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WHEN THE NIGHTMARE IS REAL: CHILDHOOD & ADOLESCENT TRAUMASeptember 11th, 2017 ● OBJECTIVES: ○ Epidemiology/definitions of various types of trauma ○ Common psychological consequences of exposure to trauma during childhood and adolescence ○ PTSD and other conditions ○ How trauma-related stress...

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WHEN THE NIGHTMARE IS REAL: CHILDHOOD & ADOLESCENT TRAUMA September 11th, 2017 ● OBJECTIVES: ○ Epidemiology/definitions of various types of trauma ○ Common psychological consequences of exposure to trauma during childhood and adolescence ○ PTSD and other conditions ○ How trauma-related stress affects the brain ○ Basics of evidence-based treatments for trauma, in addition to alternative methods like music/art therapy ○ Concepts of vulnerability and resilience and the factors that contribute to resilience vs. pathology ● Foundations of Childhood Traumatic Stress ○ What is trauma? ↙ ■ Type 1 trauma: single exposure  as researched by Lenore Terr ■ Type 2 trauma: chronic/ongoing exposure ■ Usually  an uncontrollable  , unpredictable event ■ Unpredictable in the sense of a sudden event or sudden change in mood of a violent parent ■ Beyond scope of ordinary human experience (rare or infrequent) ■ The person is changed in an effort to process the event ■ Common for people to blame themselves, or have trust issues w/ others & the world ○ Traumatic stress is mediated by s  urvival circuits: fight, flight, or freeze ○ Normal path: stimulus → sensory thalamus → cortex → hippocampus → amygdala (limbic system) ○ During trauma, amygdala takes over and cuts off higher cortex functioning since  l ow road it takes too much time in the face of danger. This is also known as functioning ○ Depending on nature of event, hippocampus could be cut off (memory never formed to begin with) because of low road functioning, or memory is repressed ● Other sources of trauma include: ○ Removal from home ○ Multiple foster placements ○ Extreme neglect ○ Extreme poverty ○ Home and community violence ○ Emotional/psychological abuse ○ Loss of significant others (not only death; also abandonment, incarceration, etc) ○ Debilitating medical/psychiatric condition ○ Having a primary caretaker w/ a debilitating medical/psychiatric condition ○ Natural disasters

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Kidnapping Sexual trafficking Extreme bullying

September 18th, 2017 ● Social & emotional deficits in maltreated children ○ Maltreated children have lower social competence ○ Have less empathy for others ○ Have difficulty in recognizing others’ emotions ○ Are less able to recognize their own emotional states ○ Are more likely to be insecurely attached to their parents ● Child maltreatment as a risk factor for school problems ○ > 50% of abused children have significant school problems (including conduct problems) ○ > 25% of abused children require special education programs ○ Several studies suggest a history of trauma decreases IQ ○ 2x more likely to be unemployed as adults with a trauma history ● How does it exert such powerful effects? ○ Occurs during sensitive developmental periods (e.g. Synaptogenesis, Experience-Dependent Maturation of Neuronal Systems) ○ Impacts on fundamental developmental processes (e.g. Attachment, Emotional Regulation, Impulse Control, Integration of Self, Socialization) ● Epidemiology of children’s exposure to disasters ○ The prevalence of psychiatric disorders in children after the exposure to a disaster varies significantly ○ 6 months after 9/11, approx. 10.6% of NYC public school children met criteria for PTSD ○ Children exposed to a flood in Poland had rates of PTSD of 17.7% 28 months after the event ○ On the other hand, 52% of Australian children exposed to a bush fire met criteria for PTSD ● Some children are more at-risk of developing lasting consequences from exposure to trauma: ○ Chronic poverty/unstable, violent communities ○ Major armed conflicts/civil disturbances ○ Being in detention centers & jails ○ Children who require residential treatment for medical/psychiatric reasons ● ACE Study ○ Adverse Childhood Experiences ○ 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, & liver disease

