Assignment: Abused children

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Assignment: Explain the reason why Abused children may, as adults, be more likely to mistreat their own children.

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Through a discussion of the common developmental consequences of experiencing any type of maltreatment as a child, explain the reason why abused children may, as adults, be more likely to mistreat their own children.

Child Maltreatment and Trauma

Child Maltreatment Classifications

—  Physical abuse —  The “Spanking” Law: Section 43 of Canadian criminal

code

—  Neglect —  Physical, educational, emotional

—  Sexual abuse

—  Emotional abuse

Some Stats —  Overall incidence of child maltreatment is approx

14 per 1000 children in Canada (2010)

—  Primary caregiver maltreatment breakdown reported in Canada (2008) —  Exposure to intimate partner violence – 34% —  Neglect – 34% —  Physical abuse – 20% —  Emotional maltreatment – 9% —  Sexual abuse – 3%

Common Characteristics of Maltreated Children

—  Academic difficulties —  Depression/anxiety/withdrawal —  Aggression —  Attachment issues —  Intellectual/developmental disability —  ADHD —  See more “externalizing” in physically abused kids,

but more “internalizing” in sexually abused kids

Characteristics of Caregivers

—  Victims of domestic violence

—  Having few social supports

—  Mental health issues

—  Alcohol/drug abuse

—  Perpetrator of domestic violence

—  Physical health issues

—  Single parent homes and large families

—  Low SES

—  Single-parent females most common perpetrator overall

—  Males most common perpetrator of sexual abuse

Victimized Children —  Effects of age:

—  Younger children more at risk for physical neglect —  Toddlers, preschoolers, and young adolescents more

at risk for physical and emotional abuse

—  Sexual abuse more common in children > 12

—  Effects of gender —  80% of sexual abuse victims female —  Boys more likely to be sexually abused by male non-

family members; girls by male family members

Developmental Projection? —  Maltreatment does not affect children in

predictable or consistent ways

—  Outcomes depend on severity/chronicity and a host of other interacting factors

—  Protective factors —  Positive relationship with at least one consistent

person providing support/protection —  Personality characteristics

—  Removing kids from families can have significant negative effects

Common Developmental Consequences

—  Attachment issues —  More likely to have insecure attachment —  Leads to struggles in emotion regulation

—  Understanding, labeling, regulating emotional states —  Increases likelihood of emotional distress

—  Neurocognitive issues —  Kindling of neurological systems involved in physiological and

emotional reactivity

—  Views of self/others —  Betrayal and powerlessness become part of world view —  Internalized blame for maltreatment

—  Social issues —  Hostile attributions; sensitivity; withdrawal; social skills

Parents are Someone’s Children too…

—  Common for parents who maltreat children to have been exposed to maltreatment as well —  Little exposure to “positive” parenting models

—  Consider children who suffer from the issues already discussed —  How would this affect their own parenting?

—  Lack of awareness of developmentally appropriate expectations increases likelihood of maltreatment

Duty to Report —  Child, Family and Community Service Act

—  Obligation to report if you have “reason to believe” a child is in need of protection —  Covers physical, sexual, and emotional abuse; neglect —  Defines markers of emotional abuse

—  Emotionally harmed if child demonstrates severe anxiety, depression, withdrawal, or self-destructive/ aggressive behaviour

—  Overrides confidentiality

Challenges with Treatment —  Maltreating parents have to agree to treatment (or

at least be open to it) —  Those most in need are least likely to seek it out

—  Starting out on the wrong foot —  First contact usually after law has been violated (or

report made) —  Parents do not want to admit to behaviour out of fear

of losing child/being charged

Interventions —  Major focus is on psychoeducation

—  Child development (helps with expectations) —  Parenting skills/basic child rearing skills —  Why isn’t there a manual needed for this?

—  Increase positive interactions

—  Provide parents with coping strategies —  Relaxation, cognitive restructuring, problem solving,

anger management

Posttraumatic Stress Disorder

—  Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways —  Directly experiencing the traumatic event(s) —  Witnessing, in person, the event(s) as it occurred to

others —  Learning that the event(s) occurred to a close relative

or close friend

—  Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

PTSD —  Criterion B: Presence of one (or more) of the following

intrusions symptoms: —  Recurrent involuntary and intrusive distressing memories

of the traumatic event(s) —  Recurrent distressing dreams related to the traumatic

event(s) —  Dissociative reactions (e.g., flashbacks) where the

individual feels or acts as if the traumatic event(s) were recurring

—  Intense or prolonged psychological distress at exposure to cues that resemble traumatic event(s)

