The neurobiological complex trauma model And its relevance in work with refugee children
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1 The neurobiological complex trauma model And its relevance in work with refugee children Nordisk konferanse for behandlere som arbeider med flyktninger Bergen, April, 2013 Dag Ø Nordanger RKBU Vest / RVTS Vest
2 My starting point Dag Ø. Nordanger, 2013
3 Many things are culturally relative Photo of informant Expressions of psychological pain are culture-bound If there are universal trauma symptoms, there is no universal experience of them Photo of informant There is no coping strategy which works for all independent of culture Coping which works, works because it makes meaning in its context Dag Ø. Nordanger, 2013
4 But some things are universal Every child needs to be regulated to develop in a healthy way Infants cannot regulate their bodily states or affects themselves If the baby is scared or frustrated, somebody must be there to regulate the affect down to restore comfort If not, in the long run there will be dysfunction, no matter place or culture Dag Ø. Nordanger, 2013
5 DEVELOPMENTAL PSYCHOLOGY Its probably the most important function of early caregiving NEUROBIOLOGIAL RESEARCH A child s brain totally depends on it for developing normally REGULATION TRAUMA PSYCHOLOGY OF TODAY The most harmful traumas: Those occurring in childhood, and where the child is left alone to regulate intense fair E.g. violence on or within families Refugees are vulnerable for both Dag Ø. Nordanger, Palestine 2013
6 Complex trauma Prolonged/repeated exposure to traumatic stress combined with missing help to regulate affect This means; to understand complex trauma, we need to understand two things: 1. How traumatic stress shapes our neural system 2. How missing help to regulate affect shapes it Dag Ø. Nordanger, 2013
7 10 How traumatic stress shapes our neural system
8 Keep in mind how our brain develops Use it, or lose it! The brain is «use dependent» (Bruce Perry). What fires together, wires together (Hebb s law) Develops first and foremost though social interaction, and more than anytime in infancy Dag Ø. Nordanger, 2013
9 15 Keep also in mind the layers of our brain Survival brain (Brain stem) Emotional brain (Limbic system) Logical brain (Cortex) Dag Ø. Nordanger, 2013
10 Prefrontal cortex (Reasoning) Amygdala (Alarm central) Hippocampus (Learning & memory) Structures of our brain that are particulary central in the understanding of trauma 20 Pituary glands (Chemical plant) Dag Ø. Nordanger, 2012
11 Dag Ø. Nordanger, 2012
12 Come on! I am sitting safely here listening to a lecture at the Nordic refugee conference! He showed it just for pedagogical reason (that sadist)! False alarm! The stress-responsesystem Threat! Prefrontal cortex Amygdala Hippocampus Experiences from earlier in life tell me that snakes cannot hurt me as long as they are on a photo HPA-aksen Release of adrenaline a. m. Fight, flight & freeze Release of cortisol Dag Ø. Nordanger, 2012
13 After life-threatening events The stress-response system is sensitised, almost all of us will have symptoms of PTSD Threat! Prefrontal cortex Hippocampus Watchful and on the alert - generalization Intrusive memories Amygdala Avoidance of reminders HPA-aksen Normal phenomenon developed by evolution: We need to remember well life-threating events Release of adrenaline a. m. Fight, flight & freeze For some it becomes chronic Release of cortisol Dag Ø. Nordanger, 2012
14 How co-regulation shapes our neural system
15 Video early interaction, example of coregulation 30
16 Sensitive care shapes the same structures First, we ARE the child s prefrontal cortex and hippocampus Prefrontal cortex We stimulatate the regulating connections Amygdala Hippocampus Good bodily experiences linked to movement and language > integration HPA-aksen Gradually, it becomes internalised as own skills Release of adrenaline a. m. Fight, flight & freeze Binyrene Gives cognitive control Stored memories of other persons as good Dag Ø. Nordanger, 2013
17 When there is no help around to regulate affect
18 Video Still Face situation, example of how dependent children are on a coregulating adult
19 How trauma stress + missing help to regulate affect, shape our neural system
20
21 When violence infiltrates the care Traumatic stress + the one who should help regulating affect is put out of function (or represents the threat) Prefrontal cortex Amygdala Utskilling av adrenalin Fight, flight or freeze Binyrene Hippocampus HPA-aksen Double negative effect Overstimulated stress response system + underdeveloped regulation system Goes very easily into «fightflight» modus, and cannot calm down Or into «freeze» modus if «fight-flight» is not functional Stored representations of other people as dangerous Those representations are hard to correct because of the weak hippocampus Dag Ø. Nordanger, 2012
22 A summary on the way It is not the «Learning brain» (exploration, curiosity) that is developed in these children, but the «Survival brain» (protection, watchfulness) Not just PTSD; the survival mode will be seen as problems in same functions as early care normally should promote Since a crucial function of early care is to learn to regulate oneself, problems are particularly seen there The most significant consequence of early relational trauma is the loss of the ability to regulate the intensity and duration of affects (Alan Schore) Dag Ø. Nordanger, 2013
23 If a fight/flight reaction like crying functional, if it saves the child from the situation Hyper-activation Threat! If fight/flight is not possible, like if the person who should protect the child is put out of function or is the threat Hypo-activation (Dissociation)
24 The window of tolerance Hyper-activation Fight/flight modus: Unrest, aggression, acting out, impulsivity, chaos, etc. A K T I V E R I N G WINDOW OF TOLERANCE The optimal zone of activation Hypo-activation Freeze modus: Emptiness, depression, numbness, dissociation, etc.
