Down will come baby, cradle and all: diagnostic and therapeutic implications of chronic trauma on child development

Neurocognitive considerations in the treatment of attachment and complex trauma in children

Accumulating evidence suggests that children suffering deprivation and maltreatment at critical times in their development often pay a cognitive toll. While children vary to the extent that neurocognitive domains are affected, those factors influence how children process, manage and understand traumatic and attachment experiences as well as how they respond to treatment. Current research on trauma and attachment favor some aspects of cognition over others. The literature discusses attention, memory, cognitive biases, internal working models, beliefs and attributions as ways that impact an individual's understanding of experience. Other categories such as working memory, processing speed, verbal, auditory or perceptual processing, metacognitive skills, and cognitive rigidity or flexibility rarely surface. This paper examines what is and is not known about the interface of cognition with attachment and complex trauma and how that knowledge can inform treatment. It explores existing research and offers a case vignette as an example of how that knowledge can be integrated into treatment strategies.

Towards a richer understanding of school-age children's experiences of domestic violence: the voices of children and their mothers

Millions of children are exposed to domestic violence. How children negotiate and make sense of living with domestic violence is still under-researched. This study sought to capture the dual-perspectives of school-aged children and their mothers, to develop a richer understanding of children's experiences of domestic violence, using a community-based sample. A qualitative research design was employed, with interpretative phenomenological analysis used to interpret the data. Five school-aged children and three of their mothers participated in the study. Two master themes are discussed from the analysis of the children's perspective: domestic violence through the eyes of children; and learning from children's experiences. Two master themes are discussed from the analysis of the mothers' perspective: reflecting on the child in the context of domestic violence; and learning from mothers: insights, support and services. The crucial importance of the mother-child relationship in shaping children's experience of domestic violence was illustrated in both the perspectives; a finding which may have important implications for the development of interventions. It was also evident that children as young as eight were able to powerfully articulate their experiences of domestic violence.

Infant pain-related negative affect at 12 months of age: early infant and caregiver predictors

OBJECTIVES

To examine the predictive relationships of early infant and caregiver variables on expressed pain-related negative affect duration at the 12-month immunization.

METHODS

Infants and their caregivers (N = 255) were followed during immunization appointments over the first year of life. Latent growth curve modeling in a structural equation modeling context was used.

RESULTS

Higher levels of initial infant pain reactivity at 2 months and caregiver emotional availability averaged across 2, 4, and 6 months of age were related to larger decreases in the duration of infant negative affect over the first 6 months of life. Longer duration of infant negative affect at 2 months and poorer regulation of infant negative affect over the first 6 months of life predicted longer durations of infant negative affect by 12 months.

CONCLUSIONS

Infant negative affect at 12 months was a function of both infant factors and the quality of caregiver interactive behaviors (emotional availability) in early infancy.

Does child abuse and neglect explain the overrepresentation of Aboriginal and Torres Strait Islander young people in youth detention? Findings from a birth cohort study

OBJECTIVE

Determine whether a history of family social disadvantage and/or child abuse and neglect explain the overrepresentation of Indigenous Australian young people in youth detention.

METHODS

Maternal survey data from the Mater University Study of Pregnancy was linked with child abuse and neglect and youth justice data from the Queensland Department of Families, Youth and Community Care.

RESULTS

Indigenous Australian children were 1.81 times more likely to be notified to child protection authorities for maltreatment and 1.77 times more likely to have that maltreatment substantiated. Indigenous Australian young people were 3.07 times more likely to have a youth justice history. When adjusted for social disadvantage, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.51 times that of their non-Indigenous peers. When adjusted for substantiated maltreatment, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.83 times that of their non-Indigenous peers. When adjusted for both social disadvantage and substantiated maltreatment, the odds of the Indigenous Australian youth having had involvement with the youth justice authorities remained 2.48 times that of their non-Indigenous peers.

CONCLUSIONS

The overrepresentation of Australian Aboriginal and Torres Strait Islander young people in the youth justice system, including Youth Detention, is only partly explained by their greater social disadvantage and by their greater experience of substantiated maltreatment, either separately or combined.

From traumatic attachment to somatization disorder

OBJECTIVE

This paper emphasizes attachment trauma as an important etiological factor in somatization disorder and psychoanalytic psychotherapy as an effective treatment.

METHOD

Weekly psychotherapy with an 18 year old with somatization disorder, using the Conversational Model, is described.

CONCLUSION

Early cumulative trauma has far-reaching health consequences. Brief psychotherapy produces symptom relief, and long-term analytic therapy is necessary for sustained improvement.

