Max Horovitz, Ph.D., presented a guided poster tour of his research regarding working memory in children who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD) or both ADHD and ASD as part of the 6th World Congress on ADHD hosted by the World Federation ADHA, April 20-23, 2017, in Vancouver, Canada.
Working memory is the thinking skill that focuses on memory-in-action, which is the ability to remember and use relevant information while in the middle of an activity. For example, a child is using working memory as the child recalls the steps of a recipe while cooking a favorite meal.
Children who have trouble with their working memory skills will often have difficulty remembering instructions, recalling rules or completing tasks
Children who have trouble with their working memory skills will often have difficulty remembering their teachers’ instructions, recalling the rules to a game, or completing other tasks that involve actively calling up important information. There are two types of working memory: auditory memory and visual-spatial memory. Auditory memory records what you’re hearing while visual-spatial memory captures what you’re seeing. Weak working memory skills can affect learning in many different subject areas including reading and math.
For Keystone, Dr. Max serves as a clinical child psychologist, director of Keystone’s Attention Deficit Hyperactivity Disorder (ADHD) Clinic. Keystone’s Anxiety & Obsessive Compulsive Disorder (OCD) Clinic is a specialty clinic designed to provide evaluation, intervention and medication management for children and adolescents who experience anxiety. The Anxiety & OCD Clinic offers comprehensive assessments to accurately diagnose anxiety disorders. Common diagnoses include separation anxiety, phobias, social anxiety, generalized anxiety disorder, OCD, and selective mutism.
Dr. Max has experience working with individuals diagnosed with intellectual and developmental disabilities, particularly autism spectrum disorder (ASD), and children with attention-deficit/hyperactivity disorder in various capacities across development. He additionally has experience working with children with a wider range of emotional and behavioral needs, including oppositional and defiant behaviors, anxiety, depression, toileting issues, and sleep difficulties. He currently provides a range of services including developmental, psychoeducational, and diagnostic assessments; individual therapy; parent training and school consultation. Dr. Max also has extensive research experience in the areas of ASD and intellectual disability. Dr. Max received a bachelor’s degree in psychology from the University of Florida. He subsequently obtained master’s and doctoral degrees in clinical psychology from Louisiana State University. Dr. Max completed an APA-accredited, predoctoral internship at the Devereux Foundation in Pennsylvania, where he provided clinical services at a residential center for adults with intellectual and developmental disabilities. Following his internship, he completed a postdoctoral fellowship at Keystone Behavioral Pediatrics and then joined the staff at Keystone as a licensed clinical child psychologist. Dr. Max is a qualified supervisor in the state of Florida for mental health counseling interns.
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)
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:
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:
Previous trauma exposure
Preexisting psychiatric disorders
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.
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.
Under the direction of Brian Ludden, MS, LMHC, NCC, CCMHC, Keystone’s Military Transitions Clinic focuses on those issues that are unique to service members and their families. Our experience with military families allows us to provide the support these families need through a variety of military-life transitions; for example, preparations for permanent changes of station, deployment readiness, deployment separation, reintegration, separation from the Armed Forces, and even death and loss.
Keystone’s proximity to Mayport Naval Station and Naval Air Station Jax (NAS Jax), as well as NAS Jax’s designation as an EFMP (Exceptional Family Member Program) provider makes us ideally situated to meet the mental health and behavioral health needs of Northeast Florida’s very mobile military service members and their families. The clinic uses evidence-based therapeutic practices to treat military-transition related concerns. Some of these therapies include Cognitive-Behavior Therapy, Rogerian Therapy, Family-Systems Therapy, and more. Keystone’s compassionate and caring clinicians acknowledge and va
Our highly trained, experienced and compassionate staff is eager to support and assist families through any and all transitions, struggles and successes they may experience, military related or not.
Common diagnoses include:
Separation Anxiety: The experience of inappropriately extreme or excessive fear or distress when separating from parents/caregivers or other major attachment figures or items in the child’s life. It can cause a reluctance to leave home or significant individuals, as well as causing nightmare, sleep disturbances and physical symptoms including headaches and stomachaches.
Generalized Anxiety Disorder: Uncontrollable worry about multiple situations, performance, social, academic and health; “what if” concerns that span far into the future, physical symptoms including headaches and stomachaches, inability to unwind, low risk-taking and needing constant reassurance
Major Depressive Disorder: A significant depressed mood, loss of interest in pleasure and activities, or both, nearly every day. It can impact appetite, sleep, concentration and cognitive function, and reflexes.
Adjustment Disorder: Emotional or behavioral issues in relation to an identifiable stressor. Stressors can include changing schools, moving, parental separation, loss of friendships, and more and can be accompanied by depression, anxiety and conduct issues.
Posttraumatic Stress Disorder (PTSD): For children of military service members, learning that their parent/sibling/loved-one has been involved in a traumatic event can be enough for them to experience PTSD symptoms. It is characterized by intrusive thoughts of the event; hypervigilance; extreme avoidance of distressing thoughts, memories, or feelings about the event; frightening dreams; problems with concentration; sleep disturbances; irritability, and more.
Before joining Keystone, Brian spent three years working as a mental health counselor in Clay County School in northeast Florida as the county’s Military Connected Student Support Specialist, where he provided counseling support for military families and children coping with transitions, deployments, separations and grief. Brian’s primary experience has been in supporting and assisting children with anxiety disorders through art therapy and guided visualization, as well as intensive cognitive behavior therapy and exposure and response prevention.
Brian is a licensed mental health counselor, national certified counselor and certified clinical mental health counselor with a Master of Science degree in clinical mental health counseling from the University of North Florida. He is currently a doctoral candidate in educational leadership at UNF and will be defending his dissertation later this year, with a focus on the availability of adolescent mental health services in urban public school settings.
