Midterm: Study Guide
Midterm: Study Guide V05.0203
Popular in When the Nightmare Is Real: Trauma In Childhood and Adolescence
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This 13 page Study Guide was uploaded by Brianda Hickey on Thursday February 25, 2016. The Study Guide belongs to V05.0203 at NYU School of Medicine taught by Adam Brown in Spring 2016. Since its upload, it has received 252 views. For similar materials see When the Nightmare Is Real: Trauma In Childhood and Adolescence in Cinema And Media Studies at NYU School of Medicine.
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Midterm: Study Guide When the Nightmare is Real: Trauma in Childhood and Adolescence Midterm Exam Study Guide Class 1-Introductory Class 1. Major ﬁndings from the Challenger Study Children might be traumatized by events that do not directly aﬀect their personal safety or the safety of their loved ones Closeness to the traumatic event plays a role in the severity of symptoms Adolescents may have fewer symptoms because they can place the event within a larger context Emotional involvement and frequency of exposure play a role in the development of post traumatic symptoms Although many children don’t meet full criteria for a psychiatric disorder, they have frequently signiﬁcant symptoms 1. ACE study (discussed on slides) In the Adverse Childhood Experiences (ACE) study of over 17,000 enrollees in an insurance plan, a host of challenging childhood events were the most signiﬁcant predictors of adult ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease ACE Categories: emotional abuse; physical abuse; sexual abuse; emotional neglect; physical neglect; mother treated violently; household substance abuse; household mental illness; parental separation/divorce; incarcerated household member Child Maltreatment as a Risk factor for poor physical health † Multiple adverse childhood experiences increase adjusted odds ratio Ischemic heart disease - 2.2 X's Any cancer - 1.9 X's Stroke - 2.4 X's Chronic bronchitis/emphysema -3.9 X's Diabetes - 1.6 X's Hepatitis - 2.4’x PDF File 2. Deﬁnition of trauma and its challenges Trauma: American Psychological Association: An emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, ﬂashbacks, strained relationships and even physical symptoms like headaches or nausea. It is usually an uncontrollable event The nature of the event is usually beyond the scope of ordinary human experience (usually rare or infrequent) It is usually unpredictable in the sense of a sudden event or a sudden change in mood of a violent parent. In an eﬀort to process the event, the person is changed. Types of Traumatic Events 2 categories: type 1 - single exposure type 2 - chronic exposure Neglect Physical Abuse Sexual Abuse Medical Neglect Social and Emotional Deﬁcts in Maltreated Children Maltreated children have lower social competence Have less empathy for others Have diﬃculty in recognizing other’s emotions Are less able to recognize their own emotional states Are more likely to be insecurely attached to their parents Child Maltreatment ( a version of trauma) exerts powerful eﬀects It occurs during sensitive developmental periods (e.g., Synaptogenesis, Experience-Dependent Maturation of Neuronal Systems) It impacts on fundamental developmental processes (e.g., Attachment, Emotional Regulation, Impulse Control, Integration of Self, Socialization) It occurs during sensitive developmental periods It impacts fundamental developmental processes Attachment Emotional regulation Impulse control Integration of self Socialization Childhood is a time for learning (languages, music, motor skills most easily acquired) Number of synapses increases dramatically after birth Environment-stimulated neuronal activity is critical for elaboration of synaptic territories and ‘proper’ connections Children are more at risk of developing lasting consequences form exposure to trauma if... Chronic poverty and unstable and violent communities Major armed conﬂicts or civil disturbances Being in detention centers and jails Children who require residential treatment for medical/psychiatric reasons Class 2- A Child’s World 1. What children need for healthy development Adequate Nutrition Education and Gender Equality Adequate Healthcare A Healthy Mother/caregiver A Healthy Environment 2. Bowlby’s Attachment theory Human behavior can only be understood through considering the environment in which it evolved Infants and children have developed attachment behaviors to get their needs met by their caregivers For example, an infants cry is a signal that the caregiver needs to attend to the child This signal keeps the caregiver within the child’s proximity and fosters a relationship of attachment 3. Phases of Attachment Phase 1: Birth to 3 months Babies prefer proximity to humans over objects; however, who the human is does not matter to the infant At 6 weeks, the baby will begin to smile socially This social smile is positive reinforcement to the caregiver for the attention they give the infant The caregiver remains in close proximity and thereby promotes attachments Phase 