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SEEING THE WORLD THROUGH THE LENS OF TRAUMA: Age Differences and Intervention Artwork from The Anna Institute.

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Presentation on theme: "SEEING THE WORLD THROUGH THE LENS OF TRAUMA: Age Differences and Intervention Artwork from The Anna Institute."— Presentation transcript:

1 SEEING THE WORLD THROUGH THE LENS OF TRAUMA: Age Differences and Intervention
Artwork from The Anna Institute

2 WHAT IS TRAUMA? Traumatic Event A person experiences, witnesses or is confronted with actual or threatened death or serious injury or threat to the physical integrity of oneself or others Often includes a response of intense fear, helplessness or horror Can result from private or public experiences APA – DSM-IV The National Institute of Mental Health describes trauma as a normal reaction to an extreme event (Substance Abuse and Mental Health Services Administration, 2007). It is important to remember that it is not necessarily the event itself that causes trauma, but a person's thoughts, feelings, beliefs, and experience surrounding that event (Boscarino, 1996).

3 Developing Definition of Trauma
Event Actual or extreme threat of physical or psychological harm or the withholding of material or relational resources essential to healthy development. It can be a single event or repeated events Experience How the person assigns labels or meaning to the event, depends on the perception of the individual Effects Result of the person’s experience of the event. This can include neurological, physical, emotional or cognitive effects Working definition – SAMHSA, Trauma and Justice As awareness of the impact of trauma grows it is important to understand the key factors in assessing an individual's trauma history. At the national and state levels dialogues have begun to develop a common understanding of trauma.

4 What We Know Trauma occurs when external events overwhelm a person’s coping responses Severe and/or chronic trauma can have lasting adverse effects on physical, psychological, and social well-being Trauma is prevalent, at least 50% in general population have at least one traumatic event; more than 25% have two or more. In the human service field the majority of the population served have a trauma history The next few slides introduce some of the things we know about trauma.

5 What We Know Trauma can result from adverse childhood experiences, natural disasters, accidents, interpersonal violence or war Early, severe and/or chronic trauma can affect the brain which can result in behaviors and emotions that appear maladaptive Trauma has an extremely high correlation with poor health and social outcomes Private events – Sexual, physical abuse Secrecy Power Imbalance Raging Hopelessness Sense of Isolation Sense of Irretrievable Loss Emotional and physical reaction, fight or flight Public events – natural disasters, car accidents, war, crime victimization Can be a shared experience No judgment attached Sense of Helplessness Forces beyond control Emotional and physical reaction

6 Why Do I Need to Understand Trauma
Nearly one in three adolescents have been physically or sexually assaulted by the age of 16 (Boney-McCoy & Finkelhor, 1995) Violent Crime victimization in youth is twice as high as that for adults (Hashima and Finkelhor, 1999) Rates of PTSD among adults who were formerly placed in foster care was found to be twice as high as rates as in US War veterans ( Northwest Foster Care Alumni Study, Pecora, et al., 2005) Something to point out 1 in 3.

7 Chronic Trauma Chronic trauma refers to the
experience of multiple traumatic events. These multiple events may be varied, such as a person who is exposed to domestic violence, involved in a serious car accident, and then becomes a victim of community violence. Chronic trauma may refer to longstanding physical abuse, neglect or war. Chronic trauma represents cumulative effects. Each new event reminds the individual of prior trauma and reinforces its total negative impact. To the person it feels relentless and uncontrollable 50% of the general population have experienced at least one adverse event, many of those will have few or minimal long term impact. For one serious life threatening event, about 1/3 of involved individuals will have no impact, about 1/3 will have some issues that are minor or short term with full recovery with some support. However 1/3 will have ongoing emotional or physical reaction. When someone experiences multiple traumas the effect can be cumulative and although they may initially be resilient enough to heal from the events, at some point the body may not be able to handle further stress. So chronic trauma significantly increases the probability of negative health and social outcomes. We also know that adverse events that occur in childhood are more likely to impact brain functioning because childhood is such a critical time for brain development.

8 Transgenerational Trauma
Violent trauma is often self-perpetuating Trauma affects the way people approach potentially helpful relationships Relationship with caregivers plays a critical role in regulating stress hormone production (study showed link between quality of childcare linked to stress hormone levels) The way an adolescent adapts to stressors has a lot to do with how well his or her family is functioning (Stern & Zevon, 1990). It has been found that when adolescents lack parental support, they are more likely to have behavioral problems and emotional distress (Garber & Little, 2001).

