State of the Art - Prevention, Evaluation and Treatment of

Childhood PTSD Steven Berkowitz, M.D.

Director Penn Center for Youth and Family Trauma Response and Recovery

sberko@upenn.edu

Eco-biodevelopmental Model

Relational Experiences

Behavior

Brain/Mind/Body

Physical, Social, Cognitive and Emotional Well-being

Culture

DNA- resulting Neurobiology

Biological Program Childhood Experience

DEFINITIONS

Stress Actual or implied threat

to the psychological and/or physiological integrity of an individual. (WHO, available on website)

Trauma

• Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (US Substance Abuse and Mental Health Agency)

Trauma as Injury

• Trauma is ancient Greek for injury • Psychological trauma like injury is on a

spectrum – Injury e.g. paper cut hurts with quick recovery – Injury e.g. ankle sprain may need some

intervention, but relatively quick recovery – Injury e.g. compound fracture, requires

intensive treatment (multiple surgeries, rehab)

Complex Trauma

• Multiple Injurious experiences – Causes a range of symptoms and disorders

• Same or similar experiences (e.g. sexual abuse) akin to lung cancer due to smoking

• Different experiences (e.g. sexual abuse, poverty, domestic violence, etc.) akin cardiovascular disease (sex, smoking, obesity, sedentary etc.)

Traumatic Stress and PTSD? • Traumatic Stress (PTSS) refers to specific

physical and emotional responses or symptoms to events that are perceived as threatening to the integrity of the child.

• Posttraumatic Stress Disorder is a particular set of Traumatic Stress symptoms that constitute a particular diagnostic entity

• Other Common posttraumatic diagnoses: – Reactive attachment disorder – Acute Stress Disorder – Disruptive Behavior Disorders – Depression – Anxiety Disorders – Adjustment Disorders – Personality Disorders – Substance Use Disorders

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PTSD: DSM 5 Criteria • A. The person was exposed to: death, threatened death,

actual or threatened serious injury, or actual or threatened sexual violence, as follows:

1. Direct exposure 2. Witnessing, in person 3. Indirectly, by learning that a close relative or friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. 4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies or pictures.

PTSD Criteria

B. Intrusion symptoms (Need1/5 symptoms) C. Persistent avoidance of stimuli associated with the trauma (1/2) D. Negative alterations in cognitions and mood (Need 2/7) E. Alterations in arousal and reactivity that are associated with the traumatic event (2/6) F. Persistence of symptoms (in Criteria B, C, D and E) for more than one month G. Significant symptom-related distress or functional impairment H. Not due to medication, substance or illness

Preschool Subtype: 6 Years or Younger

• Criterion B – no change (1 Sx needed) • Criteria C/D-1 Sx from EITHER C or D

• C cluster – no change (2 Avoidance Sx) • D cluster – 4/7 adult Sx • Does not include: amnesia; foreshortened

future; persistent blame of self or others

• Criterion E-5/6 adult Sx (2 Sx needed) • Preschool does not include reckless behavior

Dissociative Subtype of PTSD

• New subtype for both age groupings • Meets PTSD diagnostic criteria • Experiences additional high levels of

depersonalization or derealization • Dissociative symptoms are not related to

substance use or other medical condition • Common in youth

Evaluation of Child and Adolescent for PTSD

Assessing Children • As always interview caregivers and

child separately and together –Obtain information about caregiver

reactions and symptoms • Parents and caretakers are

notoriously poor at identifying internalizing (depression, anxiety) symptoms.

• Children are also best to ask about nightmares and sleeping difficulties

Assessment

• Screening tools and diagnostic instruments should be used as to facilitate an interview or a supplement to a face-to-face diagnostic interview

• Pen and paper measures should

never replace a face to face meeting.

Assessing Children • If children deny a trauma, we know they

have experienced – evidence of ‘‘avoidance” – let them know what we learned from the other

source – not going to ask them too much about those

experiences, – want to know if they have any problems a lot

kids experience who have been through the type of things they have.

