Medical Traumatic Stress in Pediatric HIV by sammyc2007

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									Medical Traumatic Stress in
      Pediatric HIV

         Kimberly Shaw, PhD
         University of Florida
 Dept of Clinical & Health Psychology

      Disclosure of Financial Relationships

  This speaker has no significant financial relationships with
                commercial entities to disclose.

This slide set has been peer-reviewed to ensure that there are no conflicts of
                   interest represented in the presentation.
             Our Journey
• Overview: Defining the Issues
• Neurobiology of Interpersonal
• Chronic Effects of Unrepaired Stress
• Implications for Pediatric HIV
• Pediatric Toolkit
• Describe a system of understanding
  psychosocial risk and protective factors
  that leads to focused assessment and
  tailored psychosocial intervention for
  children and families affected by HIV
• Describe the mechanisms by which
  “unrepaired” psychophysiological
  'memories' of fear and arousal resulting
  from traumatic stress has significant
  public health implications
     •   Poor adjustment
     •   Increased symptoms, pain reports
     •   Unusual presentation
     •   Medical non-adherence
     •   Immuno-functioning???
       Awareness of Traumatic Stress
• Minimize potentially traumatic aspects of
  medical care
• Identify children and families with (or at
  higher risk for) persistent distress and
  provide appropriate intervention
• Provide anticipatory guidance to help
  prevent long-lasting traumatic stress
•   (National Child Traumatic Stress Network)
    Range of Traumatic Events
• Humanitarian crises
   • Natural and man-made disasters
      •   Earthquakes
      •   Floods, mudslides
      •   Hurricanes
      •   Tornadoes
      •   Volcanic eruptions
      •   Major transportation accidents
      •   Industrial accidents
      •   Technological disasters
   • Catastrophes of human origin
      • Armed conflicts/wars
      • Genocide
      • Terrorist attacks
      Range of Traumatic Events
• Trauma embedded in the fabric of daily life
  •   Child abuse and maltreatment
  •   Domestic violence
  •   Community violence and criminal victimization
  •   Traumatic loss
  •   Accidents
  •   Fires
  •   Medical trauma*
  Prevalence of Medical Traumatic
      Stress Reactions (
• Many ill or injured children, and their families (up to 80%)
  experience some traumatic stress reactions following a life
  threatening illness, injury, or painful medical procedure
   • May help the individual to process the experience

• Between 20 - 30 % of parents and 15 - 25% of children and
  siblings experience persistent traumatic stress reactions that
  impair daily functioning and affect treatment adherence and

• New area – HIV???
 Potentially Traumatic Events
• The same objective event doesn‟t produce
  same traumatogenic process across
  individuals or families
• PTEs are nonlinear and may be recurrent
  and/or cyclical, with the possibility of
  subsequent episodes of trauma (Kazak, et
  al 2006)
 A model of pediatric medical traumatic stress (PMTS) for pediatric patients and their families

     Kazak, A. E. et al. J. Pediatr. Psychol. 2006 31:343-355; doi:10.1093/jpepsy/jsj054

Copyright restrictions may apply.
    Why Do Medical Events
 Potentially Lead To Traumatic
• These events challenge beliefs about the
  world as a safe place harsh reminders of
  one‟s own (and child‟s) vulnerability.
• There can be a realistic (or subjective)
  sense of life threat.
• High-tech, intense medical treatment may
  be frightening, and the child or parent may
  feel helpless.
Why Do Medical Events Potentially
   Lead To Traumatic Stress?
• There may be uncertainty about course
  and outcome
• Pain or observed pain is often involved
• Exposure to injury or death of others can
   • In HIV – Parent morbidity/mortality
• The family is often required to make
  important decisions in times of great
  Trauma: Hidden Morbidity

• Traumatic experiences often
  go unnoticed and unrepaired
   Neurobiology of Interpersonal
• Links relationship-
  based approaches
  and other aspects of
  clinical intervention
  to brain research

   • Empathy
   • Narratives
   • Cognitive v emotion
     regulation strategies
Attachment and Stress Regulation

