Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)

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Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) University of Wisconsin-Madison Conference on Child Sexual Abuse October 28, 2015 Cheryl Lanktree, Ph.D. USC-Adolescent Trauma Training Center Department of Psychiatry and Behavioral Sciences Keck School of Medicine University of Southern California National Child Traumatic Stress Network attc.usc.edu Complex trauma exposure • Multiple exposures to multiple types of traumatic events, simultaneous and/or sequential – emotional abuse and neglect – child sexual abuse and exploitation – physical abuse – witnessing domestic violence – Peer or gang assault, “drive bys” – traumatic loss – trauma associated with immigration – serious medical illness or injury • Insecure attachment with primary caretakers Contextual aspects of complex trauma exposure • Trauma intensifiers – Early onset – Extended and frequent exposure; ubiquity – Relational context • Social marginalization – Poverty – Social discrimination • Race/ethnicity • Sexual orientation – Inadequate education – Reduced access to services • , Complex trauma outcomes and attachment effects

• Anxiety, depression, anger • Posttraumatic stress • Affect dysregulation • Negative relational and self schema • Identity/self-reference issues • Medical issues, physical neglect of self Complex trauma outcomes and attachment effects (continued)

• Avoidance responses – Dissociation – Tension reduction behaviors • Self-injurious behavior • Dysfunctional sexual behavior, • Bulimia • Aggression – Substance abuse – Suicidality “Borderline” or Complex Trauma?

• Frantic efforts to avoid real or imagined abandonment • Pattern of unstable and intense interpersonal relationships • Identity disturbance: unstable self-image or sense of self • Impulsivity in areas that are potentially self-damaging: spending, sex, substance abuse, reckless driving, binge eating • Recurrent suicidal behavior, gestures, threats, or self- mutilating behavior • Affective instability, marked reactivity of mood • Chronic feelings of emptiness • Inappropriate, intense anger or difficulty controlling anger • Transient, stress-related paranoid ideation or severe dissociation DSM-V (APA, 2013) Comparing BPD, PTSD & CT Study by Cloitre, et al. (2014) ! BPD symptoms more likely to lead to BPD diagnosis than Complex PTSD: frantic efforts to avoid abandonment, unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness ! Complex PTSD: chronic and repeated traumas, symptoms of PTSD plus disturbances of self- organization--- emotion dysregulation, self- concept and relational difficulties Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)

• Initial development: MCAVIC (2001-2005) and MCAVIC-USC (2005-2009) – Multiply traumatized, socially marginalized youth and children – Multi-ethnic, multi-racial, multi-disciplinary staff – Structured, component-based but individualized for each client (assessment-based) – Relational but also cognitive-behavioral – Intensive treatment and advocacy Consultation Community Individual Referral School-based Therapy Group

Collateral

Referral Screen Assessment Clinic-based Individual Therapy Family

Group

Hospital-based Therapy Individual &/or Family Forensic Interview Importance of Cultural Focus and Advocacy in ITCT-A • Cultural background and beliefs in assessment and treatment---e.g., importance of family, religion, community, immigration issues, discrimination experiences. Seek consultation from colleagues. • Avoid assumptions: Ask client(s) to describe their cultural and racial identity. • Consider impact of therapist’s cultural background. • Assessment and treatment are culturally appropriate and in client’s primary language. • Agency staff are culturally diverse, opportunities for clients to learn about other cultural groups.

• . Creating a welcoming and inviting setting Culturally Diverse Team, Client Art Create a Welcoming Setting Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)

• Current project status: USC-Adolescent Trauma Training Center (2012-2016) – Second edition of ITCT-A treatment guide (Briere & Lanktree, 2013; attc.usc.edu) – Substance use/abuse treatment guide (attc.usc.edu) – Mindfulness treatment guide (in progress) – Trainings and conferences, consultations (monthly Zoom calls), website: usc.attc.edu, publications – Multi-site collaborations – National conferences in California (2014, 2015) Collaborations and Adaptations • Centers throughout the U.S.: – El Paso, TX – Southwest Keys Programs: TX, AZ, NM,CA -- Oakland, Los Angeles, Orange County, CA -- U. of Missouri-St. Louis – Denver and other communities, CO – Chicago and other communities, IL – Boston and surrounding communities, MA – Delaware – Adelphi University, Long Island, New York – Oklahoma Collaborations and Adaptations (continued)

