Adverse childhood experiences and vulnerability for early onset of drug use and dependence

1. Adverse childhood experiences and vulnerability for early onset of drug use and dependence Dr. Maria A. Elisa Alessi Paediatric Neuropsychiatrist UNODC - 23-25 November 2010

2. Summary • Vulnerability factors • Individual factors • Complex trauma • Post traumatic stress disorder • Assessment • Approach to treatment

3. Introduction • Wide range of adverse experience: • Food-insecure household • Loss of a caregiver • Drug addicted family members • Family mental health problems • Threatening life experiences / war • Abuse/neglect/maltreatment Adverse experiences can have a profound devastating impact on children’s development.

4. Vulnerability factors • Genetic: studies on genetic polymorphism and neurochemical alterations in the brain (HVA, 5HTT, Prolactine) • Neurobiology: morphological changes in some areas of the brain. • Family: parenting, cohesion, substance use, mental illness, discipline. • Educational: attainment, school rules, problems in school. • Psycho-social: low income, living conditions, peers relationships, exposition to drugs. • Environmental factors: health services, crime prevention. • Individual, psychological

5. Individual factors • self-esteem • self-control • lack of trust in themselves and in others • coping skills • positive internal working model • clear identity • characteristic of personality (risk-taker, inihibited) • planning capacities • negative feelings: exclusion, shame, guilt, victimization • vision of the future • Security of attachment • moral values

6. Complex Trauma also called “Developmental Trauma Disorder” (van der Kolk, 2005) • the experience of multiple traumas • developmentally adverse • often within child’s caregiving system • rooted in early life experiences • responsible for emotional, behavioral, cognitive, and meaning-making disturbances “Chronic trauma interferes with neurobiological development (Ford, 2005) and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole.” (van der Kolk, 2005).

7. Biological effects of stress Parasympathetic and sympathetic nervous systems Hypothalamic-pituitary-adrenal system Limbic system and hippocampus Amigdala Neocortex Corpus callosum

8. Domains of impairment • Attachment: Uncertainty about reliability of the world, problems with boundaries, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty with perspective taking • Biology: sensorimotor developmental problems, analgesia, hypersensitivity to physical contact, problems with coordination, balance, body tone, localization of stimuli • Affect regulation: difficulty with emotional self-regulation, describing feelings and internal experiences. Difficulty communicating wishes and desires • Dissociation: thoughts and emotions are disconnected, alterations in states of consciousness, amnesia, physical sensations without conscious awareness, depersonalization and derealization

9. Domains of impairment • Behavior control: self-destructive behavior, aggression, impulsivity, sleep and eating disturbances, substance abuse, oppositional behavior, excessive compliance, difficulty understanding rules, traumatic reenactment in behavior or play • Cognition: impaired cognitive functioning, language delay, learning difficulties, deficit in attention, abstract reasoning, planning and problem solving; acoustic and visual perceptual problems, overall IQ deficit • Somatic: headache, stomachache, cardiovascular problems, immunological problems, pelvic pain, asthma • Self-concept: lack of continuous and predictable sense of self, poor sense of separateness, low self-esteem, shame and guilt, disturbances of body image * Adapted from “National Child Traumatic Stress Network” – www.NTSCnet.org

10. Attachment • Asecure attachment with the caregiver is fundamental for developing capacity of self regulation and interpersonal relatedness. • Secure children can rely on their emotions and thoughts • Secure children know how to react to any given situation • Secure children are confident that they can make good things happen • Secure children know that they can rely on others

11. Post-traumatic stress disorder • PTSD can develop at any age • The symptoms of PTSD can start immediately or after a delay of weeks or months. They usually appear within 6 months of the traumatic event. 3 types of symptoms: • Intrusive recollections • Numbing and withdrawal • Increased arousal

12. PTSD symptoms in children • Sleeping difficulties (difficulties in falling asleep, or frightening awakenings, or upsetting dreams, nightmares of monsters) • Persisting reenactment play (post-traumatic play). For example, a child involved in a serious road traffic accident might re-enact the crash with toy cars, over and over again.  • Aggressive behavior or angry outburst (tearing up toys, hitting other children, acting defiantly towards caregivers) • Refuse to accept reality (children who deny a parent died or express the wish to join father in heaven) • Self-injury • Separations fears, • Startle reactions, fear of darkness, of sleeping alone

13. PTSD symptoms in children (cntd) • Hyperactivity, reduced attention span, distractibility, impulsivity. Children are often misunderstood and misdiagnosed with Attention-deficit/Hyperactivity Disorder (ADHD). • Regressive behavior (Language regression or bedwetting as disruption of toilet training) • Changes is personality (sadness, withdrawal, dissociative states) • Avoidance of stimuli associated with the trauma: children may lose interest in things they used to enjoy. They avoid any activity which could bring memories of the trauma. They may find it hard to believe that they will live long enough to grow up. • Somatic symptoms, headache, stomachache

14. Differential diagnosis • Reactive attachment disorder • Delay in the developmental acquisitions • Posttraumatic Stress Disorder • Depression / Suicide • Attention Deficit/Hyperactivity Disorder • Oppositional Defiant and Conduct Disorder • Anxiety Disorder • Eating / Sleeping disorders • Dissociative disorder • Borderline personally disorder • Drug abuse • Medical health problems

15. Assessment • Early assessment and intervention are crucial to prevent the long term developmental consequences of traumatic events. • A multidisciplinary, integrated approach to assessment is needed • Assessments should be culturally sensitive, and language appropriate

16. Comprehensive assessment • Collect information from different sources (child or adolescent, caregivers, teachers) • Observations of the child in different contexts (play observation, interaction with adults) • Standardized assessment procedures • Socio-cultural evaluation • Medical evaluation • Court evaluation

17. Approach to treatment • Complex trauma intervention • Associated psychiatric disorders • Drug abuse intervention • Psycho-social interventions • Promotion of physical health • Education

18. Trauma intervention • Safety • Self regulation • Self-reflective information processing • Traumatic experiences integration • Relational engagement • Positive affect enhancement Alexandra Cook, 2007 (adapted from the National Child Traumatic Network)

19. Conclusions • Adverse experiences can have a profound devastating impact on children’s development, and increase their vulnerability to manifest psychiatric disorders and drug use in childhood and adolescence. Increased vulnerability is due to adverse family life conditions and environmental factors. • Because of traumatic experiences, several domains of children’s development are affected in a disruptive way, resulting in complex physical, behavioural, emotional and mental impairment. • In light of many individual and contextual differences in the lives of children affected by complex trauma, a comprehensive assessment is required, to identify treatment strategies tailored on specific needs.

20. Thank you for your attention!