—  Marked physiological reactions to internal or external cues that resemble the traumatic event(s)

PTSD —  Criterion C: Persistent avoidance of stimuli

associated with the traumatic event(s) including one or both of the following: —  Avoidance of distressing memories, thoughts, or

feelings about or closely associated with the traumatic events

—  Avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

PTSD —  Criterion D: Negative alterations in cognitions and

mood associated with the traumatic event(s), as evidenced by two (or more) of the following: —  Inability to remember an important aspect of the

traumatic event(s) —  Persistent and exaggerated negative beliefs or expectations

about oneself, others, or the world —  Persistent distorted cognitions about the cause or

consequences of the traumatic event(s), leading to blaming others

—  Persistent negative emotional state —  Marked anhedonia —  Detachment or estrangement from others —  Persistent inability to experience positive emotions

PTSD —  Criterion E: Marked alterations in arousal and

reactivity associated with the traumatic event(s), as evidenced by two (or more) of the following: —  Irritable behaviour and angry outbursts —  Reckless or self-destructive behaviour —  Hypervigilance —  Exaggerated startle response —  Problems with concentration —  Sleep disturbance

PTSD: Children 6 and under —  Criterion A: exposure

—  Add qualifiers about witnessing event (especially primary caregivers)

—  Learning events occurred to caregiver

—  Criterion B: intrusion symptoms —  All except dreams and physiological reactions may

occur in play

—  Can show either avoidance or negative alterations in cognitions (don’t need both)

Treatment —  Trauma focused CBT

—  Heavy emphasis on inclusion of parents to enhance attachment/coping with emotions

—  Teach relaxation skills, problem solving skills, cognitive restructuring

—  Main focus is building a trauma narrative and working on mastery of trauma reminders

—  Somatic approaches —  Incorporate mindfulness; body awareness

—  Non-exposure treatments?

Psychosis —  Delusions

—  Hallucinations

—  Disorganized Speech

—  Disorganized or catatonic behaviour

Gender Dysphoria and Gender Variant Youth

Formerly Gender Identity Disorder

Gender Dysphoria —  Criteria for children

—  Marked incongruence between one’s experienced/expressed gender and assigned gender (at least 6 months’ duration), manifesting at least 6 of the following (one of which must be the first one) —  Strong desire to be of the other gender or insistence that one is the

other gender —  Strong preference for wearing attire typical of the other gender —  Strong preference for cross-gender roles in make-believe or fantasy

play —  Strong preference for the toys, games, or activities stereotypically

used by other gender —  Strong preference for playmates of other gender —  Strong rejection of toys, games, activities typical of assigned gender —  Strong dislike of one’s sexual anatomy —  Strong desire for the sex characteristics that match experience

gender

Gender Dysphoria (adolescents and adults)

—  Marked incongruence between one’s experienced/expressed gender and assigned gender (at least 6 months’ duration), manifesting at least 2 of the following —  Marked incongruence between one’s experienced/expressed

gender and primary and/or secondary sex characteristics —  Strong desire to be rid of one’s primary and/or secondary sex

characteristics because of marked incongruence with one’s experienced/expressed gender

—  Strong desire for the primary and/or secondary sex characteristics of the other gender

—  Strong desire to be of the other gender —  Strong desire to be treated as the other gender —  Strong conviction that one has the typical feelings and

reactions of the other gender

Problematic Reactions —  Cross gender behaviour very anxiety provoking for

parents

—  Reactions of school staff and peers

—  Youth may not be able to access health care independent of parents —  May be brought for “medical attention” by parents in

an attempt to “treat” or “cure” gender variant behaviour

—  Pathologizing atypical gender behaviour

Trends in Gender Variant Youth

—  Not all will seek sex reassignment after puberty —  Gender variant behaviour in childhood more

strongly predictive of homosexuality than transsexualism

—  Not all youth with gender dysphoria continue to have gender concerns into adulthood

—  Significant variation amongst youth presenting with gender variant behaviour

Treatment Options —  “Wait and see”

—  Hormone blockers

—  Cross-sex hormones

—  Sex re-assignment surgery

Treatment (cont’d) —  Psychotherapy

—  Explore ambivalence, how to come out, assess for underlying factors, explore body image; family therapy

— Hormones —  Fully reversible: puberty delaying hormones —  Partially reversible: cross-sex hormone therapy

—  Surgery —  Not all gender dysphoria clients request this

Real Life Experience —  Live full time in sex role transitioning to —  Provides exposure to all consequences of

transition (family, interpersonal, legal)

