Associate professor Vera Clemens, child and adolescent psychiatrist working in clinical and preclinical trauma consequences at Ulm University Hospital.
Childhood trauma is a daily occurrence for psychiatrists working in the field, and what is clear is the long-term outcome of these traumas can inflict the patient into their adulthood. Vera Clemens is a child and adolescent psychiatrist working in clinical and preclinical trauma consequences at Ulm University Hospital. Her research focuses on the neurobiological and clinical consequences of adverse childhood experiences. Here, she summarises the key things she will discuss in her upcoming keynote presentation at the ESCAP Expert Day – Changing perspectives.
Subclassification of trauma
The complexity of dealing with trauma is dependent on the type of trauma and the different developmental age the trauma is inflicted on a child. “Adverse childhood experience is the common umbrella term that encompasses a variety of traumas, on the one side child maltreatment (physical, sexual or emotional abuse) and physical and emotional neglect, and on the other, household dysfunction, such as parental separation, mental illness of parent, substance use of the parent, incarceration of the parents etc., so we have two different concepts” Clemens states. “Usually in research, we sum them up and obtain a score, and some studies have shown that by summing these traumas up in early life do correlate strongly with increasing problems in later life, which corresponds to mental illnesses but also physical disorders. What’s important is that if we focus on our patients and go to a more individual level, we need more facts and knowledge about the influence of the signal times and also the prevention time, and what intervention is needed and when”.
Neurobiology of trauma and later life illnesses
Research has shown that individuals who are affected by adverse childhood experiences later on in life have an increased risk of developing certain somatic or physical health conditions, such as cancer, mental health issues, cardiovascular disease, diabetes. But how can this be explained? “You could assume that these share a common neurological pathway, that on one side it can lead to mental health issues and on the other physical conditions develop. The common denominator in these disorders is that they are often stress-related. We know that the HPA axis has been shown on numerous occasions to have disturbances in relation to stress and certain disorders. I’m interested in understanding more about the inflammatory system. For example, we do know that some children and adolescents who exhibit depressive or anxious symptoms also have increased cytokine levels, so biomarkers of inflammation in their systems. And we also know that increased inflammatory markers are associated with cardiovascular disorders. It is just one brief example but it is clear that there is this interplay between stress, the HPA axis and inflammation that could then play a role in the development of physical conditions or mental health issues or a combination of the two. It is interesting field to explore and understand further”.
Stopping the vicious circle
What is important to state is that not all children experiencing maltreatment will develop mental health issues, so there are protective factors. “One of our studies showed that parents with mental health problems have an increased risk for maltreatment. However, if parents that suffer mental health illness do not inflict maltreatment on to their children, then these long-term consequences on children that we speak about will be significantly reduced. Meaning that if we work with these families and explain about child maltreatment and the negative long-term effects of it, meanwhile, give the parents support on how to integrate and help their children, then it can reduce the long-term consequences. The important message is as clinicians, we can do something to stop these long-term consequences by working with these families. This also applies to substance abuse or parental separation, if we reduce the maltreatment then the long-term consequences are dramatically reduced too”.
COVID-19 and trauma
In May 2020, along with several colleagues, Clemens co-authored a well-received editorial in the ECAP issue, which addressed social distancing and school closures. She states that “since the publication of the ECAP editorial, we do have more data, and what is clear and actually obvious to so many, is that children and adolescents are suffering from the pandemic. The risks of mental health problems in children and adolescents are increasing. In some cases, we already know there are certain risk factors in a child’s environment i.e., parents who have mental health problems or have themselves experienced an adverse childhood event, the pandemic has put these children in a vulnerable situation, and we’re fully aware that we need to be there and support these children to prevent or stop maltreatment occurring. The main aspect of this editorial is that it emphasized the need to keep wards open and for children and families to have access to clinicians and care. We continue to learn from this situation, but we know that during the pandemic, we need to maintain psychotherapy, ensure patients get the medication they need, make sure if there’s any suicidal crisis then we are available to offer support and help. When the publication was released in May 2020, I feel that there was an insecurity with clinicians about how to treat and maintain contact with patients, the editorial gave some clarity, and as the pandemic continues, we’re learning so much about the importance of continuity of care for existing patients and maintaining access to services for new patients”. There’s been a huge increase in public awareness for mental health during the pandemic, even at a political level. Clemens states that “this is due to the amount of clinicians who have stepped forward and insisted and protected the continuity of care for their patients, as well as point out how important social contact is for all children and adolescents, and the detrimental effects of school closures”.
But what does the future hold for the young generation living through this pandemic? “Of course, we are not fully aware of the long-term consequence of the pandemic, lockdown, school closures etc. We are doing research to try to anticipate the pathophysiology that may develop. We are hopeful that for issues such as anxiety, CBT can work effectively, so if children and adolescents develop anxiety because of the pandemic, we can address it, of course, if they can get access to treatment. It’s also important to listen to parents, to understand what types of issues or changes they are seeing in their children. In the aftermath of the pandemic, we will be able to see what children coped well with the situation and those who haven’t, but it will be of prior importance to identify these children in order to provide targeted support as soon as possible to diminish potential long-term consequences”.
Find out more by registering and joining Vera Clemens as she talks more about trauma in childhood. She will present at 13h45 CET on the 25th June.
Clemens, V. et al. Hypothalamic-pituitary-adrenal axis activation in a high-risk sample of children, adolescents and young adults in residential youth care - Associations with adverse childhood experiences and mental health problems. Psychiatry Res. 2020. 284:112778.