2: 3 - 6 months The baby begins to focus on familiar people The baby’s social responses become more selective The baby appears to develop the strongest attachment to the person who responds most readily to the child Phase 3: 6 months to three years An intense attachment develops The infant /child actively seeks the attention and proximity of the primary caregiver The child demonstrates separation anxiety when the caregiver lives the room A fear of strangers develops The child demonstrates preferential attachment to the primary caregiver Phase 4: 3 years to the end of childhood Children continue to form attachments throughout life These attachments are arguably aﬀected but he early attachment experiences of the child People continue to seek out their early attachment ﬁgures in times of crisis and pain 4. Mary Ainsworth’s strange situation Ainsworth visited the homes of Baltimore families every 3 weeks from birth; at 12 months she began to consider how the infants handled separations Ainsworth created“The Strange Situation”, wherein the infant was brought into a playroom by their mothers. In the ﬁrst separation she left the child with a stranger, in the second separation she left the child alone. The separation lasted 3 minutes, but was shortened if the child experienced too much distress. 5. Patterns of Attachment Insecure-Avoidant Infants The infant appeared independent throughout the strange situation As soon as they entered the room, they rushed oﬀ to see the toys They did not use the mother as the secure base When the mother left the room, they did not seem upset and they did not seek proximity when she returned Ainsworth argued that these children reacted in this way because they had learned they could not count on their mothers These mothers had previously been more likely to be rated as insensitive, interfering, and rejecting Insecure-Ambivalent Infants These infants were “clingy” and preoccupied with the mother’s whereabouts They became extremely upset when the mother left the room They were markedly ambivalent when she returned; at one moment reaching for the mother, at the next pushing her away These mother’s had been described as inconsistently responsive to the infant When Trauma Interrupts Attachment The various types of trauma, including war, violence, abuse, neglect, and separation can all aﬀect attachment Bowlby studied institutional attachment in particular and he found that the children he studied who were separated at a young age from their caregivers secondary to hospitalization went on to have diﬃculty forming lasting relationships later in life He termed these individuals as “aﬀectionless characters”; individuals who use others solely for their own ends and have a inability to form lasting, loving, reciprocal relationships 6. Reactive attachment disorder A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts; beginning before age 5 years, as evidenced by either 1 or 2 1. persistent failure to initiate or to respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper vigilant, or highly ambivalent and contradictory responses 2. diﬀuse attachments as manifest by indiscriminate sociability and marked inability to exhibit appropriate selective attachments B. The disturbance of criterion A is not accounted for solely by developmental delay of pervasive developmental disorder C. Pathogenic care as evidenced by at least one of the following: 1. persistent disregard of the child’s basic emotional needs for comfort, stimulation, and aﬀection 2. persistent disregard of the child’s basic physical needs 3. repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent changes in foster care) 2 Subtypes: Inhibited Type The child fails to approach the caregiver Or, the child approaches the caregiver in a abnormal way when they are distressed For instance, the child is fearful of the caregiver They also demonstrate diﬃculties in social reciprocity and emotional regulation Disinhibited Subtype The child lacks a wariness of strangers They demonstrate symptoms of hyperactivity and inattention They may willingly wander oﬀ with strangers and seek physical contact with unfamiliar adults This subtype is more prevalent than the inhibited subtype, especially in formerly institutionalized children Some argue that other psychiatric diagnosis such as conduct disorder or oppositional deﬁant disorder are actually attachment disorders 7. Developmental changes seen in children who have been abused and neglected Studies have found that children who have been maltreated and/or neglected perform lower on developmental scales and on tests of intellectual and academic functioning (Erickson et al). A history of maltreatment and neglect has been found to be predictive of problems in expressive and receptive language (Allen et al). Children who have suﬀered neglect and/or maltreatment are more likely to be placed in special education (Egeland et al). Children who have been maltreated or neglected are more likely to have insecure attachments and reactive attachment disorders (Egelandet al). They are more likely to have negative mental representations of themselves and others (Tothet al). They are more likely to have abnormal social interactions including social withdrawal and aggression (Boushaet al andEgelandet al). They have been found to have higher levels of pathological behaviors including tics, tantrums, stealing, somatic symptoms, and self injurious behaviors (Egelandet al). 