assignment assihnmne

Psychological Trauma in Children

What is a Stressor?

• An event or experience for which you do not have coping or adaptive skills easily available

• These can be major or minor

• Stressors do not necessarily involve intense fear

• Even major stressors, involving fear, do not necessarily rise to the level of traumatic stressors

Traumatic Stressors

• Involve fear for the life/safety of self or others; developmentally inappropriate sexual experiences w/o violence also included

• Accompanied by feelings of fear, helplessness, or horror – In children, this may be expressed instead by

disorganized or agitated behavior – Requires an understanding of danger

(developmental issue) – Not everyone experiences this (essence of a

traumatic stressor) in response to a traumatic event, especially if person has well-practiced coping skills that are successful

Traumatic Event Variables

• Exposure: public v private

• Source: natural v human

• Intentional: directed at victim v not directed at victim

• Frequency: single v recurring

Type I Traumatic Events

• Single events

• Typically in a public or semi-public context

• Often natural or non-interpersonal events

• When they are inflicted by other people, often those individuals are strangers to the victim

Type II Traumatic Events

• Recurrent events

• Typically occur in the individual’s immediate or surrounding environment

• Typically are people are the source

• Often the perpetrators are well known to the victim

Variables Affecting Development of PTSD

• Significant long-term changes as a result of event(s)

• Developmental factors: disruptions interfere with achievement or maintenance of developmental tasks

• Prior coping strategies/difficulties

• Social support (reactions of others, ability of others to focus on victim)

• Belief systems (schemas)

• Gender

• Type of event (e.g., rape)

Psychobiology of Trauma

• Hyperarousal: release of neurohormones that mobilize the body to deal with stress (fight or flight response) – In adult animal—effective counterattack or leaving scene

– In young animal – attracts protection

– This state produces more attention to (nonverbal) signs of danger and less to verbal information and processing

• Stress-induced analgesia: release of endogenous opioids that inhibit pain and panic – Helps organism focus on emergency response

– Is associated with freeze response, when trapped (or young)

– Is associated with interference with memory

– Some individuals respond with this earlier during arousal than others

Posttraumatic Stress Disorder (Biphasic/bimodal disorder)

• Hyperarousal becomes chronic

– Reactivity to reminders of stimuli (not always with cognitive awareness)

– General heightened level of reactivity

– Non-verbal information more important than verbal

– Very present focused

• Emotional numbing

– Avoidance regarding stimuli

– General flattening and numbing

Diagnostic Criteria for PTSD

• Presence of a traumatic event

• Re-experiencing symptoms

• Avoidance symptoms

• Hyperarousal symptoms

• Symptoms last for more than 1 month

• Symptoms interfere with functioning or cause significant subjective distress

PTSD in Children: Often Missed

• Traumatic event is not reported: abuse

• Reexperiencing symptoms look different from adults

• Avoidance symptoms misunderstood, not well reported by children

• Hyperarousal symptoms misdiagnosed

• Younger children may be somewhat protected if they do not understand the danger

Persistent Reexperiencing – Looks Different

In children, typically more behavioral or sensory rather than narrative

• Intrusive recollections, images, thoughts: REPETITIVE THEMES IN PLAY

• Dreams: FRIGHTENING DREAMS W/O RECOGNIZABLE CONTENT

• Flashbacks: TRAUMA SPECIFIC REENACTMENT

• Distress in response to cues

• Physiological reactivity in response to cues

Persistent Avoidance – Children Often Do Not Report

• Avoidance of internal cues

• Avoidance of external cues

• Amnesia for important aspect of trauma

• Diminished interest in activities

• Detachment from others

• Restricted range of affect

• Sense of foreshortened future

Persistent Hyperarousal – Adults Misinterpret

• Difficulty sleeping

• Irritability

• Difficulty concentrating

• Hypervigilance

• Exaggerated startle response; does not habituate

Learning Mechanisms Underlying PTSD: Classical

Conditioning (reexperiencing phase/symptoms)

• UCS elicits UCR

• UCR: innate or reflexive responses, including emotions (not learned)

• UCS is paired with a CS

• CS produces CR: this is new (learned) association

Classical Conditioning • Model of Re-experiencing

Unconditioned Stimulus (dog bite)

Unconditioned Response (fear)

Conditioned Stimulus (sight of dog)

Conditioned Response (fear)

Inborn

Learned

Learned

Learning Mechanisms Underlying PTSD: Operant

Conditioning (avoidance phase/symptoms)

• Operant conditioning following classically conditioned fear

• Fear serves as a motivation, and reduction of fear is a reinforcement

• By avoiding the feared stimulus, the fear is reduced, and therefore the avoidant behavior is reinforced

Operant Conditioning

• Model of Avoidance

Fear of dog- classically conditioned

Crossing street- avoidance behavior

Reduction of fear- reinforce- ment

Learned

Impact of Chronic Trauma

• Less evident anxiety and hyperarousal symptom because…

• Avoidance symptoms become prominent

How Bad is PTSD?

