Transcript Parental Empathic Understanding: Impacting the Parent

THROUGH A TRAUMA LENS: IS THE
ADOLESCENT CONDUCT
DISORDERED OR SUFFERING
FROM TRAUMA?
Douglas Goldsmith, Ph.D.
Executive Director
The Children’s Center
Annual Troubled Youth Conference
2013
Referral concerns for 14 year old
• Withdrawn from others at home
• Extreme aggression toward parents and siblings
• Furious if wants and needs are not quickly satisfied
• Avoids or dismisses comforting comments or gestures
• Aggressive toward peers
• Fails to engage in social interactions
• Extreme bouts of anger and destructive behavior
• Multiple referrals to juvenile court for theft and assault
• Failing school
• Alcohol and drug abuse
Clinical Presentation
• Angry tone when greeted in waiting room
• Extremely hesitant to come to office. Does so only when
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threatened by his parents.
Poor eye contact
Difficult to hear
Defiant and oppositional when asked questions
Frequently shrugs shoulders or says, “I don’t know”.
Exhibits little insight into emotional functioning of self or
others
Sees future as hopeless but denies suicidal ideation
Diagnosis?
• Conduct
Disordered?
• Depressed?
• Traumatic Stress
Response?
Traumatic Experiences are Inherently
Complex
• Traumatic events include varying degrees of
objective life threat, physical violation, and
witnessing of injury or death.
• Trauma exposed children experience subjective
reactions to those events that include changes in
feelings, thoughts, and physiological responses;
and concerns about the safety of others.
NCTSN 2007
Children’s Response to Trauma
• Children’s reactions are strongly influenced by
prior experience and developmental level.
• Complexity increases in cases of multiple or
recurrent trauma exposure.
• Complexity increases when the primary caregiver
is a perpetrator of the trauma.
Early Trauma
“The earliest and possibly most
damaging psychological trauma is the
loss of a secure base.“
van der Kolk (1987)
Traumatic Events Generate Secondary
Adversities
• Family separations
• Financial hardship
• Legal proceedings
• These adversities may be sources of stress in
their own right
• Trauma reminders and loss reminders may
further increase the impact of trauma
NCTSN
Wide range of reactions to trauma
• Post trauma reactions can vary in nature, onset,
intensity, frequency, and duration
• Pattern and course of reactions influenced by the
traumatic experience and its consequences
• Child factors including prior trauma or loss and
post trauma physical and social environment
Post Traumatic Stress
• Post traumatic stress and grief reactions can
develop over time into psychiatric disorders
including PSTD, separations anxiety, and
depression.
• May disrupt child development, attachment, peer
relationships, emotional regulation
• May exacerbate pre-existing anxiety and
depression
Danger and Safety
• Trauma may
undermine children’s
sense of protection
and safety
• May magnify concerns
about danger to self
and others
Trauma Impacts the Family
• Losses and ongoing danger can impact
caregiving systems and lead to serious
disruptions in caregiver-child interactions and
relationships.
• Caregivers personal stress and concerns may
impair their ability to support the child.
• Child’s reduced sense of protection and security
may impact ability to respond positively to
caregiver’s efforts to provide support.
Prevalence
• Great Smokey Mountains Study
• Longitudinal study of children
• By age 16, 67% of children exposed to one
or more traumatic events.
Prevalence
• NIMH
• Life-time prevalence of PTSD for 13 to 18 year
olds is 4-6%
• National Intimate Partner and Sexual Violence
Survey
• 1 in 5 women report having been the victim of
rape at some time during their lives.
• 42% were abused prior to age 18
Prevalence
• NCTSN
• 80 percent of children referred for screening
and evaluation reported at least one trauma
• 77 percent of adolescents experienced more
than one trauma
• 31 percent of adolescents had five or more
Effects of Maltreatment
• Elevated rates of
aggression
• Over attribution of hostile
intent
• Lower social competence
• Less empathy
• Insecure attachments
• Lower IQ, language
ability, and school
performance
Children’s Response to Domestic Violence
“ Witnessing violence and
being the victim of violence
shatter the child’s confidence
that his well-being matters
and that adults will take care
of him.”
Lieberman and Van Horn (2005)
Effects of Exposure to Violence
• High levels of internalizing and externalizing
problems
• Affect dysregulation
• Difficulty establishing relationships
• Reenact the traumatic experience
• Sleep disturbance
• Intense fear and uncontrolled crying
• Aggression and noncompliance
Reactions to Trauma
• Distressing thoughts and images
• Upsetting emotional or physical reactions to
reminders of the experience – it might feel to the
child like it’s happening all over again
• Avoid talking or thinking about it. Go to great
lengths to avoid reminders of the event.
