Wrap up lecture

1. Wrap up lecture

2. Traumatic Events and PTSD

3. Traumatic events in childhood • What’s considered traumatic event • Experienced, witnessed, learned about • Subjective response • Types • acute – chronic • interpersonal – acts of nature • “Discrepancy between experience of threatening situation and situation and recourses to cope, accompanied by feelings and enduring concussion of conceptions of self and world “ (Fischer & Riedesser, 2003)

4. Prevalence of traumatic events • 1 in 4 children by age 16 • Most common types • death of loved one • witness/learning about event • sexual abuse • serious illness/accident • disaster • High and low magnitude events (e.g., moving house, drop in standard of living) • High magnitude event four-times as likely if low magnitude

5. Prevalence continued • Rise after age 15 years • Return to earlier rate at age 20/21 • Males twice those of females • International perspective • Similar rates in Japan (12% even in preschool) and Germany • Most common in German sample: physical attacks, accident, witness event, sexual abuse • Unevenly distributed in population

6. Risk and vulnerability factors • Some groups at risk for repeated exposure • Abuse/neglect, domestic violence, out-of-home placement, in juvenile justice system • Witness violent death, from countries with armed conflict, victims of disaster, hospitalization • Vulnerability factors • Parental psychopathology, family relationship problems, family/community environment • Increase some types of events (e.g., sexual abuse)

7. Consequences of traumatic events • Impact on development • Achieve normal developmental milestones • Cognitive development, language, IQ, school performance • Even when not objectively threatened • Affects children’s sense of personal safety, predictability, and protection

8. Impact on development • Emotion regulation • Especially violence and abuse • Sexual abuse affects brain development • Academic performance and IQ • Attention, reasoning, EF • 8 points decrease in IQ in children exposed to domestic violence • Intergeneration transmission of trauma (?)

9. Psychopathology • Range of psychopathological outcomes • Alcohol/drug abuse, suicide attempts, poor physical and mental health (health risk behaviors) • Childhood trauma predicts mental and physical health in adulthood

10. CTS and PTSD • Child Traumatic Stress (CTS) • Set of reactions to traumatic event (when overwhelms ability to cope with) • Intrusive re-experiencing • Avoidance • Physical hyper-arousal • Posttraumatic Stress Disorder (PTSD) • Diagnostic category (DSM-IV)

11. PTSD • Historical background • Post Vietnam Syndrome • PTSD first appeared in DSM-III (1980) • DSM-IV • (objective) experienced, witnessed or confronted, • subjective emotional response • Only disorder with causal factor (exposure to traumatic stressor) integral to definition

12. PTSD criteria (DSM-IV) • A: (1) traumatic event, and (2) subjective response • B: re-experiencing (1) • C: Avoidance (3) • D: Increased arousal (2) • E: lasts for more than 1 mo • F: clinically significant distress or impairment • Duration and onset • Duration: < 3 mo = acute, >3mo = chronic • Onset: >6mo = delayed

13. PTSD in children • Age and symptoms • Preschool: overly anxious, regressive, hyper • School-age: intrusive re-experiencing, fear of repetitions, thoughts of revenge, ambivalent/restless, sleep problems • Adolescents: realize regressive, feel isolated, left alone, upset about lack of support/protection

14. Measures of PTSD • C-PTSD Reaction Index • Clinical-Administered PTSD Scale • Other: Impact of Events Scale, Trauma Symptom Checklist, C-PTSD Symptom Scale

15. Prevalence of PTSD • Variability in rates • ~1% - 6.8% in general population (life-time) • Conditional probability (% of trauma exposed) • 13% women, 6% men • Dependent on type of event • Up to 40% combat, rape, physical violence • Up to 30% sudden, unexpected death of relative/friend • Course of disorder • 50-75% remit after 1 year • Male remit sooner than female

16. Child specific prevalence rates • Variability in rates • 3.7% - 11% • Rates higher for females than males (in most studies) • Higher rates in • youth in juvenile detention (~11%) • Youth exposed to events affecting entire community (up to ~60%)

