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How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

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How to Spot Severe Depression vs Feeling Depressed

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Give the child time and space to heal. Provide a place at school or home where the child can turn to with calming tools and resources to aid in releasing the stresss.

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Edutopia is a free source of information, inspiration, and practical strategies for learning and teaching in preK-12 education. We are published by the George Lucas Educational Foundation, a nonprofit, nonpartisan organization.

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Teach the child to recognize what triggers them and teach them to use rhythm to regulate their nervous system.

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For some students, school is not just a place of learning and growth but also a refuge from abuse.

Data suggest that, on average, every classroom has at least one student affected by trauma. According to the National Child Traumatic Stress Network, close to 40 percent of students in the U.S. have been exposed to some form of traumatic stressor in their lives, with sexual assault, physical assault, and witnessing domestic violence being the three most prevalent.

These types of stressors, known as complex trauma, have the added wound of being perpetrated by a person with whom the child or teen has an ongoing relationship. The very people who are supposed to support and protect are those who wound and abuse. This leads to continuing states of grief, loss, abandonment, and neglect as well as persistent anxiety, fear, and depression-all at a time when the brain is in crucial stages of development.

For some young people, school is the only place in their lives where they know they are safe and can form trusted, enduring relationships. It is, therefore, a cruel irony that many students who are affected by trauma also have trouble engaging at school. They may attend school with the best of intentions, hoping to form friendships, feel connected to their teachers, and succeed at the day's tasks. Yet they can find themselves defiant, demanding, and disengaged -unable to learn and confused about why they can't relate and bond with others.

What do the latest scientific findings from the fields of traumatology, neuroscience, and positive education tell us about how to best help students who are affected by trauma? Below, we highlight some of the new practices that teachers can use to not only help students heal but also help them grow.

Healing and repair

The new field of "trauma-informed learning" has made great strides in helping teachers to better understand the developmental, emotional, and social challenges that students who are impacted by trauma face at school. While teachers are not mental health professionals, trauma-informed learning trains teachers in therapeutic approaches that can be woven into the classroom to redress the delayed development, underdeveloped neural pathways, and over-regulated nervous systems that students experience as a result of trauma.

For example, teachers can directly teach students about their body's own stress activation response and help them find techniques to regulate their heart rate, body temperature, and blood pressure. Teaching through rhythm-for example, learning about math to the beat of a drum, reading an English text while riding an exercise bike, or having a disciplinary conversation while walking around the school yard together-is now an accepted classroom technique that assists trauma-affected students to regulate their nervous system through rhythmic movement.

Feeling calmer in class has the knock-on effects of helping students get along better with others, think more clearly, and stay on task. These approaches nurture students' stamina and persistence, allowing them to better deal with frustration, which benefits their social behavior in class and their capacity to take on greater academic challenges. This is indeed a hopeful approach.

Growth and strength

Trauma-informed education has helped teachers to evolve from the question of "What is wrong with this student?" to "What has this student been through?" In the field of positive psychology, we add a further question: "What does this student need to reach their potential?" This allows teachers to extend the focus from what is wrong, to what is needed, to what is possible. Building the mental health and academic capacities of students affected by trauma requires more than repairing psychological disorder and developmental delays-it requires the dual mantra of healing and growth. Of repairing and rising up.

Research by Corey Keyes shows us that healing and growth can be simultaneous processes. We don't always need to wait until something is fixed before we work on building our strengths. Indeed, growing the psychological strengths of a student affected by trauma can be a core part of healing their psychological struggles.

Working with students who are affected by trauma requires schools to assist in providing individual counseling services, safety and crisis planning, behavior plans, self-care plans to address triggers, and case management. Most of these services are not provided by the classroom teacher, yet the teacher is the person who spends the most time with trauma-affected students. A key way in which positive psychology adds to the trauma-informed strategies above is by empowering teachers in the classroom to help their students on a daily basis.

Here are five teaching techniques that you can use in your class, knowing that these approaches also assist your mainstream students.

1. Positive relationships. Trauma-affected students have more relationship challenges to navigate than most. These students can be dealing with harmful relationships at home and then come to school to manage relationships not only with their teachers but also with social workers, police officers, and clinicians-all while living out their daily lives.

It is critical that we help these students feel safe and trusting where possible, so they learn to develop social intelligence and seek out positive bonds with others. Teachers may be the only people who help these students learn what a healthy, supportive relationship feels like. Building relational trust involves simple teaching practices such as smiling, sharing parts of your life with your students, getting to know your students as individuals, and using yourself as a role model of a reliable and regulated adult.

2. Positive physical space. The physical layout and look of your classroom can be used to build positive emotions. Putting up positive visuals and quotes can inspire creative thinking and teamwork in your students. Increased natural light or soft lighting can enhance an open, warm, and relaxing environment.

Consider how the furniture and seating is arranged in your class. Is it helping students to feel safe and connected? You could also bring plants into the room or create a mindfulness corner, a dedicated space that students can visit when they need to regulate their stress response. The corner can include a bean bag, mindful coloring books, squeeze toys, noise-cancelling headphones, and more.

3. Positive priming. Following the research of Barbara Frederickson, you can use simple priming techniques to foster positive emotions such as contentment, pride, awe, and wonder in class.

Brain breaks are one helpful technique. The teachers who work with us have found that brain breaks are most effective when students reflect on the type of energy they need at that moment for learning: Escalating brain breaks build positive energy and emotions such as joy, happiness, and wonder (e.g., clapping games, thumb wars, laughter yoga, racing around the desk), while de-escalating brain breaks build calm emotions such as contentment and serenity, which help a student to feel safe and focused (e.g., silently tracing the movements of a partner, triangle breathing, playing music or repeating mantras, and body movements such as shoulder shrugging or pumping your toes inside your shoes).

You can also use positive primers to boost positive emotion when students first enter the classroom (such as by greeting them with the healthy touch of a handshake or a high five), during transitions (by turning transition routines into a silent game such as "follow the leader"), or during independent work breaks (by having students deliberately savor their accomplishment and share with a peer).

According to Fredrickson's theory, helping your students build up their bank account of positive emotions over time changes their brain to help them learn more effectively, form better relationships, and become more resilient. Next time you are planning a lesson, think about how you can use positive primers throughout the learning experience.

4. Using character strengths. Teaching strengths in schools has been shown to increase achievement and well-being. All students, especially trauma-affected students, need opportunities to identify, recognize, practice, and use their character strengths, which include qualities like kindness, humor, creativity, and bravery.

Ways to help students learn about their own strengths and the strengths of others include strengths surveys (if their literacy skills allow), strengths cards, and strengths spotting exercises-like identifying strengths in their heroes or playing a secret agent game where they are invited to "spy" on a fellow student to identify the strengths of that student. To teach about particular strengths, you could focus on stories in English and Humanities curriculums where characters or historical figures displayed those strengths. Strengths can also be developed through performing arts, sports, and other co-curricula.

5. Building resilience. Sadly, you cannot always impact the life of a student outside of school, but you can teach resilience strategies that help a student affected by trauma to gain a better understanding of their situation and to counteract the negative messages of shame they often internalize.

Students can practice resilience skills through role plays that help them to act out skills such as setting boundaries and verbalizing their feelings, all while in the safety of a classroom. Literature, poetry, and song lyrics can help students identify examples of resilient thinking-for example, Ariana Grande's song "No Tears Left to Cry" following the London terrorist attack at her concert. Analyzing the ways in which media figures, sports heroes, and other high-profile people explain their successes and failures showcases the difference between optimism and pessimism.

Teachers can also use moments in the learning process when students feel frustration or self-doubt to coach them on how to dispute their pessimism and automatic negative thinking ( "I can't do this"; "I'm dumb") to make room for optimism and constructive thinking ( "Maybe I'm tired and I need a break"; "I solved the problem last week and I can do it again"; "It takes me a little longer than others, but I've come a long way"). Learning resilience skills can provide an internal psychological buffer for students when they are outside of school, as well as providing empowering experiences at school.

Every teacher wants to positively impact the lives of their students. For students who are affected by trauma, the teacher plays an even more vital role. The introduction of positive psychology into the classroom has huge potential to change the trajectories of the lives of many of these young people by moving beyond repair to also inspire growth.

Greater Good wants to know: Do you think this article will influence your opinions or behavior?

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Five Ways to Support Students Affected by Trauma

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Teachers can help students recognize their strengths and build resilience.

