Trauma: What are the Effects and What Helps them Recover? Jennifer Wilgocki, MS LCSW Adolescent Trauma Treatment Program Mental Health Center of Dane.

Trauma: What are the Trauma: What are the Effects and What Effects and What

Helps them Recover?Helps them Recover?

Jennifer Wilgocki, MS LCSWJennifer Wilgocki, MS LCSW

Adolescent Trauma Treatment ProgramAdolescent Trauma Treatment Program

Mental Health Center of Dane County, Inc.Mental Health Center of Dane County, Inc.

September 27, 2006September 27, 2006

National Child Traumatic Stress National Child Traumatic Stress NetworkNetwork

Established in 2001Established in 2001 Funded by SAMHSAFunded by SAMHSA Headquartered at Duke and UCLAHeadquartered at Duke and UCLA 45 sites 45 sites Level I, II, III sitesLevel I, II, III sites www.nctsn.orgwww.nctsn.org

Adolescent Trauma Treatment Adolescent Trauma Treatment ProgramProgram

Established October 1, 2003Established October 1, 2003 $1.6 million for 4 years until 9/30/07$1.6 million for 4 years until 9/30/07 Trauma defined broadlyTrauma defined broadly Adolescents = 11-17 year oldsAdolescents = 11-17 year olds

Mission: To improve the quality and Mission: To improve the quality and availability of services for availability of services for traumatized adolescents in Dane traumatized adolescents in Dane County.County.

Trauma Principle #1Trauma Principle #1

If everything is trauma, If everything is trauma, nothing is trauma.nothing is trauma.


It is the child’s experience It is the child’s experience of the event, not the event of the event, not the event itself, that is traumatizing.itself, that is traumatizing.


If we don’t look for or If we don’t look for or acknowledge trauma in acknowledge trauma in the lives of children and the lives of children and adolescents, we end up adolescents, we end up chasing behaviors and chasing behaviors and

limiting the possibilities limiting the possibilities for change.for change.


The behavioral and emotional The behavioral and emotional adaptations that maltreated adaptations that maltreated children make in order to children make in order to

survivesurvive

are brilliant, creative are brilliant, creative solutions, solutions,

and are personally costly.and are personally costly.


If you don’t ask, they won’t If you don’t ask, they won’t tell.tell.

Child Traumatic Stress is Child Traumatic Stress is SeriousSerious

Interferes with children’s ability to Interferes with children’s ability to concentrate and learnconcentrate and learn

Can delay development of their Can delay development of their brains/bodiesbrains/bodies

Leads to depression, substance Leads to depression, substance abuse, health problems, school abuse, health problems, school failure, delinquency, and future failure, delinquency, and future employment problemsemployment problems


Changes how children view the Changes how children view the world and their own futures, their world and their own futures, their behavior, interests, and behavior, interests, and relationships with family and friendsrelationships with family and friends

Takes a toll on families and Takes a toll on families and communitiescommunities


Educational impact Educational impact Lower GPALower GPAMore absencesMore absencesMore negative comments in More negative comments in

permanent recordpermanent record


More than 1 in 4 American children will More than 1 in 4 American children will experience a serious traumatic event by experience a serious traumatic event by their 16th birthday.their 16th birthday.

Children with developmental disabilities are Children with developmental disabilities are 2 - 10 times more likely to be abused or 2 - 10 times more likely to be abused or neglected.neglected.

Children are at greatest risk of sexual abuse Children are at greatest risk of sexual abuse between 7 - 13. Four of every 20 girls will between 7 - 13. Four of every 20 girls will be sexually assaulted before age 18; one be sexually assaulted before age 18; one or two of every 20 boys.or two of every 20 boys.

Child Traumatic Stress Child Traumatic Stress and Juvenile Justiceand Juvenile Justice

Criminal/juvenile justice impactCriminal/juvenile justice impact Increases risk of arrest as Increases risk of arrest as

juveniles/adults juveniles/adults Increases risk of committing violent Increases risk of committing violent

crimecrime Increases risk of perpetration of Increases risk of perpetration of

domestic violence domestic violence Increased risk of problem drug use as Increased risk of problem drug use as

an adultan adult

Child Traumatic Stress Child Traumatic Stress and Juvenile Justiceand Juvenile Justice

““Recognizing [traumatic} Recognizing [traumatic} victimization as a potential victimization as a potential source of abusive behavior source of abusive behavior does not excuse such behavior, does not excuse such behavior, but may provide a basis for but may provide a basis for preventing or treating it more preventing or treating it more effectively.”effectively.”