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Child maltreatment as a risk factor for poor physical health ○ Multiple adverse childhood experiences increased adjusted odds ratio ■ Ischemic heart disease - 2.2x ■ Any cancer - 1.9x ■ Stroke - 2.4x ■ Chronic bronchitis/emphysema - 3.9x ■ Diabetes - 1.6x ■ Hepatitis - 2.4x Factors that ‘increase’ trauma effects ○ Exposure to direct life threat ○ Injury to self - extent of physical pain ○ Witnessing of mutilating injury/grotesque death (esp. family/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 adults ○ Ability to create/find safety ○ Previous trauma ○ Family history of psychological or substance abuse problems ○ Gender ○ Age ○ Low SES ○ Being widowed or divorced The Challenger tragedy ○ Terr et al studied children w/ different levels of exposure to the tragedy (watched directly, watched on TV, did not watch but heard afterwards) ○ Looked at differences between east and west coast children and young and older children ○ 62% of east coast children had dreams related to Challenger ○ At 5-7 weeks after the explosion, 44% of children between the age of 6-11 had made drawings related to the explosion, in comparison to 6% of adolescents ○ Adolescents used writing as a coping skill more frequently (26%) ○ 21% of east coast children reported clinging habits, in comparison to 3% of west coast children ○ 90% of latency age (6-11) kids had some type of fear (e.g. fears of death, dying, explosions, fires, taking risks) ○ East coast significantly more symptomatic than west coast (dreaming, drawing, behavioral re-enactment, fears, less interest in a space-related career)

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Children w/ a history of personal traumatic events had more symptoms than children who reported no previous exposure to trauma ○ Interestingly, watching at Cape Canaveral vs. watching it live on TV did not have an effect in terms of symptoms ○ Immediacy of the media (TV) seems almost as real as the real event A child needs: ○ Adequate nutrition ○ Adequate healthcare ○ Education ○ Gender equality ○ Healthy mother/caregiver ○ Healthy environment Psychological needs of a child ○ John Bowlby (1907-1990) notable for his pioneering work in attachment theory ○ Found that deprivation could result from separation from the primary caregiver or from a cold, inconsistent relationship with the primary caregiver Phases of Attachment ○ Phase 1: birth - 3 months ■ Babies prefer proximity to humans over objects; however, who the human is does not matter to the infant ■ 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 ■ Caregiver remains in close proximity and thereby promotes attachment ○ Phase 2: 3 - 6 months ■ Baby begins to focus on familiar people ■ Baby’s social responses become more selective ■ Baby appears to develop the strongest attachment to the person who responds most readily to the child ○ Phase 3: 6 months - 3 yrs ■ Intense attachment develops ■ infant/child actively seeks attention and proximity of caregiver ■ Child demonstrates separation anxiety when caregiver leaves room ■ Fear of strangers develops ■ Child demonstrates preferential attachment to the primary caregiver ○ Phase 4: 3 yrs - end of childhood ■ Children continue to form attachments throughout life ■ These attachments are arguable affected by the early attachment experiences of the child ■ People continue to seek out their early attachment figures in times of crisis and pain

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Mary Ainsworth’s theories of attachment ○ Secure ○ Insecure-Avoidant ■ Infant appeared independent throughout strange situation ■ As soon as they entered room, rushed off to see toys ■ Did not use mother as secure base ■ Did not seem upset when mother left the room, did not seek proximity when she returned ■ Ainsworth argued that these children reacted in this way because they had learned they could not count on their mothers ■ These mothers had previously been more likely to be rated as insensitive, interfering, and rejecting ○ Insecure-Ambivalent ■ “Clingy” and preoccupied w/ mother’s whereabouts ■ Became extremely upset when mother left room ■ Markedly ambivalent when she returned; at one moment reaching for mother, at next pushing her away ■ Mothers had been described as inconsistently responsive to the infant When trauma interrupts attachment ○ Bowlby studied institutional attachment in particular and found that the children he studied that were separated at a young age from their caregivers secondary to hospitalization went on to have difficulty forming lasting relationships later in life ○ Termed these individuals as “affectionless characters”; individuals who use others solely for their own ends and have an inability to form lasting, loving, reciprocal relationships Reactive Attachment Disorder ○ A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts; beginning before age 5, as evidenced by either 1 or 2: ■ 1. Persistent failure to initiate or to respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses ■ 2. Diffuse attachments as manifest by indiscriminate sociability and marked inability to exhibit appropriate selective attachments ○ B. the disturbance of criterion A is not accounted for solely by developmental delay of pervasive developmental disorder ○ C. pathogenic care as evidenced by at least one of the following: ■ 1. Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection ■ 2. Persistent disregard of the child’s basic physical needs ■ 3. Repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent changes in foster care) Subtypes of Reactive Attachment Disorder ○ Inhibited subtype:

