Maltreatment

What is Maltreatment?

The physical or mental injury, exploitation, negligent treatment, etc of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed or threatened

What are the Economic Impacts of Maltreatment?

• Direct financial costs (i.e., healthcare costs, justice system, mental health services, special education)

• Indirect financial costs (i.e., productivity costs)

What are the four types of child maltreatment?

• Neglect

• Physical abuse

• SA

• Psychological abuse

What is the role of parents and caregivers?

They provide protection, nurturance, and direction, and it’s necessary for children to form attachments with them and seek them out during stressful times.

However, in the absence of caregivers, infants and young children find it difficult to cope effectively with their surroundings

What is Child Neglect in the DSM-5?

An action by a parent or caregiver that deprives the child of basic age-appropriate needs and thereby results in physical or psychological harm to the child

• Abandonment

• Lack of appropriate supervision

• Failure to attend to necessary emotional or psychological needs

• Failure to provide necessary education, medical care, nourishment, shelter, and/or clothing

• Socio-emotional deprivation: Extreme absence of emotional attention and/or response given to an infant or child by their primary caretaker

What is one prominent example of social-emotional deprivation in infancy?

Institutionalized care / Orphanages

Why is there social-emotional deprivation in institutionaized care facilities?

• High child-to-caregiver ratios

• Many are located in countries ruled or plagued by war, disease, financial instability, and violence

• High caregiver turnover

• Many children spend long periods of time in isolation and in bed

• Caregivers focus mainly on children’s physical health but not social and emotional wellbeing

What are the 2 DSM-5 Diagnosed Disorders as a result of child maltreatment?

Reactive Attachment Disorder (RAD) & Disinhibited Social Engagement Disorder (DSED)

What is Reactive Attachment Disorder (RAD)?

A rare and lack of attachment behavior where infants or young children do not seek or respond to comfort from caregivers when distressed

They are emotionally withdrawn and are present as sad, anxious, or irritable

What are the causes of RAD? (How does it develop?)

It is most often seen among international adoptees who spent their first 12 to 24 months of life in low-quality orphanages, or in young children who experienced extreme neglect or multiple foster homes during their first year of life

What is the treatment and its core goals for RAD?

• Cultivating Nurturance: parents learn to meet child’s needs even when not clearly expressed, in a warm and sensitive way

• Improving Synchronicity: Gocus on the give-and-take of parent-child interaction, parents respond to children’s cues in real time

• Reducing Intrusive or Frightening Behavior: Have parents learn to replace their past trauma or own caregiving history with calm, sensitive responses

How did the orphans compare to the group of infants raised in a prison nursery?

• By 1 year, children from orphanages were less playful and less interested in their surroundings

• Less responsive to staff

• Did not seek contact comfort

• Developed infections more

• Didn’t meet developmental milestones

What were the effects of Romania’s Communist Regime?

Children were undernourished, thousands were left in orphanages bc parents could not afford their care, children were left in cribs for extended periods, little to no social interaction between children and staff

What were the objectives of the Bucharest Early Intervention Project?

• Examined effects of early institutionalization on brain and behavioral development

• Tested whether high-quality foster care could improve outcomes for institutionalized children

What were the three groups of the Bucharest Early Intervention Project?

1. 68 children raised in Romanian orphanages

2. 68 children initially raised in Romanian orphanages but placed in foster homes before 24 months of age

3. 72 Romanian children living with their biological families

What were the results of the Bucharest Early Intervention Project?

• Orphans adopted prior to 24 months did not develop RAD; however 1/3 of children who remained in the orphanage developed RAD signs and symptoms

• Those raised by biological parents fared much better than those placed in foster homes and those who stayed in institutions

• There was a significant portion of children who showed features of DSED

What did the Bailey Scale of Infant Mental Development Show?

• Children placed in foster care had significantly higher IQs than those in institutions

• IQ was higher if they were placed by 2 years old

What are the Features of DSED?

• A pattern of culturally and developmentally inappropriate, overly familiar and friendly behavior with strangers

• These children displayed difficulty with attention and social inhibition later in childhood

• They do not “check back” with their caregivers to make sure that they are safe

True or False: DSED is an attachment disorder and severity is based on the quality of care

False

What are the Causes of DSED?

• Lack of social inhibition

• High number of caregivers between 6-24 months

What is the treatment for DSED?

• Studies strongly suggest infants adopted into nurturing homes within the first 6 months won’t develop these symptoms

• Prevention is the best approach

What is physical abuse?

• Nonaccidental physical injury to a child, ranging from minor bruises to severe fractures or death

• Regardless of whether the caregiver intended to hurt the child

• DSM - Harm standard

• Legal System - Endangerment standard

What is psychological abuse?

Repeated acts or emissions by the parents or caregivers that have caused or could cause serious behavioral cognitive, emotional, or mental disorders

What are the five types of psychological abuse?

• Spurning: Verbal and nonverbal acts that reject or degrade a child

• Terrorizing: Threatening to hurt or abandon a child or his or her loved one

• Isolating: Denying opportunities to interact with peers or adults outside the home

• Exploiting: Encouraging a child to adopt maladaptive or antisocial behaviors

• Denying emotional responsiveness/neglect: Ignoring the child’s bids for attention and emotional interactions

What is Child SA?

The involvement of a child in activity that violates the laws or social taboos of society and that he/she:

• Does not fully comprehend

• Does not consent to or is unable to give informed consent to, or

• Is not developmentally prepared for and cannot give consent

What are the signs and symptoms of childhood SA?

