Trauma and TF-CBT

Reactive Attachment Disorder

• R/O ASD 1st

• Must be apparent before 5yo

• Must be at least 9mo old

• Does not seek out/respond to comfort from an adult caregiver when distressed

• Due to not experiencing opportunities for attachment due to: social neglect, Repeated changes of primary caregiver, Institutionalization

Disinhibited Social Engagement Disorder

• Must be at least 9mo old

• Children seeks out anyone, even strangers

RAD Diagnosis

• Inhibited behavior

• Internalizing disorder w/ depressive symptoms & withdrawal/avoidant behavior

• Persistent social neglect from adults

• >9mo <5yo

• Cognition & language delays

• Disturbed behavior

  • Rarely/minimally seeks comfort when distressed

  • Rarely/minimally responds to comfort when distressed

• Social and emotional disturbance

  • Minimal social & emotional responsiveness to others

  • Limited positive affect

  • Episodes of unexplained irritability, sadness, fearfulness that are evident even during nonthreatening interactions w/ adult caregivers

• Evident in young children, may persist for several years, rarely seen in older children

• Mutual exclusivity

  • ASD

DSED Diagnosis

• Disinhibited behavior

• Externalizing disorder w/ impulsive symptoms and approaching/attention-seeking behavior

• Persistent social neglect from adults

• >9mo

• Cognition & language delays

• Disturbed Behavior (need 2 of 4)

  • Reduced/absent reticence in approaching & interacting with unfamiliar adults

  • Overly familiar verbal/physical behavior

  • Diminished/absent checking back with adult caregiver

  • Willingness to go off with an unfamiliar adult w/ minimal/no hesitation

• Early childhood through adolescence has not been described in adults

Acute Stress Disorder

• Directly experienced/witnessed a traumatic event that involved death, threats of death, grave injury, or sexual violation. Learned about violent accidental events that occurred to a close family member or friend. Or repeated exposure to traumatic events in a professional capacity.

• Cause significant distress.

• 9 of 14 potential symptoms across 5 categories

  • Intrusion symptoms

  • Negative mood

  • Dissociative symptoms

  • Avoidance symptoms

  • Arousal symptoms

Adjustment Disorders

• Development of specific emotional or behavioral symptoms in response to an identifiable stressor

• Symptoms are not longer than after 6 months of the stressor

• Depressed mood

• Anxiety

• Mixed anxiety & depressed mood

• Disturbance of conduct

• Mixed disturbance of emotions and conduct

• Unspecified

PTSD

• Requires actual or threatened death, serious injury, or sexual violation in one of the following ways

  • Direct experience

  • Witnessed in person

  • Learned of trauma events to a close family member or friend

  • Experienced repeated or extreme exposure to aversive details of trauma

PTSD Avoidance Symptoms

• 1 or both of the following

  • Avoidance of distressing memories, thoughts, or feelings associated with the traumatic event

  • Avoidance of external reminders that arouse distressing memories thoughts or feelings of the event

PTSD Negative Alterations of Cognitions and Mood

• 2 or more of the following

  • Inability to remember an important aspect of the traumatic event

  • Exaggerated and persistent negative beliefs about self, others, and/or the world

  • Persistent distorted beliefs, causing the individual to blame themselves for the traumatic event

  • Persistent negative emotional state

  • Diminished interest or participation in important activities

  • Feeling detached or estranged from others

  • Persistent inability to experience positive emotions

PTSD Arousal Symptoms

• 2 or more of the following

  • Irritable behavior and angry outbursts

  • Reckless or self-destructive behavior

  • Hypervigilance

  • Exaggerated startle response

  • Problem with concentration

  • Sleep disturbance

PTSD < 7

• Dev of characteristic symptoms following exposure to 1 or more traumatic events

• Exposure to actual threat

• Direct recipient, Witness, Learning

• Intrusion Symptoms (1 of 4)

  • Psychological distress

  • Distressing memories

  • Distressing dreams

  • Dissociative reactions

  • Physiological reactions

• Persistent Avoidance (0 or 1 of 2)

