1. The European Network for Traumatic Stress Training & Practice www.tentsproject.eu

2. Development and interventions among trauma-affected children and families Raija-Leena Punamäki, Kirsi Peltonen & Esa Palosaari University of Tampere

3. Prevalence of childhood trauma Children < 16 years 1 or more trauma  13-43% Europe  68-71% USA Prevalence of childhood PTSD Meta-analysis (34 samples,2697 children)  36% of children exposed to trauma suffered PTSD  24% among trauma exposed adults  No differences in PTSD according to age

4. Prevalence of childhood PTSD Nature of trauma Natural disasters  30-50% moderate to severe symptoms  5% -10% criteria for a full diagnosis War and military violence  17-80% Severe personal atrocities ->dose-effect Accidents  25-50% E.g. vehicle, boat and traffic, fires Sexual or physical abuse, family violence  3-90%, sexual trauma with high rate rates

5. Screening for PTSD and other post-trauma responses  Reliable results in using DSM-IV diagnosis  Important to get information:  Current symptoms and concerns  Attempts to managege and cope with trauma  Timing and course of symptoms  Developmental and family history  Information from both the parent/guardian and directly children themselves

6. Screening for PTSD II  A brief PTSD assessment at 1 months after trauma among survivor families  Parental and/or self-reports (e.g. IES-R, CPSD-RI)  Interviews (The Child PTSD Interview)

7. Comprehensive assessment of trauma responses  Depressive symptoms (CDI)  Bereavement: absence and overhelming grief (PGI)  Excessive and generalized fears  Increased life threat; separation anxiety, worry about safety of family, shortened views of future  Somatic symptoms: headaches, stomach aches, disturbances and changes in sleeping patterns

8. PTSD in toddlers (2- 4 year olds)  One symptom per Intrusive, Avoidance & Arousal category of PTSD may count for clinical diagnosis  Changes in behavior  Repeated and ritualistic play (flashback)  Developmental delays (language, sensomotor)  Loss of acquired skills (language, toileting)  New symptoms: aggression to others, separation anxiety, fear of dark and dark of being alone

9. Compex & comprehensive nature of childhood traumatization Sensomotor Cognitive Emotional Social Coordination Timing Complexity Speed Attention Language Memory Problem solving Attachment Experiences Maturation Empathy Friendship Attachment Neurofysiology

10. Why children differ in their reaction to traumatic stress? Population Traumatic event By Helen Christie During Trauma After trauma Before trauma Vulnerability and risk factors Protective and modifying factors High symptom group Low symptom group From birth Later reactions

11. Developmental aspects I  Children of all age are vulnerable, but react in age-specific ways  Each developmental stage provides both protective self-healing processes and vulnerabilities  Traumatic experience may slow down or expedite developmental transition  The target of worries and threats age-specific  Families respond as a system

12. Developmental aspects II Uniqueness of children in traumatization :  Personality: temperament  Age  Family relations  meanings of trauma  Cognitive capacity  Developmental concerns New diagnosis: Developmental Trauma Disorder (DTD)

13. Affect regulation – emotions  Biased; either numbing or escalating of feelings  Lack of synchrony between levels (psychological/physiological)  Fear dominates

14. Trauma and memory  Traumatic  Sensory & emotional  Visual, auditory, kinesthetic, smell, taste  Memories unchanged  Sensory memory easily recalled : flashbacks  Multiple cues for evoke memories  Involuntary & uncontrollable  Neutral  The meaning is constructed  Can be verbalized and presented in symbols  Memories fade & disappear with time  Conscious links between cues & memory  Voluntary control

15. Symbolic processes Traumatized play interfers recovery  Narrow and lacks repertoire – trauma focused  Concrete and low symbolic activity  Themes, roles and plots are repetitious and unchanging  Compulsive, ritualistic features  Lack joy and progres  Lack of narratives and fantasy  Absense of play is the most worrying

16. Social relations  Negative interactions: scapecoting, rigid & reversed roles  Family secrets and silence: every members protects the other  Communication fragmented: ”knowing-not- knowing”  Vicious circle: good peer relations protect mental health, but trauma exposure deprives children from friendships

17. Family approach to trauma  Family roles crystallize in the face of danger and trauma  Distinct roles in emotional, cognitive and behavioral ‘share of work’  Serves family’s survival and adaptation  If flexible and short-living  Prevent child development and effective coping  If ‘cemented’, rigid and permanent

