The Role of Mental Health following Acute Trauma

Elissa J. Brown, Ph.D.Professor of Psychology

Director, Child HELP PartnershipScarsdale High School, January 23, 2013

Workshop Outline

• Mental health reactions to acute trauma from early to late childhood

• Risk factors for post-trauma mental health problems

• Immediate, short-term, and long-term interventions

• Resources and opportunities for training

What is a Traumatic Event?• An experience that is emotionally painful,

distressing, and shocking, which can result in lasting physical and/or mental effects.

– Actual or threatened death or serious injury– Witnessed or experienced– Response includes intense fear, helplessness,

horror• In children, may be disorganization or agitation

Characteristics of Traumas

• Acute versus chronic• Interpersonal versus non-interpersonal• Solitary versus group• Perceived as common versus rare• Degree and type of impact

Consequences of trauma: PTSD· A. Traumatic event· B. Re-experiencing

· Intrusive thoughts· Nightmares· Repetitive play involving the event

· C. Avoidance/Numbing symptoms· Efforts to avoid thoughts, feelings, or conversations· Inability to recall important aspect of the trauma· Detachment from others

Consequences of trauma: PTSD· D. Arousal symptoms

· Difficulty falling or staying asleep· Irritability· Hypervigilance· Exaggerated startle response· Psychosomatic symptoms

· Even if they do not meet full criteria for PTSD, the majority of children report some re-experiencing, avoidance, and/or hyperarousal

Consequences of trauma: Differential Diagnosis

· Attention Deficit/Hyperactivity Disorder· Traumatized children may remain motorically active

in an effort to keep their minds otherwise occupied· Psychosis

· Need to distinguish between psychotic intrusive thoughts and PTSD re-experiencing. Presence of otherwise intact reality testing in PTSD

Trauma-Related Mental Health Problems PTSD and other forms of anxiety Grief and depression Somatic symptoms Risky behavior (alcohol/drug use, self-injury) Aggressive and oppositional behaviors Physical problems (gastrointestinal problems) Attachment and social deficits Academic and learning problems

Consequences of trauma: Anxiety Disorders

· Separation anxiety: fear for loved ones

· Generalized anxiety: excessive worry

· Panic attacks

Consequences of trauma: Depression• Depressed mood most of the day (irritable)• Loss of interest or pleasure in activities• Significant weight loss (failure to gain weight)• Insomnia or hypersomnia nearly every day• Psychomotor agitation or retardation• Fatigue or loss of energy nearly every day• Feelings of worthlessness or guilt• Poor concentration• Suicidal ideation

Consequences of trauma:Behavioral Problems

· Aggression· Oppositional behavior· Conduct disorder/juvenile delinquency

· Toward parents, teachers, and peers· In home and school/academic settings

Consequences of trauma: Attachment and Social Deficits

• Insecure attachments: anger, noncompliance, lack of persistence, little positive affect

• Misread social cues• Lower peer status• Fewer social skills• Social networks are more insular and negative

Consequences of Trauma Exposure: Academic and Learning Problems

• No overall deficits in cognitive functioning• Receptive and expressive language• Learning problems• Reading ability• Comprehension and abstraction

Consequences of trauma: In adulthood

· Major risk factor for:· Aggressive and violent behavior· Nonviolent criminal behavior· PTSD, depression and substance abuse· Interpersonal problems· Vocational difficulties· Medical problems (e.g., cardiovascular)

Mental Health Reactions to Traumatic Events

• May appear immediately after the trauma or days and even weeks/months later

• Reactions of children and adolescents vary according to age, developmental level, and proximity to the event

Children’s Reactions to Trauma

• Infants and Toddlers (age 3 and under)– Crying– Searching for parents/caregivers– Clinging– Change in sleep and eating habits– Regressive behavior (e.g., thumb sucking, wetting)– Repetitive play or talk

Children’s Reactions to Trauma• Preschoolers and Young Children (ages 3-5)

– Fear of separating from parents/loved ones– Clinging– Tantrums or irritable outbursts– Sleep disturbance (e.g., wanting parents, nightmares)– Regressive behaviors (e.g., wetting, thumb-sucking)– Withdrawal– Increase in fears (in general: dark, monsters)