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Helping Children Cope After a Traumatic Event

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Your comfort and support can help children cope with trauma. Advice from the Child Mind Institute on how to what to do and what to look out for.

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The death of a parent in childhood is a traumatic experience. An estimated 3.5% of children under age 18 (approximately 2.5 million) in the United States have experienced the death of their parent. So how does the death of a parent affect a child?

What Is The Worst Age To Lose A Parent

Grief and pain are not a competition. The lifelong impacts of losing a parent in childhood depend on the parent-child relationship before and the support the child receives after the death. There is really no such thing as the worst age to lose a parent.

Most people assume that losing a parent as a child at a younger age is the hardest thing because losing an attachment figure is a painful thing. However, if the child has a strong support system to help them process grief, they can still develop a secure attachment and thrive.

On the other hand, older or even adult children may suffer a great deal because it is a significant loss in that person's life or they don't have close friends to pull them through this period. So there is really no need to compare.

How Does The Death Of A Parent Affect A Child

An early loss of parents usually increases the probability of inadequate child care and worsens the family's economic status.

In some families, that means increased pressures for the grieving child to take on the responsibilities of the dead parent and to isolate from friends. In others, The death of their parents will result in the child's poor psychosocial well-being, changes in behavior, increase in stress and sleep disturbances.

The psychological effects of losing a mother or a father during formative years are significant. Children who experience parental loss are at a higher risk for many negative outcomes, including mental issues (e.g., depression, anxiety, somatic complaints, post-traumatic stress symptoms), shorter schooling, less academic success, lower self-esteem, and more sexual risk behaviors.

Given the negative long-term effects associated with parental death, it is imperative that society helps children grieve in a healthy way. However, cultural beliefs and persistent misunderstandings are often standing in the way of appropriate support for children and doing them a disservice.

How Does The Surviving Parent's Reaction Affect A Child

Children look to their parents to love them unconditionally while protecting them from the uncomfortable realities of life. When a parent dies, life for the child often becomes infinitely scarier and uncertain, leaving the child to wonder what's next.

This understandably places a large burden on the remaining parent, and other family members who want to help the child grieve, while they are also managing their own pain following the death of a loved one.

While some cultures approach bereavement in a positive way, others encourage the adults around grieving children to place their emotions on hold. These cultures often rationalize the practice by citing that children look towards their grownups to remain strong in times of uncertainty.

These adults then have suppressed emotions or repressed emotions.

Suppressing emotions is making a conscious and deliberate attempt to hide emotions from others. A parent or guardian may feel sadness, but instead of expressing it, they decide to hide it while in the presence of their child.

Repressed emotions are often unconscious. Having repressed emotions is a body's attempt to do away with bad thoughts. Repressed individuals may not be consciously aware of their emotions at the moment. These pent-up emotions may eventually spill out over time.

On one hand, research has found that it hinders the healing process for the parent and the child. But on the other hand, a study finds that repressed emotions serve an adaptive role in the grieving process.

Whether a parent's emotion suppression or repression is a good coping mechanism is still in debate. A parent's suppressing or repressing may or may not be healthy for their own mental well-being. But what's more important is how their beliefs in emotion negation affect how they help their child deal with the loss.

When the surviving parents believe children are not capable of understanding death or successfully dealing with the emotions and fears it brings, they tend to avoid the topic at home and act "normal" around the child.

But the truth is, children's ability to positively cope with death can be increased by the actions taken by influential adults in the days, weeks, and months following the loss.

Rather than sweeping the issue under the rug and pretending everything is fine, caretakers of the grieving children can use the following strategies to help them cope successfully.
Also See: What to Say to a Child Who Lost a Parent

How to Help a Grieving Child

The Family Bereavement Program (FBP) developed by Arizona State University (ASU) is an evidence-based intervention that is directed at parentally bereaved families. It aims to promote the resilience of young children and surviving parents.

Here are the strategies.

1. Normalize the Grieving Process

How the death of a parent in childhood affects a child depends on how the influential adults around them react to their grief. A child who has lost a parent needs to know that it is acceptable to show emotions and talk about the person who died. Normalizing the grieving process is important. It allows kids to reduce anxieties about the future.

Children can feel a variety of emotions following a parent's death, including anger and guilt. They need to know that death is never the child's fault. It is also normal that the child may think they see or dream about their deceased parent. They don't have to forget about their parents who died.

2. Use Positive Parenting

Quite often, children may communicate their difficulty adjusting to the changes following death by misbehaving. By using positive parenting, parents create a positive parent-child relationship and an environment that allows for open communication.

Parents who practice positive parenting are warm and supportive. They use effective positive discipline in which the parent is kind and firm. Effective positive parenting can help children's adjustment after their parent's death. It reduces the likelihood of child mental illness like major depressive disorder and promotes better adaptation in bereaved children.

3. Reduce Child Exposure to Negative Life Events

Negative life events following parental loss are linked to an increase in child mental health problems. For example, holidays can be difficult for bereaved families in the first two years, especially the children. Parents can use good listening skills to provide children with a safe environment to talk about their feelings about the holiday.

One area that is often of concern to bereaved children is their parent's beginning to date and develop new long-term love interests. Parents can introduce a new partner or family member slowly. Talk with their children openly and in an age-appropriate manner about the relationship.

4. Improve Child Coping Skills

Active coping strategies are associated with more positive adaptation following the death of one or both parents. These strategies include:

reframe negative self-statements into more positive self talk and include optimism

give up the belief that one can control uncontrollable events and identify events one can control

focus on problem solving

seeking out emotional support to help manage stressful situations.

To help bereaved children gain a sense of efficacy, parents can ask their children to set goals in practicing these skills. They can provide specific positive feedback when the kids make use of these strategies. Parents should also express an ongoing belief in their children's ability to deal with their problems.

Bereaved children can feel more helpless and believe that they have less control over events happening to them than their non-bereaved peers.

Helping children manage this anxiety after losing a parent at a young age can be done by focusing on teaching children where their responsibilities lie. Promote "an adaptive sense of control by focusing on distinguishing the problems that are the child's 'job to fix' versus the problems that are adult's responsibility".

For example, if the remaining parent finds it difficult for themselves to cope with the loss, they should first be honest with the child about their struggles. The parent can then let them know they do not expect the child to help them and will instead go to a trained professional.

Children benefit from hearing that the parent will be able to manage his/her distress better over time and that their job involves focusing on tasks such as completing homework assignments and spending time with friends.

Final Thoughts on How The Death of a Parent Affects a Child

When working with FBP practices, be mindful that some strategies will work right away and some won't. Allow for grace. Understand that this journey must be taken one day at a time. The pain associated with the loss of a parent will likely never go away completely but the surviving parent and their children will find happiness again.

References

Social Security A. Washington, DC: Office of the Chief Actuary of the Social Security Administration; 2000:1.

About Pamela Li

Pamela Li is an author, Founder, and Editor-in-Chief of Parenting For Brain. Her educational background is in Electrical Engineering (MS, Stanford University) and Business Management (MBA, Harvard University). Learn more

View all posts by Pamela Li | Website

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How Does The Death Of A Parent Affect A Child

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The death of a parent in childhood is a traumatic experience. An estimated 3.5% of children under age 18 (approximately 2.5 million) in the United States have experienced the death of their parent. So how does the death of a parent affect a child? Grief and pain are not a competition.

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We easily understand how beating a child may damage the developing brain, but what about the all-too-common psychological abuse of children? Because the abuse was not physical, these children may be told, as adults, that they should just "get over it." But as developmental neuropsychiatrist Martin H. Teicher reveals, scientists are discovering some startling connections between abuse of all kinds and both permanent debilitating changes in the brain and psychiatric problems ranging from panic attacks to post-traumatic stress disorder. In these surprising physical consequences of psychological trauma, Teicher sees not only a wake-up call for our society but hope for new treatments.

Published: October 1, 2000

We know that the abuse or neglect of children is tragically common in America today. Nor are most of us surprised when studies point to a strong link between the physical, sexual, or psychological maltreatment of children and the development of psychiatric problems. To explain how such problems come about, many mental health professionals resort to personality theories or metaphors. Perhaps the child's adaptive or protective mechanisms have become counterproductive or self-defeating in the adult. Perhaps childhood abuse has arrested psychosocial development, leaving a "wounded child" within the adult. Although such explanations may offer genuine insight and may support patients in therapy, too often they instead minimize the impact of early abuse. They make it easy to reproach the victims, to say, in so many words, "Get over it."

