The October 2010 edition of the Journal of Traumatic Stress is publishing the results of a study of diagnosis of trauma in the lives of at risk youth in northeastern Pennsylvania. This study, "Underdiagnosis of posttraumatic stress disorder in at risk youth," was authored by Mr. Drew Miele and Dr. Edward O'Brien. Miele is a former student in the Psychology and Counseling Department at Marywood University and Dr. O'Brien is the former chair of the Psychology and Counseling Department.
This research examines children and adolescents who have been the victims of severe trauma, which includes such issues as sexual victimization, family and community violence, bullying, abandonment and neglect. The youth in this research have typically experienced multiple placements outside their homes.
The American Academy of Child and Adolescent Psychiatry (AACAP) published a position paper in 1998 that cited the dangers of under-diagnosis of Posttraumatic Stress Disorder (PTSD) in children and adolescents. At that, time Mr. Miele was completing his master's thesis under the supervision of Dr. O'Brien, which was focused on examining this issue. The research revealed that PTSD was rarely diagnosed in at risk youth who were being treated in residential and outpatient programs (4% base rate of diagnosis in a total sample of 100 clients). However, when trauma-specific assessments were conducted by Mr. Miele and Dr. O'Brien, the actual rate of PTSD was observed to be 47.7% and 46.5% in the residential and outpatient settings, respectively. This research was presented at national and international conferences (American Psychological Association, International Society for Traumatic Stress Studies) and generated considerable interest at the time.
After this initial research, and over the past decade, Mr. Miele and Dr. O'Brien continued their work in the area of traumatic stress issues in at risk youth. This work involved developing a screening protocol to facilitate assessment of trauma issues in at risk youth, participating in efforts to increase awareness of trauma in at risk youth (as part of a Trauma Task Force organized in Luzerne County under the leadership of Joe DeVizia and others), and continued to develop treatment approaches to deal with complex trauma in youth. After ten years of involvement in raising awareness of trauma issues, Mr. Miele and Dr. O'Brien decided that it was time to re-examine diagnostic processes in the agencies they had studied earlier. This follow-up study examined the diagnoses of 195 youth currently in treatment at these agencies and found that the increased awareness of trauma issues over the past decade had led to some increase in diagnosis at one treatment program, with 10% of youth being currently diagnosed with PTSD, whereas at the other treatment program the diagnosis of PTSD remained unchanged from rates observed ten years earlier. The program with an increased rate had begun to implement a PTSD screening program, whereas the program that showed no change in diagnosis rates of PTSD had not implemented a screening program (though there has been increased training in understanding PTSD). The Miele and O'Brien article in the Journal of Traumatic Stress examines what steps agencies may need to take in order to achieve adequate screening of PTSD in these vulnerable youth.
In addition to PTSD, Mr. Miele and Dr. O'Brien found evidence of a wide range of symptoms that are consistent with the emerging work on Complex PTSD. Many of the at-risk youth in their studies have experienced early, chronic traumatic stress within relationships, which is associated with a wide range of symptoms, including depression, anxiety, emotion dysregulation, self-destructive behavior, shame, hopelessness, social withdrawal and alienation, hostility and acting out disorders. The Miele and O'Brien screening protocol for PTSD/Complex PTSD integrates predisposing biological and individual vulnerabilities with trauma exposure and ongoing environmental vulnerabilities. In a substantial number of cases, they find parental trauma history in at-risk youth, where parents have unresolved trauma issues from their own childhoods. In many cases, work to help the parents resolve their own trauma histories is necessary to allow these parents to become more effective in coping with the trauma experienced by their children.
Mr. Miele and Dr. O'Brien cite evidence and examples in their study to show that an awareness of the trauma and chaotic environment in which at risk youth live can help in formulating treatment plans for a wide range of clinical conditions. Clients who have unresolved PTSD are different from clients who do not have this disorder. For example, a youth who presents with acting out behavior problems or attention deficit problems and also is coping with unresolved traumatic life events needs different treatment from a client who presents with acting out or attention deficit problems and no evidence of PTSD. Mr. Miele and Dr. O'Brien argue in their article that better outcomes will be achieved when clinicians take into account how PTSD may interact with acting out or attention problems. Recent experience with abuses of at risk youth in the Luzerne County juvenile courts suggests the need for considerable work in order to improve the quality of care being offered to these most vulnerable members of our community.
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