In this Papers Podcast, Assistant Professor Jacqueline Samson and Associate Professor Martin Teicher discuss their co-authored JCPP paper ‘Practitioner Review: Neurobiological consequences of childhood maltreatment – clinical and therapeutic implications for practitioners’ (https://doi.org/10.1111/jcpp.13883). Jacqueline and Martin are the lead authors of the paper.
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- How childhood maltreatment alters threat detection and the impact of childhood maltreatment on the area and integrity of white matter tracts.
- What happens in terms of hippocampal and subfield activation.
- Definition and insight into the concept of latent vulnerability and ecophenotypes, and the impact of maltreatment.
- The problematic behavioural presentations that you would expect to see in individuals exposed to childhood maltreatment.
- Evidence-based tools for treatment and how knowledge about alterations in brain functioning changes the clinical approach to treatment.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Jacqueline A. Samson, PhD, is a clinical associate at McLean Hospital and an assistant professor of psychology in the Department of Psychiatry, part-time, at Harvard Medical School. Her chief research interests involve understanding the biopsychosocial underpinnings of depressive illnesses, particularly the contributions of developmental trauma to psychopathology.
Dr. Samson is active in both teaching and research and maintains a clinical practice in adult psychotherapy. She is a recipient of numerous awards including a 2013 Media Award: Written from the International Society for the Study of Trauma and Dissociation. (Image and bio from Mass General Brigham, McLean)
Martin Teicher, MD, PhD, has been director of the Developmental Biopsychiatry Research Program at McLean Hospital since 1988. He was chief of the former Developmental Psychopharmacology Laboratory (now the Laboratory of Developmental Neuropharmacology) and is currently an associate professor of psychiatry at Harvard Medical School. He is a member of several editorial boards, including the Journal of Child Psychology and Psychiatry. Dr. Teicher is a member of the Scientific Advisory Council of the Juvenile Bipolar Research Foundation and the SmartFIT company, and a board member of organizations including the Trauma Research Foundation and the Board of Children, Youth and Families at the National Academies of Sciences, Engineering and Medicine. He has served on or chaired numerous review committees for the National Institutes of Health, published more than 200 articles, and has been awarded 19 U.S. patents.
Dr. Teicher is the recipient of numerous honors. Recent awards include the Robert S. Laufer, PhD, Memorial Award for Outstanding Scientific Achievement from the International Society for Traumatic Stress Studies, and the Pierre Janet Writing Award from the International Society for the Study of Trauma and Dissociation. (Image and bio from Mass General Brigham, McLean)
Transcript
[00:00:00.299] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, I’m a Freelance Consultant. Today, I’m really pleased to be talking to Dr. Jacqueline Samson and Dr. Martin Teicher, who are the Lead Authors of a paper entitled “Practitioner Review: Neurobiological Consequences of Childhood Maltreatment – Clinical and Therapeutic Implications for Practitioners,” recently published in the Journal of Child Psychology and Psychiatry. Welcome Jacqui and Marty. Lovely to be speaking to you today.
[00:00:40.840] Dr. Jacqueline Samson: Thank you. Same here.
[00:00:43.540] Mark Tebbs: Good stuff. So, you’re the Lead Authors for the paper. So, if we could start with just – if you could introduce yourself, and I think you worked with another colleague. So, if you could introduce them at the same time, that’d be great.
[00:00:56.160] Dr. Jacqueline Samson: Sure. Okay, I’m Dr. Jacqueline Samson. I’m a Clinical Psychologist and Research Associate at McLean Hospital in Boston area and an Assistant Professor of Psychology in the Department of Psychiatry at Harvard Medical School. My chief research interests involve understanding the underpinnings of depressive illnesses and especially the contributions of developmental trauma to psychopathology. My colleague, Thatcher Newkirk, who is not here with us today, well, at the time that we began this project, Thatcher was a fourth year Resident in the Psychiatry Residency Training Program at Saint Elizabeth’s Hospital in Boston completing a year of directed research with me. He went on to complete a geriatric fellowship at Dartmouth and is currently a Clinical Instructor in the Department of Psychiatry at the Geisel School of Medicine at Dartmouth University and Medical School and on staff at the Dartmouth Hitchcock Medical Center.
