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Title: Complex%20Trauma%20in%20Adolescents:%20Developmental%20Trauma%20Disorder


1
Complex Trauma inAdolescents Developmental
Trauma Disorder
  • Brian L. Meyer, Ph.D.
  • Interim Associate Chief,
  • Mental Health Services
  • H.H. McGuire VA Medical Center
  • Richmond, Virginia
  • April 9, 2015

2
Disclaimer
  • The views expressed in this presentation are
    solely those of the presenter and do not
    represent those of the United States government.

3
Trauma and PTSD
4
Prevalence of PTSD
  • More men (61) than women (51) experience a
    trauma at some point in their lives, but women
    experience PTSD at twice the rate of men (10 vs.
    5) (Kessler et al., 1995 Tolin and Foa, 2006)

5
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6
Post-Traumatic Stress Disorder
  • PTSD is characterized by
  • Exposure to a severe life-threatening event
  • Repetitive re-experiencing of the LT event
  • Avoidance of stimuli associated with trauma
  • Negative mood and cognitions
  • Increased arousal

7
Changes to PTSD Diagnosis in DSM 5
  • Trauma and Stressor-Related Disorders are placed
    in their own category
  • Loss of loved one must be traumatic or accidental
  • Elimination of B criterion of reaction of horror,
    terror, or helplessness

8
Changes to PTSD Diagnosis in DSM 5
  • Addition of new criteria involving negative
    cognitions (negative beliefs about the world,
    blame of self or others for the trauma) and mood
    (anxiety, anger, guilt)
  • Addition of a new arousal criterion
    self-destructive or reckless behavior
  • Addition of a dissociative subtype
  • They also move PTSD closer to the definition of
    Complex Trauma

9
Implications of Changes to PTSD Diagnosis in DSM 5
  • Angry, depressive, and anxious affects now apply
  • This is a rejoinder to the fear-based model of
    the past, recognizing greater complexity
  • The existence of a dissociative subtype, combined
    with the new affective criteria and the new
    arousal criterion of self-destructive behavior,
    moves the description closer to Complex Trauma

10
LIFE-THREATENING EVENTS
IMPERSONAL
PERSONAL
TRAUMATIC
11
Who Gets PTSD?
  • It depends on
  • Severity
  • Duration
  • Proximity
  • PTSD is mitigated or worsened by
  • Childhood experience
  • Personality characteristics
  • Family history
  • Social support

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14
PTSD and Child Abuse
  • Not all trauma leads to PTSD
  • Depending on the study, the type of trauma, and
    the group studied, 3-58 get PTSD
  • Not all abuse leads to PTSD
  • Many abused children do not develop PTSD

15
PTSD in Children
  • Nightmares of danger, monsters, etc.
  • Repetitive play
  • Re-enacting of traumatic event
  • A sense they wont live to be adults
  • Regression
  • Headaches and stomach aches

16
Which Children Get PTSD?
  • Best predictors
  • Severity of exposure
  • Dissociation during and after LT event
  • Other risk factors
  • Prior psychopathology
  • Prior history of trauma
  • Children get more PTSD than adults
  • But children and adolescents are at equal risk

17
Children with PTSD
  • View the world as a dangerous place
  • Often identify with victims or aggressors
  • May solidify views as they age
  • Repeated patterns become personality styles

18
Other Common Psychiatric Diagnoses in Abused and
Neglected Children
  • Dysthymic Disorder
  • Major Depressive Disorder
  • Mood Disorder NOS
  • Bipolar Disorder
  • Generalized Anxiety Disorder
  • Phobic Disorder
  • Panic Disorder

19
More Common Psychiatric Diagnoses in Abused and
Neglected Children
  • ADHD
  • Oppositional Defiant Disorder
  • Conduct Disorder
  • Reactive Attachment Disorder
  • Borderline Personality Disorder
  • Antisocial Personality Disorder
  • Narcissistic Personality Disorder

20
Diagnosing Traumatized Children
  • The current psychiatric diagnostic
    classification system does not have an adequate
    category to capture the full range of
    difficulties that traumatized children
    experience.
  • -White Paper for the NCTSN Complex Trauma Task
    Force, 2003

21
Complex Trauma
22
What is Complex Trauma?
  • Childrens experiences of multiple traumatic
    events that occur within the caregiving
    systemthe social environment that is supposed to
    be the source of safety and stability in a
    childs life
  • -White Paper for the NCTSN Complex Trauma Task
    Force, 2003
  • Chronic and early childhood exposure to
    simultaneous or sequential traumatic events

23
What is Complex Trauma?
  • The psychological effects of chronic and
    cumulative traumas
  • Results from interpersonal victimization,
    multiple traumatic events, and/or traumatic
    exposure of prolonged duration
  • Sexual and physical abuse
  • Domestic violence
  • Ethnic cleansing
  • Prisoners of war
  • Torture
  • Being held hostage

