MODULE 4 CHAPTER 12.pdf

MODULE 4 CHAPTER 12 PTSD in older children and adolescents ○ Children are at a high risk for physical maltreatment, sexual victimization, and physical or emotional neglect ○ As many as 30% of youths are exposed to a traumatic event at some point in...

MODULE 4 CHAPTER 12 PTSD in older children and adolescents ○ Children are at a high risk for physical maltreatment, sexual victimization, and physical or emotional neglect ○ As many as 30% of youths are exposed to a traumatic event at some point in childhood. ⅓ of these children will develop PTSD ○ PTSD is defined by a characteristic set of behavioural, emotional, and physiological symptoms that emerge following exposure to a serious or life-threatening event 4 clusters of symptoms: 1) instrusive symptoms associated with the trauma, 2) avoiding stimuli associated with the trauma, 3) a negative alteration in the person’s feelings or thoughts, and 4) alteration in physical arousal or reactivity ○ Traumatic event → a psychosocial stressor that involves actual or threatened death, serious physical injury, or sexual violation. Events can be intentional, accidental, or natural. A person must show PTSD symptoms at some point after the trauma. It may take time for symptoms to show up. Event must occur either to the person or to a close family member/friend ○ PTSD usually greatly interferes with all aspects of a person’s life and functioning ○ Associated features: 1) depersonalization → recurrent experiences of feeling detached from ones own body or mental processes 2) derealization → recurrent thoughts and feelings that ones own surroundings arent real ○ Not required for a diagnosis but often seen with the diagnosis, BUT DSM-5 instructs clinicians to add the specificer “with dissociative symptoms” to the diagnosis. Attempts to distance themselves from the memories or effects of the traumatic event PTSD in preschoolers ○ May not show PTSD the same way as older individuals ○ Very young children often have trouble articulating their thoughts; diagnostic criteria used for adults can be difficult to use with young children  It is more likely that parents will notice behaviours that suggest intrusive thoughts or dreams, avoidance of people or places associated with trauma, and negative changes in overt behaviour and mood ○ DSM-5 includes specific criteria for PTSD in preschoolers that differ in 3 important ways: 1) symptoms are expressed in terms of actions or observable behaviours, 2) preschoolers need to only show 1 persistent avoidance symptom OR 1 negative alteration in cognition and mood symptom, and 3) symptoms must cause them distress, interfere with their behaviour at school, OR impair their relationships with parents, siblings or caregivers In contrast, adults and older children 1) report their feelings more accurately, 2) must show 1 persistent avoidance symptom AND 2 symptoms of negative alteration in cognition and mood, and 3) must experience distress or impairment to their individual self but not necessarily others. # of children who meet full criteria for PTSD is less than 1% for a lifetime prevalence. As many as 5% of older adolescents, however, have experienced PTSD at some point in their lives, according to more recent studies. Lifetime prevalence of adults is about 8%, and girls are more likely to develop it than boys ○ Pediatric prevalence → 40-60% of refugees from war torn countries, chronic victims of physical or sexual abuse, and children who are repeatedly exposed to domestic violence meet diagnostic criteria for PTSD Prevalence among youths exposed to single-incident traumatic events is lower, around 25-30%. For single-incident household accidents, prevalence is between 14-26% PTSD Course and Comorbidity ○ Varies; some recover without treatment ○ Longitudinal studies with children suggest that childhood PTSD often persists over time. Although symptoms may decrease over time, many still meet criteria for PTSD after time has gone by ○ Many youth who recover from PTSD continue to show subthreshold PTSD symptoms and problems with depression and anxiety, including irritability and sleep disturbance  ○ Early treatment might prevent long-term problems or facilitate the recovery of PTSD once it emerges ○ PTSD can trigger development of other psychiatric disorders Depression and suicidal ideation are often comorbid with PTSD What Predicts the Emergence of PTSD? ○ Risk and resilience approach: risk factors increase the likelihood that children will develop a particular disorder, whereas resilience factors buffer children from the potentially harmful effects of risk. The emergence of PTSD depends largely on this interaction Socio-emotional functioning before the traumatic event predicts the severity of their posttraumatic symptoms Children with higher anxiety/depression symptoms → more susceptible to PTSD The child’s proximity to the traumatic event Traumatic events can cause disruption in the body’s stress response system. Children with PTSD have lower resting cortisol levels and blunted corticotropin responses to stress, likely reflecting the body’s way of compensating for chronic stress by down-regulating its stress response system. This may help the body cope with chronic stress, but can be maladaptive in the long term. When children with low resting cortisol levels are exposed to another major stressor, they may show an exaggerated