© Laura E. Fischer 2019

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 Trauma  what is it?

Disclaimer: This synthesis is based on extensive scientific literature and evidence-based research, but whilst every effort has been made to insure accuracy, the information provided here is for guidance only. Additionally, these are my own words and they may not in any way be copied, reproduced, or utilised without my prior agreement.

 

 

Overview

Traumatic experiences vary in the type of violence inflicted, the source of the adversity, the duration and chronicity, the context, the different developmental stages, and in the resulting imprints and the corresponding trauma diagnosis. There are 3 main types of conditions: Post-Traumatic Stress Disorder – generally following a single traumatic event in adulthood, developmental trauma – prolonged abuse or neglect in childhood, and trauma following prolonged abuse in adulthood, with a yet-to-be agreed distinct denomination. Some of the underpinnings of trauma are common to all types, whilst developmental trauma in particular also holds a symptom cluster of its own.

Currently, Post-Traumatic Stress Disorder (PTSD) remains the most recognised trauma condition, though its symptomatology does not correspond adequately to trauma which is subsequent to prolonged exposure to violence during childhood. The majority of resources are deployed for PTSD, with most trauma treatments modelled for this population. Yet, millions of children’s development occur in dysfunctional caregiving systems with prolonged threat and exposure to maltreatment, abuse, or neglect and endure, as a result, a breadth of severe health conditions both in the immediate and long term which are not systematically recognised as sequelae of childhood trauma and therapeutically approached as such. Adverse childhood experiences are a ‘silent epidemic’ (Kaffman, 2009, title) where behavioural control is favoured over treatment responding comprehensively to a wider context of interpersonal trauma.

PTSD vs Developmental Trauma

As defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013), an individual can develop PTSD from the direct experiencing or the ‘witnessing, in person’ of events that ‘involved actual or threatened death, serious injury, or sexual violence’ or learning of the ‘violent or accidental’ death of a ‘close family member or close friend’. The subsequent effects are manifested in symptoms of re-experiencing: ‘recurrent, involuntary, and intrusive distressing memories of the traumatic event’, or in a similar manner in nightmares, ‘dissociative reactions’ where the person ‘feels or acts as if the traumatic event(s) were recurring’, ‘intense or prolonged psychological distress at exposure to internal or external’ stimuli that is in resemblance or in symbol somewhat connected to the traumatic experience, and ‘marked physiological reactions’ to such cues. There are also symptoms of ‘persistent avoidance of stimuli associated with the traumatic event(s)’, as well as ‘negative alterations in cognitions and mood’, ‘marked alterations in arousal and reactivity’, and consequential ‘clinically significant distress or impairment’ in functioning (p.271-272).

In other words,  a person is confronted to an unexpected, unavoidable, and overwhelming event of direct or indirect extreme violence, survives, but is fundamentally changed; by means of a reorganised nervous system and altered physiological states, the traumatic experience is unresolved, unprocessed, and is continuously relived. While a singular traumatic event could occur in childhood and children can indeed develop PTSD symptoms comparable to those of adults (APA, 2013, p.272), this narrative does not fit that of children who are exposed to prolonged or chronic abuse. As it is based on circumscribed experiences and modelled on ‘prototypes of combat, disaster, and rape’, the criteria for PTSD ‘fails to capture either the protean symptomatic manifestations of prolonged, repeated trauma’ or the resultant ‘profound deformations of personality’ (Herman, 2015, p.119). In fact, of the traumatised children treated by the National Child Traumatic Stress Network, 82% do not meet the diagnostic criteria for PTSD (Spinazzola et al., 2005).

Survivors of childhood trauma present a cluster of multifaceted symptoms that do not fit properly those of PTSD yet are significant in severity, in complexity, and in number. Indeed, the psychological, cognitive, social, and biological development of children subjected to interpersonal adversity is pervasively modified (Burns et al., 1998; Cook et al., 2005; Spinazzola et al., 2005), which causes an array of mental and physical health problems, self-destructive behaviours, and somatic disruptions, with extremely high levels of comorbidity. More specifically, the interconnected set of chronic symptoms of childhood trauma include ‘dysregulation of affect and behaviour’, ‘disturbances of attention and consciousness’, ‘distortions in attributions’ about the self and others, and ‘interpersonal difficulties’ – all appearing as both concurrent and interrelated (D’Andrea et al., 2012, p.188-192). In addition, biological correlates are not only numerous but neurobiological alterations have been found to be more specific to childhood abuse than any other psychopathology (De Bellis & Kuchibhatla, 2006).

