Course Overview: Stress Session One: Last Week

Transcription

1 Stress: The Good, Bad, and the Ugly Part Two: Research Catherine Nelson, Ph.D. University of Utah Course Overview: Stress Session One: Last Week Definitions Physiology Toxic Stress Risk factors for experiencing toxic stress Protective Factors Stress and individuals with disabilities Course Overview Session Two: Today Research on stress and children and youth Early care-giving experiences Autism Social-Emotional, Behavior Disorders Deafblindness Research on stress and families of children with disabilities Implications of the research for teaching 1

2 Course Overview Session Three Prevention of Toxic Stress Preventing toxic stress in children and youth with disabilities Supporting families of children with disabilities Dealing with your own stress Review SAM system: rapid fire system with hormones that are involved in fight or flight HPA system: slower, longer acting system that produces cortisol Review Cortisol varies on diurnal cycle with normal peak in the morning (CAR response) and gradual decline over the day Dysregulation may be either heightened or flattened response Cortisol also varies reactively Reaches peak 20 to 30 minutes after onset of stressor Gradually returns to baseline over course of 40 to 60 minutes 2

3 Questions Early Care Experiences and Stress If infants have secure attachment relationships with caregivers, they cry to get care, but do not have elevated cortisol (Gunnar & Quevado, 2007) In insecure relationships or with unsupportive caregivers, stressors elevate cortisol and heart rate (Spangler & Schieche, 1998). Insensitive patterns of parental care in the first year of life predict larger cortisol responses to stressors (Gunnar, et al., 2006). Early Experiences Maternal sensitivity and responsiveness predict lower cortisol reactivity to a everyday stressor and better recovery from the stressor (Elbers, Riksen-Walraven, Sweep, & de Weerth, 2007) Toddlers who are securely attached do not show elevations of cortisol to distressing events but those in insecure attachment relationships do (Gunnar & Donzella, 2002). 3

4 Early Experiences Traumatic family events associated with elevated cortisol (Flinn & England, 1995). Maternal depression beginning in child s infancy most powerful predictor of children s cortisol levels in preschool (Essex, et al., 2002; Dawson & Ashman, 2000). Maternal severe stress at two points correlated with high cortisol preschoolaged children (Essex, et al., 2002). Early Experiences Early disruptions in parent-child relationship may produce higher cortisol levels by preschool and thus lead to behavioral, emotional problems in first grade (Essex, et al., 2002). In study of children in full day child care setting, majority of 2 to 4 year olds children had increases in cortisol over the day not true in 5-8 year olds (Dettling et al., 2000). Early Experiences Such increases in cortisol are not observed when child receives individualized, supportive care from care-providers (Dettling et al., 2000). Cortisol levels of children attending highquality child-care programs has been demonstrated to decrease across the day. In low quality-programs, it increased (Sims, Guilfoyle, & Perry, 2006). 4

5 Early Experiences Peer rejected children produce higher levels of cortisol in the preschool classroom (Gunnar et al., 2003) Children with PTSD have elevated cortisol relative to controls but adults with PTSD and adult survivors of childhood abuse have low basal cortisol activity (Gunnar & Quevado, 2007). Early Experiences Children reared in orphanages tend to have low cortisol in morning with atypical diurnal cortisol patterns- neglect vs. abuse (Gunnar, et al., 2001) 3 to 11 years post adoption, only those with extreme growth retardation had abnormal cortisol patterns (Kertes, et al., 2008). Stress reactivity increases in adolescence (Gunnar & Quevado, 2007) Questions 5

6 Activity How can you apply the research on early caregiving experiences to your own setting? Can you think of examples from your practice that fit with the research findings? Stress, Cortisol, and Autism Corbett, et al., 2008 Looked at both reactive salivary cortisol and diurnal cortisol following exposure to novel stimulus (mock MRI) and repeat exposure 22 children with autism and 22 without Children with autism had decrease in morning cortisol and higher evening cortisol (flattened pattern) and more variability from day to day Both groups had heightened reactive response to second exposure of MRI Stress, Cortisol and Autism Corbett, Schupp, Levine, and Mendoza(2009) Compared cortisol, stress, and sensory sensitivity in children with autism Stress Survey Schedule (SSS), Short Sensory Profile (SSP) Children with autism had higher SSS scores and lower SSP scores Higher SSS score correlated with lower AM cortisol and higher PM cortisol 6