Julian Ford, 2005Julian Ford, 2005


Car accidents are the leading cause of Car accidents are the leading cause of death in adolescence.death in adolescence.

In 2002 in Wisconsin, 10,000 car In 2002 in Wisconsin, 10,000 car accidents involved teen drivers. accidents involved teen drivers. 2,114 of those accidents involved 2,114 of those accidents involved passenger fatalities or injuries.passenger fatalities or injuries.


Health impact:Health impact: Smoking, including early onset of Smoking, including early onset of

regular smokingregular smoking Sexually transmitted diseases and Sexually transmitted diseases and

hepatitishepatitis IV drug use and alcoholismIV drug use and alcoholism Heart disease, diabetesHeart disease, diabetes ObesityObesity Unintended pregnancyUnintended pregnancy Avoidance of preventative careAvoidance of preventative care

The Under-recognized The Under-recognized TraumaTrauma

National survey (1998) of 12 to 17 year olds:National survey (1998) of 12 to 17 year olds:8% reported sexual assault in lifetime8% reported sexual assault in lifetime17% reported physical assault in lifetime17% reported physical assault in lifetime39% reported 39% reported witnessing violencewitnessing violence in in lifetimelifetime

Study (1995) of adolescents:Study (1995) of adolescents:2% experienced direct assault2% experienced direct assault23% experienced assault and witnessed 23% experienced assault and witnessed violenceviolence48% 48% witnessed violencewitnessed violence27% no violence27% no violence

The Under-recognized The Under-recognized TraumaTrauma

““Rates of interpersonal violence and Rates of interpersonal violence and victimization of 12-17 year olds in victimization of 12-17 year olds in the US are extremely high, and the US are extremely high, and witnessing violence is…common.”witnessing violence is…common.”

US Department of Justice , US Department of Justice , 20032003

Exposure to violence: 7 out of 10 Exposure to violence: 7 out of 10 adolescents vs 4 out of 10 adults. adolescents vs 4 out of 10 adults. Youth Violence Youth Violence

Research Bulletin, 2002Research Bulletin, 2002

What do kids learn from What do kids learn from trauma?trauma?

Negatives:Negatives:Traumatic expectations of the worldTraumatic expectations of the world

No one can protectNo one can protect

Laws don’t really workLaws don’t really work

Learned helplessnessLearned helplessness

What do kids learn from What do kids learn from trauma?trauma?

Positives:Positives:How to conduct themselves in the How to conduct themselves in the midst of dangermidst of danger

Others do protect and rescueOthers do protect and rescue

Helpful support is available after Helpful support is available after traumatrauma

Increased compassionIncreased compassion

Traumatic StressTraumatic Stress

Traumatic StressTraumatic Stress is the response is the response to events that can cause death, to events that can cause death, loss, serious injury, or threat to loss, serious injury, or threat to a child’s well being or the well a child’s well being or the well being of someone close to the being of someone close to the child.child.


Traumatic StressTraumatic Stress causes the primal fight or causes the primal fight or flight or freeze response.flight or freeze response.

Traumatic StressTraumatic Stress involves terror, involves terror, helplessness, horror.helplessness, horror.

Traumatic StressTraumatic Stress results in physical results in physical sensations -- rapid heart rate, trembling, sensations -- rapid heart rate, trembling, sense of being in slow motion.sense of being in slow motion.


Not every event that is distressing Not every event that is distressing necessarily results in traumatic necessarily results in traumatic stress.stress.

An event that results in traumatic An event that results in traumatic stress for one person may not stress for one person may not necessarily result in traumatic stress necessarily result in traumatic stress for another.for another.

The thing that The thing that upsets people is upsets people is

not what happens not what happens but what they but what they

think it means.think it means.