• Range of settings and duration of treatment • Residential treatment facilities, outpatient clinics, schools—short-term and longer-term treatment • Adaptations include Spanish translations of ITCT-A tools • Community collaborations including trauma-informed services Adaptation of ITCT-A: Storefront/School- Based Program ITCT Treatment Outcome Study (Lanktree et. al., 2012) • 151 clients (children and adolescents) – Similar findings for adolescents-only subsample • Mean age 11.43 years (range: 8-17 yrs.). • 48% Hispanic, 25% Black, 14% non-Hispanic White, 13% Asian • 52% CSA, 27% PA, 17% CV, 31% TL, 31% DV. • 62%: 2 or more types of trauma, 14%: 4 or more traumas • 67% in treatment for 3 to 8 months (Mean=6.79) Evidence-Based Research: Pre-Post Data Average of >40% improvement across symptoms ITCT-A: Core aspects • Assessment-based • Focus beyond posttraumatic stress – Relational issues – Affect dysregulation – Problematic avoidance and “acting out” behaviors • Centrality of therapeutic relationship • Safety within therapy and environment • Customization: Age, gender, culture, affect regulation capacity ---not “one-size-fits-all” • Cultural diversity of clients and economic disadvantage incorporated into interventions ITCT-A: Core aspects (continued)

• Focus on the client’s experience – Taking him/her where he/she is – Avoidance of judgmental/authoritarian therapist behaviors • Titrated exposure and cognitive interventions • Affect regulation training and behavior control – including Trigger Identification and Intervention, mindfulness, “urge surfing” • Parent/family interventions • Advocacy and system intervention • Beyond the traditional therapist role ITCT-A Tools (Briere & Lanktree, 2013)

• Initial Trauma Review-Adolescent Version (ITR-A) • Possible Interview Question Topics for ITCT-A (PIQT-A) • What Triggers Me? (The Trigger Grid) • Assessment Treatment Flowchart for Adolescents (ATF-A) • Problems-to-Components Grid for Adolescents (PCG-A) Assessment-Treatment Flowchart (ATF-A) • Usually following the Initial Trauma Review (ITR-A) and/ or Possible Interview Question Topics (PIQT) • Completed at intake and each 2-3 month period

Priority ranking (circle one for each symptom): 1 = Not currently a problem 2 = Problematic, but not an immediate treatment priority 3 = Problematic, a current treatment priority 4 = Most problematic, requires immediate attention (S) = Suspected, requires further investigation Available at attc.usc.edu ATF-A items (examples)

Problem area Tx priority 1. Safety – environmental 1 2 3 4 (S) 2. Caretaker support issues 1 2 3 4 (S) 5. Anxiety 1 2 3 4 (S) 6. Depression 1 2 3 4 (S) 7. Anger/aggression 1 2 3 4 (S) 8. Low self-esteem 1 2 3 4 (S) 9. Posttraumatic stress 1 2 3 4 (S) 10. Attachment insecurity 1 2 3 4 (S) Problems–to-Components Grid for Adolescents (PCG-A)

Problem (from ATF-A) Treatment components Safety (environmental) Safety training, system interventions, psychoeducation Caretaker support Family therapy, intervention with caretakers Anxiety Distress reduction/affect regulation training, titrated exposure, cognitive processing Depression Relationship building and support, cognitive processing, group therapy Case study: Tanya

