Conditions: Chp 12
Definition and Description (6)
As a result, these children often receive a cluster of diagnoses to identify their complex behaviors and negative emotional reactions, which can impair their ability to successfully participate in age-appropriate daily activities (e.g., school, play, self-care, toilet training, etc.) and to develop positive peer relationships.
Dissociation
Dissociation is a predominate attribute in children exposed to complex trauma. Essentially, dissociation is a loss in the ability to process and integrate information and experiences. As a result, conscious awareness fails to respond to physical sensations, disconnection between thought and emotion is facilitated, and involuntary repetitive behavior may emerge.
Neurobiologic (2)
Taylor et al. (2006) found decreased amygdala activation among children who experienced detached emotional engagement from parents. In a task requiring identification of emotions, Taylor also found a significant positive correlation between the activation of the amygdala and right ventrolateral prefrontal cortex, a finding that indicates reduced inhibition of the amygdala.
Course and Prognosis (2)
The ACE study examined 17,337 middle-class multiethnic Kaiser Permanente health care insurance members by means of a general medical questionnaire that included 10 questions related to potential adverse experiences, that is, witness to parental violence, household dysfunction, neglect, and abuse. Results identified that the number of adverse experiences in the first 18 years of life increased the probability to develop cancer, heart disease, diabetes, liver disease, and stroke. Elevated ACE scores were also associated with depression, alcoholism, drug use, obesity, cigarette smoking, sexual promiscuity, and domestic violence.
Education (4)
A cycle is often created whereby a student's lack of success in school reduces his or her self-esteem and increases a lethargic response that is often perceived by adults as laziness or willful disobedience. A variety of school intervention programs, with a focus on creating trauma-informed or trauma-sensitive classrooms, have been utilized and are described in the literature as a means of addressing these students' needs.
Personal Activities of Daily Living (PADL): Bathing
As a result of physiological manifestations of stress, regulations of bodily functions are compromised leading to difficulties in PADL. Stress responses are especially impacted by children with a history of sexual abuse while being bathed as well as being physically abused by immersion in hot or cold water.
Biology
As a result of being in a state of chronic fear and stress, the child's brain alters its typical bottom-up organization (i.e., brainstem, midbrain, limbic structure, and cerebral cortex) and redirects neural systems to support repeated survival-based reactions or "flight, fight, or freeze" to stressful experiences. Due to repeated activation of the HPA axis, which controls stress responses, traumatized children can habitually be in a continuous hyperarousal state.
Cognition
Exposure to maltreatment can be associated with impairment in cognitive function, which can be identified by late infancy. By early childhood, maltreated children may display less cognitive flexibility and problem-solving skills, which can affect their future academic growth and performance.
Definition and Description (7)
Frequent inaccurate disorders include bipolar disorder, attention deficit/hyperactivity disorder (ADHD), anxiety disorders, oppositional defiance disorder (ODD), conduct disorder, obsessive-compulsive disorder (OCD), and sensory processing disorder (SPD).
Multiple risk factors related to complex trauma have been identified: (7)
-Neglect and medical neglect are most often attributed to female caretakers, while sexual abuse is most often associated with male offenders. -Younger children are at risk: If the child is unwanted, 67% of abused children are <1 year old, and 80% are <3 years -Adopted and foster children are at higher risk.
Multiple risk factors related to complex trauma have been identified:
-Parental risk factors include young or single parents, those who did not graduate from high school, and those who either were abused themselves as children or endured a severely dysfunctional home life. Difficulty providing quality care to a large number of dependent children can also increase the risk of abuse. -Adults with psychiatric disorders such as depression and bipolar disorder are more likely to abuse children.
Multiple risk factors related to complex trauma have been identified: (6)
-Parents' or caregivers' characteristics that may increase child maltreatment include difficulty bonding with their newborn, involvement in criminal activity, and inability to provide quality nurturing to their child. -Multiple nonbiological, transient caregivers living in the home.
Multiple risk factors related to complex trauma have been identified: (3)
-Substance abuse: Children in alcohol-abusing families are nearly four times more likely to be mistreated, almost five times more likely to be physically neglected, and 10 times more likely to be emotionally neglected than children in non-alcohol-abusing families. -Family support systems: Other factors include the disintegration of the nuclear family and violence between other family members and, in addition, the loss of child-rearing support from the extended family members.
Transgenerational
Acting across multiple generations; that is, the caregiver's actions are based on his or her own previous parenting experiences.