stress response, increasing their likelihood of greater distress and impairment Cognitive appraisal theory: the way people feel about a situation depends on their evaluation (appraisal) of that situation. Personally relevant → more distress than children who cognitively distance themselves from the events Coping strategies following the event can greatly influence behavioural and social-emotional functioning. Coping mediates the relationship between stress and a person’s behavioural or emotional response; it largely determines the response to a psychosocial stressor, rather than aspects of the stressor itself 1) problem-focused coping → more adaptive. Involves modifying or eliminating the conditions that gave rise to the psychosocial  stressor or changing the perception of an experience in a way that reduces or neutralizes the problem 2) escape-avoidance coping → disengaging from a stressful situation and its behavioural, cognitive, and emotional consequences. Many people want to avoid anything associated with the event. They might become increasingly isolated, distracted, shut down, or self medicate. It is negatively reinforced because it temporarily reduces psychological distress. Can be adaptive short term (allows people to meet demands and responsibilities immediately after) but is maladaptive long term. Lack of confrontation and healing allows the negative thoughts and feelings to linger, causing long-term impairment What Evidence-Based Treatments are Effective for Children with PTSD? ○ Psychological first aid (PFA) → evidence-based intervention usually provided by first responders or mental health professionals at the site of a traumatic event. Provides victims with a sense of safety and security and meets their immediate physical, social, and emotional needs Objectives → fostering a sense of safety, promoting a sense of calmness, increasing self-efficacy, achieving connectedness and social support, and instilling hope for the future. Focus on meeting IMMEDIATE, TANGIBLE needs. Let the child know adults are willing to listen and connect with the trauma if they do need that. Might involve teaching relaxation and breathing techniques. Providers will validate and normalize the child and family’s stress response. Supported by research. Associated with better coping ○ Trauma-Focused CBT → exposing children to stimuli associated with traumatic events and then encouraging them to think about and cope with the trauma in more adaptive ways Early treatment sessions are used to teach families about PTSD The therapist teaches the child coping skills to deal with negative emotions (relaxation skills, positive self talk) Children are gradually exposed to stimuli associated with the traumatic event. Moves from imagining the event to exposing the child to  anxiety-provoking stimuli for extended periods of time. The therapist wants to use this to correct avoidance Childrens maladaptive cognitions about the event are identified and changed. Children might believe they caused or are to blame for the event or the misery the event placed on others Children who participate in TF-CBT show reductions in PTSD symptoms and increases in social competence ○ Eye Movement Desensitization and Reprocessing (EMDR) Developed to treat PTSD in adults. Involves asking an adult patient to generate a mental image related to the traumatic experience; with this in mind, they then follow the therapist’s finger as they rapidly move it across the patient’s visual field back and forth for approx 30 seconds. The patient reports their thoughts and feelings verbally. Repeated several times in one session As effective as CBT at alleviating PTSD in adults. For children, EMDR has been shown to yield benefits in fewer sessions than TF-CBT Main drawback? The mechanism by which it reduces PTSD is unknown. Some say saccadic eye movements somehow integrate memories of traumatic events into the long-term memory, reducing intrusive thoughts, images, and dreams. Some say the effects are attributable to exposing patients to painful memories and allowing them to process them Promising treatment for children Role of parents and caregivers ○ Protection, nurturance, direction ○ Attachment is normal - they provide comfort ○ Children find it difficult to cope with their surroundings without their parents and/or primary caregiver ○ 15 million youths have no parents or primary caregivers. Most of these are raised in orphanages (often ruled by totalitarian regimes, disease and war, financially unstable) May be abusive and deplorable High child to caregiver ratio (1:8-1:31). May be exposed to as many as 50-100 caregivers in the first year of life  Isolation and lack of play (maybe 3.5 hours of play a day, usually in cribs or beds) Physical wellbeing may be looked after, but social and emotional wellbeing are highly neglected ○ Reactive Attachment Disorder (RAD) Most commonly seen in children of orphanages or foster homes, or severely neglected homes Lack of developmentally appropriate care from parents or caregivers Inhibited, emotionally withdrawn behaviour toward caregiver. Failure to respond to comfort, episodes of irritability and negative affect Characteristics include: disturbed or developmentally inappropriate behaviour such as crying, clinging, gesturing to be picked up Children with this may be labeled as emotionally absent due to lack of social reciprocity. Social