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Wrap up lecture.

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Presentation on theme: "Wrap up lecture."— 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: < 3 mo = acute, >3mo = chronic Onset: >6mo = delayed

13 ASD vs. PTSD ASD PTSD A: (1) + (2) B: re-experiencing (1)
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 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: < 3 mo = acute, >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 Dependent on type of event
~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
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 Complex PTSD (DESNOS)
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 and Posttraumatic Growth
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 Trauma and Culture 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 Secondary adversities (additional losses)
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 Complicated/ traumatic 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 Maltreatment Different approaches Specific acts endangering child
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 Maltreatment Classification System
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 This has been a great class!
Thank you! This has been a great class!

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