Lay Not Thine Hand Upon the Lad: The Importance of Childhood Trauma for Forensic Science

After this presentation, participants will be able to:

(1) To document child maltreatment (CM), abuse and trauma across history and cultures as examples of Adverse Childhood Experiences (ACEs) and Social Determinants of Health (SDH)

(2) To illustrate the clinical impacts of ACEs and SDHs on lifelong health and mental health

(3) To plan Trauma-Informed Care (TIC) for CM

(4) To show the relevance of CM, ACEs and SDHs for forensic psychiatry

1. Professor Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA, FACP
October 3, 2024
“Lay Not Thine Hand Upon the Lad”
The Importance of Childhood Trauma
for Forensic Science

2. Professor of Psychiatry, University of Montreal
Clinical Professor, The George Washington University
President, World Association of Social Psychiatry (WASP)
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA, FACP
Email: [email protected]

3. •The presenter has no financial conflicts of interest to declare
Conflicts of Interest

4. After this presentation, participants will be able to:
1.To document child maltreatment (CM), abuse and trauma across history and
cultures as examples of Adverse Childhood Experiences (ACEs) and Social
Determinants of Health (SDH)
2.To illustrate the clinical impacts of ACEs and SDHs on lifelong health and
mental health
3.To plan Trauma-Informed Care (TIC) for CM
4.To show the relevance of CM, ACEs and SDHs for forensic psychiatry
Learning Objectives

5. •b. Cardiff, Wales (1917) –d. Hamilton, ON (2001)
•Trained in London, UK (FRCP)
•Founding Head, Dept. of Paediatrics, McMaster Medical School
(FRCPC, 1969)
•Emeritus Professor of Paediatrics, McMaster University
•“During the 15 years as head of department, his interests slowly shifted from
neonatology and ‘organic’ problems, to more socio-political, behaviouraland
psychosomatic areas of paediatrics. He regarded the role-modelling functions of
parents and grandparents as being highly significant.”
–Royal College of Physicians (London)
Dedication: Joseph Jacobs, MD, FRCP, FRCPC

6. I Child Maltreatment (CM) and Trauma
II Adverse Childhood Experiences (ACE)
& Social Determinants of Health (SDH)
III Trauma-Informed Care
IV Relevance of CM, ACE, SDH & Trauma for Forensic Science
Overview

7. I Child Maltreatment and Trauma

8. The
Akedah
“The Sacrifice of Isaac”
Caravaggio (1603)

9. Lay not thine hand upon the lad, neither do thou
any thing unto him: for now I know that thou fearest
God, seeing thou hast not withheld thy son, thine
only son from me.
–Genesis 22:12

10. The
Akedah
“The Sacrifice of Isaac”
Peter Paul Rubens (1614)

11. The
Akedah
“The Sacrifice of Isaac”
Marc Chagall (1966)

12. •What binds together Bob Dylan (“Highway 61 Revisited”)
•Leonard Cohen (“Story of Isaac”)
•Three Abrahamic faiths –Jewish, Christian and Muslim
•Caravaggio, Rubens and Marc Chagall
•Child sacrifice and trauma
•With child psychiatry and trauma-informed care?
•The binding or sacrifice of Isaac
The Binding of Isaac

13. •My doctoral dissertation on philosophy & psychiatry,
Trauma and Event, is an archaeology of trauma.
•Trace the origins of child trauma to the Akedah, the binding of Isaac.
•Following a certain train of thought in philosophy, I call the Akedah
an apparatus for desubjectivation, the evacuation of the human, and
•the name for this apparatus is “Isaac machine” or in its Germanic
form, Isaacmaschine.
The Binding of Isaac

14. Commentariesfocus on Abraham
•Whatabout Isaac?
•Whatabout hismotherSarah?
The Binding of Isaac

15. •“Spare the rod, spoil the child”
–Proverbs 13:24
•There was an American Society for the Protection of Cruelty to
Animals (ASPCA) BEFORE there was one for the protection of
children
•Pioneers in this are US paediatricians(Kempe & Kempe) and
internists/epidemiologists (Felitti& Anda)
Child Maltreatment