reciprocity is the hallmark of most parent/caregiver-child relationships Rarely smile, hug or kiss; instead seem sad, anxious, irritable Prevalence and diagnosis → most prevalent in the US among international adoptees who spent the first 12-24 months of their lives in a low-quality orphanage or foster home. Absence of first caregiver-child relationship Also pervasive in children of extreme neglect or who have had many foster homes Diagnosis → not recommended before 9 months or after 5 years of age as a diagnosis History → Anna Freud studied how maternal deprivation was harmful for emotional health during the war, looked at survivors of concentration camps Rene Spitz and Katherine Wolf compared babies raised in institutions that only had their physical needs met in institutions to babies raised in jail with emotional warmth from their mothers ○ Babies in institutions showed sadness and withdrawal, as well as developmental delays (physical and cognitive) John Bowlby → reported warm, intimate, and continuous relationships with caregivers is fundamental to development.  Noted a characteristic form of depression in children who grew up without this (listless, unhappy, unresponsive) Causes → lack of developing an attachment. Think attachment theory. Children may form working models of themselves and of their caregivers. Some infants develop models based on attachment security (proper support in a healthy fashion), some may have a model based on attachment insecurity (they have an expectation that their caregivers are not going to provide proper care; intrusive, dismissive, or inconsistent), and some may have a disorganized model (incoherent expectations of their caregivers) Experience-expectant process: aspect of development that is biologically predisposed and requires minimal presence of external stimuli. The baby will form an attachment to anyone who is caring for them during the sensitive period, even if they are abusive. 6-12 months → most attachments are formed due to the development of the CNS, and stranger anxiety appears. Experience-dependent process: development is dependent on duration, nature, and quality of the environment According to Bowlby’s concept, RAD develops when infants are deprived of proper care from their caregivers after that sensitive age of 6 months. The absence of a clear attachment relationship and warm behaviours may create listlessness, withdrawn, and sad behaviours in the child. Unlike the different types of attachments, infants with RAD dont form ANY close attachment to any caregiver whatsoever. ○ Disinhibited Social Engagement Disorder (DSED) Most commonly seen in children of orphanages or foster homes, or severely neglected homes, inconsistent care, abuse, neglect Not an attachment disorder; associated only with a social inhibition Lack of developmentally appropriate care from parents or caregivers DSM-5 disorder where infants and young children repeatedly approach and interact with strangers in a manner that is not consistent with development. Common strange behaviours are talking to strangers, sitting on their lap, going places with them - very disinhibited.  Only children with a history of severe neglect or deprivation merit this diagnosis ○ The Bucharest Early Intervention Project Showed that RAD is likely caused by lack of attachment to a caregiver in infancy Families in Romania were encouraged by the regime to have more children; after the fallout of the regime, the parents couldn’t take care of all of their children and many of them went into low quality orphanages. There was also an absence of effective foster care homes in the country Families in the West agreed to take care of some of these children. Children were randomly assigned. The researchers observed the children’s development to 54 months and found an association between RAD and a lack of early attachment. Institutionalized children showed no clear attachment, whereas non-institutionalized children did. An infant removed from institutionalization before 24 months can actually form attachments with their new families and caregivers ○ Treatment for Reactive Attachment Disorder (RAD) Attachment and behavioural catch-up (ABC) 10 1-hr sessions with the parent and child Cultivate nurturance, improve synchrony, and reduce intrusive, frightening behaviour in parents. Synchrony can encourage the child to begin initiating interactions. Parents are educated about how their parenting styles are affecting the child. Parents learn to cater to the child’s needs even if its not clearly communicated The parent records instances where the child resists care, and the therapist reviews it to figure out how the parent can offer the sensitive care needed Benefits? → higher rates of secure attachment, improved psychological stress response which can be sustained for more than 3 years, improved regulation of negative emotion. Supported as a 1st line of treatment ○ Treatment for Disinhibited Social Engaging Disorder (DSED) Trained caregivers who provide specific, sensitive care  Low caregiver-to-child ratio Can promote more positive emotions, more initiation to play, and more initiation to attach to caregivers Early adoption for institutionalized children is best. Infants placed in foster care before 24 months showed a decrease in DSED symptoms, whereas infants that stayed in the institutions showed stable signs of DSED up to age 