Mental Health Issues of Child Maltreatment

Chapter 1

CHILD ABUSE AND THE EMERGENCE OF THE DIAGNOSIS OF DEVELOPMENTAL TRAUMA

*

Richard A. van den Pol, PhD‡

Richard Manning‡

KEY POINTS:

1.Trauma is a normal response to an abnormal situation.

2.Developmental trauma resulting from emotional abuse physically injures the brain.

3.The understanding of developmental trauma is rooted in knowledge of posttraumatic stress disorder (PTSD) but grew from the landmark Adverse Childhood Experiences (ACE) Study and the National Child Traumatic Stress Network (NCTSN).

4.Developmental trauma differs from PTSD in that the injury, often inflicted by a caregiver, occurs while the brain is developing and arrests part of that brain development.

5.Traumatic stress is a combination of mental and somatic responses to a perceived threat mediated by the limbic system and the vagus nerve.

6.Interventions for developmental trauma are based on cognitive behavioral therapy but also address somatic elements with relaxation techniques and exposure by recall of the traumatic event.

INTRODUCTION

The understanding of psychological trauma in the development of children builds on earlier research into posttraumatic stress disorder (PTSD) in combat survivors. The problem of childhood exposure to multiple traumatic events is different, however, in that it is far more prevalent than most assume and, perhaps most importantly, because it victimizes individuals whose brains are still developing and, as a result, alters that course of development. Psychological trauma in children is not a separate issue from physical head trauma; rather, psychological trauma is simply another way of physically damaging children’s brains through child abuse. Frequent co-occurrence of physical and psychological abuse further blurs the distinction.

Many researchers describe PTSD as a failure of recovery because most children and adults exposed to only a single trauma demonstrate transient symptoms and then return to their former levels of functioning.¹-² PTSD sufferers cannot return to a normal condition and, as a result, remain locked in the moment of trauma. PTSD produces a classic set of symptoms, including flashbacks, re-experiencing traumatic events, nightmares, depression, and suicide. Children who suffer repeated traumatic events, which is typical of child abuse victims, may show some of these symptoms, but PTSD does not adequately describe the cause and effect; this led to the proposal of a new diagnosis of developmental trauma. The evidence supporting this shift emerged from nearly two decades of epidemiological research, the efforts of a formal network designated by Congress to study the effects of childhood trauma, and the rapidly increasing capabilities of neuroscience. See Figure 1-1 for a timeline of major developments in understanding trauma.

Figure 1-1. Conceptualizing psychological trauma: battleground to playground.

ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY

The foundation of the epidemiological research is the landmark Adverse Childhood Experiences (ACE) study, a continuing project headed by the Centers for Disease Control and Prevention (CDC).³ The ACE study originated in the early 1980s with an intervention for obesity sponsored by Kaiser Permanente, a health maintenance organization based in California. When clinicians noticed that people enjoying success in their weight reduction tended to drop out of the program and then regain the weight, the clinicians began systematically questioning the dropouts. The questioning produced anecdotal accounts of child abuse, especially sexual abuse, occurring more frequently than the participating physicians had previously thought.

The epidemiological research of child abuse has spawned more than 50 publications,⁴ but through the long history of this body of research, the key findings have produced a remarkably consistent and urgent message. The results claim that:

—Child abuse is more common than generally acknowledged.

—Child abuse is a significant cause of our world’s leading social, economic, and public health problems.

—The damage from child maltreatment plagues individual health and well-being for decades, even a lifetime.

A recent ACE publication⁵ concludes that adults who were significantly abused as children die, on average, 20 years earlier than the rest of the population.

As the trend became more apparent, Robert Anda, an epidemiologist with the CDC, joined Kaiser Permanente’s Vincent Felitti in designing a follow-up questionnaire to measure the effects of child abuse. They called the questionnaire ACE’s affected health. The researchers administered the questionnaire to 17 000 middle-class, educated clients of Kaiser Permanente. It consisted of a simple list of questions concerning the following eight categories of childhood experiences:

—Recurrent and severe physical abuse

—Recurrent and severe emotional abuse

—Contact sexual abuse

—Growing up in a household with an alcoholic or a drug user

—Growing up in a household with a member being imprisoned

—Growing up in a household with a mentally ill, chronically depressed, or institutionalized member

—Growing up in a household with the mother being treated violently

—Growing up in a household with both biological parents being absent

For each yes answer, a respondent was given 1 point on his or her ACE score. Fewer than half of the respondents had an ACE score of zero, meaning a majority of this middle-class, employed sample had suffered some form of child abuse, and 7% had a score of 4 or more. These findings speak to issues beyond prevalence. Researchers correlated ACE scores against the 10 leading causes of premature death in the nation. CDC summarizes the findings:

The ACE Score is used to assess the total amount of stress during childhood and has demonstrated that as the number of ACEs increase, the risk for the following health problems increases in a strong and graded fashion: alcoholism and alcohol abuse, chronic obstructive pulmonary disease, depression, fetal death, health-related quality of life, illicit drug use, ischemic heart disease, liver disease, risk for intimate partner violence, multiple sexual partners, sexually transmitted diseases, smoking, suicide attempts, unintended pregnancies.

In addition, the ACE Study has also demonstrated that the ACE Score has a strong and graded relationship to health-related behaviors and outcomes during childhood and adolescence including early initiation of smoking, sexual activity, and illicit drug use, adolescent pregnancies, and suicide attempts. Finally, as the number of ACEs increases, the number of co-occurring or co-morbid conditions increases.⁶

The results presented strong correlations between high ACE scores and addictive behaviors, such as smoking, intravenous drug use, and alcohol abuse, all of which have long-term, negative health effects. The researchers, however, normalized their data for these problematic behaviors and found that these addictive behaviors alone did not account for early death and or morbidity; rather, they concluded that child abuse, by itself, was harmful to health.

The data ultimately generate the basis of what qualifies as a paradigm shift in our conception of the human condition, with the following conclusion reached by Felitti:

The current concept of addiction is ill-founded. Our study of the relationship of adverse childhood experiences to adult health status in over 17 000 persons shows addiction to be a readily understandable although largely unconscious attempt to gain relief from well-concealed prior life traumas by using psychoactive materials. Because it is difficult to get enough of something that doesn’t quite work, the attempt is ultimately unsuccessful, apart from its risks. What we have shown will not surprise most psychoanalysts, although the magnitude of our observations is new, and our conclusions are sometimes vigorously challenged by other disciplines.

