Long Term Impact of Adverse Childhood Experiences and Trauma Part 1

Foreign. I'd like to welcome everybody today's presentation on adverse childhood experiences and trauma. I'm your host, Dr. Donnelly Snipes. In this segment we're going to explore the relationship between adverse childhood experiences, hencefor referred to as ACEs and trauma. Identify the impact of ACES and traumatic injury on mental, physical and interpersonal health in adults. So what, what are the long term consequences? And explore risk factors for ACES and subsequent prevention and intervention measures. So one of the things that I did with this presentation, different than other presentations on ACEs that I've done, is I really want to connect the dots so we can see or we can start to really highlight the impact that ACEs have and how a lot of the symptoms of behavioral health issues that we see in adolescents and adults actually do make sense from a survival standpoint, from a coping standpoint, if you will, for a child that was may have experienced ACEs. What are ACEs? You know, just if you haven't heard that the spiel, let me go over that. ACEs are adverse childhood experiences and we're generally grouped into or I generally group them into three categories. The first one is family violence. And under family violence is exposure to intimate partner violence, either dating violence or exposure to parents or caregivers that are violent with one another or child abuse or neglect. So any kind of violence that is within the family or within intimate relationships falls in that category. Now the estimation is that 10 million people each year are exposed to family family violence. My guess is all of these statistics for mental illness and family violence are far lower than what actually happened. These are only the ones that we know about 10 million people is still a lot. Family mental illness is the next category. And what we're looking at are mental health or addictive behaviors or addictive illnesses in caregivers, in people in the household. Family mental illness. About 19% of people have a mental health diagnosis. That's about 47 million people. 19% just doesn't sound like too much. But when you round it up to 20% just for, for giggles, that's one in five. One in five people adults is, according to the CDC, has a mental illness, substance use disorders. 29%. We'll round that up to 30. Just, you know, for round numbers. That's about one in three people have a substance use disorder according at some point in their lives, according to the cdc. That's a lot. That is a lot of people. So we can expect that there are a lot of children that are being born into families in which one or more caregivers has a mental health or an addictive behavior, and then family instability and parental separation. When one of the caregivers goes away, it can be extremely traumatic for the child. If the. If the caregiver goes away to jail, you know, that's a lot. You know, If Tommy is 3 years old and one of his caregivers goes away to jail for five years, then they're in. Well, it's actually prison. But if they're in prison for five years, when they get out, he's more than twice as old as he was when they went to prison. And think about how much happens between the age of three and eight. You know, there's a lot of stuff and development that goes on. And think about how much happened prior to the age of three. You know, when in infancy, Tommy may not have really connected as much with certain caregivers. So it's important to recognize that jail can be an adverse childhood experience because that caregiver is basically ripped out of the life of the child. And a lot of times children don't understand why it happened or how it happened. Death, Divorce, especially the nasty divorces, tend to produce more traumatic injury jobs that make people relocate, if you will. If, especially the military, when people are deployed overseas for 18 months or 2 years or however long they're deployed, that can be very stressful on a child, even in the best of circumstances. Not saying that every child of a service member is experiencing, you know, trauma. No, I'm not saying that. Don't want anybody to assume that. But in some circumstances, especially if the caregiver at home is not able to help the child feel like they're still connected with the caregiver that's overseas, it can be traumatic. And then foster care, when a child is removed from the home for whatever reason, that is obviously an example of family instability. Let's think about this from the perspective of a child. Children may not be able to articulate it, but they know somewhere in the back of their primitive brain that they can't survive on their own. They. They know they need somebody to give them food, to keep them safe, to help them survive. So when they experience these things, it is an intensified threat. When they're witnessing violence, when they're seeing one caregiver, you know, have violence on another caregiver, then we might have a child going, well, what's going to happen if one of my caregivers is killed or injured? And that's extremely threatening because then the child fears not only that the violence is going to be turned on them, but they also fear that they won't be able to survive if one of their caregivers is, is injured or killed. Obviously child abuse or neglect don't need to explain how that's traumatic. In terms of mental health and addictive behaviors. What we're really looking at is uncontrolled. If you have somebody who has recurrent clinical depression or bipolar depression, bipolar disorder, and it is well controlled on medication, that's far different than if you have someone