[00:01:57.480] Dr. Martin Teicher: Okay, I’m Martin Teicher. I’m a Psychiatrist at McLean Hospital for a very long time, where I am a Research Psychiatrist and run a research programme called the Developmental Biopsychiatry Research Program. I’m also a Senior Faculty in the Department of Psychiatry at Harvard Medical School. My focus in the research has been very much on the effects of childhood adversity on brain development and risk for various psychiatric disorders. And I’m also doing a fair amount of research on the neurobiology and treatment of ADHD and depressive illness, and looking forward to talking today.
[00:02:36.269] Mark Tebbs: Likewise. Thanks for the introductions. So, let’s start with just a brief overview of the review paper just to, kind of, set the scene for our listeners.
[00:02:44.830] Dr. Jacqueline Samson: So, the title of our paper is, “Neurobiological Consequences of Childhood Maltreatment – Clinical and Therapeutic Implications for Practitioners.” And the purpose of it is threefold. First, our hope was to provide a summary of what is known about the neurobiological consequences of exposure to maltreatment in childhood. The second, to discuss what problems we might expect to see behaviourally in individuals exposed to childhood maltreatment, and third, how we as Clinicians might help patients who have been exposed to maltreatment overcome these problems.
[00:03:28.120] Mark Tebbs: Thank you. So, if I could, sort of, take you back to the start, could you describe and just, like, unpack a little bit your original, like, research aims, some of your, like, original hypotheses?
[00:03:37.890] Dr. Jacqueline Samson: In 2013 and 2016, our group published a comprehensive, or several comprehensive, reviews of research linking exposure to childhood maltreatment with alterations in brain structures and circuitry. For me, working on these reviews while continuing to treat patients who have these types of histories, it created a new frame for my clinical work, and I found myself talking with patients about emerging findings observed in groups of maltreated individuals. My patients were extremely interested in learning more about this and together we talked about the implications of the neurological alterations found in the MRI studies that were included in these reviews, and how they might dovetail with some of the behavioural struggles these patient – my patients were having.
So, the clinical areas we’ve chosen to highlight in this paper were selected specifically because they reasonably connect with the altered brain structures reported in the literature. We haven’t discussed a variety of other symptoms that have been included in descriptions of developmental trauma or complex PTSD that have been based on clinical observations alone. And in this way, we’ve attempted to begin to develop a clinical toolkit that is specifically assembled to identify and address some features found in patients exposed to childhood maltreatment that are reasonably speculated to be associated with reported brain abnormalities in this population.
Secondly, in our clinical experience, we have found that including discussions, discussions that are age appropriate, of course, these reported brain abnormalities, those that might be reasonably speculated to be associated with certain clinical presentations, helps to provide a rationale that may make the clinical interventions more understandable to the patients and the – to their families.
Now, I do want to point out that we do not see these symptoms as equivalent to a diagnosis of complex PTSD, although there is overlap. Not all persons exposed to childhood maltreatment do suffer from PTSD, and it’s possible that maltreatment may be ongoing and damaging, but not acutely life-threatening, such as people who’ve been exposed to chronic emotional abuse or emotional neglect. Or the trauma exposure may not be remembered or may not emerge until much later in life. So, we’re proposing here a toolkit that may identify clinical interventions to be used for various other behavioural symptoms that may present episodically or sporadically in individuals exposed to childhood maltreatment, but likely don’t or may not meet criteria for PTSD.
[00:06:26.310] Mark Tebbs: Is there, like, a personal or professional connection to the research field? I’m just wondering whether you were trying to address a particular research gap or is there a, kind of, a central research question that you were trying to address?