Affect Regulation (3)
Alexithymia, or the impaired capacity to describe emotions or bodily states, is a persistent sign of affect dysregulation. This includes difficulty describing internal states and communicating basic needs such as hunger or elimination, as well as expressing emotions, wishes, and desires. Due to difficulty with identifying, interpreting, and regulating emotions, traumatized children may avoid emotional situations including positive experiences, display dissociation, or chronic emotional "numbing" and develop maladaptive coping strategies.
Attachment (5)
Disorganized attachment develops when children are traumatized by repeated exposure to uncontrollable and unpredictable stress, for example, physical or sexual abuse, in conjunction with the consistent absence of a nurturing, reliable, and protective caregiver. Children who demonstrate difficulty organizing an adaptive response to daily experiences, due to childhood trauma, display significant challenges regulating their emotions. In addition, they experience problems in managing stress and developing empathy.
Cognition (2)
Further attributes related to cognitive dysfunction as a result of complex trauma include the following: -Delayed language development -Problems with object constancy -Difficulties with sustained attention to task to complete a task -Visual perceptual problems -Difficulty understanding complex visual-spatial patterns -Lack of persistent curiosity
Behavioral Regulation (3)
Furthermore, the alteration of affective states may lead to misperception of risk, combined with poor impulse control and difficulty understanding consequences of negative behaviors. When experiencing a sense of threat, maladaptive attempts at self-soothing may include head banging, body rocking, and compulsive masturbation. Self-harm among chronically traumatized children and adolescents has been described in the literature. These include dangerous actions such as setting fires, sexual promiscuity, and actions of self-harm such as cutting, picking, and burning one skin and other self-mutilation actions.
Definition and Description (8)
Furthermore, the impact of receiving multiple mental health diagnoses most often leads to interventions focusing on behavioral control. This can limit a clinician's ability to provide effective research-based interventions as reflected by addressing symptoms based on a single etiology (e.g., complex trauma).
Resiliency Factors
Human resiliency refers to the ability of an individual to recover from adverse or traumatic events in a manner that is adaptive and nonpathologic. While the risks of pathologic responses are indeed great among children who have experienced trauma, there is the potential to gain competence across a variety of domains if provided with the necessary intervention, including those that address both internal and external factors. Resilience is most threatened by the loss of organic and relational protective systems, which occur in response to traumatic events.
Affect Regulation (2)
Impaired affect regulation is the result of exposure to inconsistent displays of affect and behavior (e.g., a cheerful expression combined with rejecting behavior) or to inconsistent responses to display of emotion (e.g., infant distress is united inconsistently with rejection, anger, nurturance, or detachment).
Multiple risk factors related to complex trauma have been identified: (2)
-A common theme when interviewing abusive individuals is their unrealistic expectations of infant or child development. Often, they expect maturation of developmental milestones significantly beyond the age of the child. This is especially true for toilet training expectations. -The perpetrator's childhood: Approximately 80% of offenders were themselves abused as children.
Multiple risk factors related to complex trauma have been identified: (4)
-Children at higher risk for abuse include infants who are felt to be "overly fussy," as well as children with congenital anomalies, chronic/recurrent conditions, and children with chronic diseases as well as children with learning disabilities, speech/language disorders, and intellectual disability. -Specific "trigger" events that occur just before many fatal parental assaults on infants and young children include an infant's inconsolable crying, feeding difficulties, a toddler's failed toilet training, and exaggerated parental perceptions of acts of "disobedience" by the child.
Multiple risk factors related to complex trauma have been identified: (5)
-Family income strongly correlates to incidence rates. Children from families with annual incomes below $15,000 per year are more than 25 times more likely than are children from families with annual income above $30,000 to be harmed or endangered by abuse or neglect. Poverty clearly predisposes a person to child abuse. However, it must be recognized that all data available can only be based on reported cases. It is very likely that trauma exposure exists among other classes as well, but those families are often protected by position and wealth and thus their cases do not necessarily become part of a community's child protective services system.
Affect Regulation
A common deficit observed in children with complex trauma histories is their inability to distinguish and interpret internal states of arousal in conjunction with difficulty accurately identifying emotions, for example, mad, happy, and sad, in self and others.
Parentification
A common occurrence among a group of siblings in an abusive and neglectful environment is for one child, usually the oldest, to take on the role of a parent; as there is an absence of an adult care provider willing or able to provide care for others, this may occur.
Definition and Description (14)
As defined by experts in the field of childhood trauma, complex traumas "describe both a constellation of causal risk factors involving repeated interpersonal trauma by caregivers early in life; and the resulting dysregulation that occurs across a range of areas including emotional, behavioral, interpersonal, physiological, and cognitive functioning". Therefore, this chapter will focus on the complex trauma because this is the condition most relevant to occupational therapy practice.