who has bipolar disorder or clinical depression that is not controlled. And they are just struggling to get through through on a day to day basis. They are struggling to do what they need to do to survive, which means they don't have the energy or even the capacity sometimes to emotionally and, or physically connect with that child. Therefore, secure attachments just not developed. They cannot be consistent, responsive, attentive, validating, encouraging and supportive. They just can't do it. So we do need to recognize that even when a parent has best intentions, if they are struggling with mental health or addictive issues, including postpartum depression, which both men and women can get, it can impair that attachment relationship in terms of family instability, parental separation. Remember, children, especially before the age of like 11, tend to think very concretely. They think about what they can see, what they can manipulate. When they're younger, you know, like preschool and, and, and younger, they tend to also be extraordinarily egocentric and think in dichotomies, it's you all good or all bad. And when the parent goes away, the child often tries to make sense of what's going on. They don't understand what happened, what did they. A lot of times they internalize it and they say, what did I do wrong that made this person go away? If it happens during a period where a child is developmentally engaging in a lot of magical thinking, they may think that because they got angry at a caregiver that that is what caused their illness and death. So we, we want to recognize that people can experience some of these things and have good support and have good intervention from the caregivers that are there and not experience significant traumatic injury. But the more of these experiences that someone has, the more likely it is that they are going to have difficulty coping with it. So as service providers, you know, it's so important for us to talk about people, to, to, to talk about what's going on in their lives, to understand, to hear what's going on and help them figure out how to be able to be good parents with their children at home. If they're really struggling with what can we do to help you? We need to create that recovery oriented system of care where there are a lot of different outlets that parents can tap into, caregivers can tap into in order to help them with the whole nurturing process. Parenting is hard work. Adverse childhood experiences are stressful traumatic events that children experience before age 18. Studies have linked exposure to ACEs and negative health, developmental and behavioral outcomes. And again, I want to emphasize the fact that exposure does not necessarily mean injury. A traumatic event is direct or indirect exposure to an event that involved the possibility of death or serious injury to the individual. So to the child or to someone that is important to the child like the caregiver. So if they're seeing these things, if they're seeing domestic violence, that qualifies as a, as a traumatic event. You know, obviously it doesn't take a lot of. It is not a stretch to figure that one out. But traumatic injury refers to the psychological consequences and physical consequences sometimes experienced after a trauma. 61% of adults surveyed across 25 states and I don't know why it was just 25 states, but that's just what they did reported that they had experienced at least one type of ACE and nearly one in six reported they had experienced four or more types of adverse childhood experiences. So let's just go back up here and look four or more. So a caregiver that had an addictive behavior mental health issue and was involved in a relationship that was violent and maybe was neglectful because of all of the aforementioned things or mental health and addictive behaviors and the. And then they got divorced because of intimate partner violence. It's not hard to see how people can quickly add up to four or more. And a lot of times I'm not going to say all the time, but there is a pretty strong correlation between intimate partner violence and mental health and addictive behaviors. So one of the things as behavioral health professionals we can do is advocate for prevention activities. What can we do to help improve the mental health and reduce the addictive behaviors in the adults in our community? And each community is going to be a little bit different. Welcome to the all CEU's education channel where you will find long form counselor education training videos as well as shorter overview videos geared toward the general public. We have over 900 videos, so using the search function that is underneath the subscribe button on our homepage can help you find the videos that you really want to watch. You can also find an alphabetized set of some of my most popular playlists@allceus.com YouTube playlists. I absolutely love hearing from you, so keep those comments coming. We actually do read all of them and try to respond within a few days. Have a fabulous day and don't forget to click subscribe and the bell if you haven't already. So you can be notified when I release new videos. 