Traumatically Disrupted Attachment

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Traumatically Disrupted Attachment

• How to recognize, diagnose, and treat toward
  optimal healing

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Health Choices of Somerset and Bedford Counties,
PA

• Lark Eshleman, PhD
• www.LarkEshleman.com
• November 3, 4, 2010

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Day 1

• 9 1015            Brain-based research on
  attachment and trauma
• 1030 1200     Brain research (continued)

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Day 1

• 1 215 Best Practice based on
  neurological understandings sensory processing
  disorder and other interrupted developmental
  processes
• 230 430  Best practice based on neurological
  understandings  narrative, Theraplay, EEG
  Biofeedback, EMDR

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Day 1

•  Brain-based research on attachment and trauma

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Understanding Our Neuroanatomy

• Dr. Shores Central Assumption
• The social environment changes over the stages
  of infancy and induces the reorganization of
  brain structures

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Dr. Schores Central Tenets

• The growth of the brain occurs in critical
  periods and is influenced by the social
  environment.
• The infant brain develops in stages and is
  hierarchically organized.
• Genetic systems that program brain development
  are activated and influenced by the postnatal
  environment.

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Overview of Critical Brain Structures
Brainstem

• Controls
• Heart Rate
• Blood Pressure
• Body Temperature
• Respiration

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Overview of Critical Brain
Structures
Midbrain

• Part of brain stem that controls
• Arousal
• Appetite
• Satiety
• Sleep
• Motor Regulation

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Overview of Critical Brain Structures
Limbic System

• Locus for
• Affiliation
• Attachment
• Sexual Behavior
• Emotional Reactivity

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Cerebral CortexThe Cortical Layers

• Enable
• Abstract Thinking
• Concrete Thought
• Cause Effect Thinking
• Reasoning

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Dopamine, Norepinephrine, Endorphins

• Regulate neuronal growth and the time frame of
  brain growth
• The normal time frame for the onset of the
  critical period of orbitofrontal maturation is 10
  to 12 months.
• Decreased production of appropriate amounts of
  these substances can disrupt the onset of frontal
  lobe maturation.

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Starting in the first year of life

• A centralized set of neurons containing dopamine
  arises from the midbrain and helps promote
  activation of the right prefrontal cortex.
• The activation leads to the engagement of the
  child with her environment and the stimulation of
  reward centers that produce endogenous
  endorphins.

Image of a Neuron
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The Effects of Deprivation on the Developing
Brain

• The right prefrontal cortex develops normally
  only if a child receives emotionally attuned
  interaction with primary caregivers.
• The right prefrontal cortex is highly involved in
  creating social interaction and the recognition
  of attachment figures.

Schore A. (1994). Affect Regulation and the
Origin of the Self The Neurobiology of Emotional
Develoment. Hillsdale, NJ, Lawrence Erlbaum
Associates.
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The Effects of Deprivation on the Developing
Brain

• Lack of emotionally
• attuned interaction
• leads to decreased growth and differentiation of
  this portion of the brain and impaired affect
  regulation.
• Schore A. (1994). Affect Regulation and the
  Origin of the Self The Neurobiology of Emotional
  Develoment. Hillsdale, NJ, Lawrence Erlbaum
  Associates.

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Problems in Brain Timing

• Ongoing research suggesting much of
  psychopathology could be attributed to problems
  in brain timing.
• Dr. Rodolfo Llinas, of NYU Medical School,
  suggests that psychiatric and neurological
  conditions could be attributed to dysrhythmia
  between thalamus and cortex.

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Dysfunctional parenting and attachment can
contribute to

• Hyper or hypo-activation of the sympathetic an/or
  parasympathetic nervous systems
• The lack of Central Nervous System shift from
  sympathetic to parasympathetic predominance
  between 14-18 months of age

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Stress Impairs Prefrontal Cortex (PFC) Function

• This region of the brain is critical for the
  performance of working memory.
• High levels of dopamine and norepinephrine
  (catecholamines) are released in the PFC during
  stress exposure, causing working memory
  deficits.
• Humans with lesions of the PFC demonstrate poor
  attention regulation, disorganized and impulsive
  behavior, and hyperactivity.

