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Wrap up lecture. Traumatic Events and PTSD Traumatic events in childhood What’s considered traumatic event – Experienced, witnessed, learned about –

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Presentation on theme: "Wrap up lecture. Traumatic Events and PTSD Traumatic events in childhood What’s considered traumatic event – Experienced, witnessed, learned about –"— Presentation transcript:

1 Wrap up lecture

2 Traumatic Events and PTSD

3 Traumatic events in childhood What’s considered traumatic event – Experienced, witnessed, learned about – Subjective response – Types acute – chronic interpersonal – acts of nature “Discrepancy between experience of threatening situation and situation and recourses to cope, accompanied by feelings and enduring concussion of conceptions of self and world “ (Fischer & Riedesser, 2003)

4 Prevalence of traumatic events 1 in 4 children by age 16 Most common types – death of loved one – witness/learning about event – sexual abuse – serious illness/accident – disaster High and low magnitude events (e.g., moving house, drop in standard of living) – High magnitude event four-times as likely if low magnitude

5 Prevalence continued Rise after age 15 years – Return to earlier rate at age 20/21 Males twice those of females International perspective – Similar rates in Japan (12% even in preschool) and Germany – Most common in German sample: physical attacks, accident, witness event, sexual abuse Unevenly distributed in population

6 Risk and vulnerability factors Some groups at risk for repeated exposure – Abuse/neglect, domestic violence, out-of-home placement, in juvenile justice system – Witness violent death, from countries with armed conflict, victims of disaster, hospitalization Vulnerability factors – Parental psychopathology, family relationship problems, family/community environment – Increase some types of events (e.g., sexual abuse)

7 Consequences of traumatic events Impact on development – Achieve normal developmental milestones – Cognitive development, language, IQ, school performance – Even when not objectively threatened – Affects children’s sense of personal safety, predictability, and protection

8 Impact on development Emotion regulation – Especially violence and abuse Sexual abuse affects brain development Academic performance and IQ – Attention, reasoning, EF – 8 points decrease in IQ in children exposed to domestic violence Intergeneration transmission of trauma (?)

9 Psychopathology Range of psychopathological outcomes – Alcohol/drug abuse, suicide attempts, poor physical and mental health (health risk behaviors) Childhood trauma predicts mental and physical health in adulthood

10 CTS and PTSD Child Traumatic Stress (CTS) – Set of reactions to traumatic event (when overwhelms ability to cope with) Intrusive re-experiencing Avoidance Physical hyper-arousal Posttraumatic Stress Disorder (PTSD) – Diagnostic category (DSM-IV)

11 PTSD Historical background – Post Vietnam Syndrome – PTSD first appeared in DSM-III (1980) – DSM-IV (objective) experienced, witnessed or confronted, subjective emotional response Only disorder with causal factor (exposure to traumatic stressor) integral to definition

12 PTSD criteria (DSM-IV) A: (1) traumatic event, and (2) subjective response B: re-experiencing (1) C: Avoidance (3) D: Increased arousal (2) E: lasts for more than 1 mo F: clinically significant distress or impairment Duration and onset – Duration: 3mo = chronic – Onset: >6mo = delayed

13 ASD vs. PTSD ASD A: (1) traumatic event, and (2) subjective response B: dissociative symptoms (3) C: persistent re-experiencing (1) D: marked avoidance (?) E: marked anxiety or increased arousal (?) F: clinically significant distress or impairment G: Lasts for min. 2 days, max. 4 weeks, within 4 weeks of event H: not due to effects of substance (drug) or medical conditions PTSD A: (1) + (2) B: re-experiencing (1) C: Avoidance (3) D: Increased arousal (2) E: lasts for more than 1 mo F: clinically significant distress or impairment Duration and onset – Duration: 3mo = chronic – Onset: >6mo = delayed

14 PTSD in children Age and symptoms – Preschool: overly anxious, regressive, hyper – School-age: intrusive re-experiencing, fear of repetitions, thoughts of revenge, ambivalent/restless, sleep problems – Adolescents: realize regressive, feel isolated, left alone, upset about lack of support/protection

15 Measures of PTSD C-PTSD Reaction Index Clinical-Administered PTSD Scale Other: Impact of Events Scale, Trauma Symptom Checklist, C-PTSD Symptom Scale