68 point. Oops, sorry. Over 50% of adolescents have been exposed to ACEs, which have detrimental effects on learning and behavior and is associated with increased suicidal ideation. That HPA axis gets activated when the child is exposed to ACEs and experiences traumatic injury. Then, you know, they're somewhere in that realm of ptsd. You know, maybe they don't qualify for full blown ptsd, maybe it's subclinical, but they're in that realm. They're, they're on the, on the continuum, which means they're probably experiencing hypervigilance, they're probably experiencing difficulty sleeping, they're probably experiencing, experiencing changes in their gut microbiome, which is changing their neurotransmitter balances. So it makes sense that when they're going through this, their neurotransmitters responsible for learning and behavior, norepinephrine, dopamine and serotonin, are probably going to be out of whack 50% of adolescents. So let's think about the graduation rate. Let's think about students and whether they, how they do in school. Let's think about what we usually attribute school failure to. Not trying hard enough, maybe impoverished environments. But a lot of times we don't go back and say, hey, was it a traumatic event that is still continuing to impact this person, this child, this adolescent? Now, 68% of people who reported homelessness in childhood also reported experiencing four or more ACEs. Now remember, homelessness doesn't necessarily mean living on the street. It could mean sleeping on somebody's couch, having to move in with a friend or a family member because you can't afford your own, your own dwelling. So homelessness is actually defined as sheltered and unsheltered homelessness. But across the spectrum, 68% reported four or more adverse childhood experiences. Well, so what leads up to homelessness? Mental health issues, addiction issues, interpersonal violence, and, and yes, stays in domestic violence shelters when the whole family has to move. That can qualify, especially if it's sustained. So there's a lot of, and, and you know, by virtue of that, by virtue of being homeless, that's often contributes to family instability. Only 16% of people were never homeless in childhood reported experiencing four or more ACEs. So we can really cut down on the number of people experiencing that threshold of four or more. Aces. If we start looking at what's causing homelessness in our community, not everybody who's homeless is mentally ill. Not everybody who's homeless is, you know, necessarily struggling. Some people choose to live a more nomadic lifestyle. So we definitely need to be culturally sensitive, not try to put everybody in permanent housing. You know, some people want to travel the world. They don't want to have something that is a permanent house. Aces have a different impact on the brain based on the age of exposure, individual factors, and microsystem protective factors. Now think back to Brofen Brenner's model. You have your microsystem, which is the individual, what's going on in the individual? What are their, what's their age? What are their coping strategies? What confounding issues do they have? Did, were they, did they already have clinical depression, you know, et cetera? What protective factors did they have? Did they have a lot of social support? Did they have good self esteem? Did they have, you know, adequate cognitive processing? So that's the individual in terms of their immediate environment, you know, what was there to provide them support? Did they have a safe place where they could get adequate sleep? We know that lack of adequate sleep contributes to or intensifies the impact of traumatic events. Did they have an environment which they got enough nutrition? We grow based on what we eat. You know, we need to give our body the nutrients our body makes neurotransmitters and hormones from the foods that we eat. So if they have an impoverished nutritional environment, then it's al often going to contribute to an imbalance in neurotransmitters. All of these things can contribute to changes in brain structure. The strongest impacts are found for younger children ages 2 to 5 and those living in households with incomes below 200% of the federal poverty level. So let me ask you, why is it that the strongest impacts are in this narrow range for children ages 2 to 5 and 200% below the poverty level? When we're thinking about younger children, we know that the child and adolescent brain is much more malleable, much more sensitive to insults than the older, than somebody whose brain is fully formed, you know, at about age 24. Children ages 2 to 5 are very likely, I agree, dory likely, the ones not eating enough good food and getting enough quality sleep. For infants, a lot of time, infants may, they may get agitated, they may get irritable, but, but it may not impact their sleep as much. When children are 2 to 5 years old, that's when they're going through. If you think back to Ericson's stages, you have trust versus mistrust and then you move into toddlerhood. When they're trying to develop autonomy and a little bit later industry and they require, when they're trying to navigate this psychosocial crisis, it, it's scary. They're going to try to take chances. And it, they require a caregiver that is there to form a secure home base, a caregiver that can nurture them, a caregiver that can encourage them to take that next step. And if they're in an environment where there's a lot of chaos and in an environment in which there may be, you know, not enough nutrition, they're not sleeping well, they may be homeless, then the child is probably not going to be developing the secure attachments that would buffer against the stressors. So you've got two. It's a double whammy. Not only is there a trauma there, but there's also a lack of any buffers and, and protective factors. Children do need consistency and stability to create stronger connections in their brain, including food, sleep, et cetera. And this is, is very true. Any of those things that we discussed as far as aces do represent inconsistency. A parent who is clinically depressed may, you know, have good days and bad days. The kid doesn't