Establishing Traumatic Experience

• Children – Young children don’t remember and/or don’t

understand – Reluctant to report intra-familial violence

• If unclear attempt to gain information from other sources – School – Counselors – Other caregivers

Instruments: Traumatic Exposures

• The Children’s Impact of Traumatic

Event Scale-Revised • The Impact of Events Scale • The Traumatic Events Screening

Inventory (TESI) • Violence Exposure Scales (VEX-R) • Caregiver report (DV)

Assessing Children symptoms

• Then query for symptoms • Ask the more benign hyperarousal items (sleep • difficulties, concentration problems, irritability)

first • ask about the avoidance/numbing symptoms and

the more stressful re-experiencing items • Just as the assessment of PTEs requires the

collection of data from multiple informants, the assessment of symptoms does as well.

• Use expeditious measures with caregiver, child and others if relevant.

Symptom Measures (children)

• The Children’s Impact of Traumatic Event Scale-Revised

• The Trauma Symptom Checklist for Children • The Clinician Administered PTSD Scale for

children and adolescents • Child Trauma Questionnaire (maltreatment) • UCLA Post-Traumatic Stress Disorder Reaction

Index (PTSD-RI) • Child Posttraumatic Symptom Scale (CPSS)

Young Children (< 6 y.o.)

• Currently primarily from caregiver and other report with little assessment of child other than observational

• Measure for Young Children Posttraumatic Stress Disorder Semi-Structured

• Interview and Observation Schedule (most comprehensive)

• Pediatric Emotional Distress Scale (PEDS) • Preschool Aged Psychiatric Assessment (PAPA) • The Trauma Symptoms Checklist for Young Children

(TSCYC) • The Levonn (cartoon interview was originally developed

for preschoolers)

Diagnostic issues

Diagnostic Issues

• Many youth will present with Depressive SX, Disruptive behaviors and Anxiety without disclosing trauma history

• Always ask about abuse, neglect and other exposures as part of complete evaluation

TREATMENT

CBT • CBT treatments usually involve some combination of

psychoeducation and therapeutic relationship • Other CBT treatment methods may be added to address related

problems – anger (anger management training, assertiveness training) – social isolation (social skills training, communication skills training)

• Have proven very effective in producing significant reductions in

PTSD symptoms (generally 60-80%) especially rape survivors • Magnitude and permanence of treatment effects appears greater

with CBT than with any other treatment • Question of Efficacy versus Effectiveness (see Cochrane Reports)

Some CB Interventions

• Trauma Focused CBT (most evidence) • EMDR • Systematic Desensitization • Prolonged Exposure (some evidence in

adolescents)

Theoretical Underpinnings of TF-CBT

• A hybrid model incorporating CBT, attachment, family, psychodynamic and empowerment principles

• Goals: resolve PTSD, depressive, anxiety and other trauma-related symptoms in children and adolescents; optimize adaptive functioning; and enhance safety, family communication and future developmental trajectory

Pharmacotherapy

• Treat Hyperarousal • Treat Comorbid symptoms • Clonidine and Prazosin for nightmares

– Guanfacine has not demonstrated effectiveness

• SSRIs-not that useful • MAOIs-best evidence in Adults only • TCA-no evidence of effectiveness • Atypical Antipsychotics

– Consider for seriously “disruptive symptoms”

Exposure in general • Consistently proven effective in both

children and adults – Imaginal exposure commonly practiced

in kids – TF-CBT more used than PE

• Use in combo with psychoeducation, cognitive restructuring, coping skills

Exposure Therapy • Exposure results in habituation so trauma can be

remembered without intense anxiety- ability to think without reexperiencing

• Framing therapy – Opportunity to process/digest the trauma, organize memories,

make sense of the experience, appropriately compartmentalize. – Clear rationale: unrealistic/excessive fears

• Introduce SUDS and create hierarchy

• “Expose” to anxiety provoking cues until anxiety

decrease

Exposure Techniques

• A lot of variation in implementation and duration – Imaginal: think about it – In vivo: feared persons or situations that are

realistically safe

– In virtuo: i.e virtual reality, images – Narrative: tell your “story”

• Form of imaginal

Self Care

• Negative effects of working with those with trauma

• “Disruption of the therapists schemas about the self and world”

• Recognize and acknowledge • Avoid isolation • HALT!

