Dr. Georgie Siggers Consultant Community Paediatrician Kent Community Health Trust

Transcription

1 Consultant Community Paediatrician Kent Community Health Trust Despite the fact that an estimated 70% of all psychiatric inpatients and 30% of outpatients have histories of psychological trauma, the effects of those histories often go unrecognized or underestimated. Janina Fisher, Ph.D. Instructor and Supervisor, The Trauma Center, Boston, Massachusetts

2 Because of our work in Safeguarding and with Children in Care we recognise these histories and we have had to make ourselves aware of the implications. We are counselling prospective adopters on the impact of these histories but. How much do we really know? Dissociation Disorder Substance Abuse Trauma Attachment Disorder Conduct Disorder Neglect Verbal Abuse ASD Complex PTSD Disinhibited Attachment Disorder Borderline Personality Disorder Post Deprivation Syndrome ADHD Reactive Attachment Disorder Traumatised from Sexual Abuse Emotional Abuse Depression Hippocampal Abnormalities Insecure attachment Frontal Lobe Syndrome Emotional & Behavioural Disorders Post Abuse Syndrome Generalised Anxiety Disorder PTSD Alcohol Abuse Parentified Child Disinhibited Social Engagement Disorder ADD

3 ATTACHMENT What is neglect? The persistent failure to meet a child's basic needs (such as love, safety, food, and warmth)in a way that seriouslyaffectstheir health, development or safety. Or the absence of critical organising experiences at key times during development

4 TRAUMA: any physical wound or injury; physical shock following this DSM: "The person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganizedor agitated behavior Bowlby: any events that seriously threatened the attachment relationship; which could include parental death, divorce, psychoses etc. A collection of interconnected brain nuclei that play a pivotal role in the regulation of emotion and memory. The hippocampus is thought to be important in the formation and retrieval of both verbal and emotional memories The amygdala is concerned with creating the emotional content of memory e.g.. feelings relating to fear conditioning and aggressive responses.

5 When we are threatened our limbic system is activated. Information from senses is transmitted to the thalamus, our sensory information center, where it is evaluated by both the amygdala and by the left orbital prefrontal cortex (LeDoux, 2002) to determine if it is a true orfalse alarm. If the stimulus is recognized as benign, the amygdala does not respond If a true threat the amygdala signals the hypothalamus to turn on the sympathetic nervous system. A cascade of neurochemicals from the adrenal glands initiates the adrenaline stress response in preparation for fight or flight. This puts us in the survival mode state : increased HR, RR, O2 flow etc. and turning off other non-essential organ systems, including the frontal cortex.

6 As we are mobilizing to flee or fight, the adrenal glands initiate reciprocal activity in the parasympathetic nervous system, preparing us for the cessation of danger and recovery from the event. Production of cortisol increases; heart rate and respiration slow down; and frontal lobe activity resumes but often hyperactively, causing intrusive thoughts and images of the event. In case fighting or fleeing is not adaptive or possible, the parasympathetic nervous system also offers two other survival alternatives, freeze and submission. Children, for example, are almost entirely dependent on freeze and submission responses, as are battered wives, prisoners of war, and hostages. Following the event, after we have shaken and wept and trembled until our bodies recalibrate (attachment), the hippocampus is responsible for putting the experience into chronological order and perspective preparatory to its transfer to verbal memory areas in the cortexduring sleep. If the experience is a single event, and we have adequate support afterward (attachment), and we have had little or no prior trauma, then we will be left shaken, but the events will feel behind us now. If traumatic events have been recurrent, and/or we are developmentally vulnerable, and/or we have inadequate support (no attachment figure) we can be left with a host of implicit memories, intense responses and symptoms that tell the story but without words and without the knowledge that we are remembering (Siegel, 1999).

7 Innate instinct to get close to the attachment figure when frightened in the belief that the attachment figure will provide protection Activated by internal & external stressors Requires a consistent, sensitive response Process results in deactivation/ removing cause of the attachment behaviour Placeholder for your own sub headline DANGER REQUIRES RESPONSE CALM / STRESS SET GOAL Proximity Care giving BOND Building block

8 Rocky foundation = unstable building Hippocampus Slows down/ modulates Amygdala off Child feels secure, loved, safe Stress response Child seeks Attachment Figure (AF) Child able to learn Calm Amygdala activated Fear stimulus Calm

9 For children, these threats are 90% likely (van der Kolk, 1996) to emanate from the immediate family. Thus, the very person to whom the child would instinctively turn at the moment of danger is also the source of danger or the source of non-protection from danger. Attachment process activated but attachment figure doesn t deactivate the process. Child has no strategy This dilemma lays the groundwork for disorganized attachment, : she or he turns or moves toward the parent, but then stops, freezes, backs up or turns away, often with a glazed or frightened look. In the context of abusive or neglectful parenting, the attachment drive is intensified, but so are the survival responses of freeze or flight. AF not available Stress response Hippocampus Remains active Attachment behaviours shown Child seeks AF Amygdala on Child unable to learn Constant stress response leads to physical effects on brain Stress Amygdala activated Fear Prolonged & overwhelming

