Outline for today...........
• Adolescent development, including
neuroscience
• Introduction to adolescent mental health
problems; and some treatments you may
come across (e.g. ADHD,ASD,PTSD,
depression, anxiety, eating disorders,
psychosis, self harm, substance misuse)
• Risk and resilience
Different aspects of development
• Physical – growth and maturation of the brain and body.
• Cognitive – skills associated with perception, such as thinking,
memory, problem solving, attention, perseverance and
language skills.
• Emotional – awareness, expression and management of
feelings and ability to empathise.
• Social – making, maintaining and ending relationships,
understanding of social roles, rules, morals, customs and
values. Vocation/occupation
• Identity – self-evaluations (e.g. self-esteem and self-efficacy),
autobiography (i.e. life stories) and sense of belonging.
What impacts on early years development?
•
Parental factors – attachment history and resources, health and wellbeing,
abuse, loss and trauma, disabled parent/child, Domestic violence,
Substance misuse, Parental MH, neglect and abuse, expectations (gender,
reminders of ex- or abusive partners)
•
Child factors – risk and resilience, prenatal factors (e.g. chromosome
abnormalities, intra-uterine growth, pre-natal infection, congenital
abnormality), temperament, disabling conditions (hearing loss, physical
and learning disabilities, developmental disorders), premature
•
Environmental factors – social network, connectedness, resources and
poverty, gains and losses, transitions, severe illness, lack of opportunity to
practice skills, poverty
•
Cultural factors – awareness and definitions of development and abuse
•
THESE FACTORS ALL INTERACT…..
What interferes with ‘healthy’ brain
development?
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•
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Prenatal exposure to drugs and alcohol
Malnutrition
Neglect – lack of stimulation
Poor attachments
Physical and sexual abuse
Parental ill-health
Chronic stress
Stages of Adolescence
So what happens in Adolescence?
• Critical period of brain development
• 2nd wave of overproduction of gray (thinking)
matter
• Frontal cortex myelination (insulation)
• “Pruning” (cut back weak branches)
• Continuing process until early 20s at least
• SO – A WORK IN PROGRESS
The Whole Brain is Affected
The Pre-frontal cortex and the amygdala
PFC – involved in
executive function:
Increase in pfc neurons
just before puberty
Pruning.
Thickening & myelination
The amygdala is involved in
the unconscious processing
and memory of reactions to
emotional events.
Increases in size
Emotional Functioning in
Adolescence
• There is a mismatch between emotional and
cognitive regulatory modes in adolescence
• Brain structures mediating emotional experiences
change rapidly at the onset of puberty
• Maturation of the frontal brain structures
underpinning cognitive control lag behind by
several years
• Adolescents are left with powerful emotional
responses to social stimuli that they cannot easily
regulate, contextualise, create plans about or
inhibit
The PFC
Executive function
The Amygdala
Processes and interprets sensory data
Assigns emotional meaning, especially
negative
Modulates the flow of information from the
cortex to the hypothalamus
Affects autonomic, endocrine and
affective responses
Reading Emotion from Facial Expressions
1. This face is expressing...
Embarrassment
Fear
Sadness
Surprise
http://greatergood.berkeley.edu/ei_quiz
This face is expressing...
Sadness
Pain
Anger
Disgust
http://greatergood.berkeley.edu/ei_quiz
http://greatergood.berkeley.edu/ei_quiz
This face is expressing...
Sadness
Shame
Disgust
Contempt
MAIN ISSUES
1.
2.
3.
4.
5.
6.
7.
Substance Use
School/occupation
Identity
Family/whanau support
Multiple needs – comorbidities
Social disadvantage & exclusion
Appropriate & accessible services
Implications
• Brain more sensitive to experiential input
during adolescence (executive function)
• ?These skills may be more difficult to
“hardwire” after puberty
• ?So should we be looking at specific
interventions at this age
USE IT OR LOSE IT??
Social Cognition
• Perspective taking – “step into other’s shoes”
• Experiment – shown a face & word, need to name
the emotion (uses working memory & decision
making) – pubertal “dip”
• “Face processing” –
(happy,sad,angry,fearful,disgusted,surprised)
Young teens use “gut reactions”
These abilities develop during puberty
(fear,disgust,anger) and then can use reasoning
EXECUTIVE FUNCTION
• The capacity that allows us to control &
coordinate our thoughts & behaviour
• Different skills involved e.g.:
• ability to initiate and stop actions
• control impulses and regulate emotions
• monitor and change behaviour as needed
DOMAINS OF IMPAIRMENT
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Attachment
Biology
Affect/emotional regulation
Dissociation
Behavioural control
Cognition
Self concept
Adolescent changes 2
• The adolescent capacity to inhibit responses is not
fully mature; mortality rises in adolescence due to
risk taking behaviour
• Adolescents tend to take greater risks than adults.
• Adolescents tend to foresee fewer possible
outcomes of their risk-taking, underestimate the
likelihood of negative outcomes, and overvalue the
benefits of having fun and obtaining the approval of
others
• BUT is some risk taking essential for healthy
development?
So what happens in Adolescence?
• Adolescence, (esp 14 to 16), constitutes
another “critical” period” of particularly
dramatic developmental changes
• Neural pathways are “hardwired’ by the
process of pruning and myelinisation
• Parietal and temporal lobes mostly mature in
adolescent brain – vision, hearing, spatial
awareness, language
And also…….
