Working With Teens Who Have

Experienced Trauma

Gloria Castro Larrazabal, Psy.D.

Infant-Parent Program

UCSF/SFGH

Trauma Principles

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

If we do not look for or acknowledge trauma in the lives of children and adolescents, we end up chasing behaviors and limiting the possibilities for change.

Trauma

The behavioral and emotional adaptations that

maltreated children and adolescents make in

order to survive are brilliant, creative solutions,

and are personally costly.

If you do not ask, they will not tell your.

Since Trauma = Chaos

Structure = Healing

Children and Adolescents are Exposed to

Traumatic Life Events

Traumatic Event: is one that threatens

injury, death, or the physical integrity of

self and others.

It causes horror, terror, or helplessness at

the time it occurs.

Traumatic Events

Sexual, physical, and emotional abuse.

Domestic, school and community violence

Medical trauma.

Motor vehicle accidents.

Acts of terrorism and war experiences.

Natural and human-made disasters.

Suicide and/or loss of a loved one.

In community samples more than two thirds

of children report experiencing a traumatic

event by age 16.

Witnessing community violence: the range

goes from 36% to 85% and estimated rates

of victimization go up to 66%

Exposure to sexual abuse: the estimated

rates go from 25% to 44%

Reactions Displayed by Children and

Adolescents

The development of new fears

Separation anxiety (particularly in young children

Sleep disturbances, nightmares

Sadness, anger, irritability

Loss of interest in normal activities

Reduced concentration

Declined in schoolwork

Somatic complaints

SCHOOL

COMMUNITY

ADOLESCENT

RESILIENCE

moderates risk factors

on outcomes at the level

of neighborhood, family,

and child.

TRAUMA

FAMILY

PEERS

Complex Trauma in

Adolescents

Complex Trauma describes the dual problem

of adolescent’s exposure to multiple

traumatic events and the impact of this

exposure on immediate and long-term

outcomes.

Complex Trauma results when a child is

abused or neglected.

Impact of Complex Trauma

Normative development

Psychiatric and addictive disorders

Chronic medical illness

Legal, vocational, and family problems

These difficulties may extend from childhood

through adolescence and into adulthood

Impact of Complex Trauma on

Development

Attachment

Neurobiology and neurophysiology

Affect regulation

Dissociation

Behavioral regulation

Cognition

Self-Concept

Attachment

Secure Attachment: children learn about themselves, their emotions, and their relationships with others within the relationship of the caregiver.

Secure Attachment: supports a child’s development in areas, including his capacity for regulating physical and emotional states, his sense of safety (this allows him to explore the world), his early knowledge about how he can have an impact on his environment, and his early capacity for communication.

How Trauma Impacts

Attachment

Disconnecting from social relationships

Acting coercively towards others

Due to the unpredictable violence or repeated abandonment, they tend to cope by restricting their processing of what is happening around them

When they are confront with a challenging situation, they cannot formulate a coherent, organized response

Neurobiology

Toddlers and preschool age children: they are at risk

for failing to develop brain capacities necessary for

regulating emotions in response to stress.

Trauma interferes with the integration of left and

right hemisphere brain functioning. The child cannot

access rational thought in the face of overwhelming

emotions.

They tend to react with extreme helplessness,

confusion, withdrawal, or rage when stressed.

In middle childhood and adolescence, the

most rapidly developing brain areas are those

that are crucial for success in forming

interpersonal relationships and solving-

problems.

Traumatic stressors can lead to difficulties in

emotional and behavioral regulation,

consciousness, cognition, and identity

formation.

Neurobiology of Adolescents Expose

to Trauma

Substance abuse to cope with hypersrousal,

numbness, and reexperiencing the event

Indiscriminant sexual behavior

Cutting and suicidal gestures

Continued contact with the abuser

The freeze response

Engaging in high risk behaviors

Conceptual Framework

Trauma is a neurophysiologic state stemming

from neurobiological injury.

The brain is plastic and has the ability to

change its structure and function in response

to experience.

Sympathic Nervous System

Response

Catecholamine are increased: damage to

memory, rational thought, hypervigilance,

inability to distinguish danger signals

Corticosteroids are low: reduced immune

functioning

Opioids levels increase: flat affect (equivalent

of 8 mg of morphine)

Other Neurotransmitters

Serotonin: inhibitory; involved in emotion and mood. Low levels of serotonin lead to depression, problems with anger control, obsessive-compulsive disorder, and suicide.

Dopamine: inhibitory; controls arousal, alertness, attention; gives motivation (drugs like cocaine, opium, heroin, alcohol and nicotine increase the levels of dopamine).

GABA: inhibitory; acts like a brake to the excitatory neurotransmitters that lead to anxiety.

Supportive relationships with adults and

peers can protect children and adolescents

from many of the consequences of traumatic

stress.

The role adults play in the life of adolescents

is crucial.

Affect Regulation

The identification of internal emotional

experiences.

It requires the ability to discriminate among

states of arousal, interpret these states, and

apply appropriate labels (e.g. “happy”,

“frightened”).

Able to express emotions safely and to adjust or

regulate internal experience.