Tanya is a 15-year-old bi-racial female with African- American/Hispanic background, referred for outpatient treatment after disclosing sexual abuse by her step-father since age 9. He was also physically abusive toward her mother and threatened to kill Tanya and her siblings. She has been depressed and suicidal, cutting on herself, and engaging in substance abuse and high-risk sexual behaviors. Tanya currently lives with her mother, and describes her relationship with her as “OK.” Her mother appears disengaged from her during the intake interview, and generally has failed to intervene in Tanya’s self- endangering behaviors. ITCT-A Possible Interview Question Topics (PIQT): Examples of what to evaluate • Safety: Is Tanya currently safe? Does she fear others? • Anxiety: Worrying? Feeling something bad might happen? • Depression: Feelings of sadness? Crying? Hopelessness? • Anger/aggression: Getting into fights? Getting mad easily? • Low self-esteem: Feeling bad about herself? Not liking herself? • Post-traumatic stress: Nightmares? Flashbacks? Avoidance? Hyperarousal? ITCT-A Possible Interview Question Topics (PIQT)-- (continued)

• Attachment security: Trust of others? Worry about abandonment? • Identity issues: Confused about what she wants? Self-confidence? • Relationship problems: Trouble making friends? • Suicidality: Thoughts about suicide? Wanting to die? • Dissociation: ”Spacing out”? Watching from outside herself? • Substance abuse: Alcohol/drug use? Getting into trouble because of drug or alcohol use? Practice Session Overview of ITCT-A Treatment Components (Briere & Lanktree, 2013)

• Relationship Building and Support • Safety Interventions • Psychoeducation • Distress Reduction and Affect Regulation Training • Mindfulness Training • Cognitive Processing • Titrated Exposure • Trigger Identification and Intervention • Interventions for Identity Issues • Relational/Attachment Processing • Intervening in Maladaptive Substance Use • Interventions with Caretakers and Family Members Challenges in Working with Adolescents with Complex Trauma: ITCT-A interventions • Premature termination/limited sessions - focus on affect regulation, building self- capacities, increasing self-efficacy, strategies for safety and support - may need to address caretaker support and involvement in treatment • Issue of avoidance - therapeutic relationship, self-capacities, safety, therapeutic window, titrated exposure, address caretaker support Challenges and ITCT-A Interventions (cont’d.) • Inconsistent, unavailable, abusive caretaker - collateral, family, group treatment: support, address trauma and attachment issues

• Multiple placements, foster family, residential treatment - collaboration with system(s): advocacy, psychoeducation - support, address attachment issues Acute safety issues

• Environmental • Self-endangering • Maladaptive survival behaviors • Interventions: – Place to stay and safety plans – Safer-sex – Suicide prevention – Addressing substance abuse, prostitution, gangs – Child protection referrals To sense the client’s private world as if it were your own—-but without ever losing the “as if” quality—this is empathy, and this seems essential to therapy.

Carl Rogers (1961, p. 284) Therapeutic Relationship • “Active Ingredient” of effective therapy • Safety within session—through therapist behaviors • Empathic attunement, acceptance, active relatedness, patience • Necessary condition for treatment of complex trauma---relational processing • Important whether shorter-term or longer-term Rx • Longer-term therapy---more easily able to address attachment issues within therapeutic relationship • Consider role of gender, cultural background for both client and therapist Distress reduction and affect regulation training • Relaxation • Breath training • Identifying emotions – “emotional detective work” • Mindfulness and meta-cognitive awareness – Appropriateness for youth – Moment-by-moment attention to experience – Observation without attachment – Reduced identification: “Just thoughts, not facts” – “Sitting with” distress – Nonjudgment and acceptance Distress reduction and affect regulation training (continued) • “Urge surfing” • Delaying tension-reduction behaviors (TRBs) • Trigger identification and Intervention: Working with the Trigger Grid – Learned in sessions, before triggering event occurs – Trigger Grid updated as needed – Identify triggers and triggered states – Reinterpret intrusive phenomena as “only” thoughts – Learn coping strategies (self-talk, problem-solving) Distress reduction and affect regulation training • Breath training • Progressive relaxation • Visualization—their idea of a relaxing place. • Meditation—combining focus on breath, not criticizing or judge self, and “let go” of upsetting thoughts, feelings, and memories. • Physical activity. • Self talk. • Creative projects—writing, drawing. • Seek support from others. Mindfulness training: Approximations of meditation