  • Activities, places, or physical reminders that arouse recollections of the event

• Alterations in cognitions and mood (0 or 1 of 4)

  • Significantly increased frequency of negative emotional states

  • Socially withdrawn behavior

  • Markedly diminished interest or participation in significant activities

  • Persistent reduction in expression of positive emotions

• Alterations in arousal and reactivity (2 of 5)

  • Hypervigilance

  • Exaggerated startle response

  • Problems w/ concentration

  • Sleep disturbance

  • Irritable behavior and angry outbursts (extreme temper tantrums)

• > 1 month after trauma exposure

• Relationships with parents, siblings, peers, other caregivers or with school behavior

PTSD > age 6

• Dev of characteristic symptoms following exposure to 1 or more traumatic events

• Exposure to actual threat

• Direct recipient, Witness, Learning, Exposure

• Intrusion symptoms (1 of 5)

  • Psychological distress

  • Distressing memories (repetitive play)

  • Distressing dreams (may be frightening w/o recognizable content)

  • Dissociative reactions (trauma-specific reenactment in play)

  • Physiological reactions (to internal/external cues that symbolize/resemble)

• Persistent Avoidance (1 or 2)

  • Memories, thoughts, feelings about or closely associated with the event

• Alterations in Cognitions and mood (2 of 7)

  • Persistent negative emotional state

  • Feelings of detachment or estrangement from others

  • Markedly diminished interest/participation in significant activities

  • Persistent inability to experience positive emotions

  • Inability to remember an important aspect of event

  • Persistent & exaggerated negative beliefs/expectations about oneself, others, or world

  • Persistent, distorted cognitions about the cause/consequences of traumatic event that lead the individual to blame self or others

• Alterations in arousal and reactivity (1 of 6)

  • Hypervigilance

  • Exaggerated startle response

  • Problems w/ concentration

  • Sleep disturbance

  • Irritable behavior and angry outbursts

  • Reckless / self-destructive behavior

• > 1 month after trauma exposure

• Social, occupational, or other important areas of functioning

Assessment Measures (0-12)

• PTSD Semi-Structured Interview and Observations

• Trauma Symptoms Checklist for Young Children TSCYC

Assessment Measures (6-18)

The Early Development and Home Background Measures

DSM Severity Measures (6-18)

• Severity of Posttraumatic Stress Symptoms – age 11-17 – National Stressful Events Survey PTSD Short Scale (NSESSS)

• Severity of Acute Stress Symptoms – age 11-17 – National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS)

• Severity of Dissociative Symptoms – age 11-17 – Brief Dissociative Experiences Scale – Modified (DES-B)

Other Assessment Measures for PTSD

• Trauma Symptoms Checklist for Children (TSCC)

• Children’s PTSD Inventory (CPTSD-I)

• Child PTSD Symptom Scale (CPSS)

• Clinician-administered PTSD Scale for Children (CAPS-CA)

• My Worst Experiences Scale (MWES)

• Trauma and Attachment Belief Scale TABS)

• UCLA-PTSD-Reaction-Index (UCLA-PTSD-RI)

Treatment and Interventions for RAD and DSED

• Working through the caregiver

• Dyad or family system

• Circle of security

• Play therapy

• At-home practice

• Child alone

Treatment and Interventions for PTSD

• Cognitive model of PTSD

• CBT

• Anxiety management components

• Trauma narrative

• Cognitive restructuring

• Caregivers

TF-CBT Workbook

• The workbook was created as a supplemental resource to assist therapists as they work through each component of the TF-CBT model with their child clients

• The workbook activities were developed for implementing the PRACTICE components of the TF-CBT model:

  • Psycho-education, Relaxation, Affective regulation and modulation, Cognitive coping and processing, Trauma narrative and cognitive processing of the traumatic experience(s), In vivo mastery of trauma reminders, Conjoint sessions and Enhancing future safety and development.