16 Prevalence of PTSD Variability in rates – ~1% - 6.8% in general population (life-time) – Conditional probability (% of trauma exposed) 13% women, 6% men Dependent on type of event – Up to 40% combat, rape, physical violence – Up to 30% sudden, unexpected death of relative/friend Course of disorder – 50-75% remit after 1 year – Male remit sooner than female

17 Child specific prevalence rates Variability in rates – 3.7% - 11% – Rates higher for females than males (in most studies) Higher rates in – youth in juvenile detention (~11%) – Youth exposed to events affecting entire community (up to ~60%)

18 Traumatic experiences vs. PTSD 22.5% Traumatic experiences vs. 1.6% PTSD Males have higher rate of traumatic experiences Females have higher rate of PTSD Traumatic experiences and PTSD increase with age (peak at 16-17year)

19 Other disorder Acute Stress Disorder – Widely criticized – Dissociation not that predictive – Earlier PTSD predicts later PTSD Complex PTSD (DESNOS) – Linked to chronic trauma (especially beginning in childhood) – Not recognized in DSM-IV Secondary PTSD

20 Resilience and Posttraumatic Growth

21 Resilience = positive adaption despite adversity Posttraumatic Growth (PTG) = growth, positive change resulting from trauma

22 Resilience Threat, adaption/developmental outcome ‘good/OK’ Ordinary phenomenon Historical overview – Parental mental illness (i.e., schizophrenia)

23 Factors associated with resiliency Variable focused – Parenting quality – Intellectual functioning – SES – Positive self-perception Person focused – Average+ on academic, conduct, social Suggested role of positive emotions?

24 Posttraumatic Growth Some changes in – personal strength – new/shifting perspectives – salient characteristics in others Can co-exists with posttraumatic stress symptoms Some important factors – Age (o), gender (f), severity/type, income, time since (more), religiosity, social support (higher)

25 Measures of PTG PTGI-revised for children and adolescents – Five domains: New possibilities, relating to others, personal strength, appreciation of life, spiritual changes – Used with children as young as 7 years Other measures – PTGI-C, Perception of Changes in Self Scale, Secondary (qualitative) analysis of PTSD interviews

26 PTG and negative live events PTG linked to negative life events – mild amount of change – No difference between type of life event (traumatic?) – No difference in gender, ethnicity – Correlation with age (+), religiosity (+), substance use (-)

27 PTG in children with traumatic experiences Cancer survivors – More time since/higher perceived life threat /treatment intensity, Older age – Age at diagnosis (+) – ~85% one positive change, 32% four+ changes Road traffic accidents – 42% PTG (37% also PTSD), appreciation of life Natural disaster – PTG correlation with competency beliefs, PTSS

28 Developmental consideration Only theoretical considerations so far PTG requires certain level of cognitive development – Cognitive capabilities influence understanding appraisal – Important developmental domains Theory of mind Attachment (internal working models) Developmental level maybe risk or protection – But PTG more likely in older age (?)

29 Trauma and Culture

30 Distinction race, ethnicity and culture All humans have capacity to experience fear, helplessness, horror to meet (A2) DSM-IV Cultural factors may influence likelihood or nature of expression Culture = protective or risk factor Developmental considerations – No systematic review, no direct comparisons

31 Theoretical and other considerations Culture as mediator of trauma – E.g., range of PTSD response, coping Acculturation and assimilation Intergeneration transmission of trauma

32 Limited empirical evidence PTSD cross-cultural applicable? – PTSD can be detected among non-Westerns – Goodness-of-fit? – Somatization, Dissociation claimed to be common in non-Westerns Direct comparison: American Vietnam Veterans from different cultural backgrounds – Race/ethnicity only weak predictor Review of disaster literature – Minority youth at greater risk of PTSS – Hypothesized that culture can impede help-seeking

33 Natural and manmade disaster

34 Children and Disaster History of disaster studies Most common responses – Specific fears, separation difficulties, PTSS Specific PTSD/ stress-responses in children – re-enactment in play, sleep problems, increased irritability, regression, somatic complaints, guilt Other symptoms/disorders – Anxiety, Depression, School problems

35 Factors in influencing response Disaster characteristics – Life threat, bereavement, separation, physical loss/disruption Child characteristics – Age (o), gender, prior psychopathology and traumatic experience Family/Community effects – Parental distress, communication patterns, evacuation without return (relocation), community support (e.g. rebuilding)

