Trauma and DevelopmentHarvard Summer School

Julia Schmidt MasoJuly/2009

Prevention and Intervention

Main Points

The different kinds of InterventionsPreventionIntervention EffectivenessInterventions compared with

controls groupsComparison of InterventionsAssessmentConclusion

What are the goals of intervention?

Figure 1. Analytic framework: reducing psychological harm among children and adolescents following trauma (Holly et. al., 2008)

The different kinds of Interventions

1.COGNITIVE–BEHAVIORAL THERAPY

Used for child and adolescence victims of traumatic exposures:Sexual and physical abuse, domestic violence,

natural disasters, community violence, and life threatening illnesses

Usually combines :

Psychoeducation, skills training, stress management, cognitive coping, muscle relaxation, thought stopping, exposure–based exercises and relapse prevention (Saxe et. al, 2007)

Psycho- EducationAim: Provide a rationale for treatment and to allay

youngster and parents’ fear for the child “going mad”

How:Explaining strategies prevent to traumatic

memories from being processedBringing these traumatic memories to

consciousness, habituate and process them and then, be presented as the rationale for exposure-based treatment

Re-establishing routinesGetting support from the family, friends and school

staffDeveloping parents strategies for managing

behavioural problemsTrying to find out if the youngster is using drugs Symptom-Monitoring

(Carr. 2004)

Coping Skills Training

Managing: Anxiety associated with flashbacks and nightmaresAnxiety evoked during therapeutic exposure to trauma- related cues and memories

Relaxation Skills Training:Sequence of exercise to reduce muscle tension

Cognitive coping Skills Training:The learning to challenge fearful or threatening cognitionsAppraisel anxiety-evoking situations in less threatening ways

(Carr, 2004)

Format of Exposure SessionsAim:

Hold their traumatic memories vividly in consciousness until their SUD rating drops to an agreed level

SUDs will rise, reach a peak and then gradually decrease by:

- relaxation skills and cognitive coping skills

- reinforcement with praise and, if appropriate, with tokens or stars that can be accumulated and exchanged for valued prizes or treats

- listening of audiotapes of exposure sessions and/or writing a detailed account of the traumatic memories addressed in exposure therapies, both each day

(Carr, 2004)

Imaginal ExposureSit in a comfortable position with their eyes closed

Relax using relaxation and breathing exercises

Visualize the traumatic scene as vividly as possible

Verbally recount and give account details of what the youngster sees, hears, smells, tastes and feels

Repeat exposure, facilitates habituation

When habituation to the most anxiety-provoking anxiety scene has occurred, it may be appropriate to progress to media assisted exposure and in vivo exposure, particularly where residual PTSD symptoms remain.

(Carr, 2004)

Vivo exposure

Youngsters, by verbalizing memories, evoke and use coping strategies to help them to habituate being at the trauma site

Confrontation of and exposure to abusers:Involves staying in the presence of the

imagined or actual abuser Must clearly and forcefully state how the abuse

has hurt them How angry and betrayed they feel as a result of

this How they will never let the abuse recur because

they now have the skills to protect themselves in the future and the support of the non-abusing parent

(Carr, 2004)

Parents Training To provide appropriate support as they

progress through an exposure program and to manage trauma-related behavioral problems:

separation anxiety, avoidance of routine social activities, sleep difficulties, aggression, defiance and over sexualized behavior.

Common goals include:Completing daily therapeutic exposure

homework assignments, school attendanceEngaging in daily social interactions with

peers Sleeping in their own beds for some or all of

each night Regulating intense anger using relaxation and

breathing exercisesManaging sexual urges in a socially

appropriate way (Carr, 2004)

School Consultations

School staff require psycho-educational information

Have a designated member of the school staff to whom they can go if they become particularly distressed during school hours.

(Carr, 2004)

2. EMDR

How does EMDR work?http://www.youtube.com/watch?v=gZ5MLn1Cc94

3. PLAY THERAPYIt is believed that play links a child’s

internal thoughts to the outer world by allowing the child to control or manipulate outer objects. Play connects concrete experience and abstract thoughts;

An approach that uses play as the principal mean for facilitating the expression, understanding, and control of experiences, and not simply a way of facilitating communication.