• Frontal & prefrontal cortex continue to
develop until early 20s – cognitive processing
and executive function
• Development is idiosyncratic and non-linear
• The brain regions undergoing transformation
during adolescence are highly sensitive to
stressors, including environmental influences
Adolescent changes 1
• Continued improvement on:
• Selective attention, working memory, problem
solving
• Perspective taking – “step into other’s shoes”
• Social cognition - Young teens use “gut
reactions”, abilities develop during puberty
and then can use reasoning
Why would anyone DO that?
The Pros and Cons
 Increased risk of damage from drugs/alcohol
 Increased risk of developing addiction
 Increased risk of mental illness
 Increased risk-taking
 Areas of the brain controlling impulsive behaviour, judgement and
emotional control mature last.
 Greater capacity to learn and create.
 Greater capacity to embrace high risk/high reward decisions.
Sleep
Family Influences
• Increase in parent-child conflict, mostly mothers –autonomy,
authority
• Conflict may be valuable as part of development – may
encourage advanced reasoning
• Midlife crisis for parents???
• Sibling relationships – high degree of conflict common!
• Children don't present themselves to services
• Still low cultural competency of professionals?
• Cultural difference in expression and tolerance of symptoms
More specifically…..
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Prosocial father’s absence
Antisocial father’s presence
Coercive parenting
Mothers with depression (whilst rearing children)
Concentration of crime in families
Marital conflict and domestic violence
Low supervision, weak parent child attachment
Genetic liability and effect of children's behaviour on parents
Effects of Trauma
• Chronic stress can lead to changes in brain
structure and function because it occurs at a
sensitive developmental period
• This can present as: fluctuations in mood,
suicidal thoughts, and intense distress which
may lead to self harm.
• Acting out, risk taking behaviour, self
destructiveness, and delinquency
• Depression, withdrawal
Some clinical implications
• Neurochemical changes, leading to increased
physiological responsivity
• Dysregulation of biological stress system
• Decreased cognitive function, attention,
concentration, executive function, memory &
learning
• Can interfere with the capacity to integrate
sensory, cognitive & emotional information.
Difficult to organise & express feelings, struggles
to allow others to help
• Hyper arousal, fighting, avoidant, dissociative. ….
Some Important Considerations
• EF -The capacity that allows us to control & coordinate
our thoughts & behaviour
• Different skills involved e.g. working memory, voluntary
response inhibition, decision making, filtering out
unimportant information, holding in mind a plan to
carry out in the future, inhibiting impulses, Problem
solving!!
• Social Cognition - Perspective taking – “step into other’s
shoes”, “Face processing” –
(happy,sad,angry,fearful,disgusted,surprised)
• Young teens use “gut reactions” - these abilities develop
during puberty (fear,disgust,anger) and then can use
reasoning
Ripples in a Pond - Why Violence and Abuse Happens
Interpersonal and Family Factors
Abusive
parenting
Abusive expression of
power differentials
Poor conflict resolution
& communication skills
Lack of
interpersonal respect
Types of Violence
Child Abuse Sexual Violence
Dating Violence Domestic Abuse
Bullying Youth Violence
Hate Crimes Elder Abuse
Individual
Factors
Genetics
Hormones
Nutrition
Males
Alcohol
Drugs
Tobacco
Emotional
intelligence
Past abuse
Genetics
Hormones
Nutrition
Females
Physiological
Learning
Disability
Individual
Factors
alterations in
Increased
Brain
risk of
brain following
perpetrating
abuse affect
abuse
the limbic
ADHD
Conduct
system,
Disorder
midbrain
Anti-Social
& frontal lobes
Behaviour &
Offending
Personality
PTSD
behaviour
Disorders
Risk behaviour
Brain
Dissociative
Disorders
Increased
risk of
re-abuse
Learning
Disability
Withdrawal
Alcohol
Drugs
Tobacco
Past abuse
Depression
Borderline & Suicide
Personality
Disorder
STIs
Pregnancy
Obesity
CHD
Cancer
CHD
Cancer
-Plasticity of the brainAlterations in the brain are adaptable especially until the mid- 20’s
CBT/ therapy, protective & pro-social skills reduces harm & aids recovery
Community and Societal Factors
Legislation re
alcohol & drugs
Deprivation
& economic inequalities
Historical &
cultural norms
Prejudice & inequalities re
gender, age, race, sexuality
Nurse J
2006
33
Psychiatric Diagnoses…….
• EMOTIONAL DISORDERS – adjustment disorders,
anxiety disorders, depression
• DISRUPTIVE BEHAVIOUR – O.D.D., Conduct disorders
• DEVELOPMENTAL – ADHD, Autistic spectrum
• INTELLECTUAL DISABILITY
• SUBSTANCE USE
• PSYCHOSIS (inc Bipolar I Disorder)
Psychosocial Immaturity
• Susceptibility to peer influence
• Attitudes towards & perception of risk
• Future orientation
• Capacity for self management
These factors may affect decision outcomes,
even if cognitive processes are mature
Also consider “identity crisis”, short lived risky
behaviours – mostly stop with settled identity
(grow out of it).
So why join a gang?
• "The gang has taken on the responsibility of
doing what the family, school, and other social
agencies have failed to do – provide
mechanisms for age and sex development,
establish norms of behaviour, and define and
structure outlets for friendship, human
support an the like." (Vigil 1988:168)
21st Century Issues?
• The changed nature of the social environment in which young
people find themselves compared with that of previous
generations.
• The nature of peer pressure and role models has been
radically altered by exposure to electronically connected
social networks and to very different media content.
• The human brain continues to mature into the early 20s; the
nature of brain maturation and the complicated environment
in which young people are currently living place adolescents
at higher risk for mental health disorders, particularly anxiety
and depression.