9 Adverse Childhood Experience (ACE) Study
Without intervention, adverse childhood events (ACEs) may result in long-germ disease, disability, chronic social problems and early death. Importantly, intergenerational transmission that perpetuates ACEs will continue without implementation of interventions to interrupt the cycle. Long-Term Consequences Of Unaddressed Trauma Adverse Childhood Experiences Impact of Trauma & Adoption of Health Risk Behaviors Disease & Disability Neurobiologic Effects of Trauma Abuse of Child Psychological abuse Physical abuse Sexual abuse Trauma in Child’s Household Environment Substance Abuse Parental separation &/or Divorce Mentally ill or suicidal Household member Violence to mother Imprisoned household member Neglect of Child Abandonment Child’s basic physical &/or Emotional needs unmet Ischemic heart disease Cancer Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health HIV/AIDS Disrupted neuro-development Difficulty controlling anger Hallucinations Depression Panic reactions Anxiety Multiple (6+) somatic problems Impaired memory Flashbacks Social Problems Health Risk Behaviors Homelessness Prostitution Delinquency, violence & criminal Behavior Inability to sustain employment- Re-victimization: rape; domestic Violence Inability to parent Inter-generational transmission Of abuse Long-term use of health & social services The Adverse Childhood Experience study or ACES remains the seminal research on the long term impact trauma can have on social and health outcomes. The study done in XXXX was conducted by Kaiser Permenente as a study of the impact of obesity. Individuals involved had commercial insurance and basically middle class and above. The level of correlation between traumatic events and adverse outcomes is an epidemiologists dream. The more traumatic events the higher the correlation. Long term impact, cost to society, physical health The financial burden to society of undiagnosed and untreated trauma is staggering Shows up in schools, at home, in the community, work, social relationships Maine study – lack of recognition impact on tx outcomes $94 billion/year or 258 million per day is the estimated cost to society of child abuse and neglect For child abuse survivors, long term psychiatric and medical health care costs are estimated at $100 billion per year Smoking &/or Drug abuse Severe obesity Physical inactivity Self Injury &/or Suicide attempts Alcoholism 50+ sex partners Sexually transmitted disease Repetition of original trauma Eating Disorders Dissociation Perpetrate domestic violence Adapted from presentation Jennings (2006). The Story of a Child’s Path to Mental Illness.

10 Three Major Findings Experiences are vastly more common than recognized or acknowledged, The ACE Study reveals a powerful relationship between our emotional experiences as children and our physical and mental health as adults, as well as the major causes of adult mortality in the United States, and Documents the conversion of traumatic emotional experiences in childhood into organic disease later in life.

11 Brain Development Brain at Birth
25% the size of the adult brain in weight and volume (less than 1lb) Nearly the same number of neurons as adult brain (100 billion) 50 trillion synapses (connections between neurons) Brain stem and lower brain well developed (reflexes), higher regions more primitive

12 Developmental Implications
More stimulation, the better for neural development Genetics form the basis (nature), but environment and experience (nurture) drive the developmental processes Adverse inputs (abuse, chemical exposure, malnutrition) likely to have lasting effects

13

14 General Principles Regarding the Effects of Early Experience on Development
Brain Architecture and Skills are Built in a Hierarchical “Bottom-Up” Sequence Neural circuits that process basic information are wired earlier than those that process more complex information. Higher circuits build on lower circuits, skills beget skills, and the development of higher level capabilities is more difficult if lower level circuits are not wired properly. Social, Emotional, and Cognitive Development are Highly Interrelated Brain Plasticity and the Ability to Change Behavior Decrease Over Time Relationships are the “Active Ingredients" of Early Experience

15 Impact of Trauma Strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of adult support, disrupts brain architecture and leads to stress management systems that respond at relatively lower thresholds, thereby increasing the risk of stress- related physical and mental illness

16 Body Chemistry Recognition of threat stimulates stress- response pathways. Adrenaline and several endocrine hormones are released into the bloodstream. Repeated acute stress response takes a toll on the body over time The individual may not fully return to baseline so may function at a hyer or hypo state of arousal These chemicals act on the hippocampus, amygdala, and frontal lobes. We know that the hippocampus is responsible for converting sensory experience into enduring memory, when the hippocampus is stimulated by the release of stress hormones it then creates vivid sensory memories of the event. Often times this is how trauma triggers are created because of these vivid sensory memories, it may be a specific smell, sound, word, taste, color etc. We may not recognize these as trauma triggers and therefore not see the precipitating event to the aggression or other emotional response. For example a teacher placing a hand on a student’s shoulder may be a trigger of past physical abuse, so when the student jumps up and throws a chair we may see that as unpredictable behavior rather than a response to trauma. Some other effects of increased adrenaline and other endocrine hormones in combination include: Increased cortisol production which counters pain and inflammation and keeps blood-sugar at a certain level. Increased blood sugar. This blood sugar is used to feed the brain and muscles. Increased heart rate. Blood is pumped more quickly around the body. Changes in blood-flow. Arterial blood pressure increases. Blood is diverted away from hands, feet and stomach, and towards your brain and major muscle groups. This helps the brain assess the threat and prepares the muscles for action. Increased platelet levels. More platelets in the bloodstream helps blood clot better and faster if physically injured. Increased endorphin levels. Endorphins help to dull pain which may allow the body to ignore the pain long enough to engage in survival behaviors. All of these physiological responses have developed over time as a species as a manner to help us survive and address threats. Unfortunately, Acute stress response takes a toll on our body over time if these biological responses do not return to normal baseline levels fairly rapidly

