Keystone Staff Invited to Present Childhood Trauma Study

Brian Ludden, Ed.D., MS, LMHC, NCC, CCMHC Licensed Mental Health Counselor National Certified Counselor Certified Clinical Mental Health Counselor Director, Anxiety & Obsessive Compulsive Disorders (OCD) and Military Transitions Clinic

Children with trauma are often misdiagnosed with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), mood disorder or a combination of these disorders, because diagnosis can be difficult without knowing about any abuse history. This is what Rea Romero, Ph.D., neuropsychologist, and Brian Ludden, Ed.D., M.S., LMHC, NCC, CCMHC, also noted in their work with Jacob, an 8-year-old boy, who was permanently removed from his mother’s care due to abuse and neglect, possibly including sexual abuse.

They submitted a case study about Jacob that was accepted in late 2016 for a poster presentation at the 2017 American Psychological Association (APA) Convention. Dr. Romero will present the poster of their work on Aug. 5, 2017 in Washington, D.C.

Jacob has a history of erratic mood swings, anger outburst, impulse control, fire-setting, stealing, lying and aggression. Before coming to Keystone Behavioral Pediatrics to work with Dr. Brian and Dr. Rea, Jacob had been given Adderall for two years, with minimal benefit. Prior to receiving a neuropsychological assessment at Keystone, Jacob’s treatment had focused on ADHD and disruptive behaviors.

 

Regilda Romero, Ph.D. Neuropsychologist Director, Trauma & Grief Clinic Co-Director, Neuropsychological Clinic and Educational & Learning Clinic

Jacob’s assessment revealed average to superior cognitive functioning, and academic achievement, visual-spatial skills and language skills also ranged from average to superior. Likewise, other neuropsychological assessments results were at the expected level or well above the expected level.

The assessments did reveal that Jacob has problems with adaptive, emotional and behavioral functioning. Research shows that abuse and neglect can affect neurobehavioral development that is necessary for efficient behavioral/emotional control and regulation. This led Dr. Rea and Dr. Brian to believe that Jacob’s difficulties in emotional and behavioral regulation are related to his history of significant traumas associated with abuse and neglect.

Patients will receive a better treatment plan and interventions if complete biopsychosocial history is taken into account

While Jacob denied suffering from increased startled response, flashbacks and psychological symptoms, which are usually an indication of posttraumatic stress disorder (PTSD), his emotional and behavioral problems and patterns are indicative of trauma. Jacob also struggles with handling interpersonal relations and maintaining meaningful relationships, also symptoms of trauma.

Currently, Jacob is receiving a combination of individual mental health sessions and family mental health sessions. Dr. Brian and Dr. Rea have focused on helping Jacob improve his communication with his family and on reducing behavioral concerns, anxiety and the impact of persistent thoughts related to traumatic childhood experiences. He has been taught the use of mindfulness meditation, guided visualizations, compartmentalization, diaphragmatic breathing and other adaptive coping skills for managing and reducing his emotional and behavioral issues.

Over the course of six months of treatment, Jacob’s behavior has improved considerably. As a result of ongoing family mental health sessions, Jacob has come to develop a relationship with his biological mother. Jacob should continue to progress through treatment and master the various mindfulness and self-regulating skills that he has learned in treatment.

As a result of this case study, Dr. Rea and Dr. Brian are presenting to conference attendees that patients will receive a better treatment plan and interventions if complete biopsychosocial history is taken into account. Keystone supports Dr. Brian and Dr. Rea’s research efforts and encourages all therapists to engage in research that continues to improve clinical results for the kids we serve.

For Keystone, Dr. Rea is the director of the Trauma & Grief Clinic and co-director of the Neuropsychological Clinic and Educational & Learning Clinic. Dr. Brian is the director of Keystone’s Anxiety & Obsessive Compulsive Disorders Clinic and the Military Transitions Clinic.

June is Post-Traumatic Stress Disorder Month

By Jessica Hamblen, PhD and Erin Barnett, PhD, for PTSD: National Center for PTSD

Children and Adolescents Experience PTSD, Too

What events cause PTSD in children?

