The Effects of Trauma on the Child and Implications for Treatment

1. The Effects of Trauma on the Child and Implications for Treatment Sarah Landy, Ph.D. Family Pathways

2. Development of Psychopathology: A Model Children who develop severe psychopathology typically have: • Constitutional or genetic vulnerability towards affect dysregulation • Find it difficult to contain affective arousal, because cognitive, language, and other delays contribute • Develop an insecure or disorganized attachment as parent(s) not able to consistently contain their distress

3. Development of Psychopathology: A Model (cont.) • Exposure to stress or trauma that cannot be managed • Results in sensitization of certain pathways in the brain and increased hypersensitivity and hyperarousal • Balance between these will vary from one child to another

4. Development of Psychopathology: A Model • For individuals with severe psychopathology often find genes, biological factors (e.g. pregnancy, obstetric complications), and multiple environmental factors contribute • In other words it is multidetermined and we need to do thorough assessments to understand the contributions of each and to choice the most useful interventions • Need a triple lens of genetics and biological, attachment or parenting, and trauma

5. Need to consider the biological and genetic basis • New research is showing us about the importance of the heredity gene structure on reaction to stress and trauma • Genes for serotonin transporter (anxiety and depression) and monoamine oxidase (MAOA) (related to aggression and impulsivity) have been studied

6. Need to consider the biological and genetic basis • The genes for these neurotransmitters come in 2 lengths (long allele and short allele and each has 2) • In Dunedin temperament study children followed from birth into 20s • Children with 2 long alleles did much better if they had trauma or were brought up in poor circumstances than children with 2 short alleles and those with one of each were in-between (Caspi, 2003) • Trend the same for both genes

7. Need to consider the biological and genetic basis • Temperament studies now looking at disinhibited, impulsive children and how difficult they are to manage and often become conduct disordered or violent • Other researches have studied very shy and inhibited children over time and find the same vulnerability but towards anxiety and depression

8. New Research – Boyce (2002)

9. Using vulnerability information to help the child • New information about disinhibited impulsive children and that they do not respond to consequences because do not have same arousal levels • Discipline must be attachment based and need to support parent around this • Ordinary parenting classes do not help as the children do not respond to consequences only

10. Trauma: The Problem • Societies across the world are not able to ensure that children grow up in safe and predictable environments • Millions of children are terrorized, abused, neglected and otherwise traumatized throughout the world every year • Research shows that these children are at great risk for developing chronic emotional, behavioural, social, and physical health problems

11. Trauma: The Problem (cont.) • Intergenerational parenting problems often occur • These children and their families are challenging to treat and systems are often not set up to do it • The costs (both human and economic) are incalculable

12. What is Trauma? • Trauma can be one event or an ongoing situation over which the person has no control. • Exposure to threatened death, serious injury, or threats to the integrity of self or others • The experience of trauma is a psycho-physical one that overwhelms the person’s capacity to regulate their affective state and exacts a toll on the body as well as the mind.

13. Types of Trauma • Neglect (physical and emotional) may be most destructive for a child • Living in an institution where there is a lack of responsive interactions • Abuse (physical, emotional, or sexual) • Loss of primary caregiver (particularly parent) • Man made disaster (e.g. fire, bombing, kidnapping, traffic accidents) • Refugees who have experienced torture, etc.

14. Types of Trauma (cont.) • Natural disasters (e.g. fires, hurricanes, floods) • Children who have frequent, painful medical interventions or a chronic illness that is life threatening • Witnessing domestic or community violence

15. Small “t” traumas without Traumatic Stress Reaction • An infant living in a situation that is chaotic or who receives inconsistent responses when upset (e.g. substance abuse or maternal depression) • Children can be traumatized by chronic failure on the part of the parent to provide nurturing care • A very temperamentally sensitive or genetically vulnerable infant who consistently does not receive the calming she needs

16. Incidence of Trauma • Across the world millions of children are exposed to trauma each year • Oppression of whole nations is common (e.g. indigenous people in Australia, First Nations in Canada, genocide in a number of countries) • Millions of children in many countries are exposed to domestic and community violence in a year

17. Incidence of Trauma (cont.) • In U.S. child abuse is the leading cause of death in young children • Up to 5 million children in U.S. traumatized (often maltreated) each year • 90% of inner city children in U.S. witness a murder by the time they are 18 years of age • 90% of parents surveyed believe spanking infants and toddlers is necessary and right • Majority of older adopted children or those in foster care will have experienced trauma and loss which is unlikely to have been resolved

18. Traumatic Stress Reaction at Time of Trauma Sympathetic Nervous System (SNS) branch of Autonomic Nervous System (ANS) is aroused leading to: • Increased heart rate and blood flow • Rapid breathing • Increase in muscle tone, hypervigilance • Elevated blood pressure

