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    Gaskill Perry 2012

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    Lolis Rios

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    WANDBOOK OF CHTLD SIEUAL. ABUSE ‘Wentifieation, Assesment, and Treatment Bdited by Paris Goodyear-Brows Copyright 2017 by Jon Wiley & Sons, Inc. CHAPTER 2 Child Sexual Abuse, Traumatic Experiences, and Their Impact on the Developing Brain RICHARD L. GASKILL and BRUCE D, PERRY INTRODUCTION ic US, Depaxment of Health and Human Services documented that ‘lion children were allegedly maltreated in 2007, O! these eases, nore than $0000 were saspacied to have been sexually abused, The sexually abused children inthe summary report were more likely female than male are 20% were under 8 yenre atthe time of the assault. Forty petoent ofthe assaults were perpetrated by family snenbers ("Statistics Surrounding Child Sexual Abuse,” 2006). rhas been estimated that, in the United States alone, there ae 38 million survivors of chichoed seal suse (“Satistics Surrounding Child Sexual Abuse” 2008). The magni tude ofthis problem is enormous when one realizes child sexual abuse is Isst one of many co-occurring maladies in children’s lives Child sexual abuse has commonly been viewed as if it were an iso- tate traumatic event, but nething coud be farther froma the tr In fact ‘hitahood sexual abuse seldom occurs as an isolated event. Rather, Senual abuse is more likely one adverse event coexisting among a hest of otter averse crcumstances ina childs life (Anda eta 2000), Among the concomitant suessful events are physical and stil abuse, Darental paychitrie history: parental history of lgal involvement ester fare; meats) Ulness of a parent parental marital discord; family history 20 lopemearins of violence; and alcohol and drug use in the family. Evidence from ‘neurobiology and epidemialogy research suggests these carly le adverse ‘experiences cause long-term changes in multiple brain systems (Anda tial, 2006). Ware, increasing frequencies of ely mdverce childhood fexperiences in a childs life were highly correlated with enduring brain dysfunction and were also linked t deleterious effects on health and ‘quality of life (Anda etal, 2006). ‘Van der Kolk @2001) found thatthe majority of people secking care for ‘rouna resulting from malizeatment sufered {kom multiple poychological problems between 75% ancl 98.6% ofthe time. This apparent comorbidity of Psychopathology became a destructive experince iaipacting the develop 2g child, incrensing risk of emotional, behavioral, academic, sonal, ard physical probiem throughout tech’ lifespan (Anda etal, 2006 Perry Pollacd, 1997 1996; Spinazzola, Blaustein, van der Kok, 2008), Among the ‘omorbi neuropsychintrie diagnoses associated with chido tra ee ‘najor depression, dssocative disorder, oppositional defiant disorder cot ‘duct disorder, dystaymia, obsessive-compulsivedisordes, phobic disorder, PTSD, subslance abuse, borderline personality disorder, allention dei, and hyperactivity disorder, various developmental disorders, schizophee- hia, and ultimately neary al DSM IV diagnoses (Perry, 2008, This cbse ‘vation eas trauma researchers inchidesexual abuse as only one ofa host of traumatic childhood experiences comprising, larger complex web of ‘lui! maltreatment conthbutory 40 long-term dysfunctional emotional, behavioral, cognitive, social, and physieal development, nnd Health out. ‘comes (Anda et], 2006; Perry, 2008; Perry & Pollard, 1998; Spnarzola tal 2005, van der Kolk, 2001, 2008). Perry and Pollard (1958 cated that more UUun 8 milion childven suffer from a trautha-related neuropsyehiae disorder at any given moment. This chapter addzesees child sexual abuse 4s one of a number of adverse events inciuded in the evolving neurer biological view of complex childhood maltreatment (wan der Kolk, 2001), Further, due tothe negative impact of eild maltrentinent on specie Low brain structures and the historical neglect of remediation for such trina, ‘seatment discussions focus on child maltreatment frtn » neurobiological perpective Although the neurobiological view of trnuma offers enor Sdvancesin treatment design itdoes require fundamental faulty with 2 few base brain development prinepes. HUMAN BRAIN DEVELOPMENT ‘The human brain isa surprisingly dynamic structure, mediating not only Iifesuppor functions, but abe these Faneons that make us moet hua (Cehrer, 2005), Unlike oar heart lungs, or most other organs dhe brain (Chit Sexual Abuse, Traumatic Esprincs, and Tr Impact 31 ‘constructs iself through an extraordinary interaction of genetics and ‘experience. All we are and all we wil become-—our hopes our dreasns, jour knowledge, our relationships and our emotional health depend on ‘te successul development of the rain. As human beings