Family relationships and children's stress responses

In this chapter, the theoretical and empirical associations between family relationships and children's responses to stressors are reviewed. Family relationships explored are primarily dyadic, representing the emphasis of past empirical research; these include parent-parent, parent-child, and sibling relationships. However, in recognition of the more complicated and interconnected nature of family relationships, also reviewed are associations between the broader family context and children's stress responses. Multiple measures of stress responses are considered, including both physiological and emotional responses to and recovery from stressful experiences. Overall, the studies reviewed suggest that poor-quality family environments, including those characterized by low emotional support or high conflict, are associated with dysregulated stress responses throughout childhood and adolescence. In contrast, children and adolescents in families with high emotional support or low conflict seem to be protected from developing stress regulatory problems. Limitations in this body of research as well as directions for future research are discussed.

Psychopharmacologic treatment of traumatized youth

PURPOSE OF REVIEW

To review and summarize existing literature regarding pharmacological interventions for post-traumatic stress disorder (PTSD) in children and adolescents. A literature search limited to articles focused on the pharmacological treatment of children aged 0-18 years with a history of trauma and/or PTSD was conducted through the National Library of Medicine and PsychInfo, 1967-present, and each citation manually reviewed.

RECENT FINDINGS

Pharmacologic trials for pediatric PTSD are limited in scope and number, with one small double-blind, randomized controlled trial of the selective serotonin reuptake inhibitor (SSRI) sertraline. Two brief, small, double-blind, randomized controlled trials of imipramine for children and adolescents with acute stress disorder have been conducted, with mixed results. Only case reports or open-labeled trials have been conducted with alpha-adrenergic agents, other antidepressants, atypical antipsychotics, and antiepileptic agents.

SUMMARY

Data supporting the use of medications in the treatment of PTSD in children and adolescents are limited. SSRIs show promise and deserve additional study, but conclusive support for their use is not available as it is in adults. Additional research is needed, with other drugs of interest including other antidepressants, alpha-adrenergic agents, and possibly the antiepileptic agent carbamazepine.

[Developmental trauma disorder: towards a rational diagnosis for chronically traumatized children]

Less than eight years after the establishment of the National Child Traumatic Stress Network in 2001 it has become evident that the current diagnostic classification system is inadequate for tens of thousands of traumatized children. While the inclusion of PTSD in the psychiatric classification system in 1980 led to extensive scientific studies of that diagnosis, over the past 25 years there has been a parallel emergence of the field of Developmental Psychopathology, which has documented the effects of interpersonal trauma and disruption of caregiving systems on the development of affect regulation, attention, cognition, perception, and interpersonal relationships. Another significant development has been the increasing documentation of the effects of adverse early life experiences on brain development. The goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma. Whether or not they exhibit some symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms.

'It's been really, really hard': a qualitative study of the health problems of people receiving emergency relief in Australia

The aim of the research reported in this paper was to explore the perspectives and insights of emergency relief recipients in relation to their complex health problems, which had contributed to their position of needing to seek emergency relief. The sample consisted of 20 adults aged between 19 and 51 years who had received emergency relief in a regional city in Victoria, Australia. Non-probability sampling was used, employing the convenience sampling procedure. A qualitative, exploratory research approach utilising in-depth interviews was selected to obtain data from the respondents. The method of data analysis used involved open, axial and selective coding. The main findings were that the participants experienced abuse and neglect in childhood, the effects of mental health problems, going without food, lack of access to and the high cost of health care, and the interactive aspects of health problems and poverty. Implications for policy and service delivery are outlined.

The important role of the school following suicide in Norway. What support do young people wish that school could provide?

Little knowledge has been documented on the experiences of young suicide survivors, how they are coping with schooling and what kind of support they think they need. Thirty-two adolescents who had lost a close family member or friend by suicide participated in a research project by filling in questionnaires and participating in focus group interviews. The article explores the young people's experiences with and wishes for help from the school, including teachers and school nurses. The results show that the young people struggle with concentration and learning new material. Although many are satisfied with care and support while at school, the young bereaved do not receive all the assistance they wish for and need. In order to adequately support young suicide survivors to continue schooling, it is worth listening to their opinions about how they may be approached.

Childhood maltreatment in patients with somatization disorder

OBJECTIVE

There is converging evidence indicating a close association between trauma, particularly childhood trauma, and adult somatization, but studies using both structured interviews and self-report measures to assess childhood adversities in patients with somatization disorder are scarce.