(Holly et al., 2008)

4. ART THERAPY

Considered that trauma is stored in memory as an image; therefore, expressive art techniques are an effective method for processing and resolving it (Appleton, 2001)

It has been proposed that drawing, like play, allows for visual and other perceptual experiences of the traumatic event to become represented and transformed by a child’s activity (Pynoos, 1993)

5. PSYCHODYNAMIC THERAPY

To allow the traumatized individual to release unconscious thoughts and emotions and to integrate the traumatic event into his or her understanding of life and self-concept (Solomon et al., 1992);

Usually lasts many months

(Holly et al., 2008)

6. PHARMACOLOGIC THERAPY

Address neurochemical disruptions in mechanisms controlling arousal, fear, memory, and other aspects of emotional processing that are implicated in the development and maintenance of PTSD (Van Etten & Taylor, 1998);

The intent : is to relieve disabling symptoms and to increase tolerance to emotionally distressing material (Donnelly CL, Amaya-Jackson, 2002)

A survey indicates that many medical believe that medications are the most effective treatment for specified symptoms - 41.6% support the use of medicine for re-experiencing trauma, 20.8% for avoidance/numbing, and 76.7% for hyper arousal (Cohen & Marinno, 2001)

7.PSYCHOLOGICAL DEBRIEFING

Normally a group meeting arranged between 24–72 hours after a traumatic event is intended to mitigate psychological harms associated with the trauma.

These include discussion of the traumatic event and the group members’ reactions, normalization of those reactions, and education in steps useful in controlling those reactions.

Purpose is to aid recovery, not to treat symptoms, participants in psychological debriefing are not screened for symptoms (Mitchell, 1993)

Prevention

Safety Skills and self-regulation

Safety skills training is an essential part of treatment for survivors of abuse and violence

Need to be coached in anticipating and recognizing situations in which they may be victimized again

Coached in planning how to avoid or escape from potentially risky situations

Coached in socially appropriate ways to regulate and express the intense feelings, like aggressive and sexual urges

(Carr, 2004)

Relapse PreventionRelapses are more probable:

Where there are many trauma related cues; Where the person has little social support and

a high level of other life stresses; When entry into the situation occurs

unexpectedly or at a trauma anniversary.

Relaxation skills, cognitive coping skills, especially retaining an optimistic perspective and arranging social support from family, close friends or a therapist are useful elements to include in a relapse management plan.

(Carr, 2004)

Treating Pervasive co-morbid difficulties

Adolescents with complex PTSD following chronic victimization, borderline personality disorder and substance abuse are among the more challenging co-morbid difficulties

Dialectical behavior therapy (Lihenan, press) to deal with self-mutilation and pervasive relationship management difficulties with borderline personality disorder.

Family therapy for substance abuse and an established evidence based treatment - drug and alcohol abuse have become the youngsters main way of managing unprocessed traumatic memories

(Carr, 2004)

So which intervention do you think is better to treat traumatic events in youngster?

Intervention Effectiveness

CBTEleven Studies - most were sexual and physical

abuse

Conclusion :

Result for PTSD and anxiety were significant, whereas those for internalizing and externalizing behavior, and depression were not;

Greater when compared with untreated;

The benefits were: decreased shame, improved trust, enhanced emotional strength and parent–child relationships (Cohen et al., 2004)

Participating parents may be a mediator of effects on children.

No potential harms of individual CBT were noted. (Holly et al., 2008)

CBT… continuing

Most efficacious child treatments include cognitive and behavioral parental components (Cohen & Mannarino,1993, Cohen et a., 2000, Saigh, Yule & Inamdar, 1996)

BUT, the number of studies was small, it was difficult to determine whether the effectiveness of group CBT varied by index trauma

USUALLY in group therapy, some studies excluded children who were too disruptive or had severe mental health problems.

(Holly et al., 2008)

Other TherapiesPlay Therapy : Four Studies- effectiveness of play

therapy in reducing psychological harm to children exposed to traumatic events. In contrast to other interventions reviewed, did not exclude suicidal.

Art Therapy: One Study: effect of art therapy on psychological harm.