• The relationships children have with their
  caregivers play critical roles in regulating
  stress hormone production during the
  early years of life
Attachment Styles: Related to
      Health Outcomes

  In children who have been exposed to
  severe stressors, the quality of attachment
  is probably the single most important
  determinant of long-term morbidity
        Secure Attachment
• Better regulated stress hormone reaction
  when they are upset or frightened

  • Presence of a sensitive and responsive
    caregiver can prevent elevations in cortisol
    among toddlers, even in children who tend
    to be temperamentally fearful or anxious
       Insecure Attachment
• Higher stress hormone levels when they
  are even mildly frightened
   • Elevated cortisol levels may alter the
     development of brain circuits

  • Less capable of coping effectively with
    stress as they grow up
Sensitive and Responsive Care

• Powerful buffer against stress
  hormone exposure, even in
  children who might otherwise be
  highly vulnerable to stress-
  system activation (Gunnar, 2006)
  Chronic Effects of Stress in
      Early Development
• Developmental neurobiological
  studies demonstrate:
     • early adverse experiences result in
       an increased sensitivity to the
       effects of stress later in life and
       render an individual vulnerable to
       stress-related psychiatric disorders
• Growing evidence that chronic early
  unrepaired stress affects physical
• Loss of the ability to regulate the
  intensity of feelings (physiological
  response) is the most far-reaching
  effect of early trauma and neglect
   • Overall brain growth
   • Growth of the connecting fibers that
     link the right and left sides (Debellis,
     et al)
Chronic Unrepaired Stress
• Impairment of the counter-
  regulatory mechanisms
  producing hyperactivity of the
  hypothalamic –pituitary –adrenal
  and sympathetic nervous
  • Absence of appropriate caregiving
    The Invisible Epidemic: Post-
 Traumatic Stress Disorder, Memory
            and the Brain

• It's Not Just “Psychological”
• While PTSS are commonly understood to
  be psychological, some or all of them may
  well be related to the physical effects of
  extreme stress on the brain
    Post Traumatic Stress
• Originates from the maladaptive persistence of
  appropriate and adaptive responses present
  during traumatic stress
   • Physiological, biochemical, behavioral
• The organ mediating the adaptive – and the
  maladaptive – responses related to traumatic
  stress is the human brain
   • Relationship experiences modulate!!!
• Even when a person does not develop a
  full-blown condition, the extent of distress
  is positively associated with HPA
   • Distress is an important pathway linking
     stress and endocrine response (S. Cohen
     et al., 1995; Baum et al., 1993).

                                Remember it is:

POST             =              PAINFUL
TRAUMATIC           =           TREATABLE
STRESS             =            SENSORY
DISORDER           =            DYSFUNCTION
    Traumatic Distress Can Be
    Distinguished From Routine
     Stress by Residual Effect:

• How quickly upset is triggered
• How frequently upset is triggered
• How intensely threatening the source of
  upset is
• How long upset lasts
• How long it takes to calm down
     PTSD: at Least Two Different Abnormal
    Levels of Psychophysiological Responses
               to Their Environment
• (1) conditioned responses to specific
  reminders of the trauma
• (2) generalized hyperarousal to intense
  but intrinsically neutral stimuli
   • Pain response, somatic interpretation

Foa, E. B. et al. “Symptomatology and Psychopathology of Mental health
  Problems After Disaster. Journ of Clin Psych (2006) 67:15-25.
Yehuda, R. (2001) “Biology of Posttraumatic Stress Disorder.” Journal of
  Clinical Psych 62(17):41-46.
  (Traumatic) Stress & Coping
• Continuum of key symptoms of PTSD
  (e.g., Arousal, reexperiencing, avoidance)

• Examining PTSS may be a more useful
  approach to understanding adjustment in
  children and families than traditional
  “psychiatric diagnoses” – matches
  family‟s understanding
     • Avoidance of stimuli and numbing of general
       responsiveness indicated by  3 of the following:
           •   avoid thoughts, feelings, or conversations*
           •   avoid activities, places, or people*
           •   inability to recall part of trauma
           •    interest in activities
           •   estrangement from others
           •   restricted range of affect
           •   sense of foreshortened future

