When Nightmare is Real: Trauma in Child & Adolescence

Children of Chowchilla

Masked kidnappers accosted a school bus on the way home from school and abducted the bus driver and 26 children, ages 5 to 14. The kidnappers transported the children and driver to a quarry, loaded them into a buried moving truck. They were buried for 16 hours. The driver and children were able to dig themselves out and escape unharmed. Police soon arrested the quarry owner's son and his accomplices.

• The children escaped unharmed

• They returned to their homes

• They went back to school and everyday routines right away

• Everyone assumed that the kids were in fact alright

• Experts consulting at the time did not suspect that there would be psychological repercussions to the kidnapping because of:

  • The age of the children

  • The limited exposure time

  • The lack of physical injuries

  • The quick arrest of the suspect

Children were assessed 5 to 13 months following the event and then again in adulthood. Each child suffered post traumatic symptoms acutely and over the following year:

• Acute findings:

  • Fears of further trauma

  • Hallucinations

  • "Omen" formation

• Later Findings:

  • Post-traumatic play

  • “Personality changes”

  • Repeated dreams of the event and of dying during the event

  • Ongoing fears of being kidnapped again

  • Heightened generalized fears not necessarily related to the trauma

Contact with the survivors continued for 25 years after the kidnapping. They described their ongoing post-traumatic symptoms:

• Anniversary triggers lead to heightened emotional response: “Every year at this time I just get kind of weird [in] the way that I rage and the way that I am hot-headed” (Larry Park)

• Experience of being forever altered by the event and loss of trust in the world generally: “I will never get back the kid that I was. That kid stayed underground, and it was a different kid that came home. And I think that that happened for each and every one of us – a different child came home” (Larry Park)

• Fear that outlives the trauma, hypervigilance to risk, disruption of sleep and disruption of the sense of safety: “Kids are supposed to adjust to things, but I still have not gotten over it. As a kid, I was scared of the dark, I was scared of strangers. Even now, I still sleep with a nightlight and I’m way into my 20’s”

Children have profound reactions to traumatic events both in the short and long term.

“These kids were heroes of medicine because their experience awakened the world that children can be traumatized and the kids are not ‘too young to understand.’”

- Lenore Terr

Lenore Terr published her book Too Scared to Cry in 1990 about the negative consequences of childhood trauma, but the fact that children could experience PTSD was not recognized until the late 90s

What is trauma?

Definitions:

• 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. (Wikipedia)

• An emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea. (American Psychological Association)

• “Traumatization occurs when both internal and external resources

  are inadequate to cope with external threat.” Bessel van der Kolk, 1989

• “Childhood trauma is the mental result of a blow, or a series of blows,

  rendering the young person temporarily helpless and breaking past

  ordinary coping and defensive operations.” Lenore Terr, 1991

• What makes an experience traumatic?

• Can one person experience something as traumatic and another not? Why or why not?

• Are the following experiences examples of “trauma?”

  • Watching the aftermath of a hurricane or tornado on TV?

  • Having surgery as a young child?

  • Watching 9/11 from an apartment ten blocks away?

  • Being removed from your parents who were physically abusing you, and placed into foster care?

  • Being in a car accident?

  • Living in an neighborhood where there are nightly shootings?

  • Living with extreme poverty?

  • Having a friend who was injured in a school shooting

Different magnitudes of trauma

Big T Trauma: An event that most people would consider traumatic, such as a plane crash or sudden and unexpected loss of a loved one

Little T Trauma: An event experienced as traumatic at a personal level, such as the loss of a pet or a relationship break-up

Key Elements of Trauma, Defined Across Studies

• The individual experiencing the event has minimal or NO personal control to stop the event.

• The nature of the event is usually beyond the scope of ordinary human experience (usually rare or infrequent).

• It is unpredictable in the sense of a sudden event (or a sudden change in mood/behavior of an abusive parent).

• In an effort to process the event, the person is changed

Epidemiology

The branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health

• By age 16, more than 67.8% were exposed to one or more traumas, such as child maltreatment, domestic violence, traffic injury, major medical trauma, traumatic loss of a significant other, or sexual assault.

• Copeland et al. (2007) reported that children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.