• Can be incapacitating

• But it is still reflecting discrete conditioned responses (behavioral and biological) to reminders of the trauma

Complex Trauma (Developmental Trauma Disorder)

• Child abuse is the most common type of chronic traumatic event for a child in this country

• Child abuse, by definition, occurs within the caregiving system

• Chronic child maltreatment beginning in infancy=complex trauma

• Unlike PTSD, it has pervasive effects on the development of the mind and brain

Brain Development in Infancy

• Considerable brain development from 0-3 – Right brain growth dominates in first two years,

when emotional and relational foundation is developed

– Growth is from the “bottom-up”, as higher, more complex areas eventually begin to control and modulate the more reactive, primitive parts (connections between right and left brain)

• Brain development is use-dependent – Neurons are “pruned” – Connections between neurons are formed or not – This happens within critical periods

Brain Development and Trauma in Infancy

• Overresponsiveness of brain centers responsible for arousal and vigilance

• Overuse of dissociative mechanism – Learned helplessness, passivity

– Disengagement from external world

• Underdevelopment of brain centers responsible for cognitive processing of events (may actually be killed or not fully developed)

Domains of Impairment in Children Exposed to Complex

Trauma

• Attachment

• Biology

• Affect Regulation

• Dissociation

• Behavioral Control

• Cognition

• Self-Concept

Attachment

• Distrust of others and the world: internal working models, preverbal

• Uncertainty about predictability

• Social isolation

• Interpersonal problems; deep sense of betrayal

• Difficulty attuning to other’s emotions

• Difficulty with perspective taking

• Problems with boundaries

Dissociation- Have you ever.. • Become so involved in watching TV, reading, or the

computer that you had no idea what was going on around you?

• Driven a car and suddenly realized you didn’t remember what happened during all or part of the drive (e.g., lost track of exits)?

• Sat in a class and realized you didn’t hear part of all of what was said for several minutes?

• Been confused about whether you have done something or just thought about doing it (e.g., mailing a letter)?

• Felt as though you are looking at the world in a fog so that people or object appear far away or unclear?

Dissociation

• complex psychophysiological process that produces an alteration in a person’s consciousness

• thoughts, feelings, and experiences are not integrated into individual’s awareness or memory in normal way (BASK: behavior, affect, sensation, knowledge)

Normal Dissociation

• Common experience

• Common particularly in children; tendency to engage in dissociation decreases with age

• Can be used deliberately (e.g., meditation, hypnosis)

Pathological Dissociation

• Controversy regarding whether pathological dissociation is increase in degree of normal dissociation, or whether it is qualitatively different

• Examples of pathological dissociation:

– Amnesias for complex behavior

– Extreme depersonalization/derealization

– Experiences of identity alteration

– Feelings of being possessed/passive influence phenomena

Childhood Trauma and Dissociation

• Clear evidence in literature of relationship between pathological dissociation and chronic childhood trauma

• Coping mechanism gone awry: Habitual (avoidant) response to anxiety

• Family environment, and especially disorganized attachment, seems to play a role

• Presence of pathological dissociation is associated with: – Many other psychiatric symptoms – Greater severity of other symptoms

Dissociation and Development of Sense of “Self”

• Self-agency disrupters: sense of control and responsibility for one’s behavior

• Self-coherence: sense of continuity across different contexts

• Self-affectivity: specific internal events (physiological, thoughts) associated with specific emotional states

• Self-continuity: consistency across time and context

Biology

• Sensorimotor developmental problems

• Hypersensitivity to physical contact

• Analgesia

• Problems with coordination, balance, body tone

• Somatization

• Variety of medical problems (pelvic pain, skin problems, pseudoseizures)

Affect Regulation

• Difficulty with emotional self-regulation (intense reactions, slow return to baseline)

• Resort to avoidance strategies (dissociation, substance abuse, external tension-reduction)

• Difficulty identifying and describing feelings and internal states

• Difficulty communicating wishes and desires

Behavioral Control

• Poor modulation of impulses

• Self-destructive behavior

• Aggression against others

• Pathological self-soothing behaviors

• Sleep disturbances

• Eating disorders

• Substance abuse

Behavioral Control-continued

• Excessive compliance

• Oppositional behavior

• Difficulty understanding and complying with rules

• Communication of traumatic past by reenactment in day-to-day behavior or play (sexual, aggressive, etc.)

Cognition

• Difficulties in attention regulation and executive functioning

• Lack of sustained curiosity

• Problems with processing novel information

• Problems with object constancy

• Difficulty planning and anticipating

Cognition-continued

• Problems understanding own contributions to what happens to them

• Learning difficulties

• Problems with language development

• Problems with orientation in time and space

• Acoustic and visual perceptual problems

• Impaired comprehension of complex visual- spatial patterns

Self-Concept

• Lack of a continuous, predictable sense of self

• Poor sense of separateness

• Disturbances of body image

• Low self-esteem; sense of powerlessness

• Shame and guilt; stigmatization

Impairment from Complex Trauma Raises Further Risk

• Impaired relationships

• Testing caregiver

• Rage reactions, assaults

• Lack of memory for behavior

• Not learning from punishment

• Self-destructive behavior

• Sexualized behavior

• Revictimization generally

• Triggering physical or psychological abuse by caregivers

• Removal from placements/schools/

programs

• Juvenile justice involvement

Major Misconceptions

• Traumatized children will remember the trauma

• Traumatized children will tell you about the trauma

• Traumatized children will present primarily as anxious and frightened

Major Points to Remember

• Children will not have narrative memories for early complex trauma

• Early complex trauma has serious, long-term consequences

• Children may have amnesia for traumatic events

• Children will be frightened to talk about traumatic events, even if they remember them

• Children may be blunted in their affect when discussing traumatic events

Memory Controversy

• Legal issues

– Tolling statute of limitations for “repressed memories”

– Law suits against therapists accused of implanting “false memories”

• Williams (1994,1995): some people with sexual abuse histories do not recall the abuse

• Loftus (2004): people can be led to believe that events happened in their childhoods that did not occur