EpictetusEpictetus

Trauma SymptomsTrauma Symptoms

Subjective Characteristics of TraumaSubjective Characteristics of Trauma Appraisal of event: uncontrollable Appraisal of event: uncontrollable

or malicious?or malicious? Appraisal of action: ineffective or Appraisal of action: ineffective or

effective?effective? Appraisal of self: helpless and Appraisal of self: helpless and

shameful or brave and capable?shameful or brave and capable? Appraisal of others: impotent or Appraisal of others: impotent or

dangerous vs safe and protective?dangerous vs safe and protective?

Traumatogenic FactorsTraumatogenic Factors

AgeAgeRelational vs non-relationalRelational vs non-relationalRelationship between victim and Relationship between victim and

perpetratorperpetratorSeverity/Duration/FrequencySeverity/Duration/FrequencyProtectionProtectionCaregiver responseCaregiver responseResponsibility and blameResponsibility and blameCommunity or societal responseCommunity or societal response

Risk FactorsRisk Factors

Poor, anxious, or disrupted attachmentPoor, anxious, or disrupted attachmentPrior traumaPrior traumaPre-existing anxiety or depression, Pre-existing anxiety or depression,

especially maternal depressionespecially maternal depressionNeurological issuesNeurological issuesPrematurityPrematurityCaregiver with “active” trauma symptomsCaregiver with “active” trauma symptomsCaregiver with AODA issuesCaregiver with AODA issuesOwn AOD useOwn AOD usePovertyPoverty

Protective FactorsProtective FactorsSecure attachment to caregiverSecure attachment to caregiverCaregiver’s resolved trauma issues Caregiver’s resolved trauma issues Two-parent familyTwo-parent familyThe “resiliency” factor and temperamentThe “resiliency” factor and temperamentIntelligence/neurological resourcesIntelligence/neurological resourcesShielding adultShielding adultNo blame placed on the childNo blame placed on the childAffirming and protective parental responseAffirming and protective parental responseCaregiver’s ability to tolerate child’s Caregiver’s ability to tolerate child’s reactions reactions SpiritualitySpirituality

DiagnosisDiagnosis

Acute Stress Disorder:Acute Stress Disorder:• One or more symptom(s) lasts for a One or more symptom(s) lasts for a

minimum of 2 days and a maximum of minimum of 2 days and a maximum of 4 weeks4 weeks

PTSD:PTSD:• One or more symptom(s) occurs more One or more symptom(s) occurs more

than 1 month post eventthan 1 month post event

Post-traumatic Stress Post-traumatic Stress DisorderDisorder

1. Re-experiencing1. Re-experiencingImageryImagery Misperceiving danger Misperceiving dangerNightmaresNightmares Distress when cued Distress when cuedBody memoriesBody memories

2. Avoidance2. AvoidanceNumbing outNumbing out Diminished interestDiminished interestDissociationDissociation Self isolationSelf isolationDetachmentDetachment

3. Increased arousal3. Increased arousalAnxietyAnxiety Sleep disturbancesSleep disturbancesHypervigilanceHypervigilance Irritability or quick to Irritability or quick to angerangerStartle responseStartle response Physical complaintsPhysical complaints

Limitations of PTSD Limitations of PTSD DiagnosisDiagnosis

• • Conceptualized from an adult perspectiveConceptualized from an adult perspective

• • Developed as a diagnosis via Vietnam vets Developed as a diagnosis via Vietnam vets and adult rape victimsand adult rape victims

• • Focuses on single event traumasFocuses on single event traumas

• • Fails to recognize chronic and multiple Fails to recognize chronic and multiple traumastraumas

Limitations of PTSD Limitations of PTSD DiagnosisDiagnosis

• • Is not developmentally sensitiveIs not developmentally sensitive

• • Many traumatized children do not Many traumatized children do not meet diagnosis or they meet meet diagnosis or they meet diagnosis of partial PTSD.diagnosis of partial PTSD.

