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Screening for Trauma (symptoms or experiences?) Brooks Keeshin, MD Center for Safe and Healthy Families University of Utah Department of Pediatrics I have a problem… Felitti, et al. 1998 Exposure versus Distress • Which is more important – ACES – Evidence based treatment targets symptoms, not experience • Child Welfare/Justice Dept/Health Care – Population – Goals of individual system • Mental Illness/Family Dynamics – Capability, investment and need In Practice Application • What is your goal? – Improve trauma reaction/decrease repeated trauma – Decrease emotional distress – Decrease interference with “real” treatment objective • Treating patient versus family versus community • Piece of the overall picture TRAUMA EXPOSURE ACEs • The deadly ACEs include: – Physical Abuse – Sexual Abuse – Psychological Abuse – Witnessed Domestic Violence – Family Mental Illness – Family Substance Abuse – Family Incarceration Cross Sectional Studies Study Population Childhood Adult Medical Experience Correlation Adult Psychiatric Correlation Felitti >9,500 et al., adult 1998 members of Kaiser Health Plan in 19951996 Odds Ratios: >3 ACEs Suicide 12.2 Depressed 4.6 Alcoholism 7.4 Illicit drug use 4.7 IV drug use 10.3 Adverse Odds Ratios: Childhood >3 ACEs Experiences Heart dx 2.2 (ACE) Cancer 1.90 Stroke 2.4 Severe lung disease 3.9 Obesity 1.6 Cross Sectional Studies Study Population Childhood Experience Molnar >5800 adults Childhood et al., in 1990-1992 Sexual 2001 National Abuse Comorbidity Survey Adult Psychiatric Correlation Green et al., 2010 Population Attributable Risk Proportions: >5600 adults Childhood in 2001-2003 Adversity National Comorbidity Survey Odds Ratios: Females Depression 1.9 PTSD 10.2 Severe drug dependence 1.9 Any mental illness 2.3 Males PTSD 5.3 Any mental illness 2.3 Mood 26.2% Anxiety 32.4% Substance use 21% Disruptive behavior 41.2% Cross Sectional Studies Study Population Childhood Experience Adult Medical Correlation Dube et al., 2010 >5,300 adults in the Texas Behavioral Risk Factor Surveillance System Survey of 2002 Adverse Childhood Experiences (ACE) Odds Ratios: Any Childhood Abuse >18,00 adults from various countries Childhood Family Adversities Scott et al., 2011 Obesity 1.5 Fair or poor health 1.7 Abuse and Household Dysfunction Obesity 1.3 Fair or poor health 2.0 Hazard Ratios: >3 adversities Heart Disease 2.19 Asthma 1.55 DM 1.59 OA 1.44 DEFINITIONS Definition of Child Abuse • CDC – “Words or overt actions that cause harm, potential harm, or threat of harm to a child” • WHO – “…all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.” Definition of Child Abuse • Nelson’s – “Child maltreatment encompasses a spectrum of abusive actions, or acts of commission…that result in morbidity or death” • DSM-IV TR – regards both physical and sexual abuse of children and adults as “severe mistreatment of one individual by another…” Definition of Child Abuse • “Man’s inhumanity to man in its most extreme form – mistreatment and murder of his off-spring – has been well documented throughout each era of recorded history. There has been virtually no conceivable form of inhumanity to children that has not been documented…” – Spitz and Fisher’s Medicolegal Investigation of Death National Incidence Study National Incidence Study Sexual Abuse • Sexual abuse occurs when a child is engaged in sexual activities that – the child cannot comprehend – the child is developmentally unprepared and cannot give consent – and/or that violate the law or social taboos of society. Age of Consent wikimedia How about the line between corporal punishment? Corporal Punishment vs Physical Abuse Corporal Punishment vs Physical Abuse Gershoff, 2008, Report on Physical Punishment in the United States IT IS ALL HOW YOU ASK THE QUESTION… Physical Abuse Questions Sexual Abuse Questions (part 1) Lifetime Incidence of Traumatic