Children’s Reactions to Trauma• Children ages 6 to 11 years

– Regressive behaviors (e.g., school refusal)– Anger and aggression– Avoidance and social withdrawal– Inability to concentrate– Depression and irritability– Fears and worry– Physical complaints (stomach, headaches)– Self-blame

Children’s Reactions to Trauma• Adolescents ages 12-17

– Responses may be more similar to adults and specific to the trauma

– Depression, guilt/shame, helplessness– General anxiety, panic attacks, dissociation– Numbing, re-experiencing– Mood swings, irritability– School refusal (or academic decline)– Concentration difficulties

Children’s Reactions to Trauma• More adolescent symptoms:

– Fears: usually event-related (e.g., planes, death)– Anger/resentment– Sleep and appetite changes– Withdrawal (becomes quiet and/or isolates self)

from peers, family, teachers, coaches– Physical complaints – Substance abuse

Importance of Caregiver Response

• Children, particularly young children, tend to be strongly affected by their caregivers’ reactions to the traumatic event

• Parents tend to underestimate both the intensity and duration of their children’s stress reactions

How long do these reactions last?

• Disruptive feelings and behaviors found after an extreme trauma are typical reactions

• Need to distinguish immediate phase (hours-weeks after the trauma) from short-term phase (weeks to 2-3 months after the trauma)

• There have been few prospective, longitudinal studies of the trajectory of post-trauma mental health problems

Children in Decimated Areas: Stress Reactions post-Hurricane Andrew (La Greca et al., 2005)

Moderate Stress Severe Stress0%

5%

10%

15%

20%

25%

30%

35%

3 Months7 Months10 Months

Children in Decimated Areas: Stress Reactions post-Hurricane Andrew (La Greca et al., 2005)

• At 3 months, 55% of children with moderate-to-severe distress– 2/3rds of those children were without distress by end

of 1-year post-hurricane– 1/3rd of those children (less than 20%) had chronic

dysfunction until 10-year post-hurricane• Applying to decimated areas in Queens, we

should expect to have 6,600 children continuing to have mental health problems in one year

Vulnerability to Post-Disaster Mental Health Problems (e.g., La Greca et al.,

2010, in press; Lai et al., 2012)

· Closer physical and emotional proximity· Sense of control, predictability, and safety· Exposure to secondary adversities (e.g., displacement)

· Loss of home, school, community· Level of functioning prior to the trauma· History of previous traumas

Vulnerability to Post-Disaster Mental Health Problems

· Other stressful life events during recovery period· Co-morbid diagnoses· Coping style/skills of child and parents· Lack of social support of child and family· Cognitive processing (e.g., self-blame)· High family conflict; low family cohesion· Media exposure

Summary of Literature (Bonanno et al., 2010)• Disasters cause serious psychological harm in a minority

of exposed individuals• Disasters produce multiple patterns of outcome,

including resilience• Disaster outcome depends on a combination of risk and

resilience factors• The remote effects of a disaster in unexposed

populations are generally limited and transient• Disasters put families, neighborhoods, and communities

at risk—need to invest now to save later

Stages of Intervention• Use research to guide our practice

– Immediate/Crisis intervention• Safety and routine are primary• Intervention goal: Educate and normalize

– Short-term/Preventive intervention• Identify children and adults at risk• Promote coping and social support

– Long-term/Treatment• Treatment of PTSD and other trauma-related symptoms

Model of Research/Intervention

Trauma MH Diagnosis

Prevention Crisis and Treatment Preventive Interventions

Prevention• Goals: Prevent emotional and physical trauma• Existing programs

– Tend to focus on one form of trauma– Limited research– Poor engagement of participants

• Avoidance of topics/trainings• Avoidance of discussion with children

Prevention• KEYS: Keeping Every Youth Safe (Brown & Beekman)

– Present proven steps for children’s safety• Protecting against sexual abuse• Protecting against excessive physical and verbal discipline

– Discuss barriers to taking action– CPR and choking relief– Emergency preparedness

• Preliminary research reveals improvements in knowledge and behavior

Immediate/Crisis Intervention• Goals: If normal and will heal, why intervene?

