David Howe

1
Relationships, Resilience and Turning Points
Home Truths Conference Norwich 12 October 2009
David Howe University of East Anglia Norwich
2
Brain
Environment
Genes
G X E Nature via nurture Genes are
designed to work in an environment
3
cortex
limbic system
brain stem
cerebellum
4
Brain development and the early caregiving
environment
Allan Schore
The brain is a self-organising developmental
system.
Brains feed on experience particularly social
and emotional experience (nb deprived versus
enriched environments).
An individuals brain develops capabilities
suited for the environment in which he or she is
raised.
The self-organisation of the developing brain
takes place in the context of a relationship
with other selves.
5
Neurosequential development From the bottom up,
and the inside out. The foundational principle
of brain development is that neural systems
organize and become functional in a
sequential manner. (B. Perry and M. Szalavitz
2006 The Boy Who Was Raised as a Dog NY
Basic Books)
6
cortex
limbic system
brain stem
cerebellum
7
Neurosequential development Each brain area
has its own timetable for development abuse,
neglect or trauma experienced at these sensitive
times affect neurodevelopment (the development
of functional neural networks).
8
Neurosequential development Children who are
regulated gradually learn to regulate themselves
physiologically, emotionally, cognitively. They
can think about and reflect on feeling. They
become less reactive, less impulsive, more
reflective, more thoughtful.
9
Neurosequential development The development of
each system to some extent depends on the
coherent and satisfactory development of earlier
systems. If earlier experiences compromise a
systems neurological development, even if
later experiences are appropriate, the more
mature system cant necessarily take advantage of
it. The key to healthy development is
getting the right experience at the right time
(Perry 2006)
10
Bruce Perry The ChildTrauma Academy, 5161 San
Felipe,  Suite 320Houston, Texas 77056
11
Neurosequential development Neglect lack of
sensory experience during sensitive periods of
brain development the absence of critical
organising experiences at key times during
development. Although critical, neglect is hard
to see. Abuse extreme sensory
experiences during sensitive periods of
brain development (eg hyperarousal,
trauma) (Perry 2002)
12
Bruce Perry 2002 Childhood experience and the
expression of genetic potential Brain and Mind
79-100
When children suffer neglect and
repeated abandonment, there is no pattern
or rhythm to their day. Their cries go
unheard. They rarely enjoy the comfort of
human warmth and touch. The brain needs
patterned, repetitive stimuli to develop
properly. Neglect, abandonment, unpredictability,
loneliness, hunger, discomfort and fear keep a
babys stress system on high alert, unregulated,
chaotic and disorganised.
13
John Bowlby 1907 - 1990
14
DEVELOPMENT OF MIND AND PSYCHOLOGICAL SELF
SURVIVAL
Attachment system
Intersubjectivity
15
Affect regulation
How young minds form in the context of close
relationships
(Allan Schore)
16
ATTACHMENT
None of us in born with the capacity to regulate
our own emotions. The caregiver- child
regulatory system evolves where the infants
signals of changes in state are understood and
responded to by the caregiver, thereby becoming
more regulated.
Peter Fonagy 2000
17
Psychological availability mind-mindedness 'Mental
isation' attunement sensitivity
18
Sensitivity and mentalisation
The parents capacity to observe the childs mind
seems to facilitate the childs general
understanding of minds, and hence his/her
self-organisation through the medium of a secure
attachment.
The child has the opportunity to
find himself/herself in the other as
someone with thoughts and feelings - with a
mind. The child recognises themselves as
an intentional being.
Peter Fonagy
19
Social cognition Social understanding
20
Birth of the Psychological Self
A. Bateman and P. Fonagy 2004 Psychotherapy for
BPD, Oxford UP
Attachment figure discovers infants mind
(subjectivity)
Internalization
Core of psychological self
Representation of infants mental state
Inference
Attachment figure
Infant
Child
Infant internalizes caregivers representation to
form psychological self
21
Disorganised/disorientated attachments infancy
Disorganised attachments arise when the attached
infant has been alarmed by the parent rather than
the external situation.
The parent is experienced as
Frightening physically alarming/hostile
dangerous parental behaviour
Frightened psychologically alarming
parental behaviour/helpless
22
DISORGANISED/ DISORIENTED ATTACHMENTS
Simultaneous activation of two
incompatible behavioural responses FEAR
and ATTACHMENT (avoidance)
(approach)
fear without escape fright without solution
(Mary Main and
Eric Hesse).
23
Relational trauma
24
Caregiving and disorganised attachments

