Understanding Trauma Effects On Children Session I and II

1. Understanding Trauma Effects On Children Session I and II Lois A. PessolanoEhrmann PhD, LPC, NCC ATTACh Registered Clinician; Certified Attachment Focused Family Therapist EMDR Certified Clinician and Approved Consultant & Certified IFS Therapist ATTACh Board of Director Founder and Executive Director of the Individual and Family CHOICES Program State College, PA Most Important Credential: Mom of a previously attachment challenged and traumatized child Northeast Adoption Summit

2. WELCOME!!!! Who are you? Clinicians? Parents? Educators? Advocates? Double Duty?

3. Learning Objectives As a result of finishing this training participants will be able to: • Describe theoretical foundations and core concepts related to childhood traumatic stress. • Discuss the impact of simple and complex trauma on the developing brain. • Describe the impact of traumatic stress on a child’s daily functioning.

4. The Tentative Schedule Before the Break: Part I • What is Trauma ? • Simple versus complex? • Hey what is your ACE number? • Child traumatic stress: Core Concepts and theoretical foundations After the Break: Part II • Trauma and the Brain: A sad and terrible mix • Trauma and daily functioning: Really NO Fun • Treatments that show promise!

5. What is Trauma?

6. Definitions- Trauma • Traumatic event- one in which a person experiences, witnesses or is confronted with threatened death, or serious injury, or threat to the physical integrity of oneself or others. • Person’s response- intense fear, helplessness or horror • Private versus Personal From DSM-IV , Fourth Edition; American Psychiatric Association

7. The Expansion of the Definition • Experiences of threatened death • Witnesses of threatened death • Serious injury • Threat to the physical integrity of oneself or others • ACE Study (Felitti et. Al., 1998)

8. Two Categories of Trauma • One-Episode Trauma (Type I post-traumatic stress disorder PTSD) • Retain detailed memories • Intrusive recollections • Nightmares • Startle and vigilance • Why me? • Repeated Trauma(Type II post-traumatic stress disorder PTSD) • All of the above plus • repeated trauma occurs in children who have been abused often and for a long time. common in children who have been reared in violent neighborhoods or war zones • witness violence in the home or in their communities • sickening anticipation and dread of another episode. After being repeatedly confusing combination of feelings, at times angry and sad, at others fearful • appear detached and seem to have no feelings (emotional numbness)

9. Let’s Make it even MORE Complex! • What is Complex Trauma? • Also called developmental trauma • Involves multiple traumatic experiences • Defining factor is chronic early maltreatment within a caregiving relationship

10. Complex Trauma:Where Trauma and Attachment Collide • Trauma is perpetrated by the child’s caregiver so • Maltreatment itself • + • Loss of caregiver as safe base • + • Overwhelming distress with which the child must cope and navigate developmental challenges mostly alone

11. Maltreatment by Primary Caregiver • Results in amplified damage that is pervasive • Erosion and damage of the child’s normal developmental pathways • Places individual at risk for chronic and recurrent anxiety • Breaks down fundamental psychobiological development in the body, healthy identity, coherent personality secure attachment • Disturbed relationships

12. Complex Trauma Impairs 7 Domains • Attachment • Biology • Emotional regulation • Behavioral regulation • Defenses • Cognition • Self concept

13. And Let Us NOT Forget SIT…..

14. Children and Trauma Often Misdiagnosed

15. The Misdiagnosis of Trauma in Children ADHD/ADD Bipolar Disorder Schizophrenia Generalized anxiety disorder Depression Elective Mutism Intermittent explosive disorder ODD RAD Enuresis/encopresis Eating Disorders Stereotypic movement disorder

16. Still Expanding the Definition… • ACE Study (Felitti et. Al., 1998) http://www.cdc.gov/ace/outcomes.htm • What is Your ACE Score???

17. Family Centered Practice, June 8, 2007 Regional Child Abuse Prevention Councils 2011

18. The ACE Score In your family of origin have you experienced any of the following? If so give yourself 1 point for each one. • Recurrent physical abuse • Recurrent emotional abuse • Contact sexual abuse • An alcohol and/or drug abuser in the household • An incarcerated household member • Someone who is chronically depressed, mentally ill, • institutionalized, or suicidal • Mother is treated violently • One or no parents • Emotional or physical neglect

19. The Important Implications of The ACE Study http://www.azpbs.org/strongkids/

20. Adverse Childhood Experiences vs. Smoking as an Adult Regional Child Abuse Prevention Councils 2011

21. Adverse Childhood Experiences vs. Adult Alcoholism Regional Child Abuse Prevention Councils 2011

22. ACE Score vs. Intravenous Drug Use Regional Child Abuse Prevention Councils 2011

23. Adverse Childhood Experiences vs. Likelihood of > 50 Sexual Partners Regional Child Abuse Prevention Councils 2011

24. ACE Score vs. Unintended Pregnancy or Elective Abortion Regional Child Abuse Prevention Councils 2011

25. Childhood Experiences Underlie Chronic Depression Regional Child Abuse Prevention Councils 2011

26. Childhood Experiences Underlie Later Suicide Regional Child Abuse Prevention Councils 2011

27. ACE Score vs. Serious Job Problems Regional Child Abuse Prevention Councils 2011

28. Again Expanding the Definition of Trauma Untreated Trauma linked to negative outcomes (Mueser et. al., 2002) Trauma survivors are at risk (Felitti et. al., 1998) Between 51% and 98% of public mental health clients diagnosed with severe mental illness have trauma histories. (Mueser et. al., 1998) Trauma linked to social, emotional, economic costs and cognitive impairments, disease, disability, serious social problems and premature death (Center for Substance Abuse Treatment, 2000). In children trauma may be incorrectly diagnosed (Shonkoff, 2000; Cook, Blaustein, & van der Kolk, 2003).