The evidence supporting our conclusions about the basic cause of addiction is powerful and its implications are daunting. The prevalence of adverse childhood experiences and their long-term effects are clearly a major determinant of the health and social well-being of the nation. This is true whether looked at from the standpoint of social costs, the economics of health care, the quality of human existence, the focus of medical treatment, or the effects of public policy.⁷

NETWORK SCIENCE

A second line of research independently provided a closer link to earlier work on PTSD in combat veterans. Bessel van der Kolk, a lead researcher in both PTSD and developmental trauma at the Trauma Center in Boston, worked with veterans in the 1970s and was a part of the research that formally identified and categorized the diagnosis. PTSD itself is not new and had been known as battle fatigue or shell shock in earlier wars.

van der Kolk founded a clinic for the treatment of adult victims with PTSD and anticipated that it would specialize in combat victims and survivors of various catastrophes, such as natural disasters and automobile wrecks; however, he found, that the patients who sought his help for traumatic stress were overwhelmingly victims of domestic violence. His work eventually evolved into the National Child Traumatic Stress Network (NCTSN), sanctioned by Congress in 2000 and funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (DHHS). NCTSN has two hubs, the Neuropsychiatric Institute at the University of California, Los Angeles (UCLA) and the Duke University Medical Center, that house the network’s core data set, a compilation of research by the 60 member centers of the network. The core data set includes research on more than 20 000 children, most of whom are survivors of abuse. NCTSN also includes seven treatment adaptation centers responsible for modifying evidence-based treatments to meet the cultural and developmental needs of diverse populations of children and youth with trauma.

NCTSN’s research produced a long list of key findings that paralleled those of the ACE study, helped explain the long-lasting effects of child abuse, and established causal links to explain the correlations that emerged in the ACE study. The formal proposal for the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to include a new diagnostic category of developmental trauma emerged from the NCTSN and was written by van der Kolk; Robert S. Pynoos, codirector of the UCLA center; and 10 other physicians and clinical psychologists in the network.

Much of the NCTSN’s work has filled in details that support ACE findings about the spinoff effects of child abuse. For instance, one study in Cook County, Illinois found that more than 90% of the children adjudicated in the juvenile justice system had been abused.⁸ Child abuse is widespread, with one study having found that more than half of the children in a representative national sample had been subject to some sort of physical assault within one year. In that same study, one in eight children were found to have been victims of physical abuse or neglect.⁹

Child abuse presents economic costs to society because it is pervasive and it contributes to a range of problems, including crime, substance abuse, suicide, and poor performance in school. One NCTSN study concluded that annual costs related to child abuse, not including indirect medical costs, amounted to $103.8 billion nationwide.⁹ The network’s research goes beyond establishing a statistical case that the problem exists; it also assembles a conceptual framework for understanding the unique nature of child abuse, which is the core argument for creating a diagnosis separate from PTSD.

Network researchers argued there is a critical distinction between adult PTSD and what those researchers prefer to label developmental trauma, the parallel problem in children. Adult PTSD victims usually suffer a traumatic response to a single readily identifiable and catastrophic event, such as combat, that occurred while they were adults. Developmental trauma, on the other hand, usually stems from multiple events and clusters of problems that may occur over the course of several years and, more importantly, occur as a child’s brain is developing. The critical distinction is that damage caused by developmental trauma interrupts normal brain development.

The proposal for a potential future revision of the DSM summarizes this critical distinction between adult PTSD and developmental trauma in the following core argument:

In fact, multiple studies show that the majority [of abused children] meet criteria for multiple other DSM diagnoses. In one study of 364 abused children, 58% had the primary diagnosis of separation anxiety/overanxious disorders, 36% phobic disorders, 35% PTSD, 22% attention deficit hyperactivity disorder (ADHD) and 22% oppositional defiant disorder. In a prospective study¹⁰ of a group of sexually abused girls, anxiety, oppositional defiant disorder and phobia were clustered in one group, while depression, suicidality, PTSD, ADHD and conduct disorder represented another cluster.

A survey of 1699 children receiving trauma-focused treatment across 25 network sites of the National Child Traumatic Stress Network (NCTSN) showed that the vast majority (78%) was exposed to multiple and/or prolonged interpersonal trauma, with a modal 3 trauma exposure types; less than one quarter met diagnostic criteria for PTSD. Fewer than 10% were exposed to serious accidents or medical illness. Most children exhibited posttraumatic sequelae not captured by PTSD: at least 50% had significant disturbances in affect regulation; attention & concentration; negative self-image; impulse control; aggression & risk taking. These findings [2009] are in line with the voluminous epidemiological, biological and psychological research on the impact of childhood interpersonal trauma of the past two decades that has studied its effects on tens of thousands of children. Because no other diagnostic options are currently available, these symptoms currently would need to be relegated to a variety of seemingly unrelated co-morbidities, such as bipolar disorder, ADHD, PTSD, conduct disorder, phobic anxiety, reactive attachment disorder and separation anxiety.¹¹

The evidence indicates that a cluster of problems in abused children leads to a cluster of outcomes and behavioral problems. The greater the number of incidents and forms of abuse and maltreatment a given child suffers, the greater the number of diagnoses the child is given under existing categories of the DSM.¹² The emerging body of neuroscience supports and even explains this core finding.

TRAUMA IN THE BODY

The proposed diagnosis is called developmental trauma because the injury occurs before a child is 17 years old, while the brain is physically developing. The human birth canal cannot accommodate a fully developed brain, so evolution devised an elegant solution to the problem, analogous to building a ship in a bottle. Genes influence this development, but brains only reach their genetic potential if they are guided by appropriate relationships with other humans, especially caregivers.

Child maltreatment is a breakdown in a child’s relationship with caregivers in which caregivers either directly inflict violence and neglect or, due to being traumatized by violence, cannot engage the child in a healthy relationship. Children do not have the cognitive tools to understand or process these threats, which are the key elements to understanding developmental trauma. A child’s responses to abuse are largely handled by the infratentorial brain, the primitive lower part of the brain that is the only portion fully developed in children and common to humans and the rest of the animal kingdom. The primitive brain delivers a response that is common in all animals, an evolved and necessary response to danger that allows them to survive existential threats.

The only major nerve in the body that leads directly from the brainstem is the vagus nerve, the primitive portion of the brain that enervates the body cavity containing all of the major organs. These major organs carry out routine body functions that are largely involuntary responses, such as heart rate and digestion. Similarly, in animals, a response to an immediate threat is also involuntary and telegraphed by the vagus nerve. The human body responds to threats by increasing heart rate and respiration and tensing the muscles, measures designed to deal with threats. The body also takes less obvious steps when confronting a threat, such as shutting down the digestive and immune systems. Both systems are energetically expensive and can be temporarily shut down to channel all available energy to meeting the threat. These responses are mediated by complex biochemistry, especially glucocorticoids and cortisol. Elevated cortisol levels are a reliable indicator of stress in both animals and humans. Cortisol serves a unique function in that it does not trigger the traumatic response but, rather, triggers the body’s return to normal after the trauma has passed. Once a threat passes, all of the body’s emergency measures need to be cancelled because a living being cannot live for long with a permanently elevated pulse, without digestion or an immune system, or in a permanent state of terror.

