Complex posttraumatic stress disorder treatment considerations

Evidence In-Sight: Complex posttraumatic stress disorder treatment considerations Date: November, 2011 www.excellenceforchildandyouth.ca www.excellencepourenfantsados.ca

The following Evidence In-Sight report involved a non-systematic search and summary of the research and grey literature. These findings are intended to inform the requesting organization, in a timely fashion, rather than providing an exhaustive search or systematic review. This report reflects the literature and evidence available at the time of writing. As new evidence emerges, knowledge on evidence-informed practices can evolve. It may be useful to re-examine and update the evidence over time and/or as new findings emerge. Evidence In-Sight primarily presents research findings, along with consultations with experts where feasible and constructive. Since scientific research represents only one type of evidence, we encourage you to combine these findings with the expertise of practitioners and the experiences of children, youth and families to develop the best evidence-informed practices for your setting. While this report may describe best practices or models of evidence-informed programs, Evidence In-Sight does not include direct recommendations or endorsement of a particular practice or program. This report was researched to address the question: According to the literature, what are recommended treatment approaches for children and youth with symptoms of complex posttraumatic stress disorder? We prepared the report given the contextual information provided in our first communications (see Overview of inquiry). We are available at any time to discuss potential next steps. We appreciate your responding to a brief satisfaction survey that the Centre will e-mail to you within two weeks. We would also like to schedule a brief phone call to assess your satisfaction with the information provided in the report. Please let us know when you would be available to schedule a 15-minute phone conversation. Thank you for contacting Evidence In-Sight. Please do not hesitate to follow up or contact us at evidenceinsight@cheo.on.ca or by phone at 613-737-2297. Page 2

1. Overview of inquiry The requesting organization is seeking to build capacity in providing services for clients with histories of trauma, including those diagnosed with or exhibiting symptoms of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD). The agency has a working group trying to address this issue and are developing a questionnaire that will be distributed across the agency to help identify needs, but have little additional time to conduct an in-depth literature review. Question statement: What are recommended treatment approaches for children/youth presenting with symptoms of Posttraumatic Stress Disorder and complex Posttraumatic Stress Disorder? 2. Summary of findings Multiple traumatic events, particularly the experience of sexual abuse, can constitute what is termed complex trauma. Insecure attachment may leave a child vulnerable to complex trauma exposure, and if the source of the trauma originates from the primary caregiver, a child is at increased risk of pathological traumatic adaptation. Complex post-traumatic stress disorder is likely a subtype of PTSD and reflects a broader, more severe type of trauma that results from early and repetitive trauma. Treatment approaches should seek to build resilience in youth including enhancing self-esteem, social support, the ability to adapt and be flexible to changes, and coping, as these skills will later serve as a protective mechanism in adulthood. Cognitive behavioural therapy is a recommended treatment for children/youth with PTSD. Specifically, traumafocused cognitive behavioural therapy is a validated treatment for children who have experienced trauma. Treatment programs geared towards youth with CPTSD have been found to be effective at providing symptom relief and improving social competence and emotional management. Treatment for complex trauma should be sequential and stage-oriented, where skills learned in a module can build on previously learned skills. In addition, some research indicates preference for a multidimensional approach where several forms of therapy are used in conjunction with others. Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) is a manualized program for adolescents that treats chronic traumas (including symptoms of PTSD and CPTSD), and may be suited to the needs of the youth at the requesting agency. The program relies on cognitive-behavioural and dialectical treatment modalities and has been empirically evaluated. 3. Answer search strategy Search Tools: EBSCO Host (Medline, PsycInfo, CINAHL, Health Business Elite, Nursing & Allied Health Connection: Comprehensive, Psychology and Behavioral Sciences Collection, Biomedical Reference Collection, Comprehensive), Google Scholar, and The Cochrane Library. Search Terms used: trauma, complex trauma, posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder, multiple traumas, children, youth, adolescents, treatment, programs. Page 3

