Stepping Up To BAT: Understanding Brain Development, Attachment, & Trauma When Working With Children and Families

Sherri L. Alderman, MD, MPH, IMH-E, FAAPDevelopmental Behavioral Pediatrician

Therapy in Educational Settings ConferenceApril 15, 2013

Objectives:• Describe the hierarchal structure of brain

development and resultant influence on behavior

• Identify behavioral miscues stemming from insecure attachment and history of traumatic experiences

Part 1

Brain Development:Infant brains have neuroplasticity. Neuroplasticity is both an opportunity and vulnerability.

Development of the Brain—Neural Tube

• Development of the nervous system begins at 3 weeks gestation

Nilsson 1990

Development of the Brain—Fetal Development• Development of the nervous system during gestation

Moore 1988

Development of the Brain—Early Childhood

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Brain Weight by AgeW

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Development of the Brain

• Brain architecture and function are determined by:• Genetics and epigenetics• Internal stimulations (sleep is critical)• External stimulations (including the quality of the

dyadic/parent-child relationship)• The physical, chemical (nutrition and toxins), sensory

and social-emotional environment.

“Human development is shaped by a dynamic and continuous interaction between biology and experience.” (National Research Council & IOM 2000)

Development of the Brain: Stages

• Synaptogenesis• Mylenation• Synaptic pruning• Memory, procedural and declarative• Neuronal networking• Inhibiting networks

Development of the Brain: 4 General Principles• Critical periods influenced by the social environment• Development is staged and hierarchically organized• Directed by epigenetics• Social environmental changes reorganization of brain

structures

Schore 1994

Development of the Brain

Video #1: Experiences Build Brain Architecture

Harvard Child Development Center

Development of the Brain

Neocortex

Limbic

Diencephalon

Brainstem

Abstract ThoughtConcrete Thought

"Attachment"Sexual Behavior

Emotional Reactivity

"Arousal"Appetite/Satiety

Blood PressureHeart Rate

Body Temperature

Sleep

Motor Regulation

B. Perry

Development of the Brain—Diencephalon• Hypothalamus, thalamus, pineal gland, others• Function

• Relays sensory information (hearing, vision, taste, tactile) between brain regions

• Controls autonomic functions (sympathetic, parasympathetic)• Connects endocrine system with nervous system• Communicates with limbic system to generate and manage

emotions and memories• Motor function control

Development of the Brain—Limbic System • Cortical and subcortical regions of brain• Functions necessary for self- and species preservation• “Feeling and reacting brain”

Medicalartlibrary.com

Development of the Brain—Limbic System (cont.)

• Amygdala

• Hippocampus

Joseph 2000

Development of the Brain—Limbic System (cont.)

• Amygdala• Critical center for coordinating behavioral, autonomic, and

endocrine responses to environmental stimuli, especially those with emotional content and stress

• Arousal and rage• Learned emotional responses (fear and anxiety)

• Hippocampus

Joseph 2000

Development of the Brain—Limbic System (cont.)

• Amygdala

• Hippocampus• Encoding and retrieving declarative memory• Helps control corticosteroid production• Active in understanding spatial relations

Joseph 2000

Development of the Brain—2 Response Pathways

Joseph 2000

Development of the Brain—(Hypothalamic) Pituitary Axis

Carpenter 1985

Development of the Brain—Prefrontal Cortex

• Highly connected with cortical, subcortical and brain stem sites

• Function• Planning complex cognitive behavior• Personality expression• Decision-making• Moderating social behavior• Executive functions

Development of the Brain—Memory• Signifies the way an event in the past influences a

process in the future.• Experiences prime neural pathway activity increasing

the likelihood of being activated again.• Development of memories involves:

• Encoding (activation of neurons)• Storage (alteration in neural connectivity)• Retrieval (reactivation of patterns similar to initial coding)

• Memory is layered: implicit, explicit, and narrative

Siegel 2012

Development of the Brain—Implicit Memory

• Our earliest memories before development of the hippocampus (first year after birth)

• Perceptual, emotional, behavioral, and bodily sensory memories

• Top-down processes where prior experiences shape ongoing perception and behavior and build mental models—invariant representations

• Created without focal attention

Siegel 2012

Development of the Brain—Explicit Memory

• Hippocampus-mediated• Requires focal or conscious attention• 2 types: factual information & autobiographical memory• Autobiographical memory begins with episodic memory

with which we encode and recall the self and later builds in complexity to more organized clustering

• Narrative memory merges implicit and explicit memory describing stories in our lives.

Siegel 2012

Development of the Brain—Memory

• How memories are encoded is state-of-mind dependent

Siegel 2012

Cortisol stress hormone

Impedes hippocampal functioning

Blocks explicit processing

Adrenaline flight or fight hormone

Increases implicit encoding of fear by the amygdala

Enhances implicit processing (bodily sensations & emotions)

Development of the Brain—Memory

• Early experiences critically affect enhancement or inhibition of experience-dependent maturation of structural systems in the brain.

• Healing of implicit memories from traumatic experiences requires building inner mindfulness within the context of relationship.

