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  1. Prevention and Intervention Trauma and Development Harvard Summer School Julia Schmidt Maso July/2009

  2. MainPoints • The different kinds of Interventions • Prevention • Intervention Effectiveness • Interventions compared with controls groups • Comparison of Interventions • Assessment • Conclusion

  3. What are the goals of intervention?

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

  5. The different kinds of Interventions

  6. 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)

  7. Psycho- Education Aim: 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 processed • Bringing these traumatic memories to consciousness, habituate and process them and then, be presented as the rationale for exposure-based treatment • Re-establishing routines • Getting support from the family, friends and school staff • Developing parents strategies for managing behavioural problems • Trying to find out if the youngster is using drugs • Symptom-Monitoring (Carr. 2004)

  8. Coping Skills Training Managing: Anxiety associated with flashbacks and nightmares Anxiety 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 cognitions Appraisel anxiety-evoking situations in less threatening ways (Carr, 2004)

  9. Format of Exposure Sessions Aim: • 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)

  10. Imaginal Exposure • Sit 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)

  11. 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)

  12. 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 attendance • Engaging 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 exercises • Managing sexual urges in a socially appropriate way (Carr, 2004)

  13. 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)

  14. 2. EMDR • How does EMDR work?

  15. 3. PLAY THERAPY • It 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)

  16. 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)

  17. 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)

  18. 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)

  19. 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)

  20. Prevention

  21. 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)

  22. Relapse Prevention • Relapses 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)

  23. 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)

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

  25. Intervention Effectiveness

  26. CBT Eleven 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)

  27. 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)

  28. Other Therapies • Play 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)

  29. Interventions x Controls groups

  30. 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)

  31. 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)

  32. CSA – Study 1….Continues • Where 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 Behaviour Checklist (Achenbach, 200) Depression with the Children’s Depression Inventory Kovacs (Kovacs, 1992)

  33. CSA – Study 2 Participants: 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)

  34. 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)

  35. 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)

  36. 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)

  37. 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)

  38. Disaster and Accident SurvivorsStudy 6 Earthquake survivors in Armenia,1.5year after disaster: • Mean age: 13.2 years • 4 Sessions were within a group (1.5 hr) and 2 sessions were individual (1hr) – 6 weeks • Child 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 )

  39. 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)

  40. Disaster and Accident SurvivorsStudy 8 • Hurrican Survivors: 32 participants between 6 and12 years Three 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 PTSD • Fewer health visits to the school nurse compared with the control group (Chemtob et al. 2002)

  41. Disaster and Accident SurvivorsConclusion 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)

  42. Comparison of Interventions

  43. Another Study: – EMDR X CBT CSA: 14 participants: 12-13 years old • Max. 12 session- intervention with parents attending one psychoeducational session • Focused 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 group • EMDR more efficient 6.1 sessions compared to 11.6 in the CB (Jaberghaderi et al., 2004)

  44. 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

  45. EXPOSURE THERAPY • Reduction of avoidance • BUT, 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)

  46. Relaxation Training • 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)

  47. ExposureTherapy 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)

  48. PTSD Treatment: Efficacy, SpeedandadverseEffects • 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 Interview • CAPS (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),

  49. 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)

  50. 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)