4. Findings Discussion of complex trauma originates from clinical experience and has not been validated by the scientific community (Ford, Courtois, Steele, van der Hart, Nijenhuis, 2005). Complex PTSD is not a formal diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). PTSD is a diagnostic category in DSM-5, and in a change from the previous version of the DSM, PTSD is now considered a Trauma and Stressor-related Disorder instead of an Anxiety Disorder. Diagnostic criteria in the DSM-5 identify exposure to actual or threatened death, serious injury or sexual violation as the triggers to PTSD (American Psychiatric Association, 2013). While most articles cited in this report are peer-reviewed, some are not, and this should be taken into account when considering some of the findings. Despite a lack of formal recognition of complex PTSD, the new DSM recognizes a preschool subtype and recognizes the role of a history of trauma in causing a disorder. Although there is a body of literature on service provision and treatment for trauma, in particular PTSD, treatments for children and youth with complex PTSD are relatively new and more work is needed to evaluate interventions. 4.1 Posttraumatic stress disorder Symptoms that may follow trauma exposure include avoidance behaviours (i.e., avoiding activities, people, and places associated with the trauma; Van-Minnen & Hagenaars, 2010), re-experiencing or flashbacks of the trauma (Bourne, Frasquilho, Roth, & Holmes, 2010), and general numbing, hyperarousal, and disturbed sleep (Ohayon & Shapiro, 2000). Posttraumatic stress reactions can occur at any age, including childhood (DSM-IV-TR, 2000). Childhood PTSD closely resembles the profile of that of adults with a few notable differences: symptoms for children may manifest as repetitive play where themes of the trauma are enacted, and they can have separation anxiety, frightening dreams, and disorganized or agitated behaviours (DSM-IV-TR, American Psychiatric Association, 2000). PTSD was first introduced in the third edition of the DSM in response to a need for a diagnosis for returning war veterans who were experiencing symptoms of re-experiencing, numbing/avoidance, and hyperarousal (Courtois, 2008). At the time, it was thought that those seeking support for trauma experienced a single provoking event, and therefore early treatments for PTSD were designed to address symptomatology of a single event (Jackson, Nissenson, & Cloitre, 2010). It is now known that the experience of a single traumatic event is rare, and in fact the majority of people will experience multiple traumatic events (Kessler, 2000). Multiple and ongoinag traumatic events, particularly a history of sexual abuse, can lead to what is termed complex trauma (Zlotnick et al., 1996). 4.2 Complex posttraumatic stress disorder Complex trauma outcomes refer to the range of symptomatology that extends beyond PTSD (Cook, Blaustein, Spinazzola, & van der Kolk, 2003). CPTSD reflects a broader, more pronounced reaction to trauma that may follow exposure to early, repetitive, or prolonged trauma of an interpersonal nature (van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman, 1996; Ide & Paez, 2000). Extreme forms of trauma that constitute complex trauma include being held in captivity where the victim is unable to escape, being under the control of a perpetrator, emotional abuse, physical neglect, sexual abuse, physical abuse, and witnessing domestic violence (Ide et al., 2000; Cook et al., 2003). It is not necessarily the type of event that is of importance in predicting CPTSD what is more important is that the abuse or maltreatment be chronic, early, either sequential or simultaneous, and within a care-giver relationship (Becker Weidman, 2006). Page 4

