Trauma- and Stressor-Related Disorders

1. 12 Trauma- and Stressor-Related Disorders

2. Introduction • Trauma- and stressor-related disorders is new category in DSM-5 • Includes: • Acute Stress Disorder • Adjustment Disorder • Posttraumatic Stress Disorder (PTSD) • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder

3. Child Abuse and Neglect • Child abuse and neglect have been recognized as a significant problem since the early 1970s • In North America, it is estimated that one in ten children experience some form of sexual victimization by an adult or peer • They also receive harsh physical punishment by a parent or other caregiver that puts them at risk of injury

4. Child Abuse and Neglect (cont’d.) • Four primary acts of child maltreatment • Physical abuse, neglect, sexual abuse, and emotional abuse • Non-accidental trauma • Wide-ranging effects of maltreatment on the child’s physical and emotional development • Victimization • Abuse or mistreatment of someone whose ability to protect himself or herself is limited

5. Overview (cont’d.) • Abused or neglected children face paradoxical dilemmas • The victim wants to stop the violence but also longs to belong to the family in which they are being abused • Affection and attention may coexist with violence and abuse • Violence intensity tends to increase over time, but in some cases, physical violence may decrease or stop

6. History and Family Context • Major cultural traditions have condoned abuse of family members • Absolute authority over the family by the husband • Roman Law of Chastisement (753 B.C) • English common law allowed “moderate and reasonable” chastisement • The right to family privacy

7. History and Family Context (cont’d.) • 1989 Convention on the Rights of Children • Spurred efforts to value the rights and needs of children, to recognize their exploitation and abuse in developed countries • Today, 42 countries have established an official government policy regarding child abuse and neglect

8. Healthy Families • Healthy parenting includes: • Knowledge of child development and expectations • Adequate coping skills and ways to enhance development through stimulation and attention • Normal parent-child attachment and communication

9. Healthy Parenting (cont’d.) • Home management skills • Shared parenting responsibilities • Provision of social and health services

10. Healthy Families (cont’d.) • A fundamental and expectable environment: • Requires protective and nurturing adults, as well as opportunities for socialization within a culture for infants • Includes a supportive family, peer contact, and opportunities to explore and master their environment for older children • Provides a gradual shift of control from parent to the child and the community

11. Continuum of Care • Child care along a continuum • Positive end - appropriate and healthy forms of child-rearing actions that promote child development • Middle range - poor/dysfunctional actions represent irresponsible and harmful child care • Negative end - parents who violate their children’s basic needs and dependency status in a physically, sexually, or emotionally intrusive or abusive manner, or by neglect

12. Continuum of Care (cont’d.)

13. Trauma, Stress, and Maltreatment: Defining Features • DSM-5 considers some forms of child stress and maltreatment under the category “Other conditions that may be a focus of clinical attention.” • A child who was abused and also suffering from a clinical disorder (e.g., depression) • The maltreatment would be noted as part of the diagnosis in order to ensure proper treatment

14. Trauma and Stress • Trauma and stressful experiences in childhood or adolescence may involve: • Actual or threatened death or injury, or a threat to one’s physical integrity. • Children exposed to chronic or severe stressors, e.g., major accidents, natural disasters, kidnapping, brutal physical assaults, war and violence, or sexual abuse, have an elevated risk of PTSD

15. How Stress Affects Children • Children and youths need a basic expectable environment to adapt successfully • Stressful events affect each child in different and unique ways • Hyperresponsive reactions • Hyporesponsive reactions • Allostatic load: progressive “wear and tear” on biological systems due to chronic stress

16. Maltreatment “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm” Child Welfare Information Gateway, 2011

17. Types of Child Maltreatment by Percentage

18. Neglect • Physical neglect includes: • Refusal or delay in seeking health care, expulsion from the home, or refusal to allow a runaway to return home, abandonment, and inadequate supervision • Educational neglect involves: • Allowing chronic truancy, failing to enroll a child of mandatory school age in school, or failing to attend to a child’s special educational needs

19. Neglect (cont'd.) • Emotional neglect: • Marked inattention to a child’s needs for affection, refusal or failure to provide needed psychological care, spousal abuse in the child’s presence, and permission of drug/alcohol use by the child • Neglected children show behavior patterns vacillating between undisciplined activity and extreme passivity

20. Three Forms of Child Neglect

21. Physical Abuse • Multiple acts of aggression, including punching, beating, kicking, biting, burning, shaking, or otherwise physically harming a child • Injuries are often the result of over discipline or severe physical punishment • Physically abused children are often described as more disruptive and aggressive

22. Psychological (Emotional) Abuse • Repeated acts or omissions that may cause serious behavioral, cognitive, emotional, or mental disorders • Exists in all forms of maltreatment • Can be as harmful as to a child’s development as physical abuse or neglect

23. Sexual Abuse • Fondling a child’s genitals, intercourse with the child, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials • May significantly affect behavior, development, and physical health of sexually abused children

24. Sexual Abuse (cont'd.) • Reactions and recovery of sexually abused children vary, depending on the nature of the assault and responses of important others • Many acute symptoms resemble children’s common reactions to stress

25. Exploitation • Commercial or sexual exploitation, such as child labor and child prostitution • Significant form of trauma for children and adolescents worldwide • As many as ten million children may be victims of child prostitution, the sex industry, sex tourism, and pornography

