Toxic Stress and Children CCNC Medical Home Training Jean Smith, MD, FAAP.
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Transcript of Toxic Stress and Children CCNC Medical Home Training Jean Smith, MD, FAAP.
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
0
10
20
30
40
50
60
70
80
90
100
ACE Score
0 1 2 3 4 >=5
P
resc
rip
tio
n r
ate
(p
er
10
0 p
ers
on
-ye
ars)
The ACE Score and the Prevalence of Attempted Suicide
0
5
10
15
20
0 1 2 3 >=4
ACE Score
Perc
ent a
ttem
pted
(%)
Number of Adverse Childhood Experiences
and Teen Sexual Behaviors
0
5
10
15
20
25
30
35
40
45
Per
cen
t W
ith
Hea
lth
Pro
ble
m
(%) 0 1 2 3 4 or more
Number of adverse factors:
Intercourse byage 15
Teenpregnancy
Teenpaternity
ACE Score and the Prevalence of
Severe Obesity
0
2
4
6
8
10
12
14
0 1 2 3 >=4
ACE Score
Perc
ent o
bese
(%)
0
2
4
6
8
10
12
14
16
18
20
Per
cen
t W
ith
Hea
lth
Pro
ble
m
(%) 0 1 2 3 4 or more
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