Symptomatology that accompanies CPTSD differs from that of PTSD (Ford et al., 2005), and it has been suggested that standard treatments do not address the symptomatology that accompanies CPTSD (Ford & Kidd, 1998). Symptoms can include difficulty regulating extreme emotion states, bodily distress, negative beliefs about the self and relationships, and dissociation (Herman, 1992). Dissociation is a protective factor that is used in the face of overwhelming trauma and is a key feature of complex trauma in children (Cook et al., 2003). In a dissociative state, thoughts are disconnected and physical awareness is outside of conscious awareness (Cook et al., 2007). Dissociation starts as a protective mechanism (i.e., getting lost in a thought) and can become a serious disorder (Cook et al., 2007). As the theory of complex trauma is relatively new, proponents continue to work to bring it into acceptance in the scientific community, and ultimately to recognition in the DSM (Ford et al., 2005; Ide et al., 2000). Although support for a diagnosis of CPTSD (which some refer to disorders of extreme stress not otherwise specified, or DESNOS) is growing (Courtois, 2008), valid diagnostic classification of complex trauma requires epidemiological research (Cook et al., 2003). 4.3 Treatment PTSD PTSD is often treated with cognitive-behavioural interventions, exposure, and cognitive restructuring (Foa, Keane, Friedman, 2000). Treatment can include validating a victims experience, adopting a multidimensional therapeutic approach, and focusing on the present (Ide et al., 2000). Although drug therapy is the most investigated form of treatment for childhood PTSD, cognitive behavioural therapy (CBT) is the most recommended therapy for traumatized children PTSD (Ahmad, Larsson, & Sundelin-Wahlstein, 2007; Foa, Chrestman, & Gilboa-Schechtman, 2009; National Institute for Clinical Excellence, 2005). CBT programs include components of psychoeducation, exposure therapy, and anxiety management, and vary based on their emphasis of these different components (Rachamim, Nacasch, Shafran, Tzur, & Gilboa-Schechtman, 2009). Trauma-focused cognitive behavioural therapy (TF-CBT) is the most common, validated treatment for children and parents of traumatized children (Cohen & Mannarino, 2008). TF-CBT uses the acronym PRACTICE, which identifies key treatment components(cohen et al., 2008): psychoeducation parenting skills relaxation affective modulation cognitive coping and processing trauma narrative in vivo mastery of trauma reminders conjoint child-parent sessions enhanced future safety and development TF-CBT can be supplemented by sessions of eye movement desensitization and reprocessing (National Institute for Clinical Excellence, 2005). TF-CBT consists of individual and child-and-parent-treatment sessions where both the child and parent attend parallel sessions (Cohen et al., 2008). TF-CBT relies heavily on gradual exposure and uses a graded Page 5

exposure to the child s traumatic experience that progresses as both the parent and child move through a hierarchy (Cohen et al., 2008). TF-CBT may not be appropriate for children whose primary problem is not trauma related (Cohen et al., 2008). TF-CBT has been empirically tested in several randomized controlled trials with sexually abused children, and those who have experienced multiple traumatic events, and it has been found to be effective in treating PTSD in children/youth of a wide range of ages (Cohen et al., 2008). Complex PTSD The effectiveness of using interventions that have been evaluated for children with PTSD to help children with CPTSD is unknown, and in general, research on treatments for CPTSD are limited (Holowka & Marx, 2010; Resick, Nishith, & Griffin, 2003). Treatment for PTSD typically takes a singular focus, while treatment for CPTSD should make use of several forms of therapy and use one in conjunction with the others (Ide et al., 2000). Therapy for individuals presenting with CPTSD should be longer in duration and may need to occur on an ongoing basis (Courtois, 2008). Survivors of severe sexual abuse or other forms of severe trauma may need an initial period of skill development to learn to maintain friendship, cope with symptoms, improve functioning, and establish a positive identity (Chu, 1998). For instance, a controlled trial with adult females with PTSD from childhood sexual abuse compared a group receiving standard CBT with a test group receiving CBT preceded by a preparatory phase of skills training in affect and interpersonal regulation (Cloitre et al., 2010). The study assumed that childhood abuse can lead to PTSD that is made more complicated by impaired emotion regulation, which makes it more difficult to cope with distress provoked by trauma-focused CBT. Training clients in emotion regulation seemed to help those in the test group be better prepared to compensate for the particular challenge of having complex PTSD. Treatment for individuals who experienced severe child abuse should be phase or stage-oriented (Lebowitz, Harvey, & Herman, 1993). A staged treatment is one where different techniques and therapies are applied at different stages of treatment (Centre for Addiction and Mental Health, 2009). Therapists should avoid using any strategies that overwhelm patients without creating significant progress (Chu, 1998), so treatments that treat every symptom at one time may prevent any learning from occurring (Cook et al., 2003). Research with adults suggests that treatment for complex trauma should be sequential and follow a three-stage process (Courtois, 2008). The first stage includes the development of a treatment alliance, establishing safety, skill building, and providing support. This first stage is likely the longest of the three. The second stage involves processing the traumatic material. It involves decoding, mourning, resolution, and integration of the trauma. The third stage focuses on consolidation and restructuring. The clinician provides a secure base wherein the client does the work and builds on the work established in the first two stages. This type of treatment is likely to start and stop (Courtois, 2008). Final termination of the program should be discussed, and both the client and the clinician should be in agreement. As children have not fully developed the ability to attend to and process information (Cook et al., 2003), this flexible, sequential treatment approach recommended for adults is particularly relevant for children. This staged process should not be linear as it may be necessary to re-visit earlier phases of the treatment process. Good treatment requires flexible Page 6