—  Tests the capacity to function in preferred gender and adequacy of social supports —  Also an opportunity to experience cross gender

role before making irreversible changes

—  One year if MSP paying for surgery

MSP Requirements for Sex Reassignment Surgery

—  One full year of real life experience

—  Demonstrate emotional and psychological stability

—  Recommendation for surgery by two psychiatrists with expertise

Learning Disorders

Specific Learning Disorder —  Criterion A:. Difficulties learning and using

academic skills (reading, writing, spelling or math), as indicated by the presence of at least one of the following symptoms that have persisted for at least six months, despite the provision of interventions that target those difficulties: —  Inaccurate or slow and effortful word reading —  Difficulty understanding the meaning of what is read —  Difficulties with spelling —  Difficulties with written expression —  Difficulties mastering number sense, number facts, or

calculation —  Difficulties with mathematical reasoning

LD Criterion B —  Academic skills significantly below age expectations

and cause Impairment —  Affected academic skills are substantially and

quantifiably below those expected for the individual’s chronological age —  Standard is difference of at least 2 SD between

achievement and IQ score

—  Cause significant interference with academic or occupational performance, or with activities of daily living

Assignment: Abused children

More LD Criteria —  Onset: begin during school-age years

—  With impairment in reading: —  word reading accuracy —  reading rate or fluency —  reading comprehension

—  With impairment in written expression: —  spelling accuracy —  grammar and punctuation accuracy —  Clarity/organization of written expression

—  With impairment in mathematics: —  number sense —  memorization of arithmetic facts —  accurate or fluent calculation —  accurate math reasoning

Treatment/Remediation —  Response to Intervention

—  Small-group, intensive instruction in school —  Attempt to provide appropriate level of instruction —  More individualized than mainstream classroom

—  Direct Instruction —  Tutoring; teaching direct skills required for the task —  Break task down into components

—  Phonemic awareness/decoding —  Fluency of word recognition —  Determining word meaning —  Enhancing vocabulary —  Improving spelling

Treatment —  Cognitive-Behavioural Techniques

—  Written rules instead of relying on memory —  Self-monitoring —  Self-evaluation —  Self-reinforcement

Intellectual Disability and Fetal Alcohol Spectrum

Assignment: Abused children

Disorders

Intellectual Disability —  Onset during the developmental period that

includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met: —  A: Intellectual Deficits —  B: Deficits in Adaptive Functioning —  C: Onset of intellectual and adaptive deficits during

the developmental period

Criterion A: Intellectual Deficits

—  Deficits in intellectual functions, such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing

—  No more IQ cut off scores

Criterion B: Deficits in Adaptive Functioning

—  Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.

Specify Severity —  Mild, Moderate, Severe, Profound —  Rate severity for each of the 3 domains

—  Conceptual —  Academic skills (reading, writing, math), memory,

executive functioning, abstract thinking —  Social

—  Communication/language use, maintaining friendships, social skills, regulating behaviour/emotions, social judgment

Assignment: Abused children

—  Practical —  Self-care, using transportation, time/money, vocational

skills

Causes —  Early alteration of embryonic development (30% of cases)

—  E.g., Down’s syndrome, prenatal use of alcohol/drugs

—  Environmental influences (15-20% of cases) —  E.g., Deprivation of nurturance, deficiencies in health care,

lack of social/cognitive stimulation

—  Pregnancy and perinatal problems (10% of cases) —  E.g., Fetal malnutrition, hypoxia, trauma

—  Inherited/Hereditary factors (5% of cases) —  Phenylketonuria (PKU), Tay-Sachs disease, Fragile X syndrome

—  No clear etiology in 30-40% of cases

Fetal Alcohol Spectrum Disorder

—  Umbrella term for range of outcomes associated with all levels of prenatal alcohol exposure

—  The most widely preventable cause of Intellectual Disability

—  Fetal Alcohol Syndrome: most extreme form of FASD —  A leading cause of Intellectual Disability —  0.5-2.0 per 1000 live births —  Under-diagnosed

Fetal Alcohol Syndrome —  Characterized by

—  Central Nervous System dysfunction —  Microcephaly: smaller, underdeveloped brain

—  Abnormalities in facial features —  Growth retardation below 10th percentile —  Generally in mild range of Intellectual Disability —  Socioemotional difficulties

—  Attention deficits —  Hyperactivity —  Poor impulse control —  Significant behaviour problems

—  Most difficulties persist into adulthood

—  Fetal Alcohol effects vs. Fetal Alcohol Syndrome

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