8. Basic ﬁndings of the Romanian Adoption study Adoption: Children in the system Positive correlation btwnlength of time in orphanage and risk of developmental, behavioral, and emotional concerns. Lower child to staﬀ ratios have been shown to improve outcomes, even in orphanages where basic facilities are lacking. Physical Health Children tend to be smaller in height, weight, head and chest circumference Behavioral Health lower IQ hyperactivity and impulsivity Self Stimulation is common Rocking behavior Head banging Shaking Visual stimulation with hand wiggling and ﬂapping Agression Basic Findings: The children adopted later were more likely than the early adoption or those raised by bio parents to have: Insecure attachments Those RO children with insecure attachments were also more likely to have Behavior problems Lower scores on the Stanford Binet IQ test Familial stressors Class 3- PTSD 1. Deﬁnition of PTSD and acute stress disorder (DSM-V criteria) a. PTSD a failure to contain the biological stress response at the time of the trauma, resulting in a cascade of alterations that lead to intrusive recollections of the event, avoidance of the reminders of the event and symptoms of hyperarousal Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. Criteria A: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more of the following ways: 1. Direct experience 2. Witness 3. Happened to close family member or friend 4. Repeated or extreme exposure to unpleasant details of the traumatic event (ex. First responders – police officers) Criteria B: Intrusion Symptoms [Experiencing Symptoms] – involuntary intrusive thoughts and memory that pop into someone’s mind Criteria C: Persistent Avoidance of Stimuli Associated With The Trauma: Person avoids reminders, intentionally or unconsciously Criteria D: Negative Alterations In Cognitions and Mood Criteria E: Marked Alterations In Arousal and Reactivity: 1. Irritable behaviors /angry outbursts 2. Self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance Criteria F: Symptoms must last more than a month Criteria G: Trauma must cause signiﬁcant distress or impairment in social, occupational, or other important area of functioning Criteria H: The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition. b. Acute Stress Disorder: Exact thing as PTSD, but symptoms last less than a month the criteria for ASD contain a greater emphasis on dissociative symptoms and the diagnosis can only be given within the first month after a traumatic event 2. Diﬀerences in PTSD in children vs. adults Stress Disorder in Children (Diﬀerences recognized by DSM): Trauma Exposure: disorganized or agitated behavior may be an expression of intense fear, helplessness, or horror Re-Experiencing: repetitive play may occur in which themes or aspects of the trauma are expressed (intrusive thoughts). there may be frightening dreams without recognizable content (dreams). trauma-speciﬁc reenactments may occur (ﬂashbacks) 3. Factors (risk, protective, etc.) associated with PTSD Prevention of Psychiatric Sequelae of trauma Normalizing the child’s reaction to the trauma. Ensuring safety, consistency, and predictability Explaining to the child that there is nothing about the child which led to the trauma. If applicable, discussing that this trauma is unlikely to happen again. Elimination of ongoing stressors. Protective Factors: An internal locus of control A sense of self eﬃcacy and a lack of feelings of helplessness An optimistic cognitive schema Social Support Lack of ongoing psychosocial stressors Risk Factors: Adolescence Juvenile oﬀenders have been found to be high risk for exposure to trauma and development of PTSD (Burton et al) Substance abusing teens (Buka et al, Berton et al) Exposure to previous trauma Previous diagnosis of anxiety disorder or other psychiatric disorders More severe and more frequent trauma has been linked to more severe psychopathology Ongoing psychosocial stressor Trauma: 1. type of trauma: single vs. chronic 2. dose of trauma: magnitude and severity of the traumatic event 3. physical proximity to the event: in general the closer the proximity the more traumatic 4. emotional proximity: the closer the child is to the loss emotionally the more risk that they will develop PTSD Individual and social factors 1. Age: some argue that trauma has less eﬀect on younger children 2. Gender: some studies have found that girls report symptoms more often than boys Explanations: Girls talk about their internal symptoms & Boys tend to externalize their symptoms 3. Cognitive appraisal factors: did the child think they were in a safe place?, guilt, shame, and extreme fear can contribute 4. Social factors: family support, SES 4. Other psychiatric illnesses associated with trauma Eating Disorders Studies