Download Keeshin - Academy on Violence and Abuse

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