Childhood Trauma:Childhood Trauma:An Overview An Overview

Steven Marans, PhDSteven Marans, PhDProfessor of Child Psychiatry and PsychiatryProfessor of Child Psychiatry and Psychiatry

Director, National Center for Children Director, National Center for Children Exposed to ViolenceExposed to Violence

Yale Child Study CenterYale Child Study Center

The Anatomy of Nightmare The Anatomy of Nightmare ExperienceExperience

Acute reactionsAcute reactions

Search for protectionSearch for protection

Hyper-vigilanceHyper-vigilance

Reasserting safe realityReasserting safe reality

Return to sleepReturn to sleep

Sources of dangerSources of danger

Loss of one’s own lifeLoss of one’s own life

Loss of the life of a significant otherLoss of the life of a significant other

Loss of love or another or of oneselfLoss of love or another or of oneself

Damage to the bodyDamage to the body

Loss of control of impulses, affects and Loss of control of impulses, affects and thoughtsthoughts

Loss of control of sense of agencyLoss of control of sense of agency

Psychological TraumaPsychological Trauma

Overwhelming, unanticipated danger that Overwhelming, unanticipated danger that leads to:leads to:

• Subjective experience of helplessness, Subjective experience of helplessness, loss loss

of control and terrorof control and terror• Immobilization of usual methods for Immobilization of usual methods for decreasing danger and anxiety (fight or flight)decreasing danger and anxiety (fight or flight)• Neurophysiological dysregulation that Neurophysiological dysregulation that compromises affective, cognitive and compromises affective, cognitive and behavioral responses to stimulibehavioral responses to stimuli

Post-Traumatic Stress Post-Traumatic Stress Reactions in ChildrenReactions in Children

A.A. Traumatic repetitionsTraumatic repetitions

1. Traumatic play1. Traumatic play

2. Play reenactment2. Play reenactment

3. Nightmares3. Nightmares

4. Flashbacks/dissociation4. Flashbacks/dissociation

5. Distressed when reminded5. Distressed when reminded

6. Somatic complaints when reminded6. Somatic complaints when reminded

Post-Traumatic Stress Post-Traumatic Stress Reactions in ChildrenReactions in Children

B. Avoidance, Numbing, RegressionB. Avoidance, Numbing, Regression 1. Avoids thinking or talking about1. Avoids thinking or talking about eventevent 2. Avoids reminders of event2. Avoids reminders of event 3. Impaired recollection/memory3. Impaired recollection/memory 4. New fears (e.g. Separation, 4. New fears (e.g. Separation, toiletting, darkness)toiletting, darkness) 5. Sense of a foreshortened future or 5. Sense of a foreshortened future or

impending doomimpending doom

Post-Traumatic Stress Post-Traumatic Stress Reactions in ChildrenReactions in Children

C. Increased arousalC. Increased arousal

1. Night terrors1. Night terrors

2. Difficulty falling/staying asleep2. Difficulty falling/staying asleep

3. Decreased attention/concentration3. Decreased attention/concentration

4. Irritability/anger 4. Irritability/anger

5. Increased aggression5. Increased aggression

6. Hypervigilance6. Hypervigilance

7. Exaggerated startle response7. Exaggerated startle response

Post-Traumatic Stress Post-Traumatic Stress Reactions in ChildrenReactions in Children

D. Decreased responsiveness, numbing, D. Decreased responsiveness, numbing, regressionregression

1. Constriction of play1. Constriction of play

2. Diminished interest in activities2. Diminished interest in activities

3. Social withdrawal/feelings of3. Social withdrawal/feelings of

detachmentdetachment

4. Restricted range of emotion 4. Restricted range of emotion

5. Developmental regression5. Developmental regression

Neuropsychological ResponsesNeuropsychological Responses in Children Exposed to Traumain Children Exposed to TraumaResponses in children are heterogeneous and dependent Responses in children are heterogeneous and dependent on a variety of factorson a variety of factorsExposure to trauma results in activation of stress-response Exposure to trauma results in activation of stress-response systemssystemsChildren attempt to apply an adaptive or learning responseChildren attempt to apply an adaptive or learning responseFollowing prolonged or intense exposure neural systems Following prolonged or intense exposure neural systems may changemay changeChanges occur due to prolonged neural activation and may Changes occur due to prolonged neural activation and may result in neurochemical imbalances, altered neural result in neurochemical imbalances, altered neural microarchitecture (synaptic sculpting) and changes in microarchitecture (synaptic sculpting) and changes in neural organization and functioningneural organization and functioningChanges may result in imbalances in children’s Changes may result in imbalances in children’s physiological homeostasisphysiological homeostasis

Long-term ConsequencesLong-term Consequences of exposure to traumaof exposure to trauma