• Avoidance causes feelings of detachment
• Always being on the “look out” for danger, jumpy,
irritable, angry outbursts, can’t sleep
PTSD
Post Traumatic Stress Disorder
• Persistent re-experiencing of trauma
• Avoidance of stimuli associated with
trauma
• Increased arousal
• Impairments in social, emotional, and
occupational functioning
PTSD à deux
• “ The parents own traumatic response to the
trauma endured by the child creates a complex
system that may maintain or contribute to
dysfunction in both parent and child”
Appleyard & Osofsky (2003)
Relational PTSD
• Parents may be traumatized even if not present at the
trauma:
• Withdrawn/Unresponsive/Unavailable
• Emotionally and functionally unavailable
• May have suffered trauma in the past
• Overprotective/Constricting
• Preoccupied about the trauma re-occuring
• Reenacting/Endangering/Frightening
• Repeatedly ask about the event
Scheeringa & Zeanah (2001)
Impact of Trauma on Attachment
• Damage to child’s expectation that parents can
provide protection and comfort
• Those closest to me can cause the greatest hurt
• Sense of self and trust in others becomes
permeated with fear, anger, mistrust, and
hypervigilance
• These feeling conflict with the desire to be close
to parents
Lieberman and Van Horn (2005)
Attachment and Trauma
• “Young children’s ability to recover from the
damaging impact of traumatic events is deeply
influenced by the quality of the child’s
attachments and by the parents’ ability to
respond sensitively to the infant’s traumatic
responses”
Lieberman (2004)
Attachment and Trauma
• “Real-life
events can derail a previously secure
attachment by inducing in the parent emotionally
alienating responses such as guilt, fear, anger,
overprotectiveness, and affective dysregulation,
and by damaging the child’s trust in the parent as
a reliable protector.”
Lieberman (2004)
Reactive Attachment Disorder
• A rare, but serious condition, in which infants and
young children fail to establish healthy bonds with
parents or caregivers
• Child is typically neglected, abused, or orphaned.
• Need for comfort, affection, and nurturing are not
met and loving caring attachments are not
established.
Mayo Clinic
Reactive Attachment Disorder
• Begins before age 5
• Withdrawn, sad, listless
• Failure to smile
• Fail to visually follow others in the room
• Fail to reach out to be picked up
• No interest in interactive games
• Soothes self with rocking or self-stroking
• Calm when left alone
Signs of RAD in Adolescence
• Withdrawal from others
• Avoid or dismiss comforting comments or
gestures
• Aggressive toward peers
• Fail to engage in social interaction
• Fail to ask for support or assistance
• Mask feelings of anger or distress
• Alcohol or drug abuse
Causes of RAD
• Institutionalized care
• Frequent changes in caregivers
• Inexperienced parents
• Extreme neglect
• Extreme poverty
• Physical, sexual, or emotional abuse
• Forced removal from abusive home
• Impaired caregiver(s)
Complications of RAD
• Delayed learning or physical growth
• Poor self-esteem
• Delinquency, anti-social behavior
• Relationship problems
• Temper or anger problems
• Eating problems
• Depression / anxiety
• Academic problems
• Drug & alcohol addiction / sexual problems
Understanding Complex Trauma
• The dual problem of children’s exposure to
traumatic events and the impact of this exposure
on immediate and long term outcomes.
• Exposure to multiple traumatic events that occur
within the caregiving system – the social
environment that should be the source of safety
and stability for the child.
• Includes emotional, physical, sexual abuse and
witnessing domestic violence. (NCTSN, 2003)
Response to trauma
Parental neglect and abuse
Emotional dysregulation, loss of safe base, loss of
direction, and inability to detect or respond to danger
cues
Leads to subsequent trauma exposure, physical abuse,
sexual abuse, community violence
Complex Trauma Outcomes
• Multiple domains of impairment:
• Self-regulatory, attachment, anxiety, and
affective disorders in infancy and childhood
• Addictions, aggression, social helplessness and
eating disorders
• Dissociative, somataform, cardiovascular,
metabolic, and immunological disorders
• Sexual disorders in adolescence
• Revictimization
(NCTSN, 2003)
Children with disorders of attachment
Abused, rejected and neglected children develop
adaptive strategies based on control, avoidance,
and arrested affect.
When they join new families they bring with them
the fearful-aggressive controlling behaviors
developed in early years
Placements run high risk of major difficulties
Howe & Fearnly (2003)
Behavioral Concerns
• Lack of impulse control
• Self-destructive behaviors
• Destruction of property including favorite and
precious objects
• Verbal and physical aggression
• Stealing
• “Crazy” and obvious lying
• Inappropriate sexual conduct
• Cruelty to animals
Behavioral Concerns
• Preoccupation with violence, gore, fire
• Sleep disturbance
• Enuresis and encopresis
• Oppositional defiant behaviors
• Hyperactivity, constant need for stimulation
• Behave as though new caregivers are
responsible for past abuse
• Blame others
• Self endangerment
Emotional Concerns
Intense displays of anger, rage, violence
Inconsolable sadness, helplessness and
depression
Inappropriate emotional responses
Marked mood changes
Inappropriately demanding and clingy
Resentful
Social Concerns
• Superficial and charming with strangers
• Little eye contact
• Poor peer relationships
• Fight for control over everything
• Bossy
• Manipulative, controlling, exploitive
• Lack remorse or conscience
Physical and Developmental Concerns
• Poor hygiene, self-neglect
• Confusion over physiological states
• Abnormal eating patterns
• Body tension
• Accident prone
• High pain tolerance, over-reactive to minor
injuries
• Dislike being touched
Maltreated Children
• Poor understanding of emotions and theory of
mind and poor capacity for empathy
• Caregiving relationships are:
• Frightening and dangerous
• Hurtful and unpredictable
• Careless and confusing
• Don’t feel safe in intimate environments
• Loving care is best avoided
Attachment related situations
Caregiver seeks to care and protect
Produces intense arousal and results in
frightened and angry, hostile and helpless, bossy
and despairing behavior by the child.