Complex TraumaComplex Trauma

• • new concept, new languagenew concept, new language• “• “Developmental Trauma Disorder” Developmental Trauma Disorder”

(van der Kolk, 2005)(van der Kolk, 2005)• • Complex Trauma is:Complex Trauma is:

the experience of multiple traumasthe experience of multiple traumasdevelopmentally adversedevelopmentally adverseoften within child’s caregiving systemoften within child’s caregiving systemrooted in early life experiencesrooted in early life experiencesresponsible for emotional, behavioral, responsible for emotional, behavioral,

cognitive, and meaning-making disturbancescognitive, and meaning-making disturbances

Complex Trauma and the Complex Trauma and the BrainBrain

““Chronic trauma interferes with Chronic trauma interferes with neurobiological development (Ford, neurobiological development (Ford, 2005) and the capacity to integrate 2005) and the capacity to integrate sensory, emotional and cognitive sensory, emotional and cognitive information into a cohesive whole.” information into a cohesive whole.” (van der Kolk, 2005)(van der Kolk, 2005)

Consequences of Consequences of Complex TraumaComplex Trauma

1.1. Dysregulated emotions - rage, Dysregulated emotions - rage, betrayal, fear, resignation, defeat, betrayal, fear, resignation, defeat, shame.shame.

2.2. Efforts to ward off the recurrence of Efforts to ward off the recurrence of those emotions - avoidance via those emotions - avoidance via substance abuse, numbing out, self substance abuse, numbing out, self injury.injury.

3.3. Reenactments with others.Reenactments with others.

ReenactmentReenactment

Recreating the trauma in new situations Recreating the trauma in new situations with new people.with new people.

Examples:Examples:• after a serious car accident, adolescent after a serious car accident, adolescent

begins to drive recklesslybegins to drive recklessly• after rape adolescent becomes after rape adolescent becomes

hypersexualhypersexual• after being physically abused adolescent after being physically abused adolescent

gets into fist fightsgets into fist fights

ReenactmentReenactment Recreates old relationships with Recreates old relationships with

new peoplenew people Tests the negative internal working Tests the negative internal working

model for “proof” that it’s rightmodel for “proof” that it’s rightI am worthlessI am worthless

I am unsafeI am unsafe

I am ineffective in the worldI am ineffective in the world

Caregivers are unreliableCaregivers are unreliable

Caregivers are unresponsiveCaregivers are unresponsive

Caregivers are unsafe and will ultimately Caregivers are unsafe and will ultimately reject me.reject me.

ReenactmentReenactment

Provides opportunity for masteryProvides opportunity for mastery Vents frustration and angerVents frustration and anger Mitigates building anxietyMitigates building anxiety Contributes to sabotageContributes to sabotage Pushes caregivers/other adults in Pushes caregivers/other adults in

ways they may not expect to be ways they may not expect to be pushed pushed

Complex TraumaComplex Trauma

6 Domains of Complex PTSD6 Domains of Complex PTSD

1. Affect and impulse regulation problems1. Affect and impulse regulation problems

2. Attention and consciousness2. Attention and consciousness

3. Self perception3. Self perception

4. Relations with others4. Relations with others

5. Somatization5. Somatization

6. Alterations in systems of meaning6. Alterations in systems of meaning

1st Domain - Affect and 1st Domain - Affect and Impulse RegulationImpulse Regulation

Affect intensity - easily triggered, slow to calmAffect intensity - easily triggered, slow to calm

Tension-reducing behaviors - AODA, self injuryTension-reducing behaviors - AODA, self injury

Suicidal preoccupationSuicidal preoccupation

Sexual involvement or sexual preoccupationSexual involvement or sexual preoccupation

Excessive risk takingExcessive risk taking

2nd Domain - Attention2nd Domain - Attention

Amnesia - memory loss or gapsAmnesia - memory loss or gaps

Dissociative episodes - spacing out Dissociative episodes - spacing out or fantasy worldor fantasy world

Depersonalization - “not me”Depersonalization - “not me”

3rd Domain - Self 3rd Domain - Self PerceptionPerception

Ineffectiveness and permanent damage - Ineffectiveness and permanent damage - can’t do anything right, something is can’t do anything right, something is wrong with mewrong with me

Guilt and responsibility/shame Guilt and responsibility/shame

Nobody can understand - alienation, feeling Nobody can understand - alienation, feeling differentdifferent

