Developmental Tasks and Challenges Related to Stress and Coping

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134 Chapter 8 Maltreatment and Trauma- and Stressor-Related Disorders

From birth onward, stressors abound. They include everyday events such as parent-child arguments about screentime or curfews, playground mishaps and sports injuries, the birth of a sibling, conflicts with friends, and end-of-year school exams. They also include more challenging events such as parental divorce, a move to a new state, failing a grade, and breaking up with one’s first romantic partner. For some youth, there are traumatic events such as maltreatment, persistent family conflict and chaos, poverty and discrimination, and the experience of life-threatening danger.

Each of these stressful events requires some kind of coping response from a child or adolescent. Stress-andcoping episodes add up over time, influencing daily functioning and developmental pathways related to adaptation and well-being. For many youth, experiences of mild to moderate stressors coupled with mostly positive coping outcomes provide a foundation for emotional, cognitive, and behavioral resilience. However, countless children and adolescents in the United States and around the world encounter stress and trauma that overwhelm their capacities for coping and adaptation. This chapter focuses on those children and adolescents and includes discussions of typical and atypical experiences of stress, disorders related to stress and trauma, and prevention and treatment efforts.

Developmental Tasks and Challenges Related to Stress and Coping

Stress occurs when the demands of the individual exceed

available resources. Coping involves the regulatory processes that are activated in response to stress. The stress–response system is an evolutionarily influenced, hierarchically organized, and integrated brain-body system (Ellis & Del Giudice, 2019; Engel & Gunnar,

2020). Brain regions involved in stress responses include the hippocampus, the amygdala, and the prefrontal lobes, along with the circuitry that connects those regions. Stress triggers the activation of the hypothalamuspituitary-adrenocortical (HPA) axis and the release of stress hormones such as cortisol. Receptors for these stress hormones are located throughout the brain. The stress hormones initiate a coordinated physiological response involving autonomic, neuroendocrine, metabolic, and immune system components. Following activation of the stress system, feedback loops signal for regulation and shutdown of the HPA axis and a return to homeostasis (Engel & Gunnar, 2020; McEwen & Akil, 2020).

The stress system is organized to expend both physiological and psychological energy as it attempts to meet typical (or expected) and atypical (or unexpected) demands. Given the ubiquity of typical challenging

events, the activation-and-return-to-baseline cycle occurs frequently and supports physiological and behavioral adaptation to one’s unique environmental setting. Gunnar and Loman (2011, p. 97) provide additional details about typical and atypical events: “If there is an immediate threat to our survival, we do not need to put energy into fighting off a virus, digesting our lunch, or growing an extra inch. We need that energy to fuel the mental and physical processes that increase our chances of surviving to face tomorrow. As this example suggests, stress is not necessarily detrimental. The capacity to mount an effective stress response allows us to adapt to the changing and sometimes extreme demands of our daily existence, to stretch our abilities, and to achieve more than we might were we to avoid situations of high demand.” These high-demand circumstances need to be followed by periods of rest and repair. If rest and repair occur rarely or not at all, there are negative consequences, both in the immediate aftermath and in upcoming months and years.

The effects of stress are observed across the lifespan, from the prenatal period, across infancy and childhood, and through adolescence and adulthood. A life cycle model of stress describes changes in various brain structures related to the timing of stress (Lupien et al., 2009; Figure 8.1). Exposure to prenatal and postnatal stress has programming effects on the developing brain and HPA axis (Engel & Gunnar, 2020; McEwen & Akil, 2020; Tottenham, 2020). With both typical and atypical development, the activity of stress-response processes “sensitize and shape brain systems that are involved in (1) processing and remembering threat, (2) activating the HPA axis and other stress-responsive behavioral and physiological systems, and (3) altering thresholds for terminating stress responding” (Engel & Gunnar, 2020, p. 43). These neurobehavioral programming effects involve changes in gene function (not in the genetic code or composition, but in the way in which the genetic information operates). These effects are examples of epigenetics, the environmental regulation of gene expression (refer to the epigenetics discussion in Chapter 2).

Early adversity—such as traumatic events or multiple, accumulating stressors— alters the magnitude and regulation of the stress response. Both hyper-reactivity (exaggerated response patterns) and hypo-reactivity (blunted patterns) have been described (Engel & Gunnar, 2020; Smith & Pollak, 2021; Young et al., 2021). Early adversity also impacts the amygdala, the hippocampus, the immune system, cardiometabolic processes, and brain network connectivity (Chahal et al., 2022; Doom et al., 2020; Elwenspoek et al., 2017; Weems, 2017). The epigenetic processes related to the stress, immune, and cardiometabolic systems are core components of biological embedding models, models that explain how “adversity gets under the skin” and the links between exposure to early adversity and higher rates of poor physical and mental health outcomes (McEwen & Akil, 2020).

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Developmental Tasks and Challenges Related to Stress and Coping 135

Figure 8.1 A life cycle model of stress and brain development

Changes in various brain structures are influenced by the timing of stressful experiences.

