Dealing with Abuse, Trauma & Neglect - a Health Workers Perspective

Negative experiences which can impact negatively on brain development include abuse, trauma and neglect.
 
When the developing brains of children in early childhood are controlled by experiences, it is no surprise that the results are negative when these experiences are of persistent fear and danger. When we face danger the brain releases hormones so that we can respond to that danger quickly. These hormones are for `fight or flight.’
 
The origins of the stress response take place in the brain stem - a bump at the base of the brain.  When the stress response is activated, the cerebral cortex - the area of the brain which allows us to think - shuts down. At least 30 hormones, or chemical neurotransmitters, are involved in brain functions. Catecholamines and cortisol in particular are most important in the damage aspects of brain development.
 
Cortisol in increased amounts and accruing for long periods is toxic to neurons and growing neurons are most sensitive. It independently inhibits synaptogenesis.  A prolonged excess of cortisol causes brain dysfunction and destruction.

In chronic stressful situations, such as violence and abuse, there is a higher set point of, and sensitivity to, receptors for cortisol.
In abused children the trauma over-stimulates the stress response.
Because the stress response is being constantly and repeatedly triggered - it becomes the template for brain development. The child living with persistent stress lives in a constant state of alertness and arousal - watching for signs of danger. The future for these children is marked by unfettered impulsivity, easy arousal and the unthinking release of aggression.

Hyper-arousal and dissociation

The children’s brains have adapted to their home environment and to their parents but they are now exposed to interaction with other children and adults. Their responses are now maladaptive and another set of brain mediated responses deepens their disadvantage- responses from hyper-arousal to dissociation, with many aspects of both. Small children trapped in violence and unable to escape are more likely to dissociate - detaching from reality and the searing emotional pain.
 
In the case of boys the result of trauma is likely to be hyper-arousal, where-as girls and very young children tend to retreat into a dissociative state. When these damaged children go to preschool, crèche, or school, their behaviour is often misinterpreted, (as ADHD in the case of hyper-arousal), or ignored. Early recognition, assessment, diagnosis and treatment will give these children the best chance of recovery.
 
Boys

In boys hyper-arousal is more common as the persistent firing of the stress response; its heightened sensitivity and responsivity lead to an internal state of anxiety and arousal, with the risk of being catapulted into terror with no access to the cerebral cortex or any sense of time.
Hyper-aroused boys are driven by catecholamines, neurotransmitters including adrenaline, with associated markers of raised pulse, b/p, and temperature, plus sleep disturbances, irritability, and high metabolic rate. At school this cluster of symptoms compromises learning and is often mistaken for ADHD.
 
Arousal not hyperactivity is the driving force leading to a destruction of attention and cutting any access to the cerebral cortex. Their time is spent watching for unspoken cues and other types of movement or behaviour in an adult, which are internally signaled as a need for escape or confrontation. All this reduces the ability for rational thought.
 
Boys are likely to have a high pulse rate, high blood pressure, slightly higher temperature and a higher metabolic rate. They lack access to the cerebral cortex so they seem difficult, unmanageable and irrational. These boys often display sudden outbursts of anger, violence and defiance.

They seem unable to pay attention or listen. Their behaviour is erratic, disturbs other children and mystifies caregivers. Even more important is that it occurs without any cognitive attachment. The children themselves are unaware why this happens; why they are suddenly fearful, confused or need to lash out.

Girls

Girls rarely present at this age as they tend to internalize their feelings through dissociation, a technique used by very small children in the face of inescapable trauma.

This detachment from emotional pain is caused by the release of opoid peptides (triggered by some external or internal cue), that dismiss pain, dampen fear and shut down the locus caerulus - the area of the brain involved in hyper-arousal. This is reflected in a lowering of the pulse and blood pressure. Dissociation cuts out the conscious mind in a more complete although less overt way, so the child’s behaviour does not upset other pupils or challenge the teacher. The girl seems dreamy, inattentive and unable to learn.

Anxious, depressed and dissociating, these girls can present to medical settings because of fainting spells or absence seizures, which are often misdiagnosed as some form of epilepsy, while the social setting and the abuse of the girl is disregarded or missed.