• Specific time and place • Attending to breath • Notice your thoughts • Learn to let your thoughts come and go – Don’t fight it, don’t hold on • Simply listening, touch points, finding the breath (Pollak, Pedulla, & Siegel (2014). Sitting together: Essential skills for mindfulness-based psychotherapy. • Awareness/focusing attention to present, increasing compassion, equanimity

• Metacognitive awareness Substance use and abuse (SUA)

• New treatment guide available at attc.usc.edu • More common in traumatized youth, commonly associated with PTSD • Interferes with internal trauma processing • ITCT-A does not require substance-abstinence in all but most extreme cases – Screening removes most traumatized clients – Treating trauma symptoms may decrease SUA Substance use and abuse (continued) • Generally, substance abuse means – Start with safety assessment, stabilization – Use both trauma- and substance abuse-focused interventions:Simultaneous treatment – Empowerment – Slower, less intense exposure treatment, greater attention to therapeutic window – More attention to affect regulation skill development – Avoid confrontation – Nonjudgmental, focus on SUA as coping strategy with major downsides Emotional processing of trauma memories • Titrated exposure – Limited by affect regulation skills – Multiple sources versus systematized • Permission to change topic, follow associations • Reflects complexity associated with multiple traumas • Parallel processing – Self-titration (versus “resistance”) • A central difference from prolonged exposure • Balance between unnecessary avoidance and self- protection • May increase self-exposure by increasing sense of control Emotional processing of trauma memories (continued) • The therapeutic window: The “place” between insufficient and overwhelming exposure – Overshooting versus undershooting – Variation as function of time in session, relational activations, stressors – When activation level is hard to determine • Avoidance, client differences in acceptable activation – Narrative/explicit versus relational/implicit exposure • Intensity control within session Cognitive processing • Cognitive reconsideration – Alternative to cognitive restructuring • Framed as logical results of abuse-era conditions • Client, not therapist, generates new/updated cognitions – Detailed verbalization of trauma while listening to self, in context of nonjudgmental, supportive other; while processing trauma-related feelings – Parallel to – but not same as – emotional processing • “Hearing what you think/thought” from current perspective • Epiphany • More coherence over time Increasing self-reference and positive model of self • During abuse/neglect, child develops – External referencing/other-directness – Associated problems with self-reference • Yet, treatment encourages client to explore own internal state, personal reality, own truths, and to introspect rather than just cope. – Therapist avoids over-use of interpretation, lecturing, informing, increases use of open-ended questions – Client increasingly comes to value own perspectives and needs, and to be less hypervigilant to inappropriate demands/expectations of others Increasing self-reference and positive model of self (continued) • Social messages reflecting racism, sexism, homophobia, and harsh cultural judgments can also be seen as abusive/traumatic. Therapist – Supports increased client self-determination, discovery of own needs, desires, and interests – Avoids conscious or unconscious support/demands for client to accept and adjust to negative social models and expectations regarding • Gender identity • Sexual orientation • Adherence to ethnic/racial stereotypes Relational processing of trauma memories

• More focused on implicit, attachment-level sensory/emotional/schematic memories – Assumptions, beliefs, expectations inferred from early treatment by caretakers – Associated conditioned emotional responses – Activated when triggered by relational stimuli during therapy – Often associated with “source attribution errors” Relational processing of trauma memories

• Therapy evokes relational memories, which emerge as “transferential” responses • These thoughts/feelings/emotions can intensify as therapeutic relationship deepens – Dependency, neediness, demands, anger, desperation, sexualization, rebellion • Are slowly extinguished in the context of disparity from actual therapeutic conditions – Caring, positive regard, boundary integrity, support, validation, positive (attachment-related) neurobiology Relational processing