understand why. So there's not the consistency. And they may not consistently get their needs met. You know, back to the trust versus mistrust. So it is definitely important to recognize this. And if a caregiver is not able to be attentive and responsive to the child, then at 2, from 2 to 5 years old, they're not making or maybe up around 5, they start. But you know, 2, 3 years old, they're not making their own cereal and sandwiches and whatever. So they're just, they're hungry and they're not putting themselves to bed. If their caregivers are not putting them to bed, they're just, you know, falling asleep wherever they happen to be. And that would certainly contribute to issues between 2 and 5. And, and that's a good hypothesis, Kathy, that children start having or start wanting to communicate, but they are not effective at communicating between two and five. You know, they're still learning words. They're starting to string words together and make sentences, but it's harder for them to communicate what's going on. So a lot of children in this stage, when they're not getting their needs met, instead of being able to use their words they act out, they throw a temper tantrum, they cry, they withdraw, they do something that in a different situation would elicit the attention of the caregiver. But in this particular situation, it may elicit the anger or the frustration of the caregiver and compound the negativity of the situation. When this happens, the child's not getting their needs met. They start to cry, they're fussy, they're irritable. Whatever's going on, parent gets angry. Children at this age, very egocentric, personalize a lot of things. What did I do? My parent must hate me. So they start internalizing these negative messages that they're responsible for the status of their caregiver. And if they don't, quote, behave, then they're in jeopardy of not having that caregiver be there to take care of them or in jeopardy of abuse. So there are a lot of things that can happen. Children ages you two to five, their brain is extremely malleable at this point in time too. So not only do they have needs, not only is the world just. I mean, they're learning everything. They are literally experiencing everything for the first time. So they're getting a lot of input and life can be kind of overwhelming. They can get over stimulated even with good things. And without a caregiver to help them buffer that, to help them moderate that, the HPA axis can get activated in the child. But because the child starts feeling nervous and out of control, and that can cause neurodegeneration, ACEs contribute to disturbances in cognitive and affective processing. And this is long term, not just, you know, in the moment, including heightened attention toward threatening stimuli. If ch children grow up, you know, there was a. It's not really a poem, but there was a poster I remember from back when I was little. Children learn what they live. And so think about a child growing up in an environment where there was family instability, abuse, neglect, mental health issues and, or addiction. Okay, just kind of think about what that would look like. They grow up with heightened attention toward threatening stimuli. Well, yeah, it was important for them to pay attention to those threats because they had to mitigate them. They had to protect themselves, and they had to be super attentive to micro expressions and things of their caregivers. If there was violence or even verbal, you know, verbal aggressiveness, they learned very quickly how to monitor the situation to prevent being on the wrong end of a caregiver's wrath and to try to get their needs met. They started noticing what needed to be done. If they noticed that caregiver was Starting to. And they obviously wouldn't think decompensate, but I'm going to use that because it's easiest to describe. They may say, okay, why don't caregiver, why don't you sit down and I'll try to make dinner or, and, and you know, little kids, when they try to make dinner, it's usually a disaster. You know, peanut butter and mustard or something. But you know, they try because they're so worried that their caregiver might go away, that they need to be on top of it. They need to notice as early as possible increased experience of loneliness leading to isolation and withdrawal. Well, if you're always walking on eggshells, so to speak, if you are hyper vigilant a lot of time, if when you're in around people you are hyper vigilant not only to your caregivers stuff, but to everybody's stuff, your have heightened attention toward threatening stimuli. Well, you're going to see threatening stimuli wherever you are, and that can be exhausting. So it might be easier to just withdraw. You know, I can't take it, I can't shut it off, so I just need to remove myself. There's increased HPA axis dysregulation and reduced impulse control. As that HPA axis is activated and persistently activated, then it starts to become dysregulated. We go into what's called the, what I call the flat and the furious. The receptors in the brain start to become resistant to or tolerant to, however you want to think about it. The effects of glutamate and cortisol, your stress hormones. So when the HPA axis dumps those, because it's always dumping them, the tissues aren't responsive to it. So the person feels flat a lot of the time. You need norepinephrine, you need glutamate, you need those dopamine in order to feel happy as well as to feel angry and scared. You know, it's kind of interesting. They're involved in anything that gets you revved up. So when the tissues start to become desensitized to it, they're just like, yeah, whatever. Then the