Module 4: Trauma and the Brain

Transcription

1 Module 4: Trauma and the Brain It is important for professionals and caregivers to understand the motives behind a child s actions. The following questions are common when dealing with children who struggle with emotional and behavioral dysregulation. Why does he act like this? What is she trying to accomplish? Why would he do that when he knows it will hurt him? Why doesn t she care if she hurts others? What is his motivation behind this behavior? Why would she get upset about something so unimportant? Why won t he let us help him? Why does she act out if she knows it will not get her what she wants? When caregivers are unable to find answers to these questions, sometimes they resort to putting their personal beliefs on the child to try and make sense of the behavior. Caregivers can sometimes describe a child s behaviors with the following statements: He doesn t care anymore. Or He has given up. She is just defiant, because she didn t get what she wanted. She is trying to manipulate people to get what she wants. She is out of control. He is just being a brat. He is always trying to bully people to get what he wants. She just won t let people help her. This module will help caregivers begin to understand behaviors as neurological responses to triggers. Behaviors are simply the response to emotional and physical distress within the body. Treatment of traumatized children requires

2 51 focus on decreasing their emotional responses to triggers. We will discuss steps to help youth maintain regulation when they are unable to do so themselves. The Brain s Role As covered in Module 1, the brain often develops survival patterns in response to traumatic events. These survival patterns become ingrained in the youth s responses to future triggers, even if the triggers are not seen by adults as threatening. While many parts of the brain are affected by traumatic experiences, a review of the effects on the limbic system can help make sense of behavior that is often thought to be irrational or inappropriate. Hyperarousal and dissociation Children s reaction to traumatic stress is often referred to as hyperaroused or dissociated. These reactions are directly tied to the inborn instincts to fight/flight/freeze when there is danger. The brain s hyperaroused state is tied into the fight/flight response patterns and dissociation is often representative of the freeze response (Perry, 1995). These responses are run by the limbic system, and more specifically, the autonomic nervous system (ANS). When the ANS is affected by experiencing trauma, children become unable to regulate their response patterns. This inability to regulate means that the ANS will over react to triggers/stimulation. Let s review the table of response patterns for children experiencing trauma from Module 1: Patterned Response Hyperaroused Response Patterns for Children Experiencing Trauma Calm Trigger Arousal Alarm Fear Terror Return to Calm or Baseline Vigilant Resistant Defiance Aggression Occurs

3 Dissociated Avoidance Goes Through Motions, Compliant Disengages, Emotion and Behavior Shut Down Fainting or Self-harm Hyper-arousal Example Travon Travon is an 11-year-old male with a history of seeing domestic violence who has seen physical abuse by both his parents. Travon is sitting in class one day when a classmate begins to get upset about an assignment. When the other child begins yelling at the teacher, Travon becomes visibly upset-- fidgeting in his desk, body shaking, muscles tensing up and focusing on the adults in the room. When the para-educator approaches the upset child, Travon gets overwhelmed, stands up, and charges at the para-educator. Assessment It is clear that Travon became hyperaroused when he was triggered by the student s aggressive behavior toward the teacher and the para-educator s move toward the student. Travon s history of domestic violence and physical abuse suggests that his brain s ANS was over used because of the amount of fear and violence in his home. Travon now struggles to regulate his level of arousal when he sees aggressive or violent stimuli. Before the problem in the classroom, Travon was in a regulated state and his ANS was working properly. When the aggression started, Kyle s ANS began re-experiencing his past trauma and he was no longer able to regulate his arousal. Patterned Response Calm Trigger Arousal Alarm Fear Terror Return to Calm or Baseline

4 53 Exercise 4.1: Read the following example and answer the questions that follow: Zach is a fifth grader. Zach has been doing well all morning but on the first day at his new school he begins showing behavioral dysregulation when given assignments to complete. The teacher reports that he does well with active assignments, but when she gave him a longer reading assignment, he got frustrated. The teacher stated that he lost focus, tried to get a girl s attention and became angry when she told him to stop. When the teacher redirected him, he became frustrated and yelled at the teacher, slamming his fist down on the desk. 1. What are some signs that Zach copes with triggers with a hyperarousal response? 2. How might one know if this is a reaction from attention deficit disorder or traumatic stress (change in affect, action and awareness all at the same time)? Hyperaroused Sitting in desk working quietly Occurs Focuses attention on child and paraeducator Loses all focus on his work and is unable to perceive he or the other child is safe. Travon stops considering consequences for behavior. In that moment, his brain isn t able to access higher levels of thinking. Travon gets up and charges the paraeducator. Travon later calms himself and is able to walk with staff Dissociation Example

