NR606 / NR 606 Week 7 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Week 7 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions What did the CDC and Kaiser Permanente investigate? Childhood abuse, neglect, and stressful events What did the study find? Strong relationship between ACEs and health risk behaviors and disease in adulthood What did later studies find? ACEs increase likelihood of adversity, chronic illness, and early death What are some examples of later studies? Boppre & Boyer (2021), LaNoue et al. (2020), Lee et al. (2020), Struck et al. (2021) What are some examples of ACEs? Sexual or domestic violence, abuse, neglect, unsafe home environment. How do ACEs affect the developing brain? They adversely affect brain structure and functioning. What factors impact a child's response to trauma? Frequency, seriousness, type of traumatic event, prior trauma history, and availability of support. How common are ACEs in adults? One in six adults have experienced four or more ACEs. What are the leading causes of death related to ACEs? Five or more of the top 10 leading causes of death. Who is at greater risk of experiencing four or more ACEs? Females and racial/ethnic minority groups. What is the ACE Pyramid? Conceptual framework for studying ACEs. What did the ACE study reveal? ACEs are strongly related to risk factors for poor health and social consequences. What did the ACE study identify? Risk factors for ACEs and informed prevention programs. What does the ACE Pyramid represent? Mechanisms by which ACEs influence health and well-being. What is at the top of the ACE Pyramid? Generational embodiment / Historical trauma. What is in the middle of the ACE Pyramid? Social conditions / Local context. What is at the bottom of the ACE Pyramid? Early death. What is disrupted by ACEs? Neurodevelopment. What impairments can result from ACEs? Social, emotional, and cognitive impairment. What behavior may be adopted as a result of ACEs? Health risk behavior. What problems can arise from ACEs? Disease, disability, and social problems. What are individual risk factors for ACEs? Factors specific to the individual's circumstances. What is a lack of closeness to parents/caregivers? Emotional distance from parents or caregivers. What is early sexual activity? Engaging in sexual behavior at a young age. What does it mean to have few or no friends? Having a small or nonexistent social circle. What are friends who engage in aggressive or delinquent behavior? Peers who participate in violent or criminal activities. What are caregiving challenges related to children with disabilities, mental health issues, or chronic physical illnesses? Difficulties faced by caregivers of children with special needs. What is a limited understanding of children's needs or development? Lack of knowledge about child development and their requirements. What are caregivers who were abused or neglected as children? Parents or caregivers who experienced abuse or neglect during their own childhood. Who are young caregivers or single parents? Individuals who take care of children at a young age or without a partner. What are the effects of low income or low levels of education? Negative impact of poverty and limited education on parenting. What are high levels of parenting stress or economic stress? Significant stress experienced by parents due to financial or parenting challenges. What is isolation in the context of risk factors? Being socially isolated or lacking a support network. What are high conflict and negative communication styles? Frequent arguments and unhealthy communication patterns within the family. What are attitudes accepting of or justifying violence or aggression? Beliefs that condone or rationalize violent or aggressive behavior. What are high rates of violence and crime in the community? A community with a significant amount of violent and criminal activities. What are high rates of poverty and limited educational and economic opportunities? A community with a large number of people living in poverty and lacking educational and economic prospects. What are high unemployment rates? A community with a high percentage of people without jobs. What is easy access to drugs and alcohol? Readily available substances that can be abused. What are few community activities for young people? Limited opportunities for youth engagement and involvement in the community. What is unstable housing and frequent resident movement? Lack of stable housing and frequent relocation of residents. What is food insecurity? Lack of consistent access to nutritious and sufficient food. What is intimate partner violence? Abuse or violence within a romantic or domestic relationship. What is physical abuse? Parent or caregiver causing physical injury to a child. What percentage of child maltreatment cases involve physical abuse? Approximately 10%. What are some effects of physical abuse on children? Struggle with self-esteem, social relationships, trust, stress reactions. What is sexual abuse? Any interaction where a child is used for sexual gratification. What percentage of child maltreatment cases involve sexual abuse? Approximately 7%. What are some long-term consequences of sexual abuse? Increased risk for substance abuse, risky sexual behaviors, self-harm, PTSD, depression, and anxiety. What is child neglect? Failure to provide for a child's needs. What percentage of child maltreatment cases involve neglect? Approximately 60%. What are some age-appropriate needs that can be neglected? Food, shelter, clothing, education, medical care, supervision, and emotional needs. What can neglect result in? Long-lasting physical or psychological harm. What is neglect often tied to? Poverty. What are some signs of neglect in children? Poor hygiene, inadequate weight gain, inappropriate clothing. What is household instability? Contributing factor to adverse childhood experiences (ACEs). What can cause family instability? Parental mental illness, stress, substance abuse, or suicide. How does parental mental health problems affect children? Positively associated with mental health problems in children and adolescents. What is a risk factor for family instability? Violence toward the mother in the family. What can children exposed to family instability struggle with? Social, cognitive, or behavioral difficulties. What can cause instability in children? Loss of a parent or caregiver due to death, divorce, abandonment, or incarceration. How many children worldwide lost a parent or caregiver due to the COVID-19 pandemic? Over 5.2 million by 2022. Why was the loss of a parent or caregiver included in the National Survey of Children's Health? Due to its profound impact on a child's psychological well-being. What are cultural challenges? Challenges related to a person's cultural background. How does community violence affect children? Can have negative effects on their well-being and development. What are some examples of community violence? Gang violence, shootings, or domestic violence. How can cultural challenges impact children? Can affect their sense of identity, belonging, and well-being. What are some examples of cultural challenges? Language barriers, discrimination, or conflicting cultural values. What is community violence? Exposure to interpersonal violence in public settings Give examples of community violence. Shootings, fights, bullying, war, terrorist attacks What is bullying? Aggression or harassment causing harm to someone perceived as less powerful What are the types of bullying? Physical, verbal, social, cyberbullying What