29. Common Observations by Adults of Children who have Experienced Maltreatment (Hodas, 2006) page 26 “A casual adult observer, unfamiliar with maltreatment and its potential effects, might obtain a highly skewed impression of a child so affected.” Many of the following characteristics apply to both males and females, but tend to be more extreme in males: • Guarded, defensive, and angry behavior; Difficult to redirect, and dismisses support. • High degree of reactivity. • Behaviors may be extremely inappropriate and offensive. • Slow recovery and holds onto grievances

30. Common Observations by Adults of Children who have Experienced Maltreatment (Hodas, 2006) page 26 Continued • Blames others or minimizing the event • Oppositional and disruptive “on purpose”. • Overly sexualized behaviors and a lack of interpersonal and physical boundaries. • Social withdrawal and lack of response to adult efforts at engagement.

31. Common Cognitions & Beliefs of Children (and Adults) Who have Experienced Trauma – Page 27 “The world is threatening and bewildering.” “The World is punitive, judgmental, humiliating and blaming.” “Control is external, not internal and therefore I don’t have control over my life.” “People are unpredictable. Very few are to be trusted.” “When challenged, I must defend myself- my honor and my self-respect. Above all else I must defend my honor-at any price.” “If I admit a mistake, things will be worse than if I don’t.”

32. Overview of Attachment Theory

33. Common Language Attachment “the deep and enduring connection established between a child and caregiver in the first several years of life. This connection profoundly influences every component of the human condition- mind, body, emotions, relationships and values.” From: Attachment Trauma and Healing: Understanding and Treating Attachment Disorder in Children and Their Families by Terry Levy and Michael Orlans

34. Founders of Attachment Theory • First Wave John Bowlby Mary Ainsworth • Second Wave Mary Main Sroufe Trevarthen Tronick Others

35. Recent Influences in Attachment Theory and Therapy Kicked it up a Notch or Two Trauma researchers and clinicians Schore Perry Van der Kolk Neurobiological Focus Siegel Emotion Focused Therapy out of Canada Leslie Greenberg & Susan Johnson

36. Bonding • Focuses on caregiver rather then the child. • child attaches to a parent but a caregiver bonds to the infant. • Related to choices a caregiver makes in order to bring the caregiver/ child relationship into attunement.

37. Conscience • Development of an internally modulated sense of caring about what happens to others, the world and the self. • This sense of caring helps the individual to decipher right from wrong.

38. Internal Working Model The template or blue print that a person develops internally about him or her self, other people, and the world in general.

39. Why is Attachment so Important to the Development of a Healthy Individual ? 1. Basic Trust and Relationship Reciprocity  2. A Secure Base  3. Formation of an Identity 4. Self Regulation Ability  5. Pro-social Moral Framework  6.   Positive Internal Working Model  7.   Defense against Stress and Trauma

40. Touch Eye Contact Smile and Positive Affect Need Fulfillment The Context in Which Attachment and Bonding Occurs

41. The Healthy Attachment/ Bonding CycleAttachment occurs between the infant and caregiver within the context of the baby’s needs. When they are met most of the time, trust in relationships and attachment occurs. Source: Dr. Greg Keck Clinical Psychologist ABC of OHIO

43. What Happens when the Healthy Attachment Bonding Cycle is Broken 1st- NEED 4th- TRUST 3rd-GRATIFICATION 2nd- AROUSAL X BREAKING THE CYCLE Baby does not get needs met consistently. Baby tries to fulfill own needs by head banging hair pulling or other destructive behavior. Baby does not develop trust, becomes full of RAGE. Source: Dr. Greg Keck Clinical Psychologist, ABC of Ohio

44. Intersubjectivity • Refers to those moments when the parent and child are in synch with each other. • Both child and parent or caregiver are affectively (emotionally) and cognitively (thoughts) present to each other. • Vitality of their affective states are matched and their cognitive focus is on the same event or object. • Affect is being co-regulated and within the dyad parent and child are co-creating meaning. Attachment Focused Family Therapy by Dan Hughes

45. The Brain….What is Happening in there?

47. What is Happening in the BrainThe Harlow Monkey StudiesNeglect as far worse then abuseVan der Kolk and Perry: Trauma is stored/ stuck in the right hemisphere Amygdala issues The reason for the stuckness is underdevelopment/ Trauma and Learning DisabilitiesOverstimulated Stress ResponseCortex Damage

48. On Line 3-D Images of the Brain http://www.g2conline.org/2022

49. The Harlow Monkey Studies • Experiments in the 1960s with Rhesus Monkeys • Cloth mothers or wire mothers with food • Role of the mother as a secure base • The babies had behavior problems • Clinging desperately/trauma bonded • Freeze flight fight • Motherless monkeys • Love at Goon Park: Harry Harlow and the Science of Affection (2002) by Deborah Blum

50. Effects of Abuse and Neglect on the Brain Neglect has been found to be far more a factor for attachment disorder then abuse. Bessel Van Der Kolk and Bruce Perry did Pet Scans on the brains of various children and adults. The following findings were documented: