ERIKSONIAN STAGES OF DEVELOPMENT AND THE IMPACT OF CATEGORIES OF TRAUMA (Note: Each stage has developmental milestones that if unattained and issues that if unresolved will impact later stages) STAGE Infancy (Birth to 18 months) BASIC CONFLICT IMPORTANT EVENTS Trust vs. Mistrust Feeding & Basic Bonding through eye contact and touch Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Training GENERAL OUTCOME Children develop a sense of trust when caregivers provide reliability, care, and affection. A lack of such conditions can lead to mistrust, regression, fear of separation and delay in language acquisition Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feeling of autonomy; failure or overly restrictive parenting can result in shame and doubt with potential disturbances in attachment formation. IMPACT OF PARENTAL/CAREGIVER LOSS/IRREGULAR PRESENCE, OR PSYCHIATRIC/MEDICAL SERIOUS ILLNESS Parental impairment absence disrupts the delivery of consistent physical and emotional sustenance and can impact bonding and eye contact Without a good substitute, the person may experience increased difficulty forming and sustaining relationships that support self-care as well as care for others. Lack of food and infant care can result in mental and physical growth delays as well as fixation or regression of developmental milestones such as crawling, walking Schizophrenic parents increase the sense of fear and mental confusion becoming the child's perceived normal state Any irregular parenting can compromise a sense of hope in or distrust of any future caregivers and can be maintained even into adult relationships Absent parents or parents with serious mental illness increase th se the predisposition to more serious for s forms of depression Imegular presence of caregivers deprives the toddler of needed structure to proceed with the mastery of toilet training Difficulty with toilet rating can be related to difficulties in developing organization, boundaries, self-control and cleanliness Overly strict parents increase the likelihood of preoccupations can could potentially lead to obsessive and compulsive traits and anxiety IMPACT OF DOMESTIC VIOLENCE OR SEXUAL ABUSE (never occurs outside the context of abandonment and deprivation) Violence and abuse in the home is experienced by the infant as an unreliable and dangerous environment which can increase the child's feelings of irritability and and fear-based crying which can lead to withdrawal an behavior. Future issues can include increased likelihood of chaotic and disorganized attachment patterns. Infants may experience difficulty trusting people or environments to be able to provide their needs. If the child experience physical injury/neurological injury a potential impact could be compromised normal physical and neuropsychological growth negatively impacting normal development People who develop panic disorder sometimes show a relationship to having experienced childhood sexual abuse. A childhood in which violence and abuse is present increases the risk of the child for the following: o Potential for perceiving the world as unpredictable and dangerous Increased potential of an enhanced startle response Potential of experiencing insomnia Possible increase in irritability ENVIRONMENTAL SOCIO-POLITICAL TRAUMA (lack of resources and disruption of physical and emotional care). . Decreased availability of resources such as housing money, food or tation interferes with Potential of developing a specific fear of the caregivers transportation int adequate physical sustenance for the infant and increases the anxiety of the caregivers. Disruption of meeting the infants emotional needs will diminish appropriate bonding occurring. Characteristics in previous stage may occur along with and increased potential for separation anxiety and the startle response. Increased potential for somatic complaints Atainment of developmental milestones can be delayed. Preschool (3 to 5 years) Initiative vs Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. The development of autobiographical memory may be affected along with a decreased ability to cope with stress and the possible initiation of permanent changes in neurobiology. If the child experiences extensive shame there is an increase in the vulnerability to developing issues such as ciety Disorder and Selective Mutism Separation Anxiety 1 Mothers with eating disorders increase the risk of the development of Eating Disorders in the teen years and young adulthood. Guilt-laden responsibility for the condition of the parents can occur Autobiographical memory may be compromised Tendency toward depression and suicide increases if a parent dies Confusion, denial through over activity and compromised self-esteem may be increased. The child is bereaved and needs an alternative caregiver to help them grieve. Older siblings tend to be relied on as caregivers which interferes with them recovering or grieving. This may compromise their own achievement of age-appropriate developmental tasks Separation of siblings by placement in different homes constitutes yet another loss. This can worsen the psychological symptoms such as: Hopelessness, anger, demoralization and feeling of abandonment, as well as guilt for feeling these emotions. This will tend to prolong the recovery process. . Parental overprotection can increase the risk of developing