25 3 implications 45
26 1 We must look for patterns of general regulation problems, not just diagnoses! Because regulation problems cross diagnoses Consequently, these children get numbers of diagnoses which are not always updated according to our current knowledge base Dag Ø. Nordanger, 2013
27 To illustrate our challenge; Anxiety, depression or other emotional problems, ADHD, behavioral problems, personality disorders and PTSD are all common among Unaccompanied Minors (bl.a. Huemer et al., 2009) Half of children exposed to physical or sexualised violence meet the criteria for oppositional defiant disorder (Lyttle & Brodie, 2007) Half of children exposed to sexual abuse meet the criteria for ADHD (the most common diagnosis in this group) (McLeer et al., 1994). And when they grow up Adults with experiences of four or more childhood adversities meet the criteria for 6,2 DSM-diagnosis, in average! (Putnam et al., 2008) Dag Ø. Nordanger, 2012
28
29 Is DTD the pattern we should look for? Affective and physiological dysregulation Inability to modulate, tolerate, or recover from strong affect states (e.g. fear, anger) Dysregulation of bodily functions (e.g. sleep, eating, reactivity to touch and sounds) Reduced awareness of sensations, emotions, and bodily states Impaired capacity to describe emotions or bodily states Attentional and behavioral dysregulation Preoccupation with threat or impaired capacity to perceive threat Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking Maladaptive attempts at self-soothing (such as self harm) Self and relational dysregulation Preoccupation with safety of the caregiver or other loved ones Persistent negative sense of self (including feeling of worthlessness) Extreme and persistent distrust, defiance or reciprocity in close relations Reactive physical or verbal aggression toward peers, caregivers, or other adults, Inappropriate (excessive or promiscuous) attempts to achieve intimate contact Impaired capacity to regulate empathic arousal NB! Not exact phrasing, I have condenced some criteria to get them into a slide
30 We must redefine our treatment goals! 2 For the most complexly traumatised children, healing is not just about processing traumatic memories. Do we still have a tendency to speak to the logical brain, when the problem is in the survival brain? Improve the ability to stay inside the tolerance window Improve the ability to regulate oneself back into the tolerance window at hyper- or hypo-activation Expand the tolerance window (often very narrow) Dag Ø. Nordanger, 2012
31 Many youth develop complex trauma, which includes regulation problems in the domains of affect, attachment, behavior, biology, cognition, and perception The duration [ ] needs to be extended, from the typical 8 16 sessions to 25 sessions and occasionally up to sessions Dedicate [ ] half of the [ ] sessions to the coping skill building phase [To] ask youth to identify a single worst trauma experience [ ] rarely captures the essence of the youth s complex traumatic experiences or outcomes Dag Ø. Nordanger, 2012
32 3 We must acknowledge which competence these children primarily need from us! They do not first and foremost need highly specialised therapeutic expertise (at least not in the first round) They need new life experiences which represent the opposite of what they have got So first and foremost they need normal care (help to be regulated) just an overdose of it But how to give that to a child who resists it?! In my view, that is the most important competence we need! Dag Ø. Nordanger, 2012
33 Kids in stress create in adults their feelings and, if not trained, the adults will mirror their behaviour (Long & Fecser, 2000)
34 Let s imagine a situation Where all people in a child s network (therapists, social workers, teachers, foster parents & football coaches) and the child itself... shared the neurobiological understanding of complex trauma, and the idea of the tolerance window Dag Ø. Nordanger, 2012
35 Heine Steinkopf, RVTS SØR, 2012
36 Heine Steinkopf, RVTS SØR, 2012
37 The window of tolerance What happened here? A K T I V E R I N G What happened here? WINDOW OF TOLERANCE Dag Ø. Nordanger, 2012
38 And what if We all worked systematically together to improve the child s body & affect awareness and regulation skills Body & affect AWARENESS Create settings for good bodily and tactile experiences Practice naming feelings and bodily sensations Comment on feelings rather than behaviour Identify triggers of affect, investigate their forewarnings Etc. (creativity permitted) Self & affect REGULATION Being regulators through our own voice and gestures Being models for good selfsoothing strategies Prioritise relation and closeness, rather the correction Practise alternative strategies when triggers occur Etc. (creativity permitted) Dag Ø. Nordanger, 2012
39 Then we could make a huge difference!
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