we are not fast, lange strong nor do we have sharp teeth orclaws compared to many’ othe txeatures of the earth, Insteed, our survival is largely contingent om the unique properties of eur brain’ Unlike any other species on the earthy we sense, pereive, process, store, and act on information from both extemal ‘nd internal environment in evalutionarly profound ways, To accomplish {his fat the brain has evolved an efficent, predictable, and hierarchical process of development and organization. Understanding this organiza. fon and essential brain. processes holds valuable keys to successfel ‘peatment of maltreated children, “The human brain develops and organizes in a systematic and hierar- hic fashion beginning very carly in utero, First deiven by genetics and Ibter by experience the brain ts constructed through the interpiay between rafure and nurture, Because of this interaction between nature and ‘numure, the brain wil become uniquely designed to eupport the survival ofthe young child in the world he or she experiences, This organizational process was fist conceptualized as being from the botom wp in the early hineteenth century Jackson, 1958). Maturation and developinent of the ‘naman brain recpitulates evolution, with brainstem and diencephalon regions developing first (Lehver, 200). These lower brain regions organize and develop early in utero and will continue i a systematic and predict. ble fashion, being Functional before preschool. As isthe case with most eurl activity are again matched against previously stoted potters of sctivation and placed in conscious memory (Perry, 2006, van der Kall, 26). The neural event can now be categorized, contextualized, under, stood, stored, and recalled consciously within a larger pereepial or ‘cognitive framework (Perry, 2006; van der Kalk, 2006) This fw traly remarkable mental ability of the tuman brain. Its at tis level of prc cessing that neuronal activity first resulls in conscious emotional eehene tons (Perry, 2008; Perry & Pollard 199; van der Kolk, 2006) ‘THREAT ASSOCIATIONS ‘As these sensory stimuli are matched and sorted, signals that are associ ated with previously identified tment or unkown potential tie {nigger an intial alarm response atthe most primitive levels of te brain This alarin response activates neuronal activity in key brainstem and fiencophalon nuclei, which contain neurotransmitter (Perry, 2006; von ‘er Kolk, 2008). The fact that sensory input can automaticaly stntalate hormonal secretions and influence the activation of brain regions Involved in attotion and memory points to the limitations of tonscious control ‘over our actions and emotions. This is particularly relevant in under standing and treating traumatized Individuals. It explains why tasers survivors are prone to display irrational, subeortclly initiated resportces that might be irelevant, unproductive, or even harmful in te hurent context (van der Kolk 2506), “This initial threat respons initiates brainstem and midbrain activity, ‘niggering immediate responses to the perceived threat, in neat reflexive oe Pavlovian fashion (van der Kolk, 199). Responses a this level of brain fonction occur long before the signals react higher cortical areas 10 be interpreted and ultimately acted on. This process has remarkable survival ‘value asthe low brain is making critical decisions for safety and survival ‘when waiting for more detailed and analytical decisions would be deta mental (Lehrer, 2009; Perry, 2006, 2008, van der Kolk, 2006) Obviously, such immediate responses suggest thatthe lower bral regions are abe {o compare old paltems associated with thteat to pattems just perceived. Perry (2006) calls these associations slate memory. This nonverbal, log ‘al, unconscious association resulng in alarm activation occurs betore ‘complete processing and interpretation is completed by te eorex (Pery, 2006). tshould also be noted that the cortex is easly overwhelined. Under stress, the lower brain regions simply take over and shut down higher comical regions. The cortex is in many ways» puny organ (Lene, 2009; van der Kolk, 2006) an der Ketk (2006) states thatthe rational brain (cortex), while ble to fonganize feelings and impulses, does not soem to be pasticlarly wll ‘quipped to abolish emotions, thoughts, and smpulses, Neural imasing ‘of humans in highly emetional states revels that intense emotions of fear, sadness, anger, and happiness cause increased activation of sub cortical ‘bain egions and signifeant reduction in Blood flow in various areas in the frontal ibe (van der Kolk 2006) Van der Kelk (7984) alga points out tht leauinatc experiences activate brain regions that tigger intense emokons nd decrease activation of the central nervous system (CNS) regions {nwolve! in integration of sensory input, motor output attention, mentor), ‘memory