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The Effects of Abuse and Neglect: A Child’s Perspective

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1 The Effects of Abuse and Neglect: A Child’s Perspective
Jordan Greenbaum, MD Stephanie V. Blank Center for Safe and Healthy Children Children’ Healthcare of Atlanta Children’s Healthcare of Atlanta

2 Imagine this… 9 year old girl comes to school with a black eye, limping and tells her teacher, “I’m scared because I don’t know why I was punished or when it will happen again…I don’t feel safe…will you keep me safe? I don’t ever want to go home again.” If she didn’t like it why didn’t she just cooperate? (mom)

3 Police and CPS open an investigation and find evidence of:
Beating, choking, dragging Waterboarding Severe emotional abuse Poured coffee, pickle juice on her head Videotaped her being humiliated Made to stand with arms outstretched for hours For 3 years the child has been tortured by her father, while mom looks on and condones behavior. Mom videotaped child with arms outstretched; you could hear her giggling Mom referred to waterboarding as ‘washing her hair’ Scapegoating child and favoring other child over this one Forced to wear a sign saying ‘Shame” Not told why dad angry so child could not prevent it from happening again No birthday cake for years while sibling got one Blamed this child for other child’s misbehavior

4 Father: “No one will believe you if you tell, because I’m a good person.”
“Why don’t you just swallow your pride and admit it’s your problem?” Mother: “If she didn’t like it why didn’t she just cooperate?”

5 Overview Effects of child maltreatment from a child’s perspective
Early brain development and toxic stress The trauma of intervention Trauma-informed care of the abused child Have you had the experience of hearing a case of infant or small child abuse, working with the family on that, then 12 years later encountering that’ same child all grown up now involved in juvenile dlelinquency issues, CSEC, runaway beahvior, and in antoher 5 years you see him/her again with their own child who has been abused? And you wonder why is it that this woman/man, who suffered such abuse as a youngster, is now so very troubled??

6 What is the experience of a maltreated child?
Fear Uncertainty Lack of control Anxiety Anger Guilt Shame Extreme, recurrent stress

7 “I would have to say it would have to be when my father locked my mother in the bedroom for 3 days and just the sounds coming from that room not knowing what was going on, that was the most violent” “I was always afraid to go over to my neighbors’ because I thought that if I did, [mother’s paramour] was going to hunt me down and come get me.” Male victim of CSEC describing home experiences Child of meth-using parent McIntyre, 2009 Osler, 2007

8 “He told me not to tell or he’d got to jail and mommy would cry.”
“He told me he’d break every bone in my body. If I cried he said he’d tape my mouth shut with duct tape.” Child victim of sexual abuse Child victim of ongoing torture including waterboarding, choking, beatiing, dragging, emotional abuse by father, witnessed and condoned by parent (Mom said ‘if she’d only do what he wanted he wouldn’t do that to her’) “He’d wiggle his thing against my privates and it felt horrible, sometimes it hurt.”

9 How do children and youth respond to trauma?

10 Reactions to Trauma Depend On…
Child’s Age, developmental stage Perception about danger of event Victim vs witness status Relationship to victim, perpetrator Prior experiences with trauma Adversities in aftermath of trauma Availability of protective, responsive adults The child’s age and developmental stage The child’s perception of the danger faced Whether the child was the victim or a witness n The child’s relationship to the victim or perpetrator n The child’s past experience with trauma n The adversities the child faces in the aftermath of the trauma n The presence/availability of adults who can offer help and protection National Child Traumatic Stress Network (NCTSN)

11 Symptoms of Traumatic Stress
Symptoms may not be manifest immediately Variable period to resolution Some children don’t show obvious symptoms Over control may be as symptomatic as acting out Still waters…. Symptoms may not be manifest immediately—may take time to develop May resolve in few weeks or months, or may take much longer Some children don’t show obvious symptoms of trauma, but they may be feeling them Still waters run deep—quiet children aren’t necessarily symptom free: may be dissociating, numbing, avoiding NCTSN

12 Potential Signs of Traumatic Stress
Physical Nightmares, sleep problems Altered appetite, eating patterns Chronic pain complaints Irritable bowel syndrome Emotional PTSD Depression, withdrawal Anxiety/panic Dissociation, numbness NCTSN

13 “I just liked getting away from the house…There was too much arguing, too much stress.”
Child of meth-abusing parent Ostler, 2007