36 Example Study: Hurricane Katrina Intrusive thoughts and knowledge about thinking following Hurricane Katrina (Sprung, 2008) Hurricane Katrina survivors vs. control group No significant group difference in overall frequency of intrusive thought – BUT imbalance of positive – negative valence – Recurrent intrusive thought more likely Relationship between Theory of mind (i.e. knowledge about thinking) and self-report of (negative) intrusive thoughts

37 Violence in School and Community Inga Brege

38 Refugee and War Trauma Regina Musicaro

39 Terrorism Sandra Valdes-Lopez

40 Child Traumatic Grief

41 Conceptual considerations Bereavement (objective), grief (reaction), mourning (cultural) Uncomplicated vs. complicated and traumatic Stage models of grief (uncomplicated) – Denial, anger, bargaining, depression, acceptance (Kuebler-Ross) – Disbelief, yearning, anger, depression, acceptance (YBS) Acceptance most common, yearning strongest negative

42 Childhood (uncomplicated) grief Harvard Child Bereavement study (4) Tasks of mourning – Accepting reality, experience painful emotions, adjust to new situation, relocate person within one’s life and memorize (8) NCTSN (Goodman et al., 2004) – Accepting, experiencing, adjusting, new/deepening relationships, invest in new relationships/activities, maintain attachment (reminiscing, memorizing), making meaning, continue normal states of development

43 Clinical considerations Bereavement (uncomplicated grief) mentioned in DSM-IV – ‘other conditions that may be a Focus of Clinical Attention’ – Resembles MDD, but MDD not diagnosed in first 2 months (unless symptoms about other than the diseased person)

44 Complicated and Traumatic Grief (Adult) complicated/traumatic Grief – Separation distress (i.e., intrusive thoughts about deceased, yearning, search, excessive loneliness) + Traumatic distress – Symptoms last at least 6 months, significant functional impairment Measure – Inventory of Complicated Grief – Texas Revised Inventory of Grief

45 Child Traumatic Grief Objectively/subjectively perceive death as traumatic Overwhelmed by trauma response + unable to accomplish normal grieving tasks Complicated (unresolved) grief symptoms + PTSD symptoms (often also depressive) Measures – Grief Screening Scale – Extended Grief Inventory (Traumatic grief, positive memory, ongoing presence)

46 Trauma reminders, loss reminders, change reminders impinge on ability to reminisce Secondary adversities (additional losses) CTG as a new mental health disorder (?) – Some empirical evidence for unique contribution – Diagnostic criteria suggested for ‘Traumatic grief disorder’ and ‘Complicated Grief Disorder’ Other symptoms and disorders – Somatization, serious illness/accident, substance use, suicidal ideation

47 Prevalence Uncomplicated grief – Lifetime almost everyone – ~40% of college students Complicated/ traumatic grief – No empirical studies (to date) – CTG not normative (even if objectively traumatic) Factors possibly affecting response – Emotional proximity, physical proximity, secondary adversities, poor pre-trauma/death functioning, poor coping

48 Developmental and other considerations Children’s understanding of death – Influenced by age, experience, cognitive development – Cultural difference Grief and spirituality – Maybe helpful coping strategy – Developmental implications (?)

49 Maltreatment

50 Different approaches – Medical-diagnostic, legal, ecological – Issues of definition raise methodological concerns Specific acts endangering child – Operation definition! What’s acceptable parental discipline? – Corporal punishment (home, school, quasi- judicial)

51 Maltreatment 4 general categories – Sexual abuse, physical abuse, neglect, emotional maltreatment Psychological maltreatment – Subtype rarely in isolation, majority of maltreated children more than one Maltreatment Classification System Interaction severity and frequency (chronicity), severity and subtype – Predictive of maladaptive outcome

52 Issues of operationalization (i.e. neglect) and strategy and assessment (self-report, official record) – Official records seriously underestimate Prevalence – Neglect most common, then physical and sexual abuse – Parents in majority of cases Etiology – Ecological-transactional model

53 Intergenerational transmission Family dynamics Parenting style Mental health of maltreated children – Depression, anxiety disorder, disruptive behavior, personality disorder Impact on child Development – Emotional Development, attachment, self autonomy, symbolic development, moral development

54 Intervention and Prevention Julia Schmidt Maso

55 Medical illness and injury

56 “Although the world is full of suffering, it is also full of the overcoming of it” Helen Keller

57 Thank you! This has been a great class!

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