5 Let s assume that another child in the same class witnessed the same event, but due to their trauma history, had a much different reaction. Jackson The previous example showed an external response pattern, as Travon became hyperaroused. However, Jackson showed an internal response pattern of dissociation. When the other child begins to yell at the teacher, Jackson responds by completely stopping what he is doing, his body language clearly shows fear as he is leaning away from the peer. Jackson focuses his attention downward, stares at his desk, and begins covering his face. He is visibly shaking. When staff approach the child, who has been yelling at the teacher, Jackson begins to rock in his desk, causing his forehead to hit the desk each time he rocks forward. When the staff member attempts to redirect the other child, Jackson begins to mumble the phrase, Leave him alone. Leave him alone! Assessment Similar to the hyperarousal example, Jackson s ANS is overwhelmed by the trigger and his brain is no longer able to regulate his level of arousal. In this example, Jackson s learned reaction pattern is to dissociate, or hide, from the trigger. During Jackson s ongoing abuse, his ANS became ingrained to decrease stimulation by, freezing, and shutting down from the violence and/or abuse. Patterned Response Calm Trigger Arousal Alarm Fear Terror Return to Calm or Baseline

6 55 Dissociated Sitting in his desk working quietly Occurs Jackson is fearful; he leans away from the incident. Jackson focuses his attention on his desk. Jackson covers his face and begins to rock back and forth. He begins mumbling and hitting his head on his desk. Jackson calms and is able to walk with staff. Arousal-Regulated-Dissociation Scale Hyperarousal Regulated Dissociation As we see in this diagram, regulation falls between hyperarousal and dissociation in terms of level of emotion and awareness. Regulation is the ideal level of arousal. All humans are born become hyperaroused or dissociated when Exercise 4.2: Read the following example and answer the questions that follow: William, a youth in a foster care placement, is refusing to take part in family activities. Resource parents report that when they try to get him to join an activity, he Shuts down. Caregivers report that before being asked to participate, he is happy, able to interact with others and focuses on what is going on around him. After being asked, he sits and stares at the floor, ignoring the resource parent s direction. Sometimes it can take up to 30 minutes just to get him to look at us. 1. What are some signs that William copes with triggers with a dissociative response? 2. How might one know if this is a reaction from a depressive disorder or traumatic stress?

7 in danger; but, we often see traumatized children move to these areas when they are even reminded of past danger. Well-regulated individual Individuals with hyperarousal response Regulated Hyper-arousal Hyperarousal Dissociation Regulated Dissociation Individual with dissociation response Hyperarousal Regulated Dissociation When children have an over used survival system because of too many or too scary dangerous events, he/she may shift to a state more quickly and with no or little danger present. It can be helpful to think of these response patterns in terms of energy levels. Individuals with a hyperarousal response pattern show increased levels of energy. Those children that typically dissociate often show a decrease in energy levels. Memory and Communication So what is it about hyperarousal and dissociation that prevents children from being able to process their feelings and make better decisions when experiencing stress? Why does TST believe that traumatic stress leads to behavior that is not wilful? When the ANS fails to regulate arousal, it is directly related to how the traumatic experience affects the hippocampus and amygdala. The hippocampus is responsible for thought, speech, understanding and putting things in order. The amygdala regulates emotions, senses and automatic responses. The hippocampus and amygdala are equally important to surviving stressful situations. The amygdala increases the body s awareness of stimuli and

8 57 prepares for the flight/fight/freeze responses, while the hippocampus should remain functioning to help the individual be able to process information quickly and communicate with others. When the brain senses trauma or is reminded of trauma, the brain slows down the working of the hippocampus and speeds up, the working of the amygdala so that if there is danger, the body can work quickly. If the hippocampus fails to function properly in a child s brain, he/she will be unable to fully understand or talk about and remember events. This leads to problems talking during a crisis and trouble with remembering or talking about the incident when it is over. This may explain why children often report blacking out during a crisis or they respond with wrong information about the event. As the hippocampus is slowed down, the amygdala is acting on high gear. This speeding up leads to increases or decreases in emotions and automatic responses, such as fight, flight or freeze. When regulated the amygdala is balanced by the hippocampus, but when the hippocampus is slowed down, the amygdala s fight, flight, or freeze actions are on over drive. (van Der Kolk, 1999).