14 Potential Signs of Traumatic Stress
Behavioral Regression in developmental milestones Refusal to separate from caregiver Hyperactivity, poor attention Re-creating trauma Abrupt change in behavior or new fears Anxiety about safety of self and others Focus on death and dying Re-enactment may be shown by play, writing, art Behavior changes related to stress may appear suddenly (new fear, sudden withdrawal from friends) or gradually Another one: avoidance of places/people/situations that remind child of trauma NCTSN

15 Potential Signs of Traumatic Stress
Behavioral Hyperarousal Aggression, antisocial behavior Hypervigilance Lack of control of mood, behavior Misinterpretation of others’ intentions Distrust of others Difficulty with authority, criticism Impulsive behavior, quick to react to perceived danger/threat May be hyper-reactive to loud noise, yelling, touch, changes in lighting, sudden movements, etc Somatization Poor self esteem Shame, guilt View of world as unsafe place Hopelessness, helplessness Can also show very over-controlled behavior, resistance to change, as way of coping with feelings of helplessness NCTSN

16 Problems identifying emotions in others
PA kids can differentiate between emotions such as happiness, fear and sadness as well as nonmaltreated kids, but they differ in processing of anger. They very easily identify facial expressions of anger, may selectively orient and attend to angry faces, use more energy in the process, and have more difficulty disengaging once attentions has been allocated. Thus, the process anger differently. (this likely involves amygdala and PFC) Study of kids being read a vignette in which character experienced one of 5 emotions (disguse, sadness, happiness, anger or fear). Then kids presented with pic’s of different facial expressions. All kids easily identified happy expressions Kids with PA were biased in their selection of angry faces (they required less evidence in identifying the xpression) Neglected kids were biased in selection of sad faces Neglected kids had more difficulty differentiating facial expressions than did PA and nonmaltreated kids. Implication: kids’ experiences of stress and associated memories related to maltx may influence their understanding and interpretation of other people’s facial expressions. (neglected kids don’t get opportunities to develop social-emotional understanding so have hard time differentiating expressions; PA kids experience anger more often, and feel fear more often so this leads to hypersensitivity to those social cues. They may pay greater attention to threats.

17 Child Maltreatment Problems with attachment Depression, anxiety
Developmental delays Abuse/Neglect Behavior problems Lower IQ Personality disorders Substance abuse Correlation doesn’t equal causation Begin to see how changes in PFC, amygdala, HPA axis can help explain some of these behaivors and outcomes (problems with executive funcitoning, identifying emotions in others, aggression, etc). Poor school performance Low self esteem Problems with attention, problem solving 17

18 Trauma and Brain Development

19 Brain Development Depends on genes, experience, other factors
Adapts to environment Different areas develop at different rates Creating and strengthening circuits, influencing structure and function of the brain Different areas mature at different times, rates Effect of an experience on brain development depends on when the experience occurs (since maturation is varying over time) Age-appropriate experiences: you can’t teach a 6 mo to read—his brain isn’t ready for that. Areas controlling lower order functions (ex, vision: color, shape, movement, light) mature early, usually before or shortly after birth Higher order function areas(ex, recognizing familiar objects, recognizing facial expression) depend on development of lower order areas (so if maldeveloped this can affect maturation of higher order areas) Many higher order function areas have not begun, or are in early stages of maturing by age 3.

20 Sensitive Periods Windows of opportunity
Effects of experience on brain are very strong Vary with area of brain Initial experience is more influential Plasticity persists (it’s never too late!) A period during which…. Period of sensitivity is limited Duration of period varies, there is overlap; low level circuits have earlier periods Different areas of brain have different sensitive periods for development Sensitive period may be triggered by the progress of development or by intense impulse activity related to experience 20 20 20

21 Neural Plasticity Continues to a certain extent throughout life
Decreases with age Allows us to compensate for injuries, change behavior, learn Sensitive periods end when conditions causing state of plasticity no longer operate or operate with less efficiency. Some plasticity continues after the period ends, and the amount varies with the circuit. Changes in the circuit that occur after the sensitive period ends must operate within the constraints set by the sensitive period Sensitive periods may end abruptly (imprinting) or gradually (language acquisition) But adult plasticity doesn’t involve significant structural change, is mostly involving increasing efficacy of certain connections Complex behaviors involve many circuits and problems with lower level circuits may be partially compensated for by development in higher level circuits (sensitive period has stayed open longer) Plasticiity continues throughout life, but to maximize benefit, you need to activate the relevant circutis and actively engage (attend to ) the task. 21