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
4th ed. 1994.
   (Traumatic) Stress & Coping
• Tailored interventions
   • Narrative therapy
   • Emotion regulation (biofeedback)
   • Cognitive behavioral
   • Pain interventions

**Empirically supported treatments needed
   Chronic Effects of Unrepaired
• In much the same way that repeated exposure to
  a cognitive stimulus results in a cognitive
  memory, repeated or continuous exposure to this
  state of arousal results in a 'state memory„
• Early adverse experiences result in an increased
  sensitivity to the effects of stress later in life
• In the absence of repair!
  Positron Emission tomography
  (PET) Scan Study (Rauch et al
• When people with PTSD are exposed to stimuli
  reminiscent of their trauma, there is an increase
  in perfusion of the areas in the right hemisphere
  associated with emotional states and autonomic
• Simultaneous decrease in oxygen utilization in
  Broca's area-the region in the left inferior frontal
  cortex responsible for generating words to attach
  to internal experience
              • Amygdala responds
                to affective stimuli;
                Even if presented
                outside of conscious
              • Amygdala well-
                situated to
                coordinate rapid
                affective responses
                and direct attention
                to emotionally salient
              •   Gunnar et al 2006

• Erupt in the body after a traumatic event
• May “attack” the hippocampus
  • studies have shown the hippocampus of
    adults with PTSD being unusually small
Stress Predicts Brain Changes in Children: A Pilot
Longitudinal Study on Youth Stress, Posttraumatic
     Stress Disorder, and the Hippocampus
 Carrion, Weems, Reiss, (2007) PEDIATRICS Vol. 119 No. 3 March 2007,

  • Longitudinal study of children (n = 15) with history
    of maltreatment who underwent clinical evaluation
    for posttraumatic stress disorder, cortisol, and
      • Glucocorticoids secreted during stress can be neurotoxic
        to the hippocampus
      • Prebedtime salivary cortisol levels demonstrated the
        largest difference in values between children with PTSD
        and controls
      • High levels of cortisol in children with PTSD,
      • Stress is associated with hippocampal reduction in
        children with posttraumatic stress disorder symptoms
  Impairment of the Hippocampus
• Dissociation

• Unconscious separation of some mental processes from
  the others, e.g., mismatch between facial expression and
  thought or mood

• Damage to the hippocampus, which processes memory,
  may explain why victims of childhood abuse often seem to
  have incomplete or delayed recall of their abusive
               Neuropeptide Y
• Neuropeptide Y (NPY) is a 36 amino acid peptide
  neurotransmitter, the most abundant neuropeptide in the
  brain also ANS
• has been associated with a number of physiologic
  processes in the brain, including the regulation of energy
  balance, memory and learning, circadian rhythms, sexual
  function, anxiety responses and vascular resistance
• has been considered to be involved in the pathogenesis of
  affective disorders
          Neuropeptide Y
• Lower NPY levels have been observed in
  posttraumatic stress disorder (PTSD)
  (Rasmusson et al 2000) and depressive
  disorder (Heilig et al 2004);
  correspondingly, antidepressant drugs
  increase NPY levels (Mathe 2002).
• Remember Pediatric HIV?
                Kimberly Shaw, Ph.D.
             Patricia McLendon, A.R.N.P.
              Lawrence Friedman, MD.
               Marylyn Broman, M.D.
           University of Miami School of Medicine
• HIV seroprevalence rising among teens
• Unprotected sex is a major mode of transmission
• Minority females especially at risk
• Little is known about sexual practices and correlates of HIV+ minority female
• Social support and coping strategies are related to health behaviors of HIV+
• There is little theory-driven research specifically linking coping strategies and
  interpersonal style with high risk sexual practices.
• Attachment       Representational Model of
  Self & Others     Perceived Self-efficacy
  Self-regulatory Behavior (e.g. safer sexual
          Subjects (N = 30)
• Primarily low SES, resided within the inner
  city catchment area of a medical center
• Mean duration of HIV was 31.45 months
• All had remained sexually active in the
  previous six months
• 60% African American who had been
  exposed to HIV through heterosexual
• Age of first sexual encounter (m = 13.4 Years,
  range 6-18)
• High rates of sexual victimization (33%)
• Low consistent condom use (33%)
• Frequent multiple partners (33% reported 6 or
  more lifetime partners)
• 67% Reported another sexually transmitted
   • 50% had two or more std’s
   • 15% had three or more std’s
• 37% Reported using no type of contraception
• 50% Unable to count on partner to have a condom
• Low social support
  • 50% Unable to rely on friends or
    family for support
• Table. Attachment Dimensions
•                          CLOSE      DEPEND      ANXIETY
•   Condom Use               .22          .26 *       -.44**
•   # Partners               .27         -.29*         .45**
•   # of STD’s               .08         -.12          .03
•   Sexual Victim           -.23         - .18         .35**
•   Social Support           .56***       .34*        -.21
•   Sexual Debut             .08          .20         -.28*
•   *p<.05; **p<.01; ***p<.001
• Anxious attachment style associated with: (RR)
       •   Less consistent condom use          (2.4)
       •   Sexual abuse                        (5.2)
       •   Less perceived social support       (3.6)
       •   Increased social isolation          (4.5)
       •   Multiple partners                   (2.3)