[00:06:40.980] Dr. Jacqueline Samson: Well, when we began this work, we asked Clinicians the question, what are the best treatments for individuals exposed to maltreatment as children? And the answer we usually received was, “Oh, trauma-focused CBT.” And when we went on to start our literature review and look into it a little bit more, it became clear that exposure to childhood maltreatment does not constitute a diagnosis. It defines a population at heightened risk for developing psychiatric or physical disorders and a wide variety of behavioural presentations that may bring these individuals into treatment. In and of itself, it’s not a diagnosis.
So, while there is now a convincing body of evidence that supports the effectiveness of trauma-focused cognitive behavioural therapy and other trauma-focused interventions, including EMDR, for the treatment of PTSD in children and adolescents, it’s unclear how effective these modalities are in treating the vast array of other psychiatric disorders that emerge in maltreated youths. In the paper we quote a Cochrane Review of treatments for children and adolescents exposed to trauma that reported most PTSD treatments studied produced moderate improvement for PTSD symptoms, but also note that the outcomes for subjects with exposure to trauma who did not meet diagnostic criteria for PTSD were less favourable than the outcomes for those diagnosed with PTSD.
So, addressing a similar issue, other outcome studies of adult PTSD treatment identified subsets of subjects meeting additional ICD-11 criteria for complex PTSD. And these resulting meta-regression analyses revealed that subjects with complex PTSD did not respond as well to standard PTSD treatments. So, even though there were a number of treatments that are known to be effective for addressing the specific symptoms associated with PTSD, not all maltreated children develop PTSD or even meet criteria for complex PTSD. So – in fact, some reports we reviewed in the paper have shown that only 35% of severely maltreated and psychologically traumatised children have met structured interview criteria for PTSD.
So, then the question changed a bit and became, how do we treat these other sequelae of exposure to childhood maltreatment? And another question became, what are the behavioural problems we would expect to see in children and adolescents experiencing the neurobiological alterations reported in the literature and how might those be treated? So, this review addresses these last two questions.
[00:09:27.100] Mark Tebbs: Okay, brilliant. So, we’ll come onto the toolkit and the clinical implications in the second half of the podcast. I think it’d be useful if we focus this next bit on those neurobiological changes. So, the paper is divided into those two main sections. So, the first describes the, kind of, alterations in brain structure. The second half then summarises the behavioural presentations associated with those neurobiological alterations. So, I’m going to suggest we, kind of, follow that format for the rest of this podcast. So, could you start by explaining how childhood maltreatment alters threat detection and the response in the brain?
[00:10:08.420] Dr. Martin Teicher: So, one of the fascinating things that we found in doing research on the effects of childhood maltreatment on brain structure and function is that many of the regions that have been identified as being different in individuals with maltreatment histories are all part of a circuit that plays an important role in detecting and responding to threat. This circuit was laid out a while ago by Joseph LeDoux.
It’s been amplified by a number of people, and it’s a very sophisticated circuit that picks up salient stimuli, and one of the most salient stimuli that it’s concerned with detecting, you know, are threats. And what’s, sort of, central in this circuit is the amygdala and there’s two pathways from the sensory systems to the amygdala. There’s a direct pathway that goes very rapidly to the amygdala and there’s a longer, more complicated path that goes through sensory cortical regions and to other limbic and prefrontal cortical regions that takes longer to process the information, but then can moderate the response.
So, we can have one level of response at an unconscious level, where, you know, we detect something that’s a threat and we respond immediately, like we freeze or something like that. And then, as the higher processing regions come through, it may then help us realise that it’s really not a snake that we’re looking at. It’s really a stick and that we can, you know, take a deep breath. It’s just interesting how almost every component of the higher part of this pathway is shaped and affected by exposure to childhood maltreatment.
The most interesting wrinkle that’s come out most recently is that these brain regions have sensitive periods when they’re particularly susceptible to different types of maltreatment at specific ages and that the number of these regions, like the amygdala and the hippocampus and aspects of the prefrontal cortex, have two sensitive periods. They have an early sensitive period in childhood, and they have a later sensitive period in adolescence. They’re modified by exposure to maltreatment during both of these, you know, windows of vulnerability, but in opposite ways.
