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The Impact of Early Childhood Trauma on Brain, Behavior and Child Development OJDDA Conference September 28, 2010

The Impact of Early Childhood Trauma on Brain, Behavior and Child Development OJDDA Conference September 28, 2010. David W. Willis, M.D., FAAP President, Oregon Pediatric Society Developmental-Behavioral Pediatrics Artz Center for Developmental Health Portland, Oregon .

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The Impact of Early Childhood Trauma on Brain, Behavior and Child Development OJDDA Conference September 28, 2010

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  1. The Impact of Early Childhood Trauma on Brain, Behavior and Child DevelopmentOJDDA ConferenceSeptember 28, 2010 David W. Willis, M.D., FAAP President, Oregon Pediatric Society Developmental-Behavioral Pediatrics Artz Center for Developmental Health Portland, Oregon

  2. Eco-biodevelopmental Model Biological Program Childhood Experience Culture Relational Experiences Brain/Mind/Body Genetics and Neurobiology Behavior Physical, Social and MentalWell-being

  3. Science of Early Brain and Child Development Shonkoff, 2002 • Cognitive, emotional and social capacities are inextricably intertwined and learning, behavioral and physical and mental health are interrelated over the life coarse • Toxic stress in early years can damage developing brain architecture and lead to learning and behavioral problems and susceptibility to physical and mental illnesses • Brain plasticity and the ability to change behavior decrease over time

  4. Science of Early Brain and Child Development Shonkoff, 2002 • Brain architecture is constructed by processes that begins before birth and continues into adulthood • Skill begets skill as brains are built in a hierarchical fashion – bottom up, increasing complex circuits and skills built on top of simple circuits and skills over time • The interaction of genes and experience shapes the circuitry of the developing brain

  5. “Three-legged stool” for “predicting” developmental and health trajectories Genetic, Prenatal and Neurodevelop-mental Factors Attachment and Relational Patterns (ACE Scores) Social-economic environment

  6. Neurodevelopmental Processes • Synaptogenesis • Mylenation • Synaptic pruning • Procedural and declarative memory • Neuronal networks coming “on-line” • Maturing inhibiting networks

  7. Synaptogenesis Courtesy of Bruce Perry, MD, PhD

  8. Synaptic Sculpting Courtesy of Bruce Berry, MD, PhD

  9. Myelination Courtesy of Bruce Perry, MD, PhD

  10. 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

  11. Principles of Neurodevelopment • The brain is underdeveloped at birth • The brain organizes from the “bottom” up - brainstem to cortex and from the inside out • Organization and functional capacity of neural systems is sequential • Experiences do not have equal influence throughout development (sensitive periods)

  12. Regulation of Affect Right brain development by relational co-regulation Early childhood sensitive period Core skill for social and emotional well-being

  13. “The Social Brain” Dan Siegel, M.D. 2000 • The brain is the organ of social communication • The mind exists between people • We have always had a psychology of the individual brain….but now we focus on the mind as developed “between” brains • Mindsight – “the ability to know the mind of others”

  14. The Developing Mind Fundamental Principles • The mind emerges from the activity of the brain • The human mind involves the flow of energy and information within the brain and between brains • The mind emerges at the interface of neuropsychological processes and interpersonal experiences • Emerges as the genetically programmedmaturation of the brain responds to ongoing experience

  15. Interpersonal Neurobiology Dan Siegel, M.D.

  16. Attachment SystemJ. Bowlby, M. Ainsworth, M. Main • An inborn system in the brain that influences and organizes motivational, emotional and memory processes with respect to significant care-giving figures • Involves seeking of proximity and protection from danger • Provides communication processes with others • Highly responsive to indications of danger • Serves to create a central foundation from which the mind develops

  17. Attachment • Genes have little to do with Attachment • Temperament and attachment are independent! • Attachment patterns are solely built by experience • L. Alan Sroufe, et al “The Development of the Person,” 2005. • In every culture, healthy relationships are contingent on relational interactions

  18. Adult state of mind with respect to attachment Secure/autonomous (F) Dismissing (D) Preoccupied (E) Unresolved/Disorganized (U) Infant Strange Situation Secure (B) Avoidant (A) Resistant or ambivalent C Disorganized/disoriented (D) AAI Classifications and Corresponding Patterns in Infant Strange Situation BehaviorM. Main

  19. “Ghosts in the Nursery”Selma Fraiberg, 1975 “Angels in the Nursery” Alicia Liberman, PhD 2005

  20. “DIR” Model S. Greenspan and S. WeiderDevelopmental bio-psychosocial model Developmentally-based Individual differences Relationship focused