person doesn't feel much and they start to feel flat. But when a threat is severe enough, the body amps up the amount of cortisol, norepinephrine, adrenaline being, glutamate being secreted, and finally it gets through. And finally the tissues pay attention and the neurons pay attention and they, the person reacts in an exaggerated fashion. And I don't like the word exaggerated. And if you can think of another word, please throw it out there. But not saying that they are being overly dramatic, but their body has actually dumped so much excitatory neurochemical stuff that they go from flat to enraged. They go from flat to terrified. Unfortunately it doesn't usually work in the other, in the happy direction where they go from flat to euphoric. But unless they're abusing substances, but which is a reason unfortunately that they are at more risk of addiction. But it is interesting to recognize that HPA axis dysregulation, that Flat and the Furious. Think about the kids that are brought in with behavioral disorders. How many of those are caused by neurological or neurochemical dysfunction? Dory, I just have a quick question. Can you go back to why they got flat in the first place? You said it was. Sure, sure, sure. Hang on. So. I'll give you the example of addiction. You know, let's just start there. Because the process is basically the same. When somebody abuses a drug, they, they take it and eventually the tissues, the receptors on the receptors become desensitized. The brain says, I can't run this hot, I can't keep doing this. There's too much dopamine, there's too much glutamate, there's too much cortisol going through the system. And it's not healthy for this organism. So I need to, you know, just stop paying attention to it. I need to stop letting it activate me. And so the tissues become tolerant to the effects of those neurotransmitters. So when somebody's taking a drug of abuse, you know, initially when they drink or use opioids or whatever it is, it produces a euphoric feeling of some type. But after a little while it doesn't produce that same feeling. It's because the tip, the neurons have started to say, you know what? No, that can't, that's too much dopamine going through the system. And it's not healthy. Which is a really cool self preservatory thing that our brain does. Unfortunately then when the person's not using, they're not using whatever substance it is, the amount of cortisol and dopamine and norepinephrine that are going through just naturally, it ain't enough. It's just not enough getting through because the tissues, you know, just don't respond in the same way. So that's where the tolerance comes and the person starts to feel very flat. They feel bad, they feel depressed when, when they're not using, which often leads them to use again. Well, and we'll see in a little while that the same thing happens with trauma. When people are exposed to trauma, their HPA axis revs up. Cortisol, norepinephrine and dopamine are released, and glutamate. So those four chemicals are released as part of the stress response. Because dopamine, remember, is your motivation chemical, your motivation to get up and get the heck out of there. But all of those are excitatory neurotransmitters. And all of those can create a neurotoxic environment if they are present for long enough and in great enough quantities. So the brain says, no, we don't. We can't just keep bathing the neurons in this stuff because it's causing neuronal damage. So when the person is not engaging in some sort of addictive behavior to artificially stimulate those chemicals, they feel flat. You know, it's kind of like the person with an addiction who's not using, they're just, they're, they're feeling flat. The brain has decided, no, I'm protecting myself. But when the stressor gets intense enough, which is why we see emotional dysregulation, for example, in people with borderline personality disorder and others. You know, it's not just bpd. The. Eventually the brain reaches a point where it feels enough of a threat that it just starts dumping immense amounts. And that's a huge overgeneralization. I'm just kind of using a analogy here, but sending immense amounts of the excitatory neurochemicals through with people who have trauma, who have ptsd. They've shown that the amount of neurotransmitters that are secreted, the amount of neurons that are activated, is significantly more in people with trauma than in people who don't have a trauma history, which leads, leads them to believe that, that HPA axis dysregulation does cause an extreme reaction to stimuli that someone without trauma may not react as strongly to. Does that answer your question? Okay. There are also functional alterations in key stress and emotion associated brain regions, particularly the anterior cingulate cortex, the amygdala, and the hippocampus. Now, the hippocampus is one of those areas that's involved in emotional processing. It shrinks. There's, there's, it doesn't do both, it just shrinks. The amygdala is kind of interesting. Remember, the amygdala is where we do a lot of our fear processing. And initially after a trauma, there's an increase in amygdala volume, which, which Corresponds with training, so to speak, the organism to be more attentive to threat stimuli. However, when there's persistent distress in later life, exposure of those neurons to persistent stress chemicals ends up leading to a decrease in volume, which also can affect fear processing and reactivity and mood. The brain regions are particularly susceptible to damage from trauma or HPA axis hyperactivation due to the high density of glucocorticoid receptors. Now, glucocorticoids are cortisol, basically, and