Chapter 12: Trauma- and Stressor-Related Disorders

Adjustment Disorders

• Individuals can experience an adjustment disorder based on their response to a stressor, which can be single or multiple events, and which may be recurring or continuous.

• The symptoms must begin within three months of the onset of the stressor and last no more than six months after the stressor, or its consequences, have resolved

Reactive Attachment Disorder (RAD)

• the clinician must rule out autism spectrum disorder

• must be evident before the child is 5 years old and the child must have a developmental age of at least nine months

• child’s disinclination to seek out, or even to respond to, comfort from an adult caregiver when the child is distressed

• insufficient opportunities for attachments because of social neglect, repeated changes of primary caregivers, or institutionalization

Disinhibited Social Engagement Disorder (DSED)

• the child must be a developmental age of at least nine months

• pattern of behavior whereby the child will approach and engage with adults they do not know with little or no hesitation

• basic emotional needs have not been met because their primary caregivers did not comfort them, pay attention to them, or interact with them to provide stimulation

Posttraumatic Stress Disorder (PTSD) - Children Older than Seven, Adolescents, and Adults

• clinician will need to establish that the individual meets the criteria for trauma exposure, intrusive symptoms, persistent avoidant symptoms, negative changes in cognitions and mood, and marked alterations in arousal and reactivity associated with actual or threatened trauma

• The trauma exposure can be direct (experiencing the trauma), witnessing it live, or learning of a traumatic experience of a close family member or friend.

• Finally, individuals experiencing PTSD will often have irritable behavior, angry outbursts, concentration deficits, participate in reckless or self-destructive behavior

Posttraumatic Stress Disorder (PTSD) - Children 6 Years and Younger

• mirror many of the criteria for older individuals but include possibilities for how younger children may experience exposure, intrusive symptoms, avoidant behaviors, and arousal

• arousal associated with PTSD can appear as outbursts of unprovoked anger and irritable behavior

• may be vulnerable to PTSD when they learn of a traumatic event that happened to a parent or caregiver

• ay appear as them being more, or more frequently, fearful, confused, or sad; they may withdraw from social situations, including play, and there may be a marked decrease in the positive emotions that they are experiencing or expressing

Assessment for ages 0-12

• PTSD Semi-Structured Interview and Observation

• Trauma Symptom Checklist for Young Children

Trauma Symptom Checklist for Young Children (TSCYC, Briere, 2005)

is a 90-item measure designed to be administered to caretakers of a child (ages three to 12) to assess for the presence of PTSD symptoms

PTSD Semi-Structured Interview and Observation (Sheeringa & Zeanah, 1994)

• children ages 0 to 6

• a caregiver is asked if a child has been exposed to 11 different traumas

• The assessment is 29 questions and takes approximately 45 minutes to complete

Assessment for ages 6-18

• The Early Development and Home Background Measures

• DSM-5 Severity Measure

DSM-5 Severity Measures

• designed to assess the extent to which an individual is bothered by problems becoming worse after a trauma- or stressor-related event

• Severity of Posttraumatic Stress Symptoms—Child Age 11–17—National Stressful Events Survey PTSD Short Scale

• Severity of Acute Stress Symptoms—Child Age 11–17—National Stressful Events Survey Acute Stress Disorder Short Scale

• Severity of Dissociative Symptoms—Child Age 11–17—Brief Dissociative Experiences Scale—Modified

• Trauma Symptom Checklist for Children

• Children’s PTSD Inventory

• Child PTSD Symptoms Scale

• Clinician-Administered PTSD Scale for Children

• My Worst Experiences Scale

• Trauma and Attachment Belief Scale

Trauma and Attachment Belief Scale

• is an 84-item self-report assessment designed to the cognitive beliefs related to experiencing a trauma

• is scored using a six-point Likert-type scale on five major areas across 10 subscales

• The test will likely take between 10 to 20 minutes to complete

My Worst Experiences Scale

• is a self-report measure designed for children ages 9 to 18

• MWES asks children about the worst trauma-related experience they have experienced and then assesses for symptoms related to that experience

• children are asked to check the worst experience they have had from 21 options that are likely to cause stress or trauma

• children are asked to answer 105 Likert-type scale questions (0 = not at all to 5 = all the time) about their thoughts, feelings, and behaviors in the past month related to the worst experience

Clinician-Administered PTSD Scale for Children

• is a 33-item measure that is administered by a trained mental health professional.

• The CAPS-CA can be administered to children ages 8 to 18 to assess for PTSD symptoms.

• The average time of completion is 52 minutes, though it can range between 30 and 120 minutes to administer

• an interviewer asks a child questions about symptoms over the past month and the child answers using a Likert-type scale (0 = none at this time to 4 = most of the time, daily or almost every day)

Child PTSD Symptoms Scale

• paper-and-pencil, self-report measure designed for children ages 8 to 18 who have experienced a traumatic event

• averages 15 to 20 minutes to complete the CPSS and can be scored in five minute

Children’s PTSD Inventory

• is a structured interview designed to assess PTSD symptoms in children ages 6 to 18.

