Child maltreatment and trauma presentations in children and adolescents

What is child maltreatment?

developmental risk factor for mental and physical health and social and educational difficulties

Acts of commission (abuse) or omission (neglect) that result in actual or potential harm to a Child’s health, development, wellbeing or dignity within a relationship of responsibility, trust or power.

Can be

• physical

• emotional / psychological

• sexual

• neglect

• exposure to family or domestic violence

Children frequently experience multiple forms simultaneously (polyvictimisation)

severity varies according to frequency, duration, developmental timing, relationship to perpetrator, and cumulative adversity

Aetiology of childhood sexual abuse

mostly male perpetrators (20% female) (40% adolescents)

Mostly perpetrated by someone the child knows

Boys more likely to experience outside home, girls intrafamilial abuse as such more vulnerable (source of threat and comfort)

intrafamilial abuse common (20% father/stepfather, 30% another relative)

More often (50%) repeated than single event

Contributing factors to neglect

one of the most prevalent forms of maltreatment

usually chronic, cumulative and pervasive rather than acute

• material hardship and social disadvantage (not neglect in themselves)

• Mental health difficulties, poor knowledge of child development

Areas of neglect

• health, physical, emotional, responsiveness, educational

Is poverty a risk factor for maltreatment?

No

only ever identified because those living in poverty more likely to be exposed to other forms of risk

What does Belskys developmental, ecological model

Everything impacts everything else

Ontogenic development, microsystem, exosystem, macro system ven diagram

overlap in middle is where child maltreatment occurs

What are the strongest protective factors to maltreatment?

Social support

positive parenting

stable relationships

school connectedness

How does maltreatment effect development?

ACE’s and cumulative risk

Child adversity is common, adversities co occur, and greater exposure is associated with increased risk for later mental health and physical health difficulties

NOTE:

• counting ACEs important however does not take into account

  • why outcomes differ (multifinality, equifinality)

  • how adversity affects development

  • when adversity is most impactful (timing)

  • what promotes resilience

What developmental systems can maltreatment impact?

Attachment systems

emotion regulation systems

cognitive and social processing

neurobiological systems

How does maltreatment effect attachment?

Can develop an insecure attachment, reduced trust in others and difficulties seeking help

• May lead to parentification, relationship difficulties and sensitivity

• Caregiver as source of fear and comfort

How does child maltreatment effect emotion regulation

difficulties identifying, expressing, and managing emotions

• can result in anxiety, depression, self harm, or aggression

• No modelling of emotion regulation strategies

How does maltreatment effect Cognitive and social processing?

Threat biases, hypervigilance, negative self-beliefs

• can result in PTSD symptoms, anxiety, and interpersonal difficulties

How does maltreatment effect neurobiological systems?

Altered stress responses, heightened threat detection, executive dysfunction

• leads to emotional reactivity, attentional difficulties, increased sensitivity to stress

what are the behaviours observed in response to maltreatment called?

Adaptations. These are not problematic in themselves, and can be of benefit for the child to work in that environment. however they can create difficulties in safer contexts later in development

What does the threat and deprivation model posit? (mclaughlin)

That maltreatment exists on continuum of high and low threat, and high and low deprivation

Where would neglect, institutionalisation, poverty, community violence, domestic violence anad physical / sexual abuse sit on Mclaughlins model?

Neglect: low threat, high deprivation

Institutionalisation: mid threat, high deprivation

Poverty: mid threat, mid deprivation

Community violence: mid threat, mid deprivation

domestic violence: high threat, low deprivation

Physical / sexual abuse: low deprivation, high threat.

what does threat result in

Fear and survival networks activated

amygdala, hippocampus and PFC

Hypervigilance and threat detection

emotional reactivity

all lead to INCREASED PSYCHOPATHOLOGICAL RISK

What does deprivation result in

EF delays, language and cognitive delays

PFC, parietal cortex, temporal cortex

learning and cognition networks

all lead to INCREASED PSYCHOPATHOLOGICAL RISK

Why is the developmental timing of maltreatment important?

the timing, chronicity and developmental stage influence outcomes

what impact did this maltreatment have on developmental tasks?

What are the developmental tasks of infancy

attachment, stress regulation

What are the developmental tasks of childhood?

