NYU CAMS: The Nightmare is Real: Trauma in Childhood, Prof. A. Brown - Midterm Study Guide

Challenger Study

Topic of Study: PTSD Factors

Major/Take-away: The Challenger tragedy presented a prime opportunity to explore how various factors influence mass reaction to a collective trauma.

Implications: To the authors, distant traumas appear to be one of a newly defined spectrum of trauma-related conditions that include relatively evanescent symptoms and a few longer-lasting ones.

Child Neglect: Developmental Issues and Outcomes

Topic of Study: Impact of Child Neglect on Development

Major Findings/Take-away:

Child abuse and neglect have considerable psychological importance because they occur within ongoing relationships that are expected to be protective, supportive, and nurturing.

Children from abusive and neglectful families grow up in environments that fail to provide consistent and appropriate opportunities that guide development.

Child neglect can have severe, deleterious short- and long-term effects on children's cognitive, socio-emotional, and behavioral development. Neglect is associated with effects that are, in many areas, unique from physical abuse, especially throughout childhood and early adolescence. Relative to physically abused children, neglected children have more severe cognitive and academic deficits, social withdrawal and limited peer interactions, and internalizing (as opposed to externalizing) problems.

Implications: With the growing awareness of the harmful, enduring effects of child neglect comes the urgent responsibility to develop effective treatment and prevention programs. researchers need to take into account important developmental contexts and processes, as well as the severity and chronicity of traumatic events themselves.

Epidemiology of Child Traumatic Stress

Topic of Study: Child Traumatic Stress

Major Findings/Take-away: Children's exposure to traumatic events is more frequent than was once believed. Exposure to traumatic events is associated with a diverse array of serious adverse mental health, physical health, developmental, and functional outcomes. Multiple cumulative exposures to traumatic stress are generally associated with worse outcomes than fewer exposures and that the adverse outcomes of cumulative exposures to trauma during childhood extend well into adulthood.

Implications: These findings are consistent with a growing body of research showing a strong relationship between cumulative exposures to traumatic events in childhood and a wide array of health and mental health impairments in youth and adulthood.

Long-Term Developmental, Behavioral, and Attachment Outcomes After International Adoption

Topic of Study: This article highlights the potential impact of children's institutional living on their development, behavior, and attachment after international adoption. Focuses on maltreatment/neglect.

Major Findings/Take-away: Children who've experienced maltreatment/neglect demonstrate issues with behavior, cognition, motor abilities, emotions, language development, and attachment.

Implications: Primary care providers working with internationally adopted children and their families need to be aware of the potential vulnerabilities of adoptive families. As a result, development, behavior, attachment, parent stress, and parent-child interactions need to be monitored routinely and systematically during primary care visits so that appropriate services for children and families can be provided if needed.

Posttraumatic Stress Disorder in Maltreated Youth: A Review of Contemporary Research and Thought

Topic of Study: PTSD

Major Findings/Take-away: This review covers key aspects of post- traumatic stress disorder in maltreated youth, including epidemiology, symptomatology, outcome, and risk factors as well as assessment and treatment strategies and challenges for these youths.

Implications: Researchers will need to identify precisely how different aspects of mal-treatment, including neglect or family separation, lead to various aspects of PTSD or lack of symptoms. Greater consideration is needed of developmental changes, culture, and other contextual variables with respect to assessment measures.

Challenger Study Findings

The Challenger Tragedy

On January 28 1986, the space shuttle Challenger broke apart 73 seconds after it launched into space, killing the entire crew. A school teacher was selected to join the launch, and millions of American school children were watching the event.

Terr et al studied children with different levels of exposure to the Challenger tragedy (children who had watched the launch from Cape Canaveral, children who watched it directly on TV and children who did not watch it but heard about it afterwards). She looked at differences between east and west coast children and young and older children.

East Coast children were significantly more symptomatic than West Coast children (dreaming, drawing, behavioral re-enactment, fears, less interest in a space-related career)

Children might be traumatized by events that do not directly affect their personal safety or the safety of their loved ones.

Children with a history of personal traumatic events had more symptoms than children who reported no previous exposure to trauma.

Children might be traumatized by events that do not directly affect their personal safety or the safety of their loved ones.

Closeness to the traumatic event plays a role in the severity of symptoms.

Adolescents may have fewer symptoms because they can place the event within a larger context.

ACE Study

Adverse Childhood Experiences (ACE) Study: (Felitti et al., 1998)

In the Adverse Childhood Experiences (ACE) study of over 17,000 enrollees in an insurance plan, a host of challenging childhood events were the most significant predictors of adult ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

ACE Categories: emotional abuse; physical abuse; sexual abuse; emotional neglect; physical neglect; mother treated violently; household substance abuse; household mental illness; parental separation/divorce; incarcerated household member.