Research on the effects of early maltreatment, including the work of my colleagues and myself at McLean Hospital in Belmont, Massachusetts, appears to tell a different story: that early maltreatment, even exclusively psychological abuse, has enduring negative effects on brain development. We see speciﬁc kinds of brain abnormalities in psychiatric patients who were abused as children. We are also beginning to understand how these abnormalities may account directly for the personality traits and other symptoms that patients manifest.

With The Etiology of Hysteria (1896), Sigmund Freud ﬁrst introduced the topic of childhood sexual abuse in a scientiﬁc context. He was convinced that, as children, many of his patients had been sexually abused by their parents, older siblings, or other relatives. Furthermore, he claimed, based on his new analytical method, that their hysterical and neurotic symptoms could be traced directly to repressed memories of that early abuse. This hypothesis marked the birth of psychoanalysis. Freud later retreated from this theory, though, refusing to believe that childhood abuse could be as prevalent as he had initially claimed. He evolved the more complex theory that "memories" of early sexual abuse were merely repressed childhood fantasies. This theory has so swayed psychiatry for almost a century that it has largely blinded us to the frequency of real abuse in psychiatric patients' childhoods and to the role of abuse in psychopathology.

Physical abuse of children by their parents remained a hidden problem until 1962, when C. Henry Kempe published The Battered Child Syndrome, and an avalanche of publicity led to the enactment of child abuse reporting laws. During the 1970s, case reports of sexual abuse and incest appeared with increasing frequency in medical literature. By the 1980s, scientiﬁcally valid studies of the incidence and consequences of childhood sexual abuse were being published.

Today, episodes of serious neglect and physical abuse are featured regularly in the news, constantly reminding us of the horrifying cruelty adults inﬂict on children. In separate surveys in San Francisco, Los Angeles, and Canada, and of college students in New England and Texas, the percentage of women reporting sexual abuse during childhood ranged from 19 to 45. The medical literature is replete with research on this problem; clinicians, super-sensitized to it, increasingly suggest that childhood abuse lies behind a patient's problem, even in the absence of direct evidence. Despite occasional hysteria and misuse of the diagnosis, however, the problem is all too real.

It is our hope that as we identify the speciﬁc physiological pathways by which abusive experiences alter brain development, our society will take more seriously the challenge of uprooting the violence against the children in our midst.

A Harvest of Psychiatric Disorders

Physical, sexual, and psychological trauma in childhood may lead to psychiatric difﬁculties that show up in childhood, adolescence, or adulthood. The victim's anger, shame, and despair can be directed inward to spawn symptoms such as depression, anxiety, suicidal ideation, and post-traumatic stress, or directed outward as aggression, impulsiveness, delinquency, hyperactivity, and substance abuse. ¹

Childhood trauma may fuel a range of persistent psychiatric disorders. One is somatoform disorder (also known as psychosomatic disorder), in which patients experience physical complaints with no discernible medical cause. Another is panic disorder with agoraphobia, in which patients experience the sudden, acute onset of terror and may narrow their range of activities to avoid being outside, especially in public, in case they have an attack.

More complex, difﬁcult-to-treat disorders strongly associated with childhood abuse are borderline personality disorder ² and dissociative identity disorder. ³ Someone with borderline personality disorder characteristically sees others in black-and-white terms, ﬁrst putting them on a pedestal, then vilifying them after some perceived slight or betrayal. Such people have a history of intense but unstable relationships, feel empty or unsure of their identity, often try to escape through substance abuse, and experience self-destructive impulses and suicidal thoughts. They are plagued by anger, most often directed at themselves.

In dissociative identity disorder, formerly called multiple personality disorder (the phenomenon behind Robert Louis Stevenson's "Dr. Jekyll and Mr. Hyde"), at least two seemingly separate people occupy the same body at different times, each with no knowledge of the other. This can be seen as a more severe form of borderline personality disorder. In borderline personality disorder, there is one dramatically changeable personality with an intact memory, as opposed to several distinct personalities, each with an incomplete memory. People with dissociative identity disorder have two or more (on average, eight to ﬁfteen) personalities or personality fragments that control their behavior at different times. Often there is a passive, depressed primary identity who cannot remember personal history as fully as can the other more hostile, protective, or controlling identities.

Post-traumatic stress disorder (PTSD) afﬂicts some people who have undergone a traumatic event involving serious injury or a threat to life or limb. Initially identiﬁed in combat veterans, PTSD seems to result as well from natural disasters, child abuse, and other devastating experiences. People with PTSD keep re-experiencing the traumatic event in waking life or in dreams, and they actively avoid situations that might bring back memories of the trauma. They may also suffer a general numbing of their responsiveness, show diminished interest in signiﬁcant activities, restrict the range of their emotions, or have feelings of detachment or estrangement from others. Finally, they may also experience increased arousal (such as difﬁculty falling or staying asleep), irritability or outbursts of anger, difﬁculty concentrating, hyper vigilance, and an exaggerated startle response.

Abuse and the Developing Human Brain

For a century or more, scientists have hotly contested the relative importance of experience versus genetic endowment in the development of the brain and behavior. We know now that our genes provide the foundation and overall structure of our brain, but that its myriad connections are sculpted and molded by experience. Based on animal studies, scientists have long believed that early deprivation or abuse may result in neurobiological abnormalities, but until recently there has been little evidence for this in humans.

Then, in 1983, A. H. Green and his colleagues suggested that many abused children evidenced neurological damage, even without an apparent or reported head injury. Interestingly, although minor neurological disturbances and mild brain-wave abnormalities were more common in children who had been abused than in those who had not, Green and his colleagues did not believe that the abuse had caused them. Instead, they saw these neurological disturbances as a possible additional source of trauma, amplifying the damaging impact of an abusive environment. In 1979, R. K. Davies reported that in a sample of 22 patients involved as a child or as the younger member in an incestuous relationship, 77 percent had abnormal brain waves and 36 percent had seizures. In Davies's interpretation, however, these children were more vulnerable to being sexually abused by family members because of their neurological handicap.

My hypothesis is that the trauma of abuse induces a cascade of effects, including changes in hormones and neurotransmitters that mediate development of vulnerable brain regions. Testing this hypothesis in humans is difﬁcult because abuse is not always a random act. If we observe an association between a history of abuse and the presence of a physical abnormality, the abuse may have caused that abnormality. But it is also possible that the abnormality occurred ﬁrst and elevated the likelihood of abuse, or that the abnormality ran in the family and led to more frequent abusive behavior by family members or other relatives. To try to sort out these competing hypotheses, we conducted studies of analogous early stress in animals, where the potentially confusing elements can be carefully controlled. Observing parallel outcomes in animals and people has bolstered our belief that trauma causes brain damage, not the other way around.

A Constellation of Abnormalities

Our research (and that of other scientists) delineates a constellation of brain abnormalities associated with childhood abuse. There are four major components:

Limbic irritability, manifested by markedly increased prevalence of symptoms suggestive of temporal lobe epilepsy (TLE) and by an increased incidence of clinically signiﬁcant EEG (brain wave) abnormalities.

Deﬁcient development and differentiation of the left hemisphere, manifested throughout the cerebral cortex and the hippocampus, which is involved in memory retrieval.

Deﬁcient left-right hemisphere integration, indicated by marked shifts in hemispheric activity during memory recall and by underdevelopment of the middle portions of the corpus callosum, the primary pathway connecting the two hemispheres.

Abnormal activity in the cerebellar vermis (the middle strip between the two hemispheres of the brain), which appears to play an important role in emotional and attentional balance and regulates electrical activity within the limbic system.

Let us look brieﬂy at the main evidence for each of these abnormalities.

