Trauma Final Study Guide PDF

When the Nightmare is Real: trauma in Childhood and Adolescence Final Exam Study Guide Class 5 - Child Maltreatment 1. 1. Know the different types of child maltreatment a. Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting kicking sha...

When the Nightmare is Real: trauma in Childhood and Adolescence Final Exam Study Guide Class 5 - Child Maltreatment 1. 1. Know the different types of child maltreatment a. Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting kicking shaking burning or other shows of force against a child b. Sexual abuse - involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling penetration and exposing a child to other sexual activities c. Emotional abuse - refers to behaviors that harm a child self worth or emotional well being. Examples include name calling , shaming rejection, withholding love, and threatening. d. Neglect is the failure to meet a childs basic physical and emotional needs. These needs include housing, food, clothing, eduction, medical care 2. 2. Be able to discuss the main findings of the studies on corporal punishment (discussed in class) a. Spanking is likely to be used by parents who are younger , less educated, of lower income, single, and or more depressed and stressed b. In 1992, 70% of family physicians and 59% of pediatricians supported mild spanking in some situations c. Some child characteristics place them at higher risk of being spanked d. Study of 2500 toddlers from low income white, african american and mexican families found that younger maternal age, maternal depression, lower family income, living alone, predicted more frequent spanking would predict ta child’s aggressive behavior problems at age 2 and lower cognitive abilities e. Meta analysis of 88 studies found that almost without exception there is a negative relationship between normative physical punishment and children's mental health f. Spanking at age 1 predicted child aggressive behavior problems at age 2 and lower cognitive development score at age 3 g. Spanking usually followed by short term compliance can lead to longer term aggressive children h. Rather than teach right from wrong - Spanking predicts weaker internalization of moral values - empathy - altruism - resistance to temptation i. Study of 3000 families in quebec, children who experienced minor physical violence were seven times more likely to also experience severe violence than those who had not experienced minor physical violence j. American academy of pediatrics - spanking effectiveness decreases with subsequent use. Only way to maintain conditioned effect is to increase intensity - which can escalate into abuse 3. How can parental beliefs about physical punishment be changed in a positive way? (3 factors) a. Help parents realize how their children feel when they are spanked b. Have parents acknowledgetheir own childhood memories of being hit c. The third was the availability of information and instruction through a supportive context to help parents adopt new approaches to disciplining their children Class 6 - Sexual Abuse of Children and Adolescents 1. What are the similarities and differences between males and females in terms of sexual abuse (prevalence, risk factors, consequences, etc). a. Study by velente et al 2005 foudn that boys experience similar to girls which include i. Anxiety ii. Denial iii. Dissociation iv. self -mutilation b. Female sexual abuse i. Females reported greater prevalence and severity ii. Females reported more stress and self blame iii. Females more likely to disclose and receive positive reactions iv. Females were also more likely to report ptsd symptoms c. Sexual abuse of boys i. unlikely to disclose history of abuse ii. deny impact that abuse has on their lives iii. Professionals fail to hypothesize that their male clients have been abused iv. Professionals do not create the conditions that would allow male clients to talk about their abuse 1. 8-16 % of general male population has sexual abuse history 2. Boys at high risk were a. <13 b. Non white c. Low SES d. Not living with father e. Abuse most commonly i. Occurred outside the home ii. By known, but unrelated males iii. Involved penetration and took place more than once 2. What are the consequences of sexual abuse? a. sexually inappropriate behaviors b. running away and truancy c. Identity confusion and low self esteem d. depression e. substance use f. suicidality g. Increased rates of teen pregnancy h. Increased rates of abuse of others; 40% of sex offenders report sexual abuse as children i. Increased rate of prostitution 3. What are the signs of sexual abuse? * a. Child has difficulty walking or sitting b. Suddenly refuses to change for gym or participate in physical activity c. Reports nightmares or has sudden onset bedwetting d. Change in Appetite e. Unusual sexual behavior or knowledge f. withdrawn or isolated g. somatic complaints 4. Discuss child prostitution risk factors for being exploited and consequences. i. Average age of girls 12-13, boys 11-13 ii. Risk factors 1. Poverty 2. history of sexual or physical abuse 3. substance abuse 4. Loss of a parent 5. Running away/thrown away 6. Lack of support 7. Special education needs 8. HIV and STDS, 