  21. FUNCTIONAL EMOTIONAL DEVELOPMENTAL LEVELSS. Greenspan 2-3 mo. Shared attention 3-5 mo. Engagement 6-9 mo. Two-way intentional communication 12-18mo. Behavioral elaboration Complex non-verbal gestural communication 24-36mo. Representational communication Ideas and words 36-48mo. Emotional thinking Linking ideas and thoughts

  22. DIR - Individual Differences • Sensory Processing systems • Cortical processing systems • Auditory processing • Visual-spatial processing • Intelligence • Memory systems • Motor output processes

  23. DIR - Relational Context in Early ChildhoodParent – Child Interactions • Attachment patterns • Cooperation patterns • Conflict-doing and conflict-resolution patterns • Regulation patterns of negative and positive affects • Intimacy communication patterns Sibling and Peer Interactions

  24. DIR - Relational Context in Early ChildhoodCultural Patterns • Parenting styles reflect societal values • Early childcare variations (e.g. co-sleeping) • Social clans and multiple early relationships • Role of older children in child-rearing • Imitative roles • Toys and play

  25. Adverse Childhood Experiences Are Common Household dysfunction: Substance abuse 27% Parental sep/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6% Abuse: Psychological 11% Physical 28% Sexual 21% Neglect: Emotional 15% Physical 10%

  26. Adverse Childhood Experiences Score Number of categories of adverse childhood experiences are summed … ACE score Prevalence 0 48% 1 25% 2 13% 3 7% 4 or more 7% • More than half have at least one ACE • If one category of ACE is present, there is an 86% likelihood of additional categories being present.

  27. ACE Score vs. Smoking and COPD

  28. Childhood Experiences vs. Adult Alcoholism 4+ 3 2 1 0

  29. Childhood Experiences Underlie Chronic Depression

  30. Childhood Experiences Underlie Suicide 4+ 3 2 1 0

  31. ACE Score vs. Intravenous Drug Use N = 8,022 p<0.001

  32. Evidence from ACE Study indicates…Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs

  33. Maternal MH, Substance Use and Domestic Violence in the Year after Delivery and Subsequent Behavioral Problems in Children at Age 3 YearsWhitaker, R, et al, 2006

  34. Health Consequences of Early Life TraumaVincent Felitti, M.D., • Health in all domains is related to childhood experience • Health risks: • Stroke • Heart disease • Depression and suicide • Substance abuse • Smoking

  35. Positive Stress • Moderate, short-lived physiological response • Increased heart rate, higher blood pressure • Mild elevation of stress hormone, cortisol , levels • Activated by: • Dealing with frustration, meeting new people National Scientific Council on the Developing Brain, Harvard University 2006

  36. Tolerable Stress • Physiological responses large enough to disrupt brain architecture • Relieved by supportive relationships: • that facilitate coping, • restore heart rate and stress hormone levels • reduce child’s sense of being overwhelmed Activated by: • Death of loved one, divorce, natural disasters National Scientific Council on the Developing Brain, Harvard University 2006

  37. Toxic Stress • Strong & prolonged activation of stress response systems in the absence of buffering protection of adult support • Recurrent abuse, neglect, severe maternal depression, substance abuse, family violence • Increased susceptibility to cardiovascular disease, hypertension, obesity, diabetes and mental health problems

  38. Institutionalization and Neglect of Young Children Disrupts Their Body Chemistry 35% Percent of Childrenwith Abnormal Stress Hormone Levels 30% 25% 20% 15% 10% 5% Middle Class US Toddlersin Birth Families Neglected/Maltreated ToddlersArriving from Orphanages Overseas Source: Gunnar & Fisher (2006)

  39. Types of Trauma • Witnessing violence (domestic and other) • Natural disaster • Terrorism • Accidents • Abuse/Neglect • Loss of caregiver

  40. Types of Trauma: Acute Trauma • Acute trauma is a single traumatic event that is limited in time. Examples include: • Serious accidents • Community violence • Natural disasters (earthquakes, wildfires, floods) • Sudden or violent loss of a loved one • Physical or sexual assault (e.g., being shot or raped) • During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.

  41. Acute Response To Trauma Terror Vulnerable few supports Normal with supports Fear Vulnerable “with supports” Alarm Dissociation or Resilient Vigilance Calm Traumatic Event

  42. Types of Trauma: Chronic • Chronic traumarefers to the experience of multiple traumatic events. • These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war. • The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

  43. Multiple Traumatic Events Terror Fear Alarm Vigilance Calm Event #1 Event #3 Event #2

  44. Types of Trauma: Complex • Complex traumadescribes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child. • Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age. • Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

  45. Additional Sources of Stress • Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include: • Poverty • Discrimination • Separations from parent/siblings • Frequent moves • School problems • Traumatic grief and loss • Refugee or immigrant experiences

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