The Effects of Trauma on the Child and Implications for Treatment

The Effects of Trauma on the Child and Implications for Treatment

Sarah Landy, Ph.D.Family Pathways

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Development of Psychopathology:

A Model

Children who develop severe psychopathologytypically 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

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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

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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

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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

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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

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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

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New Research – Boyce (2002)

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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)

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Hippocampus

Midbrain

Spinal Cord

Broca’s Area

Pituitary Gland

Motor Cortex

Orbitofrontal Cortex

The Stress ReactionBrain Organization and Function

(Visual Cortex)

CRH

ACTH

HPA axis

CORTISOL from Adrenal Medulla

CRH

ACTH

HPA axis

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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

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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

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Cortical

Limbic

Midbrain

Brainstem

Brain Development

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Brain Development (cont.)Hierarchical Organization of

BrainAbstract ThoughtProblem Solving

Affiliation/Socialization“Attachment”

MemoryEmotional Reactivity

Motor Control“Arousal”

Appetite/SatietySleep-Wake Cycle

Blood PressureHeart Rate/Breathing

Body Temperature

Cortical

Limbic

Midbrain

Brainstem

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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

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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.

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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

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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.

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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

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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

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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

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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

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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)

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© 1997, Bruce D. Perry, M.D., Ph.DCIVITAS ChildTrauma Programs

Normal Extreme Neglect

3 Year Old Children

Traumatic Reactions in the Brain (Perry)

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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

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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

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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)

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Key Features of Traumatized Children and Adolescents

As many as 58% of children who experience abuse, neglect, or witness violence will have symptoms of PTSD

78.6% of disorders have their onset after trauma exposure (e.g. ODD, SAD, ADHD, depression)

Increases difficulties in parent-child interactions and with teachers and other caregivers

Develop generalized hyper-reactivity to several cues that remind them of trauma

Hypervigilant, difficulty concentrating

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Key Features of Traumatized Children and Adolescents Trauma can cause multisystemic

developmental delays in behavioral, cognitive, emotional, and social areas of development

Get considerable misdiagnosis with these children as do not display similar symptoms to adults with PTSD

Symptoms of acute stress disorder, adjustment disorder, and reactive attachment disorder may be similar to other disorders (e.g. ADHD, ODD, generalized anxiety disorder, etc.)

May take 2 years for a diagnosis to be made

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Key Features of Traumatized Children and Adolescents (cont.)

Symptoms of PTSD in children: Re-experiencing trauma Avoidance of reminders/numbing of

responsiveness and restricted range of affect

Play re-enactments of trauma (very repetitive or constriction in play)

Recurrent recollections/preoccupation Nightmares Loss of skills (e.g. toileting, independent

sleeping)

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Key Features of Traumatized Children and Adolescents

Emotional Dysregulation Overreaction to minor stressors may be

triggered by something at sensory-motor or emotional level and may react with aggressive or startle reaction

May be chronically hyperaroused with higher heart and pulse rate, higher cortisol levels

Difficulty calming and soothing themself Depression and anxiety common in girls Readiness for “fight”, “flight” or “freeze”

reaction

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Key Features of Traumatized Children and AdolescentsEmotional Dysregulation (cont.)

Easily triggered into terror, despair, rage, and violence

New fears and aggression that were not present before the trauma

May respond by using alcohol, drugs, cutting, or an eating disorder

Sleep-wake cycle may be upset Inability to use small emotions or small

events as signals that getting upset (alexithymia) or as a cue to pay attention and act

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Traumatized Children: How Triggering Occurs

TERROR

FEAR

ALARM

AROUSAL

CALM

State of Traumatized and Non-Traumatized

Children

Nontraumatized Child

Traumatized Child

Neurological Functioning

Brainstem/autonomic in effect, reflexive responses

Midbrain/brainstem in effect, reactive

Limbic midbrain in effect, emotional responses

Limbic sub-cortical processes in effect, concrete thinking

Cortical processes in effect, abstract reasoning, planning & problem-solving

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Dissociation or Changes in Consciousness

Hyperamnesia (heightened recall) for traumatic event and constant retriggering

Transient episodes of dissociation, “spacing out” or losing conscious awareness

Amnesia or total loss of memory for event Depersonalization (not sure for brief time

who or where are)

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Dissociation or Changes in Consciousness (cont.)