9 Hippocampus Cognition Verbal Description of events Factual Processing Amygdala Emotions Conditioned Responses Auto-matic Responses Example of effects of traumatic stress on memory and communication During a time in the resource parent home, Jackson is getting ready for bed. Jackson s brother is already in bed, and the light in the room is off. Jackson doesn t feel safe walking into his room in the dark. The darkness is a reminder for Jackson of past times in his bio home when he was being hurt in the dark. As he looks into his room, his brain begins to revert back to a patterned response. The hippocampus function decreases and his amygdala s action increases. The part of Jackson s brain that would allow him to think about whether this room is safe now slows down, but the part of the brain that raises emotions and increases automatic responses such as fight/flight/freeze works overtime. Jackson is left to respond to his fear, which may be displayed through avoidance, crying, or even self-harming behavior.

10 59 As the Hippocampus Is Supressed: Jackson's ability to problem solve decreases. Jackson is unable to use his words to ask for help As the Amygdala is overactivated: Jackson is overcome with fear Jackson's brain reverts to responses programed during previous trauma Jackson's fight/flight/ Jackson will have little memory freeze responses are of events during situation activated

11 Module 4 test Instructions: Read the following example and answer the questions that follow. Example 1: Carl is a 12-year-old male admitted to the hospital unit for dangerous behavior. His foster mother reported that Carl got in trouble at school for stealing and, after being sent to the principal s office, he ran away from the school, threw rocks at his teachers when they attempted to follow him and jumped into a deep lake without knowing how to swim. He has a history of physical abuse by his biological parents and has been in foster care for six years. Upon entering the unit, Carl is outgoing; introducing himself to staff and acting excited about seeing everything on the unit. Staff members assume Carl will do well since he is happy and outgoing. Shortly after admission, Carl is sitting on the unit with the other children and constantly shifts his attention from one child to another. Staff struggle to get Carl to focus on the tasks at hand, and he often appears to ignore the staff member s request to complete some paperwork. Carl gets up several times during the meeting with the staff member to look around corners, check out who is coming down the hall and to grab something he is interested in. The staff member reports, Wow, he really struggles to stay in one place. I had to really work hard to get him to complete his work! 1. According to the information given, Carl likely copes with traumatic triggers with a what type of response Hyperarousal Dissociation 2. How might one know if this is a reaction from attention deficit disorder or traumatic stress? 3. Knowing how Carl responds to trauma, what are some effective interventions that can be used to help Carl maintain regulation?

12 61 Example 2: Tye is a 12-year-old male admitted to the hospital unit following an episode where he locked himself in a closet and tied a garment around his neck. This occurred after his foster brothers were teasing him about his new hair cut. His foster parents reported he frequently zones out when he gets upset. Upon admission, the child follows staff directions and appears to be doing well. When completing his admission paperwork, Tye answers every question with a simple, yes or no. When he walks into the milieu he stops, and stares at the other child. The staff member attempts to direct him to sit at a table, but he appears to ignore the direction. He slowly moves to the table, but when the staff asks questions, Tye puts his head down and refuses to answer any questions. 1. According to the information given, Tye likely copes with traumatic triggers with a what type of response Hyperarousal Dissociation 2. How might one know if this is a reaction from a depressive disorder or traumatic stress? 3. Knowing how Tye responds to trauma, what are some effective interventions that can be used to help Tye keep regulated or balanced? Practice Notes for Child Welfare Case Managers, Resource Parents and Support Staff: 1. Knowing the primary trauma response for children you are working with will assist you in providing appropriate support and effective recommendations to caregivers. Asking caregivers to complete Moment by Moment Assessments (in the back of the book) will provide the clinical evidence needed to understand more about the child s triggers and response patterns.

13 2. Be mindful of the labels caregivers use when describing a child or the motives for their behavior. Helping caregivers to describe behavior in trauma language i.e. as regulated, emotionally dysregulated or behaviorally dysregulated will likely reduce the risk of caregivers applying mean intent to the child and their reactions. It will also lower the likelihood of caregivers personalizing the child s behaviors. Providing psychoeducation about what motivates a traumatized child s behavior is critical in helping caregivers understand it. 3. Remembering to provide pre-teaching, structure, predictability and support in your interactions with children as you visit them, transport them, observe visits or take them to court will increase the sense of safety and nurturing the child feels while decreasing the risk of emotional or behavioural dysregulation. 4. Being mindful of the difference between physical safety and psychological safety can guide workers in creating safe places to talk with children, their families and resource parents about stressful, painful or difficult topics. 5. Sights, sounds, smells and other sensory based experiences can trigger trauma. 6. Remember, most emotional and behavioral problems in children with plausible trauma histories are survival strategies that worked to help them cope in their traumatic environments.