Trauma and Associated Disorders
Toi Blakley Harris MD
John Sargent MD
Introduction
Millions of youth are exposed to traumatic events every year. Some are exposed to a singular event, whereas others have histories of multiple traumatic events. In Neria et al.’s 2007 systematic review of post-traumatic stress disorders (PTSDs) following disasters, they reported that greater than two thirds of the population will experience some form of traumatic event during their life span. Children and adolescents experience potentially traumatic events of varying degrees. These events may be secondary to man, nature, or medical illness. They may be intentional or unintentional, singular or repetitive. The National Child Traumatic Stress Network and others have identified traumatic stress associated with the following events: terrorism, natural disasters, refugee and war-zone trauma, medical trauma, community and school violence, domestic violence, traumatic grief, complex trauma, sexual abuse, physical abuse and neglect, and psychological maltreatment.
Since the 1980s, there has been an increased emphasis on evaluating the impact of trauma experienced during childhood and adolescence. Childhood trauma may lead to subsequent medical and psychiatric comorbidity. Examples of psychiatric comorbidity following childhood trauma include behavioral and psychological maladaptation with strongest links to anxiety and depressive disorders. Although there are a host of psychiatric conditions that may be the sequelae of childhood trauma, this chapter reviews the concepts of traumatic stress and relates them to the development of PTSD and acute stress disorder (ASD).
Background
Historically, traumatic events experienced by youth were not felt to lead to long-term adverse psychological or physical sequelae. In 1980, the term PTSD was first described by the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, it was not until 1987 that the DSM discussed PTSD with specific reference to children victimized by trauma. Since that time, researchers have proposed additional classification systems for PTSD applicable for children, as discussed later in this chapter.
Following a traumatic event, acute and chronic physiological changes can develop. Bell has asserted that understanding these findings can assist clinicians to conceptualize how traumatic stress and PTSD can form a “biopsychosocial trap” that may result in permanent change of the neurobiological system. As a result, the literature has documented negative impacts on emotions, learning, attention, memory, and the ability to sustain life. Whether or not a child progresses to develop short- or long-term psychological ill effects after trauma is not only related to the specifics of traumatic exposure, but also to individual, family, and social—cultural or community factors.
Culture has been documented to influence the individual and collective response to trauma. Marsella and Christopher also note that culture influences the meaning of a traumatic
event, subsequent symptom formation, and help-seeking behaviors. Although childhood traumatic experiences have been linked to a multitude of psychiatric disturbances and impaired legal, social, vocational, and relationship outcomes, this section will focus on ASD and PTSD.
event, subsequent symptom formation, and help-seeking behaviors. Although childhood traumatic experiences have been linked to a multitude of psychiatric disturbances and impaired legal, social, vocational, and relationship outcomes, this section will focus on ASD and PTSD.
Clinical Features and Diagnosis
Pathophysiology
Bell has reviewed the neurobiology of trauma and described the effect of trauma on multiple domains: the catecholamine system, hypothalamic—pituitary—adrenal axis (HPA), hypothalamic— pituitary—gonadal axis (HPG), and neuropsychiatric status. Increased reactivity of the sympathetic nervous system has been reported in chronically traumatized children and has manifested as physiological hyperarousal and hyperactivity. Studies have documented chronic stress alteration of the HPA system and subsequent neuroendocrine disturbances (i.e., corticosteroid and thyroid) in sexually abused girls. Additionally, research has shown the relationship between aggressive behaviors in males as the result of the HPG’s response to trauma that affects cortisol, testosterone, dehydroepiandrosterone, and androstenedione. In sexually abused females, clinical observation has linked early physical maturation to a neuroendocrine response to trauma. Adult studies have examined the hippocampal volumes of adult survivors of childhood abuse with PTSD and found a smaller left hippocampal volume in comparison to matched controls. These alterations in neuroendocrine and neurocircuitry domains can manifest on physical examinations, neuroimaging, and laboratory data collection.