The ACE study's results suggest that maltreatment and household dysfunction (adverse experiences) in childhood contribute to health problems decades later.

Definitions of Trauma

Wikipedia: A single experience, or repeating events that completely overwhelm the individual's ability to cope or integrate the ideas or emotions involved with that experience.

American Psychological Association: An emotional response to a terrible event like an accident, rape or natural disaster.

Psychological Research: Usually described as uncontrollable, beyond scope of ordinary human experience, unpredictable, and the person is changed.

Bessel Van der Kolk, 1989: "Traumatization occurs when both internal and external resources are inadequate to cope with external threat."

Lenore Terr, 1991: "Childhood trauma is the mental result of one or more blows rendering the young person temporarily helpless and breaking past ordinary coping and defensive operations."

Shared qualities of traumatic events

* Uncontrollable.

* Unpredictable.

* Beyond scope of ordinary human experience.

* The person is changed.

Acute Stress Disorder

Acute Stress Disorder: ASD typically occurs within one month of a traumatic event. It lasts at least three days and can persist for up to one month. Requires exposure to traumatic event(s).

Symptoms include: intrusion, negative mood, dissociative symptoms, avoidance symptoms, arousal symptoms.

Adjustment Disorders

Characterized by abnormal onset of depression, anxiety, difficulty moving forward, and reckless behavior, lasting approximately six months. DSM-V criteria include:

Having emotional or behavioral symptoms within three months of a specific stressor occurring in your life.

Experiencing more stress than would normally be expected in response to a stressful life event and/or having stress that causes significant problems in your relationships, at work or at school.

Symptoms are not the result of another mental health disorder or part of normal grieving.

PTSD Diagnostic Criteria

Post-Traumatic Stress Disorder: Functional impairment tracing back to previous traumas. Exposure to traumatic event(s), intrusion symptoms, persistent avoidance, negative alterations in cognition and mood, marked alterations in arousal and activity.

Complex Trauma

The experience of multiple, chronic and prolonged developmentally adversive traumatic events, most often an interpersonal nature and early-life onset.

Developmental Trauma Disorder

A trauma disorder in reaction to complex trauma. Involves exposure to trauma, triggered pattern of repeated triggered dysregulation, persistently altered attributions and expectancies, and functional impairment.

Situational Factors that increase traumatization

Exposure to direct life threat, Injury to self - extent of physical pain, Witnessing of mutilating injury/grotesque death (especially to family or friends), Hearing unanswered screams or cries of distress, Being trapped or helpless, Unexpectedness or duration of the experience, Number and nature of threats during episode, Degree of violation of physical integrity of child, Degree of brutality and malevolence.

Personal factors that influence trauma impact

IQ, Presence/absence of supportive adult(s), Ability to create/find safety, Previous trauma, Family history of psychological or substance abuse problems, Gender, Age, Low SES, being widowed or divorced.

Risk Factors Associated with PTSD

* Adolescence

* Previous Trauma Exposure

* Previous Anxiety/Psychiatric Disorder

* Ongoing Psychosocial Stressors

Protective Factors Associated with PTSD

Internal Locus of Control

Sense of Self-Efficacy and a lack of feelings of helplessness.

An optimistic cognitive schema.

Social support.

Lack of ongoing psychosocial stressors.

Differences in PTSD in Children vs. Adults

Girls will often express symptoms more than boys.

Report: Younger children may not explicitly report their traumas, but rather tell through their play, drawings, and stories. May be fixated on irrational and unrealistic fears.

Behavior: Abnormal degree of oppositionality, impulsivity, aggression, and inattention.

Regression: Bed-wetting, thumb-sucking.

Delay in cognitive/social development.

Higher rates of: Suicide, Anxiety, Depression, Eating Disorder, Dissociating.

What children need for healthy development

* Nutrition

* Education

* Environmental Health

* Healthcare

* Health of Mother

Bowlby's Attachment Theory

Attachment Theory: Bowlby's theory that a strong emotional and physical attachment to at least one primary caregiver is critical to personal development. Deprivation could result from separation from the primary caregiver or from a cold, inconsistent relationship with the primary caregiver. Prolonged exposure to deprivation could have lasting effects on the child.

Phases of Attachment

Phase 1: Birth to 3 months (preattachment)

Babies prefer proximity to humans over objects; however, who the human is does not matter to the infant. The caregiver remains in close proximity and thereby promotes attachment.

