Working with Low Functioning Clients & Sexual Perpetrators

1. Working with Low Functioning Clients & Sexual Perpetrators Definition of Low Functioning Abuse & Brain Damage Behavioral Interventions

2. Preface • Psychiatrist • Medical doctor • Trained in medicine, labs, NOT trained in psychometrics or behavior • Following medical school, training in specializations (residency): • Neurosurgery, Oncology, pediatrics • Obstetrics & Gynecology, psychiatry • Podiatry, Ophthalmology, cardiology • Allergy, Dermatology, anaesthesiology • In-field exposure (residency) to CBT • Psychologist • Ph.D. or Psy.D.: Cognitively (CBT) trained • Trained in psych testing, behavior mod/mgt NOT trained in medicine • Specialization in pre-/post-doc internship • Child, Gerontology, Sports, Diversity, sex-abuse psychologists • Forensic, Clinical, Counseling, School, Research psychologists • Disabilities: LD/MR, low functioning, developmental disabilities • Neuro-psychologist: neurological assessment, PET scan • 1-class in psychopharmacology

3. Foreword • Nonverbal Therapeutic interventions to work with lower functioning individuals: • Neuro-Linguistic Programming (mid 1980s) • Educational-Kinesiology (70 yr) • Sand-play, Cognitive-behavioral play therapy • EEG neuro-feedback, bio-feedback • Eye Movement Desensitization and Reprocessing, EMDR • American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.
*    EMDR was determined to be an effective treatment of trauma. • Department of Veterans Affairs and Department of Defense (2004, 2010). VA Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC.
*    EMDR was placed in the "A" category as “strongly recommended” for the treatment of trauma. • Associate Professor 5 yr • University of Hawaii; Chaminade University; Heald College • Behavioral Consultant to Hawaii School System 10 yr • Autism/disabilities Specialist • Applied Behavioral Analysis [Felix Waihee Consent Decree 1999-2005] • Lovass’ 1987 landmark Young Autism Study • Wikipedia: Preferred treatment for individuals with disabilities • 2 courses integrated into MFT program at U of G

4. DSM-IV-TRBorderline Intellectual Function • V62.89 Borderline Intellectual Functioning • IQ in the 71-84 range. • Differential diagnosis between Borderline Intellectual Functioning and Mental Retardation (IQ 70 or below) can be difficult, especially with coexisting mental disorders. • Coded on Axis II

5. Low Functioning: RC, age 16, CSC ScaleScorePercentileRange Verbal, VCI 67 1 Extremely Low Performance , PRI 67 1 Extremely Low Working Memory, WMI 94 34 Average Processing Speed, PSI 80 9 Low Average Full Scale IQ 70 2 Borderline

6. DSM-IV-TR: Mental Retardation • Essential Feature • Significantly sub-average general intellectual functioning: IQ of about 70 or below (range 55-75) • Exhibits significant deficits in adaptive behavior: social blindness. • Not diagnosed MR w/o significant adaptive behavior deficits. • General Intellectual Functioning: Intelligence Quotient (IQ) • “1” or more standardized assessments, individually administered intelligence tests: WISC-IV, Kaufman, Stanford-Binet, TONI-4 • Adaptive Functioning • How effectively the individual copes with common life demands • Determined by presenting symptoms versus low IQ • Problems in adaptation can improve with repetition, but cognitive IQ tends to remain relatively stable.

7. Low Functioning: AC age 14 female CSC • Scale ScorePercentileRange • Verbal, VCI 55 Extremely Low • Perceptual, PRI 82 Low Average • Working Memory, WMI 77 Borderline • Processing Speed, PSI 85 Low Average • Full Scale IQ 68 Extremely Low

8. DSM-IV-TR: 317 Mild Mental Retardation • IQ level 50-55 to approximately 70 • Educable, 85% of population. • Typically develop social/communication skills during preschool, have minimum sensory-motor impairment. • Not distinguishable from children w/o MR until later age. • Adolescents: Can acquire academic skills up to 6th grade level. • Adults: Usually achieve social/vocational skills adequate for minimum self-support; may need supervision. • Can usually live successfully in community, independently or in supervised settings.