7 Stress, Cortisol and Autism Corbett, Shupp, and Lanni (2012) 27 children with ASD, 22 typically developing Used observation Peer Interaction Playground Paradigm (PEER) and Trier Social Stress Test (novel academic tasks) Reactive cortisol significantly higher for both groups to social stress in PEER than in home. Higher in children with ASD and those who willingly engaged in social interaction Corbett, et al., cont. Responsivity of children with ASD to novelty was higher and more prolonged than in predictable social situations in children Typically developing children had more rapid recovery to stress induced by novel situation Stress, Cortisol and Autism Spratt, et al., 2012) Measured cortisol at rest, in novel environment, and in response to blood draw stressor 20 children with autism and 28 typically developing Early morning urine cortisol- not significant Serum cortisol higher in autism Baseline salivary: same for both, autism group higher cortisol 20 and 40 minutes after blood draw 7

8 Stress, Cortisol, and Autism Kidd, et al., (2012) Diurnal salivary cortisol and alpha-amylase (saa) which is a SAM hormone Preschool-aged children- 26 with autism, 26 typically developing Modest increases in waking cortisol and saanot statistically significant- no other differences Children with autism were more variable in both cortisol and saa Cortisol and saa higher when IQ was lower Activity Stress and Autism What are some common findings of the research on autism? How could the research translate to classroom? Questions 8

9 Cortisol, Behavior, and Stress Child maltreatment and the developing HPA axis (Tarullo & Gunnar, 2006) Maltreated children with internalizing problems have elevated early morning basal cortisol Adults maltreated as children often have low basal cortisol levels Basal cortisol levels of maltreated boys with externalizing behaviors same average basal as controls, lower AM levels (Cicchetti & Rogosch, 2001). Behavior and Stress Maltreatment continued Children in foster care who had been maltreated had normal circadian cortisol rhythms when foster parents were given intervention to be more sensitive, responsive caregivers. Control group in foster homes without intervention did not improve in cortisol curve or behavior (Fisher et al., 2000). Behavior and Stress Disruptive Behavior Disorders (van de Wiel, et al., 2004) 22 children with DBD before therapeutic treatment (parent behavior management training and cognitive behavioral therapy) Behavior problems of group with high cortisol stress response lower after intervention than group with low cortisol response 9

10 Behavior and Stress Self-Injurious behavior (SIB) and Sterotyped-movement disorder (SMD) (Symons, et al., 2011). Salivary cortisol and alpha-amylase 366 individuals with severe to profound ID Significantly higher cortisol in SIB group than non-sib group saa was higher in SIB +SMD than SIB alone and went up with # of sterotyped behaviors Questions Deaflblindness: Nelson, Greenfield, Hyte, & Shaffer Single case, multiple baseline across activities with sequential withdrawal 3 children identified as deafblind Measures: Frequency (# divided by number of minutes) and % duration behaviors indicating stress). % duration of active participation Time to regulation Reactive salivary cortisol- before, 20 minutes after (peak) 40 minutes after 10

11 Salivary Cortisol Salivette saliva collection ARUP Laboratories Enzyme Immunoassay Coefficient of variation <8% Norms for age and time of day established by ARUP on non-cushing population 3 days of sampling (3 samples each day) in baseline and 3 days of sampling in each phase of intervention. 27 samples per child Deafblind Research Study Interventions Environmental (Making activity meaningful, interactive, and participatory) Anticipatory (Touch cues, object cues, calendar or scheduling systems) Calming (slow rhythmic voice, stroking arm, massage, proximity) David 13 year old male Inclusive middle school with intervener/interpreter Profound hearing loss, new cochlear implant that was generally not on, high myopia, eyes did not work together Hydrocephalus, absent corpus callosum, developmental delays Cerebral palsy on one side but was mobile 11

12 David Communicated mostly through Signed English, some home signs Stress behaviors: refuse, shut eyes, hit, freeze, avoidance behaviors, cry, yell Regulation behaviors: Smile, laugh, sign ready, sign better, participate in activity David s Activities PE Transition from computer Science Cortisol Activity: David Physical Education Baseline Physical Education in inclusive gym class Street clothes Rolled ball back and forth with intervener did not participate with other students Did not want to go to school 12