is cyberbullying? Bullying that occurs through electronic means What are the effects of bullying? Stress, trauma, anger, isolation, poor self-esteem, school issues, health problems, self injury, eating disorders, suicidal or homicidal thoughts What are the effects of community violence? Heightened fear and stress What is peer victimization? Another term for bullying What is the definition of racism? Discrimination based on race What is structural racism? Systemic discrimination embedded in institutions and policies What are traumatic stress reactions? Psychological responses to traumatic events What is school avoidance? Avoiding school due to bullying or other reasons What is racism? System of assigning value based on physical properties. Give an example of overt racism. Hate crimes and slurs. Give an example of subtle racism. Discrimination, marginalization, prejudice in everyday interactions. What are the potential health consequences of racism? Health disparities, trauma. How is racism considered a major life stressor for Black youth? Bernard et al. propose it as a culturally informed ACE. What are the lasting health consequences of childhood adversity perpetuated by racism? Health disparities. Give examples of ACEs that place a child in immediate physical danger. Traumatic brain injury, fractures, burns. What are some mental health consequences of ACEs? Depression, anxiety, PTSD. How can ACEs impact maternal health? Unintended pregnancy, pregnancy complications, fetal death. What infectious diseases can be impacted by ACEs? HIV, STDs. What are some physical health consequences of ACEs? Cancer, diabetes. What risky health behaviors can be influenced by ACEs? Alcohol and drug abuse, unsafe sex. What are some autoimmune disorders that can be increased by ACEs? Arthritis. What is the relationship between ACEs and type 2 diabetes? Increased risk. What are some mental illnesses that can be influenced by ACEs? Depression, anxiety, PTSD. What are some risky behaviors associated with ACEs? Substance use disorder, suicide, unemployment. What are the potential impacts of ACEs on education, occupation, and income? Opportunity disparities. How does the wounded child adapt? Develops protective behaviors that hinder healthy relationships. What is the wounded child? A young, vulnerable child wounded by abuse or neglect. What are some characteristics of the wounded child? Overwhelmed, longing for connection, focus of trauma work. Who usually brings dysfunction into adult relationships? Not usually the wounded child. What is the adaptive child? A child's version of an adult that protects the wounded child. What are some characteristics of the adaptive child? Perfectionist, sees world in black and white, cares only about self-preservation. How does the adaptive child view intimacy? As a threat. Who does the adaptive child react to and identify with? Both the aggressor and themselves. What is the functional adult? The part of the psyche that makes thoughtful decisions. What are some characteristics of the functional adult? Mature, thoughtful, forgiving, understands trauma's impact on relationships. How is the functional adult different from the child parts? Adaptable and capable of learning and using new skills. According to Terry Real, who creates problems in a client's relationships? The adaptive child. What do interventions need to focus on? The adaptive child to engage the functional adult. What is the ACE questionnaire? Assessment of childhood adversity exposure. What does a high ACE score indicate? High exposure to adversity in childhood. Does a high ACE score guarantee negative outcomes? No, it does not guarantee negative outcomes. What can providers do to support children with high ACE scores? Teach stress-reduction techniques and positive coping skills. How can parent training help caregivers? Learn healthy ways to manage child behaviors. What can early childhood programs provide? Protective factors for positive development in young children. What is resilience? Ability to adapt and recover from adversity. What are some factors that promote resilience? Close relationships, positive parenting, sense of purpose, individual competencies, social connections, support services, community support. What does trauma-informed care mean? Approach that recognizes and responds to the impact of trauma. What are the six guiding principles of trauma-informed care? Understanding trauma's impact, determining treatment plan, avoiding retraumatization. Why is trauma-informed care important? To effectively care for clients who have experienced adversity. What can trauma-informed care help providers with? Better understanding the impact of trauma and developing appropriate treatment plans. What does trauma-informed care aim to avoid? Retraumatization of clients. What can providers do to enhance resilience? Enhance biological and developmental characteristics, provide external protective factors. What can resilience help offset? Neurobiological changes associated with trauma. What does resilience protect? Developing brain, immune system, and body from negative effects of trauma. What is the role of caregivers in promoting resilience? Close relationships and positive parenting skills. What are some individual competencies that promote resilience? Problem-solving skills, self-regulation, autonomy. What are some community resources that support resilience? Access to support services for parents and families, community support resources. What is safety in trauma-informed care? Creating physical and psychological safety to avoid retraumatization. Why is trust and transparency important in trauma-informed care? Establishing a therapeutic alliance and empowering intake procedures. How does peer support contribute to trauma-informed care? Fosters safety, hope, and healing through shared experiences. What is the role of collaboration in trauma-informed care? Empowering clients to be active in treatment decisions. How does empowerment and choice impact trauma-informed care? Gives clients a sense of control and promotes self-efficacy. Why is cultural, historical, and gender awareness important in trauma-informed care? Acknowledges trauma related to culture, history, or gender identity. What are some psychological distress symptoms after a traumatic event? Anxiety, fear, anhedonia, anger, aggression, dissociative symptoms What are some long-term reactions to traumatic events? Depression, anxiety, behavioral changes, academic difficulties When do symptoms often present in children? When reminded of the traumatic event What manual provides diagnostic criteria for disorders associated with traumatic events? DSM-5-TR What percentage of adolescents experience PTSD each year? Approximately 5% What are some factors that increase the risk of developing PTSD? Prior trauma, adverse childhood experiences, personal or family history of psychiatric disorders, female gender, severe trauma exposure What are some consequences of PTSD? Social, occupational, and physical impairment, physical health problems, reduced quality of life, increased risk of suicide What are some common comorbidities with PTSD? Major depressive disorder, anxiety disorder, substance use disorder What is PTSD? Occurs after exposure to death, injury, or violence. What are intrusion symptoms? Recurrent memories, nightmares, flashbacks, distress when exposed to trauma cues. What are avoidance symptoms? Avoidance of distressing memories, reminders of the trauma. What are negative cognitive or mood symptoms? Memory deficits, negative beliefs, distorted cognitions, persistent