9. Low Functioning: RM age 16 male, CSC • Scale ScorePercentileRange • Verbal 69 2 Extremely Low • Performance 59 .3 Extremely Low • Full Scale IQ 61 .5 Extremely Low • Low Functioning: EA age 16 female, SC • Scale ScorePercentileRange • Verbal 57 .02 Extremely Low • Performance 80 18 Low Average • Working Memory 74 4 Borderline • Processing Speed 70 4 Borderline • Full Scale IQ 65 1 Extremely Low

10. DSM-IV-TR:318 Moderate Mental Retardation • IQ level 35-40 to 50-55 • Trainable; 10% of population. • Acquire communication skills during early childhood. • Can attend to personal care. • Can benefit from social/occupational skills training. • Unlikely to progress beyond 2nd grade level academics. • Adolescents: difficulties recognizing social conventions interfere with peer relations. Can profit from vocational training. • Adults: Can perform unskilled/semi-skilled work, supervised, in sheltered workshops/workforce. • Adapt well to life in community, usually in supervised settings.

11. Moderate MR: DC age 14 male CSC • Scale Score Percentile Range • Verbal 50 <.1 Extremely Low • Performance 71 3 Borderline • Working Memory 50 <.1 Extremely Low • Processing Speed 59 .3 Extremely Low • Full Scale IQ 49 <1 Extremely Low

12. How is Level of Functioning Determined? • IQ tests • Wechsler Intelligence Scale for Children, fourth edition, WISC-IV • Wechsler Adult Intelligence Scale, fourth edition, WAIS-IV • Test of Nonverbal Intelligence, fourth edition, TONI-4 Myth of IQ tests • True IQ • No true IQ: Genetics can be enhanced or impeded.* • IQ is a measure in one point in time. • IQ is less stable in childhood & adolescence than in adults. • Factors affecting IQ • Heavy metal/toxin exposure, TBI, prenatal alcohol/drug use, birth trauma • Physical/emotional traumas: violence, child/sex abuse, abandonment. • Nutrition, digestion (McBride, 2010), exercise • Early training: music, sign, (whole brain learning age 0-5) • IQ is most flexible throughout childhood

13. Experiential/Kinesthetic/Tactile Learners • Learning style: Learning takes place by actually carrying out a physical activity, versus listening (lecture) or watching a demonstration. Classroom = visual-auditory NOT kinesthetic • Aka tactile learner, doers, physically oriented. • Realizations occur through doing versus thinking. • It helps them to move while learning, movt increases understanding. • They do well with lab experiments, sports, art, acting, dancing. • They remember things by recalling what their body was doing. • Short and long-term memory is strengthened by body movement. • They NEED to move, may seem restless, impatient, or bored. • Various types of learning styles: • Visual • Auditory • Kinesthetic

14. “Myths” of ‘Low Functioning’ • There are obvious indicators: False • Speech-impaired: good articulation is deceptive • Thought processes impaired: limited, not impaired • Physically recognizable: attractiveness is deceptive • Their feelings are like my feelings: hypersensitive • False assumptions: • If he talks then he understands me: limited comprehension • He needs counseling: CBT is insufficient. • Since he talks, he can say what’s bothering him: no • He is choosing not to talk: not necessarily • Conflicting emotions confuse/block concept formation • Emotions impede verbalization • Unable to conceptualize response

15. AbuseAffects the Brain and Functioning • R: Alcohol Abuse • L: Head Trauma, Drug Abuse • Arlene Gadia, CPS supervisor: 1200 referrals/yr child abuse; KUAM • LyndiaTenorio, CPS supervisor: 2000 referrals/yr child abuse; KUAM

16. Childhood maltreatment changes brain structure and function. Abuse/chronic trauma hx = Left Prefrontal Cortex Damage

17. Effects of Left Prefrontal Damage • Damaged left prefrontal • Corticotrophin, epinephrine, norepinephrine released when stressed….damaged left prefrontal cortex cannot mediate overwhelm. • Impaired left prefrontal ability to mediate right prefrontal cortex results in continued sympathetic response at high rate, extended time. • Impaired brain status is exacerbated by stress, re-traumatization (flooding) = reoccurring chemical cascade. • Vicious cycle • Imbalance impairs functioning in other parts of brain (pouring battery acid over brain) • Sleep deprivation impairs repair of brain; insomnia common • Symptoms: shut-down/acting-out, suicidal ideation/gestures = distress • Emotional pain drives compulsions, precipitates self-medication (alcohol-substance abuse, neg. compulsive behaviors) = lifelong institutionalization