Prenatal stress

Amygdala Amygdala Frontal cortex Hippocampus

Effect on

HPA axis

Outcome

Source: Lupien, McEwen, Gunnar, & Heim (2009). Effects of stress throughout the lifespan on the brain, behaviour, and cognition.

programming effects

glucocorticoids

Postnatal stress

Birth 28 18 30 60 90

differentiation effects

glucocorticoids (maternal separation)

glucocorticoids

(severe trauma)

The powerful impact of early adversity on stress response systems is associated with young children’s greater neural plasticity. The effects of early adversity, however, may be modifiable. Beyond the early years of life, sensitive periods for the calibration and recalibration of stress response systems include middle childhood and the onset of puberty (Ellis et al., 2022; Gunnar et al., 2019). Puberty, for example, is associated with increases in stress sensitivity as well as greater male-female differentiation in stress response. In addition, there are differences in plasticity depending on the brain region or system. The amygdala, for example, is less likely to recover from chronic stress than the hippocampus or prefrontal cortex (Engel & Gunnar, 2020).

Early adversity is often discussed in tandem with toxic

stress (Shonkoff et al., 2012). The National Scientific

Council on the Developing Child describes three types of stress responses observed in young children. Positive stress responses include brief, mild-to-moderate responses, usually with a supportive caregiver (e.g., dealing with everyday frustration or typical experiences such as the first day of preschool). Tolerable stress responses involve atypical stressors (such as serious illness, frequent interparental conflict, or a natural disaster) that trigger a more widespread and possibly longer-lasting response. For many children in these situations, protective adults help buffer the stress response and promote a return to typical functioning. Toxic stress responses are the result of “strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship” (Shonkoff et al., 2012, p. e236). It is important to emphasize that children are not just passive recipients of stress; they are also active agents

Stress in

adolescence

potentiation/ incubation effects

glucocorticoids

in dealing with it. Indeed, as noted, exposure to multiple instances of stress (or challenge) may be necessary for the typical development of problem-solving or coping strategies.

Two constructs help define this stress-and-response process: allostasis, “meaning the process of maintaining stability (homeostasis) by active means, namely, by putting out stress hormones and other mediators,” and al lostatic loa d (or allostatic overload), “meaning the wear and tear to the body and the brain by use of allostasis, particularly when the mediators are dysregulated, i.e., not turned off when the stress is over or not turned on adequately when they are needed” (McEwen, 2007, p. 874; refer to Figure 8.2). The constructs of allostasis and allostatic load make clear the role of the brain in the regulation of feedback, that biological set points are dynamic (in that they respond to changing contexts), and that there are predictable variations in stress sensitivity across development (Engel & Gunnar, 2020).

Another perspective on early stress and adversity highlights individuals’ potential for adaptation, even in very difficult environments. Because “stress and adversity have always been part of the human experience,” it makes sense within an evolutionary framework that individuals are able to adapt to many kinds of current and future challenging environments (Ellis & Del Giudice, 2019, p. 4). This developmental-evolutionary approach identifies various patterns of physiological and psychological reactivity and regulation that provide benefits in specific environments (often accompanied by physiological and psychological costs). Attention is focused on plasticity, with multiple plasticity periods across development providing opportunities to adapt in different

Stress in

adulthood

maintenance/ manifestation effects

glucocorticoids (depression)

glucocorticoids (PTSD)

Stress in aging

maintenance/ manifestation effects

glucocorticoids

(cognitive decline)

glucocorticoids (PTSD)

Frontal cortex

Hippocampus

136 Chapter 8 Maltreatment and Trauma- and Stressor-Related Disorders

Homeostasis and Allostasis

onmental

ways to changing circumstances (Ellis et al., 2022; Ellis &

Figure 8.2 Stress exposure influences allostasis and allostatic load

Del Giudice, 2019). What is important to emphasize here is that children who grow up in high-stress environments display a variety—positive, problematic, and mixes of positive and problematic—of adaptations and outcomes (Ellis & Del Giudice, 2019).

Homeostasis

Seeking balance

there are many different types of adversity (e.g., food or shelter insecurity, maltreatment, pandemic-related losses). Different stressors, such as those associated with threat and those associated with deprivation, are sometimes associated with specific stress responses, adaptations, and specific trajectories and outcomes (Ellis et al., 2022; Guyon-Harris et al., 2020; Roubinov et al., 2021). We also need to account for dimensions of stress such as harshness (intensity), predictability (or unpredictability), and chronicity (Ellis et al., 2022; Smith & Pollak, 2021). What is likely most important to appreciate is that categories of adversity are complex, that adverse experiences tend to co-occur, and that there are individual differences in response to similar stressors and overlapping developmental pathways for children and adolescents experiencing varied combinations

Allostasis

Long-term adaptations to maintain balance

of stressors (Smith & Pollak, 2021; refer to Figure 8.3).

are linked to both genes and experience. Temperament (e.g., high reactivity) is one factor that influences the development and functioning of the stress response system (Gunnar & Quevedo, 2007; Obradović, 2012). Another key contributor

Envir

stressors

to individual differences in the organization of the stress– response system is early caregiving and attachment security. The experience of stress in early development is buffered by responsive caregiving. Research has confirmed the extremely important role of the attachment relationship in regulating and lessening the impact of stress in infants and toddlers (Gunnar, 2016). Current studies are focused on better understanding the mechanisms and outcomes of social buffering across childhood, adolescence, and adulthood (Engel & Gunnar, 2020; Smith & Pollak, 2021).