negative emotions. What are arousal or reactivity symptoms? Irritability, aggression, risk-taking, hypervigilance, concentration difficulty, startle response, sleep disturbances. When do symptoms of PTSD typically begin? Within the first 3 months after the traumatic event. How long must symptoms persist for a PTSD diagnosis? At least 1 month. What are some examples of traumatic events that can cause PTSD? Actual or threatened death, serious injury, sexual violence. Can PTSD be caused by exposure to traumatic events through media? No, the source of exposure must not be through media. Can witnessing a traumatic event cause PTSD? Yes, witnessing a traumatic event can cause PTSD. Can learning about the violent or accidental death of a loved one cause PTSD? Yes, learning about the death of a loved one can cause PTSD. What are some examples of intrusion symptoms in children? Repetitive play expressing themes of the trauma. What are some examples of avoidance symptoms? Avoidance of distressing memories, thoughts, feelings, and reminders of the trauma. What are some examples of negative cognitive or mood symptoms? Memory deficits, negative beliefs, distorted cognitions, persistent negative emotions, detachment from others, inability to experience positive emotions. What are some examples of arousal or reactivity symptoms? Irritability, aggression, risk-taking, hypervigilance, concentration difficulty, exaggerated startle response, sleep disturbances. What are some examples of sleep disturbances in PTSD? Difficulty falling asleep, staying asleep, or having nightmares. What are screening instruments used for in children? To assist with the diagnosis of trauma. How are screening tools selected for children? Based on the age of the child. Who completes the screening tool for children under the age of 6? Parent or caregiver. Who may complete the screening for children ages 7-17? Both the child and parent. What are some evidence-based treatments for children and adolescents with PTSD? Trauma-focused cognitive behavior therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), narrative exposure therapy, and classroom-based interventions. What types of therapy can be used for the treatment of PTSD in children and adolescents? Individual or group-based therapy. Why is parental involvement important in the treatment of children and adolescents with PTSD? To help establish family resilience. What is acute stress disorder? A diagnosis given when a child or youth experiences symptoms after a traumatic event. What are some symptoms of acute stress disorder? Intrusive thoughts, negative mood, dissociative symptoms, avoidance, or arousal symptoms. How long do the symptoms of acute stress disorder typically last? From three days to 1 month immediately following exposure to the traumatic event. What are some additional symptoms that clients with acute stress disorder may experience? Catastrophic thoughts, panic attacks, guilt, separation anxiety (in young children), and post-concussive symptoms. What are post-concussive symptoms? Symptoms such as headaches, sensitivity to light, difficulty concentrating, irritability, and dizziness that can occur even without a head injury. Which type of trauma is associated with a higher incidence of acute stress disorder? Interpersonal trauma, such as assault or rape. What types of trauma can lead to acute stress disorder? Interpersonal trauma (assault, rape) or traumatic motor vehicle/industrial accidents. What is the difference between acute stress disorder and PTSD? Acute stress disorder occurs immediately following a traumatic event and lasts up to 1 month, while PTSD is diagnosed when symptoms persist for longer than 1 month. What is the timeframe for diagnosing acute stress disorder? Symptoms must last from three days to 1 month immediately following exposure to the traumatic event. What is the incidence of acute stress disorder compared to traumatic motor vehicle or industrial accidents? Higher in clients who experienced interpersonal trauma (assault, rape). What are dissociative symptoms? Depersonalization and derealization. What is the Structural Dissociation Model? A model that explains the internal conflict between defense and attachment systems. What is the defense system in the Structural Dissociation Model? The system that shields a child from harm. What is the attachment system in the Structural Dissociation Model? The system that seeks love and care from a parent. What can happen when the defense and attachment systems conflict? Conflicting parts can separate, leading to a split sense of self and dysregulated nervous system. How many symptoms must be present for a diagnosis of acute stress disorder? Nine symptoms of intrusion, negative mood, dissociation, avoidance, or arousal. When do symptoms of adjustment disorders typically develop? Within 3 months of the onset of a new stressor. How long do symptoms of adjustment disorders persist? They do not persist past 6 months after the initial stressor has resolved. When can persistent adjustment disorder occur? When stressors have no clear resolution, such as physical disability or living in a community with high crime rates. Who is at high risk for adjustment disorders? Children with multiple adverse childhood experiences (ACEs). What are the specifiers used to classify adjustment disorders? Depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct. What is the initial treatment for adjustment disorders? Family therapy and/or individual therapy What is the purpose of parent training in adjustment disorders? To ensure consistent addressing of behavior problems When is medication used in adjustment disorders? If symptoms persist beyond 6 months What is reactive attachment disorder (RAD)? A trauma- and stressor-related condition where a child fails to form an emotional bond with caregivers What are common causes of RAD? Abandonment, severe neglect, or maltreatment What are the characteristics of children with RAD? Difficulty forming emotional attachments, decreased ability to experience positive emotions, inability to seek or accept physical or emotional closeness, violent reactions to attempts of holding or cuddling How do children with RAD behave? Unpredictable behavior and moods, living in a constant state of fight, flight, or freeze mode, difficult to discipline or console Do children with RAD struggle even with treatment? Yes What can be helpful for children with RAD? Early identification and intervention What is critical in the care of children with RAD? Parent education and support What kind of team is involved in the care of children with RAD? An interprofessional team of providers What is prolonged grief disorder? Persistent, maladaptive grief causing significant impairment in functioning. How long do symptoms of prolonged grief disorder persist in adults? At least one year following the death of a loved one. How long do symptoms of prolonged grief disorder persist in children and adolescents? 