agoraphobia, generalized anxiety disceder, Exhibitionistic Disorder and Pedophilia o Increased potential for clingy behavior Over time, the person is prone to increased potential for fear and paranoia Higher probability of experiencing regression to earlier stages of development in adulthood May experience love/relationships as dangerous. Child likely to fear caregivers and demonstrate temper outbursts. May acquire chaotic and disorganized attachment patterns in adolescence and adulthood. The child may experience increased confusion about love or may associate love with violence in future relationships a may Sexual traunty make toilet training and normal sexual exploration may be interrupted leading to potential marked confusion. Potential for PTSD symptoms with nightmares and intrusive recollections specific to the trauma. Potential for identification with the perpetrator and may identify with being a victim with a possible inclination to form relationships with the potential of abuse Potential impact resulting in learning difficulties, acting out, difficulty making friends, bedwetting and poor self-esteem Will tend to retreat from caregivers, showing a tendency towards passivity, withdrawal and the disruption of normal separation and individuation Child's reactions commonly interferes with normal Increased risk of developing psychological disorders substance abuse, criminal behavior and sexual risk-taking. Increased risk of difficulty in the intimacy vs isolation stage Formation of healthy conscience can be effected regarding what constitutes appropriate actions empathy, appropriate guilt and self-control. Because of these types of reaction there is an increased risk of Intermittent Explosive Discoder, Conduct Disorder, and/or bulimia nervosa The child's attempts to exert control over the environment are thwarted by forced relocation and/or the reduction of resources. Identification with parent's anxiety, rage and or confusion about what i occurring is more likely. Typically, children require stable parents who give age appropriate explanations about changes in the environment. Multiple and varied adverse experiences can strongly increase the potential risk for the development of Major Depressive Disorder Extensive changes in ambient light, noise and environmental disruption can lead towards the School Age (6 to 11) Industry vs. Inferiority School Adolescence(1 2 to 18 years) Identity vs. Role Confusion Social Relationships Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure leads to role confusion and a weak sense of self. Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to self, while failure leads to role confusion and a weak sense of self. Children can experience increased confusion, denial through over activity and compromised self-esteem The child experiences bereavement which is best addressed by having an alternative caregiver to help them Older siblings tend to be relied on as caregivers which prevents them from effectively recovering or grieving which can compromise the child achieving age-appropriate developmental tasks. Separation of siblings by placement in different homes constitutes another loss which can worsen the psychological symptoms. Feeling of accomplishment with school success can be reduced as being perceived as a part of ego-building unless a nurturing caregiver is stably present. A nurturing Poor school performance is more likely Progression through the grades can be negatively impacted Acting out behavior, development of bullying. withdrawal and school refusal are more likely Prolonged and complicated grief is more likely if the relationship with parents was ambivalent. This condition is commonly associated as a basis for potentially displaying Oppositional Defiant Disorder The on effects on the previous developmental stage can be present with the potential addition to poor grades, grade retention, and higher dropout rates. Peer relationships can be negatively affected. Dropout rates are the lowest with the youngest sons, highest with eldest children, especially daughters. Acting out behavior, drug abuse and behavior problems are common Age appropriate struggle to find identity is interrupted which can lead to identity confusion. Increased risk of Obsessive Compulsive Discoder and Body Dysmorphic Discoder increased. Characteristic effects of earlier ages may be present with stronger tendencies towards poor emotional control and extreme vacillations in behavior. Children tend to have increased expectation that others are dangerous and are unable to judge if a threat is serious. The child feeling the need to protect parents can increase the potential for school phobia, acting out at school, learning disabilities, and overprotective behavior regarding the parents. Condition is the previous stage can continue with the addition of PTSD consistent with nature of the threat/injury. There may be out of control behavior, poor school performance, truancy and drug and alcohol abuse, self-injury as the retroflection (turning against oneself) with rage or violent acting out. Higher potential for the poor formation of healthy guilt, a poor development of a sense of responsibility and higher potential for the development of an identity crisis Acceptance in the school community tends to be interrupted by bullying/cyber-bullying, development of Insomnia Disorder Displacement from school interrupts