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					Welcome


                 Adolescent
                    Trauma



          Andrea Carroll, MS
     Adolescent and Family Therapist
The Prevalence of
 Trauma in Youth
       Trauma Statistics

• General abuse and neglect statistics indicate that at
  least 5,000,000 of our youth are exposed to a serious
  traumatic event each year (Ziegler, 2002).
• In 2003 in Wisconsin there were:
           40,471 reports of child abuse
           1,336 substantiated cases of physical abuse
           4,076 substantiated cases of sexual abuse
           36 substantiated cases of emotional abuse
           2,546 substantiated cases of child neglect
           12 substantiated cases of a child having died because of child
            abuse or neglect
Annual Report to the Governor and Legislature on Wisconsin Child Abuse and Neglect.
Wisconsin Statutes, Section 48.981, Annual Report. (2003).
       Adolescent Statistics

Between 1993-2003
Adolescents between 12-17 were:
 2.5 times more likely than adults to be the victim of a nonfatal crime.
   2.5 x more likely to be raped or sexually assaulted
   2x more likely to suffer an aggravated assault
   3x more likely to suffer a simple assault
   2x more likely to be robbed

Snyder, H.N., & Sickmund, M. (2006). Juvenile Offenders and Victims: 2006 National Report. Washington D.C.:
U.S. Department of Justice. Office of Justice Programs, Offcie of Juvenile and Delinquency Prevention.
   Impact on Development

• Abused and neglected youth have shown a higher
  incidence of MR and significantly lower IQ scores
  than non-abused youth (Armsworth & Holiday)
• Brains of abused and neglected youth have been
  found to be smaller in overall size (Ziegler, 2002)
• Numerous psychiatric disorders can result, including
  depression, anxiety, and disruptive disorders (Silva,
  2004)
    Impact on Development

• Speech delays are common in homes with domestic
  violence as children cannot learn speech when there
  is a lot of background noise from shouting and
  arguing in the home.
• Brain development is impaired when child is exposed
  to or experiencing ongoing trauma while brain is
  developing.
    Libric system develops last and is referred to as the
      “emotional center of the brain”. It is responsible for memory
      and affective experience. This area is more vulnerable to
      stress due to the slow rate of development and the high
      number of cortisol receptors.
Symptoms


        PTSD:
Post Traumatic Stress
       Disorder
   PTSD

           DSM-IV Criteria for PTSD:
          Defining a “Traumatic Event”
  The person was exposed to a traumatic event in
      which both of the following were present:
• …There was actual or threatened death or serious
  injury or a threat to the physical integrity of self or
  others
• The person’s response involved intense fear,
  helplessness or horror
  Trauma


Overwhelming, uncontrollable experiences that
  psychologically impact victims by creating in
  them feelings of helplessness, vulnerability,
       loss of safety, and loss of control.

                                        -Beverly James
   PTSD

          DSM-IV Criteria for PTSD:
   3 Areas of Symptomotology are present
• Re-experiencing Symptoms:
  Nightmares, intrusive thoughts, feeling as if the event is
  happening again
• Avoidance Symptoms:
  Avoid reminders of the trauma, don’t want to talk about it, can’t
  remember the important aspects of it…
• Hyperarousal Symptoms/Increased Arousal Level:
  Difficulty sleeping, difficulty concentrating, hypervigilance…
   PTSD

            DSM-IV Criteria for PTSD:
              Additional Criteria
• Duration of symptoms is longer than 1 month (for the
  first month, the diagnosis is “Acute Stress Disorder”)
• The disturbance causes significant distress or
  impairment in social, occupational, or other areas of
  functioning.
    PTSD in youth

           Issues in diagnosing youth…
• PTSD in the DSM-IV does not adequately represent the
  presentation of the traumatized youth. The criteria is
  based on an adult model: primarily those symptoms seen
  in Viet-Nam War Veterans
• While youth may have symptoms of avoidance, hyper-
  arousal and re-experiencing, the presentation style is
  different
• Youth behavioral presentations make it difficult to make a
  differential diagnoses. A wide variety of psychiatric
  disorders have a similar presentation in youth.
Types of Traumatic
      Stress
   Traumatic Stressors