School readiness, social development

What are the developmental tasks of adolescence

Identity formation, peer relationships

What does the developmental cascade mean?

Highlights the importance of early intervention

early adversity alters developmental pathway > effects accumulate across different domains > skills in one domain scaffold into others > missed milestones compound later risk

Recovery also cascades across domains - as such timing of support matters

What does the transdiagnostic model of risk and resilience posit?

Childhood trauma leads to difficulties with

• social information processing

  • enhanced threat detection

  • hostile attribution bias

• Emotion processing

  • heightened emotional reactivity

  • poor emotion regulaiton

• Accelerated biological ageing

  • pubertal timing

  • cellular ageing

All of which lead to

• Transdiagnostic psychopathology

  • internalising and externalising

Indicators of maltreatment

Injuries inconsistent with explanation

Extreme behaviour changes

Poor supervision

Caregiver impairment

Developmental concerns

Chronic school absence

sexualised behaviour

family violence exposure

Look for: pattern, context, accumulation

What to do with a disclosure of maltreatment

Content: who / what / severity

Process: thank, stay calm, open-ended questions, don’t go into details, no leading questions; clarify words used (i.e., bash) let child / adult know what will happen with information

After: consult supervisor, decide whether to talk to parent, clear detailed notes. Questions asked and responses, decisions made, oranga tamariki or police, document all decisions. whether other services need to be involved

What are parenting factors that increase risk?

assess parent ability to:

• prioritise child needs, provide supervision and protection, respond sensitively, set developmentally appropriate expectations, engage with support and intervention

• mental health difficulties, substance use, trauma, stress

• use general psychometrics to support

Parenting cognitions

What are some parenting cognitions that increase risk of maltreatment?

Attribution errors: view child as intentionally difficult, manipulative or bad. Unrealistic developmental expectations

Hostile interpretation biases: “She knew what she was doing”

Parent-centred thinking: prioritise own needs over child, view needs as excessive or unreasonable

Minimising and externalisation: downplaying impact of behaviour, blaming others for concerns.

What is our role in safeguarding children?

Inform decision making NOT make child protection decisions

Trauma = PTSD

No

of those exposed to trauma 12% will meet criteria

F>M

interpersonal exposure increases risk of PTSD development

Trauma is simply a risk factor with many outcomes

What could be the possible outcomes of trauma?

• Recovery + resiliance

• PTSD

• Anxiety

• Mood disorders

• Behavioural difficulties

• emotional dysregulation

• complex trauma

What are the trauma and stressor related disorders in the DSM-IV-TR

• PTSD

• Adjustment disorder

• Disinhibited social engagement disorder

• Acute stress disorder

• Reactive attachment disorder

What makes child trauma different from adults?

Responses differ because cognitive, emotional, social and biological systems are still developing

What do you need to consider with child presentations of trauma

Developmental stage (understanding)

Attachment and caregiving (source of threat and protection)

emotion regulation (somatic presentations)

Developmental tasks

Developmental expression of symptoms

What are the types of trauma presentations

Single incident trauma and PTSD (e.g., serious accident, medical, natural disaster, assault, witnessing violence, sudden bereavement)

Complex trauma

Developmental trauma

are complex and developmental trauma in DSM?

Not yet

What are the criteria for children aged 6+ to be diagnosed with PTSD?

The same as adults

• intrusions (1+)

  • nightmares, memories, trauma, play

• Avoidance (1+)

  • internal (thoughts, feelings, reminders)

  • and or external (people, places, activity)

• Negative cognition and mood (2+)

  • Guilt, fear, detachment, negative beliefs, withdrawal

• Hyperarousal (2+)

  • irritability, hypervigilene reckless behaviour

What are the criteria for children under 6 to be diagnosed with PTSD

• The same just need 1+ negative emotional states or avoidance rather than 2+

• You will see more reenactment in play, recurrent stress dreams

• General increase in negative emotional states

How may trauma show up for younger children

play based reexperiencing

regression

clinginess / separation anxiety

somatic

generalised fears

How may trauma show up for school aged children?

start to show more classic PTSD symptoms

avoidance

hyperarousal

mood changes

learning difficulties

anger

oppositional behaviour

How might trauma show up for adolescents?