So, that exposure early on will lead to an enduring effect on the amygdala to blunt the amygdala’s response to threat. Whereas exposure during the adolescent period will actually wind up enhancing the amygdala’s response to threat. And these probably have adaptive significances that, you know, an adolescent, a 16/17-year-old who’s responding to threat, can, you know, mount an appropriate fight-or-flight response. Whereas, you know, a six-year-old isn’t going to be able to manifest an appropriate fight-or-flight response and may need to actually submit and self-soothe. And that if they actually had too much of a fight-or-flight response, it might actually disrupt the attachment bond.
So, that, you know, they have these changes and these changes are – the brain isn’t damaged by these things. It’s modified by these effects and these modifications are probably of adaptive significance and helpful in childhood, but later, as you go into adolescence, as you go into adulthood, there can be, you know, significant ramifications from these changes that set you up, you know, to develop different psychiatric disorders and vulnerabilities.
[00:13:09.390] Mark Tebbs: And so, the paper then describes the, kind of, second impact of childhood maltreatment on the area and integrity of the white matter tracts. Could you explain that a little bit for us?
[00:13:21.220] Dr. Martin Teicher: So, maltreatment is affecting, as far as we can tell, you know, all aspects of brain development. So, what I was just talking about are, you know, effects on the brain regions which are, you know, called the grey matter portions of the brain and then there are white matter portions of the brain where there are fibre tracts. These are myelinated fibre tracts that interconnect brain regions in which signals go, you know, between the brain regions and that there’s this substance called myelin that wraps around neurons and facilitates neurotransmission.
It’s very important for rapid neurotransmission and the production of myelin can be affected by stress, and you can get alterations in myelin. You can also get alterations in the inner integrity of the axons. So, not only does it, you know, influence, you know, the structure and connectivity of the neurons, but it influences the flow of information from brain region to brain region. And interestingly, there’s pretty prominent sex differences in what gets affected. Found, for instance, in the corpus callosum that in females it’s primarily affecting myelination, whereas in males it tends to be more affecting the integrity of the axons themselves. So, interesting how these – they’re both affected, but in somewhat different ways.
[00:14:32.360] Mark Tebbs: Okay, and what happens in relation to the hippocampal and the, kind of, subfield activation?
[00:14:37.990] Dr. Martin Teicher: So, the hippocampus is one of the most stress-sensitive structures in the brain. It’s sensitive in two ways. One portion of the hippocampus is called the dentate gyrus, and the dentate gyrus is a portion of the brain in which there’s active postnatal neurogenesis. So, there’s production of new neurons coming into this portion of the hippocampus and getting, to some degree, integrated. And this can be really suppressed by exposure to stress or adversity. And then there’s also the large neurons in the hippocampus, called pyramidal cells because they have, like, a pyramid shape, and these neurons are affected by stress, which can affect, you know, the complexity and the dendritic branching of these neurons. It’s – this is one of the major targets. These neurons are found in the hippocampus, they’re found in the amygdala and they’re found in the prefrontal cortex, and they’re, you know, portions of the brain that particularly vulnerable, you know, to stress.
And the hippocampus plays an important role in the threat detection circuit, modifying the amygdala response portion of that, the subiculum particularly, involved in modifying response to psychological threats. It also plays an important role in learning and memory, particularly retrieval of information and in spatial navigation. So, there are a myriad of consequences from – affecting the hippocampus.
[00:15:58.220] Mark Tebbs: The paper talks about the concept of ‘latent vulnerability’. Could you describe and explain that to our listeners?
[00:16:05.520] Dr. Martin Teicher: This idea of latent vulnerability has been advocated by Eamon McCrory, in a very nice paper in the Journal of Child Adolescent Psychiatry and Psychology in 2017. And he talks about maltreatment as affecting a number of brain functions, like threat detection or reward response or short-term memory. And that, as Jacqui was saying, it’s not directly tied to pathology, but it’s associated with a latent vulnerability where down the road, you may develop a psychopathology. We see this very nicely in our data that we can find these abnormalities in the brain structure and they, you know, correlate rather modestly with current symptoms, but they correlate very strongly with lifetime risk for developing different psychiatric disorders.
