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

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

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

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)

“ 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 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

“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….

Modern Western society has benefited (beyond the dreams of our ancestors) from many advances in:

Technology

Communications

Transportation

Social Justice

Economy

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

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?

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

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

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)

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

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)

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

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

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

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

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

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)

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?

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

“ Discovered” in 1968 & 1973

Specific pattern of facial features

Evidence of Central Nervous System (CNS) dysfunction / damage

Growth deficiency

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

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 )

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)

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

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”)

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

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

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…

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)

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

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

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

5 CNS pathways to explosive / inflexible kids:

Executive Function Skills

Language-Processing Skills

Emotion regulation Skills

Cognitive Flexibility Skills

Social Skills

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

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)”

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

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

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

“ 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

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

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

Please proceed to Part 2, Module 2