• Physical, emotional and/or sexual abuse,
  including rejection
• Severe neglect and deprivation
• Misuse/abuse of alcohol/drugs
• Serious affective disorder eg
• depression
• Unresolved losses/childhood traumas
• Domestic violence
• Multiple placements

25
Stress-response system Small to moderate amounts
of stress experienced in predictable or patterned
situations, help children develop brains that can
regulate arousal, and minds that can
develop coping strategies and resilience. However
, if the stress is great, sudden, unpredictable,
and threatening, it will be experienced as trauma
with which young brains and minds cannot cope.
26
Hyper-reactivity of the HPA axis One consequence
of early interpersonal trauma with parents
and caregivers is persistent hypervigilance becaus
e they need to scan the environment for the
possibility of others who may be dangerous,
harmful and neglectful ? hypersensitivity
27
Developmental trauma
In the event of a traumatic event, responses to
sights, sounds, smells, touch and kinetic stimuli
join with a rapid accelerating cascade of
feelings from within to overwhelm the traumatised
person.
(Lieberman and van Horn 2008)
28
Early life trauma produces oversensitive
stress-response systems. The brain loses
its ability to regulate other functions including
sleeping, eating, emotions, social relationships,
and cognition.
29
It is as if the switch that controls the
production of stress hormones is recalibrated and
rest to a position where less frightening stimuli
are sufficient to activate the stress-trauma respo
nse system. ( Yehuda et al
1991 Lieberman and van Horn 2008)
30
The brain is most vulnerable to trauma in the
early years, particularly trauma experienced in
the context of a close, attachment relationship
relational trauma.
31
The stress-response systems are among only a
handful of neural systems in the brain that, if
poorly regulated or abnormal, can
cause dysfunction in all four of the main brain
areas. (Perry 2006 23)
Cortex cognition,
reflection Limbic system emotions Diencephalon
motor Brainstem bodily states,
core regulatory
functions
32

Controlling Children
Many abused and neglected children find
mentalisation hard, particularly in interpersonal
and intimate relationships because mentalising
interactively is one of the most complex tasks.
It is at these times that we are all vulnerable
to hyperarousal and we need a buffer to protect
us against overwhelming affect it is
mentalisation that acts as a cushion.
A. Bateman and P Fonagy 2004
33

Controlling Children
For maltreated children, hyperarousal throws
mentalisation off-line the result is panic,
impulsive behaviour, fight-flight response makes
children aggressive, impulsive,
needy, frightened. Under extreme trauma, a
freeze- dissociative response is more likely.
Bateman and Fonagy 2004
34
Feelings of helplessness and powerlessness
increase the risk of trauma. Responses include
hyperarousal, and under extreme trauma
even dissociation. fight flight freeze The
need to feel in control is high in situations of
helplessness, powerlessness, vulnerability and
trauma.
35
Secure/optimal development
Age
Sub-optimal/ Insecure/trauma etc
36
Secure/optimal development
Interventions eg adoption, relationship support, t
herapy
Age
Sub-optimal/ Insecure/trauma etc
Birth
37
Secure/optimal development
Intervention
Intervention
Age
Intervention
Sub-optimal/ Insecure/trauma etc
38
Secure/optimal development
Attuned, psychologically minded
teacher, drama/music therapy
Emotionally intelligent best friend
Intervention eg foster/ residential care.
Age
Sub-optimal/ Insecure/trauma etc
39
Bruce Perry The ChildTrauma Academy, 5161 San
Felipe,  Suite 320Houston, Texas 77056
40
Bottom-up, inside to outside Respond to
developmental age and not chronological
age Relationships as the most powerful of
therapeutic experiences
behavioural and cognitive development social
support and relationships peer relationships socia
l cognition, understanding, empathy mentalisation,
play, attunement, affect regulation predictab
ility, repetition, routines, structure safe and
in control music, movement and dance sensory
integration treatments rocking, touch, massage
41
A developmental base for
interventions
When intervening with children, it is important
to assess their developmental age rather
than their chronological age.
42
It is difficult for children to change without
their environment also changing.
43
David Howe Child Abuse and Neglect attachment,
development and intervention Palgrave/Macmillan 2
005
44
David Howe The Emotionally Intelligent Social
Worker Palgrave Macmillan 2008