Safety Without Restraints:
Trauma Informed Care
The Neurobiological & Psychological
Effects of Trauma
Dr. Janice LeBel
Rhode Island College ~ Sherlock Center on Disabilities
March 9, 2015
Adapted Presentation Developed by Glenn Saxe, MD for NASMHPD OTA 2002
“Without understanding the basic
principles of how the brain develops
and changes, we cannot expect to
design and implement effective
interventions.”
Bruce Perry, M.D.
NCTSN.ORG
Boston Medical Center
Intensive Residential Treatment Program
Total Seclusion, Restraint & Injury Episodes
09/00 - 01/08
80
SR Episodes
60
Kid Injury
50
Staff Injury
40
St
30
20
10
Significant Periods
Jan-08
Sep-07
May-07
Jan-07
Sep-06
May-06
Jan-06
Sep-05
May-05
Jan-05
Sep-04
May-04
Jan-04
Sep-03
May-03
Jan-03
Sep-02
May-02
Jan-02
Sep-01
May-01
Jan-01
0
Sep-00
SR & Injury Episodes
70
Longitudinal Course of PTSD Symptoms
in Children with Burns
50
45
40
PTSD-RI Score
35
30
25
20
15
10
5
0
Acute Assessment
3 Month Assessment
Time Period
Lateral Ventricles Measures in an 11 Year Old
Maltreated Male with Chronic PTSD, Compared with
a Healthy, Non-Maltreated Matched Control
(De Bellis et al, 1999)
From Neurons to Neighborhoods:
The Science of Early Child
Development
Report from the Institute of Medicine/National
Academies
National Research Council
Trauma in U.S.A.
• 3 million children were suspected of being
victims of abuse and/or neglect
(Mazelis, 1999)
• 3.9 million adolescents have been victims
of serious physical assault, and almost 9
million have witnessed an act of serious
violence
(Kilpatrick et al, 2001)
• In 1998, 92% of incarcerated girls
reported sexual, physical or severe
emotional abuse in childhood
(Acoca & Dedel, 1998)
PTSD in U.S.A.
• Over 50% of U.S. women & 60% of men report experiencing
at least 1 traumatic event at some point in their lives. But,
only a minority (10% of women & 5% of men) report
developing posttraumatic stress disorder, the most prominent
psychiatric disorder associated with traumatic events.
(Koenen, 2005; Kessler et al, 1995)
• More than 80% of those diagnosed with PTSD will suffer
from other psychiatric disorders. (Solomon & Davidson, 1997)
• For more than 1/3 with PTSD, it will be a persistent
condition and experienced for several years.
(Solomon & Davidson, 1997)
Impact of Adult PTSD
• Childhood trauma, compared to adult-onset trauma:
• results in a greater probability of developing psychiatric disorders
(particularly anxiety disorders and PTSD) throughout the lifetime
(Zlotnick et al., 2008), and
• is believed to have a long-term impact in the frontal, temporal and
parietal regions of the brain and how information is processed (Cook
et al., 2009)
• Studies have identified 4 main risk factors for PTSD
in adults: 1) a pre-existing psychiatric disorder; 2) a family history of
disorders; 3) childhood trauma and 4) being female (Breslau, 2002)
• Late-onset PTSD is under recognized and undertreated in
adults and creates greater probability of additional psychological difficulty
and physical health symptoms later in life (Snyder, 2008)
What is PTSD, really?
“PTSD should not be considered
a ‘disorder.’ It is a
psychological and emotional injury –
a natural reaction to an unnatural
situation.
Why turn it into ‘pathology’
and make it a disorder?”
Jonathan Shay, M.D., 2011
Boston V.A.
Effective Treatment Must Account
For:
1) A dysregulated nervous
system
2) A social-environment that
cannot contain this
dysregulation
Core Concepts of Development
1) Human development unfolds
along individual pathways whose
trajectories are characterized by
continuities and discontinuities,
as well as by a series of
significant transitions.
