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Presentation on theme: "THROUGH A TRAUMA LENS: IS THE ADOLESCENT CONDUCT DISORDERED OR SUFFERING FROM TRAUMA? Douglas Goldsmith, Ph.D. Executive Director The Children’s Center."— Presentation transcript:

1 THROUGH A TRAUMA LENS: IS THE ADOLESCENT CONDUCT DISORDERED OR SUFFERING FROM TRAUMA? Douglas Goldsmith, Ph.D. Executive Director The Children’s Center Annual Troubled Youth Conference 2013

2 Referral concerns for 14 year old Withdrawn from others at home Extreme aggression toward parents and siblings Furious if wants and needs are not quickly satisfied Avoids or dismisses comforting comments or gestures Aggressive toward peers Fails to engage in social interactions Extreme bouts of anger and destructive behavior Multiple referrals to juvenile court for theft and assault Failing school Alcohol and drug abuse

3 Clinical Presentation Angry tone when greeted in waiting room Extremely hesitant to come to office. Does so only when threatened by his parents. Poor eye contact Difficult to hear Defiant and oppositional when asked questions Frequently shrugs shoulders or says, “I don’t know”. Exhibits little insight into emotional functioning of self or others Sees future as hopeless but denies suicidal ideation

4 Diagnosis? Conduct Disordered? Depressed? Traumatic Stress Response?

5 Traumatic Experiences are Inherently Complex Traumatic events include varying degrees of objective life threat, physical violation, and witnessing of injury or death. Trauma exposed children experience subjective reactions to those events that include changes in feelings, thoughts, and physiological responses; and concerns about the safety of others. NCTSN 2007

6 Children’s Response to Trauma Children’s reactions are strongly influenced by prior experience and developmental level. Complexity increases in cases of multiple or recurrent trauma exposure. Complexity increases when the primary caregiver is a perpetrator of the trauma.

7 Early Trauma “The earliest and possibly most damaging psychological trauma is the loss of a secure base.“ van der Kolk (1987)

8 Traumatic Events Generate Secondary Adversities Family separations Financial hardship Legal proceedings These adversities may be sources of stress in their own right Trauma reminders and loss reminders may further increase the impact of trauma NCTSN

9 Wide range of reactions to trauma Post trauma reactions can vary in nature, onset, intensity, frequency, and duration Pattern and course of reactions influenced by the traumatic experience and its consequences Child factors including prior trauma or loss and post trauma physical and social environment

10 Post Traumatic Stress Post traumatic stress and grief reactions can develop over time into psychiatric disorders including PSTD, separations anxiety, and depression. May disrupt child development, attachment, peer relationships, emotional regulation May exacerbate pre-existing anxiety and depression

11 Danger and Safety Trauma may undermine children’s sense of protection and safety May magnify concerns about danger to self and others

12 Trauma Impacts the Family Losses and ongoing danger can impact caregiving systems and lead to serious disruptions in caregiver-child interactions and relationships. Caregivers personal stress and concerns may impair their ability to support the child. Child’s reduced sense of protection and security may impact ability to respond positively to caregiver’s efforts to provide support.

13 Prevalence Great Smokey Mountains Study Longitudinal study of children By age 16, 67% of children exposed to one or more traumatic events.

14 Prevalence NIMH Life-time prevalence of PTSD for 13 to 18 year olds is 4-6% National Intimate Partner and Sexual Violence Survey 1 in 5 women report having been the victim of rape at some time during their lives. 42% were abused prior to age 18

15 Prevalence NCTSN 80 percent of children referred for screening and evaluation reported at least one trauma 77 percent of adolescents experienced more than one trauma 31 percent of adolescents had five or more

16 Effects of Maltreatment Elevated rates of aggression Over attribution of hostile intent Lower social competence Less empathy Insecure attachments Lower IQ, language ability, and school performance

17 Children’s Response to Domestic Violence “ Witnessing violence and being the victim of violence shatter the child’s confidence that his well-being matters and that adults will take care of him.” Lieberman and Van Horn (2005)

18 Effects of Exposure to Violence High levels of internalizing and externalizing problems Affect dysregulation Difficulty establishing relationships Reenact the traumatic experience Sleep disturbance Intense fear and uncontrolled crying Aggression and noncompliance

19 Reactions to Trauma Distressing thoughts and images Upsetting emotional or physical reactions to reminders of the experience – it might feel to the child like it’s happening all over again Avoid talking or thinking about it. Go to great lengths to avoid reminders of the event. Avoidance causes feelings of detachment Always being on the “look out” for danger, jumpy, irritable, angry outbursts, can’t sleep