• Exposure • Activation • Disparity • Counterconditioning • Desensitization Attachment Behaviors and Patterns Across the Lifespan (Cassidy & Shaver, 2008) Develop. Secure Avoidant Resistant Disorganized/ Stage or disoriented Ambivalent Infancy/ Secure- Defended- Dependent- Controlling- Toddlerhood/ optimal disengaged deprived confused /Preschool- School Age Adolescence Secure/ Dismissing Preoccupied Unresolved -Adulthood Autonomous -entangled/ loss/trauma- enmeshed disorganized Parenting Secure base Dismissive/ Preoccupied Disorganized/ Style Avoidant /ambivalent/ Helpless Rejecting Uncertain Insecure Avoidant/Dismissive- Avoidant Attachment • Avoidant of therapist and trauma-related material • Appears disengaged: “I don’t care” attitude. • May be nonverbal, unresponsive • May miss sessions, late for sessions • Dismissive-avoidant caretaker denies impact of trauma, minimizes adolescent’s feelings, may abruptly end therapy Insecure Resistant/Ambivalent/ Preoccupied Attachment

• Actively changes subject, distracts • Seeks attention and support from others, then resistant to interventions • Hypervigilant to caretakers’ needs – Caretaker may be dependent on adolescent • Especially at risk for being revictimized as they are seeking attachments even when they may be harmful Insecure Disorganized Attachment Style

• Behaves in unpredictable, chaotic manner; has extensive unresolved abuse trauma which may include violence and severe neglect. • May be very regressed, aggressive, withdrawn. • Often dissociated • Significant emotional and behavioral disturbance. Evaluating Attachment History and Treatment Goals

• Have they ever experienced empathic attunement from a caretaker? • If so, have they lost that attachment figure? • Have there been multiple caretakers? • Attachment history of primary caretaker(s)? • Who are the potential attachment figures now? Or are there any? Reunification issues? • Caretaker’s report of adolescent’s dev.milestones? • Changes in attachment relationships over time (early childhood, middle childhood, adolescence Questions often asked about ITCT-A caretaker/ systemic interventions

• When should caretakers/families be involved in therapy with the traumatized adolescent client? • What are the steps to take if caretakers need to be involved in treatment? • How do you decide which modalities will be most helpful----individual collateral, caretaker group, individual therapy for caretaker, family therapy? • When and who does what? Interventions with caretakers/ family • Goals of interventions – Increasing caretaker understanding of trauma and trauma responses, exploring their own traumas and impacts – Emotional support for nonoffending caretakers – Increasing caretakers’ parenting skills • Challenges – Caretaker antipathy, abusiveness, or noninterest – Youth desire to avoid contact with family/ caretaker – Youth emancipation or homelessness ITCT-A Interventions with Caretakers • Collateral sessions focused on support, education, parenting skills – May parallel ITCT-A interventions for child client: affect regulation and distress reduction, relational processing, trigger identification • Trauma processing and processing of reactions/triggers for caretaker may be a priority to improve support of the adolescent • Caretaker groups: 12-session module • Caretaker individual therapy ITCT-A Possible Interview Question Topics: Questions to ask client for ATF-A Caretaker Support Issues (ITCT-A Guide pg. 17) • Does the client feel like parent(s) or family members are “on their side?” • Does he/she feel that his/her parent(s) take good care of him/her? • Is there someone in his/her family with whom he/ she can talk? • Are parent(s)/family supportive of him/her being in therapy? • Does he/she feel loved by parent(s) or family members? ITCT-A Treatment Modalities: When and How?

