trauma and ptsd assessment and interventioncdc – “words or overt actions that cause harm,...

TRAUMA AND PTSDASSESSMENT AND INTERVENTION

Brooks Keeshin, MDUniversity of Utah

Disclosures

■ I receive funding from SAMHSA and Utah Department of Health, Uppsala University and Hunter College. I receive royalties from UpToDate. I have no other potential conflicts.

DEFINING TRAUMA

Definition of Child Abuse

■ CDC – “Words or overt actions that cause harm, potential harm, or threat of harm to a child”

■ WHO – “…all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.”

Harm - not objectively reported - requires interpretation

■ Sexual abuse occurs when a child is engaged in sexual activities that– the child cannot comprehend– the child/adolescent is developmentally unprepared and cannot consent– and/or that violate the law or social taboos of society.

Sexual Abuse

Age of Consent

*Image source: Wikimedia

Gershoff, 2008, Report on Physical Punishment in the United States

Standardized Measures

■ ACES questionnaire(s)■ UCLA PTSD Reaction Index■ Childhood Trauma Questionnaire

(CTQ)■ Lifetime Incidence of Traumatic

Events (LITE)■ Traumatic Events Screening Inventory

(TESI)■ Childhood Trust Events Survey (CTES)■ Conflict Tactics Scale Parent Child

Version (CTSPC)

■ DSM V Criteria for PTSDThreatened death, serious injury or sexual violence

1. Direct experience2. Witnessing in person3. Learning event occurred4. Experiencing repeated or

extreme details of event

Post Trauma Experience

■ Additional Experiences and Adversities

■ Suicidality

■ Traumatic Stress Symptoms– Intrusive Symptoms– Avoidance– Negative Thoughts and Mood– Hyperarousal – +/- Dissociation

How do we know about symptoms?

■ Ask about symptoms– Sleep

■ Standardized screens:– UCLA PTSD RI– CPSS– Trauma Symptom Checklist for Children– Trauma Symptom Checklist for Young Children

IF IT IS TRAUMA, WHAT NOW?

“Trauma-focused psychotherapies should be considered first-linetreatments for children and adolescents with PTSD.”

Cohen et al. J. Am. Acad. Child Adolesc.Psychiatry, 2010;49(4):414 – 430.

Efficacy for Youth with PTSD SymptomsTrauma Focused CBT

Child Parent Psychotherapy

Prolonged Exposure (A)

EMDR

CBT for PTSD

KIDNET

Cue-Centered Treatment

CFTSI (prevention)

Keeshin and Strawn. Child and Adol Psych Clinics of NA 2014

Trauma-Focused Cognitive Behavioral TherapyPsychoeducation and parenting skillsRelaxationAffective expression & modulationCognitive copingTrauma narrative processingIn vivo mastery of traumaConjoint parent-child sessionsEnhancing safety and future development

Cohen et al., 2006

Prepare and Cope

Exposure and Process

Safety and Stability

Effect Sizes

Wait list■ PTSD 0.83

■ Exposure based 1.44

■ Depression 0.3

■ Exposure based 0.59

Active control■ PTSD treatment 0.41

■ Exposure based 0.56

■ Depression 0.32

■ Exposure based 0.48Morina 2016

Relative Effectiveness of Psychotherapy & SSRI treatment

CAMS effect size

Combo 0.86 Sertraline 0.45 CBT 0.31

TADS effect size

Combo 0.98Fluoxetine 0.68 CBT -0.03

TF-CBT effect size

Combo -0.53 Sertraline -1.42 CBT 1.44/0.56

Cohen 2007; Robb 2010; Morina 2016

PTSD Anxiety Depression

Sleep

Pre Sleep DifficultiesVolitional vs. Avolitional

Volitional

Anticipatory anxiety

Feeling unsafe

Avolitional

Difficulty going to sleep

Persistent hyperarousal

Within Sleep DifficultiesIneffective vs. Disrupted

Ineffective

Increased motoric activity

Easily awakening

Disrupted

Nightmares

Night Terrors

Sleep Interventions for Traumatized Children■ Parent proximity/support

■ Coping skills

■ Sleep routine/negotiation

■ Hygiene

■ Trauma therapy referral

■ Temporary use of medications:– Melatonin – Prazosin (in PTSD) or Clonidine

Potential Red Flags

■ Benzodiazepine use– No efficacy

■ Second generation antipsychotic use for PTSD– High risk of obesity– No efficacy – Exacerbation of dissociation

■ Lack of referral for psychotherapy– Trauma or Behavioral

BEFORE COMPREHENSIVE

TRAUMA TREATMENT

Child and Family Traumatic Stress Intervention■ 4-8 Session Family Based

model

■ Assessment of both child and caregiver(s)– Current distress– Risk factors for distress

■ Targeted case management

■ Focus of treatment– Symptom identification– Improved communication

within the family – Enhancement of coping

strategies

■ No Trauma Narrative!

Non-Trauma Focused Psychotherapies

■ Dialectical Behavior Therapy (DBT)

■ Parent Child Interaction Therapy (PCIT)

■ Effective treatment for specific conditions often found among those who experience trauma

■ Do not necessarily treat PTSD/trauma symptoms

Traumatic Stress Clinical Decision Tree

■ Recent trauma

■ Behaviors > Trauma specific symptoms

■ Ongoing PTSD or increased PTSD risk

■ Brief Intervention and follow

■ Address behaviors first – Younger children - PCIT– Adolescents – DBT

■ Exposure based trauma treatment

Children with known trauma exposure and current trauma symptoms

Traumatic Stress Medication Decision Tree

■ Sleep Problems

■ Anxiety and Depression Sx

■ ADHD and or increased reactivity symptoms

■ Melatonin/Prazosin

■ Address sleep first – Consider SSRI for clearly

independent anxiety/depression

■ EBT first– Re-evaluate – Consider Alpha 2 Agonists

Children with current trauma symptoms SGAsBenzos

CARE PROCESS MODEL FOR PEDIATRIC

TRAUMATIC STRESS

Determine if reportable event

Assess suicide risk

Assess for trauma treatment

SAFETY

Address Ongoing Risk & Suicide 1st

Low Risk –Follow up or

MHI

Mod Risk –MHI or

Trauma Tx

High Risk –Trauma

Informed Eval

Focus on Sleep

Focus on Coping with

Distress

Focus on Activation

Resources PTSD Coach

Follow Up –Repeat PRN

Discussion

• Brooks.Keeshin@hsc.utah.edu

Example Screener

Primary Care setting

Recent Trauma

Low Risk PTSD

Suicide Not Endorsed

Example Screener

Primary Care setting

Recent & Past Trauma

Moderate Risk PTSD

Suicide Endorsed

Trauma-EBT Referral

Example Screener

Primary Care setting

Depression sx

Suicide Endorsed

Fluoxetine and MH referral

Recent & Past Sexual Abuse

High Risk PTSD

Trauma-EBT Referral & MHI