6 months following the death of a loved one. What are some symptoms of prolonged grief disorder? Disbelief, avoidance, emotional pain, difficulty engaging, loneliness, meaninglessness. How do children express distress in prolonged grief disorder? Through play, behavior changes, regression, separation anxiety. What are some specific behaviors children may exhibit in prolonged grief disorder? Excessive worry about health, asking questions about death. How might children with prolonged grief disorder feel different from their peers? Difficulty with loss reminders at school or with peers. What feelings might adolescents with prolonged grief disorder endorse? Feelings of 'giving up' on hopes and aspirations. What are some consequences of prolonged grief disorder? Increased substance use, risk for cardiovascular disease, risk of dropping out of school. What are some potential interventions for clients with prolonged grief disorder? Referral to grief specialist, bereavement support groups. Adverse childhood experiences (ACEs) traumatic events that occur before a child reaches age 18 -Growing up in a family with mental health or substance use problems can also cause traumatic injury -ACEs, stressful or traumatic experiences • sexual or domestic violence, physical or emotional abuse, or neglect • home environment that cause them to feel unsafe or under constant threat growing up in a family with substance misuse or mental health problems • situations that create instability death, divorce, separation, or incarceration of family members in adults have experienced four or more types of ACEs one in six Trauma- and Stressor-Related Disorders Post-traumatic stress disorder Acute stress disorder Adjustment disorders Reactive attachment disorder Prolonged grief disorder freeze vs. shutdown trauma responses -Freeze • client is HYPERaroused. • muscles are tense, full of energy, but can't release it. • similar levels of sympathetic & parasympathetic activation. • Increased heart rate/BP. • pt might say, "I feel stuck," "I can't move," or "I feel like I am encased in cement." • Eyes widen. • body is ready to return to fight/flight as soon as the threat passes. -Shutdown/Collapse • client is HYPOaroused. • muscles are flaccid & loose. • parasympathic nervous system is dominant. • Decreased heart rate/BP/temp. • pt may not be able to speak at all. • Blank stare. • Sensory info stops at the thalamus. It doesn't reach the cortex. pt less aware of their internal & external world. • Endorphins release to numb pain. Dynorphins release, which can make the client feel detached from their body. • Can result in fainting. How Trauma Impacts Four Different Types of Memory: Semantic Memory -What it is: memory of general knowledge & facts. -Explicit Memory -Example: You remember what a bicycle is. -How trauma can affect it: Trauma can prevent info (like words, images, sounds, etc.) from different parts of the brain from combining to make a semantic memory. -Related brain area: The temporal lobe and inferior parietal cortex collect information from different brain areas to create semantic memory. How Trauma Impacts Four Different Types of Memory: Episodic Memory -What it is: The autobiographical memory of an event of experience - including the who, what, and where. -Explicit Memory -Example: You remember who was there and what street you were on when you fell off your bicycle in front of a crowd. -How trauma can affect it: Trauma can shutdown episodic memory and fragment the sequence of events. -Related brain area: The hippocampus is responsible for creating and recalling episodic memory. How Trauma Impacts Four Different Types of Memory: Emotional Memory -What it is: The memory of the emotion you felt during an experience. -Implicit Memory -Example: When a wave of shame or anxiety grabs you the next time you see your bicycle after the big fall. -How trauma can affect it: After trauma, a person may get triggered and experience painful emotions, often without context. -Related brain area: The amygdala plays a key role in supporting memory for emotionally charged experiences. How Trauma Impacts Four Different Types of Memory: Procedural Memory -What it is: The memory of how to perform a common task without activtely thinking about it. -Implicit Memory -Example: You can ride a bicycle automatically without having to stop and recall how it's done. -How trauma can affect it: Trauma can change patterns of procedural memory. For example, a person might tense up and unconsciously alter their posture, which could lead to pain or even numbness. -Related brain area: The striatum is associated with producing procedural memory and creating new habits. Four Key Ways Collapse/Submit response to trauma Can Present in a Client. 1. Compliance / Obedience: -going through the motions of life on autopilot -feel detached from bodily experiences -feelings no longer guide their actions • Ex: domestic violence pt may no longer be aware of fear, which keeps the person in the situation. 2. Treatment-Resistant Depression: -ongoing, inescapable traumatic stress can lead to treatment-resistant depression. • defining feature: learned helplessness. 3. Interpersonal Conflict: -difficulty engaging with others &/or setting boundaries. 4. Social Avoidance / Desire to Isolate: C -difficult to engage in basic daily activities • making meals or personal hygiene -may withdraw socially. Brain-based approaches to help clients after trauma -Top-down approaches • Encourage different ways of thinking • Cognitive-Behavioral Therapy (CBT) • Dialectical-Behavior Therapy (DBT) • Mindfulness-based Cognitive Therapy (MBCT) -Bottom-up approaches • Ways to cope with emotions and defenses • Eye Movement Desensitization and Reprocessing (EMDR) • Yoga • Trauma Resiliency Model (TRM)® greater risk of experiencing four or more ACEs. Females and racial/ethnic minority groups ACEs statistics -almost half U.S. children (about 35 million) have had 1+ ACEs -over 1/4 of child abuse/neglect is children 3 • victimization most common for children under a year Tips when working with traumatized children -establish a daily routine • predictability can be calming -concentrate on support -help build self-regulation • schedule regular brain breaks to help children stay focused -lead with empathy -provide encouragement -see what you can do to help • ask children directly what you can do to help them make it through the day. Challenging behaviors that result from toxic stress: -Suffer anxiety in unfamiliar situations -Difficult to soothe -Aggressive or impulsive -Prone to bedwetting -Become withdrawn -Tend to lose recently acquired skills The Adverse Childhood Experiences (ACE) Study -assessing, retrospectively & prospectively, the long-term impact of abuse & household dysfunction during childhood on the following outcomes in adults: • disease risk factors & incidence, quality of life, health care utilization, & mortality. -Largest investigation between childhood adversities and adult wellbeing • conducted at a Kaiser Permanente Facility in California from -Study looked at 10 ACEs (3 categories) • Abuse • Neglect • Household Challenges ACE Pyramid -represents the conceptual framework for the ACE study -top to bottom the pyramid shows the mechanisms by which ACEs influence health and well-being from conception to death • Early death (TOP) • Disease, disability, and social problems • Adoption of health risk behavior • Social, emotional, and cognitive impairment • Disrupted neurodevelopment • ACEs • Social conditions / Local context • Generational embodiment / Historical trauma (BOTTOM) ACE Risk Factors: Individual Risk Factors • lack of closeness to parents/caregivers • Early sexual activity • Few or no friends • Friends who engage in aggressive or delinquent behavior ACE Risk Factors: Family Risk Factors • Caregiving challenges related to children with disabilities, mental health issues, or chronic physical illnesses • limited understanding of children's needs or development • Caregivers who were abused or neglected as children • Young caregivers or single parents • Low income or low levels of education • High levels of parenting stress or economic stress • Isolation • High