1. PSYC S-1016 Trauma and Development Manuel Sprung Summer 2009

2. Introduction Ph.D. University of Salzburg Theory of mind –Social-cognitive and linguistic development

3. Hurricane Katrina August 29, 2005 Click picture for video

6. Introduction continued Current research project –Boston Children’s Hospital –Schools in greater Boston area Visiting Scholar in Dept of Psychology (until summer 2011) –WJH 1232 –Manuel.sprung@gmail.com

7. Your background? Name Contact information Study subject/program Any other info you’d like to share

8. The course See syllabus (course website) Topic and content Course admin –Readings online (course website)

9. What are traumatic experiences? What’s traumatic for you?

10. Traumatic events listed in UCLA PTSD index Earthquake Other Disaster (flood, hurricane, etc.) Bad accident War Violence at home Family violence (other family members) Community violence Witnessing community violence Seeing dead body Sexual Abuse Violent death or serious injury of loved one Painful and scary medical treatment Other situations (scary, dangerous, violent)

11. DSM-IV list of extreme stressors Events experienced directly Witnessed events Events experienced by others

12. Directly experienced events Military combat Violent personal assault Kidnapped, Hostage Terrorist attack Torture, Incarceration Natural or manmade disaster Automobile accident Life threatening illness (children) Sexually traumatic events

13. Witnessed events Serious injury/death of another person due to –violent assault –accident –war –disaster Unexpectedly witnessing a dead body or body parts

14. Events experienced by others Violent personal assault Serious accident Serious injury (family members/close friend) Sudden, unexpected death of family members/close friend –Learning that one’s child has life-threatening disease

15. Event in which person …experienced, witnessed, or was confronted with event(s) involving actual or threatened death/ serious injury, or threat to the physical integrity of self/others ‘s…response involved intense fear, helplessness, or horror (children: disorganized or agitated behavior)

16. Acute traumatic eventChronic traumatic situation Interpersonal violence Act of nature beyond control School Shooting Terrorist attach Rape, Mugging Physical and Sexual abuse Bullying, War Natural disaster Loss of loved one Sever accident Serious illness Serious injury Dearth, Drought Figure 1: Types of traumatic events as a function of frequency and cause

17. Event type and effects Effects especially sever or long lasting when stressor is of a human design (e.g. maltreatment) Effects increase as the intensity of and physical proximity to stressor increase

18. Prevalence Estimated (for adolescents aged 12-17) –5 mio. experienced serious physical assault –1.8 mio. experienced sexual assault –8.8 mio. Witnessed interpersonal violence Recent survey in nationally representative sample (2-17 years) –More than half experienced physical assault (in study year) –More than 1 in 8 child maltreatment –More than 1 in 12 sexual victimization –More than 1 in 3 witnessed violence –Child victimized once had a 69% chance of revictimization Rural areas (NC) Urban areas (NY)

19. Prevalence in rural areas By age 16, more than 25% exposed to one or more incidents of acute and chronic trauma –Maltreatment/domestic violence –Traffic injury –Major medical trauma –Traumatic loss –Sexual assault 72% experienced only one, 18% experienced two, 10% experienced three or more (thus: 7% overall experienced two or more)

20. High and low magnitude events DSM’s extreme stressors = high magnitude events However, may not encompass all the events that trigger psychiatric disorder in children Other events known to increase risk for anxiety and depression in children and adolescents = low magnitude events –(relationship to PTSD unclear)

21. High magnitude events Death of a loved one (4.8%) –Parent, caretaker, sibling, or best friend Witness a traumatic event (4.9%) Learning about traumatic event (4.7%) Sexual abuse (2.6%) –1.8% boys, 3.4% girls Serious illness (2.2%) Serious accident (2.2%) Natural disaster (2.1%) Fire (1.2%) Other events (< 1%)

22. Low magnitude events More than one in four children (last 3 months) –71% only one, 21% two, 8% three or more Most common events –Moving house (6.2%) –Marked drop in standard of living (3.9%) –Changing school (3.8%) –Breaking up with boy/girl friend (3.6%) –Lost best friend trough move (3.3%) –Breakup with best friend (2.3%) –New child in home (2.5%) Girls more likely to report parental separation and breakups with best friends or boyfriends

23. Discussion What do you think about these high- und low magnitude events

24. Prevalence in urban areas Grade 4-12, over 60% experienced at least one major traumatic event (even prior to 9/11) –Seeing someone killed/seriously injured (39%) –Seeing violent/accidental death of a close friend (29%) or family member (27%) 25% experienced two or more Likelihood of multiple trauma ~ 3 times higher in NYC than in rural NC

