Reducing Risk and Preventing Violence, Trauma, and the Use of Seclusion and Restraint Neurobiological & Psychological Effects of Trauma

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1 Reducing Risk and Preventing Violence, Trauma, and the Use of Seclusion and Restraint Neurobiological & Psychological Effects of Trauma Module created by Glenn Saxe, MD: 2002 revised 2009, 2011, 2013, 2016

2 Without understanding the basic principles of how the brain develops and changes, we cannot expect to design and implement effective interventions. Bruce Perry, M.D. 2

4 SR & Injury Episodes Boston Medical Center Intensive Residential Treatment Program Total Seclusion, Restraint & Injury Episodes 09/00-01/08 St SR Episodes Kid Injury Staff Injury Significant Periods

6 PTSD-RI Score Time Period Longitudinal Course of PTSD Symptoms in Children with Burns Acute Assessment 3 Month Assessment

7 Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al, 1999)

8 From Neurons to Neighborhoods: The Science of Early Child Development Report from the Institute of Medicine/National Academies National Research Council

9 Trauma in U.S.A. 3 million children were suspected of being victims of abuse and/or neglect (Mazelis, 1999) 3.9 million adolescents have been victims of serious physical assault, and almost 9 million have witnessed an act of serious violence (Kilpatrick et al, 2001) In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood (Acoca & Dedel, 1998)

10 PTSD in U.S.A. Over 50% of U.S. women & 60% of men report experiencing at least 1 traumatic event at some point in their lives. But, only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events. (Koenen, 2005; Kessler et al, 1995) More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders. (Solomon & Davidson, 1997) For more than 1/3 with PTSD, it will be a persistent condition and experienced for several years. (Solomon & Davidson, 1997)

11 Impact of Adult PTSD Childhood trauma, compared to adult-onset trauma: results in a greater probability of developing psychiatric disorders (particularly anxiety disorders and PTSD) throughout the lifetime (Zlotnick et al., 2008), and is believed to have a long-term impact in the frontal, temporal and parietal regions of the brain and how information is processed (Cook et al., 2009) Studies have identified 4 main risk factors for PTSD in adults: 1) a pre-existing psychiatric disorder; 2) a family history of disorders; 3) childhood trauma and 4) being female (Breslau, 2002) Late-onset PTSD is under recognized and undertreated in adults and creates greater probability of additional psychological difficulty and physical health symptoms later in life (Snyder, 2008)

12 Effective Treatment Must Account For: 1) A dysregulated nervous system 2) A social-environment that cannot contain this dysregulation

13 Core Concepts of Development 1) The development of children unfolds along individual pathways whose trajectories are characterized by continuities and discontinuities, as well as by a series of significant transitions. (Shonkoff & Phillips, 2000)

14 PTSD-RI Score Time Period Longitudinal Course of PTSD Symptoms in Children with Burns Acute Assessment 3 Month Assessment

15 PTSD Definition The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons experience of: Actual or threatened death Actual or threatened serious injury Threat to physical integrity

16 Post Traumatic Stress Disorder Characterized by: Re-experiencing the event Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories Avoidance and emotional numbing Flattening of affect, detachment from others, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience

17 Core Concepts of Development 2) The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains. (Shonkoff & Phillips, 2000)

18 22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained. State Change

19 12 year-old sexually abused girl in school when provoked by older male peer. State Change

20 Parameters that change between state Affect Thought Behavior Sense-of-self Consciousness

21 Emotional States and Child Development Discrete behavioral states are a central organizing experience of infancy Infants experiential world is divided into separate and definable emotional/behavioral states Critical task of early child development is to build smooth transitions/bridges between states Regulation of emotion is initially contingent on caregivers facilitating these transitions (Wolff, 1987)

22 Goal of Treatment Maintain Calm/ Continuous/ Engaged State Prevent Discontinuous States Build Cognitive Structures that allow Choices

23 Between Stimulus and Response Stimulus Response

24 Between Stimulus and Response Stimulus Traumatic Reminder Response Socialenvironmental intervention Neuroregulatory Intervention Traumatic State Intervention

25 Between Stimulus and Response Stimulus Traumatic Reminder COGNITION!!! Response Traumatic State Socialenvironmental Intervention Neuroregulatory Intervention Intervention

