Recommendations for Research-‐Based Trauma-‐Informed Care (1) Single-‐event traumas can have lasting impact • 5 years post 9-‐11, New York residents still had over-‐activity in brain threat detection regions (heightened amygdala reactivity) (Ganzel et al., 2007) • Adults who report episodes of early life stress exhibit brain differences from adults who do not report such experiences. These differences include smaller Anterior Cingulate Cortex (ACC) and caudate volumes. The reasons for these brain effects likely reflect the influence of early stress and traumatic events on the developing brain (Cohen, Grieve, Hoth, Paul, Sweet, Tate, et al., 2006). Parents and caregivers need to be aware that even a single traumatic event can have a lasting effect on brain development. (2) Early sustained trauma has lasting impact in on brain chemistry and brain development • Megan Gunnar found dramatic changes in brain chemistry of children 5 years after adoption from deprived environment. The cortisol level was 2 standard deviations higher for significant percentage of these children (Gunnar, Morison, Chisholm, & Schuder, 2001). • The cumulative exposure of the developing brain to the stress response results in a corresponding impairment in multiple brain structures and functions. Thus, increased stress exposure is correlated with increased impairment (Anda, et al., 2006). • Early trauma and stress can have a lasting effect on development, resulting in altered brain chemistry and dysfunctional coping behaviors, particularly when the condition is chronic and the child lacks a nurturing caregiver (Bremner, 2003; Carrion, 2006). Parents and caregivers need to be aware of… (3) Traumatic impact occurs not only postnatally but also prenatally • Example: Prenatal maternal biochemistry predicts neonatal biochemistry (Field, Diego, Hernandez-‐Reif, et al., 2004). • Unhealthy maternal mental state and increased stress during pregnancy often negatively impact children’s temperament and development (e.g., physical, cognitive, self-‐regulation, and sensory processing abilities) in children (Foster, 2006). Parents and caregivers need to be aware of… (4) Trauma impacts biological development • Ex. Changes in insulin receptors (cite) • Changes in central nervous system (CNS) reactivity Parents and caregivers need to be aware of… (5) Most trauma is relationally induced resulting in disorganized attachment. • Ex: A meta-‐analytic study examined the impact of maltreatment on attachment security and disorganization (55 studies w/4,792 children) and showed that children living under high-‐risk conditions (including maltreatment studies) showed fewer secure and more disorganized attachments than children living in low-‐risk families(Chantal CYR, a,b, Eveline M. Euser, a, Marian J. Baerkermans-‐Kranenburg,a, and Marinush. Van Ijzendoorna, a Leiden University; and bUniversity of Que’bec at Montre’al). • Ex: Parental unresolved loss or trauma, as assessed in the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985), appears to be significantly associated with infant disorganized attachment (for a meta-‐analysis, see Van IJzendoorn, 1995). • Parents and caregivers need to be aware of the importance of quality attachment and attunement with their children. They also need to search for precursors and determinants of attachment disorganization and work to resolve these problems. (6) Disorganized attachment impacts long term mental/emotional health, ability to trust, ability to form healthy relationships. • Ex: Decreased behavioral, emotional, and social outcomes into adulthood. Further transfer of negative parenting style to the next generation (Sroufe, L.A.(2005); Waters, E., Merrick, S., Treboux, D., Crowell, Jl, & Albersheim, L. (2000). • Ex: The predictive validity of disorganized attachment has established in terms of problematic stress management, the elevated risk of externalizing problem behavior, and even the tendency of disorganized infants to show dissociative behavior later in life (van IJzendoorn, M. H., Schuengel, C., & Bakermans-‐Kranenburg, M. J. (1999). TCU Institute of Child Development – TCU Box 298920 Fort Worth TX 76129 – (817) 257-‐7415 – www.child.tcu.edu Because of the associations between infant disorganized attachment and later maladaptive social behaviors, parents and caregivers should be trained early with trauma-‐informed interventions to be effective in preventing attachment disorganization. (7) Trauma-‐based changes in attachment, trust, biology, brain development and brain chemistry induces greatly increased risks for violence, mental illness and later sociopathic, antisocial and or criminal behavior. • Ex: Individuals who had been physically abused in the first 5 years of life were at greater risk for being arrested as juveniles for violent, nonviolent, and status offenses. Moreover physically abused youth were less likely to have graduated from high school and more likely to have been fired in the past year, to have been a teen parent, and to have been pregnant or impregnated someone in the past year while not married (Lansford, J. E., Miller-‐Johnson, S., Berlin, L. J., Dodge, K. A., Bates, J. E., & Pettit, G. S. (2007). • Ex: Complex trauma exposure results in a loss of core capacities for self-‐regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and cumulative impairment (e.g., psychiatric and addictive disorders; chronic medical illness; legal, vocational, and family problems)( Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). • Structure, predictability and nurturance are key elements to a successful early intervention with a traumatized infant. It is crucial that the primary caretaker understand as much as possible about post-‐traumatic responses, and if the caretakers were impacted by the same trauma, it is imperative that they get treatment which complements the work with the child. Nutrients such as Stabilium is a dietary supplement composed of Garum Armoricum which has been used since the time of the Roman Army to help stress levels and balance brain chemisty. (8) The human brain is designed to mature with three years of mentoring by a loving adult. • Ex: Children with histories of chronic early maltreatment within a caregiving relationship may develop complex trauma and suffer from a variety of developmental deficits as shown for the children in this study which yielded a developmental