The Role of Mental Health following
Acute Trauma
Elissa J. Brown, Ph.D.
Professor of Psychology
Director, Child HELP Partnership
Scarsdale High School, January 23, 2013
Workshop Outline
• Mental health reactions to acute trauma from
early to late childhood
• Risk factors for post-trauma mental health
problems
• Immediate, short-term, and long-term
interventions
• Resources and opportunities for training
What is a Traumatic Event?
• An experience that is emotionally painful,
distressing, and shocking, which can result in
lasting physical and/or mental effects.
– Actual or threatened death or serious injury
– Witnessed or experienced
– Response includes intense fear, helplessness,
horror
• In children, may be disorganization or agitation
Characteristics of Traumas
•
•
•
•
•
Acute versus chronic
Interpersonal versus non-interpersonal
Solitary versus group
Perceived as common versus rare
Degree and type of impact
Consequences of trauma: PTSD
 A. Traumatic event
 B. Re-experiencing
 Intrusive thoughts
 Nightmares
 Repetitive play involving the event
 C. Avoidance/Numbing symptoms
 Efforts to avoid thoughts, feelings, or conversations
 Inability to recall important aspect of the trauma
 Detachment from others
Consequences of trauma: PTSD
 D. Arousal symptoms





Difficulty falling or staying asleep
Irritability
Hypervigilance
Exaggerated startle response
Psychosomatic symptoms
 Even if they do not meet full criteria for PTSD,
the majority of children report some reexperiencing, avoidance, and/or hyperarousal
Consequences of trauma:
Differential Diagnosis
 Attention Deficit/Hyperactivity Disorder
 Traumatized children may remain motorically active
in an effort to keep their minds otherwise occupied
 Psychosis
 Need to distinguish between psychotic intrusive
thoughts and PTSD re-experiencing. Presence of
otherwise intact reality testing in PTSD
Trauma-Related Mental Health Problems








PTSD and other forms of anxiety
Grief and depression
Somatic symptoms
Risky behavior (alcohol/drug use, self-injury)
Aggressive and oppositional behaviors
Physical problems (gastrointestinal problems)
Attachment and social deficits
Academic and learning problems
Consequences of trauma:
Anxiety Disorders
 Separation anxiety: fear for loved ones
 Generalized anxiety: excessive worry
 Panic attacks
Consequences of trauma: Depression
•
•
•
•
•
•
•
•
•
Depressed mood most of the day (irritable)
Loss of interest or pleasure in activities
Significant weight loss (failure to gain weight)
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation
Fatigue or loss of energy nearly every day
Feelings of worthlessness or guilt
Poor concentration
Suicidal ideation
Consequences of trauma:
Behavioral Problems
 Aggression
 Oppositional behavior
 Conduct disorder/juvenile delinquency
 Toward parents, teachers, and peers
 In home and school/academic settings
Consequences of trauma:
Attachment and Social Deficits
• Insecure attachments: anger, noncompliance,
lack of persistence, little positive affect
• Misread social cues
• Lower peer status
• Fewer social skills
• Social networks are more insular and negative
Consequences of Trauma Exposure:
Academic and Learning Problems
•
•
•
•
•
No overall deficits in cognitive functioning
Receptive and expressive language
Learning problems
Reading ability
Comprehension and abstraction
Consequences of trauma:
In adulthood
 Major risk factor for:






Aggressive and violent behavior
Nonviolent criminal behavior
PTSD, depression and substance abuse
Interpersonal problems
Vocational difficulties
Medical problems (e.g., cardiovascular)
Mental Health Reactions to
Traumatic Events
• May appear immediately after the trauma or
days and even weeks/months later
• Reactions of children and adolescents vary
according to age, developmental level, and
proximity to the event
Children’s Reactions to Trauma
• Infants and Toddlers (age 3 and under)
– Crying
– Searching for parents/caregivers
– Clinging
– Change in sleep and eating habits
– Regressive behavior (e.g., thumb sucking, wetting)
– Repetitive play or talk
Children’s Reactions to Trauma
• Preschoolers and Young Children (ages 3-5)
– Fear of separating from parents/loved ones
– Clinging
– Tantrums or irritable outbursts
– Sleep disturbance (e.g., wanting parents, nightmares)
– Regressive behaviors (e.g., wetting, thumb-sucking)
– Withdrawal
– Increase in fears (in general: dark, monsters)
Children’s Reactions to Trauma
• Children ages 6 to 11 years
– Regressive behaviors (e.g., school refusal)
– Anger and aggression
– Avoidance and social withdrawal
– Inability to concentrate
– Depression and irritability
– Fears and worry
– Physical complaints (stomach, headaches)
– Self-blame
Children’s Reactions to Trauma
• Adolescents ages 12-17
– Responses may be more similar to adults and
specific to the trauma
– Depression, guilt/shame, helplessness
– General anxiety, panic attacks, dissociation
– Numbing, re-experiencing
– Mood swings, irritability
– School refusal (or academic decline)
– Concentration difficulties
Children’s Reactions to Trauma
• More adolescent symptoms:
– Fears: usually event-related (e.g., planes, death)
– Anger/resentment
– Sleep and appetite changes
– Withdrawal (becomes quiet and/or isolates self)
from peers, family, teachers, coaches
– Physical complaints
– Substance abuse
Importance of Caregiver Response
• Children, particularly young children, tend
to be strongly affected by their caregivers’
reactions to the traumatic event
• Parents tend to underestimate both the
intensity and duration of their children’s
stress reactions
How long do these reactions last?