Siegel 2012

Part 2

Early Childhood Development:Development across all domains is interwoven and interdependent. Social emotional development is fundamental to all development.

Early Childhood Development

• Babies are born learning• Children learn within relationship • Human development is hierarchal

Early Childhood Development

• Babies are born seeking human connections

• Social emotional development is fundamental for all development

Video #2: Serve and Return

Development of the Relationship— Attachment

Harvard Child Development Center

• Secure attachment requires caregiver emotional availability that can be disrupted by:• Maternal depression• Affect dysregulation• Lack of parental self-efficacy/confidence• Chronic stress• Unhealthy externalizing behaviors

Development of the Relationship— Attachment

Kim 2012, Fulton 2012

Video #3: Tronick’s Still Face

Development of the Relationship—Maternal Emotional Availability

• Moments of asynchrony in the dyadic dance are natural occurrences.

• Secure attachment facilitates the transfer of regulatory capacities from the caregiver to the infant enabling the mother to participate in “interactive repair”.

Development of the Relationship— Attachment

Schore 1994

Development of the Relationship— Attachment

Video #4: Schore on Relationships and Brain Development

Development of the Relationship— Attachment

Video #5: Insecure attachment

• Attachment insecurity (12-18 months) is significantly related to behavior problems in preschool.

• Behavior problems in pre-school predict behavior problems in the first grade.

• Early behavior problems forecast and lay the foundation for academic problems throughout the school years.

• School achievement can be forecasted long before school entry.

Development of the Relationship—Insecure Attachment

Winnicott 1962

Early Childhood Development—An Integrated Process

• Social connections stimulate visual tracking and head control

• Engagement promotes secure relationships & stimulates oral motor (feeding & babbling)

• Vestibular balance promotes sitting• Core strength facilitates lateral rotation & pulling to

standing• Standing & walking prompts diaphragmatic

excursion, vocalizations & speech• Mobility and language acquisition facilitate

development of autonomy

Executive Function: The Cognitive Process That Regulates an Individual’s Ability to:

• emotionally self-regulate, • focus and shift attention, • control impulsivity and behavioral responses, • exercise mindfulness of self-understanding

and empathy, • organize thoughts and activities, • prioritize tasks, • manage time efficiently, and • make decisions.

Development of the Mind—Executive Function

Video #6: A Typical 3-year-old Sorting Cards—Flexibility and Shifting Construct

Video #7: The Marshmallow Test—Inhibiting Impulsivity

Development of the Mind—Executive Function

• “What to do”

• “How to do it”

• “When to do it”

Lillas 2009

Development of the Mind—Executive Function

“What to do”

• Exercising and expanding sensory-motor chains, learning to tolerate mild discomfort

• Attend to salience, habituate to nonrelevant distractions, tolerate challenge, exhibit a stress response to threat with recovery back to baseline

• Select goals that satisfy personal needs and engage in effective behaviors, sustain optimal regulation, form relevant memories, build social learning and adaptation

Lillas 2009

Development of the Mind—Executive Function

“How to do it”

• Initiate appropriate sensorimotor programs to get needs met, learning behavioral sequences, learning how to manipulate and use objects

• Inhibit actions, increase working memory span, self- correct and monitoring behavior, planning ahead, engaging in personal and social problem solving, using hindsight and foresight to inform current plans

Lillas 2009

Development of the Mind—Executive Function

“When to do it”

• Build “learning associations” (behavior— consequence), anticipation, forming model for prediction of events, capacity for self-regulation

• Inhibiting personal drives when not appropriate to the social context, engaging in the prosocial behaviors at the appropriate time, delaying gratification in lieu of a sustained goal, prioritizing activities, adjusting plans when circumstances change

Lillas 2009

Development of the Mind—Executive Function

Video #8: Dr. Perry on executive function and regulation11:02-13:00

Part 3

Trauma and Chronic Stress:Chronic stress is neurotoxic.Traumatic events have an adverse impact across the life span and from one generation to the next.

Development of the Brain—Stress

Harvard Child Development Center

Development of the Brain—Neurobiology and Trauma

• Amygdala, hippocampus, and prefrontal cortex have abundant glucocorticoid receptors.

• Chronic stress is associated with amygdala and orbitofrontal cortex hypertrophy and overactivity

• Chronic stress is associated with loss of neural connections in the hippocampus and medial PFC.

Shonkoff 2012

Development of the Brain—Neurobiology and Trauma

• Allostatic Load:• The cumulative, stress-induced burden on overall

body functioning and the aggregated physiologic and psychological costs required for coping and returning to homeostatic balance

• Amygdala hyperactivation causes increased anxiety• PFC atrophy causes loss of top-down control • Hippocampal reduction causes impaired memory and

mood control

Shonkoff 2012

Development of the Brain—Stress

Example:Stress

Amygdala activation

Hypothalamus releasesCRH

Pituitary releasesadrenaocorticotropicHormone

Adrenal glands releasecortisol

Glaser 2005

Development of the Brain—Stress

Video #9: Toxic Stress Derails Healthy Development

Harvard Child Development Center

Development of the Brain—Stress

Development of the Brain—Neurobiology and Trauma• Maltreatment is trauma occurring within an interpersonal

relationship• Effect is determined by timing of maltreatment relative to

stages of brain development and development of relationship

• Early trauma, prolonged separation, and insecure attachment produce permanent changes in the neurochemistry of children that continue into adulthood:

• Neurobiological sensitivity to loss• Fear of abandonment• Hyperarousal• Sensitivity to environmental threat

Van der Kolk, 1987

• Chronic abnormally high levels of cortisol (stress hormone) adversely affect brain development, stress responsiveness, emotion, and memory. (National Scientific Council on the Developing Child 2005)

• Insecure attachment and early trauma produce extreme affect dysregulation with concomitant difficulty in modulating aggression in adults.