Allostatic Load/Overload

Long-term adaptations become problems

stress a nd adversity in early development: 1. Biologica l systems interact with environments. 2. Adverse environments lead to changes in physiological structures and functions and alter developmental pathways. 3. Children and adolescents vary in differential susceptibility to environments. 4. Sensitive periods provide opportunities for positive and/or negative

Envir

stressors

influences and change (Boyce et al., 2021).

participants in stress-and-coping experiences. Coping can be conceptualized at many levels, from the broad level of domains to mid-level factors to more specific strategies (Compas et al., 2017). Most of the coping research is focused on factors and strategies. The factor level of

Source: Harvard Center on the Developing Child (2020). Connecting the brain to the rest of the body: Early childhood development and lifelong health are deeply intertwined.

coping includes multiple categories: problem-focused coping, emotion-focused coping, engagement/approach coping, disengagement coping, primary control coping, secondary control coping, and social support coping.

In all these stress-focused discussions, keep in mind that

Individual differences in stress reactivity and regulation

Four key concepts summarize the theory and research on

Children and adolescents, as described, are active

Maltreatment 137

Although hundreds of individual coping strategies have been identified, most fit into the following categories: acceptance, cognitive reappraisal, emotional expression, emotional suppression, problem solving, distractions, avoidance, denial, and wishful thinking (refer to Table 8.1). [Note: The construct of coping overlaps with the construct of emotion regulation (discussed in more detail in Chapter 11). “Coping is a narrower construct in that it is limited to responses in the context of stressors while emotion regulation occurs in response to both stressful and nonstressful circumstances. However, coping is also a broader construct in that it encompasses the regulation of a wider range of processes that includes not only emotions, but also cognition, behavior, physiology, and sources of stress in the environment” (Compas et al., 2017, p. 942).]

Developmental approaches provide important information about coping across time (Compas et al., 2017; Zimmer-Gembeck & Skinner, 2011, 2016). Age-related transitions in coping occur from infancy to toddlerhood (about age 2), between ages 5 and 7, from late childhood to early adolescence (from ages 10 to 12), from early to middle adolescence (from ages 14 to 16), and from middle to late adolescence (from ages 18 to 22). Across age, the

Table 8.1 Categories and Examples of Coping and Emotion Regulation

Coping strategies Examples

Acceptance Acceptance, resignation,

tolerating situation

Cognitive

reappraisal

Emotional

expression

Emotional

suppression

Problem solving Decision making, analysis

Distraction Cognitive or behavioral

Avoidance Distancing or withdrawal,

Denial Ignoring problems,

Wishful thinking Fantasizing, superstitious

Source: Adapted from Compas et al. (2017). Coping, emotion regulation, and psychopathology in childhood and adolescence: A meta-analysis and narrative review. Psychological Bulletin, 143(9), 939 –991.

Cognitive restructuring, interpretive control, focusing on the positive, minimization, seeking understanding

Focusing and venting feelings, sharing emotions, seeking support

Inhibiting or concealing emotions, repressing emotions

and planning, behavioral coping, seeking help

distracting, media use, diverting attention

avoiding social support

blaming others

thinking

most common types of coping are problem solving, support seeking, distraction, and escape. Escape is the most common maladaptive strategy. There are, however, developmentally influenced changes in the frequency and flexibility of strategy use. In the preschool period, for instance, young children seek safety and support from adults or use specific behaviors to achieve a coping goal. Support seeking is the primary coping strategy, and escape is the most frequent response when other strategies are ineffective. In middle childhood, children are more independent, and their coping strategies become more numerous and effective. Cognitive strategies are increasingly deployed, and support seeking appears more focused. In adolescence, there is an overall increase in coping repertoires, with more planful problem solving and better emotion regulation as well as increases in seeking peer support and the matching of coping strategies to types of stressors (Zimmer-Gembeck & Skinner, 2011,

2016). Descriptions of effective (and ineffective) coping in

varied stressful situations provide important information about immediate and ongoing adaptations to stress and adversity (Compas et al., 2020). Many factors influence individual differences in coping repertoires and coping success. These include physiological factors such as brain development, psychological factors such as temperament and the development of the self, and social factors, including parent and peer relationships (Compas, 2020; Kopp, 2009; Wadsworth, 2015). Parental social scaffolding of children’s coping, providing appropriate support and assistance, may be especially important when high levels of stress are encountered and/or when the child’s coping resources are taxed (Gruhn & Compas, 2020; Gunnar, 2020; Tottenham,

2020). Indeed, social relationships across development,

involving parents, peers, and others, serve to protect youth from stress and help youth regulate stress when it is unavoidable (Saxbe et al., 2020).