9. mental illness, 10. violence, 11. malnutrition Class 9 - War, Terror, and Community Violence 1. Be able to discuss the findings on child soldiers as discussed in class a. Child Soldiers i. Approximately 250,000-300,000 children have fought in armed conflicts ii. • Children are especially vulnerable to army recruitment; they are frequently displaced from home and their families, and have little means of support and access to education • iii. They have a need for security, access to food, and sometimes a surrogate family • iv. Once recruited—or abducted—they often serve as porters, cooks, couriers and spies, as well as human shields, sexual entertainment, and war fighters • v. Front line combat puts children at risk for rape, torture, war injuries, substance abuse, depression, anxiety, and suicidal ideation • vi. Witness, receive, and perpetuate violence b. Ugandan and congolese Child Soldiers i. Study population: • Mean age at time of recruitment into armed forces: 12.1 years, range 5-18 years • Mean months served: 38.3 months, range 0-96 months • 34.9% met criteria for PTSD • 70.4% had been exposed to threats of being killed or injured • 54.4% had killed others • 34.9% had forced sexual contact ii. • Study findings: • The more PTSD symptoms, the less likely the willingness to reconcile and the more they harbored feelings of revenge toward those who harmed them • In contrast, nonviolence as a means to achieve peace was less likely to be reported by those with depression and more likely to be reported by those with at least a primary education. c. Challenges to Reintegration i. Some youth combatants describe sense of belonging and support system within armed groups, similar to surrogate family ii. Histories of violence and perpetration of violence iii. Disrupted education • Psychiatric symptoms including persistent fears of death, violent memories, and nightmares iv. Separation from biological families, community of origin v. Rejection by community Class 10 - Trauma of Living Through a Life-Threatening or Chronic Medical Illness * 1. Effects of hospitalization at different stages of development a. (0 to 18 months) i. Greater sense of helplessness ii. Anxiety and confusion with any separations iii. Disruption of attachment to caregivers (issues with trust) b. (18 months - 3 years) i. Delayed motor and language development ii. increased oppositional behaviors due to parental reluctance to set limits iii. Problems with bowel and bladder function iv. Regression to younger stages of development due to the infantilizing effect of medical care c. Preschool-age children i. Possible reactions to chronic illness 1. Regression 2. Limited initiative 3. Compromised social skills 4. fear of abandonment 5. fear of mutilation. d. School age children i. Possible reaction to chronic illness 1. Alienation from peers 2. Fewer social interactions 3. Parental overprotection 4. Fear repeated pain 5. Low self worth 6. Fears around Identity, sexuality, relationships and vocational possibilities e. Adolscents i. Possible reaction to chronic illness 1. Noncompliance with treatment 2. Immaturity and increased dependence on parents 3. Identity formation is affected 4. Fear alienation from peers 5. They have ongoing concerns about their appearance and effect that illness/hospitalization may have on identity, sexuality, relationships, and vocational possibilities 2. Be able to discuss the traumas and challenges associated with medical illness (both for the child and the family) a. Potential traumas of illness and injury i. Seperation ii. Medication side effects iii. Painful or time consuming procedures iv. Disrupted sleep v. Pain vi. Fear of unknown vii. Chronic stress for the child and family viii. Anxiety and financial stress in the family ix. Ptsd associated with serious accidents and hospitalizations after acute physical trauma x. Parental distress coreelates with increased risk of ptsd development in children xi. Treatment may be experienced as trauma xii. Long term effects on affect modulation and interpersonal relationships xiii. ACute/chronic illness and the family 1. Financial burden 2. Time lost from work 3. Marital strain 4. Uncertainty about treatment and prognosis 5. Isolation from friends and family 6. Increased frequency of guilt, anxiety, depression and PTSD 3. Describe supports that exist in hospitals to help reduce trauma (eg. child life) a. Family centered Care i. Helping children and adolescent to adapt to illness hospitalization involves child parent family and medical staff ii. Child care is planned around whole family with parents considered an integral piece iii. Parents of children with life threatening illnesses often feel guilty and need support to maintain usual parenting practices iv. Support is provided for parents by medical staff and through facilitation of support from other parents 1. 