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Louise Newman presentation

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  4. 4. TRAUMA IN INFANCY & CHILDHOOD<br />Psychic trauma occurs when a sudden unexpected intense external experience overwhelms the individuals’ coping and defensive operations, creating the feeling of utter helplessness<br /> Lenore Terr (1987)<br />
  5. 5. TRAUMATISED AND TRAUMATISING PARENTS<br />Parents with unresolved traumatic attachment issues and histories of maltreatment/neglect<br />Range of issues and conflicts when they attempt to parent – from anxiety to avoidance to repetition<br />Opportunity for the prevention of disturbed parenting and abuse<br />
  6. 6. CHRONIC TRAUMA AND DEVELOPMENT<br />Child adapts to enduring stress according to developmental stage and capacities<br />Chronic stress will effect all domains of development and neurobiological functioning<br />Vulnerability is greatest at stages of rapid neurobiological organisation<br />
  7. 7. TASKS OF BIRTH<br />Adaptation to the particular infant<br />Coping with loss of fusion<br />Coping with fears of harming the infant<br />Tolerance of dependency<br />Tolerance of physicality<br />
  8. 8. BABY AT BIRTH<br />Imaginary Baby<br />Relationship with developing fetus<br />Actual Infant<br />
  9. 9. HIGH RISK PARENTING<br />Parenting relationships which impact adversely on child development and particularly on security of attachment<br />Spectrum of parenting behaviors, emotional responses, attitudes and conflicts (conscious and unconscious) which are traumatizing for the child and result in disorganization of attachment and impact on emotional and behavioral regulation<br />Influenced by parental attachment history, reflective capacity and mental state<br />
  10. 10. TRANSGENERATIONAL TRAUMA<br />Patterns of traumatising parenting are often repetitions<br />Maltreatment, abuse and exposure to violence in infancy are risk factors for later abusive behaviour and revictimisation<br />Prevention of child maltreatment involves identification of high-risk parents and early intervention<br />
  11. 11. THE LEGACY OF TRAUMA<br />Trauma is reenacted in the relationship with the infant<br />Unresolved parental attachment trauma is reflected in the handling and care of the infant<br />Trauma disrupts emotional interaction and regulation<br />
  12. 12. TRAUMATISED PARENT<br />Unprocessed traumatic memories<br />Infant as a projective focus – misinterpretation<br />Infant experienced as anxiety provoking, persecutory, hostile<br />
  13. 13. Patterns in high risk families<br />Distorted representation of the child<br />Parental preoccupation with past trauma<br />Parental anxiety<br />Parental deficit in interpretation of the infant emotional communication<br />Problems in interpersonal functioning<br />Limited reflective capacity<br />
  14. 14. PARENTAL REFLECTIVE FUNCTIONING<br />Capacity to understand own and child's behaviour in terms of underlying mental states<br />Basis of parents ability to hold the infants affective experience in mind<br />Gives meaning to the child’s affective experience and re-presents it to the child in a regulated fashion<br />
  15. 15. PARENTAL REFLECTIVE FUNCTIONING<br />RF is the basis of parental access to their own emotions and memories of their own early attachment experiences<br />Mediates the reworking of parents early relationships in the transition to parenthood and representation of the child<br />Impacts on interactive and parenting behaviours<br />
  16. 16. THINKING ABOUT THE BABY<br />Crucial in establishment of attachment relationship and emotionally attuned early interaction<br />Gives infant experience of being validated and contained and is the beginning of self development<br />
  17. 17. TRAUMA AND DEVELOPMENT<br />Effects of trauma during critical periods of development<br />Long-term implications of attachment disruption and maltreatment<br />New infant brain research and implications for decision-making, intervention and child protection<br />
  18. 18. SPECTRUM OF TRAUMA<br />Single overwhelming events<br />Chronic enduring stressors<br />Indirect exposure<br />Transgenerational trauma<br />
  19. 19. DEVELOPMENT IN INFANCY<br />Neuropsychological processes<br />Affect regulation<br />Representations of self, other<br />Attachment Style<br />Adaptation to Stress<br />Capacity for intimacy and empathy<br />
  20. 20. INFANT CAPACITIES<br />Programmed for social interaction<br />Ability to communicate emotional experience<br />Move towards development and self-regulation<br />
  21. 21. EARLY BRAIN DEVELOPMENT<br />Promoted by secure attachment<br />Sharing of positive affective states<br />Carer maintains optimal level of arousal<br />Mutually attuned synchronized interactions promote affective development<br />