Any life threatening event or event that threatens physical harm can cause PTSD. These events may include:

  • Sexual abuse or violence (does not require threat of harm)
  • Physical abuse
  • Natural or manmade disasters, such as fires, hurricanes, or floods
  • Violent crimes such as kidnapping or school shootings
  • Motor vehicle accidents such as automobile and plane crashes

PTSD can also occur after witnessing violence. These events may include exposure to:

  • Community violence
  • Domestic violence
  • War

Finally, in some cases learning about these events happening to someone close to you can cause PTSD.

What are the risk factors for PTSD?

Both the type of event and the intensity of exposure impact the degree to which an event results in PTSD. For example, in one study of a fatal sniper attack that occurred at an elementary school proximity to the shooting was directly related to the percentage of children who developed PTSD. Of those children who directly witnessed the shooting on the playground, 77% had moderate to severe PTSD symptoms, whereas 67% of those in the school building at the time and only 26% of the children who had gone home for the day had moderate or severe symptoms (6).

In addition to exposure variables, other risk factors include:

  • Female gender
  • Previous trauma exposure
  • Preexisting psychiatric disorders
  • Parental psychopathology
  • Low social support

Parents have been shown to have protective factors (practice parameters). Both parental support and lower levels of parental PTSD have been found to predict lower levels of PTSD in children.

There is less clarity in the findings connecting PTSD with ethnicity and age. While some studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure. It is not clear how a child’s age at the time of exposure to a traumatic event affects the occurrence or severity of PTSD. While some studies find a relationship, others do not. Differences that do occur may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels.

 

Keystone recognizes June as PTSD month in support of the children we serve who work to manage PTSD.

As in adults, PTSD in children and adolescence requires the presence of re-experiencing, avoidance and numbing, and arousal symptoms. However, researchers and clinicians are beginning to recognize that PTSD may not present itself in children the same way it does in adults.

 What does PTSD look like in children?

Criteria for PTSD include age-specific features for some symptoms.

Elementary school-aged children

Clinical reports suggest that elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. However, they do experience “time skew” and “omen formation,” which are not typically seen in adults.

Time skew refers to a child mis-sequencing trauma-related events when recalling the memory. Omen formation is a belief that there is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas.

School-aged children also reportedly exhibit post-traumatic play or reenactment of the trauma in play, drawings, or verbalizations. Post-traumatic play is different from reenactment in that post-traumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety.

An example of post-traumatic play is an increase in shooting games after exposure to a school shooting. Post-traumatic reenactment, on the other hand, is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).

Adolescents and Teens

PTSD in adolescents may begin to more closely resemble PTSD in adults. However, there are a few features that have been shown to differ. As discussed above, children may engage in traumatic play following a trauma. Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.

Besides PTSD, what are the other effects of trauma on children?

Besides PTSD, children and adolescents who have experienced traumatic events often exhibit other types of problems. Perhaps the best information available on the effects of traumas on children comes from a review of the literature on the effects of child sexual abuse.

In this review, it was shown that sexually abused children often have problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, substance abuse, and sexual maladjustment.

These problems are often seen in children and adolescents who have experienced other types of traumas as well. Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.

Along with associated symptoms, there are a number of psychiatric disorders that are commonly found in children and adolescents who have been traumatized. One commonly co-occurring disorder is major depression. Other disorders include substance abuse; anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivitiy disorder, oppositional defiant disorder, and conduct disorder.

How is PTSD treated in children and adolescents?

Although some children show a natural remission in PTSD symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated. Trauma Focused psychotherapies have the most empirical support for children and adolescents.

Cognitive-Behavioral Therapy (CBT)

Research studies show that CBT is the most effective approach for treating children. The treatment with the best empirical evidence is Trauma-Focused CBT (TF-CBT). TF-CBT generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts.

Although there is some controversy regarding exposing children to the events that scare them, exposure-based treatments seem to be most relevant when memories or reminders of the trauma distress the child. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories.

CBT also involves challenging children’s false beliefs such as, “the world is totally unsafe.” The majority of studies have found that it is safe and effective to use CBT for children with PTSD.

CBT is often accompanied by psycho-education and parental involvement. Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function. Therefore, it is important for parents to seek treatment for themselves in order to develop the necessary coping skills that will help their children.

