Stepping Up To BAT: Understanding Brain Development, Attachment, & Trauma When Working With Children and Families

Transcription

1 Stepping Up To BAT: Understanding Brain Development, Attachment, & Trauma When Working With Children and Families Sherri L. Alderman, MD, MPH, IMH-E, FAAP Developmental Behavioral Pediatrician Therapy in Educational Settings Conference April 15, 2013

2 Objectives: Describe the hierarchal structure of brain development and resultant influence on behavior Identify behavioral miscues stemming from insecure attachment and history of traumatic experiences

3 Part 1 Brain Development: Infant brains have neuroplasticity. Neuroplasticity is both an opportunity and vulnerability.

4 Development of the Brain Neural Tube Development of the nervous system begins at 3 weeks gestation Nilsson 1990

5 Development of the Brain Fetal Development Development of the nervous system during gestation Moore 1988

6 Development of the Brain Early Childhood Whole Brain Weight (grams) Conception Brain Weight by Age 3yo birth Birth 12m 36m Age (note different units) 12y

7 Development of the Brain Brain architecture and function are determined by: Genetics and epigenetics Internal stimulations (sleep is critical) External stimulations (including the quality of the dyadic/parent-child relationship) The physical, chemical (nutrition and toxins), sensory and social-emotional environment. Human development is shaped by a dynamic and continuous interaction between biology and experience. (National Research Council & IOM 2000)

8 Development of the Brain: Stages Synaptogenesis Mylenation Synaptic pruning Memory, procedural and declarative Neuronal networking Inhibiting networks

9 Development of the Brain: 4 General Principles Schore 1994 Critical periods influenced by the social environment Development is staged and hierarchically organized Directed by epigenetics Social environmental changes reorganization of brain structures

10 Development of the Brain Video #1: Experiences Build Brain Architecture Harvard Child Development Center

11 Development of the Brain Neocortex Abstract Thought Concrete Thought B. Perry Limbic Diencephalon Brainstem "Attachment" Sexual Behavior Emotional Reactivity Motor Regulation "Arousal" Appetite/Satiety Sleep Blood Pressure Heart Rate Body Temperature

12 Development of the Brain Diencephalon Hypothalamus, thalamus, pineal gland, others Function Relays sensory information (hearing, vision, taste, tactile) between brain regions Controls autonomic functions (sympathetic, parasympathetic) Connects endocrine system with nervous system Communicates with limbic system to generate and manage emotions and memories Motor function control

13 Development of the Brain Limbic System Cortical and subcortical regions of brain Functions necessary for self- and species preservation Feeling and reacting brain Medicalartlibrary.com

14 Development of the Brain Limbic System (cont.) Amygdala Hippocampus Joseph 2000

15 Development of the Brain Limbic System (cont.) Amygdala Critical center for coordinating behavioral, autonomic, and endocrine responses to environmental stimuli, especially those with emotional content and stress Arousal and rage Learned emotional responses (fear and anxiety) Hippocampus Joseph 2000

16 Development of the Brain Limbic System (cont.) Amygdala Hippocampus Encoding and retrieving declarative memory Helps control corticosteroid production Active in understanding spatial relations Joseph 2000

17 Development of the Brain 2 Response Pathways Joseph 2000

18 Development of the Brain (Hypothalamic) Pituitary Axis Carpenter 1985

19 Development of the Brain Prefrontal Cortex Highly connected with cortical, subcortical and brain stem sites Function Planning complex cognitive behavior Personality expression Decision-making Moderating social behavior Executive functions

20 Development of the Brain Memory Signifies the way an event in the past influences a process in the future. Experiences prime neural pathway activity increasing the likelihood of being activated again. Development of memories involves: Encoding (activation of neurons) Storage (alteration in neural connectivity) Retrieval (reactivation of patterns similar to initial coding) Memory is layered: implicit, explicit, and narrative Siegel 2012

21 Development of the Brain Implicit Memory Our earliest memories before development of the hippocampus (first year after birth) Perceptual, emotional, behavioral, and bodily sensory memories Top-down processes where prior experiences shape ongoing perception and behavior and build mental models invariant representations Created without focal attention Siegel 2012

22 Development of the Brain Explicit Memory Hippocampus-mediated Requires focal or conscious attention 2 types: factual information & autobiographical memory Autobiographical memory begins with episodic memory with which we encode and recall the self and later builds in complexity to more organized clustering Narrative memory merges implicit and explicit memory describing stories in our lives. Siegel 2012

23 Development of the Brain Memory How memories are encoded is state-of-mind dependent Cortisol stress hormone Adrenaline flight or fight hormone Impedes hippocampal functioning Increases implicit encoding of fear by the amygdala Blocks explicit processing Enhances implicit processing (bodily sensations & emotions) Siegel 2012

24 Development of the Brain Memory Early experiences critically affect enhancement or inhibition of experience-dependent maturation of structural systems in the brain. Healing of implicit memories from traumatic experiences requires building inner mindfulness within the context of relationship. Siegel 2012

25 Part 2 Early Childhood Development: Development across all domains is interwoven and interdependent. Social emotional development is fundamental to all development.