Minimizing - “pain competition” or denialMinimizing - “pain competition” or denial

4th Domain - 4th Domain - RelationshipsRelationships

Inability to trustInability to trust

Re-victimization - reenactmentRe-victimization - reenactment

Victimizing others - reenactmentVictimizing others - reenactment

5th Domain - 5th Domain - SomatizationSomatization

Chronic pain - no origin, repeat doctor Chronic pain - no origin, repeat doctor visits, school nursevisits, school nurse

Digestive complaintsDigestive complaints

Cardiopulmonary symptomsCardiopulmonary symptoms

Sleep problemsSleep problems

6th Domain - Meaning 6th Domain - Meaning MakingMaking

Foreshortened futureForeshortened future

Loss of previously sustaining Loss of previously sustaining beliefsbeliefs

Justice and fairnessJustice and fairness

Trauma and Trauma and DevelopmentDevelopment

• • young childrenyoung children

• • school-aged childrenschool-aged children

• • adolescentsadolescents


• • infants and young children evaluate infants and young children evaluate threats to the integrity of their self threats to the integrity of their self based on the availability of a familiar based on the availability of a familiar protective caregiverprotective caregiver

• • example: WWII London (Bowlby)example: WWII London (Bowlby)• • recent research has determined that recent research has determined that

threat to a caregiver is strongest threat to a caregiver is strongest predictor of PTSD in children under predictor of PTSD in children under 55

The Attachment ContextThe Attachment Context

The symptomatic impact of traumatic events The symptomatic impact of traumatic events has largely been considered outside the has largely been considered outside the context of the attachment relationships context of the attachment relationships that buffer or augment the fear-arousing that buffer or augment the fear-arousing potential of the event itself….For example, potential of the event itself….For example, recent longitudinal studies from infancy recent longitudinal studies from infancy indicate that chronic impairment in indicate that chronic impairment in caregiver responsiveness may be more caregiver responsiveness may be more central to the etiology of central to the etiology of dissociative dissociative symptomssymptoms than abusive events per se. than abusive events per se.

(Lyons-Ruth et al, in (Lyons-Ruth et al, in press)press)


School-aged Children:School-aged Children: Thoughts of revenge they cannot solveThoughts of revenge they cannot solve Self blame, guilt fueled by magical thinkingSelf blame, guilt fueled by magical thinking Sleep disturbances, fear of sleeping aloneSleep disturbances, fear of sleeping alone Impaired concentration: ADHD vs anxietyImpaired concentration: ADHD vs anxiety Learning delays and learning interruptionsLearning delays and learning interruptions Physical complaintsPhysical complaints Failure to master developmental tasksFailure to master developmental tasks Close monitoring of parental responsesClose monitoring of parental responses Traumatic playTraumatic play


AdolescentsAdolescents May believe they are going crazyMay believe they are going crazy EmbarrassmentEmbarrassment Isolation and feeling differentIsolation and feeling different Grief may be easier to understand than Grief may be easier to understand than

PTSDPTSD Repetitive thoughts about death and Repetitive thoughts about death and

dyingdying Revenge fantasies that can be acted outRevenge fantasies that can be acted out Avoidance or social withdrawalAvoidance or social withdrawal

Tension-Reducing Tension-Reducing BehaviorsBehaviors

The goal -- despite sometimes terrible The goal -- despite sometimes terrible consequences -- is to consequences -- is to escape distressescape distress and and overwhelming emotion.overwhelming emotion.

““I’m not in control -- I’m not in control -- itit is in control of me. I is in control of me. I have to do something to control it.”have to do something to control it.”

Tension-reducing behaviors DO WORK by Tension-reducing behaviors DO WORK by bringing bringing temporarytemporary relief from distress. relief from distress.