– Symptoms are painful– Symptoms cause impairment

• In child development– Academic functioning– Peer relationships

• In adult functioning– Job performance– Friendships and romantic relationships– Parenting

• Which, in turn, cause long-term MH problems

Research on Crisis Interventions• No randomized trials of hotlines and other forms of

crisis intervention• No randomized trials of post-disaster Psychological

First Aid or Project Liberty—evidence-informed• Research on Critical Incidence Stress Debriefing

– Developed for emergency service personnel– Designed to prevent PTSD– Detailed account of their traumatic experiences

• This “debriefing” has been shown to be iatrogenic—associated with higher likelihood of developing PTSD

Lessons Learned from 9/11

• Lack of coordination of services/chaos• FEMA funded Project Liberty

– Crisis counseling– Provided psychoeducation– Centralized services– Aided with referral

• For Hurricane Sandy: Project Hope– Crisis counseling and Psychological First Aid

Psychological First Aid—Delivery• Helpers: Adults on the front-line (paras and profs)• Days-weeks after a disaster• Be emotionally ready• Consider the setting, participants, etc.• Maintain a calm presence• Be sensitive to culture and diversity• Be aware of at-risk populations• Be informed of available services

Psychological First Aid—Core Actions• Contact and Engagement • Safety and Comfort • Stabilization (of emotionally overwhelmed)• Information Gathering: Current Needs and Concerns

– Too early for MH screening—will over-identify number of children who need services (false positives)

• Practical Assistance • Connection with Social Supports • Information on Coping and stress reactions• Linkage with Collaborative Services

Psychological First Aid: Resources• Outline and materials

– http://www.nctsn.org/content/psychological-first-aid

• Web-based training– http://learn.nctsn.org/course/category.php?id=11

• App for Iphone– PFA Mobile

• In progress: PFA for schools

Short-Term/Preventive Intervention• Goals:

– Reduce current symptoms– Prevent the development of long-term problems– Identify existing coping skills– Improve functioning– Potentially lower the need for formal mental health

treatment– Identify need and refer for treatment if warranted

Research on Preventive Interventions

• Brief CBT (Psychoeducation and Coping Skills) – Prevented the development of PTSD following a

sexual assault (Foa et al., 1995)– More efficacious in preventing anxiety disorders than

debriefing or routine community care in children who came through the ED (Silovsky et al., 2004)

– 65% less likely than comparison youth to meet criteria for PTSD 3 months post-disclosure of trauma (CFTSI; Marans et al., 2009)

Lessons Learned from 9/11

• Continuum-of-care was incomplete– Crisis intervention was available in form of Project

Liberty and other services– Evidence-based therapies were available through

Child and Adolescent Trauma Services (CATS), NYU Child and Family Recovery Program, and others

– There was no preventive intervention

Skills for Psychological Recovery: Delivery• After safety, security, and other needs have been met

and community is rebuilding• For children and adults

– In the short-term– In the long-term who are minimally symptomatic

• Minimum of 3-5 sessions; driven by assessment and time since trauma

• Helpers: Professionals who provide ongoing support and assistance to children, families and adults (e.g., clergy, educators, librarians)

Screening and Assessment Tools• Constructs

– PTSD and other mental health problems– Risk and protective factors

• Procedures– Structured versus unstructured– Screening versus comprehensive evaluation– Standardized Assessment Instruments

• Paper and pencil (e.g., Child PTSD Symptom Scale)• Interview (e.g., UCLA PTSD Reaction Index)

• Sources– Child, parent, teacher

Skills for Psychological Recovery• Core skills

– Building problem-solving skills– Promoting positive and pleasurable activities– Managing physical and emotional reactions to

upsetting situations (e.g., triggers, sleep problems)– Promoting helpful thinking– Rebuilding healthy social connections

• Done it in Haiti, Puerto Rico—incorporated cultural adaptations

Skills for Psychological Recovery: Resources

• Information on the National Child Traumatic Stress Network website:– http://www.nctsn.org/nctsn_assets/pdfs/

newsletters/Impact_Summer_2010.pdf• Child HELP Partnership will be providing

training and supervision on the model starting in early 2013

Long-Term Solutions• Repeat assessment of trauma-related mental

health symptoms and functional impairment • If trauma-related symptoms continue or

worsen, access evidence-based, trauma-informed therapies– Trauma-Focused Cognitive Behavioral Therapy (TF-

CBT; Cohen, Mannarino, & Deblinger, 2006)– Cognitive Behavioral Intervention for Trauma in

Schools (CBITS; Jaycox, 2003)