conflict & negative communication styles • Attitudes accepting of or justifying violence or aggression ACE Risk Factors: Community Risk Factors • High rates of violence & crime • High rates of poverty & limited educational & economic opportunities • High unemployment rates • Easy access to drugs & alcohol • Few community activities for young people • Unstable housing & where residents move frequently • Food insecurity ACE Categories -Abuse -Neglect -Household Instability -Cultural Challenges ACE: Abuse -Intimate Partner Violence (IPV) -Intimate Partner Violence (IPV) • AKA domestic violence • ind harms or threatens to harm a current or past partner or spouse • controlling or coercive behavior or physical, sexual, verbal, financial, or emotional abuse • can include: stalking, terrorizing, blame, humiliation, manipulation, or intentional isolation from family and friends • Children may witness or be directly injured ACE: Abuse -Psychological Maltreatment (PM) -Psychological Maltreatment (PM) • AKA emotional abuse • failure of a parent or caregiver to meet a child's psychological or emotional needs • attacks a child's sense of self, is demeaning or humiliating • acts of commission, such as verbal attacks, or acts of omission, such as emotional unresponsiveness • embedded in all other forms of child maltreatment ACE: Abuse -Physical Abuse -Physical Abuse • parent or caregiver commits an act that causes physical injury to a child or adolescent • approx 10% of child maltreatment cases • may struggle with self-esteem or social relationships • may have trouble trusting authority figures • Some children develop stress reactions • may act out, become aggressive or develop behavior problems, while others may become anxious, numb, or withdrawn • Some lose typical fight-or-flight reactions, making them more susceptible to danger ACE: Abuse -Sexual Abuse & Sexual Violence -Sexual Abuse & Sexual Violence • any interaction between a child and an adult or another child in which the child is used for the sexual gratification of the perpetrator or an observer • approx 7% of child maltreatment cases • may include touching and non-touching behaviors • long-term consequences for physical & mental health: increased risk for substance abuse, engagement in risky sexual behaviors, self-cutting or suicidal behavior, PTSD, depression, anxiety ACE: Neglect -most common forms of child maltreatment • approx 60% of cases investigated by CPS -occurs when a parent/caregiver fails to provide for a child's age-appropriate needs • food, shelter, clothing, education, medical care, supervision, emotional needs -can result in long-lasting physical or psychological harm -often tied to poverty -may present with poor hygiene, inadequate weight gain, clothing that fits poorly/is inappropriate for weather -can disrupt healthy development ACE: Household Instability -may be caused by: parental mental illness, stress, substance abuse, suicide, presence of violence toward the mother in the family -Children exposed to family instability may struggle socially, cognitively, or behaviorally. -instability from the loss of a parent or caregiver due to death, divorce, abandonment, or incarceration • 2022, 5.2 million children worldwide lost a parent/caregiver due to COVID ACE: Cultural Challenges -Community Violence • exposure of a child to acts of interpersonal violence in a public setting by individuals not intimately connected to the child • Ex: shootings in public areas, fights, bullying, war or warlike conditions, terrorist attacks • often occurs suddenly, without warning -Bullying • AKA peer victimization • form of aggression or harassment • inflicts social, emotional, physical, or psychological harm on someone a perpetrator perceives to be less powerful • Cyberbullying: via text, email, or social media. -Racism and Structural Racism • assigning value and providing opportunity based on physical properties such as skin color • hate crimes, slurs, discrimination, marginalization, prejudice • major life stressor for Black youth Effects of Bullying -Stress, anxiety, or depression -Traumatic stress reactions -Anger or frustration -Isolation or loneliness -Poor self-esteem or self-image -School avoidance or poor school performance -Separation anxiety -Health complaints -Self-injury -Eating disorders -Suicidal or homicidal ideations or actions Consequences of ACEs Untreated, short- & long-term health outcomes -immediate physical danger -cumulative & prolonged stress -Toxic stress can disrupt brain development • negative forms of stress • cortisol produced -stress response system constantly activated and other neuropathways not getting as much energy -Parts of the brain that might be weakened, those regulating complex functions like: • emotional self-regulation • social interactions • abstract thinking -social, behavioral, and cognitive challenges -Risk for: Major depression, suicidality, anger management, high risk behavior, adult criminality Exposure to ACEs increases the risk for: autoimmune disorders, arthritis, type 2 diabetes, cancer, and mental illness how childhood trauma affects adult relationships -Wounded Child: Was wounded by abuse or neglect • A young, vulnerable, possibly pre-verbal child • Often overwhelmed, yet longs for connection • Much trauma work focuses on the wounded child • But it's NOT usually the wounded child that brings dysfunction into adult relationships -Adaptive Child: A child's version of an adult that developed to protect the wounded child • Often a perfectionist, harsh and unforgiving • Sees the world in black and white • An older child • Unable to learn skills • Cares only about self-preservation • Views intimacy as a threat • Not only reacts to aggressor, but also identifies with aggressor Interventions for ACEs and Toxic Stress -support to prevent lifelong consequences -work with parents & children to teach stress-reduction techniques to enhance (+) coping skills -Parent training • help caregivers learn healthy, alternative ways to manage child behaviors -Early childhood programs • provide protective factors, support (+) development in young children -Factors That Promote Resilience • Close relationships with skilled caregivers or other caring adults • Caregiver knowledge & use of (+) parenting skills • Having a sense of purpose (faith, culture, identity) • Individual competencies (problem-solving skills, self-regulation, autonomy) • Opportunities to connect socially • Access to support services for parents & families • Community support resources 5 strategies to stop ACEs before they start 1. Strengthening economic supports for families 2. Changing social norms 3. Quality child care & education early in life 4. Enhancing parenting skills 5. Intervening to lessen harms & prevent future risk , , and are essential to prevent child abuse and neglect and to assure that all kids reach their full potential Safe, stable, nurturing relationships and environments Trauma-Informed Care -essential for caring for clients who have experienced adversity -Substance Abuse and Mental Health Services Administration ID'd 6 guiding principles: • Safety • Trust and Transparency • Peer Support • Collaboration • Empowerment & Choice • Cultural, Historical, & Gender Awareness At risk for PTSD -Prior trauma -Adverse childhood experiences -Personal or family history of psychiatric disorders -Female gender -Severe trauma exposure consequences of PTSD -social, occupational, & physical impairment -physical health problems -reduced quality of life -increased risk of suicide -more likely to present with comorbidities: • MDD • anxiety disorder • substance use disorder DSM-5-TR trauma- and stressor-related diagnoses: PTSD -client may have experienced the event personally or may have been a witness to the event • source of the exposure must not be through media, including movies, television, or the internet -Symptoms typically begin within the first 3 months after the traumatic event occurred, and the client must have symptoms for at least 1 month to be diagnosed -Intrusion symptoms • Recurrent, intrusive memories of the trauma; children may engage in repetitive play expressing themes of the trauma. • Distressing dreams or nightmares • Dissociative reactions, or flashbacks • Intense psychological distress or physiological reactions when exposed to cues that symbolize or represent an aspect of the trauma -Avoidance symptoms • Avoidance of distressing memories, thoughts, or feelings • Avoidance of reminders, including people, places, situations, of the traumatic event -Negative cognitive or mood symptoms • Memory deficits surrounding the traumatic event • Exaggerated negative beliefs of self or environment • Distorted cognitions and self-blaming behaviors r/t the cause or consequences of trauma • Persistent (-) emotions, including anger, guilt, fear, or shame • Feelings of detachment from others • Persistent inability to experience (+) emotions • Social withdrawal in children under the age of 6 -Arousal or reactivity symptoms • Irritability & verbal or physical aggression • Reckless or risk-taking behaviors • Hypervigilance • Concentration difficulty • Exaggerated startle response • Sleep disturbances ways early life trauma can effect people later in life Problems with emotional awareness Emotion dysregulation Social functioning Screening instruments for children to assist with the diagnosis of trauma. selected based on the age of the child -child under the age of 6, a parent or caregiver completes the tool • Child and Adolescent Trauma Screen-Caregiver (CATS-C) - 3-6 Years -children ages 7-17, both child & parent may complete the screening. • Child and Adolescent Trauma Screen (CATS) - 7-17 Years children and adolescents with PTSD tx -trauma-focused cognitive behavior therapy (TF-CBT) -eye movement desensitization and reprocessing (EMDR) -narrative exposure therapy -classroom-based interventions *Therapy may be individual or group-based *Parental involvement is important to help establish family resilience DSM-5-TR trauma- and stressor-related diagnoses: Acute Stress Disorder -To be diagnosed, client must present with nine symptoms of intrusion, negative mood, dissociation, avoidance, or arousal beginning or worsening after the traumatic event occurred. -differentiated from PTSD based on the timeframe in which the symptoms occur • acute stress disorder: symptoms that last from 3 days to 1 month immediately following exposure to the traumatic event -may experience catastrophic thoughts, panic attacks, separation anxiety & guilt r/t the event -Post-concussive symptoms: headaches, sensitivity to light, difficulty concentrating, irritability, dizziness, are common, even though a head injury may not have occurred Dissociative symptoms are common in both acute stress disorder and PTSD -may include: • depersonalization (feelings of detachment from one's own body) • derealization (feelings that one's surroundings are not reality) and Cherie is a 5-year-old whose uncle was killed in a drive-by shooting last week. Cherie has heard her mother and aunt talking about the murder in detail. For the past three nights, Cherie has woken from nightmares; she is not able to describe details from her dreams. Cherie's mother describes her as "jumpier" than usual since they learned of the event and she is concerned because she saw Cherie reenact a drive-by shooting while playing with her Barbie dolls. Does Cherie meet the diagnostic criteria for acute stress disorder? yes no no Rationale: Although Cherie presents with several symptoms that may be associated with acute stress disorder, she does not currently meet diagnostic criteria. Cherie has been exposed to the violent death of a loved one and is experiencing intrusion symptoms including nightmares and distressing memories of the event as evidenced by themes of the event used in play. Her mother has also noticed an exaggerated startle response. To be diagnosed with acute stress disorder, a client must present with nine symptoms of intrusion, negative mood, dissociation, avoidance, or arousal beginning or worsening after the traumatic event occurred. DSM-5-TR trauma- and stressor-related diagnoses: Adjustment Disorder -development of emotional or behavioral symptoms within 3 months of the onset of a new stressor -Symptoms cause significant impairment in social or occupational functioning but do not persist past 6 months after the initial stressor has resolved -Persistent adjustment disorder may occur when stressors have no clear resolution • physical disability or living in a community with high crime rates -classified using specifiers with: • depressed mood • anxiety • mixed anxiety & depressed mood • disturbance of conduct • mixed disturbance of emotions & conduct DSM-5-TR trauma- and stressor-related diagnoses: Reactive Attachment Disorder (RAD) -rare, occurs when a child fails to form an emotional bond with caregivers -commonly caused by abandonment, severe neglect, or maltreatment -difficulty forming emotional attachments to others -decreased ability to experience (+) emotions -unable to seek or accept physical or emotional closeness -can react violently to attempts to hold or cuddle them -Behavior & moods can be unpredictable • some children appearing to live in a constant state of fight, flight, or freeze mode -often difficult to discipline or console -Parent education and support are critical DSM-5-TR trauma- and stressor-related diagnoses: Prolonged Grief Disorder -persistent, maladaptive grief that causes significant impairment in social, occupational, or other areas of functioning -Symptoms persist for at least one year following the death of a loved one in adults and 6 months in children & adolescents • disbelief surrounding the death • avoidance of reminders that their loved one is dead • intense emotional pain or numbness • difficulty engaging with friends or interests • loneliness • sense of meaninglessness -Children may express their distress through: • play, behavior changes, regression, and separation anxiety, excessive worry about their health, questions about death -Adolescents may endorse feelings of "giving up" on hopes and aspirations due to the death of their loved ones Consequences of prolonged grief: -increased substance use -increased risk for cardiovascular disease -increased risk of dropping out of school Clients who experience prolonged grief disorder may benefit from: referral to a grief specialist and bereavement support groups Brief Grief Questionnaire -aid in the diagnosis of prolonged grief disorder • How much are you having trouble accepting the death of • How much does your grief still interfere with your life? • How much are you having images or thoughts of other thoughts about the death that really bother you? • Are there things you used to do when ? when s/he died or was alive that you don't feel comfortable doing anymore, or that you avoid? How much are you avoiding these things? -All questions answered with: Not at all: 0 Somewhat: 1 A lot: 2 -score of 4+ suggests ind may have complicated grief • Refer to grief specialist for further eval Rochelle is a 16-year-old high school junior who presents with her mother for an initial