• Disruptive feelings and behaviors found after
an extreme trauma are typical reactions
• Need to distinguish immediate phase (hoursweeks after the trauma) from short-term phase
(weeks to 2-3 months after the trauma)
• There have been few prospective, longitudinal
studies of the trajectory of post-trauma mental
health problems
Children in Decimated Areas: Stress Reactions postHurricane Andrew (La Greca et al., 2005)
35%
30%
25%
20%
3 Months
15%
7 Months
10 Months
10%
5%
0%
Moderate Stress
Severe Stress
Children in Decimated Areas: Stress Reactions postHurricane Andrew (La Greca et al., 2005)
• At 3 months, 55% of children with moderate-tosevere distress
– 2/3rds of those children were without distress by end
of 1-year post-hurricane
– 1/3rd of those children (less than 20%) had chronic
dysfunction until 10-year post-hurricane
• Applying to decimated areas in Queens, we
should expect to have 6,600 children continuing
to have mental health problems in one year
Vulnerability to Post-Disaster Mental
Health Problems (e.g., La Greca et al.,
2010, in press; Lai et al., 2012)
 Closer physical and emotional proximity
 Sense of control, predictability, and safety
 Exposure to secondary adversities (e.g., displacement)
 Loss of home, school, community
 Level of functioning prior to the trauma
 History of previous traumas
Vulnerability to Post-Disaster
Mental Health Problems







Other stressful life events during recovery period
Co-morbid diagnoses
Coping style/skills of child and parents
Lack of social support of child and family
Cognitive processing (e.g., self-blame)
High family conflict; low family cohesion
Media exposure
Summary of Literature (Bonanno et al., 2010)
• Disasters cause serious psychological harm in a minority
of exposed individuals
• Disasters produce multiple patterns of outcome,
including resilience
• Disaster outcome depends on a combination of risk and
resilience factors
• The remote effects of a disaster in unexposed
populations are generally limited and transient
• Disasters put families, neighborhoods, and communities
at risk—need to invest now to save later
Stages of Intervention
• Use research to guide our practice
– Immediate/Crisis intervention
• Safety and routine are primary
• Intervention goal: Educate and normalize
– Short-term/Preventive intervention
• Identify children and adults at risk
• Promote coping and social support
– Long-term/Treatment
• Treatment of PTSD and other trauma-related symptoms
Model of Research/Intervention
Trauma
Prevention
MH Diagnosis
Crisis and
Preventive
Interventions
Treatment
Prevention
• Goals: Prevent emotional and physical trauma
• Existing programs
– Tend to focus on one form of trauma
– Limited research
– Poor engagement of participants
• Avoidance of topics/trainings
• Avoidance of discussion with children
Prevention
• KEYS: Keeping Every Youth Safe (Brown & Beekman)
– Present proven steps for children’s safety
• Protecting against sexual abuse
• Protecting against excessive physical and verbal discipline
– Discuss barriers to taking action
– CPR and choking relief
– Emergency preparedness
• Preliminary research reveals improvements in
knowledge and behavior
Immediate/Crisis Intervention
• Goals: If normal and will heal, why intervene?