Parent Resource: U.S. Department of Veterans Affairs PTSD: National Center for PTSD

Keystone offers ABA services on Florida’s Emerald Coast

Keystone recently announced that ABA services are available to the Emerald Coast. The mission of Keystone Behavioral Pediatrics – Emerald Coast is to provide Okaloosa and neighboring counties with the same standard of excellence which has been established by KPB in the Jacksonville area. 

Presently, behavior therapists are offering ABA services in Emerald Coast homes, with the eventual goal of offering therapy in a variety of settings including a clinic, community settings and schools, in addition to in-home. Therapy is individualized to each child based on an initial assessment (ABLLS-R, VB-MAPP, AFLS, essentials for living, functional assessments of problem behaviors, etc.) and continually modified based on the child’s progress.

Laura Mathisen, M.S., BCBA, leads the team of ABA therapists for Keystone Behavioral Pediatrics – Emerald Coast.

Applied Behavior Analysis (ABA) therapy is a systematic teaching approach based on B.F. Skinner’s analysis of behavior and the subsequent contributions of other behavior analysts. ABA focuses on changing behavior in socially significant ways to improve the lives of the children and families who seek ABA services.

Keystone’s Emerald Coast team is led by Laura Mathisen, M.S., BCBA, who serves as senior clinical supervisor. She has experience providing behavior analytic services for children and adults with developmental disabilities, genetic disorders and traumatic brain injuries. Mathisen specializes in early intervention services, problem behavior reduction and supervision of BCBA candidates. She worked at Keystone Behavioral Pediatrics for three years and eventually served as director of behavior analysis. After her military husband was transferred to Destin in 2013, she continued to work for Keystone as a senior clinical supervisor and board certified behavior analyst (BCBA), while also working as a BCBA clinical supervisor for a private ABA clinic in the Florida Panhandle, where her caseload primarily focused on problem behavior reduction and early intervention cases.

For questions and to make an appointment with the team at Keystone Behavioral Pediatrics – Emerald Coast, complete the Appointments or Contact form at www.keystonebehavioral.com or call 904.619.6071.

Keystone Behavioral Pediatrics, based in Jacksonville, Fla., offers consultation and integrated healthcare to children who may have one or more behavioral, developmental, socio-emotional or learning issues, for example, autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), intellectual delays, aggression, self-injury, tantrums, anxiety, compliance, self-help skills, toileting, speech/language or cognitive, physical, sensory, and motor skills. Keystone’s comprehensive and highly skilled team of providers – child psychologists, board certified behavior analysts, licensed mental health counselor, occupational therapists, speech/language pathologists, feeding therapists, registered behavioral technicians and clinical assistants – work together to develop a plan of action to provide success for each child through change. Medication management is also available, if medication is recommended as part of a child’s plan.

Keystone discusses child behavior disorders in Jacksonville publication

Child behavior disorders such as oppositional defiant disorder (ODD) and childhood apraxia of speech (CAS) were the topics discussed in Jax4Kids.com‘s November 2015 issue by Dr. Andrew Scherbarth, clinical child psychologist, and Kaitlyn Kludjian Shrum, a licensed speech pathologist, part of Keystone Behavioral Pediatric’s integrative team in Jacksonville, Florida.

In his article, Andrew acknowledges that ODD symptoms such as aggression, tantrums and refusal are annoying and frustrating for parents and peers. But, he also reassures parents that ODD “is entirely treatable by a clinician skilled in one of several Behavioral Parent Training programs.” BPT is effective in changing the parental factors in the Coercive Family Cycle that develops in families with a child experiencing ODD. The cycle consists of a parent who gives an instruction to which the child reacts negatively, and then both the parents and child proceed with increased negativity until one or the other gives up.

Kaitlyn discusses the struggle that children with childhood apraxia of speech face of knowing what they want to say but not being able to get the words to come out right. She points out that the first step in determining if a child has apraxia of speech is to rule out normal, but delayed, development through an evaluation by an ASHA certified speech language pathologist (SLP). If a differential diagnosis is made, the SLP will determine the best course of treatment.

Read the articles at http://bit.ly/1RLPTIw to learn more.

Aggression storyApraxia story