NEUROPSYCHOLOGICAL ASSESSMENTS OF STUDENTS WITH COMPLEX TRAUMA; HELPING DEVELOPING BRAINS GET BACK ON TRACK MAKING A DIFFERENE: FIFTH ANNUAL SURROGATE PARENT CONFERENCE, FEDERATION FOR CHILDREN WITH SPECIAL NEEDS NOVEMBER 15, 2016 STEPHANIE MONAGHAN-BLOUT, PSY.D. PEDIATRIC NEUROPSYCHOLOGIST, NESCA
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NEUROPSYCHOLOGICAL ASSESSMENTS OF STUDENTS WITH … · 2016. 11. 12. · beginning in childhood or early adolescence B. Affective and Physiological Dysregulation C. Attentional and
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NEUROPSYCHOLOGICAL ASSESSMENTS OF STUDENTS WITH COMPLEX TRAUMA;
HELPING DEVELOPING BRAINS GET BACK ON TRACK
MAKING A DIFFERENE: FIFTH ANNUAL SURROGATE PARENT CONFERENCE,
THE MOST VULNERABLE POPULATION: CHILDREN IN INSTITUTIONAL CARE
• US children in foster care 2015 has reached 427,910
• From peak of 524,000 in 2002
• Lowest number of 397,000 in 2012
• -Associated Press, 10/27/16
THE MOST VULNERABLE POPULATION: CHILDREN
Number of children adopted through public welfare
system and number of Massachusetts children adopted
through this system 2010 2011 2012 2013 2014
52,891 50,875 52,035 50,608 50,644
726 724 754 799 589
OUTLINE
-Trauma and the Developing Brain
-Developmental Trauma and FASD: Developing a
Blueprint for Understanding
-Neuropsychological and Psychological Testing
TRAUMA AND THE DEVELOPING BRAIN
TRAUMA
• “Psychological trauma is an affliction of the powerless. At the
moment of trauma, the victim is rendered helpless by overwhelming
force. When that force is of nature, we think of disasters. When that
force is that of other human beings, we speak of atrocities. Traumatic
events overwhelm the ordinary systems of care that give people a
sense of control, connection, and meaning”.
• -Judith Herman, M.D. (1992) Trauma and Recovery
WHAT CONSTITUTES TRAUMA
1. Witnessing domestic violence or community violence
2. Abuse: physical, sexual, or psychological, especially that
occurring within the context of relationship
3. Neglect of physical, social, or emotional needs
WHAT CONSTITUTES TRAUMA: NOT SO SIMPLE
• Neglect, abuse, and witnessing violence often co-occur
• Some children are more vulnerable due to prenatal factors
( exposure to drugs, malnutrition, maternal stress)
• Children are also exposed to secondary impacts such as
maternal depression or physical injuries
DIFFERENTIAL IMPACT OF TRAUMA: WHY KIDS ARE SO VULNERABLE
Developmental Vulnerability
- Helplessness of young children: what is
life-threatening to young children is not the
same as for adults
-Trauma to growing brains alters the
trajectory of development
TWO KEY FACTORS MITIGATING IMPACT OF TRAUMA
Resiliency related to:
• Psychosocial support, including the caregiver’s
response to the traumatized child
• Child’s sense of mastery
CHILDREN’S RESPONSE TO TRAUMATIC EVENTS VARIES
-Stage of development
-Cognitive profile
-Duration, severity, frequency of trauma
-Presence of Protective Factors, especially attachment
A SHORT COURSE IN BRAIN DEVELOPMENT
• Development is “hardwired”-
• Orderly, Sequential Process of Maturation
• Proliferation
• Organization
• Specialization
PROLIFERATION
• During the last trimester of pregnancy and the first 18
months of life, the brain, the brain increases to four
times its size, close to the final weight during adulthood
ORGANIZATION
• After this period of rapid growth, the focus turns to
organization and specialization. Unutilized or redundant
neurons are “pruned” (eliminated) in the service of
greater efficiency.