Psychodynamic Therapy: One Study - Child exposed to violence between their parents

Pharmacologic Therapy :Two Studies: One - Substantial Burns

Psychological Debriefing: One Study: (Traffic crash) approximately 4 weeks after the crash;

Conclusion: It is insufficient to determine the effectiveness in preventing or reducing psychological harm among children and adolescents who have developed symptoms of PTSD following traumatic exposures. (Holly et al., 2008)

Interventions x Controls groups

Studies

Child sexual abuse (CSA) - most of them have suffered repeated abuse

Earthquake survivors in Armenia and Italy

Survivors of the cruise ship Jupiter in Greece

Hurricane survivors in the US

Survivors of single stressing incidents

(Carr, 2004)

Child sexual abuse CSA – Study 1

Participants: 7–13 year old with clinical significant PTSD symptomatology (Psycho-education about trauma reactions, graded exposure to trauma-related cues and memories until habituation occurred, coping skills training for anxiety management(Assesments – pre, pos, 3, 6, 12, and 24 months):

Training in safety skills and behavioral parent

Therapy - only 16% continued with PTSD

(Deblinger et. al, 1996)

CSA – Study 1….ContinuesWhere non-offending mothers participated

in behavioural parent training, only 36% of children with significant behaviour problems and depression before treatment continued to do so after treatment.

Where mothers did not receive behavioural parent training, 80% of children continued to have behaviour problems and 62% continued to have significant depressive symptoms after treatment.

Behaviour problems were assessed with the Child BehaviourChecklist (Achenbach, 200)

Depression with the Children’s Depression Inventory Kovacs (Kovacs, 1992)

CSA – Study 2Participants: 3–7 year old CSA survivors (psycho-education, graded exposure, coping skills training, safety skills training and behavioural parent training) compared with controls group (non directive supportive therapy)

Received 12 X 1.5 hr treatment sessions; Duration 12-16 weeks (Assessments: pre, post, 6 and 12 months):

7% scored in the Child Behavior Checklist compared with 30% of controls

4% scored in the Child Sexual Behavior Inventory compared with 40% of controls

(Cohen & Mannarino, 1996, Cohen and Mannarino, 1997)

CSA Study 3

Participants: 7-15 year old CSA survivors (psycho-education, graded exposure, coping skills training and behavioral parent training) compared with control group (non directive supportive therapy)

Received 12 X 1.5 hr treatment sessions; Duration 12 weeks (Assessments: pre, post, 6 and 12 months):

Showed improvement in the Children’s Depression Inventory and the Child Behavior Checklist

(Cohen & Mannarino, 1998)

CSA Conclusion

Psycho-education, graded exposure, coping skills training, safety skills training and behavioural parent training were significantly more effective in alleviating PTSD anxiety, depression and adjustment problems than supportive therapy or referral to social services

(Carr, 2004)

Disaster and Accident SurvivorsStudy 4

Ship Jupiter: 5-9 months after attending one debriefing session and two open group sessions: Child survivors showed fewer PTSD

symptoms from the Impact of Events Scale and fewer fears on a modified version of The Fear Survey Schedule if compared with untreated controls

(Yule, 1992)

Disaster and Accident SurvivorsStudy 5

Single incident traumas who participated in group-based psycho-education, graded exposure and coping skills training showed reduced PTSD symptomatology, anxiety and depression compared with baseline measures:

57% no longer meet the criteria for PTSD immediately after treatment

86% free of PTSD symptoms at 6 month follow-up

(March et. al., 1998)

Disaster and Accident SurvivorsStudy 6

Earthquake survivors in Armenia,1.5year after disaster:

Mean age: 13.2 years4 Sessions were within a group (1.5 hr) and

2 sessions were individual (1hr) – 6 weeksChild in a therapeutic program (group and

individual sessions focusing on psycho education, coping skills training and grief work) showed greater improvement in PTSS and depressive symptomatology compared with controls group (no treatment)

(Goenjian et al., 1997 )

Disaster and Accident SurvivorsStudy7

Earthquake in Italy: Children who attended 1-hr debriefing

sessions for seven months show fewer PTSD symptoms and behavior problems if compared with controls groups .

