Transcript Child and Adolescent Psychopathology

Chapter 19:
Trauma-Related Problems
and Disorders
Brian Fisak
Brief Overview
 Potentially traumatic events (PTEs) include a
range of experiences:
 Physical or sexual abuse
 Exposure to domestic or school violence
 Traumatic death of a loved one
 Injuries and accidents
 Exposure to community violence
 Severe illness
 Approximately 25% of children and adolescents
experience a PTE (Costello et al., 2002)
Potentially Traumatic Events
 Children/adolescents at risk:
 Poverty
 Single parenting
 Parent depression symptoms
 Long-term disruption after exposure to PTE is not
uncommon
 Rate of PTSD for children/adolescents exposed to PTE
varies considerably and is influence by:
 Nature of the trauma
 Pretrauma psychopathology
 Duration of time following the occurrence of the traumatic event
Trauma-Focused Cognitive
Behavioral Therapy (TF-CBT)
 Manualized treatment
 Help children/adolescents experiencing PTSD and
other trauma-related symptoms (e.g., anxiety,
externalizing)
 Only top-rated treatment (Saunders et al., 2004)
 TF-CBT can be applied to children with a history of
sexual abuse and/or physical abuse, and children who
have witnessed violence
TF-CBT Components
 Nine modules
 12 to 16 sessions of therapy
 Can be extended if necessary
 Modules designed to be implemented in a flexible
manner
TF-CBT: Psychoeducation
 Beginning of treatment
 Normalization of child and parent experiences in
response to the trauma
 Three components:
 Information about the traumatic event is provided
 Sexual education
 Risk reduction
Parenting Skills
 Clinician discusses basic parenting skills (e.g.,
praise, selective attention, time-out, contingency
reinforcement)
 Serve to improve parent-child relationship and reduce
disruptive behavior
 Skills may enhance the effectiveness of other
components of TF-CBT
Relaxation/Stress Management
 Relaxation strategies can be particularly beneficial
to manage physiological arousal due to traumarelated memories and triggers
 Introduce:
 Controlled breathing (diaphragmatic breathing)
 Mediation (for older children)
 Muscle relaxation
 Strategies to manage intrusive thoughts
 Skills are introduced and practiced in session
Affective Expression and
Cognitive Coping
 Affective expression and modulation training:
Help children to develop the ability to identify and
label emotions so that emotions can be
appropriately expressed and managed
 Cognitive coping: Children discuss how to
identify and challenge inaccurate and unhelpful
thoughts
 Review how thoughts are inaccurate and/or unhelpful and
how these thoughts may lead to negative emotions and
behaviors
Trauma Narrative
 Trauma narrative development and processing:
break the connection between thoughts and
memories of the traumatic event, negative
emotions, and physiological arousal
 Developed in a gradual, progressive manner
 Child is asked to provide an account of the trauma over
time, with increasing detail
 Cognitive and emotional processing typically
occurs following the completion of the narrative
Exposure, Parent-Child,
Enhancing Safety
 In vivo exposure: used to overcome fear and
avoidance of external cues that may remind child
of trauma
 Conjoint parent-child sessions: sessions with
parent and child occur throughout treatment;
important component of the trauma narrative
 Enhancing safety: end of treatment; development
of skills to enhance safety, including assertiveness
training, problem-solving skills, and body safety
TF-CBT Contraindications
 Clinical issues should be addressed before
implementation of TF-CBT or where TF-CBT may be
contraindicated
 Conduct problems and significant premorbid
behavioral problems need to be addressed before TFCBT is implemented
 Exposure not appropriate for youths who are acutely
suicidal, exhibit substance abuse symptoms, engage in
self-harm and parasuicidal behavior, or are
experiencing severe depression
Parental Involvement
 Parent involvement important component of TF-
CBT
 Circumstances where treatment can be
implemented without parent involvement
 E.g., Cognitive-Behavioral Intervention for Trauma in
Schools model (CBITS)
 Group-based program conducted in school settings
 Clinicians need to use discretion regarding level of
parent involvement
Adaptations and Modifications
 Traumatic grief: occurs when a child is exposed
to a death of a love one and the death was violent,
gory, and/or unexpected (Cohen et al., 2006)
 Intensive intervention is typically indicated
 Childhood Traumatic Grief model is used in conjunction
with TF-CBT
 Cultural adaptations: suggestions for adapting for
specific cultural groups, including Latinos and
Native Americans, in TF-CBT
 International adaptations
Modifications: Complex Trauma
 Complex trauma: when a child/adolescent has
been exposed to multiple and often chronic trauma
experiences, resulting in substantial impairment in
a number of areas of functioning (e.g., Cohen et
al., 2012)
 Significant modifications may be needed to
traditional TF-CBT model for individuals with
complex trauma
 E.g., treatment extended to 25 sessions, including an
initial stabilization phase
Modifications: Ongoing Trauma
 Children/adolescents who are at substantial risk for
ongoing trauma will most likely need modifications
to TF-CBT
 Maximizing safety will need to be primary focus of
treatment
 Level of risk related to the perpetrator being in
child’s life or home and risk related to disclosure of
information about the perpetrator’s behavior should
be addressed
Modifications: Additional
 Treatment with an offending parent: Involvement
with offending parents is contraindicated
 Intervention for trauma other than sexual abuse:
TF-CBT was developed primarily as a treatment for
children/adolescents who have experienced sexual
abuse
 Early intervention: Early intervention may call undue
attention to the trauma, which can increase a child’s or
adolescent’s negative perceptions about the trauma
 Prevention of PTSD symptoms can be detrimental, however
(Cohen, 2003)
Measuring Treatment Effects
 CRAFTS: relevant domains of function
 Cognitive problems
 Relationship problems
 Affective problems
 Family problems
 Traumatic behavior problems
 Somatic problems
 A number of assessment tools available: Clinician-
Administered PTSD Scale for Children, Children’s
Revised Impact of Events Scale
Clinical Case: Brittany
 10-year-old Caucasian female
 Experienced ongoing sexual abuse that occurred 6 months prior
to the intake
 Symptoms: embarrassment, shame, nightmares, fear,
avoidance of stimuli that reminded her of the event
 Diagnosis: PTSD, Separation Anxiety Disorder
 Treatment: TF-CBT; psychoeducation, relaxation training,
trauma narrative, in vivo exposure
 Outcome: Brittany and mother responsive to treatment; Brittany
no longer met criteria for PTSD and separation anxiety disorder