Dissociation (2)
As described by Putnam (1997), dissociation serves three primary functions during exposure to overwhelming trauma, which is evident by a protective "freeze" response, suppression of painful emotions and memories, and detachment from one's self. Unfortunately, a child who habitually dissociates as a coping strategy can intensify difficulties with self-concept, behavior management, and affect regulation.
Attachment (8)
Attachment dysfunction leads to intense preoccupation with the safety of the caregiver or other loved ones and difficulty tolerating reunion with them after separation. Other outcomes that emerge due to poor attachment include the following: -Problems with personal boundaries -Chronic feelings of distrust and suspicion -Social isolation -Establishing and maintain healthy relationships thought life -Difficulty attuning to other people's emotional states and perspective taking
Attachment (4)
Avoidant attachment develops as a result of persistent caregiver rejection and failure to provide basic emotional and physical support to his or her child. These children often become skilled at distancing their emotions in conjunction with avoiding the establishment of meaningful relationships with peers and adults. Children with ambivalent attachment experience a range of predictable patterns of detachment and neglect to excessive intrusiveness from their parents.
Neurobiologic (4)
Bevans, Cerbone, and Overstreet (2008) found that exposure to childhood trauma was related to alterations in diurnal cortisol variation. Cortisol, a steroid hormone, is released in response to stress and acts to restore homeostasis. However, prolonged cortisol secretion results in significant physiological changes including immunological and neurological changes.
Education (3)
By middle school and high school, they are more likely to be considered having a lack of motivation and learning below average, and there is a higher incidence of disciplinary referrals and suspensions. Developmental delays and emotional/behavioral dysregulation, learning disabilities, and intellectual impairment that cannot be accounted for by neurological or other factors that are experienced by children exposed to trauma can profoundly affect their school performance.
Education (2)
By preschool, trauma-exposed children demonstrate problems in both of these areas as demonstrated by poor frustration tolerance, a higher incidence of anger and noncompliance, and significantly higher dependency on others for support. In elementary school, children are more likely to avoid challenging tasks, and thus are overly reliance on teachers' guidance and feedback. Complexly traumatized children may further demonstrate negative attention-seeking behaviors, poor attendance, and incomplete homework assignments.
Incidence and Prevalence
Child maltreatment most often occurs within the home (Perry, 1997) and an estimated 91.6% of maltreated children are victimized by one or both parents. Bruce Perry, MD, PhD, best describes infants and children raised in violent and erratic settings as "incubated in terror". Data collected during the 2014 financial fiscal year and analyzed by the National Child Abuse and Neglect Data System (NCANDS) indicate that an estimated 702,000 victims experienced child abuse and neglect.
Incidence and Prevalence (2)
Child victims were similar for both boys (48.9%) and girls (50.7%). Three-quarters (75%) of maltreated children were victims of neglect, while 17% of the children experienced physical abuse and 8.3% were victims of sexual abuse. Approximately 75% of sexual abuse is inflicted upon girls. Girls also are more likely to suffer from sexual abuse, emotional abuse, and neglect. Boys, on the other hand, are more likely to experience physical trauma (other than sexual abuse). Data from the Child Maltreatment 2014 report (US Department of Health & Human Service, 2016) also indicate more than one-half (54.1%) of perpetrators were women and 44.8% were men.
Instrumental Activities of Daily Living (IADLs)
Childhood maltreatment has a significant impact on IADLs. A common occurrence among a group of siblings in an abusive and neglectful environment is for one child, usually the oldest, to take on the role of a parent, referred to as parentification as there is an absence of an adult care provider willing or able to provide care for others. Oftentimes, neglected children are exposed to dangerous in-home situations such as fire hazards, firearms, and insect and animal infestation from parents operating methamphetamine labs. Parents might become physically or mentally unable to care for a child. Other times, alcohol or drug abuse may seriously impair judgment and the ability to keep a child safe.
Incidence and Prevalence (4)
Children <1 year old were the most vulnerable to maltreatment, and almost three-quarters (70.7%) of all child fatalities were younger than 3 years old. Boys had a higher child fatality rate than did girls, and 79.3% of child fatalities involved at least one parent. Further, 2014 child maltreatment data indicate that 72.3% of child fatalities were due to neglect, and 41.3% of child deaths were the result of physical abuse. Retrospectively, 1.1% of the child fatalities were caused by emotional and sexual abuse (US Department of Health & Human Service, 2016).