(Shonkoff & Phillips, 2000)
Longitudinal Course of PTSD Symptoms
in Children with Burns
50
45
40
PTSD-RI Score
35
30
25
20
15
10
5
0
Acute Assessment
3 Month Assessment
Time Period
309.81 PTSD Definition
• The development of characteristic
symptoms, following exposure to a
traumatic stressor involving direct
personal experience or witnessing
another persons’ experience of:
– Actual or threatened death
– Actual or threatened serious injury
– Threat to physical integrity
Post Traumatic Stress Disorder
• Characterized by:
– Re-experiencing the event
• Intrusive thoughts, nightmares, or flashbacks that
recollect traumatic images and memories
– Avoidance and emotional numbing
• Flattening of affect, detachment from others, loss of
interest, lack of motivation, and constant avoidance of
any activity, place, person, or event associated with the
traumatic experience
Core Concepts of Development
2) The growth of self regulation
is a cornerstone of early
development that cuts across all
behavioral domains.
(Shonkoff & Phillips, 2000)
State Change
22 year-old man
with history of
childhood physical
abuse displayed
aggressive behavior
on psychiatric unit
and was physically
restrained.
State Change
12 year-old
sexually abused
girl in school
when provoked
by older male
peer.
Parameters that change between
state
•Affect
•Thought
•Behavior
•Sense-of-self
•Consciousness
Emotional States and Child Development
• Discrete behavioral states are a central
organizing experience of infancy
• Infants experiential world is divided into
separate and definable emotional/behavioral
states
• Critical task of early child development is to
build smooth transitions/bridges between states
• Regulation of emotion is initially contingent
on caregivers facilitating these transitions
(Wolff, 1987)
Goal of Treatment
• Maintain Calm/ Continuous/
Engaged State
• Prevent Discontinuous States
• Build Cognitive Structures
that allow Choices
Between Stimulus and Response
Stimulus
Response
Between Stimulus and Response
Stimulus
Traumatic
Response
Reminder
Socialenvironmental
intervention
Traumatic State
Neuroregulatory
Intervention
Intervention
Between Stimulus and Response
Stimulus
Traumatic
COGNITION!!!
Reminder
Response
Traumatic State
Socialenvironmental
Intervention
Neuroregulatory
Intervention
Intervention
Core Concepts of Development
3) Human development is shaped
by a dynamic and continuous
interplay between biology and
experience.
(Shonkoff & Phillips, 2000)
Emotional Brain
(Restak, 1988)
Between Stimulus and Response
Stimulus
(LeDoux, 1996)
Between Stimulus and Response
Sensory Thalamus
Stimulus
(LeDoux, 1996)
Between Stimulus and Response
Very Fast
Sensory Thalamus
Amygdala
Stimulus
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
Stimulus
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
Stimulus
Response
(LeDoux,
1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Social
Environmental
Intervention
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Neuroregulatory
Psychotherapy Intervention
Psychopharmacology
Slower
Amygdala
Stimulus
Response
(LeDoux, 1996)
Rauch Brain scans
Play
Play and Fear
(Panksepp, 1998)
Social-Ecological Model
Culture
Neighborhood
School
Peer Group
Family
Individual
Individual
Core Concepts of Development
4) Human relationships, and the
effects of relationships on
relationships, are the building
blocks of healthy development.
(Shonkoff & Phillips, 2000)
Attachment
• Earliest relationships critical for
capacity to regulate state
• Early traumatic relationships set up
person to respond with state
dysregulation to interpersonal cues in
subsequent relationships
Attachment & Relational Deficits
•Appear guarded & anxious
•Difficult to re-direct, reject support
•Highly emotionally reactive
•Hold on to grievances
•Do not take responsibility for behavior
•Make the same mistakes over and over
•Repetition compulsion / traumatic reenactment
(Hodas, 2004)
Trauma eats Attachment for
Lunch...
Core Concepts of Development
5) People are active participants
in their own development,
reflecting the intrinsic human
drive to explore and master one’s
environment.