16. C. Henry Kempe, MD, US Pediatrician
First described the battered child syndrome in 1962
Photograph: University of Colorado Health Sciences Center, late 1960s.
16

17. TheHistoryofChildhood
(1974)
Lloyd deMause

18. •Psychoanalyst
•Social historian
•Createdthefieldofpsychohistory
•Mostfamouswork: TheHistoryofChildhood(1974)
•Controversial forattemptstolink patternsofbehaviourwith
historicalevents
•Mostegregiouserror: supportedthe“Satanicritual abuse”
hysteriaoftheearly1990s
Lloyd deMause(1931-2020)

19. “The history of childhood is a nightmare from which we
have only recently begun to awaken. The further back in
history one goes, the lower the level of child care, and the
more likely children are to be killed, abandoned, beaten,
terrorized, and sexually abused. It is our task here to see
how much of this childhood history can be recaptured
from the evidence that remains to us.”
– Lloyd deMause, The History of Childhood (1974)
TheHistoryofChildhood

20. Dr. Miller caused a sensation with the English publication in 1981 of her first book,
“The Drama of the Gifted Child.” Originally titled “Prisoners of Childhood,” it set forth,
in three essays, a simple but harrowing proposition. All children, she wrote, suffer
trauma and permanent psychic scarring at the hands of parents, who enforce codes of
conduct through psychological pressure or corporal punishment: slaps, spankings or,
in extreme cases, sustained physical abuse and even torture.
– “Alice Miller, Psychoanalyst, Dies at 87; Laid Human Problems to Parental Acts,”
The New York Times, April 26, 2010.
Alice Miller (1923-2010)

21. Alice Miller

22. Alice Miller

23. •“No one is born evil. It is our experience that shapes us.”
•“Every child comes into the world with the right to emotional and
physical safety and respect.”
•“We must open our eyes, hearts and minds to the emotional suffering
of our children and understand the power of even small hurts to shape
their emotional development.”
•“The truth of our childhood experiences, even if painful, must be
acknowledged if we are to move forward and find inner peace.”
Alice Miller

25. II Adverse Childhood Experiences (ACE)
& Social Determinants of Health (SDH)

26. Adverse Childhood Experiences (ACEs)
Adverse Childhood Experiences (ACEs – Felitti, et al, 1998) are
strongly associated with negative health outcomes

•Physical, emotional and sexual abuse, neglect and household
dysfunction
•Linear gradient between the number of ACEs and worsening
health outcomes
Reference: Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, etal. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes of death
in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine,
14 (4): 245–258.

27. Social Determinants of Health (SDH)
•Sir Michael Marmot – WHO Study (2008)
•Social Determinants of Health and Mental Health (SDH/MH)
•The most robust and relevant research done in medicine
•Key concept: Mental health gaps
•Children and women are the most vulnerable populations
•“There is no health without mental health” has become the
mantra of the Global Mental Health Movement
Reference: CSDH (2008). Closing the gap in a generation: Health equity through action on the social
determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva,
Switzerland: World Health Organization.

28. III Trauma-Informed Care

29. •Trauma as an event that is generally outside the range of
usual human experience
– DSM-III (1980)
•An event involving actual or threatened death or serious
injury or a threat to the physical integrity of self or others –
DSM-IV (1994)
Definitions of the Concept of Trauma

30. •There has been a loose application of the term trauma
(e.g., divorce or living with a parent who has an alcohol
problem).
•When dealing with preverbal children it is difficult to say if
the event has been perceived as life threatening.
•For this reason, some researchers try to draw connections
between certain events and PTSD.
Critiques of Trauma

31. Types of Trauma – Lenore Terr
TYPE I TRAUMA
Description: Single event,
dangerous, isolated, sudden
Response: Recalled vividly,
quicker recovery time,
better prognosis
Examples: Motor vehicle accident,
witnessing homicide or suicide
TYPE II TRAUMA
Description: Multiple, chronic,
repetitive
Response: Memories are fuzzy,
helplessness, dissociation, character changes,
more long-standing problems
Examples: Institutional care, physical & sexual
abuse, war, social violence