19. Traumatic Stress Reactions at Time of Trauma (cont.) • “Fight” reactions much more common in adult males (SNS reaction) • “Flight” reactions can occur in adult males and females and may go away in their head if cannot run away (SNS reaction) • “Freeze” (complete immobility) reactions most common in women, infants and young children who can neither fight the abuser or flee (SNS and PNS reactions)

20. The Stress Reaction Brain Organization and Function Motor Cortex CRH ACTH HPA axis CORTISOL from Adrenal Medulla CRH ACTH HPA axis Broca’s Area (Visual Cortex) Midbrain Hippocampus Orbitofrontal Cortex Spinal Cord Pituitary Gland

21. The Stress Reaction (cont.) • Get cascade of neurohormones or stress hormones in the Hypothalamic-Pituitary- Adrenal (HPA) axis beginning in the brain and ending up in the adrenal gland in the kidneys • They are released into the bloodstream • Other neurotransmitters are also released from other systems and include serotonin, epinephrine, dopamine, endorphins, and endogenous opioids

22. Brain Development • Need to consider the development of the brain and the effect of trauma on it • Brain processes and internalizes traumatic and therapeutic experiences • Brain mediates all emotional, cognitive, behavioural, social, and physiological experiences • From the mind the brain is affected and by altering the mind we can affect the brain

23. Brain Development Cortical Limbic Midbrain Brainstem

24. Brain Development (cont.)Hierarchical Organization of Brain Abstract Thought Problem Solving Affiliation/Socialization “Attachment” Memory Emotional Reactivity Motor Control “Arousal” Appetite/Satiety Sleep-Wake Cycle Blood Pressure Heart Rate/Breathing Body Temperature Cortical Limbic Midbrain Brainstem

25. Development of the Brain • Development of the midbrain and limbic system depends on touch and the containing and sensitive interactions of caregivers • Face-to-face interactions seem to be particularly important when the parent provides stimulation from their voice, eyes and facial expression, touch, and emotionality • Develops the orbitofrontal cortex that has a significant role in bringing emotional reactions under control

27. Development of the Brain (cont.) • Development of the cerebral cortex depends on hearing language and is responsible for abstract reasoning and for controlling the more primitive reactions of lower structures • The connection between the HPA axis and the limbic system and the frontal cortex (area of the brain responsible for cognitive control and executive functioning) is developed between 14 months and 3 years.

28. Development of the Brain (cont.) • Developing emotion regulation depends very much on the development of this connection and its ability to bring the immediate impulsive and emotional reactions under control • Connection depends on interactions with caregivers that are nurturing and containing of the child and his emotions and having emotions discussed and explained. • About talking to the child about what is going on in their mind

29. Development of the Brain (cont.) • Amygdala in the limbic system is functioning at birth and is responsible for the expression of intense emotional reactions and the storing of emotional memories and sensory motor experiences. • The hippocampus that stores verbal and narrative memories does not function until 3 years of age • Explains infantile amnesia or failure to consciously remember what happened in earliest years although there will be unconscious sensory motor memories.

30. Trauma and the Developing Brain • Young children more affected by trauma than older children, adolescents, and adults because it affects the organization of the developing brain • Lack of stimulation (neglect) or ongoing trauma can disrupt the unfolding and organization of the brain and alter neuronal activity • Children who are traumatized through neglect or abuse are likely to develop generalized hyper-reactivity causing excessive arousal and chronic secretion of stress hormones

31. Trauma and the Developing Brain (cont.) • The more that circuits of the brain are activated by the stress reaction kindling takes place that makes the stress circuits more readily activated • Neural activation can then be elicited by decreasingly intense external stimulation • Cortisol can be chronically secreted and can destroy the synapses or the connections between the neurons or not be secreted enough • Other neurohormones that are secreted affect other behavioural systems such as sleeping and eating

32. Trauma and the Developing Brain (cont.) • More activity in right hemisphere responsible for withdrawal emotions than in left hemisphere responsible for approach emotions and language (depressed mothers) • Can become a chronic reaction or a trait by 6 months • Left hemisphere has fewer nerve-cell connections between different areas in these children and those that are seriously abused or neglected

33. Trauma and the Developing Brain (cont.) • The connections between the frontal cortex and the limbic system may fail to develop adequately • As a consequence the child may be unable to control negative emotions • Thymus gland that is one of the primary organs of the immune system has been found to be significantly smaller in abused and neglected children • Compromises the immune system

34. Trauma and the Developing Brain (cont.) • Abused children have smaller Broca’s area responsible for speech • Hippocampus (responsible for storing semantic, conscious memories) is smaller in children with PTSD • DeBellis also found smaller cerebral volumes correlated with age of onset and duration of abuse • Neglected children have smaller brains, cortical atrophy, and larger ventricles in the brain (Perry)

35. Traumatic Reactions in the Brain (Perry)

36. Incidence of Sequelae of Trauma • Everyone suffers a stress reaction at the time of the trauma • Post traumatic stress persists following a traumatic event • Posttraumatic Stress Disorder (PTSD) occurs when symptoms last for more than a month and result in loss of function (20%) • PTSD is a chronic disorder and untreated seldom remits spontaneously