In sum, childhood trauma is distinct from PTSD in the prolonged and/or repetitive nature of the adversity, in the specificity of the developmental timeframe, in the context of compromised attachment, and in the variety and characteristics of the symptoms. As demonstrated by Trickett, Noll, and Putnam (2011) in their multigenerational longitudinal study on the repercussions of sexual abuse on female development, childhood sexual abuse pervasively impacts survivors far beyond the trauma picture depicted by the symptomatology of PTSD. Compared to girls of the same age and ethnicity and from the same social background, sexually abused girls suffer from a range of severe consequences and have an altogether distinctly altered developmental pathway:

‘[…] deleterious sequelae across a host of biopsychosocial domains including: earlier onsets of puberty, cognitive deficits, depression, dissociative symptoms, maladaptive sexual development, hypothalamic-pituitary-adrenal attenuation, asymmetrical stress responses, high rates of obesity, more major illnesses and healthcare utilization, dropping out of high school, persistent posttraumatic stress disorder, self-mutilation, [DSM] diagnoses, physical and sexual revictimization, premature deliveries, teen motherhood, drug and alcohol abuse, and domestic violence.’

Prevalence & Consequence

Violence is omnipresent in today’s societal climate; more than half of the population is exposed to at least one potentially traumatic incident in their lifetime (Kessler, 1995), and over a third of women experience sexual abuse, physical abuse, or both, at some point during their life (Agnihotri et al., 2006). Moreover, from a database of 38 reports covering 96 countries, it is estimated that in a single year over half of all children aged 2 to 17 years, or one billion children globally, are subjected to emotional, physical, or sexual abuse (Hillis et al., 2016). UNICEF (2014), furthermore, affirms that such violence is vastly concealed and under-reported. Meta-analyses of global prevalence of abuse suggest that child physical abuse is 75 times higher and child sexual abuse 30 times higher than official numbers (Stoltenborgh, 2011a; Stoltenborgh, 2011b). From a mental health perspective, despite the fact that most individuals with adverse childhood experiences never access psychiatric treatment and only proportionally few survivors of such adversity become psychiatric ‘patients’, the mental health system is largely composed of people with experiences of pervasive childhood abuse (Herman, 2015, p.122). Reports from Jacobson and Richardson (1987), Bryer et al. (1987), and Jacobson (1989) show that 50-60% of psychiatric inpatients and 40-50% of outpatients disclose histories of childhood physical abuse, sexual abuse, or both.

 

The World Health Organization (2016a) confirms that one of the impacts of child maltreatment is lifelong mental and physical impairment. In an initiative articulating strategies to end violence against children, they state that the direct and long-term repercussions of child abuse on public health paired with the associated financial costs decelerate social and economic growth, destabilise investments in health and education, and corrode the productive potential of following generations (World Health Organization, 2016b). Moreover, in a longitudinal study conducted by Sroufe & Collins (2009) aimed at understanding the developmental role of nature versus nurture and personality versus environment, childhood abuse and neglect emerged as the most important predictors of adult (dys)functioning and (ill) health. The population attributable risk was also calculated and it was estimated that eliminating child abuse would lower ‘the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters’ (Van Der Kolk, 2015, p.148). It is thus unsurprising that childhood trauma was characterised as a ‘hidden epidemic’ (p.149).

 

The ACE Study examined the health and social effects of adverse childhood experiences (ACEs) by surveying over 17’000 adults on their childhood experiences, their current state of health, and their behaviour (Felitti et al., 1998). Three categories of abuse, two categories of neglect, and five categories of household dysfunction were identified as ACEs. The key findings were: although infrequently recognised due to being concealed by time, shame, and stigma, ACEs are in fact outstandingly common (two-thirds of the participants had at least one ACE with 87% of these having two or more); ACEs are decisive predictors of health risks, disease, and premature mortality; there is a graded relationship between breadth of ACEs and lifetime health outcomes; ACEs are the leading determinant of a population’s health and social states (Felitti et al., 1998). Furthermore, Spinazzola et al. (2005) analysed the records of almost 2000 children treated by the National Child Traumatic Stress Network and found that the results mirrored those of the adults in the ACE Study; the majority of the children had developed in the context of highly dysfunctional caregiving, had a history of abuse and/or neglect, and nearly half had been raised by persons other than their parents.

 

Note: This text is part of a longer document I am writing to explain the mechanisms of childhood trauma, the current state of research, and future treatment avenues. If you are interested in knowing more, feel free to sign up to the newsletter for updates.