10 This leads to a hyper activated autonomic nervous system and disorganized attachment patterns which will have become wellentrenched, familiar, habitual responses. Secure attachment buffers biological stress response Effects on neurogenesis, synaptic overproduction and pruning, and myelination during specific sensitive periods. Major consequences include reduced size of the mid-portions of the corpus callosum; attenuated development of the left neocortex, hippocampus, and amygdala along with abnormal frontotemporal electrical activity; and reduced functional activity of the cerebellar vermis. This negative impact on developing brain structures is associated with changes in brain chemistry. Overwhelming stress early in life also alters the production of both the stress-regulating hormone cortisol and key neurotransmitters such as epinephrine, dopamine and serotonin, the chemical messengers in the brain that affect mood and behavior. These biochemical imbalances can have profound implications. For example, abuse typically lowers serotonin levels, leading to depression and impulsive aggression.

11 Safety is destroyed and developmental patterns become disorganised Disturbed attachment patterns Rapid shifts in emotional states Aggressive behaviour against self and others Anticipatory behaviour Multiple somatic problems Self endangering behaviours Self hatred and self blame etc. etc. etc. The aftermath of childhood abuse can manifest itself at any age in a variety of ways. Internally it can appear as depression, anxiety, suicidal thoughts or posttraumatic stress; it can also be expressed outwardly as aggression, impulsiveness, delinquency, hyperactivity or substance abuse. One of the more perplexing psychiatric conditions that is strongly associated with early ill-treatment is borderline personality disorder.

12 Lives Across Times 132 infants yrs. NAI by father, all had current psych diagnosis All had shown symptoms at 7 yrs. When Bowlby s def. of trauma used, a child who had 2 or more traumas had reduced adult functioning Kaiser Health Plan With increased ACE score, found increase in rates of Depression Risk suicide Prescription rate Memory impairment And effect on physical health

13 Size affected by early experience Diminished size associated with learning defects Male monkeys in isolation study Reduced CC size most prominent finding in children with hx abuse & PTSD In boys, particularly affected by neglect Vulnerable to ravages of stress Reduced volume assoc with PTSD & DID & BPD & hx childhood abuse Reduced volume found in children with hx PA or SA & depression cf depression alone Reduction only seen in adults Could reduced volume be a risk factor for PTSD or could it be caused by alcohol? Rats exposed to maternal isolation stress- decreased H vol

14 Impact on behavioural control Repeated abuse causes the amygdala to signal danger even when there is no apparent threat. Dr. Bruce Perry ''A maladaptive amygdala makes an abused child recoil in fear at the drop of a hat.'' Early stress precocious maturation.parentified child Arrested development and reduced adult capacity Evidence to suggest trauma assoc with alterations in symmetry, grey matter volume, neuronal integrity and EEG coherence

15 Seen for Initial Statutory Health Assessment Chronic neglect Undernourished, Placement changes Transfer to secondary school Remanded into secure accommodation Adopted Severe eczema Speech delay ASD ADHD Depression

16 Placeholder for your own sub headline LBW Faltering growth Hypotonia Drug & alcohol misuse Joint problems Teenage pregnancy Bruising Rashes Repeated infections Dental decay Physical Signs SYNDROME N Complications Emotional Unemployment Offending Self Harm Poor parenting capacity Difficulties with relationships Global delay Social interaction? ASD Attachment problems Cognitive deficit Repetitive behaviour Impulsive?ADHD Neurodevelopmental Depression Anxiety Low self esteem Eating disorder Aggression Lack of empathy Placeholder for your own sub headline Corpus callosum HIPPOCAMPUS CEREBRAL CORTEX AMYGDALA BRAIN GROWTH EEG CHANGES Normal Severe Syndrome N NEURAL PRUNING CHEMICAL CHANGES

17 Learning difficulties Lack of parenting capacity Abused as a child Mental health problems Drugs and alcohol POVERTY During which different brain regions maximally sensitive to effects of exposure to childhood stress? Different neuropsychiatric sequelae of maltreatment may arise based on ages of exposure Resilience?

18 Placeholder for your own sub headline Frequency Severity Duration Age ATTACHMENT Developmental status Placeholder for your own sub headline Awareness Intervention Educate ourselves & others Raise awareness/prevent Awareness Intervention Never lose sight of the child Lower our thresholds Consequences Consequences Appreciate effect of early years on current functioning Acknowledge that it may take years to undo the damage of neglect Support Support Give these children the on-going professional support they require

19 Early abuse increases the risk of developing post-traumatic stress disorder (PTSD), depression, symptoms of attentiondeficit/hyperactivity, borderline personality disorder, dissociative identity disorder, and substance abuse. Animal studies showing that new experiences can regenerate brain cells Promoting a secure attachment is key to protection The impact of trauma & neglect can be seen across all areas of child development (Syndrome N) It affects structure & function of brain Trauma and neglect severely damages attachment process Promoting a secure attachment is key to protection Effects can last for generations

20 Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife but at the cost of deep, enduring wounds. Teichner 2000 Georgie.siggers@nhs.net