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■ Child fails to approach caregiver ■ Or child approaches caregiver in abnormal way when distressed ■ For instance, child is fearful of caregiver ■ Also demonstrate difficulties in social reciprocity/emotional regulation ○ Disinhibited subtype: ■ Child lacks wariness of strangers ■ Demonstrate symptoms of hyperactivity/inattention ■ May willingly wander off w/ strangers and seek physical contact w/ unfamiliar adults ■ This subtype is more prevalent than inhibited, esp. In formerly institutionalized children Diagnosis & Treatment ○ Some argue that other psychiatric diagnosis such as conduct disorder or oppositional defiant disorder are actually attachment disorders ○ Limited longitudinal data on the course of RAD ○ Also limited evidence based treatments of RAD ○ Some argue for multisystemic treatment including CBT for symptoms, stable therapeutic relationship, counseling for caregiver, & psychoeducation Developmental psychopathology perspective on abuse/neglect ○ Takes into account how trauma affects development and how development affects outcome of trauma ○ Looks at interaction of child, parent, & their environment ○ Examines roles each play in development of psychopathology ○ Considers certain factors in outcome of trauma including: ■ Vulnerability factors ■ Transient challenges in environment ■ Protective factors ■ Transient buffers International adoption studies ○ Physical Health ■ Children reared in globally deficient orphanages tend to be smaller in height, weight, head, and chest circumference ■ Some studies have found that physical growth falls behind by approx. 1 month for every 5 months spent in an orphanage ○ The Romanian orphans & attachment patterns ■ During the Ceausescu Regime birth control was banned, resulting in hundreds of thousands of orphans ■ Placed in orphanages w/ low staff to infant ratio and deplorable living conditions (10 babies to 1 nurse) ○ Crisholm’s study ■ Compared attachment patterns of children who had been adopted from a Romanian orphanage after 8 months of age (RO) w/ children who had

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been adopted before 4 months of age (EA) and children raised by their biological parents (CB) Assessed attachment via the separation reunion procedure and preschool assessment of attachment RO children w/ insecure attachments also more likely to have ● Behavioral problems ● Lower scores on Stanford Binet IQ test ● Familial stressors However, RO children showed more secure attachment over time In fact no differences between CB and RO groups over time Early institutional experience had an impact on security of attachment only when coupled w/ other stressors in the adoptive home

September 25th, 2017 ● History of PTSD ○ “Da Casta Syndrome” ■ Described by surgeon in the US Civil War, Dr. Jacob Mendes Da Costa ■ Recognized heart disease symptoms w/o physical findings ■ Symptoms included shortness of breath, fatigue, palpitations, sweating, and chest pain ■ Thought to be possible precursor to PTSD/panic disorder diagnosis ● Hysteria ○ First described in women in late 19th century in Paris by J ean-Martin Carcot ○ Occurred in political climate wherein secular men of science were attempting to establish supremacy over the reign of religion, women were not valued as equal members of society, and the truths about prevalent sexual abuse denied ○ Carcot focused on symptoms of motor paralysis, sensory loss, convulsions, and amnesias - referred to hysteria as the “ Great Neurosis” ○ Would demonstrate his patients’ “neurosis” during his “Tuesday Lectures” ● Freud and hysteria ○ Began to study hysteria in search of its underlying cause through analyzing his patients - noted the almost universal experience of childhood sexual trauma ○ “The Aetiology of Hysteria” thesis: “At the bottom of every case of hysteria there are one or more occurrences of premature sexual experience” ○ Judith Herman argues that Freud was forced to renounce this theory because of its radical social implications - changed by beginning of 20th century ○ Now argued that “hysterics” claims of sexual abuse were untrue and were rather repressed desires ● Forgotten history of hysteria ○ Shell shock - WWI ■ Victims would scream uncontrollably, weep, lose their memory/capacity to feel, and experience paralysis which was not based in any neurological cause