Across multiple surveys of large, nationally representative samples of youth:

• 19% reported physical abuse, whereby an adult hit, beat, kicked, or physically hurt the child in any way (other than spanking)

• 70% of adolescents age 14-17 reported witnessing violence

• 6% of youth age 0-17 experienced at least one episode of sexual victimization in the past year

• 2% of American adolescent girls experienced a drug- or alcohol- facilitated sexual assault

• Nearly 1 in 5 (18%) of American youth experienced a traumatic death of a loved one

• Approx. one-quarter of adolescents were involved in a natural disaster in their lifetime

• 10% reported involvement in a motor vehicle accident

• The prevalence of psychiatric disorders in children after the exposure to a disaster varies significantly (between 4 to 6% in low violence and disaster areas to up to 70 to 80% for those directly experiencing violence such as a school shootings).

• Six months after 9/11, approximately 10.6% of NYC public school children met criteria for Post Traumatic Stress Disorder (PTSD)

The stress response system

Fight, flight, freeze

Ex: Walking in the calm woods, but disrupted by the fright of a bear in sight

National Prevalence of Child Maltreatment

Nationally during FFY 2022, 3,096,101 children received either an investigation response or alternative response at a rate of 42.4 children per 1,000 in the population.

• 74.3% of victims experience neglect

• 17.0% percent are physically abused

• 10.6% percent are sexually abused

• 6.8% percent are psychologically maltreated

Types of traumatic events

Neglect, physical abuse, sexual abuse

Additional types of trauma and stressors:

• Removal from Home

• Multiple Foster Placements

• Extreme Neglect

• Extreme Poverty

• Systemic Racism

• Domestic Violence (IPV)

• Community Violence

• Natural Disasters

• Emotional/Psychological Abuse

• Loss of Significant Others

• Debilitating Medical or Psychiatric Condition

• Medical Instrumentation/Procedures

• Primary Caretaker with a Debilitating

• Medical or Psychiatric Condition

• Terrorism

• Immigration

• Kidnapping

• Sex Trafficking

• Extreme Bullying

• High Conflict Divorce

• Discrete (Single Incident) – Car

• Accident/Dog Bite

Effects of trauma

• Disruption of healthy development

• Higher risk of emotional and behavioral problems in the present and future

Trauma symptoms: attached image

Maltreatment

A person who is supposed to protect you from harm, keep you safe becomes a source of alarm/danger/pain

Maltreated children:

• Tend to have lower social competence

• Are less able to recognize their own emotional states

• Have greater difficulty in recognizing other’s emotions

• Have greater difficulty regulating their own emotions

• Tend to over-read anger

• Are more likely to be insecurely attached to their caregivers

• Are frequently hypervigilant to threat

Child Maltreatment as a Risk Factor for School Problems

• Greater than 50% of abused children have significant school problems (including conduct problems)

• Greater than 25% of abused children require special education programs

• Several studies suggest a history of trauma decreases IQ

• Greater than 50% of abused children have significant school problems (including conduct problems)

• Greater than 25% of abused children require special education programs

• Several studies suggest a history of trauma decreases IQ

How and Possibly Why Does Childhood Maltreatment Exert Such Powerful Effects?

• It occurs during sensitive developmental periods

• It may be a way of helping the organism adapt to an anticipated dangerous, unpredictable environment (Kurt Fischer, 1997)

It impacts fundamental developmental processes:

• Attachment

• Emotional regulation

• Impulse control

• Integration of self

• Socialization

Adverse childhood experiences

• Vincent Felitti MD & Robert Anda, MD, MS

• Kaiser San Diego’s Department of Preventive Medicine &

• The Center for Disease Control (CDC)

• 17,000 patients participated (out of 26,000 adults asked to participate)

• Began 1995 and followed long term for health outcomes

Results Revealed:

• 50% female

• 75% white

• average age 57

• 75% college educated

• 100% employed

• 100% health insurance

ACE Trauma Types

Household Dysfunction:

• Substance abuse - 27%

• Parental sep/divorce - 23%

• Mental Illness - 19%

• Mother treated violently - 13%

• Incarcerated Relative - 5%

Abuse

• Psychological - 11%

• Physical - 28%

• Sexual - 21%

Neglect

• Emotional - 15%

• Physical - 10%

Beyond the Original ACEs Study

ORIGINAL ACEs Study

Surveyed middle-class, primarily white (non- Hispanic) individuals with some college education.

64% At least 1 ACE

12.5% 4 or more ACEs

Philadelphia Urban ACEs Study

Surveyed racially diverse sample of adults who completed high school.

