Trauma and mental health

As a systemic family psychotherapist, my natural inclination is to view difficulties as relational and socially constructed, but working with young people who have developmental trauma has challenged some of my assumptions. Developmental trauma has a physical effect on the developing brain of the child. Despite having a demonstrable biological impact, it is also socially constructed; how we think about and respond to developmental trauma can be through several lenses, be they neuro-physiological, based upon attachment theory, from a social justice perspective and so on, locating the problem as being in the brain of the child, or being in the child’s relationships, as a result of structural violence or somewhere in between them all. Another significant reflection upon how I position myself as a therapist is that I tend to be collaborative, curious and neutral in my practice. However, I have found that there is often a need to step outside of that and be more directive by using psychoeducation or offering advice.


One recent and significant change in my thinking has been regarding the concept of psychiatric diagnoses, even though I taught about psychosis, depression, personality disorders and anxiety over many years to student mental health nurses. Nowadays, I struggle with the concept of psychiatric diagnoses or labels of ‘disorder’. In my view, most mental distress stems from trauma and the consequent survival strategies adopted by the individual (be they an adult or child) out of necessity. The questions we might ask of people with emotional distress should not be ‘What is wrong with you?’ but ‘What happened to you?’ (Johnstone et al., 2018).


Further, I believe that much trauma can be associated with broader contextual issues of poverty, inequality and structural violence. Therefore, many problems of modern society, including mental distress, some physical illness and crime, for example, are a result of political choices and policies.

Developmental Trauma
In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Centre for Disease Control (Felitti et al., 1998), 17,337 adults participated by responding to a questionnaire about adverse childhood experiences, including childhood abuse, neglect, and family dysfunction. The respondents indicated a great deal of trauma; 11.0% reported emotional abuse as a child, 30.1% reported physical abuse, 19.9% sexual abuse; 23.5% reported exposure to family alcohol abuse, 18.8% to mental illness, 12.5% witnessed their mothers being battered and 4.9% reported family drug abuse.


It is important to note that ACEs do not necessarily predict inevitably poor outcomes; for some, protective factors and resilience can prevent problems in later life. Unfortunately for many children, prolonged exposure to these adverse experiences can have a lasting impact upon their brain development which makes the child even more sensitive to stressors, makes it hard for them to regulate their emotions and behaviour, impairs their ability to concentrate and learn and makes it difficult to trust or relate with other people.


Trauma does not necessarily need to be experienced first-hand to influence a child’s developing brain. Some schools of thought suggest trauma can be handed down generationally, through epigenetic means (Kellerman, 2013, Yehuda & Lehrner, 2018) or via social means. For example, the effect upon younger generations experiencing the stories and the lived experience of survivors of trauma (Shevlin & McGuigan, 2003). What is evident is that developmental trauma can begin in the womb, and children removed at birth still can be affected; if the mother is stressed, maternal cortisol levels and other stress hormones can impact the brain of her foetus, as can alcohol and other substances.

The impact of trauma on the child’s brain
Understanding how trauma can affect the brain of an infant helps us to think about ways to help children who have been through such experiences. It is not possible to describe all of the neurological effects here, but I will attempt to illustrate critical aspects.


Changes to amygdala function can make the child more likely to react to triggers, especially emotional ones and the child can experience emotional extremes and struggle to regulate their emotions (dysregulation). Children who have experienced childhood trauma often react to minor triggers because trauma sensitises the amygdala to the perception of threat, which means that fear responses are triggered over time by less and less stress. 

A child who is experiencing extreme stress will have increased cortisol in their system, which can stop the hippocampus from working and reduce its volume. This is associated with impaired declarative memory (the ability to bring back to mind facts and episodes), depression and physical inflammation. The impact upon recall is marked when a child is triggered; time effectively has no meaning for them, their memories are jumbled, and they may regress to a much younger age.


The corpus callosum, which connects the left and right sides of the brain, is reduced, and this can prevent the two sides of the brain from working in a coordinated way. As Seigel and Bryson (2012) note, the functions of the right and left hemispheres are different; broadly, the right hemisphere is holistic and nonverbal, and the left is logical and linear. The less integrated these halves are, the harder it is for the child to make sense of triggers and threats.


