effects of traumatic stress on the family - healthy...
TRANSCRIPT
Effects of Traumatic Stress on the Family Sue Brown, LCSW-C
Child & Family Therapist, Clinical Services
March 2014
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Introductions
Who’s here today? Health care professionals
Therapists
Clergy
Legal Field AIP
Students
Other
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Learning Objectives
A?er the training, parAcipants will be able to; – Define traumaAc stress – IdenAfy three physiological effects of traumaAc stress on the individual
– IdenAfy three ways trauma might manifests in the family
– IdenAfy three ways to intervene between child and non abusing parent
– IdenAfy three ways trauma effects child development
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What is Traumatic Stress
• Traumatic stress refers to a psychological and physiological response to an extreme event that overwhelms a person's ability to cope.
• An individual's subjective experience determines whether an event is or is not traumatic.
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The Body’s Physiological Response to Trauma
• When faced with a real or perceived threat, our nervous system responds by releasing a flood of stress hormones.
• These hormones prepare the body for emergency acAon.
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3 Primary Stress Hormones
1. Adrenaline 2. Norepinerphrine 3. CorAsol
These stress hormones are designed to protect us from danger.
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HPA Axis
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Negative Feedback loop
• CorAsol, a hormone produced from stress, loops back around and feeds back to the anterior pituitary and hypothalamus to say “I’m here”, you can stop producing the hormones.
• Chronic stress breaks this system down, it was designed for short term and infrequent crisis.
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Normal Cortisol Production
• We have corAsol produced at night, so we have more in the morning, and none at night. – CorAsol is designed to help wake us in the morning and it declines as the day goes on. By bedAme we have almost zero corAsol allowing us to sleep.
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The Physiological Response
• The heart pounds faster, muscles Aghten, blood pressure rises, breath quickens, and your senses become sharper.
• These physical changes increase your strength and stamina, speed your reacAon Ame, and enhance your focus – preparing you to either fight, flee or freeze from the danger.
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Stress Hormones Activate Some Systems, and Turns Others Off • As we prepare to fight/flee/freeze, these neurochemicals cause an increase in heart rate and respiraAon, maximizing oxygen flow to muscle Assue and ‘turning off’ other non-‐essenAal organ systems, including the prefrontal cortex.
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Physiological Impact from Stress Continues
• Even mild stress can flood the prefrontal cortex with the neurotransmicer Dopamine, which causes execuAve funcAoning to shut down.
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Executive Functioning
• ExecuAve FuncAoning, includes cogniAve flexibility, self-‐control, working memory, organizing, planning prioriAzing, and self-‐awareness.
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The Hippocampus also Shuts Down
• The hippocampus is the part of the brain that is involved in memory forming, organizing and storing.
• The hippocampus is responsible for forming new memories and connecAng emoAons and senses, such as smell and sound, to memories.
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Not Able To Make Sense of What’s Happened
• So, for the very worst of human experiences, the human mind and body are impeded from the job of preparing us to make meaning and sense of what has happened.
• People are frequently le? with fragmented memory.
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How Might This Person Present?
– She doesn’t have it together – Discombobulated – She can’t think straight – Confused – Angry/depressed – Incapable – Totally together – Slow (Hotline call and acempted murder vicAms)
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How Might this Person Feel?
– I’m crazy
– Can’t get it together – It my fault, look at me – I’m all over the place
– I’m a mess – Guilty for puhng the children through this – Overwhelmed with everything
– Feels bad about who she is (Woman whose husband broke in)
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Common Problems with Chronically Elevated Cortisol • Suppressed immune system • Hypertension • High blood sugar (hyperglycemia)
• Metabolic syndrome and type 2 diabetes
• Bone loss
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Effects of Prolonged Activation of the Stress Response
• Anxiety • DigesAve problems
• Heart disease • Sleep problems
• Depression • Weight gain
• Memory and concentraAon impairment – (stomach ulcers, weight gain, etc)
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Whew…..
• How are we all doing?
• Some people enjoy the physiological aspect and some hate it.
– Why is it important for us to have a command of our understanding of the physiological impact of trauma?
– How can we use this informaAon to benefit clients?
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Families Develop Themes When They Experience Trauma
Families believe…. • ‘Bad things happen’ • ‘The world is a scary place’
• ‘You can’t trust anyone’ • ‘Bad things will happen’
(Research done with a photo shown to children who were and were not trauma@zed)
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Beliefs and Assumptions are Shattered
• TraumaAc experiences shake the foundaAons of our beliefs about safety, and shacer our assumpAons of trust.