• The adolescent brain is clearly more sensitive to both alcohol
and cannabis, with potential long-lasting adverse
consequences
Key Messages
1.
2.
3.
4.
•
Secure & healthy relationships provide building blocks for
human health & development
These begin in infancy and support healthy brain, social and
emotional development.
Humans are born with predisposition for relatedness; a sense
of belonging and connectedness to others (we are social
beings); the opposite –alienation; disconnection; no sense of
belonging relate to wide range of problems.
Difficulties children experience and present to others are
outcomes of difficulties in their relationships; harm; loss and
trauma and how these are internalised.
Theories include evolutionary biology and attachment –the
importance of safety for survival (Crittenden); neuroscience,
attachment and brain development; Developmental psychopathology
emphasising the importance of early attachment history and trauma
& later mental health difficulties
.
Why Adolescent/Youth Mental Health?
• Adolescence and early adulthood is a critical time for personal
development. The major threat to this comes from mental ill health
with 75% of mental and substance use disorders emerging by age
25. More severe disorders are typically preceded by less severe
disorders that are rarely brought to clinical attention. By age 21, just
over half of young people will have experienced a diagnosable
psychiatric disorder.
• Latest research reveals the complex interplay of genes,
environment, psychological and social factors underpinning the
development of these conditions in young people. These conditions
can have a devastating impact on young people’s potential to
establish their own independence and goals.
• Mental health problems that commence in young adulthood have
important long-term vocational consequences, including reduced
workforce participation, lower income and lower economic living
standards at age 30.
“Roughly half of all lifetime mental disorders in most studies start
by the mid-teens and three quarters by the mid-20s. Later onsets
are mostly secondary conditions. Severe disorders are typically
preceded by less severe disorders that are seldom brought to
clinical attention”
Kessler et al, Current Opinion Psychiatry, 2007
Common Psychological problems of Looked
after Children
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Attachment problems
Relationship problems
Attention and Concentration Difficulties
Low tolerance/control/emotional regulation
Anger and aggression
Conduct difficulties
Anxiety
Depression
Substance misuse
Self-harm
High rates of risk taking behaviours
DOMAINS OF IMPAIRMENT
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Attachment
Biology
Affect/emotional regulation
Dissociation
Behavioural control
Cognition
Self concept
AFFECT/EMOTION REGULATION
• Easily aroused, high intensity emotions
• Difficulty describing feelings and internal
experience
• Chronic and pervasive low mood, or sense of
emptiness & dread
• Chronic suicidality
• Over-inhibition or excessive expressions of anger
• Difficulty communicating desires and wishes
ATTACHMENT
• Uncertainty about reliability & predictability of
the world
• Problems with boundaries
• Distrust, suspiciousness
• Social isolation
• Difficulty attuning to other people’s emotional
states and point of view
• Difficulty with perspective taking
SELF CONCEPT
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Lack of continuous sense of self
Low self esteem
Shame & guilt
Poor sense of separateness
Body image disturbance
Sense of being ineffective in dealing with
environment
BEHAVIOUR
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Poor impulse control
Self destructive
Aggression
Sleep disturbance
Eating disorders
Substance abuse
Oppositionality
Excessive compliance
Difficulty understanding & complying with rules
Re-enactment of past trauma
Therapeutic models
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Developmental
Attachment
Trauma
Loss
Systemic Theory
Cognitive Behavioural Theory
Ethical Issues
• Lots, particularly with this client group
– Informed Consent
– Confidentiality
– Testing procedures
– Practical considerations
– Legal
How resilience has been defined?
“Resilience is the process of adapting well in the face
of adversity, trauma, tragedy, threats, or even
significant sources of stress – such as family and
relationship problems, serious health problems, or
workplace and financial stressors. It means
“bouncing back” from difficult experiences…
….The road to resiliency is likely to involve
considerable emotional distress.”
American Psychological Association
Important Adolescent Factors
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School – Achieving? Attending??!!
Leisure/recreation opportunities
Family/parental relationships
Peer group
Drugs & Alcohol
Impulsivity, Risk taking
What is resilience?
• Individual attributes or trait? (i.e. fairly fixed,
such as high intellect)
• Factors which predict vulnerability/risk or
strengths/protection? (i.e. internal or external,
such as educational attainment and family
stability)
• Processes and mechanisms (i.e. ways in which
people deal with adversity, such as ability to
seek support and availability of support)
So what is resilience?
• It’s the process of adapting well in the face of adversity, trauma, tragedy,
threats, or even significant sources of stress, such as family and
relationship problems, serious health problems, education/workplace and
financial stresses.
• Although resilience often refers to the ability to “bounce back” from
difficult experiences before this starts to happen people have experienced
emotional pain and sadness as a result of a major adversity or trauma in
their lives.
• The road to resiliency often involves considerable emotional distress – it
comes later on rather than immediately.
• Resilience is related to the nature of the risk or adversity, our previous
experiences, the quality of our relationships and attachments and the
environment in which we live.
• Resilience is not a trait that people have or don’t have.
Factors associated with resilience
The importance of relationships
• The primary factor is having caring & supportive relationships within & outside the family.
Relationships that offer love, trust and security, provide role models & offer encouragement
& reassurance.
• Resilient people don’t go it alone, when bad things happens they reach out to the people
who care about them and they ask for help
The importance of our own personal qualities, attributes and skills
• The capacity to make realistic plans and take steps to carry them out;
• Having a positive view of yourself and confidence in your strengths and abilities;
• The ability to recognise your own feelings & read & understand other people’s feelings;
• The capacity to manage strong feelings and impulses;
• Being prepared to take appropriate risks and a willingness to try things and think failure is
part of life – mistakes are learning opportunities
NOTE: the road to resilience is different for everyone. What works for one person may not work
for another.