Arnsten, A. (1998). Development of the Cerebral
Cortex XIV. Stress Impairs Prefrontal Cortex
Function. Journal of Am. Acad. Child Adol.
Psychology, 37 (12) 1337-1339.
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Early abuse neglect create longstanding
neuro-physiological changes

• Dr. Michael De Bellis, a Child Psychiatrist at
  WPIC, studied the excretion of catacholamines
  (ephinephrine, norepinephrine, and dopamine), and
  cortisol in prepubertal children who had
  experienced PTSD secondary to abuse
• These children lived in stable home environments
  during the study

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Rachel Yehuda Research/ PTSD

• Intergenerational transmission of altered DNA
• Predisposes subsequent generations to PTSD and
  anxiety disorders

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Short-Term Long-Term Outcomes

• Dr. Schore defines psychopathology as
• A limitation of adaptive
• stress-regulating capacities
• This is more likely to occur if right prefrontal
  cortex, limbic system, and hypothalamic
  development is hampered by lack of appropriate
  interaction with attachment figures
• Leads to impaired affect regulation

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Short-Term Long-Term Outcomes

• Short-Term
• Anxious, depressed, agitated, and excessively
  angry
• Long-Term
• Aggressive and oppositional
• Some may develop a form of Attachment Disorder

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To Summarize

• The attachment figure is the regulator of the
  infants endocrine and nervous systems.
• Attuned caregivers of securely attached infants
  maintain the childs arousal.
• Within a moderate range that is high enough to
  maintain interaction
• Without causing distress and avoidance through
  over-intensity

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Day 1, 1 215 PM

• Neurological understandings sensory processing
  disorder and other interrupted developmental
  processes

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Sensory Integration Neurology

• The brains food is sensory input. Attachment
  theory and its neurological underpinnings teaches
  that sensory input in early childhood determines
  later behavior and ability to cope. Deprived
  environments compromise achievement of
  developmental milestones, at least temporarily.
• The nervous system learns movement and
  behaviors (output) by repetition of the sensory
  (afferent) input, coordination of motor
  (efferent) output and the resulting sensory
  feedback for further refinement.

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What is Sensory Processing Disorder?

• SPD was formerly known as Dysfunction in Sensory
  Integration. It is currently being considered for
  inclusion in the DSM-V.
• SPD occurs in 5-15 of the general population.
• SPD causes a child or adult to interpret sensory
  information differently than the typical person.
  It can impact 1 or all of the sensory systems.
• Research and treatment has been around since the
  1960s starting in OT with Dr. A. Jean Ayres, an
  OT and clinical psychologist.

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Why do we care about SPD?

• Check out behaviors from morning presentation.
• How many are similar to following behaviors
  manifested in SPD?
• What do current studies tell about impact of
  traumatic interruption in attachment and
  occurrence of SPD?

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How does SPD manifest?

• SPD can compel a person to behave differently
  than others. The world can be perceived as a
  potentially painful or offensive place and so
  anxiety or defensiveness can develop.
• SPD can impact one or many life activities
  including self care, work, school, relationships,
  sleep, etc.
• SPD often is comorbid with other
• diagnoses such as learning disorders,
• autism, mental health diagnoses.

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Current nosology for SPD
Miller et al Am J Occ Ther Mar/Apr 2007 612
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Sensory Modulation Disorder

• Also called sensory regulation.
• Child/adult has difficulty with incoming sensory
  information and responding to it in an
  appropriate manner.
• Often seen in auditory sense but any sense or
  combination of senses can be involved.
• Child cannot always identify what is wrong.
• Behaviors can become entrenched.
• Small amount of sensory input can be perceived as
  extreme or vice versa. Reactions are typically in
  response to the perceived sensory message.

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Sensory over-responsivity

• The person responds with what is seen as a
  dramatically increased proportion to the sensory
  input
• The neurological threshold is assumed to be very
  low hair trigger.
• Child may respond to this tendency by trying to
  avoid the stimulus input, controlling the
  environment so they can reduce the stimuli, or
  develop other skills to spare their nervous
  system from experiencing the sensory insults.
• They often learn that their behavior is seen as
  weird or unusual and may try to hide their true
  response or avoid trying to explain it.