At 6 weeks, the baby will begin to smile socially. This social smile is positive reinforcement to the caregiver for the attention they give the infant.

Phase 2: 3 to 6 months (attachment in making)

The baby begins to focus on familiar people. The baby appears to develop the strongest attachment to the person who responds most readily to the child.

Baby's social responses become more selective.

Phase 3: 6 months to three years (clear cut attachment phase)

An intense attachment develops. A fear of strangers develops.

The child demonstrates preferential attachment to the primary caregiver. The infant/child actively seeks the attention and proximity of the primary caregiver. The child demonstrates separation anxiety when the caregiver leaves the room.

Phase 4: 3 years to the end of childhood (formation of reciprocal relationship)

These attachments are arguably affected by the early attachment experiences of the child. People continue to seek out their early attachment figures in times of crisis and pain.

Mary Ainsworth's Strange Situation

"The Strange Situation": Visited homes in Baltimore, studied how mothers interacted with their babies throughout the year, characterized parenting styles.

Bowlby's assistant Mary Ainsworth created "The Strange Situation", wherein the infant was brought into a playroom by their mothers. In the first separation she left the child with a stranger, in the second separation she left the child alone.

Ainsworth's Patterns of Attachment

Securely-Attached Infants

* Use mother as a base. Cries when mother leaves room.

* These mothers had previously been rated responsive to their baby's cries and signals.

Insecure-Ambivalent Infants

* Rushed to toys, clingy and preoccupied with mom's whereabouts, extremely upset when mother left room, but independent in strange situation. Ambivalent upon her return, sometimes engaging, sometimes avoiding.

* These mother's had been described as inconsistently responsive to the infant.

Insecure-Avoidant Infants

* Rushed to toys, mother not used as base, not upset when mom left. The infant appeared independent throughout the strange situation. No change upon her return.

* These mothers had previously been more likely to be rated as insensitive, interfering, and rejecting.

Romanian Adoption Study

Banning of birth control led to increased orphan population in Romania, orphanages had an average ratio of 10 babies to 1 nurse, leading to mass disruptions in attachment development.

Chisholm's Study compared attachment patterns of children who had been adopted from a Romanian orphanage after 8 months of age (RO) with children who had been adopted before 4 months of age (EA) and children who were raised by their biological parents (CB)

The children adopted later were more likely than the early adoption or those raised by bio parents to have:

Insecure attachments

Those RO children with insecure attachments were also more likely to have:

Behavior problems

Lower scores on the Stanford Binet IQ test

Familial stressors

RO children showed more secure attachment over time

And in fact, there were no differences between the CB and RO groups in attachment over time.

Early institutional experience had an impact on security of attachment only when coupled with other stressors in the adoptive home

Reactive Attachment Disorder

Definition: A rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers, characterized by:

* Withdrawal from adult caregivers

* Persistent Social/Emotional Disturbance

* Pattern of Extremes or Insufficient Care

Disinhibited Social Engagement Disorder

A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: The child rarely or minimally seeks comfort when distressed or the child rarely or minimally responds to comfort when distressed.

Two or more of following symptoms:

1) Intense excitement or lack of inhibition over meeting or interacting with strangers or unfamiliar adults.

2) Overly friendly, talkative, physical (generally non-age-appropriate or culturally acceptable) interaction with strangers.

3) Willingness or desire to leave a safe place or situation with a stranger.

History of the diagnosis of PTSD as outlined in Judith Herman's book.

Judith Herman argues that the history of trauma and PTSD is greatly influenced by the political climate of the times in which the trauma occurred.

History has shown us that "the systematic study of psychological trauma depends on the support of a political movement".

1800s - Da Casta Syndrome: Recognized symptoms of heart disease (shortness of breath, fatigue, palpitations, sweating, and chest pain) without any physical findings.

1800s - Hysteria: See amongst women who likely survived sexual abuse. Symptoms of motor paralysis, sensory loss, convulsions, and amnesias.

Freud: "I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience."

WWII - Shell Shock: Men who had been exposed to the horrors of trench warfare displayed symptoms of "nervous breakdown." Symptoms included screaming uncontrollably, weeping, losing their memory and capacity to feel, and experiencing paralysis with no neurological explanation.

Late 20th Century - Rape Trauma Syndrome: Recently raped women experienced insomnia, nausea, increased startle, nightmares, and dissociative symptoms.

Late 20th Century - Formal PTSD Diagnosis: DSM III included trauma diagnosis crafted around the experiences of Vietnam veterans and rape victims.