                   Attachment Trauma
Occurs in attachment relationships with primary
caregivers
    Lack of attunement
    Lack of caring and reflection of self worth
    Caregiver as both source of fear and comfort
Includes witnessing domestic violence and experiencing
child abuse of all types
    Often occurs simultaneous/in context of attachment insecurity
    Neglect, abandonment, physical and sexual abuse, verbal assault,
     non response
                                                           Courtois, C. 2008.
    Traumatic Stressors

Relational trauma
• Interruptions in the sense of security and trust that may block
  connections and communication in the family of origin and
  subsequently extend to other relationships
Betrayal trauma
• Betrayal of a role or relationship
Secondary trauma
• Lack of response/insensitivity by caregivers who are supposed to
  coordinate assistance or intervene
    Traumatic Stressors

                     Complex trauma
Attachment/relational trauma
Other forms of continual trauma
• Domestic violence
• Community violence
• Political trauma: refugee status, displacement
• Chronic illness with invasive treatment
• Bullying
• Sexual harassment/assault
Age Specific Reactions
   Age Specific Reactions

                   Young children
• Feel totally helpless and passive
• May cry for help or desperately wish for someone to
  intervene
• Rely on the “protective shield” of adults to judge the
  seriousness of the danger and keep them safe
• Can witness violence in the family and then be left
  helpless with an injured caregiver
• Are extremely upset by caregiver’s distress
• Have tremendous difficulty with the residual intense
  physical and emotional reactions they are left with
  resulting from the trauma
   Age Specific Reactions

                      School-age children
• Face additional dangers as they develop the ability to
  think about how to protect themselves and the family
• Usually don’t think that they can do anything to help,
  but imagine actions that they wish they could take
• Because they can only “wish” and not really intervene,
  can feel like failures for not having helped
• Frequently feel shame or guilt
• Are scared of the internal reactions that they feel when
  exposed to danger, such as the heart speeding up.
  Ex. “My heart was beeping so fast I thought it would break or I was going to die.”
    Age Specific Reactions

                     Adolescents
• Start to develop the skill of judging and addressing
  dangers on their own or with friends.
• During traumatic situations, teens make decisions
  about how to intervene and about whether to use
  violence to counter violence.
• Their choices in how to intervene or not intervene can
  lead to feelings of guilt if they believe their actions or
  inactions made things worse.
      Long Term Impacts of
      Childhood/Adolescent Trauma

• Anxiety, depression,                                   • Aggression
  and/or anger                                           • Suicidality
• Cognitive distortions                                  • Personality disorder
• Dissociation                                           • Bingeing or purging
• Affect dysregulation                                   • Unsafe/dysfunctional
• Identity disturbance                                     sexual behaviors
• Interpersonal problems                                 • Sleep disturbance
• Substance abuse                                        • Somatization
• Self mutilation                                        • Disorganized
  (cutting/burning)                                        attachments
Briere, J. & Lanktree, C., 2008. Integrative Treatment of Complex Trauma for Adolescents: A Guide for the
Treatment of Mulitply Traumatized Youth.
Discerning Between Mental
     Health Issues and
   Trauma Based Issues
  How does a symptom serve to
     protect the individual?
    Presenting                          Trauma-based                           Other
   Symptoms/                                                              (Behavior-based)
    Behaviors
•Nightmares                            Sleep is unsafe                   Attention-seeking
•Night terrors

•Inattentive                             Dissociation/                   ADHD
•Daydreaming                              escapism

Crisci, G, 2006. Trauma Assessment and Treatment (Children and Adolescents).
 Common                              Trauma-based                         Other
 Behavioral                                                               (Behavior-based)
 Presentations
 Difficulty                          Fear                                 Defiance
 complying with
 directives
 Challenging                         Fear                                 Oppositional
 authority

 Psychosomatic                       Fear/anxiety                         Attention seeking
 complaints

Crisci, G, 2006. Trauma Assessment and Treatment (Children and Adolescents).
Assessment
     Trauma Assessments