Development of the Brain—Neurobiology and Trauma

Lawson, 2001, p. 505

National Scientific Council on the Developing Child 2005

• Separating a child from family adversely affects the child’s behavior

Placement decision Clinical-level behaviors• Remain in home 22%• Placed in relative foster care 22%• Placed in non-relative foster care 32%• Placed in group home or residential care 50%

Development of the Brain—Neurobiology and Trauma

Casaneuva, et al. 2011

• Untreated effects of trauma on the developing brain become chronic “maladaptive” reactions to nonthreatening situations (e.g., hyperarousal, dissociation).

Development of the Brain—Neurobiology and Trauma

Perry 1995

Development of the Brain

B. Perry

Acute Response To TraumaAcute Response To Trauma

Terror

Fear

Alarm

Vigilance

Calm

Vulnerable “with supports”

Normalwith

supports

Dissociationor

Resilient

Vulnerablefew

supports

Traumatic Event

Development of the Brain

B. Perry

Multiple Traumatic EventsMultiple Traumatic Events

Terror

Fear

Alarm

Vigilance

CalmEvent

#1Event

#2Event

#3

Development of the Brain

Bruce Perry

• Relationship between traumatic stress in childhood and the leading causes of morbidity, mortality, and disability in USA

• Cardiovascular disease• Chronic lung disease• Chronic liver disease• Depression and other mental health conditions• Obesity• Smoking• Alcohol and drug abuse

Development of the Brain—Adverse Childhood Experiences

Felitti 2010

Development of the BrainVideo #10: Reading her cues

ReferencesCarpenter MB, (1985). Core Text of Neuroanatomy, 3rd Ed. Williams and

Wilkins: Baltimore. Casaneuva C, Ringeisen H, Wilson E, et al., (2011). OPRE Report #2011-27b,

Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, US Department of Health and Human Services.

Felitti VJ, Anda RF, (2010). “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare,” The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic, RA Lanius, E Vermetten, C Pain, Cambridge University Press.

Fulton JM, Mastergeorge AN, Steele JS, et al., “Maternal Perceptions of the Infant: Relationship to Maternal Self-Efficacy During the First Six Weeks Postpartum,” Infant Mental Health Journal 33(4):329-338.

Glaser R, Kiecolt-Glaser JK, (2005). “Stress-Induced Immune Dysfunctions: Implications for Health,” Nature Reviews Immunology 5:243-251.

ReferencesJoseph R, (2000). Neuropsychiatry, Neuropsychology, Clinical Neuroscience,

New York: Academic Press. Kim B-R, Teti DM, Cole PM, (2012) “Mothers’ Affect Dysregulation, Depressive

Symptoms, and Emotional Availability During Mother-Infant Interaction,” Infant Mental Health Journal 33(5):469-476.

Lillas C, Turnbull J, (2009) Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework for Interdisciplinary Practice, Norton: New York.

Moore KL, (1988). The Developing Human: Clinically Oriented Embryology Fourth Edition. W.B. Saunders Company: Philadelphia.

National Research Council and Institute of Medicine (2000) From Neurons to Neighborhoods: The Science of Early Childhood Development. Jack P. Shonkoff and Deborah A Phillips, eds. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, D.C.:

ReferencesNational Academy Press. National Scientific Council on the Developing Child,

(2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3, Accessed November 4, 2012, at http://www.developingchild.net.

Nilsson L, (1990). A Child Is Born, New York: Bantam Doubleday Dell Publishing.

Perry BD, (1995). “Childhood Trauma, the Nuerobiology of Adaptation, and the ‘User-Dependent’ Development of the Brain: How ‘States’ Become “Traits,” Infant Mental Health Journal 16(4):271.

Schore AN, (1994). Affect Regulation and the Origin of the Self, Lawrence Erlbaum Associates: New Jersey.

Seneff S, (2009). “Is ADHD Caused by Insufficient Dietary Fat?” http//people.csail.mit.edu/seneff/adhd_low_fat_diet.html Accessed November 10, 2012.

Shonkoff JP, Garner A, et al., (2012). “The Lifelong Effects of Early Childhood Adversity and Toxic Stress,” Pediatrics 129(1):e232-e246.

Van der Kolk, (1987). Psychological Trauma, Washington D.C.: American Psychiatric Press.

ReferencesWinnicott DW, (1962). The Maturational Process and the Facilitating

Environment, International Universities Press: NY.