Central lung cancer

1. Adverse childhood experiences
and vulnerability for early onset of
drug use and dependence
Dr. Maria A. Elisa Alessi
Paediatric Neuropsychiatrist
UNODC - 23-25 November 2010

2. Summary
 Vulnerability factors
 Individual factors
 Complex trauma
 Post traumatic stress disorder
 Assessment
 Approach to treatment

3. Introduction
 Wide range of adverse experience:
◦ Food-insecure household
◦ Loss of a caregiver
◦ Drug addicted family members
◦ Family mental health problems
◦ Threatening life experiences / war
◦ Abuse/neglect/maltreatment
Adverse experiences can have a
profound devastating impact on
children’s development.

4. Vulnerability factors
 Genetic: studies on genetic polymorphism and
neurochemical alterations in the brain (HVA, 5HTT,
Prolactine)
 Neurobiology: morphological changes in some areas of
the brain.
 Family: parenting, cohesion, substance use, mental
illness, discipline.
 Educational: attainment, school rules, problems in
school.
 Psycho-social: low income, living conditions, peers
relationships, exposition to drugs.
 Environmental factors: health services, crime
prevention.
 Individual, psychological

5. Individual factors
 self-esteem
 self-control
 lack of trust in themselves and in others
 coping skills
 positive internal working model
 clear identity
 characteristic of personality (risk-taker, inihibited)
 planning capacities
 negative feelings: exclusion, shame, guilt,
victimization
 vision of the future
 Security of attachment
 moral values

6. Complex Trauma
also called “Developmental Trauma Disorder” (van der Kolk,
2005)
 the experience of multiple traumas
 developmentally adverse
 often within child’s caregiving system
 rooted in early life experiences
 responsible for emotional, behavioral, cognitive,
and meaning-making disturbances
“Chronic trauma interferes with neurobiological
development (Ford, 2005) and the capacity to
integrate sensory, emotional and cognitive
information into a cohesive whole.” (van der
Kolk, 2005).

7. Biological effects of stress
 Parasympathetic and sympathetic nervous
systems
 Hypothalamic-pituitary-adrenal system
 Limbic system and hippocampus
 Amigdala
 Neocortex
 Corpus callosum

8. Domains of impairment
1. Attachment: Uncertainty about reliability of the world,
problems with boundaries, distrust and
suspiciousness, social isolation, interpersonal
difficulties, difficulty with perspective taking
2. Biology: sensorimotor developmental problems,
analgesia, hypersensitivity to physical contact,
problems with coordination, balance, body tone,
localization of stimuli
3. Affect regulation: difficulty with emotional self-
regulation, describing feelings and internal
experiences. Difficulty communicating wishes and
desires
4. Dissociation: thoughts and emotions are
disconnected, alterations in states of consciousness,
amnesia, physical sensations without conscious
awareness, depersonalization and derealization

9. Domains of impairment
5. Behavior control: self-destructive behavior, aggression,
impulsivity, sleep and eating disturbances, substance
abuse, oppositional behavior, excessive compliance,
difficulty understanding rules, traumatic reenactment in
behavior or play
6. Cognition: impaired cognitive functioning, language delay,
learning difficulties, deficit in attention, abstract reasoning,
planning and problem solving; acoustic and visual
perceptual problems, overall IQ deficit
7. Somatic: headache, stomachache, cardiovascular
problems, immunological problems, pelvic pain, asthma
8. Self-concept: lack of continuous and predictable sense of
self, poor sense of separateness, low self-esteem, shame
and guilt, disturbances of body image
* Adapted from “National Child Traumatic Stress Network” – www.NTSCnet.org

10. Attachment
 A secure attachment with the caregiver is
fundamental for developing capacity of self
regulation and interpersonal relatedness.
 Secure children can rely on their emotions and
thoughts
 Secure children know how to react to any given
situation
 Secure children are confident that they can
make good things happen
 Secure children know that they can rely on
others

11. Post-traumatic stress disorder
 PTSD can develop at any age
 The symptoms of PTSD can start immediately or
after a delay of weeks or months. They usually
appear within 6 months of the traumatic event.
3 types of symptoms:
 Intrusive recollections
 Numbing and withdrawal
 Increased arousal

12. PTSD symptoms in children
 Sleeping difficulties (difficulties in falling asleep, or
frightening awakenings, or upsetting dreams, nightmares of
monsters)
 Persisting reenactment play (post-traumatic play). For
example, a child involved in a serious road traffic accident
might re-enact the crash with toy cars, over and over again.
 Aggressive behavior or angry outburst (tearing up toys,
hitting other children, acting defiantly towards caregivers)
 Refuse to accept reality (children who deny a parent died or
express the wish to join father in heaven)
 Self-injury
 Separations fears,
 Startle reactions, fear of darkness, of sleeping alone

13. PTSD symptoms in children
(cntd)
 Hyperactivity, reduced attention span, distractibility,
impulsivity. Children are often misunderstood and
misdiagnosed with Attention-deficit/Hyperactivity Disorder
(ADHD).
 Regressive behavior (Language regression or bedwetting
as disruption of toilet training)
 Changes is personality (sadness, withdrawal, dissociative
states)
 Avoidance of stimuli associated with the trauma: children
may lose interest in things they used to enjoy. They avoid any
activity which could bring memories of the trauma. They may
find it hard to believe that they will live long enough to grow
up.
 Somatic symptoms, headache, stomachache

14. Differential diagnosis
 Reactive attachment disorder
 Delay in the developmental acquisitions
 Posttraumatic Stress Disorder
 Depression / Suicide
 Attention Deficit/Hyperactivity Disorder
 Oppositional Defiant and Conduct Disorder
 Anxiety Disorder
 Eating / Sleeping disorders
 Dissociative disorder
 Borderline personally disorder
 Drug abuse
 Medical health problems

15. Assessment
 Early assessment and intervention are
crucial to prevent the long term
developmental consequences of
traumatic events.
 A multidisciplinary, integrated
approach to assessment is needed
 Assessments should be culturally
sensitive, and language appropriate

16. Comprehensive assessment
 Collect information from different sources
(child or adolescent, caregivers, teachers)
 Observations of the child in different
contexts (play observation, interaction with
adults)
 Standardized assessment procedures
 Socio-cultural evaluation
 Medical evaluation
 Court evaluation

17. Approach to treatment
 Complex trauma intervention
 Associated psychiatric disorders
 Drug abuse intervention
 Psycho-social interventions
 Promotion of physical health
 Education

18. Trauma intervention
 Safety
 Self regulation
 Self-reflective information processing
 Traumatic experiences integration
 Relational engagement
 Positive affect enhancement
Alexandra Cook, 2007 (adapted from the National Child
Traumatic Network)

19. Conclusions
 Adverse experiences can have a profound
devastating impact on children’s development, and
increase their vulnerability to manifest psychiatric
disorders and drug use in childhood and
adolescence. Increased vulnerability is due to
adverse family life conditions and environmental
factors.
 Because of traumatic experiences, several
domains of children’s development are affected in
a disruptive way, resulting in complex physical,
behavioural, emotional and mental impairment.
 In light of many individual and contextual
differences in the lives of children affected by
complex trauma, a comprehensive assessment is
required, to identify treatment strategies tailored on
specific needs.

20. Thank you for your
attention!