– Symptoms are painful
– Symptoms cause impairment
• In child development
– Academic functioning
– Peer relationships
• In adult functioning
– Job performance
– Friendships and romantic relationships
– Parenting
• Which, in turn, cause long-term MH problems
Research on Crisis Interventions
• No randomized trials of hotlines and other forms of
crisis intervention
• No randomized trials of post-disaster Psychological
First Aid or Project Liberty—evidence-informed
• Research on Critical Incidence Stress Debriefing
– Developed for emergency service personnel
– Designed to prevent PTSD
– Detailed account of their traumatic experiences
• This “debriefing” has been shown to be iatrogenic—
associated with higher likelihood of developing PTSD
Lessons Learned from 9/11
• Lack of coordination of services/chaos
• FEMA funded Project Liberty
– Crisis counseling
– Provided psychoeducation
– Centralized services
– Aided with referral
• For Hurricane Sandy: Project Hope
– Crisis counseling and Psychological First Aid
Psychological First Aid—Delivery
•
•
•
•
•
•
•
•
Helpers: Adults on the front-line (paras and profs)
Days-weeks after a disaster
Be emotionally ready
Consider the setting, participants, etc.
Maintain a calm presence
Be sensitive to culture and diversity
Be aware of at-risk populations
Be informed of available services
Psychological First Aid—Core Actions
•
•
•
•
Contact and Engagement
Safety and Comfort
Stabilization (of emotionally overwhelmed)
Information Gathering: Current Needs and Concerns
– Too early for MH screening—will over-identify number of
children who need services (false positives)
•
•
•
•
Practical Assistance
Connection with Social Supports
Information on Coping and stress reactions
Linkage with Collaborative Services
Psychological First Aid: Resources
• Outline and materials
– http://www.nctsn.org/content/psychological-firstaid
• Web-based training
– http://learn.nctsn.org/course/category.php?id=11
• App for Iphone
– PFA Mobile
• In progress: PFA for schools
Short-Term/Preventive Intervention
• Goals:
– Reduce current symptoms
– Prevent the development of long-term problems
– Identify existing coping skills
– Improve functioning
– Potentially lower the need for formal mental health
treatment
– Identify need and refer for treatment if warranted
Research on Preventive Interventions
• Brief CBT (Psychoeducation and Coping Skills)
– Prevented the development of PTSD following a
sexual assault (Foa et al., 1995)
– More efficacious in preventing anxiety disorders than
debriefing or routine community care in children
who came through the ED (Silovsky et al., 2004)
– 65% less likely than comparison youth to meet
criteria for PTSD 3 months post-disclosure of trauma
(CFTSI; Marans et al., 2009)
Lessons Learned from 9/11
• Continuum-of-care was incomplete
– Crisis intervention was available in form of Project
Liberty and other services
– Evidence-based therapies were available through
Child and Adolescent Trauma Services (CATS), NYU
Child and Family Recovery Program, and others
– There was no preventive intervention
Skills for Psychological Recovery: Delivery
• After safety, security, and other needs have been met
and community is rebuilding
• For children and adults
– In the short-term
– In the long-term who are minimally symptomatic
• Minimum of 3-5 sessions; driven by assessment and
time since trauma
• Helpers: Professionals who provide ongoing support
and assistance to children, families and adults (e.g.,
clergy, educators, librarians)
Screening and Assessment Tools
• Constructs
– PTSD and other mental health problems
– Risk and protective factors
• Procedures
– Structured versus unstructured
– Screening versus comprehensive evaluation
– Standardized Assessment Instruments
• Paper and pencil (e.g., Child PTSD Symptom Scale)
• Interview (e.g., UCLA PTSD Reaction Index)
• Sources
– Child, parent, teacher
Skills for Psychological Recovery
• Core skills
– Building problem-solving skills
– Promoting positive and pleasurable activities
– Managing physical and emotional reactions to
upsetting situations (e.g., triggers, sleep problems)
– Promoting helpful thinking
– Rebuilding healthy social connections
• Done it in Haiti, Puerto Rico—incorporated
cultural adaptations
Skills for Psychological Recovery:
Resources
• Information on the National Child Traumatic
Stress Network website:
– http://www.nctsn.org/nctsn_assets/pdfs/newslett
ers/Impact_Summer_2010.pdf
• Child HELP Partnership will be providing
training and supervision on the model starting
in early 2013
Long-Term Solutions
• Repeat assessment of trauma-related mental