37. Incidence of Sequelae of Trauma (cont.) • Complex PTSD that results from multiple traumas that occur over different ages cause personality changes and disorders • Post Duress Disorder where the person does not identify any distinct traumas but may have been small “t” traumas that did not cause a complete stress reaction

38. Causes of Long Term Effects • Age at time of trauma with young children more affected than older children, adolescents, and adults (not resilient as believed by some people) • Children <18 months at time of trauma have more re-experiencing • Severity and chronicity of event • Meaning of an event to the person (e.g. trauma by someone the child trusted or event may relate to a previous trauma)

39. Causes of Long Term Effects (cont.) • Predisposing characteristics of child such as temperament or genetic vulnerability or other biological impairments • If physically injured • Witnessed or experienced the trauma • Caregiver threatened best predictor of PTSD • Support system available to child following the event and if it can be nurturing of child • If treatment or chance to review event (e.g. through play therapy or psychological debriefing) did not happen close to event

40. Effect on Memory Systems • Have different memory systems (e.g. short and long term memory) • Unconscious or implicit memories and conscious or recallable/explicit memories • Explicit memories are semantic, organised or episodic and can be talked about • Implicit memories are procedural and imaged and are also conditioned memories and bypass language and are difficult to talk about

41. Effect on Memory Systems (cont.) • For individuals with PTSD thoughts and cognitions of events are separated from emotions, images, and sensations • With conditioned memories the original stimulus gets linked with the fear stimulus and its physiological reactions • Related stimuli may get the same reaction or become triggers (e.g. running shoes, raised voices)

42. Effect on Memory Systems (cont.) • Memory of trauma is stored in the amygdala and is of emotions and sensory-motor experiences during trauma (procedural, imaged, conditioned memories) • Memory of our personal history or narratives and making sense of it is stored in the hippocampus and does not function during trauma (semantic and episodic memories) • Memories in the amygdala can be triggered outside of rationale control leading to sudden acting out or dissociation

43. Ongoing Effects of Trauma on Mind and Body Influences: • Immediate and future functioning (cognitive and social) • Brain, mind, and body that continually influence each other • Long term behavioural patterns and personality • Sense of control and of self and other

44. Adverse Childhood Experiences (Chapman et al., 2004) • Abuse (28.3%, sexual, 20.7%, emotional, and 10.6% physical) • Neglect (9.9% physical, 14.8% emotional) • Household dysfunction (12.7%, partner abuse, 26.9%, substance abuse, 19.4%, parent mental illness, 23.3%, parental separation/ divorce, 4.4%, incarcerated family member

45. High magnitude events in childhood( Egger, 2004) • Motor vehicle accident, 9.9% • Hospitalized, 16.7% • Serious fall, 9.5% • Burned, 7.9% • Death of loved one, 6.2% • 52.5% had experienced a high magnitude stressor • 100% of children who had experienced 5+ of these events had DSM-IV diagnosis

46. Ongoing Effects of Trauma on Mind and Body: The Adverse Childhood Experience Study (Felitti et al., 1998) • Graded relationship between the number of Adverse Childhood Events and mental and physical health and risk taking behaviours • 50% reported adverse childhood events • 4+ events compared to no events 4-12 fold increase in substance abuse, depression, and suicide attempts • 4+ events compared to no events 2-4 fold increase in smoking, poor health, multiple sex partners, ischemic heart disease, and history of STD

47. Relationship of Trauma with Mental and Physical Illness • Compelling evidence that early life stress or trauma is a major risk factor for the development and persistence of mental disorders • Early trauma also related to increased risk for heart disease, diabetes, hypertension, and immune disorders • Other disorders such as chronic fatigue syndrome, chronic pain and fibromyalgia

48. Ongoing Traumatic Stress Reactions • Hyperarousal and constant retriggering results in hypersensitized system, constant hypervigilance, and hyperreactivity • “Fight” may become aggressive move from anxious to terrorized very quickly • “Flight” may go aware in head (dissociate), withdraw from social contact, daydreaming, or show oppositional-defiant behaviour, • “Freeze” leads to dissociation or even fainting or Dissociative Identity Disorder

49. Intergenerational Repetition of Trauma • Caregiver with unresolved trauma often has limited ability to tolerate child’s distress • Clear evidence that parents with unresolved loss and trauma often show “frightened” or “frightening” or (“fr”) behaviour in interactions with their infants and children • This leads to disorganised attachment in the child that in turn is associated with psychopathology in children 85% of the time

50. Intergenerational Repetition of Trauma (cont.) • In this way the trauma of the parent is passed on to the child unless the parent receives supportive or intervention services • 1/3 of parents who are abused will abuse their children, 1/3 will provide “marginal parenting”, and 1/3 will resolve the trauma and parent well