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The Identification Assessment and Treatment of PTSD atStephen E Brock Ph D NCSPCalifornia State University Sacramento Adapted from .Nickerson A B Reeves M A Brock S E Jimerson S R 2009 Assessing identifying and treatingposttraumatic stress disorder atschool New York Springer .Brock S E Nickerson A B Reeves M A Jimerson S R Lieberman R Feinberg T 2009 School crisisprevention and intervention ThePREPaRE model Bethesda MD . PTSD necessarily involves exposure to atraumatic stressor A traumatic stressor can generate initial stressreactions in just about anyone However not everyone exposed to these.events develops PTSD Among those who develop PTSD significantimpairments in daily functioning includinginterpersonal and academic functioning are Developmentally younger individuals are more.vulnerable to PTSD Prevalence among school age youth Trauma Exposure 68 37 report two or more traumatic events Lifetime prevalence of PTSD 6 to 10 . 30 among some urban populationsBerton Stabb 1996 Buka et al 2001 Copeland et al 2007 Dyregrov Yule 2006 Seedat et al 2004 4 The role of the school based mental healthprofessional is to be . able to recognize and screen for PTSD symptoms aware of the fact PTSD may generate significantschool functioning challenges knowledgeable of effective treatments forPTSD and appropriate local referrals . cognizant of the limits of their training It is not necessarily to diagnose PTSD treat PTSD Cook Cattone 2004 5. Seminar Outline Characteristics of PTSD Causes of PTSD Identification Assessment of PTSD Preventing Mitigating PTSD. Responding to PTSD Seminar Objectives From participation in this workshopparticipants will 1 be able to recognize the characteristics of.2 understand the school psychologist s role inthe identification and assessment of PTSD 3 be able to identify strategies designed toprevent mitigate and respond to PTSD 4 Be better prepared for the Masters Exam . Seminar Outline Characteristics of PTSD Developmental Variations Manifestations at School Causes of PTSD. Identification Assessment of PTSD Preventing Mitigating PTSD Responding to PTSD Characteristics of PTSD A Trauma and Stressor Related disorder that.develops secondary to exposure experiencing witnessing or learning about to an extremetraumatic stressor An event that involves actual or threatened death orserious injury or threat to ones physical integrity .APA 2013 9 Characteristics of PTSD Core Symptoms1 Intrusion symptoms 2 Persistent avoidance of stimuli associated with the.3 Negative alterations in cognitions and mood4 Alteration in arousal and reactivity Duration of the disturbance is more than one The disturbance causes clinically significantdistress or impairment in social occupational or.other important areas of functioning APA 2013 10 Characteristics of PTSD Intrusion Symptoms1 Recurrent intrusive distressing memories .2 Recurrent distressing dreams 3 Acting feeling as if the event were recurring 4 Psychological distress at exposure to cuesthat symbolize resemble the traumatic event 5 Physiological reactivity on exposure to cues.that symbolize resemble the traumatic event APA 2013 11 Characteristics of PTSD Avoidance Symptoms1 Avoids distressing memories thoughts or feelings.2 Avoids external reminders that arouse distressingmemories thoughts or feelingsAPA 2013 12 Characteristics of PTSD Negative alterations in cognitions and mood.1 Inability to remember an important aspect of the event2 Persistent and exaggerated negative beliefs or expectations3 Persistent distorted cognitions about cause orconsequence of the event4 Persistent negative emotional state.5 Diminished interest participation in significant activities 6 Feelings of detachment or estrangement7 Inability to experience positive emotionsAPA 2013 13 Characteristics of PTSD. Increased Arousal Symptoms1 Irritability or outbursts of anger 2 Reckless self distructive3 Hypervigilance 4 Exaggerated startle response .5 Difficulty concentrating 6 Difficulty falling or staying asleepAPA 2013 14 Characteristics of PTSD PTSD may be specified as. Chronic Delayed onsetAPA 2013 15 Characteristics of PTSD Associated Features. Survivor guilt Impaired social interpersonal functioning Auditory hallucinations paranoid ideation Impaired affect modulations Self destructive and impulsive behavior. Somatic complaints e g headaches Shame despair or hopelessness Hostility Social withdrawalAPA 2013 16. Characteristics of PTSD Associated Mental Disorders Major Depressive Disorder Substance Related Disorders Panic Disorder. Agoraphobia Obsessive Compulsive Disorder Generalized Anxiety Disorder Social Phobia Specific Phobia. Bipolar DisorderAPA 2013 17 Characteristics of PTSDDevelopmental Variations Preschoolers. Reactions not as clearly connected to the crisisevent as observed among older students Reactions tend to be expressed nonverbally Given equal levels of distress and impairment may not display as many PTSD symptoms as.older children Temporary loss of recently achieveddevelopmental milestones Trauma related play APA 2000 Berkowitz 2003 Cook Cottone 2004 Dulmus 2003 Joshi Lewin 2004 NIMH. 2001 Yorbik et al 2004 18 Characteristics of PTSDDevelopmental Variations School age children Reactions tend to be more directly connected to.crisis event Event specific fears may be displayed Reactions are often expressed behaviorally Feelings associated with the traumatic stress areoften expressed via physical symptoms . Trauma related play becomes more complex andelaborate Repetitive verbal descriptions of the event Problems paying attention APA 2000 Berkowitz 2003 Cook Cottone 2004 Dulmus 2003 Joshi Lewin 2004 NIMH. 2001 Yorbik et al 2004 