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  25. 25. EXPERIENCE & DEVELOPMENT<br />Experience activates specific neuronal connections<br />Sharing positive emotional states with a caretaker promotes brain growth and the development of regulatory capacities<br />Secure attachment promotes neuobiological functioning, emotional regulation and adaptation to stress<br />
  26. 26. NEUROBIOLOGY OF ATTACHMENT<br />Secure attachment promotes brain growth<br />Attachment relationship regulates emotional experience and level of arousal<br />Attachment figure acts as an external neurobiological regulator<br />
  27. 27. NEUROBIOLOGY OF ATTACHMENT<br />SECURE ATTACHMENT – optimal level of arousal<br />AVOIDANT ATTACHMENT – downplaying of emotional display<br />AMBIVALENT ATTACHMENT – heightened emotional display<br />DISORGANISED ATTACHMENT – high arousal and stress<br />
  28. 28. ATTACHMENT DISORGANISATION<br />Associated with trauma and abuse<br />Lack of effective strategy for dealing with caretaker<br />High levels of stress and related hormones<br />Defensive exclusion of understanding of caretaker<br />Excessive use of dissociation and opioid related states<br />
  29. 29. ATTACHMENT DISORGANISATION<br />Poor development of internal state language<br />Poor reflective function<br />Deficits in empathy<br />Contradictory representations of self and other<br />Dysregulation of behaviour, affect and impulses<br />
  30. 30. MODERATE STRESSORS<br />Emotionally unavailable carer - depression,anxiety, bereavment<br />Parental hostility and anger<br />Family conflict and domestic violence<br />Unpredictability and inconsistency<br />Neglect and stimulus deprivation<br />
  31. 31. EXTEME & CATASTROPHIC STRESSORS –NCCIP Classification<br />Loss of attachment figure<br />Continued physical/sexual abuse<br />Family overwhelmed- war, displacement, terror<br />Abandonment and gross neglect <br />
  32. 32. TRANSGENERATIONAL TRAUMA<br />Repetition of disturbed interactions and patterns of relationships<br />Repetition of abuse and maltreatment<br />Issues for abused parents - anxiety, compensation and reparation, envy<br />Re-enactment of unresolved attachment trauma<br />
  33. 33. NEURODEVELOPMENT & TRAUMA<br />Dysregulation of HPA axis functioning - stress system<br />Altered cortisol pattern- stress hormone<br />Reduced volume of hippocampus- memory<br />Reduced volume of corpus callosum- information processing<br />Potential effects on mood and impulse control, emotional regulation<br />
  34. 34. BRAIN FUNCTION & EXPERIENCE<br />STRESS – hyperactive stress response<br />CHAOS – poor sensory integration, attentional and processing problems<br />NEGLECT – poor emotional regulation, deficits in processing of socioemotional information and attachment<br />ABUSE – poor regulation of anger, aggression, impulses, anxiety; deficits in emotional understanding,<br />
  35. 35. IMPACT OF TRAUMA<br />Severity of the stressor<br />Developmental level of the child<br />Availability and capacity of adult support<br />
  36. 36. CHILDRENS’ RESPONSES TO TRAUMA<br />Children process and recall acute traumatic events<br />Persistent high arousal and anxiety<br />Immediate reactions include regression,clinging, muteness<br />Traumatic re-enactment in play and behaviour<br />
  37. 37. RESPONSES TO THREAT<br />HYPERAROUSAL – fight or flight response; adrenaline/noradrenaline; sympathetic<br />DISSOCIATIVE – freeze or play dead response; opiods and dopamine; parasympathetic<br />
  38. 38. TRAUMA SPECIFIC DIAGNOSES<br />Acute stress responses in infants - dissociation<br />Post-traumatic stress disorder - traumatic play, fears<br />Disruptive Behaviour Disorders<br />Attachment Disorders<br />
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  40. 40. TRAUMA AND THE BRAIN<br />Stress hormones and cortisol are neurotoxic<br />Sensitised pathways develop in R orbito-frontal brain regions - PTSD<br />Long lasting impairment in brain regions involved in regulation of the intensity of feelings<br />Persistent dissociation<br />
  41. 41. CHRONIC TRAUMA<br />Persistent orientation to threat and activation of stress response<br />Altered opioid, dopaminergic and serotinergic systems<br />Hyperarousal and overactivity<br />Affective dysregulation and impulsivity<br />
  42. 42. CHRONIC TRAUMA AND DEVELOPMENT<br />Child adapts to enduring stress according to developmental stage and capacities<br />Chronic stress will effect all domains of development and neurobiological functioning<br />Vulnerability is greatest at stages of rapid neurobiological organisation<br />
  43. 43. TYPE 2 TRAUMA - TERR<br />Adaptation - avoidance, repression, dissociation<br />Repetition – re-enactment, play, identification<br />Anxiety - arousal, aggression, self-harm<br />Self-Concept - depression, guilt, shame<br />
  44. 44. CORE DEFICITS<br />Problems with interpersonal relationships<br />Problems with affect regulation<br />Ongoing vulnerability to stress<br />Self and other representations- negative self-concept, mistrust of others<br />Deficits in reflective function and empathy<br />