20 PTSD Post Traumatic Stress Disorder Persistent re-experiencing of trauma Avoidance of stimuli associated with trauma Increased arousal Impairments in social, emotional, and occupational functioning

21 PTSD à deux “ The parents own traumatic response to the trauma endured by the child creates a complex system that may maintain or contribute to dysfunction in both parent and child” Appleyard & Osofsky (2003)

22 Relational PTSD Parents may be traumatized even if not present at the trauma: Withdrawn/Unresponsive/Unavailable Emotionally and functionally unavailable May have suffered trauma in the past Overprotective/Constricting Preoccupied about the trauma re-occuring Reenacting/Endangering/Frightening Repeatedly ask about the event Scheeringa & Zeanah (2001)

23 Impact of Trauma on Attachment Damage to child’s expectation that parents can provide protection and comfort Those closest to me can cause the greatest hurt Sense of self and trust in others becomes permeated with fear, anger, mistrust, and hypervigilance These feeling conflict with the desire to be close to parents Lieberman and Van Horn (2005)

24 Attachment and Trauma “Young children’s ability to recover from the damaging impact of traumatic events is deeply influenced by the quality of the child’s attachments and by the parents’ ability to respond sensitively to the infant’s traumatic responses” Lieberman (2004)

25 Attachment and Trauma “ Real-life events can derail a previously secure attachment by inducing in the parent emotionally alienating responses such as guilt, fear, anger, overprotectiveness, and affective dysregulation, and by damaging the child’s trust in the parent as a reliable protector.” Lieberman (2004)

26 Reactive Attachment Disorder A rare, but serious condition, in which infants and young children fail to establish healthy bonds with parents or caregivers Child is typically neglected, abused, or orphaned. Need for comfort, affection, and nurturing are not met and loving caring attachments are not established. Mayo Clinic

27 Reactive Attachment Disorder Begins before age 5 Withdrawn, sad, listless Failure to smile Fail to visually follow others in the room Fail to reach out to be picked up No interest in interactive games Soothes self with rocking or self-stroking Calm when left alone

28 Signs of RAD in Adolescence Withdrawal from others Avoid or dismiss comforting comments or gestures Aggressive toward peers Fail to engage in social interaction Fail to ask for support or assistance Mask feelings of anger or distress Alcohol or drug abuse

29 Causes of RAD Institutionalized care Frequent changes in caregivers Inexperienced parents Extreme neglect Extreme poverty Physical, sexual, or emotional abuse Forced removal from abusive home Impaired caregiver(s)

30 Complications of RAD Delayed learning or physical growth Poor self-esteem Delinquency, anti-social behavior Relationship problems Temper or anger problems Eating problems Depression / anxiety Academic problems Drug & alcohol addiction / sexual problems

31 Understanding Complex Trauma The dual problem of children’s exposure to traumatic events and the impact of this exposure on immediate and long term outcomes. Exposure to multiple traumatic events that occur within the caregiving system – the social environment that should be the source of safety and stability for the child. Includes emotional, physical, sexual abuse and witnessing domestic violence. (NCTSN, 2003)

32 Response to trauma Parental neglect and abuse Emotional dysregulation, loss of safe base, loss of direction, and inability to detect or respond to danger cues Leads to subsequent trauma exposure, physical abuse, sexual abuse, community violence

33 Complex Trauma Outcomes Multiple domains of impairment: Self-regulatory, attachment, anxiety, and affective disorders in infancy and childhood Addictions, aggression, social helplessness and eating disorders Dissociative, somataform, cardiovascular, metabolic, and immunological disorders Sexual disorders in adolescence Revictimization (NCTSN, 2003)

34 Children with disorders of attachment Abused, rejected and neglected children develop adaptive strategies based on control, avoidance, and arrested affect. When they join new families they bring with them the fearful-aggressive controlling behaviors developed in early years Placements run high risk of major difficulties Howe & Fearnly (2003)

35 Behavioral Concerns Lack of impulse control Self-destructive behaviors Destruction of property including favorite and precious objects Verbal and physical aggression Stealing “Crazy” and obvious lying Inappropriate sexual conduct Cruelty to animals

36 Behavioral Concerns Preoccupation with violence, gore, fire Sleep disturbance Enuresis and encopresis Oppositional defiant behaviors Hyperactivity, constant need for stimulation Behave as though new caregivers are responsible for past abuse Blame others Self endangerment

37 Emotional Concerns Intense displays of anger, rage, violence Inconsolable sadness, helplessness and depression Inappropriate emotional responses Marked mood changes Inappropriately demanding and clingy Resentful