• The traumaAc event commonly include abuse of power, betrayal of trust, entrapment, helplessness, pain confusion or loss.
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Traumatic Stress Results in Poor Family Functioning
Decreased time spent together Instability and/or rigidity Hyper vigilance Less relational security Less emotional understanding/connection Heightened levels of negativity/conflict Chronic crisis and survival modes Chronic disequilibrium Lack of future orientation
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Impact of Trauma on the Survivor
• The survivor may have traumaAc events from her own childhood.
• She likely has flat corAsol levels throughout the day; causing poor sleep and a slow start in the morning.
• Her execuAve funcAoning may be impaired, causing difficulAes in the daily rouAnes.
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Impact of Trauma on the Survivor
• She could also flashbacks
– She may have panic acacks – She fears he’ll show up again – She fears he’ll try to take the children – She fears for her and her children’s safety – She fears he’ll never leave her alone
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The Survivor as a Caregiver
The caregiver doesn’t feel empowered as a caregiver. – IPV creates chaos in the home, disrupAng rouAnes and parenAng strategies
– Abusers o?en ridicule their vicAms in front of the children or tell the children not to listen to their mother
– Children may act out more when the abuser is no longer living with the family.
(Dad “look at your mom now, or dad who wouldn’t let the boy leave the room)
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Impact of Trauma on the Survivor
• She may move in with family, where her authority as a parent conAnues to be undermined, similar to the abuser.
• She may be isolated and have very licle emoAonal support.
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The Survivor as a Caregiver
• The caregiver may have trouble toleraAng the child’s sadness, anxiety or aggression.
(Seeing the child’s behavior through the lens of being abused. Hands on face, neck, etc.)
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Child Witnesses
• While o?en characterized as witnesses, implying a passive role, children who live with violence are acAvely engaged in interpreAng, predicAng and assessing their role in causing the violence, worrying about consequences, problem solving and/or taking measures to protect themselves, physically and emoAonally (Cunningham 2004).
(6 yr. old in room, listening, but not seeing)
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What we Know About Baby’s and IPV
• Children under the age of 2 are most frequently injured in DV incidents
(Child injured, and mom’s eye messed up. 8 yr. old went to ask quesAon, dad choking mom, 5 day old on bed next to them)
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Effects of IPV Exposure on Pre-School Children
• Preschool-‐age kids who witness IPV are likely to: – Appear withdrawn, clingy, or anxious about separaAng from a parent
– Regress to behaviors they had outgrown, such as thumb-‐sucking or bed-‐wehng
– Act out scenes of IPV in their play – Have increased nightmares
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Impact of IPV Exposure Pre-School Children
In a study of 3-‐5 year olds in families with IPV, 60-‐74% of children were in the clinical range on standardized measures of behavioral adjustment problems of aggression, anxiety, and social withdrawal. (Howell, Graham-‐Bermann, Czyz, & Lilly 2010)
• This rate is 30 Ames higher than expected in the general populaAon (Graham-‐Bermann 2005)
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Impact of IPV Exposure for School Age Children
School-‐age children can develop a range of behaviors as a result: • Change in temperament
• Unpredictable or uncharacterisAc reacAons • Poor behavior or academic performance at school
• Complaints of headaches and stomachaches
• Feeling responsible for the violence • Feeling compelled to stop the violence; may be injured when they intervene
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Impact of IPV Exposure for Adolescents
• Adolescents who witness IPV at home may: – Exhibit feelings of shame, betrayal, and rage – Cope by running away, cuhng class, dropping out, and/or using drugs & alcohol
• Teen boys are significantly more likely to use aggressive control and violence in relaAonships
• Teen girls are significantly more likely to tolerate violence in relaAonships, and experience depression as adults
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Effects of Trauma on the Parent-Child Relations • ParenAng under high stress and trauma is associated with negaAve parenAng characterisAcs such as; – insensiAvity, lack of responsiveness withdrawal, low warmth, reacAvity, irritability, negaAvity, harshness and puniAve.
– Kids say, mom is scary like dad.
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Co-Occurrence of Child Abuse & Intimate Partner Violence
• Children who witness IPV are physically abused and neglected at a rate 15 Ames higher than the naAonal average.
• Studies have found that child abuse occurs in up to 70% of families that experience domesAc violence.