22 Amygdala Roles Regulated by hippocampus and prefrontal cortex
Emotional center of brain Assessing threat Initiating stress response Regulated by hippocampus and prefrontal cortex Regualted by PFC and aneterior Amygdala Fear conditioning Aggression, oral, sexual behavior Emotional memory Relatively primitive area of brain, matures relatively early (lower animals have amygdala, to respond quickly to threatening situaitons; the ability to process emotions, decide on appropriate response is new (neocortex) Very fast to respond (faster than neocortex) Ssnsory info goes from thalamus to amygdala (fast response) and from thalamus to PFC, where it gets processed and a slower response is generated. When amygdala is stimulated, stress hormone levels rise and so do norepinephrine levels Repeated trauma may lead to fear conditioning (a relatively innocuous stimulus is associated with feeling of fear) Amygdala may become hyperactive and under-controlled (hypersensitive to fearful stimuli, exhibit impulsive behaviors, anxiety

23 Hippocampus Learning and memory Contextual detail of events
“Just the facts, Ma’am” Sends info to amygdala Long period maturation esp episodic memory (e.g. memories involving events, including facts and details about event). Hippo is associated with memories concerning the context within which the emotional memories were created. Amygdala relies on information from the hippo when evaluating the emotional significance of an event. (ex, info regarding the context of door slamming on TV vs in real life, and helps child determine whether or not stimulus is dangerous) Damage to hippo interferes with the interpretation and categorization of incoming info Hippo has long period of development and lots stress receptors Twin studies suggest that perhaps reduced hippo size prior to stressful event predisposes a child to developing PTSD afterwards. Memory storage and retrieval Helps arrest ongoing inappropriate behavior 23 23

24 Prefrontal Cortex (PFC)
Self regulation Emotional regulation Executive functioning Interacts with amygdala Important in executive functions, including attention, working memory, control of impulsivity, response selection, planning, reasoning, decision-making and coordination of info from other parts of the brain It uses info from the limbic system to guide behavior (ex, amygdala) (we need emotion to decide on our behavior) PFC develops all the way into adolescence and early adulthood; different areas develop at different rates. Cingulate cortex and dorsolat PFC are higher order cortical areas and mature last. ACC is thought to be involved in the need for control and in conflicts between cognition and emotion. The ventromedial PFC is especially important in decision-making and for processing reward and punishment. When damage involves this area, adults have impairments in impulsivity, social behavior, planning and decision-making and cannot learn from prior experiences. 24 24

25 Normal Child Development
Infancy Ability to regulate behavior, emotion, physical functioning Attachment develops Caregiver input is critical Develops ability to regulate behavior (crying), emotion (distress) and physical functioning (sleep cycle), but must rely on caregiver being sensitive and responsive Caregiver role in helping infant regulate distress becomes increasingly important between 3-6 months of age.(help infant maintain organization during episodes of increased tension or stimulation; help child develop ‘nascent sense of self efficacy’ Attachment really begins to develop in the second half of the first year of life. Above studies and others suggest that attachment behavior remains flexible throughout first year of life, and during second year, is less flexible but still plastic (older infants eventually develop secure attachment under good conditions) Identification of emotion in facial expression starts in 1st year of life 25 25

26 The World According to the Child
Myself: Unable to influence others, impact environment Worthless, undeserving Unsafe in world, and among other people Others: Unreliable, unpredictable, uncaring Insensitive, rejecting Dangerous Unwilling to negotiate, give-and-take Feel they cannot influence their world—impacts self-esteem, willingness to take on challenges, solve problems, engage with others. They feel parent will not negotiate with them, that they have no ability to be a partner and work through differences in relationship. Any partnership with parent is nonexistent or dysfunctional. You can’t negotiate well if you can’t identify and clearly express your own needs believe the parent will recognize or care about your needs parent is insensitive, unavailable, unpredictable and/or threatening

27 Maltreatment and Attachment
Likely that most have attachment problems By 2-3 yo may show behavior ‘problems’ Mixed feelings for caregivers yield unclear signals of needs Have pessimistic expectations, negative working model And likely that attachment problems are relatively fixed in nature. The behavior problems are efforts to engage the parent, reduce danger, obtain attention VERY hard for foster parent to interpret signals, recognize needs and respond sensitively as child may rebuff, actively resist or seem indifferent to parental efforts Despite negative internal model, may have idealistic view of bio parents (The working model is unconscious (negative view of bio parents, self, world) yet consciously the child considers bio parents perfect. The early attachment of a child to his caretaker helps shape the child’s beliefs and expectations about the environment and his interaction with it. Early experiences are later generalized to expectations about adults’ availability, the contingency of others’ behaviors, and self worth and ability to influence the environment. These generalizations become ‘working models’ that filter experiences and guide behavior in future relationships. Our self-perceptions affect or behavioral and social competence, and later adjustment Stress-resilient children have been found to hold more positive self-perceptions, and more positive perceptions of their relationships with parents, their family environment and their expectations for the future. There is also evidence that characteristics of the maltreatment (type, severity, duration, etc) are more predictive of a chld’s functioning that the presence/absence of maltreatment and this may help determine why some kids do well and others don’t when in foster care. Children with disorganized attachments are at increased risk of later problems socially, including aggression toward peers and dissociative symptomatology. (Organized but insecure attachment (avoidant, resistant) may not render child at increase risk for future) School-age kids show negative attributional biases, assuming peers intent harm when intentions are ambiguous Also show inadequate inhibitory control Aggressive, inappropriate behavior with peers

