Texas School for the Blind and Visually Impaired
Outreach Programs
www.tsbvi.edu | 512-454-8631| 1100 W. 45th St. | Austin, TX 78756
2015 Texas Symposium on Deafblindness
Saturday 2:00-3:30 PM General Session
Stress in Children with Deafblindness
Presented by
Catherine Nelson, PhD, University of Utah
Cathy.nelson@utah.edu
Developed for
Texas School for the Blind & Visually Impaired
Texas Deafblind Outreach
Stress, Behavior and Children who are Deafblind
Catherine Nelson, Ph.D.
University of Utah
Cathy.nelson@utah.edu
Figure 1 Clipart image of a human character with bloodshot eyes, hair thin and standing straight up, with a grimace.
Definitions of Stress
Psychological
Stress occurs when an individual perceives challenges as overwhelming when compared to
resources and coping abilities (Greenberg, Carr & Summers, 2002; Gunnar & Quevedo, 2007).
Definitions of Stress
Biological
Organism’s digression from a state of homeostasis and its activation of neurobiological systems
(stress response) that enables it to return to a point of homeostasis (McEwan & Seeman, 1999).
Stress: The Good
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Stress is a part of a process we use to evaluate and attempt to cope with challenges
Normal process if time limited
Time limited stress is protective
Stress: the Good and Bad
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Under conditions of normal stress, children learn how to cope and manage
Need supportive adults if they are to do this
Prolonged stress can damage the body including the brain
Activity
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Think of a time when you felt you were under stress but actually performed better
because of the stress
Think of a time when the stress seemed to be more long term
o How did you react physically?
o Emotionally?
Figure 2 Clipart showing a "smiley face" image with one finger on his chin and a thought balloon above his head as if he is
thinking.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Physiology of Stress
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Sympathetic nervous system (SNS): Activates physiological responses to stress
Parasympathetic nervous system: Activates relaxation response
Tug of war to achieve balance or equilibrium
Physiology of Stress Brain
Figure 3 Grapic of the brain showing the Cerebrum, Corpus Collosum, Basal Ganglia, Thalamus, Hypothalamus, Amygdala,
Hippocampus, and Cerebellum.
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Triune brain
o Reptilian
o Limbic brain
o Neocortex
Physiology of Stress
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SAM System (Sympathetic-adrenomedullary system) Rapid fire system that releases
epinephrine (adrenaline), fight or flight response
HPA Axis (hypothalamic-pituitary-adrenocortical system). Produces a cascade of longer
acting hormones that ends in production of glucocorticoids including cortisol
Figure 4 Graphic showing the HPA Axis. Three circle start in the upper left corner move down to the lower right corner and are
labelled from left to right Hypothalamus, Anterior Pituitary, and Adrenal Cortex. Each circle is slightly smaller than the previous
one and an arrow between each indicates movement from top to bottom. The space between the first and second circle is
labeled CRH: Corticotropin Releasing Hormone. The space between the second and third circle is labeled ACTH:
Adrenocorticotropic Hormone. After the third circle is the labeled CORT. Two arrows arch back from this position to the two
prior circles (Anterior Pituitary and Hypothalamus) and the label underneath them reads Negative Feedback.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Cortisol
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Glucocorticoids take many minutes or hours to produce and affect physiology for long
periods (Sapolsky, et al., 2000)
Cortisol distributes glucose to critical organs and away from ones not immediately
needed
Crisis passes
o Body attempts to return to homeostasis through parasympathetic nervous system
including feedback loop of HPA axis
Stress and Physiological Processes: Parasympathetic Nervous System
(PNS)
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Feedback loop reversal of HPA
Counter defenses protect hippocampus from too much cortisol ordered by hypothalamus
SNS is slow to shut down leaving the individual in a state of readiness for awhile
Cortisol
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Varies on a circadian cycle and reactively in response to an acute stressor
Circadian cycle
o Highest when you first wake up (Cortisol awakening response)
o Decreases throughout the day
Curve may be elevated or flattened
o More likely to be flattened in chronic illness, PTSD
Reactive cortisol response
o Reaches peak 20 to 30 minutes after onset of stressor
o Gradually returns to baseline over course of 40 to 60 minutes (Nicolson, 2007;
Ramsay & Lewis, 2004).
Poll
Figure 5 Clipart showing a purple button with a question mark on it.
