Developmental Trauma

Elizabeth T Jacko

Attachment

• “No variables have more far-reaching effects on personality development than a child’s experiences within the family. Starting with his first months in his relation to both parents, he builds up working models of how attachment figures are likely to behave towards him in any of a variety of situations and on all those models are based all his expectations and therefore all his plans, for the rest of his life”

– Bowlby, 1973 (Attachment and Loss)

Attachment

• To the degree that we feel connected to others, we feel safe and secure.

• To the degree that we do not feel connected to others we feel less safe and increasingly insecure– Hoffman, 2004

Attachment

• We are all hard-wired for relationships and we are relational beings (Allan Schore, 2002)

• Relationships organise our entire life

Neurodevelopment

• Brain development is sequential from brainstem to cortex

• Connections develop between neurones in response to activation by experiences

‘Neurones that fire together, wire together’ (Daniel Siegel)

• Synapses and connections develop into neural pathways that reflect the degree and type of input.

• The more a pathway is activated, the more the system changes to reflect that pattern – ‘states become traits’

Neocortex

Limbic

Diencephalon

Brainstem

Abstract thought

Concrete Thought

Affiliation

"Attachment"

Sexual Behavior

Emotional Reactivity

"Arousal"

Appetite/Satiety

Blood PressureHeart Rate

Body Temperature

Sleep

Motor Regulation

Stress regulation and attachment

• Secure children learn how to effectively take care of themselves as long as the environment is more or less predictable while simultaneously they know how to get help when they are distressed.

• So fear danger and reach out to caregiver

• I rely on people when I need to -, or I can do this on my own.

Trauma

• At the core of traumatic stress is the inability to modify the effects of overwhelming events.

• When children are unable to respond appropriately, they become helpless. Being unable to grasp what is going on, they go immediately from (fearful) stimulus to (flight/flight) response without being able to learn from the experience.

Trauma and the BrainTrauma/ Neglect -> smaller brain

esp Limbic System reduced in size:

Amygdala – emotional regulation

Hippocampus – forming+ retrieving verbal + emotional memories

PFC – executive function

Smaller Corpus Callosum (connects L and R brain) (ADHD)

Cerebellar Vermis (regulates production / release of neurotransmitters)

Anterior cingulate – emotional responsiveness + affect regulation

Neglect causes diminished growth of L hemisphere -> Depression

HPA AxisStress activates adrenergic (SNS) and glucocorticoid system:

Normal feedback: Stress -> high cortisol + NPY -> down-regulation adrenal system -> return to baseline

If overwhelmed (chronic stress): low cortisol and NPY-> ongoing adrenal hyperactivity (ACH, A, NA) with no return to baseline -> Sx of PTSD as no down-regulation of SNS

HPA related disruption of normal immune response with chronic stress-> susceptible to physical illness

High normal thyroid

More research is required!

Impact on the BodyModerate levels of stress build resilience and capacity to

handle a wider range of new experiences.

Chronic childhood stress does not built capacity – child overwhelmed, no healthy template exists, no adult to help make sense - hence no capacity to cope.

Impact: constant state of arousal even to minor issues, hyper-vigilance, mood swings, attention and sleep problems.

Heightened arousal means the child never re-sets itself –heightened anxiety becomes the norm – child ‘explodes’easily, the body never gets to rest and recharge

The body eventually shuts down and ceases processing all non-essential input – survival mode

Brain so focused toward threat and survival – no capacity left for normal development -> Optimal learning windows missed = vulnerability

Heightened state of arousal –> less access to higher order brain, less capacity left for learning

Survival themes: Sensory info is processed through templates associated with past traumatic experiences

As neural firing becomes repetitively stressful, other aspects of experience (ie emotions) are coded into memory as threatening +terrorizing to the child.

Central focus on survival – all other experiences are less important if not totally irrelevant

Poor self regulation – learned in partnership and modelled

Many other gaps including, problem solving, social responsiveness, understanding motivation of others, cause and effect thinking, memory

Gaps in milestones, speech & language and educational learning

Child’s emotional development can arrest at the age of first significant trauma.

Evolve Therapeutic Services

Trauma ResponsesHEALTHY CHILDREN TRAUMATISED CHILDREN

Know they are safe with the parent

Have learnt the only way to be safe is to make themselves safe

Rely on parental judgement (TRUST)

Rely on their own judgement and can be very controlling

Believe parents have good motives

Believe parents’ motives are selfish or mean defy you

Know where the “line” is Are going to make their point & nothing else matters

Complex trauma response

• In response to reminders of the trauma (sensations, physiological states, images, sounds, situations) they behave as if they were traumatised all over again.