The traumatic response is more complex than the elevated cortisol response and involves a chain reaction in the brain and the rest of the body. The traumatic response begins in the amygdala, a central area of the primitive brain, and then stimulates in succession the hypothalamus; the pituitary, through corticotropin-releasing hormone; adrenocorticotropin; and the adrenal gland. Researcher Michael De Bellis summarizes the results of this chain reaction: This results in tachycardia, hypertension, increased metabolic rate, hypervigilance, and increased levels of epinephrine, norepinephrine, and dopamine. Cathecholamines contribute to dilation of pupils, diaphoresis, renal inhibition, and decreases in peripheral blood flow.¹³

Three distinct behavioral characteristics of a traumatic response correspond to this physical response: fight, flight, or freeze. Each response can be adaptive and successful depending on the nature of the threat, the person’s or animal’s position in the pecking order, and the skills and resources of the person or animal; however, it is important to remember that this traumatic response is a normal response to an abnormal situation. In the case of traumatized children, the abnormal situation becomes routine, ie, the threat is repeated, sometimes daily, and becomes a way of life.

Children lack the resources and developed brains that might allow them to devise solutions to permanently escape threats, so they cope and devote all of their personal resources to daily survival. Meanwhile, their bodies gradually lose the ability to turn off the traumatic response and return to normal; in other words, they enter a permanent state of terror. There are clear and famous examples of diagnosing childhood trauma. Childhood trauma is not diagnosed through psychological screening but, rather, by recording an elevated pulse rate lasting long after immediate danger has passed.

The body’s normal response to trauma explains the somatic issues that surface in the lives of adults who were abused as children, as demonstrated in the landmark ACE study. Several issues stem from compromised immune systems. While these issues appear as behavioral and psychological problems in children, they emerge more frequently as somatic issues as children age. In adults, physical problems, such as unexplained neck pain, obesity, and susceptibility to a range of illnesses as a result of compromised immune systems, are observed; however, the behavioral and psychological issues of these children are rooted in the physical damage inflicted by repeated abuse. The brain is probably the most damaged organ in children who experience abuse and domestic violence.

TRAUMA IN THE BRAIN

The implications for brain functioning in the flight, fight, or freeze response include the key neurotransmitters dopamine, epinephrine, and norepinephrine. These neurotransmitters are intimately connected to brain functioning, especially with problems such as substance abuse, depression, and anxiety. Beyond neurochemistry, one can also approach this issue using recent findings of developmental psychology and neurobiology. Infants are born with primitive regions of the brain, such as the infratentorial, already well formed; however, the new brain, the supratentorial region that includes the prefrontal cortex, is largely absent. The region is known as the higher region of the brain because it is physically above the infratentorial region and allows the functioning that makes people uniquely human and social. The supratentorial region controls self-conscious behavior and allows reasoning, self-control, learning, language, and other skills that enable an individual to negotiate by engaging with fellow humans.

Neither the physical dimensions of the prefrontal cortex nor its function are wholly determined by genetics. The neural pathways and the cellular structure of this part of the brain hold the physical record of an individual’s relations with his or her social environment. The higher brain is built by relationships, especially early relationships with caregivers, particularly mothers. To a profound degree, interactions with caregivers build a child’s brain over the course of the first 17 years of his or her life.¹⁴-¹⁶ The neurochemistry outlined above suggests how this process might be disrupted by abusive behavior in social relationships. Neuroimaging is very suggestive of this disruption (see Figure 1-2).

Figure 1-2. fMRI data on abused youths with PTSD shows pronounced activation in the left amygdala and hippocampus (pictured) and lower activation in the dorsolateral prefrontal cortex (not pictured). This activation pattern, the neural response to photographs of angry, fearful, happy, sad, and neutral facial expressions, suggests that abused children have exaggerated fear responses to social cues and deficient responses in regulatory, executive control regions.¹⁷ (Contributed by Amy Garrett, PhD; Stanford, CA.)

Magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) are recently developed tools that give science profound insights into the functioning of the brain and its development. These tools have been directed at the problem of child abuse and have made important findings. A series of studies by De Bellis and colleagues reveal that brain imaging shows a smaller intracranial volume in children with a history of abuse when compared to children with less-troubled histories. Brain volume, which is crucial to processing long-term memory, is reduced in the prefrontal cortex as well as in the corpus callosum and hippocampus in children with histories of abuse.¹³

TREATMENT

Child abuse has existed throughout history, but there has been a lack of proper understanding of its long-term effects until recently, leading to misdiagnoses. These recent findings not only generate new insights into a serious social problem but also provide for potential approaches to treatment. Pinpointing the roots of the problem, in addition to realizations from neuroscience about neurogenesis and neuroplasticity, implies that much of this damage is reversible with proper evidence-based treatment.

The NCTSN recognizes at least 40 evidence-based practices with a proven ability to improve the lives of traumatized children. The first tool toward dealing with this issue is proper diagnosis. The DSM attempted to deal with all traumatic events with the diagnosis of PTSD. However, PTSD is best applied to adults who experience exposure to a one-time event like combat or a natural disaster; therefore, children with a history of abuse often do not meet the criteria for a PTSD diagnosis. Many children suffering developmental trauma are sorted into existing DSM categories, such as bipolar disorder, attention deficit hyperactivity disorder (ADHD), or depression. All of these diagnoses involve medication, many times with serious side effects.

An interesting finding of recent work offers a separate term for developmental trauma: complex trauma. The rationale for using the term complex trauma is that it often involves many and varied traumatic events and, therefore, a complex number of causes. The researchers also found that the more complex a trauma history, the more diagnoses a given child would meet under the existing criteria of the DSM.

Nonetheless, researchers have now developed and deployed screening instruments that reliably identify both the existence and severity of trauma in children. This opens the way to treatment that ranges in intensity according to the degree of trauma in and resilience of an individual child.

The suite of available interventions is largely based on cognitive behavioral therapy and rarely involves medication, at least not in the long term. In all of these interventions, there tends to be a key common factor that acknowledges the somatic side of trauma and its effects. Therapists use a variety of devices to help clients remember traumatic events, and these memories can trigger a traumatic response. The therapist then teaches both cognitive and relaxation techniques to help clients process traumatic memories.

Trauma-Focused Cognitive Behavior Therapy (TF-CBT) incorporates psychoeducation about sexual abuse and PTSD; a description of the cognitive behavioral triad, ie, the interrelationships among thoughts, feelings, and behaviors; affect regulation; and relaxation skill training. It typically entails 12 therapeutic sessions. A critical element of TF-CBT is reciprocal inhibition, first described in 1958 by Wolpe in his work with World War II combat veterans.¹⁸ In a classical sense, reciprocal inhibition refers to the prevention, inhibition, or interruption of a conditioned trauma response in the presence of a trauma stimulus, sometimes called a trauma trigger. Reciprocal inhibition can be effected by presenting the trauma stimulus abruptly, eg, implosion therapy or flooding, or gradually, eg, systematic desensitization. The effectiveness of reciprocal inhibition treatments seems to depend on the patient’s exposure to the trauma stimulus while successfully practicing a relaxation skill in lieu of a trauma response. Regardless of the therapeutic regimen, if the therapist terminates the trauma exposure while the patient is in an elevated state of arousal, ie, making a trauma response, instead of during relaxation, the trauma exposure is likely to produce an exacerbation of trauma symptoms. This potential for negative therapeutic consequence, coupled with frequently reported patient discomfort, make trauma exposure one of the more clinically complex and risky mechanisms of cognitive behavioral therapy.