25. Prevalence (extended into young adulthood) 60.7% males and 51.2% females aged 14-24 reported exposure to one or more traumatic events By age 22-23 years lifetime occurrence was 82.5% –males = 87.2%, females = 78.4% Most common –Learning about sudden, unexpected death of a significant other (51.9%) –Exposure to interpersonal violence higher in males 62.2.% males, 33.7% females)

26. Age-specific prevalence rate Rate of exposure rises after age 15 years (peak at 16-17 years) –Males’ rates more than twice those of females 15-16% males, 5-6% females By age 20-21 years rate of exposure to violence returned to what it had been at early adolescents

27. Prevalence in Japanese women 12% experienced traumatic event even during preschool years Rate of exposure increasing –during primary school (21.2%) –Peaking during high school (27.5%) –Decreasing in college and young adulthood (23.8%) Consistent with studies in US –Mid- to late adolescence time of peak

28. Prevalence in Germany Of 14- to 24-year-old adolescents and young adults 21.4% reported at least one lifetime event (exposure only) 26% males, 17.7% females With intense fear, hopelessness, horror (irritability) –17% overall (18.6 males, 15.5% females) Most prevalent events –Physical attacks (7.5%) –Serious accidents (5.4%) –Witness to event (3.6%) –Childhood sexual abuse (2.0%)

29. Age-specific rates in Germany Dramatic increase at about 11 years –Sexual abuse and rape accounting for much of increase in females (up to age 15 years) Between 15-21 years physical attacks and witnessing events most prevalent –Increase in males largely accounted for by physical attacks and serious accidents

30. At-risk children Prevalence rates suggest that exposure to traumatic events = public health problem Trauma exposure unevenly distributed within population

31. Higher risk for children known to have been abused/neglected in out-of-home placement exposed to domestic violence witness violent death of family member/ close friend in juvenile justice system victims of catastrophic accident/ mass causality events –including school violence, terrorism, natural disasters from countries with armed conflicts or civil disturbance require residential treatment or hospitalization (mental health/behavioral problems) –such as substance abuse or suicide attempts

32. Youth in juvenile justice system Youth ages 10-18 held pretrial in an urban detention center –92.5% had experienced one or more traumatic events –84% reporting more than one –Majority exposed to six or more More males (93.2%) than females (84.0%) More youth aged 14 years or older reported trauma than did youth age 10-13 years

33. Children from countries with armed conflict Palestinian school children aged 12-16 years –Majority (54.7%) at least one traumatic event Trauma associated with –armed conflict, including personal physical injury (22.9%) –Traumatic death of family member (17.6%) –Motor vehicle accident (30.9%) –Nearly drowning (3%) –Sexual assault (0.7%)

34. Children and adolescents in clinical treatment 77.6% experienced prolonged exposure to multiple traumatic events Interpersonal victimization in home was most prevalent type of trauma (in treatment-seeking subjects)

35. Factors increasing risk Gender, socioeconomic status and race/ethnicity –Overall no sex difference –Female more likely to report rape, sexual abuse, coercion –Males more likely to report causing death or sever harm to someone else –Cumulative occurrence of assaultive violence varied sign. By socioeconomic states and race/ethnicity Males only Not true for other types of trauma –Males with African heritage more likely to be exposed to interpersonal violence Risk factors in Germany Vulnerability factors

36. Risk factors in Germany being female being older having low socioeconomic status living in Urban environment

37. Vulnerability factors Strong, graded relationship between number of family vulnerability factors Children with no vulnerability factors have 12% chance of experiencing trauma Risk of recent high magnitude event in children who had recently experienced low magnitude event increased fourfold –From 24% at no vulnerability factor to 92% at 10 or

38. Types of vulnerability factors Parental psychopathology Family relationship problems Family/ community environment

39. Type of event and vulnerability Some events distributed throughout population irrespective of level of vulnerability –Deaths of loved ones –Serious illness and accidents –Physical (nonsexual) violence Events whose likelihood increased in vulnerable children (network events) –Sexual abuse –Events occurring to people whom the child knew, or knew about

40. Gender and vulnerability Parental history of mental illness only factors increased boys’ risk (double the risk of high magnitude event Girls –Family with mental illness –Parents with criminal record –Impoverished or poorly educated homes In neither sex parental history of drug problems did increase risk

41. Thus Vulnerability factors such as poverty increase the risk –of some events (sexual abuse, network events) –but not others (death of loved ones, serious illness, or accident) Family history of mental illness double the risk of exposure Children experiencing one or more low magnitude events at greater risk of high magnitude events Even among the most fortunate group of children (whose lives were free from vulnerability factors) –one in six had suffered at least one traumatic event

42. Historical trends in the US Only data for maltreatment Contrary evidence from different sources –Increase –Decrease New data yet to be released/reported Missing data on other types of trauma