28 “He’d yell at the baby to stop crying, and sometimes I’d be in the other room and suddenly the baby would just go silent” (mother of baby with AHT) “He was crying and walked toward her, and she grabbed him, set him down to change his diaper and pinched him.” parent watching nannycam of child being abused

29 Normal Child Development
Toddler/Preschooler Developing sense of self Improved self-regulation Start to delay gratification Talk about causes of emotion Can hide emotions Very concrete thinking Develop an integrated, organized sense of self based on past experiences Increase in self-regulatory abilities (behavior, emotions and physiology) Start to develop an ability to delay gratification and inhibit a prepotent response (prefrontal cortex and other structures) Inhibiting prepotent response allows child to consider possibilities and consequences before acting. One study showed that maltreated kids in intact bio families seemed to dissociate more and this increase with age, suggesting the sense of self was becming more fragmented instead of integrated. Another study showed foster kids also developed a fragmented sense of self and family (and likely this interferes with ability to regulate behavior and emotions). Interventions focus on helping child develop adequate behavioral control strategies, and on developmental delays By 5 yo child is as good at identifying emotions in others as adults are. 29 29

30 Does NOT weigh risks/benefits effectively
Does NOT remember rules from last week Does NOT understand others’ perspectives, desires DOES understand fear, danger, threats DOES form view of self from experiences The world revolves aroudn them, not other people. They cannot stop to think what someone else would want, and why. They don’t gain insight from explanations or think abstractly about the future. They want what they want, when they want it.

31 Normal Child Development
Middle childhood Increase ability to regulate behavior & emotion Begins to reflect on consequences before acting Consider consequences of expressing emotion Peer relationships very important Starting to develop abstract thought Key task at this age is developing ability to control own behavior Reflect on consequences before acting Peer relationships very important (and development of these depends in part of relationship with caregiver) Foster kids have trouble with both above tasks (hard to control own behavior; interpret ambiguous cues from others as hostile and act aggressively), but so do kids who have been abused. Foster interventions need to focus on effective parenting of children with behavior problems and enhancing FP’s ability to communicate with child How do kids learn to regulate emotions: observe caregivers managing their own emotions, observe how caregiver (and others) respond to the child’s emotions and the child’s management of emotions. 31 31

32 PA at this time is modeling behavior to child—instructing them that violence is appropriate when your’e angry, that hurtin gothers is an appropriate way to express disapproval and alter others’ behaiovrs. May be associated with bullying others at school PA continues to communicate to child that he/she is bad, worthless, unlovable and the world is a violent, threatening place.

33 Normal Child Development
Adolescence Increased independence Better at regulating emotions More self-aware and self-reflective than children Model behavior on others’ actions Risk-taking behavior common Impulsive behavior common 33 33

34 May know better but do impulsive or risky things anyway
May know better but do impulsive or risky things anyway. Parts of brain associated with risk-taking behavior very active, prominent PFC is not as well developed as areas invovled with emotion, risk-taking, impulsive behavior so the latter wins out.

35 Let’s Talk About Stress!!

36 The Stress Response Stress can change the architecture, function of brain Damage or kill cells, alter connections Alter cell activities Early experience shapes later reaction to stress Early relationships are critical Early intervention, nurturing, support can have positive impact on child’s responses to stress Stress hormones affect Myelination Neuron structure Production of new neurons connections between neurons 36 36 36

37 So, how does this work? There are different ways to define ‘prefrontal cortex’ and they suggest differing sizes for the PFC (e.g., smaller area than above) 37 37

38 BANG! Arousal, Focusing FFF Prefrontal Cortex Thalamus Brainstem
Hypothalamus Amygdala Pituitary Hippocampus Adrenal Gland Cortisol

