12
Trauma- and Stressor-Related Disorders
Eric J. Mash
A. Wolfe
©David
Cengage Learning
2016
© Cengage Learning 2016
Introduction
• Trauma- and stressor-related disorders is
new category in DSM-5
• Includes:
– Acute Stress Disorder
– Adjustment Disorder
– Posttraumatic Stress Disorder (PTSD)
– Reactive Attachment Disorder
– Disinhibited Social Engagement Disorder
© Cengage Learning 2016
Child Abuse and Neglect
• Child abuse and neglect have been
recognized as a significant problem since
the early 1970s
• In North America, it is estimated that one
in ten children experience some form of
sexual victimization by an adult or peer
– They also receive harsh physical punishment
by a parent or other caregiver that puts them
at risk of injury
© Cengage Learning 2016
Child Abuse and Neglect (cont’d.)
• Four primary acts of child maltreatment
– Physical abuse, neglect, sexual abuse, and
emotional abuse
• Non-accidental trauma
– Wide-ranging effects of maltreatment on the
child’s physical and emotional development
• Victimization
– Abuse or mistreatment of someone whose
ability to protect himself or herself is limited
© Cengage Learning 2016
Overview (cont’d.)
• Abused or neglected children face
paradoxical dilemmas
– The victim wants to stop the violence but also
longs to belong to the family in which they are
being abused
– Affection and attention may coexist with
violence and abuse
– Violence intensity tends to increase over time,
but in some cases, physical violence may
decrease or stop
© Cengage Learning 2016
History and Family Context
• Major cultural traditions have condoned
abuse of family members
– Absolute authority over the family by the
husband
• Roman Law of Chastisement (753 B.C)
• English common law allowed “moderate and
reasonable” chastisement
– The right to family privacy
© Cengage Learning 2016
History and Family Context (cont’d.)
• 1989 Convention on the Rights of Children
– Spurred efforts to value the rights and needs
of children, to recognize their exploitation and
abuse in developed countries
• Today, 42 countries have established an
official government policy regarding child
abuse and neglect
© Cengage Learning 2016
Healthy Families
• Healthy parenting includes:
– Knowledge of child development and
expectations
– Adequate coping skills and ways to enhance
development through stimulation and
attention
– Normal parent-child attachment and
communication
© Cengage Learning 2016
Healthy Parenting (cont’d.)
• Home management skills
• Shared parenting responsibilities
• Provision of social and health services
© Cengage Learning 2016
Healthy Families (cont’d.)
• A fundamental and expectable
environment:
– Requires protective and nurturing adults, as
well as opportunities for socialization within a
culture for infants
– Includes a supportive family, peer contact,
and opportunities to explore and master their
environment for older children
– Provides a gradual shift of control from parent
to the child and the community
© Cengage Learning 2016
Continuum of Care
• Child care along a continuum
– Positive end - appropriate and healthy forms
of child-rearing actions that promote child
development
– Middle range - poor/dysfunctional actions
represent irresponsible and harmful child 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
© Cengage Learning 2016
Continuum of Care (cont’d.)
© Cengage Learning 2016
Trauma, Stress, and Maltreatment: Defining
Features
• DSM-5 considers some forms of child
stress and maltreatment under the
category “Other conditions that may be a
focus of clinical attention.”
• A child who was abused and also suffering
from a clinical disorder (e.g., depression)
– The maltreatment would be noted as part of
the diagnosis in order to ensure proper
treatment
© Cengage Learning 2016
Trauma and Stress
• Trauma and stressful experiences in
childhood or adolescence may involve:
– Actual or threatened death or injury, or a
threat to one’s physical integrity.
• 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
© Cengage Learning 2016
How Stress Affects Children
• Children and youths need a basic
expectable environment to adapt
successfully
• Stressful events affect each child in
different and unique ways
– Hyperresponsive reactions
– Hyporesponsive reactions
– Allostatic load: progressive “wear and tear” on
biological systems due to chronic stress
© Cengage Learning 2016
Maltreatment
“Any recent act or failure to act on the part of
a parent or caretaker, which results in death,
serious physical or emotional harm, sexual
abuse, or exploitation, or an act or failure to
act which presents an imminent risk of
serious harm”
Child Welfare Information Gateway, 2011
© Cengage Learning 2016
Types of Child Maltreatment by Percentage
© Cengage Learning 2016
Neglect
• Physical neglect includes:
– Refusal or delay in seeking health care,
expulsion from the home, or refusal to allow a
runaway to return home, abandonment, and
inadequate supervision
• Educational neglect involves:
– Allowing chronic truancy, failing to enroll a
child of mandatory school age in school, or
failing to attend to a child’s special
educational needs
© Cengage Learning 2016
Neglect (cont'd.)