In addition to serving as director of Keystone’s Military Transitions Clinic, Brian serves as the director of the Anxiety and OCD Clinic and provides mental health counseling and support to children and their families. Additionally, he provides supervision to master’s level mental health interns seeking to gain experience in the field of counseling.
Depending on the nature of your child’s challenges, group therapy can be an ideal choice for addressing your child’s concerns and making positive changes in your child’s life. Group therapy may look different depending on a variety of factors including the ages and developmental levels of the attendees, the issues that various children have and the purpose of the therapy program as developed by the therapist.
Groups may be designed to target a specific problem, such as depression, obesity, panic disorder, social anxiety or chronic pain. Other groups focus more generally on improving social skills, helping people deal with a range of issues such as anger, shyness, loneliness and low self-esteem. Groups often help those who have experienced loss, whether it be a parent, a sibling or friend.
Your child may find joining a group of strangers intimidating at first, but group therapy provides benefits that individual therapy may not. Psychologists say, in fact, that group members are almost always surprised by how rewarding the group experience can be.
Groups can act as a sounding board
Other members of the group often help your child come up with specific ideas for improving a difficult situation or life challenge and hold your child accountable along the way.
Regularly talking and listening to others also helps your child put his own problems in perspective. It can be a relief to hear others discuss what they’re going through, and realize you’re not alone.
Diversity is another important benefit of group therapy. Children have different personalities and backgrounds, and they look at situations in different ways. By seeing how other children tackle problems and make positive changes, your child can discover a whole range of strategies for facing concerns.
While group members are a valuable source of support, formal group therapy sessions offer benefits beyond informal self-help and support groups. Group therapy sessions are led by one or more psychologists with specialized training, who teach group members proven strategies for managing specific problems. That expert guidance can help your child make the most of the group therapy experience.
All groups meet for one hour, once a week.
Regular attendance of group sessions is a requirement, with no more than one or two absences allowed. This ensures continuity of sessions and allows skills to be built over sessions. If your child misses multiple sessions, he or she may be asked to sit out until the next running of the group.
Depending on the group, group size may vary from 4-12 clients at any time.
All groups are led or co-led by the highly qualified staff at Keystone, including psychologists, post-doctoral residents, mental health interns, psychological assistants, BCBAs, BCaBAs and behavior therapists.
If a group that is currently running is full, your child will be put on the wait list for the next time the group runs.
Currently, Keystone is offering the following therapy groups:
8-Week Beginning Social Skills Group – Wednesdays; Winter Round begins February 2017; led by Keri Franklin, Psy.D.
An eight-week group focusing on getting children ready to play well with others and succeed in their social environment
For children between the ages of 5-8 years old who are able to walk/transport independently to group from reception and minimally maintain attention, have minimal expressive communication skills and are able to participate minimally in group without significant disruption.
Skills targeted in this group include appropriate communication with peers, emotional identification and self-regulation, ability to gain attention appropriately, how to meet new people, how to share and take turns, good sportsmanship, conflict resolution and establishing and maintaining personal boundaries
8-Week Intermediate Social Skills Group – Wednesdays; Winter Round begins February 2017; led by Yadira Torres, Psy.D.
An eight-week social skills group aimed at elementary-aged children who need help and guidance with making and keeping friends, as well as understanding boundaries and emotional skills needed to handle social situations
For children between the ages of 8-12 years old who meet the following criteria: have adequate expressive communication skills and are able to participate minimally in group without significant disruption
Topics include what communication is, how to make and keep friends, what a friend is, establishing and maintaining appropriate boundaries, hygiene, good sportsmanship, perspective taking, understanding facial expressions and body language, and building conversation.
8-Week Advanced Social Skills Group – Mondays, Jan. 16 – March 6 2017; led by Andrew Scherbarth, ph.D., BCBA-D
An eight-week group focused on pre-teens and adolescents who need help and guidance with making and keeping friends, as well as age-appropriate emotional skills needed to handle social situations
Appropriate for pre-teens and adolescents between the ages of 12-16 years old
Skills targeted in this group include what social skills are and why they are important, levels of friendship, appropriate boundaries, emotional awareness of self and others, perspective taking, decoding body language, problem solving and conversations.
Other Group Therapy Opportunities – will start based on sufficient enrollment to from a group
8-Week Worry Busters Group: Teaches children 6-10 years old the skills needed to overcome anxiety and worries such as learning about feelings, identifying scary situations, building the coping skills to handle things independently when worries or fears come up and practicing their new skill
8-Week Anger Management Group: Teaches children 8-12 years old the skills needed to manage anger and helps them develop appropriate, alternative coping skills such as identifying anger triggers, monitoring anger, deep breathing, muscle relaxation, imagery and problem solving
12-Week Managing Deployment Group: Guides youth 8-12 years old through the unique challenges of having an immediate family member deployed or about to leave for military deployment by teaching skills such as emotion training, management of negative emotions, learning coping strategies, building connections with similar children and identifying how to manage living without the deployed family member, as well as how to prepare for the return of their loved one
10-Week Children of Divorce Group: Uses Children of Divorce Intervention Program curriculum to help children 6-8 years old increase their ability to identify and appropriately express divorce/separation related feelings, reduce worry and anxiety about family circumstances and build confidence by teaching coping and problem-solving skills.
If you feel that your child might benefit from participation in a group therapy program, but do not see a group that matches your child’s needs and characteristics, please let your Keystone therapist know or contact us online, email firstname.lastname@example.org or call 904.619.6071