13 Intervention: David PE Environmental: Gym shirt, put on gym shirt in locker room, included in all activities with other students, instructions from intervener with encouragement to look at what other students are doing, 5 minute breaks when tired Intervention: David PE Calming: If he became upset, intervener took hand and led him back to gym floor with other students, stayed 5 feet away 13

14 Graph: David PE Data Summary: David PE Frequency behaviors went from 0 behaviors per minute to 0 Duration behaviors went from mean of 44% of activity to 0% Active Participation went from 55.5% of activity to 96% Length of time from onset of stressor until regulation - went from minutes to 0. 14

15 4 Year old male Michael Self-contained special education preschool Deafblind- cataract on right eye, no lens on left, CVI on right side, diagnosed with functional hearing loss, inconsistent auditory responses Cerebral Palsy Michael Nonsymbolic level of communication Seven medications- seizure control, reflux, sleep Stress behaviors: low continuous vocalization, grimace, grinding teeth, resistive behaviors including high pitched vocalization, pulling away and continuous grimacing Michael Regulation behaviors- smile, active participation, active looking, happy vocalizations 15

16 Michael s Activities Hand-over-hand activities Having neck brace put on Wooden box with sensory objects termed little room Michael: Hand Over Hand Baseline Hand over Hand Activities Coloring Cutting Pasting Drawing Interventions: Michael Environmental position, noise level, choice of tactile activity- toy guitar with hand-under-hand assistance Anticipatory verbal, visual, tactile cuestell him play music, show guitar, movement right side, hand under hand exploration Calming deep pressure, rocking wheelchair and verbal soothing 16

17 Graph: Michael: Hand over hand activity Data summary: Michael Hand- Over-Hand Frequency behaviors went from 2 behaviors per minute to 0 Duration behaviors went from mean 57% of activity to 0% Active Participation went from 14.4% of activity to mean of 94% in last phase Length of time from onset of stressor until regulation - went from 13.3 minutes (did not regulate) to 0. 17

18 Alik 6 year old male Self contained class for children with visual impairments Totally blind Varying levels of hearing- severe to profound loss, bilateral hearing aids but very seldom worn Alik Cerebral palsy, mobile with the aid of a walker Nonsymbolic communication level Stress behaviors: Resisting, self-abuse, aggression toward others, yelling, crying, sleeping Alik Regulation behaviors: Stilling, smiling, laughing, affectionate behavior, flapping, participating in activity 18

19 Alik s Activities Table activities termed goals Transition from sensory activities Alik: Goal Activity Baseline Table activities in wooden chair with seat belt Coloring Cutting Goals: Intervention: Alik Environmental: Change activity to communication and listening with hearing aids in and on the floor with intervener Imitation of repetitive syllables, switches with music, finger plays, music and singing with movement, turn-taking with movement, musical instruments, choice making with objects from various activities, respect signals for breaks 19

20 Intervention: Alik Anticipatory: Briefly tell A what is coming up, activity bin with material from communication and listening activity presented, bin of objects from next activity given at end Calming: Affectionate hugging, stroking his arm, vibrating toy, vibrating furry lady bug Graph: Alik Goals Data Summary Alik Goal Activity Frequency behaviors went from 5.2 behaviors per minute to 0 Duration behaviors went from 44.6% of activity to 1.1% Active Participation went from mean of 10.5% to 63% in last phase -83% in 2nd Length of time from onset of stressor until regulation - went from 9.4 minutes (did not regulate) to 0. 20

21 Cortisol Data Cortisol Summary Buffering effect of secure attachments Behaviors may not equal stress- may be proactive, communicative measures to protect against stress if supportive persons are present Affirmation of protective factors Behavior changes, marked increase in participation without rise in cortisol 21

22 Lessons Learned Paramount importance of meaningful, enjoyable activities Importance of routines In some cases, added anticipatory strategies important but can be successfully faded if predictable, meaningful routines are in place and if natural cues are utilized-must be individual Lessons Learned May be differences between congenital and acquired deafblindness Importance of planned relationships across adults and peers and careful transitions when someone leaves Resilience and strengths of the children Questions 22

23 Activity Ideas for how to apply information learned from this study in your classroom? Questions 23