Childhood Stress and Trauma

Introduction

Many children presenting with mental health challenges have or are subject to childhood stress and traumatic (CST) experiences. CST increases the risk of developing a range of issues across the life span that affect functioning. The most common reasons that children and adolescents are referred to treatment are for disruptive behaviors and attention deficit hyperactivity disorder (ADHD) ; in both cases it is highly likely that the problematic behaviors have been caused or exacerbated by CST.

Over the last 20 years and, in part, because of the catastrophe of 9/11, the importance of “trauma” has been recognized as a key factor in the development of psychopathology. More recently, the role of early life stress in the etiology of both mental and physical health issues, as well as the associated biologic mechanisms and related brain changes, has been elucidated. The term “trauma” has now become part of our daily language. Systems and organizations are implementing “trauma-informed” models and, in popular parlance, “traumatizing” and “upsetting” have become interchangeable. Although the increased recognition of trauma and stress and its ubiquity is undoubtedly a positive development, there are inherent dilemmas for the field in integrating new knowledge and concepts into practice.

This chapter offers providers across child-serving disciplines with a comprehensive framework that, we think, supports more effective assessment and treatment of childhood psychiatric disorders. Its goals are to (1) elaborate and clarify the meaning of CST, (2) establish a common language, (3) enhance providers’ understanding of the association between CST and psychopathology, and (4) provide current best practices on assessment and treatment of CST.

Clarifications

As the correlation between various negative childhood experiences and changes in neurophysiology, brain structure and related psychiatric issues are clarified; the meaning of “ Trauma ” requires a corresponding clarification. Our growing understanding has led to disparate and confusing language. Perhaps the first confusion is the shorthand use of a “ Trauma ” to signify an upsetting event rather than the symptomatic reaction to an event. In an attempt to alleviate some of this confusion, we will refer to the traumatic event as trauma and the symptomatic response to the event as TRAUMA. Further inadvertent confusion has been caused by terminology used to distinguish CST from a single-event TRAUMA. Terms such as adverse childhood experiences (ACEs), toxic stress, and early life stress are used both interchangeably with trauma and as an attempt to be more precise in discussing CST. Unfortunately, the manner in which these terms are used further confuses our communications. Youth exposed to CST may not only develop traumatic stress symptoms and posttraumatic stress disorder (PTSD) but also present with a range of emotional and behavioral issues; diagnoses such as complex PTSD, complex trauma, and developmental trauma disorder were proposed in an attempt to capture individuals’ heterogeneous symptom presentations. The complexity of CST-induced symptomatology makes it imperative that the field clarifies its terminology to avoid continued confusion and miscommunication.

Pathophysiology: The Injury Paradigm

TRAUMA is an ancient Greek word for wound or injury; injuries may be caused by a single event or by repetitive insults to one’s body. Injuries are on a spectrum from minor with minimal or no impact and of brief duration (even minutes) to severe and causing profound functional problems and lifelong duration. Conceiving of TRAUMA as injury allows us to understand psychologic TRAUMA as caused by a range of negative experiences with a range of outcomes. With this in mind, psychologic TRAUMA may be best defined as an experience or a series of experiences that cause changes (injury) to neurophysiology and potentially to brain structure, resulting in dysregulation of psychologic, cognitive, and behavioral functioning.

An injury model incorporates the notion that most injuries do not cause lasting damage and physical dysfunction and that most people return to baseline functioning while recognizing that they suffered some form of injury. Similarly, in most cases of psychologic TRAUMA, individuals, after brief symptomatology, return to baseline functioning after a stressful event. Yet despite transient symptoms, we disregard that any injury, however minor, has occurred. Conceptualizing TRAUMA as an injury places natural recovery into a dimensional and consistent framework.

In medicine, an injury or illness demonstrates a change to a specific structure(s) in the human body that may be considered damaging or benign. These changes may occur in an individual’s molecular structure (e.g., epigenetic methylation, DNA mutations), musculoskeletal system (e.g., fractures, changes in bone density, muscle tone), integumentary system (e.g., melanoma, hives), or central nervous system (e.g., head trauma, stroke, cortical thinning).

By viewing CST within an injury paradigm, the various terms to describe experiences that cause symptoms and impairment may all be considered TRAUMA. This conceptualization ameliorates the current confusion and unifies the varied methodologies used to describe the multitude of stressful experiences and resulting symptoms and impairment. Neuroscience research has now confirmed through molecular investigation and brain imaging that the CST leading to psychopathology or a single-incident event leading to PTSD is caused by injury to neurophysiology such as hypothalamic-pituitary-adrenal axis dysregulation, genes via epigenetic mechanisms (e.g., methylation/demethylation, telomeric shortening), and brain structure through multiple pathways.

Tables 8.1 and 8.2 explicate our trauma paradigm along a spectrum by comparing physical injuries to psychologic injuries and offer examples to illustrate the similarities between these injuries, which support the injury model for psychologic TRAUMA. The comparison between a single-incident physical injury and a psychologic injury such as a motor vehicle crash (MVC) should be fairly evident. After an MVC, one can have a range of physical symptomatic responses from a minor (abrasion) requiring no intervention to a severe (internal bleeding) injury requiring intensive and multiple interventions. Similarly the time course can be brief to lifelong in some instances.

Chronic physical injuries are more complex. Perhaps the best example of a chronic injury is a stress fracture where the individual does an activity that puts continuous physical strain on bone, resulting in a fracture. However, CST rarely involves one type of negative experience, but typically there are multiple types that covary with experiences as described in Table 8.2 . The potentially injurious physical experiences mentioned in the table are more analogous to CST and frequently covary and may cause damage at the genetic, physiologic, and, ultimately, structural level. Again, a minor injury in which there may be no obvious sequelae may heal without intervention for both physical and psychologic issues but may ultimately result in a range of injury severity, intervention need, and time course.

Stress-Related Diagnoses