2. b. Interventions i. Child centered care 1. Considering whole child and not condition 2. Treat children as children and young people as young people 3. Be concerned with the overall experience of the child and family 4. Treat children - young people and parents as partners in care 5. Integrate and coordinate services around the childs and families particular needs 6. Graduate smoothly into adult services at the right time 7. Work in partnership with children, young people and parents to plan and shape service ii. Pain Management 1. There is now a greater understanding of children's experience of pain and how to to best manage it 2. There is regular assessment of pain in children using age appropriate measures 3. The use of relaxation techniques and pharmacological measures to minimize painful procedures has become more commonplace iii. Education 1. Helps retain routine and structure of everyday life 2. Collaboration with child’s school iv. Open and careful communication about threat to life is essential v. Interventions should restore child’s sense of control vi. Interventions by Developmental Stage 1. Infancy to 18 months a. Few staff there are consistent and maintained to allow for regular schedule 2. INterventions with Toddlers a. Transitional objects like toys, blankets, or familiar objects can help calm an anxious toddler. 3. Interventions with Preschoolers a. Consistent parental visitation b. Preparation for procedures through medical play c. Presenting explanations of illness and treatment in a manner which is in line with their cognitive development 4. Interventions with School Age children 5. Interventions for Adolescents a. Participation in treatment decisions can help them feel more independent b. If death is a possibility - adolescents often recognize this 6. Child Life Programs a. Support and normal routines for chronically ill children - art - music therapy etc b. Minimize disruption in child's development c. Mental health Interventions i. Child life interventions can help a child cope with hospitalization and procedures ii. CBT can help treat anxiety and depression surrounding illness iii. Distraction, guided imagery, and relaxation can help with painful procedures as well as anxiety and depression iv. Behavioral plans can help manage children with disruptive behaviors in the hospital v. Medications for psychiatric illness are also often indicated vi. NCTSN Resources for Parents 4. Be able to discuss a child’s conceptualization of death by developmental stage a. b. Class 11 - Resilience and Treatment 1. How is resilience defined? a. “Good outcomes” in spite of threats to adaptation b. From a psychiatric standpoint, resilience is often defined as the absence of psychopathology i. Ie did the child develop PTSD after years of abuse c. Developmental psychs define resilience based on meeting developmental milestones i. Did the child develop speech, language, and cognitive skills, on a normal trajectory ii. Meeting cultural/social expectations ? iii. Did the child graduate high school, go to college, hold down a job, have a lasting relationship? d. Patterns of positive adaptation in the context of situations that threaten life or development - the process of, capacity for, or outcome of success adaptation despite challenging or threatening circumstances (Masten, Best, & Garmezy, 1990, p. 426) e. APA - Resilience is the process of adapting well in the face of adversity f. Devereaux center for resilient children and dynamic systems theory i. Someone who is resilient can identify problems, find ways to address challenges, recover quickly and move on” 2. Do all children exposed to difficult events develop trauma? a. No. Having protection can mitigate against trauma. Ie. Masten - Ordinary Magic i. Normal brain chemistry ii. Strong families iii. Communities with resources iv. Children who demonstrate resilience in the face of adversity often have a combination of a biological resistance for vulnerability to stress AND a protective supportive environment ✤ v. Children who demonstrate resilience to one type of adversity may not demonstrate it to another 3. What are thought to be factors that lead to resilience? a. b. c. Factors in outcomes i. Biological factors 1. family history of psychiatric illness 2. Epigentetic factors 3. History of prenatal or neonatal insults ot brain or other central nervous system disease ii. Psychological factors 1. Altered patterns of attachment 2. Identity formation in the face of trauma 3. Temperament iii. Social factors 1. Low ses 2. Minimal family support 3. Number of traumatic events iv. 4 factors that predispose children to do well 1. Facilitating supportive adult child relationships a. Mentorships b. coaches 2. Building a sense of self-efficacy and perceived control a. Giving children right to make decisions b. Allowing children to make mistakes 3. Providing opportunities to strengthen adaptive skills and self regulatory capacities a. Modeling ways to maintain self control under stress or adversity - exercise, good diet, sleep b. Opportunity to express all emotions safety , learn self reg and stress reduction 4. Mobilizing sources of faith, hope and cultural traditions. v. APA - Primary factor in resilience is having caring and supportive relationships within and outside the family 1. Capacity to make realistic plans and take steps to carry them out 2. A positive view of yourself and confidence in your strengths 3. Skills in communication and problem solving 4. Capacity to manage strong feelings and impulses 4. What are elements common to various approaches to treatment of childhood