Neurobiologic (5)
Cicchetti and Rogosch (2001) found that maltreated children with internalizing problems and coexisting internalizing and externalizing problems had elevated cortisol compared to nonmaltreated children. Neuroimaging studies have indicated reduced growth of the hippocampus and limbic abnormalities as well as diminished growth in the left hemisphere and compromised function of the corpus callosum, the structure that allows for efficient interhemispheric connectivity (Teicher, 2000).
Definition and Description (13)
Clinicians, including occupational therapists, who treat children with a history of chronic trauma, have increasingly called for a diagnosis that more adequately addresses the multiple domains of concern that result from developmentally adverse interpersonal trauma because the multitude of signs and symptoms cannot be accurately described by current diagnoses. As of the date of the publication of this chapter, the term complex trauma most accurately describes and represents children and adolescent subjected to repetitive adverse experiences.
Trauma
Comes from the Greek word meaning "wound," was originally used in medicine for a serious physical injury, but it is more widely used now to refer to emotional shock following a stressful event or an experience that is deeply distressing; this chapter is focused on the second component of this definition, which is "an emotional wound or shock that creates substantial, lasting damage to the psychological development of a person, often leading to neurosis, and an event or situation that causes great distress and disruption.
Self-Concept (3)
Common symptoms associated with an impaired self-concept identified in traumatized children consist of feeling unsuccessful, powerless, helpless, incompetent, and unlovable. As a result of a lack of reoccurring positive experiences to develop a healthy self-concept beginning in early infancy through adolescent by adulthood, these children can endure a substantial degree of self-blame.
Etiology
Complex trauma can be the result of multiple exposure to traumatic events, maltreatment, or polyvictimization beginning in early childhood or adolescent, occurring within the context of unpredictable, uncontrollable, and violent environments in conjunction with inconsistent or absent protective caregiving. The abuse, whether it is physical, sexual, or emotional, and neglect a child experiences from a caregiver are often transgenerational, that is, the caregiver's actions are based on his or her own previous parenting experiences.
Signs and Symptoms
Complex trauma is composed of seven domains of impairment observed in children subjected to reoccurring trauma exposure. Those domains include attachment, biology, affect regulation, dissociation, behavioral regulation, cognition, and self-concept.
Course and Prognosis
Complex trauma is marked by observable alterations in behavior across multiple domains with prognosis directly related to the extent of exposure, the application of appropriate interventions, and resiliency factors. Signs and symptoms and associated impairments are characterized by progressive deterioration with episodic signs of symptom severity in childhood and adolescence, as well as persistent challenges across the lifespan in many cases as evident by the Adverse Childhood Experiences (ACE) study.
Personal Activities of Daily Living (PADL): Personal Hygiene and Grooming
Complex trauma often results in children who lack the attention needed to provide proper hygiene and grooming, which often comes to the attention of school personnel and may facilitate a referral to child protective services. This may be the result of incompetent parents who lack the intellectual requirements to facilitate a child's awareness of healthy grooming or willful neglect of one, but not all, children among a set of siblings.
Neurobiologic (3)
Curtis and Cicchetti (2007) found that maltreated children categorized as nonresilient had decreased left hemisphere activation when compared to resilient maltreated children and decreased left parietal activity compared to nonmaltreated children. Neuroendocrine changes have been documented in the aftermath of childhood interpersonal trauma.
Definition and Description (11)
DTD symptoms include affective and physiological dysregulation, attentional and behavioral dysregulation, and self- and relational dysregulation (van der Kolk, 2014). Furthermore, to meet the criteria for DTD exposure, the child must have experienced or witnessed multiple adverse events over a minimum period of 1 year that begins in early childhood or adolescent, in conjunction with chronic exposure to interpersonal violence and significant interruptions of protective caregiving, which may include exposure to severe and repeated emotional abuse.
Medical Management
Due to the impact of chronic polyvictimization, or multiple types of trauma, the child may demonstrate signs of comorbid psychiatric disorders. These common mental health disorders include posttraumatic stress disorder, depression, attention deficit/hyperactivity disorder, oppositional defiant disorder, anxiety disorders, bipolar disorder, dissociative disorders, and personality disorders. Traditional medical management of trauma will include psychopharmacological intervention, which, in best practice, is prescribed as an adjunct to psychosocial treatment modalities.