24
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26
What is Complex Trauma?
  • Complex trauma is often relational
  • Trauma creates vulnerability to further trauma
    children who are traumatized may be revictimized

27
Experiencing Complex Trauma
  • Loss of a sense of trust, safety, and self-worth
  • Loss of a coherent sense of self
  • Belief of being bad or unlovable
  • Insecure attachments/damaged interpersonal
    relationships
  • Difficulty functioning in social settings,
    including school
  • Loss of faith
  • Enduring personality changes

28
Experiencing Complex Trauma
  • Emotional instability
  • Self-destructive or violent behavior
  • Feelings of rage, guilt, shame, despair,
    ineffectiveness and/or hopelessness
  • Damaged interpersonal relationships
  • Social withdrawal
  • Loss of faith

29
Complex Trauma May be Confused With
  • ADHD
  • Other anxiety disorders
  • Bipolar Disorder
  • Mood Disorder NOS
  • Psychotic Disorder NOS
  • Reactive Attachment Disorder

30
Complex Trauma Often Appears as or Co-Occurs with
  • Mood Disorders
  • Anxiety Disorders
  • Behavior Disorders, especially ADHD
  • Substance Abuse and Dependency Disorders

31
Complex PTSD Is Conceptually Related to
  • Anxiety Disorders
  • Dissociative Disorders
  • Somatization Disorders
  • Personality Disorders

That is why DSM 5 places trauma in a new category
entitled Trauma and Stressor-Related Disorders
32
Complex Trauma in Children
  • Impairment in
  • Attachment
  • Biology
  • Affect regulation
  • Dissociation
  • Behavioral regulation
  • Cognition
  • Self-concept

33
Developmental Trauma Disorder
  • A. Exposure
  • To one or more forms of developmentally adverse
    interpersonal traumas (i.e., abandonment,
    betrayal, physical/sexual abuse, emotional abuse)
  • Subjective feelings of shame, defeat,
    resignation, rage, betrayal, fear
  • Van der Kolk, 2005

34
Developmental Trauma Disorder
  • B. Dysregulation
  • Disturbances in
  • Emotions
  • Health
  • Behavior (i.e., self injury)
  • Cognition (i.e., dissociation)
  • Relationships
  • Self-attributions

  • Van der Kolk, 2005

35
Developmental Trauma Disorder
  • C. Negative attributions and expectations
  • Negative beliefs in line with experience of
    interpersonal trauma
  • May stop expecting protection from others and
    believe future victimization is inevitable
  • D. Functional impairments
  • Academic, peer, family, legal
  • Van der Kolk, 2005

36
Sequelae of Complex Trauma in Children
  • Self-regulatory, attachment, anxiety, and
    affective disorders in infancy and childhood
  • Addictions, aggression, social
  • helplessness, and eating disorders
  • Dissociative, somatoform, cardiovascular,
    metabolic, and immunological disorders
  • Sexual disorders in adolescence
  • Revictimization

37
The Catalyzing Effect of Child Abuse Neglect
Running Away
Substance Abuse Problems
Mental Health Problems
Child Abuse Neglect
Juvenile Delinquency
Educational Problems
Teenage Pregnancy
38
Cost of Complex Trauma
  • 258 million/day
  • Direct costs hospitalization, chronic health
    problems, mental health, child welfare, law
    enforcement, judicial system
  • Indirect costs special education, adult mental
    health and health care, adult criminality, lost
    productivity to society
  • Pelletier, 2001

39
  • Treatment of Children
  • with Complex Trauma

40
Treatment of Complex Trauma Medication
  • Antidepressants
  • Mood stabilizers
  • Anticonvulsants
  • Anxiolytics
  • There is no medication that specifically treats
    PTSD

41
Treatment of Complex Trauma Psychotherapy
  • Parent-Child Interaction Training (PCIT)
  • Trauma-focused Cognitive-Behavioral Therapy
    (TF-CBT)
  • Integrative Treatment of Complex Trauma (ITCT)
  • Eye Movement Desensitization and Reprocessing
    (EMDR)
  • Dialectical Behavior Therapy (DBT)
  • Seeking Safety
  • Abuse-Focused Cognitive-Behavioral Therapy
    (AF-CBT)

42
Core Components in Treatment of Complex Trauma in
Children
  • Enhance internal and environmental safety
  • Enhance self-regulation across the domains of
    affect, behavior, physiology, cognition,
    interpersonal relations, and self-attribution
  • Develop executive functioning to construct
    self-narratives, reflect upon experiences,
    anticipate and plan, and make decisions
  • NCTSN, 2007