Treatment Research• TF-CBT and CBITS are the most rigorously tested

treatments for traumatized children• More than 12 randomized trials

– Improved PTSD, depression, anxiety, and behavior problems compared to supportive treatments

– TF-CBT improved parental distress, parental support, and parental depression compared to supportive treatment

– Effective in individual/family and group formats– Symptom decreases maintained at 2-year follow-up– Findings replicated and generalized across racial, ethnic, and

geographic boundaries (King et al., 2000)

Lessons Learned from Hurricane Katrina• Field trial of TF-CBT and CBITS (Jaycox et al., 2010)• Assessment 15 months after the hurricane• 60.5% of children screened positive for PTSD and

were offered CBITS at school or TF-CBT at a mental health clinic

• Both lead to significant symptom reduction• More children chose CBITS• Greater symptom reduction for TF-CBT

Difficulties Addressed by TF-CBT• CRAFTS

Cognitive Problems Relationship Problems Affective Problems Family Problems Traumatic Behavior Problems Somatic Problems

Core Values of TF-CBT• CRAFTS

Components-Based Respectful of Cultural Values Adaptable and Flexible Family Focused Therapeutic Relationship is Central Self-Efficacy is emphasized

TF-CBT Components • PRACTICE

Psychoeducation and Parenting Skills Relaxation Affective Modulation Cognitive Processing Trauma Narrative In Vivo Desensitization Conjoint parent-child sessions Enhancing safety and social skills

TF-CBT Sessions Flow

Sessions 1-4 5-8 9-12Psychoeducation Trauma Narrative Conjoint ParentParenting Skills Development and Child Sessions

ProcessingRelaxation Enhancing

In-vivo Gradual Safety andAffective Exposure FutureExpression and DevelopmentRegulationCognitive Coping

Entire Process is Gradual ExposureBaselineAssessment

TF-CBT: Child and Parent Components

• Individual sessions for both child and parent

• Parent sessions - generally parallel child sessions

• Same therapist for both child and parent

•Web-based learning•Learn at own pace•Concise explanations•Video demonstrations•Clinical scripts•Cultural considerations•Clinical Challenges•Resources•Links•10 hours of CE•Free of charge

A Learning Resource for TF-CBT

Access at:

www.musc.edu/tfcbt

Structure of CBITS• School-based intervention

–10 week groups–1 class period/week–Individual sessions for trauma narrative–6-8 children per group–Run by a clinician

Difficulties Addressed by CBITS• Reduce symptoms of:

– PTSD– Depression– Behavioral problems

• Improve:– Functioning– Grades and attendance– Peer and parent support– Coping skills

CBITS Components • Psychoeducation• Relaxation• Social problem solving• Cognitive restructuring• Exposure• Between• Homework assignments and activities• 2 parent and 1 teacher education sessions

CBITS Resources• Developer: Lisa Jaycox, PhD, Rand Corporation

• Website:– http://cbitsprogram.org/

• Audra Langley, PhDDirector of Training – alangley@mednet.ucla.edu

Taking Care of the Care Takers

• Protect against your own secondary stress / vicarious trauma response:– Use your colleagues/supervision to process your

own feelings and experiences– Engage in self-care

• Basics: eating, sleeping• Exercise• Social support • Coping skills

Resources• Resources for Traumatized Children and their

Caregivers– National Child Traumatic Stress Network

http://nctsn.org/trauma-types/natural-disasters– TF-CBT web www.musc.edu/tf-cbt

• Resources for Adults– National Center for PTSD http://www.ptsd.va.gov/– International Society for Traumatic Stress Studies

http://www.istss.org/Home.htm

Resources• Mental Health Support and Services in Your Area

– Disaster Distress Helpline1-800-985-5990; text 'TalkWithUs' to 66746 (Spanish-speakers can text 'Hablanos' to 66746)

– LIFENET• 1-800-LIFENET; 1-877-AYUDESE (for Spanish speakers)• 1-877-990-8585 (for Korean and Mandarin and Cantonese

speakers)

– Health Information Tool for Empowerment (HITE) • www.hitesite.org

Resources• Mental Health Support and Services in Your Area

– The Child HELP Partnership• 718-990-2367• www.stjohns.edu/thechildhelppartnership• browne@stjohns.edu

• Developers/trainers of Keeping Every Youth Safe• Trainers in Skills for Psychological Recovery• Trainers in trauma-specific therapies