  45. 45. HEALTH SERVICE APPROACHES<br />Screening by health care professionals and training for health professionals<br />Therapeutic approaches and services for children<br />Services for children who witness violence<br />Services for adults abused as children<br />
  46. 46. TRAUMA & PERSONALITY DEVELOPMENT<br />Dysregulation of affect and impulses<br />Disorganised attachment<br />Multiple models of self and others<br />Poor reflective function<br />Negative self-introject<br />
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  48. 48. SEVERE PERSONALITY DISORDER<br />Syndrome of neurophysiological and psychosocial dysregulation<br />Symptoms as attempts to reestablish homeostasis<br />Basis in traumatic early attachment experiences and neurodevelopmental effects of trauma<br />
  49. 49. PERSONALITY DISORDER<br />Dysregulation of affect and intolerance of anxiety<br />Limited internal state language<br />Contradictory representations of self and other<br />Limited reflective capacity<br />Unintegrated traumatic memories<br />
  50. 50. NEURODEVELOPMENT IN PD<br />Limbic irritability<br />Reduced size of hippocampus<br />Reduced left temporal lobe development<br />Reduced left-right integration<br />Reduced volume of corpus callosum<br />Decreased blood flow to cerebellar vermis<br />
  51. 51. FEATURES OF BPD<br />Self-destructive behaviour<br />Dissociation<br />Psychotic-like symptoms<br />Relationship disturbances<br />Affective disturbances<br />Identity disturbances<br />
  52. 52. Borderline Disorder <br />Current Issues<br />Diagnosis and classification<br />Relationship to early trauma<br />Early intervention and prevention<br />Effective intervention<br />
  53. 53. Borderline Disorder<br />Failure of caretaking environment<br />Maltreatment and abuse<br />Trauma in infancy and brain development<br />Inadequate social support and structure<br />
  54. 54. Borderline Disorder - Biopsychosocial Model<br />Genetics<br />Neurodevelopmental<br />Self disorder<br />Social fragmentation<br />
  55. 55. CONTEMPORARY MODELS OF BPD: FONAGY AND TARGET<br />BPD as deficit state<br />Defensive exclusion of reflective capacity - mentalization<br />Role of child maltreatment and trauma<br />Implications of disorganization of attachment<br />
  56. 56. Borderline Personality Disorder - Psychological<br />Unresolved trauma and loss<br />Poor reflective self function<br />Disturbed self-experience<br />Disorganized attachment<br />Maladaptive defense style<br />
  57. 57. CHRONIC TRAUMA<br />Persistent orientation to threat and activation of stress response<br />Altered opioid, dopaminergic and serotinergic systems<br />Hyperarousal and overactivity<br />Affective dysregulation and impulsivity<br />
  58. 58. CHRONIC TRAUMA AND DEVELOPMENT<br />Child adapts to enduring stress according to developmental stage and capacities<br />Chronic stress will effect all domains of development and neurobiological functioning<br />Vulnerability is greatest at stages of rapid neurobiological organisation<br />
  59. 59. Genetics<br />Environment<br />Disorganised attachment system<br />Temperament Traits<br />Maltreatment Chronic Stress<br />Integrative processing problem Dissociation<br />Emotional dysregulation<br />Behavioural dysregulation<br />Cognitive dysfunction<br />Intense Unstable relationships<br />Identity diffusion<br />Integrated model of borderline personality disorder<br />
  60. 60. INTERVENTION APPROACHES<br />Cognitive behavioral and psychoeducational<br />Attachment based – importance of parental capacity to perceive and sensitively respond to child's emotional needs<br />Without emotional attunement parenting programs may improve management but not the emotional aspects of the parent-child relationship<br />
  61. 61. EMOTIONAL REGULATION<br />Parent has difficulty in recognizing infant affect and may misinterpret signs of distress. This reflects their own distorted or denied affect related to early experiences<br />Limited reflective function related to maladaptive parenting such as withdrawal, hostility and intrusiveness<br />
  62. 62. ATTACHMENT BASED INTERVENTION<br />Early intervention – antenatal, infant and toddler<br />Program incorporating focus on emotional development and child’s needs for attachment<br />Focus on improving maternal emotional availability and reflective capacity<br />Evidence for medium term programs<br />
  63. 63. SERVICE ISSUES<br />Need for integrated child protection mental health early intervention approaches – risk assessment, parenting capacity and identification of infant trauma. This has training, workforce and redesign implications<br />Role and place of infant mental health programs – across maternal health, paediatrics, CAMHS, child protection<br />
  64. 64. RESEARCH ISSUES<br />Neurobiology of aberrant parenting- fMRI <br />Targeted interventions for parents with histories of abuse and neglect<br />Antenatal Interventions for women affected by substance abuse<br />Child abuse prevention – improving parental reflective capacity with attachment and trauma focused approaches<br />