18. Dr. JD Bremner: Incest • Yale Psychiatric Institute. April 1999, Biological Psychiatry • The problem is not that incest survivors want to stay miserable— • Research: childhood sexual trauma causes actual shrinkage, damage to the hippocampus of the brain. Hippocampal loss of neurons related to stress documented. • Hippocampus: associated with learning, memory. PTSD from Vietnam war and childhood abuse have neuropsychological deficits in hippocampal functioning. • Symptoms associated with shrinkage of the hippocampus resemble Post Traumatic Stress Disorder, PTSD • Mind plays tricks on survivors: flashbacks, feeling uneasy and "on edge,” on guard constantly, nightmares, problems associated with memory. • Gaps in memory occur, a few minutes to a few days; abuse memories suddenly "pop up” in a survivor's life. • The hippocampus affects the prefrontal cortex, where stress responses occur. • Incest survivors have a far more serious response to stress than those who have not experienced severe childhood abuse. • All survivors need to watch and monitor their stress carefully ; brain damage is a side effect of sexual abuse, precipitates.

19. Childhood Sexual Abuse Causes Physical Brain Damage: An Alarming New Study

20. Frontal Temporal BeforeAfter Tx

21. Frontal-Temporal Rotated

22. McLean Researchers Document Brain Damage linked to Child Abuse & Neglect • Harvard Medical School Affiliate. December 2000, Cerebrum. Early damage to developing brain causes anxiety & depression in adulthood. • 4 types of permanent abnormalities caused by abuse/neglect: • Limbic irritability: emotion; EEG abnormalities are associated with more self-destructive behavior and aggression. • Arrested L hemisphere development: language, perception/expression of negative affect; contributes to depression, memory impairment. • Corpus Collosum deficiency: 24-42% size reduction = neglect, 18-30% size reduction = sex abuse; effects dramatic mood/personality shifts. • Increased Cerebellar Vermis activity: emotion, limbic activity, trauma impairs ability to maintain emotional balance. Brain is wired to experience fear, anxiety, stress.

23. Irritable Limbic System: more self-destructive behaviors & aggression

24. Corpus Collosum: deficit in size of 24-42% in neglect, 18-30% in sex abuse, affects dramatic mood & personality shifts.

25. Hyperactive CerebellarVermis:Impaired ability to maintain emotional balanceBrain wired for fear, anxiety, stress

26. Daniel Amen, M.D.: Magnificent Mind at Any Age (2008)Treat Anxiety, Depression, Memory Problems, ADD, and Insomnia • Cerebellum: 10 % of brain volume, 50% of brain’s neurons. • Functions: • Involved with processing speed, how quickly you can make cognitive/emotional adjustments in stressful/new situations • Motor control, posture, gait • Executive function, connect to prefrontal cortex, speed of cognitive integration • Problems in the cerebellum = easily confused. • Slowed thinking • Slowed speech • Trouble learning routines • Disorganization • Sensitivity to noise, touch; light sensitivity • Tendency to be accident prone • Found low in activity in autism, ADD, learning disabilities • Major coordination center in the brain • Major strategies to optimize: coordination exercises as sports and music, dancing or table tennis • Healthy diet, targeted behavioral exercises, mental exercises, supplements (multiple, fish oil, vit D, medications.

27. Neurobiology • Trauma affects both structure & chemistry of a developing brain. • Behavior-learning problems plague 3/4 of children in child welfare system. • Altered stress-regulating hormone production • Altered key neuro-transmitters: epinephrine, dopamine and serotonin, chemical messengers in the brain affecting mood and behavior. • 1993 Dr. Martin Teicher linked abuse to brain wave abnormalities. The Journal of Neuropsychiatry and Clinical Neurosciences. • Greater the severity of the abuse, the greater the impact on brain function. • ''Sex abuse by a family member is worse than abuse by a priest or a baby-sitter.'’ • Several studies document abuse damages key brain structures: the cortex, associated with rational thinking, and the hippocampus. • 1998 study showed left cortex of the abused group underdeveloped. • Abuse typically lowers serotonin levels, leading to depression and impulsive aggression.