Personal Activities of Daily Living (PADL): Toileting
Encopresis, or the act of passing feces in inappropriate places such as in clothing or other places, is known to occur more frequently among children who have experienced sexual abuse, although it is not a specific indicator of child abuse. Enuresis, or the repeated voiding of urine in the clothing and in inappropriate places, often accompanies encopresis among traumatized children. Whether intentional or not, it is essentially an expression of the child's only mechanism of control in the midst of complete submission to the perpetrators of abuse.
Rest and Sleep
Exposure to trauma often results in substantial difficulty with rest and sleep patterns as the child often exhibits hypervigilance and overactive. Multiple exposures to violence and trauma result in autonomic and endocrine hyperarousal, which are observed overreactions to stimuli. This may include being easily startled and craving high-risk, stimulating, or dangerous activity, all of which impair the balance of play, work, and rest. The NCTSN clinician survey found that 73% of children with complex trauma histories experienced sleep disturbances, a finding that has been supported by additional studies.
Definition and Description (9)
In 2009, the Consensus Proposed Criteria for Developmental Trauma Disorder (DTD) was established by the National Child Traumatic Stress Network (NCTSN)-affiliated Task Force led by Bessel A. van der Kolk, MD, and Robert S. Pynoos, MD. The cornerstone of the Task Force was to develop proposed criteria that reflect the true reality and outcomes in children exposed to chronic interpersonal trauma experience. The authors of the Task Force hoped that this new set of criteria would lead to the acceptance of the diagnosis of DTD in the publication of the revision of DSM-5.
Definition and Description (2)
In 2013, the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) in response to an abundance of new research data and practical knowledge related to mental health disorders. To represent children who experienced or witnessed the traumatic event(s), the DSM-5 Task Force established posttraumatic stress disorder for children 6 years and younger under the classification of a trauma- and stressor-related disorder.
Social Participation
In a sample of 9,336 children with a history of trauma who were receiving intervention across the United States, 48% were reported to have had difficulty with social engagement within the home and in the community. Within peer groups, there is a significant degree of isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, and age-inappropriate affiliations or style of interaction. Family interaction is marked by interpersonal conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, or nonfulfillment of responsibilities within the family.
Attachment (2)
In a secure attachment, the caregiver responds to stressful situations by providing the child a safe environment and a sense of protection. This in turn influences the child's ability to appropriately regulate affect and behavior. Over 80% of children who experience chronic trauma demonstrate insecure attachment patterns.
Biology (3)
In a study of 900 children with a history of maltreatment, caregiver-generated survey data of sensory processing indicated difficulty with sensory modulation. It has been postulated that sensory modulation disorder is a result of difficulty in the brain's ability to filter and inhibit extraneous environmental stimuli. Survey data indicated 53.1% of the sample population demonstrating signs associated with difficulty filtering auditory sensations, 51.7% displaying sensory-seeking responses, and 23.8%demonstrating patterns of sensory overresponsivity to tactile input.
Education
In a study that included a sample of 9,336 children receiving trauma intervention across the United States, 41% had academic problems including behavior problems in school settings, including preschool programs. Academic functioning is a significant area of developmental competence beginning with preschool to higher education. In addition to intellectual abilities, success is significantly tied to a child's ability to regulate internal events or experience and to effectively interact with peers and teachers.
Incidence and Prevalence (3)
In addition, mothers (40.7%) were the most frequent perpetrator of maltreatment in relation to 20.5% of fathers. With regard to age of perpetrator, 83.2% of perpetrators were between the ages of 18 and 44 years in conjunction with ages 25 through 34 years representing the highest group of perpetrators. Unfortunately, an estimated 1,580 children nationally died from abuse and neglect during the 2014 financial fiscal year.
Attachment (6)
It has been hypothesized that disorganized attachment interferes with efficient neurodevelopmental connections between the right and left hemispheres of the orbital prefrontal cortex, which is responsible for regulating emotions, conscious decision-making, and social behavior.
Dissociation
It is a predominate attribute in children exposed to complex trauma. Essentially, dissociation is a loss in the ability to process and integrate information and experiences.
Behavioral Regulation (2)
Maladaptive behaviors include difficulty with arousal regulation and modulation, which is demonstrated by the lack of and recovery from extreme affective states such as fear, anger, and shame that emerge from chronic trauma exposure. These affective states may be manifested by prolonged and extreme emotional tantrums on one side of the spectrum to catatonic-like immobilization. Disorders of bodily functions may occur including disturbances in sleeping, eating, and elimination.
Social Participation (2)
Many individuals with complex trauma histories are at high risk for dysfunctional social participation within their communities. This includes a high incidence of arrests and recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, and disregard or contempt for the law and conventional moral standards (Pynoos et al., 2008). In addition, any inappropriate, avoiding, or aggressive behaviors as a result of poor mental health can greatly impact the child's ability to develop and maintain healthy peer relationships.