How Trauma Impacts Affect Regulation

Dissociation

Chronic numbing of emotional experience

Dysphoria

Avoidance of emotional situations (including

positive experiences)

Maladaptive coping strategies ( substance

abuse)

Dissociation

It is the failure to integrate information and

experiences

Thoughts and emotions are disconnected

Physical sensations are outside conscious

awareness

Repetitive behaviors take place without

conscious choice, planning, or self-

awareness

Behavioral Regulation

Behavioral patterns that represent

adolescents’ defensive adaptations to

overwhelming stress.

They may reenact behavioral aspects of their

trauma (e.g., through aggression, self-

injurious, or sexualized behaviors).

They can be attempts to gain mastery or

control over their experiences.

Behavioral Regulation

They may use alcohol or drugs to avoid

experiencing intolerable levels of arousal.

They may engage in sexual behaviors in

order to achieve acceptance and intimacy.

Cognition

Attention.

Abstract reasoning.

Problem solving.

They have three times the drop out rate of

the general population.

Self-Concept

If adolescents perceive themselves as

powerless or incompetent and expect others

to reject or despise them are likely to:

A) Blame themselves for negative

experiences.

B) Have problems eliciting and responding to

social support.

Family’s Contribution to Healing

Process

Believing and validating the adolescent’s

experience.

Tolerating the adolescent’s affect.

Managing the caregiver’s own emotional

response.

ASSESSMENT AND TREATMENT

ASSESSMENT

The adolescent’s own disclosures

Collateral reports from caregivers and other providers

The therapist’s observations

Standardized assessment measures that have been completed by

the adolescent, parents, and by the teachers

Assessments need to be cultural sensitive

The Adolescent Sexual Behavior Inventory

(ACSBI)

It is used to assess sex-related behaviors that

might suggest a need for intervention.

It assess: sexual risk taking, nonconforming

sexual behaviors, sexual interest, and sexual

avoidance/discomfort.

It is used for children age range from 12 to 18.

There are two versions , a parent report version

(ASBI-P)

TREATMENT The Complex Trauma Workgroup

NCTSN

1. Safety: Creating a safe home, school, and

community environment.

2. Self-regulation: enhancing his/her

capacity to modulate arousal and restore

equilibrium following disregulation of affect,

behavior, physiology, cognition, interpersonal

relatedness and self-attributions.

3. Self-reflective information processing: consists in helping the adolescent to construct self-narratives, reflect on past and present experiences, and develop skills in planning and decision-making.

4. Traumatic experience integration: enabling the adolescent to transform or resolve traumatic memories or reminders. It can be done by using techniques as meaning making, traumatic memory containment or processing, mourning of the traumatic loss, managing symptoms, developing coping skills, and cultivation of present-oriented thinking and behavior.

5. Relational engagement: helping the adolescent

to form appropriate attachment and to apply this

experience to current interpersonal relationships.

6. Positive affective enhancement: enhancing the

adolescent sense of self-worth, esteem and positive

self-appraisal through the cultivation of personal

creativity, imagination, future orientation,

achievement, competence, mastery, community-

building and the capacity to experience pleasure.

A Phase-Based Approach

Treatment proceeds through a series of phases that focus on different goals. This avoids overloading the adolescent with too much information at one time.

This approach begins with providing safety followed by teaching self-regulation

Gradually incorporates self-reflective information processing, relational engagement, and positive affect enhancement

Establish a substantial period of stabilization

in which internal and external resources have

been established.

Foster integration of traumatic experiences

by identifying and coping with present

triggers.

Interventions should build strengths and

decrease symptoms.

Compassion Fatigue Secondary Traumatization

Compassion: feeling of deep sympathy for

another’s suffering.

Compassion Stress: is the feeling of tension or

demand associated with feelings of compassion.

Compassion Fatigue: progresses from

Compassion Stress and is an overwhelming

state of tension and preoccupation with the

cumulative trauma experienced and reported by

clients.

Compassion Fatigue

Internal images are created within the

professional’s mind and can stimulate intense

feelings of compassion which can result in

vicarious experiences of the actual trauma.

Risk Factors to develop Compassion

Fatigue

Professionals who have poor boundaries

Have unresolved traumatic experiences in

their own lives

May be exhausted from the demands of their

work

Professionals who are driven to rescue

clients or whose self-worth is tied to being

liked by their clients

Coping With and Managing

Compassion Fatigue

Develop self-care behaviors.

Examine within themselves any unresolved trauma

issues of their own.

Be alert of the symptoms of compassion fatigue.

Be aware of their feelings and mood states.

Recognize when additional support is needed.

Talk to fellow professionals.

Set realistic goals and boundaries in your work.

Additional training and education about trauma.

References

Cook, A., Blaustein, M., Spinazzola, J., van der Kolk, B. (Eds.). Complex

Trauma in Children and Adolescents. National Child Traumatic Stress

Network. www.nctsnet.org/nccts/nav.do?pid=typ_ct

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.,Cloitre, M.,

DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., &

van der Kolk, B. (2005). Complex Trauma in Children and Adolescents.

Psychiatric Annals, 35, 390-398.

Frederick, W.N., Lysne, M., Sim, L., & Shamos, S. (2004). Assessing sexual

behavior in high-risk adolescents with the Adolescent Clinical Sexual

Behavior Inventory. Child Maltreatment, 9(3), 239-250

Wilgocki, J. (2008). The Effects of Trauma on Children and Adolescents.

Mental Health Center of Dane County. The National Child Traumatic Stress

Network.