43
Core Components in Treatment of Complex Trauma in
Children
  • Transform or resolve traumatic memories through
    meaning-making, traumatic memory containment or
    processing, mourning of the traumatic loss,
    developing coping skills, and cultivating
    present-oriented thinking and behavior
  • Repair or create attachment through current
    relationships and the therapeutic alliance and
    develop interpersonal skills
  • Enhance positive affect and self-worth through
    creativity, imagination, achievement, competence,
    and mastery
  • NCTSN, 2007

44
The Treatment of Child Abuse and Complex Trauma
  • Evidence-Based Social Treatments
  • Treatment Foster Care
  • Multi-Dimensional Treatment Foster Care

45
Psychological Treatment of Complex PTSD
  • Evidence-based psychotherapies are not, by
    themselves, enough, since they are designed for
    specific diagnoses careful clinical attention
    must be paid to the disruptions of cognition,
    emotion, body, sense of self, and interpersonal
    relationships associated with complex trauma
  • Ford and Courtois, 2009

46
  • How You Can Help

47
Become Trauma-Informed
  • Learn to recognize the signs and symptoms of
    trauma reactivity
  • Support the mother to restore stability to the
    family
  • Promote awareness of trauma and its effects
  • National Child Traumatic
    Stress Network

48
Agencies Must Provide Trauma-Specific Services
  • Train agency staff to understand the link between
    traumatic experiences and negative health and
    mental health outcomes
  • Screen the child for a trauma history
  • Assess whether the child is meeting developmental
    milestones and progressing normally
  • Screen the mother for a trauma history
  • Link shelters, schools, and community-based
    trauma services
  • National Child Traumatic Stress Network

49
Create a Safe, Supportive, Non-Threatening
Environment
  • Maximize choice and control
  • Avoid provocation and power assertion
  • Model prosocial behavior and skills
  • Maintain clear and consistent boundaries
  • Share power
  • National Child Traumatic
  • Stress Network

50
Create a Safe, Supportive, Non-Threatening
Environment
  • Provide services in a respectful and
    nonjudgmental manner
  • Provide support groups on trauma and its effects
  • Provide a range of culturally competent services
  • National Child Traumatic Stress Network

51
Orient Families Toward Resilience
  • Teach and practice
  • Anger management strategies
  • Problem-solving skills
  • Problem-focused coping strategies
  • Communication skills
  • Cooperation
  • Turn-taking
  • How to cope with stress
  • Relaxation

52
More Ways Agencies Can Help
  • Intervention programs must address the mental
    health and substance abuse needs of both mothers
    and children
  • Provide developmentally appropriate
    trauma-informed parent education
  • Provide evidence-based trauma treatment

53
Ways You Can Help
  • Dont re-traumatize children by having them
    recount their abuse
  • Make a distinction between the trauma and the
    child
  • Show interest in what the child is interested in
  • Reassure children that they are safe
  • Provide a stable, encouraging presence in the
    lives of families

54
More Ways You Can Help
  • Access foster care prevention services
  • Help families become primary decision-makers in
    their lives
  • Help parents become involved in their childrens
    schoolwork
  • Seek resources food, clothing, school supplies,
    toys, stuffed animals, etc.
  • Create a lifebook with a child

55
Remember
  • Children have PTSD, but they arent defined by
    PTSD
  • Children have been victimized, but they arent
    victims
  • Children can do more than survive they can
    thrive

56
  • Resources

57
Resources
  • Treating Complex Traumatic Stress Disorders in
    Children and Adolescents by Julian Ford and
    Christine Courtois
  • Treating Complex Trauma in Adolescents and Young
    Adults by John Briere and Cheryl Lanktree
  • Developmental Trauma Disorder with Bessel van der
    Kolk (DVD)
  • Treating Trauma and Traumatic Grief in Children
    and Adolescents by Judith Cohen, Anthony
    Mannarino, and Esther Deblinger

58
Resources
  • DBT Skills Manual for Adolescents by Jill Rathus
    and Alec Miller
  • Seeking Safety by Lisa Najavits
  • EMDR Therapy and Adjunct Approaches with
    Children Complex Trauma, Attachment, and
    Dissociation by Ana Gomez
  • Assessing and Treating Physically Abused Children
    and Their Families by David Kolko and Cynthia
    Swenson

59
Internet Resources
  • National Child Traumatic Stress Network
    http//www.NCTSNet.org
  • International Society for Traumatic Stress
    Studies http//www.istss.org
  • The Trauma Center (Bessel van der Kolk)
    http//www.traumacenter.org/
  • Child Trauma Academy (Bruce Perry)
    http//childtrauma.org/

60
Internet Resources
  • Trauma Focused-Cognitive Behavioral Therapy
    http//tfcbt.musc.edu
  • Dialectical Behavior Therapy http//www.behaviora
    ltech.com
  • Seeking Safety http//www.treatment-innovations.o
    rg/seeking-safety.html
  • EMDR www.emdr.org

61
  • Contact
  • Brian L. Meyer, Ph.D.
  • Brian.Meyer_at_va.gov
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