17 This slide shows how with repeated stressors a person may not return to the normal baseline and may function in a constant state of hyper or hypo- arousal. The first may manifest itself with hyperactivity, mania, rage and panic attacks. The latter, when someone is under aroused may lead to depression, fatigues and numbness.

18 Developmental Response To Trauma
The meaning of a traumatic event is based on the individual’s stage of neurological, cognitive and emotional development. In general, young children lack the cognitive capacities to understand cause and effect; they are less able to anticipate danger or to know how to keep themselves safe, thus being particularly vulnerable to the effects of violence exposure. A study by Davidson and Smith1 reported results consistent with this view, finding that traumatic events experienced prior to age twelve are three times more likely to result in Post Traumatic Stress Disorder than such events experienced after age twelve.

19 Identifying Children Be aware of both the children who act out AND the quiet children who don’t appear to have behavioral problems. Internalizing These students often “fly beneath the radar” and do not get help. They may have symptoms of avoidance and depression that are just as serious as those of the acting out student.

20 Impact on Relationships
Relationships are developed through the emotional bond between the child & primary caregiver. It is through this relationship we learn to: Regulate emotions/“self soothe” Develop trust in others Freely explore our environment Understand ourselves & others Understand that we can impact the world around us complex trauma exposure typically interferes with the formation of a secure attachment bond between a child and her caregiver. Normally, the attachment between a child and caregiver is the primary source of safety and stability in a child's life. Lack of a secure attachment can result in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and other difficulties, including psychiatric and addictive disorders, chronic medical illness, and legal, vocational, and family problems. Toddlers or preschool-aged children with complex trauma histories are at risk for failing to develop brain capacities necessary for regulating emotions in response to stress. Trauma interferes with the integration of left and right hemisphere brain functioning, such that a child cannot access rational thought in the face of overwhelming emotion. Abused and neglected children are then prone to react with extreme helplessness, confusion, withdrawal, or rage when stressed

21 Young Children Lacking an accurate understanding of the relationship between cause and effect, young children believe that their thoughts, wishes, and fears have the power to become real and can make things happen. Young children are less able to anticipate danger or to know how to keep themselves safe, and so are particularly vulnerable to the effects of exposure to trauma. Children may blame themselves or their parents for not preventing a frightening event or for not being able to change its outcome. early childhood trauma, especially sexual abuse, dramatically increases risk for major depression, as well as many other negative outcomes. Not only does childhood trauma appear to increase the risk for major depression, it also appears to predispose toward earlier onset of depression, as well as longer duration, and poorer response to standard treatments. Exposure to complex trauma can lead to severe problems with affect regulation. Affect regulation begins with the accurate identification of internal emotional experiences. This requires the ability to differentiate among states of arousal, interpret these states, and apply appropriate labels (e.g. "happy," "frightened"). When children are provided with inconsistent models of affect and behavior (e.g., a smiling expression paired with rejecting behavior) or with inconsistent responses to affective display (e.g., child distress is met inconsistently with anger, rejection, nurturance, or neutrality), no coherent framework is provided through which to interpret experience. Following the identification of an emotional state, a child must be able to express emotions safely and to adjust or regulate internal experience. Complexly traumatized children show impairment in both of these skills. Because they have difficulty in both self-regulating and self-soothing, these children may display dissociation, chronic numbing of emotional experience, dysphoria and avoidance of emotional situations (including positive experiences), and maladaptive coping strategies (e.g., substance abuse). Dissociation is one of the key features of complex trauma in children. In essence, dissociation is the failure to take in or integrate information and experiences. Thus, thoughts and emotions are disconnected, physical sensations are outside conscious awareness, and repetitive behavior takes place without conscious choice, planning, or self-awareness. Although dissociation begins as a protective mechanism in the face of overwhelming trauma, it can develop into a problematic disorder. Chronic trauma exposure may lead to an over-reliance on dissociation as a coping mechanism that, in turn, can exacerbate difficulties with behavioral management, affect regulation, and self-concept. Complex childhood trauma is associated with both under-controlled and over-controlled behavior patterns. As early as the second year of life, abused children may demonstrate rigidly controlled behavior patterns, including compulsive compliance with adult requests, resistance to changes in routine, inflexible bathroom rituals, and rigid control of food intake. Childhood victimization also has been shown to be associated with the development of aggressive behavior and oppositional defiant disorder. Toddlers (up to five years old) Typical reactions in this age group include clinging to parents, crying and a return to regressive behaviors, which are typical of earlier periods of development. These behaviors often include bed wetting, finger sucking and fear of the dark.