Judith Cohen and colleagues have demonstrated that TF-CBT can reduce trauma symptoms, depression, and anxiety in preschool children (3 to 6 years old) who are victims of sexual abuse and that those outcomes sustain over time.¹⁹ They reported similar results for 7- through 11-year-old children.¹⁹ Esther Deblinger and colleagues provided TF-CBT to children only and TF-CBT to children plus a nonoffending parent and then compared those regimens with standard community care. They described numerous additive benefits when TF-CBT was delivered to children plus parents, including reductions in the children’s trauma symptoms, depression, and behavioral problems. These results were maintained at a two-year follow-up.²⁰

While clinic-based CBT has proven to be of great value in treating children with PTSD symptoms, recent research has explored alternatives to clinic-based services. In 2010, Jaycox and colleagues compared completed referral rates for post-Katrina children with trauma symptoms who were randomly assigned to either a clinic- or a school-based CBT. While only 14 of 60 (23%) students referred to clinic-based CBT began treatment, 57 of 58 (98%) children referred to school-based CBT began treatment. The number of children completing treatment was also higher for school-based CBT.²¹

The treatment model used by Jaycox et al is Cognitive Behavioral Intervention for Trauma in Schools (CBITS).²² CBITS is an annualized-group CBT with therapeutic components similar to those of TF-CBT; however, CBITS typically involves 10 sessions rather than 12; is delivered in groups of up to eight students, thus affording economies in scale; and can be delivered by master’s-level mental health school staff.

In 2003, Stein et al evaluated CBITS using a randomized delayed treatment comparison design. A total of 125 inner-city middle school students received CBITS either early or late in the school year. With CBITS treatment, both groups showed reductions in PTSD symptoms, depression, and psychosocial dysfunction. The delayed-treatment group showed some symptom reduction prior to CBITS implementation, but symptoms improved further with CBITS treatment.²³

While CBITS offers some enhancements over TF-CBT in terms of rates of completed referrals, rates of treatment completion, and economies of scale, CBITS also has some limits in treating developmental trauma. CBITS incorporates strong mechanisms to maintain confidentiality of group proceedings. It also involves group discussion of trauma etiology that can be uncomfortable or inappropriate when the cause of the trauma is sexual and the peers are adolescents. Thus, the developers of CBITS discourage the use of the treatment with adolescents whose sole trauma cause is sexual abuse; however, since the majority of students with developmental trauma have multiple trauma experiences, it is possible to include a student with a history of sexual abuse in CBITS provided the student identifies one of his nonsexual trauma experiences to work on in group sessions. The 10-session CBITS protocol includes individualized meetings with the adult facilitator, thus, it is possible to promote stimulus generalization of the targeted trauma to the sexual trauma in a private setting.

CONCLUSION

The expanding capabilities of neuroscience and a large body of research conducted by the NCTSN have greatly expanded the understanding of the deleterious effects of child abuse and neglect. The terror associated with abuse triggers a fundamental and primal response in children that is typical of most animals, ie, the self-protective and adaptive trigger to freeze, fight, or flee; however, repeated threats of multiple events typical of child abuse overtax the biochemistry that, in the normal course of events, allows homeostasis and returns the child’s arousal state to normal after the threat has passed. This phenomenon in turn interferes with the child’s normal physical brain development, potentially laying the foundation for permanent damage. Nonetheless, a more comprehensive understanding of the mechanisms of developmental trauma has helped illuminate successful interventions.

REFERENCES

1.Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder: a critical review. Annu Rev Psychol. 1997;48:449-480.

2.Rothbaum BO, Davis M. Applying learning principles to the treatment of post-trauma reactions. Ann N Y Acad Sci. 2003;1008:112-121.

3.Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.

4.Adverse Childhood Experiences (ACE) Study: publications on major findings. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nccdphp/ace/publications.htm. Accessed June 27, 2012.

5.Anda RF, Dong M, Brown DW, et al. The relationship of adverse childhood experiences to a history of premature death of family members. BMC Public Health. 2009;9:106.

6.Adverse Childhood Experiences (ACE) Study: major findings. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nccdphp/ace/findings.htm. Accessed June 27, 2012.

7.Felitti VJ. Ursprünge des Suchtverhaltens: Evidenzen aus einer Studie zu belastenden Kindheitserfahrungen [Origins of addictive behavior: evidence from a study of stressful childhood experiences]. Prax Kinderpsychol Kinderpsychiatr. 2003;52(8):547-559.

8.Abram KM, Teplin LA, Charles DR, Longworth SL, McLelland GM, Duncan MK. Posttraumatic stress disorder and trauma in youth in juvenile detention. Arch Gen Psychiatry. 2004;61(4):403-410.

9.Gerrity E, Folcarelli C. Child traumatic stress: what every policymaker should know. National Child Traumatic Stress Network Web site. http://www.nctsnet.org/nctsn_assets/pdfs/PolicyGuide_CTS2008.pdf. Published 2008. Accessed June 27, 2012.

10.Noll JG, Trickett PK, Putnam FW. A prospective investigation of the impact of childhood sexual abuse on the development of sexuality. J Consult Clin Psychol. 2003;71(3):575-586.

11.van der Kolk BA, Pynoos RS. Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Trauma Center at Justice Resource Institute Web site. http://www.traumacenter.org/announcements/DTD_NCTSN_official_submission_to_DSM_V_Final_Version.pdf. Published 2009. Accessed June 27, 2012.

12.Cloitre M, Stolbach BC, Herman JL, et al. A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress. 2009;22(5):399-408.

13.De Bellis MD, Hooper SR, Spratt EG, Woolley DP. Neuropsychological findings in childhood neglect and their relationships to pediatric PTSD. J Int Neuropsychol Soc. 2009;15(6):868-878.

14.De Bellis MD, Kuchibhatla M. Cerebellar volumes in pediatric maltreatment-related posttraumatic stress disorder. Biol Psychiatry. 2006;60(7):697-703.

15.Parsons CE, Young KS, Murray L, Stein A, Kringelbach ML. The functional neuroanatomy of the evolving parent-infant relationship. Prog Neurobiol. 2010;91(3):220-241.

16.Spangler G, Johann M, Ronai Z, Zimmermann P. Genetic and environmental influence on attachment disorganization. J Child Psychol Psychiatry. 2009;50(8):952-961.

17.Garrett AS, Carrion V, Kletter H, Karchemskiy A, Weems CF, Reiss A. Brain activation to facial expressions in youth with PTSD symptoms. Depression and Anxiety. 2012;29(5):449-459.

18.Wolpe J. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press; 1958.

19.Cohen JA, Deblinger E, Mannarino A. Trauma-focused cognitive-behavioral therapy for sexually abused children. Psychiatric Times. 2004;21(10):1-4.

