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Hsv 6350 Module I Part 1 Neurobiology Of Trauma Dr. Mark Sloane






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Hsv 6350 Module I  Part 1 Neurobiology Of  Trauma Dr. Mark Sloane Hsv 6350 Module I Part 1 Neurobiology Of Trauma Dr. Mark Sloane Presentation Transcript

  • The Impact of Child Trauma & Prenatal Alcohol Exposure on Neurobiological Development & Function Western Michigan University College of Health & Human Services HSV 6350-105 Special Topics Course: Child Trauma Module I , Part I Mark A. Sloane, DO Center for Behavioral Pediatrics WMU Children’s Trauma Assessment Center Kalamazoo, MI
  • Western Michigan University
  • Western Michigan University SW MI Children’s Trauma Assessment Center
  • Module 2
    • Brief review of normal brain development
    • Review of “Brain-Behavior Connections” in FASD & child traumatic stress
    • Neurodevelopmental Function in FASD & child traumatic stress
    • Treatment overview in FASD & child traumatic stress
  • The Harsh Reality…
    • Research continually demonstrates the harmful effects of child traumatic stress & prenatal alcohol exposure
    • We have a reactive system rather than a proactive system
    • We minimize the impact to these children to protect ourselves from the overwhelming awareness of how damaging their experiences are
  • Exploring the “Why” Behind Problematic Behavior
    • Requires a reframing of often long-standing paradigms re the etiology of “bad behavior”
    • Multiple factors: This is complex !!!
    • Requires a community-wide shift of thinking differently
    • The power of the trans-disciplinary mindset
  • Paradigm Shift: Reframing Our Understanding of Behavior
    • “ Bad” behavior in children & adolescents is often about faulty & defective brain wiring
    • It is not disrespect because the child is “ BAD ”
    • Perceived “bad” children:
      • Do NOT have adequate skills of flexibility/adaptability…
      • Often have low frustration tolerance…
      • and also have significant difficulty applying these skills when they are most needed. (Greene, 2001)
  • Our typical response to “bad” behavior in children
    • These kids get all kinds of labels
      • Educational System (special education classifications)
      • Medical System (DSM-IV diagnostic categories)
      • Legal System (at-risk teen, juvenile delinquent)
    • They often get labels that imply they are BAD or NAUGHTY
    • ADHD, Oppositional Defiant Disorder (ODD), Conduct Disorder, Bipolar Disorder (& even PTSD) diagnoses do NOT capture the full extent of the neurodevelopmental & neurobehavioral impact for kids with problem behaviors
  • These labels just don’t fit!!!
  • The challenge of dealing with difficult children…
    • “It may be when we no longer know what to do…
    • we come to our real work …
    • And…when we no longer know which way to go…
    • we have begun our real journey .”
    • Wendell Berry
  • News Flash : We live in strange times!
    • Modern Western society has benefited (beyond the dreams of our ancestors) from many advances in:
      • Technology
      • Communications
      • Transportation
      • Social Justice
      • Economy
    … however….
  • News Flash: We live in strange times!
    • Our society seems incapable of ensuring that our children grow up in environments that are:
      • Safe
      • Predictable
      • Rich in positive relationships
      • Humane
  • News Flash: We live in strange times!
    • Hundreds of thousands of children are terrorized, abused, neglected, maltreated, exposed to alcohol/drugs each year
    • These kids are at great risk for emotional, behavioral, social, cognitive, and physical health problems
    • The overall costs are incalculable
    • How can we really measure the lost potential here?
  • News Flash: We live in strange times!
    • How “advanced” is our society when…
      • We have to create vast expensive government agencies whose sole purpose is to protect children from their parents!
      • These very agencies (despite our best efforts) truly fail these unfortunate children by…
        • Recreating the chaos, fragmentation, trauma, and neglect these kids experienced in their biological homes
  • A Step Closer… to understanding these kids
    • The Brain – Behavior Connection
  • Normal Brain Development and Organization
  • Brain Glossary
    • Neuron (nerve cell)
      • “Raw material” of the brain
      • 100 billion neurons at birth (most of what we will need throughout life)
    • Synapse
      • The connection between neurons
      • 1,000 trillion synapses by age 3
      • 500 trillion synapses by adolescence
        • Due to “pruning” (discarding)
  • Brain Development / Learning
    • The process of creating, strengthening, & discarding synapses
    • Synapses organize the brain by forming neuronal pathways that connect the parts of the brain governing everything we do:
      • Breathing
      • Sleeping
      • Thinking
      • Feeling
  • Neurobiology of Development
    • Nature PLUS nurture !!!