other chemicals, but the one we're really talking about right now is cortisol. So the amygdala and the hippocampus are just chock full of receptors for stress chemicals. And when it's constantly bathed in stress chemicals, it, the brain starts pruning back, so to speak, those, those neurons. Exposure to specific types of ACEs, and I thought this was really interesting, selectively affect the sensory systems which were involved in perceiving the trauma. So people may not remember what they saw, or they may have heightened memories of what they smelled during a particular traumatic event. It's hypothesized that those sensory processes that were involved in the traumatic event will also be stronger triggers for PTSD symptoms if the person ends up developing ptsd. Mental disorders in individuals with ACE exposure tend to have more symptom, more severe symptomatology, increased risk of comorbidity, and are less likely to respond to standard treatments. So when you have an adult that presents with a behavioral health issue who has ACE exposure, they don't respond the way we had necessarily, necessarily would expect. Why do you think that is? I would hypothesize that people who present with clinical depression or generalized anxiety, who, as adults, who didn't have exposure to a multitude of aces, may not have the structural changes in their hippocampus and amygdala, their fear processing and emotion processing areas that people with ACEs do. So if you want to think about it this way, people with ACEs, not only are they presenting with mental health issues, they're also presenting with traumatic brain injury because the structure, the density of the amygdala and the hippocampus are actually different. There is a change in the brain structure. People with ACEs, Melissa points out, may also, because they never felt safe or often didn't feel safe in childhood, may not know how to feel safe now, may not feel safe now, and so it may be difficult for them to be vulnerable. Likewise. And, and I'm, I'm trying to interpret what you said there and correct me if I'm wrong, but the Symptoms that they have may be long standing symptoms and they know what to expect with these. And the symptoms, you know, may not lead them to have the happiest life possible. But they have been protective until now. So until we provide them a sense of safety, which we'll get to in trauma informed approaches, it's going to be hard for them to consider relinquishing some of the protective behaviors that they've developed. Kathy points out it could be that there's an addictive like quality to the trauma drama response and normal feels like, may feel just kind of, may feel kind of blah. So when they are in engaging in, when they've got anxiety, revving them up, at least they feel something. They're not flat, they're in that furious category. In adults, adverse childhood experiences are associated with a wide range of physical disorders, not just emotional disorders, but also physical disorders including obesity, dysregulation of the immune system, autoimmune disorders, abnormal pain perception with and without underlying causes, stress itself, and I thought that was, this is really interesting. Stress itself, and we've all experienced it, can sensitize pain neurons in the spinal cord which result in changes in pain perception and related behavior. So the person who experiences a lot of stress may also experience more pain because there are actual changes in the responsivity of their nociceptive, their pain neurons in their spine. Stress itself also reduces serotonin, certain types of serotonin levels that are responsible for pain perception as well. So there's a lot of things that stress does that can contribute to an increased perception of pain. There's an increase in levels of pro inflammatory cytokines throughout the body. So when people are under stress, when people have experienced trauma and have a underlying sense of unsafeness that contributes to an underlying sense of stress. The body actually is sending out pro inflammatory molecules. Disruptions in the intestinal microbiota and the mucosal immune system are also the result of ACEs. 90% of our neurotransmitters are made in our gut. So when that intestinal microbiota gets wonky, that means that our gut is not going to be as effective or efficient and it actually can contribute to what's called leaky gut where toxins are able to permeate through the intestines, get into the system, get into your, you know, your general system which causes more inflammation. 2 to 400% increased risk, 2 to 400% increased risk of heart disease, cancer, chronic lung disease, skeletal fractures, depression, diabetes and pre diabetes and liver disease. They have found that there is an autoimmune connection with both type 1 and type 2 diabetes, which so it would make sense that that could be, in part, a stress related condition. We know that cancer is strongly associated with inflammation and inflammation is associated with stress. Heart disease is the same. So you can see how it's not just, you know, somebody developing ptsd, and that's the only thing that's going on. Generally, if somebody has experienced traumatic events and a traumatic injury, there are going to be corresponding physiological effects if if not impairments. So let's go ahead and take a break for about five minutes, stretch your legs, and then we will come back and discuss this slide. How do these behaviors make sense for somebody who has experienced adverse childhood experiences? You know, they come to your Office as a 20, 30, 40 something year old person and are evidencing these behaviors. How might or why might they have developed.