Traumatically Disrupted Attachment:

1. Traumatically Disrupted Attachment: How to recognize, diagnose, and treat toward optimal healing

2. Health Choices of Somerset and Bedford Counties, PA Lark Eshleman, PhD www.LarkEshleman.com November 3, 4, 2010

3. Day 1 • 9 – 10:15            Brain-based research on attachment and trauma • 10:30 – 12:00     Brain research (continued)

4. Day 1 • 1 – 2:15 Best Practice based on neurological understandings: sensory processing disorder and other “interrupted” developmental processes • 2:30 – 4:30  Best practice based on neurological understandings:  narrative, Theraplay®, EEG Biofeedback, EMDR

6. Day 1 Brain-based research on attachment and trauma

7. Understanding Our Neuroanatomy Dr. Shore’s Central Assumption: The social environment changes over the stages of infancy and induces the reorganization of brain structures

8. Dr. Schore’s Central Tenets • The growth of the brain occurs in critical periods and is influenced by the social environment. • The infant brain develops in stages and is hierarchically organized. • Genetic systems that program brain development are activated and influenced by the postnatal environment.

9. Overview of Critical Brain Structures Controls: • Heart Rate • Blood Pressure • Body Temperature • Respiration Brainstem

10. Overview of Critical Brain Structures Part of brain stem that controls: • Arousal • Appetite • Satiety • Sleep • Motor Regulation Midbrain

11. Overview of Critical Brain Structures Locus for: • Affiliation • Attachment • Sexual Behavior • Emotional Reactivity Limbic System

12. Cerebral CortexThe Cortical Layers Enable: • Abstract Thinking • Concrete Thought • Cause & Effect Thinking • Reasoning

13. Dopamine, Norepinephrine, & Endorphins • Regulate neuronal growth and the time frame of brain growth • The normal time frame for the onset of the critical period of orbitofrontal maturation is 10 to 12 months. • Decreased production of appropriate amounts of these substances can disrupt the onset of frontal lobe maturation.

14. Starting in the first year of life: • A centralized set of neurons containing dopamine arises from the midbrain and helps promote activation of the right prefrontal cortex. • The activation leads to the engagement of the child with her environment and the stimulation of reward centers that produce endogenous endorphins. Image of a Neuron

15. The Effects of Deprivation on the Developing Brain • The right prefrontal cortex develops normally only if a child receives emotionally attuned interaction with primary caregivers. • The right prefrontal cortex is highly involved in creating social interaction and the recognition of attachment figures. Schore A. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Develoment. Hillsdale, NJ, Lawrence Erlbaum Associates.

16. The Effects of Deprivation on the Developing Brain • Lack of emotionally attuned interaction leads to decreased growth and differentiation of this portion of the brain and impaired affect regulation. Schore A. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Develoment. Hillsdale, NJ, Lawrence Erlbaum Associates.

17. Problems in Brain Timing • Ongoing research suggesting much of psychopathology could be attributed to problems in brain timing. • Dr. Rodolfo Llinas, of NYU Medical School, suggests that psychiatric and neurological conditions could be attributed to dysrhythmia between thalamus and cortex.

18. Dysfunctional parenting and attachment can contribute to: • Hyper or hypo-activation of the sympathetic an/or parasympathetic nervous systems • The lack of Central Nervous System shift from sympathetic to parasympathetic predominance between 14-18 months of age

19. Stress Impairs Prefrontal Cortex (PFC) Function • This region of the brain is critical for the performance of “working memory”. • High levels of dopamine and norepinephrine (catecholamines) are released in the PFC during stress exposure, causing “working memory” deficits. • Humans with lesions of the PFC demonstrate “poor attention regulation, disorganized and impulsive behavior, and hyperactivity”. Arnsten, A. (1998). Development of the Cerebral Cortex XIV. Stress Impairs Prefrontal Cortex Function. Journal of Am. Acad. Child Adol. Psychology, 37 (12): 1337-1339.

20. Early abuse & neglect create longstanding neuro-physiological changes Dr. Michael De Bellis, a Child Psychiatrist at WPIC, studied the excretion of catacholamines (ephinephrine, norepinephrine, and dopamine), and cortisol in prepubertal children who had experienced PTSD secondary to abuse • These children lived in stable home environments during the study

21. Rachel Yehuda Research/ PTSD • Intergenerational transmission of altered DNA • Predisposes subsequent generations to PTSD and anxiety disorders

22. Short-Term & Long-Term Outcomes • Dr. Schore defines psychopathology as: • A limitation of adaptive stress-regulating capacities • This is more likely to occur if right prefrontal cortex, limbic system, and hypothalamic development is hampered by lack of appropriate interaction with attachment figures • Leads to impaired affect regulation

23. Short-Term & Long-Term Outcomes • Short-Term • Anxious, depressed, agitated, and excessively angry • Long-Term • Aggressive and oppositional • Some may develop a form of Attachment Disorder

24. To Summarize • The attachment figure is the regulator of the infants’ endocrine and nervous systems. • Attuned caregivers of securely attached infants maintain the child’s arousal. • Within a moderate range that is high enough to maintain interaction • Without causing distress and avoidance through over-intensity

26. Day 1, 1 – 2:15 PM • Neurological understandings: sensory processing disorder and other “interrupted” developmental processes

27. Sensory Integration: Neurology • The brain’s “food” is sensory input. Attachment theory and its neurological underpinnings teaches that sensory input in early childhood determines later behavior and ability to cope. Deprived environments compromise achievement of developmental milestones, at least temporarily. • The nervous system “learns” movement and behaviors (“output”) by repetition of the sensory (afferent) input, coordination of motor (efferent) output and the resulting sensory feedback for further refinement.