20.Deblinger E, Steer RA, Lippmann J. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl. 1999; 23(12):1371-1378.

21.Jaycox LH, Cohen JA, Mannarino AP, et al. Children’s mental health care following Hurricane Katrina: a field trial of trauma-exposed psychotherapies. J Trauma Stress. 2010;23(2):223-231.

22.Jaycox L. CBITS: Cognitive Behavioral Intervention for Trauma in Schools. Longmont, CO: Sopris West; 2004.

23.Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA. 2003;290(5):603-611.

*This work was supported in part by DOJ COPS Office Grant #2009CKWX0632, SAMHSA Grant #5U79SM058145, OJJDP Grant #2009-TY-FX-0010, and OJJDP Grant #2007-JL-FX-0041 to the University of Montana; however, the authors’ opinions are their own and no official sponsorship or university endorsement should be inferred.

‡The authors thank Amy Garret, PhD; Victor Carrion, MD; and their colleagues with Stanford University School of Medicine for sharing and interpreting fMRI images of traumatized youth.

Chapter 2

NEURODEVELOPMENTAL IMPACT OF CHILD MALTREATMENT

Margaret Richardson, PhD, LMSW

Constance Black-Pond, MA, LMSW, LPC

Mark A. Sloane, DO

Ben Atchison, PhD, OTR/L, FAOTA

Yvette Hyter, PhD, CCC-SLP

James Henry, PhD, MSW

KEY POINTS

1.Children who are exposed to multiple traumatic events are frequently referred to mental health settings.

2.The emotional and behavioral disturbances they exhibit interfere in their functioning at home, school, and in relationships with others.

3.Neurobehavioral effects of trauma on language, memory, sensory processing, executive functioning, and cognition are the unrecognized primary contributors to these difficulties.

INTRODUCTION

Trauma disrupts a child’s normal brain development, interfering with neurological, cognitive, and developmental functioning from the cellular to the social level, or from communication between cells to communication between people.¹ The recognition of the neurodevelopmental impact of child maltreatment and subsequent traumatization is a relatively new phenomenon. An increasing body of research now highlights the deleterious neurodevelopmental effects of maltreatment, suggesting that children who experience multiple chronic traumatic events, including abuse, neglect, and sexual abuse, often develop relational disturbances, deficits with language and cognition, dysregulation of mood and behavior, and social/emotional disturbances.²-⁴ Physiologically, the experience of trauma affects core regulatory systems, compromising the processing and modulation of sensory experience, increasing sensitivity to or need for sensory stimuli, and preventing optimal integration of sensory experience.⁵-⁸ A child’s inability to modulate physiological responses to environmental demands creates chronic internal stress. Changes in the hypothalamic-pituitary-adrenal (HPA) axis, which is the body’s critical stress response system, prevents modulation of the resulting distress and frustration that accompanies sensory dysregulation, rendering a child incapable of efficient self-regulation of both affective states and behavioral self-control.⁴

Given what is known about the global neurodevelopmental impact of trauma, the most effective assessment of this impact must examine not only the effects on particular areas of functioning, but effects occurring between areas of functioning. Therefore, a team of professionals at the Southwest Michigan Children’s Trauma Assessment Center (CTAC), under the auspices of Western Michigan University, came together to address the need for this type of comprehensive transdisciplinary trauma assessment, one which is vastly different from the medical or mental health models of assessment. This multidisciplinary team includes professionals from occupational therapy, neurobehavioral pediatrics, speech-language pathology, psychology, and social work, with the objective of providing a more holistic view of trauma assessment. Creating an assessment environment, in which multiple specialties can contribute, ensures a more comprehensive understanding of trauma and enables the team to better understand the world as seen through a child’s eyes.

NEURODEVELOPMENTAL IMPACT OF TRAUMA

The complex interplay between genetics, prenatal environment, and postnatal environment is central to all observed behavior in humans. This interplay also contributes to aberrant thought, emotion, and behavior seen in children and adolescents exposed to chronic and significant traumatic stress. In the collective clinical experience of the CTAC team, insufficient understanding of this complex interplay is one of the primary reasons that traumatized children and adolescents are not often comprehensively assessed and frequently do not consistently respond optimally to various traditional treatment strategies.⁹

GENETIC FACTORS

The genetic component of this paradigm is exceedingly complex and includes the inheritance of personality and temperament,¹⁰ neurobiological disorders and/or mental illness (eg, attention-deficit/hyperactivity disorder [ADHD], thought disorders, mood disorders, and anxiety disorders), various neurodevelopmental/neurocognitive components (eg, attention,¹¹,¹² language,¹³ visual-spatial processing,¹⁴ memory,¹⁵ sensory processing,¹⁶ and neuromotor abilities¹⁷), and learning.¹⁸ Clinicians working with traumatized children and adolescents often limit the clinical familial history to a simple review of the family history of mental illness or are unable to interview the biological parents to obtain any pertinent information. A parent’s diagnosis of a mental illness indicates possible genetic inheritance of the disorder; yet this assumption does not account for the possibility of intergenerational traumatic experience. While the role of genetics in some mental health conditions is not to be discounted, it is important to realize that a bipolar parent does not necessarily translate to a bipolar child based solely on inheritance of the characteristic, understanding family trauma history is crucial before making the diagnosis. Otherwise, if a clinician elicits a positive family history of severe mental illness during an assessment of a traumatized child or adolescent, they may be tempted to attribute the child’s severe behavioral problems solely to the presumed genetic risk of mental illness. As the CTAC has demonstrated, many of the biological parents of traumatized clients are adult survivors of childhood abuse and/or neglect, and these individuals have their own complex genetic endowment and set of environmental influences. Differential diagnosis must, therefore, consider genetic predisposition to mental illness, a child’s vulnerability to genetically driven disorders when exposed to chronic stress,¹⁹ and/or the transmission of traumatic stress reactivity as a result of a parent’s own trauma history and self-regulatory dysfunction.²⁰

PRENATAL FACTORS

Another key component of this gene-plus-environment model involves the prenatal period. The lifelong environmental sculpting of the inherited genetic blueprint begins prenatally. Traumatized children and adolescents frequently have significant and prolonged prenatal exposure to a number of deleterious influences including maternal traumatic stress²¹ (eg, domestic violence, poverty, homelessness, and untreated clinical anxiety disorders), prescription medications, alcohol, and drugs (ie, nicotine,²² cannabis,²³ methamphetamine,²⁴,²⁵ and cocaine²⁶). Prenatal alcohol exposure in particular is associated with profound deleterious effects.²⁷ The authors have previously reported that 37% of the CTAC clinical sample of 274 known traumatized children and adolescents met clinical criteria for fetal alcohol spectrum disorder (FASD).⁹