Clinical Evaluation
Primary care providers are frequently the first to encounter and evaluate maltreated children and adolescents. Clinical presentations following childhood traumatic experiences may vary depending upon the proximity of the event, the developmental level of the child, and cultural influences. Authors have discussed the impact of an individual’s developmental level on trauma symptom formation. In 2003, Terr described four distinct features of childhood trauma: (1) “strongly visualized or otherwise repeatedly perceived memories,” (2) “repetitive behaviors,” (3) “trauma-specific fears,” and (4) “changed attitudes about people, aspects of life, and the future.” Clinically, these types of trauma patterns have different presentations.
The Diagnostic and Statistical Manual, 4th Edition-Text Revision (DSM-IV-TR) delineated criteria for PTSD and ASD. Following an event that included threatened serious harm or death or threat to the bodily integrity of others and or self, youth may exhibit re-experiencing, avoidance, or hyperarousal symptoms. Temporal relationships and duration and intensity of features are used to differentiate ASD from PTSD, as noted in Table 8-1.
Authors have delineated trauma types and clinical presentations based upon traumarelated factors that manifest differentially through pathophysiologic, neurocircuitry, and neuroendocrine mechanisms. Terr and the AACAP suggested that type I trauma results from a singular traumatic event and leads to the traditional DSM symptoms of PTSD (i.e., reexperiencing, avoidance, and hyperarousal). However, type II trauma or complex trauma, as described by Cook, Spinazzola, and colleagues, is due to multiple and ongoing events, and does not necessarily solely manifest as “classic” PTSD symptoms. Type II or complex trauma presents with difficulties with self-regulation in behavioral and affective domains along with physiological, cognitive/perceptual, relational, and self-attributional aberrancies. This can manifest in many variations that include mood dysregulation, aggression, dissociation, numbing, and denial. Clinical features of these forms of trauma will be highlighted later in this chapter.
TABLE 8-1 ASD and PTSD Criterion Symptoms | ||||||||||||||||||||||||
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DSM-IV-TR utilized alternative descriptors for children while evaluating for PTSD or ASD. Children may not have the capacity to verbalize horror, fear, or helplessness and may exhibit agitated or disorganized behavior following a traumatic event. During evaluation for re-experiencing symptoms, children may display repetitive play, trauma-specific re-enactments, and have dreams without clear or recognizable content.
Although the DSM-IV-TR made reference to some differences in the clinical presentations involving young children, more scientific rigor is needed to differentiate diagnosis based upon the trauma survivor’s developmental level. Lubit has noted key differences between youth and adults that make the diagnosis of PTSD problematic. Because of these challenges, children and adolescents often fail to meet full criteria for PTSD. Children’s verbal abilities often render them incapable of articulating their thoughts and feelings. They may also fluctuate between numbing/withdrawal and hyperarousal symptoms.
Other authors have proposed modified criteria for PTSD that do not require the child to endorse helplessness, fear, or horror following the traumatic event and require only one symptom in the avoidance and hyperarousal categories to meet diagnostic criteria for youth. These authors have suggested these revised criteria be employed while assessing children for PTSD.
Culture influences the meaning of the traumatic event and symptom formation for the individual and the family. Researchers in the field of trauma and cross-cultural psychiatry have contributed to our understanding of this influence. Marsella and Christopher explored how cultural internal and external representations have a bearing on traumatic responses to disasters. These representations define “the way they experience the nature, meaning, and content of reality.” As delineated in DSM-IV-TR, cultural variables may have a role in symptom expression and the outline for cultural formulation and culture-bound syndromes are steps to increase the clinician’s understanding of the interface between culture and mental health. Within these syndromes are symptoms that overlap with criteria for many psychiatric disorders including ASD and PTSD. For example, re-experiencing symptoms such as flashbacks may be perceived as “visions.” Dissociation could be seen as “spirit possession.” Hyperarousal symptoms may be viewed as “ataque de nervios” depending upon an individual’s cultural background and/or acculturation to western views of psychological disturbance. The interpretation of a child’s response to a traumatic event determines the caregiver’s response and whether subsequent assistance outside of the family system will be sought and accepted.