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Sensory under-responsivity

• May respond to sensory input slowly or only after
  a lot of input to the sensory receptors (greater
  spatial or temporal summation).
• May appear to be unresponsive to their name or
  have a high pain threshold.
• They are more at risk for injury and exposure to
  dangerous situations. Parents need to be more
  vigilant with these kids to avoid danger.
• Often accompanied by other behaviors that cause
  them to appear apathetic and assumptions may be
  made about their intellect.

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Sensory seeking/craving

• Occupational Therapy assumes that people are
  driven to normalize their nervous system.
  Children with dysregulated systems often seek out
  sensory experiences to help move them into the
  normal range.
• Movement, tastes, smells, textures, touch input,
  multisensory experiences can be compelling
  stimuli for this person.
• A daily sensory diet helps provide the input
  this person needs. They may need help choosing
  the appropriate input. Ex bike riding instead of
  kicking.

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Sensory based motor disorder

• May be seen as clumsy or uncoordinated.
• May have low muscle tone.
• May have handwriting issues.
• May have right/left discrimination issues.
• Motor output manifests poor processing in the
  brain.
• May have poor posture.
• May have gross and/or fine motor
• un-coordination.
• May have poor self-esteem from self perception of
  motor incompetence. May give up trying new skills.

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How does SPD manifest?

• can compel a person to behave differently than
  others. The world is seen as a potentially
  painful or offensive place anxiety or
  defensiveness can develop.
• can impact many life activities including self
  care, work, school, relationships, sleep, etc.
• is comorbid with other
• diagnoses such as learning disorders,
• autism, mental health diagnoses.

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Treatment

• Thorough Evaluation, starting with Sensory
  Profile
• Sensory Diet
• EEG Biofeedback
• Parent and Professional Education
• Parent/Child Group Practice

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Treatment

• Treating Sensory Processing Disorder increases
  chances of better healing of attachment and
  trauma difficulties.
• Practice With eyes covered, how frightening is
  it for someone you dont know to tell you theyre
  going to touch you, but you cant see it coming?
  
• Ever feel upset and dont know why? How about
  if its all the time?

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The Regulated Brain

• Creates a fuss when unhappy, calms when needs are
  met
• Plays and enjoys it!
• Can change activity relatively easily (mastery)
• Engages in reciprocal affection/attachment
• If not (all of these things), somethings wrong

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The Regulated Brain

• How do we achieve this for our children?
• Parents mental and physical health
• Right brain to right brain download of healthy
  attachment
• Attunement
• Safe environment for learning regulation

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The Regulated Brain

• External regulation to teach and support internal
  regulation
• Expectations must meet ability to develop
  positive self-esteem
• Most predictive? Positive coherent narrative of
  parent and good parental attachment 75 85

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Dysregulated Brain

• Opposing Poles of Complexity
• Rigidity . Chaos

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Considerations for Diagnoses

• These are for consideration only
• Overanxious Disorder of Childhood
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Substance-Induced Anxiety Disorder?
• Mood Disorders, including Depression, Dysthymic
  Disorder, Bipolar Disorder, Substance-Induced
  Mood Disorder?
• Dissociative Disorders.

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Dysregulated Brain

• By Circumstance Examples
• Too many stressors
• Not enough resources/support
• Traumatic Event
• Others?

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Dysregulated Brain

• 2. By Teratogens, or other injury, pre-birth or
  during critical brain development periods. While
  we still dont know the totality of effects of
  teratogens, we are beginning to see building
  block damage on brain scans.

