Developmental Trauma

1. Developmental Trauma Elizabeth T Jacko

2. 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)

3. 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

4. Attachment • We are all hard-wired for relationships and we are relational beings (Allan Schore, 2002) • Relationships organise our entire life

5. 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’

6. Abstract thought Neocortex Concrete Thought Affiliation "Attachment" Sexual Behavior Limbic Emotional Reactivity Motor Regulation "Arousal" Diencephalon Appetite/Satiety Sleep Blood Pressure Brainstem Heart Rate Body Temperature

7. 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.

8. 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.

14. Trauma Responses

15. 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’.

16. Trauma • Isolated traumatic incidents: • Produce discrete conditioned behavioural and biological responses to reminders of the trauma. • Chronic maltreatment or traumatisation • Pervasive effects on development.

18. 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.

19. “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)

20. 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

21. 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’

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

24. 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).

25. 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.

26. 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

27. Frequently made diagnoses • ODD • ADHD • Conduct Disorder • PTSD • Borderline Personality disorder • Childhood Bipolar Disorder

29. Risks of diagnosing Diagnosis carry with it potential for stigma Scapegoating and narrowing of expectations (“Reputation Disorder”) Closing down on reflection – loss of curiosity, danger of not noticing significant developments Limiting therapy – children miss out on what they need Limiting expectations for the children

30. “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).

32. “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)

33. Maslow’s Hierarchy of Needs

35. Pharmacotherapy medication symptoms Symptoms of ADHD dysregulation Extreme aggression Insomnia (initial) Anxiety Depression Agitation, self-harming • Methylphenidate • Atomoxetine • Clonidine • Risperidone • Melatonin • Fluvoxamine • Fluoxetine • Quetiapine