METHODS

A total of 28 patients (82% women, mean age=41.7+/-10.1 years) meeting DSM-IV criteria for somatization disorder as confirmed by the Structured Clinical Interview for DSM-IV, Axis I (SCID-I) underwent the Structured Trauma Interview (STI) and the Childhood Trauma Questionnaire (CTQ). The comparison group consisted of 28 patients with major depression, but without a lifetime diagnosis of somatization disorder matched for gender and age.

RESULTS

Univariate analyses of both the STI and the CTQ data showed that somatizing patients had been exposed to childhood sexual and physical abuse significantly more often than major depressive disorder (MDD) patients. In logistic regression analysis with somatization disorder as the dependent variable, sexual abuse emerged as the only significant predictor, and the odds of having been sexually abused were ninefold higher in patients with somatization disorders relative to MDD subjects (odds ratio=9.39; 95% confidence interval=1.73-50.96). There were no differences between somatizing and depressed participants with respect to other types of maltreatment.

CONCLUSION

Childhood sexual abuse is an important factor in the multifactorial aetiopathogenesis of somatization disorder. Diagnostic and therapeutic implications are discussed.

Biology, childhood trauma, and murder: rethinking justice

This article reviews recent findings in the developmental neurophysiology of children subjected to psychological trauma. Studies link extreme neglect and abuse with long-term changes in the nervous and endocrine systems. A growing body of research literature indicates that individuals with severe trauma histories are at higher risk of behaving violently than those without such histories. This article links these two research areas by discussing how severe and protracted child abuse and/or neglect can lead to biological changes, putting these individuals at greater risk for committing homicide and other forms of violence than those without child maltreatment histories. The implications of these biological findings for forensic evaluations are discussed. Based on new understanding of the effects of child maltreatment, the authors invite law and mental health professionals to rethink their notions of justice and offender accountability, and they challenge policymakers to allocate funds for research into effective treatment and for service delivery.

Are Reports of Childhood Abuse Related to the Experience of Chronic Pain in Adulthood?

BACKGROUND

Recent empirical evidence suggests that childhood abuse may be related to the experience of chronic pain in adulthood. To date, a systematic quantitative review of the literature has not been presented.

OBJECTIVES

The purpose of this study was to use meta-analytic procedures to evaluate the strength of existing evidence of the association between self-reports of childhood abuse and the experience of chronic pain in adulthood.

METHODS

Analyses were designed to test the relationship across several relevant criteria with 4 separate meta-analyses.

RESULTS

Results of the analyses are as follows: 1) individuals who reported being abused or neglected in childhood also reported more pain symptoms and related conditions than those not abused or neglected in childhood; 2) patients with chronic pain were more likely to report having been abused or neglected in childhood than healthy controls; 3) patients with chronic pain were more likely to report having been abused or neglected in childhood than nonpatients with chronic pain identified from the community; and 4) individuals from the community reporting pain were more likely to report having been abused or neglected than individuals from the community not reporting pain.

CONCLUSION

Results provide evidence that individuals who report abusive or neglectful childhood experiences are at increased risk of experiencing chronic pain in adulthood relative to individuals not reporting abuse or neglect in childhood.

Cardiovascular stress responses in young adulthood associated with family-of-origin relationship experiences

OBJECTIVE

The impact of relationships within the family-of-origin on the development of physiological stress responses has significant consequences for long-term vulnerability to stress-related illness.

METHODS

The current study evaluated systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) responses to a challenge task in 150 young adults from families characterized by parental loss, divorce, or intact marriages.

RESULTS

Overall, higher-quality family relationships were associated with stronger recovery of SBP. For DBP and HR, interactions were found in which higher-quality family relationships were associated with stronger recovery in the loss group relative to the divorce and intact groups. Good support was found for a mediational model outlining self-regulatory abilities as a pathway linking family relationships to SBP reactivity and recovery.

CONCLUSIONS

Findings provide further evidence that family-of-origin relationship experiences can affect cardiovascular responses to later-life stress.

Recognizing the potential effect of stress and trauma on premature infants in the NICU: how are outcomes affected?

Extensive research of the long-term outcomes of premature infants has shown significant risk for emotional, behavioral, and psychological problems. Chronic stress and trauma have not been researched specifically in this population, however, studies of the neurobiological impact of traumatic stress on infants and children in the general population show noteworthy parallels in symptomotology. Careful consideration should be given to practitioner caregiving, parent education, future research, assessment, and interventions while being mindful of the impact that chronic stress and trauma may have on the developing brain of the premature infant.