Prevention Definitions • Universal prevention: Involves whole population

(nation, local community, school) and aims to prevent problem behaviors that are know to lead to disease. All individuals, without screening, are provided with information and skills needed to prevent the problem.

• Selective prevention: Involves groups whose risk of developing problems disease is above the mean. Subgroups may be distinguished by traits such as age, gender, family history, or economic status.

• Indicated prevention: Involves a screening process, and aims to identify individuals who exhibit early signs of other problem symptoms or behaviors.

Secondary Prevention: Trauma • By definition secondary prevention is at least selective

– Opportunity to identify children in need – May serve as both intervention and assessment – Regarding Traumatic Events secondary prevention can have

2 strategies • All youth who have had a recent potentially traumatic event (PTE) • Have had a PTE and have screened as at risk (targeted)

• Rationale • PTSD is a failure of recovery Foa, 1998

– probably true of the post traumatic disorders spectrum disorders

• Secondary Prevention Interventions focus on decreasing vulnerabilities or improving capacities (psychological, social or physiological) that are amenable to change in the peri-traumatic period

Why Secondary Prevention? • Childhood trauma exposure is inevitable • Any decrease in distress, symptoms, post

trauma-related disorders benefits children, families and health care

• Cost Effective – Decreases cost of later treatment – May improve medical outcomes post trauma

• Opportunity Out of Crisis – Opportunity to identify children and families in

need of range of services – Serves as both preventative intervention and

assessment

Propranolol: Pre-Clinical Studies

• Animal research – Pre-training propranolol counteracts Epi – Post-training propranolol impairs task memory

• Translational Research – Propranolol reduced memory of emotional images – Pre-/post-retrieval propranolol decreased

psychophysiological response to imagery in PTSD – Propranolol decreased BLA responses

Placebo-controlled double-blind trial 40 mg qid initiated within 6 hours 10-day (plus taper) 18 propranolol, 23 placebo Significantly decreased physiological

reactivity Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of

posttraumatic stress disorder with propranolol. Biological Psychiatry. 2002

10% propranolol vs 30% placebo PTSD No Evidence of effectiveness in other

studies Vaiva, G., Ducrocq, F., Jezequel, K., Averland, B., Lestavel, P., Brunet, A., & Marmar, C. R. (2003).

Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biological psychiatry, 54(9), 947-949.,

Stein, M. B., Kerridge, C., Dimsdale, J. E., & Hoyt, D. B. (2007). Pharmacotherapy to prevent PTSD: Results from a randomized controlled proof-of-concept trial in physically injured patients. Journal of traumatic stress,

Morphine: Adults

• Protective effect appears to be due to inhibition of norepinephrine release – decrease in memory consolidation

• May also be related to effects on pain • Motor vehicle crash survivors who developed PTSD had

been given lower doses of morphine in the 48 hr than

those with no PTSD at three month follow up. (Bryant RA, Bryant,

R. A., Creamer, M., O'Donnell, M., Silove, D., & McFarlane, A. C. (2009). A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder. Biological psychiatry,

• Acute morphine administration has also been associated with a lower likelihood of subsequent PTSD in US military personnel serving in Iraq (Holbrook, T. L., Galarneau, M. R., Dye, J. L., Quinn, K., & Dougherty, A. L. (2010). Morphine use after combat injury in Iraq and post-traumatic stress disorder. New England Journal of Medicine, 362(2), 110-117.)