26 Core Concepts of Development 3) Human development is shaped by a dynamic and continuous interplay between biology and experience. (Shonkoff & Phillips, 2000)

27 Emotional Brain (Restak, 1988)

28 Between Stimulus and Response S Stimulus (LeDoux, 1996)

29 Between Stimulus and Response Sensory Thalamus S Stimulus (LeDoux, 1996)

30 Between Stimulus and Response Very Fast Sensory Thalamus Amygdala S Stimulus (LeDoux, 1996)

31 Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus (LeDoux, 1996)

32 Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)

33 (LeDoux, 1996) Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response

34 Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)

35 Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)

36 Between Stimulus and Response Cortex Hippocampus Slower Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)

37 Between Stimulus and Response Social Environmental Intervention Cortex Neuroregulatory Psychotherapy Intervention Hippocampus Slower Psychopharmacology Sensory Thalamus Very Fast Amygdala S Stimulus Response (LeDoux, 1996)

38 Rauch Brain scans

39 Play (Panksepp, 1998)

40 Play and Fear (Panksepp, 1998)

41 Social-Ecological Model Culture Neighborhood School Peer Group Family Individual Individual

42 Core Concepts of Development 4) Human relationships, and the effects of relationships on relationships, are the building blocks of healthy development. (Shonkoff & Phillips, 2000)

43 Attachment Earliest relationships critical for capacity to regulate state Early traumatic relationships set up person to respond with state dysregulation to interpersonal cues in subsequent relationships

44 Attachment & Relational Deficits Appear guarded & anxious Difficult to re-direct, reject support Highly emotionally reactive Hold on to grievances Do not take responsibility for behavior Make the same mistakes over and over Repetition compulsion / traumatic reenactment (Hodas, 2004)

45 Traumatic Relationships Emotions expressed in interpersonal relationships can be extremely painful and can be related to trauma experience These trauma-based emotions (e.g. anger, fear, hopelessness, sexual arousal) can be very hard for clinicians to tolerate Clinicians must be mindful about their experience of trauma-based emotion so that this emotion is not enacted in the clinical relationship

46 Core Concepts of Development 5) Children are active participants in their own development, reflecting the intrinsic human drive to explore and master one s environment. (Shonkoff & Phillips, 2000)

47 Traumatic Mastery Many children have primarily experienced abusive and neglectful relationships Extreme behaviors within relationships can be seen as defensive or self-protective Traumatized children respond to their trauma history in the present. They are not able to discern that the context has changed This behavior must be seen as an attempt to master extremely difficult environments. In this way, traumatized children are doing the best that they can

48 Core Concepts of Development 6) The course of development can be altered by effective interventions that change the balance between risk and protection, thereby shifting the odds in favor of more adaptive outcomes. (Shonkoff & Phillips, 2000)

49 Recovery from Trauma Brain plasticity & traumatic brain injury Promote neurogenesis Exercise and gross motor movement Increased V02, increased blood flow x 2 to hippocampus, new blood vessels, strengthens neural connections (Pereira et al., 2007; Snyder & Cameron, 2011) Use of anti-depressant medications (Surget et al., 2011) Cognitive stimulation Procedural learning (Grigsby & Stevens, 2002) Deconstruct behavioral sequence Teach new patterns of response

50 CONCLUSIONS Response to traumatic stress is learned behavior, mediated by the brain & the social environment Traumatic stress brings the past to the present The survival response impacts the mind, body, behavior & speech the amygdala leads a hostile takeover of consciousness by emotion. (LeDoux, 2002 ) To change the response, create new learning & skills: Analyze & adapt Buffer & bolster Teach, support, & build that cognitive wedge

53 Cowardice asks the question is it safe? Expediency asks the question is it politic? Vanity asks the question is it popular? But conscience asks the question is it right? And there comes a time when one must take the position that is neither safe, nor politic, nor popular. But one must do it because it is right Martin Luther King, Jr.

55 Time for Lunch / Lounas

Impact of Trauma. Consultant

Impact of Trauma. Consultant Understandin g the Biopsychosocial Impact of Trauma Brian Sims, M.D., NASMHPD Consultant Module created by Saxe, 2002 Longitudinal Course of PTSD Symptoms in Children with Bur ns 50 45 40 35 PTSD- -RI