have found higher levels of eating disorders in victims of childhood sexual abuse 1. In particular, binge eating and purge behaviors 2. Bulimia Nervosa more likely to have insecure attachments and reactive attachment disorders Substance Abuse The negative inﬂuences of trauma on the stress response systems (including the Hypothalamic pituitary adrenal axis and the catecholamine system) may increase the risk for alcohol and substance dependence. Depression Higher rates of depression have been found in adolescents and adults with history of childhood trauma. Genetic studies have demonstrated a gene environment reaction between trauma and the development of depression. Anxiety Studies have found that lifetime prevalence of anxiety disorders, including phobias, panic disorder, and obsessive compulsive disorders were higher in people who had been sexually assaulted. It has also been demonstrated that patients with a history of childhood sexual or physical abuse had higher rates of anxiety disorders. In addition, the presence of childhood sexual and physical abuse may aﬀect the severity of the anxiety disorder. Suicidality Increased rates of suicidal gestures and ideations are seen in people with history of trauma. This suicidality manifests itself as a symptom of depression, or borderline personality disorder, or can occur in the context of severe PTSD. Dissociation Studies have found that symptoms of dissociative disorders and conversion disorders are seen in children who have suﬀered trauma; this is particularly true of children of borderline intellectual functioning. Not unlike Charcot’s women with hysteria, there are case reports of children who have sudden onset of paralysis of limbs, blindness, or aphonia in the context of severe trauma. Psychosis Children who have experienced trauma may report symptoms of auditory or visual hallucinations, which can be misdiagnosed as a psychotic disorder. Higher rates of psychotic disorders are also associated with a history of trauma. Prenatal exposure to severe stress secondary to traumatic loss in the pregnant mother’s life has also been associated with an increased risk or psychotic disorders. Class 4 - Biology of Stress 1. Major brain areas involved in the stress response The amygdala perceives emotions The hippocampus stores emotional memory for reference later The prefrontal cortex dictates the response to the stressor or emotion These areas of the brain work in concert with other organ systems to create the stress response 2. HPA Axis and the stress response Hypothalamic-Pituitary Axis (HPA) Diﬀerent pathways can activate the HPA Axis: Limbic structures through psychological stress Brain Stem Pathways that send visceral and sensory stimuli we ar getting both emotional triggers from the amygdala and sensory triggers from the brain stem cortisol is the chemical that propels the ﬁght ﬂight freeze response Immediate Stress Response (Fight or Flight) If the limbic system perceives a threat: the hypothalamic-pituitary-adrenal system is activated through release of hormones by the amygdala Noradrenergic system is activated Norepinephrine is released from the locus ceruleus in the brain which stimulates the sympathetic response The sympathetic response leads to increase in arousal, heart rate, and blood ﬂow to essential organs Cortisol is released form the adrenal glands We go into “ﬁght or ﬂight” response 3. Changes in the brain and the role of cortisol How the Brain Adapts to Stress The stress system system has two modes of operation Acute: behavioral ‘ﬁght-ﬂight’ response which serves to respond to the immediate danger Chronic: promotes long-term adaptation and recovery to stress Both systems are driven by the HPA axis If one thing happens to us, we are not likely then to have a long term reaction. It is when we are exposed to a thing in an ongoing chronic way is when we develop a long term reaction Cortisol Operates in both stress-system modes through mineralocorticoids receptors and glucocorticoid receptors throughout the body (MR and GR) MR: mediates the stress response GR: stores memories in preparation for future events and terminates stress reactions The Role of Cortisol in Stress In addition, cortisol targets gene networks involved in acute and late - recovery phases of the stress response not just about the hormonal stress being activated, but also about a person’s genes If it happens to an adult that everything is redeveloped, it is one thing. But if it happens to a child who have not yet developed their brain cells…may cause them to develop incorrectly For Example When MR and GR are activated, 70-100 genes are altered in the hippocampus Some of these genes are responsible for growth factors, electrical activation of neurons and cell death Cortisol and Genes Overtime, the eﬀects of MR and GRs on genes in a speciﬁc brain area can alter its structure and composition (e.g. loss of a speciﬁc type of neuron which can have longterm aﬀects on function) Recent science has been showing us that genes CAN change The way genes are expressed is determinate of our environment 4. Factors that contribute