• Emotional neglect:
– Marked inattention to a child’s needs for
affection, refusal or failure to provide needed
psychological care, spousal abuse in the
child’s presence, and permission of
drug/alcohol use by the child
• Neglected children show behavior patterns
vacillating between undisciplined activity
and extreme passivity
© Cengage Learning 2016
Three Forms of Child Neglect
© Cengage Learning 2016
Physical Abuse
• Multiple acts of aggression, including
punching, beating, kicking, biting, burning,
shaking, or otherwise physically harming a
child
• Injuries are often the result of over
discipline or severe physical punishment
• Physically abused children are often
described as more disruptive and
aggressive
© Cengage Learning 2016
Psychological (Emotional) Abuse
• Repeated acts or omissions that may
cause serious behavioral, cognitive,
emotional, or mental disorders
• Exists in all forms of maltreatment
• Can be as harmful as to a child’s
development as physical abuse or neglect
© Cengage Learning 2016
Sexual Abuse
• Fondling a child’s genitals, intercourse
with the child, incest, rape, sodomy,
exhibitionism, and commercial exploitation
through prostitution or the production of
pornographic materials
• May significantly affect behavior,
development, and physical health of
sexually abused children
© Cengage Learning 2016
Sexual Abuse (cont'd.)
• Reactions and recovery of sexually
abused children vary, depending on the
nature of the assault and responses of
important others
– Many acute symptoms resemble children’s
common reactions to stress
© Cengage Learning 2016
Exploitation
• Commercial or sexual exploitation, such
as child labor and child prostitution
• Significant form of trauma for children and
adolescents worldwide
– As many as ten million children may be
victims of child prostitution, the sex industry,
sex tourism, and pornography
© Cengage Learning 2016
Characteristics of Children Who Suffer
Maltreatment
• Age
– 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
• Sex
– 80% of sexual abuse victims are female, but
with that exception, boys and girls are victims
of maltreatment almost equally
© Cengage Learning 2016
Characteristics of Children Who Suffer
Maltreatment (cont’d.)
• Racial characteristics
– The majority of substantiated maltreated
victims are white (44%), African-American
(22%), or Hispanic (21%)
– Compared to children of same race or
ethnicity in the U.S.
• Highest rates of victimization are for children who
are African-American (15.1/1000), American Indian
or Alaska Native (11.6/1000), and multiple race
(12.4/1000), White and Hispanic (8/1000), and
Asian (2/1000)
© Cengage Learning 2016
Family Context
• Relational disorders are an important
factor for physical abuse and neglect
– These forms of maltreatment occur most often
during periods of stress
• Sexual abuse is primarily a premeditated
act —the adult offender plays a purposeful
and intentional role
• Maltreatment is seldom caused by severe
forms of adult psychopathology
© Cengage Learning 2016
An Integrated Model of Physical Child
Abuse
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Reactive Attachment Disorder
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Disinhibited Social Engagement Disorder
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Post-Traumatic Stress Disorder
• 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
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Post-Traumatic Stress Disorder (cont’d.)
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Post-Traumatic Stress Disorder (cont’d.)
© Cengage Learning 2016
Trauma- and Stress-Related Disorders:
Post-Traumatic Stress Disorder (cont’d.)
© Cengage Learning 2016
Post-Traumatic Stress Disorder For
Children Six and Younger
© Cengage Learning 2016
Post-Traumatic Stress Disorder For
Children Six and Younger (cont’d.)
© Cengage Learning 2016
Post-Traumatic Stress Disorder For
Children Six and Younger (cont’d.)
© Cengage Learning 2016
Associated Problems and Adult Outcomes
• PTSD can become a chronic psychiatric
disorder for some children and youths
– May persist for decades and in some cases
for a lifetime (Nader & Fletcher, 2014).