Epilepsy-Like Symptoms
People with temporal lobe epilepsy (TLE)-.25 percent to .5 percent of the U.S. population-have seizures in the temporal or limbic areas of the brain. Because these areas constitute a sizable, varied part of the brain, TLE has a veritable catalog of possible symptoms, including sensory changes such as headache, tingling, numbness, dizziness, or vertigo; motor symptoms such as staring or twitching; or autonomic symptoms such as ﬂushing, shortness of breath, nausea, or the stomach sensation of being in an elevator. TLE can cause hallucinations or illusions in any sense modality. Common visual illusions are of patterns, geometric shapes, ﬂashing lights, or "Alice-in-Wonderlandlike" distortions of the sizes or shapes of objects. Other common hallucinations are of a ringing or buzzing sound or repetitive voice, a metallic or foul taste, an unpleasant odor, or the sensation of something crawling on or under the skin. Feelings of déjà vu (the unfamiliar feels familiar) or jamais vu (the familiar feels unfamiliar) are common, as is the sense of being watched or of mind-body dissociation-the feeling that one is watching one's own actions as a detached observer. Emotional manifestations of temporal lobe seizures usually occur suddenly, without apparent cause, and cease as abruptly as they began; they include sadness, embarrassment, anger, explosive laughter (usually without feeling happy), serenity, and, quite often, fear. ⁴

TLE is difﬁcult to diagnose because its symptoms can mimic those of other psychiatric and nonpsychiatric illnesses. The characteristic electrical discharge of TLE can be observed only in an electroencephalogram (EEG) during a seizure that is close enough to the brain's surface to be picked up by scalp electrodes. Without this objective EEG data, a diagnosis must be based on the frequency and severity of symptoms and the ruling out of other likely causes of those symptoms.

To explore the relationship between early abuse and dysfunction of the temporolimbic system, we devised the Limbic System Checklist-33 (LSCL-33), which calibrates the frequency with which patients experience symptoms of temporolimbic seizures. 5 We studied 253 adults who came to an outpatient mental health clinic for psychiatric assessment; slightly more than half reported having been abused physically, sexually, or both. Compared to patients who reported no abuse, average LSCL-33 scores were 38 percent greater in the patients with physical (but not sexual) abuse, and were 49 percent greater in the patients with sexual (but not other physical) abuse. Patients who acknowledged both physical and sexual abuse had average scores 113 percent greater than patients reporting no abuse. Males and females were similarly affected by abuse.

As we expected, abuse before age 18, when the brain is still rapidly developing, had a greater impact on limbic irritability than later abuse. Patients physically or sexually abused after age 18 had scores not signiﬁcantly different from nonabused patients. Patients with both physical and sexual abuse, however, were strongly affected regardless of when the abuse occurred, and those ﬁrst abused after age 18 were almost as affected as those ﬁrst abused earlier.

Brain Wave Abnormalities
Our second study tried to ascertain whether childhood physical, sexual, or psychological abuse was associated with speciﬁc evidence of neurobiological abnormalities. We reviewed the records of 115 consecutive admissions to a child and adolescent psychiatric hospital to search for a link between different categories of abuse and evidence of abnormalities in brain-wave studies. We found clinically signiﬁcant brain-wave abnormalities in 54 percent of patients with a history of early trauma but in only 27 percent of nonabused patients. Among patients who had been abused, abnormal EEG ﬁndings were observed in 43 percent of those with psychological abuse; 60 percent of the sample with a reported history of physical abuse, sexual abuse, or both; and 72 percent of the sample in which serious physical or sexual abuse had been documented. The overall prevalence of abnormal EEG studies in patients with a signiﬁcant history of abuse or neglect was the same for boys and girls and for children and adolescents.

The salient speciﬁc difference between abused and nonabused patients was in left-sided EEG abnormalities. In the nonabused group, left-sided EEG abnormalities were rare, whereas in the abused group they were much more common, and more than twice as common as right-sided abnormalities. In the psychologically abused group, all the EEG abnormalities were left-sided.

To dig deeper into the possibility that abuse may affect development of the left hemisphere, we looked for evidence of right-left hemispheric asymmetries in the results of neuropsychological testing. We compared patients' visual-spatial ability (predominantly controlled by the right hemisphere) to their verbal performance (predominantly controlled by the left hemisphere). In the nonabused group, left-hemisphere deﬁcits were about twice as prevalent as right-hemisphere deﬁcits, but in patients with physical, sexual, or psychogical abuse, left-sided deﬁcits were more than six times as prevalent as right. In patients with a history of psychological abuse, left-hemisphere deﬁcits were eight times as prevalent as right-sided deﬁcits. This corroborated our hypothesis that abuse is associated with an increased prevalence of left-sided EEG abnormalities and of left-hemisphere defects in neuropsychological testing.

Problems on the Left
In order to investigate the effects of childhood trauma on development of the left hemisphere, we then used a sophisticated quantitative method of analyzing EEG that provides evidence about the brain's structure. ⁷ In contrast to conventional EEG, which reveals brain function, EEG coherence provided information about the nature of the brain's wiring and circuitry. In general, abnormally high levels of EEG coherence are evidence of diminished development of the elaborate neuronal interconnections in the cortex that would process and modify the brain's electric signals.

We used this technique to study 15 child and adolescent psychiatric inpatients who had a conﬁrmed history of intense physical or sexual abuse compared with 15 healthy volunteers. Patients and volunteers were between 6 and 15 years of age, right-handed, and with no history of neurological disorders or abnormal intelligence. Measuring EEG coherence indicated that the left cortex of the healthy controls was more developed than the right cortex, which is consistent with what is known about the anatomy of the dominant hemisphere. The abused patients, however, were notably more developed in the right than the left cortex, even though all were right-handed. The right hemisphere of abused patients had developed as much as the right hemisphere of the controls, but their left hemispheres lagged substantially, as though arrested in their development.

This abnormality in the cortex showed up regardless of the patient's primary diagnosis, which could be depression, PTSD, or conduct disorder. It extended throughout the entire left hemisphere, but the temporal regions were most affected. This ﬁnding of left cortex underdevelopment is consistent with our earlier ﬁnding that abused patients had increased left-hemisphere EEG abnormalities and left-hemisphere (verbal) deﬁcits as shown by neuropsychological testing.

Effects on the Hippocampus
The hippocampus, located in the temporal lobe, is involved in memory and emotion. Developing very gradually, the hippocampus is one of the few parts of the brain that continues to produce new cells after birth. Cells in the hippocampus have an unusually large number of receptors that respond to the stress hormone cortisol. Since animal studies show that exposure to high levels of stress hormones like cortisol has toxic effects on the developing hippocampus, this brain region may be adversely affected by severe stress in childhood.

J. Douglas Bremner and his colleagues at Yale Medical School compared magnetic resonance imaging (MRI) scans of 17 adult survivors of childhood physical or sexual abuse, all of whom had PTSD, with 17 healthy subjects matched for age, sex, race, handedness, years of education, body size, and years of alcohol abuse. ⁸ The left hippocampus of abused patients with PTSD was 12 percent smaller than the hippocampus of the healthy controls, but the right hippocampus was of normal size, as were other brain regions, including the amygdala, caudate nucleus, and temporal lobe. Not surprisingly, given the role of the hippocampus in memory, these patients also had lower verbal memory scores than the nonabused group.

Murray Stein and his colleagues also found left hippocampal abnormalities in women who had been sexually abused as children. Their left hippocampal volume was signiﬁcantly reduced, but the right hippocampus was relatively unaffected. Fifteen of the 21 sexually abused women had PTSD; 15 had a dissociative disorder. They suffered a reduction in the size of the left hippocampus proportionate to the severity of their symptoms.

These studies suggest that child abuse may alter development of the left hippocampus permanently and, in so doing, cause deﬁcits in verbal memory and dissociative symptoms that persist into adulthood.

Shifting from Left to Right
The left hemisphere is specialized for perceiving and expressing language, the right hemisphere for processing spatial information and also for processing and expressing negative emotions. We wondered, then, whether abused children might store their disturbing childhood memories in the right hemisphere, and whether recollecting these memories would activate the right hemisphere more than it is activated in those without such a history.

To test this hypothesis, we measured hemispheric activity in adults during recall of a neutral memory, then during recall of an upsetting early memory. ¹⁰ Those with a history of abuse appeared to use predominantly their left hemispheres when thinking about neutral memories and their right when recalling an early disturbing memory. Those in the control group had a more integrated bilateral response.

A Deficient Pathway
Since childhood abuse (as we found) is associated with diminished right-left hemisphere integration, we wanted to know whether there was some deﬁciency in the primary pathway connecting the two hemispheres, the corpus collosum. We found in boys who had been abused or neglected that the middle portions of the corpus collosum were signiﬁcantly smaller than in the control groups. Furthermore, in boys, neglect exerted a far greater effect than any other type of maltreatment; physical and sexual abuse exerted relatively minimal effects. In girls, however, sexual abuse was a more powerful factor, associated with a major reduction in size of the middle portions of the corpus collosum. These results were independently replicated by Michael De Bellis at the University of Pittsburgh, and the effects of early experience on the development of the corpus collosum have been conﬁrmed by research in primates.