    • “ Hard-wired” genetic programs (blueprints) are continuously modified by the environment (from conception  death)
    • Brain “sculpts” itself in response to the environment AT THE SAME TIME it is developing (via genetic blueprints)
    • “ These interactions organize our brain’s development and thus shape the person we become” (Shore 1997)
  • From simple to complex: Hierarchy of brain function Brain- stem Diencephalon Limbic Neocortex Abstract Thought Concrete Thought Affiliation w/ mate Attachment Sexual Behavior Emotional Reactivity Motor Regulation Arousal Appetite / Satiety Sleep BP / Heart Rate Respiratory Drive Body Temperature Perry 2006 All sensory input enters here
  • Neural systems change in a use-dependent fashion during development
    • Healthy organization of all neural networks depends upon:
      • Pattern
      • Frequency
      • Timing
    • of key experiences during development
    • Example : Child must be exposed to language-rich environment to develop optimal language function
  • Brain develops in sequential fashion: from simple to complex Brain- stem Diencephalon Limbic Neocortex Development begins here
  • The brain develops most rapidly early in life
    • By age 4, the brain is 90% of adult size!
    • It is much easier to organize the brain in healthy ways in early childhood…
    • It is much more difficult to re-organize a poorly organized brain due to traumatic stress and / or FASD
  • Neural systems can be changed… but some systems are easier to change Brain- stem Diencephalon Limbic Neocortex Complexity Plasticity & Ease of change
  • The Brain-Behavior connection: three primary components
    • Genetics
      • What you inherit from both parents
    • Intrauterine environment
      • During pregnancy
    • Extrauterine environment
      • After pregnancy
  • The Brain-Behavior Connection
    • Genetics
      • Neurodevelopmental strengths / weaknesses
      • Temperament / Personality
      • Family history of:
        • Attentional disorders
        • Learning disorders
        • Mood disorders
        • Neuropsychiatric disorders
  • The Brain-Behavior Connection (cont.)
    • Intrauterine environment
      • Exposure to drugs (legal / illegal)
      • Exposure to alcohol
      • Maternal stress
      • Maternal nutrition
  • The Brain-Behavior Connection (cont.)
    • Extrauterine environment
      • Parental attachment / nurturing
      • Parental style / psychopathology
      • Overall family climate
      • Influence of extended family system
      • Inadequate nutrition
      • Exposure to violence, natural disasters
      • Exposure to neglect
      • Exposure to abuse (verbal / emotional / physical / sexual)
  • Brain-Behavior Connection: Embracing Complexity Genetic Risk Trauma Prenatal Exposure Genetic Potential Behavior
  • Effects of Traumatic Stress on “Normal” Individuals Normal Gene Normal Behavior normal development Normal Circuit Normal Gene normal development Normal Circuit T R A U M A Normal Behavior Neurodevelopmental Delays Neurobehavioral Symptoms Stahl 2002
  • Effects of Prenatal Alcohol Exposure on “Normal” Individuals Normal Gene Normal Behavior normal development Normal Circuit Normal Gene abnormal development Compromised Circuit Normal Behavior Neurodevelopmental Delays Neurobehavioral Symptoms P A R L E C N O A H T O A L L
  • Worst-case scenario: The “Triple-Whammy” Vulnerable Gene +MH Family History Development Compromised Circuit Most severe: Neurobehavioral Symptoms Neurodevelopmental Delays P A R L E C N O A H T O A L L Abnormal T R A U M A Normal Behavior
  • Influence of Prenatal Alcohol Exposure
  • Fetal Alcohol Syndrome
    • FAS is among the most common of the known causes of cognitive impairment
      • A major public health problem.
      • How common is it? (1-3/1000 live births in US?)
      • Regional variations
      • How does it affect the CNS?
      • What can we do about it?
      • Why don’t more professionals know about it?
  • Fetal Alcohol Syndrome
    • “ Discovered” in 1968 & 1973
    • Specific pattern of facial features
    • Evidence of Central Nervous System (CNS) dysfunction / damage
    • Growth deficiency
    Photo courtesy of Teresa Kellerman
  • FAS: only the tip of the iceberg!