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Dysregulated Brain

• 3. By genetic damage
• New research by Rachel Yehuda,
• Epigenetic research through several major
  research organizations

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Rachel Yehuda and Others

• Neuropsychopharmacology
• Twin studies suggest that genes play an
  important role in vulnerability to PTSD and other
  anxiety disorders, but not the entire role. The
  overall result of studies to date is that risk is
  the product of multiple genes and nongenetic
  factors working together. (2010)
  http//www.acnp.org/

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The Over-Aroused Brain

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Right Brain Over-Arousal

• Impulsive
• Distractible
• Hyperactive (driven-type)
• Anxious (fear and physiological arousal)
• Agitation/Agitated depression
• Emotional reactivity to small pain
• Shame (despair)
• Non-verbal LD, poor visuaspatials

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Right Brain Over-Arousal

• Manipulative
• Holds a grudge
• Lacks empathy
• Poor comprehension and expression of emotions
• Lack of body awareness
• Poor balance/coordination
• Nervous habits

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Right Brain Over-Arousal

• Unmodulated voice
• Poor eye contact
• Poor social awareness
• Lack of cause effect thinking
• Impatience
• Aggressive
• High pain tolerance
• Lack of common sense

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Under-Aroused Brain
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Left Brain Under-Activation

• Spaciness/daydreaming
• Poor concentration
• Lack of motivation
• Slow, variable response time
• Cognitive anxiety
• Depression/helplessness/hopelessness
• Perfectionist/low self-esteem

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Left Brain Under-Activation

• Poor receptive or expressive language
• Poor sequential processing
• Poor reading comprehension
• Poor calculation
• Poor logic
• Immune deficiency
• Low thyroid function

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Instability

• Hyperactivity following sugar (Hypoglycemia)
• Hyperactivity with fatigue
• Racing thoughts
• Mood seings
• Suicidal thoughts or actions
• Panic attacks
• Obsessive thoughts

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Instability

• Compulsive behaviors
• Rages
• Conduct disorder
• Oppositional defiant behaviors
• Encopresis
• Posttraumatic stress symptoms
• Anorexia/bulemia/compulsive overeating

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Instability

• Addictions (bipolar type)
• Dissociative symptoms
• Delusions
• Pervasive developmental delays
• Auditory processing deficits
• Visual processing deficits
• Scotopic sensitivity
• Chemical sensitivities/autoimmune dx

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Instability

• Seizures
• Vertigo
• Tinnitus
• Tremors
• Motor or vocal tics
• Spasticity
• Headaches

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Instability

• Chronic nerve pain
• Sciatica
• Sleep walking
• Nocturnal enuresis
• Manic sleep behavior
• Bruxism
• Narcolepsy

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3 Examples of efficacious interventions

• Theraplay play can go under, around, over,
  when we cant get through.
• EEG Biofeedback (Neurofeedback) bringing your
  brain to the gym, to help the brain effortlessly
  repair itself
• EMDR (Eye Movement Desensitization
  Reprocessing) open and secure pathways from
  pre-verbal, locked trauma to allow for safe
  processing

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See Theraplay.org (the Theraplay Institute,
Chicago, IL)

• Theraplay Right-brained, pre-verbal, structured
  interactive play between parent and child to
  enhance attachment, process trauma, and teach
  regulation.
• Structure, Nurture, Challenge Engagement
• Lets play!

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EEG Biofeedback

• Brain wants to heal itself
• Children love to play novel games
• Repetition of a healthy brain state creates a
  healthier processing brain
• Beeps and points are their own reward, but
  feeling better is the ultimate reward!
• Numbers of games/programs, but I like EAGER
  system of EEG Spectrum the best
• (EEGSpectrum.com)

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EMDR

• Eye Movement Desensitization and Reprocessing
  (EMDR)1 is a comprehensive, integrative
  psychotherapy approach. It contains elements of
  many effective psychotherapies in structured
  protocols that are designed to maximize treatment
  effects. These include psychodynamic, cognitive
  behavioral, interpersonal, experiential, and
  body-centered therapies2.

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EMDR

• EMDR psychotherapy is an information processing
  therapy and uses an eight phase approach to
  address the experiential contributors of a wide
  range of pathologies. It attends to the past
  experiences that have set the groundwork for
  pathology, the current situations that trigger
  dysfunctional emotions, beliefs and sensations,
  and the positive experience needed to enhance
  future adaptive behaviors and mental health.

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See you tomorrow ?