PTS reactions can be PTS reactions can be chronic chronic

If untreated, can persist If untreated, can persist for long periods of time for long periods of time and into adulthoodand into adulthood

Can result in a variety Can result in a variety of emotional, of emotional, behavioral, social and behavioral, social and psychiatric psychiatric consequencesconsequences

Examples of long-term Examples of long-term sequelae:sequelae:

DepressionDepression Anxiety Anxiety Attachment problems Attachment problems

Learning problemsLearning problems Eating disorders Suicidal Eating disorders Suicidal

behaviorbehavior Substance abuseSubstance abuse Violent/Abusive behaviorsViolent/Abusive behaviors Somatic problemsSomatic problems

Event FactorsEvent Factors

How directly events affect their lives:How directly events affect their lives:Physical proximity to eventPhysical proximity to event

Emotional proximity to event (threat to Emotional proximity to event (threat to child, parent versus stranger)child, parent versus stranger)

Secondary effects-of primary importanceSecondary effects-of primary importance– Physical Displacement and Social DisruptionPhysical Displacement and Social Disruption

Individual FactorsIndividual Factors

Genetic vulnerabilities and capacitiesGenetic vulnerabilities and capacities

Prior history (i.e. consistent stress or one Prior history (i.e. consistent stress or one or more stressful life experience/s)or more stressful life experience/s)

History of psychiatric disorderHistory of psychiatric disorder

Familial health or psychopathologyFamilial health or psychopathology

Family and social supportFamily and social support

Age and developmental levelAge and developmental level

Exposure RatesExposure RatesChild abuse and neglect cases are substantiated at the rate of 1 million per Child abuse and neglect cases are substantiated at the rate of 1 million per year, with 3 million yearly reports (USDHHS, 2005 )year, with 3 million yearly reports (USDHHS, 2005 )

At least one traumatic event was experienced by 64% of children in grades 4 At least one traumatic event was experienced by 64% of children in grades 4 through 12 in NYC through 12 in NYC prior toprior to the September 11, 2001 attacks on the World Trade the September 11, 2001 attacks on the World Trade Centers (Hoven et al., 2002)Centers (Hoven et al., 2002)

More than 500,000 children are placed in the foster care system each year More than 500,000 children are placed in the foster care system each year (Administration for Children and Families, 2005). Of these, 48% have been (Administration for Children and Families, 2005). Of these, 48% have been placed due to physical abuse and 45% due to sexual abuse (Dwyer & Noonan, placed due to physical abuse and 45% due to sexual abuse (Dwyer & Noonan, 20012001

The long-term effects are evident in reports that nearly two thirds of people in The long-term effects are evident in reports that nearly two thirds of people in drug treatment programs reported being abused as children (Swan, 1998)drug treatment programs reported being abused as children (Swan, 1998)

Sexual abuse has been reported by 62% of teenage mothers, and traumatic Sexual abuse has been reported by 62% of teenage mothers, and traumatic childhood events are documented in the histories of as much as 98.6% of childhood events are documented in the histories of as much as 98.6% of juvenile delinquents (Carrion & Steiner, 2000)juvenile delinquents (Carrion & Steiner, 2000)

Exposure and ConsequencesExposure and Consequences3-10 million3-10 million children each yearchildren each year (Carlson, 1984; Carter, Weithorn, Behrman, (Carlson, 1984; Carter, Weithorn, Behrman, 1999; Silvern, et al., 1995; Strauss and Gelles, 1990).1999; Silvern, et al., 1995; Strauss and Gelles, 1990).

A more recent study indicates closer to 15.5 million children exposed to A more recent study indicates closer to 15.5 million children exposed to domestic violence annually; 7 million exposed to violence characterized as domestic violence annually; 7 million exposed to violence characterized as severe (McDonald, Jouriles, Ramisetty-Mikler, Caetano and Green, 2006)severe (McDonald, Jouriles, Ramisetty-Mikler, Caetano and Green, 2006)

Children who have been exposed to domestic violence are 158% more likely to Children who have been exposed to domestic violence are 158% more likely to be victimized by violence themselves than counterparts from non-violent be victimized by violence themselves than counterparts from non-violent households—the risk was 115% higher for boys and 229% higher for girls households—the risk was 115% higher for boys and 229% higher for girls (Mitchell and Finkelhor, 2001).(Mitchell and Finkelhor, 2001).

For example, 60%-75% of families where there is domestic violence also have For example, 60%-75% of families where there is domestic violence also have children who are battered (Osofsky, 1999; McKibben, Devos, and Newberger, children who are battered (Osofsky, 1999; McKibben, Devos, and Newberger, 1989).1989).

Battered women are more likely to abuse their children more than non-battered Battered women are more likely to abuse their children more than non-battered women (Straus and Gelles, 1990; Ross, 1996). women (Straus and Gelles, 1990; Ross, 1996).

