.1%

59.9%44.0%21.7%

14.6%21%

12.3%15.3%12.5%12.5%

• Impairments in multiple domains

Review: Criteria for Post-traumatic Stress Disorder (PTSD) in DSM-5

Exposure to trauma, previously described One or two symptoms in each of these four categories:

o Intrusion: recurrent intrusive memories; nightmares; dissociative reactions (e.g., flashbacks); distress and physiological reactivity after exposure to reminders

o Avoidance: effortful avoidance of trauma-related thoughts, feelings, or reminders

o Negative alterations in cognitions and mood: Negative beliefs about oneself or the world; persistent negative emotions; constricted affect; feel alone; anhedonia; distorted blame of self or others

o Changes in arousal and reactivity: Irritable or aggressive; reckless; hypervigilance; exaggerated startle; sleep disturbance; problems with concentration or attention

Greater than one month duration Significant functional impairment

Negative alterations in cognitions and mood

1. Inability to remember an important aspect of the traumatic event(s)(not related to alcohol, drugs or head injury).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themself or others.

4. Persistent negative emotional state.5. Markedly diminished interest or participation in

significant activities.6. Feelings of detachment or estrangement from others.7. Persistent inability to experience positive emotions.

Complex Stress Disorder Events accompanied by chronic

coercion Changes in affect regulation Changes in consciousness

(depersonalization) Changes in self-perception Cognitive distortions regarding trauma

and perpetrator Changes in relationships Changes in systems of personal

meaning

Herman, 1992

Developmental Trauma Disorder (DTD)

A. Exposure + disruptions in protective caregiving

B. Affective and Physiological Dysregulation

C. Attentional and Behavioral Dysregulation

D. Self and Relational DysregulationE. Posttraumatic Spectrum SymptomsF. Duration of disturbanceG. Functional Impairment

van der Kolk, 2005

Trauma-Informed Care

Core Components of Effective Trauma-Informed Practice

Understand Trauma

Identify Trauma Exposures and Responses

Safely intervene

From: Modified National Child Traumatic Stress Network

Identify Trauma Exposure

Identify Trauma Exposure: Adolescents’ Obstacles to Reporting

Compared to other age groups, teens are least likely to report victimization Lack of understanding Fear they will not be believed Fear of blame or punishment Feeling shame or guilt Fear of retaliation Mistrust of adults Belief that nothing will be done Lack of knowledge about available services Perceived and real limits of confidentiality

Source: National Crime Prevention Council and The National Center for Victims for Crime. (2005). Reaching and Serving Teen Victims: A Practical Handbook.

Identify Trauma ExposureOpen-Ended Questions

o What is the most upsetting or overwhelming event that has ever occurred in your life?..

o After a very upsetting event we sometimes feel and act differently. Can you tell me whether you have experienced any of these changes since that most overwhelming or very upsetting event in his or her life, …if so did it last for more than one month? (Graham-Bremann, 2008; Cohen, Kellener, & Mannarino, 2008)

Self-report Screenerso UCLA PTSD Index

for DSM-5o Traumatic Events

Screening Inventory (TESI)

Identify Trauma Symptoms: Standardized AssessmentTrauma Questionnaire for Adolescents-

Revised Copied with permission from J. Benamati, 2002

1. I avoid thinking about bad things that happened to me.

2. I have trouble concentrating on things.

3. I have dreams about the bad things that happened to me.

4. I feel afraid whenever I think about the bad things that happened to me.

5. When I have thoughts about these things I cannot control how my feelings are expressed.

6. I feel like the same bad things are happening all over again.

7. I get jumpy when I hear loud noises or when there is unexpected activity around me.

8. I feel alone even when I am with my family and friends.

9. I feel I will not have a normal life.

10.I feel my life is in danger.

Identify Trauma Symptoms: Standardized AssessmentUCLA PTSD Index for DSM-5Pynoos, R., & Steinberg, A. (2013). UCLA PTSD Index for DSM-5.oChild/adolescent (ages 7 older) and parent-

report of youth symptomsoMost commonly used measure in the fieldoThe score sheet provides instructions for

calculating a total PTSD severity score, and severity subscale scores for each of the DSM symptom categories.

oRatings can be used to calculate whether partial or full criteria are met for PTSD diagnosis

Safely InterveneManaging your client’s trauma response

Pediatric PTSD treatment From AACAP Practice Parameter for the Assessment and

Treatment of Children and AdolescentsWith Posttraumatic Stress Disorder, 2010

Treatment planning should incorporate appropriate interventions for comorbid psychiatric disorders.Trauma-focused psychotherapies should be considered first-line treatments for adolescents with PTSD.Treatment planning should consider a comprehensive

treatment approach which includes consideration of the severity and degree of impairment of the youth’s PTSD symptoms.