It’s a vulnerability that’s not necessarily manifest but could be manifest and so, you’re at risk for developing a host of different disorders because of these things. And that degree of separation between how the neurobiology has changed and what you see clinically is quite important. I think it’s also important that it means that there’s also ways to pre-empt the onset of psychiatric disorders in individuals who’ve been exposed, and that’s something that we need to learn much more about.
[00:17:20.830] Mark Tebbs: And the last bit of the, kind of, neurobiology section of the paper, kind of, reviews the evidence around ecophenotypes. Could you just describe what those are, for maybe listeners that don’t understand, and explain there the impacts of maltreatment?
[00:17:35.049] Dr. Martin Teicher: Jacqui and I wrote a paper back in 2013 where we made a hypothesis that maltreated and non-maltreated individuals with the same DSM or ICD diagnosis are actually clinically and neurobiologically distinct. And that even though we’re giving them, you know, the same diagnosis that we might call the – both give them a diagnosis of major depression, that they’re very different. And in particular, the individuals with the maltreated variant, which we call the ecophenotype, have alterations in the morphology and connectivity of stress susceptible brain regions. They also tend to have an earlier onset, a more severe clinical course, more frequent comorbidities and poorer response to first-line treatments.
And the difference in response to first-line treatments can be quite dramatic. It can be the difference between 80% response and 16% response, in between the phenotypes, and we talked about this in terms of depression and anxiety and substance use disorder, but it extends beyond that. It’s also now been observed in schizophrenia. It’s been observed in bipolar illness. There really do seem to be important variations between these individuals who do or don’t have a maltreatment history. And we really were trying to advocate that it’s important for Clinicians to note this. It’s important to keep records of this. You know, what may be recommended as a first-line treatment for the average person may not work all that well in the individuals who have a maltreatment history. So, we have a lot to learn about this subtype and how it compares.
[00:19:06.080] Mark Tebbs: Thank you, Martin, for that, kind of, comprehensive coverage. Jacqui, we’re going to move on to the clinical implications, so – and I’m going to ask you the question that you, kind of, posed yourself in the paper. So, what are the problematic behavioural presentations would you expect to see in individuals exposed to childhood maltreatment?
[00:19:26.030] Dr. Jacqueline Samson: Well, we might expect to see symptoms such as functional alterations in threat processing, and what we mean by that is either overreacting or underreacting to threats in the environment. We might see less conscious awareness of the actual environmental threat that exists, but at the same time, showing a preserved unconscious behavioural activation of the threat response. Showing behaviours such as fight, flight or freeze, but without knowing why these behaviours are coming up. We might see problems with accurately integrating signals from the left and the right hemisphere, with the left hemisphere having signals that have to do with describing what is happening, just in terms of the details and the particulars of the moment, and the right hemisphere picking up on the emotions or the implications of the moment. And the patient having a hard time integrating these signals and possibly toggling between states of unemotional recounting of information, flipping over to a state of affective flooding.
We might see things like a negative cognitive mindset. We might see over-general memories or fewer memories of personal experience or what we call in the field autobiographical memory. And as a result of all of these kinds of problems, we might see difficulty learning from experience. We might see difficulties interpreting social interactions, we might see poor judgment, and we might also expect to see problems with affect regulation and difficulties maintaining relationships, what Eamon McCrory has referred to as ‘social thinning’. And lastly, we might expect to see diminished response to reward anticipation and reward receipt, or what some might call anhedonia, but on the other hand, hyperresponsivity to potent rewards, such as drugs of abuse or risky rewards.
[00:21:30.930] Mark Tebbs: In your introduction, you’ve mentioned the list of evidence-based tools for treatments. Could you, kind of, describe those a little for us?