adaptation of treatment strategies and should be adapted based on age, developmental stage, gender, ethnicity and other affiliations (Cook et al., 2007). For children/youth, the first step in treatment should include a comprehensive assessment (Cook et al., 2007). Information can be gathered from a number of sources including the child/youth, their teacher, caregiver and other providers, the therapist s observations and formal assessments. Attachment theories play a role in the development of complex trauma, therefore when assessing a traumatized child, it is important to consider relationships (Cook et al., 2003). Complex trauma is most likely to develop if a child is exposed to an unpredictable or uncontrolled environment, and therefore if the caregiver relationship is itself the source of trauma, attachment may be severely compromised (Cook et al., 2007). Early caregiver relationships set the stage for a child to develop models of their self, others, and the self in relationship to others (Cook et al., 2003). As the caregiver relationship may be the cause of the trauma, this important developmental experience is disrupted (Cook et al., 2003). The goal of therapy with children with complex trauma is to enable them to experience emotional states as tolerable and manageable (Ford & Cloitre, 2009). According to Cook et al., 2003, treatment for youth presenting with complex trauma has four main goals: 1) Establish safety in the client s environment, including home, school, and community 2) Development emotion regulation and interpersonal functioning skills 3) Process and make meaning of past traumatic events they have experienced so that youth can consider more positive, adaptive views about themselves in the present, and experience hope about their future 4) Enhance resiliency and integration into a social network No child is able to receive new information when they fear for their safety, so the first stage of treatment involves building a network and addressing the needs of the child and the family (Cook et al., 2007). In the second stage, children learn emotion regulation skills and this helps them deal with the trauma they have experienced. With coping skills and an increased capacity for emotion regulation, they are better able to communicate and process traumatic memories. The children are then able to see themselves as different people and view themselves more confidently. The goal of the final stage is to instill principles of resiliency so that they are able to develop in positive, healthy ways. It may not be appropriate to revisit traumatic memories, but it may be of benefit to integrate traumatic experiences and focus on recognizing and coping with triggers (Cook et al., 2007). Interventions should build strengths in addition to reducing symptoms; this will later serve as a protective mechanism in adulthood (Cook et al., 2007). The National Child Traumatic Stress Network conducted a large-scale survey (1,699 children and 62 clinicians) to evaluate exposure, outcomes, and treatment approaches on trauma-exposed children. Clinician rankings were based on direct clinical observation and/or empirical evidence at their site. Curiously, the top five of seven rated treatments for complex trauma were also ranked among the least effective forms of therapy. The top five rated treatments by clinicians were play therapy, expressive therapies, multi-systemic therapy, group therapy, and self-management/coaching. The only consistently positively rated treatments by clinicians were individual therapy and family therapy. Consistently ranked as ineffective were pharmacotherapy and home-based therapies (Spinazzola, Ford, van der Kolk, Balustein, Page 7