39 Toxic Stress Toxic stress: Strong, frequent or prolonged
Often uncontrollable No supportive adult Impact of stressful event on a child depends on degree of stress response provoked and duration of response These depend on past experience with stress and ameliorating factors (like supportive adult) Prolonged elevations leads to changes in architecture affecting learning and memory Regulates gene expression in neurons involved with modulating stress responsiveness, emotion and memory 39 39 39

40 Effects of Chronic Stress
Arousal, Focusing FFF Prefrontal Cortex Prefrontal Cortex Brainstem Hypothalamus Hypothalamus Amygdala Amygdala Pituitary Pituitary Adrenal Gland Cortisol If you chronically infuse cortisol in rats, you get upregulatin of amygdala acitivy, biasing function toward rapid, emotion-charged fight/flight/freeze responses, while at the same time downregulating paraventricular activity, resulting in normal to hyporesponsiveness of the HPA axis. Cortisol acts on the amygdala, hippocampus, PFC and CC. Animal studies show that chronic stress is associated with overgrowth of dendrites in amygdala and atrophy of dendrites in mPFC (there is bidirectional communication between these structures normally) Adults with PTSD have difficulty with this modulation between cortex and limbic system, so are hypervigilant at all times, even when no threat is around. They also demonstrate decreased mPFC activity and increased amygdala activity There is a co-occurrence of problems with mPFC fxning and stress responsiveness and this likely reflects interactions between neuroendocrine stress systems and frontal functioning. mPFC helps regulate behavioral, endocrine and autonomic responses to stress. Abused kids with PTSD have been show to have general deficits and deficits in executive functions (PFC domain). Interestingly, maltreated kids have not shown problems with memory processes that are associated with hippocampal functioning. Imaging studies suggest an impact on the development of the mPFC in maltreated kids (reduced white matter in the PFC and CC). Studies indicate that chronic stress (maltreatment) increases both the learning and the expression of ‘fear-learning’ (develop fear response to innocuous stimulus) and decreases the ability of the PFC to control fear-related responses. Stress-related changes to the PFC are reversible potentially, but those to amygdala are not. Will kids experiencing chronic stressors necessarily have low cortisol levels? Unlikely. Rather, we might expect that acute psychosocial stressors could still produce large HPA axis responses in chronically stressed maltreated kids. Study of 7-13 yo depressed, abused kids: With CRF challenge, there were two groups having different responses (level of ACTH response): one group was normal to hyporesponsive; the other was hyper=responsive. Kids in the latter group were experiencing continued, ongoing emotional abuse (not seen in other group). Hippocampus Hippocampus Adrenal Gland Cortisol 40 40

41 Fear-Conditioning Strong or prolonged fear leads to conditioning
Neutral stimulus associated with aversive one that causes fear Gradually neutral stimulus comes to elicit fear Can generalize further to other neutral stimuli Can be learned early in life Amygdala, hippo mature relatively early; PFC matures late However, when young children are chronically exposed to perceived or real threat, fear-system activation can be prolonged. In research studies, fear conditioning involves the pairing of a neutral stimulus (e.g., a tone or a light) that normally does not elicit a negative emotional response with an aversive stimulus (e.g., pain) that produces fear. As this conditioning evolves, it solidifies the relation between the two stimuli and then generalizes the fear response to other neutral stimuli that may share similar characteristics with the aversive stimulus. Conditioned fear is apparent when individuals come to experience and express fear within the context in which the learning occurred. For example, a child who is physically abused by an adult may become anxious in response to both the person and the place where the fear learning occurred. Over time, the fear elicited and the consequent anxiety can become generalized, and subsequent fear responses may be elicited by other people and places that bear sometimes only small resemblances to the original conditions of trauma. Consequently, for young children who perceive the world as a threatening place, a wide range of conditions can trigger anxious behaviors that then impair their ability to learn and to interact socially with others. The extent to which these problems affect physical and mental health is influenced by the frequency of the stressful exposure and/or the emotional intensity of the fear-eliciting event.

42 Fear Conditioning Stress hormones contribute to generating memory of danger Inhibit extinction of memory Emotional memory of fearful event can be very strong, very stable over time An increase in cortisol can have a dramatic impact on how memories are processed and stored. The production of cortisol and adrenalin (as well as noradrenaline in the brain) in a normal stress response leads to memory formation for events and places that generate danger. More specifically, elevated cortisol levels can strengthen the formation of memories of emotional events, block the ability to unlearn fear memories, and enhance the formation of memories of the surrounding context in which the fearful event occurred. Interestingly, too much cortisol can also have the opposite effect and actually impair memory and learning in non-threatening contexts. Thus, the biological response to stress is intimately involved in both fear learning and unlearning. Fear learning can form emotional memories that are extremely powerful and long lasting. These memories are relived by individuals who experienced a traumatic event when cues in the environment activate those memories. This repeated recall or retrieval of the memory makes emotional memories both more easily activated and more resistant to being forgotten. The repeated recall of a traumatic event can lead to additional release of cortisol, even in the absence of the actual event. Behavioral neuroscience research with animals has shown that chronic elevation of cortisol can have a number of detrimental effects, including increased damage to brain cells in areas that support learning, thereby leading to increased impairment in subsequent memory formation