Living in danger: the impact of chronic traumatization and the traumatic context on posttraumatic stress disorder

In this article on the effects of chronic traumatization, research is reviewed regarding the association between chronicity of traumatization and posttraumatic stress disorder (PTSD) symptomatology. The contribution of the broader traumatic context to PTSD symptomatology is also examined. This review focuses on three populations: combat veterans, child sexual abuse survivors, and survivors of domestic violence. The challenges of defining chronicity of a traumatic event and traumatic context are addressed. Finally, suggestions for future directions are provided.

Maltreatment and trauma: tracking the connections in adolescence

Posttraumatic stress disorder is one of the most common and often prolonged consequences of childhood maltreatment. In this article the authors consider theories of trauma continuity, with emphasis on a relational path to maladjustment that links childhood maltreatment to elevated trauma symptomatology and intimate victimization in adolescent dating relationships.

The neurobiology of childhood trauma and abuse

During the past decade there has been rapid progress in the understanding of the effects of exposure to traumatic life experiences on subsequent psychopathology in children. Trauma exposure affects what children anticipate and focus on and how they organize the way they appraise and process information. Trauma-induced alterations in threat perception are expressed in how they think, feel, behave, and regulate their biologic systems. The task of therapy is to help these children develop a sense of physical mastery and awareness of who they are and what has happened to them to learn to observe what is happening in present time and physically respond to current demands instead of recreating the traumatic past behaviorally, emotionally, and biologically.

Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder

OBJECTIVE

This review integrates recent advances in attachment theory, affective neuroscience, developmental stress research, and infant psychiatry in order to delineate the developmental precursors of posttraumatic stress disorder.

METHOD

Existing attachment, stress physiology, trauma, and neuroscience literatures were collected using Index Medicus/Medline and Psychological Abstracts. This converging interdisciplinary data was used as a theoretical base for modelling the effects of early relational trauma on the developing central and autonomic nervous system activities that drive attachment functions.

RESULTS

Current trends that integrate neuropsychiatry, infant psychiatry, and clinical psychiatry are generating more powerful models of the early genesis of a predisposition to psychiatric disorders, including PTSD. Data are presented which suggest that traumatic attachments, expressed in episodes of hyperarousal and dissociation, are imprinted into the developing limbic and autonomic nervous systems of the early maturing right brain. These enduring structural changes lead to the inefficient stress coping mechanisms that lie at the core of infant, child, and adult posttraumatic stress disorders.

CONCLUSIONS

Disorganised-disoriented insecure attachment, a pattern common in infants abused in the first 2 years of life, is psychologically manifest as an inability to generate a coherent strategy for coping with relational stress. Early abuse negatively impacts the developmental trajectory of the right brain, dominant for attachment, affect regulation, and stress modulation, thereby setting a template for the coping deficits of both mind and body that characterise PTSD symptomatology. These data suggest that early intervention programs can significantly alter the intergenerational transmission of posttraumatic stress disorders.

Traumatic stress in the 21st century

OBJECTIVE

The introduction to a series of articles on traumatic stress aims to examine the ambivalent relationship between traumatic stress and psychiatry. It provides an outline to the very significant contribution that this field made before the conceptualisation of posttraumatic stress disorder (PTSD) and how the research and theoretical thinking in this field can provide many insights into the relationship between environmental factors and psychological health. It focuses on the relevance of this field to general psychiatry.

RESULT

Posttraumatic stress disorder has emerged as the most common anxiety disorder in women. As well, there are high rates discovered in a range of chronically ill psychiatric patient populations. In particular, strategies for dealing with the issues of childhood abuse and neglect are not often considered by adult psychiatric services for the chronically and severely mentally ill, despite there being important predictors of suicidal behaviour, hospitalisation and prolonged disability. An effective consideration of the available evidence is often complicated by concerns about the impact of financial compensation on the presentation of psychopathology. This is a complex social dialectic whose impact is important to the practise of psychiatry. Equally, this field in itself must avoid becoming excessively rigid in its clinical definitions and the particular interventions which are espoused.

CONCLUSIONS

The impact of traumatic events on long-term psychological adjustment and physical health have been under estimated. Identification of those at risk is an important issue given that effective treatments are now available. This is an area in which further conceptual thinking is required. It also provides particular opportunities to explore the biological processes of, and interaction between, the environment and the underlying genetic and neurobiological processes which are critical to the modulation of psychopathology.