• Among subjects reporting sexual abuse:
       • Younger age of 1st intercourse        (3.5)
       • Greater # of other STD’s              (2.3)
     Risky Sexual Behavior Among
    Minority Youth: An Attachment
          Theory Perspective
•   Kimberly Shaw, PhD, Lawrence Friedman, MD, Karen Hoffman, PhD, Mary
    Reyes, MS.
    University of Miami School of Medicine,
    Miami, FL.
    Funded by HRSA - BRH970186-01

• Sexually active, minority, low SES adolescents (N =
  250) residing in inner-city neighborhoods
• 13-18 years old (M = 15.7)
• 56% Female
• 75% born in the USA
• 52% identified themselves as African-American or
  Caribbean; 48% Hispanic
• Exclusionary criteria: presence of any known or
  clinically detectable mental retardation.
• Anxious attachment style associated with:   (RR)
        •   Less consistent condom use        (2.4)
        •   Sexual victimization              (5.2)
        •   Depression                        (4.3)
        •   Anxiety                           (3.6)
        •   Somatization                      (6.0)
        •   Greater # of other STD’s          (2.3)
        •   Younger age of 1st intercourse    (1.9)
• Risky sexual behaviors among adolescents (HIV/At-
  Risk) cluster together and are related to an insecure
  attachment style marked by emotional and behavioral
  dysregulation (unrepaired trauma!)
• Increasing focus on interpersonal relationships as
  motivational factors appears to be crucial for effective
  intervention to reduce risky sexual behavior
• Results of intervention pending
                       PTSD-HIV (Adults)

• Many exposed to some type of traumatic lifetime

• Substantial numbers substance use disorders

• Behaviors negatively impact immune system and

  Brief, D. J. et al. “Understanding the interface of HIV, trauma, post-traumatic stress disorder, and
  substance use and its implications for health outcomes.” AIDS CARE (2004) 16 Supplement 1:S97-

• Fluctuation in CD4

• Elevated VL / poor response to HAART

• Poor adherence

• Unexplainable symptoms, including pain

• Exacerbation of other health problems (DM, Cancer,
  HTN, Heart Disease)
                          PTSD-HIV (Adults)

• May experience faster rates of disease progression,
  especially if PTSD complicated by depression

• The longer a person lives with HIV the greater the
  likelihood s/he will develop an anxiety disorder

• Over 50% of PLWHA found to have PTSD in a
  community setting
•   Boarts. J. M. “The differential impact of PTSD and depression on HIV disease markers and adherence to HAART in
    people living with HIV.” AIDS and Behavior, Vol 10, No. 3, May 2006; 253-261.
    Uldall, K. K. et al. AIDS Care 2004; 16 (supplement 1) S71-S96 “Adherence in people living with HIV/AIDS, mental illness,
    and chemical dependency: a review of the literature.”