Calming Irritability in the Brain
Decades ago, Harry Harlow compared monkeys raised with their mothers to monkeys raised with wire or terrycloth "surrogate mothers." Monkeys raised with the surrogates became socially deviant and highly aggressive adults. Building on this work, other scientists discovered that these consequences were less severe if the surrogate mother swung from side to side, a type of movement that may be conveyed to the cerebellum, particularly the part called the cerebellar vermis, located at the back of the brain, just above the brain stem. Like the hippocampus, this part of the brain develops gradually and continues to create new neurons after birth. It also has an extraordinarily high density of receptors for stress hormone, so exposure to such hormones can markedly affect its development.

New research suggests that abnormalities in the cerebellar vermis may be involved in psychiatric disorders including depression, manic-depressive illness, schizophrenia, autism, and attention-deﬁcit/ hyperactivity disorder. We have gone from thinking of the entire cerebellum as involved only in motor coordination to believing that it plays an important role in regulating attention and emotion. The cerebellar vermis, in particular, seems to be involved in the control of epilepsy or limbic activation. Couldn't maltreating children produce abnormalities in the cerebellar vermis that contribute to later psychiatric symptoms?

Testing this hypothesis, we found that the vermis seems to become activated to control- and quell-electrical irritability in the limbic system. It appears less able to do this in people who have been abused. If, indeed, the vermis is important not only for postural, attentional, and emotional balance, but in compensating for and regulating emotional instability, this latter capacity may be impaired by early trauma. By contrast, stimulation of the vermis through exercise, rocking, and movement may exert additional calming effects, helping to develop the vermis.

Attention, Hormones, and the Brain

We know that through their effects on hormone levels, early experiences inﬂuence brain development. Fifty years ago, Seymour Levine and Victor Denenberg showed that small alterations in their environment led to lasting changes in rats' development, behavior, and response to stress. Something as seemingly inconsequential as ﬁve minutes of human handling during a rat's infancy produced lifelong beneﬁcial changes. We now understand through the reserach efforts of Michael Meany and Paul Plotsky that the effects of brief handling were highly beneﬁcial and were due to increased maternal attention. Those pups whose mothers spontaneously lick and groom them the most (about one-third in a laboratory setting) display the same beneﬁts as the rats with the human handling. By contrast, long isolation produces stress that has a deleterious effect on brain and behavior development.

If we assume that lots of attention, licking, and grooming are the natural state of affairs and that lower levels of attention are a form of neglect, we can use this model to explore some of the biological consequences of neglect or abuse in children. Low rates of maternal attention decrease the production of thyroid hormone by the rat pups. This, in turn, decreases serotonin in the hippocampus and affects the development of receptors for the stress hormone glucocorticoid. Since corticosterone, one of our primary stress hormones, is kept in check by a complicated feedback mechanism that depends on these same stress hormone receptors, their inadequate development increases the risk of an excessive stress hormone response to adversity. For this and certain other reasons, lack of maternal attention predisposes the animals to have a heightened level of fear and a heightened adrenaline response. Some of the consequences of this are altered metabolism and suppressed immune and inﬂammatory responses, neuronal irritability, and enhanced susceptibility to seizures. Still other consequences of an abnormally intense corticosterone response are reduced brain weight and DNA content, suppressed cell growth in the cerebellum and hippocampus, and interference with myelinization-the process of sheathing nerve ﬁbers to enhance conduction of electrical impulses.

These consequences seem consistent with inadequate development of the corpus collosum, which is a highly myelinated structure, and abnormal development of the hippocampus and cerebellum. High levels of cortisol can also hinder development of the cerebral cortex, the extent of vulnerability dependent on how rapidly the brain was growing at the time of the insult. During the years of rapid language acquisition (approximately 2-10 years of age), the left brain develops more rapidly than the right, making it more vulnerable to the effects of early maltreatment.

Finally, diminished maternal attention also appears to be associated with a lifelong decrease in production of the hormone oxytocin in the brain, and enhanced production of the stress hormone vasopressin. Recent research by Thomas Insel suggests that oxytocin is a critical factor in afﬁliative love and maintaining monogamous relationships. Both hormones may also help control sexual response, with vasopressin enhancing sexual arousal and oxytocin triggering climax and release. By affecting these hormones, early neglect or abuse theoretically could predispose mammals to experience enhanced sexual arousal, diminished capacity for sexual fulﬁllment, and deﬁcient commitment to a single partner.

From Neurobiology to Symptomatology

In summary, we now know that childhood abuse is linked with excess neuronal irritability, EEG abnormalities, and symptoms suggestive of temporal lobe epilepsy. It is also associated with diminished development of the left cortex and left hippocampus, reduced size of the corpus callosum, and attenuated activity in the cerebellar vermis. We see a close ﬁt between the effects of early stress on the brain's transmitters-our discoveries about the negative effects of early maltreatment on brain development-and the array of psychiatric symptoms that we actually observe in abused patients.

Many disorders are associated with childhood abuse. One is depression or heightened risk for developing it. Many scientists believe that depression may be a consequence of reduced activity of the left frontal lobes. If so, the stunted development of the left hemisphere related to abuse could easily enhance the risk of developing depression. Similarly, excess electrical irritability in the limbic system, and alterations in development of receptors that modulate anxiety, set the stage for the emergence of panic disorder and increase the risk of post-traumatic stress disorder. Alterations in the neurochemistry of these areas of the brain also heighten the hormonal response to stress, producing a state of hyper vigilance and right-hemisphere activation that colors our view with negativity and suspicion. Alterations in the size of the hippocampus, along with limbic abnormalities shown on an EEG, further enhance the risk for developing dissociative symptoms and memory impairments.

We have also found that 30 percent of children with a history of severe abuse meet the diagnostic criteria for attention-deﬁcit/hyperactivity disorder (ADHD), although they are less hyperactive than children with classic ADHD. Very early childhood abuse appears particularly likely to be associated with emergence of ADHD-like behavior problems. Interestingly, one of the most reliable neuroanatomical ﬁndings in ADHD is reduced size of the cerebellar vermis. Some studies have also found an association between reduced size of the mid portions of the corpus callosum and emergence of ADHD-like symptoms of impulsivity. Hence, early abuse may produce brain changes that mimic key aspects of ADHD.

Our discoveries that abused patients have diminished right-left hemisphere integration and a smaller corpus callosum suggest an intriguing model for the emergence of one of psychiatry's least understood afﬂictions: borderline personality disorder. With less well integrated hemispheres, borderline patients may shift rapidly from a logical and possibly overvaluing left-hemisphere state to a highly negative, critical, and emotional right hemisphere state. This seems consistent with the theory that early problems of mother-child interaction undercut the integration of right and left hemispheric function. Very inconsistent behavior of a parent (for example, sometimes loving, sometimes abusing) might generate an irreconcilable mental image in a young child. Instead of reaching an integrated view, the child would form two diametrically opposite views-storing the positive view in the left hemisphere, the negative view in the right. These mental images, and their associated positive and negative world views, may remain unintegrated, and the hemispheres remain autonomous, as the child grows up. This polarized hemispheric dominance could cause a person to see signiﬁcant others as overly positive in one state and as resoundingly negative in another. Couple this with possible alterations in oxytocin- and vasopressin-mediated sexual arousal, and you see why patients with borderline personality disorder have tumultuous relationships.

Dealing with the Damage

I hope that new understanding of childhood abuse's impact on the brain will lead to new ideas for treatment. The most immediate conclusion from our work, however, is the crucial need for prevention. If childhood maltreatment exerts enduring negative effects on the developing brain, fundamentally altering one's mental capacity and personality, it may be possible to compensate for these abnormalities-to succeed in spite of them-but it is doubtful that they can actually be reversed in adulthood.

The costs to society are enormous. Psychiatric patients who have suffered from childhood abuse or neglect are far more difﬁcult and costly to treat than patients with a healthy childhood. Furthermore, childhood maltreatment can be an essential ingredient in the makeup of violent individuals, predisposing them to bouts of irritable aggression.

One day we will ﬁnd ways to chart the progress of brain development so that we can spot early signs of stress-mediated abnormalities and monitor each patient's progress and response to treatment. In the meantime, early intervention should be our priority. The brain is more plastic and malleable before puberty, increasing our chances of minimizing or reversing consequences of abuse. If we are right that many abuse-related changes result from a cascade of stress-mediated neuronal and hormonal responses, then we could minimize the impact of abuse by ﬁnding ways to reduce ongoing stress or suppressing an excessive stress response.