Epidemiology
Primary care physicians frequently encounter children and adolescents who have been traumatized. The agents of childhood and adolescent trauma may be multifactorial. These sources of trauma are due to man, nature, medical illness, or combinations. Evidence has suggested that traumatic events that were interpersonal in nature, recurrent, or those that involved a life threat carried a greater risk for psychological distress including PTSD than other sequelae of trauma.
According to the United States Department of Health and Human Services, more than 3.5 million children and adolescents received evaluations by children’s protective services for suspected neglect or abuse in 2007; 794,000 of these youth were determined to have experienced maltreatment. During 2007, Child Protective Services reported the following data regarding youth maltreatment in the United States: 59% neglect, 10.8% physical abuse, 7.6% sexual abuse, 4.2% psychological maltreatment, 4.2% “other” maltreatment (abandonment, threats to the child, congenital drug addiction), <1% medical neglect, and 13.1% multiple maltreatments.
According to the literature, the population sampled and the criteria used to define a traumatic event each has bearing on the prevalence rates. There are no available data on the lifetime prevalence of ASD. Studies conducted with children exposed to traumatic injuries did not support childhood ASD as a predictor for subsequent PTSD. These studies did not demonstrate significant clinical correlations between those who met criteria for ASD at 1 month follow-up, 8—10%, and those with PTSD diagnosed between 3 and 6 month followup visits, 6—25%. Acute stress reactions where dissociation was not present proved to be a stronger prediction of PTSD.
A review of the PTSD prevalence literature found that 16-43% of rural youth and 39—75% of urban youth had exposure to the type of a traumatic event described as “actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” prior to the age of 16. Furthermore, up to 68% of youth in a primary care setting have reported being exposed to potentially traumatic events and greater than half of these youth encountered multiple such events. As a result, 25% of exposed youth met full or partial criteria for PTSD. Data also suggest that the likelihood of developing PTSD and other mental health disorders increases with each traumatic exposure.
Comorbidity and Differential Diagnosis
As discussed previously, children and adolescents exposed to traumatic events may develop a myriad of psychological sequelae and psychiatric disorders. They may present to primary care offices with high-risk behaviors such as sexual acting out, self-harming behavior, or externalizing disorders that manifest as aggression towards others. In addition to screening for ASD and PTSD, youth who are traumatized have an increased risk for frequently occurring comorbid psychiatric disorders. Therefore, it is prudent that they are screened for high-risk behaviors such as sexual acting out, self-harming behaviors, and the following diagnostic groups: (1) other anxiety disorders, (2) mood disorders (major depressive disorder, dysthymia), (3) disruptive behavior disorders (attention-deficit hyperactive disorder subtypes, oppositional defiant disorder, and conduct disorder), (4) substance-use disorders, (5) somatoform disorders, (6) eating disorders, and (7) borderline personality disorder.
Risk-Resilience Factors
As described above, all youth exposed to a traumatic event do not go on to develop adverse psychological sequelae. Collingshaw and colleagues studied resilience, defined as “positive adaptation in the face of adversity.” In this study of individuals who experienced repeated sexual and or physical abuse, 44.5% were found to not develop psychiatric disorders or suicidality over a 30-year period. Similar rates of resilience were found by DuMont who identified 48% without difficulties during adolescence. Almost 33% were found to manifest resilience in adulthood despite prior trauma histories.
Protective circumstances that contribute to a child’s or adolescent’s resilience appear to include genetic, biological, cognitive, interpersonal, and social factors. Individual attributes that promote resiliency include intelligence, easy or positive temperament, internal locus of control, effective coping strategies, a secure attachment relationship, special talents, and spirituality. These strengths often recruit adults to be engaged with and support youth in adverse circumstances.