to the stress response 1. Genetic Background Infants have diﬀerent temperance that are genetically based and associated with diﬀerent behaviors when exposed to novel stimuli or stress. Temperaments are taken with them throughout all their life: Easy : Soothed easily, don’t cry as often Slow To warm up - reserved, shy more likely to have anxiety issues Diﬃcult - crying, bad with change Temperament Not written in stone, can shift The way we were as infants is probably the way we are now, unless something caused our temperament to shift An Infant’s temperament is based on: activity level Approach or withdrawal in new situations Intensity of reaction, quality of mood Attention span and persistence Temperament is something an infant is born with and the pattern of its interaction with the world is stable over time and genetically based 2. Early life traumatic experiences A traumatic event that occurs from ages 0-3 may be more likely to have lasting consequences on brain development and function than one that happens when a child is older So, if a person is exposed to an early life trauma their reaction to a later trauma may be more extreme A secure attachment can attenuate the risk early life events can place on a child Allows you to have a home base when something stressful happens - self-soothing Had a nurturing attentive caregiver, that met their needs consistently 3. Chronic exposure to stress and subsequent changes in the brain smaller hippocampus and amygdala in adults who were traumatized impact on the ability of memories to be formed and retrieved Smaller corpus callous in children Decrease in GABA-ergic neurons in cortical areas (such as the prefrontal cortex) 5. Epigenetic Epigenetic’s is the study of the functional modiﬁcation of the genome that do not involve a DNA nucleotide change For example, genetic function can be altered through environmental inﬂuences on the expression of genetic material Epigenetic modiﬁcations to proteins alter the transcription of DNA Signals from the environment act on the epigenemone to activate or silence diﬀerent genes Diet, diﬀerences in physical activity, stress, and exposure to toxins can all aﬀect the epigenome On the genetic level, DNA methylation and histone acetylation alter the epigenome and expression of genetic material Epigenetic Changes Epigenetic’s Modiﬁcations to histone proteins and the DNA can alter the chance of a gene being transcribed, DNA methylation-leads to gene silencing Genes can either be activated or silenced based one experience 6. Clinical eﬀects of stress in humans earl life experience and chronic life stress can alter the expression of the epigenome Through the eﬀects of stress and trauma on the neuroendocrine system, certain genes can be turned on or turned oﬀ This can result in downstream clinical manifestations of illness and disease Stress and Illness Over activation of the stress response system increases the risk for: obesity type 2 diabetes hypertension depression anxiety suicide accelerated again degeneration brain structures including the hippocampus 7. Relevant alleles and genes regarding risk for depression or diﬃculties following trauma Reading- Soumi et al Studied rhesus monkeys who are genetically similar to humans Identiﬁed in monkeys similar alleles of the Serotonin transporter Gene found in humans: Long/long: protective against depression Short/long: moderate risk for depression Short/short: severe risk for depression Studied monkeys reared by their mothers vs monkeys reared as orphans by their peers Monkeys reared by their mothers all metabolized serotonin well regardless of allele type Monkeys reared by peers who have long/long allele had no change in metabolism of serotonin Monkeys reared by peers who had small/long alleles has poor metabolism of serotonin and were at high risk for development of depression and anxiety Reading - Caspi and Moﬃt et al Nature and Nurture work together Found: short allele of MAOA gene increased the chance of the development of antisocial behavior in human adults abused as children In another study, they documented that if a human has the s/s or s/l version of the serotonin transporter gene plus a trauma then they have an increased risk for developing depression vs if they have the l/l version of the gene plus trauma or s/s, s/l and no trauma Reading - Baker man-Kranenburg et al Looked at the DRD4 gene a dopamine processing gene Studied children with the “protective allele” and the “risk allele” of this gene Created an intervention for externalizing behaviors of ADHD Found that those with the risk allele who got the intervention had much greater improvement in behavior than those with protective allele who received the intervention This indicates that while the risk allele may confer more risk in stressful situations, it may also confer more beneﬁt in highly nurtured environments Thus, those individuals with high risk genes, may actually do better than those with low risk genes, if they are int he right environment ADHD hyperactivity impulsivity overly reactive/moody
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