One consequence of childhood maltreatment is limbic irritability, which tends to produce dysphoria (chronic low-level unhappiness), aggression, and violence toward oneself or others. Even into adulthood, drugs can be useful in alleviating this set of symptoms. Anticonvulsant agents can help, as can drugs that affect the serotonin system.

Abuse also causes alterations in left-right hemisphere integration. Some research suggests that anticonvulsant drugs may facilitate the bilateral transmission of information. Left-right hemisphere integration may also improve through activities that require considerable left-right hemisphere cooperation, such as playing a musical instrument. Certain existing psychotherapies may be helpful. Cognitive-behavioral psychotherapy, which emphasizes correcting illogical, self-defeating perceptions, may work by strengthening left-hemisphere control over right-hemisphere emotions and impulses. Traditional, dynamic psychotherapy may work by enabling patients to integrate right-hemisphere emotions while maintaining left-hemisphere awareness, strengthening the connection between the two hemispheres.

A powerful new tool for treating PTSD is eye-movement desensitization and reprocessing (EMDR), which seems to quell ﬂashbacks and intrusive memories. A moving visual stimulus is used to produce side-to-side eye movements while a clinician guides the patient through recalling highly disturbing memories. For reasons we do not yet fully understand, patients seem able to tolerate recall during these eye movements and can more effectively integrate and process their disturbing memories. We suspect that this technique works by fostering hemispheric integration and activating the cerebellar vermis (which also coordinates eye movements), which in turn soothes the patient's intense limbic response to the memories.

Their Choice-or Ours?

Society reaps what it sows in nurturing its children. Whether abuse of a child is physical, psychological, or sexual, it sets off a ripple of hormonal changes that wire the child's brain to cope with a malevolent world. It predisposes the child to have a biological basis for fear, though he may act and pretend otherwise. Early abuse molds the brain to be more irritable, impulsive, suspicious, and prone to be swamped by ﬁght-or-ﬂight reactions that the rational mind may be unable to control. The brain is programmed to a state of defensive adaptation, enhancing survival in a world of constant danger, but at a terrible price. To a brain so tuned, Eden itself would seem to hold its share of dangers; building a secure, stable relationship may later require virtually superhuman personal growth and transformation.

At the extreme, the coupling of severe childhood abuse with other neuropsychiatric handicaps (for example, low intelligence, head trauma, or psychosis) is repeatedly found in cases of explosive violence. Dorothy Otnow Lewis and Jonathan Pincus have analyzed the neurological and psychiatric history of violent adolescents and adults. In one study they evaluated all 14 juveniles condemned to death in four states and found that all had suffered head injuries, most had major neurological impairment, 12 had subnormal IQ's, 12 had been severely physically abused as children, and 5 had been sodomized by relatives. In another study, they reviewed the childhood neuropsychiatric records and family histories of incarcerated delinquents. What might have been a tip-off to those who later were arrested for murder? The future murderers were distinguished from other delinquents by psychotic symptoms, major neurological impairment, a psychotic ﬁrst-degree relative, violent acts during childhood, and severe physical abuse.

In a follow-up study of 95 formerly incarcerated juvenile delinquents, they found that the combination of intrinsic neuropsychiatric vulnerabilities and a history of childhood abuse or family violence effectively predicted which adolescents would go on to commit violent crimes. Lewis concludes that child abuse can engender all pivotal factors associated with violent behavior, namely, impulsivity, irritability, hyper vigilance, paranoia (which she interprets as an extreme version of hypervigilance), decreased judgment and verbal ability, and diminished recognition of pain in oneself (dissociation) and others. As our review shows, these factors ﬁt closely with the enduring neurobiological consequences of abuse.

To be convicted of a crime in the United States, one supposedly must have the capacity both to know right from wrong and to control one's behavior. Those with a history of childhood abuse may know right from wrong, but their brains may be so irritable and the connections from the logical, rational hemisphere so weak that intense negative (right-hemisphere) emotions may incapacitate their use of logic and reason to control their aggressive impulses. Is it just to hold people criminally responsible for actions that they lack the neurological capacity to control?

Prosecutors and pundits are quick to coin catchphrases like the "abuse excuse" to dismiss childhood trauma's pervasive and enduring consequences for behavior. This is as unthinking as the exhortation to "get over it." Childhood trauma is not a passing psychological slight that one can choose to ignore. Even if the abused person comes to terms with the traumatic memories and chooses (for the sake of sanity) to forgive the perpetrator, this will not reverse the neurobiological abnormalities. The only sound legal approach to a person with a history of abuse who commits a violent crime is to take into account the person's neurobiological capacity to control his behavior. If it is irrational and hypocritical to hold a minor to the same standard of behavioral control as a mature adult, it is equally unjust to hold a traumatized and neurologically impaired adult to the same standard as one not so afﬂicted. Childhood abuse, age, and neurological impairments can be critical mitigating factors that a just society should not ignore.

If we know that the roots of violence are fertilized by childhood abuse, can we make a long-term commitment to reduce violence by focusing on our children rather than our criminals? What if we set a goal of reducing the cases of childhood abuse and neglect by 50 percent a year? What if we monitored statistics on childhood abuse as avidly as we track housing starts, inﬂation, or baseball scores? We would have to commit ourselves, seriously, to improving access to quality day care and after-school programs. We might need to educate and support parents so they could know how to nurture their children more effectively. We certainly would need to foster better relationships among peers and siblings.

Think of what we could save if we needed fewer prisons and fewer mental health professionals. Think of the beneﬁts of moving one step closer to a society that everyone could experience and enjoy.

Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds. Childhood abuse isn't something you "get over." It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence in this country.

References

1. Finkelhor DA. A Sourcebook on Child Sexual Abuse. Beverly Hills, CA: Sage Publications; 1986.

2. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. American Journal of Psychiatry. 1989;146:490-5.

3. Putnam RW, Post RM, Guroff JJ. One hundred cases of multiple personality disorder. Journal of Clinical Psychiatry. 1986;47:285-93.

4. Spiers PA, Schomer DL, Blume HW, Mesulam MM. Temporolimbic epilepsy and behavior. In: Mesulam MM, ed. Principles of Behavioral Neurology. Philadelphia: F.A. Davis; 1985:289-326.

5. Teicher MH, Glod CA, Surrey J, Swett C. Early Childhood Abuse and Limbic System Ratings in Adult Psychiatric Outpatients. Journal of Neuropsychiatry and Clinical Neurosciences. 1993;5:301-6.

6. Ito Y, Teicher MH, Glod CA, Harper D, Magnus E, Gelbard HA. Increased prevalence of electrophysiological abnormalities in children with psychological, physical, and sexual abuse. Journal of Neuropsychiatry and Clinical Neurosciences. 1993;5:401-8.

7. Ito Y, Teicher MH, Glod CA, Ackerman E. Preliminary evidence for aberrant cortical development in abused children: a quantitative EEG study. The Journal of Neuropsychiatry and Clinical Neurosciences. 1998;10:298-307.

8. Bremner JD, Randall P, Vermetten E, et al. Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse-a preliminary report. Biological Psychiatry. 1997;41:23-32.

9. Stein MB. Hippocampal volume in women victimized by childhood sexual abuse. Psychology Medicine. 1997;27:951-9.

10. Schiffer F, Teicher MH, Papanicolaou AC. Evoked potential evidence for right brain activity during the recall of traumatic memories. Journal of Neuropsychiatry and Clinical Neurosciences. 1995;7:169-75.

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Wounds That Time Won't Heal: The Neurobiology of Child Abuse

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We easily understand how beating a child may damage the developing brain, but what about the all-too-common psychological abuse of children? Because the abuse was not physical, these children may be told, as adults, that they should just "get over it." But as developmental neuropsychiatrist Martin H.

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Child sexual abuse is a crime and form of abuse that involves sexual activity with a minor. Children cannot consent. Sexual abuse does not always involve physical contact between perpetrator and child. These can include:

Exposing oneself to a minor

Fondling

Intercourse

Masturbation in the presence of a minor or forcing the minor to masturbate

Obscene conversations, phone calls, text messages, or digital interaction

Producing, owning, or sharing pornographic images or movies of children

Sex of any kind with a minor, including vaginal, oral, or anal

Sex trafficking

Any other contact of a sexual nature that involves a minor.