17. Traumatic experiences vs. PTSD • 22.5% Traumatic experiences vs. 1.6% PTSD • Males have higher rate of traumatic experiences • Females have higher rate of PTSD • Traumatic experiences and PTSD increase with age (peak at 16-17year)

18. Other disorder • Acute Stress Disorder • Widely criticized • Dissociation not that predictive • Earlier PTSD predicts later PTSD • Complex PTSD (DESNOS) • Linked to chronic trauma (especially beginning in childhood) • Not recognized in DSM-IV • Secondary PTSD

19. Resilience and Posttraumatic Growth

20. Resilience and Posttraumatic Growth • Resilience = positive adaption despite adversity • Posttraumatic Growth (PTG) = growth, positive change resulting from trauma

21. Resilience • Threat, adaption/developmental outcome ‘good/OK’ • Ordinary phenomenon • Historical overview • Parental mental illness (i.e., schizophrenia)

22. Factors associated with resiliency • Variable focused • Parenting quality • Intellectual functioning • SES • Positive self-perception • Person focused • Average+ on academic, conduct, social • Suggested role of positive emotions?

23. Posttraumatic Growth • Some changes in • personal strength • new/shifting perspectives • salient characteristics in others • Can co-exists with posttraumatic stress symptoms • Some important factors • Age (o), gender (f), severity/type, income, time since (more), religiosity, social support (higher)

24. Measures of PTG • PTGI-revised for children and adolescents • Five domains: New possibilities, relating to others, personal strength, appreciation of life, spiritual changes • Used with children as young as 7 years • Other measures • PTGI-C, Perception of Changes in Self Scale, Secondary (qualitative) analysis of PTSD interviews

25. PTG and negative live events • PTG linked to negative life events • mild amount of change • No difference between type of life event (traumatic?) • No difference in gender, ethnicity • Correlation with age (+), religiosity (+), substance use (-)

26. PTG in children with traumatic experiences • Cancer survivors • More time since/higher perceived life threat /treatment intensity, Older age • Age at diagnosis (+) • ~85% one positive change, 32% four+ changes • Road traffic accidents • 42% PTG (37% also PTSD), appreciation of life • Natural disaster • PTG correlation with competency beliefs, PTSS

27. Developmental consideration • Only theoretical considerations so far • PTG requires certain level of cognitive development • Cognitive capabilities influence understanding appraisal • Important developmental domains • Theory of mind • Attachment (internal working models) • Developmental level maybe risk or protection • But PTG more likely in older age (?)

28. Trauma and Culture

29. Trauma and Culture • Distinction race, ethnicity and culture • All humans have capacity to experience fear, helplessness, horror to meet (A2) DSM-IV • Cultural factors may influence likelihood or nature of expression • Culture = protective or risk factor • Developmental considerations • No systematic review, no direct comparisons

30. Theoretical and other considerations • Culture as mediator of trauma • E.g., range of PTSD response, coping • Acculturation and assimilation • Intergeneration transmission of trauma

31. Limited empirical evidence • PTSD cross-cultural applicable? • PTSD can be detected among non-Westerns • Goodness-of-fit? • Somatization, Dissociation claimed to be common in non-Westerns • Direct comparison: American Vietnam Veterans from different cultural backgrounds • Race/ethnicity only weak predictor • Review of disaster literature • Minority youth at greater risk of PTSS • Hypothesized that culture can impede help-seeking

32. Natural and manmade disaster

33. Children and Disaster • History of disaster studies • Most common responses • Specific fears, separation difficulties, PTSS • Specific PTSD/ stress-responses in children • re-enactment in play, sleep problems, increased irritability, regression, somatic complaints, guilt • Other symptoms/disorders • Anxiety, Depression, School problems

34. Factors in influencing response • Disaster characteristics • Life threat, bereavement, separation, physical loss/disruption • Child characteristics • Age (o), gender, prior psychopathology and traumatic experience • Family/Community effects • Parental distress, communication patterns, evacuation without return (relocation), community support (e.g. rebuilding)