43 Generalized Fear-Conditioning
Generalized fear-conditioning leads to multiple triggers of fear memory Strengthens memory, leads to more stress Stress impairs memory, learning for non-threatening experiences Interestingly, too much cortisol can also have the opposite effect and actually impair memory and learning in non-threatening contexts. Fear learning can form emotional memories that are extremely powerful and long lasting. These memories are relived by individuals who experienced a traumatic event when cues in the environment activate those memories. This repeated recall or retrieval of the memory makes emotional memories both more easily activated and more resistant to being forgotten. The repeated recall of a traumatic event can lead to additional release of cortisol, even in the absence of the actual event. Behavioral neuroscience research with animals has shown that chronic elevation of cortisol can have a number of detrimental effects, including increased damage to brain cells in areas that support learning, thereby leading to increased impairment in subsequent memory formation

44 Generalized Fear-Conditioning
Increases fear, stress, anxiety in ‘safe’ situations Impacts social interaction, behavior, learning Damage to the ‘executive center’ of brain is key Can occur even in infants Removing the danger doesn’t ‘fix’ the child Child generalizes fear response to situations that may vaguely resemble original fearful event, so has anxiety, fear, and perceives threat even in situations that are non-threatening. May misinterpret facial expressions, statements, gestures, actions as dangerous and react to them in a way that is inappropriate to the real situation. Can lead to anxiety, PTSD, withdrawal, aggression. Chronic stress impairs functioning of PFC so this impairs child’s ability to attend to tasks, learn (impairs working memory), control emotions If cannot keep data in working memory, cannot learn effectively; to learn must be able to fix attention, and shift attention appropriately Infants are able to learn to fear certain conditions. But they are very vulnerable since they cannot remove the danger, have immature responses to stress, have difficulty regulating their emotions anyway. If no supportive caregiver, situation is even worse. Fear-conditioning can lead to impaired stress response and affect stress response in future Fear-conditioning doesn’t just go away over time, without effort. simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious. Science clearly shows that reduc- ing fear responses requires active work and evidence-based treatment. Children who have been traumatized need to be in responsive and secure environments that restore their sense of safety, control, and predictability—and supportive interventions are needed to assure the provision of these environments. Where indicated, children with anxiety can benefit from scientifically proven treatments, such as cognitive behav-ioral therapy, which have been shown to reduce anxiety and fear.

45 Fear Extinction Fear not simply forgotten Requires active ‘unlearning’
Process distinct from fear-conditioning Executive area of brain learns to control emotional area Can only occur later in life, when executive area is more mature “extinction” and actually involves physically separate and distinct areas of the brain’s architecture from those into which fear responses are first incorporated. Generally speaking, the unlearning process involves activity in the pre-frontal cortex, which decreases the fear response by regulating the activity of the amygdala. Studies show that fear learning can occur relatively early in life, whereas fear unlearning is only achieved later, when certain structures in the brain have matured. Consequently, early fear learning can have a significant impact on the physical and mental health of a young child that can take years to remediate.

46 The Trauma of Intervention
So now we’ve got a child who has been chroncially traumatized, may have altered brain function (not damage, because the brain is adapting to a dangerous environment), has aggression, hyperarousal, PTSD, depression, self-medicates with drugs. Now we expose them to our ‘intervention’.

47 “I’ve got a lot of history that really hurts.”
Child of meth-abusing parent

48 How Does Child Welfare System Add to Traumatic Stress?
Stress related to Forensic interviews (and more!) Behavioral health therapy Medical exam Medical exam may trigger trauma reminders, inflict pain; FI may trigger reminders,; having to testify….