(Galante et al., 1986)

Disaster and Accident SurvivorsStudy 8

Hurrican Survivors: 32 participants between 6 and12 yearsThree session (EMDR) program showed significantly greater improvement on the Children’s Reaction Inventory, the Revised Children’s Manifest Anxiety Scale and the Children’s Depression Inventory compared with untreated controls:After treatment, 56% no longer met the

criteria for PTSDFewer health visits to the school nurse

compared with the control group

(Chemtob et al. 2002)

Disaster and Accident Survivors

Conclusion

These programmes, which included debriefing, psycho-education, graded exposure, coping skills training and grief work using both group and individual therapy formats were:

Effective in treating PTSD and related adjustment problems

Led to reductions in behaviour problems and symptoms as rated by teachers, therapists and researchers

Maintained short-term gains at long-term follow-up

(Carr, 2004)

Comparison of Interventions

Another Study: – EMDR X CBT

CSA: 14 participants: 12-13 years oldMax. 12 session- intervention with parents

attending one psychoeducational sessionFocused upon exposure to traumatic

memories, but CBT had a greater empahsis upon development of symptom management skills.

Conclusion:Significant post-treatment reductions in post

traumatic symptoms and improvements in general behavior.

No significant difference between groupEMDR more efficient 6.1 sessions compared

to 11.6 in the CB(Jaberghaderi et al., 2004)

Another StudyPTSD Treatment : Efficacy, Speed and

adverse Effects (Taylor el al. 2003)

EXPOSURE THERAPY – It is considered an established treatment (Chambless & Ollendick, 2001) so, it is a benchmark to compare with other intervention;

But, little is known about the breadth and speed of its effects.

EMDR (Eye Movement Desensitization and Reprocessing )

claims to be faster and more effective.

RELAXATION TRAINING – used at times of anxiety or distress.

Seems to be potentially useful, but understudied. Also little information on the breath or speed of its effects or on the incidence of symptoms worsening

EXPOSURE THERAPY

Reduction of avoidanceBUT, not necessarily reduces other features of

PTSD such as numbing symptoms ? Not beneficial for all patients?

According to Tarrier el al, (1999) 31% reported worsening of PTSD symptoms from pre-to post treatments:

– Validity of this study was debated (Devilly &Foa, 2001, Tarrier, 2001)

More research on symptom worsening be more common in Exposure Therapy then other treatments

(Taylor el al. 2003)

Moderately effective in reducing global severity of PTSD symptoms (Marks et al., 1998), but less effective then Exposure Therapy (Taylor et al.,2001; van Etten & Taylor, 1998).

Reduction of hyperarousal symptoms, patients less disstressed by trauma-related stimuli, so less avoidance?

(Taylor el al. 2003)

Relaxation Training

Exposure Therapy X EMDR

Exposure Therapy and EMDR - Meta-analyses suggest equally effective (Davidson & Parker, 2001; van Elten & Taylor, 1998) – Methodological limitation.

Some researches suggest that exposure-based treatment is more effective than EMDR (Devilly & Spence, 1999)

Whereas other studies suggest that EMDR is somewhat more effective (Ironson, Freund, Strauss, & Williams, 2002; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Vaughan et al., 1994)

Each of these studies has important methodological limitations

(Taylor el al. 2003)

PTSD Treatment: Efficacy, Speed and adverse Effects

Assessed each of the four dimensions of PTSD symptoms—re-experiencing, avoidance, numbing, and hyperarousal—to determine whether treatments had differed in their effects.

Methods: Participants 60 with chronic PTSD mean duration over 8.7 years.

Measure: Structured InterviewCAPS (Clinician Administered PTSD subscales)

(Blake et al., 1997);

Beck Depression Inventory (Beck & Steer,1987).

PTSD Symptom Severity Scale which is part of the Posttraumatic Stress Diagnostic Scale (Foa, 1995);

Reactions to Treatment Questionnaire (Borkovec & Nau, 1972),

Continuing….

