Transcript Trauma: Definitions & Impact

Toxic Stress and Children
CCNC
Medical Home Training
Jean Smith, MD, FAAP
What is Trauma?
Injuries to the mind
and body that
overwhelm our
ability to cope
Trauma Affects Behavior,
Development, Emotion, Cognition,
Social Functioning and Physical
Health
Building Brain Architecture
The early years of life
matter because early
experiences affect the
architecture of the
maturing brain. As it
emerges, the quality of
that architecture
establishes either a
sturdy or a fragile
foundation for all of the
development and
behavior that follows.
© FrameWorks Institute 2009
Experiences Wire the Brain
• Brain’s wiring will develop based on a
child’s experiences – good and bad.
• Repeated experiences create strong
“wiring”
Chronic trauma alters brain
chemistry and changes the
structure of the brain
Toxic Stress
When interpersonal experiences
are disruptive, neglectful, abusive,
unstable, or otherwise stressful,
they increase the probability of
poor outcomes.
Serious and prolonged stress -toxic stress --releases harmful
chemicals in the brain that impair
cell growth and make it harder for
neurons to form healthy
connections.
Neurophysiology of
the Stress Response
Sensory/Transitional Cortex
Emotional Stimulus
(Initial actual threat &
Subsequent reminders)
Hippocampus
Amygdala
Thalamus
CORT
Hypothalamus
CRF
Pituitary Gland
ACTH
Adrenal Cortex
CORT
Consequences of Child Maltreatment
Brain Growth and Child Abuse
• Smaller overall brain mass in children who have been
abused
• Effect more pronounced in males
• The earlier abuse occurs and the longer it lasts, the smaller
the brain
• Decrease in brain size is correlated with an increase in PTS
and behavioral symptoms
» DeBellis and Thomas, 2003
Lateral Ventricles Measures in an 11- Year-Old
Maltreated Male with Chronic PTSD, Compared
with a Healthy, Non-Maltreated Matched
Control
De Bellis et al., Biological Psychiatry, 1999.
Why Problems Occur
• Toxic stress negatively impacts the
architecture of the brain
• Changed architecture will lead to impaired
development – cognitive, emotional,
behavioral
• Impaired development will lead to risky
behaviors and/or emotional issues
(substance use, promiscuity, aggression)
• These behaviors hinder opportunity for
success and often result in failure in school,
youth violence, teen pregnancy, addictions
Adverse Effects of CAN: Cognition
• Deficits in attention
• Deficits in abstract reasoning
• Deficits in executive function
• Deficits in memory
• Lower IQ
• Poor language development
• Difficulty with rapid decision making
Putnam, 2006
Resulting in: Poor academic performance, repeat
grades, and special education
Donna Potter, 2008
Changes in Processing Information
• Focus on nonverbal communication
• Tune out all non-critical information
• Decision making becomes black and
white
• Thinking part of the brain is less
active/functioning on reflexes
• Difficulty Speaking/accessing
language
Development and Trauma
• Speech and language delays
• Gross motor delays
• Poor fine motor coordination
• Sensory integration problems
Donna Potter, 2008
Alters Developmental Trajectory
• Sexually abused girl as a teen may become
promiscuous or avoid dating
• Child who witnesses father murder mother
withdraws from relationships, unable to trust
anyone, does not have any friends
• A toddler who witnesses domestic violence may
have his curiosity and increasing exploration of
the environment compromised.
Can’t Do One Without The Other
• Cognitive, emotional, and social
capacities are inextricably
intertwined, and learning, behavior
and physical and mental health are
inter-related over the life course.