trauma? a. Psycho-dynamic psychotherapy • i. Acknowledgement of unconscious processes along side conscious and preconscious (Sigmund Freud and more) • ii. Transference and Countertransference • Understanding how the past informs the present • iii. Focus on affect and motivation for thoughts and actions iv. Clarification, confrontation, interpretation b. Cognitive Behavioral Therapy • i. Maladaptive cognitions (Aaron Beck and more) • ii. Connections between thoughts, feelings, and behaviors (cognitive triangles) • iii. Developing awareness and trying to change feelings and behaviors by changing thoughts and related “schema” • iv. May involve imaginary and in vivo exposure c. Systemic and Parent-Child Therapy • i. Recognizing importance of recurring patterns in interpersonal relationships within a given system (Minuchin, Bowen and more) • ii. Focus on changing interactive patterns • iii. Requires more than one patient/client in bidirectional or multi-directional system(s) • 1. Can as other therapies involve videofeedback iv. Other Psychotherapeutic Approaches • Creative arts therapies: Visual art, music, dance/movement, drama, creative writing • v. EMDR is Eye-movement desensitization and reprocessing (Shapiro) – Shapiro (1995, 2001) hypothesizes that EMDR therapy facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. 5. What do you know about the role of psychopharmacology in treating Trauma? a. Very little evidence to guide psychopharmacologic treatment of PTSD in children and adolescents • b. Maybe the result of a poor response to psychotherapy c. Hyperarousal most amenable to this treatment i. Sleep disturbances Irritability Difficulty concentrating Hypervigilance ii. Improvement in 1 symptom + effect on functioning d. SSRI’s address i. Ptsd symptoms ii. Anxiety (comorbid) iii. Depression (comorbid) e. Alpha agonists i. Decrease norepinephrine release or attenuate its effect s 1. Addresses hyper arousal and sleep. 2. Meds like clonidine or guanfacine f. Benzos/antipsychotics/anticonvulsants i. Benzos address mood lability ii. Anti psychiatric medications address psycho spectrum, aggression, self injurious behavior iii. Risperdone g. Alternative and experimental agents i. Alpha adrenergic blockers for nightmares ii. Beta blockers during acute traumatic stress iii. Melatonin iv. Cortisone and anti inflammatory agents v. Nasal oxytocin vi. CBD and ptsd 1. Cbd take immediately after trauma might make it more difficult for brain to form memories that may later develop and cause ptsd - by affecting the amygdala and hippocampus 6. What do you know about creative arts therapy? a. Visual art, music, dance/movement, drama, creative writing b. Are non verbal ways to access trauma and learn self regulation c. Drama therapy- helps person to access emotions in a safe way • Experience their emotions/trauma from a distance first to allow for eventual processing of feelings and thoughts related to their own trauma » Trauma is about fear of feeling » Drama is about embodying emotions » Trauma is about feeling isolated from human condition » Drama is about expressing the commonality of the human experience Class 12 - Trauma-Focused Cognitive Behavioral Therapy 1. What are the various components and the acronym that contains them? a. Psychoeducation and Parenting skills b. Relaxation c. Affective modulation d. Cognitive coping and processing e. Trauma narrative f. In vivo mastery of trauma reminders g. Conjoint child-parent sessions h. Enhancing future safety and development 2. How do the different components work together? i. P-sychoeducation and parenting skills 1. General info about abuse and trauma and effects of traumatic events 2. Specific info about types of traumatic events (sexual abuse, physical abuse, witnessing domestic violence, others) 3. Sex education 4. Risk reduction a. Education i. Different types of trauma ii. Why does this type of trauma occur iii. Effects of trauma iv. Why children may not like to talk about trauma ii. R-elaxation 1. Controlled breathing (belly breathing) 2. Relaxation training 3. Thought stopping iii. A-effective modulation - understanding appropriate vs inappropriate display of affect (what emotions go with what situations ) 1. Feeling identification a. Games, feeling faces, etc b. Rationale for feeling identification c. Generating feelings d. Rating intensity e. Appropriate expression of feelings iv. C-ognitive coping and processing 1. Teaching difference between accurate and inaccurate and helpful and unhelpful thoughts and beliefs 2. The cognitive triangle a. thoughts<->behavior<->feeling 3. Differentnce btw thoughts and feelings 4. Examples of how thoughts affect behavior 5. Generate scenarios and have child identify thoughts, feelings, and likely behaviors 6. Help child generate more accurate or helpful thoughts 7. Discuss how to apply in real life 8. Developmental considerations a. Restructuring b. Coping thoughts v. T-rauma narrative vi. I-n vivo mastery of trauma reminders - helping kids cope in the moment vii. C-onjoint child-parent sessions viii. E-nhancing future safety and development b. Function of Gradual exposure Goal 1 i. c. d. e. f. g. h. i. Break connection between trauma reminders/memories and unpleasant and overwhelming