[00:21:38.560] Dr. Jacqueline Samson: Well, we’ll start with the, actually in many ways the most important, which are tools for an overactive threat response system, which I think we described in the paper as probably the overall biggest issue one sees in persons presenting with a history of maltreatment. For those, we’re recommending lifestyle type changes, changes that would result in an overall decrease in the level of arousal or the level of anxiety the individual is feeling.
Things such as daily positive mental health practices that encourage a more resilient baseline. Daily sleep hygiene, because quality of sleep relates to the effects of maltreatment on hippocampal and the growth in integrity of myelin in the uncinate fasciculus, the things that Marty was speaking about earlier. Daily structure and minimising stress exposure in order to help maintain an optimal level of stimulation. Behavioural practices, such as paced deep breathing pract – on a daily basis, attention to breath exercises, progressive muscle relaxation, mindfulness training and physical exercise, which has been shown to improve executive functioning.
In addition to specific lifestyle practices such as these, specific behavioural treatments could also help. Among those would be dialectical behaviour therapy, training skills, modules for distress tolerance, emotion regulation, interpersonal effectiveness training. Relying on cognitive reappraisal and biofeedback could be helpful with older teens in order to gain a greater control over amygdala reactivity. And for young children, ARC affect modulation exercises might be helpful. Neurofeedback procedures can help reduce amygdala reactivity. Moving onto tools to identify the source of activation for individuals who don’t have information coming in from the – what we refer to in the paper as the ‘high road’ or the higher cognitions that have to do with sensory input and conscious awareness.
In therapy, a key goal would be to identify and manage the triggers in the environment. In order to do this, a Therapist can ask about the most recent previous time the patient felt ‘normal’ and together with the patient, identify each and all activities, including books, movies, internet, conversations, thoughts and exposures that have occurred since the time the person started to notice a difference in feeling activated, in order to create hypotheses about the potential sources of perceived threat. Identifying patterns and content over time can go on to help the patient and those who care for them, too, because they’re going to be part of the team, become more alert to environmental triggers and work on anticipating them. And this kind of approach is consistent with Carrion’s cue-centred therapy for child and adolescent complex trauma.
More tools, tools for toggling between verbal logic and emotional states. One of the most problematic correlates of this kind of toggling may be getting triggered into a state of extreme emotional intensity without the ability to access linear thinking or verbal abilities. Meaning patients might become flooded with affect and find themselves unable to put their experiences into words. So, if you ask a patient to write about their feelings, that can be a good check on their ability to access verbal logic. If they can’t write and if they can’t describe it, put it into words, they probably need to focus on self-soothing activities using non-verbal methods, similar to emotion regulation skills outlined in DBT. Only when the patient is more settled can you try to access verbal abilities and introduce activities that involve logic. Puzzles, non-emotional and distracting mental activities may be helpful then. Many patients can actually feel the shift in affect and describe that the emotional outburst has passed and these rapid shifts in mood can be addressed.
And lastly, a word on the working alliance. Establishing a consistent and affirming working alliance can create the base for building more positive social expectations. This may be both the most critical and the most difficult component of the treatment regimen. Childhood neglect and physical abuse are predictors of adult anxious attachment styles, avoidant attachment and problems with depression, anxiety, poor self-esteem. Some brain areas noted to be altered in maltreated individuals have also been cited as central to social processing in individuals with insecure attachment styles. Extensive discussion of relationship models and modules for addressing maladaptive connections can also be found in the treatment manual for STAIR Narrative Therapy by Cloitre et al.
[00:26:26.929] Mark Tebbs: Thank you. So, I’m just wondering whether it’s possible to summarise how knowledge about the alterations in brain functioning changes the clinical approach to treatment.
[00:26:36.970] Dr. Jacqueline Samson: I think the best summary would be to say that it can reduce blame for behaviours that may be extremely difficult for patients to change or control. This framework links neurobiology to clinical presentations in a form that we hope will enable Clinicians to convey to their patients that there is good reason to believe that maltreatment can result in neurobiological adaptations to the brain that can make it difficult to function well at times and help to reduce blame for behaviours that may be extremely difficult for them to change or control. If we understand that this is, indeed, the case, then there is a starting point for a compassionate discussion about not necessarily reversing these neurobiological changes, but finding ways to compensate for them.