Caregiver Response
• In danger of feeling helpless and angry by facing
so much aggression, confusion, need and mental
fragmentation
• Want to abdicate their role
• “I give up!”
• “I feel exhausted and depressed and helpless.”
Abused and Rejected Children
• Survive by downplaying negative affect
• Assume that protective care is not available at
times of need
• Develop high levels of self reliance and self
containment
• Are emotionally self-sufficient with new caregivers
Adoptive Parent Response
• Adoptive parent feels unneeded and unwanted
• As a result the parent backs off
• Deactivates caregiving
• May ignore the child
Impact on Parent-child Relationship
• “The replication is not inevitable, but the child’s
mental representation of how relationships work,
based on past experiences of rejection, can set
up powerful transactional forces into which new
parents can easily be drawn.”
Howe & Fearnley (2003)
Abuse, neglect and rejection
• Children deactivate attachment behavior
• Exhibit compulsive compliance
• Suppress or deny affect, power, and aggression
• Low on empathy due to defense against affect
Parent-child relationship
• “If the attachment figure is the source of the fear,
distress or confusion, the child is presented with a
psychological dilemma. The child experiences
simultaneous feelings of escape and approach
which cannot be resolved.”
Howe & Fearnley 2003
Parentified Behavior
• Carers whose own needs are greater than those
of their children include victims of DV, addiction to
drugs/alcohol, suffer major depression, or
struggle with unresolved trauma.
• Parentified behavior
• Children maintain false, brittle cheerfulness
• Constantly fear the loss of the parent
emotionally and psychologically
Abusive/neglectful Caregivers
• Children experience parents as out of control and
aggressive or helpless and needy
• Parents abdicate their role as protector
• Children avoid being cared for because it implies
danger, abandonment, rejection, confusion and
hurt.
• They seek to be in control rather than be
controlled
• Child becomes bossy, aggressive, violent, selfabusive, fearful, helpless, sad
Screening and Assessment
• Have you ever been traumatized?
Screening and Assessment
• Have you ever been
abused?
Screening
Has your child experienced any of the following? Please check all that apply:
______Physical abuse
______Emotional abuse
______Witnessed domestic violence
______Sexual abuse
______Loss of parent or caregiver
______Painful medical treatment/life threatening illness/hospitalization
______Severe dog bite
______Severe burns that required medical attention
______Death of close family member
______Auto accident requiring emergency medical attention
______Parent/caregiver deployed in the military
______Witnessed a parent being arrested
______Witnessed extreme neighborhood/community violence
______Other (please explain) ___________________________________
Screening
Therapeutic Goals
• Contain and reduce acting out behavior
• Identify and express emotions verbally
• Experience a safe, caring, nurturing, interested
relationship with significant adults
• Facilitate descriptions of past traumas and the
expressions associated with them
• Help child direct anger and sadness to the
perpetrators and not the current carers
Fearnly 2000
Treatment
• “Replicate developmental characteristics of
secure caregiving but with a child who deeply
mistrusts being looked after, cared for, protected
and benignly controlled by his attachment
figures.”
• Help child develop mentalizing capacity
• Understand themselves and others as
psychological and intentional beings
• How feelings affect behavior and how behavior
affects other people
Treatment
• Learn how to regulate emotions within the context
of close relationships
• Understand how social emotional information is
expressed and reflectively processed
• Address grief, loss, sadness and depression
associated with past and traumatic events
• Learn how feelings can be handled and
discharged appropriately
Model self-soothing
• What do you say to yourself?
• What do you do?
• Listen to music?
• Go for a run?
• Read?
• Eat?
• Watch TV?
Developing a Secure Base
• “When a child is held in mind, the child feels it,
and knows it. There is a sense of safety, of
containment, and, most important, existence in
that other, which has always seemed to me
vital. . . It seems to me that one of life’s greatest
privileges is just that – the experience of being
held in someone’s mind.”
Pawl (1995)
Reference
• Howe, D. & Fearnley, S. (2003). Disorders
of attachment in adopted and fostered
children: Recognition and treatment. Clin
Child Psychol and Psychiatry, 8, 369-387.
DOUGLAS GOLDSMITH, PH.D.
[email protected]
(801) 582 - 5534