Overall, across development, the ongoing interactions

of stress and coping are evident every day. For many children, whose stressful experiences are typical and whose coping is supported by concerned adults, these interactions contribute to a sense of self-efficacy, accomplishment, and well-being. For other children, whose stressful experiences are unusually frequent and severe and whose coping is not adequately supported, developmental outcomes are more likely to include significant distress and dysfunction. These children and their experiences are the focus of the rest of this chapter.

Maltreatment

The Case of Wyatt

Wyatt is a four-year-old boy who was recently removed from his home and placed in foster care along with his younger sister. Until recently, Wyatt and his sister lived with his mother and her current boyfriend in a

138 Chapter 8 Maltreatment and Trauma- and Stressor-Related Disorders

somewhat isolated rural community. Wyatt’s mother has struggled with polydrug addiction, including alcohol and methamphetamine, since before Wyatt’s birth. Although not physically abusive to her children, Wyatt’s mother’s cycle of addiction, recovery, and relapse has led to multiple periods of physical neglect and emotional unavailability.

Wyatt was removed from the home by child protective services when he was one year old, when a visiting county social worker found him suffering from severe neglect, including untreated eye and ear infections and signs of malnutrition. He spent several months in a foster home while his mother completed a rehab program and gave birth to his sister. Wyatt was then returned home, where he and his sister lived for the next three years. During this time, Wyatt’s mother continued to cycle through periods of active drug and alcohol abuse followed by brief periods of sobriety.

While assessing Wyatt as part of a prekindergarten screening program, the evaluator noted multiple bruises on Wyatt’s face and legs. A follow-up evaluation by child protective services found further bruising on Wyatt’s back and buttocks. Wyatt told the child protection worker that his mother’s boyfriend routinely struck him with his hand or a stick in response to any behaviors of which he disapproved. This included even mild oppositional behavior, as well as unintentional behaviors such as wetting the bed or spilling a drink. Wyatt’s mother confirmed that the abuse had been occurring, but she defended her boyfriend by noting that he behaved violently only when drunk or high and was otherwise kind to her and provided for her family. Following the investigation, both Wyatt and his sister, who was not physically abused, were removed from the home and placed in separate foster care homes. Wyatt’s mother again entered a residential treatment program, and her boyfriend was arrested and charged with multiple counts of child abuse.

Wyatt now lives with experienced and loving foster parents and is enrolled in a therapeutic preschool. Wyatt’s foster parents express surprise that he almost never mentions his mother or sister. They report that he settled quickly into his new surroundings and routine. Both at home and at preschool, Wyatt is noted to be acutely aware of and reactive to even mild disapproval. In fact, he quickly focuses on frustration or anger in his environment even when it is not directed toward him. Over time, Wyatt has become more trusting of his foster parents, though he also becomes anxious if he is not in the same room as them. Wyatt has struggled to manage the complexity and energy typical of a preschool classroom. He has difficulty joining in with other children and becomes easily frustrated and emotionally reactive to even minor frustrations and problems. At such times, he may exhibit either internalizing behaviors, such as hiding or crying, or externalizing behaviors, such as throwing toys or hitting other children.

Further assessment indicates that Wyatt is experiencing mild-to-moderate delays in general cognitive functioning and expressive language ability. Wyatt’s teachers are developing a comprehensive plan combining structured,

small-group play opportunities with speech therapy and remedial school readiness training. All the adults currently working with Wyatt remain both hopeful that he can continue to make progress and concerned about whether his mother will continue Wyatt’s current therapeutic program if he returns home to live with her.

As described in Chapter 3, maltreatment is a broad category including physical abuse, sexual abuse, psychological abuse, and neglect, reflecting the “gross violation of the rights of a vulnerable and dependent child” (Cicchetti & Toth, 1995, p. 541). Child maltreatment is not a diagnosis that is assigned to a child. Rather, as emphasized in many other chapters, it is a risk factor that is associated with an increased likelihood of immediate, short-term, and long-term negative developmental outcomes. Indeed, “although the thought of a maltreated child conjures up images of head trauma, bruises, broken bones, malnutrition, and the like, it appears that emotional damage, not physical damage, may exert the most long-term harmful effect” (Cicchetti & Toth, 2003, p. 190).

Definitions of maltreatment vary, depending on context and culture, professional background, and purposes of definition (e.g., involving lawmakers and legal issues or mental health professionals and treatment issues) (Cicchetti,

2016). Even so, basic definitions can be provided. Sexual

abuse involves sexual contact or attempted sexual contact

between an adult and a child. Physical abuse refers to injuries that are inflicted by nonaccidental means. Neglect involves failure to provide minimum standards of care (e.g., regarding shelter, safety or supervision, nutrition) that leads to harm or endangerment. Emotional (or psychological) abuse refers to ongoing and extreme disregard or thwarting of basic emotional needs. Additional classification considerations include the frequency, severity, and timing of maltreatment.