83% At least 1 ACE

37% 4 or more ACEs

ACEs as a Risk Factor for Health

Multiple Adverse Childhood Experiences increase adjusted† odds ratios (= more likely to have) for:

• Ischemic heart disease - 2.2 X's

• Any cancer - 1.9 X's

• Stroke - 2.4 X's

• Chronic bronchitis/emphysema -3.9 X's

• Diabetes - 1.6 X's

• Hepatitis - 2.4’x

Cumulative ACES

Impact of Cumulative ACES & Social Dysfunction

• Lower educational, occupational attainment

• Increased social services cost

• Increased Medical cost

• Shortened life span

• Increased risk for HIV, teen pregnancy, maternal depression

• Intergenerational transmission of ACEs to offspring

Implications of Cumulative ACEs

• “Dose-Effect” - increasing ACES increases number of problems

• Child Maltreatment victims have 2-7 times higher risk of being re-victimized in the future compared with non victims

• Preventing ACES in previously traumatized children is an important intervention

• Systems that serve traumatized children - e.g child protection, juvenile justice, mental health - should include trauma screening and prevention intervention

How ACES work

Adverse Childhood Experiences:

• Abuse and Neglect (e.g psychological physical, sexual)

• Household Dysfunction (e.g domestic violence, substance abuse, mental illness)

Impact on Child Development

• Neurobiological Effects (e.g brain abnormalities, stress hormone dysregulation)

• Psychosocial Effects (e.g poor attachment, poor socialization, poor self- efficacy)

• Health Risk Behaviors (e,g smoking obesity, substance abuse, promiscuity)

Long-term consequences:

• Major Depression

• Suicide

• PTSD

• Homelessness

• Drug Alcohol Abuse

• Prostitution

• Heart Disease

• Criminal Behavior

• Cancer

• Unemployment

• Chronic Lung Disease

• Parenting problems

• Sexually Transmitted Disease

• High Utilization of health and social services

• Intergenerational transmission of abuse

Examples of Differential Impact

• Children exposed to a flood in Poland had rates of PTSD of 17.7%, 28 months after the event

• On the other hand, A year post-wildfire, the rate of PTSD in children and adolescents has been found to be between 27 and 37%

What factors do you think might contribute to these different rates?

• Proximity

• Direct threat of loss of life or limb

• Exposure to loss of life or limb among others, particularly loved ones

• Time since the event

• Availability of emergency relief and support services

• Availability of a perceived way out, an escape

• Premorbid nature of the population affected (high vs low risk– see next slide

Factors that ‘Increase’ Trauma Effects

• Exposure to direct life threat

• Injury (oneself) – 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

Factors that Influence Trauma Effects

• 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 (socio-economic-status)

Risk Factor Timeline

Pre-traumatic Risk Factors

• Quality of Attachment during early development

• Neurobiological factors: Dysregulation of the Hypothalamic Pituitary

• Adrenal axis (low cortisol levels, lack of reactivity, disruption of circadian rhythms)

• Genetics and Epigenetics

Peri-traumatic Risk Factors(during or immediately after)

• Duration and severity of the traumatic exposure

• Uncertainty that the danger has passed

Post-traumatic Risk Factors

• Sufficient access to needed resources

• Real vs Perceived Social Support

• Cognitive belief (i.e. a bad coincidence vs. trauma was deserved)

• Physical activity, capacity to place attention elsewhere during critical period of memory consolidation

• Memory reconsolidation and updating with reinforcement of trigger

A Developmental Psychopathology Perspective on Abuse and Neglec

• Takes into account how trauma affects development & how development affects the outcome of trauma

• Considers the interaction of the child, parent, and their environment

• Examines the roles each play in the development of psychopathology

• Considers Vulnerability and protective factors in the outcome of trauma

Developmental Psychopathology and Trauma

• Studies have found that children who have been maltreated and/or neglected perform lower on developmental scales and on tests of intellectual and academic functioning (Erickson, et al, 1989)

• A history of maltreatment and neglect has been found to be predictive of problems in expressive and receptive language (Allen et al, 1982)

• Children who have suffered neglect and/or maltreatment are more likely to be placed in special education (Egeland et al, 2009)

• For every additional ace, the risk of psychopathology augments geometrically

• 1 in 5 children in the US is raised below the poverty line, and is at greater risk for adversity (McLaughlin, 2017)

• Children who have been maltreated or neglected AND WHO HAVE PARENTS WHO SUFFER FROM SIGNIFICANT PSYCHOPATHOLOGY are more likely to have insecure attachments and reactive attachment disorders (Egeland et al, 2007)

• They are more likely to have negative mental representations of themselves and others (Toth et al, 2007)

• They are more likely to have abnormal social interactions, including social withdrawal and aggression (Bousha et al and Egeland et al, 2007)

• They have been found to have higher levels of pathological behaviors including tics, tantrums, stealing, somatic symptoms, and self injurious behaviors (Egeland et al, 2007)

What are the Essential Elements that Children Need to Develop Normatively?