Death
Early
Death
Disease, Disability
and Social Problems
Adoption of
Health-risk Behaviors
Social, Emotional, &
Cognitive Impairment
Adverse Childhood Experiences
Conception
Source: ACE Study, The ACE Pyramid, Centers
for Disease Control
Scientific
gaps
The ACE Study
• The ACE Study = Adverse Childhood
Experiences Study
• Surveyed 17,000 adults
• Compared childhood experiences with
adult health records
• Found adverse childhood experiences
= greater likelihood of future problems
with physical health
Prevalence of Adverse Childhood
Experiences (ACE Study Wave 2)
Adverse Exposure
Prevalence (%)
Emotional Abuse
10.5%
Physical Abuse
28.3%
Sexual Abuse
20.7%
Household Substance Abuse
11.6%
Household Mental Illness
19.4%
Battered Mother
12.7%
Incarcerated Family Member
4.7%
Parental Separation or
Divorce
23.2%
At Least One ACE
60.5%
20
Prescription rate
(per 100 person-years)
ACE Score and Rates of
Antidepressant Prescriptions
100
90
80
70
60
50
40
30
20
10
0
0
1
2
ACE Score
3
4
>=5
The ACE Score and the Prevalence of
Attempted Suicide
Percent attempted (%)
20
15
10
5
0
0
1
2
ACE Score
3
>=4
Number of Adverse Childhood Experiences
and Teen Sexual Behaviors
45
Number of adverse factors:
Percent With Health Problem (%)
40
0
1
2
3
4 or more
35
30
25
20
15
10
5
0
Intercourse by
age 15
Teen
pregnancy
Teen
paternity
ACE Score and the Prevalence of
Severe Obesity
Percent obese (%)
14
12
10
8
6
4
2
0
0
1
2
ACE Score
3
>=4
ACEs, Smoking, and Lung COPD
20
ACE Score
Percent With Health Problem (%)
18
0
1
2
3
4 or more
16
14
12
10
8
6
4
2
0
Early smoking
initiation
Current smoking
COPD
Consequences of Child Maltreatment
Health-risk
Behaviors
Sexual promiscuity
Sexual perpetration
Alcohol abuse
Illicit/injected drug
use
Smoking
Behavior problems
Child
Maltreatment
Mental/Social
Problems
PTSD
Depression
Anxiety
Eating Disorders
Academic Failure
Unwanted Pregnancy
Obesity
Revictimization
Source: ACE Study, Centers for Disease Control
Disease and Injury
Conditions
Ischemic heart disease
Diabetes
Stroke
Cancer
Suicide
Skeletal Fractures
Chronic
bronchitis/emphesema
STDs (e.g., HIV)
Hepatitis
Impact of Child Maltreatment
Juvenile
Crime
Sexual
Violence
Foster Care
Domestic
Violence
Gang
Violence
Child
Protection
U.S. Child Abuse
and Neglect
School
Drop Out
Court
Alcohol and
Drug Use
Mental
Health
3 million reports
Long-Term Health
Issues
Emergency Room
Loss of
Wages
Teen
Pregnancy
$104 Billion Annually
Children in foster care are children
with special health care needs.
Trauma Causes…..
•
•
•
•
Loss of Predictability
Loss of Trust
Loss of Safety
Loss of Control
•
40-60% of maltreated children will have significant emotional and behavior
problems
•
25% of accidentally injured children will have serious emotional problems with up
to 88% having at least one significant symptom
» puntam
Most common childhood psychiatric
conditions associated with
childhood trauma
(in order from most to least
common)
•
•
•
•
•
Separation anxiety disorder
Oppositional defiant disorder
Phobias
PTSD
ADHD

(Ackerman et. al., 1998)
Posttraumatic Stress Disorder
• Avoidance = “Never pass this way again”
• Re-experiencing = “Remember this experience so it isn’t repeated”
• Increased arousal = “Stay on guard”
Trauma Reminders
Secondary Stressors
Leaving family/pets
Change in physical
abilities
Changing schools
Leaving friends
Moving
Mediating Factors in Impact
of Trauma:
Individual child, event, and family social system
characteristics
Characteristics of the Child
• subjective experience of threat to life and
limb
• history of previous traumatic exposures
• coping style
• general level of anxiety
• Age, developmental stage
• meaning child makes of event
• genetic predisposition
• intelligence
• temperament
Characteristics of the Event
•
•
•
•
•
•
Nature of the event
Direct physical harm
Proximity to threat (emotional, physical)
Pattern
Duration
Relationship to perpetrator
Characteristics of the Family/Social System
• Supportive, calm, nurturing, vs chaotic, distant, absent, anxious
• Reactions of loved ones, calm nurturing, and sense of safety will
decrease vulnerability.
• If caregiver is traumatized their capacity to provide a consistent,
predictable, and nurturing environment is compromised
• Factors that increase stress related reactivity- will make children
more vulnerable while factors that provide structure,
predictability, nurturing and sense of safety will decrease
vulnerability
• Reactions of loved ones during the event
Medical Homes Can Make a Difference
• Foster children: one of most vulnerable populations
with complex needs due to the impact of trauma,
environmental instability
• Medical homes are in unique position to support
these children’s health and development with:
continuity of care, health &
developmental expertise,
community linkages, care
coordination, education/
support for caregivers and
child welfare staff
Credits for slides
Donna Potter – Center for Child and
Family Health
Michelle Hughes – Benchmark
Editing by Jean Smith &
Michelle Hughes