age (age equivalency) of 4.4 years, while the average chronological age was 9.9 years(Becker-‐ Weidman, 2009). • Ex: Stress during infancy that is severe enough to create insecure attachment has a dissociative effect, disrupting right hemispheric emotional functioning and species preservative behavior, and a permanent bias towards self preservation can become an adult trait (Henry, J. P., & Wang, S. (1998). • Parents and caregivers need early assessment and intervention which wil be prophylactic in helping prevent a prolonged acute neurophysiological, neuroendocrine and neuropsychological trauma response. • We need to be training foster and adopted parents with a holistic approach to complex developmental trauma disorder. This training needs to include education about several domains including attachment, biology, affect or emotional regulation, dissociation, behavioral control, cognition and self-‐concept. We need to empower our caregivers with particular features of preferred Trauma-‐Informed Therapeutic Models. TREATMENT OF COMPLEX TRAUMA Ko, S. J., Ford, J. D., Kassam-‐Adams, N., Berkowitz, S. J., Wilson, C., Wong, M., Brymer, M. J., & Layne, C. M. (2008). Creating trauma-‐informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39(4), 396-‐404. doi: 10.1037/0735-‐ 7028.39.4.396 Children and adolescents who are exposed to traumatic events are helped by numerous child-‐serving agencies, including health, mental health, education, child welfare, first responder, and criminal justice systems to assist them in their recovery. Service providers need to incorporate a trauma-‐informed perspective in their practices to enhance the quality of care for these children. This includes making sure that children and adolescents are screened for trauma exposure; that service providers use evidence-‐informed practices; that resources on trauma are available to providers, survivors, and their families; and that there is a continuity of care across service systems. Weitzman, J. (2005). Maltreatment and trauma: Toward a comprehensive model of abused children from developmental psychology. Child & Adolescent Social Work Journal, 22(3/4), 321-‐341. doi: 10.1007/s10560-‐005-‐0014-‐9 • TCU Institute of Child Development – TCU Box 298920 Fort Worth TX 76129 – (817) 257-‐7415 – www.child.tcu.edu Knowledge of how maltreatment and trauma affects personality functioning in abused children has been greatly enhanced by clinical theory and research in developmental psychology. Developmental research and theory has allowed the child abuse field to move beyond symptom-‐lists toward broader models of how trauma impacts major domains of personality functioning. However, these models continue to be based largely on discrete theories of development that parallel, if not confound, one another. We need a comprehensive model that promotes a more holistic and comprehensive view of the abused child and, thus, enhances clinical theory and intervention. Limitations of therapeutic models: Cognitive limitations due to chronological and/or developmental age of the child. These therapeutic models are cognitively-‐driven rather than relationally-‐driven interventions. In these cases unfortunately, the interventions are not holistic and do not meet the needs of the “whole” child. Because complex trauma affects many different domains, it can be very difficult and challenging to treat. It is vital that a comprehensive assessment is conducted in order to provide appropriate treatment. Of primary importance in the assessment process is an evaluation of the child’s attachment relationships. It should also include a trauma history and information on past and current behaviors, moods and level of functioning in all areas: social, physical, emotional, sensory and mental. The most effective treatments provide the child with felt safety, self-‐regulation, self-‐processing, trauma experience integration, relational engagement, and positive affect enhancement. This holistic approach to treatment for complex developmental disorder is encompassed within the TBRI® empowering, connecting, and correcting principles. The TBRI® empowering principles address both ecological and physiological needs of the child. They provide a foundation that increases the effectiveness of the connecting and correcting principles. Second, the connecting principles address the relational needs of the child; focusing on awareness, engagement, and attunement. Third, the correcting principles are designed to teach appropriate boundaries and promote healthy behaviors of both caregiver and child. The National Child Traumatic Stress Network http://www.nctsnet.org/nccts/nav.do?pid=hom_main National Center for Children Exposed to Violence http://www.nccev.org/ Prevent Child Abuse America http://www.preventchildabuse.org/index.shtml References Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256, 174-‐186. doi: 10.1007/s00406-‐005-‐0624-‐4 Bremner, J. D. (2003). Long-‐term effects of childhood abuse on brain and neurobiology. Child and Adolescent Psychiatric Clinics of North America, 12, 271-‐ 292. Carrion, V. G. (2006). Understanding the effects of early life stress on brain development. In Lieberman & R. DeMartino (Eds.), Interventions for children exposed to violence (Vol. IV) (pp. 45-‐64). New Brunswick, NJ: Johnson & Johnson Pediatric Institute. Cohen, R., Grieve, S., Hoth, K., Paul, R., Sweet, L., Tate, D., et al. (2006). Early life stress and morphometry of the adult anterior cingulate cortex and caudate nuclei. Biological Psychiatry, 59, 975–982. Field, T., Diego, M., Hernandez-‐Reif, M., et al. (2004). Prenatal maternal biochemistry predicts neonatal biochemistry. International Journal of Neuroscience, 114(8), 933-‐945. Foster, S. (2006). A literature review: The effects of maternal stress in pregnancy on sensory integration in children. Journal of Prenatal and Perinatal Psychology and Health, 21(1), 83-‐90. Ganzel, B., Casey, B., Glover, G., Voss, H., & Temple, E. (2007). The aftermath of 9/11: Effect of intensity and recency of trauma on outcome and emotion. Emotion, 7(2), 227-‐238. Gunnar, M. R., Morison, S. J., Chisholm, K., & Schuder, M. (2001). Salivary cortisol levels in children adopted from Romanian orphanages. Development and Psychopathology, 13(3), 611-‐628. TCU Institute of Child Development – TCU Box 298920 Fort Worth TX 76129 – (817) 257-‐7415 – www.child.tcu.edu