    • Fetal Alcohol Spectrum Disorders (FASD)
    • Fetal Alcohol Syndrome
    • Alcohol-related Neurodevelopmental Disorder (ARND) (“mild-moderate” FAS)
    • Prenatal Exposure to Alcohol (clinically suspected to have FAS but appear physically normal )
    Adaped from Streissguth
  • Smooth philtrum Thin upper lip  palpebral fissure ( small eyes) FASD: Critical Facial Abnormalities
  • Hoyme, H. E. et al. Pediatrics 2005;115:39-47 Assessment of FAS: Lip-Philtrum guides
  • Hoyme, H. E. et al. Pediatrics 2005;115:39-47 Measurement of palpebral fissures in FAS
  • Chudley, A. E. et al. CMAJ 2005;172:S1-21S FAS Assessment: Measuring palpebral fissure length
  • Hoyme, H. E. et al. Pediatrics 2005;115:39-47 Genetic Disorders with some of the Craniofacial Features of FAS Williams Syndrome DeLange Syndrome VCFS
  • Fetal Alcohol Syndrome: It doesn’t always look like this
  • FAS : It can also look like this!
  • … and this!…clinical examples of FAS: transcending race
  • … and even this!!!... Facial features of FAS in a mouse Adapted from Sulik & Johnston, 1982 Small eyes Flat philtrum Normal control mouse FAS mouse
  • Growing up with FAS Courtesy of Ann Streissguth
  • Hippocampus Amygdala Cingulate Hypothalamus Major brain areas affected by prenatal alcohol exposure Thalamus Corpus Callosum
  • Sensorimotor Cortex Cerebellum Dorsolateral Pre-frontal Cortex (PFC) Brainstem (Locus Ceruleus, Raphe, Ventral Tegmentum) Other key brain structures also affected by prenatal alcohol exposure Orbital PFC Corpus Callosum
  • Severe brain damage caused by prenatal alcohol exposure photo: Clarren, 1986 5-day old infants Severe FAS Normal Brain
  • Corpus callosum abnormalities in FASD Mattson, et al., 1994; Mattson & Riley, 1995; Riley et al., 1995
  • Mechanisms of cellular damage by ethanol in FASD
    • Timing is everything!
    • Binge drinking vs chronic alcohol use
    • John Olney (Wash U. – St. L) mouse model:
      • GABA A & glutamate (NMDA) receptor dysfunction
      • Serotonin system dysfunction
      • Disrupted synaptogenesis (neurons making connections with other neurons)
      • Results in  programmed cellular suicide (apoptosis)
  • Risk Factors for FASD: Why doesn’t every fetus exposed to alcohol look the same?
    • Dose of alcohol (mom’s blood alcohol level = fetal blood alcohol level)
    • Pattern of exposure : binge > chronic drinking
    • Developmental timing of alcohol exposure
    • Genetic variations
    • Synergistic reactions with other drugs
    • Interaction with nutritional variables
    • Socio-economic status
    • Possible neuroprotective factors
  • Child Traumatic Stress & the Developing Brain
  • Traumatic Stress & the Child’s Developing Brain
    • Research reveals a strong link between all types of child abuse and the subsequent development of psychiatric illness in adulthood
    • Until recently, many/most MH professionals felt that these psychiatric conditions developed via psychological means:
      • “software” problems amenable to reprogramming (talk therapy) or simply erasable (“Just get over it”)
  • Traumatic Stress & the Child’s Developing Brain
    • Early childhood traumatic stress to the developing brain results in:
      • Physical (not always permanent) changes :
        • “ Hard-wired” neurological changes
        • Causes abnormal CNS organization / function
        • Profound implications re behavior / development / learning / cognition
        • Prevents realization of genetic potential
  • What does traumatic stress change in the brain?