• Health: nutrition, hygiene, environment, healthcare, education, maternal health

• Stimulation and the opportunity to interact with the environment in ways that support cognitive, motor, language, and social-emotional development

• Stable supportive interpersonal relationships: attachment to a consistent primary caregiver

Adequate Nutrition

Undernutrition Results in:

• Wasting (low weight-for-height), Stunted growth (low height-for-age) and Underweight (low weight-for-age)

• 1/2 of deaths in children under 5

• Decreased cognitive, social, and emotional capacities

• Behavioral dysregulation

Hunger in America

Facts about Child Hunger:

• More than 13 million children experienced hunger in 2022

• Black and Latino children are twice as likely to face hunger

• 33% of households headed by single moms experienced food insecurity

Hunger risks for development:

• Physical: Stunted growth, abnormal brain development, low energy, increased susceptibility to infection

• Emotional: Irritability, helplessness, depression, hallucinations, decreased ability to accurately assess reality

• Cognitive: Difficulty with attention, concentration, decision making, acquiring new knowledge and memories, poor academic performance

• Behavioral: Impulsivity, stealing, aggression

Education

• Over 140 million children in developing countries have never attended school

• 122 million, or 48% of the out-of-school population, are girls and young women

• Educated children are more likely to be productive in the home and in the workplace

• Educated children are less likely to be victims of abuse and exploitation

Adequate Healthcare

• An estimated 5.2 million children under 5 years died mostly from preventable and treatable causes. Children aged 1 to 11 months accounted for 1.5 million of these deaths while children aged 1 to 4 years accounted for 1.3 million deaths. Newborns (under 28 days) accounted for the remaining 2.4 million deaths

• Leading causes of death in children under-5 years are: preterm birth complications, birth asphyxia/trauma, pneumonia, congenital anomalies, diarrhoea and malaria, all of which can be prevented or treated with access to simple, affordable interventions including immunization, adequate nutrition, safe water and food and quality care by a trained health provider when needed

• Six million children who die each year could be saved by low-tech measures such as vaccines, antibiotics, insecticide-treated bed nets and improved breastfeeding practices

Maternal Health

• A woman dies from complications in childbirth every minute – the vast majority of them in developing countries

• At least 20% of the burden of disease in children below the age of 5 is related to poor maternal health and nutrition, as well as quality of care at delivery and during the newborn period

Environmental Health

• More than 1,300 children under the age of five die every day because of diseases caused by unsafe drinking water, poor sanitation and hygiene

• These diarrhoeal diseases include cholera and dysentery

• Unsafe drinking water also puts children at risk of malnutrition, as well as the risk of contracting typhoid and polio

• 400 million children have no access to clean water

Temperament

Easy:

• Biological regularity

• Positive approach to most situations

• Easy adaptability to change

• Mild or moderately intense mood that is predominantly positive

Difficult:

• Biological irregularity

• Negative withdrawal from most new situations

• Slow adaptability to change

• Intense mood that is predominantly negative

Slow to Warm:

• Negative response to new situations

• Slow adaptation

• May have good biological regularity

• Mild expressions of mood

Characteristics of Temperament

• Activity Level

• Regularity

• Approach or Withdrawal

• Adaptability

• Sensory Threshold

• Quality of Mood

• Intensity of Reaction

• Distractibility

• Persistence and Attention Span

Early Brain Development

• Brain at birth weighs about 1/3 of adult brain

• 83% of dendritic growth occurs after birth

• By age 2-3 years, the brain is 80% of adult brain size

• By age 5, the brain is 90% of adult brain size

The Experience Dependent Brain

• Synapses are overproduced

• Pruning of synapses takes place from early childhood through adolescence

• The least used synapses are pruned

• Experience determines which synapses will be the most used – therefore retained