22 Young Children Young children cannot express in words whether they feel afraid, overwhelmed, or helpless. Traumatic events have a profound sensory impact on young children. Young children who experience trauma are at particular risk because their rapidly developing brains are very vulnerable. Young children depend exclusively on parents/caregivers for survival and protection―both physical and emotional When trauma also impacts the parent/caregiver, the relationship between that person and the child may be strongly affected. Without the support of a trusted parent/caregiver to help them regulate their strong emotions, children may experience overwhelming stress, with little ability to effectively communicate what they feel or need. They often develop symptoms that parents/caregivers don’t understand and may display uncharacteristic behaviors that adults may not know how to appropriately respond to. Child Accidents and Physical Trauma Children aged five and under are hospitalized or die from drowning, burns, falls, choking, and poisoning more frequently than do children in any other age group.2 One in three children under the age of six has injuries severe enough to warrant medical attention.3 Child Abuse and Neglect Young children have the highest rate of abuse and neglect, and are more likely to die because of their injuries. Children younger than three years of age constituted 31.9 percent of all maltreatment victims reported to authorities in Infants are the fastest growing category of children entering foster care in the United States.5 Infants removed from their homes and placed in foster care are more likely than are older children to experience further maltreatment and to be in out-of-home care longer.6 Child Exposure to Domestic or Community Violence In a survey of parents in three SAMHSA-funded community mental health partnerships, 23 percent of parents reported that their children had seen or heard a family member bring threatened with physical harm.7 Nearly two-thirds of young children attending a Head Start program had either witnessed or been victimized by community violence, according to parent reports.8 In a survey of parents of children aged six and under in an outpatient pediatric setting, it was found that one in ten children had witnessed a knifing or shooting; half the reported violence occurred in the home.9

23 Young Children Separation anxiety or clinginess towards teachers or primary caregivers Regression in previously mastered stages of development (e.g., baby talk or bedwetting/toileting accidents) Lack of developmental progress (e.g., not progressing at same level as peers) Re-creating the traumatic event (e.g., repeatedly talking about, “playing” out, or drawing the event)

24 Young Children Difficulty at naptime or bedtime (e.g., avoiding sleep, waking up, or nightmares) Increased somatic complaints (e.g., headaches, stomachaches, overreacting to minor bumps and bruises) Changes in behavior (e.g., appetite, unexplained absences, angry outbursts, decreased attention, withdrawal) Over- or under-reacting to physical contact, bright lighting, sudden movements, or loud sounds.

25 Assess Reactions of the child and caregivers
Changes in the child’s behavior Resources in the environment to stabilize the child and family Quality of the child’s primary attachment relationships Ability of caregivers to facilitate the child’s healthy socio-emotional, psychological, and cognitive development PTSD Semi-Structured Interview and Observation Record (0–4 y/o ) Posttraumatic Symptom Inventory for Children (PT-SIC) (4–8 y/o) Preschool Age Psychiatric Assessment (2–5 y/o) PTSD Symptoms in Preschool Aged Children (3–5) Traumatic Events Screening Inventory-Parent Report Revised (0–6 y/o) Trauma Symptom Checklist for Young Children (3–12 y/o) Violence Exposure Scale for Children-Preschool Version (4–10 y/o)

