Toxic Stress and Children

CCNCMedical Home TrainingJean Smith, MD, FAAP

WHAT IS TRAUMA?

Injuries to the mind and body that

overwhelm our ability to cope

Trauma Affects Behavior, Development, Emotion, Cognition,

Social Functioning and Physical Health

Building Brain Architecture The early years of life matter because early experiences affect the architecture of the maturing brain. As it emerges, the quality of that architecture establishes either a sturdy or a fragile foundation for all of the development and behavior that follows.

© FrameWorks Institute 2009

Experiences Wire the Brain• Brain’s wiring will develop based on a

child’s experiences – good and bad.• Repeated experiences create strong

“wiring”

Chronic trauma alters brain chemistry and changes the

structure of the brain

Toxic StressWhen interpersonal experiences are disruptive, neglectful, abusive, unstable, or otherwise stressful, they increase the probability of poor outcomes.

Serious and prolonged stress -- toxic stress --releases harmful chemicals in the brain that impair cell growth and make it harder for neurons to form healthy connections.

Neurophysiology of the Stress Response

Adrenal Cortex

Pituitary Gland

Hypothalamus

Amygdala Hippocampus

Sensory/Transitional Cortex

Emotional Stimulus(Initial actual threat &

Subsequent reminders)

Thalamus

-

CRF

ACTH

CORTCORT

-

Consequences of Child Maltreatment

Brain Growth and Child Abuse• Smaller overall brain mass in children who have been

abused• Effect more pronounced in males • The earlier abuse occurs and the longer it lasts, the smaller

the brain• Decrease in brain size is correlated with an increase in PTS

and behavioral symptoms» DeBellis and Thomas, 2003

Lateral Ventricles Measures in an 11- Year-Old Maltreated Male with Chronic PTSD, Compared

with a Healthy, Non-Maltreated Matched Control

De Bellis et al., Biological Psychiatry, 1999.

Why Problems Occur• Toxic stress negatively impacts the

architecture of the brain• Changed architecture will lead to impaired

development – cognitive, emotional, behavioral

• Impaired development will lead to risky behaviors and/or emotional issues (substance use, promiscuity, aggression)

• These behaviors hinder opportunity for success and often result in failure in school, youth violence, teen pregnancy, addictions

Adverse Effects of CAN: Cognition

Donna Potter, 2008

• Deficits in attention• Deficits in abstract reasoning• Deficits in executive function• Deficits in memory• Lower IQ• Poor language development• Difficulty with rapid decision making

Putnam, 2006

Resulting in: Poor academic performance, repeat grades, and special education

Changes in Processing Information

• Focus on nonverbal communication• Tune out all non-critical information• Decision making becomes black and

white• Thinking part of the brain is less

active/functioning on reflexes• Difficulty Speaking/accessing

language

Development and Trauma

Donna Potter, 2008

• Speech and language delays• Gross motor delays• Poor fine motor coordination• Sensory integration problems

Alters Developmental Trajectory

• Sexually abused girl as a teen may become promiscuous or avoid dating

• Child who witnesses father murder mother withdraws from relationships, unable to trust anyone, does not have any friends

• A toddler who witnesses domestic violence may have his curiosity and increasing exploration of the environment compromised.

Can’t Do One Without The Other• Cognitive, emotional, and social

capacities are inextricably intertwined, and learning, behavior and physical and mental health are inter-related over the life course.

Adoption of Health-risk Behaviors

Social, Emotional, & Cognitive Impairment

EarlyDeath

Adverse Childhood Experiences

Death

Disease, Disabilityand Social Problems

Conception

Scientific gaps

Source: ACE Study, The ACE Pyramid, Centers for Disease Control

The ACE Study

• The ACE Study = Adverse Childhood Experiences Study

• Surveyed 17,000 adults• Compared childhood experiences with

adult health records• Found adverse childhood experiences

= greater likelihood of future problems with physical health

20

Adverse Exposure Prevalence (%)