Morphine: Children

• 24 children, 6-16 y.o. hospitalized for acute burn administered UCLA PTSD-RI 2x while hospitalized and at 6 month follow up

• Children receiving higher doses of morphine had a greater reduction in PTSD symptoms over 6 months

(Saxe, Glenn, et al. "Relationship between acute morphine and the course of PTSD in children with burns." Journal of the American Academy of Child & Adolescent Psychiatry )

• Reduction of Separation Anxiety may mediate the association between morphine and reduction of PTSD Symptoms (Saxe, Glenn, et al. "Separation anxiety as a mediator between acute morphine administration and PTSD symptoms in injured children." Annals of the New York Academy of Sciences 1071.1 (2006)

• Morphine effects hold ups for children 12-48 months (Stoddard, Frederick J., et al. "Acute stress symptoms in young children with burns." Journal of the American Academy of Child & Adolescent Psychiatry45.1 (2006)

Cortisol

• Cortisol shuts down the stress response . (Simon A, Gorman J, 2004)

• Those that develop PTSD evidence that regulation fails and peri-traumatic cortisol levels are lower than in individuals who recover or develop other disorders such as depression (Ehring T, 2008)

• High Cortisol levels predictive in children (boys only?) (Delahanty, 2007)

• No studies in Children

• Adult Studies promising – 26 adults with ASD randomized to bolus of high dose hydorcortisone vs

placebo – Significant decrease in development of PTSD

(Zohar, J., Yahalom, H., Kozlovsky, N., Cwikel-Hamzany, S., Matar, M. A.,Kaplan, Z., Cohen, H. (2011). High dose hydrocortisone immediately after trauma may alter the trajectory of PTSD: Interplay between clinical andanimal studies. European Neuropsychopharmacology.

Oxytocin • Oxytocin triggers the release of ACTH • Is a critical factor in affiliative love,

maintenance of monogamous relationships, and normal nonsexual social interactions

• Current Trials Occuring • Produces an anti-stress response:

– Through a reduction of fear response (decreasing amygdala activation, inhibiting fear response, and enhancing extinction learning) and through an increase of social interaction (activating social reward-related brain regions increasing engagement in the therapeutic alliance)

(Olff, Miranda, et al. "A psychobiological rationale for oxytocin in the treatment of posttraumatic stress disorder." CNS spectrums 15.08 (2010):

Psychosocial Interventions

The Child and Family Traumatic Stress Intervention

Currently the only secondary prevention model for youth with significant evidence

http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)14697610/earlyview

Capitalizing on Protective Factors

• Family and social support are best predictors for good post-trauma outcomes

– Primary caregiver/s are central to CFTSI

• Improves support through improving communication:

– Helps child communicate about reactions and feelings more effectively

– Increases caregiver’s awareness and understanding of child’s experience

• CFTSI provides skills to help children and families cope with trauma reactions

CFTSI: What and How?

Session 1 – Meeting with Caregiver • Provide psychoeducation about trauma and trauma symptoms • Assess caregiver’s and child’s trauma symptoms • Address case management and care coordination issues

Session 2, Part A: Meeting with Child • Provide psychoeducation about trauma and trauma symptoms • Assess child’s symptoms Session 2, Part B: Family Meeting - Key part of intervention • Begin discussion by comparing caregiver and child’s reports

about trauma symptoms • Identify the specific trauma reactions to be the focus of

behavioral interventions and introduce coping skills

Randomized Effectiveness Trial

CFTSI versus 4 session psychoeducation/supportive comparison condition N=106 (53-CFTSI, 53-Comparison) Mean age: 12 in both groups Participants recruited from:

Forensic Sexual Abuse Program Pediatric Emergency Department New Haven Department of Police Service

• Funded by SAMHSA

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Baseline 3-Month FU

Children who Received CFTSI Were 65% Less Likely to Meet

Full Criteria for PTSD

Comparison (N=53)CFTSI (N=53)

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*p<.01

Children Who Received CFTSI Were 73% Less Likely

to Meet Partial or Full Criteria for PTSD

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Baseline 3 Mos FU

Comparison

CFTSI

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*p<.05