49 Parent and Child Stress Related to Medical Exam
Parents more stressed than children Older children (>12 yr) more distressed Examiner behavior important Parental stress related to lack of knowledge regarding exam Preparation of parent and child before exam very important Older childrens’ distress may be related to more cases needing rape kit, more finidngs, more understanidng of criminal, legal implications of evidence found on exam/rape kit, perhaps more issues with privacy. Parents/children appreciated calm, nonjudgmental behavior or examiner, explanations and reassurances, empathy. Although 97% of parents expected the medical would be stressful for their child, only 66% of children reported feeling scared before the medical (P < 0.05). Negative feelings expressed by children (54%) included embarrassment, concerns about equipment and procedures (including blood draws), the unknown (what will be found on exam) and outcomes (what will happen next). Most child negative comments referred to blood tests rather than the anogenital exam. Citation: Do no more harm: The psychological stress of the medical examination for alleged child sexual abuse Susan Marks,1 Robyn Lamb1 and Dimitra Tzioumi2; Journal of Paediatrics and Child Health 45 (2009) 125–132. Thorough preparation Child has control No pain “just looking on the outside” Marks, 2009

50 Center for Safe and Healthy Children
Patient Comments from Center for Safe and Healthy Children “I am very glad I came, because when I talk to someone I can usually forget about the things that have happened to me.” “Today’s visit helped me a lot. And thank everyone for wasting their time for me.” I liked it a lot better than going to my doctor’s office.” CSHC patients, 2009

51 And then there’s foster care…
Disrupt primary relationship(s) Possible separation from Caregiver, sibs/loved ones Familiar people and surroundings Visitation with abusive/neglectful caregiver Adults can cope with inpermanence because they have a sense of self-reliance, and can visualize a more stable time in the future. Young kids, however, have limited life experience so don’t have a strong sense of self. They live in the present and don’t understand ‘temporary’ vs ‘permanent’ or what will happen in the future. Weeks vs months is not comprehensible. Many kids entering foster care do so for maltx. Their early maltx may have led to delays in language, attachment problems, antisocial behavior, etc—all of which can make adjustment in foster care very hard. Older kids have longer relationship with mom so is more stable and they don’t need close physical proximity to sustain it Foster kids at high risk for psychopathology: one study found 9 x the risk for showing psychological disturbance compared with home-reared kids

52 Why is foster care so difficult?
Multiple placements and prolonged instability Start with hx of maltreatment Young kids Lack strong sense of self Poor concept of time Poor language skills Less time building primary attachment

53 Re-enactment In Foster Care
Re-enact prior engagement strategies Transfers feelings, expectations, conflicts to new parents The familiar is comforting Parent may not understand function of behavior Behaviors that worked in abusive environment are maladaptive in foster care and can lead to negative reaction from parent, and this can confirm child’s underlying negative working model of self and others Re-enactment can be almost automatic, and compulsive Foster parent can unwittingly fall into roles ‘assigned’ to him by child Child’s old models, even if painful, are familiar and therefore may bring some comfort and predictability to world. A new, supportive environment is needed, but may not be desired by child since is unfamiliar and perhaps threatening to his view of world. Parent may strive for compliance and age-appropriate behavior, not understanding the function of the conduct problems, the re-enactment concept

54 Negative working model
Abuse/Neglect Negative working model Failed foster care Conduct Problems Foster Care Negative response by foster parent Cycle of behavior problems started by abuse/neglect environment leads to re-enactment in foster care, an inappropriate response from foster parent who is not trained to interpret and understand function of child’s behavior and who falls into role ‘assigned’ by child, completing the re-enactment and reinforcing child’s negative internal working model. The conduct problems increase, child is put into new foster home and cycle repeats itself. The more severe the prior danger the child experienced, the stronger his/her hold on the working model and adapted behaviors (very reluctant to give these up) *if parenting has been unpredictable in the past, danger comes unexpectedly, child will also be reluctant to change working model and behavior. Re-enactment (conduct problems)

55 Functions of Conduct Problems
Reduce danger Engage parent Communicate need or feeling Shape caregiver behavior Maximize chance of self-survival Not an all-inclusive list May function to reduce child’s anxiety, feeling of insecurity, loneliness Child may isolate self in room, avoid eye contact as way of reducing likelihood of verbal or physical abuse May act aggressively, disruptively (whine, shout, nag) to gain parent’s attention (negative attention better than no attention) Sexualized behavior may gain attention, affection of adults Shadowing parent constantly reduces separation anxiety Lying, bragging may increase child’s self-esteem Very compliant, noncomplaining children may wish for parent attention, approval, may want to avoid parental aggression/abuse. Self-harm or harm to younger children may be expressions of anger toward parent or self-loathing