Tension-Reducing Tension-Reducing Behaviors Substance UseBehaviors Substance Use

Vicious cycle of substance abuse and traumaVicious cycle of substance abuse and trauma

Self medicating trauma symptomsSelf medicating trauma symptoms

70% adolescents with AODA diagnoses have 70% adolescents with AODA diagnoses have trauma historytrauma history

Most adolescent AODA treatment programs Most adolescent AODA treatment programs do NOT screen for or include trauma in do NOT screen for or include trauma in treatmenttreatment

Tension-Reducing Tension-Reducing BehaviorsBehaviorsSelf InjurySelf Injury

Self injury:Self injury:is not the same as suicideis not the same as suicideis not an exit strategyis not an exit strategyis a strategy for self preservationis a strategy for self preservationcan be contagiouscan be contagiouscan become addictivecan become addictivecan be used to anesthetizecan be used to anesthetizecan be used to feel alivecan be used to feel alivereduces distress -- reduces distress -- temporarilytemporarily

Neurobiology and Neurobiology and TraumaTrauma

Early trauma, prolonged separation and Early trauma, prolonged separation and insecure attachment produce insecure attachment produce permanent permanent changeschanges in the neurochemistry of children in the neurochemistry of children that continue into adulthood: that continue into adulthood: • a neurobiological sensitivity to lossa neurobiological sensitivity to loss• fear of abandonmentfear of abandonment• hyperarousalhyperarousal• sensitivity to environmental threat sensitivity to environmental threat (Van der Kolk, (Van der Kolk,

1987)1987)

Together, insecure attachment and early trauma Together, insecure attachment and early trauma produce extreme affective dysregulation with produce extreme affective dysregulation with concomitant difficulty in modulating aggression concomitant difficulty in modulating aggression in adults. in adults. (Lawson, 2001, p. 505)(Lawson, 2001, p. 505)

Neurobiology and Neurobiology and TraumaTrauma

It occurs during sensitive neuro-It occurs during sensitive neuro-developmental periods developmental periods (e.g., Synaptogenesis, Experience-Dependent (e.g., Synaptogenesis, Experience-Dependent Maturation of Neuronal Systems)Maturation of Neuronal Systems)

It impacts on fundamental psycho-It impacts on fundamental psycho-developmental processes developmental processes (e.g., Attachment, Emotional Regulation, Impulse (e.g., Attachment, Emotional Regulation, Impulse Control, Integration of Self, Socialization)Control, Integration of Self, Socialization)

Trauma & Brain DamageTrauma & Brain Damage

Corpus Callosum - mid sagital regions were smaller in Corpus Callosum - mid sagital regions were smaller in maltreated children with PTSD.maltreated children with PTSD.

Correlates with: Correlates with: Intrusive thoughtsIntrusive thoughts AvoidanceAvoidance Hyperarousal Hyperarousal DissociationDissociation Effects boys > girlsEffects boys > girls

De Bellis, et.al., 1999De Bellis, et.al., 1999

Trauma & Brain DamageTrauma & Brain DamageImplicationsImplications

Maltreated children have lower social Maltreated children have lower social competencecompetence

Have less empathy for othersHave less empathy for others Are more likely to be insecurely attached to Are more likely to be insecurely attached to

their parentstheir parents Are less able to recognize their own Are less able to recognize their own

emotional statesemotional states Have difficulty in recognizing other’s Have difficulty in recognizing other’s

emotions emotions Putnam, 2006Putnam, 2006

Frank Putnam,

The Maze of The Maze of (Mis)Diagnosis(Mis)Diagnosis

Oppositional Defiant Disorder?Oppositional Defiant Disorder? PTSD??PTSD??

Depression?Depression? Substance Abuse?Substance Abuse?

ADHD?ADHD? Conduct Disorder?Conduct Disorder?

Anxiety?Anxiety?Bipolar Bipolar

Disorder?????Disorder?????

Personality Disorder??? Attachment Disorder?Personality Disorder??? Attachment Disorder?

refusal to follow rules or engage avoidance

anger, irritability anxiety/depression

callous indifference to others numbing

resentful suspiciousness hypervigilance

ODD & Conduct Disorder PTSD

So, how do we So, how do we know if it’s know if it’s

trauma?trauma?Answer: Answer:

Do a trauma-informed Do a trauma-informed assessmentassessment

[email protected]@mhcdc.orgorg

280-2537280-2537

Trauma: What are the Effects and What Helps them Recover? Jennifer Wilgocki, MS LCSW Adolescent Trauma Treatment Program Mental Health Center of Dane.

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