26. Characteristics of Children Who Suffer Maltreatment • Age • Younger children are more at risk for abuse and neglect, while sexual abuse is more common among older age groups (over 12) • Except for sexual abuse, the victimization rate is inversely related to the child’s age • Sex • 80% of sexual abuse victims are female, but with that exception, boys and girls are victims of maltreatment almost equally

27. Characteristics of Children Who Suffer Maltreatment (cont’d.) • Racial characteristics • The majority of substantiated maltreated victims are white (44%), African-American (22%), or Hispanic (21%) • Compared to children of same race or ethnicity in the U.S. • Highest rates of victimization are for children who are African-American (15.1/1000), American Indian or Alaska Native (11.6/1000), and multiple race (12.4/1000), White and Hispanic (8/1000), and Asian (2/1000)

28. Family Context • Relational disorders are an important factor for physical abuse and neglect • These forms of maltreatment occur most often during periods of stress • Sexual abuse is primarily a premeditated act —the adult offender plays a purposeful and intentional role • Maltreatment is seldom caused by severe forms of adult psychopathology

29. An Integrated Model of Physical Child Abuse

30. Trauma- and Stress-Related Disorders:Reactive Attachment Disorder

31. Trauma- and Stress-Related Disorders:Disinhibited Social Engagement Disorder

32. Trauma- and Stress-Related Disorders:Post-Traumatic Stress Disorder • Acute stress disorder is characterized by: • The development during or within 1 month after exposure to an extreme traumatic stressor of at least nine symptoms associated with intrusion, negative mood, dissociation, avoidance, and arousal • Children who react to more common (and less severe) forms of stress in an unusual or disproportionate manner may qualify for a diagnosis of adjustment disorder

33. Trauma- and Stress-Related Disorders:Post-Traumatic Stress Disorder (cont’d.)

34. Trauma- and Stress-Related Disorders:Post-Traumatic Stress Disorder (cont’d.)

35. Trauma- and Stress-Related Disorders:Post-Traumatic Stress Disorder (cont’d.)

36. Post-Traumatic Stress Disorder For Children Six and Younger

37. Post-Traumatic Stress Disorder For Children Six and Younger (cont’d.)

38. Post-Traumatic Stress Disorder For Children Six and Younger (cont’d.)

39. Associated Problems and Adult Outcomes • PTSD can become a chronic psychiatric disorder for some children and youths • May persist for decades and in some cases for a lifetime (Nader & Fletcher, 2014). • Children and youths with chronic PTSD may display a developmental course marked by remissions and relapses • In a less common delayed variant, children exposed to a traumatic event may not exhibit symptoms until months or years later

40. Mood and Affect Disturbances • Symptoms of depression, emotional distress, and suicidal ideation are common among children with histories of physical, emotional, and sexual abuse • Teens with histories of maltreatment have a much greater risk of substance abuse • Childhood sexual abuse also can lead to eating disorders, such as anorexia nervosa and bulimia nervosa

41. Mood and Affect Disturbances (cont'd.) • In reaction to emotional and physical pain from abusive experiences, children or adults voluntarily or involuntarily may induce an altered state of consciousness known as dissociation

42. Sexual Adjustment • Sexual abuse, in particular, can lead to traumatic sexualization, in which a child’s sexual knowledge and behavior are shaped in developmentally inappropriate ways

43. Causes: Poor Emotion Regulation • Maltreated infants/toddlers have difficulty establishing reciprocal, consistent interaction with caregivers • Exhibit insecure-disorganized attachment • Have difficulty understanding, labeling, and regulating internal emotional states • Learn to inhibit emotional expression and regulation, remaining more fearful and on alert

44. Causes: Emerging View of Self and Others • Maltreated children’s emerging views of self and their surroundings are not fostered by healthy parental guidance and control • Emotional and behavioral problems are likely to appear • Negative representational models of self and others develop based on a sense of inner “badness,” self-blame, shame, or rage

45. Emerging View of Self and Others (cont'd.) • Feelings of powerlessness and betrayal are internalized as part of the child’s self-identity • Maltreated girls show internalizing signs of distress, such as shame and self-blame, while maltreated boys show heightened levels of verbal and physical aggression

46. Causes: Neurobiological Development • Children and adults with a history of child abuse show long-term alterations in the hypothalamic–pituitary–adrenal (HPA) axis and norepinephrine systems • These alterations have a significant affect on responsiveness to stress • Affected brain areas: • Include the hippocampus, prefrontal cortex, and amygdala

47. Neurobiological Development (cont'd.) • Acute and chronic forms of stress associated with maltreatment may cause changes in brain development and structure from an early age • The neuroendocrine system becomes highly sensitive to stress • Causing neurobiological changes that may account for later psychiatric problems

48. Prevention and Treatment • Obstacles to intervention and prevention services for maltreating families • Those most in need are least likely to seek help • They are brought to the attention of professionals after norms or laws have been violated • Parents do not want to admit to problems for fear of losing their children or being charged with a crime

49. Exposure-Based Therapy • Following acute stress or trauma, such as motor vehicle accidents, shootings, bombings, and hurricanes • Early exposure intervention has reduced acute stress symptoms • Many of these interventions are brief, ranging from 1 to 10 sessions • Are often delivered in groups to reach as many children as possible. • Psychological First Aid (PFA)

50. Exposure-Based Therapy (cont’d.) • In-depth psychological interventions are for children who are severely affected by a traumatic event • The child typically begins by describing a particular traumatic incident and their feelings and thoughts about it • Types • Grief and Trauma Intervention for Children • Trauma-focused cognitive-behavioral therapy (TF-CBT)