consult with the PMHNP. Two months ago, another high school student brought a gun to school and shot eight students and two teachers. Three victims died. Rochelle did not know any of the victims personally. Since the shooting, Rochelle has frequently been tearful, and she is angry at times. She and her classmates have been attending school virtually, but Rochelle has had difficulty with concentration and often skips classes. and she told her mother she will "never go back to that building again." Rochelle has also told her mother that she feels guilty for "making it out alive" and that life does not seem worth living any longer. Her mother reports that Rochelle, once a happy child, does not seem capable of happiness any longer, and she has started to stay out all night with friends; when she comes home in the morning, her PTSD Rationale: Rochelle meets the diagnostic criteria for PTSD. She has been involved in a traumatic event and has experienced recurrent memories of the event. Avoidance symptoms: she avoids external reminders of the trauma by refusing to go to the school building where the trauma occurred. Negative cognition/mood symptoms: she experiences a persistent negative emotional state as evidenced by crying, anger, and guilt. She is unable to experience positive emotions such as happiness. Arousal symptoms: she has difficulty concentrating and has engaged in risk-taking behaviors that were not present before the trauma. Her symptoms have lasted over a month, which rules out a diagnosis of acute stress disorder. Which of the following is the priority intervention for Rochelle? trauma-focused cognitive behavior therapy complete a suicide screening start sertraline 50 mg daily family-based therapy complete a suicide screening Rationale: Rochelle has expressed that life does not seem worth living. She is also experiencing survivor guilt which increases the risk of suicide. Although trauma-based therapy is essential to recovery, the client's immediate safety is the priority. Pediatric Mental Health Crisis -when a child is at risk of harm to self or others or if behaviors & emotions seem extreme or out of control -may occur due to mental health diagnoses, substance use, medical condition -may require emergency intervention or inpatient tx !!!!!!!!!Warning signs of a pediatric mental health crisis!!!!!!!! -expressing suicidal thoughts -threatening harm to self or others -engaging in self-harm such as cutting -displaying severe agitation or aggression -experiencing hallucinations or delusions -isolating from family & friends *If child or those close to them are in immediate danger of harm, safety is the priority. PMHNP should instruct parent/caregiver to contact 911 or go to the nearest emergency room Crisis resources for families -Crisis Text Line • text HOME to 741741 (volunteer crisis counselor) -State crisis hotlines • Michigan, Third Level Crisis Center, -NAMI Navigating a Mental Health Crisis guide • a-Mental-Health-Crisis/Navigating-A-Mental-Health Crisis?utm_source=website&utm_medium=cta&utm_campaign=crisisguide Suicide -2nd leading cause of death for people age 10 to 24 -younger children, suicide is often an impulsive act • associated with feelings of sadness, anger, confusion, or problems with attention & hyperactivity -teenagers, suicide attempts may stem from feelings of stress, insecurity, pressure to succeed, disappointment, or loss Risk factors in youth suicide -Hx of substance abuse -Physical disability or illness -Losing a friend or family member to suicide -Ongoing exposure to bullying behavior -Mental health condition -Recent death of a family member or a close friend -Access to harmful means -Relationship problems -Previous suicide attempts Protective factors in youth suicide -Connections to other non-parental adults -School safety -Closeness to caring friends -Overall resilience -Neighborhood safety -Awareness of & access to local health services -Academic achievement -Parent connectedness !!!!!!!!Warning signs for suicide include:!!!!!!!!! -openly suicidal statements or comments such as "I wish I was dead," or "I won't be your problem much longer." -changes in eating or sleeping patterns -frequent or pervasive sadness -complaints about emotion-related physical symptoms such as headaches or stomachaches -worsening school performance -preoccupation with death & dying suicides in children and adolescents -vast majority occur in the family home (95.5%) -most common cause, suicide by hanging (78.4%) -firearms are used in many cases (18.7%) -Education & support for children, adolescents, & their families in suicide prevention, identification of warning signs, & appropriate responses are essential • safely securing firearms and high-risk medication and being aware of materials that could be used for hanging or suffocation -National Suicide Prevention Hotline • 988 Suicide & Crisis Lifeline What is the ACEs Pyramid? From top to bottom the pyramic shows the mechanisms by which Adverse Childhood Experiences influence health and well-being from conception to death Bottom of ACEs pyramid to top Generational Embodiment / Historical Trauma Social Considerations / Local Context Adverse Childhood Experiences Disrupted Neurodevelopment Social, Emotional, and Cognitive Impairment Adoption of Health Risk Behavior Disease, Disability, and Social Problems Early Death What are the potential physical health consequences associated with exposure to ACEs and how might these manifest across the lifespan? Can impact short and long-term health outcomes Increases the risk for autoimmune disorders, arthritis, type 2 dm, cancer, and mental illness Increases risk health behaviors (suicide, substance use disorder, unemployment) What are the lasting effects on health due to ACEs? Obesity, diabetes, depression, suicide attempts, STDs, heart disease, cancer, stroke, COPD, broken bones What are the lasting effects on behavior due to ACEs? Smoking, alcoholism, drug use What are the lasting effects on life potential due to ACEs? Graduation rates, academic achievement, lost time from work What are the types of ACEs? Abuse Neglect Household instability Cultural challenges ACE: abuse Intimate partner violence (domestic violence) Psychological maltreatment (emotional abuse) Physical Sexual abuse / violence ACE: intimate partner violence (abuse) individuals purposely harm or threatens to harm a current or past partner or spouse; may involve controlling or coercive behavior or physical, sexual, verbal, financial, or emotional abuse • Children - more likely to experience emotional or physical abuse, neglect, and community violence ACE: psychological maltreatment (abuse) failure of a parent or caregiver to meet a child's psychological or emotional needs; directly attacks a child's sense of self, demeaning or humiliating, involving acts of commission, such as verbal attacks, or acts of omission • Children - increases vulnerability to depression and produces psychological trauma ACE: physical (abuse) parent or caregiver commits an act that causes physical injury to a child or adolescent • Children - struggle with self-esteem or social relationships and may have trouble trusting authority figures; develop stress reactions (may act out, aggressive / anxious, numb, withdrawn) ACE: sexual (abuse) interaction between a child and an adult or another child in which the child us used for sexual gratification of the perpetrator or an observer (touching and non-touching) • Children - risk for substance abuse, engagement in risky sexual behaviors, self-cutting or suicidal behavior, PTSD, depression, anxiety ACE: neglect most common forms of child maltreatment; occurs when a parent or caregiver fails to provide for a child's age-appropriate needs, such as food shelter, clothing, education, medical care, supervision, or emotional needs; often tied to poverty **Children - present with poor hygiene, inadequate weight gain, or clothing that fits poorly or is inappropriate for the weather ACE: Household Instability caused by parental mental illness, stress, substance abuse, suicide, or violence towards the mother in the family; loss of a parent or caregiver due to death, divorce, abandonment, or incarceration **Children - may struggle socially, cognitively, or behaviorally ACE: community violence (cultural challenges) exposure of a child to acts of interpersonal violence in a public setting by individuals not intimately connected to the child (shootings, fights, bullying, war, terrorism) ACE: bullying (cultural challenges) form of aggression or harassment that inflicts social, emotional, physical, or psychological harm on someone a perpetrator perceives to be less powerful; can be physical, verbal, and social; cyberbullying ACE: racism (cultural challenges) system of assigning value and providing opportunity based on physical properties such as skin color; can be overt (hate crimes or slurs) or subtle (discrimination, marginalization, and prejudice) ACE screening and scoring 10-question survey about childhood trauma, with each questions representing one point for a "yes" response Higher score = more exposure to ACEs with an increased risk of negative health and social outcomes later in life Family Risk Factors for ACEs (caregiving challenges) o Caregiving challenges related to children with disabilities, mental health issues, or chronic physical illnesses o A limited understanding of children's needs or development o Caregivers who were abused or neglected as children o Young caregivers or single parents o Low income or low levels of education o High levels of parenting stress or economic stress o Isolation Individual Risk Factors for ACEs A lack of closeness to parent/caregivers Early sexual activity Few or no friends Friends who engage in aggressive or delinquent behavior Community Risk Factors for ACEs High rates of violence and crime High rates of poverty and limited educational and economic opportunities High unemployment rates Easy access to drugs and alcohol Few community activites for young people Unstable housing and where residents move frequently Food insecurity Factors that promote resilience o Close relationships with skilled caregivers or other caring adults o Caregiver knowledge and use of positive parenting skills o Having a sense of purpose (faith, culture, identity) o Individual competencies (problem-solving skills, self-regulation, autonomy) o Opportunities to connect socially o Access to support services for parents and families o Community support resources Trauma-informed care elements Safety Trust and Transparency Peer Support Collaboration Empowerment and Choice Cultural, Historical, Gender Awareness Trauma-informed care: Safety most fundamental principle to avoid retraumatization; creating a physical setting and client-provider interactions that generate physical and psychological safety are foundational to providing trauma-informed care Trauma-informed care: Trust and Transparency trust may be established through engagement in kind, respectful interactions, empowering intake procedures, and transparency in discussions of treatment goals and modalities Trauma-informed care: Peer Support providing opportunities for connecting with other trauma survivors may help to establish safety, foster hope, and promote healing through shared experience Trauma-informed care: Collaboration empowering the client to play an active role in decisions about their treatment, when developmentally appropriate, fosters a sense of responsibility and helps to balance the level of power between the provider and client Trauma-informed care: Empowerment and Choice listening to and acknowledging the client will help them find their voice and give them a sense of control over their story; can promote self-efficacy, agency, and dignity Trauma-informed care: Cultural, Historical, Gender Awareness sensitivity to a client's culture, historical events, or gender identity is importance to ensuring their comfort and safety during treatment Risk factors for PTSD Prior trauma Adverse childhood experiences Personal or family history of psych disorders Female gender Severe trauma exposure Consequences of PTSD Social Occupational Physical impairment Physical health problems Reduced quality of life Increased risk of suicide Co-morbidities of PTSD MDD GAD SUD Symptoms of PTSD Intrusion Avoidance Negative cognitive / mood Arousal / reactivity PTSD symptoms: intrusion recurrent, intrusive memories of the trauma; children may engage in repetitive play expressing themes of trauma; distressing dreams/nightmares; dissociative reactions or flashbacks; intense psychological distress or physiological reactions when exposed to cues that symbolize or represent an aspect of the trauma Dissociative intrusions depersonalization (feelings of detachment from one's own body); derealization (feelings that one's surroundings are not reality) PTSD symptoms: avoidance avoidance of distressing memories, thoughts, feelings; avoidance of reminders, including people, places, situations, of the traumatic event PTSD symptoms: negative cognitive / mood memory deficits surrounding the traumatic event; exaggerated negative beliefs of self or environment; distorted cognitions and self-blaming behaviors related to the cause or consequences of trauma; persistent negative emotions, including anger, guilt, fear, or shame; feelings of detachment from others; persistent inability to experience positive emotions; social withdrawal in children under the age of 6 PTSD symptoms: arousal / reactivity irritability and verbal or physical aggression; reckless or risk-taking behaviors; hyper vigilance; concentration difficulty; exaggerated startle response; sleep disturbances PTSD diagnostic criteria Symptoms begin within the first 3 months after the event occurs and the client must have symptoms for at least 1 month Screening for PTSD Child less than 6 = a parent/caregivers screens Child 7-17 = child and parent complete the screen Treatment for PTSD Trauma-focused CBT, EMDR, narrative exposure therapy, classroom-based interventions Adjustment Disorder Diagnostic Criteria Development of emotional or behavioral symptoms within 3 months of the onset of a new stressor Symptoms cause significant impairment in social or occupational functioning but do not persist past 6 months after the initial stressor has resolved Adjustment Disorder Dx's With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Adjustment Disorder Treatment Family therapy and/or individual therapy for the children is INITIAL Medications may be used if symptoms persist, however medications are usually not indicated Reactive Attachment Disorder Rare trauma- and stressor-related condition that occurs when a child fails to form an emotional bond with caregivers Reactive Attachment Disorder Causes Abandonment Severe neglect Maltreatment Reactive Attachment Disorder Symptoms Difficulty forming emotional attachments to others Have a decreased ability to experience positive emotions Unable to seek or accept physical or emotional closeness Can react violently to attempts to hold or cuddle them Behavior and moods in Reactive Attachment Disorder Unpredictable and often difficult to disciple or console