• Age-inappropriate knowledge of SA

• Regressive behavior

• Physical complaints

• Anger

What is Poly-Victimization?

• Experiencing different kinds of victimization, rather than multiple episodes of the same kind of victimization

• Typically occurs during transitions when children are most vulnerable

What is Maltreatment Chronicity?

Higher levels of children’s aggressive behavior reported by peers, teachers, and children

• Aggressive behavior is a result of maltreatment and rejection

• However, there is more peer rejection reported for children who have experienced more maltreatment

What are the effects of maltreatment chronicity?

• Deleterious effects on cognitive functioning

• Adults, children, and teens performed poorly on tasks meant to assess verbal episodic memory, working memory, attention, and executive functions

• Young maltreated children have been shown to exhibit difficulties with correctly identifying and discriminating facial expressions of emotions

• Children exposed to severe early life stress also experience emotion regulation difficulties, which are thought to confer risks for later psychopathology

Maltreated Children & Ability to Discriminate Facial Expressions of Emotions

• These children are highly sensitive to threatening stimuli and situations

• They had significantly faster reaction times than controls when labeling emotional facial expressions, and this result was most pronounced for fearful faces

How does the brain development appear in children who have been in prolonged institutional rearing?

• Atypically larger amygdala volume

• Poorer emotion regulation; less top-down control

• Higher anxiety and internalizing symptoms

True or False: For children who have been sa, disclosure about it is a process beginning with a behavioral problem or physical manifestation

True

True or False: Poly-Victimization typically occurs during transitions

True

Why does poly-victimization occur typically during transitions?

Because the children are most vulnerable. These are periods of disruptions in stability, supervision, and support systems

What are the types of trauma?

Discrete Trauma and Complex Trauma

What is Discrete Trauma?

A single, identifiable traumatic event that occurs at a specific point in time

What is Complex Trauma?

Exposure to multiple, prolonged, or repeated traumatic events, often in contexts where escape is difficult or impossible (typically occurs in interpersonal settings)

What is Omen Formation?

Belief that there were signs that predicted the traumatic event. Children tell themselves to be more alert so they can recognize warning signs of future events and be more prepared

What is Time Skew?

Incorrect recall of the sequence of the traumatic events

What is PTSD?

A DSM-5 psychosocial stressor that involves actual or threatened death, serious physical injury, or violation. It must occur to the child or close person

What are the types of PTSD?

Intentional, accidental, natural

True or False: Hearing about a car crash on television can be classified under a PTSD Dx

False

What is the criteria for PTSD in individuals older than 6 years in the DSM-5?

1. Exposure to actual or threatened death, serious injury, or violence

2. Presence of one or more intrusion symptoms associated with the event (i.e., distressing memories, dreams, dissociative reactions)

3. Persistent avoidance of stimuli associated with the traumatic event, beginning after the event occurred (i.e., trying to avoid external reminders that are closely associated with the event)

4. Negative alterations in cognitions and mood after the event

5. Marked alteration in arousal and reactivity associated with the event (i.e., irritable behavior, reckless behavior, exaggerated startle response, sleep disturbance)

6. Duration of the disturbance is more than 1 month

What are the types of dissociative symptoms?

Depersonalization and derealization

What is Depersonalization?

Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body

What is Derealization?

Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted)

What is Adjustment Disorder?

Emotional or behavioral symptoms in response to an identifiable stressor

Occurs within 3 months of the stressor onset

Typically lasts less than 6 months

What are the four dissociative disorders that the DSM-5 recognizes?

• Depersonalization/Derealization Disorder

• Dissociative Identity Disorder

• Dissociative Amnesia

  • Dissociative Disorder Not Elsewhere Classified

What is Dissociation?

One of the consequences of developmental trauma

Characterized by a disruption of usually integrated functions of memory, consciousness, identity, or perception of the environment

How can Maltreatment lead to PTSD-Dissociative Disorders?

It can activate both the sympathetic nervous system and the parasympathetic nervous system, and constant cycling between these states can shape how a person responds to the world

Dissociative detachment or “shutting down” may be the most likely way of surviving inescapable threat, leading to more persistent activation of the parasympathetic system

Over time, these protective responses can become habitual patterns for managing emotions

What are the two types of emotion dysregulation associated with Childhood Interpersonal Trauma and Post traumatic stress?

Under-regulation and overregulation

What is under-regulation?

Limited access to or capacity for deploying strategies to reduce intense affective states and associated difficulties with impulse control and goal-directed behavior

What is Overregulation?

Non-acceptance and limited awareness or clarity of emotions (cannot tolerate negative emotional states)

What are the functional and structural changes in the limbic system decades after the trauma?

Strong association of CTQ scores with amygdala responsiveness to threat-related facial expression (functional)

Reduced gray matter volumes in the hippocampus, insula, orbitofrontal cortex, anterior cingulate gyrus, and caudate in subjects with high CTQ scores (structural)

What are the other psychiatric conditions associated with childhood abuse?

It is strongly associated with increased risk of psychotic disorders, personality disorders, and dissociative disorders

What are the physical health problems associated with abuse?

Severely neglected infants can exhibit nonorganic failure to thrive: an inability to make age-exptected gains in weight and head circumference, brain abnormalities, increased rates of obesity, smoking, and SUDs

What variables do children’s responses to trauma depend upon?

• Child’s age and developmental status

• Previous experiences of trauma

• Family risk and resiliency factors (having a consistent, safe relationship with a trusted adult)

• Ability to engage in regulated, normal, stressful events that are predictable and controllable