consolation, modulation of physiological arousal, and the ety ‘ocommunicate with words. Sympathetic nervous sytem arousal is geay ‘mobilized preparing the body fora physical fghtor Might response Neatly !wwothirds of trsumatizod children show such symptoms resulting re increased sdrenerpic activity (van der Kolk, 200. Physiological esporsea ‘commonly involved include: tinnlated sweat glands inhiation Of gastos Intestinal processes, inereased cardiac activity, increased blood presse, Increased respiration, anxiety, or hypervigilance Mopper, Spinarzole, Simpson, & van der Kelk, 2006) Finally, such intense responses to sts experiences decease the child's ability t organize a thodulated behavioral ‘ction and tobe engaged in the present (Hooper eal, 2006, Perry, 2008; vvan der Kelk, 2008). ‘Perry 2008) pointed ou, from a neurcbiological pointof view, excessive fr protracted traumatic experiences unmistakably cause profound ale ‘ations in the regulation and functioning’of many bodily systems This in ‘en can result in new dysfunctional rnin patter idloencing the org nization and function of higher brain areas The ests in compromised function and ulliately psychopathology. Experience, positive or nega tive, Becomes the neural architecture of the child's brain (Pery, 2008), (Gile Sexuat Abuse, Traumatic Experience, end Ther Ipact 38 STATES BECOME TRAITS Faly, s has been previously allied to, brain development is pro- foundly guided by experience. The sequential nate of neural develop ‘mont and bai function hen ives by snd mated by tees interaction withthe ewironoent ins postive sense the aby fo create am internal represetaton of the enteral wor or inert word though repeated acvotion fa uefa memory and leaning foo ery {Hamrick 208. Ths mens that he geste ch requeney oF netivaon ofa neural system, the more permaneat the neta state becomes, Perey ‘nd ilambice 2008 described neurone snd necronal etwas erly ‘bang modifed through repeated experiences n what they called an Aety oF use depenent process Tust asthe use dependent process can create positive Kamsing and semi, soca rate negative leag and menry de To meget tama orcs. The prctcal asec inthe cae of tains oe tic ae betwen senoory eoes ad tbe stonomiersponse of teol ‘These subcortical signals are capable ofelciingm fear response, tering emtiors, betaviow, so physiology In the cise of ogi He neal System ges so tte stimulation that newal systems ol to form and ‘mone auophy and disappear Sadly thee changes con become per nent Perey 2a) Physiological arousal in general riggers traums related memories, wile conversely, tauina felted metarles precipitate: generalized Physiological arousal, Studies have demonstrated haw the response 1 potent environmental stonull (unconditional simul) becomes 9 Com Aidoned reaction. Alter repeated aversive stilton, intently on Shyeateing cuss assocated with the tnuina (conditional, stan) become capable of eliciting the defensive reaction by themacves (con dione response ina casical Pavlovian fashion (an der Kole 998) ‘Theclicng cue can be any sensory experience that becomes associated ‘withthe uauina I could be ope contact, a smile, 8 smell ora pate {eny, 2006; van der Koll, 2080. uc ofthe resullng dystaetiona ‘elonalineracon wil be Deyo the awarensse andFanderstanding of the developing eld or youth Perry, 2008). Ifthe numsatie exper tnces crate a use-dependent sate powerful taough, profound Fog. sive changes will be noted in the chil’ tieking, behavor nd perceptions Perry and Pollard (908) deneibed these changes ee poi Eve bsnstem aifven behaviors “Trans induces a ttl brain response. All parts of the bran wil bo atlecte by the survival reaction. Carex, bic diencephalon, an baie ‘tem wll all reat llezedsnemores based on the teamatc experience. 36 Ioaenaeamon ‘The bain’s prior homeostatic state memories will be changes cognitively, emotionally, motorcally, and. physiologically (Persy & Pollaa, 198) Children experiencing Such allertuons often express these alterations ‘vough academic problems, emotional or relational problems, sensory ‘motor problems, oF core physiological problems, These ifcltes wl also res i the child having great dffculty benefiting from therapies Using cognitive methods, lnyguage, or therapeutic selationshipe as ene: lial interventions (erry, 2006, van der Koll, 2006), INCREASED VULNERABILITY OF CHILDHOOD ‘The brains response to threat is well documented, bt the incomplete ‘neural developmental architecture of the child's brain presents addi onal concerns for treatment of traumatized children (Perry & Pollard, 1998; van der Kolk, 2006), Perry and Pollard (1998) pointed out that adults sometimes believe and speak of children as being resilient to traumatic ‘events because oftheir youngage. In these cases, adults percelve children as possessing qualities