• Individual therapy for adolescent/young adult client – usually weekly, may continue for several months • Individual and/or dyadic collateral sessions for caretaker(s)—when and how will depend on age adolescent’s age, availability, how receptive • Family therapy---usually not immediately, at least 6 sessions if possible, pre-conditions met • Individual therapy for caretaker(s) to focus on their trauma-related issues ---not adolescent’s therapist • Group therapy for adolescent and/or caretaker Case Example • Shaggy is a 13 year old boy referred for aggressive behavior and reported abuse and neglect. • Mother and stepfather divorced a year before. S. reports “He beat me lots of times. He said I was stupid and no good.” Mother recently made him sleep outside because he didn’t cut the grass and locked the door….” • Mother works full-time and is seldom home. S. says, “she ignores me a lot …that’s what she has done for the past 13 years.” • Shaggy began attending alternative school because he was considered “uncontrollable” in regular public school. Admits gang involvement (says “they’re my real family”) and heavy marijuana use. • Shaggy has a 16 year old sister who reported sexual abuse by an uncle who lived with them when he was 10 to 12 yrs old ITCT-A Family Therapy Interventions (Briere & Lanktree, 2012,2013) • Time line • Genogram • Family drawings • Role playing • Sessions address: assessment and planning, effective communication, roles and boundaries,exploration of trauma exposures, enhancing attachment relationships and support Supervision and Professional Support (Lanktree & Briere, in press)

• Trust and safety in the supervision relationship • Documentation and consultation: using ITCT-A tools • Regular trainings, discussion of ITCT-A materials @ agency • Train others on ITCT-A: training-of-the-trainers • Observations of sessions, mixed cases, balanced workload • Team meetings: supervision, case presentations • Staff retreats and celebrations • Treatment teams may wish to designate ITCT-A leader(s) • Participate in monthly USC-ATTC consultation calls, Skype/ Zoom meetings with other colleagues re: ITCT-A cases • Participate in national organizations and conferences Therapist Self-Care Strategies

• Humor; increase fun in your life • Mindfulness and meditation: RAIN (Brach, 2013)-- Recognition, Acceptance or Allowing, Investigation, and Nonidentification • Balance in life: Self-awareness and insight • Personal therapy, retreats, vary workday • Exercise, family & friends, pets and children, travel, creative pursuits “YOU GET PAID TO DO THIS?” The Use of Humor in Working with Complex Trauma Suggested Readings: Therapist Self-Care Fields, Richard (2012). Quotes and weekly mindfulness practices. Faces Conferences. Follette, V.M., Briere, J., Rozelle, D., Hopper, J.W., & Rome, D.I. (2015). (Eds.). Mindfulness-oriented interventions for trauma: Integrating contemplative practices. NY: Guilford. Gilbert, P. (2009). The compassionate mind: A new approach to life’s challenges. Oakland, CA: New Harbinger Pub. Pollak, S.M., Pedulla, T., Siegel, R.D. (2014). Sitting together: Essential skills for mindfulness-based psychotherapy. NY: Guilford. Weiss, Lillie (2004). Therapist’s guide to self-care. NY: Brunner- Routledge. Yalom, I.D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. NY: Harper- Collins. References Briere, J. & Lanktree, C.B. (2012). Treating complex trauma in adolescents and young adults. Thousand Oaks, CA: Sage.

Lanktree, C.B. & Briere, J. (in press). Treating complex trauma in children and their families: An integrative approach. Thousand Oaks, CA: Sage. References Lanktree, C.B. & Briere, J.(2013). Integrative treatment of complex trauma. In J.D. Ford & C.A. Courtois (Eds.). Treating complex traumatic stress disorders in children and adolescents: Scientific foundations and therapeutic models. New York: Guilford.

Lanktree, C.B., Briere, J., Godbout, N., Hodges, M., Chen, K., Trimm, L., Adams, B., Maida, C.A., & Freed, W. (2012). Treating multi- traumatized, socially-marginalized children: Results of a naturalistic treatment outcome study. Journal of Aggression, Maltreatment & Trauma. References

Briere, J., & Lanktree, C.B. (2013). Treating substance use issues in traumatized adolescents and young adults: Key principles and components. Los Angeles, CA: USC Adolescent Trauma Training Center. (available at attc.usc.edu)

Briere, J., & Lanktree, C.B. (2013). Integrative treatment of complex trauma for adolescents (ITCT-A): A guide for the treatment of multiply-traumatized youth, 2nd edition. Los Angeles, CA: USC Adolescent Trauma Treatment Training Center. (available at attc.usc.edu) References