Medical Management (2)
Medication should only be used in conjunction with trauma-specific treatment and not in the absence of it. In a survey sample representing 1,699 children, ages infancy through 18 who were exposed to chronic trauma, it was determined that most trauma intervention occurs in an outpatient setting with varied treatment modalities.
Complex trauma
Most accurately describes and represents children and adolescent subjected to repetitive adverse experiences. As defined by experts in the field of childhood trauma, complex traumas "describe both a constellation of causal risk factors involving repeated interpersonal trauma by caregivers early in life; and the resulting dysregulation that occurs across a range of areas including emotional, behavioral, interpersonal, physiological, and cognitive functioning"
Developmental trauma disorder
Multiple or chronic exposure to one or more forms of developmentally adverse interpersonal trauma (abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death).
Impact on Occupational Performance
Occupational performance areas are significantly compromised as a result of complex trauma, Evidence of compromised client factors has been determined including those related to motor and praxis skills, sensory-perceptual skills, emotional regulation skills, cognitive skills, and communication and social skills, which impact on all areas of occupation. In addition, the physical context in which the trauma occurs can greatly impact the child's ability to engage in an activity in the same or similar location, due to overwhelming reminders or "trauma triggers" of the event.
Attachment (7)
Other brain structures associated with the development of attachment that can be affected by complex trauma include the amygdala, hippocampus, hypothalamic-pituitary-adrenal (HPA) axis, and the neurotransmitters oxytocin, dopamine, and norepinephrine, which impact, respectively, on threat detection, new memory and learning, response to threat detection, and release of hormones critical for healthy emotional states that are critical for affective development.
Biology (2)
Other brain structures impacted by maltreatment include the thalamus, which is vital for sensory and motor signal relay and the regulation of consciousness and sleep. The thalamus plays a role in controlling the motor systems of the brain, which are responsible for voluntary bodily movement and coordination and the corpus callosum, the structure connecting the two cerebral hemispheres.
Play and Leisure (2)
Persistent themes may be noted as the child is essentially reliving the event in an attempt to control or gain mastery over fears that continue to create fear or that overwhelm the child. The child may be easily triggered by environmental stimuli, including other children and adults, which result in rage and physical aggression during play sessions with other children or alone. As the child transitions to adolescence and adulthood, the pursuit of leisure interests is compromised due to these maladaptive play behaviors.
Work
Persons exposed to reoccurring early childhood trauma typically show disinterest in work, with ill-defined employment interests and poor employment-seeking skills or vocational interests. Acquisition of job performance skills, due to the lack of antecedent skills that typically emerge from home as well as academic environment, leads to the inability to get or keep jobs. Persistent conflict with coworkers or supervisors is also a significant barrier to successful work performance. Other factors, which influence low work performance and employment, include impaired emotional regulation during stressful situations and an absence of self-awareness as noted by a lack of appropriate hygiene and social skills.
Definition and Description (3)
Posttraumatic stress disorder (PTSD) was originally created and published in the DSM-III in 1980 in response to the large number of Vietnam veterans returning home with psychiatric problems. Until the publication of the DSM-5, PTSD was the only trauma-related diagnosis used for both children and adults.
Definition and Description
Prior to the 19th century, child abuse was not only acceptable but was, essentially, legally sanctioned. At that time, children did not receive equal legal status like domesticated animals with regard to protection against cruelty and/or neglect. It was not until 1962 that the term "battered child syndrome" became part of the medical terminology and not until 1976 that all of the states in the United States had adopted laws mandating the reporting of suspected child abuse.
Personal Activities of Daily Living (PADL): Sexual Activity
Reactions to chronic sexual abuse include significant dysfunction in sexual activity including hypersexuality, which is often demonstrated by a preoccupation with sexual organs of self, parents, and others expressed in drawings and in language. Children with a history of molestation are seven times more likely to become drug/alcohol dependent (Pynoos et al., 2008). In a study on the effects of sexual abuse of 938 adolescents admitted to residential, therapeutic communities for the treatment of substance abuse and related disorders, 64% of the girls and 24% of the boys reported histories of sexual abuse.
Neurobiologic (6)
Recognition of the brain behavior connection linking trauma and neurodevelopmental function is critical to occupational therapists working with this population so that appropriate intervention is provided to improve the prognosis for healing and engagement and participation in occupations.