32. Types of Trauma – Judith Herman
DSM-IV (1994): PTSD
(Terr’s TYPE I)
Description: Single event, dangerous,
sudden, isolated
Examples: Motor vehicle accident,
witness to homicide or suicide
Herman (1992): C-PTSD
(Terr’s TYPE II)
Description: Multiple, chronic,
repetitive
Examples: Physical, emotional or sexual
abuse, conjugal violence, accumulation of
stress in therapists and healers

33. • Age of the child
• Characteristics of neighbourhood
• Degree of community resources
• Amount and quality of support
• Experience of previous abuse
• Proximity to violent event
• Familiarity with victim or perpetrator
DevelopmentalModel

34. •Appraisal of the threat
•Intra-psychic meaning attributed to event
•Emotional and cognitive means of coping
•Capacity to tolerate strong affects
•Ability to adjust to other’s life changes
•Ability to deal with loss and grieving
FactorsThatInfluenceChild’sReaction

35. •“Derail” a child’s developmental trajectory
•Compromise a child’s ability to regulate affects
•Compromise early and future relationship problems
EarlyAdverse Experiences

36. •Affects the way children think about themselves and the
world around them
•Affects the extent to which they view relationships as
trustworthy and dependable
ExposuretoViolence

37. •Characteristics of the violence itself
•Developmental phase of the child
•Family and community context
•Response to violence exposure by family, school, community
institutions
EffectsofExposuretoViolenceDependsOn:

38. •The nature of the threat and the damage
•The child’s relationship with the victim or perpetrator
•Severity and duration of violence
•Proximity of violence to child
InfluencesontheMeaningofViolence
fortheChild

39. •A supportive person
parent, relative, friend, teacher
• A safe place
home, safe haven in the neighbourhood
• Resources to find alternative ways of coping
adaptive temperament, intelligence
Prospective FactorsforChildrenExposedto
Violence

40. •Safety in the environment
•Caregivers who can mediate the dangerous environment and
help regulate experiences
•Support systems in the environment
ProtectiveFactorsforChildren

41. •Caregiver’s ability to listen may be limited
•Caregiver may not be able to hear child’s distress
•Caregiver may need to protect herself from feelings of
vulnerability and trauma
•Parent may have more trouble tolerating child’s resultant
anxiety and aggression
EffectonCaregivers

42. •Greater risk for children who have not yet attained optimal
potential development
•Knowing developmental status is crucial to understanding
the experience of infant and childhood exposure to violence
and trauma
Developmental Outcomes With Trauma

43. •Crucible of infant experiences are in caregiving relationships.
•Nurturing and responsive relationships build healthy brain
architecture that provides a strong foundation for learning,
behavior and health.
•When protective relationships are not provided, elevated
levels of stress hormones disrupt brain architecture by
impairing cell growth and interfering with the formation of
healthy neural circuits.
Relationships are “Active Ingredients" of
Early Experience

45. •Ambulance arrives AFTER the traumaticexperience
•Principles of triage, crisisintervention
•Identify, removechildfromtraumaticsituation
•Secondaryprevention:
•attenuatesymptoms
•redirectthe traumaticpathway
Trauma-InformedCare

46. •Beforeanypossibilityof treatmentwemust establisha relationshipwith
traumatizedchildren.
•Wecreatea healingenvironmentthatincludesourownself-carebasedon
empathyin orderto hearthe trauma story(Richard Mollica, 2006).
•Wemust honourinterpersonalethicsin workingwithchildrenand families
(Di Nicola, 2011).
•The face-to-face encounter–the ethicsof meeting strangers(Emmanuel
Levinas, 1998).
Trauma-InformedCare

47. •Cognitive therapy(mentalization)
•Critical Incident Stress Management (CISM)
•Eye MovementDesensitizationand Reprocessing(EMDR)
•Medications(treatsymptoms)
•Treatmentof comorbidity(substance abuse)
•Cultural familytherapy
•Combinedtherapies
Trauma-InformedCare