 

 

 

References

 

Agnihotri, A.K. et al. (2006). ‘Domestic Violence Against Women – An International Concern’, Torture, 16(1), pp. 30-40.

 

APA: American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. 5thed. Arlington: American Psychiatric Association.

 

Bryer, J.B. et al. (1987). ‘Childhood Sexual and Physical Abuse as Factors in Adult Psychiatric Illness’, American Journal of Psychiatry, 144, pp. 1426-1430.

 

Burns, B. et al. (1998). ‘Improving Outcomes for Children and Adolescents with Serious Emotional and Behavioural Disorders’. In Epstein, M. et al. (eds.) Outcomes for Children and Youth with Emotional and Behavioural Disorders and their Families: Programs and Evaluation Best Practices. Austin: PRO-ED, pp. 685-707.

 

Cook, A. et al. (2005). ‘Complex Trauma in Children and Adolescents’, Psychiatric Annals, 35(5), pp. 390-398.

 

D’Andrea, W. et al. (2012). ‘Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis’, American Journal of Orthopsychiatry, 28(2), pp. 187-200.

 

De Bellis, M.D. & Kuchibhatla, M. (2006). ‘Cerebellar Volumes in Pediatric Maltreatment-Related Posttraumatic Stress Disorder’, Biological Psychiatry, 60, pp. 697-703.

 

Felitti, V.J. et al. (1998). ‘Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study’, American Journal of Preventive Medicine, 14(4), pp. 245-258.

 

Herman, J. (2015). Trauma and Recovery: The Aftermath of Violence. 2nded. New York: Basic Books.

 

Hillis, S. et al. (2016). ‘Global Prevalence of Past-Year Violence Against Children: A Systematic Review and Minimum Estimates’, Pediatrics, 137(3).

 

Jacobson, A. (1989). ‘Physical and Sexual Assault Histories Among Psychiatric Outpatients’, American Journal of Psychiatry, 146, pp. 755-758.

 

Jacobson, A. & Richardson, B. (1987). ‘Assault Experiences of 100 Psychiatric Inpatients: Evidence of the Need for Routine Enquiry’, American Journal of Psychiatry, 144, pp. 908-913.

 

Kaffman, A. (2009). ‘The Silent Epidemic of Neurodevelopmental Injuries’, Biological Psychiatry, 66, pp. 624-626.

 

Kessler, R.C. et al. (1995). ‘Posttraumatic Stress Disorder in the National Comorbidity Survey’, Archives of General Psychiatry, 52(12), pp. 1048-160.

 

Spinazzola, J. et al. (2005). ‘Survey Evaluates Complex Trauma Exposure, Outcome, and Intervention among Children and Adolescents’, Psychiatric Annals, 35(5), pp. 433-439.

 

Sroufe, L.A. & Collins, W.A. (2009). The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guildford Press.

 

Stoltenborgh, M.A. et al. (2011a). ‘Cultural - Geographical Differences in the Occurrence of Child Physical Abuse? A Meta-Analysis of Prevalence Around the World’, International Journal of Psychology, 48, pp. 81–94.

 

Stoltenborgh, M.A. et al. (2011b). ‘A Global Perspective on Child Sexual Abuse: Meta-Analysis of Prevalence Around the World’, Child Maltreatment, 16, pp. 79–101.

 

UNICEF (2014). Hidden in Plain Sight: A Statistical Analysis of Violence Against Children. New York: United Nations Children’s Fund.

 

Van Der Kolk, B. (2015). The Body Keeps the Score: Mind, Brain, and Body in the Transformation of Trauma. 3rded. London: Penguin Books.

 

World Health Organization (2016a). Child Maltreatment: Fact Sheet. Available at: http://www.who.int/mediacentre/factsheets/fs150/en/ (Accessed 20 July 2018).

 

World Health Organization (2016b). INSPIRE: Seven Strategies for Ending Violence Against Children. Luxembourg: WHO Publications.

Recommended resources

Books

 

The Body Keeps The Score: Mind, Brain and Body in the Transformation of Trauma, Van Der Kolk, B., 2015

Trauma and Recovery: The Aftermath of Violence, Herman, J., 2015

The Boy Who Was Raised Like A Dog, Perry, B., 2017

The Compassionate Mind, Gilbert, P., 2010

Talks

Cultivating the Courage to Acknowledge Trauma

Laura E. Fischer (2017)​​

How Childhood Trauma Affects Health Across a Lifetime
Nadine Burke (2014)​​

Towards a New Understanding of Mental Illness
Thomas Insel (2013)

The Neuroscience of Restorative Justice
Daniel Reisel (2013)