Events Please circle yes or no to show which things have happened to you. If yes, also fill in the rest of the line. Did this ever happen to him/her How How old How much it many was s/he upset him/her times? (first time) then How much it upset him/her now No Yes Been in a car accident None Some Lots Non e Some Lots No Yes Been hurt in another kind of accident or sick in the hospital None Some Lots Non e Some Lots No Yes Seen someone else get hurt None Some Lots Non e Some Lots LITE 2.1 copyright Greenwald, 1999 Traumatic Events Screening Inventory • 24 Item scale for ages 6-18 • Wide array of exposure to community, disaster individual and interpersonal violence • Each positive response requests clarifying details – Age, first and last time, most stressful time, how affected • 20-30 minutes to complete Caregiver Form ID ___________________ Date ____________________ Childhood Trust Events Survey DOB/age ____________________ The Childhood Trust Events Survey Children and Adolescents: Caregiver Form Version 2.0; 10/10/2006 It is important for us to understand what may have happened to your child. The questions below describe some kinds of upsetting experiences. Since we give these questions to everyone, we list a lot of possible events that may have happened at any time in your child’s life. If one or more of these experiences has happened at some time in your child’s life, please circle Y for Yes. If not, circle N for No. If you are unsure, circle DK for Don’t Know. Thank you for completing this survey. 1. Was your child ever in a really bad accident, such as a serious car accident? Y N DK 2. Was your child ever in a disaster such as a tornado, hurricane, fire, big earthquake, or flood? Y N DK 3. Was your child ever so badly hurt or sick that he/she had to have painful or frightening medical treatment? Y N DK 4. Has your child ever been threatened or harassed by a bully (someone outside of his/her family)? Y N DK 5. Has your child ever repeatedly had a parent swear at him/her, insult him/her, or had hurtful things said to him/her such as “You are no good,” “You will be Y N DK Conflict Tactics Scale PC Version • Filled out by parent or guardian regarding interpersonal violence only • Focuses on last 12 months – Once, twice, 3-5, 6-11, 12-20 and >20 times • Includes non-violent, psychologically violent and violent interpersonal acts as well as history of sexual abuse • Can be adapted for interview with older child TRAUMATIC STRESS Child Abuse Outcomes • • • • • • • • PTSD Anxiety Disorders Depression Eating Disorders Substance Abuse/Dependence Domestic Violence/Revictimization Parenting Challenges Medical Problems Corwin and Keeshin, Child Adol Psych Clinics of North America, 2011 PTSD and Abuse • Sexual Abuse – 1/3 of foster children have PTSD – 1/3 of victims have PTS symptoms at 3 months • Physical Abuse – Up to 80% have some PTS symptoms, with 30-50% meeting criteria for PTSD Corwin and Keeshin, Child Adol Psych Clinics of North America, 2011 Criteria A • Threatened death, serious injury or sexual violence • 1. Direct experience • 2. Witnessing in person • 3. Learning event occurred • 4. Experiencing repeated/extreme details of event Criteria B • Intrusion Symptoms 1.Memories 2.Dreams 3.Flashbacks 4.Psychological distress after exposure to cue 5.Physical distress after exposure to cue Criteria C • Avoidance 1.Avoidance of memories, thoughts or feelings 2.Avoidance of external reminders Criteria D • Negative alterations in cognition and mood 1.Poor memory of event 2.Negative beliefs towards self 3.Self blame 4.Persistent negative emotional state 5.Loss of interest 6.Detachment 7.Lack of positive emotions Criteria E • Increased arousal and reactivity 1.Irritable and angry 2.Reckless and self-destructive behavior 3.Hypervigilance 4.Exaggerated startle 5.Poor concentration 6.Sleep disturbances Dissociation 1.Depersonalization 2.Derealization Adult