TF-CBT TFCBT for Children and 1. What does childhood traumatic Adolescents : Assessing Trauma look like? Symptoms ! 2. How to assessment for Trauma Symptoms? By Janelle Vonstorch, LPC Adam H. Benton, PhD, LPP

How Big is the Problem? What is Child Traumatic Stress (CTS) ? The Epidemiology of Child Traumatic Stress

! General population • Child Maltreatment • Medical Trauma studies ! ! • Domestic Violence • Traumatic Loss ! ! ! Disaster studies • Natural Disasters • Terrorism • Terrorism ! ! • Natural disasters • Community and School • War-Zone Trauma ! Violence Child maltreatment studies General Population Studies of Child General Population Studies of Child Traumatic Stress Traumatic Stress

National Survey of Adolescents (Kilpatrick & Saunders, 1997) Developmental Victimization Study (Finklehor et al., • Representative US sample: 12-17 yrs 2005) • Serious physical assault: 5 million • Representative US sample: 2-17 yrs • Sexual assault: 1.8 million • 1 in 8 experienced a form of child maltreatment ! • 1 in 3 witnessed violence Youths in Urban America study (Breslau et al., 2004) ! • Mid-Atlantic US city – The Great Smoky Mountains Study (Copeland, et al., Baseline 6 yrs; follow-up 20-22 yrs 2007) • 82.5% one or more lifetime traumatic events: 87.2% males, 78.4% females • A majority of children (67.8%) were exposed to • Exposure to violent assault one or more traumatic events by age 16. – Increase after 15 years, peaked @ 16-17 yrs – Major decrease by age 21 • Children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.

National Estimated Child Maltreatment Reports 3.5 3 Disaster Studies 2.5 n

o 2 i l l i 1.5 M New! York City, NY Department of Education Study (Hoven et al., 2005) 1 • At 6 months post World Trade Center attack, the prevalence of: 0.5 – PTSD was 10.6% 0 – was 14.8% – was 12.8% 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 – separation anxiety was 12.3% – !alcohol problems was 4.5% Year • Over 60% experienced at least one major traumatic event prior to the attacks. Victimization Rates by Age Group, 2000 ! ! age 16-17 5.8 Gulf Coast Child & Family Health Study (Abramson et al., 2007) ! age 12-15 10.4 • At 2 years after Hurricane Katrina. ! age 8-11 11.8 – 46,000 children were displaced – 51% of displaced children had at least 1 risk factor for poor long term outcomes age 4-7 13.3

age 0-3 15.7

0 5 10 15 20 Rate per 1,000 children of same age group

Child Maltreatment Prevalence 2007 Comparisons

Nationally Arkansas 1 out of every 71 children in Arkansas were victims of abuse or 6. million Child maltreatment 58,000 child maltreatment neglect investigations investigations • 1 out of every 6250 children were diagnosed with cancer (U.S. Department of Health and Human Services, 2009) 794,517 confirmed cases of abuse / 9,847 confirmed cases of abuse / neglect (1 out of every 94 children) neglect (1 out of every 71 children) • 1 out of every 4032 individuals under 24 had a confirmed case of • 59% Neglect (436,944 children) • 55% Neglect (5,439 children) H1N1 (Centers for Disease Control and Prevention, 2009) • 8% Sexual Abuse (56,460 children) • 20% Sexual Abuse (1,961 children) • 1 out of every 30,303 individuals under 24 had a confirmed case on H1N1 that required hospitalization (Centers for Disease Control and Prevention, • 11% Physical Abuse (79,886 • 12% Physical Abuse (1,135 2009) children) children) • 1 out of every 1,514,175 individuals under 24 died from a confirmed case on H1N1 (Centers for Disease Control and Prevention, 2009) • 13% Multiple types (97,123 • 7% Multiple types (711 children) • 1 out of every 150 eight-year-old children were diagnosed with an children) • 1% Psychological Abuse (31,366 Spectrum Disorder (Centers for Disease Control and Prevention, 2002) • 4% Psychological Abuse (31,366 children)

Incidence of PTSD in Children Posttraumatic Stress Disorder

• 6% life-time prevalence in • Exposure to war A. Exposure C. Persistent Avoidance (3+) older adolescents – Experienced or witnessed… • 25 – 70% – Avoiding thoughts, ! actual or threatened injury or feelings etc death • Natural Disasters • Diseases or hospitalization – Responded with intense fear, – Places, activities, or – 30-50% moderate symptoms • X < 15% helplessness, or horror people – 5-10% full criteria B. Reexperiencing – Inability to recall events ! • Sexual and Physical Abuse • Intrusive recollections – Diminished interests in • Traffic Accidents • 11 – 20% • Recurrent dreams significant activities – 29% at 4 wks ! • Acting or feeling as if the – Detachment or – 36% at 6 wks event were recurring • Symptoms often remain for estrangement from others – 6 – 25% at 12-15 wks years without treatment • Intense distress triggered by – Restricted affect – 14% at 9 months (15-29% still meet criteria 5- 33 internal or external cues • Physiological reactivity – Foreshortened future years later) Dyregrov & Yule, 2005 What is the impact of Child Traumatic Posttraumatic Stress Disorder Stress? D. Persistent Increased • Capacity to regulate emotion and attention Arousal (2+) • Social development • Difficulty sleeping • Cognitive development: IQ and language • Irritability • Academic performance • Difficulty • Substance use/abuse concentrating • Numbness, desensitization to threat • Hypervigilance • Re-victimization • Recklessness and reenacting behavior • Exaggerated startle • Posttraumatic stress and other disorders response (, anxiety, , panic) E. Duration of 1 month or • Developmental Trauma Disorder more • Health effects F. Clinical impairment