Polyvictimization
Refers to having experienced multiple victimizations such as sexual abuse, physical abuse, bullying, and exposure to family violence. The definition emphasizes experiencing different kinds of victimization.
Resiliency
Refers to the ability of an individual to recover from adverse or traumatic events in a manner that is adaptive and nonpathologic.
Attachment (3)
Repeated exposure to unpredictable and uncontrollable stressful environments, in conjunction with erratic, hostile, rejecting, or abusive caregiving, is a precursor to an insecure child-caregiver attachment. Insecure attachment and associated signs can be subcategorized into three typologies: avoidant, ambivalent, and disorganized.
Resiliency Factors (3)
Several factors have been found to be the most critical for promoting resilience, including (a) positive attachment and connections to emotionally supportive and competent adults within a child's family or community, (b) development of cognitive and self-regulation abilities, (c) positive beliefs about oneself, and (d) motivation to act effectively in one's environment.
Resiliency Factors (2)
The extent of brain damage and associated cognitive, perceptual, and self-regulatory dysfunction, along with severely compromised caregiver relationships, are key factors that compromise resilience. In addition, loss of motivation to seek out interpersonal relationships, to interact with one's environment, and to learn and to develop new skills greatly inhibits recovery. However, supportive relationships, family connections, and cognitive resources help protect one and serve as "inoculations against adversity".
Medical Management (3)
The frequency of intervention modalities identified is as follows: -Weekly psychotherapy (78%) -Self-management/coaching (62%) -Family therapy (56%) -Play therapy (55%) -Expressive therapies (41%) -Pharmacotherapy (27%) -Community outreach (25%)
Neurobiologic
The impact of chronic trauma on brain development has been reported in the literature with the primary benefit of these studies being a better understanding of the scope of the problems associated with trauma exposure as well as informing clinicians about the intervention approaches necessary to improve the prognosis for healing and recovery. Ito, Teicher, Glod, and Harper (1993) reported that children exposed to chronic trauma had left hemisphere EEG abnormalities in anterior, temporal, and parietal areas.
Alexithymia
The impaired capacity to describe emotions or bodily states, is a persistent sign of affect dysregulation. This includes difficulty describing internal states and communicating basic needs such as hunger or elimination, as well as expressing emotions, wishes, and desires.
Education (5)
The key components of a trauma-sensitive classroom that emerge from descriptions of intervention programs for children exposed to chronic trauma include: -Establishing and maintaining a safe classroom -Predictability -Acquiring affective regulation skills through positive adult interactions -Considering the classroom's level of sensory input (i.e., bright-colored posters, objects hanging and moving from the ceiling, noise volume, and rich-stimulating scents). -Assistance in making meaning of students' experiences
Play and Leisure
The lack of acquisition in the components of interpersonal competence, poor self-concept, difficulty with social communication, sensory processing disorders, and intellectual impairment have a significant impact on play exploration, constructive play, and symbolic play. Typical early childhood behavior among those exposed to complex trauma will often reflect traumatic events, which may include sexual acting out or violent play with dolls, seemingly disorganized and nonpurposeful interaction with items that may indicate a reenactment of events.
Definition and Description (4)
The main attributes used to describe PTSD for children 6 years and younger include experiencing, witnessing, or learning about death, violence, or injury, especially toward a caregiver, one or more times. As a result of the trauma experience, children may encounter intrusive thoughts, avoidance, or negative emotional reactions to reminders of the traumatic event in conjunction with physiological dysregulation, as demonstrated by disturbance in sleep, hypervigilance, concentration difficulties, and angry outbursts.
Etiology (2)
The most deadly form of child trauma is caused by neglect, as death can occur from accidents that occur in the absence of supervision or during abandonment. Failure to seek necessary medical attention in cases of injury, illness, or a life-threatening medical condition places a child at risk for death as well. Fatal injuries are caused by a variety of traumatic actions including severe head trauma, such as violently shaking an infant or small child; forceful punching of the fist to the abdomen, chest, or head; scalding; intentional drowning; suffocation; poisoning; and starvation.
Attachment
The most significant signs of exposure to interpersonal trauma are maladaptive behaviors related to the disruption of attachment. The type of relationship between a child and caregiver influences the response to present and future emotional and physical experiences. A normal child-caregiver relationship develops into a secure attachment in about 55% to 65% of the general population
Self-Concept
The sense of feeling worthy and belonging and being accepted and the perception of being capable of engaging and completing novel and challenging tasks are frequent deficients in complexly traumatized children. The early caregiver relationship significantly influences the development of an unblemished sense of self.