Emotional Abuse 10.5%

Physical Abuse 28.3%

Sexual Abuse 20.7%

Household Substance Abuse

11.6%

Household Mental Illness 19.4%

Battered Mother 12.7%

Incarcerated Family Member

4.7%

Parental Separation or Divorce

23.2%

At Least One ACE 60.5%

Prevalence of Adverse Childhood Experiences (ACE Study Wave 2)

ACE Score and Rates of Antidepressant Prescriptions

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10

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ACE Score

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The ACE Score and the Prevalence of Attempted Suicide

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ACE Score

Perc

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Number of Adverse Childhood Experiences

and Teen Sexual Behaviors

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Number of adverse factors:

Intercourse byage 15

Teenpregnancy

Teenpaternity

ACE Score and the Prevalence of

Severe Obesity

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0 1 2 3 >=4

ACE Score

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ACE Score

Early smokinginitiation

Current smoking COPD

ACEs, Smoking, and Lung COPD

Consequences of Child Maltreatment

Child Maltreatment

Health-risk BehaviorsSexual promiscuitySexual perpetrationAlcohol abuseIllicit/injected drug useSmokingBehavior problems

Mental/Social ProblemsPTSDDepressionAnxietyEating DisordersAcademic FailureUnwanted PregnancyObesityRevictimization

Disease and Injury Conditions

Ischemic heart disease

Diabetes

Stroke

Cancer

Suicide

Skeletal Fractures

Chronic bronchitis/emphesema

STDs (e.g., HIV)

Hepatitis

Source: ACE Study, Centers for Disease Control

Impact of Child Maltreatment

U.S. Child Abuse and Neglect

3 million reports

School Drop Out

Alcohol and Drug Use

Teen Pregnancy

Loss of Wages

Gang Violence

Domestic Violence

Sexual Violence

Juvenile Crime

Long-Term Health Issues

$104 Billion Annually

Child Protection

Foster CareCourt

Emergency Room

Mental Health

Children in foster care are children with special health care needs.

Trauma Causes…..

• Loss of Predictability• Loss of Trust• Loss of Safety• Loss of Control

• 40-60% of maltreated children will have significant emotional and behavior problems

• 25% of accidentally injured children will have serious emotional problems with up to 88% having at least one significant symptom

» puntam

Most common childhood psychiatric conditions associated with childhood

trauma (in order from most to least common)

• Separation anxiety disorder• Oppositional defiant disorder• Phobias• PTSD• ADHD

(Ackerman et. al., 1998)

Posttraumatic Stress Disorder

• Avoidance = “Never pass this way again”

• Re-experiencing = “Remember this experience so it isn’t repeated”

• Increased arousal = “Stay on guard”

TRAUMA REMINDERS

Secondary Stressors

Moving

Leaving friendsChange in physical abilities

Leaving family/pets Changing

schools

Mediating Factors in Impact of Trauma:

Individual child, event, and family social systemcharacteristics

Characteristics of the Child

• subjective experience of threat to life and limb

• history of previous traumatic exposures• coping style• general level of anxiety• Age, developmental stage• meaning child makes of event• genetic predisposition • intelligence• temperament

Characteristics of the Event

• Nature of the event• Direct physical harm• Proximity to threat (emotional, physical)• Pattern• Duration• Relationship to perpetrator

• Supportive, calm, nurturing, vs chaotic, distant, absent, anxious• Reactions of loved ones, calm nurturing, and sense of safety will

decrease vulnerability.• If caregiver is traumatized their capacity to provide a consistent,

predictable, and nurturing environment is compromised• Factors that increase stress related reactivity- will make children

more vulnerable while factors that provide structure, predictability, nurturing and sense of safety will decrease vulnerability

• Reactions of loved ones during the event

Characteristics of the Family/Social System

Medical Homes Can Make a Difference

• Foster children: one of most vulnerable populations with complex needs due to the impact of trauma, environmental instability

• Medical homes are in unique position to support these children’s health and development with:

continuity of care, health & developmental expertise, community linkages, care coordination, education/

support for caregivers and child welfare staff

Credits for slides

Donna Potter – Center for Child and Family Health

Michelle Hughes – Benchmark Editing by Jean Smith &

Michelle Hughes