POSTNATAL FACTORS

The final component of this gene-environment model involves children’s and adolescents’ ongoing environmental experience with a number of critical factors including parental attachment and nurturing, parenting style and psychopathology, nutritional status, exposure to violence, natural disasters, chronic neglect, and maltreatment (ie, abuse, neglect, exposure to familial violence). Neuroscientific evidence explaining the deleterious impact of maltreatment is steadily accumulating²⁸ and may involve novel mechanisms such as the mirror neuron system.²⁹,³⁰ Additionally, behavioral epigenetics, or the chemical and/or structural alteration of DNA after conception, has recently emerged in the neuroscience literature as an essential link between all 3 gene-environment components already discussed.³¹,³² The authors’ data demonstrated a significant and previously unreported additive neurodevelopmental impact in children and adolescents with both traumatic stress and prenatal alcohol exposure.⁹

THE CTAC MODEL OF TRANSDISCIPLINARY NEURODEVELOPMENTAL TRAUMA ASSESSMENT

Based on this understanding of the complexity underlying children’s neurodevelopmental functioning, the CTAC model of assessment for traumatized children was developed. The CTAC transdisciplinary team was formed in 1999 with the goal of conducting neurodevelopmentally comprehensive assessments for maltreated children in order to provide the courts, agencies, resource parents, and biological parents with comprehensive neurodevelopmental results, facilitating a better understanding of the multiple needs of a child and supplying recommendations on how best to address those needs.

The original CTAC transdisciplinary assessment components included: an ethnographic interview with the current caregivers of the child before the assessment, a physical examination, neurodevelopmental testing,³³ intelligence testing (Kaufman Brief Intelligence Test), behavioral questionnaires (Connors, ADHD Rating Scale, Child Sexual Behavioral Inventory), a sensory questionnaire (Sensory Profile), trauma self-report tools (Trauma Symptom Checklist), and a psychosocial interview of the child. Subsequently, the CTAC assessment added a pragmatic protocol,³⁴ an alexithymia scale, and an enhanced medical exam including a standardized Fetal Alcohol Syndrome (FAS) assessment protocol.³⁵,³⁶ CTAC also became 1 of 5 FAS diagnostic clinics in the State of Michigan and an FAS-Diagnostic Prevention Network site associated with the University of Washington, Center on Human Development and Disability.

CTAC recognizes that exposure to potentially traumatic events can affect a child’s functioning across multiple developmental domains. To assess this potentially global impact, a transdisciplinary team provides the most effective method for understanding the needs of each child. However, the continuum of neurodevelopmental trauma assessment protocols provides a myriad of choices for professionals to utilize depending on their professional training, interest and availability, and the cost of components of the protocol.

OVERVIEW OF THE CTAC TRAUMA ASSESSMENT

Required information from the referral source includes reasons for referral, past assessments (eg, psychological, academic), and current reports from child welfare for children that are temporary or permanent wards. This historical information in the referral packet often fails to capture a child’s current situation, so a clinician is assigned to contact the current caregiver and gather a recent history from the caregiver’s perspective. An ethnographic interview is conducted over the phone. The history is then typed up and distributed to the team on the day of assessment at the pre-assessment team meeting. In addition, previous testing results, child welfare records, and medical records are reviewed.

Two clinicians from the team, usually from different disciplines, are assigned to assess 1 child. Assignments are made according to the child’s specific needs based on the case history information gathered by a CTAC member. Team members, particularly those representing disciplines different from those of the assigned clinicians, view the assessment from an observation room. Social workers are assigned the psychosocial portion of the assessment. Speech and occupational therapy team members conduct assessments from their areas of specialty if the child has articulation issues and/or sensory processing concerns. The morning session lasts up to 2 hours. In addition to gathering information from instruments and protocols, the assessment involves an engagement process with the child, making the child feel safe and comfortable in order to optimize the child’s ability to perform the variety of tasks involved in the assessment.

The child is given a lunch break after the morning session, at which time the team reconvenes in order to report findings and to plan for the afternoon session. The team discusses the child’s functioning, performance during activities, and interaction with clinicians. It is through this clinical observation that sensory processing disorders, language impairments, attachment concerns, and behaviors are also considered in the context of the child’s reported history and of the known traumatogenic factors that affect children’s performance. This process is central to the transdisciplinary assessment. Strategies for working with the child are offered, especially if the child had difficulty regulating and attending to morning testing demands. Priorities for the afternoon session are established (ie, focus on pragmatic language, attachment assessment, and audiology). In addition, consultation for the psychosocial interview is provided to the social work clinician. Of paramount importance is gauging the child’s ability to continue with the assessment process and then readjusting the focus of the afternoon session accordingly.

The psychosocial interview and structured observations comprise the final phase of the assessment, after which the team meets again. The child’s performance and interaction are discussed, and all team members from all disciplines are encouraged to offer their observations and insight into the child’s overall performance. It is in this meeting that the process of synthesizing all the testing information begins, starting the process of framing disparate testing results into a comprehensive understanding of the child. Understandably, the observations over a full day assessment are qualitatively different from those generated by a series of shorter sessions. Typically the child’s demeanor and interaction with the clinician change over the course of the day, and if the child has difficulty regulating cognitive, emotional, or behavioral control, this becomes clear by the end of the assessment. The goal of the post-assessment meeting is to revisit referral concerns regarding the child and to gain a new understanding of a child’s behavior from a trauma-informed perspective. Immediate concerns related to safety issues, medical needs, or other issues are identified by the team, and contact with the referring worker or family is made to facilitate necessary services promptly.

DETAILED DESCRIPTION OF ASSESSMENT COMPONENTS

The assessment process is deconstructed in this section so that each component is delineated separately for instructional purposes. Assessment sections include:

—Cognition

—Development (speech/language, sensory, memory, visual processing)

—Affect and behavior

—Family observations

—Determination of traumatic impact

—Medical evaluation

This deconstruction is an artificial separation, as the assessment process involves considerable overlap and integration of specific domains. Each subsection that follows first includes the rationale for obtaining the assessment, including the empirical base, in order to contextualize why the area is assessed and what functions the clinicians are seeking to observe throughout the assessment process. This is followed with a description of relevant tools and methods used towards a sample of children utilizing tools, such as CTAC specific to neurodevelopmental function, where the information is then presented.

1. Cognitive Assessment

An individual’s intellectual capacity is clearly associated with functional performance across multiple domains and for this reason it is the first test administered during a CTAC assessment. The CTAC model uses the Kaufman Brief Intelligence Test, 2nd edition (K-BIT 2),³⁷ which is a brief measure of intellectual capacity normed for ages 4 to adulthood. The nonverbal score reflects nonverbal and abstract reasoning, as well as the ability to integrate information and experiences. K-BIT 2 results correlate well with more comprehensive instruments such as the Wechsler Intelligence Scale for Children, 4th edition,³⁸ but the K-BIT 2 takes less time to administer. Reliability coefficients specific to this sample of children (aged 6-16) range from .79 to .95 (M = .90), with the lowest value specific to reliability for 6-year-olds on the nonverbal subscale. Verbal scores reveal fund of knowledge, verbal reasoning, and language conceptualization. The K-BIT 2, in combination with neurodevelopmental and psychosocial assessment, is usually manageable for children who have problems with attention and self-regulation, which constitutes the majority of children referred to CTAC. Further, the K-BIT 2 is a viable tool for social workers and other non-psychology professionals working with traumatized children.