Treatments:Eight 90-min individual sessions of either

exposure therapy, EMDR or relaxation training.Exposure Therapy: 4 sessions of imaginal

exposure and 4 sessions of in vivo exposure to harmless but distressing Trauma-related stimuli

Relaxation training: 3 different relaxation exercises

EMDR: procedures and phases described by Shapiro (1995)

All sessions audio-taped: Participants are asked to listen to it for an hour each day

(Taylor el al. 2003)

Figure 1. Percentage of participants no longer meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria for posttraumatic stress disorder (PTSD) after treatment. (Sustained no longer met criteria at posttreatment (post) and follow-up.) EMDR eye movement desensitization and reprocessing. (Taylor et al., 2003)

Figure 2. Means and standard errors for the four posttraumatic stress disorder (PTSD) dimensions, as assessed by the Clinician Administered PTSD Scale. Pre pretreatment; Post posttreatment; EMDR eye movement desensitization and reprocessing. (Taylor et al., 2003)

PTSD Treatments : Efficacy, Speed and adverse

Effects

Exposure Therapy EMDRRelaxation Training

Did not differ in attrition incidence of deteriorate symptoms or in numbing and hyper arousal symptoms effects

(Taylor et al., 2003)

However , Exposure Therapy shows to:

1) Produce significantly larger reductions in avoidance and re-experiencing symptoms

2) Tend to be faster by reducing avoidance

3) Tend to yield a greater proportion of participants – no longer meet criteria for PTSD

(Taylor et al., 2003)

Assessment

Assessment in clinical Practice

The 13 item children’s version of the Impact of Events Scale may be used as a reliable and efficient way to screen for PTSD (Pynoos and Eth, 1986)

The Child PTSD Interview – child’s account of the trauma and reactions (Fletcher, 1997)

The Childhood PTSD Interview (Nader et al., 2004)

Clinician Administered PTSD Scale-Child and Adolescent Version (Saigh et. al., 2000)

Child Post-Traumatic Stress Disorder Reaction Index (Nader, 1996)

Assessment in clinical Practice

To evaluated associated symptoms:Revised Children’s Manifest Anxiety Scale (Reynolds

& Richmond, 1985)

Revised Fear Survey Schedule for Children (Ollendick, 1983)

Children’s Depression Inventory (Kovacs, 1992)

For victims abuse:Trauma Symptom Checklist (Briere, 1998)

Revised Children’s Impact of Traumatic Events Scale (Wolfe et al., 1991)

Others:Kidcope (Spirito, 1988)

Child dissociation Scale (Wolfe et al., 1997; Putman, 1993)

Assessment in clinical Practice

For Parents:

Child Behavior Checklist (Achenbach, 2000);

Child Sexual Behavior Inventory (Friedrich, 1992);

Child Dissociation Checklist (Wolfe and Birt, 1997)

ConclusionHoagwood et al. (1996) proposed a model comprising five domains:

1) Symptoms: Emotional or behavioral

2) Functioning: Competencies and impairments reflecting children’s ability to adapt

3) Consumer perspectives: Children and families’ subjective experience

4) Environments: Settings in which the children spend time

5) Systems: Aspects of community care

Conclusion…continuing

Studies: Suffer a number of methodological problems:

Different length interventionsSample size and Follow-upComparatively there are few

methodologically robust treatment trialsSome suffered high rates of drop out, why?

(Cohen and Mannarino (1998) study 40%; Celano et al. (1996) study, 17 (35%), dropped out of treatment, Cohen and Mannarino (1997) study (50%), Cohen et al. (2005) study (52%)

More research is needed

Conclusion…continuing

Age: little information from young children

Gender: most included are girls;

Should parents be involved in the treatment?

Treatment: Post-traumatic symptoms with other co-morbid conditions

Acute x Chronic trauma (Stallard, 2005)

Different trauma x different intervention?

Different development x different intervention?

Different ethnicity x different reactions? (Saxe et al., 2007)

Conclusion…continuing

CBT showed the most common and study therapy used in PTSD treatment (Holly et al, 2008)

Statistical change may not necessarily equate to clinically significant improvements in functioning (Stallard, 2005)

Important to care also about acute stress disorder (ASD), depression, generalized anxiety disorder, childhood traumatic grief, specific phobias and separation anxiety

Youngster that have been traumatized and may need treatment for PTSD or other psychological conditions – generally do not receive treatment (Holly et al., 2008)

THANK YOU