26 Support for Young Children
Helping children and caregivers reestablish a safe environment and a sense of safety Helping parents and children return to normal routines An opportunity to talk about and make sense of the traumatic experience in a safe, accepting environment Explaining the trauma and answering questions in an honest but simple and age- appropriate manner Child Trauma Toolkit for Educators, NCTSN The family, particularly the child's mother, plays a crucial role in determining how the child adapts to experiencing trauma. In the aftermath of trauma, family support and parents' emotional functioning strongly mitigate the development of PTSD symptoms and enhance a child's capacity to resolve the symptoms. There are three main elements in caregivers' supportive responses to their children's trauma: Believing and validating the child's experience, Tolerating the child's affect, and Managing the caregiver's own emotional response. When a caregiver denies the child's experiences, the child is forced to act as if the trauma did not occur. The child also learns she cannot trust the primary caregiver and does not learn to use language to deal with adversity. It is important to note that it is not caregiver distress per se that is necessarily detrimental to the child. Instead, when the caregiver's distress overrides or diverts attention away from the needs of the child, the child may be adversely affected. Children may respond to their caregiver's distress by avoiding or suppressing their own feelings or behaviors, by avoiding the caregiver altogether, or by becoming "parentified" and attempting to reduce the distress of the caregiver. Caregivers who have had impaired relationships with attachment figures in their own lives are especially vulnerable to problems in raising their own children. Caregivers with histories of childhood complex trauma may avoid experiencing their own emotions, which may make it difficult for them to respond appropriately to their child's emotional state. Parents and guardians may see a child's behavioral responses to trauma as a personal threat or provocation, rather than as a reenactment of what happened to the child or a behavioral representation of what the child cannot express verbally. The victimized child's simultaneous need for and fear of closeness also can trigger a caregiver's own memories of loss, rejection, or abuse, and thus diminish parenting abilities. While exposure to complex trauma has a potentially devastating impact on the developing child, there is also the possibility that a victimized child may function well in certain domains while exhibiting distress in others. Areas of competence also can shift as children are faced with new stressors and developmental challenges. Several factors have been shown to be linked to children's resilience in the face of stress: positive attachment and connections to emotionally supportive and competent adults within the family or community, development of cognitive and self-regulation abilities, and positive beliefs about oneself and motivation to act effectively in one's environment. Additional individual factors associated with resilience include an easygoing disposition, positive temperament, and sociable demeanor; internal locus of control and external attributions for blame; effective coping strategies; a high degree of mastery and autonomy; special talents; creativity; and spirituality. The greatest threats to resilience appear to follow the breakdown of protective systems. This results in damage to brain development and associated cognitive and self-regulatory capacities, compromised caregiver-child relationships, and loss of motivation to interact with one's environment. Safety: Creating a home, school, and community environment in which the child feels safe and cared for Self-regulation: Enhancing a child's capacity to modulate arousal and restore equilibrium following disregulation of affect, behavior, physiology, cognition, interpersonal relatedness and self-attribution. Self-reflective information processing: Helping the child construct self-narratives, reflect on past and present experience, and develop skills in planning and decision making. Traumatic experiences integration: Enabling the child to transform or resolve traumatic reminders and memories using such therapeutic strategies as meaning-making, traumatic memory containment or processing, remembrance and mourning of the traumatic loss, symptom management and development of coping skills, and cultivation of present-oriented thinking and behavior. Relational engagement: Teaching the child to form appropriate attachments and to apply this knowledge to current interpersonal relationships, including the therapeutic alliance, with emphasis on development of such critical interpersonal skills as assertiveness, cooperation, perspective-taking, boundaries and limit-setting, reciprocity, social empathy, and the capacity for physical and emotional intimacy. Positive affect enhancement: Enhancing a child's sense of self-worth, esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery-seeking, community-building and the capacity to experience pleasure. In light of the many individual and contextual differences in the lives of children and adolescents affected by complex trauma, good treatment requires the flexible adaptation of treatment strategies in response to such factors as patient age and developmental stage, gender, culture and ethnicity, socioeconomic status, and religious or community affiliation. However, in general, it is recommended that treatment proceed through a series of phases that focus on different goals. This can help avoid overloading children-who may well already have cognitive difficulties-with too much information at one time. A phase-based approach begins with a focus on providing safety, typically followed by teaching self-regulation. As children's capacity to identify, modulate and express their emotions stabilizes, treatment focus increasingly incorporates self-reflective information processing, relational engagement, and positive affect enhancement. These additional components play a critical role in helping children to develop in positive, healthy ways, and to avoid future trauma and victimization. While it may be beneficial for some children affected by complex trauma to process their traumatic memories, this typically can only be successfully undertaken after a substantial period of stabilization in which internal and external resources have been established. Notably, several of the leading interventions for child complex trauma do not include revisiting traumatic memories but instead foster integration of traumatic experiences through a focus on recognizing and coping with present triggers within a trauma framework. Best practice with this population typically involves adoption of a systems approach to intervention, which might involve working with child protective services, the court system, the schools, and social service agencies. Finally, there is a consensus that interventions should build strengths as well as reduce symptoms. In this way, treatment for children and adolescents also serves to protect against poor outcomes in adulthood. Preschooler Stick to regular family routines. Make an extra effort to provide comfort and reassurance. Avoid unnecessary separations. Permit a child to sleep in the parents' room temporarily. Encourage expression of feelings and emotions through play, drawing, puppet shows, and story telling. Limit media exposure. Develop a safety plan for future incidents.

