Safety Without Restraints Trauma Informed Care The Neurobiological

Safety Without Restraints: Trauma Informed Care The Neurobiological & Psychological Effects of Trauma Dr. Janice Le. Bel Rhode Island College ~ Sherlock Center on Disabilities March 9, 2015 Adapted Presentation Developed by Glenn Saxe, MD for NASMHPD OTA 2002

“Without understanding the basic principles of how the brain develops and changes, we cannot expect to design and implement effective interventions. ” Bruce Perry, M. D.

NCTSN. ORG

Longitudinal Course of PTSD Symptoms in Children with Burns 50 45 40 PTSD-RI Score 35 30 25 20 15 10 5 0 Acute Assessment 3 Month Assessment Time Period

Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al, 1999)

From Neurons to Neighborhoods: The Science of Early Child Development Report from the Institute of Medicine/National Academies National Research Council

Trauma in U. S. A. • 3 million children were suspected of being victims of abuse and/or neglect (Mazelis, 1999) • 3. 9 million adolescents have been victims of serious physical assault, and almost 9 million have witnessed an act of serious violence (Kilpatrick et al, 2001) • In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood (Acoca & Dedel, 1998)

PTSD in U. S. A. • Over 50% of U. S. women & 60% of men report experiencing at least 1 traumatic event at some point in their lives. But, only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events. (Koenen, 2005; Kessler et al, 1995) • More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders. (Solomon & Davidson, 1997) • For more than 1/3 with PTSD, it will be a persistent condition and experienced for several years. (Solomon & Davidson, 1997)

Impact of Adult PTSD • Childhood trauma, compared to adult-onset trauma: • results in a greater probability of developing psychiatric disorders (particularly anxiety disorders and PTSD) throughout the lifetime (Zlotnick et al. , 2008), and • is believed to have a long-term impact in the frontal, temporal and parietal regions of the brain and how information is processed (Cook et al. , 2009) • Studies have identified 4 main risk factors for PTSD in adults: 1) a pre-existing psychiatric disorder; 2) a family history of disorders; 3) childhood trauma and 4) being female (Breslau, 2002) • Late-onset PTSD is under recognized and undertreated in adults and creates greater probability of additional psychological difficulty and physical health symptoms later in life (Snyder, 2008)

What is PTSD, really? “PTSD should not be considered a ‘disorder. ’ It is a psychological and emotional injury – a natural reaction to an unnatural situation. Why turn it into ‘pathology’ and make it a disorder? ” Jonathan Shay, M. D. , 2011 Boston V. A.

Effective Treatment Must Account For: 1) A dysregulated nervous system 2) A social-environment that cannot contain this dysregulation

Core Concepts of Development 1) Human development unfolds along individual pathways whose trajectories are characterized by continuities and discontinuities, as well as by a series of significant transitions. (Shonkoff & Phillips, 2000)

Longitudinal Course of PTSD Symptoms in Children with Burns 50 45 40 PTSD-RI Score 35 30 25 20 15 10 5 0 Acute Assessment 3 Month Assessment Time Period

309. 81 PTSD Definition • The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of: – Actual or threatened death – Actual or threatened serious injury – Threat to physical integrity

Post Traumatic Stress Disorder • Characterized by: – Re-experiencing the event • Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories – Avoidance and emotional numbing • Flattening of affect, detachment from others, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience

Core Concepts of Development 2) The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains. (Shonkoff & Phillips, 2000)

State Change 22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained.

State Change 12 year-old sexually abused girl in school when provoked by older male peer.

Parameters that change between state • Affect • Thought • Behavior • Sense-of-self • Consciousness

Emotional States and Child Development • Discrete behavioral states are a central organizing experience of infancy • Infants experiential world is divided into separate and definable emotional/behavioral states • Critical task of early child development is to build smooth transitions/bridges between states • Regulation of emotion is initially contingent on caregivers facilitating these transitions (Wolff, 1987)

Goal of Treatment • Maintain Calm/ Continuous/ Engaged State • Prevent Discontinuous States • Build Cognitive Structures that allow Choices

Between Stimulus and Response Stimulus Response

Between Stimulus and Response Stimulus Traumatic Reminder Response Socialenvironmental intervention Traumatic State Neuroregulatory Intervention

Between Stimulus and Response Stimulus Traumatic Reminder COGNITION!!! Response Traumatic State Socialenvironmental Intervention Neuroregulatory Intervention

Core Concepts of Development 3) Human development is shaped by a dynamic and continuous interplay between biology and experience. (Shonkoff & Phillips, 2000)

Emotional Brain (Restak, 1988)

Between Stimulus and Response Stimulus (Le. Doux, 1996)

Between Stimulus and Response Sensory Thalamus Stimulus (Le. Doux, 1996)

Between Stimulus and Response Very Fast Sensory Thalamus Amygdala Stimulus (Le. Doux, 1996) 1996

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala Stimulus (Le. Doux, 1996)

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala Stimulus Response (Le. Doux, 1996)

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala Stimulus Response (Le. Doux, 1996)