56 Foster Parent Beliefs Child will be happy in new, supportive environment Behavior will improve immediately Child will welcome nurturance, love Child will appreciate parenting and guidance A recipe for disaster.. If child believes caregivers are dangerous, insensitive or unresponsive, he may not communicate his needs to parent, but instead suppress them or try to meet them himself (self-parenting, stealing) The unfamiliar can be uncomfortable and child may resist nurturance, support; may be suspicious of it if prior caregiver was unpredictable with affection Examples: hoarding food even in foster care; refusing to allow foster parent to take care of self or child’s sibling; not going to parent when stressed or afraid

57 How can we minimize child stress and maximize placement success?

58 Maximize Physical and Psychological Safety
May feel unsafe due to trigger memories, real danger, perceived danger Strategies Assess child’s perception of risk Develop a plan for physical safety Help child feel safe during transition periods Listen to child and reassure All of these components refer to both the child and the family Help child feel safe during transition periods by having birth parent give foster parent info at time of removal, explaining to child where they are going and with whom they’ll be staying Predictability and sense of control are critical to child NCTSN

59 Maximize Physical and Psychological Safety
Strategies Reduce exposure to trauma triggers Let child and family know what will happen Give child some control Establish routine Maintain connections between child and important contacts Work with caregivers to respond to emotional outbursts, and to predict and minimize them. Help child understand trauma triggers and teach foster parent and others about those triggers; have FP keep track of potential triggers (what happened right before child began acting out?, for example) Caregivers can be trained to react to ‘hot spots’ like bedtime, mealtime, school time. Establish routine: bedtime, pick up at school promptly, mealtimes Tell child where parent is NCTSN

60 Identify Trauma-Related Needs
Trauma screen for child and caregiver Bioparent Foster parent Trauma assessment if needed Obtain info from variety of sources Screening to identify type, duration and severity of traumas and the nature and severity of symptoms; may also help understand triggers done by front-line worker, not necessarily a MH professional Assessment is comprehensive and done by MH professional: it looks at traumas experienced, developmental hx of child, assessment of risk behaviors, trauma-related emotional, physical and social reactions and general mental health symtpoms. Common tools: Trauma symptom checklist for children and UCLA PTSD index Collateral sources of info: child’s records, interviews of those who know child Appendix A of Toolkit’s Comprehensive Guide lists questions to ask potential MH providers to determine if they have experience with trauma-informed therapy NCTSN

61 Enhance Child Well-Being & Resilience
Identify child’s protective factors Caregiver and social support (at least 1 adult) Community involvement Good relationships with peers Able to regulate emotions Positive self-esteem, self-efficacy Special talents/creativity Religious beliefs Intelligence Caregiver and others believe child’s report of trauma Ability to blame external factors, not self for what’s happened NCTSN

62 Enhance Family Well-being and Resilience
Caregiver support is critical in child’s recovery Caregivers often have own trauma hx, with Trauma triggers Poorly controlled emotions, behaviors Limited coping skills Trauma screening and assessment for caregiver NCTSN

63 Teach parents Sensitivity to cues and signals from child
To reinterpret conduct problems About social learning approaches Reasonable expectations of change Reinterpret conduct problems by considering the underlying negative working model and function of behavior. Teach parent to aid child in communicating needs, views, feelings Social learning approaches include operant conditioning (principles of reinforcement, punishment, extinction) Examples: Behavior contracts Limit setting Time-outs Parents may need to decrease expectations so that bad behavior is toned down rather than totally eliminated (hoard food less often, tantrums less severe and shorter, for example) Make negative emotions parent feels less horrifying by understanding that they are normal reactions shared by other parents. Encourage parent not to take behavior of child at face value (child rebuffing comfort still needs comfort) Don’t take child’s rejecting behavior personally; if study the function of child’s behaivor, this is more objective and allows parent to give more appropriate, less reactive response Teach parent that child’s behaivors were developed as survival techniques for previous dangerous environment.

64 Conclusions Child abuse and neglect has profound effects on its victims Influences brain development, long term behavior, emotional well being, social development We need to avoid adding to the problem as we try to help There are effective ways we can help an abused child Support includes M Modeling good parenting behavior providing parents with support in times of stress and need helping parents become reslient themselves (if they’re strong, they can help child) Early intervention helps parents deal with problem behaviors so they don’t make things worse, by reacting to child’s aggression, withdrawal, etc and cause more stress Per Yang, 2013, there is research that shows that some epigenetic changes that were previously thought to be permanent (e.g.experiences of monocula deprivation during sensitive period eladin gto long term changes in brain developmetn and visual processing—blindness in kitten) can be reversed with pharmacologic intervention and experiences of environmental enrichment later in development, with complete restoration of function.

65 My contact info: Jordan Greenbaum, MD Cell: Call anytime!

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