26 Early Childhood Development Babies are born learning Children learn within relationship Human development is hierarchal

27 Early Childhood Development Babies are born seeking human connections Social emotional development is fundamental for all development

28 Development of the Relationship Attachment Video #2: Serve and Return Harvard Child Development Center

29 Development of the Relationship Attachment Secure attachment requires caregiver emotional availability that can be disrupted by: Maternal depression Affect dysregulation Lack of parental self-efficacy/confidence Chronic stress Unhealthy externalizing behaviors Kim 2012, Fulton 2012

30 Development of the Relationship Maternal Emotional Availability Video #3: Tronick s Still Face

31 Development of the Relationship Attachment Moments of asynchrony in the dyadic dance are natural occurrences. Secure attachment facilitates the transfer of regulatory capacities from the caregiver to the infant enabling the mother to participate in interactive repair. Schore 1994

32 Development of the Relationship Attachment Video #4: Schore on Relationships and Brain Development

33 Development of the Relationship Attachment Video #5: Insecure attachment

34 Development of the Relationship Insecure Attachment Attachment insecurity (12-18 months) is significantly related to behavior problems in preschool. Behavior problems in pre-school predict behavior problems in the first grade. Early behavior problems forecast and lay the foundation for academic problems throughout the school years. School achievement can be forecasted long before school entry. Winnicott 1962

35 Early Childhood Development An Integrated Process Social connections stimulate visual tracking and head control Engagement promotes secure relationships & stimulates oral motor (feeding & babbling) Vestibular balance promotes sitting Core strength facilitates lateral rotation & pulling to standing Standing & walking prompts diaphragmatic excursion, vocalizations & speech Mobility and language acquisition facilitate development of autonomy

36 Executive Function: The Cognitive Process That Regulates an Individual s Ability to: emotionally self-regulate, focus and shift attention, control impulsivity and behavioral responses, exercise mindfulness of self-understanding and empathy, organize thoughts and activities, prioritize tasks, manage time efficiently, and make decisions.

37 Development of the Mind Executive Function Video #6: A Typical 3-year-old Sorting Cards Flexibility and Shifting Construct Video #7: The Marshmallow Test Inhibiting Impulsivity

38 Development of the Mind Executive Function What to do How to do it When to do it Lillas 2009

39 Development of the Mind Executive Function What to do Exercising and expanding sensory-motor chains, learning to tolerate mild discomfort Attend to salience, habituate to nonrelevant distractions, tolerate challenge, exhibit a stress response to threat with recovery back to baseline Select goals that satisfy personal needs and engage in effective behaviors, sustain optimal regulation, form relevant memories, build social learning and adaptation Lillas 2009

40 Development of the Mind Executive Function How to do it Initiate appropriate sensorimotor programs to get needs met, learning behavioral sequences, learning how to manipulate and use objects Inhibit actions, increase working memory span, selfcorrect and monitoring behavior, planning ahead, engaging in personal and social problem solving, using hindsight and foresight to inform current plans Lillas 2009

41 Development of the Mind Executive Function When to do it Build learning associations (behavior consequence), anticipation, forming model for prediction of events, capacity for self-regulation Inhibiting personal drives when not appropriate to the social context, engaging in the prosocial behaviors at the appropriate time, delaying gratification in lieu of a sustained goal, prioritizing activities, adjusting plans when circumstances change Lillas 2009

42 Development of the Mind Executive Function Video #8: Dr. Perry on executive function and regulation 11:02-13:00

43 Part 3 Trauma and Chronic Stress: Chronic stress is neurotoxic. Traumatic events have an adverse impact across the life span and from one generation to the next.

44 Development of the Brain Stress Harvard Child Development Center

45 Development of the Brain Neurobiology and Trauma Amygdala, hippocampus, and prefrontal cortex have abundant glucocorticoid receptors. Chronic stress is associated with amygdala and orbitofrontal cortex hypertrophy and overactivity Chronic stress is associated with loss of neural connections in the hippocampus and medial PFC. Shonkoff 2012

46 Development of the Brain Neurobiology and Trauma Allostatic Load: The cumulative, stress-induced burden on overall body functioning and the aggregated physiologic and psychological costs required for coping and returning to homeostatic balance Amygdala hyperactivation causes increased anxiety PFC atrophy causes loss of top-down control Hippocampal reduction causes impaired memory and mood control Shonkoff 2012

47 Development of the Brain Stress Example: Stress Amygdala activation Hypothalamus releases CRH Pituitary releases adrenaocorticotropic Hormone Adrenal glands release cortisol Glaser 2005

