Trauma and Stress+Related Disorders Study Guide.pdf

Trauma- and Stressor-Related Disorders in Children and Stressor-Related Disorders in Children Trauma- and stressor-related disorders consist of acute stress disorder, adjustment disorder, posttraumatic stress disorder (PTSD), reactive attachment disorder, and disinhibited social engagement disor...

Trauma- and Stressor-Related Disorders in Children and Stressor-Related Disorders in Children Trauma- and stressor-related disorders consist of acute stress disorder, adjustment disorder, posttraumatic stress disorder (PTSD), reactive attachment disorder, and disinhibited social engagement disorder Child abuse and neglect have been recognized as a significant problem since the early 1970s In North America, it is estimated that 1 in 10 children experience some form of sexual victimization, as well as harsh physical punishment that puts them at risk of injury Non-accidental trauma includes physical abuse, neglect, sexual abuse, and emotional abuse Abused or neglected children face paradoxical dilemmas, longing to belong to their family despite the violence and abuse they experience Major cultural traditions have condoned the abuse of family members, with the husband holding absolute authority over the family Efforts to value the rights and needs of children have been spurred by the 1989 Convention on the Rights of Children Healthy parenting involves knowledge of child development, coping skills, parent-child attachment, and communication A fundamental and expectable environment for children requires protective and nurturing adults, socialization opportunities, and a gradual shift of control from parent to child and the community Healthy parenting also involves home management skills, shared parenting responsibilities, and provision of social and health services Child care exists along a continuum, from appropriate and healthy forms of child-rearing actions that promote development to ineffective and abusive actions that hinder development. Child Care Continuum of Care Negative end: parents who violate their children’s basic needs and dependency status in a physically, sexually, or emotionally intrusive or abusive manner, or by neglect Most Positive Parenting Style: Provides a variety of sensory stimulation and positive emotional expressions, engages in competent, child-centered interactions to encourage development, demonstrates consistency and predictability to promote their relationship, occasionally scolds, criticizes, interrupts child activity, uses emotional delivery and tone that are firm but not frightening Most Negative Parenting Style: Shows rigid emotional expression and inflexibility in responding to child, insensitive to child's needs, emotionally or physically rejects child's attention, often responds unpredictably with emotional discharge, uses cruel and harsh control methods that frighten child Trauma, Stress, and Maltreatment: A child who was abused and also suffering from a clinical disorder (e.g., depression), DSM-5 considers some forms of child stress and maltreatment under the category “Other conditions that may be a focus of clinical attention.” Continuum of Care (2 of 3): Stimulation and Emotional Expressions: Provides a variety of sensory stimulation and positive emotional expressions Expresses joy at child's efforts and accomplishments Shows rigid emotional expression and inflexibility in responding to child Seems unconcerned with child's developmental/psychological needs Expresses conditional love and ambivalent feelings toward child Shows little or no sensitivity to child's needs Interactions: Engages in competent, child-centered interactions to encourage development Friendly, positive interactions that encourage independent exploration Often insensitive to child's needs; unfriendly Poor balance between child independence and dependence on parent Emotionally or physically rejects child's attention Takes advantage of child's dependency status through coercion, threats, or bribes Consistency and Predictability: Demonstrates consistency and predictability to promote their relationship Makes rules for safety and health, appropriate safeguards for child's age  Often responds unpredictably, sometimes with emotional discharge Responds unpredictably, accompanied by emotional discharge Continuum of Care (3 of 3): Disciplinary Practices: Occasionally scolds, criticizes, interrupts child activity Teaches child through behavioral rather than psychological control methods Frequently uses coercive methods and minimizes child’s competence Uses psychologically controlling methods that confuse, upset child Uses cruel and harsh control methods that frighten child Violates minimal community standards on occasion Emotional Delivery and Tone: Uses emotional delivery and tone that are firm but not frightening Uses verbal and nonverbal pressure, often to achieve unrealistic expectations Frightening, threatening, denigrating, insulting Trauma and Stress: Children exposed to chronic or severe stressors, e.g., major accidents, natural disasters, kidnapping, brutal physical assaults, war and violence, or sexual abuse, have an elevated risk of PTSD Trauma and stressful experiences in childhood or adolescence may involve: actual or threatened death or injury, or a threat The Impact of Stress on Children and Child Maltreatment Children and youths require a basic, stable environment to adapt successfully. Stressful events can affect each child in different and unique ways, leading to hyperresponsive or hyporesponsive reactions, as well as an allostatic load, which is a progressive "wear and tear" on biological systems due to chronic stress.  