48. •Become well informed about trauma
•Engage in de-briefing about the event(s)
•Engage in ongoing self-care
•Frequently examine responses, resistances, and tensions
related to trauma materials
PreparingforTrauma-InformedCare

49. •Childrenare the “canaryin the goldmine”
•Theyare the mostsensitive indicatorsof trauma, embodied
and enactedin theirownlives
•“Truthtellers”of the trauma of theircommunity
•Tellingtheirstories throughtheirplay, drawings,
embodimentand enactment
Conclusion

50. Childhoodisa knife
plantedin yourthroat.
You don’tremoveit
easily.
–Wajdi Mouawad
Play & film, Scorched
Image courtesy of publisher

51. Four papers or studies:
•Impact of CM
•Impact of child relational adversities on community violence
•Psychophysiological sequelae of CM
•Practice parameter for CAP forensic evaluations

IV Relevance of CM, ACE, SDH & Trauma
for Forensic Science

52. This study underlines the importance of carefully examining
the history of ACEs and CM in forensic psychiatric patients and
considering this in forensic risk assessment and risk guided
treatment. More research is needed to draw conclusions about
whether and how histories of ACEs should be considered and
targeted during treatment trajectories.
Reference: Koolschijn M, Janković M, Bogaerts S. The impact of childhood
maltreatment on aggression, criminal risk factors, and treatment trajectories in
forensic psychiatric patients. Front Psychiatry. 2023 Nov 30;14:1128020.
Impact of childhood maltreatment (CM)

53. We studied the impact of child relational adversities on community
violence in 52 male forensic inpatients. The majority of patients were
diagnosed with psychotic disorders and had co-occurring substance
abuse, which are significant, established risk factors for violent behavior.
In this high-risk group, the frequency of community violence was higher
when patients had been exposed to each of child physical abuse,
emotional abuse, emotional and physical neglect, and bullying.
Moreover, the frequency of community violence increased linearly with
accumulated exposure to multiple types of child adversities.
Reference: Fosse R, et al. Strong associations between childhood victimization and community
violence in male forensic mental health patients. Front. Psychiatry, 31 January 2021.Vol 11.
Childhood victimization and community violence
in male forensic patients

54. We did not find that war trauma was associated with community
violence. On the contrary, in regression analysis with control for
concomitant effects of cumulative child victimization, we observed
a trend for war trauma to be associated with less community
violence. We are not aware of other studies on how war trauma
affects violence risk in forensic patients, with more studies needed
to illuminate this issue.
Reference: Fosse R, et al. Strong associations between childhood victimization and community
violence in male forensic mental health patients. Front. Psychiatry, 31 January 2021.Volume 11,
Childhood victimization and community violence
in male forensic patients – II

55. Findings: Repeated exposure to traumatic experiences changes the responsiveness
in the hypothalamus-pituitary-adrenal axis with lasting consequences in the
developing brain for structures, such as the hippocampus and amygdala. These
physiological changes are thought to cause a range of mental disorders, which are
associated with poor affect regulation, anxiety, depression, and substance abuse.
Conclusions: The importance of developing our understanding of the long-term
effects of child abuse and neglect cannot be overestimated as the result of child
maltreatment will perpetrate criminal acts since offenders have higher rates of
mental illness than the general community.
Reference: Mallett X, Schall U. The psychological and physiological sequel of child maltreatment: A
forensic perspective. Neurology, Psychiatry and Brain Research, 2019; 34:9-12.
Psychological and physiological sequel of child
maltreatment

56. Common Types of Child Forensic Evaluations
•Juvenile justice
•Child custody
•Child maltreatment
•Personal injury
Reference: Kraus LJ, et al. Practice parameter for child and adolescent forensic evaluations.
Journal of the American Academy of Child & Adolescent Psychiatry, 2011, 50(12): 1299-
1312.
Practice parameter for CAP forensic evaluations