Useful websites…………..
• International Association for Youth Mental
Health www.iaymh.org
• www.youngminds.org.uk
• www.rcpsych.ac.uk
• www.camh.org.uk
• www.chimat.org.uk
• Locally – Cornwall intranet, CPFT
• Cornwall Council – Families Information Service
• Children's Care Management Centre 01872
221400
Acknowledgements
AND
Prof Sarah-Jayne Blakemore
Institute of Cognitive Neuroscience
University College London
Much of the material in this talk is taken from the 1st Edition of
Nicola Morgan’s very readable book “Blame My Brain”, the 3rd
edition of which has just been published, and from the many
excellent papers published by Sarah-Jayne Blakemore.
Any errors in the information in this talk are entirely my own.
May 2nd 2013
Criterion A: DSM-IV
The person was exposed to: death, threatened
death, actual or threatened serious injury, or actual or threatened sexual violence, as follows:
(one required)
• Direct exposure.
• Witnessing, in person.
• Indirectly, by learning that a close relative or close friend
was exposed to trauma. If the event involved actual or
threatened death, it must have been violent or accidental.
• Repeated or extreme indirect exposure to aversive details
of the event(s), usually in the course of professional duties
(e.g., first responders, collecting body parts; professionals
repeatedly exposed to details of child abuse). This does not
include indirect non-professional exposure through
electronic media, television, movies, or pictures.
Criterion B: Intrusion Symptoms The traumatic event
is persistently re-experienced in the following way(s): (one required)
• Recurrent, involuntary, and intrusive memories. Note:
Children older than six may express this symptom in
repetitive play.
• Traumatic nightmares. Note: Children may have frightening
dreams without content related to the trauma(s).
• Dissociative reactions (e.g., flashbacks) which may occur on
a continuum from brief episodes to complete loss of
consciousness. Note: Children may reenact the event in
play.
• Intense or prolonged distress after exposure to traumatic
reminders.
• Marked physiologic reactivity after exposure to traumarelated stimuli.
Criterion C: Avoidance Symptoms
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
• Trauma-related thoughts or feelings.
• Trauma-related external reminders (e.g.,
people, places, conversations, activities,
objects, or situations).
Criterion D:Negative alterations in
cognitions or moods
• Inability to recall key features of the traumatic event (usually dissociative
amnesia; not due to head injury, alcohol, or drugs).
• Persistent (and often distorted) negative beliefs and expectations about
oneself or the world (e.g., "I am bad," "The world is completely
dangerous").
• Persistent distorted blame of self or others for causing the traumatic event
or for resulting consequences.
• Persistent negative trauma-related emotions (e.g., fear, horror, anger,
guilt, or shame).
• Markedly diminished interest in (pre-traumatic) significant activities.
• Feeling alienated from others (e.g., detachment or estrangement).
• Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and
reactivity
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•
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•
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Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
Specify if: With dissociative symptoms
• Depersonalization: experience of being an
outside observer of or detached from oneself
(e.g., feeling as if "this is not happening to
me" or one were in a dream).
• Derealization: experience of unreality,
distance, or distortion (e.g., "things are not
real").
Specify if: With delayed expression.
• Full diagnosis is not met until at least six
months after the trauma(s), although onset of
symptoms may occur immediately.
Family Systems
• Complex factors relating to family systems must
be considered in children with PTSD
• Parent’s reports of their child’s experience of
symptoms following trauma generally minimise
the level of distress as described by the child
• Secondary stressors are often involved in cases of
childhood or adolescent trauma (relocation,
changing schools, separation from family
members, financial difficulties of the family)
Complex PTSD
It is worse if:
• it happens at an early age – the earlier the age,
the worse the trauma
• it is caused by a parent or other care giver
• the trauma is severe
• the trauma goes on for a long time
• you are isolated
• you are still in touch with the abuser and/or
threats to your safety
Complex PTSD
• Lack of trust in other people – and the world
in general – is central to complex PTSD.
Treatment often needs to be longer to allow
you to develop a secure relationship with a
therapist – to experience that it is possible to
trust someone in this world without being
hurt or abused. The work will often happen in
stages: stabilisation, trauma-focussed therapy
Psychological theories..........
• When we are frightened, we remember things very clearly.
Although it can be distressing to remember these things, it can help
us to understand what happened and, in the long run, help us to
survive.
• The flashbacks can be seen as replays of what happened. They
force us to think about what has happened so we might be betterprepared if it were to happen again.
• It is tiring and distressing to remember a trauma. Avoidance and
numbing keep the number of replays down to a manageable level.
• Being 'on guard' means that we can react quickly if another crisis
happens. We sometimes see this happening with survivors of an
earthquake, when there may be second or third shocks. It can also
give us the energy for the work that’s needed after an accident or
crisis.
Physical theories.........
• Adrenaline is a hormone our bodies produce when we are under
stress. It 'pumps up' the body to prepare it for action. When the
stress disappears, the level of adrenaline should go back to normal.
In PTSD, it may be that the vivid memories of the trauma keep the
levels of adrenaline high. This will make a person tense, irritable,
and unable to relax or sleep well.
• The hippocampus is a part of the brain that processes
memories. High levels of stress hormones, like adrenaline, can stop
it from working properly – like 'blowing a fuse'. This means that
flashbacks and nightmares continue because the memories of the
trauma can’t be processed. If the stress goes away, and the
adrenaline levels get back to normal, the brain is able to repair the
damage itself, like other natural healing processes in the body. The
disturbing memories can then be processed and the flashbacks and
nightmares will slowly disappear.