The K-BIT 2 instrument is administered by a clinician to the child immediately after greeting the child and a brief period of rapport building. Administration typically takes less than a half hour. Results of the K-BIT 2 help clinicians determine the extent to which the child may find language or visual processing tasks challenging or whether maintaining attention may require adaptations to the testing environment to optimize the child’s potential, during the administration period.

2. Developmental Assessment

The Pediatric Early Elementary Examination, 2nd edition (PEEX 2) and The Pediatric Examination of Educational Readiness at Middle Childhood, 2nd edition (PEERAMID 2)³⁹ explain measures of developmental functioning. These are standardized neurodevelopmental and neurobehavioral assessments available for children and adolescents between the ages of 6-8 years (PEEX 2) and 9-14 years (PEERAMID 2). Reliability values are not available for these tests because they do not yield an overall score; rather, they generate a narrative description of a child’s neurodevelopmental profile. Each subtest is made up of 5 or more experiential activities, ranging from paper-and-pencil activities to copying clinician finger movements, as well as responding orally to clinician questions regarding short passages read aloud. Tests are typically administered to the child by 2 clinicians in an assessment room, and are administered according to a standardized manual in order to meet standards of reliability. The instruments are subdivided into 5 sections:

1.Fine motor

2.Language

3.Gross motor

4.Memory

5.Visual processing

Within each domain, 2 tasks below age norms indicate a moderate delay for that specific domain, and 3 or more tasks below age norms indicate a major delay for that domain. Areas of function that are comprehensively assessed include attention, memory, neuromotor function, visual—spatial processing, temporal–sequential function, and higher level cognition. The full PEEX/PEERAMID battery of tests takes about 1 ½ hours to administer. Rationale for assessment and specifics for each area, along with additional tools, are detailed below in Table 2-1. In addition to these assessments, there is also a set of instruments used to determine developmental status among infants, toddlers, and preschool-age children.

Speech/Language Assessment

Speech-language pathologists (SLPs) have considerable exposure to traumatized children and the complexity of their neurodevelopmental, social/emotional, and behavioral impairments. A recent study noted that preschool children who had been exposed to traumatizing violence were more than 7 times more likely to be referred to speech-language pathology services than children who had not been exposed.⁴⁰ Traumatized children often have delays in grammar and vocabulary comprehension and production, conversational skills, receptive and expressive syntactic skills, and semantic skills, including difficulties with multiple word and sentence meanings.³⁴,⁴¹ Katz⁴² reviewed research that was conducted from 1975 to 1992, finding that both physically abused and neglected children evidenced language delays and disorders, with those of neglected children being more severe. In retrospective studies examining the effects of complex trauma on the social communication and language skills of children aged 6-16 years, data showed that this population had significant deficits in receptive and expressive language skills.⁹ At the sound, word, and sentence levels of communication, difficulties were exhibited in the areas of phonological awareness, expressive vocabulary, complex sentences formulation, as well as in comprehending, remembering, and following verbal instructions.⁹ The CTAC assessment examines language functioning through the use of the PEEX/PEERAMID expressive and receptive language sections and the Hyter Pragmatic Protocol,⁴³ which is described in detail in the following section.

Social Communication and Pragmatic Language

Complex trauma disrupts brain development and functioning, including functions that support communication and social interactions.¹ Several neurological structures interact to facilitate social communication, defined as the ability to make sense of social situations and function effectively within them. Structures relevant to social communication function to: (1) support the perception of socially relevant input (ie, thalamus), (2) link socially relevant input to emotional and cognitive processes (ie, amygdala, right somatosensory, orbitofrontal, and cingulate cortices), and (3) produce conscious control or regulation of goal-directed behaviors (ie, prefrontal cortex).⁴⁴-⁴⁶ Consequently, assessing the social communication and pragmatic language skills of children affected by complex trauma is critical for understanding this population, explaining their needs, and developing effective intervention strategies.

The Hyter Pragmatic Protocol⁴⁴,⁴⁷ and the Pragmatic Protocol Revised,⁴⁸ which include procedures reported in the extant literature, are used to examine discourse level processes, including examining a range of discourse genres, social cognitive skills, and executive functions. At the discourse level of communication, children with significant histories of complex trauma have exhibited difficulties with narrative discourse (ie, story retelling) and social cognitive skills including intention reading, both of which have implications for daily functioning and academic success.⁴³ Psychometrics for reliability and validity are not yet available, but the empirically-based protocol does have strong face and content validity. The Pragmatic Protocol is appropriate for multidisciplinary administration, but is overseen by the speech or language team member. Pragmatics are typically administered after the morning session and following the child’s lunch break. For younger children, toy props are used to act out some of the items on the Pragmatic Protocol in order engage the child’s imagination during the activities while the understanding of social communication is being tested. The Pragmatic Protocol typically takes from 15 to 30 minutes to administer.

Assessment of Sensory Processing

Sensory processing involves the detection, registration, and modulation of sensory modalities and, ultimately, the organization of sensory information by the central nervous system to allow for an adaptive response that is meaningful and relevant to a given situation. It is hypothesized that children who demonstrate sensory processing disorders experience errors in the interpretation of sensory information at both a subcortical and cortical level. The lack of habituation and adaptation to sensory input results in chronic expressions of poorly organized, maladaptive responses.⁴⁹ Sensory modulation, 1 of 3 sensory processing typologies refers to the action that takes place in the central and autonomic nervous system in response to internal and external sensory stimuli. A disorder in sensory modulation occurs when there is difficulty in the grading of responses to the quality or nature of the stimulus as well as the quantity of sensory stimuli, resulting in maladaptive responses. There are 3 subtypes within sensory modulation dysfunction (SMD), including sensory overresponsivity (SOR), sensory underresponsivity (SUR), and sensory seeking (SS).⁵⁰ Sensory deprivation or any form of maltreatment or neglect may produce either sensory over-responsivity, a persistent fear response and constant hyperarousal, or a dissociative, under-responsive surrender response.⁸ Henry, Sloane, and Black-Pond reported that children who had prenatal exposure to alcohol along with postnatal abuse had severe neurodevelopmental deficits in language, memory, visual processing, motor skills, attention, and behavior.⁹ Atchison reported significant sensory modulation and sensory discrimination disorders among the same population.⁵¹ It is evident that the severity of trauma on sensory processing behaviors varies, ranging from the absence of signs and symptoms to significant dysfunction that interferes with daily life. It is essential, therefore, to include a measure of sensory processing status in trauma assessment to ensure that those who are experiencing these problems are identified and provided necessary support.