• Pruning makes our mental processes more streamlined and coherent

Origins of Attachment Theory- John Bowlby

• British psychoanalyst and psychiatrist

• Early work with institutionalized “juvenile delinquents” (“44 Juvenile Thieves”)

• Established the Separation Research Unit in 1948 at the Tavistock Clinic (where he was Deputy Director)

• Interest in the “Ill effects on personality development of prolonged institutional care and/or frequent changes of mother-figure during the early years of life” (Bowlby, 1988)

Findings:

• “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

• The World health organization invited Bowlby to study maternal deprivation and in 1951 he published “maternal care and mental healt

Konrad Lorenz - Imprinting

• Austrian zoologist, ethnologist, and ornithologist, founder of Ethology

• Studied instinctive behavior in animals (1930s)

• Gave the name “Imprinting” to the behavior of Greylag Goslings who followed the first moving object they saw after hatching

• Imprinting occurs during a 12-17 hour “critical period” after hatching – suggesting that “attachment is innate” (Hess, 1958)

• If no attachment has developed within 32 hours, it is unlikely that any attachment will ever develop (Hess, 1958)

Shift to Direct Child Observation 1940s/1950

• WWII parent-child separation in London (Anna Freud & Dorothy Burlingham, 1944)

• Phases of Response to Hospitalization and Parent-Child Separation (A Two Year Old Goes to Hospital (documentary)

• Protest

• Despair

• Detachment

Comfort > Food

Wire Mother vs. Cloth Mother

John Bowlby: A Theory of Motivation and Behavior

• Psychoanalysis

• Ethology

• Evolutionary Biology

• Control Systems Theory

• Cognitive Science

• Direct Child Observation

• Primate Research

Attachment Behavioral System

• A Caregiver-infant behavioral system that insures species survival

• The Centrality of Threat / Fear

• A Purposeful goal of achieving “Felt-Security”

Attachment Behavioral System

Proximity-Seeking When There Is Threat vs. Exploration When There Is Safety

Infant Attachment Behavioral System:

Cry, grasp, babble, smile, cling, protest separation, visual checking/following, following by crawling/walking

Caregiver Behavioral System:

Watchfulness, protective behavior, response to distress, closeness

Multiple Attachments

• Attachments are consolidating between 6 and 24 months of age

• Definitive attachment preferences are established by 18-24 months of age

• Children will develop an Attachment relationship to any caregiver providing regular care, regardless of the quality of the care provided. Play partners are not necessarily attachment figures

• Children may have multiple Attachment figures (e.g. mother, father, grandmother, nanny, day care provider)

• The quality of Attachment to each of these significant figures can be hierarchical (per need) and different (e.g. secure, insecure, disorganized)

• Secure Attachment to at least one significant caregiver is considered to be a buffering agent against stress

Mary Ainsworth 1913-1999

• Canadian psychologist who began her career as a research assistant to John Bowlby

• Studied children in Kampala, Uganda and made careful observations of mother-child interaction, published “Infancy in Uganda” (1967)

• Back in the United states, initiated a study of middle-class babies and their mothers in Baltimore, Maryland

The “Strange Situation”

• Ainsworth visited the homes of Baltimore families every 3 weeks from birth

• At 12 months she began to consider how the manner in which infants coped with separation, and behaved upon reunion, reflected the quality of the caregiver-infant relationship

• Ainsworth created “The Strange Situation”, a research paradigm consisting of 8 episodes, 3 minutes each

  • First separation mother leaves the child with a stranger

  • Second separation mother leaves the child alone

• Ainsworth developed a coding system to categorize the child’s pattern of attachment behaviors as reflective of the quality of caregiver-infant attachment relationship

Patterns of Attachment: Behavioral adaptations to manage stress/felt-anxiety/fear

Organized:

• Secure (B)

• Insecure Avoidant

• Insure Ambivalent

Disorganized/Disoriented (D)

Attachment Classifications

Secure:

• Distressed, seeks contact, easily soothed, returns to play

• Parent is responsive and available

Insecure-Avoidant:

• Not overtly distressed, ignores or turns away, does not resume prior level of play

• Parent is unavailable and rejecting

Insecure-Ambivalent:

• Distressed, seeks then angrily rejects contact, not soothed, does not return readily to play

• Parent is inconsistent, unreliable, sometimes intrusive

Disorganized:

• Distressed, approach/avoid, mistimed, incoherent, freezing

• Irresolvable dilemma: Parent is source of security AND ALSO source of fear, typically associated with parental trauma and maltreatment