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