Childhood Trauma: An Overview

1. Childhood Trauma:An Overview Steven Marans, PhD Professor of Child Psychiatry and Psychiatry Director, National Center for Children Exposed to Violence Yale Child Study Center

2. The Anatomy of Nightmare Experience • Acute reactions • Search for protection • Hyper-vigilance • Reasserting safe reality • Return to sleep

3. Sources of danger • Loss of one’s own life • Loss of the life of a significant other • Loss of love or another or of oneself • Damage to the body • Loss of control of impulses, affects and thoughts • Loss of control of sense of agency

4. Psychological Trauma Overwhelming, unanticipated danger that leads to: • Subjective experience of helplessness, loss of control and terror • Immobilization of usual methods for decreasing danger and anxiety (fight or flight) • Neurophysiological dysregulation that compromises affective, cognitive and behavioral responses to stimuli

5. Post-Traumatic Stress Reactions in Children A.Traumatic repetitions 1. Traumatic play 2. Play reenactment 3. Nightmares 4. Flashbacks/dissociation 5. Distressed when reminded 6. Somatic complaints when reminded

6. Post-Traumatic Stress Reactions in Children B. Avoidance, Numbing, Regression 1. Avoids thinking or talking about event 2. Avoids reminders of event 3. Impaired recollection/memory 4. New fears (e.g. Separation, toiletting, darkness) 5. Sense of a foreshortened future or impending doom

7. Post-Traumatic Stress Reactions in Children C. Increased arousal 1. Night terrors 2. Difficulty falling/staying asleep 3. Decreased attention/concentration 4. Irritability/anger 5. Increased aggression 6. Hypervigilance 7. Exaggerated startle response

8. Post-Traumatic Stress Reactions in Children D. Decreased responsiveness, numbing, regression 1. Constriction of play 2. Diminished interest in activities 3. Social withdrawal/feelings of detachment 4. Restricted range of emotion 5. Developmental regression

9. Neuropsychological Responsesin Children Exposed to Trauma • Responses in children are heterogeneous and dependent on a variety of factors • Exposure to trauma results in activation of stress-response systems • Children attempt to apply an adaptive or learning response • Following prolonged or intense exposure neural systems may change • Changes occur due to prolonged neural activation and may result in neurochemical imbalances, altered neural microarchitecture (synaptic sculpting) and changes in neural organization and functioning • Changes may result in imbalances in children’s physiological homeostasis

10. PTS reactions can be chronic If untreated, can persist for long periods of time and into adulthood Can result in a variety of emotional, behavioral, social and psychiatric consequences Examples of long-term sequelae: Depression Anxiety Attachment problems Learning problems Eating disorders Suicidal behavior Substance abuse Violent/Abusive behaviors Somatic problems Long-term Consequencesof exposure to trauma

11. Event Factors • How directly events affect their lives: • Physical proximity to event • Emotional proximity to event (threat to child, parent versus stranger) • Secondary effects-of primary importance • Physical Displacement and Social Disruption

12. Individual Factors • Genetic vulnerabilities and capacities • Prior history (i.e. consistent stress or one or more stressful life experience/s) • History of psychiatric disorder • Familial health or psychopathology • Family and social support • Age and developmental level

13. Exposure Rates • Child abuse and neglect cases are substantiated at the rate of 1 million per year, with 3 million yearly reports (USDHHS, 2005 ) • At least one traumatic event was experienced by 64% of children in grades 4 through 12 in NYC prior to the September 11, 2001 attacks on the World Trade Centers (Hoven et al., 2002) • More than 500,000 children are placed in the foster care system each year (Administration for Children and Families, 2005). Of these, 48% have been placed due to physical abuse and 45% due to sexual abuse (Dwyer & Noonan, 2001 • The long-term effects are evident in reports that nearly two thirds of people in drug treatment programs reported being abused as children (Swan, 1998) • Sexual abuse has been reported by 62% of teenage mothers, and traumatic childhood events are documented in the histories of as much as 98.6% of juvenile delinquents (Carrion & Steiner, 2000)

14. Exposure and Consequences • 3-10 millionchildren each year(Carlson, 1984; Carter, Weithorn, Behrman, 1999; Silvern, et al., 1995; Strauss and Gelles, 1990). • A more recent study indicates closer to 15.5 million children exposed to domestic violence annually; 7 million exposed to violence characterized as severe (McDonald, Jouriles, Ramisetty-Mikler, Caetano and Green, 2006) • Children who have been exposed to domestic violence are 158% more likely to be victimized by violence themselves than counterparts from non-violent households—the risk was 115% higher for boys and 229% higher for girls (Mitchell and Finkelhor, 2001). • For example, 60%-75% of families where there is domestic violence also have children who are battered (Osofsky, 1999; McKibben, Devos, and Newberger, 1989). • Battered women are more likely to abuse their children more than non-battered women (Straus and Gelles, 1990; Ross, 1996).