affect and cognitions Gradual exposure Goal 2: integration i. Create trauma narrative enables child to integrate experience Trauma narrative i. Choose format - book, picture, computer, song, poem) ii. Choose where to start narrative iii. Child describes perceptions of events iv. Child reads narrative v. Child adds thoughts feelings vi. Child inclues worst moment, memory or part of traumatic event Creating the trauma narrative i. Variety of formats can be used ii. Starting point iii. Encourage child to describe their experience in the moment of the trauma iv. Adding thoughts and feelings v. Worst moment vi. Therapist should periodically assess symptoms vii. End each narrative development session with something fun or relaxing Pre for gradual exposure i. Establish rapport ii. Assess communication skills iii. Assess anxiety responses to trauma related stimuli iv. Formulate tentative hierachy of increasingly anxiety provoking stimuli. v. Benign narrative. Facilitating detailed narratives i. Ask broad open ended questions 1. What were you thinking? 2. What were you saying to yourself? 3. How were you feeling? 4. What happened nexxt? ii. Make clarifying and reflective statements 1. Tell me more about it 2. I wasn’t there, so tell me 3. I want to know all about it 4. Repeat the part about Managing avoidance i. Praise child for her efforts ii. Repeat treatment rationale as necessary iii. Slow down pace or take a step back iv. Encourage use of coping skills v. Be even more creative vi. Gently persist Organizing the narrative i. ii. iii. Help child put chapters in chronological order Re-read the book together for accuracy and to do cognitive processing Create a positive ending - what was learned in therapy personal strengths and resilience , expectations for the future) j. Function of cognitive processing i. To identify and correct unhelpful and inaccurate cognitions about the traumatic events k. Cogntive processing i. Employ role playing or experiential exercises 1. Best friend role play responsibility play 2. Talk show host role play ii. Parent session 1. My child will never be happy again iii. Challenge unhelpful or inaccurate cognitions l. Dispute dysfunctional thoughts i. Examine contradictory evidence ii. Test the accuracy of thoughts iii. Use the socratic method iv. Use role plays m. Examples of cognitive processing i. Safety concern 1. “I will never trust another man” 2. “I can’t go anywhere alone” ii. Self image 1. “I am stupid” 2. I’m unlovable iii. Sexuality 1. “Am i gay?” 2. I was abused because i dressed sexy” iv. Interpersonal concerns 1. Family - I tore m yfamily apart, my friends think i’m a slut” n. Cognitive and affective processing for caregivers i. Examine thoughts which are permanent pervasive or too personalized 3. How are sessions structured? a. Parent sessions i. Explain why its important ii. Work closely with the caregiver iii. Prepare parents iv. A good way to prepare the parents v. Ensure parents reponds in helpful and supportive manner vi. Sharing trauma narrative is ongoing event vii. Devote parallel parent session to parent reading child’s book b. Parent-Child Sessions i. Assessing the parent readiness 1. Is the parent emotionally ready? 2. Does the parent have the ability to actively support the child? 3. Does the parent have any specific or unique concerns? ii. Assessing the childs readiness iii. Rationale for parent chidl sessions 1. Parent demonstrate ability to handle talking about trauma 2. Children have a sense of pride about being able to cope with trauma 3. Enhancing ocmmunication about trauma 4. Groudnwork for parent child interactions iv. Prepare the parent v. Prepare the child c. Function of joint sessions i. Caregiver seres as a role model for coping ii. Facilitates open communication regarding the traumatic events iii. Can serve to repair relationship which was damaged bc of trauma d. Joint sessions i. Child teaches parent ii. Child shares narrative e. Terminating therapy i. Review skills and progress achieved ii. Fade out and plan booster sessions iii. Discuss and plan for expectable setbacks iv. Encourage clients confidence in managing setbacks v. Emphasize parents role as a continued supportive resource for the child vi. Celebrate clients therapy graduation 4. Be prepared to discuss how you would approach a case from the perspective of this model Class 12 - Trauma Systems Therapy 1. What is meant by a trauma system? a. The interplay between a traumatized child who shifts to survival states in specific definable moements and the social environment or system of care that is not able to help the child regulate these states. 2. What are the 4 service elements? a. psychiatry/psychopharmacology b. Home and community based services c. Skills based psycho therapy d. Legal advocacy 3. What is meant by “cat hair?” a. Cat hair refers to the traumatic triggers that remind children of their trauma. Cat hair to a mouse/rat creates arousal and shifts them into fight or flight. 4. How are the two aspects of the trauma system assessed, and why are they both important? a. 5. How does a TST team intervene on both aspects of the trauma system? a. 6. Be prepared to discuss how you would approach a case from the perspective of this model