Complex PTSD
• This can start weeks or months after the
traumatic event, but may take years to be
recognised.
• Trauma affects a child's development - the earlier
the trauma, the more harm it does. Some
children cope by being defensive or aggressive.
Others cut themselves off from what is going on
around them, and grow up with a sense of shame
and guilt rather than feeling confident and good
about themselves.
Complex PTSD
•
•
•
•
•
•
•
•
•
•
As well as many of the symptoms of PTSD described :
feel shame and guilt
have a sense of numbness, a lack of feelings in your body
can't enjoy anything
control your emotions by using street drugs, alcohol, or by
harming yourself
cut yourself off from what is going on around you
(dissociation)
have physical symptoms caused by your distress
find that you can't put your emotions into words
want to kill yourself
take risks and do things on the 'spur of the moment'.
Family Systems
• Threat to caregiver is a strong predictor of the
development of PTSD in infants and young
children
• Parents experiences of trauma may precipitate
PTSD in their children
• Children’s experiences of trauma may
precipitate PTSD in their parents
• Parents may inflict trauma onto their children
(in cases of physical or sexual abuse)
Attachment and trauma
• Infant and child attachment to a caregiver
provides the infant/child with a context
through which to organise emotional,
cognitive and behavioural interactions (Finzi
et. al., 2001).
• Three attachment styles; secure,
avoidant/ambivalent, and avoidant.
Attachment and trauma
• Infant and child attachment to a caregiver
provides the infant/child with a context
through which to organise emotional,
cognitive and behavioural interactions (Finzi
et. al., 2001).
• Three attachment styles; secure,
avoidant/ambivalent, and avoidant.
Insecure attachment
• Child does not see their caregiver as being responsive in
times of need
• Caregivers may induce traumatic states in their children
(e.g., abuse)
• Caregivers tend not to interactively repair their child’s
negative affective states
• Children of abusive caregivers may react with fight-or-flight
responses, develop ‘freezing’ responses, or enter a state of
‘fear without solution’ which can result in early dissociative
states
• Children of abusive caregivers are still dependent on their
caregiver; dissociation may allow maintenance of
attachment whilst ‘escaping’ harm
Implications for therapeutic alliance
• Children who have experienced abuse may apply
coping strategies informed by early insecure
attachment to future relationships
• Children may expect similar maltreatment in
future relationships
• Clinicians need to be mindful of this phenomena
when treating traumatised children
Shattered Assumptions
Shattered assumptions about safety and control can
be considered as part of the ‘meaning making’
process that occurs following significant trauma.
Prior to a traumatic event;
My parents are in control
My parents will keep me safe
Bad things happen to other people, not me
I am worthy and life has meaning
Shattered Assumptions
Trauma can alter children’s core beliefs about their
sense of self and the world. The basic assumptions
listed previously can be shattered and reconstituted
in forms such as;
I am not in control and neither are my parents
I am not safe and my parents are unable to keep me
safe
Bad things can happen to me
If bad things happen to me I must deserve it
I am not worthy of safety
Building relationships with
traumatised children and adolescents
• Relationships with therapists may be especially
important for traumatised populations
• Building relationships with traumatised young
people can be challenging for therapists
• Therapists should foster predictability,
consistency and safety in the relationship and in
sessions
– Use ritual greetings, session format, taking things out
and putting away, goodbye
Building relationships with
children
and people
adolescents
• traumatised
Traumatised children
and young
may test
out the limits of the relationship with their
therapist
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–
–
–
Rule breaking
Dangerous behaviour
Physical aggression
Inappropriate sexual behaviour
Therapists must set limits on behaviour whilst
maintaining relationship; the young person needs to
know that their behaviour does not change the
therapists view of them as a person.
Treatment of PTSD in children and
adolescents
Treatments that have been found to effectively
treat PTSD in children and adolescents include;
• Trauma-focused Cognitive Behaviour Therapy
• Systemic family systems approaches
• Eye Movement Desensitisation and Reprocessing
Posttraumatic Growth and TraumaInformed Resilience.
• Positive change arising from a persons’ recovery
from trauma, through the effective use of coping
skills following exposure to trauma
• Trauma-informed resilience is a similar concept
whereby a person’s ability to ‘bounce back’ from
adversity is strengthened following successful
recovery from trauma (Steele & Kuban, 2011).
Posttraumatic Growth and TraumaInformed Resilience
Trauma informed therapy will foster;
• physical and emotional safety of the child
• self-regulation
• sensory cognitive integration
• trauma-informed relationships and environments
• trauma integration.
References
•
•
•
•
•
•
•
American Psychiatric Association (2000). Diagnostic and Statistical Manual of
Mental Disorders (4th Ed., Text Revision). Washington, DC: APA.
Brewer, J. & Sparkes, A. (2011). Parentally bereaved children and posttraumatic
growth: Insights from an ethnographic study of a UK childhood
bereavement service. Mortality, 16, 204-222.
Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002). Toward an empirical
definition of pediatric PTSD: The phenomenology of PTSD symptoms in
youth. Journal of the American Academy of Child and Adolescent
Psychiatry, 41, 166-173.
Critendon, P. M. & Ainsworth, M. D. S. (1989). Child maltreatment and
attachment theory. In Child Maltreatment: Theory and research on the
causes and consequences of child abuse and neglect by Cicchetti, D. &
Carlson, V. Cambridge University Press: United Kingdom.
De Zulueta, F. (2009). Post-traumatic stress disorder and attachment: possible
links with borderline personality disorder. Advances In Psychiatric
Treatment, 15, 172-180.