• Parents who witnessed domesAc violence as children are more likely to abuse their own children. (1 in 4)
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Effects of Trauma on Parent-Child Relations
The parent and children tend to have their HPA axis acAvated by one another. • Triggering a trauma response.
They all experience anAcipatory anxiety. • They may perceive danger when it is not there, believing the world is a scary place.
• The child watches how the parent acts, and may worry about the parents ability to funcAon, and care for them.
(This is where our psycho-‐educaAon helps everyone)
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Effects of Trauma on the Parent-Child Relations • Watching the parent re-‐experience the trauma, or have panic acacks is distressing to children.
• We see children taking on parent responsibiliAes when the parent is not able to do so.
• This parenAficaAon may cause the child to feel more grown than they are. (Bossy or responsible? Controlling? You are in charge, now your
in trouble, eldest and confidant)
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Effects of Trauma on Sibling Reactions
• Adult hosAlity, and harsh, low-‐nurturing, or intrusive parenAng increases sibling aggression and self-‐protecAve behavior.
• Children tend to act out with siblings the aggression that they saw between the adults.
– Kids have knocked out a sibling, hit each other over the head with metal chairs. Fight with huge belt buckles
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IPV is a Form of Primary Oppression
• We know that people feel devalued as human beings when they have been oppressed. – This plays out in the family by everyone feeling disrespected by one another.
– Family members will yell at one another or jump to conclusions quickly.
– This over reacAon is the Trauma Response, or the AcAvaAon of the HPA Axis, they are ready to slay a dragon, but they are with loved ones.
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Self-Regulation
We need to help people move out of the sympatheAc and into their para-‐sympatheAc system
• SympatheAc sAmulaAon is the alarm system – This is what sets off our alarm system
• Para-‐sympatheAc sAmulaAon calms us – This provides a natural tranquilizing effect, and calms the body
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Parasympathetic Stimulation
Trauma1zed clients need help self-‐regula1ng
• Breathe in such a way that your inhalaAon is a count 1-‐2-‐3-‐4 through your nose and exhalaAon through your mouth in the count of 1-‐2-‐3-‐4-‐5-‐6-‐7-‐8.
• We want to breathe through our diaphram, so our abdomen comes out, not our chest. SomeAmes it helps to put our hand on our abdomen to ensure it moves in and out.
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Let’s Rehearse this Technique
• Sit up straight • Feet on the floor • Best to not have body parts crossing • Close your eyes if you would like • You can put your hand on your abdomen
• Now breathe in through your nose, to a count of 4, and out through your mouth a count of 8-‐10, and repeat three Ames.
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Brain Development
The brain systems develop in a sequenAal and predictable fashion -‐-‐ from the most primiAve, brainstem, to most complex, cortex. (Bruce Perry)
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Brain Development
• Because the brain system develops in a sequenAal fashion, from brainstem to cortex, opAmal development of more complex systems, such as the cortex, require healthy development of less complex systems, like the brainstem and midbrain. (Bruce Perry)
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Brain Development
• There are criAcal periods or windows of vulnerability during which the organizing brain systems are most sensiAve to environmental input -‐-‐ including traumaAc experience. (Bruce Perry)
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Brain Development
• Therefore, if the regulaAng parts of the brain (brainstem and midbrain) develop in a less than opAmal fashion (e.g., following excessive traumaAc experience) this will impact development of all other regions of the brain. (Bruce Perry)
(Hernia)
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Brain Development
• Experience can change the mature brain, but experience during the the criAcal periods of early childhood organizes brain systems.
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Brain Development
• Trauma during infancy and childhood, has the potenAal effect of influencing the permanent organizaAon -‐-‐ and all future funcAonal capabiliAes -‐-‐ of the child. (Bruce Perry)
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The Response to Trauma
• Two primary adapAve response pacerns in the face of extreme threat are the hyper-‐arousal conAnuum (defense -‐-‐ fight or flight) and the dissociaAon conAnuum (freeze and surrender response).
• Each of these response 'sets' acAvate a unique combinaAon of neural 'systems'.
(Bruce Perry)
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The Response to Trauma
• In general, the predominant adapAve style of an individual in the acute traumaAc situaAon will determine which symptoms will develop – hyper-‐arousal or dissociaAve. (Bruce Perry) – Child goes in cave when anything stressful is brought up
– 17 yr. old, smart, capable, and feels he doesn’t understand the assignment. (ACT/SAT)
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Treatment
• Anything that can decrease the intensity and duraAon of the acute response (alarm or dissociaAve) will decrease the probability of persisAng symptoms.