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala Stimulus Response (Le. Doux, 1996)

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala S Stimulus Response (Le. Doux, 1996) 1996

Between Stimulus and Response Cortex Hippocampus Sensory Thalamus Very Fast Slower Amygdala S Stimulus Response (Le. Doux, 1996)

Between Stimulus and Response Social Environmental Intervention Cortex Hippocampus Sensory Thalamus Very Fast Neuroregulatory Psychotherapy Intervention Psychopharmacology Slower Amygdala Stimulus Response (Le. Doux, 1996)

Rauch Brain scans

Play

Play and Fear (Panksepp, 1998)

Social-Ecological Model Culture Neighborhood School Peer Group Family Individual

Core Concepts of Development 4) Human relationships, and the effects of relationships on relationships, are the building blocks of healthy development. (Shonkoff & Phillips, 2000)

Attachment • Earliest relationships critical for capacity to regulate state • Early traumatic relationships set up person to respond with state dysregulation to interpersonal cues in subsequent relationships

Attachment & Relational Deficits • Appear guarded & anxious • Difficult to re-direct, reject support • Highly emotionally reactive • Hold on to grievances • Do not take responsibility for behavior • Make the same mistakes over and over • Repetition compulsion / traumatic reenactment (Hodas, 2004)

Trauma eats Attachment for Lunch. . .

Core Concepts of Development 5) People are active participants in their own development, reflecting the intrinsic human drive to explore and master one’s environment. (Shonkoff & Phillips, 2000)

Traumatic Mastery • Many children have primarily experienced abusive and neglectful relationships • Extreme behaviors within relationships can be seen as defensive or self-protective and adaptive • Traumatized people respond to their trauma history in the present. They are not able to discern that the context has changed • This behavior must be seen as an attempt to master extremely difficult environments. In this way, traumatized children are “doing the best that they can”

Core Concepts of Development 6) The course of development can be altered…by effective interventions that change the balance between risk and protection, thereby shifting the odds in favor of more adaptive outcomes. (Shonkoff & Phillips, 2000)

Recovery from Trauma • Stimulate the brain! ü Use of anti-depressant medications (Surget et al. , 2011) ü Cognitive stimulation • Education [Gilligan’s anti-prison model]; CBT, TF -CBT, DBT) ü Procedural learning (Grigsby & Stevens, 2002) • Deconstruct behavioral sequence • Teach new patterns of response

Recovery from Trauma • Brain plasticity • Conventional wisdom: human brain reaches 90% of adult weight by early childhood and little change in size after age 5 (Bryck & Fisher, 2012) • Conceptually adapted from TBI research • Physical stimulation to promote neurogenesis • Exercise and gross motor movement • Increased V 02, increased blood flow x 2 to hippocampus, new blood vessels, strengthens existing connections, recruits new neural connections (Bryck & Fisher, 2012; Pereira et al. , 2007; Snyder & Cameron, 2011)

Recovery from Trauma • Early studies: exposing rats to stress followed by enriched environments (complexity & novelty): • ↑ brain #, size • ↑ dendrite branching & length • changes in synaptic size & # • behavioral & memory improvements • Exercise studies with humans • ↑ cognitive abilities • ↑ academic performance • ↑ executive control / functioning • possibly continued plasticity into old age (Bryck & Fisher, 2012)

Recovery from Trauma • Current neuroplasticity research focus: • Executive functioning (AKA: cognitive control) • Lab-based training w/working memory focus – does not generalize easily • Neurobiologically informed ecological interventions – in the environment but costly • Compensatory processes brain-training – ‘overactivation; ’ recruit both hemispheres, not just where damage occurred, i. e. , ‘self-talk’ strategies (Bryck & Fisher, 2012)

Recovery from Trauma Sensori-Motor Recognition & Approaches • Recognize the impact of trauma on the body & behavior (survival strategies); • Assess Sensory Diet (Jean Ayers) & identify Sensory-Seeking / Sensory Avoiding behavior • Teach skills to promote body awareness & calming • Promote natural methods: yoga, singing, recreation, etc.

Recovery from Trauma New Language & Understanding: Steps Towards Practice & Culture Change Trauma Aware - individual impact, risk factors, brain/behavior Trauma Focused - treatment using evidence-based practices, service-specific Trauma Sensitive - awareness & provision of services oriented at the organization/system level Trauma Informed - organization/system commitment to address trauma across multiple-systems

CONCLUSIONS • Response to traumatic stress is learned behavior, mediated by the brain & the social environment • Traumatic stress brings the past to the present • The survival response impacts the mind, body, behavior & speech “… the amygdala leads a hostile takeover of consciousness by emotion. ” (Le. Doux, 2002 ) • To change the response, create new: language, learning & skills: – Analyze & adapt – Buffer & bolster – Teach, support, & build that “cognitive wedge”

“Cowardice asks the question – is it safe? Expediency asks the question – is it politic? Vanity asks the question – is it popular? But conscience asks the question – is it right? And there comes a time when one must take the position that is neither safe, nor politic, nor popular. But one must do it because it is right…” Martin Luther King, Jr.