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Raise your hand if you think women generally have a slower SNS stress reversal time.
Raise your hand if you think men have a slower SNS stress reversal time
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Stress: The Bad and the Ugly
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Sometimes stress hormones remain active for too long
Injure and kill cells in hippocampus
Hippocampus needed for memory and learning
Excessive cortisol affects long-term memory
Stress: The Bad and the Ugly
Figure 6 Cartoon drawing of a cat during the day and during the night. The caption reads, "There are only two times I feel
stress: Day and Night.
Stress: The Bad and the Ugly
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Stress hormones divert glucose from brain to muscles
Compromises ability to form new memories
Hippocampus has fewer cells in aging brain
Hippocampus tells hypothalamus to reduce cortisol
Degenerative cycle set into motion
(Lee, Ogle, & Sapolsky, 2002)
Stress: the bad and the ugly
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Increased risk of
Heart disease
Diabetes
Hypertension
Drug abuse
Alcoholism
Depression
Anxiety disorders
National Scientific Council on the Developing Child (2005)
Stress: The Bad and the Ugly
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Frequent, sustained stress hard-wires maladaptive responses
Limbic brain receives permanent insult from cortisol
Significant adversity early in life damages the “architecture of the developing brain”
(National Scientific Council on the Developing Child, 2005)
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Stress and the Developing Brain
Toxic Stress can impair
• emotional well being
• early learning
• exploration and curiosity
• school readiness
• school achievement
National Scientific Council on the Developing Child, 2008
Protective Factors
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Presence of sensitive and responsive caregivers
Secure attachment relationships
High quality early care and education
Peer acceptance
Responsive environments
Feelings of competence
Activity
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Think again of the time when you felt you were stressed for a long period of time
o Which, if any, of the protective factors were in place?
o How do you think they helped you cope with the stress?
Figure 7 Clipart showing a "smiley face" image with one finger on his chin and a thought balloon above his head as if he is
thinking.
Magnitude of Stress Response
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Novelty of threat
Unpredictable nature
Threat to person or ego
Sense of lack of control
(Guilliams & Edwards, 2010)
Figure 8 Clipart showing a woman trembling, teeth gritted, eyes twitching and hair disheveled.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Poll
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Raise your hand if you think bosses experience higher chronic stress than employees
Raise your hand if you think workers experience higher stress than bosses
Figure 9 Clipart showing a purple button with a question mark on it.
Toxic Stress
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Pathological or toxic stress occurs:
Perceived lack of control
Experience of negative emotions
Resources are judged to be not effective or not available
Absence of supportive relationships
Figure 10 A man in a suit is blindfolded with a target stuck to his forehead.
Stress and Temperament
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Variations in perception of stressful events and vulnerability to them
Temperamental characteristics play large role in vulnerability to effect of stress
Temperament must be considered in context of social relationships
(Gunnar & Quevedo, 2007)
Stress and Attachment
If early relationships are reliably warm, they can buffer child from the affects of other stressors
Individuals who have secure relationships have more controlled stress hormone reaction when
upset or frightened
Presence of sensitive responsive caregiver, can prevent elevated cortisol levels in toddlers
Figure 11 Photo of a toddler kissing his mother on the cheek.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Stress and Attachment
Many threat to secure attachment between caregiver and child with severe multiple disabilities
• Time spent in NICU units
• Severe health problems
• Low arousal levels- not enough time for attachment to occur
• Hyper arousal- unable to cope with too much interaction
• Misunderstood communication cues on both sides
Implications of Deafblindness
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May not hear or see threats approaching
People and things appear and disappear with little perceived reason
Difficulty communicating
Increased risk for attachment disorders
Research Study Nelson, Greenfield, Hyte, & Shaffer (In Press)
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Single case, multiple baseline across activities with sequential withdrawal
4 children identified as deafblind
Measures:
o Frequency and duration of behaviors indicating stress
o Duration of active participation
o Time to regulation
o Reactive salivary cortisol- before, 20 minutes after (peak) 40 minutes after
Salivary Cortisol
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Salivette saliva collection