Maltreatment has been conceptualized as a “failure of the average expectable environment” (Cicchetti & Valentino,

2006). “For infants, the expectable environment includes protective, nurturant caregivers and a larger social group

iStock.com/Stefanamer

Physical maltreatment is often accompanied by psychological and/or emotional abuse.

Trauma- and Stressor-Related Disorders 139

Rate per 1,000 children

Age

Figure 8.3 Maltreatment rate per 1,000 children ages 0–17 years, 2020

25.1

11.2

10.4

<1 1234567891011121314151617

9.7

9.0

8.8

8.3

7. 9

7. 4

7. 17.1

6.9

6.8

6.6

6.3

6.0

5.2

3.6

Source: US Department of Health & Human Services, Children’s Bureau, https://www.acf.hhs.gov/cb/report/ child-maltreatment-2020.

to which the child will be socialized, whereas for older children, the normative environment includes a supportive family, a peer group, and continued opportunities for individuals to dynamically engage in the construction of their own experiences” (Cicchetti & Valentino, 2006, p. 129). Maltreatment, then, reflects the breakdown of the most basic set of expectations for safety and security.

In 2014, almost 4 million children in the United States were involved in investigations related to allegations of maltreatment. Maltreatment was substantiated in 20% of those cases (likely a significant undercount of children who experienced neglect or abuse) (Jaffee, 2017). Children are most vulnerable in the first five years of life, with higher rates of victimization and death related to maltreatment (Zeanah & Humphreys, 2019; refer to Figure 8.3). As noted in Chapter 3, child neglect is the most common form of maltreatment, and parents or caregivers are the most frequent perpetrators. Many cases of maltreatment involve both abuse and neglect.

Trauma- and Stressor-Related Disorders

The Case of Simone

Simone is eight years old and in third grade. Until recently, she lived with her mother in an apartment in the city. Simone’s parents had a highly conflict-filled relationship

and had been separated for several months following an incident in which police responded to a domestic dispute call and found her mother badly bruised and reporting that her husband had hit her. Frightened and confused by her husband’s erratic behavior, Simone’s mother obtained a restraining order in an effort to keep herself and Simone safe.

Simone, aware of her parents’ conflict, was becoming increasingly anxious and protective of her mother. After a quiet period of several weeks, Simone woke one night to a loud argument and realized that her father was in the house. Eventually, Simone fell back asleep. In the morning, she went looking for her mother after calling to her but receiving no answer. Simone found her mother’s body on the kitchen floor in a pool of blood. Slowly realizing that her mother was dead, Simone, confused and in shock, remained alone with her mother’s body for several hours until a concerned neighbor, who had heard the argument the night before, let herself into the apartment, called the police, and took Simone to stay with her in her nearby apartment.

In the weeks following this traumatic incident, Simone went to live with her maternal grandmother. Her grandmother reports that, prior to the murder of Simone’s mother, Simone was a generally shy, quiet, and guarded girl. Although she tended to be somewhat anxious in new situations, Simone would usually become comfortable after a short time and enjoyed being with friends, both at school

140 Chapter 8 Maltreatment and Trauma- and Stressor-Related Disorders

Acute stress disorder (ASD) involves the display of

multiple symptoms from any combination of categories— intrusion, avoidance, alterations in cognition or mood, and arousal—following exposure to a traumatic event. Acute stress disorder is diagnosed when the duration of symptoms lasts up to one month. Posttraumatic stress disorder (PTSD) involves the experience or witnessing of trauma and the display of symptoms from each diagnostic category. PTSD is diagnosed when symptoms last longer than one month (refer to Table 8.2). Intrusion symptoms include recurrent memories of the trauma, frightening dreams, or flashbacks. Avoidance symptoms include efforts to avoid people, places, or situations that are associated with the trauma. Alterations in cognition or

iStock.com/Nattanon Kanchak

mood include dissociative symptoms (such as difficulties with

Parental conflict and domestic violence may be sources of stress and trauma for children.

memory), negative beliefs about the self or others or the world, or persistent negative mood (such as fear, anxiety, or shame).

Alterations in arousal and reactivity include hypervigilance, and in the neighborhood. However, since the day she found her mother’s body, she has been especially withdrawn, resists going to school, and has been unable to answer questions about finding her mother’s body. Simone now complains of frequent nightmares and insists on sleeping with her grandmother. She appears tired most days, is emotionally reactive, and reports experiencing frequent stomachaches.