Maltreatment is defined as any recent act or failure to act by a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or presents an imminent risk of serious harm. Types of child maltreatment include neglect, which can manifest as physical, educational, or emotional. Neglect can include refusal or delay in seeking health care, abandonment, inadequate supervision, chronic truancy, or refusal to attend to a child's special educational needs, among others. Physical abuse involves multiple acts of aggression toward a child, which can result in serious injuries as a result of overdiscipline or severe punishment. Psychological (emotional) abuse consists of repeated acts or omissions that cause significant harm to a child's emotional well-being. A 2-year-old found wandering alone late at night Siblings subjected to repeated incidents of family violence Children living in a home contaminated with animal feces A special education student whose mother refused to believe he needed help A child whose mother helped him shoot out windows Children living in a home with animal feces and rotting food. Types and Characteristics of Child Maltreatment Child maltreatment can cause serious behavioral, cognitive, emotional, or mental disorders and exists in all forms of maltreatment, being as harmful to a child’s development as physical abuse or neglect. Sexual abuse encompasses fondling a child’s genitals, intercourse with the child, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. It can significantly affect behavior, development, and physical health of sexually abused children, with their reactions and recovery varying depending on the nature of the assault and responses of important others. Many acute symptoms resemble children’s common reactions to stress. Exploitation, including commercial or sexual exploitation such as child labor and child prostitution, is a significant form of trauma for children and adolescents worldwide. Younger children are more at risk for abuse and neglect, while sexual abuse is more common among older age groups (over 12). Except for sexual abuse, the victimization rate is inversely related to the child’s age. Additionally, 80% of sexual abuse victims are female, but boys and girls are victims of maltreatment almost equally. In terms of racial characteristics, the majority of substantiated maltreated victims are white (44%), African-American (22%), or Hispanic (21%). The highest rates of victimization are for children who are African-American, American Indian or Alaska Native, and multiple race, followed by white, Hispanic, and Asian children. Relational disorders are an important factor for physical abuse and neglect, occurring most often during periods of stress, while sexual abuse is primarily a premeditated act, and maltreatment is seldom caused by severe forms of adult psychopathology. An integrated model of physical child abuse includes stages related to reduced tolerance for stress and disinhibition of aggression as well as poor management of acute crises and provocation, with destabilizing and compensatory factors affecting each stage. Trauma-and Stress-Related Disorders: Reactive Attachment Disorder Habitual patterns of arousal and aggression with family members are a stage in the Integrated Model of Physical Child Abuse. Destabilizing factors include parental dissatisfaction with physical punishment and a child habituating to physical punishment. Compensatory factors are when the parent is reinforced for using strict control techniques and the child responds favorably to noncoercive methods. Community restraints/services can be a factor in mitigating the problem behavior of the child. Reactive Attachment Disorder is characterized by inhibited, emotionally withdrawn behavior towards adult caregivers. It also involves minimal social and emotional responsiveness to others and limited positive affect. The child may exhibit episodes of unexplained irritability, sadness, or fearfulness during nonthreatening interactions with adult caregivers. The disorder may be caused by social neglect, deprivation, or repeated changes of primary caregivers that limit attachment formation. It is also presumed that the disturbed behavior is a result of lack of adequate care, and the criteria do not align with autism spectrum disorder. Symptoms of the disorder are evident before 5 years of age, with a developmental age of at least 9 months. Trauma-and Stress-Related Disorders: Disinhibited Social Engagement Disorder  Criterion A: Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. Criterion A: Willingness to go off with an unfamiliar adult with minimal or no hesitation. Criterion B: The behaviors in Criterion A are not limited to impulsivity but include socially disinhibited behavior. Criterion C: The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Repeated changes of primary caregivers that limit opportunities to form stable attachments. Rearing in unusual settings that severely limit opportunities to form selective attachments. Criterion D: The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A. Criterion E: The child has a developmental age of at least 9 months. Specify if: Persistent - The disorder has been present for more than 12 months. Specify if: Severe - When a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels. Acute stress disorder is characterized by the development during or within 1 month after exposure to an extreme traumatic stressor of at least nine symptoms associated with intrusion, negative mood, dissociation, avoidance, and arousal. Children who react to more common (and less severe) forms of stress in an unusual or disproportionate manner may qualify for a diagnosis of adjustment disorder. (A) Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: (1) Directly experiencing the traumatic event(s). (2) Witnessing, in person, the event(s) as it happened to others. (3) Learning that the event(s) happened to a close relative or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Trauma-and Stress-Related Disorders: Post-traumatic Stress Disorder  The presence of intrusion symptoms associated with the traumatic event(s), which may include recurrent distressing memories and dreams related to the event(s). Dissociative reactions, such as flashbacks, in which the individual feels or acts as if the traumatic event(s) were recurring. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to cues symbolizing or resembling the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s), evidenced by efforts to avoid distressing memories, thoughts, or external reminders. Exposure to actual or threatened death, serious injury, or sexual violence in different ways, such as directly experiencing the event or learning that it happened to a close relative or friend. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s), with an exception for exposure through electronic media, television, movies, or pictures unless work- related. Trauma-and Stress-Related Disorders: Post-traumatic Stress Disorder Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). In young children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. Recurrent distressing dreams related to the traumatic event(s). In children, there may be frightening dreams without recognizable content. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s). Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about the traumatic event(s).  Avoidance of external reminders that arouse distressing memories about the traumatic event(s). Negative alterations in cognitions and mood associated with the traumatic event(s). Inability to remember an important aspect of the traumatic event(s). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world. Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Persistent negative emotional state. Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions. Marked alterations in arousal and reactivity associated with the traumatic event(s). Trauma-and Stress-Related Disorders: Post-traumatic Stress Disorder Traumatic event(s) occurred, as evidenced by two (or more) of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems with concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Duration of the disturbance (Criteria B, C, D and E) is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.  Specify if: With Dissociative Symptoms: The individual's symptoms meet the criteria for post-traumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes of body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With Delayed Expression: If the diagnostic threshold is not exceeded until at least 6 months after the event (although it is understood that onset and expression of some symptoms may be immediate). In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more of the following ways): Directly experiencing the traumatic event(s). Witnessing, in person, the event(s) as it occurred to other, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or. Post-traumatic Stress Disorder in Children Six and Younger Learning that the traumatic event(s) occurred to a parent or caregiving figure. Intrusion symptoms can include distressing memories of the traumatic event(s) or distressing dreams related to the event(s). Trauma-specific reenactment may occur in play. Intense distress at exposure to reminders of the traumatic event(s) and physiological reactions to these reminders. Persistent avoidance of stimuli associated with the traumatic event(s).  Alterations in cognition and mood, including increased frequency of negative emotions, diminished interest in activities, socially withdrawn behavior, and reduced expression of positive emotions. Alterations in arousal and reactivity, such as irritable behavior and angry outbursts. Post-traumatic Stress Disorder in Young Children Symptoms of post-traumatic stress disorder (PTSD) in young children include verbal or physical aggression, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. The duration of the disturbance should be more than a month and cause significant distress or impairment in relationships with parents, siblings, peers, or school behavior. The disturbance should not be attributed to the effects of a substance or another medical condition. The dissociative subtype of PTSD includes symptoms of depersonalization and derealization, which should not be caused by the effects of substance or another medical condition. Delayed expression of PTSD may occur if full diagnostic criteria are not met until at least 6 months after the event, even though some symptoms may be immediate. PTSD can become a chronic psychiatric disorder for some children and youths, with a developmental course marked by remissions and relapses, and in some cases, persisting for a lifetime. Mood and affect disturbances, such as symptoms of depression, emotional distress, and suicidal ideation, are common in children with histories of abuse. Teens with histories of maltreatment have a greater risk of substance abuse, and childhood sexual abuse can lead to eating disorders. Causes and Effects of Child Abuse Sexual abuse, particularly, can lead to traumatic sexualization in children Poor emotion regulation in maltreated infants/toddlers leads to difficulty in establishing consistent interaction with caregivers and insecure-disorganized attachment Maltreated children develop negative views of themselves and others due to lack of healthy parental guidance and control Neurobiological alterations in the hypothalamic–pituitary–adrenal axis and norepinephrine systems are observed in children and adults with a history of child abuse Acute and chronic forms of stress associated with child abuse may cause changes in brain development and structure from an early age Obstacles to intervention and prevention services for maltreating families include reluctance to seek help, bringing attention to professionals only after norms or laws have been violated, and fear of losing children or being charged with a crime Exposure-based therapy and psychological first aid are interventions used to treat children affected by trauma, with the former involving brief, early intervention following acute stress or trauma, and the latter involving in-depth psychological interventions for severely affected children. Grief and Trauma Intervention for Children Grief and Trauma Intervention for Children is a type of therapy aimed at addressing the emotional and psychological effects of trauma and abuse on children. Trauma-focused cognitive-behavioral therapy (TF-CBT) is a specific form of intervention used to help children process and cope with trauma. Preventing Abuse and Its Long-Term Outcomes is a crucial aspect of intervention for children who have been maltreated. Special Needs of Maltreated Children: Physical Abuse and Neglect focuses on the specific types of maltreatment and the corresponding treatment and intervention approaches. Treatment for child neglect includes a focus on parenting skills and organization of family needs. Interventions for physical abuse usually involve changing parenting practices and discipline methods. Special Needs of Maltreated Children: Sexual Abuse requires programs that restore the child’s sense of trust, safety, and guiltlessness. TF-CBT has been adapted for child sexual abuse victims and children with complex trauma symptoms.