Trauma  and  Development:  An  Integrated  Best  Practice  

ApproachATTACH  Conference-­‐ September  27,  2015

Kathy  Ryan,  Ph.D.,  LCSWClinical  Coordinator,   Circle  Preschool  Program,  GRSCAN,  Richmond,   VA

Denise  Powers,  M.Ed.

Early  Childhood   Specialist,  Circle  Preschool  Program,  GRSCAN

Shelly  Lane,  Ph.D.,  OTR,  FAOTAFaculty  of  Health  and  Medicine  Department  of  Occupational  Therapy

Newcastle  University,  Callaghan,  NSW,  Australia

Workshop  Objectives

• Participants  will  explain  the  impact  of  developmental  trauma  on  function  within  the  relational,  regulatory,  and  cognitive  domains.

•

• Participants  will  list  5  essential  treatment  techniques  to  support  healing  in  a  child  who  has  experienced  developmental  trauma.  

•

• Participants  will  create  a  treatment  plan  for  a  young  child  who  has  experienced  developmental  trauma.

•

And    Who    Are    You?  

Circle  Preschool  ProgramGRSCAN  (Stop  Child  Abuse  Now)

Richmond,  VA

• Therapeutic  Classroom    within    a  typical  preschool  setting• 3-­‐5  year  olds;  trauma  backgrounds  +  unsuccessful  adaptation  to  typical  settings• Provision  of  therapeutic,  play-­‐based  ,  educational  milieu,  psychotherapy,  occupational  therapy  • Family/  Caregiver  therapy  – group  and  individual  • Goal-­‐ To  transition  into  typical  setting  and    healing  from  trauma

• Length  of  stay-­‐ dependent  on  need  or  age  

Typical  Development  

Development  is  a  neuro-­‐biologic  process…

vEpigenetics  &  Genetics…

vBrain  says…Survival  is  key!  

vOrganization  &  functional  capacity  of    brain  is  hierarchical  &  sequential

v Use  dependent  development

v State  based    dependency

Brain  is  Use  Dependent

The  brain    changes  in  response  to    specific    patterns  of  activation  (experience  )

Sensation  as  Nourishment

• Essential  for  brain  functioning• A  starting  place  for  the  development  of  adaptive  environmental  interactions

• Critical  for• Attachment  and  social  relationships• Arousal  regulation• Organization  of  action

Emphasis:  body  centered  sensory  systems

Vestibular

Sensory  intake  and  processing

• Sensory   intake:  Receptors• Organization  of  sensation: brain  structures• Brain  hierarchy• Lays  a  foundation  for  regulation  of  alertness  and  emotions

• Results  in  production  of  an  adaptive  response

Sensory  Modulation• Ability  to  grade  behavioral  responses  in  relation  to  intensity,  complexity,  or  novelty  of  sensation

•When  modulation  is  working  well,  child  can  automatically• Filter  out  non-­‐relevant  stimuli• Notice  relevant  stimuli

The    “State”  of  the    BRAIN

Function  is  STATE  Dependent  

• From  calm  to  alert  to    alarm    to    fearful  to    terror….  

• With  increasing  level  of  arousal,  the    primary  area  of    neural  activity  shifts  to  lower  levels  within  the  brain

Sensitive  periods  of  Development

“Experience  can  change  the  mature  brain,  but  experienceduring  the  critical  periods  of  early  childhood  organizes  brain  systems.”  Perry,  2006

Trauma

Trauma    is…

• Experiences  which  are  overwhelming,  and  over  stimulating    -­‐-­‐ more  than  a  person  can  cope  with  at  the  time.

• Physical  abuse,  sexual  abuse,  emotional  abuse  (relational),  domestic  violence,  chronic  neglect

• Severe  disasters,  witnessing    violence  

Healthy  Development  vs.  Developmental  Trauma  

What    Children  Need:

• Dependent  on    predictable    consistent  nurturing  attention

• Secure  attachment  patterns

• Fewer  primary  caregivers  

• Co-­‐regulation  is  needed  àindependence

What  children  experience:• Primary  caregivers  abuse• Repeated abuse  from  adults• Highly  aroused,  negative  environments• Domestic  violence• Severe  Neglect• Insufficient  nurturing

Abstract  thought

Concrete  Thought

Affiliation/reward

"Attachment"

Sexual  Behavior

Emotional  Reactivity

"Arousal"

Appetite/Satiety

Blood  Pressure

Heart  Rate

Body  Temperature

Sleep

Motor  Regulation

NEDA

ANS  -­‐ body

SER

All  rights  reserved   ©  2006-­2012   Bruce  D.  Perry  and   The  ChildTrauma  Academy  

Symptoms  of    Trauma  

Trauma  Core  symptoms  

Depressive  and  Affective  symptoms  

Relational  difficulties

Guilt    &  Shame

Alcohol  &  substance  abuse  

•Genetic  vulnerabilities  and  gifts•Age  at  which  trauma  occurred

•Nature  of  the  trauma•Pattern  of  the  trauma•Style  of  adaptation•Relational  supports

•Therapeutic  experiences

Trauma:Will    symptoms    develop?

Bruce D Perry © 2010 www.ChildTrauma.org

When  Children    Are: Caregivers  tend  to  feel…

•Worried• Anxious• Aroused    and  Reactive• Alone    &  Helpless• Hopeless• RESULTING    IMPACT  ON    CHILD?

5  min.

4  yr.  old  Michael  

M’s  Functional  Domains

Trauma-­‐informed  Interventions:  An  Integrated  Approach

Treatment  Goals  &  Interventions

Regulate  

Relate

then

Reason  Perry,  2010

Respond  to  the  developmental  age  

Quality  Relationships-­‐ Essential,    YET

•With  Complex  Trauma:    people  are  perceived  as  dangerous,  until  PROVEN  otherwise…..