– Children and youths with chronic PTSD may
display a developmental course marked by
remissions and relapses
– In a less common delayed variant, children
exposed to a traumatic event may not exhibit
symptoms until months or years later
© Cengage Learning 2016
Mood and Affect Disturbances
• Symptoms of depression, emotional
distress, and suicidal ideation are common
among children with histories of physical,
emotional, and sexual abuse
• Teens with histories of maltreatment have
a much greater risk of substance abuse
• Childhood sexual abuse also can lead to
eating disorders, such as anorexia
nervosa and bulimia nervosa
© Cengage Learning 2016
Mood and Affect Disturbances (cont'd.)
• In reaction to emotional and physical pain
from abusive experiences, children or
adults voluntarily or involuntarily may
induce an altered state of consciousness
known as dissociation
© Cengage Learning 2016
Sexual Adjustment
• Sexual abuse, in particular, can lead to
traumatic sexualization, in which a child’s
sexual knowledge and behavior are
shaped in developmentally inappropriate
ways
© Cengage Learning 2016
Causes: Poor Emotion Regulation
• Maltreated infants/toddlers have difficulty
establishing reciprocal, consistent
interaction with caregivers
– Exhibit insecure-disorganized attachment
– Have difficulty understanding, labeling, and
regulating internal emotional states
– Learn to inhibit emotional expression and
regulation, remaining more fearful and on
alert
© Cengage Learning 2016
Causes: Emerging View of Self and Others
• Maltreated children’s emerging views of
self and their surroundings are not
fostered by healthy parental guidance and
control
– Emotional and behavioral problems are likely
to appear
– Negative representational models of self and
others develop based on a sense of inner
“badness,” self-blame, shame, or rage
© Cengage Learning 2016
Emerging View of Self and Others (cont'd.)
• Feelings of powerlessness and betrayal
are internalized as part of the child’s selfidentity
• Maltreated girls show internalizing signs of
distress, such as shame and self-blame,
while maltreated boys show heightened
levels of verbal and physical aggression
© Cengage Learning 2016
Causes: Neurobiological Development
• Children and adults with a history of child
abuse show long-term alterations in the
hypothalamic–pituitary–adrenal (HPA) axis
and norepinephrine systems
– These alterations have a significant affect on
responsiveness to stress
• Affected brain areas:
– Include the hippocampus, prefrontal cortex,
and amygdala
© Cengage Learning 2016
Neurobiological Development (cont'd.)
• Acute and chronic forms of stress
associated with maltreatment may cause
changes in brain development and
structure from an early age
– The neuroendocrine system becomes highly
sensitive to stress
• Causing neurobiological changes that may
account for later psychiatric problems
© Cengage Learning 2016
Prevention and Treatment
• Obstacles to intervention and prevention
services for maltreating families
– Those most in need are least likely to seek
help
– They are brought to the attention of
professionals after norms or laws have been
violated
– Parents do not want to admit to problems for
fear of losing their children or being charged
with a crime
© Cengage Learning 2016
Exposure-Based Therapy
• Following acute stress or trauma, such as
motor vehicle accidents, shootings,
bombings, and hurricanes
– Early exposure intervention has reduced
acute stress symptoms
• Many of these interventions are brief,
ranging from 1 to 10 sessions
– Are often delivered in groups to reach as
many children as possible.
• Psychological First Aid (PFA)
© Cengage Learning 2016
Exposure-Based Therapy (cont’d.)
• In-depth psychological interventions are
for children who are severely affected by a
traumatic event
– The child typically begins by describing a
particular traumatic incident and their feelings
and thoughts about it
• Types
– Grief and Trauma Intervention for Children
– Trauma-focused cognitive-behavioral therapy
(TF-CBT)
© Cengage Learning 2016
Preventing Abuse and Its Long-Term
Outcomes
© Cengage Learning 2016
Special Needs of Maltreated Children Physical Abuse and Neglect
• Interventions for physical abuse usually
involve ways to change how parents
teach, discipline, and attend to their
children
• Treatment for child neglect focuses on
parenting skills and expectations, coupled
with teaching parents how to improve their
skills in organizing important family needs
© Cengage Learning 2016
Special Needs of Maltreated Children:
Sexual Abuse
• Treatment programs for children who have
been sexually abused provide several
crucial elements to restore the child’s
sense of trust, safety, and guiltlessness
• TF-CBT has been adapted for child sexual
abuse victims and others with complex
trauma symptoms
© Cengage Learning 2016