28. Scans Show Brain Damage in Abused Teens • University of Pennsylvania School of Medicine, 2011 • study on effects of childhood maltreatment on neuroimaging of gray matter volume in adolescents • childhood maltreatment affects subsequent psychopathology. • Adolescents reporting a history of abuse (even nonphysical) had deficits in gray-matter brain volume in the prefrontal cortex, striatum, amygdala, cerebellum. • Grey matter is made up of neuronal cell bodies. The grey matter includes regions of the brain involved in muscle control, sensory perception: seeing, hearing, memory, emotions, speech. • Girls: atrophy in regions associated w/emotional regulation • Boys: deficits concentrated in regions related to impulse control. • At risk for development of • mood disorders • addictive disorders • other psychiatric disorders

29. Striatum: grey matter volume deficit

30. Drug AbuseHealthy Brain

31. Grey Matter Deficits: Limbic, L hemisphere, corpus collosum, cerebellarvermis, prefrontal cortex, striatum, cerebellum

32. Verbal Abuse Linked to Permanent Brain Damage • Martin Teicher, Harvard Medical School associate professor of psychiatry at McLean Hospital. Biological Psychiatry, February 1, 2009. • damage to neural pathways cause medical and physical problems when the children grow to adulthood such as depression, language processing issues and anxiety. • verbal abuse of children may be just as damaging as other forms of abuse such as physical or sexual abuse. • Witnessing the abuse of others is also very damaging • multiple cases of victims who have all the symptoms of physical abuse but were never physically abused

33. What Characterizes Low Functioning ? • Characteristics of ‘Low Functioning’ • Don’t know what they’re feeling, difficulty identifying their feeling, difficulty verbalizing their feeling(s), act on feelings, overwhelmed by feelings. • Low vocabulary/comprehension (Receptive auditory)* • Interpretation of experiences may be simplistic, limited • Responses may be brief, off-subject, vague, distorted. • Common responses: No response, stare, walk-away, ‘I don’t know,’ child-like responses. • Counseling/explanations may be limited in effectiveness. • Need to do, multi-sensory to learn. • Low vocabulary/low communication (Expressive auditory)* • Communication is simple, limited; inability to describe events/feelings. • Unable to express compounded feelings, At risk for cumulative anxiety • Non-directive inquiry to assist thinking process.

34. Speech & Comprehension are different parts of the brain

35. Low Functioning Characteristics • Weak to absent problem solving ability* • Low vocabulary (limited expression) + low information + low comprehension (distorted cognition) = weak problem solving. • Teach collaborative problem solving, use inquiry to elicit thinking • Choice is insufficient • Weak coping skills* • Ineffective ability to deal with negative emotions • Explosions: physical, verbal, emotional aggression • Implosion: compulsions, self-harm, suicide • Teach emotion vocabulary, verbalizing format • Social blindness* • Unaware of social convention • Social initiative, reciprocal conversing, social inquiry are absent • Teach looking into faces (visual cues), social questions

36. Low Functioning Characteristics • Weak ability to implement learning* • Low information transfer from concept to ‘doing’. • Signs contract but repeats offenses • Repeats what you said then fails to follow through • Need for kinesthetic versus conceptual learning • Misunderstood disabilities elicit abuse in uneducated families • Low receptive auditory interpreted as Not Listening • Low information implementation interpreted as disobedience • Repeat offenses interpreted as defiance • No response, blank stare, walking away, interpreted as disrespect • Verbal, physical, emotional, sexual abuse effect 2ndary brain damage • 2ndary brain damage is exacerbated by stress, retraumatization • Difficulty learning in group format • Difficulty with sedentary learning, need to move, to do, experience. • Weak to absent assertiveness skills • Authoritarian parenting = aggress or submit • Suppression is not respectfulness

37. L: Left temporal deficit-suicidal childR: Worried & Rigid

38. Undoing Neurobiological Effects of Trauma • Alexandra Cook, Ph.D. Trauma Center at Justice Resource Institute • Positive experiences that contradict a traumatized child's negative expectations are critical to helping the brain to readjust. • Just saying to a child that you are sorry the event happened changes brain chemistry. • Temper tantrums = amygdala can’t stop firing. • Constructive ways to discharge overwhelming emotions (running, emotionally expressive activities) • Estimated 1 million children abused/yr; less than 10% receive appropriate interventions. • The more time that elapses between the abuse and appropriate treatment, the more entrenched the neurological abnormalities. • Address sensorimotordysregulation at the body level w/a new array of movement strategies to the standard mental health therapy repertoire to support children to become more organized, interpersonally available, and accessible for mental health treatments.