Personal Activities of Daily Living (PADL): Feeding and Eating
There are many relational factors between a primary caregiver and a child with regard to nutritional intake, beginning in the initial attachment process in infancy. A negative nurturing relationship with an infant including lack of attunement, irritability, depression, and other maternal problems will result in significant maladaptive, disorganized responses. These include difficulty with oral mechanisms such as suckling, sucking, swallowing and breathing, rhythm, food refusal, and overactive response to certain smells and tastes.
Self-Concept (2)
These factors include a responsive caretaker to the child's needs and a caretaker who offers quality and frequent touch and eye contact. In childhood, the development of a healthy self-concept is facilitated by the child being able to safely explore and interact successfully within his or her environment, ask questions without feeling they are an annoyance, and engage in make-believe play.
Definition and Description (10)
This more complete and holistic set of criteria would result in a more comprehensive approach to intervention so that children would receive the proper care to improve their quality of life and ability to appropriately react to daily experiences. Extensive review of empirical literature, surveys of NCTSN clinicians, discussions with clinical experts, and preliminary analysis of data representing thousands of children in various clinical and child service system settings (e.g., state child welfare systems, juvenile detention centers, and inpatient psychiatric settings) allowed the NCTSN Task Force to construct a proposed set of criteria for DTD, which contained the most clinically significant symptoms displayed by children following complex trauma.
Course and Prognosis (3)
To analyze adult death rates, a 14-year follow-up was initiated, and data indicated that participants with an ACE score of 6 or higher exhibited a shorter lifespan of almost 20 years compared to participants with ACE score 0. The multiple consequences that emerge as a result of chronic trauma and impact on the course are detailed in a seminal white paper by the NCTSN Complex Trauma Task Force titled Complex Trauma in Children and Adolescents. Two major considerations for course and prognosis are directly related to the extent of neurobiologic damage and resiliency factors.
Personal Activities of Daily Living (PADL): Feeding and Eating (2)
Toddlers will often present with severe dental decay, or "bottle rot," a condition resulting from persistently being bottle fed with high concentrates of sugar while dental development is taking place. Children exposed to chronic trauma are at a higher risk for developing an eating disorder as they grow older. In a home where physical or sexual abuse is taking place, the child may turn to an eating disorder to gain a sense of control. Similar to the psychodynamics associated with encopresis and enuresis, they are able to control their food intake or their weight. Children who are compulsive eaters or those who hoard and hide food are usually using food to help them deal with feelings of anger, sadness, hurt, loneliness, abandonment, fear, and pain.
Medical Management (4)
Traditional models of intervention are typically provided by either a social worker or a psychologist; however, there are existing models of assessment and intervention that are grounded in interdisciplinary and transdisciplinary approaches, which include several professional disciplines on a team including occupational therapy.
Behavioral Regulation
Traumatized children often demonstrate difficulty regulating their behavior to participate in age-appropriate daily activities. It is important to note that traumatized children's maladaptive behavior patterns are reflections of their difficulty adapting to significant stress.
Definition and Description (12)
Unfortunately, several months after submitting their proposal for DTD, it was rejected by the DSM subcommittee with consensus that no new diagnosis was required to fill a "missing diagnostic niche" and "The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact"
Definition and Description (5)
Unfortunately, there continues to be a population of children who continually experience a dark and unsafe world as a result of chronic exposure to interpersonal violence, neglect, abuse (e.g., physical, emotional, or sexual), and maltreatment, in addition to a caregiver who repeatedly fails to provide protection or is unavailable during times of extreme stress.
Education (6)
Unfortunately, there exists a paucity of awareness in most school systems regarding the need for classroom-based intervention that addresses the child as the victim of chronic abuse. The child, because of the many challenges he or she has in response to trauma experiences, acts out and behaves in ways that are interpreted as willful and thus being labeled as oppositional defiant or other diagnoses that lay blame solely on the child, leading to continuous conflicts with school personnel. The lack of appropriate intervention leads to academic underperformance, nonattendance, disciplinary problems, a high dropout rate, and failure to complete diplomas, which ultimately leads to poor success in vocational pursuits.
Rest and Sleep (2)
While not a common occurrence, victims of chronic abuse may experience "sleep terrors," which are also called "night terrors." In a typical episode, an individual will sit up in bed and begin to scream or shout, which may include kicking and thrashing. The child may say or shout nonsensible exclamations with an intense fearful expression with eyes wide open and heart racing. In addition, the child may sweat, breathe heavily, and be very tense. Evidence further indicates increased bed-wetting among complexly traumatized children.
