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IDD and Trauma Adaptations of TFCBT and CBT For 4/18/2017 What is Trauma? • A stressful situation which overwhelms an individual’s coping mechanisms and causes a sense of disconnection from IDD and Trauma: Adaptations of feelings of control, connection, and meaning • Trauma may lead to symptoms of post-traumatic stress or a diagnosis of post-traumatic stress disorder; not everyone who TFCBT and CBT for Depression experiences trauma develops PTSD • A traumatic response is a normal response to an abnormal situation Bob Werstlein PhD • Different Types of Trauma – Accidents, Natural Disasters, Illness verses Interpersonal, Daymark Recovery Services Relational/Attachment Trauma – “Big T” versus “Little t” Trauma – Simple versus Complex Trauma Prevalence of Trauma Among Children Prevalence of Trauma Among Women • 60 % exposed annually • Lifetime prevalence 51%(6% men), • 3.5 Million CPS reports, 794,000 substantiated 10%(5%)develop PTSD annually in US • Severe physical/sexual abuse in homeless 91% • In NC, 5000 sexual abuse and assault cases • Sexual assault during military service 33% reported to law enforcement, 1,000 of each • Lifetime prevalence of domestic violence 44% substantiated annually • Robbery victimization 1-4 per 1,000(2-4 men) age 12 and older • Aggravated assault 2-4 per 1,000(3-4 men) Prevalence of Trauma Among MH SA Public Sector Populations Prevalence of Trauma Among IDD • Exposure to multiple traumas 90% • Underreported due to lack of communication, • History reported by 75% of SA clients credibility, and inability to make a report • 55-99% of women in SA treatment • More likely to experience trauma, especially • 85-95% of women in MH treatment physical and sexual abuse in adults and kids • • 11-38% of men)33-59% of women) in SA 2.5 to 10 X higher rates of child maltreatment treatment have PTSD and SA Dx • PTSD rates from 2.5 to 50% • Interpersonal violence/crime rates 4-10% higher than general population 1 4/18/2017 IDD and Trauma: Increased Prevalence of Trauma Among IDD Vulnerability • Lifetime prevalence of sexual abuse 90% and • IDD clients are trained to be compliant, 10 or more abusive incidence 49% dependent on care givers for long periods of time, inadequate supervision, a strong desire • 44% had relationship with abuser related to for acceptance and fear of rejection, social IDD isolation, impaired communication or • Child maltreatment evident in 10-25% of all mobility, cognitive delays limit understanding IDD of what is happening, easier to manipulate, less critical thinking, less likely to receive sex education and recognize sexual abuse, discrimination, poverty and more comorbidity Examples of Trauma More Likely for Examples of Trauma IDD Clients • Sexual Abuse and assault, physical abuse and • Neglect or omission of adequate, accidents, assault, community and domestic violence, bullying, hospitalizations, restraints, historical or intergenerational violence, withholding, stealing or overdosing serious accidents, unexpected loss of loved medications, financial abuse, relocation, hate one, medical procedures or conditions, war crimes, caregiver relationship transitions, and terrorist attacks, institutional abuse, violence at the hands of housemates or second hand exposure caregivers or witnessing such Increased Health/Social Problems with Adverse Childhood Events(ACE) Higher ACE Scores • Emotional abuse, emotional neglect • SUD, Depression, suicide attempts, early • Physical abuse, physical neglect initiation of sexual activity, adolescent and • Sexual abuse unintended pregnancy, SDT’s, multiple sexual • Drug addicted or alcoholic family member partners, risk for intimate partner violence, • Incarceration of a family member early initiation of smoking, • Loss of parent to death or abandonment • COPD, Fetal death, ischemic heart • MI, depressed, or suicidal family member disease(IHD), liver disease • Witnessing domestic violence against mother 2 4/18/2017 Negative life Events More Prevalent for Factors Effecting The Response To IDD Clients Trauma • Staffing changes, people moving in and out of • Previous trauma experience(s), coping skills of positions, periods of time covered by non regular the victim prior to the experience, the nature caregivers, separation from family/caregiver, serious injury or illness, death of close friend of of the trauma, how close to the trauma, relative, moved house or room or changes in relationship to the abuse or victim, perception decorations or furniture, increased arguments of the person involved about the experience, with others, change in daily routine, subjected to chronicity and severity of the trauma, level of verbal abuse, witnessed physical violence or stress of life experiences at the time of the verbal abuse, medication changes, physical trauma, response of the support