39. Chronic trauma affects structural & functional changes in the brain

40. Evidence-based Interventions • Aerobic Exercise • 1990s research: Exercise jump-starts neuro-genesis • Mice/rats that ran a few weeks had twice as many new neurons in hippocampi as sedentary animals. *All animal studies involve running/aerobic activities. • By age 20: approx 1% human hippocampus lost annually • Exercise slows, reverses brains’ physical decay as w/muscles. • 2002 biopsychology: Increases vascular highways of brain; improves brain function • 2007 study: A mouse that runs is smarter than one that doesn’t run. • Environmental stimulus (toys/tastes), new learning, exercise compared. • No matter how stimulating, enriching environment did not improve brain. • New learning made task specific neurons that re-fire to task only. • Exercise made neurons nimble, could multitask and re-fire cognitively flexibly • Exercise doubled new neurons in hippocampi compared to sedentary animals • Only thing that mattered in improving brain: exercise. • Aerobic exercise increased Brain-derived neurotropic factor, BDNF • BDNF sparks neuro-genesis, strengthens cells, axons, neural connections. • After work-out = higher BDNF in blood stream. • 2011 Study: 1-year walking or stretching program w/age grp over 60 • Walkers had larger hippcampi after a year • Walkers regained 2+ yr of hippocampal youth (65yr -->63yr) • Stretchers lost volume to normal atrophy

41. Interventions • Daniel Amen, MD, ‘Use Your Brain to Change Your Age,’ 2012 • 1-hr aerobic exercise daily, preserves and repairs brain • Effects wear off after 24 hr. • Journal of Child Psychology & Psychiatry, January 2000, vol 41, 97-116 • Secure attachment buffers the effects of the stress response. • Medical News Today, June 2007, Mathew Lieberman, UCLA psychologist • Verbalizing Feelings Makes Sadness, Anger And Pain Less Intense • Amygdala is less active when an individual labeled a feeling (anger) (brain imaging) • Right ventrolateral prefrontal cortex is more active: region behind the forehead and eyes, associated with thinking in words about emotional experiences; implicated in inhibiting behavior and processing emotions. • Suggests thinking in words about feelings, label emotions • Enactment • Trauma therapy: Enactment is a form of therapy that facilitates trauma repair. Until expressed, the energy remains in the form of symptoms of depression and anxiety. • Journal of Marital & Family Therapy, July 2004: Enacting relationships in Marriage & Family Therapy is a medium for mediating relationships. • Handbook of Family Therapy, April 2012, Al Gurman, Ph.D. Enactments bring maladaptive interactional sequences into the therapy session and thus available for directed change.

42. Process emotions, de-intensify emotional pain: Label feelings, verbalize feelings

43. Kinesthetic Intervention • Walk through learning experience, repetitively • Enactment: experiential approach; drama therapy; Supervise enactment. • CSC-- Clarify rules, enact • You do not touch others. • You do NOT say you want to be close, or ask her to ‘do it.’ • You Can ask social questions. • Role-play, rehearse, coach Emotion Program: I feel…because…I want…. • Empowers client to verbalize fears, upsets, resentments. • Go from 2ndary to primary feelings. • Client experiences verbalizing face-to-face with support. • Win-win collaborative problem solving with client (Greene, 2001). • Client is empowered in win-win resolution, in which they participate. • Client experiences equality, to support assertiveness. • Clients wants/needs are valued. Providing choice is not cps. • Re-enactment: Coach ‘acting’ of desired behavior • Rehearse then re-enact drama while coaching appropriate behavior, words.