• The items in the CPTSD-I are divided into five sections, which correspond to the categories of the DSM-IV-TR:

  • Exposure and Situational Reactivity,

  • Reexperiencing,

  • Avoidance and Numbing,

  • Increased Arousal, and

  • Significant Distress or Impairmen

Trauma Symptom Checklist for Children

• is 54-item self-report item used to measure the presence of PTSD-related symptoms in children 8 to 16 years of age

• contains two validity scales (that measure over reporting and underreporting), six clinical scales (anxiety, depression, posttraumatic stress, sexual concerns, dissociation, and anger) and four subscales (sexual preoccupation, sexual distress, dissociation fantasy, and overt dissociation)

Severity of Dissociative Symptoms—Child Age 11–17—Brief Dissociative Experiences Scale—Modified

• This measure assess the presence of dissociative symptoms in children ages 11–17

• Children are asked to answer eight questions using a five-point Likert-type scale (0 = not at all to 4 = more than once a day)

Severity of Acute Stress Symptoms—Child Age 11–17—National Stressful Events Survey Acute Stress Disorder Short Scale

• Children are asked to answer “how bothered” they have been by symptoms over the past seven days related to a stressful or traumatic experience

• This seven-item questionnaire measures on a five-point Likert-type scale (0 = not at all to 4 = extremely)

Severity of Posttraumatic Stress Symptoms—Child Age 11–17—National Stressful Events Survey PTSD Short Scale

• assesses the presence of PTSD-related cognitive, affective, behavioral, and physiological symptoms in children ages 11 to 17

• Using a five-point Likert-type scale ranging (0 = not at all to 4 = extremely), children are asked to answer questions about the presence of symptoms over the past seven days

The Early Development and Home Background Measures

• may be useful for clinicians who are interested in better understanding the home life, both past and present, of a child with whom they are working

• 19-item measure across three domains

RAD and DSED Treatment

• Working through the Caregiver

• Dyad or Family System

• Circle of Security

• Play Therapy

• At-Home Practice

• Child Alone

Child Alone

• the therapist seeks to establish a trusting relationship with the child, with the intent of reducing behaviors that are interfering with the dyadic work.

• For the individual work to be successful, consistent collaboration with the caregivers is needed

At-Home Practice

• therapists working with a family unit may find activities that can be used at home to be a useful intervention

• to practice new skills or purposefully engage in new behaviors outside of the counseling room encourages caregivers and children to experiment with new patterns of healthy interaction

Play Therapy

• By examining the family structure, patterns of interactions may emerge that aid a clinician in choosing play therapy techniques that will most benefit the child

• create an environment of trust and security between caregiver and child and to replicate healthy caregiver–child interactions through play

Circle of Security

is a 20-week intervention that contains both educational and therapeutic components and originates from the dynamics of secure and insecure attachment

Five Goals of Circle of Security

1. Establish the therapist and the group as a secure base from which the caregiver can explore his or her relationship with the child

2. Increase caregiver sensitivity and appropriate responsiveness by providing caregivers a map of children’s basic attachment needs

3. Increase caregivers’ capacity to recognize and understand both the obvious and subtler verbal and nonverbal cues that children use to signal their internal states and needs when using the caregiver as a secure base for exploration and as a haven of safety

4. Increase caregiver empathy by supporting reflection about the caregiver’s and the child’s behaviors, thoughts, and feelings regarding attachment-oriented interactions

5. Increase caregiver reflection about how his or her own developmental history affects current caregiving behavior

Dyad or Family System

• to highlight the parenting strengths of the caregiver while the caregiver engages with the child

• the clinician can then begin to challenge caregivers in moments when harmful emotional reactions to the child’s behavior impact the engagement and establish alternative behaviors that facilitate healthy attachment

Working through the Caregiver

• it is common that they experience negative emotions toward the children because of this stress

• it may benefit the caregiver to work through his or her own negative emotions before attempting to engage with the child

• Working one-on-one with the caregiver encourages examination of the person’s own perceptions and feelings about the child and allows room for exploration around the ways in which the caregiver’s feelings about the child may be affecting his or her parenting choices

Treatment of PTSD

• Cognitive Model of PTSD

• Cognitive-Behavioral Therapy (CBT)

• Anxiety Management Components

• Trauma Narrative

• Cognitive Restructuring

• Caregivers

Caregivers

• Parents whose children have experienced trauma may find parenting effectively to be a difficult task, given the child’s new emerging behavior patterns or avoidance techniques

• counselors offer caregivers psychoeducation about trauma and trauma responses, role-play various situations with caregivers to identify or correct parenting skills, remind parents of the importance of praise, and discuss disciplinary options, such as time out.

Cognitive Restructuring

• the counselor then employs the basic cognitive-behavioral principles of teaching a child about cognitive distortions and identifying those distortions within the trauma narrative

• In vivo situations promote cognitive restructuring by demonstrating to the child that the internal dialogue that is experienced during the feared situation is not rational.

Trauma Narrative

stated that through gradual exposure and trauma narratives, counselors and children can explore the traumatic event, as well as cognitive distortions that arise.

Anxiety Management Components

PTSD in children is psychoeducational training in anxiety management techniques, such as controlled breathing and muscle relaxation

Cognitive-Behavioral Therapy (CBT)

• can be viewed from a cognitive-behavioral lens because it results from stressful trigger events that have already taken place

• Emotional reactions result from these appraisals, and many children experience a range of negative emotions at various times, depending on the appraisal that the children encounter in any given situation

Cognitive Model of PTSD

• conceptualizing PTSD is through a cognitive lens, and effective treatment for PTSD using a cognitive approach has been empirically supported

• studies have modified the cognitive-behavioral approach to better meet the needs of children and adolescents by teaching anxiety management techniques as well as including the family in treatment