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Up to 40% of British war casualties were due to mental breakdown, but military authorities attempted to suppress reports because of their demoralizing effects ■ Soldiers were treated but not excused from battle Vietnam ■ “Rap groups” organized wherein the vets would talk about their trauma ■ By mid 70s their political pressure in combination with the anti-war movement was enough to result in the initiation of systematic study and treatment of veterans’ trauma Feminist movement ■ Women’s liberation movement of 70s contributed to understanding that the most common PT disorders are those not of men of war, but of women in civilian life ■ “Consciousness raising” groups - like “rap groups” ■ Women who were raped experienced insomnia, nausea, increased startle, nightmares, and dissociative symptoms ■ 1980s - D  iana Russell (sociologist) surveyed over 900 women to find that 1 in 3 had been sexually abused in their childhood and 1 in 4 had been raped Emergence of PTSD as a formal diagnosis ■ PTSD was included in DSM-III-R in 1980 (in wake of Vietnam/feminists) ■ Late 90s led to broader view of serious illness, natural disasters, loss of a loved one, and exposure to community violence - included in DSM-IV ■ Now beginning to understand manifestation of PTSD in children

DSM-5 ○ Anxiety disorders: Obsessive-compulsive and related disorders Trauma and stressor related disorders Dissociative disorders Stress disorders in children ○ DSM makes adjustments in diagnostic criteria for children: ■ Trauma exposure: disorganized or agitated behaviour may be an expression of intense fear/helplessness/horror ■ Re-experiencing: repetitive play may occur in which themes/aspects of the trauma are expressed (intrusive thoughts), frightening dreams w/o recognizable content, flashbacks PTSD in children ○ Girls often express more symptoms than boys ○ Younger children will often display symptoms of avoidance/aggression as well as poor performance in school, social withdrawal, and isolation ○ Older children will display symptoms of reexperiencing/hyperarousal ○ Younger children may not explicitly report their traumas, will often demonstrate through play/drawings/stories

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Their fears may not reveal actual trauma content, may be preoccupied by fears of monsters/separations from caregiver/boogie man, etc. ○ Regressive behaviours such as bedwetting (e  nuresis and encopresis) or thumb sucking may emerge ○ Children/adolescents will often have no goals for their future, no fantasies about marriage/career, sense of foreshortened future ○ Highest rates of PTSD prevalence: physical violence, rape/sexual coercion Causes of PTSD ○ Psychodynamic: repetition compulsion ○ Cognitive: cognitive schemas of trauma ○ Biological: neurotransmitters, structural changes, endocrine dysfunctions ○ Behavioural: classical learning and failure of extinction ○ Developmental: interaction btwn trauma and meeting the cognitive, social, and emotional milestones of development Factors that contribute to PTSD ○ Trauma ■ Type of trauma: single vs. chronic ■ Dose of trauma: magnitude/severity of traumatic event ■ Physical proximity: generally the closer the proximity, the more traumatic ■ Emotional proximity: the closer the child is to the loss emotionally, ^ ○ Individual/social factors ■ Age: some argue that trauma has less effect on younger children ■ Gender: studies find girls report symptoms more often than boys ■ Cognitive appraisal: guilt/shame/extreme fear can contribute ■ Social: family support, SES Assessment of PTSD in children ○ 3 factors to consider: ■ Pre-event functioning, # of previous traumas ■ Characterizing the traumatic event or events ■ Child’s subsequent symptomatic response/adjustment ● Evaluation should include: ○ Clinical interviews with child, caregiver, & family ○ School-based observations ○ Symptom rating scales ○ School reports ○ Medical records in the case of abuse or neglect ○ Any statement of witnesses to the extent of the trauma ● Risk factors for PTSD ○ Juvenile offenders found to be high risk ○ Substance abusing teens ○ Exposure to previous trauma ○ Previous diagnosis of anxiety disorder/other psychiatric disorders ○ Severe psychopathology

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○ Ongoing psychosocial stressors Protective factors: internal locus of control, sense of self efficacy/no feelings of helplessness, optimistic cognitive schema, social support, lack of ongoing psychosocial stressors Prevention ○ Normalizing child’s reaction to trauma ○ Ensuring safety, consistency, and predictability ○ Explaining to the child that there is nothing about the child which led to the trauma ○ If applicable, discussing that this trauma is unlikely to happen again ○ Elimination of ongoing stressors Studies have found higher levels of eating disorders, substance abuse, depression, anxiety, suicidality, dissociation, and psychosis in those who have experienced trauma Limitations of PTSD ○ Not reflective of the vast body of research over the last two decades ■ Neuroscience ■ Importance of social environment ■ Emotional dysregulation ■ Chronic exposure

October 2nd, 2017 ● Homeostasis and Stress ○ All living organisms strive towards dynamic equilibrium known as homeostasis ○ This is threatened by physical/psychological events known as “stressors” ○ Brain mediates interaction between how we perceive stressors/threats and our subsequent behaviour i...