48 Development of the Brain Stress Video #9: Toxic Stress Derails Healthy Development Harvard Child Development Center

49 Development of the Brain Stress

50 Development of the Brain Neurobiology and Trauma Maltreatment is trauma occurring within an interpersonal relationship Effect is determined by timing of maltreatment relative to stages of brain development and development of relationship Early trauma, prolonged separation, and insecure attachment produce permanent changes in the neurochemistry of children that continue into adulthood: Neurobiological sensitivity to loss Fear of abandonment Hyperarousal Sensitivity to environmental threat Van der Kolk, 1987

51 Development of the Brain Neurobiology and Trauma Chronic abnormally high levels of cortisol (stress hormone) adversely affect brain development, stress responsiveness, emotion, and memory. (National Scientific Council on the Developing Child 2005) National Scientific Council on the Developing Child 2005 Insecure attachment and early trauma produce extreme affect dysregulation with concomitant difficulty in modulating aggression in adults. Lawson, 2001, p. 505

52 Development of the Brain Neurobiology and Trauma Separating a child from family adversely affects the child s behavior Placement decision Clinical-level behaviors Remain in home 22% Placed in relative foster care 22% Placed in non-relative foster care 32% Placed in group home or residential care 50% Casaneuva, et al. 2011

53 Development of the Brain Neurobiology and Trauma Untreated effects of trauma on the developing brain become chronic maladaptive reactions to nonthreatening situations (e.g., hyperarousal, dissociation). Perry 1995

54 Development of the Brain Acute Response To Trauma Terror Fear Alarm Vigilance Calm B. Perry Traumatic Event Dissociation or Resilient Normal with supports Vulnerable few supports Vulnerable with supports

55 Development of the Brain Multiple Traumatic Events Terror Fear Alarm Vigilance Calm Event #1 Event #2 Event #3 B. Perry

56 Development of the Brain Bruce Perry

57 Development of the Brain Adverse Childhood Experiences Relationship between traumatic stress in childhood and the leading causes of morbidity, mortality, and disability in USA Cardiovascular disease Chronic lung disease Chronic liver disease Depression and other mental health conditions Obesity Smoking Alcohol and drug abuse Felitti 2010

58 Development of the Brain Video #10: Reading her cues

59 References Carpenter MB, (1985). Core Text of Neuroanatomy, 3 rd Ed. Williams and Wilkins: Baltimore. Casaneuva C, Ringeisen H, Wilson E, et al., (2011). OPRE Report # b, Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, US Department of Health and Human Services. Felitti VJ, Anda RF, (2010). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare, The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic, RA Lanius, E Vermetten, C Pain, Cambridge University Press. Fulton JM, Mastergeorge AN, Steele JS, et al., Maternal Perceptions of the Infant: Relationship to Maternal Self-Efficacy During the First Six Weeks Postpartum, Infant Mental Health Journal 33(4): Glaser R, Kiecolt-Glaser JK, (2005). Stress-Induced Immune Dysfunctions: Implications for Health, Nature Reviews Immunology 5:

60 References Joseph R, (2000). Neuropsychiatry, Neuropsychology, Clinical Neuroscience, New York: Academic Press. Kim B-R, Teti DM, Cole PM, (2012) Mothers Affect Dysregulation, Depressive Symptoms, and Emotional Availability During Mother-Infant Interaction, Infant Mental Health Journal 33(5): Lillas C, Turnbull J, (2009) Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework for Interdisciplinary Practice, Norton: New York. Moore KL, (1988). The Developing Human: Clinically Oriented Embryology Fourth Edition. W.B. Saunders Company: Philadelphia. National Research Council and Institute of Medicine (2000) From Neurons to Neighborhoods: The Science of Early Childhood Development. Jack P. Shonkoff and Deborah A Phillips, eds. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, D.C.:

61 References National Academy Press. National Scientific Council on the Developing Child, (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3, Accessed November 4, 2012, at Nilsson L, (1990). A Child Is Born, New York: Bantam Doubleday Dell Publishing. Perry BD, (1995). Childhood Trauma, the Nuerobiology of Adaptation, and the User-Dependent Development of the Brain: How States Become Traits, Infant Mental Health Journal 16(4):271. Schore AN, (1994). Affect Regulation and the Origin of the Self, Lawrence Erlbaum Associates: New Jersey. Seneff S, (2009). Is ADHD Caused by Insufficient Dietary Fat? http//people.csail.mit.edu/seneff/adhd_low_fat_diet.html Accessed November 10, Shonkoff JP, Garner A, et al., (2012). The Lifelong Effects of Early Childhood Adversity and Toxic Stress, Pediatrics 129(1):e232-e246. Van der Kolk, (1987). Psychological Trauma, Washington D.C.: American Psychiatric Press.

62 References Winnicott DW, (1962). The Maturational Process and the Facilitating Environment, International Universities Press: NY.