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Tuesday, October 14, 2014

Dealing With Psychological Trauma in Children Part 3: The Aftermath of Trauma

From Psychology Today

By Shaili Jain, M.D.
October 2, 2014

This week, Dr. Victor Carrion finishes a three-part interview on the impact of psychological trauma on children. Dr. Carrion is a professor at the Stanford University School of Medicine and director of the Stanford Early Life Stress Research Program at the Lucille Packard Children’s Hospital at Stanford.

His research focuses on the interplay between brain development and stress vulnerability. He has developed treatments that focus on individual and community based interventions for stress related conditions in children and adolescents that experience traumatic stress.

This week, Dr. Carrion discusses the treatments and preventative interventions for children with PTSD, the factors that determine how these children will respond to treatment, and the future of the field.

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SJ: What are effective treatments for children with PTSD? (psychological therapies and pharmacotherapies)

VC: Trauma focus cognitive behavioral therapy is the treatment of choice. It is a treatment that was developed to treat children who have experienced sexual abuse but it has now been adapted to be used in different settings, including for children who have witnessed domestic violence.

One of the things that Judith Cohen (the developer of trauma focused CBT) and I are talking about is the need to develop algorithms for treatment. So, the age of the kids, the type of trauma, and duration of the trauma would determine which specific treatment a child would get.

But certainly, the first line of intervention for children that have PTSD is psychosocial interventions and it is not medication. Now, do I use medication? Yes. I use medication in 2 scenarios. One, when there is comorbidity, and the comorbidity in PTSD is high - it is 80%. So, if the child has major depression, in addition to the PTSD, I would want to treat that. That is one scenario.

The other scenario is when the severity is so high that this individual may have difficulties engaging in their psychosocial treatment.

But the reality is that we have no pharmacological agent that would target all the neurotransmitter systems that traumatic stress impacts.

We actually developed a manual to treat kids called the Cue-Centred Treatment Protocol. The whole idea here is that it is a hybrid. It has different components that we know help kids, it has: CBT, exposure and psycho-education, and insight orientated therapy. But the main thing that it does is that it empowers children to be their own agent of change.

It is not so much about processing a narrative as teaching you how important a narrative is, because the chances that these kids will continue to have traumas after we finish treatment is still pretty high and we want these kids to be equipped in knowing what to do.

We did a randomized controlled trial in East Palo Alto and Hunters Point in Bayview at some schools there and the treatment has shown efficacy to decrease PTSD symptoms and anxiety symptoms when compared to kids put on a wait list.

There are some family interventions too. One is called parent-child psychotherapy. This is work by Alicia Lieberman at UCSF where she helps children age zero to 5. It gives treatment to both the parent and the child, it is more about their dyad, their relationship, and that has also been shown to be effective.

SJ: What are the factors that determine how children with PTSD will respond to treatment?

VC: With children, there are 3 factors that we think are very important to the outcome of the psychosocial intervention: Intelligence, motivation, and psychological mindedness. If a child is motivated and they can talk about feelings and they are smart, then the treatments will likely work.

For some special populations, like children with mental retardation that get traumatized or children in the juvenile justice system, we still need more effective treatments.

SJ: What types of preventative interventions/public health measures do you think are key to reducing the amount of violence children in our society are exposed too?

VC: One of the things that I have done for the past 3 years is that I have been part of this coalition in San Francisco where we have built an ecological approach to the problem of trauma. Rather than just concentrating on models or treatments for the individual, we think of the whole system. We think about their school, we think about their family and how can we, in one place, do preventive work or treatment.

We have developed this Centre for Youth Wellness (CYW), which is a place that integrates paediatric care with mental health. So, every time they come for their paediatric checks, they get additional screenings for trauma. In that way, we know very early if they had traumatic events or not and then we start working with them, but not only with them, with their families and with the primary care team that is taking care of them in the same place.

The CYW is also co-located with the CAC, i.e., the Child Advocacy Centre. The CAC is the place where, when something traumatic happens, the child will come here to get their forensic evaluations and physical exams, etc. So, if that family shows up with kids to the CAC, the other siblings can be enrolled right away in the Centre for Youth Wellness.

So, we are concentrating a lot on prevention, on interdisciplinary work, and concentrating on developing new treatment methods that are empirically validated.

At Ravenswood Family Health Centre, here in East Palo Alto, we have this model where we have a behavioral health worker working with the pediatricians. We looked at referrals and found that when we did a “warm hand off” (between psychiatry and the behavioural health person) there was significantly more follow through and less no shows for treatment.

SJ: What do you envision will be key obstacles to progression in this field? Or what are the major controversies in this field that need to be resolved?

VC: The way that ground mechanisms work in terms of funding for 3 or 5 years or maybe even less than that. This makes follow-up research very difficult. We need longitudinal studies to advance our knowledge of what goes on in PTSD.

SJ: What do you envision will be key advances in the treatment/understanding/prevention of traumatic stress in children in the next 10-20 years?

VC: I think working with mathematicians will advance our field, because I think that mathematical formulas are going to help us understand how these variables interact with each other, e.g., like genetics and severity of the traumatic event.

I get excited about treatment interventions that can demonstrate that they can actually alter the physiology of someone who struggles with PTSD.

I am excited to know more about how stressors and traumatic events impact the physical health of the individual, for example, through atherosclerosis or pro-inflammation and things like that. This will inform not only our psychiatric practice but I think medicine in general and the role of environment in medicine.

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