• Even  then…  by  the  nature  of  interventions….  you  may  be  perceived  as  a  threat

Play-­‐ The  Language  of  children

• Child  has  an    intrinsic  motivation  to  play• Starts  with  child’s  strengths  and  interests  

• Aids  in  developing  positive  therapeutic  alliance  

Co-­‐Regulation  with  Sensory-­‐Motor  Materials

Bubbles in Jar Sand in Sensory Bin

Weighted Super Hero Vest

Basket of Weights to PullQuiet Space, Bean Bags, Balls

Reduce  sensory  overload  from  the  environment;  provide  a  safe  place

Lane,  2014

The  1st Step  ….  RESPONSIVITY• Noah      

VALIDATE

Soft    Voice  

Gentle  Tone

Kind    Face    

Healthy  Attachment    Responses  +  Regulation

Adult  Helps  Child  to  Regulate

Child Begins  to  Self-­‐Regulate  with

Adult’s  Coaching        

Child’s  Trauma  is  Triggered

Self-­‐ Esteem  in  the  beginning…..

YOU  ARE…

After  a  Positive  Relational  Climate….

I am …an artist

Cognitive  Development  emerges  when….  

Relationships with Safe Adults

Co-Regulation

Successful  Interactions  and  Experiences

Embedded  Learning

Michael    – age  4

Strengths

• Vivacious    greetings    • Outgoing,  highly  social  

• Gross  motor  skills;  sports  • Long  term  memory  • Empathetic  to  other’s  physical  pain• Stable  home

Challenges  • Interactions  shallow    • Play  skills  • Hungry  -­‐ hoards    food,  normal  wt.• Severe  ADHD,  anxiety• Changes  à anxiety• Fear  of  being  left  out• Easily  aroused  -­‐Hard  to    down  regulate  • Loud,  aggressive    verbally  &  physically    

Provide  continual  sensory  motor  opportunities

TRAUMA  TREATMENT-­‐Setting  a  Positive  Relational  Climate

Following  Interests  to  Represent  the  World  Series  and  Concession  Stand

Interventions  with  MichaelIndividual

• Proprioceptive,  vestibular,  tactile:  • Gum,  Play  Dough  • Therapy  ball• Rhythmic  activity• Regulatory  walks  with  staff

• Auditory:• Quiet,  non-­‐reactive  voices  (adults)• Rhythmic  beats/music  

• Predictable  Change;  Repetition

• Milieu  and  Play  therapy  

• Therapeutic  holds  with  rocking  and  soothing  

Family

• Parent  psycho-­‐educational  • Impact  of  trauma  • Sensory  Integration    &  Regulation  tools

• Family   change  is  gradual  process

• Ongoing  need  • strong  relationship  based  interactions• appreciation  for  severity  of  illness

• Family  acquired  ‘new  language’  and  experienced  a  paradigm  shift  in  caregiving

Trauma  informed  Interdisciplinary  Interventions  

Mental  Health

Occupational  Therapy  Education

1. Interest/  strength-­‐based

2. Regulation  3. Relational  safety4. Play-­‐based5. Embedded  

learning

Questions  and  Your  Case  Examples

Take  Away  Messages

Early    trauma  à neurodevelopmental    impact  àfunctional  consequences  (regulation,  relationships,  cognition)

HEALING from  predictable,  consistent,  repeated,  positive  experiences

Safe  relationally  

Safe  physically-­‐Sensory-­‐Motor  interventions,  Play-­‐based,  then  Cognitive

Regulate                      Relate              Reason

STATE  LEVEL  and    BRAIN  FUNCTION

Responsive  Teachable  Moments

DEFUSING  THE  FIGHTEveryone wants  to  be  heard:

• LISTEN  to  the  child  • WAIT  until  the  child  LISTENS  to  YOU• LISTEN  to  EACH  CHILD   in  the  GROUP• BRIDGE  the  GROUP’S  IDEAS• Go  meet  sensory  needs  and  try  again…

Trauma  informed-­‐Therapeutic    Interventions    

Care-­‐givers

School Community

Child

CPP  does    make  a  difference…  Even    when  healing  continues.

• Of  the      22    children        who  have  attended  Circle  Preschool    for    over  3  months  in    the  past    3  years.      

• 17  have    entered    typical  kindergarten    rooms  with  some  special  supports• 2  have  left  precipitously• 3    have  required    special  ed classroom• 20    have  required    ongoing      support  to    caregivers  /  child    therapy

• Overall-­‐ caregivers  give    positive  feedback-­‐ especially  in  noting  the    increased  play  skills  and  regulation  skills    children  are  demonstrating.  

• Changes    in    resting  heart    rates• Chronic  health  problems,    breathing    issues,  eating      issues,    sleep    difficulties

• Arousal/  Dissociative    Issues    • Clumsiness,    motor    delays• Emotional    reactivity,  attachment    difficulties

• Social  skill      issues…  lack  of  empathy• Impulsivity,  distractibility,  • Cognitive    delays…uneven  cognitive  picture• Limited  play  skills• perseveration  • poor  problem  solving  

Symptoms  of  Trauma

Trauma-­‐ informed    Interdisciplinary  Contributions

• Mental  Health• Therapy  with  regulation  &  relational  focus• Family  therapy  

• Occupational    Therapy• Trauma  sensitive-­‐ relationships• Sensory  Integration  increasing  regulation

• Education• Trauma  sensitive  relationships  • Multiple  regulation  opportunities• Strength-­‐based    learning

Relationships

Sensation  as  a  Tool

Sensory  integration  

and  processing

Trauma  informed  care

Regulating  arousal

• Deep  pressure  and  proprioception• Vestibular  • Rhythmic,  repetitive  inputs