Extreme emotional numbing to trauma related and everyday experience

Repeat the same behaviour in play, time and time again

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Changes in Self Perception

Overwhelming sense of powerlessness Need to be in “control” of parent,

teachers, therapist, and situations and react poorly to discipline

Compulsive need to overcome sense of emptiness and abandonment

Sense of stigma and being different to others

Deep sense of shame, of being bad or being worthless and unlovable

Good and bad splitting of self and others

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Disturbances in Relationships

Finds it hard to trust others or intensified, indiscriminant trust of others

Keep on getting into situations in which revictimised as it produces opioids and endorphins that provide numbing (e.g. cutting)

May isolate themselves to avoid retraumatisation

Blame everyone else for difficulties Rejects “good” parenting by being

oppositional and controlling (e.g. in foster home or with parents)

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Disturbances in Relationships (cont.)

Child lacks social skills and is withdrawn or aggressive with others

Lacks capacity for theory of mind, empathy, or caring about others

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Disrupts the parent-child or teacher-child relationship and child’s ability

touse it: Does not use the relationship to

regulate their stress responses To provide a secure base for

exploration and learning

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Somatisation Chronic and persistent physical complaints

that are difficult to diagnose and treat Headaches and stomach aches Higher rates of illness due to depleted

immune system Have found seizure (or pseudo seizure)

activity similar to those of epileptics in some children through various sectors of the brain

Higher heart rate and pulse rate even when resting

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Difficulties with Systems of Meaning and Problem-Solving

Loss of hope and sense of despair Lack of sense of control over their world

and people in it Cannot learn from experience because

numbed by it or avoid contact or lead chaotic existence

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Difficulties with Systems of Meaning and Problem-Solving (cont.)

Difficulty in using executive functioning to control triggering and impulsive acting

Difficulty attending to and processing incoming data not related to trauma

Crisis may make them feel “alive” and be calming

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Problems with Memory Systems Constant retriggering through flashbacks or

nightmares Memories of trauma cannot be integrated into

semantic memories to be worked on and understood

Can often talk about how should behave but still triggered in times of stress. Areas of stress will vary for different children

Aggressive and abusive acts may be triggered without rational control

May have difficulty with learning with increased distractibility and decreased concentration

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Principles of Treating Traumatized Children: Assessment

In-depth assessment is critical to determine impact of trauma and biological issues and to identify triggers

Include assessment of trauma (e.g. acute or chronic, relationship of child to perpetrator)

Developmental history before and after the event,

Symptom picture before and after trauma

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Principles of Treating Traumatized Children: Assessment (cont.)

Current living situation, safety and protective factors

Observations, psychological testing to determine the current functioning

Presence or absence of Attachment Disorder

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Principles of Treating Traumatized Children

Medical model and traditional treatments alone are not sufficient

Need to work in innovative ways using treatments that can affect the brain, mind, and the body of the child and parent(s)

Need to follow a neurosequential developmental model in which treatment begins with approaches that are focused on areas of the brain where the impairment is likely to have happened (Perry, 2007)

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Neurosequential Developmental Model (cont.)

Often need to begin with treatments for the brainstem (deep touch, music and rhythm, sensory-motor remediation, relaxation and breathing)

Move to limbic system where emphasise approaches to assist with emotion regulation and attachment

Later more cognitive approaches and discussion of the trauma incidence can occur

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Principles of Treating Traumatized Children (cont.) Establishing safety in the parent-child

relationship and in the school, helping caregiver to respond to threat, establish routines, structures, rituals

Address trauma-related symptoms with various types of responses depending on the child’s reactions

Development of attachment relationships with parents and teachers is key

Need to increase consistency across treatment modalities and in different contexts

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Principles of Treating Traumatized Children (cont.)