Briere, J., & Lanktree, C.B. (2013). Treating substance use issues in traumatized adolescents and young adults: Key principles and components. Los Angeles, CA: USC Adolescent Trauma

Training Center (available at attc.usc.edu) Briere, J., & Lanktree, C.B. (2013). Integrative treatment of complex trauma for adolescents (ITCT-A): A guide for the treatment of multiply-traumatized youth, 2nd edition. Los Angeles, CA: USC Adolescent Trauma Treatment Training Center, (available at

attc.usc.edu) Lanktree, C.B., Briere, J., Godbout, N., Hodges, M., Chen, K., et al. (2012). Treating multi-traumatized, socially-marginalized children: Results of a naturalistic treatment outcome study. Journal of Aggression, Maltreatment & Trauma, 21, 813–828. Source: From Appendix I of J. Briere and C. Lanktree (2011), Treating Complex Trauma in Adolescents and Young Adults. Thousand Oaks, CA: SAGE Publications.

Initial Trauma Review

Adolescent/Young Adult Version (ITR-A)

his semistructured interview allows the clinician to cover the primary forms of T trauma potentially experienced by adolescents (i.e., those between the ages of 12 and 21). The clinician may wish to paraphrase these questions in order to make them fit better into the session. However, (1) try to use the behavioral descriptors (don’t just ask about “abuse” or “rape”), and (2) only ask as many questions at a given time period as is tolerated by the adolescent. Remaining questions can be asked at later points within the first few sessions. The question How old were you the first time? usually indicates whether or not the trauma was a form of child abuse. The questions When this happened, did you ever feel very afraid, horrified, or helpless? and Did you ever think you might be injured or killed? indicate whether the trauma meets Criterion A2 for DSM-IV PTSD or ASD.

1. [Childhood physical abuse] “Has a parent or another adult who was in charge of you ever hurt or punished you in a way that left a bruise, cut, scratches, or made you bleed?” !" Yes !" No

If yes,

!" Yes !" No

1 (ITR-A)

2. [Sexual abuse] “Has anyone who was five or more years older than you ever done something sexual with you or to you?” !" Yes !" No

If yes,

“How old were you the first time?” ______“How old were you the last time?” ______

“When this happened, did you ever feel very afraid, horrified, or helpless?” [NOTE: For sexual abuse only, this part is not necessary for PTSD Criterion A] !" Yes !" No

“Did you ever think you might be injured or killed?” [NOTE: For sexual abuse only, this part is not necessary for PTSD Criterion A] !" Yes !" No 3. [Peer sexual assault] “Has anyone who was less than five years older than you ever done something sexual to you that you didn’t want or that happened when you couldn’t defend yourself (for example, when you were intoxicated or asleep)?” !" Yes !" No

If yes,

2 (ITR-A)

If yes,

“How old were you the first time?” ______“How old were you the last time?” ______“When this happened, did you ever feel very afraid, horrified, or helpless?” !" Yes !" No “Did you ever think you might be injured or killed?” !" Yes !" No 5. [Motor vehicle accident] “Have you ever been involved in a serious automobile accident?” !" Yes !" No If yes, “How old were you the first time?” ______“How old were you the last time?” ______“When this happened, did you ever feel very afraid, horrified, or helpless?” !" Yes !" No

“Did you ever think you might be injured or killed?” !" Yes !" No 6. [Partner abuse] “Have you ever been slapped, hit, beaten, or hurt in some other way by someone you were dating or who you were in a sexual or romantic relationship with?” !" Yes !" No If yes, “How old were you the first time?” ______“How old were you the last time?” ______“When this happened, did you ever feel very afraid, horrified, or helpless?” !" Yes !" No

3 (ITR-A)

“Did you ever think you might be injured or killed?” !" Yes !" No 7. [Nonintimate peer assault] “Have you ever been physically attacked, assaulted, stabbed, or shot at by someone who wasn’t a parent, date, or sexual partner?” !" Yes !" No

If yes,