12 Maltreatment ○ A broad category including physical, psychological, and sexual abuse and neglect. Involved the violation of the rights of a vulnerable and dependent child ○ Sexual abuse → 1% in youth are subjected by a caregiver or other adult. ¼ girls, 1/20 boys Girls are at an increased risk between ages 15 and 17 Youths subjected to maltreatment by peers ○ Physical Abuse → 4/10 children require medical attention Increased risk in single-parent homes Boys are at a higher risk than girls Spanking/paddling for disciplinary reasons is not considered abuse as long as it is reasonable and does not injure the child HARM standard in the DSM-5 posits that physical abuse must result in physical injury 4% of youths experience custodial kidnapping to avoid losing custody, removing them from access to another caregiver ○ Psychological Abuse → non-accidental verbal or symbolic acts by a parent or caregiver that has a reasonable potential to result in significant psychological harm to the child Spurning (public humiliation or other degradation), terrorizing (threatening the child or allowing them to witness domestic violence), isolating (denying the child access to interactions with people outside their home), exploiting, denying emotional responsiveness (ignoring the child’s plea for attention and emotional interaction) 14% of youths experience this in adolescence, higher than younger children Girls more than boys  ○ Neglect → failure to provide the minimum standards of care in a physical, medical, and educational manner that leads to harm or endangerment Accounts for 15% of maltreatment Most common form of maltreatment is parental disablement (may be due to substance abuse) or unsafe/unhygienic living arangements Most common in single-parent and low SES homes Can be hard to differentiate between neglect and a parents inability to provide because they dont have the means to do so Costs of Maltreatment ○ Direct financial costs → medical, home placement, training, rehabilitation, prosecution, incarceration ○ Indirect financial costs → low academic achievement and underemployment for the victims, job losses and decreased productivity for parents, community cost if the child shows antisocial behaviour due to lack of treatment ○ Emotional costs → psychological distress, reduced quality of life and increased conflict in families, ostracism or imprisonment for perpetrators ○ Health problems → failure to meet weight/head circumference expectations Shaken baby syndrome Vomiting, seizures, coma, death, etc Occurs around 3 months of age, when infants are at max levels of crying and sleep problems (around 27/1000 infants are victims) ○ Behaviour problems → risk for ODD, conduct disorder (which can become APD especially in boys), girls unemployed and taking up prostitution, hostile and aggressive social info processing, fewer friendships, more rejection, deviant per groups, difficulties with adaptive problem solving ○ Attachment problems and mood disorders → internal working models allow them to believe the world is dangerous and not trustworthy Depression often seen in girls especially with multiple types of maltreatment Disorganized attachment to caregivers, expectations that parents will behave in unpredictable ways Children may blame themselves for their victimization = greater mood disturbances Treatment for Child Maltreatment ○ Parent-Child-CBT Evidence-based for youths Enhances quality of parent-child communication and reduces child behavioural and mood problems 16-20 sessions Start by working separately and then coming together at the end Phases → engagement (using principles of motivation enhancement and empathy, working at helping the parents develop a willingness to change, building a rapport with the child), skill building (antecedent, belief, consequence model, improving parents problem solving skills, altering blame for bad behaviour, planning coping skills and building a parent support system), safety planning (identifying signs of abuse, engaging in behaviours to stay safe, identifying safety neutral codes to say out loud and implementing safety plans), abuse clarification (a child’s account of their abuse (narrative), a letter from the parent clarifying the acts and that its not their fault, using empathy with each other) Effective for physical maltreatment ○ Modified Parent-Child Interaction Therapy (PCIT) For caregivers of very young children Includes child and parent directed interaction (the pair practices skills together) Modified for children who may be too young to participate in PC-CBT Build rapport and motivation with parents Reframe the child’s misbehaviour in context of maltreatment Especially helpful for high-risk parents when its hands on, effective for preventing reoffending when the motivation to change is high. More effective than traditional therapy programs ○ Cognitive Restructuring for Survivors of Sexual Abuse 3 diffs compared to PC-CBT for physical abuse and neglect? Children dont attend with offenders Non-offending caregivers are worked with Cognitive restructuring for the child ○ Used in cognitive therapy where the therapist gently challenges the child’s maladaptive beliefs from the trauma that harm their own wellbeing. Reducing blame in the child; “Pie” techniques, role playing techniques (therapist is the child, child is the best friend) ← help increase empathy in the child for themselves