Validate with parents and teachers the legitimacy and universality of the trauma response (i.e., symptoms are not all about being naughty)

Intervention needs to utilize individual, parent-child, school, and group approaches for both parents and children

Intervention needs to emphasize treatment of the body and the mind

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Treatment of emotion regulation is often crucial for traumatized children

Need to give children strategies to use themselves (teaching calming and breathing, something to hold onto)

Promote pleasure in interactions with others (e.g. theraplay)

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Structure, routine, limits, and behaviour modification are absolutely necessary but not sufficient

Attunement is also key and showing understanding of their issues

Evidence-based treatments for different disorders (e.g. CBT) are not necessarily appropriate if a child is functioning at a limbic or midbrain level

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Important to eventually integrate trauma memories into coherent narratives but timing of doing this is crucial

Strategies that help children build their sense of mastery and competence and to gradually reduce feelings of shame are crucial

Environments need to be adapted to be as supportive as possible for children who need to learn to calm down and attend

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Working with Traumatized Children and Parents: Some Examples

Use problem-solving around a discipline issues (e.g. Bugental):

Identify the problem Generate possible reasons for it

happening that is not blaming of the child Generate possible solutions that are

workable Select solutions that capitalize on positive

consequences

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Working with Traumatized Children and Parents: Some Examples

Errorless Compliance Training (Ducharme) Used when teachers and children are locked

in coercive circles of negative reactions Teacher lists in order the behaviours she has

most difficulty controlling and those most likely to get compliance around

Teacher is supported to spend a week asking the child to do things that he will want to do (e.g. turn on the computer)

Child is praised for his “success” In subsequent weeks child is asked to do

things that are a little more difficult

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Working with Traumatized Parents and Children: Dyadic Developmental Psychotherapy (Hughes)

Used with children who have serious psychological problems as a result of abuse, neglect, institutionalization, and/or multiple foster home placements

For children who enter adoptive or foster homes and cannot accept the appropriate parenting that is being offered and reject the parents

Many of the children with these difficulty will need treatment with their families

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Working with Traumatised Children and Parents: Developmental Dyadic Psychotherapy (Hughes)

Based on attachment principles and aims to facilitate security of attachment to the parents

Dr. Hughes sees the children as being full of shame and desperate to have control over their situations

One of the central goals of the treatment is to eliminate the child’s shame and replace it with empathy and guilt and a sense of safety

Conducted with child and attachment figure(s) present. Focus continually on child’s relationship with parents and therapist

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Dyadic Developmental Psychotherapy (Hughes)(cont.)

PlayfulnessAcceptanceCuriosityEmpathy

PACE

These are the approaches we would use

with a young child

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Needs to provide frequent experiences of affective attunement to child

When child becomes angry or shows terror or despair must recognize and absorb it and respond with empathy and acceptance

Nonverbal attunement occurs through eye contact, positive facial expression, gestures, emotion matching

Physical contact with the child in a calming way is important at times

Using humour and playfulness to engage child in a fun and relaxing way

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Uses anything child says to insist on engagement with the child

Reframes the behaviour and provides a unique response to it

May put the child’s nonverbal messages into words for the child

Show curiosity and interest in the child as a parent would who is entrained with their baby

Emotional richness is provided

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Need frequent, repetitive experiences of being understood and accepted, not one breakthrough

The child’s symptoms or problems are understood, accepted and contained and never used to make the child feel ashamed

Child given multiple experiences of “interactive repair” when he insists on disengagement insist on reengagement

Preverbal, eye-contact, facial expressions, body movement and positive emotionality essential

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Work to help child go through crucial developmental stages of attachment, separation-individuation, integration of traumas

Must show empathy for “bad” self so good and bad can be integrated and the shame eliminated

Use various other media such as books, music, finger plays, illustrated stories, photographs

Consultation to the family and family support is an important part of the treatment in addition to the dyadic piece

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Conclusion Such treatment is difficult, and systems

are often not set up to provide it It is seen as too expensive and not

something society can afford If some of these children cannot be

helped we know the trajectories which they are on

To that I would say we cannot afford not to treat these children because currently the costs for group homes, correctional facilities, shelters, and health care continue to soar as children remain untreated

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Conclusion

Instead of having costs for treating the results of trauma soar we need to find ways so these children can soar instead as they achieve in new ways, as they become “strong at the broken places”, and as they are healed and have a new sense of acceptance, understanding, and competence

Documents

The Effects of Trauma on the Child and Implications for Treatment