Working With Teens Who Have
Experienced Trauma
Gloria Castro Larrazabal, Psy.D.
Infant-Parent Program
UCSF/SFGH
Trauma Principles
It is the child’s experience of the event, not the event itself, that is traumatizing.
If we do not look for or acknowledge trauma in the lives of children and adolescents, we end up chasing behaviors and limiting the possibilities for change.
Trauma
The behavioral and emotional adaptations that
maltreated children and adolescents make in
order to survive are brilliant, creative solutions,
and are personally costly.
If you do not ask, they will not tell your.
Since Trauma = Chaos
Structure = Healing
Children and Adolescents are Exposed to
Traumatic Life Events
Traumatic Event: is one that threatens
injury, death, or the physical integrity of
self and others.
It causes horror, terror, or helplessness at
the time it occurs.
Traumatic Events
Sexual, physical, and emotional abuse.
Domestic, school and community violence
Medical trauma.
Motor vehicle accidents.
Acts of terrorism and war experiences.
Natural and human-made disasters.
Suicide and/or loss of a loved one.
In community samples more than two thirds
of children report experiencing a traumatic
event by age 16.
Witnessing community violence: the range
goes from 36% to 85% and estimated rates
of victimization go up to 66%
Exposure to sexual abuse: the estimated
rates go from 25% to 44%
Reactions Displayed by Children and
Adolescents
The development of new fears
Separation anxiety (particularly in young children
Sleep disturbances, nightmares
Sadness, anger, irritability
Loss of interest in normal activities
Reduced concentration
Declined in schoolwork
Somatic complaints
SCHOOL
COMMUNITY
ADOLESCENT
RESILIENCE
moderates risk factors
on outcomes at the level
of neighborhood, family,
and child.
TRAUMA
FAMILY
PEERS
Complex Trauma in
Adolescents
Complex Trauma describes the dual problem
of adolescent’s exposure to multiple
traumatic events and the impact of this
exposure on immediate and long-term
outcomes.
Complex Trauma results when a child is
abused or neglected.
Impact of Complex Trauma
Normative development
Psychiatric and addictive disorders
Chronic medical illness
Legal, vocational, and family problems
These difficulties may extend from childhood
through adolescence and into adulthood
Impact of Complex Trauma on
Development
Attachment
Neurobiology and neurophysiology
Affect regulation
Dissociation
Behavioral regulation
Cognition
Self-Concept
Attachment
Secure Attachment: children learn about themselves, their emotions, and their relationships with others within the relationship of the caregiver.
Secure Attachment: supports a child’s development in areas, including his capacity for regulating physical and emotional states, his sense of safety (this allows him to explore the world), his early knowledge about how he can have an impact on his environment, and his early capacity for communication.
How Trauma Impacts
Attachment
Disconnecting from social relationships
Acting coercively towards others
Due to the unpredictable violence or repeated abandonment, they tend to cope by restricting their processing of what is happening around them
When they are confront with a challenging situation, they cannot formulate a coherent, organized response
Neurobiology
Toddlers and preschool age children: they are at risk
for failing to develop brain capacities necessary for
regulating emotions in response to stress.
Trauma interferes with the integration of left and
right hemisphere brain functioning. The child cannot
access rational thought in the face of overwhelming
emotions.
They tend to react with extreme helplessness,
confusion, withdrawal, or rage when stressed.
In middle childhood and adolescence, the
most rapidly developing brain areas are those
that are crucial for success in forming
interpersonal relationships and solving-
problems.
Traumatic stressors can lead to difficulties in
emotional and behavioral regulation,
consciousness, cognition, and identity
formation.
Neurobiology of Adolescents Expose
to Trauma
Substance abuse to cope with hypersrousal,
numbness, and reexperiencing the event
Indiscriminant sexual behavior
Cutting and suicidal gestures
Continued contact with the abuser
The freeze response
Engaging in high risk behaviors
Conceptual Framework
Trauma is a neurophysiologic state stemming
from neurobiological injury.
The brain is plastic and has the ability to
change its structure and function in response
to experience.
Sympathic Nervous System
Response
Catecholamine are increased: damage to
memory, rational thought, hypervigilance,
inability to distinguish danger signals
Corticosteroids are low: reduced immune
functioning
Opioids levels increase: flat affect (equivalent
of 8 mg of morphine)
Other Neurotransmitters
Serotonin: inhibitory; involved in emotion and mood. Low levels of serotonin lead to depression, problems with anger control, obsessive-compulsive disorder, and suicide.
Dopamine: inhibitory; controls arousal, alertness, attention; gives motivation (drugs like cocaine, opium, heroin, alcohol and nicotine increase the levels of dopamine).
GABA: inhibitory; acts like a brake to the excitatory neurotransmitters that lead to anxiety.
Supportive relationships with adults and
peers can protect children and adolescents
from many of the consequences of traumatic
stress.
The role adults play in the life of adolescents
is crucial.
Affect Regulation
The identification of internal emotional
experiences.
It requires the ability to discriminate among
states of arousal, interpret these states, and
apply appropriate labels (e.g. “happy”,
“frightened”).
Able to express emotions safely and to adjust or
regulate internal experience.