PTSD Associated with:

• Medication adherence problems

• Death anxiety

• Depression

  Bottonari, K. A. et al. (2005). “Life stress and adherence to antiretroviral therapy among HIV-Positive individuals: A
  preliminary investigation.” AIDS Patient Care and STDs 19(110: 719-727.
  Safren, S. A. et al. (2003). “Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication
  adherence difficulties.” AIDS Patient Care STDS 17(12): 657-664.
• Poor adherence to HAART

• Detectable Viral loads

• Lower T-cells

  Boarts J. M., Sledjeski E. M., Bogart L. M., Delahanty D. L. The Differential Impact of PTSD and
  Depression on HIV Disease Markers and Adherence to HAART in People Living with HIV. AIDS and
  Behavior , Vol. 10, No. 3, May 2006, pp. 253-261.
    Recommendations For Adults

    The primary care clinician should screen for PTSD annually
    or more often as clinically indicated.
    Clinicians should use the criteria listed in the DSM-IV for a
    diagnosis of PTSD in patients with HIV/AIDS
  Clinicians should screen patients with PTSD or significant
  trauma histories for clinical depression, anxiety disorders,
  or alcohol or other substance use disorders.
• Key Point:
    Patients with PTSD may have dissociative symptoms,
    which may be mistaken for HIV-related dementia or other
    HIV-related neuropsychiatric disorders.
     Related Peds Research:
• Traumatic stress responses in children
  who had cardiac surgery have been
  shown to relate to the length of
  hospitalization in intensive care (Connolly,
  McClowry, Hayman, Mahony, & Artman,
 Preoperative Anxiety, Postoperative
  Pain, and Behavioral Recovery in
 Young Children Undergoing Surgery
              (Kain, et al Pediatrics 2006)

Children (N = 241; age 5 to 12 years elective
  outpatient tonsillectomy and adenoidectomy
Anxiety associated with:
  Higher use of codeine and acetaminophen
  Higher incidence of emergence delirium (9.7%
  vs 1.5%)
• Higher incidence of postoperative anxiety; sleep
           Balluffi et al , 2004

• Prospective study of ASD and PTSD in 272
  families of children admitted to an ICU
   • 1/3 parents met symptom criteria for ASD in the
     days following their child’s hospitalization
   • 1/5 of the sample met criteria for PTSD 4 months
   • The presence and severity of ASD during the
     admission was predictive of later PTSD as was the
     parent’s subjective appraisal of life threat
      Child‟s or Family‟s Early
• Trajectory toward more problematic outcomes after a PTE
  may be evidenced quite early after trauma:

   • Child and adolescent ASD symptoms assessed in the ED
     within a few hours of a violent injury have been linked with
     the severity of PTSS months later (Fein et al., 2002)

   • Early physiological arousal in injured children (elevated heart
     rate in the ED) has also been linked to child PTSD outcome
     (Kassam-Adams, Garcia-España, Fein, & Winston, 2005)
   Risk Factors For Persistent
   Traumatic Stress Reactions
• severe early traumatic stress reactions
• experienced more severe levels of pain
• been exposed to scary sights and sounds
  in the hospital
• had prior emotional or mental health
  • is experiencing other life stressors or
  • lacks positive social support
          Future Directions
• What are the short- and long-lasting
  effects of medical traumatic stress in the
  earliest developmental stages vis-à-vis
• How can we intervene systematically to
  enhance adaptation to medical traumatic
  stress and reduce iatragenic
  psychoemotional and neurobiological
  effects in children and families affected by
              Health Care Providers Can:

• Incorporate an understanding of traumatic stress
  in their encounters with children and families
• Implement environmental changes that may be
• Minimize the potential for trauma during medical
  care provide screening, prevention, and
  anticipatory guidance
• Identify children and families in distress, or at
  risk, and make appropriate referrals
•   National Child Traumatic Stress   Network
Assessing and Treating Traumatic Stress
       Using the D-E-F Protocol

    Reduce DISTRESS
    • Remember the FAMILY

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