PTSD DSM IV vs. 5 Kilpatrick et al., J Trauma Stress 2013 Diagnostic Considerations in Youth • Diagnosis is complicated in younger children, especially pre-verbal children – Limitations in abstract thought, emotional processing, language, etc. (Scheeringa et al, 2005/2006/2003) Scheeringa et al. Am J Psychiatry 2006; 163:644–651 Diagnostic Considerations in Youth • Carrion and colleagues (2002) examined • the diagnostic requirement of meeting all DSM-IV symptom cluster criteria (i.e., criteria B, C, and D) in traumatized youth (n = 60) and; • the cumulative importance of the symptom clusters and their relationship to impairment and distress. • 3 groups • children meeting all 3 DSM-IV PTSD symptom cluster criteria • children meeting 2 symptom cluster criteria • children meeting 1 symptom cluster criterion • Traumatized youth with sub-threshold DSM-IV-TR PTSD criteria do not differ significantly from children meeting all three cluster criteria with regard to impairment and distress. • Impairment related to sub-threshold symptoms in children is not due to comorbidity but rather is specific to the posttraumatic symptoms present. Carrion et al. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. JAACAP. 2002 Are alternate diagnosis children symptomatic? Scheeringa et al, 2012, J Trauma Stress Misclassification of PTSD in children ≤ 6 using DSM-IV-TR Scheeringa et al, 2012, J Trauma Stress Trauma Symptom Checklist for Children/Young Children • • • • 54 or 90 item measure Validity Safety Screening Subscales – Depression/Anxiety/Anger – Posttraumatic Stress/Dissociation – Sexual Concerns • Results are adjusted for gender and age Child PTSD Symptom Scale • 17 item for child or parent (or both) based on DSM IV criteria • Entry screen for CFTSI (Child Family Traumatic Stress Intervention • Considered positive if at least one symptom is new or worse after a traumatic event with a score of 2 or 3 UCLA PTSD RI • Pros: – Obtain some info of traumatic events as well as assess for symptoms – Child, adolescent and parent versions – Questions assess for Criterion A – D of PTSD – 5 point Likert scale (none of the time to most of the time) is used to rate symptoms • Cons: – Focuses only on PTSD CAPS CA • Clinician administered tool • Assess for multiple types of traumatic events • Covers complete PTSD diagnostic criteria and independently assesses both frequency and intensity of symptoms • Additional questions for associated features (guilt, shame, attachment behaviors, etc) • 30 minutes to 2 hours to complete A WORD ABOUT SAFETY Suicidal Ideation • 80 teens (33%) reported “Wanting to kill myself” at least sometimes • 29 teens (12 %) reported “Wanting to kill myself” lots of times or almost all of the time (7 patients) • 27 teens (11%) had a “negative” screen but still indicated “Wanting to kill myself” at least sometimes Self Harm • 92 teens (38%) reported “Wanting to hurt myself” at least sometimes • 37 teens (15%) reported “Wanting to hurt myself” lots of times or almost all of the time (12 patients) • 29 teens (12%) had a “negative” screen but still indicated “Wanting to kill myself” at least sometimes Critical Item Take Home • Teens with suspected abuse are a high risk population for self-inflicted injury and suicidal ideation • 45% of all screens and 30% of all “negative” screens include one positive response about self-harm or suicidal ideation TASA • Factors associated with suicidal event: – – – – Self-rated depression Suicidal ideation Higher family income Number of previous suicide attempts – History of sexual abuse • OR 18.2 (95% CI 2.5-130.6) Brent et al. JAACAP 2009 COMMENTS Psychotherapeutic Treatment of Pediatric PTSD – Trauma Focused CBT Keeshin and Strawn. Child and Adol Psych Clinics of NA 2014 Latency Age • LONGSCAN analysis – 1300 at risk children • Health problems in abused children at 6 and 12 years of age. • By 6, 67% had experienced at least one