Dyb, G., Jensen, T. K., & Nygaard, E. (2011). Children’s and Parents’
posttraumatic stress reactions after the 2004 Tsumani. Clinical Child
Psychology and Psychiatry, 16, 621-634.
Fernandez, S., Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J.
L. (2013). A case series: Cognitive-behavioural treatment (exposure,
relaxation, and rescripting therapy) of trauma-related nightmares
experienced by children. Clinical Case Studies, 12, 39-59.
References
• Finzi, R., Ram, A., Har-Evan, D., Shnit, D. & Weizman, A. (2001).
Attachment styles and aggression in physically abused and neglected
children. Journal of Youth and Adolescents, 30, 769-786.
• Graham-Bermann, S. A., Castor, L. E., Miller, L. E., & Howell, K. H. (2012).
The impact of intimate partner violence and additional traumatic events
on trauma symptoms and PTSD in preschool-aged children. Journal of
Traumatic Stress, 25, 393-400.
• Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged
and repeated trauma. Journal of Traumatic Stress, 5, 377-391.
• Lemma, A. (2010). The power of relationship: A study of key working as an
intervention with traumatised young people. Journal of Social Work
Practice, 24, 409-427.
• Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002).
Trauma symptoms in preschool aged children exposed to domestic
violence. Journal of Interpersonal Violence, 17, 150-164.
• Ostrowski, S. A. (2010). Development of child posttraumatic stress
disorder in pediatric trauma
victims: The impact of initial child and
caregiver PTSD symptoms on the development of subsequent child PTSD.
Dissertation Abstracts International: Section B: The Sciences and
Engineering, 70, 5838.
References
• Pearce, J. W. & Pezzot-Pearce, T. D. (2007). The Therapeutic
Relationship in Psychotherapy of Abused and Neglected Children
(2nd Ed.). The Guilford Press: New York.
• Roth S. & Friedman M. J. (1998): Childhood Trauma Remembered: A
Report on the Current
Scientific Knowledge Base and Its
Applications, Journal of Child Sexual Abuse, 7, 83-109.
• Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012).
Diagnosing PTSD in early childhood: An empirical assessment of
four approaches. Journal of Traumatic Stress, 25, 359-367.
• Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., &
Guthrie, D. (2011). Trauma-focused cognitive-behavioural therapy
for posttraumatic stress disorder in three through six year-old
children: A randomized clinical trial. Journal of Child Psychology and
Psychiatry, 52, 853-860.
• Stafford, B., Zeanah, C. H., & Scheeringa, M. (2003). Exploring
psychopathology in early childhood: PTSD and attachment disorders
in DC: 0-3 and DSM-IV. Infant Mental Health Journal, 24, 398-409.
Category of Protective factors
• 1) Individual personality attributes
• 2) Family characteristics
• 3) Environmental influences (peers, school
and community)
Profile of the Resilient Child
•
•
•
•
1)
2)
3)
4)
Social competence
Problem-solving skills
Autonomy
Sense of purpose and future
Social Competence
• “Resilient children are
considerably more
responsive (and elicit
more positive responses
from others), more
active, and more flexible
and adaptable.”
• Bonnie Benard
Comic relief
• More likely to have a good sense of humor.
• Alternative ways of looking at things.
• Ability to laugh at themselves and ridiculous
situations.
• Humor as transcendent strength.
• Cleaning up the mess at Micky D’s.
Problem solving skills
• Ability to think abstractly and flexibly.
• Rutter study of abused and neglected girls in
British slums.
• Good planning skills led to good marriages.
• Didn’t repeat the cycle of abuse.
• Street kids have to negotiate the demands of
their world to survive.
Sense of purpose and future
• Healthy expectancies, achievement
motivation, persistence, hope.
• Strongest predictor of positive outcome.
• Education aspirations better predictor than
academic achievement.
• Children of alcoholics pin success on sense of
the future.
Peer and friends
• Often overlooked role in
school and community
environments.
• Positive peer pressure
and support.
• Particularly effective in
reducing drug and
alcohol use.
• High risk behavior.
Families and communities
• Families exist within communities.
• Communities have important role to play in
supporting families.
• Power of school to influence the outcome of
children from high-risk environments.
• Protective factors within the school.
Social Cohesiveness
• Competent community
depends on the
availability of social
networks.
• Provide links within the
community.
• Networks on campus,
extended family, musical
groups, friends.
Access to community resources
• Resources necessary to healthy human
development:
• Health care, childcare, housing, education, job
training, employment and recreation.
• Guard against risk factors of social isolation
and poverty.
• Build social bonds that link individuals and
organizations to resources.
Cultural norms
• Expectations of community.
• Community expectations of youth: resource or
source of problems?
• Youth must view themselves as stakeholders
in the community.
• Actively involved in organizations and
activities.
• Society set guidelines for youth.
Messages about young people and resilience
 Chronic stressors can cause more long term problems
than acute events.
 An accumulation of stressors is more damaging e.g.
 ‘Children may often be able to overcome and even learn
from single or moderate risks, but when risk factors
accumulate, children’s capacity to survive rapidly
diminishes’ (Newman and Blackburn, 2002).
 Over-protection from stressors can reduce
opportunities to develop the skills to deal with
adversity.