19 Characteristics of PTSDDevelopmental Variations Preadolescents and adolescents More adult like reactions. Sense of foreshortened future Oppositional aggressive behaviors to regain asense of control School avoidance Self injurious behavior and thinking. Revenge fantasies Substance abuse Learning problemsAPA 2000 Berkowitz 2003 Cook Cottone 2004 Dulmus 2003 Joshi Lewin 2004 NIMH 2001 Yorbik et al 2004 20. Characteristics of PTSDDevelopmental Variations Alternative Criteria for Diagnosing Infants andYoung ChildrenA Confirmation of exposure is not required within.the alternate criteria Preverbal children cannotreport on their reaction at the time of the traumaticevent and an adult may not have been present toobserve this Scheeringa et al 1995 21. Characteristics of PTSDDevelopmental Variations Alternative Criteria for Diagnosing Infants andYoung ChildrenB In the very young recurrences and intrusive.recollections of events need not be distressing C Markedly diminished interest in participation insignificant activities observed as a constriction ofplay behavior Feeling of detachment estrangement is mainly.evidenced as social withdrawal Additional Symptom for Group C1 Loss of a previously acquired developmental skill such as toileting or speech Scheeringa et al 1995 22. Characteristics of PTSDDevelopmental Variations Alternative Criteria for Diagnosing Infants andYoung ChildrenD The alternate criteria require only ONE or more .of Group D symptoms E New Cluster At least one or more of thefollowing 1 New separation anxiety 2 New onset of aggression .3 New fears without obvious links to the trauma such as fear of going to the bathroom alone orfear of the dark Scheeringa et al 1995 23 Characteristics of PTSD.Manifestations at School Lower GPA Lower academic achievement test scores Classroom adjustment difficulties Difficulty concentrating. Inattention Irritability Aggression WithdrawalSaigh et al 1997 Saltzman et al 2001 24. Seminar Outline Characteristics of PTSD Causes of PTSD Traumatic Stressor Event Perceptions. Identification Assessment of PTSD Preventing Mitigating PTSD Responding to PTSD Causes of PTSDTraumatic Stressor.Predictability ConsequencesTrauma TypeDuration IntensityBrock et al 2009 26 Causes of PTSD.Threat PerceptionsStressor s Trauma Threat PersonalExposure Perceptions VulnerabilityBrock et al 2009 27. Causes of PTSDThreat Perceptions Trauma Exposure Physical Proximity Emotional Proximity.Brock et al 2009 28 Causes of PTSDThreat Perceptions Physical ProximityPynoos et al 1987 29. Causes of PTSDThreat Perceptions Emotional ProximityApplied Research and Consulting et al 2002 30 Causes of PTSD.Threat Perceptions Personal Vulnerabilities External Environmental Factors Internal Personal FactorsBrock et al 2009 31. Causes of PTSDThreat Perceptions Personal VulnerabilitiesExternal Environmental Factors Parental Reactions. Social Supports Trauma History Family Mental HealthBrock et al 2009 Nickerson et al 2009 32 Causes of PTSD.Threat Perceptions Personal Vulnerabilities Internal Personal Factors Psychological Initial Reactions. Mental Illness Developmental Level Coping Strategies Locus of Control Self Esteem Hypothalmus. Genetic Pituitary Neurobiological AmygdalaHippocampusBrock et al 2009 Nickerson et al 2009 33 Seminar Outline. Characteristics of PTSD Causes of PTSD Identification Assessment of PTSD Risk Factors Warning Signs. Assessment and Evaluation Preventing PTSD Minimizing Traumatic Stress Responding to PTSD Identification Assessment of PTSD.Risk Factors Trauma History Chronic vs Acute trauma Degree of Crisis Exposure Personal Vulnerabilities.Brock et al 2009 Terr 1991 van der Kolk 2005 35 Identification Assessment of PTSDRisk Factors Psychological Trauma Risk Checklist see Handout 2 Brock Davis 2008 36. Identification Assessment of PTSDWarning Signs Acute Stress Disorder ASD Like PTSD ASD requires Traumatic event exposure. Similar symptoms Unlike PTSD ASD requires No symptom decline after two days Emphasizes dissociative symptoms i e Psychicnumbing and detachment depersonalization de .realization Has fewer avoidance and hyperarousalrequirementsAPA 2000 Brewin Andrews Rose 2003 37 Identification Assessment of PTSD.Warning Signs Preschoolers Decreased verbalization Cognitive confusion Increased anxious behaviors Regression in skills e g loss Bed wetting of bladder bowel control . Fears e g darkness language skills etc animals etc Thumb sucking Loss of increase in appetite Clinging to parents primary Fear of being abandoned or caretakersseparated from caretaker Screaming night terrors. Reenactment of trauma in Increased anxietyPfohl et al 2002 38 Identification Assessment of PTSDWarning Signs School aged. Irritability Increase in aggressive or Whining inhibited behaviors Clinging Psychosomatic complaints Obsessive retell Overt competition of adult Night terrors nightmares attention.fear of darkness sleep School avoidancedisturbances Increased anxiety Withdrawal Loss of interest and poor Disruptive behaviors concentration in school Regressive behaviors Decrease in academic. Depressive symptoms performance Emotional numbing Feelings of guiltPfohl et al 2002 39 Identification Assessment of PTSDWarning Signs. Adolescents Emotional numbing Increase in aggressive or Flashbacks inhibited behaviors Sleep disturbances Difficulty with social Appetite disturbance interactions. Rebellion Psychosomatic complaints Refusal School difficulties fighting Agitation or decrease in attendance attention Brock et al. (2009) The childâ€™s peri-trauma environment is also a factor in the development of PTSD. A given traumatic stressor will have different effects depending upon the environment that surrounds the child.