Brymer, Gardner, et al., 2003). Clinicians surveyed recommended that the caregiver of the child be involved in the process, and many clinicians noted the effectiveness of using combined approaches in therapy and tailoring the intervention to the child s specific needs. It is also important to coordinate services across sectors, including schools, mental health, and social services (Spinazzola et al., 2003). Resilience can serve as a protective factor against the effects of exposure to complex trauma (Cook et al., 2003). Resilience, defined as the capacity to thrive under conditions of adversity (Connor & Davidson, 2003), is not something an individual has, but reflects a process that can be fostered and developed at any point in life (Cicchetti, 2010; Wagnild & Young, 1993). Resilience can be promoted through positive attachment, cognitive self-regulation abilities, positive beliefs about oneself, and motivation to act effectively in one s environment. Therefore programs aimed at fostering resilience and promoting coping strategies may allow youth to develop positively and avoid future victimization (Cook et al., 2003). 4.4 Programs The following are evidence-informed treatment programs with some degree of research support for their effectiveness. PTSD: Trauma Focused Cognitive Behavioural Therapy (TF-CBT) Description Examples Evaluation More information TF-CBT is a treatment for children aged 3-18 who have experienced exposure to a traumatic event such as child sexual or physical abuse. The aim of the program is to help children and parents overcome the negative effects of trauma through a parental treatment component and multiple parent-child sessions. Outcomes include the treatment of child symptoms of PTSD, child depression, and shame. The program is designed for outpatient use and is suitable for males and females of diverse ethnicities (Cohen & Mannarino, 1996). In one study, children and a guardian were assigned to one of three intervention groups, including child only, guardian only, or guardian and child. The groups were compared to a no intervention control group who received standard community care. Children who received the intervention (those in the child only and guardian and child group) exhibited significantly fewer PTSD symptoms post-treatment than those assigned to the guardian-only group or the comparison group (p <.01). For more information on this study, see: Deblinger, Lippmann, & Steer, 1996 TF-CBT has been reviewed extensively (6 randomized controlled trials in children) and is a practice recommended by NREPP. See http://nrepp.samhsa.gov/viewintervention.aspx?id=135 Trauma-Focused Cognitive Behavioural Therapy: http://tfcbt.musc.edu/ http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135#study%202 http://www.childwelfare.gov/pubs/trauma/trauma.pdf PTSD: Eye-Movement Desensitization and Reprocessing (EMDR) Description Examples EMDR is a treatment for PTSD where clients visually track a therapist s finger waved back and forth as they engage with the traumatic memory (Feeny, Foa, Treadwell, & March, 2004). The therapist will ask the client to focus on a positive thought and focus on this thought while continuing the exercises. It is thought that the dual-attention exercises disrupt the stored memory of the event and will allow for the elimination of negative beliefs. EMDR uses principles of exposure and cognitive restructuring and is said to be faster and more effective than other treatments (Shapiro, 1999). In one study, children with a diagnosis of PTSD were compared to untreated children on a waiting list. Thirty-three children were randomly assigned to eight weekly EMDR sessions. Post-treatment scores Page 8

Evaluation More information (measured by a posttraumatic stress scale), and re-experiencing and avoidance sub-scales were significantly lower than those wait-listed. For more detail of the study, see: Ahmad et al., 2007). In children with PTSD, EMDR has been found to be effective. Although studies to-date are promising, findings are preliminary. Future studies should include a larger scale randomized study that compares interventions. See the NREPP overview and ranking at http://nrepp.samhsa.gov/viewintervention.aspx?id=199 EMDR Institute Inc. http://www.emdr.com PTSD: Prolonged Exposure Therapy for Adolescents Description Examples Evaluation More information In the treatment of PTSD, exposure-type programs use imaginal exposure (repeated recounting of the traumatic memory), in vivo exposure, and prolonged confrontation with trauma-related situations (Feeny et al., 2004). Prolonged exposure forces the victim to confront the anxiety-provoking situation in a safe situation. Prolonged Exposure uses material from TF-CBT and uses PRACTICE elements (discussed earlier in this report), with the addition of in vivo imaginal exposure and trauma processing. A study was conducted with 45 adolescents diagnosed with PTSD using a manualized program developed by Edna Foa (a lead researcher in the field) and colleagues. The number of treatment sessions received ranged from 6 20. Pre and post-treatment PTSD symptom severity decreased significantly (Foa et al., 2009). There is a lack of randomized controlled trials evaluating the effectiveness of exposure treatments in youth. Exposure therapy is one of the best-validated treatments for adults with PTSD, and therefore research involving youth would be particularly relevant (Feeny et al., 2004). Centre for Treatment and Study of Anxiety http://www.med.upenn.edu/ctsa/workshops_pet.html Manual available from: Foa et al., 2009. PTSD and Complex PTSD: Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) Description Examples Evaluation More information SPARCS is a 16-session, 1-hour per session, manualized program designed to treat chronic interpersonal traumas and other chronic traumas. This group-program is suitable for males and females aged 12 through 19. Group members are engaged by a therapist to discuss ways that trauma impacted their lives. The program is designed to help with difficulties with affect regulation, impulsivity, selfperception, relationships, somatization, dissociation, numbing, and avoidance. Goals of the program are to help adolescents cope, establish supportive relationships, and create meaning. SPARCS relies on cognitive-behavioural and dialectical treatment modalities. The program is present-focused and not an exposure based model. SPARCS was evaluated with a group of ethnically diverse youth in foster care (aged 13 to 18) who had experienced moderate to severe forms of trauma. Youth were assigned to one of three groups, including a SPARCS group, a TF-CBT group, and a Child-Parent Psychotherapy group. Post-intervention, it was found that all three groups were equally effective at addressing trauma symptoms. See: Weiner, Schneider, & Lyons, 2009 for a full description of the study. This program has been evaluated, however additional empirical studies are required. For an example of a study, see: DeRosa & Pelcovitz, 2006. More information can be obtained by contacting the developers of the program. Website: http://sparcstraining.com/index.php Page 9