Sources of resilience that are external to the trauma survivor are also essential in the mitigation against adversity. Those cited included the availability of adults who provide parental warmth, affection, and acceptance. Additionally, the role of supportive networks or “villages” was also noted as an important external support to buffer against traumatic exposures and an individual’s premorbid risk factors.
Researchers have also delineated risk factors that lead to maladaptation following a traumatic event and increase the likelihood that PTSD will develop. Vulnerability factors can be classified as individual, family, cultural/environmental, or trauma-related. According to studies, having these attributes places individuals at risk: a genetic predisposition for anxiety disorders, temperamental behavioral inhibition, having a prior anxiety disorder, female gender, and limited cognitive abilities. Kassam-Adams and colleagues noted that an early postinjury elevated heart rate can be seen as an early physiological marker of hyperarousal predictive of full or partial PTSD.
The data regarding the impact of family characteristics on later maladaptation to traumatic events has been mixed. The association of parental post-traumatic stress symptoms (PTSS) to child PTSS was found to occur not only in the face of parental distress. A myriad of factors were reported to be involved that included impaired modeling of adjustment to trauma that could directly alter the youth’s avoidance behaviors, genetic vulnerabilities, and underlying poorly perceived parental care.
A recent review outlined evidence supporting the heritability of PTSD. Studies involving 11 twin subjects have shown three major findings that support the role of genetics in PTSD.
The first one involves the gene—environment correlation that points to how an individual selects his/her environment and thus potential exposure to traumatic events. Prior longitudinal studies have shown that childhood adaptation and personality characteristics (i.e., neuroticism) are predictive of future stressful life events. Twin studies also suggest that genetics could partially account for the susceptibility to develop PTSD among adults. Lastly, limited evidence from twin studies has shown “the majority of the genes that affect risk for PTSD also influence risk for other psychiatric disorders and vice versa.” The disorders mentioned in this review were major depression, generalized anxiety disorder, panic disorder, alcohol, drug, and nicotine dependence.
The first one involves the gene—environment correlation that points to how an individual selects his/her environment and thus potential exposure to traumatic events. Prior longitudinal studies have shown that childhood adaptation and personality characteristics (i.e., neuroticism) are predictive of future stressful life events. Twin studies also suggest that genetics could partially account for the susceptibility to develop PTSD among adults. Lastly, limited evidence from twin studies has shown “the majority of the genes that affect risk for PTSD also influence risk for other psychiatric disorders and vice versa.” The disorders mentioned in this review were major depression, generalized anxiety disorder, panic disorder, alcohol, drug, and nicotine dependence.
Caregivers who are not in tune with their child’s psychological distress, either due to their own personal psychological distress or due to their lack of capacity to provide emotional validation or to psychologically support their child further inhibit the trauma victim’s ability to adapt.
Trauma-related factors predictive of PTSD involve the nature of the traumatic event and frequency of traumatic events. Traumatic events due to interpersonal traumatic events appear more likely to result in PTSD in comparison to accidental events. Chronicity versus a singular exposure to a traumatic event increases the likelihood that PTSD will ensue. Moreover, if an individual is closer in proximity to the traumatic event, the risk for psychological maladaptation is higher. These individual, family, and environmental factors determine whether trauma exposure will lead to maladaptation and subsequent psychological problems or post-traumatic growth.
Ko from the National Child Traumatic Stress Network discussed how some minority youth are at increased risk for PTSD due to a variety of political, social, and economic factors. Many minority immigrant youth are at increased risk for exposure to traumatic stress resulting from war-related violence experienced in their countries of origin and or as a result of traumatic events during immigration to the United States. Other ethnic minority youth have increased rates of violence in their communities and a disproportionate number of these youth are involved with gangs and/or impacted by gang-violence. Although all ethnic groups have children and adolescents who are maltreated, disproportionate amounts of African-American, Latino, Native American children have been placed in foster care following substantiated maltreatment. Increased rates of exposure to traumatic events are compounded by decreased access to early and accurate intervention. Inadequate responses to acute stress reactions can result from mental health disparities, and from decreased access to available social, mental health and health services following disasters/traumatic events. This further increases the likelihood of long-term adverse psychosocial adaptation to traumatic events.