Exposure and ConsequencesExposure and ConsequencesExposure to domestic violence in childhood is associated with increased Exposure to domestic violence in childhood is associated with increased likelihood of involvement in physical aggression, delinquent and violent likelihood of involvement in physical aggression, delinquent and violent behaviors (Jenkins & Bell, 1997;Thornberry, 1994; Shakoor & Chalmers, 1991). behaviors (Jenkins & Bell, 1997;Thornberry, 1994; Shakoor & Chalmers, 1991).

Children exposed to domestic violence are more prone to depressive Children exposed to domestic violence are more prone to depressive symptoms than those not exposed (Sternberg, et al., 1993).symptoms than those not exposed (Sternberg, et al., 1993).

Annual costs to US businesses in lost work time, increased health care costs, Annual costs to US businesses in lost work time, increased health care costs, higher turnover and lower productivity is about $5-10  billion (National Center higher turnover and lower productivity is about $5-10  billion (National Center for Injury Prevention and Control, 2003)for Injury Prevention and Control, 2003)

The health-related costs of rape, physical assault, stalking and homicide The health-related costs of rape, physical assault, stalking and homicide committed by intimate partners exceed $5.8 billion each year. Of that amount, committed by intimate partners exceed $5.8 billion each year. Of that amount, nearly $4.1 billion are for direct medical and mental health care services, and nearly $4.1 billion are for direct medical and mental health care services, and nearly $1.8 billion are for the indirect costs of lost productivity or wages.nearly $1.8 billion are for the indirect costs of lost productivity or wages.

Elements of ResponseElements of Response

Cross-training, collaboration and establishment of roles (e.g., safety, security, Cross-training, collaboration and establishment of roles (e.g., safety, security, communication with families, support services) of responding systems of carecommunication with families, support services) of responding systems of careDistinguishing adult and child experiences of traumatic events—considering Distinguishing adult and child experiences of traumatic events—considering developmental, family and social contextsdevelopmental, family and social contextsDetermining continuation or cessation of threat as essential to trauma assessment and Determining continuation or cessation of threat as essential to trauma assessment and intervention strategiesintervention strategiesPsycho-education for children, parents and other caregivers about traumatic experience Psycho-education for children, parents and other caregivers about traumatic experience and techniques for regaining controland techniques for regaining controlRe-establishing order and routines of daily lifeRe-establishing order and routines of daily life

Police may consult about any child or adolescent exposed to or affected by violence or Police may consult about any child or adolescent exposed to or affected by violence or other PTEother PTEPolice contact with families provides the opportunity for clinical contactPolice contact with families provides the opportunity for clinical contactAllows for immediate intervention for children exposed to violence either at the scene of Allows for immediate intervention for children exposed to violence either at the scene of the incident or within a few hoursthe incident or within a few hoursCoordination of clinical and policing services facilitates safety and security of victims and Coordination of clinical and policing services facilitates safety and security of victims and witnesseswitnesses

Intervention strategiesIntervention strategies

Acute response: stabilization, contact and Acute response: stabilization, contact and identifying trauma riskidentifying trauma risk

Monitoring/surveillance and follow-upMonitoring/surveillance and follow-up

Child and Family Traumatic Stress Child and Family Traumatic Stress Interventions (Peri-traumatic): clinic-; Interventions (Peri-traumatic): clinic-; home-; school-basedhome-; school-based

Early Intervention: CollaborationEarly Intervention: Collaboration

Early interventions require collaboration Early interventions require collaboration amongamong– Medical personnelMedical personnel– Mental health professionalsMental health professionals– Law EnforcementLaw Enforcement– FirefightersFirefighters– EMSEMS– CourtsCourts– SchoolsSchools

Immediate InterventionsImmediate Interventions

Children who are direct witnesses or Children who are direct witnesses or victimsvictims– Ensure physical health: Have medical Ensure physical health: Have medical

personnel check if concernpersonnel check if concern– First and foremost: reunite with known caring First and foremost: reunite with known caring

adults (especially parents)adults (especially parents)– If adults not available keep with teachers, If adults not available keep with teachers,

friends and peers friends and peers – Move to safe place when possible, but in Move to safe place when possible, but in

group or with familygroup or with family

An Example of Collaboration:An Example of Collaboration:The CD-CP Program The CD-CP Program

Acute Response Consultation Service (24/7)Acute Response Consultation Service (24/7)Weekly Multidisciplinary Program ConferenceWeekly Multidisciplinary Program ConferenceWeekly Clinical Case ConferenceWeekly Clinical Case ConferenceChild Development Fellowships and Training Child Development Fellowships and Training for Police Personnelfor Police PersonnelPolice Fellowships and Training for Clinical Police Fellowships and Training for Clinical FacultyFacultySeminar on Child Development, Human Seminar on Child Development, Human Functioning and Police StrategiesFunctioning and Police Strategies