35. Example Study: Hurricane Katrina • Intrusive thoughts and knowledge about thinking following Hurricane Katrina (Sprung, 2008) • Hurricane Katrina survivors vs. control group • No significant group difference in overall frequency of intrusive thought • BUT imbalance of positive – negative valence • Recurrent intrusive thought more likely • Relationship between Theory of mind (i.e. knowledge about thinking) and self-report of (negative) intrusive thoughts

36. Violence in School and Community Inga Brege

37. Refugee and War Trauma Regina Musicaro

38. Terrorism Sandra Valdes-Lopez

39. Child Traumatic Grief

40. Conceptual considerations • Bereavement (objective), grief (reaction), mourning (cultural) • Uncomplicated vs. complicated and traumatic • Stage models of grief (uncomplicated) • Denial, anger, bargaining, depression, acceptance (Kuebler-Ross) • Disbelief, yearning, anger, depression, acceptance (YBS) • Acceptance most common, yearning strongest negative

41. Childhood (uncomplicated) grief • Harvard Child Bereavement study • (4) Tasks of mourning • Accepting reality, experience painful emotions, adjust to new situation, relocate person within one’s life and memorize • (8) NCTSN (Goodman et al., 2004) • Accepting, experiencing, adjusting, new/deepening relationships, invest in new relationships/activities, maintain attachment (reminiscing, memorizing), making meaning, continue normal states of development

42. Clinical considerations • Bereavement (uncomplicated grief) mentioned in DSM-IV • ‘other conditions that may be a Focus of Clinical Attention’ • Resembles MDD, but MDD not diagnosed in first 2 months (unless symptoms about other than the diseased person)

43. Complicated and Traumatic Grief • (Adult) complicated/traumatic Grief • Separation distress (i.e., intrusive thoughts about deceased, yearning, search, excessive loneliness) + Traumatic distress • Symptoms last at least 6 months, significant functional impairment • Measure • Inventory of Complicated Grief • Texas Revised Inventory of Grief

44. Child Traumatic Grief • Objectively/subjectively perceive death as traumatic • Overwhelmed by trauma response + unable to accomplish normal grieving tasks • Complicated (unresolved) grief symptoms + PTSD symptoms (often also depressive) • Measures • Grief Screening Scale • Extended Grief Inventory (Traumatic grief, positive memory, ongoing presence)

45. Trauma reminders, loss reminders, change reminders impinge on ability to reminisce • Secondary adversities (additional losses) • CTG as a new mental health disorder (?) • Some empirical evidence for unique contribution • Diagnostic criteria suggested for ‘Traumatic grief disorder’ and ‘Complicated Grief Disorder’ • Other symptoms and disorders • Somatization, serious illness/accident, substance use, suicidal ideation

46. Prevalence • Uncomplicated grief • Lifetime almost everyone • ~40% of college students • Complicated/ traumatic grief • No empirical studies (to date) • CTG not normative (even if objectively traumatic) • Factors possibly affecting response • Emotional proximity, physical proximity, secondary adversities, poor pre-trauma/death functioning, poor coping

47. Developmental and other considerations • Children’s understanding of death • Influenced by age, experience, cognitive development • Cultural difference • Grief and spirituality • Maybe helpful coping strategy • Developmental implications (?)

48. Maltreatment

49. Maltreatment • Different approaches • Medical-diagnostic, legal, ecological • Issues of definition raise methodological concerns • Specific acts endangering child • Operation definition! • What’s acceptable parental discipline? • Corporal punishment (home, school, quasi-judicial)

50. Maltreatment • 4 general categories • Sexual abuse, physical abuse, neglect, emotional maltreatment • Psychological maltreatment • Subtype rarely in isolation, majority of maltreated children more than one • Maltreatment Classification System • Interaction severity and frequency (chronicity), severity and subtype • Predictive of maladaptive outcome