Traumatic Stress in Children Traumatic Stress Symptoms in Children

• Physical consequences can include impaired Compared to adults… brain development and/or poor physical health • (Kaufman & Charney, 2001; Perry, 2002; Shore, 1997; Springer, Sheridan, Kuo, & Carnes, 2007) • Less numbing and difficulty recognizing ! avoidance • Psychological consequences can include • More overt aggression, destructiveness, internalizing disorders, externalizing disorders, and reenactment (also in play and cognitive difficulties, and/or social difficulties • (Kaufman & Charney, 2001; Morrison, Frank, Holland, & Kates, 1999; Silverman, Reinherz, & Giaconia, 1996; Springer, Sheridan, Kuo, & Carnes, 2007; Teicher, 2000; U.S. Department of Health and Human Services, 2003; Watts-English, Fortson, Gibler, Hooper, & DeBellis, 2006) drawings) ! ! • Older children – foreshortened future • Behavioral consequences can include juvenile • delinquency, adult criminality, substance Over the age of 10 – react more like abuse, and/or abusive behavior adults • (National Institute on Drug Abuse, 1998; Prevent Child Abuse America, 2001; Widom & Maxfield, 200; Widom, White, Czaja, & Marmorstein, 2007) Dyregrov & Yule, 2005 Effect of increasing trauma exposures on cumulative rates of psychiatric diagnoses by age 16 years (Copeland et al., 2007)

60

45

30 Percent

15

0 None (32.2%) 2 (22.4%) 4 or more (7.5%) Number of Events

Any Diagnosis Any Depression Dx Any Anxiety Dx Any Behavioral Dx

Predictors of PTSD Reactions in Children

• Level of Exposure • Family history of • Lack of social support mental illness • Female gender • Cognitive variables • Previous trauma – Negative appraisal exposure – Unfairness • Prior psychiatric – Rumination problems – Thought suppression – Confusion during • Strong acute response the event Assessment of Trauma Symptoms Assessment Process

• “The development of the abused or neglected • Assess existing risk and safety child seldom follows a predictable course, because • Identify general strengths and problems child maltreatment is characterized by many other areas for family (marital problems, Family negative socialization forces, Stressors, etc.) such as family instability, • Identify parental needs (support, child parental inconsistency, and rearing, etc) socioeconomic • Identify child needs (behavior, cognitive, disadvantage.” social, mental health symptoms, etc) ! Wolf & McEachran, In Mash & Terdal, 1997) • Reporting issues

Assessment Process Assessment Process

• Cognitive problems: Maladaptive patterns of thinking • Family problems: Parenting skills deficits, poor parent- about self, others and situations, including distortions and child communication, disturbances in parent-child unhelpful thoughts, like self-blame or rumination about attachment, disruption in family relationships or the trauma functioning due to abuse. ! ! • Traumatic behavior problems: Avoidance of trauma • Relationship problems: Difficulties getting along with reminders; trauma-related, sexualized, aggressive, or peers, poor problem-solving or social skills, oppositional behaviors; unsafe behaviors hypersensitivity in interpersonal interactions, maladaptive strategies for making friends, impaired ability to trust. ! • Somatic problems: Sleep difficulties, physiological ! hyperarousal and hypervigilance toward possible trauma • Affective problems: Sadness, anxiety, fear, anger, poor cues, physical tension, somatic symptoms. ability to tolerate or regulate negative affective states, ! inability to self-soothe. Cohen, Mannarino, & Deblinger, 2006

Assessment Instruments Tracking Outcomes Strengths & Difficulties Questionnaire – Symptom Subscale Severity

• Emotional /Behavioral • Traumatic Stress 11 Emotional Distress (clinical cut =3) 10 Behavioral Difficulties (clinical cut =2) Attentional Difficulties (clinical cut =5) – Child Behavior Checklist Symptoms *Getting along with Children (clinical cut =2) 9 9 – Behavior Assessment Scale – UCLA Posttraumatic Stress 9 *Kind / helpful Behavior (clinical cut =6) for Children Index 8 – Roberts Apperception Test – – Trauma Symptom Checklist 7 2 for Children 6 – Child Depression Inventory – Child PTSD Screen 6 5 – Manifest Anxiety Scale for – Child Report of 4 4 4 4 Children Posttraumatic Symptoms 3 3 – Strengths & Difficulties – Children’s Impact of 2 2 2 2 Questionnaire Traumatic Events Scale 2 ! – Child Dissociative Checklist ! 0 ! – Traumatic Events Screening Baseline 3 Months 6 Months 9 Months ! Inventory

Tracking Outcomes UCLA PTSD Index - Overall Traumatic Stress Symptoms Tracking Outcomes UCLA PTSD Index Subscale Severity

70 Total Stress Score 65 Significant Distress (>38) Moderate Distress (33-37) 30 60 Mild Distress (27-32) 55 50 25 46 Intrusion 45 41 Avoidance Arousal 40 20 35 35 30 27 15 25 20 10 15 10 5 5 0 Baseline 3 Month Follow-up 6 Month Follow-up 9 Month Follow-up 0 Baseline 3 Month Follow-up 6 Month Follow-up 9 Month Follow-up Tracking Outcomes Presenting Diagnoses to Parents

4 Goals 4

3 • Educate the parent and child 3 • Explain treatment process 2 2 • Increase understanding of symptoms 1 1 • Monitor outcome and progress from 0 Intrusive Recollections Psychological Reactivity Avoid Reminders Detachment Sleep Problems Hypervigilence treatment