57. Each year, there are about 3 million reports of abuse and neglect in the US …
about two thirds are screened for investigation or assessment. There is a need for
mental health professionals to assist in the evaluation process of children who may
have been abused or were found to have been abused. These evaluations are often
conducted in collaboration … Working as a forensic evaluator, the practitioner may
evaluate children in a private practice for a forensic purpose; evaluate children and
collaborate with other mental health professionals in a government agency, such as
protective services; or work with an interdisciplinary team at a pediatric medical
center. The evaluator may assist the court in determining what happened to the
child; make recommendations regarding placement or treatment; or offer an
opinion on the termination of parental rights.
Reference: Kraus LJ, et al. Practice parameter for child and adolescent forensic evaluations. Journal
of the American Academy of Child & Adolescent Psychiatry, 2011, 50(12): 1299-1312.
Practice parameter – II

58. Child and adolescent psychiatrists have an important role in the forensic
evaluation of youngsters who may have been sexually abused. Because
there are typically no physical findings in child sexual abuse and there are
no witnesses, the only source of information may be the child's
statements to family members, friends, and investigators. It is important
to understand how information can be elicited about incidents in a
fashion that does not lead or prompt the child in a way that undermines
or calls into question the answers or observations.
Reference: Kraus LJ, et al. Practice parameter for child and adolescent forensic evaluations.
Journal of the American Academy of Child & Adolescent Psychiatry, 2011, 50(12): 1299-
1312.
Practice parameter – III

59. The hallmarks of child abuse and neglect include:
a)Increased risk of psychopathology
b)Increased risk of obesity
c)Increased risk of high-risk sexual behaviours
d)Increased risk of smoking
e)Risk of exposure to abuse and neglect is increased in children with
disabilities
Self-Assessment Question 1

60. The hallmarks of child abuse and neglect include:
a)Increased risk of psychopathology
b)Increased risk of obesity
c)Increased risk of high-risk sexual behaviours
d)Increased risk of smoking
e)Risk of exposure to abuse and neglect is increased in children with disabilities
Correct answer: All are true
Explanation: The systematic review by Lang et al. at McMaster established these 5 hallmarks of
child abuse and neglect
Reference: Lang J, Kerr DM, Petri-Romão P, McKee T, Smith H, Wilson N, et al. The
Hallmarks of Childhood Abuse and Neglect: A Systematic Review. PLoS ONE 2020;15(12):
e0243639. https://doi.org/10.1371/journal.pone.0243639
Self-Assessment Question 1 (answer)

61. Higher levels of child abuse and neglect are associated with all these
factors, except:
a)Immigrant parental status
b)Food insecurity
c)Housing instability
d)Poverty
e)Uninsurance (the lack of child health insurance)
Self-Assessment Question 2

62. Higher levels of child abuse and neglect are associated with all these factors, except:
a)Immigrant parental status
b)Food insecurity
c)Housing instability
d)Poverty
e)Uninsurance (the lack of child health insurance)
Correct answer: (a) Immigrant parental status
Explanation: This systematic review by Hunter & Flores demonstrated that all of these factors
are associated with higher levels of child abuse and neglect, except immigrant parental status
(which is mixed: overall abuse is lower although parental supervision may be deficient)
Reference: Hunter AA, Flores G. Social Determinants of Health and Child Maltreatment: A
Systematic Review. Pediatr Res 2021;89:269–274. https://doi.org/10.1038/s41390-020-
01175-x
Self-Assessment Question 2 (answer)

63. These approaches to child abuse and neglect are supported by robust
research, except:
a)Adverse Childhood Experiences (ACEs)
b)The Intersectional Nature of ACEs Framework
c)Social Determinants of Health (SDH)
d)Trauma-Informed Care
e)Family therapy compared to usual social care services
Self-Assessment Question 3