[00:27:25.880] Mark Tebbs: Thank you for that, Jacqui. I just wanted to turn us a little bit to the research field. So, is there any further research that you think is required in the field?
[00:27:36.610] Dr. Martin Teicher: Oh, sure. There’s a great deal of research. We’re working on a number of things and it’s really nice to see that – how many people have – also doing research in this area. When I started, there were basically just three groups, you know, doing it. Now it seems like every medical school and every major Psychology Department has somebody doing research in this area. So, it’s exploding in terms of the, you know, the number of publications. And what we’re doing, you know, we’re still doing more in terms of understanding the neurobiology, and I think we can pretty much put together soon in a more comprehensive atlas, atlas of the brain regions that change and be able to make some predictions.
One of the things that’s been particularly interesting is looking at brain changes in those individuals who are symptomatic and susceptible, versus those individuals who appear to be much more resilient and don’t have, you know, problems with psychiatric disorders.
Interestingly, we noticed that there’s also a lot of brain changes in the individuals who are resilient. Also trying to understand what specifically changed in those brains of individuals who have recovered. And I think that will give us more clues as to what we can do therapeutically to foster recovery. We are working more in the ecophenotype hypothesis. We’re looking at it particularly in terms of substance use disorder. The idea that there’s one major pathway through substance use through maltreatment, as the individuals who don’t get there through that pathway, often get there through an ADHD pathway and that because of these different subtypes, they may need different approaches to treatment.
We’re also looking in – even in the A – within ADHD, at subtypes of ADHD, where we can find differences between individuals who’ve had no exposure to maltreatment and those who’ve either had very history of early neglect, or those who have maltreatment later, after they’ve had an ADHD diagnosis. The ones with very early neglect tend to have neurocognitive problems not seen in the other group and they tend to be less hyperactive, whereas the individuals who have exposure to maltreatment, particularly during the adolescence, often wind up with high levels of comorbidity and they may be three to fivefold more likely to develop, you know, comorbid disorders than the ADHD individuals without maltreatment. So, I think that’s helping us to understand comorbidity in ADHD.
In terms of treating the disorder, there’s also a need to really focus on the underlying mechanisms. How much are these alterations in the brain mediated by processes such as inflammation or stress hormones? ‘Cause that may also give us, you know, targets for intervention. And we’re also doing studies to look at how different types of treatments, like mindfulness, we’re doing this work with Diane Joss and Sara Lazar looking at how mindfulness meditation alters the structure of these regions in individuals with maltreatment history, hopefully to move on and do these studies looking at this in terms of DBT and maybe down the roads, psychedelics. So, I think there’s a whole, you know, exciting array of research that can be done. I just wish I was younger. It’s – but sure, it’s going to be great with all the things that are going to get discovered.
[00:30:38.049] Mark Tebbs: Yeah, amazing. Very active, exciting field. So, we’ve come to the end of the podcast. Is there, like, a final take-home message for our listeners?
[00:30:47.080] Dr. Jacqueline Samson: If you are a person who has been exposed to substantial maltreatment, there are treatments that can help with some of the problems you struggle with. And your struggles may be more difficult than those of the average person, due to stress-induced changes in the way your brain works. For practitioners, even if they do not have PTSD, your patients with maltreatment are likely to be feeling overwhelmed by demands from managing innate behavioural responses shaped by exposure to adverse environments and may require specific treatment and skills training to compensate for neurobiological alterations that have occurred.
And lastly, for Researchers, not all individuals exposed to maltreatment in childhood present with PTSD syndromes, and the challenge is to understand the neurobiological underpinnings of exposure to maltreatment in childhood and to identify factors that can interrupt progression into serious mental and physical disorders.
[00:31:43.559] Mark Tebbs: Thank you so much for your time and for such an interesting discussions today. So, for more details on Dr. Jacqueline Samson and Dr. Martin Teicher, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelled A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.