27 Support for Young Children
Teaching techniques for dealing with overwhelming emotional reactions Helping the child verbalize feelings rather than engage in inappropriate behavior Involving primary caregivers in the healing process Connecting caregivers to resources to address their needs–young children’s level of distress often mirrors their caregiver’s level of distress Child Trauma Toolkit for Educators, NCTSN

28 Interventions Child Parent Psychotherapy (0-6 y/o)
Parent Child Interaction Therapy (<12 y/o) Trauma Focused Cognitive Behavior Therapy (3 to 21 y/o) Combined Parent Child CBT (4 -17 y/o) Eye Movement Desensitization and Reprocessing

29 Elementary Age Children
Anxiety, fear, and worry about safety of self and others (more clingy with teacher or parent) Worry about recurrence of violence Increased distress (unusually whiny, irritable, moody) Changes in behavior: Increase in activity level Decreased attention and/or concentration Withdrawal from others or activities Angry outbursts and/or aggression Child Trauma Toolkit for Educators, NCTSN Prospective studies have shown that children of abusive and neglectful parents demonstrate impaired cognitive functioning by late infancy when compared with non-abused children. The sensory and emotional deprivation associated with neglect appears to be particularly detrimental to cognitive development; neglected infants and toddlers demonstrate delays in expressive and receptive language development, as well as deficits in overall IQ. By early childhood, maltreated children demonstrate less flexibility and creativity in problem-solving tasks than same-age peers. By early elementary school, maltreated children are more frequently referred for special education services. A history of maltreatment is associated with lower grades and poorer scores on standardized tests and other indices of academic achievement. Maltreated children have three times the dropout rate of the general population. These findings have been demonstrated across a variety of trauma exposures (e.g., physical abuse, sexual abuse, neglect, and exposure to domestic violence) and cannot be accounted for by the effects of other psychosocial stressors such as poverty. Consumer > Disorders and Conditions > Complex Trauma in Children and Adolescents advertisement Complex Trauma in Children and Adolescents The term complex trauma describes the dual problem of children's exposure to multiple traumatic events and the impact of this exposure on immediate and long-term outcomes. Typically, complex trauma exposure results when a child is abused or neglected, but it can also be caused by other kinds of events such as witnessing domestic violence, ethnic cleansing, or war. Many children involved in the child welfare system have experienced complex trauma. Often, the consequences of complex trauma exposure are devastating for a child. This is because complex trauma exposure typically interferes with the formation of a secure attachment bond between a child and her caregiver. Normally, the attachment between a child and caregiver is the primary source of safety and stability in a child's life. Lack of a secure attachment can result in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and other difficulties, including psychiatric and addictive disorders, chronic medical illness, and legal, vocational, and family problems. These difficulties may extend from childhood through adolescence and into adulthood. The diagnosis of posttraumatic stress disorder (PTSD) does not capture the full range of developmental difficulties that traumatized children experience. Children exposed to maltreatment, family violence, or loss of their caregivers often meet diagnostic criteria for depression, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, anxiety disorders, eating disorders, sleep disorders, communication disorders, separation anxiety disorder, and/or reactive attachment disorder. Yet each of these diagnoses captures only a limited aspect of the traumatized child's complex self-regulatory and relational difficulties. A more comprehensive view of the impact of complex trauma can be gained by examining trauma's impact on a child's growth and development. advertisement Impact on Development A comprehensive review of the literature suggests seven primary domains of impairment observed in children exposed to complex trauma. Each of the seven domains is discussed below. Attachment Complex trauma is most likely to develop if an infant or child is exposed to danger that is unpredictable or uncontrollable, because the child's body must devote resources that are normally dedicated to growth and development instead to survival. The greatest source of danger and unpredictability is the absence of a caregiver who reliably and responsively protects and nurtures the child. The early care giving relationship provides the primary context within which children learn about themselves, their emotions, and their relationships with others. A secure attachment supports a child's development in many essential areas, including his capacity for regulating physical and emotional states, his sense of safety (without which he will be reluctant to explore his environment), his early knowledge of how to exert an influence on the world, and his early capacity for communication. When the child-caregiver relationship is the source of trauma, the attachment relationship is severely compromised. Care giving that is erratic, rejecting, hostile, or abusive leaves a child feeling helpless and abandoned. In order to cope, the child attempts to exert some control, often by disconnecting from social relationships or by acting coercively towards others. Children exposed to unpredictable violence or repeated abandonment often learn to cope with threatening events and emotions by restricting their processing of what is happening around them. As a result, when they confront challenging situations, they cannot formulate a coherent, organized response. These children often have great difficulty regulating their emotions, managing stress, developing concern for others, and using language to solve problems. Over the long term, the child is placed at high risk for ongoing physical and social difficulties due to: Increased susceptibility to stress (e.g., difficulty focusing attention and controlling arousal), Inappropriate help-seeking (e.g., excessive help-seeking and dependency or social isolation and disengagement). Inability to regulate emotions without outside help or support (e.g., feeling and acting overwhelmed by intense emotions), and Biology Toddlers or preschool-aged children with complex trauma histories are at risk for failing to develop brain capacities necessary for regulating emotions in response to stress. Trauma interferes with the integration of left and right hemisphere brain functioning, such that a child cannot access rational thought in the face of overwhelming emotion. Abused and neglected children are then prone to react with extreme helplessness, confusion, withdrawal, or rage when stressed. In middle childhood and adolescence, the most rapidly developing brain areas are those that are crucial for success in forming interpersonal relationships and solving problems. Traumatic stressors or