Because traumatized youth rarely seek mental health intervention on their own and families often do not recognize the signs and symptoms associated with ASD and/or PTSD, pediatricians and other primary care providers are poised to screen for traumatic exposure within the context of their working relationship with children, adolescents, and their families. This trusted therapeutic partnership represents an extraordinary opportunity for pediatricians and primary care physicians to identify and refer youth for mental health treatment if needed.
Clinical Course
The Adverse Childhood Experiences (ACE) study documented the association between childhood adverse events and negative adult outcomes. Individuals who experience traumatic events in childhood and adolescence are at risk for medical complications, psychiatric disturbances, and impaired social functioning as they develop and in adulthood. In particular, survivors of complex trauma that occurs early in life and is multiple and or chronic and prolonged have been shown to have the maximum risk for adverse outcomes. Repeated experience of victimization may occur with chronic medical conditions, but most often occurs due to interpersonal factors through maltreatment. This results in the interference with secure attachment formation and normative neurobiological processes that allow for optimum cognitive development, for an individual to
acquire the ability to modulate his/her emotions in response to stress, establish a positive selfconcept, form interpersonal relationships, and then acquire the ability to effectively solve problems. As a result, complex trauma survivors are at risk to develop psychological disturbances that overlap with anxiety, mood, disruptive, cognitive, and substance misuse disorders.
acquire the ability to modulate his/her emotions in response to stress, establish a positive selfconcept, form interpersonal relationships, and then acquire the ability to effectively solve problems. As a result, complex trauma survivors are at risk to develop psychological disturbances that overlap with anxiety, mood, disruptive, cognitive, and substance misuse disorders.
Terr’s review presents clinical correlates of differing types of trauma. Youth who sustain single-event traumas are more likely to develop symptoms characteristic of PTSD, remember detailed information about the trauma, and manifest “omens” and perceptual difficulties. If the trauma occurred after the age of 36 months, they are able to provide clear details of the event with occasional misperceptions and worries about future traumas. However, children and adolescents with prior histories of complex trauma manifest varied symptom patterns of denial, numbing, self-hypnosis, dissociation, and rage that may be confused with the following diagnoses: conduct disorder, attention-deficit hyperactivity disorders, depression or dissociative disorders.
Various studies show that exposure to at least one traumatic event in childhood can lead to PTSD in 14.5-25% of individuals. Others exposed to trauma may have symptoms of ASD. In this review, 88% of children admitted to hospital following motor vehicle accidents and 83% of their caregivers recorded symptoms in one or more of the four ASD domains (hyperarousal, re-experiencing, dissociation, and avoidance). Arousal was most often identified by parents, whereas children were more likely to endorse symptoms of dissociation.
In addition to short- and long-term psychological sequelae of childhood trauma, adverse medical outcomes for these youth have been described, such as high health care use, increased risk for many causes of early death in adulthood, increased rates of asthma, allergy, gastrointestinal disturbance, and headaches. Along with these medical concerns, primary care physicians are also called to treat medical conditions that are the direct result of maltreatment, accidents, disasters and or acts of terrorism. These medical disorders may require acute, brief care, or longer term management which may involve several providers within a multidisciplinary team.
Assessment
Trauma screening procedures for primary care physicians and other frontline clinicians have been recommended by several authors. Multiple informants should be interviewed to obtain the most accurate information. It is important to assess the current level of safety of the traumatized child or adolescent as well as determine the level of support available to that youth. This will greatly affect the manner and location of mental health services provided.
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