ARUP Laboratories
Enzyme Immunoassay
Coefficient of variation <8%
Norms for age and time of day established by ARUP on non-Cushing population
3 days of sampling (3 samples each day) in baseline and 3 days of sampling in each
phase of intervention. 27 samples per child
Research Study
Interventions
• Environmental (Making activity more meaningful, adding turn-taking, choice,
conversation, responding to communications, providing time to explore, reinforcement)
• Anticipatory (Touch cues, object cues, calendar or scheduling systems)
• Calming (slow rhythmic voice, stroking arm, massage, proximity)
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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David
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13 year old male
Inclusive middle school with intervener/interpreter
Profound hearing loss, new cochlear implant that was generally not on, high myopia,
eyes did not work together
Hydrocephalus, absent corpus callosum, developmental delays
Cerebral palsy on one side but was mobile
Communicated mostly through Signed English, some “home signs”
Stress behaviors: refuse, shut eyes, hit, freeze, avoidance behaviors, cry, yell
Function: avoidance, continue preferred activity
Regulation behaviors: Smile, laugh, sign “ready”, sign “better”, participate in activity
Cortisol Activity: David Physical Education Baseline
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Physical Education in inclusive gym class
Street clothes
Rolled ball back and forth with intervener did not participate with other students
Did not want to go to school
Intervention: David PE
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Environmental: Gym shirt, put on gym shirt in locker room, include in all activities with
other students, instructions from intervener with encouragement to look at what other
students are doing, 5 minute breaks when tired
Figure 12 Four images appear one below the other with a word beside each. Image #1 of lockers with the word "change".
Image #2 of a boy doing jumping jacks with the word "Warm Up". Image #3 shows someone holding a football with a red flag on
one side and the word “Sports”. Image #4 is the same and #1 and has the same word “Change” beside it.
Intervention: David PE
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Calming: If he became upset, intervener took hand and led him back to gym floor with
other students, stayed 5 feet away
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Graph: David Activity A, PE
Figure 13 A graph showing the % stressed and the % participates between the dates 03.21.11 and 05.06. 11. There are 18
intervals representing these dates running along the y axis. Intervals 1-4 represent the baseline. Intervals 5-8 represent
Intervention 1. Intervals 9-14 represent Intervention 2. Intervals 15-18 represent Intervention 3. Along the x axis are
percentages ranging from 0% to 100%. During the baseline participates ranges from 43.6% to 63.6% stress ranges from 31.7%
to 56.6%. During intervention #1 time participates ranges from 82.2% to 99.4% and stressed drops to between 0%-6.5%.
During intervention #2 participates ranges from 46.5% to 100% with stressed between 0% and 48.4%. In intervention #3 time
participates ranges between 87.5% and 99.4% and stressed ranges between 0% and 12%.
Data Summary: David Cortisol Activity- PE
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Frequency behaviors went from 0 behaviors per one minute interval to 0
Duration behaviors went from 31.7% of each 1 minute interval to 0%
Active Participation went from 55.5% of each one minute interval to 99.4%
Length of time from onset of stressor until regulation - went from 10.28 minutes to 0.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Michael
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4 Year old male
Self-contained special education preschool
Deafblind- cataract on right eye, no lens on left, CVI on right side, diagnosed with
functional hearing loss, inconsistent auditory responses
Cerebral Palsy
Pre-symbolic level of communication
Seven medications- seizure control, reflux, sleep
Stress behaviors: low continuous vocalization, grimace, grinding teeth, resistive
behaviors including high pitched vocalization, pulling away and continuous grimacing
Regulation behaviors- smile, active participation, active looking, happy vocalizations
Michael Cortisol Collection Activity Objects: Baseline
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Hand over Hand Activities
Coloring
Cutting
Pasting
Drawing
Graph: Michael Cortisol Activity Objects (B)
Figure 14 A graph showing the % stressed and the % participates between the 2010 and 2011. There are 37 intervals
representing these dates running along the y axis. Intervals 1-16 represent the baseline. Intervals 17-23 represent Intervention
1. Intervals 24-30 represent Intervention 2. Intervals 31-37 represent Intervention 3. Along the x axis are percentages ranging
from 0% to 100%. During the baseline stressed ranges from 24% to 99.1% and there is no participates indicated. During
intervention #1 participates ranges from 45.9% to 93.9% and stressed drops to between 0%-6.1%. During intervention #2
participates ranges from 78.9% to 92.8% with stressed between 0% and 2.2%. In intervention #3 participates ranges between
92.2% and 97.8% and stressed is 0%.