Rumination/replaying

emotional distress

withdrawal / isolation

risk taking / substance use

identity and belief changes

What are some peritrauma factors that may influence the development of PTSD

peritraumatic fear, i.e., the emotional, cognitive and physiological responses that happen during or immediately after a traumatic event, perception of threat to life

What are some post-trauma coping factors that may influence the development of PTSD

blame of others, use of distraction / thought suppression (avoidance)

What are some protective factors that may influence the development of PTSD

coping skills, Emotion regulation, internal locus of control, high self esteem, family (support and warmth) community connection, increased sensitivity to rewarding cues and stimuli, mature prefrontal-amygdala circuitry

What is complex trauma

Exposure to multiple traumatic events (invasive and interpersonal) and long term effects of exposure

events are severe and persistent (e.g., abuse + profound neglect)

usually occur early in life, can disrupt many aspects of childs development and formation of sense of self

if they occur with a caregiver - interfere with childs ability to form a secure attachment

affects many aspects of physical and mental development that rely on primary source of safety

What age is more likely to have complex trauma?

Adolescents. Developmental trauma more seen in younger children

What is Developmental trauma

Complex + pervasive exposure to life-threatening events that

• occur during sensitive periods of infant and child development

• i.e., chronic neglect, repeated caregiver maltreatment, multiple placement disruptions, severe relational trauma

Disrupts interpersonal attachments

compromises an individual's safety and security operations

often contributes to development of CPTSD in adulthood

Affects multiple developmental systems, typically more broad effects that PTSD

How might trauma show up?

Emotion regulation: dysregulation, instability, poor awareness of states

Behaviour: aggression, impulsivity, avoidance, risk-taking, compliance and control

Relationships: trust difficulties, attachment disruption, social withdrawal, poor boundaries

Cognition: attention, concentration, EF, problems with planning/problem solving

Identity/self concept: shame, self-blame, low self-worth, hopelessness

Dissociation / somatic: daydream, disconnected from self, somatic complaints, play reenactment

Define single trauma

Linked to a discrete event

commonly presents with fear based symptoms

intrusions, avoidance, hyper arousal common

Define complex trauma

Repeated interpersonal trauma

broader emotional and relational difficulties

emotion dysregulation, attachment difficulties

Define developmental trauma

Trauma disrupting developmental processes

impacts multiple developmental processed

developmental delays, identity regulation, relationship difficulties

Can you use Ehlers and clarkes cognitive model of PTSD with children?

Yes - with appropriate adaptations

works best with a single event trauma

i.e.,

• trauma memories may be fragmented, sensory-based, or expressed through play

• negative appraisals (self-blame, shame, danger) contribute to maintenance of PTSD

• Subjective threat is often more important

• avoidance maintains symptoms but may look developmentally different across ages

• Caregivers play an essential role in recovery + resistance

What does the self trauma model (Briere) posit?

More of a complex trauma model

attachment disruptions > affect dysregulation > cognitive distortions > avoidance > revictimisation > avoidance and revictimisation > fragmentation of self

all impact each other and work together

What should you assess for PTSD

• child’s experience and change over time

• reexperiencing

• avoidance

• hyperarousal

• negative cognitions and feelings

What do children with trauma present with?

• emotion dysregulation

• attachment difficulties

• school difficulties

• peer difference

• risk-taking

• somatic symptoms

• behavioural difficulties

What are the key differentials for trauma?

ADHD

Autism

Anxiety disorders

Mood

OCD and CD

Emerging personality difficulties

What are risk factors of trauma?

• peritraumatic fear

• threat perception

• family stress

• emotional dysregulation

• poor support

What are the protective factors for trauma

• supportive caregivers

• family warmth

• social support

• school connectedness

• cultural connectedness

What is the importance of dissociation in child maltreatment / trauma

childhood maltreatment associated with significantly higher levels of dissociation

risk of dissociation highest following

• early onset trauma

• chronic trauma

• caregiver perpetrated trauma

• where threat is overwhelming and escape is impossible

Dissociative processes appear to be important pathway to CPTSD

What are indicators of dissociation

staring/spacing out

feeling unreal

detached from emotions

memory gaps

sudden changes in presentation

identity confusion

disconnected from body/surroundings

Psychometrics: A-DES, CDC