15. Exposure and Consequences • Exposure to domestic violence in childhood is associated with increased likelihood of involvement in physical aggression, delinquent and violent behaviors (Jenkins & Bell, 1997;Thornberry, 1994; Shakoor & Chalmers, 1991). • Children exposed to domestic violence are more prone to depressive symptoms than those not exposed (Sternberg, et al., 1993). • Annual costs to US businesses in lost work time, increased health care costs, higher turnover and lower productivity is about $5-10  billion (National Center for Injury Prevention and Control, 2003) • The health-related costs of rape, physical assault, stalking and homicide committed by intimate partners exceed $5.8 billion each year. Of that amount, nearly $4.1 billion are for direct medical and mental health care services, and nearly $1.8 billion are for the indirect costs of lost productivity or wages.

16. Elements of Response • Cross-training, collaboration and establishment of roles (e.g., safety, security, communication with families, support services) of responding systems of care • Distinguishing adult and child experiences of traumatic events—considering developmental, family and social contexts • Determining continuation or cessation of threat as essential to trauma assessment and intervention strategies • Psycho-education for children, parents and other caregivers about traumatic experience and techniques for regaining control • Re-establishing order and routines of daily life • Police may consult about any child or adolescent exposed to or affected by violence or other PTE • Police contact with families provides the opportunity for clinical contact • Allows for immediate intervention for children exposed to violence either at the scene of the incident or within a few hours • Coordination of clinical and policing services facilitates safety and security of victims and witnesses

17. Intervention strategies • Acute response: stabilization, contact and identifying trauma risk • Monitoring/surveillance and follow-up • Child and Family Traumatic Stress Interventions (Peri-traumatic): clinic-; home-; school-based

18. Early Intervention: Collaboration • Early interventions require collaboration among • Medical personnel • Mental health professionals • Law Enforcement • Firefighters • EMS • Courts • Schools

19. Immediate Interventions • Children who are direct witnesses or victims • Ensure physical health: Have medical personnel check if concern • First and foremost: reunite with known caring adults (especially parents) • If adults not available keep with teachers, friends and peers • Move to safe place when possible, but in group or with family

20. An Example of Collaboration:The CD-CP Program • Acute Response Consultation Service (24/7) • Weekly Multidisciplinary Program Conference • Weekly Clinical Case Conference • Child Development Fellowships and Training for Police Personnel • Police Fellowships and Training for Clinical Faculty • Seminar on Child Development, Human Functioning and Police Strategies

21. Continuing Threat • Children’s worry about their safety can be a powerful contributor to or source of depressive and anxiety symptoms and may also lead to oppositional and aggressive behavior as children’s anxiety leads to a misunderstanding of environmental cues in an attempt to reassert some sense of control. (Ford, 2002)

22. Continuing Threat • Early intervention strategies are well placed to identify and assess the nature, degree and reality of the threat and, in turn, help the child and family cope with the current situation as best as possible

23. Continuing Threat • If the threat is imagined or greatly exaggerated, psychotherapeutic treatments may be very useful • However if credible, early interveners should work with law enforcement and court personnel to ensure the child and families’ physical and emotional safety

24. Physical Displacementand Social Disruption • Physical displacement and social disruption has been found to be the highest correlated factor related to outcome after traumatic events. (Laor, Wolmer, & Cohen, 2001; Laor et al., 1997; Laor, Wolmer, Mayes, Golomb, & et al., 1996; Lonigan et al., 1994)

25. Physical Displacementand Social Disruption • Advantage in recognizing this risk for a particular family and bringing community and other resources to bear • May include housing displacements, economic hardship due to job loss or expenses associated with the event, isolation from friends and extended family related to the many issues that may be associated with the episode of violence etc.

26. Physical Displacementand Social Disruption • School provides needed support and structure • When children are removed from their school environment they lose many of the resources of known adults, friends and schoolmates on whom they often rely.

27. Schools • Schools are uniquely positioned to provide normalization and security to children. • Schools provide an optimal location for discussion, peer and adult support. • Requires that teachers and staff be prepared and able to engage • Within classroom discussions are best • Schools should remain open whenever possible

28. Schools • In order for schools to support children who are having stress reactions, staff must have support and be aware of own responses to stress inducing event • Organization among staff is essential to work with situations that may cause stress reactions

29. Principles of Intervention 1. Do no harm 2. Child Development is basis of intervention 3. Parents or primary caretakers are essential therapeutic agents. 4. Restoration of external structure and authority 5. Amelioration of threat

30. Principles of Intervention 6. Do not assume knowledge of what is the most salient event, image or idea for the individual 7. Early responses require collaboration with first responders and others (police, fire-rescue, EMS, Red Cross, courts etc.)

31. National Center for Children Exposed to ViolenceAt the YALE CHILD STUDY CENTER For more information please refer to our website www.nccev.org