system to the restraint or violence event Increased IDD Vulnerability to Effects Increased IDD Vulnerability to Effects of Trauma of Trauma • Limited range of coping/adaptation skills • Less social support or ability to gather such • Less experience in managing negative life • Fewer protective factors that would limit the events effects of trauma(i.e. effective parenting or • Early separation from parents or family system caregiver supports, social connections, good communication, problem solving, and self stress may limit stress management ability regulation skills, positive beliefs about self, beliefs • More vulnerable to stress related thoughts, that life has meaning, spirituality/faith, feelings, and behaviors socioeconomic advantages, pro-social peers and • Decreased psychological flexibility friends, stable and safe effective communities Effects of Trauma: Neurological Effects of Trauma: Biological • Trauma activates stress hormones and • Somatic complaints, sleep disturbance(DFS, neurochemicals which acutely results in flight, nightmares), headaches, urological problems, fight or freeze and chronically changes brain stomach aches, fatigue, forgetfulness, functioning and structure due to confusion, concentration problems, neuroendocrine system impacts, over activation of HPA axis in the brain and flashbacks, sexual numbing, increased flight, constant production of stress hormone fight or freeze response, and chronic health cortisol, and impact on emotion and fear problems response(amygdala) and memory(hippocampus) 3 4/18/2017 Effects of Trauma: Emotional Effects of Trauma: Cognitive • Shock, numbness, restricted range of affect, • Distrust of others or expectations they may be disconnectedness, fear, anger, impatience, harmed by everyone worry, anxiety, sadness, depression, • Overestimation of and preoccupation with powerlessness, ineffective, overwhelmed, danger untrusting, unsafe, inner turmoil and pain, self • Low self esteem and self blame blame, self doubt, shame, and secrecy • Helplessness and hopelessness about the future • Shame, stigma, or survivor guilt Effects of Trauma: Behavioral Effects of Trauma: Social • Crying, agitation, irritability, rage, passiveness, • Isolation detachment, over working, diminished interest in activities, self injurious relationship strains/dysfunction, neglect of behaviors, suicidality, reenactments(right the responsibilities, poor or overprotective wrong), disassociations, risky, impulsive parenting, feeling unlikable or strange in social behaviors, compulsive behaviors, problems situations, avoidance of sexual or trauma with eating, rigid behaviors, substance abuse, related activity, passive avoidance, disengaged and panic/phobias from the dating process, and re-victimization Trauma and PTSD in the IDD Client Effects of Trauma: IDD • Symptoms overlooked due to attributing • PTSD symptoms more like those in children behaviors to IDD(diagnostic overshadowing) • Behavioral reactions-regressive or aggressive • Assessment is difficult due to receptive and • Inappropriate or unusual statements, expressive language deficits stereotypical behaviors, inappropriate speech, • Age and developmental level influence reduced self care, reduced adaptive behavior expression of PTSD symptoms and ability to • Reenactments-repetitive themes or aspects of cope with trauma the trauma expressed in interactions with • Higher IQ-greater ability to avoid exposure others played out as victim or victimizer to • More vulnerable to PTSD and trauma effects gain mastery or control over the experience 4 4/18/2017 Effects of Trauma: IDD Effects of Trauma: IDD • Interpersonal disruption-avoids connecting or • Interpersonal disruption-aggression-bold or relating-worries about who is working, secretive acting out including aggression repeated statements about unrelated events, toward self, others, property or pets, testing inability to assert or protect oneself, distant, and breaking rules, and increased impulsivity preoccupied and daydreaming, phobic mannerisms to avoid cues or situation that • Exacerbation of pre-existing psychiatric trigger unpleasant sensations or memories, conditions(i.e. depression, panic disorder) refusal to participate in activities or work without reasons, decline in skills after prior gains Key Developmental Capacities Shaped Key Developmental Capacities Shaped by Trauma by Trauma • Ability to modulate, tolerate, or recover from • Capacity for self soothing extreme affect states • Ability to initiate or sustain goal directed • Regulation of bodily functions behavior • Capacity to know emotions or bodily states • Coherent self, identity • Capacity to describe emotions or bodily states • Capacity to regulate empathic arousal • Capacity to perceive threat, safety or danger Traumatic Stress Symptoms
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