Lecture 23: Childhood Trauma an Adverse Experience, A pathway to Illness

Question 1

What does Berkowitz think about childhood maltreatment?

Answer 1

Childhood maltreatment and trauma is arguably the primary public health issue in the nation

Question 2

What are the characteristics of posttraumatic symptoms?

Answer 2

Responses are due to an injury caused by experience
Results in dysregulation of neurophysiological, psychological and cognitive functioning
Trauma = dysregulated response to a potentially injurious event…an event is NOT a trauma…usually a series of events
-response to experience is age dependent

Question 3

What is the three legged stool for predicting developmental and health trajectories?

Answer 3

1. Genetic prenatal and neurodevelopmental factors
2. Attachment and relational patterns
3. social economic environment
   Kicking out any of these three legs = stool falls down

Question 4

What is an adverse experience?

Answer 4

Adverse experience has potential to cause brain injury

-accumulation of adverse experiences are likely to cause injury, often due to caregivers in childhood

Question 5

What is PTSD?

Answer 5

One of many posttraumatic disorders
Complex and debilitating
PTSD can be induced by substance dependence, depression, separation anxiety
Rarely the result of a single incident

Question 6

What is the epidemiology of childhood trauma?

Answer 6

15.5 million children are exposed to domestic violence each year
7 million exposed to severe and chronic intrafamilial violence
45.4 million injured youth treated in ED and 20% will develop PTSD

Question 7

What is the stress circuit?

Answer 7

HPA axis or Hypothalamus-pituitary-adrenal
Cortisol is stress mediator
When cells in hippocampus detect cortisol, they send signals to hypothalamus to shut down stress circuit

Question 8

What is the significance of the rat pup study?

Answer 8

High-nurturing mothers raise high-nurturing offspring
Low-nurturing mothers raise low-nurturing offspring
-whether a pup grows up to be anxious or relaxed depends on the mother that raises it…NOT the mother that gives birth to it

Question 9

What are potential mechanisms of poor development?

Answer 9

Lower hippocampal GR methylation levels in well-nursed pups
Higher hippocampal GR methylation levels in poorly-nursed pups
-more methyl groups = less rate of transcription = fewer glucocorticoid receptors in hippocampus
-fewer GR receptors means cortisol feedback loop was impaired
-more release of cortisol

Question 10

What other genes in the HPA axis are linked to stress?

Answer 10

CRH (corticotropin releasing hormone)
AVP (vasopressin)
During stress, increase in CRH and AVP
Linked to cognitive and affective disorders

Question 11

What is the significance of methylation?

Answer 11

More methylation leads to MORE stress hormones in body
Methylation appears in hippocampal GC receptors
Shows that methylation is reversible…you can reverse effects of low-nurtured rat by injecting drug that REMOVES methyl groups
Less methylation = rat takes on more relaxed personality once GR gene turned on

Question 12

What are some genes that lead to vulnerability to stress?

Answer 12

5-HTTLRP short version
MAOA gene
-maltreated children with gene that codes for low amount of MAOA are 8x more likely to be antisocial

Question 13

What is the link between neglect/abuse and telomere length?

Answer 13

Neglect and abuse led to telomeric shrinkage

Orphans had the telomere length as 65 yo

Question 14

What are common symptoms of traumatic response in children?

Answer 14

Memory problems
Poor concentration
Anxiety
Impulsiveness
Withdrawal
Irritability
Procrastination
Fighting
Sleeping +/-
Chest pain and Increased HR

Question 15

What are potential adverse childhood experiences?

Answer 15

1. Child physical abuse
2. Child sexual abuse
3. Child emotional abuse
4. Physical neglect
5. Emotional Neglect
6. Mentally ill, depressed or suicidal person in the home
7. Drug addicted or alcoholic family member
8. witnessing domestic violence against the moher
9. loss of a parent to death or abandonment, including abandonment by divorce
10. incarceration of any family member

Question 16

What does ACE stand for?

Answer 16

Adverse childhood experiences
The higher the ACE score, the greater the incidence of co-occurring conditions from list of symptoms
Among adults exposed to physical abuse, 84% reported at least 2 additional ACEs
ACEs lead to depression, alcoholism, suicide, promiscuity (over 50 sexual partners!!)

Question 17

How do you prevent early death due to maltreatment and adverse childhood experiences?

Answer 17

Prevent maltreatment from happening in the first place!

Question 18

How is brain architecture influenced prenatally?

Answer 18

Brain is constructed by processes that begin before birth and continues into adulthood
For instance, stressed out mothers lead to more stressed out kids? Because ovum gets affected?
Grandmother is stressed and fucks with ovum (who is your mom)

Question 19

What is the relationship between age of traumatic onset and impact on brain?

Answer 19

Children have more effect on whole brain when encountering adverse event
Adults have effects SPECIFICALLY on hippocampus and amygdala

Question 20

How do ACE or stress change brain structure in children AND adults?

Answer 20

1. decrease in corpus callosum volume
2. increased hemispheric lateralization
3. decreased rate of myelination (DTI)
4. decrease medial prefrontal cortex volume
5. decrease total brain volume
6. decreased dendritic BRANCHING

Question 21

What are the key variables in brain outcomes?

Answer 21

1. Type of abuse
   -different types of maltreatment = different effect on brain
2. Gender
   Girls more susceptible to sexual abuse, boys more susceptible to neglect
3. Age of maltreatment
   -depending on stage of brain development, abuse will target what is developing

Question 22

What is the corpus callosum vulnerable to?

Answer 22

Neglect in infancy
Sexual abuse in elementary school years
Leads to decreased proficiency in math and language development

Question 23

What is the right temporal gyrus vulnerable to?

Answer 23

Emotional abuse, especially from 7-9

Leads to decreased ability for spoken language

Question 24

What is the hippocampus vulnerable to?

Answer 24

All forms of maltreatment in first 2-3 years of life

Question 25

What do results from the ACE study suggest?

Answer 25

Adverse childhood experiences are the primary cause of health risk behaviors, morbidity, disability, mortality and healthcare costs

Question 26

What is the two-tiered approach to health promotion and disease prevention in the early years?

Answer 26

1. Basic medical services and good quality early care/education to facilitate early detection of problems in all children
2. Targeted interventions for young children experiencing trauma and ACE reduce the dysregulation that leads to adverse outcome

Question 27

What can be done for adults for ACE?

Answer 27

Routinely seek history of adverse childhood experiences from all patients

• acknowledge reality by asking “how has this affected you later in life?”
• arrange a return appointment to discuss possibilities for helping them

Question 28

What are the programs for low income families for ACE prevention?

Answer 28

1. Nursing home visiting
2. The Incredible Years
   (training program for parents to deal with children’s aggression/behavior)
3. Multidimensional Foster Care
4. Parent-Child Interaction Therapy (PCIT)
   -used to help conduct disordered young children
5. Parent management training
6. Early Post Exposure Interventions (berkowitz)
7. Eye movement desensitization and reprocessing (EMDR)
   -exposure therapy that helps patient get past disturbing stored memories
8. Trauma focused CBT