Reference

Rainn (2023). Child Sexual Abuse. https://www.rainn.org/articles/child-sexual-abuse.

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Children, Violence, and Trauma—Treatments That Work

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symptoms:
Guilt, shame, confusion, low self-esteem, withdrawal from activities, changes in behaviors, depression, anxiety, nightmares, rebellious or defiant behaviors, truancy, self-harm, suicide attempts, unexplained injuries, fractures, bruises, injuries that don’t match verbal explanation.

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Cyberbullying: Online bullying affects both victims and bullies⼁CBC Kids News

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Ways Teachers Can Help Students Who Are Homeless

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Ways Teachers Can Help Students Who Are Homeless

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Teachers must remember that they cannot possibly meet all the needs of a child who is homeless. However, if they can remove just one frustration, it can make a tremendous difference for that child.

Stabilize the child’s basic needs

Have food, clothing, shelter, medical care, basic hygiene, and transportation needs resolved

Provide structure and adhere to a consistent daily routine and clear, concise rules.

Don’t assume the child knows the classroom’s behavior expectations, regardless of the student’s age. Be patient and persistent in trying to help the child adjust to the new environment.

Pair a new student with a “buddy” in the classroom on the first day of school.

Having a buddy will keep new students in contact with someone who knows their way around the school

Plan assignments so children can keep up without having to take work home.

Schedule the school day to allow teachers to help with school assignments before the end of the day
References
Evers, T. (n.d.). How teachers can help students who are homeless. Wisconsin Department of Public Instruction. Retrieved January 16, 2023, from https://dpi.wi.gov/sites/default/files/imce/homeless/pdf/teach_help_hmls_stud.pdf

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After facing trauma from different sources, natural disasters, house fires or other large-scale tragedies, children need to feel secure.
The four pillars of security

1. People

Security comes from familiar and trusted loved ones who know and understand us and whom we know and understand.
Places

An unfamiliar place makes demands on our awareness — we need to be alert. In our places, we have the freedom to find or create sanctuaries and places to pause
Routines
Routines reassure each of us and stabilize groups — the regular meal, the prompt dry diaper, the inevitability of sleep.
Rituals
Rituals join routines and our physical space as the binds that hold individuals and groups together in times of stress and uncertainty.

References
What children need: Pillars of security - bright horizons. (n.d.). Retrieved January 16, 2023, from https://www.brighthorizons.com/-/media/BH-New/WHTMW/EdDev_PillarsofSecurity.ashx

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Fight or flight + anxiety states

Students may be triggered by something non-threatening (like a loud noise, or not understanding an assignment) and feel the intense emotions and fear associated with a truly frightening event. Therefore, a student may not be able to control their emotions or reactions when they’re overwhelmed by stress chemicals.

Memory function + learning

When the primary function of a child’s brain is to protect itself and process fear, normal brain development is affected.
You might see students become forgetful, disengaged, or unable to concentrate

Emotional regulation

Children can fail to learn how to calm themselves down or regulate sadness or fear. These emotions can manifest into deeper or more long-term mental challenges such as depression, PTSD, self-hatred, guilt, or shame.
Stress chemicals cursing through the body greatly impact students' learning.

References
Gunn, J. (2021, June 8). How adverse childhood trauma affects a student's Brain: Resilient educator. ResilientEducator.com. Retrieved January 15, 2023, from https://resilienteducator.com/classroom-resources/this-is-a-students-brain-on-trauma/

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RESPONSE STRATEGIES:

Provide resources to promote positive parent-child relationships. Encourage both parents to stay engaged with their children’s learning activities at home. Encourage parent networking Incorporate classroom activities and materials that support children of divorced parents.

Reference:

Kim, L., Spengler, L. (n.d.). Helping children adjust to divorce: a guide for teachers. Extension. Retrieved from https://extension.missouri.edu/publications/gh6611

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Behavioral issues (e.g., delinquency & aggression)

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Behavioral issues (e.g., delinquency & aggression)

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RESPONSE STRATEGIES:

Teach decision-making and problem-solving skills. Interact with neglected children at their emotional age. Establish routines - be consistent, predictable, and repetitive. Model and teach appropriate social behaviors.

Reference:

Tully, J. (2017, April). What is neglect; a medical perspective and the neurobiological model. [Slideshow]. Retrieved from https://slideplayer.com/slide/12240529/

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Homeless kids can be hard to identify and even harder to help.
Students experiencing homelessness may find regular school attendance difficult. Yet school may be the only place of stability in a child’s life. Every time children change schools, they may lose between four to six months of academic progress
References
Evers, T. (n.d.). How teachers can help students who are homeless. Wisconsin Department of Public Instruction. Retrieved January 16, 2023, from https://dpi.wi.gov/sites/default/files/imce/homeless/pdf/teach_help_hmls_stud.pdf

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Reference:

Ingraham, C. (2016, July 13). Moving as a child can change who you are as an adult. The Washington Post. Retrieved from https://www.washingtonpost.com/news/wonk/wp/2016/06/13/moving-as-a-child-can-change-who-you-are-as-an-adult/

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Strategies for helping students with PTSD

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Strategies for helping students with PTSD

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1. Communicate with counselors or social workers. Besides providing specific information about your students, these are great resources for more information about recognizing and understanding the impacts of trauma.

2. Provide structure and consistency. Write the agenda on the board. Use entry and exit routines. When a student knows what to expect, it can help her to feel safe.

3. Ease transitions. Give time warnings ahead of activity transitions (“3 minutes until we switch groups...”). Warn ahead of doing something unexpected, such as turning off the lights or making a loud sound. If possible, prepare students for fire drills.

4. Provide choice. People with trauma history experience a lack of control. Provide safe ways for students to exercise choice and control within an activity and within the environment (choice of seats, choice of book, etc).

5. Develop strengths and interests. Focus on an area of competence and encourage its development to contribute to positive self-concept.

6. Be there. A lot of working with students with trauma history is just showing up, every day, and accepting the student no matter what behaviors emerge. Be an adult in that student’s life who is going to accept him and believe in him, no matter what - children can never have too many supportive adults in their lives.

7. Make an “out” plan. Create a way for a student to take space if she feels triggered or overwhelmed during class. Designate a space in the school building or outside where you will know where to find her if she needs to take time for a sensory break or to regulate her emotions. You can also provide a box or kit of sensory calming tools a student can use (Silly Putty, coloring, puzzles).

8. Take care of yourself. One of the most important things to remember. If you work with even just one student who experienced trauma, you can experience vicarious trauma or compassion fatigue. Use your own support system and make time to do things that fill your tank.

Reference:

Venet. A. S. (2014, September 14). 8 ways to support students who experience trauma. Edutopia. Retrieved from https://www.edutopia.org/discussion/8-ways-support-students-who-experience-trauma

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Strategies that can help enhance children’s social and emotional skills

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Strategies that can help enhance children’s social and emotional skills

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1. Create a trusted environment where emotions are talked about openly. Children must be taught to recognize and communicate their feelings. Do not shy away from talking about your feelings too. This will encourage your child to open up.

2. Do not shout or yell at people or become physically violent. This can have a significant adverse impact on your child’s mind. At the same time, do not raise hands on your child too. Needless to say, children learn more from observing you.

3. Practice mindfulness, it helps improve your child’s emotional regulation capacity. Mindfulness practice can help in stress management and reduce anxiety and depression.

4. Maintain a healthy and open relationship with your child. Be approachable for your child and act as a guide. This gives your child the confidence to approach you whenever he or she requires. Use every possible opportunity to talk to your child about emotions and teach them how to manage their emotions.

5. Qualities such as courtesy, compassion, tolerance and modesty are essential to bond well with others. Inculcate them in your child so that they help your child in their relationships with people around them.

6. Make your child understand the importance of empathising with others. This will help your child to avoid stereotyping people or being prejudiced towards someone.

7. Teach your child how to prevent emotional outbursts in public and how to deal with them. Teach them about the various techniques like deep breathing, counting till 10.

8. Praise your child for a task well done and ensure that you provide constructive feedback every time. Teach your child to pat his or her own back on accomplishments rather than seek appreciation from others. This will make them persevere and strive towards long-term goals, rather than seek immediate results.

9. Let your child make small decisions of life right from a young age. Let your child choose clothes, food, games, etc for himself or herself.