Messages about intervention
1. Reduce vulnerability and risk
2. Reduce the number of stressors and
‘pile-up’
3. Increase available resources
4. Mobilise protective processes
5. Foster resilience strings
(Masten, 2004)
In adolescence
 In adolescence attachments are still very important
 Patterns of behaviour will have become more
entrenched
 Young people are likely to have developed their own
repertoires of coping
‘Resilience Matrix’
Devised in collaboration with Sally Wassell and Robbie Gilligan
Resilience ‘domains’
Designed with children in mind,
but adaptable to other ages
cottish Government (2008) A Guide to ‘Getting it right for every child’
Model for Intervention
Identify and support
protective resources
Understand the
impact of adversity
of transition
Remove or reduce the
impact of adverse
effect of transition
Nurture capacity to
benefit from these
resources
Example of Social Competencies
Intervention
• Need to be clear about the aim of the intervention –
consider the comment by Masten and Coatsworth that
attempts to boost self-esteem to improve behaviour can
lead to ‘misbehaving children who think very highly of
themselves.’
 Need an ethos where the approach to self-esteem takes
account of relationships:
‘Appreciating my own worth and importance and having the
character to be accountable for myself and to act responsibly
toward others’
(California State Department of Education)
Example of Positive Values
Intervention
• Parent/carer factors associated with pro-social
behaviour (Schaffer, 1996 and Zahn-Waxler, RadkeYarrow & King 1979):
• provide clear rules and principles for behaviour, reward
•
•
•
•
108
kindness, show disapproval of unkindness and explain effects of
hurting others
present moral messages in an emotional, rather than calm
manner
attribute prosocial qualities to the child by telling him or her
frequently that they are kind and helpful
model prosocial behaviour themselves
provide empathic care-giving to the child.
Social Competencies
• Development of social competence is associated with
parenting/caring that is warm, sensitive and provides
clear boundaries and requirements for behaviour.
• Antisocial behaviour is associated with an environment
that is harsh, punitive, rejecting and inconsistent.
• Need to pay attention to:
• cognitive areas
• affective areas
• behavioural areas.
Self-efficacy and competence
 Resilience associated with sense of self-efficacy,
mastery, planful competence and appropriate
autonomy.
 Self-efficacy:
 Problem-focused coping – change the problem if you
can or
• Emotion-focused coping – change how you think and
feel about the problem
‘A body of research points to ‘problem-focused’ coping,
rather than avoidant or passive responses, as being
most successful for a range of adversities. This involves
responding to hardship by taking active steps to
modify features in the environment or oneself that are
contributing to the difficulty in question’ (Hill et al,
2007)
• ‘Planful competence’ (Rutter) – being able to
see different options.
In addition:
• Empathy, positive values, making a contribution
- all contribute to resilience.
Active coping
• ‘Many children report using avoidance or distraction
as a coping strategy when there are problems at
home’ (Gorin, 2004).
• ‘Periodically separating themselves mentally and
physically from the home’ (Bancroft et al 2004).
• ‘Some ways of ‘escaping’ are beneficial, but others
are costly in terms of an unplanned and problematic
transition to adulthood and an unsettled or unstable
early adult life.’ (Velleman and Templeton, 2003).
Work with the grain…
‘The child is a person and not an object of
concern’ (Butler-Sloss, 1988).
Therefore we need to concentrate on
building on, and enhancing, existing coping
mechanisms; involving young people as
active participants and avoiding potentially
unhelpful consequences.
Practitioners link it with
principles for practice
respectful engagement with, and involvement of the
service user in practice
2. the use of solution-focused and strengths-based
approaches to practice
3. the need to target all ecological levels
4. the need to take a holistic and multi-agency
approach.
1.
Solution focused
 It may be that these terms are being used as
‘shorthand’ for more positive approaches to practice
that counteract the preoccupation with risk and
problems that can characterise bureaucratic systems
 Further research needed to examine whether the
adoption of optimistic discourses can lead to better
outcomes for children over and above the specific
model for intervention that is used.
Ecological
 UK services focused heavily on the coping and skills of
the individual child with associated support for the
parents or carers, and the Australian services were
dedicated to improving the well-being of parents and
family unit and placing that unit within the best
possible community network.
 The research showing factors at different ecological
levels to be associated with resilience suggests should
target all levels (Werner & Smith, 1992).
Multi-agency
 The concept of resilience is one that has resonance for
all disciplines
 The promotion of the resilience of children, families
and communities can offer a shared approach for the
professional network
 Focusing on what can be done can galvanise the
protective network.
STRATEGIES
anger control / emotional intelligence
INTENDED OUTCOMES
raised self-esteem / better peer relationships / improved
school experience
Daniel, B., & Wassell, S. (2002). Assessing and Promoting Resilience
in Vulnerable Children I - III. London: Jessica Kingsley.
Gilligan, R. (1998). The importance of schools and teachers in child
welfare. Child and Family Social Work, 3(1), 13-26.
Gilligan, R. (1999). Enhancing the resilience of children and young
people in public care by mentoring their talents and interests.
Child and Family Social Work, 4(3), 187-196.
Gilligan, R. (2001). Promoting Resilience: A Resource Guide on
Working with Children in the Care System. London: BAAF.
Hill, M., Triseliotis, J., Borland, M., & Lambert, L. (1996). Outcomes
of social work intervention with young people. In M. Hill & J.
Aldgate (Eds.), Child Welfare Services: Developments in Law, Policy,
Practice and Research. London: Jessica Kingsley.
Luthar, S. S., & Zelazo, L. B. (2003). Resilience and Vulnerability:
Adaptation in the Context of Childhood Adversities. In S. Luthar
(Ed.), Resilience and Vulnerability. New York: Cambridge
University Place.
Masten, A. S., Best, K. M., & Garmezy, N. (1990). Resilience and
development: Contributions from the study of children who
overcome adversity. Development and Psychopathology, 2, 425-444.
