Amanda Paton

Parkerville Children and Youth Care

Mental Health and Complex

Trauma

Providing specialist therapeutic services to children, young people and their families who have been effected

by trauma and abuse.

Client Background

• Complex family histories ▫ Intergenerational abuse

• Multiple abuse experiences • Chronic rather than acute episodes • Multiple perpetrators • System abuse

▫ Placement breakdowns

• Early onset abuse • Disrupted attachment

Complex Trauma

• Exposure to multiple or prolonged traumatic events • Impacts development • Simultaneous or sequential occurrence of child

maltreatment ▫ psychological maltreatment ▫ neglect ▫ physical abuse ▫ sexual abuse ▫ domestic violence

• Chronic, begins in early childhood, and occurs within primary care giving relationship

Symptoms • Physiological hyper-arousal • Emotional numbing • Hyperactivity • Dysphoria • Dissociation • Distractibility and attention problems • Impulsivity • Increased startle response • Social avoidance • Poor school achievement • Sleep problems • Aggressive play/ interactions with peers • General regressed/ delayed development

PTSD

• Children exposed to trauma have higher rates than general population – 15-90%

• Ackerman ▫ 34% met criteria ▫ Over 50% of children exp SA and PA met criteria ▫ Majority met diagnostic criteria for three or more Axis

I diagnoses in addition to PTSD

• The younger a child the more likely they are to develop trauma-related symptoms

• % of children developing PTSD following a traumatic event is sign. higher than % of adults

Common Misdiagnosis

• Hyperactivity, Impulsivity and inattention – ADHD

• Cognitive profile with low verbal and average performance – Learning Disability

• Poor emotional expression and response to emotional cues – Autism Spectrum Disorder

• Behavioural problems – ODD, CD

Mental Health

• One’s ability to enjoy life, and create a balance

• Psychological resilience

• Expression of emotions

• Adaptation

• Well being

• Cope with ‘normal’ stresses of life

• Aware of ones own abilities

Poor Mental Health

• Axis I: Clinical Syndromes

▫ e.g. Depression, Schizophrenia, Anxiety

• Axis II: Developmental Disorders and Personality Disorders

▫ DD – e.g. Autism PDD and others first evident in childhood

▫ PD – e.g. Paranoid, Antisocial, and Borderline Personality Disorders.

Complex Trauma

Child and carer factors

General Poor MH and risk

Diagnosis & misdiagnosis

Symptoms

Child

Physical

Medical

Trauma Experience

Social;

Cognitive

Education

Emotional

Behavioural

11

Our assessments

are about

putting the

pieces of the

puzzle together

and working out

how the child’s

behaviours fit

with their

experience of

their world

Choosing the Intervention

Ineffective Interventions • Client directed work • Poor trauma training in the

system/ team • High staff turnover in the

system/ team • Specific single focused

interventions ▫ Conventional Western talk-

based therapy models ▫ Play therapy ▫ Non-directive ▫ Behavioural

Effective Interventions • Parents/ caregivers • Psycho-education • Therapy for the carer • Parent child dyadic work • Advocacy • Combined approaches

▫ CBT, play, psychodynamic, trauma focused, narrative, exposure, coping skills etc

• Multi system – team approach

Brain Region Age of greatest

developmental activity

Age of functional

maturity

Key functions

Neocortex Childhood Adult Reasoning

Problem solving

Abstraction

Spatial reasoning

Limbic Early Childhood Puberty Memory

Attachment

Affect regulation

Primary Sensory Integration

Diencephalon Infancy Childhood Motor Control

Balance

Brainstem In utero Infancy Core physiological state regulation

e.g. Heart rate, temperature,

breathing, blood pressure and

sucking reflex

Adapted from ‘Shifting Developmental Activity across Brain Regions; Bruce Perry 2007

Sensory Integration

e.g. Massage, touch, music, swimming, rocking, breathing

Self Regulation

e.g. Structure, predictable routine, transition cues, weighted blankets/ vests

(OT), bed time rituals

Relational

e.g. Multiple adults invested in the child, art, PCIT, dyadic,

peer groups

Cognitive

e.g. Insight oriented therapy, CBT

Treatment Plan

Laura

• Hx neglect, DV, SA

• Multiple perp

• Chronic abuse

• Parental care of siblings

• No food in house, frequent carer absence, hyper vigilant

• Poor school attendance, poor supervision

• Apprehended at 6 years

• Failed reunification attempts

• Multiple placements

• Poor family contact

• Long term placement

▫ Further SA and carer rejection

• Sibling group separated

• Long term placement – one on one care

Presentation

• Nightmares • Frequent flashbacks • Highly dis-regulated • General affect regulation difficulties • Dysphoria • Visual hallucinations • Self harm, suicidal ideation and attempt • Paranoia • Violence towards carer • Poor attention, diff at school • Peer difficulties • Fluctuating developmental presentation • Poor memory

• Diagnosis

▫ Complex PTSD, GAD, Dep, Disorganised Attachment

• Multiple hospital admissions

• Psychiatric treatment

• Medications

▫ Mood stabilisers

▫ Tranquilisers

▫ Respiratory depressant

▫ Anti depressants

▫ Anti anxiety

1

Sensory Integration

Controlled timed breathing, gentle massage by carer, touch/ hugs, rocking, nails and hair, music

Self Regulation

Highly structured and predictable environment, all changes heavily

planned in advance, verbal prompts and reminders for change/

transition, highly routine bedtime, swings, emotional prompts/ cues

Relational

Psych for six yrs, carer 4 yrs, respite 2 years, CM, 4 years, dyadic

sessions with carer, parallel play with carer, peer interactions – one on one and small groups, siblings

facilitated contact

Cognitive

CBT, trauma narrative, exposure, life story

Laura

Intervention/ Progress

• Therapy responsive to child and carer needs • Care Team approach across agencies and disciplines • Trauma informed practice • Planned co-ordinated response • Long term placement for 4 years • Emotional growth – hampered by puberty and family

factors (uncontrollable in treatment) • Dev insight into hx and current fx • Dev ability to co regulate and in certain times, self

regulate • Returned to extended family • Maintained relationship with long term carer • Avoided the ‘system’

Some helpful References

• Haddad & Garralda. 1992 • Perry, Pollard, Blakley, Baker, & Vigilante. 1995 • Perry, Pollard, Baker, Sturges, Vigilante, & Blakley.

1995; Perry. 1994; Perry. 2000 • Kaufman. 1991; Ornitz & Pynoos. 1989; Perry. 2000 • Ackerman, Newton, McPHerson, Jones, & Dykman.

1998 • Pfefferbaum. 1997 • Joseph Spinazzola, Ph.D., Julian Ford, Ph.D., Bessel

van der Kolk, M.D., Margaret Blaustein, Ph.D., Melissa Brymer, Psy.D., Laura Gardner, BsPH, Susan Silva, Ph.D., Stephanie Smith, Ph.D.