Continuing ThreatContinuing Threat

Children’s worry about their safety can be Children’s worry about their safety can be a powerful contributor to or source of a powerful contributor to or source of depressive and anxiety symptoms and depressive and anxiety symptoms and may also lead to oppositional and may also lead to oppositional and aggressive behavior as children’s anxiety aggressive behavior as children’s anxiety leads to a misunderstanding of leads to a misunderstanding of environmental cues in an attempt to environmental cues in an attempt to reassert some sense of control. (Ford, reassert some sense of control. (Ford, 2002) 2002)

Continuing ThreatContinuing Threat

Early intervention strategies are well Early intervention strategies are well placed to identify and assess the nature, placed to identify and assess the nature, degree and reality of the threat and, in degree and reality of the threat and, in turn, help the child and family cope with turn, help the child and family cope with the current situation as best as possible the current situation as best as possible

Continuing ThreatContinuing Threat

If the threat is imagined or greatly If the threat is imagined or greatly exaggerated, psychotherapeutic exaggerated, psychotherapeutic treatments may be very usefultreatments may be very useful

However if credible, early interveners However if credible, early interveners should work with law enforcement and should work with law enforcement and court personnel to ensure the child and court personnel to ensure the child and families’ physical and emotional safety families’ physical and emotional safety

Physical DisplacementPhysical Displacementand Social Disruptionand Social Disruption

Physical displacement and social Physical displacement and social disruption has been found to be the disruption has been found to be the highest correlated factor related to highest correlated factor related to outcome after traumatic events. outcome after traumatic events. (Laor, (Laor, Wolmer, & Cohen, 2001; Laor et al., 1997; Laor, Wolmer, & Cohen, 2001; Laor et al., 1997; Laor, Wolmer, Mayes, Golomb, & et al., 1996; Lonigan et al., Wolmer, Mayes, Golomb, & et al., 1996; Lonigan et al., 1994) 1994)

Physical DisplacementPhysical Displacementand Social Disruptionand Social Disruption

Advantage in recognizing this risk for a particular Advantage in recognizing this risk for a particular family and bringing community and other family and bringing community and other resources to bear resources to bear

May include housing displacements, economic May include housing displacements, economic hardship due to job loss or expenses associated hardship due to job loss or expenses associated with the event, isolation from friends and with the event, isolation from friends and extended family related to the many issues that extended family related to the many issues that may be associated with the episode of violence may be associated with the episode of violence etc. etc.

Physical DisplacementPhysical Displacementand Social Disruptionand Social Disruption

School provides needed support and School provides needed support and structurestructure

When children are removed from their When children are removed from their school environment they lose many of the school environment they lose many of the resources of known adults, friends and resources of known adults, friends and schoolmates on whom they often rely. schoolmates on whom they often rely.

SchoolsSchools

Schools are uniquely positioned to provide Schools are uniquely positioned to provide normalization and security to children.normalization and security to children.Schools provide an optimal location for Schools provide an optimal location for discussion, peer and adult support.discussion, peer and adult support.Requires that teachers and staff be Requires that teachers and staff be prepared and able to engageprepared and able to engageWithin classroom discussions are bestWithin classroom discussions are bestSchools should remain open whenever Schools should remain open whenever possiblepossible

SchoolsSchools

In order for schools to support children In order for schools to support children who are having stress reactions, staff must who are having stress reactions, staff must have support and be aware of own have support and be aware of own responses to stress inducing eventresponses to stress inducing event

Organization among staff is essential to Organization among staff is essential to work with situations that may cause stress work with situations that may cause stress reactionsreactions

Principles of InterventionPrinciples of Intervention

1. 1. Do no harmDo no harm2. 2. Child Development is basis ofChild Development is basis of

interventionintervention3. 3. Parents or primary caretakers are Parents or primary caretakers are essential essential

therapeutic agents.therapeutic agents.4. 4. Restoration of external structure and Restoration of external structure and authorityauthority5.5. Amelioration of threatAmelioration of threat

Principles of InterventionPrinciples of Intervention

6. Do not assume knowledge of what is the 6. Do not assume knowledge of what is the most salient event, image or idea for the most salient event, image or idea for the individualindividual

7. Early responses require collaboration with 7. Early responses require collaboration with first responders and others (police, fire-first responders and others (police, fire-rescue, EMS, Red Cross, courts etc.)rescue, EMS, Red Cross, courts etc.)

National Center for Children National Center for Children Exposed to ViolenceExposed to Violence

At the At the YALE CHILD STUDY CENTERYALE CHILD STUDY CENTER

For more information please refer to our For more information please refer to our websitewebsite

www.nccev.orgwww.nccev.org