Data summary: Michael Activity (B) Objects
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Frequency behaviors went from 20 behaviors per one minute interval to 0
Duration behaviors went from 36.9% of each 1 minute interval to 0%
Active Participation went from 14.4% of each one minute interval to 76%
Length of time from onset of stressor until regulation - went from 13.3 minutes (did not
regulate) to 0.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Alik
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6 year old male
Self contained class for children with visual impairments
Totally blind
Varying levels of hearing- severe to profound loss, bilateral hearing aids but very seldom
worn
Cerebral palsy, mobile with the aid of a walker
Pre-symbolic communication level
Stress behaviors: Resisting, self-abuse, aggression toward others, yelling, crying,
sleeping
Behavior Function: Avoidance, continue preferred activity
Regulation behaviors: Stilling, smiling, laughing, affectionate behavior, flapping,
participating in activity
Cortisol Activity: Alik Goals Baseline
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Table activities in wooden chair with seat belt
Coloring
Cutting
Goals: Intervention: Alik
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Environmental: Change activity to communication and listening with hearing aids in and
on the floor with intervener
o Imitation of repetitive syllables, switches with music, finger plays, music and
singing with movement, turn-taking with movement, musical instruments, choice
making with objects from various activities, respect signals for breaks
Intervention: Alik
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Anticipatory: Briefly tell A what is coming up, activity bin with material from
communication and listening activity presented, bin of objects from next activity given at
end
Calming: Affectionate hugging, stroking his arm, vibrating toy, vibrating furry “lady bug”
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Graph: Alik Activity A
Figure 15 Figure 14 A graph showing the % stressed and the % participates between the 9.27.2010 and 12.06.2010. There are
21 intervals representing these dates running along the y axis. Intervals 1-6 represent the baseline. Intervals 7-12 represent
Intervention 1. Intervals 13-16 represent Intervention 2. Intervals 17-21 represent Intervention 3. Along the x axis are
percentages ranging from 0% to 100%. During the baseline stressed ranges from 23.2% to 48.5% and participates range from
1.8-27%. During intervention #1 participates ranges from 19% to 65.6% and stressed drops to between 0%-1.7%. During
intervention #2 participates range from 78.3%-90% with stressed between 0% and 1.1%. In intervention #3 participates range
between 43% to 99.4% and stressed is 0%-27.1%.
Data Summary Alik Cortisol Activity
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Frequency behaviors went from 5.2 behaviors per one minute interval to 0
Duration behaviors went from 44.6% of each 1 minute interval to 1.1%
Active Participation went from 0% of each one minute interval to 60.6%
Length of time from onset of stressor until regulation - went from 9.4 minutes (did not
regulate) to 0.
Lessons Learned
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Paramount importance of meaningful, enjoyable activities
Importance of routines
Anticipatory strategies important but can be successfully faded if predictable routines are
in place
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Cortisol Data
Figure 16 Salivary cortisol levels compared to Reference interval across conditions. High and low values for reference interval
are provided. David shows <0.259 high normal. Michael shows 0.034 low normal and 0.645 high normal. Alik show 0.034 low
normal and 0.654 high normal.
Cortisol Summary
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Buffering effect of secure attachments
Behaviors may not equal stress- may be proactive, communicative measures to protect
against stress if supportive persons are present
Affirmation of protective factors
Behavior changes, marked increase in participation without rise in cortisol
Intervention Stress
Environments that are:
• Responsive
• Communication rich
• Predictable
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Intervention
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Routines
Support social development
Support development of attachment relationships
Kiril
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Russia
Fetal Alcohol Syndrome
Severe hearing loss
Very low vision
Reactive attachment disorder
o Video clip 1
o Video clip 4
o Video clip 5
Activity: Kiril
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What did you see that Kiril’s teacher did well to bring down his stress?
Can you think of ways you can or do use these techniques in your class already?
Figure 17 Clipart of two figures facing each other; a caption balloon is above each head indicating discussion.
Questions
Figure 18 Clipart of a "smiley face" character with one eyebrow raised while he scratches his chin. Question marks float above
his head.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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Texas School for the Blind & Visually Impaired
Outreach Programs
Figure 4, TSBVI logo.
Figure 5, IDEAs that Work logo and OSEP disclaimer.
2015 Texas Symposium on Deafblindness – Stress in Children with Deafblindness, Nelson, C.
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