Girls exposed to trauma are more likely to dissociate or cut off from the world. They tend to have a low pulse rate and low blood pressure.

It is easy to overlook these children as they try and fade into the background. A hidden trigger - such a look or movement - suddenly lowers their heart beat and blood pressure, sometimes resulting in a faint. Neglect also deprives children of the experiences that they need.

The brains of these children do not develop properly.  They have not had the stimulation needed to form sufficient neural connections.  The effects of neglect can be severe and very difficult to remedy if it happens to the child in the first three years.

The brains of these children can be 20% - 30% smaller than the brains of other children and will have fewer connections. The corpus collosum, connecting the right and left hemispheres, is smaller; the hippocampus is smaller also, affecting processing and memory. Neglect can inhibit a child’s ability to learn and to have a normal life. The child will often withdraw into their own world. In severe cases the child will have no ability to attach or empathise child will often withdraw into their own world. In severe cases the child will have no ability to attach or empathise with others and will display signs of retardation.

Trauma
 
In impaired attachment caused by trauma, the brain rules by unpredictable reactions to fear and terror causing a malignancy that colours other perceptions and close relationships throughout their lives

A lack of empathy, increasing the dangers of any aggression and precipitating impulsive, reactive violence is distressingly frequent amongst the young in NZ. Negative experiences in early childhood have also been linked with:- 

• Mental health problems including depression, pervasive anxiety, and psychological, psychiatric and psychosomatic problems.
• Relationship difficulties
• Juvenile offending including substance abuse and violence.
• Suicide
• Abusive relationships in adulthood
• Those abused are more likely to abuse their own children.
   

Those abused are more likely to abuse their own children.
Physical abuse and neglect is widespread. The ever escalating cost of attempting to control or contain these consequences is already too high for this country to sustain.
Every year thousands of NZ children are exposed to trauma. The statistics are horrific:

• 12 children each year are deliberately killed (NZ has the 6th highest rate for intentional child deaths of 23 industrialised countries)
• 200 children are hospitalised for deliberately inflicted injuries
• 6000 and 8000 children are found, by CYFS, to have been abused or neglected.- with 20 to 30,000 referrals per year
• There are many more children at risk. An estimated 27,000 unreported, many too young to disclose.
• The combined cost of abuse and neglect is assessed at $393 million per year
• Family violence affects 1:7 families; that is 480,000 New Zealanders.
• Each week 2500 Women’s Refuge beds are occupied.
   

Where possible health workers need to work together with parents.  This means ensuring that parents have: 

• Access to quality prenatal care and responsive care during and following the birth.
• Parents need more information about how the kind of care they provide will affect their children’s capacities.
• Support them in good parenting practices. If parents are unsure about how to act - offer suggestions. Suggest suitable daycare options.
• Try and model good behaviour.
• Assess children to ensure that they are progressing normally and meeting their milestones.
• Practice screening for family violence with adult female patients.
   

There are clear relationships between child abuse and poverty, transience, mental illness, disability, parental alcoholism or drug addiction, single young and socially isolated caregivers. Note, however these risk factors do not have a high positive predictive value, therefore avoid jumping to conclusions. Concealment of abuse is a universal response. Caregivers will lie to you.
 
The child is your patient and your first priority is the safety and future health of the child. Don’t end up in collusion with those responsible for the abuse!  If your answer to the question “Is this child safe”? …is “No” or “I don’t know”, urgent steps must be taken.
 
The New Zealand freecall phone number for the Child Youth and Family service is 0508FAMILY.  Do a hospital referral or, in a crisis, call the police.
 
It is stressful to raise issues of abuse, even harder with neglect.  Don’t get into ‘whodunnits’ Often it is not the person accompanying the child. Be a health professional breaking bad news, and be honest.
Section 59 of the New Zealand Crimes Act exempts parents from charges of assault in cases where reasonable force is used in disciplining children.

The protocols state that health workers are released from normal confidentiality and informed consent requirements and may disclose information to CYFS, or the police, if there is concern for a child’s immediate safety, and/or abuse by a parent or client is suspected.

Know the law.