Simone has recently begun seeing a therapist who specializes in working with children who experience trauma. Although still unable to describe the events surrounding her mother’s death, Simone has begun to draw pictures that include her mother. These pictures likely represent her initial attempts to work through the complex psychological effects of the trauma. For example, Simone has drawn a series of pictures of her mother encountering threatening creatures such as ferocious dinosaurs and monsters. Proceeding slowly and carefully, Simone’s therapist has begun to help her talk about these drawings in some detail. Although this is a tentative and indirect process at this point, Simone has begun to organize and acknowledge some of the thoughts and feelings related to both the sudden loss of her mother and the traumatic experience of finding her body. Some of Simone’s more challenging symptoms—such as emotional volatility and sleep disturbance—have begun to lessen in intensity and frequency. However, others—such as difficulty separating from her grandmother—have shown little change.

irritability, and extreme responses.

For many years, young children were not diagnosed with ASD or PTSD; their developmental status was thought to be associated with forgetting and “bouncing back” from terrible events. We now know that even infants and toddlers display symptoms after trauma experiences and these may be appropriately conceptualized as ASD and/or PTSD (Lenferink et al., 2020; Scheeringa et al., 2011). In DSM-5-TR, there are no differences in the set of diagnostic criteria for children and adolescents (compared to adults). However, there is a subtype of PTSD for preschool children, with fewer symptoms in the set of diagnostic criteria and some developmentally informed adjustment in the descriptions of symptoms. It is important to recognize that youth frequently display subclinical symptoms, particularly connected to more common stressors such as interpersonal loss.

PTSD is more likely to be diagnosed in children and adolescents if there are repeated, multiple, or prolonged experiences of trauma, more direct or severe exposure, and/ or a perceived lack of protection (e.g., trauma perpetrated by caregiver or trusted adult, or trauma experienced when a child is separated from parents) (Masten & Narayan, 2012). PTSD is a disorder that unfolds over time. In the immediate aftermath of the trauma, all domains of children’s and adolescents’ adjustment are likely to be affected (Masten & Narayan, 2012; Scheeringa et al., 2011).

During the acute stress period, emotions such as terror, helplessness, shame, and sadness are common; intense physiological responses and behaviors are additional

“Bad thing s happen. As much as we might wish ot herwise, close friends and relatives die, painful things happen to our bodies, there are natural disasters and war, and sometimes people do senselessly horrible things to other people” (Bonanno & Mancini, 2008, p. 369). When traumatic events occur, many children and adolescents experience distress and dysfunction. These patterns of distress and dysfunction are included in the trauma- and stressor-related disorders in DSM-5-TR. Reactive attachment disorder and disinhibited social engagement disorder, already presented in Chapter 5, are also in this DSM-5-TR section.

complications. Pynoos et al. (1999, p. 1544) describe a seven-year-old who reported, “My heart was beating so fast I thought it was going to break.” Cognitive functioning is disrupted, with confusion, uncertainty, and misunderstanding. Appraisal and misappraisal of ongoing events and their likely causes and consequences are particularly important developmental constructs to consider. For example, changing expectations of responsibility for personal safety and individual differences in appraisal processes and stress responses may exacerbate children’s reactions to trauma.

Trauma- and Stressor-Related Disorders 141

Table 8.2 Posttraumatic Stress Disorder: Summary of DSM-5-TR Diagnostic Criteria

A. Exposure to actual or threatened death, serious

injury, or sexual violence, including:

1. Directly experiencing the traumatic event

2. Witnessing the traumatic event (especially

primary caregivers)

3. Learning of trauma occurring to close family member or friend (parent or caregiving figure)

4. Experiencing repeated or extreme exposure to aversive details of trauma

B. Intrusion symptoms associated with the trauma,

including:

1. Recurrent, intrusive memories of traumatic event (may be expressed in play reenactment)

2. Recurrent distressing dreams related to the trauma

3. Dissociative reactions, such as flashbacks

(may be manifest in play)

C. Persistent avoidance of stimuli associated with

the trauma as evidence, for example:

1. Avoidance of distressing memories, thoughts, or feelings associated with the trauma

2. Avoidance of external reminders that arouse distressing memories

D. Negative alterations in cognitions and mood

associated with the trauma, including:

1. Inability to remember important aspects of the traumatic event

2. Persistent and exaggerated negative beliefs about oneself, others, or the world

3. Persistent distorted cognitions about the cause or consequence of the trauma

4. Persistent negative emotional state

5. Diminished interest in significant activities

(including constricted play)

6. Feelings of detachment or estrangement from others (social withdrawal)

7. Persistent inability to experience positive emotions

E. Alterations in arousal and reactivity, as indicated

by symptoms such as:

1. Irritable behavior and angry outbursts

(temper tantrums)

2. Reckless or self-destructive behavior

3. Hypervigilance

4. Exaggerated startle response

5. Problems with concentration

6. Sleep disturbance

Note: Specific criteria for children six years and younger are noted in parentheses and italics.

Adjustment to the trauma, or the lack of adjustment, is related to many child factors, including age and neurobiological maturation, temperament and attachment, and anxiety sensitivity. Outcomes are also influenced by external factors related to the nature of the trauma itself, parents and families, other life events, and schools and larger social communities (Galatzer-Levy et al., 2018; Masten & Narayan, 2012). Dimensions and characteristics of trauma include the frequency, intensity, and duration of exposure and the specific type of trauma (e.g., natural disaster versus maltreatment), with longer, more intense trauma and trauma involving human perpetrators associated with more severe and persistent PTSD. Trauma details and reminders are often upsetting. They may come from unexpected sources such as media reports. Children’s adjustments are often embedded in the adjustments of others as they witness the distress and horror of loved ones and their continuing struggles to recover after traumatic events. Indeed, there may be cascades of additional stressful experiences that continue to negatively affect children (Masten & Narayan, 2012; Pynoos et al., 1999; refer to Figure 8.4).

PTSD has been documented in children and adolescents around the world following hurricanes in New Orleans, the Carolinas, and Hawaii; earthquakes in California, Athens, Taiwan, and Turkey; and tsunamis in Sri Lanka (Asarnow et al., 1999; Catani et al., 2010; Giannopoulou et al., 2006; Hamada et al., 2003; Hsu et al., 2002; Kronenberg et al., 2010; Sahin et al., 2007). PTSD has also been described in children and adolescents exposed to war trauma in the Middle East, in Bosnia, and in Africa (Husain et al., 2008; Kithakye et al., 2010; Morgos et al., 2008; Solomon & Lavi, 2005; Thabet et al., 2008); in child refugees from Tibet and Latin America and in children adopted from Romania (Hoksbergen et al., 2003; Kinzie et al., 2006; Servan-Schreiber et al.,

1998); in children and adolescents who experienced the 9/11 attacks on the World Trade Center in New York City (Brown & Goodman, 2005; Mullett-Hume et al., 2008); and in children and adolescents who experienced school shootings (Haravuori et al., 2016; Hughes et al., 2014).

Reviews of child development in the context of mass trauma experiences such as disaster, war, and terrorism provides much-needed perspective on the scope and impact of this awful global phenomena (Masten, 2017; Masten & Narayan, 2012). Across countries and investigations, several findings are clear. First, children’s exposure to danger and disaster varies widely, depending on geography, socioeconomic status (SES), race/ethnicity, and political circumstances. Older children and adolescents experience more adversity than younger children, and there are cumulative effects with multiple stressful and traumatic experiences. Increased risks are associated with separation from parents, proximity to threat, severity of threat, dislocation, sexual violence, and greater exposure to death of family and friends (Allwood et al., 2021; Gatt et al., 2020; Masten, 2017; Masten & Narayan, 2012).

In addition to these types of natural disasters and humancaused horrors, everyday tragedies can be associated with

142 Chapter 8 Maltreatment and Trauma- and Stressor-Related Disorders

Figure 8.4 Developmental psychopathology model of PTSD

Traumatic Stress

Context

Proximal Trauma Reminders

External and Internal cues Constellation Pattern of occurrence Pattern of reactivity Challenge to regulation of aggression Trauma and loss reminders Reminders of prior trauma life

Complexity Objective features Subjective experience Coping strategies Loss

Appraisal and response to danger

Resistance and vulnerability

Proximal Trauma Reminders

Changes in family living Circumstances-resources Change in community resources Change in family constellation

and function

Change in availability and utilization

of social support

Need to assume new responsibilities Medical/surgical care-rehabilitation Altered role performance Issues of accountability Acquisition of new social skills Intercurrent trauma, loss, life

adversity

Ecology of the Child

Family Parental factors

Similar grouping as child

intrinsic factors

Parental physical illness Parent past exposure to trauma

and loss

Reactivity to reminders Loss and secondary stresses Current responsiveness

Current trauma and loss generated psychopathology Developmental cycyle of the family

Family structure and function School milieu and responsiveness Peer milieu and responsiveness Social ecology and responsiveness

Source: Pynoos, Steinberg, & Piacentini (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders.

consequence

expectancies

directed at:

the emergence of PTSD. Serious car accidents, for example, are a common cause (Schafer et al., 2006). Interpersonal trauma (such as maltreatment) is also clearly associated with heightened risk. Maltreatment coupled with exposure to family violence is a common risk combination (Cicchetti,

2016). For children who experience repeated interpersonal

trauma, it is important to keep in mind that events intended to provide safety may themselves be upsetting. For example, one function of the caregiver-child attachment relationship is to provide a safe harbor for the child in the presence of a real or perceived threat. But if the

Acute Distress

Acute posttrauma reactions Registration of personal

Attributions to self and others Failure of developmental

Other categories of reactions Early efforts at adjustment

1. Environment

2. Internal state

Resilience

early attachment relationship itself includes maltreatment, the child may not internalize this implicit, fundamental belief in the caregiver’s ability to keep the child safe. Even more problematic is the possibility that the child may see relationships in general as sources of threat. Consequently, it is not surprising that when children are removed from homes where they have been maltreated and placed in foster care for their safety, they often find that transition very upsetting. In light of their attachment history, the threat they know is, at least in that moment, preferable to the anticipated threat they do not know, regardless of how inaccurate that perception may be.