Medications may be considered for adolescents with PTSD, however there is limited evidence-base to guide medication treatment (Mostly open label and case studies, unclear differences in efficacy of agents for acute/single episode vs. chronic/recurrent trauma, evidence extrapolated from the adult literature).

Psychotherapy Techniques

Trauma Informed Psychotherapy

Recognizing and understanding emotions

Managing anxiety, fear and anger Correcting thinking Communicating and problem solving

-Mahoney, Ford, Ko, Siegfried, 2004

http://www.nctsnet.org/nctsn_assets/pdfs/edu_materials/trauma_focused_interventions_youth_jjsys.pdf

First Step to Re-Setting the Brain’s Alarm: SOS (Mental Focusing)Source: Ford, J.D. (2013). The Impact of Trauma on Adolescents: Understanding Survival Mode. Presentation given at the Ohio Family and Domestic Court Judges Annual Training.

Step I: Stop, Slow Down, Sweep Your Mind Clear Notice how your body feels as you breathe in and outLet your mind be a river that carries every thought away

Step II: Orient Yourself Focus your mind on just one thought that you choose The hope, goal, or relationship that you value most in your

life

Step III: Self Check Your Level of Alarm and FocusHow Much Stress? How Much Focused Personal Control?

7 Steps to Re-Setting Adolescents’ Alarms After Trauma Source: Ford, J.D. (2013). The Impact of Trauma on Adolescents: Understanding Survival Mode. Presentation given at the Ohio Family and Domestic Court Judges Annual Training.

Safety MappingAdolescents draw maps of their

neighborhoodsLabel areas where they feel most and least

safeMake safety plans based on perceptions of

safety in different areas

Trauma-Focused Psychotherapy for AdolescentsTrauma-Focused Cognitive Behavioral

Therapy (TF-CBT)Prolonged Exposure Therapy for

Adolescents (PE)Trauma Affect Regulation: Guide for

Education and Therapy (TARGET)Integrative Treatment of Complex Trauma

for Adolescents (ITCT-A)Structured Psychotherapy for Adolescents

Responding to Chronic Stress (SPARCS; adolescent group intervention)

Strengthening Families Coping Resources (SFCR; family group intervention)

Pharmacotherapy

WHEN SHOULD MEDICATIONS BE CONSIDERED?

Severe symptoms causing impaired functioning Prolonged symptoms (> 1m)Along with TF-CBT to help control symptoms that

therapy will evoke or to allow child to access treatment

Patient/family unable or unwilling to participate inpsychological and social treatments

Failure of psychological, supportive and family interventions

Co-morbidity

Pharmacotherapy Targets Two Central Roles in PTSD Treatment Targets disabling symptoms so the child may pursue normal

growth and developmental trajectory: o Anxiety (separation, fears, hypervigilance, etc…)o Behavior problems (aggression, etc…)o Depression, negative cognitions, irritabilityo Impulse controlo Sleep problemso Thought irregularitieso Concentration/attentiono Self-injuryo Somatic problems (GI, neuropathic)

Helps child tolerate emotionally distressing material and enables them to work through their distress in therapy, as well as improving their functionality.

Approach to Medication Treatment· Literature extremely limited, few controlled

trials.· No specific agent for Pediatric PTSD· Inventory all symptoms; focus initial therapy

on one or two most distressing symptoms· Treat comorbidity When medications are used, adjunctive

psychotherapy is critical to adequately address trauma experience

39

Serotonergic AgentsSSRI’s generally considered first line medication

intervention because of their broad spectrum of activity.

May benefit irritability/mood, anxiety, compulsive & impulsive behaviors.

BUT, SSRIs may be overly activating in some youth and lead to irritability, poor sleep, or inattention; because these are symptoms of PTSD hyperarousal, SSRIs may not be optimal medications for these youth.

Paroxetine and sertraline have FDA indication for treatment of PTSD in adults, none for PTSD in pediatrics.

Summary

Most adolescents have experienced a traumatic event; many have experienced multiple traumas. Screening for trauma exposure is recommended for every patient

Wide range of adolescent responses to trauma, which can potentially impact every domain of adolescent development

Psychotherapy is first line treatmentPharmacotherapy literature is limited, but may improve

functionality and help adolescents work through their distress in therapy

Questions???