64. These approaches to child abuse and neglect are supported by robust research, except:
a)Adverse Childhood Experiences (ACEs)
b)The Intersectional Nature of ACEs Framework
c)Social Determinants of Health (SDH)
d)Trauma-Informed Care
e)Family-based therapy compared to usual social care services
Correct answer: (e) Family-based therapy
Explanation: All of these approaches are based on research evidence but despite a strong tradition of family-based
therapy for children in abusive families, the evidence for its superiority over a suite of usual social care services is
doubtful.
References: Camacho S, Clark Henderson S. The Social Determinants of Adverse Childhood Experiences: An
Intersectional Analysis of Place, Access to Resources, and Compounding Effects. Int J Environ Res Public Health
2022;19(17):10670. doi: 10.3390/ijerph191710670. PMID: 36078386; PMCID: PMC9518506.
Economidis G, Pilkington R, Lynch J, et al. The Effect of Family-based Therapy on Child Physical Abuse and
Neglect: A Narrative Systematic Review. Int Journal on Child Malt 2023;6:633–674. https://doi.org/10.1007/s42448-
023-00170-z

Self-Assessment Question 3 (answer)

65. Dr. Gary Chaimowitz
Professor of Psychiatry and Behavioural Neurosciences
Head of the Forensic Psychiatry Program
International Forensic Psychiatry Lecture Series
McMaster University
Acknowledgements

66. Child Abuse and Neglect
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Lang J, Kerr DM, Petri-Romão P, McKee T, Smith H, Wilson N, et al. The Hallmarks of Childhood Abuse and Neglect: A
Systematic Review. PLoS ONE 2020;15(12): e0243639. https://doi.org/10.1371/journal.pone.0243639
LippardETC, NemeroffCB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease
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References

67. Adverse Childhood Experiences (ACE) and Social Determinants of Health (SDH)
Camacho S, Clark Henderson S. The Social Determinants of Adverse Childhood
Experiences: An Intersectional Analysis of Place, Access to Resources, and Compounding
Effects. Int J Environ Res Public Health 2022;19(17):10670. doi: 10.3390/ijerph191710670.
PMID: 36078386; PMCID: PMC9518506.
Hunter AA, Flores G. Social Determinants of Health and Child Maltreatment: A Systematic
Review. Pediatr Res 2021;89:269–274. https://doi.org/10.1038/s41390-020-01175-x
References

68. Trauma-Informed Care (TIC)
Champine RB, Lang JM, Nelson AM, Hanson RF, Tebes JK. Systems Measures of a Trauma-Informed Approach: A
Systematic Review. Am J Community Psychol 2019;64(3-4):418-437. doi: 10.1002/ajcp.12388. Epub 2019 Aug 30.
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Edelman NL. Trauma and Resilience Informed Research Principles and Practice: A Framework to Improve the Inclusion
and Experience of Disadvantaged Populations in Health and Social Care Research. Journal of Health Services Research
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Thomas MS, Crosby S, Vanderhaar J. Trauma-Informed Practices in Schools Across Two Decades: An Interdisciplinary
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https://doi.org/10.3102/0091732X18821123
References

69. Family-Based Therapy
Economidis G, Pilkington R., Lynch J, et al. The Effect of Family-based Therapy on Child Physical
Abuse and Neglect: A Narrative Systematic Review. Int Journal on Child Malt 2023;6:633–674.
https://doi.org/10.1007/s42448-023-00170-z
References

70. Forensic Studies
Fosse R, et al. Strong associations between childhood victimization and community violence in
male forensic mental health patients. Front. Psychiatry, 31 January 2021.Vol 11.
Koolschijn M, Janković M, Bogaerts S. The impact of childhood maltreatment on aggression,
criminal risk factors, and treatment trajectories in forensic psychiatric patients. Front Psychiatry.
2023 Nov 30;14:1128020.
Kraus LJ, et al. Practice parameter for child and adolescent forensic evaluations. Journal of the
American Academy of Child & Adolescent Psychiatry, 2011, 50(12): 1299-1312.
Mallett X, Schall U. The psychological and physiological sequel of child maltreatment: A forensic
perspective. Neurology, Psychiatry and Brain Research, 2019; 34:9-12.
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71. General Background
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health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World
Health Organization.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, etal. (1998). Relationship of
childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse
Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14 (4): 245–258.
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