the healthy development of normal social relationships with peers and ahemative authority figures. Concem for personal safety and the emotional condition of parents may result in decreased school performance as well as somatic complaints. Increased risk of developing Illness Anxiety Disorder Increased presentation of a fuller range of PTSD symptoms consistent with the nature of the trauma Decreased likelihood of parental supervision. Peer pressure increases risk drug or alcohol abuse and of drug acting out physically or sexually Identity formation may be disrupted Young Adulthood (19 to 40 years) Middle Adulthood (40 to 65 years) Young adults need to form intimate, Intimacy vs. Isolation Relationships loving relationships, while failure results in loneliness and isolation. Generativity vs. Stagnation Maturity (65 to death) Ego Integrity vs. Despair Work and Parenthood Reflection on Life Increased difficulty forming close relationships and expe a sense of isolation Increased likelihood of unemployment Fears and unhealthy dependence on a mate Potential of an unconscious tendency to find a mate with similar characteristics of the lost parent, more likely resulting in an unsuccessful relationship. This tends to perpetuate the cycle of loss in which loneliness, bitterness and isolation ensues. The formation of close friendships may be compromised. Adults need to create or nurture things Increased maturity tends to allow for the more successful that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair processing of events. However, if the development of unhealthy dependency on the parents is present or the individual is physically or mentally compromised successfully processing will be significantly hampered. Poor processing often results in sadness and depression over the losses and guilt over unresolved anger emerges, which can effect and/or displace onto work and love relationships. The loss accentuates the self-confrontation of whether they are living an authentic life and making a unique and personal contribution. Thus, sadness and deep regret may ensue. Although the parents are typically physically gone, their emotional presence and memories can present themselves with more intensity. Is with compromised emotional or Individuals with cognitive functioning, unresolved issues from the past are difficult to process. Although the parents are typically physically gone, their emotional presence and memories can present themselves with more intensity because of the preservation of remote memory with age Dating relationships tend to be unstable leading to social isolation with the increased risk of suicide, and an increased risk of developing Cannabis Abuse Education, personal and professional identity may be seriously compromised because of increased accessibility of traumatic memories compared to earlier developmental periods. Memories of previous life events may organize around coping with trauma memories to potentially produce a consolidation of an enduring life theme and expectation set Improved emotional regulation/decline in neuroticism and increased social support may decline risk of PTSD. Trauma can significantly disrupt expected life stability that one depends on if the trauma experiences are perpetrated by a spouse or family members The potential accumulation of medical problem increases the feelings of vulnerability Decreased social support from loss of family or friends, as well as declining physical health increases vulnerability to depression, memory impairment and capacity/desire for self-care The person will lead to find in more difficult to recover from PTSD which can increase the potential for demoralization and hopelessness Increased presentation of a fuller range of PTSD symptoms consistent with the nature of the trauma and increased accessibility of traumatic memories compared to earlier developmental periods. Memories of previous traumatic events may organize around the PTSD presentation which tends to intensify emotional reactions and complicating recovery. Improved emotional regulation/decline in neuroticism and increased social support may decline risk of PTSD. Severe distress may occur instead related to their ability to manage family responsibilities and increased job demands s. Loos of income may increase symptomology. The elderly are particularly vulnerable to natural disasters as rapid and effective immediate decision-making i required The need to relocate due to inability to drive, use public transportation, decrease of social networks. increased poverty and disability seriously compromises the elderly having the flexibility to demonstrate effective coping ability. Extreme fear, anxiety and disorganization increases with t the urgent need to relocate and/or the disruption of social health resources. The sense of the need to recreate their world and social matrix can be viewed as overwhelming and can lead to demoralization, impotent rage and depression Social programs may not be as beneficial if relocating, and elderly may feel as though they do not have a political voice References 1 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Press Vogel-Scibilia S, McNutty K.C., Baxter B, Miller, S., Dine M., Frese, F. The Recovery Process utilizing Erikson's Stages of Human Development. Community Mental Health J. 2009 Dec;45(6):405-414. 2. 