How Trauma Impacts Affect Regulation
Dissociation
Chronic numbing of emotional experience
Dysphoria
Avoidance of emotional situations (including
positive experiences)
Maladaptive coping strategies ( substance
abuse)
Dissociation
It is the failure to integrate information and
experiences
Thoughts and emotions are disconnected
Physical sensations are outside conscious
awareness
Repetitive behaviors take place without
conscious choice, planning, or self-
awareness
Behavioral Regulation
Behavioral patterns that represent
adolescents’ defensive adaptations to
overwhelming stress.
They may reenact behavioral aspects of their
trauma (e.g., through aggression, self-
injurious, or sexualized behaviors).
They can be attempts to gain mastery or
control over their experiences.
Behavioral Regulation
They may use alcohol or drugs to avoid
experiencing intolerable levels of arousal.
They may engage in sexual behaviors in
order to achieve acceptance and intimacy.
Cognition
Attention.
Abstract reasoning.
Problem solving.
They have three times the drop out rate of
the general population.
Self-Concept
If adolescents perceive themselves as
powerless or incompetent and expect others
to reject or despise them are likely to:
A) Blame themselves for negative
experiences.
B) Have problems eliciting and responding to
social support.
Family’s Contribution to Healing
Process
Believing and validating the adolescent’s
experience.
Tolerating the adolescent’s affect.
Managing the caregiver’s own emotional
response.
ASSESSMENT AND TREATMENT
ASSESSMENT
The adolescent’s own disclosures
Collateral reports from caregivers and other providers
The therapist’s observations
Standardized assessment measures that have been completed by
the adolescent, parents, and by the teachers
Assessments need to be cultural sensitive
The Adolescent Sexual Behavior Inventory
(ACSBI)
It is used to assess sex-related behaviors that
might suggest a need for intervention.
It assess: sexual risk taking, nonconforming
sexual behaviors, sexual interest, and sexual
avoidance/discomfort.
It is used for children age range from 12 to 18.
There are two versions , a parent report version
(ASBI-P)
TREATMENT The Complex Trauma Workgroup
NCTSN
1. Safety: Creating a safe home, school, and
community environment.
2. Self-regulation: enhancing his/her
capacity to modulate arousal and restore
equilibrium following disregulation of affect,
behavior, physiology, cognition, interpersonal
relatedness and self-attributions.
3. Self-reflective information processing: consists in helping the adolescent to construct self-narratives, reflect on past and present experiences, and develop skills in planning and decision-making.
4. Traumatic experience integration: enabling the adolescent to transform or resolve traumatic memories or reminders. It can be done by using techniques as meaning making, traumatic memory containment or processing, mourning of the traumatic loss, managing symptoms, developing coping skills, and cultivation of present-oriented thinking and behavior.
5. Relational engagement: helping the adolescent
to form appropriate attachment and to apply this
experience to current interpersonal relationships.
6. Positive affective enhancement: enhancing the
adolescent sense of self-worth, esteem and positive
self-appraisal through the cultivation of personal
creativity, imagination, future orientation,
achievement, competence, mastery, community-
building and the capacity to experience pleasure.
A Phase-Based Approach
Treatment proceeds through a series of phases that focus on different goals. This avoids overloading the adolescent with too much information at one time.
This approach begins with providing safety followed by teaching self-regulation
Gradually incorporates self-reflective information processing, relational engagement, and positive affect enhancement
Establish a substantial period of stabilization
in which internal and external resources have
been established.
Foster integration of traumatic experiences
by identifying and coping with present
triggers.
Interventions should build strengths and
decrease symptoms.
Compassion Fatigue Secondary Traumatization
Compassion: feeling of deep sympathy for
another’s suffering.
Compassion Stress: is the feeling of tension or
demand associated with feelings of compassion.
Compassion Fatigue: progresses from
Compassion Stress and is an overwhelming
state of tension and preoccupation with the
cumulative trauma experienced and reported by
clients.
Compassion Fatigue
Internal images are created within the
professional’s mind and can stimulate intense
feelings of compassion which can result in
vicarious experiences of the actual trauma.
Risk Factors to develop Compassion
Fatigue
Professionals who have poor boundaries
Have unresolved traumatic experiences in
their own lives
May be exhausted from the demands of their
work
Professionals who are driven to rescue
clients or whose self-worth is tied to being
liked by their clients
Coping With and Managing
Compassion Fatigue
Develop self-care behaviors.
Examine within themselves any unresolved trauma
issues of their own.
Be alert of the symptoms of compassion fatigue.
Be aware of their feelings and mood states.
Recognize when additional support is needed.
Talk to fellow professionals.
Set realistic goals and boundaries in your work.
Additional training and education about trauma.
References
Cook, A., Blaustein, M., Spinazzola, J., van der Kolk, B. (Eds.). Complex
Trauma in Children and Adolescents. National Child Traumatic Stress
Network. www.nctsnet.org/nccts/nav.do?pid=typ_ct
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.,Cloitre, M.,
DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., &
van der Kolk, B. (2005). Complex Trauma in Children and Adolescents.
Psychiatric Annals, 35, 390-398.
Frederick, W.N., Lysne, M., Sim, L., & Shamos, S. (2004). Assessing sexual
behavior in high-risk adolescents with the Adolescent Clinical Sexual
Behavior Inventory. Child Maltreatment, 9(3), 239-250
Wilgocki, J. (2008). The Effects of Trauma on Children and Adolescents.
Mental Health Center of Dane County. The National Child Traumatic Stress
Network.