18. Importance of attachment I The first relationship with caregiver creates inner models of:  Whether safe place is available  How to avoid rejection  Whether to trust others and oneself  How to express distress  Whether to dare explore

19. Importance of attachment II  In the first year of life: Sensory integration of eye, movement and brain connections  Emotional attunement and arousal  Re-establish the circadian rythm Main early risks: 1) Fear in mother’s eyes 2) Maternal PSTD-intrusive and dissociative states of mind

20. Importance of attachment III Attachment is a condition to survival; 4 types  Secure: access to safe base, rich emotions and cognitive framing  Insecure-avoidant: Thrusts oneself, numbing emotions and self-soothing  Insecure-ambivalent: Clinging to adults, overwhelming emotions, difficult to calm  Disorganized: not clear attachment behavior  Attachment behavior activates in face of danger and threat

21. Interventions Optimal Development -basic processes A B Mental Health Problems -maladaptive processes RESILIENCE- based preventive interventions: By enhancing A the B is avoided SYMPTOM- based interventions: By beating B the A is achieved

22. Preventive interventions in war & military violence (WHO, 2001,Jordans, 2010) Acute symptoms of depression, aggression, PTSD & dissociation Children at risk: wounded, homeless, poor, earlier trauma, family problems, low threshold temperement, poor coping Trauma-exposed children & families with no high risk factors & vulnerabilities Intervention & Treatment CBT, EMDR, Family therapy Prevention Resiliency groups Psychoeducational Family involvement Mental Health Promotion Knowledge, agency & child rights School, healthcare, civic participation National politics, strategies, rights

23. Interventions Intervention packages such as  CBT/ TF-CBT  EMDR  Interpersonal group psychotherapy  Teaching Recovery Tecniques  Health to Peace Initiatives  Critical Incident Stress Management  Narrative Exposure Therapy The components/modules/elements/ tools based on knowledge of risk and protective factors

24. Teaching Recovery Techniques as an example of GBT approach Arousal  Own experiences and learning about own body responses  Muscular relaxation and breathing - tension and release, inhaling - exhaling  Guided imagery to safe place  Self statements to reduce helplessness  Explanation of events > control arousal

25. Intrusive symptoms  Positive feedback frame, positive counter- images, lock away,  Corresponding techniques for auditory,olfactory (smell), kinesthetic (body), touching  Dreamwork  Introduce a protector whom child trusts (helper both real & fantasy)  Change dreamer position: victim – hero, active - passive, helped-helpe

26. Avoidance symptoms  Graded exposure – until habituation  use the same tools as with intrusion  imaginal  drawing, writing, talking  Safety creation and self-regulation training  Psychoeducative: give information & normalize & educate  Parallell story (indirect) & description of PTSD (direct)  Own unique experiences

27. Guidelines including children I  National Institute for Clinical Excellence (NICE) 2005  American Academy of Child and Adolescent Psychiatry, 2003  Psychological First Aid: field operation Guide. National Child Traumatic Stress Network,NCPTSD (www.ncptsd.va.gov/pfa/PFA_V2.pdf)

28. Guidelines including children II  AAP-disaster-prepadness Web www.aapp.org/terrorism www.aapp.org/terrorism  National Centre for Children Exposed to Violence Yale Child Study Center www.nccev.org www.nccev.org  IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings  IMPACT The Netherland

29. Evidence base for treatment of PTSD I Single-incident trauma  The most common treatments: CBT, EMDR,and play therapy  CBT use manualized, reproducible treatment, group and individual, school-based & clinical  EMDR treatments typically short &individual  Most studies show statistically significant improvement but lack methodological rigor

30. II Sexual abuse  10 studies on efficacy of group therapy for sexually abused girls  Treatment types: CBT, psychoeducational, psychodrama, eclectic, humanistic  Only 4 utilized comparison or control groups  Psychodrama groups: decrease in depressive symptoms,  CBT & eclectic groups (with graduated exposure): decrease in PTSD

31. III War- and military trauma  16 effectiveness studies  Only 4 randomized control studies (RCT)  Common treatment: CBT, focusing on biased cognitive processes and negative emotions  Self-reported results: PTSD and depression decreased

32. Key guidelines  All structured therapy more effective than non-therapy with children with PTSD  Scientific evidence available on Trauma Focused CBT and EMDR  No evidence on other systematic treatments e.g. play therapy, dynamic therapies (no comparison studies available)

33. Conclusions  Developmental science: sensitive & transition periods  Intervention & Prevention science: tailored & evidence based interventions with specific focus