adverse event – 1 adverse exposure doubled the risk for overall poor health – 4 or more adverse exposures tripled the likelihood of illness Flaherty et al,2006, 2009 LONGSCAN • By 12, only 10% had no adverse childhood event • More than 20% experienced 5 or more types of childhood adversity. • At ages 6 and 12, observed correlations with increased adverse experiences – Increased somatic complaints – Overall poor health as reported by the child – Illnesses requiring a doctor’s visit Flaherty et al,2006, 2009 Longitudinal Study of Low-income Children • Followed >6,000 children receiving Aid to Families with Dependent Children • Compared children with CPS reports of abuse to matched controls • Used hospitalization for asthma, cardiorespiratory and infection as primary outcome • Children with history of early child maltreatment (prior to age 12) had 75-100% higher risk of hospitalization Lanier et al., J Ped Psychology 2009 BMI %ile of Hospitalized Youth Percentage of Patients 70 p = 0.003 60 50 40 30 20 10 0 0-20 20-40 40-60 60-80 Body Mass Index Percentile Black – No reported trauma Gray – Reported history of sexual abuse 80-100 Psychotropic Treatment at Admission 2.5 2 No Trauma Physical Abuse Sexual Abuse 1.5 Physical + Sexual Abuse 1 0.5 0 Number of psychotropics Keeshin, Strawn, Luebbe, et al. 2014 (Child Abuse and Neglect). Total Medications Length of Stay 9.5 No Trauma Physical Abuse Sexual Abuse Physical + Sexual Abuse 9 8.5 8 7.5 7 6.5 6 5.5 5 Length of stay (days) Keeshin, Strawn, Luebbe, et al. 2014 (Child Abuse and Neglect). Add Health Study Study Population Hussey et >15,000 adult al., young adults 2006 who had previously completed adolescent surveys Physical Assault Sexual Abuse Odds Ratios: Poor health 1.38 Overweight 1.20 Depression 1.75 Smoking 1.22 Binge drinking 1.30 Marijuana use 1.57 Violence 1.50 Odds Ratios: Poor health 1.65 Smoking 1.80 Binge drinking 1.60 Marijuana use 2.00 Violence 1.50 Demographics Age (Mean) No Physical Sexual Sexual & All Trauma Abuse Abuse Physical Group patients (N=694 Only Only Abuse Difference (N=1079) ) (N=158) (N= 172) (N= 55) 13.6 13.5 13.3 14.20 14.33 F(3, 1075) = 3.02* Race (%) White Black Other Sex (% Female) Χ2(6) = 13.22* 64.6 67.3 56.3 64.0 52.7 28.6 25.6 38.0 28.5 38.2 6.8 7.1 5.7 7.6 9.1 47.2 40.9 40.5 75.0 58.2 Χ2(3) = 69.82*** 0.8 1.1 1.4 1.9 F(3, 1074) = 3.02* Past Psychiatric 1.0 Admission Keeshin, Strawn, Luebbe, et al. (in preparation). Diagnosis Sexual No Physical Sexual & All Trauma Abuse Abuse Physical patients (N=694 Only Only Abuse (N=1079) ) (N=158) (N= 172) (N= 55) Group Difference Diagnosis (%) Mood Anxiety (all) PTSD only Disruptive Behavior Substance Use 51.2 49.0 43.7 54.1 45.5 Χ2(3) = 3.83, ns 24.3 10.1 36.1 58.1 63.6 17.3 1.0 32.9 54.7 61.8 40.1 39.5 48.7 34.9 40.0 Χ2(3) = 241.59*** Χ2(3) = 399.00*** Χ2(3) = 6.96, ns 6.6 6.8 4.4 6.4 10.9 Χ2(3) = 2.92, ns Keeshin, Strawn, Luebbe, et al. (in preparation). BMI %ile of Hospitalized Youth Percentage of Patients 70 p = 0.003 60 50 40 30 20 10 0 0-20 20-40 40-60 60-80 Body Mass Index Percentile Black – No reported trauma Gray – Reported history of sexual abuse Keeshin, Luebee, Strawn, et al. 2013 J Peds 80-100 Cross Diagnostic Co-Morbidity • Physical abuse 2-fold increase in risk • Sexual abuse 3-fold increase in the likelihood that the patient would have crossdiagnostic comorbidity • No multiplicative risk for crosscategory comorbidity associated with sexual + physical abuse Keeshin, Strawn, Luebbe, et al. 2014 Child Abuse & Neglect Length of Stay 9.5 No Trauma 9 Physical Abuse 8.5 Sexual Abuse 8 7.5 Physical + Sexual Abuse 7 6.5 6 5.5 5 Length of stay (days) Keeshin, Strawn, Luebbe, et al. 2014 Child Abuse & Neglect Psychotropic Treatment on Admission 2.5 No Trauma Physical Abuse 2 Sexual Abuse Physical + Sexual Abuse 1.5 1 0.5 0 Number of psychotropics Keeshin, Strawn, Luebbe, et al. 2014 Child Abuse & Neglect Total Medications