10. Monitor the early instances of reactions such as jealousy, anger or sadness and work on them.

Reference:

Social-Emotional Development in School-Going Children. (2020, January 7). Beyond Academics. Retrieved from https://blog.learnbuddy.in/social-emotional-development-in-school-going-children/

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Children are exposed to acts of interpersonal violence that are largely intentional, committed in public areas by individuals who are not intimately related to the victim.

Possible Symptoms

Community violence can make children lose their sense of safety, placing them into “survival mode,” which perpetually keeps them ready to gear up for fight or flight.This can present in students who are angry, combative, fearful, frequent injury or hospitalizations, unexplained change in usual behavior, talking about violence with peers or teachers, sensitivity to sudden sounds, unexpected behavior.

Response Strategies

Teaching students about the existence of hate-based violence (whether it be violence fuelled by racial, demographic or socio-economic reasons) through facilitating effective conversations, age-specific guidelines, and actions the class, school, families and communities can take before an event occurs.

Video on talking about Violence in the school space:
Talking about Community Violence

References:

Community Violence Collaborative Group, National Child Traumatic Stress Network. (2013). Community violence: Reactions and actions in dangerous times. Los Angeles, CA, & Durham, NC: National Center for Child Traumatic Stress.

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The National Child Traumatic Stress Network

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The following resources on Community Violence were developed by the NCTSN.

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RESPONSE STRATEGIES:

Provide parent outreach programs. Resources for welcoming process. Have regular meetings with families (get to know them). Integrate the students' cultural and country information into weekly classroom routines. Pair students with peer helpers.

Reference:

Valenzuela, J. (2021, October 14). 5 trauma-informed strategies for supporting refugee students. Edutopia. Retrieved from https://www.edutopia.org/article/5-trauma-informed-strategies-supporting-refugee-students/

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Symptoms

Intrusive memories about the loss experienced. A variety of symptoms can present themselves through nightmares, guilt, or self-blame about how the person was lost, or even thoughts about the manner of loss that can be recurrent or intrusive.

Avoidance and numbing. The child can express this through withdrawal, or  acting as if not upset, blocking out reminders of the person or even acting as though nothing happened as a way of self-preservation.

Physical or emotional symptoms of increased arousal. The child can be irritable, angry, have trouble sleeping, decreased concentration in the classroom, slowing academic progress, stomachaches, headaches, increased vigilance.

Response strategies

Teachers should avail themselves to listen without bias, acknowledge the child’s feelings, and also be nonjudgmental. Use SEL strategies to assist students to express their own feelings in an open, calm, and appropriate way.  Resources like Trauma and Grief Component Therapy strategies and Trauma Focussed Cognitive Behavioral Therapy should be made available through regular talks with mental health professionals, social workers in the community linked with the school district and other stakeholders to safeguard the psychological wellbeing of children.

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The Courage to Remember: Training Video on Child Traumatic Grief

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Poor Performance in Academics

Loss of Interest in Social Activity

Difficulty Adapting to Change

Emotionally Sensitive

Anger/Irritability

Feelings of Guilt

Introduction of Destructive Behavior

Increase in Health Problems

Loss of Faith in Marriage and Family Unit

Reference:

What Are the Effects of Divorce on Children? (2023). Family Means. Retrieved from https://www.familymeans.org/effects-of-divorce-on-children.html

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RESPONSE STRATEGIES:

Provide resources at school (extra support before and after moving, welcoming practices.) Establish routines at school that can ground the student. Provide foster care system for youth to prevent disruption. Sharing student information and aligning curriculum across districts to minimize adjustments for students.

Reference:

Ingraham, C. (2016, July 13). Moving as a child can change who you are as an adult. The Washington Post. Retrieved from https://www.washingtonpost.com/news/wonk/wp/2016/06/13/moving-as-a-child-can-change-who-you-are-as-an-adult/

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Life Threatening Illness: Medical Trauma 

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Life Threatening Illness: Medical Trauma 

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This type of trauma, also referred to as Pediatric medical traumatic stress, makes reference to a host of psychological and physiological responses that children have to pain, injury, serious illness, medical procedures, as well as invasive or harrowing/frightening treatment experiences. It may also occur as a response the child has to a single or multiple different medical events.

Symptoms

1. Re-experiencing. This refers to the situation in which the child persistently ruminates on the trauma, even when they don’t want to. Re-experiencing could cause children to respond with flashbacks after unrelated situations in the classroom might trigger them,  nightmares, or even experience physical symptoms when something – a sight, a sound, a smell – reminds them of the traumatic event.

2. Avoidance. These symptoms can start by trying not to think or talk about the trauma, or anything related to it. There are times when children would rather stay away from people, places or activities because these triggers upset them, even leading to them developing new fears or worries.  In terms of injuries sustained, they can even develop over-cautious behavior and a hyper-sensitivity to safety, making them docile, neurotic and hypervigilant which could introduce distrust and mistrust.. These types of avoidance can certainly interfere with their daily life and prevent them from enjoying activities they used to.

3. Hyper-arousal. Hyper-arousal is when the child’s sense of danger, or the “fight or flight response”, operates in an extreme manner.   Post  injury, accident or traumatic event, this “fight or flight” response might be constantly activated, even when the child is safe. After a scary situation like being injured, a child might have the feeling that something negative could happen again at any given moment, developing shifty or jumpy behavior. The physical feelings that go along with hyper-arousal (e.g., heart palpitations, hyperventilation) can feel scary themselves.

Response Strategies

The teacher should exercise sensitivity, especially to the environmental cues that can potentially cause a reaction in the traumatized child. Also be mindful that trauma symptoms/related behavior may escalate near an anniversary of a traumatic event.  Creating a close relationship and gaining as much student data as possible will equip the teacher with the knowledge to set up boundaries and make provision for these situations.

Try to teach elements of tact and discretion.  Have a keen awareness of other children’s reactions to the traumatized child and also to the things they talk about/share with each other, then convert those into teaching moments. Try to protect the traumatized child from classmates’ curiosity and protect classmates from the details of a child’s trauma.

References:

NASP School Safety and Crisis Response Committee. (2015). Addressing grief: Tips for teachers and Administrators. Bethesda, MD: National Association of School Psychologists. Bethesda, MD: National Association of School Psychologists.

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The National Child Traumatic Stress Network

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Children's responses to medical trauma are often more related to their subjective experience of the medical event rather than its objective severity. Reactions vary in intensity and can be adaptive or may become disruptive to functioning. The majority of pediatric patients and their families are resilient and do well.

Many ill or injured children and their families (up to 80%) experience some traumatic stress reactions following a life-threatening illness, injury, or painful medical procedure. Between 20 - 30 % of parents and 15 - 25% of children and siblings experience persistent traumatic stress reactions that impair daily functioning and affect treatment adherence and recovery. When they persist, traumatic stress reactions can:

Impair day-to-day functioning

Affect adherence to medical treatment

Impede optimal recovery

There are three main types of traumatic stress reactions:

Re-experiencing. Re-experiencing means that the child keeps thinking a lot about the trauma, even when he does not want to. Some re-experiencing is normal and natural. Thinking a lot about what happened, especially at first, is part of how we help ourselves recover from a scary experience.Too much re-experiencing can be very distressing. A child might have nightmares or "flashbacks" that make her feel like she is going through the trauma all over again. She may feel really upset or even have physical symptoms when something - a sight, a sound, a smell - reminds her of what happened.

Avoidance. Avoidance symptoms can start by trying not to think or talk about the trauma, or anything connected with it. Sometimes kids want to stay away from people, places or activities because these reminders upset them. And children sometimes develop new fears or worries. Of course, it can be good common sense to be more cautious after an injury. Children may become more aware of safety - remembering to wear a seat belt, not running into the street after a ball, or staying away from dogs they do not know. But extreme avoidance or fears can become a real problem. Avoidance can interfere with daily life and stop a child from getting back to enjoying things that she usually likes to do.

Hyper-arousal. Hyper-arousal also starts with a natural and normal response to danger, the "fight or flight response." After an injury or accident, this "fight or flight" response might not turn off, even when the child is safe. After a scary situation like being injured, a child might have the feeling that something bad could happen again at any time, or he might jump at any loud noise. The physical feelings that go along with hyper-arousal (e.g., heart racing) can feel scary themselves.

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Children's responses to medical trauma are often more related to their subjective experience of the medical event rather than its objective severity. Reactions vary in intensity and can be adaptive or may become disruptive to functioning.