deficits in self-regulatory abilities impede this development, and can lead to difficulties in emotional regulation, behavior, consciousness, cognition, and identity formation. It is important to note that supportive and sustaining relationships with adults-or, for adolescents, with peers-can protect children and adolescents from many of the consequences of traumatic stress. When interpersonal support is available, and when stressors are predictable, escapable, or controllable, children and adolescents can become highly resilient in the face of stress. Affect Regulation Exposure to complex trauma can lead to severe problems with affect regulation. Affect regulation begins with the accurate identification of internal emotional experiences. This requires the ability to differentiate among states of arousal, interpret these states, and apply appropriate labels (e.g. "happy," "frightened"). When children are provided with inconsistent models of affect and behavior (e.g., a smiling expression paired with rejecting behavior) or with inconsistent responses to affective display (e.g., child distress is met inconsistently with anger, rejection, nurturance, or neutrality), no coherent framework is provided through which to interpret experience. Following the identification of an emotional state, a child must be able to express emotions safely and to adjust or regulate internal experience. Complexly traumatized children show impairment in both of these skills. Because they have difficulty in both self-regulating and self-soothing, these children may display dissociation, chronic numbing of emotional experience, dysphoria and avoidance of emotional situations (including positive experiences), and maladaptive coping strategies (e.g., substance abuse). The existence of a strong relationship between early childhood trauma and subsequent depression is well-established. Recent twin studies, considered one of the highest forms of clinical scientific evidence because they can control for genetic and family factors, have conclusively documented that early childhood trauma, especially sexual abuse, dramatically increases risk for major depression, as well as many other negative outcomes. Not only does childhood trauma appear to increase the risk for major depression, it also appears to predispose toward earlier onset of depression, as well as longer duration, and poorer response to standard treatments. Dissociation Dissociation is one of the key features of complex trauma in children. In essence, dissociation is the failure to take in or integrate information and experiences. Thus, thoughts and emotions are disconnected, physical sensations are outside conscious awareness, and repetitive behavior takes place without conscious choice, planning, or self-awareness. Although dissociation begins as a protective mechanism in the face of overwhelming trauma, it can develop into a problematic disorder. Chronic trauma exposure may lead to an over-reliance on dissociation as a coping mechanism that, in turn, can exacerbate difficulties with behavioral management, affect regulation, and self-concept. Behavioral Regulation Complex childhood trauma is associated with both under-controlled and over-controlled behavior patterns. As early as the second year of life, abused children may demonstrate rigidly controlled behavior patterns, including compulsive compliance with adult requests, resistance to changes in routine, inflexible bathroom rituals, and rigid control of food intake. Childhood victimization also has been shown to be associated with the development of aggressive behavior and oppositional defiant disorder. An alternative way of understanding the behavioral patterns of chronically traumatized children is that they represent children's defensive adaptations to overwhelming stress. Children may reenact behavioral aspects of their trauma (e.g., through aggression, or self-injurious or sexualized behaviors) as automatic behavioral reactions to trauma reminders or as attempts to gain mastery or control over their experiences. In the absence of more advanced coping strategies, traumatized children may use drugs or alcohol in order to avoid experiencing intolerable levels of emotional arousal. Similarly, in the absence of knowledge of how to form healthy interpersonal relationships, sexually abused children may engage in sexual behaviors in order to achieve acceptance and intimacy. Cognition Prospective studies have shown that children of abusive and neglectful parents demonstrate impaired cognitive functioning by late infancy when compared with non-abused children. The sensory and emotional deprivation associated with neglect appears to be particularly detrimental to cognitive development; neglected infants and toddlers demonstrate delays in expressive and receptive language development, as well as deficits in overall IQ. By early childhood, maltreated children demonstrate less flexibility and creativity in problem-solving tasks than same-age peers. Children and adolescents with a diagnosis of PTSD secondary to abuse or witnessing violence demonstrate deficits in attention, abstract reasoning, and problem solving. By early elementary school, maltreated children are more frequently referred for special education services. A history of maltreatment is associated with lower grades and poorer scores on standardized tests and other indices of academic achievement. Maltreated children have three times the dropout rate of the general population. These findings have been demonstrated across a variety of trauma exposures (e.g., physical abuse, sexual abuse, neglect, and exposure to domestic violence) and cannot be accounted for by the effects of other psychosocial stressors such as poverty. Self-Concept The early caregiver relationship has a profound effect on a child's development of a coherent sense of self. Responsive, sensitive caretaking and positive early life experiences allow a child to develop a model of self as generally worthy and competent. In contrast, repetitive experiences of harm and/or rejection by significant others and the associated failure to develop age-appropriate competencies are likely to lead to a sense of self as ineffective, helpless, deficient, and unlovable. Children who perceive themselves as powerless or incompetent and who expect others to reject and despise them are more likely to blame themselves for negative experiences and have problems eliciting and responding to social support. By 18 months, maltreated toddlers already are more likely to respond to self-recognition with neutral or negative affect than non-traumatized children. In preschool, traumatized children are more resistant to talking about internal states, particularly those they perceive as negative. Traumatized children have problems estimating their own competence. Early exaggerations of competence in preschool shift to significantly lowered estimates of self-competence by late elementary school. By adulthood, they tend to suffer from a high degree of self-blame. Middle childhood (six to eleven year olds) to the trauma, regressive behavior, withdrawal, restlessness, and difficulties in Typical reactions in this age group are anger, aggressiveness, avoidance of subjects related concentrating and studying