systems

competencies

Child Intrinsic Factors

Genetic history Temperament Alarm propensity Anxiety sensitivity Organization of stress response

Acquired developmental

Phase-speciﬁc concerns Pre-existing psychopathology Prior experience

Threats to attachment Trauma and loss

Coping with prior danger Modes of attachment Coping repertoire

Box 8.1 Clinical Perspectives

Developmental Trauma Disorder

Developmental Course 143

While the DSM–5–TR serves as a consensus diagnostic guide across a broad range of disorders, it necessarily has limitations, especially with regard to the role of early experience and development in underst anding psychopat hology (Conradt et al., 2021; McLaughlin et al., 2021). The Research Domain Criteria (RDoC), with its focus on underlying dimensions relevant to the development of psychopathology, provides one alternative for considering the ways in which early maltreatment may affect neurodevelopment and genetic expression (Kaufman et al., 2015). In addition, a number of researchers and clinicians working with children exposed to ongoing trauma recognize that diagnostic constructs not bounded by the DSM-5-TR are essential to understanding the unique characteristics and effects of complex trauma occurring in early childhood. Developmental Trauma Disorder (DTD) provides one way to more accurately describe, treat, and study the specific symptoms of this particular pattern of trauma (DePierro et al., 2019; Ford et al., 2018; van Der Kolk, 2019). DTD also allows for a more developmentally sensitive way to consider the effects of early maltreatment from an attachment theory perspective (Spinazzola, 2021).

The diagnosis of PTSD describes the pattern of pathological response that sometimes develops following acute trauma. Although the diagnosis of PTSD was developed primarily with adults in mind, the DSM-5-TR does include PTSD in preschool children as a subtype of the PTSD diagnosis. Typically, the term refers to a constellation of emotional, cognitive, physiological, and behavioral symptoms experienced following a traumatic episode. In contrast, the type of trauma to which children are often exposed is repetitive and chronic and occurs in the context of the very relationships that should provide a protective buffer to threats and stress (Spinazzola et al., 2021). Examples of this type of complex stress include physical and emotional abuse, witnessing domestic violence, and ongoing exposure to community violence. Although children who struggle in the face of such stressors are given a variety of diagnoses to account for their emotional and behavioral problems, proponents of the developmental trauma disorder diagnosis believe that these generally fail to adequately describe the core etiology and distinctive cluster of symptoms that these children experience (Spinazzola et al., 2021).

There is increasing evidence that experiencing this kind of trauma during early developmental sensitive periods leads not only to immediate clinical symptoms but also to more pervasive and long-term neurobiological and psychological consequences resulting from specific structural and functional changes in brain development (Copeland et al., 2018; McLaughlin et al.,

2021). Long-term difficulties associated with early trauma include problems with regulation of emotions and behavioral impulses as well as problems with memory and attention, relationships, and psychiatric disorders in adulthood.

The National Child Traumatic Stress Network (NCTSN) is a group of over 70 child mental health centers dedicated to the study and treatment of children experiencing complex trauma. This consortium is developing an extensive database based on the over 50,000 children per year who are seen at these centers, where they are studied and treated. The resulting research and clinical findings are generating a range of compelling findings that support the scientific basis for the Developmental Trauma Disorder diagnosis (NCTSN, 2011).

Work on rening the diagnostic criteria for developmental trauma disorder continues. e following criteria guide both clinical and research eorts (Ford et al., 2018; Stolbach et al.,

2013):

● Exposure: Exposure to one or more forms of developmentally adverse

interpersonal traumas, such as abandonment, betrayal, physical

or sexual abuse, and emotional abuse. May also experience

subjective feelings in relation to this trauma, such as rage,

betrayal, fear, resignation, defeat, and shame.

● Dysregulation: Dysregulated development in response to

trauma cues, including disturbances in emotions, health,

behavior, cognition, relationships, and self-attributions.

Behavioral manifestations could involve self-injury; cognitive

manifestations might appear as confusion or dissociation.

● Negative attributions and expectations: Negative beliefs in line

with experience of interpersonal trauma. May stop expecting

protection from others and believe that future victimization

is inevitable.

● Functional impairments: Impairment in any or all arenas of

life, including school, friendship, family relations, and the

law.

Many studies of children and adolescents who experience

Developmental Course

multiple and complex interpersonal trauma (e.g., recurrent or chronic physical or sexual abuse) suggest that a new diagnostic category be included in upcoming editions of the DSM: developmental trauma disorder, a disorder involving both exposure and adaptation to chronic trauma, with exposure often occurring in the context of a child’s caregiving environment (Ford et al., 2018; Spinazzola et al., 2021; refer to Box 8.1).

For children and adolescents who experience maltreatment and other types of traumatic events, there is a diversity of pathways across time. As we describe varied pathways, it is essential to recognize the many ways in which children and adolescents are embedded in, and adapt to, stressful environments as well as the ways in which those environments support or constrain a range of positive and negative outcomes.

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