    • Attachment
    • Affect / Emotion Regulation
    • Information Processing
  • Hippocampus Amygdala Cingulate Hypothalamus Major brain areas affected by traumatic stress Thalamus Corpus Callosum
  • Sensorimotor Cortex Cerebellum Dorsolateral PFC Brainstem (Locus Ceruleus, Raphe, Ventral Tegmentum) Other key brain structures also affected by traumatic stress Orbital PFC Corpus Callosum
  • It’s deja vu all over again!!! Yogi Berra Famous US philosopher
  • Neurobiologic “Controversy”
    • Two prominent researchers in FASD (Ed Riley) & traumatic stress (Martin Teicher) recently met and were unable to differentiate their MRI research slides
    • New strategies greatly needed to research these two groups separately
    • Here is a brief look at some recent functional MRI research…
  • Recent Neuroscience Research
    • New brain research has dramatically altered our thinking about traumatized / FASD children
    • New neuroimaging methods have driven this research:
      • Quantitative MRI (Magnetic Resonance Imaging)
      • Functional MRI
      • PET (Positron-Emitted Tomography)
      • SPECT (Single-Photon Emitted Computed Tomography)
      • MRS (Magnetic Resonance Spectroscopy)
      • DTI (Diffusion Tensor Imaging)
  • Adult ADHD Neuroimaging Study
    • 8 Adults with ADHD
    • 8 Controls
    • George Bush, MD, PhD
    • Functional MRI
    • Performed Stroop test while in fMRI scanner
  • Stroop Test
    • Red Blue Green Yellow
    • xxxx xxxx xxxx xxxx
    • Red Blue Green Yellow
    • Red Blue Green Yellow
  • Neuroimaging and ADHD MGH-NMR Center & Harvard-MIT CITP. Adapted from Bush, et al. Biol Psychiatry. 1999;45:1542-1552. 1 x 10 -3 1 x 10- 2 1 x 10 -3 y = +21 mm y = +21 mm Normal control ADHD Anterior Cingulate Cortex Frontal Striatal Insular network fMRI shows decreased blood flow to the anterior cingulate and increased flow in the frontal striatum in adult ADHD patients 1 x 10- 2
  • OK…it’s time to make it real!
  • What does all of this mean to health professional students?!
    • 5 CNS pathways to explosive / inflexible kids:
      • Executive Function Skills
      • Language-Processing Skills
      • Emotion regulation Skills
      • Cognitive Flexibility Skills
      • Social Skills
    Ross Greene, 2005
  • Traumatic Stress / FASD and the Developing Brain: Executive Function: Making it real
    • Working Memory (“RAM” of the brain)
      • Allows efficient multi-tasking
    • Separation of affect
      • Regulating arousal to achieve goals (e.g. learning)
    • Organization & planning
      • Facilitates problem-solving
    • Shifting cognitive set
      • Allows child to smoothly transition from their own agenda to the supervising adult’s agenda
  • Traumatic Stress / FASD and the Developing Brain: Language Processing: Making it real
    • Often unnoticed, often unassessed
    • Problems identifying internal emotions
    • Lack the capacity to “inform the world” that they are frustrated
    • Problems with conflict resolution
      • Teacher: “Use your words, young man!”
      • Student: “(expletives deleted)”
  • Traumatic Stress / FASD and the Developing Brain: Emotional Control: Making it real
    • Impaired ability of the right brain to communicate w/ the left brain
      • Via Corpus Callosum (connects R with L)
      • Balance problems
      • Sensory processing problems
      • Anger / explosiveness (  self-calming)
      • Loss of logical left brain function (language / memory) when stressed
  • Traumatic Stress / FASD and the Developing Brain: Emotional Control: Making it real
    • Traumatized / FASD kids often have significant difficulty regulating emotional experience :
      • Problems expressing emotions in a safe manner
      • Impaired modulation of emotional experience
  • Traumatic Stress / FASD and the Developing Brain: Emotional Control: Making it real
    • “ Fight-Flight-Freeze” phenomenon is common & underappreciated
      • Hypersensitive / overactive F-F-F system often a daily battle for traumatized / FASD children
      • Fear / Anxiety  Anger connection
        • “Look in their eyes during a meltdown (if you dare) and you will often see fear” …MAS
      • Amygdala is the key player here
  • Traumatic Stress / FASD and the Developing Brain: Cognitive Flexibility: Making it real
    • Concrete / literal thinkers
    • Rigid behavioral templates for specific situations
    • Rule-driven (to a fault)
    • Over-focus on details
    • Overlap with the autistic spectrum
  • Traumatic Stress / FASD and the Developing Brain: Social Skills: Making it real
    • Impulse control problems
    • Pragmatic language impairment
    • Inaccurate interpretation of social information
    • Unable to predict social outcomes
  • Time to find your happy place!
  • End of Part 1 / Module 2
    • Please proceed to Part 2, Module 2