Reduced activity in Broca’s area (the area for speech) can make it difficult for the child to talk about their trauma or describe it with detail, and in any case, as much trauma occurs pre-verbally, the words will not be available. When a child is triggered or dysregulated, the Bro’s area is also affected, which will result in them being able to articulate what is happening for them.


Lessened activity in different parts of the frontal lobe of the cortex can mean the triggering of survival responses in the absence of danger. The prefrontal cortex and the `higher’ brain are very vulnerable to traumatic stress, which impacts the child’s ability to think and to learn because they are in survival mode.


Under traumatic stress, the ‘lower’ brain stem responses predominate and impair the child’s ability to be calm, learn, think, reflect and respond flexibly because the child is stuck in survival fight/flight/freeze/fawn brain responses. When this happens, little information gets passed up to the ‘higher’ parts of their brain (cortex), where making sense of a situation takes place because all of their resources are directed to staying alive, which makes it problematic for the child to process and retain new information, to reason, to share with siblings or peers, to develop empathy (for themselves, as well as others) or to understand that adults do care for them.


Even when traumatised children move into a safe environment (i.e. foster care or adoption), they are likely to remain in survival mode. Consequently, things that to others may be insignificant, for example, even being gently told ‘no’ or everyday transitions, like moving from one room to another at home or school, can lead to a fight or flight response.


Given the impact of developmental trauma on a child, a wide range of challenging and sometimes confusing behaviour can arise. From an attachment perspective, we could think of the child as having an internal working model of the world that suggests the child is intrinsically ‘bad’ and that the world is neither a safe nor a reliable place. 


A child with developmental trauma may:
• Be violent/have meltdowns/damage property
• Be verbally abusive to others, including parents and siblings
• Hoard food
• Be unable to verbalise
• Regress
• Feel intense shame
• Be impulsive
• Chatter incessantly
• Self-harm
• Be unable to comprehend instructions
• Steal
• Lie
• Abscond (run away from home or school)
• Dissociate
• Have limited or no empathy for others (or self)
• Engage in risky behaviour (including drugs, sexual and criminal)


As can be seen from the above list, developmental trauma can look like many other recognised diagnoses, and there is a strong case for arguing that trauma is ultimately the cause of most diagnosable mental health concerns. Of course, some children with developmental trauma can, and do, have additional problems, particularly Foetal Alcohol Spectrum Disorder (FASD), which causes central nervous system anomalies and defects that complicate parenting even further.


Despite my discomfort with psychiatric diagnoses and labelling, there is a difficulty for parents in that developmental trauma is not currently a recognised disorder, despite the efforts of Bessel van der Kolk and others (van der Kolk 2005, van der Kolk, Ford, & Spinazzola, 2019) to have it recognised as such.

Because developmental trauma is not formally recognised, it can become a tricky issue for many parents who find that their CAMHS service may be unable (or unwilling) to provide interventions without a formal diagnosis and additionally that schools do not recognise the needs of the child. This lack of acknowledgement of their child’s difficulties can be very frustrating, and some parents will seek diagnoses, for example of Attention Deficit Hyperactive Disorder (ADHD), Autistic Spectrum Disorder (ASD) or Conduct Disorder, which can lead to the parents getting much-needed help for their child; however, interventions may turn out to be ineffective, or at worst, counterproductive for the child.

References

Felitti V.J., Anda R.F., Nordernberg D., et al. (1998). Relationship of childhood abuse to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 14(4): 245-258.

Johnstone, L., Boyle, M., with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D., Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester, England: British Psychological Society.

Kellermann, N.P. (2013). Epigenetic transmission of Holocaust trauma: can nightmares be inherited? Israel Journal of Psychiatry and Related Sciences. 50(1): 33-9.

Siegel, D. J. & Bryson, T. P. (2012). The Whole‐Brain Child: 12 Proven Strategies to Nurture Your Child’s Developing Mind. London: Constable and Robinson.

Shevlin, M. & McGuigan, K. (2003). The long term psychological impact of Bloody Sunday on families of the victims as measured by the revised impact of event scale. British Journal of Clinical Psychology, 42, 427-432.

van der Kolk, B. A. (2005). Developmental trauma: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals 35 (5): 401-408.

van der Kolk, B.A., Ford, J.D. & Spinazzola, J. (2019). Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: findings from the DTD field trial. European Journal of Psychotraumatology. 10(1)

Yehuda R, & Lehrner A. (2018). Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World Psychiatry. 17 (3): 243–257.