(Shonkoff & Phillips, 2000)
Traumatic Mastery
• Many children have primarily experienced abusive and
neglectful relationships
• Extreme behaviors within relationships can be seen as
defensive or self-protective and adaptive
• Traumatized people respond to their trauma history in
the present. They are not able to discern that the context
has changed
• This behavior must be seen as an attempt to master
extremely difficult environments. In this way,
traumatized children are “doing the best that they can”
Core Concepts of Development
6) The course of development
can be altered…by effective
interventions that change the
balance between risk and
protection, thereby shifting the
odds in favor of more adaptive
outcomes.
(Shonkoff & Phillips, 2000)
Recovery from Trauma
• Stimulate the brain!
 Use of anti-depressant medications
(Surget et al., 2011)
 Cognitive stimulation
• Education [Gilligan’s anti-prison model]; CBT,
TF-CBT, DBT)
 Procedural learning
(Grigsby & Stevens, 2002)
• Deconstruct behavioral sequence
• Teach new patterns of response
Recovery from Trauma
• Brain plasticity
• Conventional wisdom: human brain reaches 90%
of adult weight by early childhood and little
change in size after age 5 (Bryck & Fisher, 2012)
• Conceptually adapted from TBI research
• Physical stimulation to promote neurogenesis
• Exercise and gross motor movement
• Increased V02, increased blood flow x 2 to
hippocampus, new blood vessels, strengthens
existing connections, recruits new neural
connections (Bryck & Fisher, 2012; Pereira et al., 2007; Snyder
& Cameron, 2011)
Recovery from Trauma
• Early studies: exposing rats to stress followed by
enriched environments (complexity & novelty):
• ↑ brain #, size
• ↑ dendrite branching & length
• changes in synaptic size & #
• behavioral & memory improvements
• Exercise studies with humans
•↑ cognitive abilities
•↑ academic performance
•↑ executive control / functioning
• possibly continued plasticity into old age
(Bryck & Fisher, 2012)
Recovery from Trauma
• Current neuroplasticity research focus:
•Executive functioning (AKA: cognitive
control)
• Lab-based training w/working memory
focus – does not generalize easily
• Neurobiologically informed ecological
interventions – in the environment but costly
• Compensatory processes brain-training –
‘overactivation;’ recruit both hemispheres, not just
where damage occurred, i.e., ‘self-talk’ strategies
(Bryck & Fisher, 2012)
Recovery from Trauma
Sensori-Motor Recognition &
Approaches
• Recognize the impact of trauma on the body &
behavior (survival strategies);
• Assess Sensory Diet (Jean Ayers) & identify
Sensory-Seeking / Sensory Avoiding behavior
• Teach skills to promote body awareness &
calming
• Promote natural methods: yoga, singing,
recreation, etc.
Recovery from Trauma
New Language & Understanding:
Steps Towards Practice & Culture Change
Trauma Aware - individual impact, risk factors, brain/behavior
Trauma Focused - treatment using evidence-based practices,
service-specific
Trauma Sensitive - awareness & provision of services oriented
at the organization/system level
Trauma Informed - organization/system commitment to
address trauma across multiple-systems
CONCLUSIONS
• Response to traumatic stress is learned behavior,
mediated by the brain & the social environment
• Traumatic stress brings the past to the present
• The survival response impacts the mind, body,
behavior & speech “… the amygdala leads a hostile takeover
of consciousness by emotion.” (LeDoux, 2002 )
• To change the response, create new: language, learning
& skills:
– Analyze & adapt
– Buffer & bolster
– Teach, support, & build that “cognitive wedge”
“Cowardice asks the question – is it safe?
Expediency asks the question – is it politic?
Vanity asks the question – is it popular?
But conscience asks the question – is it right?
And there comes a time when one must take
the position that is neither safe, nor politic,
nor popular. But one must do it because
it is right…”
Martin Luther King, Jr.