38 Social Concerns Superficial and charming with strangers Little eye contact Poor peer relationships Fight for control over everything Bossy Manipulative, controlling, exploitive Lack remorse or conscience

39 Physical and Developmental Concerns Poor hygiene, self-neglect Confusion over physiological states Abnormal eating patterns Body tension Accident prone High pain tolerance, over-reactive to minor injuries Dislike being touched

40 Maltreated Children Poor understanding of emotions and theory of mind and poor capacity for empathy Caregiving relationships are: Frightening and dangerous Hurtful and unpredictable Careless and confusing Don’t feel safe in intimate environments Loving care is best avoided

41 Attachment related situations Caregiver seeks to care and protect Produces intense arousal and results in frightened and angry, hostile and helpless, bossy and despairing behavior by the child.

42 Caregiver Response In danger of feeling helpless and angry by facing so much aggression, confusion, need and mental fragmentation Want to abdicate their role “I give up!” “I feel exhausted and depressed and helpless.”

43 Abused and Rejected Children Survive by downplaying negative affect Assume that protective care is not available at times of need Develop high levels of self reliance and self containment Are emotionally self-sufficient with new caregivers

44 Adoptive Parent Response Adoptive parent feels unneeded and unwanted As a result the parent backs off Deactivates caregiving May ignore the child

45 Impact on Parent-child Relationship “The replication is not inevitable, but the child’s mental representation of how relationships work, based on past experiences of rejection, can set up powerful transactional forces into which new parents can easily be drawn.” Howe & Fearnley (2003)

46 Abuse, neglect and rejection Children deactivate attachment behavior Exhibit compulsive compliance Suppress or deny affect, power, and aggression Low on empathy due to defense against affect

47 Parent-child relationship “If the attachment figure is the source of the fear, distress or confusion, the child is presented with a psychological dilemma. The child experiences simultaneous feelings of escape and approach which cannot be resolved.” Howe & Fearnley 2003

48 Parentified Behavior Carers whose own needs are greater than those of their children include victims of DV, addiction to drugs/alcohol, suffer major depression, or struggle with unresolved trauma. Parentified behavior Children maintain false, brittle cheerfulness Constantly fear the loss of the parent emotionally and psychologically

49 Abusive/neglectful Caregivers Children experience parents as out of control and aggressive or helpless and needy Parents abdicate their role as protector Children avoid being cared for because it implies danger, abandonment, rejection, confusion and hurt. They seek to be in control rather than be controlled Child becomes bossy, aggressive, violent, self- abusive, fearful, helpless, sad

50 Screening and Assessment Have you ever been traumatized?

51 Screening and Assessment Have you ever been abused?

52 Screening Has your child experienced any of the following? Please check all that apply: ______Physical abuse ______Emotional abuse ______Witnessed domestic violence ______Sexual abuse ______Loss of parent or caregiver ______Painful medical treatment/life threatening illness/hospitalization ______Severe dog bite ______Severe burns that required medical attention ______Death of close family member ______Auto accident requiring emergency medical attention ______Parent/caregiver deployed in the military ______Witnessed a parent being arrested ______Witnessed extreme neighborhood/community violence ______Other (please explain) ___________________________________

53 Screening

54 Therapeutic Goals Contain and reduce acting out behavior Identify and express emotions verbally Experience a safe, caring, nurturing, interested relationship with significant adults Facilitate descriptions of past traumas and the expressions associated with them Help child direct anger and sadness to the perpetrators and not the current carers Fearnly 2000

55 Treatment “Replicate developmental characteristics of secure caregiving but with a child who deeply mistrusts being looked after, cared for, protected and benignly controlled by his attachment figures.” Help child develop mentalizing capacity Understand themselves and others as psychological and intentional beings How feelings affect behavior and how behavior affects other people

56 Treatment Learn how to regulate emotions within the context of close relationships Understand how social emotional information is expressed and reflectively processed Address grief, loss, sadness and depression associated with past and traumatic events Learn how feelings can be handled and discharged appropriately

57 Model self-soothing What do you say to yourself? What do you do? Listen to music? Go for a run? Read? Eat? Watch TV?

58 Developing a Secure Base “When a child is held in mind, the child feels it, and knows it. There is a sense of safety, of containment, and, most important, existence in that other, which has always seemed to me vital... It seems to me that one of life’s greatest privileges is just that – the experience of being held in someone’s mind.” Pawl (1995)

59 Reference Howe, D. & Fearnley, S. (2003). Disorders of attachment in adopted and fostered children: Recognition and treatment. Clin Child Psychol and Psychiatry, 8, 369-387.


61 DOUGLAS GOLDSMITH, PH.D. (801) 582 - 5534

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