Email: vlabruna@nshs.edu or mhabib@nshs.edu Phone: (516) 562-3245 Complex PTSD: Trauma Affect Regulation - Guide for Education & Training (TARGET) Description Evaluation More information TARGET is a flexible, manualized one-to-one or group treatment program that teaches skills that can be used by trauma survivors to regulate extreme emotional states. The program was originally developed for adults, but has been adapted for adolescents and pre-adolescents and is suitable for children/youth aged 10-18. A sequence of seven skills are taught, including: Freedom, Recognize, Emotions, Evaluate, Define, Option, Make Contributions. The program focuses on building resilience and finding adaptive ways of coping. The program teaches trauma survivors and family members approaches for the prevention and treatment of CPTSD, including skill sets that can be used to de-escalate and regulate extreme emotional states. Sessions are approximately 50-90 minutes. Group interventions range from 3-10 sessions, and individual interventions are 12 sessions. The program has yet to be reviewed to be empirically evaluated. More information can be found at the following websites: http://www.ptsdfreedom.org/ http://www.advancedtrauma.com/html/faqs.html#006 http://www.cebc4cw.org/program/trauma-affect-regulation-guidelines-for-education-andtherapy/detailed or by phone: (860)269-8663 5. Next steps and other resources Treating complex trauma in adolescents and young adults (Brière and Lanktree) presents an empirically validated, evidence-informed, multi-component approach to the treatment of multi-traumatized adolescents using Integrated Treatment of Complex Trauma for Adolescents (ITCT-A). Interventions are adapted to specific symptoms, culture, and age. Components of therapy include relationship-building, psychoeducation, affect regulation training, trigger identification, cognitive processing, emotional processing, mindfulness training, treatments with parents and families, group therapy, and advocacy. The book has been reviewed by established researchers in the field. More information can be found at: http://www.johnbriere.com/itct_a.htm Knowing what works and receiving training on an evidence-informed practice or program is not sufficient to actually achieve the outcomes that previous evaluations indicate are possible. A program that has been shown to improve mental health outcomes for children and youth but that is poorly implemented will not achieve successful outcomes (Fixsen et al, 2005). In order for a program to be evidence-informed, it needs to be applied with fidelity to the design and it needs to be implemented using supportive drivers related to staff competency, organizational leadership and organizational capacity. These drivers include assessing and monitoring the outcomes of your practice using evaluation or performance measurement frameworks, which are particularly important when there is insufficient evidence in the literature to guide clinical decisions. Choosing a practice is an initial step toward implementation, but the implementation drivers are essential to ensure that the program reaches appropriate clients, that outcomes are successful and that clinical staff members are successful in their work. The Ontario Centre of Excellence for Child and Youth Mental Health has a number of resources and services available to support agencies with implementation, evaluation, knowledge mobilization, youth engagement and family engagement. Page 10

For more information, visit: http://www.excellenceforchildandyouth.ca/what-we-do or check out the Centre s resource hub at http://www.excellenceforchildandyouth.ca/resource-hub. For general mental health information, including links to resources for families: http://www.ementalhealth.ca Page 11

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