3. Ogle, C., Rubin, D., Siegler, I. The Impact of Developmental Timing of Trauma Exposure on PTSD Symptoms and Psychosocial Functioning among Older Adults. Dev psyhol. 2013 Nov; 49 (11);. 10.1037/a0031985. 4. Santrock, J. (2013). Life Span Development (14th ed.). New York, NY: McGraw-Hill Education. Trauma and Development: Basic Data 1. Traumatic Memories have the following qualities: a. Disorganized b. May not have consistent sequence of events c. Flashbacks d. May be triggered by scent, visuals, sounds, taste, or other sensory input 2. What is traumatic to young children? Keep in mind that children are concrete thinkers. a. Physical abuse b. Sexual abuse c. Emotional abuse d. Neglect (physical or emotional) e. Domestic violence in the home f. Community violence (hearing about abuse) g. Natural disasters (to include families having "intruder drills") h. Primary caregiver mental illness or addiction i. Losing a home (eviction, fire)/homelessness/highly transient families j. Media violence (TV, movies, video and computer games) k. Death of primary caregiver or family member (don't protect children from death; don't give easy explanations that avoid the reality; but do use age-appropriate ideas for helping them understand and cope) 1. Severe illness (self) m. Severe illness (primary caregiver) n. Frequent hospitalization/medical procedures o. Foster-care placements p. Disrupted placements (including military deployment and adoption) 3. Biological Trauma that can cause behavioral symptoms a. History of head injury b. In utero drug exposure c. Prenatal issues and care (high risk pregnancy) d. Gl issues e. Compromised vision (darkened rooms may be a trigger) f. Hearing impairment g. Speech/language delay h. Seizure disorder i. Sleep deprivation i. Impacts short-term memory (hard to move these to long-term memory) ii. Reduced frustration tolerance iii. Mood swings iv. Meltdowns v. Poor judgment vi. Impacts depth perception vii. Impacts decision-making 4. Trauma and the Brain a. Babies are born with all the neurons they will ever have; approximately 100 billion, but few synapses b. Synapses develop in response to stimulation (learning) c. These synapses form networks in the brain: "Neurons that fire together, wire together." d. Unstimulated or under stimulated neurons are "pruned off" e. Traumatic events trigger chemical changes in the brain, including increases in stress hormones such as cortisol and adrenaline resulting in hyperarousal. f. The brain responds by activating the fight or flight response, including hypervigilance to threats. On-going trauma causes this to be an on-going reaction, with no relief. g. The longer children are exposed to trauma, the more affected their brains can be h. PTSD causes stress hormones to remain at high alert, never reach baseline levels i. Response to trauma is mediated in the brain by the locus coeruleus: Regulates attention, arousal, sleep, learning, memory, anxiety, pain, startle response, and irritability. j. Repeated or prolonged exposure to trauma / stress can lead to increased sensitivity in the brain to these reactions and circumstances surrounding the trauma. k. Note: You are not to diagnose ADHD until you can rule out trauma and Traumatic Brain Injury (TBI) 1. Kindling: Exposure to trauma/stress at critical phases in development becomes encoded in the brain and sensitizes the person react disproportionally when facing triggering experiences / stimuli m. Repeated exposure to trauma leads to overstimulation of the brainstem and midbrain which can result in attention problems, impulsivity, and poor emotional self-regulation. n. (Lester, et all, 2003) o. Violent behaviors in youth "...are not senseless, they are not beyond our understanding... they arise from children reflecting the world in which they have been raised." (Perry, B.D. 1996) p. Children who are exposed to violence (including domestic violence in the home, community, yelling, and physical abuse) learn to attend more to violent stimuli than other stimuli. Brains exposed. trauma are therefore primed to attend to violent stimuli at the expense of other stimuli (National Scientific Council on the Developing Child, 2008) q. Children exposed to violence perceive events as being threatening and react I accordingly. Trauma exposure in children: Shorter Telomeres and higher mtDNA content and is associated with major depression, depressive disorders, anxiety disorders, and substance abuse. These changes may represent advanced cellular aging. Basically, trauma affects genes and brains age faster if traumatized. (Tyrka, et al, 2015 5. Trauma and the Body: a. Trauma often causes either. i. Dissociations: Feeling numb, unaware of physical sensations, difficulty making connections, hurting self or doing dangerous activities in order to just feel something. This can lead to re-victimization when the alert system fails. They aren't recognizing real warning signs ii. Hyper-responsive: Avoid physical sensations t prevent reliving trauma. They cannot tolerate touch so they avoid relationships after the assault. 