that inwslate or protect the from the disorgart izing impact of psychosocial maltreatment. To the contrary, neatly 20 years of research in child maltreatment has made it abundaatly clear that this is not the case. Infact, ehildren aze much ore vulnerable to ‘waucua duting early development than duting ater development (Perry & Pollard, 1998), An uncomfortable realty of sequential brain development is thatthe organizing, sensitive brain ofan infant or young child is more malleable to experience than the mature brain. Although traumatic expertnce uy negatively atfct the fonction of an adult, this same experience erly ‘becomes he neural organization fran iniantor childs brain (Per), 2006. ‘This explains why the beneficial effect of psychotierapy was primary found in adult-onset trauma survivor. Seventy-five percent ofthe adults achieved asymptomatic ratings while only 22%" of the child ‘onset survivors achieved asymptomatic statis (van der Kolk etal, 2007) This 's not surprising given the child's immature neural developmental stats versus the adulls more mature neurological state, The result of child ‘onset anima is tha the brain becomes poorly developed and functionally lsorganizad, rendering the chld less able fo intellectually, verbally, oF ‘emotionally respond to normal experiences let alone rautati anes Perry ‘and Pollard (1998 continued by pointing out that although the young child willbe unable to effectively xespond to ie trauma, the chil is stil capable of experiencing a feacindueed stare responce, emotional distress, oF any ageappropriate reactivity in response to 4 tniumatic experience ‘What the child eanoot do is understand, symbolize, or verbalize The (Chit Sexual Abuse, Traumatic Experiences, and Tir Inpact 37 ‘perience to oles, Sometimes adults mistakenly vew the lack of a "pone as einotional eienee When cdeen sue such chsaraniong eirobilogial trauma, therapeutic change must ite eee pasted opportunities for new experionces wich allow the brain ce brook flue associations or decrease the Overgenerazntion of Goume lated associations Pery, 2000) Formilons of abused and neglecta children, thee maladaptive and trsumati experiences have profoundly altered tel brain decloreee, or reviw, sea Peary, 2008, The trstmaic experiences have ene 2 ner; fut less foncona, iss foxble sate of eqn Co Poll, 1958). Chikren living in ehnoe, neglect abuse, or theese ae, havetheopportuntyto develop the fundamental experiences regued oo express thei full potent for selfegslation, reatonshipy eran caton of thinking. They become oory socalized a0 af na fe Profound and lstng emotional, behavior, socal, cognitive and soe tathoalth problems (Anda etal, 2006; Perry 2006; erty etl, 1) Poy Pola 1998, “Trauma sympioms common to taunatized children generally feature intrusive recollections persistent avoidance ot assocted Small xeon ing of general responsivenes; and arousal symploms of Meee hypervigionce, stl respons, sep difcuesiilablty ery and physilogel hyperactivity. With repeated activation the spptons el $esin to generalize to ater stall resembling the Maumee eta elictng complex, multsystem symptomatology tery, Conroy, © Roce, 1850, Other symptoms routinely associated wath tesaationd ardren ee behavior impiity, increased muscle tone asta focus om thee slated ccs ten no-verba,alfect regulation, ngeage problone tee ad gross motor delays dcorganiznd atinchment dysphoria, ateaton, Aiicaties, memory problems, and hyperactivity Dery ot at, 95D an ‘ein, iterfamiil abuse hasbeen increasingly doctmenad ae go tbutory to complex numa involving chrome sect ciarpeletion od destructive behavior agains elf and others leaning dalton fice, Siatveprobiens, somatization and cistron in corgcpt aboct ef ok ethers (Hooper etal, 207; va der Kol, 1994; van cer Kal 001) Sc, of global neglect have farther contributed to the appaliog moe ot smalzetment identifying abnormaltics in brain size Change eect, corte atrophy, alteration inthe corpus callin: devon eeu, activin the orbital rota yrs, inlimbac peerontel cortex apes td Bend ofthe hippocampus, lateral temporal Cortes as wel eine ‘ainsi (Penry, 2005, 2008) Treat appronches nee tobe evan ine al eeexamined in ight ofthe groveing krowledgeof how the frais lene fn how tis affected by environmental ine 38 teammcanon BARRIERS TO INTEGRATION OF [NEUROBIOLOGICAL INFORMATION, “Many well intended intervention efforts have been misinformed about the fundamental principles of brain organization, development ancl functions ing, and were predestined to fail (Pery, 2006; 2008; Perry & Hamrick 2008; van der Kotk, 2004, 2006). Both Perry and van des Kolk clearly contend that trentnent designs lacking baste neurobiological principles Fogarding how the brain develops and changes cannot expec! te be

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