Newman, T. (2004). What Works in Building Resilience. London:
Barnardo's.
120
Attention Deficit Hyperactivity
Disorder (ADHD)
ADHD is a pervasive, heterogeneous
behavioural syndrome characterised by the
core symptoms of inattention, hyperactivity
and impulsivity.
Autistic Spectrum Disorder
• An intrinsic condition, ASD manifests core features which are
pervasive and include deficits in:
- Social communication
- Social interaction
- Social imagination
• Current prevalence of all ASD diagnoses: 1.6%
• Children with an ASD have a higher risk than peers of developing
other mental health problems.
• NICE have recently released a draft proposal for clinical guidelines
which will cover recognition, referral and diagnosis of ASD in
children.
Conduct disorder and ODD
• Conduct disorder: repetitive and persistent pattern
of antisocial, aggressive or defiant conduct and
violation of social norms
• Oppositional defiant disorder: persistently hostile
or defiant behaviour without aggressive or
antisocial behaviour
Associated conditions
• Conduct disorders are often seen in association
with:
– attention deficit hyperactivity disorder
(ADHD)
– depression
– learning disabilities (particularly dyslexia)
– substance misuse
– less frequently, psychosis and autism
Recommendations for children > 12 years
• There is limited evidence only for effective interventions with
older children/young people.
• Those programmes which show early promise are currently
being evaluated, for example:
- Multi-systemic therapy
- Functional family therapy
• These approaches tend to be intensive and expensive. They
are not currently available locally, though specialist CAMHS do
offer other forms of therapeutic support to some families
(family therapy, for example).
Depression
•
At any one time, the estimated number of children and young people
suffering from depression:
– 1 in 100 children
– 1 in 33 young people
•
Prevalence figures exceed treatment numbers:
– about 25% of children and young people with depression detected
and treated
•
Suicide is the:
– 3rd leading cause of death in 15–24-year-olds
– 6th leading cause of death in 5–14-year-olds
•
Transition to Adult services, where appropriate, requires careful
planning
Depression
KEY SYMPTOMS
ASSOCIATED
SYMPTOMS
persistent
poor
sadness, or low or
irritable mood:
AND/OR
loss of interests
and/or pleasure
fatigue or low
energy
or increased
sleep
poor concentration
or indecisiveness
low self-confidence
poor or increased
appetite
suicidal thoughts or
acts
agitation or slowing
of movements
guilt or self-blame
Mild
Up to 4 symptoms
Moderate
5-6 symptoms
Severe
7-10 symptoms
Depression
When to refer to the specialist CAMH service:
•
Depression with multiple-risk histories in another family member
•
Mild depression and no response to interventions in tier 1 after 2–3
months (Low level intervention and “watchful waiting”)
•
Moderate or severe depression (including psychotic depression)
•
Recurrence after recovery from previous moderate or severe
depression
•
Unexplained self-neglect of at least 1 month’s duration that could be
harmful to physical health
•
Active suicidal ideas or plans
•
Young person or parent/carer requests referral
Anxiety
• No specific NICE guidance for children and young people for
Anxiety, though guidance is available for children with Post
Traumatic Stress Disorder and Obsessional Compulsive
Disorder
• Type of anxiety experienced by the child (social, generalised,
panic, separation, specific phobia) and degree of impairment
to functioning is important to detail in referral
• Cognitive Behavioural Therapy (CBT) and other behavioural
approaches indicated for most anxiety disorders.
Obsessional-Compulsive disorder (OCD)
• Obsessive-compulsive disorder (OCD): characterised by the
presence of either obsessions (repetitive, distressing, unwanted
thoughts) or compulsions (repetitive, distressing, unproductive
behaviours) – commonly both. Symptoms cause significant
functional impairment/distress
• 1% of young people are affected – adults often report
experiencing first symptoms in childhood
• Onset can be at any age. Mean age is late adolescence for men,
early twenties for women
Anorexia nervosa
•
Severe dietary restriction despite very low weight (BMI <17.5 kg/m2)
•
Morbid fear of fatness
•
Distorted body image (that is, an unreasonable belief that one is
overweight)
•
Amenorrhoea
•
A proportion of patients binge and purge
•
In assessing whether a person has anorexia nervosa, attention should
be paid not just to one off weight and BMI but also to the overall clinical
assessment (repeated over time), including rate of weight loss, growth
rates in children, objective physical signs and appropriate laboratory
tests. Include all information in referral.
Bulimia nervosa
•
Characterised by an irresistible urge to overeat, followed by selfinduced vomiting or purging and accompanied by a morbid fear of
becoming fat.
•
Patients with bulimia nervosa who are vomiting frequently or
taking large quantities of laxatives (especially if they are also
underweight) should have their fluid and electrolyte balance
assessed.
o Selective serotonin reuptake inhibitors (SSRIs) and specifically
fluoxetine, are the drugs of first choice for the treatment of
bulimia nervosa.The effective dose of fluoxetine is higher than for
depression (60 mg daily).
•
No drugs, other than antidepressants, are recommended for
the treatment of bulimia nervosa.
“Isn’t it just bad parenting?”
• Anorexia nervosa
– Any family
• Schizophrenia
– Any family
– Genetic factors
– Environment factors
• Autism
– Any family
– Genetic factors
• ADHD
– Any family
– Genetic factors
Examples of causes
•
•
•
•
•
•
•
Genes
Bereavements
Change of school
Bullying
Trauma
Loss
Social and family stress
•
•
•
•
•
•
•
Isolation
Alcohol and drugs
School exams
Physical illness
Being a child carer
Environment
No known cause