30 Elementary Age Children
Absenteeism Distrust of others, affecting how children interact with both adults and peers A change in ability to interpret and respond appropriately to social cues Increased somatic complaints (e.g., headaches, stomachaches, overreaction to minor bumps and bruises) Changes in school performance Child Trauma Toolkit for Educators, NCTSN

31 Elementary Age Children
Recreating the event (e.g., repeatedly talking about, “playing” out, or drawing the event) Over- or under-reacting to bells, physical contact, doors slamming, sirens, lighting, sudden movements Statements and questions about death and dying Child Trauma Toolkit for Educators, NCTSN

32 Elementary Age Children
Difficulty with authority, redirection, or criticism Re-experiencing the trauma (e.g., nightmares or disturbing memories during the day) Hyperarousal (e.g., sleep disturbance, tendency to be easily startled) Avoidance behaviors (e.g., resisting going to places that remind them of the event) Emotional numbing (e.g., seeming to have no feeling about the event) Child Trauma Toolkit for Educators, NCTSN Elementary Age Children Provide extra attention and consideration. Set gentle but firm limits for acting out behavior. Listen to a child's repeated telling of his/her trauma experience. Encourage expression of thoughts and feelings through conversation and play. Provide home chores and rehabilitation activities that are structured, but not too demanding. Rehearse safety measures for future incidents. Point out kind deeds and the ways in which people helped each other during the disaster or traumatic event.

33 Interventions Cognitive Behavioral Interventions for Trauma in Schools (6 -15 y/o) Functional Family Therapy (6-21 y/o)

34 Adolescence Increased risk for substance abuse
Concern over being labeled “abnormal” or different from their peers may cause adolescents to withdraw from family and friends. Adolescents often experience feelings of shame and guilt about the traumatic event and may express fantasies about revenge and retribution. Discomfort with feelings (such as troubling thoughts of revenge)

35 Interventions Seeking Safety for Adolescents
Structured Psychotherapy for Adolescents Responding to Chronic Stress(SPARCS) (12-19 y/o) Schools Give children choices. Often traumatic events involve loss of control and/or chaos, so you can help children feel safe by providing them with some choices or control when appropriate. Increase the level of support and encouragement given to the traumatized child. Designate an adult who can provide additional support if needed. Set clear, firm limits for inappropriate behavior and develop logical—rather than punitive—consequences. Recognize that behavioral problems may be transient and related to trauma. Remember that even the most disruptive behaviors can be driven by trauma-related anxiety. While a traumatized child might not meet eligibility criteria for special education, consider making accommodations and modifications to academic work for a short time, even including these in a 504 plan. You might: Shorten assignments Allow additional time to complete assignments Give permission to leave class to go to a designated adult (such as a counselor or school nurse) if feelings become overwhelming Provide additional support for organizing and remembering assignments For example, victims of natural storm-related disasters might react very badly to threatening weather or storm warningsBe sensitive to the cues in the environment that may cause a reaction in the traumatized child. Children may increase problem behaviors near an anniversary of a traumatic event. Warn children if you will be doing something out of the ordinary, such as turning off the lights or making a sudden loud noise Understand that children cope by re-enacting trauma through play or through their interactions with others. Resist their efforts to draw you into a negative repetition of the trauma. For instance, some children will provoke teachers in order to replay abusive situations at home. ud noise.

36 Resources National Children’s Traumatic Stress Network National Center on PTSD Helping Traumatized Children Learn The Heart of Learning and Teaching (American Academy of Child & Adolescent Psychiatry) (National Institute of Mental Health)


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