1. Chapter 19: Trauma-Related Problems and Disorders Brian Fisak

2. Brief Overview Potentially traumatic events (PTEs) include a range of experiences: Physical or sexual abuse Exposure to domestic or school violence Traumatic death of a loved one Injuries and accidents Exposure to community violence Severe illness Approximately 25% of children and adolescents experience a PTE (Costello et al., 2002)

3. Potentially Traumatic Events Children/adolescents at risk: Poverty Single parenting Parent depression symptoms Long-term disruption after exposure to PTE is not uncommon Rate of PTSD for children/adolescents exposed to PTE varies considerably and is influence by: Nature of the trauma Pretrauma psychopathology Duration of time following the occurrence of the traumatic event

4. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Manualized treatment Help children/adolescents experiencing PTSD and other trauma-related symptoms (e.g., anxiety, externalizing) Only top-rated treatment (Saunders et al., 2004) TF-CBT can be applied to children with a history of sexual abuse and/or physical abuse, and children who have witnessed violence

5. TF-CBT Components Nine modules 12 to 16 sessions of therapy Can be extended if necessary Modules designed to be implemented in a flexible manner

6. TF-CBT: Psychoeducation Beginning of treatment Normalization of child and parent experiences in response to the trauma Three components: Information about the traumatic event is provided Sexual education Risk reduction

7. Parenting Skills Clinician discusses basic parenting skills (e.g., praise, selective attention, time-out, contingency reinforcement) Serve to improve parent-child relationship and reduce disruptive behavior Skills may enhance the effectiveness of other components of TF-CBT

8. Relaxation/Stress Management Relaxation strategies can be particularly beneficial to manage physiological arousal due to trauma- related memories and triggers Introduce: Controlled breathing (diaphragmatic breathing) Mediation (for older children) Muscle relaxation Strategies to manage intrusive thoughts Skills are introduced and practiced in session

9. Affective Expression and Cognitive Coping Affective expression and modulation training: Help children to develop the ability to identify and label emotions so that emotions can be appropriately expressed and managed Cognitive coping: Children discuss how to identify and challenge inaccurate and unhelpful thoughts Review how thoughts are inaccurate and/or unhelpful and how these thoughts may lead to negative emotions and behaviors

10. Trauma Narrative Trauma narrative development and processing: break the connection between thoughts and memories of the traumatic event, negative emotions, and physiological arousal Developed in a gradual, progressive manner Child is asked to provide an account of the trauma over time, with increasing detail Cognitive and emotional processing typically occurs following the completion of the narrative

11. Exposure, Parent-Child, Enhancing Safety In vivo exposure: used to overcome fear and avoidance of external cues that may remind child of trauma Conjoint parent-child sessions: sessions with parent and child occur throughout treatment; important component of the trauma narrative Enhancing safety: end of treatment; development of skills to enhance safety, including assertiveness training, problem-solving skills, and body safety

12. TF-CBT Contraindications Clinical issues should be addressed before implementation of TF-CBT or where TF-CBT may be contraindicated Conduct problems and significant premorbid behavioral problems need to be addressed before TF- CBT is implemented Exposure not appropriate for youths who are acutely suicidal, exhibit substance abuse symptoms, engage in self-harm and parasuicidal behavior, or are experiencing severe depression

13. Parental Involvement Parent involvement important component of TF- CBT Circumstances where treatment can be implemented without parent involvement E.g., Cognitive-Behavioral Intervention for Trauma in Schools model (CBITS) Group-based program conducted in school settings Clinicians need to use discretion regarding level of parent involvement

14. Adaptations and Modifications Traumatic grief: occurs when a child is exposed to a death of a love one and the death was violent, gory, and/or unexpected (Cohen et al., 2006) Intensive intervention is typically indicated Childhood Traumatic Grief model is used in conjunction with TF-CBT Cultural adaptations: suggestions for adapting for specific cultural groups, including Latinos and Native Americans, in TF-CBT International adaptations

15. Modifications: Complex Trauma Complex trauma: when a child/adolescent has been exposed to multiple and often chronic trauma experiences, resulting in substantial impairment in a number of areas of functioning (e.g., Cohen et al., 2012) Significant modifications may be needed to traditional TF-CBT model for individuals with complex trauma E.g., treatment extended to 25 sessions, including an initial stabilization phase

16. Modifications: Ongoing Trauma Children/adolescents who are at substantial risk for ongoing trauma will most likely need modifications to TF-CBT Maximizing safety will need to be primary focus of treatment Level of risk related to the perpetrator being in child’s life or home and risk related to disclosure of information about the perpetrator’s behavior should be addressed

17. Modifications: Additional Treatment with an offending parent: Involvement with offending parents is contraindicated Intervention for trauma other than sexual abuse: TF-CBT was developed primarily as a treatment for children/adolescents who have experienced sexual abuse Early intervention: Early intervention may call undue attention to the trauma, which can increase a child’s or adolescent’s negative perceptions about the trauma Prevention of PTSD symptoms can be detrimental, however (Cohen, 2003)

18. Measuring Treatment Effects CRAFTS: relevant domains of function Cognitive problems Relationship problems Affective problems Family problems Traumatic behavior problems Somatic problems A number of assessment tools available: Clinician- Administered PTSD Scale for Children, Children’s Revised Impact of Events Scale

19. Clinical Case: Brittany 10-year-old Caucasian female Experienced ongoing sexual abuse that occurred 6 months prior to the intake Symptoms: embarrassment, shame, nightmares, fear, avoidance of stimuli that reminded her of the event Diagnosis: PTSD, Separation Anxiety Disorder Treatment: TF-CBT; psychoeducation, relaxation training, trauma narrative, in vivo exposure Outcome: Brittany and mother responsive to treatment; Brittany no longer met criteria for PTSD and separation anxiety disorder