The CTAC assessment utilizes the fine motor/graphomotor, gross motor, and visual processing subtests of the PEEX/PEERAMID, as well as clinical observation by the occupational therapy team member throughout the assessment day. The Sensory Profile,⁵² a caregiver-completed instrument, is used to measure sensory functioning in the areas of taste, vestibular, tactile sensitivity, auditory filtering, sensory seeking, and low energy. The Sensory Profile has been normed on children ages 3 to 17 years, with and without disabilities. Factorial validity has been established with a 9 factor solution. The Short Sensory Profile takes approximately 10 minutes to complete. Overall, sensory processing testing and observation allow conclusions in each of the 3 typologies: sensory modulation, sensory based motor, and sensory discrimination.

Memory

Impairments with memory functions have the potential to impact performance in all other developmental domains as well as with social communication and social cognition. Understanding a child’s memory processes is critical to understanding the way in which the child processes and responds to their environment, and is a vital part of the CTAC assessment. The PEEX/PEERAMID is used to assess memory functions including visual and auditory registration, word retrieval, short-term memory, and active working memory. In addition to the scores on testing items, clinicians observe the child attempting to use these memory skills through interaction with the clinicians and other adults during the assessment day.

Visual Processing

Visual processing includes the ability to use basic functions of vision such as saccadic eye movements, visual tracking, pursuit, fixation, and localization to explore a stimulus and make cognitive level decisions about the quality of the stimulus. The quality of the stimulus includes form-related factors such as color, direction, size, shape, and texture as well as visual-spatial relationships. The ability to replicate a simple to complex design, measured in paper-pencil tasks, is dependent on these functions. Visual processing is assessed through the administration of relevant sections of the PEEX/PEEARAMID along with clinical observation of basic visual functioning, with areas assessed including visual problem-solving, visual-spatial relations, pattern recognition, and visual registration. Additionally, the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),⁵¹ a child-completed instrument administered by the clinician, is used for additional verification of a child’s visual motor integration skills, and is appropriate for preschool age through adult. Reliability (ie, interrater, test-retest, and internal consistency) averages at .89 to .92. Concurrent, construct, and predictive validity have been established. This test takes 5 to 10 minutes for the child to complete, and involves having the child view and then copy pictures of progressively more complex geometric shapes. This instrument is typically administered if other sources of information are inconclusive regarding a child’s visual integration capacity, or if substantial delays are observed and the extent to which the child is delayed needs to be more accurately documented.

3. Affect and Behavior: Self-regulation and Trauma

Children exposed to multiple or repeated traumas often demonstrate significant shifts in affective states, including both a hyper-responsiveness and underresponsiveness to benign environmental stimulation. They are often described as being unable to self-soothe, as having problems managing anger, and as demonstrating internalized negative affect. Anxiety and depression are often chronic, resulting in dysthymia and/or anxiety disorders. Similarly, they frequently demonstrate difficulty in regulating attention, bodily states (ie, sleep disturbances and disorganized behavior during transitions), and behavioral impulses that are survival-based, including aggression, avoidance, and a preoccupation with danger. Generally, referrals for mental health assessment and/or treatment are made as a result of children’s difficulty regulating mood, attention, physiological states, and risk-taking (or thrill-seeking) behavior. Diagnostically, children referred to CTAC often carry more than 1 diagnosis, which is reflective of their difficulty with self-regulation. Typical diagnoses include ADHD, mood disorders, and bipolar disorder, as well as those diagnoses reflecting behavioral disturbances, such as oppositional defiance disorder, conduct disorder, and explosive disorder.

Research demonstrates a relationship between multiple exposures to traumatic events and impairments in self-regulation. Spinazzola et al⁵³ found that at least 50% of children receiving trauma-focused treatment in 25 sites in the National Children’s Traumatic Stress Network had significant disturbances in affect regulation, attention and concentration, impulse control, aggression, and risk-taking behavior. Difficulties with observed regulation of mood and behavior were positively related to higher scores on indicators of maltreatment. Contributing to children’s ability to self-regulate both affect and behavior is their ability to identify and express emotional states. Impairment in these tasks is known as alexithymia, a term referring specifically to a failure in the identification and verbal communication of emotions through cognitive processing.⁵⁴ Children with complex trauma histories have difficulty in both identifying and discriminating their emotional states, as well as in interpreting the emotional states of others, resulting in affect regulation impairments.² In particular, a significant association between alexithymia, childhood emotional and physical neglect, and a greater number of traumas has been found based on the self-report of adult survivors of childhood trauma on the Toronto Alexithymia Scale (TAS).⁵⁵ Research also indicates an association between alexithymia and emotional numbing associated with post-traumatic stress disorder (PTSD) symptomatology.⁵⁶

There is a need to understand the similarities between self-regulation impairments resulting from traumatic exposure and the more commonly observed behaviors associated with oppositional/defiance, hyperactivity, inattention, and fluctuating moods. Trauma-informed assessment approaches that consider the impact of traumatic exposure on the skill acquisition necessary for self-regulation and the achievement of competencies necessary for emotional, behavioral, relational, and academic success are imperative. CTAC utilizes a combination of caregiver interview and standardized behavioral questionnaires to identify areas of emotional and behavioral concern related to self-regulation impairments across environments. The Child Behavior Checklist (CBCL),⁵⁷ both parent and teacher versions, and the ADHD Rating Scale⁵⁸ (home and school), are the primary tools to identify observed emotional and behavioral functioning. The Alexithymia Scale for Children⁵⁹ and, more recently, the Children’s Alexithymia Measure⁶⁰ also capture parents’ observations of behaviors associated with alexithymia. The psychosocial interview and children’s self-rating scales for depression and anxiety are used to understand the child’s perceptions and emotional experience. The instruments used for behavioral or emotional status are listed in Table 2-2 below. Additional instruments, not listed, may be employed if specific cases warrant use of other instruments (eg, screening for Asperger’s syndrome, autism, executive functioning issues).

4. Family Observations

CTAC has increasingly incorporated observations of children with their caregivers, both resource (foster or relative caregivers) and biological (parents and siblings), into the assessment process. Seeking to address attachment and relational concerns, CTAC has included both structured and unstructured methods of observation during the assessment process. As children adjust and establish rapport with the examiner over the course of the day, clinicians and team members are able to informally observe the range of a child’s interactions with evaluators, other staff, and the adults who bring them to the assessment. While there are advantages and disadvantages to conducting assessment over 1 full day, one gain is the ability to observe shifts in a child’s affect and relational comfort with others throughout the day.

To attain more qualitative information about a caregiver’s and child’s interaction style, the Marschak Interaction Method⁶³ (MIM) is often administered. The MIM is a structured observation technique that is designed to assess the quality and nature of the relationship between a child and each of his or her caretakers. This method involves assessment of how the child responds to the parent’s efforts to provide nurturing responses, structure the environment and set appropriate expectations and limits, engage the child while being attuned to the child’s response and needs, and to provide challenges appropriate to the child’s current development level. A modified version of The Strange Situation⁶⁴ is also utilized with very young children, consisting of structured observation of a child’s reactions following separation and reunion with their caregivers.

For children in out-of-home placements, and when parental rights are intact, biological parents are invited to participate in an