6. Attachment Disruption as Trauma: Expanding the Definition of Trauma 7 a. Attachment: The ability to form close, lasting relationships with others; bonding. b. Infants are born totally dependent on adults for survival c. Infants' survival instinct is to bond with primary caregivers to survive, AND to evoke desire to care for the child in the caregiver (to be cute, people pleaser, etc.) d. When this relationships becomes perverted, that instinct doesn't go away. Therefore, infants keep trying to attach and lose the sense of self-preservation. e. Secure attachments can act as buffer to stress because they perceive the attachment will keep them safe, even in the face of danger. Adverse Childhood Experiences (ACE) a. ACE disrupted neurodevelopment Social, emotional, and cognitive impairment Adoption of health risk behaviors Disease, disability, social problems, jail early death (Anda, 1995) b. Increase ACE score increases the risk for the following: (CDC, 2015) i. Alcoholism ii. Chronic obstructive pulmonary disease (390%) iii. Depression (460%) iv. Miscarriages v. Drug use vi. Heart disease vii. Liver disease (240%) viii. Domestic violence ix. Multiple sexual partners x. STDs xi. Smoking xii. Suicide attempts (1220%) xiii. Unintended pregnancies xiv. Early smoking xv. Early sexual activity xvi. Teen pregnancy c. ACES (study): www.acestoohigh.com i. Adverse childhood experiences are associated with adult sleep disorders ii. Women with early abuse history are seven times more likely t be sexually assaulted as adults 8. Proactive Factors that Build Resilience: a. Caring relationships with parents or extended family members b. Good health and a history f adequate development c. Good peer relationships (teach them how to make friends) d. Hobbies and interests e. Above average intelligence f. Easy temperament g. Positive disposition h. Active coping style i. Positive self-esteem Good social skills k. Internal locus of control 1. Balance between seeking help and seeking autonomy m. "It is easier to build strong children than to repair broken men." (Frederick Douglass) 9. Intergenerational Trauma a. Trauma affects families through the generations. Examples: Incest, physical and emotional abuse, neglect, domestic violence, attachment disruptions, foster-care, chaotic home environment / frequent moves, instability, mental illness, substance abuse. b. The patient is the relationship-you are always assessing and treating attachment. c. When stressed, we become our parents. d. Identify and break the cycle of violence. 10. Genetic Influences in PTSD (Goenjian, et al, 2015) Two gene variants are involved: COMT and TPH-2 i. COMT is an enzyme that degrades dopamine (which controls the brain's reward and pleasure centers, regulates mood/thinking/attention/behavior) 11 TPH-2 controls the production of serotonin (which regulates mood, sleep, and alertness) iii. Predisposition for PTSD up to 60 percent - you can be predisposed to PTSD b. Immune System i. Identified putative causal signatures for PTSD development displaying an over-expression f genes enriched for functions of innate-immune response and interferon signaling (Type-I and Type-II) ii. In marines with PTSD post-service: Over-expression of genes involved in hemostasis (stopping bleeding) and wound responsiveness. Chronic levels of stress impair proper wound healing during and after explore to the battlefield. c. Offspring of trauma survivors (Holocaust) with PTSD: Significantly lower cortisol levels 11. Behavioral Effects of Early Trauma Exposure: a. Inability to concentrate b. Hyperarousal (psychomotor agitation) c. Problems with memory d. Inappropriate emotional outbursts e. Difficulty trusting/attaching to others f Self-defeating behaviors g. Insomnia h. Nightmares i. Anxiety j. Dissociations k. Numbness 1. Depression m. Antisocial behavior School Effects: i. Lower grades ii. Negative attention-seeking iii. Aggression iv. Poor social experiences v. Scapegoating vi. Suspensions (This practice does not work because they would rather be home anyway) vii. Expulsions viii. Defiance ix. Bullying x. Oppositionality xi. Property damage xii. Truancy 12. Trauma vs. ADHD (Same symptoms except where modification is indicated) a. Inattention (trauma: due to preoccupation) b. Psychomotor agitation (trauma: occurs during flashbacks) c. Impulsivity (trauma: When triggered) d. Reduced concentration e. Grades falling f. Poor social skills g. Factors to consider: i. Onset ii. iii. With whom? Where are symptoms seen? iv. What are preceding conditions? v. Look for common factors vi. Did medication work? h. Rule out before diagnosing with ADHD: i. Trauma 11 Anxiety elevated lead Sensory issues iv. Sleep issues V. Head trauma References: Unless otherwise noted all references are from Miller, 2015. Anda, R. The health and social impact of growing up with adverse childhood experiences: The human and economic costs of the status http://www.acestudy.org/files/Review of ACE_Study_with_references_summary_table 2 pdf. Retrieved August 20, 2009 Goenjian, A. et al. (2015). Association of COMT and TPH-2 genes with DSM-5 based PTSD symptoms. Journal of Affective Disorders; 172:472 Lester, P., Wong, S.W., Hendren, R.L. (2003). The neurobiological effects of trauma. Adolescent Psychiatry. Retrieved August, 2009. http://findarticles.com/p/articlesmi_qa3882/is_200301/ai_n9209872/pg_4/?tag=content;c oll. Miller, J.R. (2015). Trauma-informed care: treating mental health effects of early trauma. Brentwood, TN: Cross Country Education. National Scientific Council on the Developing Child. (2008). Mental health problems in early childhood can impair learning and behavior for life: Working Paper #6. http://www.developingchild.net. Retrieved May 21, 2009