health symptoms and functional impairment
• If trauma-related symptoms continue or
worsen, access evidence-based, traumainformed therapies
– Trauma-Focused Cognitive Behavioral Therapy (TFCBT; Cohen, Mannarino, & Deblinger, 2006)
– Cognitive Behavioral Intervention for Trauma in
Schools (CBITS; Jaycox, 2003)
Treatment Research
• TF-CBT and CBITS are the most rigorously tested
treatments for traumatized children
• More than 12 randomized trials
– Improved PTSD, depression, anxiety, and behavior problems
compared to supportive treatments
– TF-CBT improved parental distress, parental support, and
parental depression compared to supportive treatment
– Effective in individual/family and group formats
– Symptom decreases maintained at 2-year follow-up
– Findings replicated and generalized across racial, ethnic, and
geographic boundaries (King et al., 2000)
Lessons Learned from Hurricane Katrina
• Field trial of TF-CBT and CBITS (Jaycox et al., 2010)
• Assessment 15 months after the hurricane
• 60.5% of children screened positive for PTSD and
were offered CBITS at school or TF-CBT at a
mental health clinic
• Both lead to significant symptom reduction
• More children chose CBITS
• Greater symptom reduction for TF-CBT
Difficulties Addressed by TF-CBT
• CRAFTS
 Cognitive Problems
 Relationship Problems
 Affective Problems
 Family Problems
 Traumatic Behavior Problems
 Somatic Problems
Core Values of TF-CBT
• CRAFTS
 Components-Based
 Respectful of Cultural Values
 Adaptable and Flexible
 Family Focused
 Therapeutic Relationship is Central
 Self-Efficacy is emphasized
TF-CBT Components
• PRACTICE
 Psychoeducation and Parenting Skills
 Relaxation
 Affective Modulation
 Cognitive Processing
 Trauma Narrative
 In Vivo Desensitization
 Conjoint parent-child sessions
 Enhancing safety and social skills
TF-CBT Sessions Flow
Baseline
Assessment
Entire Process is Gradual Exposure
Sessions
1-4
Psychoeducation
Parenting Skills
5-8
Trauma Narrative
Development and
Processing
Relaxation
Affective
Expression and
Regulation
Cognitive Coping
In-vivo Gradual
Exposure
9-12
Conjoint Parent
Child Sessions
Enhancing
Safety and
Future
Development
TF-CBT: Child and Parent
Components
• Individual sessions for both child and
parent
• Parent sessions - generally parallel child
sessions
• Same therapist for both child and parent
A Learning Resource for TF-CBT
Access at:
www.musc.edu/tfcbt
•Web-based learning
•Learn at own pace
•Concise explanations
•Video demonstrations
•Clinical scripts
•Cultural considerations
•Clinical Challenges
•Resources
•Links
•10 hours of CE
•Free of charge
Structure of CBITS
• School-based intervention
–10 week groups
–1 class period/week
–Individual sessions for trauma narrative
–6-8 children per group
–Run by a clinician
Difficulties Addressed by CBITS
• Reduce symptoms of:
– PTSD
– Depression
– Behavioral problems
• Improve:
– Functioning
– Grades and attendance
– Peer and parent support
– Coping skills
CBITS Components
•
•
•
•
•
•
•
•
Psychoeducation
Relaxation
Social problem solving
Cognitive restructuring
Exposure
Between
Homework assignments and activities
2 parent and 1 teacher education sessions
CBITS Resources
• Developer: Lisa Jaycox, PhD, Rand Corporation
• Website:
– http://cbitsprogram.org/
• Audra Langley, PhD
Director of Training
– alangley@mednet.ucla.edu
Taking Care of the Care Takers
• Protect against your own secondary stress /
vicarious trauma response:
– Use your colleagues/supervision to process your
own feelings and experiences
– Engage in self-care
•
•
•
•
Basics: eating, sleeping
Exercise
Social support
Coping skills
Resources
• Resources for Traumatized Children and their
Caregivers
– National Child Traumatic Stress Network
http://nctsn.org/trauma-types/natural-disasters
– TF-CBT web www.musc.edu/tf-cbt
• Resources for Adults
– National Center for PTSD http://www.ptsd.va.gov/
– International Society for Traumatic Stress Studies
http://www.istss.org/Home.htm
Resources
• Mental Health Support and Services in Your Area
– Disaster Distress Helpline 1-800-985-5990; text
'TalkWithUs' to 66746 (Spanish-speakers can text
'Hablanos' to 66746)
– LIFENET
• 1-800-LIFENET; 1-877-AYUDESE (for Spanish speakers)
• 1-877-990-8585 (for Korean and Mandarin and Cantonese
speakers)
– Health Information Tool for Empowerment (HITE)
• www.hitesite.org
Resources
• Mental Health Support and Services in Your Area
– The Child HELP Partnership
• 718-990-2367
• www.stjohns.edu/thechildhelppartnership
• browne@stjohns.edu
• Developers/trainers of Keeping Every Youth Safe
• Trainers in Skills for Psychological Recovery
• Trainers in trauma-specific therapies