44. Heal the brain: Exercise, verbalize feelings, laughter, secure attachment, nurture, enactment, diet

45. Relevant Intervention Tools • Differences & Perception • Acknowledge client perception regardless of cognitive distortion. • Listen to the client. Reflect to clarify what you understand, question. • It takes time to discover their feelings and thoughts. • Feelings drive behaviors. • Use collaborative problem solving (The Explosive Child, Greene). • Submission is not assertiveness, doesn’t teach assertiveness. • Equalize the playing field to elicit a win-win solution via verbalization • Assist client to verbalize • Format: ‘I feel…because…. I want….’ = assertive verbalization; respond. • Repeat for primary feeling underlying secondary feeling. • Process until underlying emotion is accessed, helps client discover their feeling • Helps access a genuine emotion versus reaction. • Discovery and disclosure to self is the goal. • Clients talk when they feel safe, they do not talk when they feel unsafe.

46. What to Do • Capitalize on strength: Kinesthetic - Engage in physical activity • Increases vascular networking to the brain. • Increases short-/long-term memory and brain function. • Increases/sustains endorphin levels, elevating mood. • Improves brain function and brain repair. Sleep is critical. • Relieves stress in high anxiety individuals. • Physical activity and/or laughter drops defenses. • Target Priority: Reduce self/other harm, repair the brain • Symptoms of a stressed brain: compulsions, suicidal ideation, aggression • Stress is cumulative, effects are often delayed • Low functioning • Low Vocabulary: Keep it Simple (KIS) • Low Information: Keep it practical • Low Comprehension: ‘do’ desired behavior • Experiential Learners • Kinesthetic learners must “do” to learn • Not visual: See to learn • Not auditory: Hear to learn

47. Intervention • Know the function the behavior serves. • Target the function not the behavior • Behaviors are symptoms; function is the purpose it serves. • Nail biting, smoking, binging, restlessness, OCD behaviors • Sleeping in class, rebellious attitude • APA Ethic: Do no harm (Iatrogenic tx) • Corroborate • Seek persons w/higher education, more experience, training • Ask questions before implementing interventions • Consult, consult consult. • Attend to client ‘feelings’ • Neither authoritarian nor permissive is therapeutic. • Attending to feelings is preventive, feelings drive behavior • Fastest way to achieve goals: ‘Motivate’ via client desired incentives. • Supportive intervention is slower, takes longer • Reduces compulsions, self-harm • Reduces suicidal ideation, suicide gestures, suicidal attempts • Reduces acting out, aggression, assault • Increases verbalization, assertiveness, and adaptive functioning

48. Insufficient Interventions • It may be insufficient to: • Repeat back to me, so I know you understand. • Talk more than the client: Repetitively explain ‘why’ • Post the instruction on the wall, medication box. • Tell client why s/he shouldn’t feel what they feel. • It is ineffective to: • Threaten client: privilege removal, loss of desired event • Punish client: item removal,

49. Interventions NOT for Low Functioning Individuals • Rewards & Punishment • ‘Incentive only’ is preferred treatment approach • Punishment= re-victimization experience, victim stance • Punishment stops behavior, doesn’t teach appropriate behavior; stacked consequences • Broad based education & experience • Target: strengths to maximize competency; income earning • Learning takes so long, focus on high risk behaviors. • Intergenerational government dependency status perpetuated • Avoid unnecessary stress: 2ndary damage suffered when stressed • Prioritize reducing self-harm/other harm • Flooding • Prolonged exposure to desensitize individual to stressful stimuli exacerbates damage in impaired brain. • Authoritarianism – Triggers victim-stance, domination-subordination.

50. Track Progress, Why? • Objective Comparison with Baseline Behaviors • Quarterly outcome data • Retain focus on original primary goals until achieved • Provides client a measure by which to chart progress • Progress is measured in quarters and years • Tracking Monitors • Intervention effectiveness • Ineffective: self-harm/other harm continues or escalates • Needs adjustment: intervention is quasi successful • Effective: target behavior reduces as intervention is mastered. • Advance intervention • Client succeeds 90%, is ready to advance intervention • From 1 emotion program daily, increase to 3-5/daily on negative feelings • From 1 collaborative problem solving daily to 2 daily on differences.