28. What is Sensory Processing Disorder? • SPD was formerly known as Dysfunction in Sensory Integration. It is currently being considered for inclusion in the DSM-V. • SPD occurs in 5-15% of the general population. • SPD causes a child or adult to interpret sensory information differently than the typical person. It can impact 1 or all of the sensory systems. • Research and treatment has been around since the 1960’s starting in OT with Dr. A. Jean Ayres, an OT and clinical psychologist.

29. Why do we care about SPD? • Check out behaviors from morning presentation. • How many are similar to following behaviors manifested in SPD? • What do current studies tell about impact of traumatic interruption in attachment and occurrence of SPD?

30. How does SPD manifest? • SPD can compel a person to behave “differently” than others. The world can be perceived as a potentially painful or offensive place and so anxiety or defensiveness can develop. • SPD can impact one or many life activities including self care, work, school, relationships, sleep, etc. • SPD often is comorbid with other diagnoses such as learning disorders, autism, & mental health diagnoses.

31. Current nosology for SPD Miller et al; Am J Occ Ther Mar/Apr 2007 61:2

32. Sensory Modulation Disorder • Also called “sensory regulation.” • Child/adult has difficulty with incoming sensory information and responding to it in an appropriate manner. • Often seen in auditory sense but any sense or combination of senses can be involved. • Child cannot always identify what is wrong. • Behaviors can become entrenched. • Small amount of sensory input can be perceived as extreme or vice versa. Reactions are typically in response to the perceived sensory message.

33. Sensory over-responsivity • The person responds with what is seen as a dramatically increased proportion to the sensory input • The neurological threshold is assumed to be very low; “hair trigger.” • Child may respond to this tendency by trying to avoid the stimulus input, controlling the environment so they can reduce the stimuli, or develop other skills to spare their nervous system from experiencing the sensory insults. • They often learn that their behavior is seen as “weird” or unusual and may try to hide their true response or avoid trying to explain it.

34. Sensory under-responsivity • May respond to sensory input slowly or only after a lot of input to the sensory receptors (greater spatial or temporal summation). • May appear to be unresponsive to their name or have a high pain threshold. • They are more at risk for injury and exposure to dangerous situations. Parents need to be more vigilant with these kids to avoid danger. • Often accompanied by other behaviors that cause them to appear apathetic and assumptions may be made about their intellect.

35. Sensory seeking/craving • Occupational Therapy assumes that people are driven to “normalize” their nervous system. Children with dysregulated systems often seek out sensory experiences to help move them into the normal range. • Movement, tastes, smells, textures, touch input, multisensory experiences can be compelling stimuli for this person. • A daily “sensory diet” helps provide the input this person needs. They may need help choosing the appropriate input. Ex: bike riding instead of kicking.

36. Sensory based motor disorder • May be seen as clumsy or uncoordinated. • May have low muscle tone. • May have handwriting issues. • May have right/left discrimination issues. • Motor output manifests poor processing in the brain. • May have poor posture. • May have gross and/or fine motor • un-coordination. • May have poor self-esteem from self perception of motor incompetence. May give up trying new skills.

37. How does SPD manifest? • …can compel a person to behave “differently” than others. The world is seen as a potentially painful or offensive place; anxiety or defensiveness can develop. • …can impact many life activities including self care, work, school, relationships, sleep, etc. • …is comorbid with other diagnoses such as learning disorders, autism, & mental health diagnoses.

38. Treatment • Thorough Evaluation, starting with Sensory Profile • Sensory Diet • EEG Biofeedback • Parent and Professional Education • Parent/Child Group Practice

39. Treatment • Treating Sensory Processing Disorder increases chances of better healing of attachment and trauma difficulties. • Practice: With eyes covered, how frightening is it for someone you don’t know to tell you they’re going to touch you, but you can’t see it coming? • Ever feel “upset” and don’t know why? How about if it’s all the time?

40. The Regulated Brain • Creates a fuss when unhappy, calms when needs are met • Plays and enjoys it! • Can change activity relatively easily (mastery) • Engages in reciprocal affection/attachment • If not (all of these things), something’s wrong

41. The Regulated Brain • How do we achieve this for our children? • Parents’ mental and physical health • Right brain to right brain “download” of healthy attachment • Attunement • Safe environment for learning regulation

42. The Regulated Brain • External regulation to teach and support internal regulation • Expectations must meet ability to develop positive self-esteem • Most predictive? Positive coherent narrative of parent and good parental attachment … 75 – 85%

43. Dysregulated Brain Opposing Poles of Complexity Rigidity ……………………. Chaos

45. Considerations for Diagnoses These are for consideration only: • Overanxious Disorder of Childhood • Posttraumatic Stress Disorder • Acute Stress Disorder • Substance-Induced Anxiety Disorder? • Mood Disorders, including Depression, Dysthymic Disorder, Bipolar Disorder, Substance-Induced Mood Disorder? • Dissociative Disorders….

46. Dysregulated Brain • By Circumstance: Examples: • Too many stressors • Not enough resources/support • Traumatic Event • Others?

47. Dysregulated Brain 2. By Teratogens, or other injury, pre-birth or during critical brain development periods. While we still don’t know the totality of effects of teratogens, we are beginning to see “building block” damage on brain scans.

48. Dysregulated Brain 3. By genetic damage New research by Rachel Yehuda, Epigenetic research through several major research organizations

49. Rachel Yehuda and Others • Neuropsychopharmacology “Twin studies suggest that genes play an important role in vulnerability to PTSD and other anxiety disorders, but not the entire role. The overall result of studies to date is that risk is the product of multiple genes and nongenetic factors working together.” (2010) http://www.acnp.org/

50. The Over-Aroused Brain