                        Tools
•   Trauma Symptoms Inventory (TSI)
•   TSI Belief Scale
•   Impact of Events Scale
•   Posttraumatic Diagnostic Scale
•   Trauma Symptom Checklist for Children (TSCC,
    TSCC-A)
   Trauma Assessment

                Report/disclosure
• Report from the client
• Report from the family of origin and/or current
  caregiver
• Reports from community collaterals (social workers,
  therapists, psychiatrists, pediatricians)
• Observations from teachers/administrators
• Student achievement
• Record of past/current services
         Trauma Assessments-Safety
• Is there imminent danger of death        •   When was the client’s last
  or injury?                                   physical/medical exam?
• Is the client acutely suicidal?          •   Does the client engage in any self-
                                               mutilating behaviors such as self cutting
• Is the client a danger to others?            and self burning?
• Is the client incapacitated (through     •   When did the client last eat?
  the use of drugs, psychosis,             •   Does the client report engaging in
  delirium) to such a degree that he           unsafe sex, drug abuse or other risk
  or she cannot focus on and assure            taking behaviors?
  his or her safety?                       •   Is there any evidence of an eating
• Is there any evidence that the               disorder?
  client’s immediate environment is        •   Is the client being exploited sexually or
  unsafe?                                      in any other way by another person?
•   Does the client have a safe place to   •   Is the client associated with a gang?
    stay?
   Assessment

                         Goals
• Identifying current vs. historical factors that impact
  presenting issues
• Developing a comprehensive case conceptualization
• Identifying functional relationships between behavior
  and environment
• Constructing treatment plans
Interventions
   Interventions

       General Guidelines for Treatment
• Safety issues addressed first
• Time spent in creating strong, therapeutic
  relationships
• Coping skills strengthened at the onset of therapy and
  consistently reinforced throughout therapy
• Treatment approach is based on the results of the
  assessments
• A flexible, step-wise treatment plan is utilized and is
  centered on the specific client’s needs and readiness
   Interventions

                         Safety
• Ensure physical safety of the client through referrals
    Social Services
    Law Enforcement
    Emergency Psychiatric or Medical Services
• Involvement of supportive, appropriate family
  members, friends
   Interventions

                Individual therapy
Provides a model of a secure, appropriate
relationship
Offers a safe, private context in which to address the
most personal and sensitive issues
    Interventions

                    Individual therapy
• Focus on the client’s rights      • Identify and work through
• Attend to reversing the other-      triggers
  centric focus of the survivor’s   • Address the issues related to
  cognitions                          the assignment of
• Encourage the client to             responsibility for the
  identify and correct cognitive      traumatic events
  distortions, recognize            • Address interpersonal
  disparities                         deficits and educate on
• Replace negative coping             appropriate relationship
  skills which, in the context of     boundaries
  the trauma, helped client to
  survive but have now ceased
  to be useful
   Interventions

                  Group therapy
The group setting offers a controlled social arena in
which traumatized youth can safely practice
replacing maladaptive behaviors with those which
are positive and age appropriate
   Interventions

                  Group therapy
• Reinforces basic social skills
• Aids clients in the development of awareness of
  others
• Facilitates a reduction of shame regarding symptoms
  and experiences
• Encourages observance of better physical and verbal
  boundaries
   Interventions

                  Family Therapy
Offers critical support to the client within the daily
family context and provides a needed forum for the
involved family members to receive education and
encouragement in an effort to change unhealthy
aspects of the system.
   Interventions

                   Family therapy
• Facilitates understanding by all family members of the
  expectations for treatment
• Reinforces positive and supportive family behaviors
• Addresses feelings of guilt, shame, or anger in client’s
  family members
• Reinforces therapy as important, necessary and
  positive
• Helps family to understand the effect of trauma on the
  functioning and roles played in the family
Case Studies
     Thank You

                 Rogers Memorial Hospital
                  1-800-767-4411
                  www.rogershospital.org


Four Locations in Southeastern Wisconsin:
•   Oconomowoc
•   Milwaukee
•   Kenosha
•   Brown Deer

				
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