• Myelinization: Creating neural “superhighways to
optimize efficiency
SPECIALIZATION: SENSITIVE PERIOD OF MAXIMAL
PLASTICITY
• Sensitive period in which brain is maximally receptive
to certain kinds of stimuli to develop certain kinds of
behavior. If these stimuli are not present and if
behavior not reinforced, brain circuit supporting the
behavior do not develop and behaviors will not
continue. “USE IT OR LOSE IT”
IMPORTANCE OF ATTUNED CAREGIVING OR THE CRITICAL IMPORTANCE OF “PEEK-A-BOO”
• When a child has consistent, attuned caretaking:
• -someone comes when they cry to alleviate their fear and discomfort. As they gain
confidence that this will happen, their tolerance grows and they begin to learn how to self-
regulate
• -someone engages with them on more than a functional level, encouraging them to
experience the world. This process develops the capacity to direct and shift attention.
• -someone gives them space to move and toys to play with, creating the opportunity to
develop fine and gross motor skills
• -someone protects them, plays with them and enjoys them, establishing a sense of mutuality
THE STRESS RESPONSE
•The Body’s Alarm System- Enable us to gear
up to respond to threat
STRESS RESPONSE- THE HYPOTHALAMIC-PITUITARY-ADRENAL
CIRCUIT (HPA)
• As the brain recognizes a threat, the hypothalamus
releases corticotropin-releasing hormone (CRH) which
stimulate the pituitary gland to release
Adrenocorticotropin (ACTH) which then prompt the
adrenal glands to release a number of other hormones
IMPACT OF HORMONES
• Switch on systems needed to respond to threat- sympathetic nervous system (Fight or Flight)
• Switch off systems not essential to crisis response – parasympathetic nervous system (Rest and Digest)- included digestive system, reproductive hormones, growth hormones
• Stimulates the release of sugar (glucose) to power muscles and brain to respond to the danger (Cortisol)
• Once danger is passed, Cortisol exerts a feedback loop to shut the production of CRH by the hypothalamus.
CHRONIC EXPOSURE TO STRESS WHAT IF THE LOOP DOESN’T SHUT
DOWN?
• Significant, ongoing stress in early childhood can cause the
HPA feedback loop to become stronger, and with each
reiteration, the loop becomes stronger, leading to a very
sensitive stress response. Which this hypervigilance may be
adaptive in highly dangerous environments, the “life or
death” response to minor irritants results in adjustment
problems in other settings
THE STRESS RESPONSE: REACTING TO THREAT
•Fight
•Flight
•Freeze
REACTING TO THREAT: FIGHT
• Argumentative
• Noncompliant
• Oppositional
• Impulsive
REACTING TO THREAT: FLIGHT
•Distractible
•Gives up quickly
•Avoidant
REACTING TO THREAT: FREEZE
•Problems with Initiation (getting started)
•Problems with Shifting (switching gears)
•Problems with Termination (letting go)
IMPACT OF TRAUMA CHRONIC “FIGHT/FLIGHT/FREEZE?
Cognitive resources mobilized for protection from danger
• Attentional system is geared to be on the lookout for signs of
danger (triggers)
• Arousal “set-points” are fixed (too much, too little)
• Distorts perceptions of people and events
• Drastically limits capacity for flexible thinking and creative
problem solving
• Creates conditions of physical discomfort
IMPACT OF TRAUMA; BEHAVIORAL PRESENTATION
• Attention and EF problems (can look like ADHD)
• Diminished Language Competency
• Behavioral Dysregulation
• Anxiety, Depression, Self-Injurious Behaviors
• Learning Issues
• Weak Social Skills
• Substance Abuse
IMPACT ON HEALTH ADVERSE CHILDHOOD EXPERIENCES STUDY (ACE)
-Data from 1998 survey of more than 17,000 members of
Kaiser Permanente HMO:
-2/3 of respondents reported at least one ACE
-44% reported experiencing sexual, physical or
psychological abuse as children
-20% reported 3 or more ACEs
IMPACT ON HEALTH ADVERSE CHILDHOOD EXPERIENCES STUDY
• Major Findings;
• Study findings report a graded dose-response relationship between
number of ACE and negative health and wellbeing outcomes.
• In other words, the more bad childhood experiences, the more likely
to contend to health risk behaviors (alcohol and other drug abuse,
depression, suicide) and negative health outcomes (heart disease,