• Adults tend to misinterpret the hostility, silence and other reactions of maltreated children as responses to current events, rather than as conditioned reactions to reminders of the past.

• Unless care givers understand the nature of such re-enactments they are liable to label the child as ‘oppositional’, ‘rebellious’, unmotivated’, and ‘anti-social’.

Trauma

• Isolated traumatic incidents: Produce discrete conditioned behavioural

and biological responses to reminders of the trauma.

• Chronic maltreatment or traumatisation Pervasive effects on development.

Complex Trauma

• Children exposed to neglect and abuse will respond to NEUTRAL triggers and to ANY emotion laden interaction as if the original threat was right there.

• They may have anxious, regressed, aggressive or numb responses – ie dysregulated state.

• “while these children may receive a variety of psychiatric labels, none of these diagnoses capture their profound developmental disturbances, nor the traumatic origins of their particular clinical presentations”

• Streek-Fischer & van der Kolk (2000)

Neurodevelopment

• Infant brain is undeveloped at birth• Infant brain adds 70% of its structure after

birth• Rapid growth occurs in the first three

years of life (connections and networks)• Neural differentiation is stimulation

dependent • Neurones change in response to patterned

repetitive stimulation

Neurodevelopment ctd

• Sharing positive emotional states with a caretaker promotes brain growth and the development of regulatory capacities

• Secure attachment is internalised at a mid-brain-limbic level as an enduring capacity to regulate, generate and maintain states of emotional security

• Activity-dependent fine-tuning of connections and pruning of surplus circuitry occurs in adolescence‘Use it, or lose it’

Prefrontal cortex

• Bodily regulation• Attuned communication• Emotional balance • Response Flexibility• Empathy• Self-knowing• Fear extinction• Intuition• Morality

Arousal

• Healthy children usually in a state of calm, can become aroused when facing a fearful/new situation will seek comfort from caregiver, arousal response will settle.

• Traumatised children’s baseline on the arousal continuum is usually low level alarm so will more quickly move to a state fear, have no one to go to seek comfort from and no ability to self soothe as have had no prior experience of this (use it or lose it).

Presentation

• Multiply abused infants and toddlers frequently experience developmental delays across a broad spectrum of domains.

• Symptoms of PTSD usually not prominent and tend to be obscured by their cognitive, affective, social and physical problems.

Behavioural Presentation

• Difficulty self-regulating• Oppositionality• Controlling behaviours• Hypervigilance• Anger• Impulsivity• Social deficits (inability to form and maintain

relationships)• Concentration and academic difficulties• Substance use, stealing, promiscuity• Self harming behaviours

Frequently made diagnoses

• ODD

• ADHD

• Conduct Disorder

• PTSD

• Borderline Personality disorder

• Childhood Bipolar Disorder

Risks of diagnosing

Diagnosis carry with it potential for stigmaScapegoating and narrowing of expectations (“Reputation Disorder”)Closing down on reflection – loss of curiosity, danger of not noticing significant developmentsLimiting therapy – children miss out on what they needLimiting expectations for the children

“The child in relationship with his caregivers slowly recognises that his emotional states affect what he does, and that those feelings also have an impact on the mind of his carers. This in turn affects how the carer responds. These psychosocial skills and self-regulating abilities are the psychological bedrock on which children develop relationship competence, social acceptance and sound mental health.”

(David Howe, 2005).

“Too narrow a focus on individual therapy can lead to an expectation that children will adjust to a world for which they are not equipped. Thus therapy becomes a way of ‘making children fit’. When therapy becomes part of a wider ecologically based and holistic approach we all have a responsibility to help children to feel comfortable and secure,”

(Golding, 2006)

Maslow’s Hierarchy of Needs

PHYSIOLOGICAL NEEDS

SAFETY NEEDS

BELONGING NEEDS

ESTEEM NEEDS

SELF-ACTUALIZATION

FEELING SAFE PHYSICALLY AND EMOTIONALLY

DEVELOPING RELATIONSHIPS

COMFORT AND CO-REGULATION ELICITING CARE FROM RELATIONSHIPS

EMPATHY AND REFLECTION MANAGING BEHAVIOUR IN RELATION TO OTHERS

RESILIENCE AND RESOURCES

SELF-ESTEEM AND IDENTITY

EXPLORE TRAUMA, MOURN LOSSES

Pharmacotherapy

medication

• Methylphenidate• Atomoxetine• Clonidine• Risperidone• Melatonin• Fluvoxamine• Fluoxetine• Quetiapine

symptoms

• Symptoms of ADHD

• dysregulation• Extreme aggression• Insomnia (initial)• Anxiety• Depression• Agitation, self-harming