• In general, structure, predictability and nurturance are key elements to a successful early intervenAon with a traumaAzed infant. (Bruce Perry)
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Treatment
• The primary source of these key elements is the primary caretaker. Therefore, it is criAcal to help the caretakers understand as much about post-‐traumaAc responses as possible.
• Early assessment and intervenAon can help prevent prolonged acute neurophysiological, neuroendocrine and neuropsychological trauma response.
• (Bruce Perry)
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Secure Attachment
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Not Crying Secure Attachment
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Avoidant Attachment
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Parent Voice
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Resistant Attachment
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Disorganized Attachment
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Overwhelming
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Adult Perceptions of Young Children and Trauma
• We o?en hear "Children are resilient," or "They'll get over it, they didn't even know what was happening.”
• It is not uncommon for adults to relate the traumaAc events to someone interviewing them in the presence of the child as if they were invisible.
(Bruce Perry)
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Adult Perceptions of Young Children and Trauma
• O?en, recounAng the event, the adults will describe how the traumaAc event was terrifying for them, but as they describe the child's reacAons they frequently misunderstand the child's unacached, nonreacAve behaviors as 'not being effected' rather than the 'surrender' response.
• This pervasive, destrucAve view of caretaking adults in a young child's life exacerbates the potenAal negaAve impact of trauma. (Bruce Perry)
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Child Disclosures
• Minors have privilege, that parents and minors can not wave. (Is acAve when possible custody case may occur) – Only a court appointed acorney called best interest acorney or privilege acorney can wave privilege.
– You must know who your client is, if the child is your client then you must not violate the child’s privilege.
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Child Disclosures
• Doctor must write lecer staAng stress is effecAng child’s health. – Child needs to have physical ailments, stomach ulcers, weight gain, chewing fingers, etc
• DocumentaAon
• CPS doesn’t want to get involved in custody issues. They want the court to decide.
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Let’s Recap
• TraumaAc stress refers to a psychological and physiological response that overwhelms a person's ability to cope.
• Some physiological effects of trauma: heart pounds faster, muscles Aghten, blood pressure rises, breath quickens, and our senses become sharper. The execuAve funcAoning and our memory is effected.
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Let’s Recap
• Effects on the family; – Belief system becomes effected
– Family members acAvate one another – Less Ame spent together – AnAcipatory anxiety – More negaAve interacAons – Kids get clingy, just when mom needs space
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Let’s Recap
• What can we do to intervene? – We can provide psycho-‐educaAon on what happens to the body, and why the home and the family might be chaoAc.
– We can teach various relaxaAon skills, so people access the parasympatheAc system to self-‐regulate. They must rehearse and rehearse.
– We can support parents in knowing that when there has been adversity, it makes parenAng much more difficult.
– We can encourage nurturing behaviors.
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Let’s Recap
• How does trauma effect child development? – The child uses coping strategies, so we need to protect them as much as possible
– Changes in the neural network has lasAng effect on the brain organizaAonal structure
– Acachment is effected by IPV – The child’s coping strategies may become problemaAc behaviors
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Select References • Appleyard, K. & Osofsky, J.D., (2003) Parenting after trauma: Supporting parents and
children impacted by violence, Infant Mental Health Journal 24(2), 111-125. • Banyard, V.L, Rozelle, D., & Englund, D. W. (2001). Parenting the traumatized child:
Attending to the needs of nonoffending caregivers of traumatized children. Psychotherapy, 38(1), 74-87.
• Bradley D. Grinage, M.D.,(2003). Diagnosis and Management of Post-traumatic Stress Disorder, University of Kansas School of Medicine–Wichita, Wichita, Kansas, Am Family Physician, 68(12) 2401-2409.
• Bremner JD, Narayan M (1998): The effects of stress on memory and the hippocampus throughout the life cycle: Implications for childhood development and aging. Developmental Psychopathology 10:871-886.
• Corsini, R. (2001) Handbook of innovative psychotherapies 133 • Entin, Esther M.D, (2012) How Family Violence Changes the Way Children's Brains
Function, The Atlantic, January 2, online. • Fisher, Janina Ph.D, (2003) Working with the Neurobiological Legacy of Early
Trauma. Instructor and Supervisor, The Trauma Center, Boston, Massachusetts Paper presented at the Annual Conference, American Mental Health Counselors.
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Select References
• Graham-Bermann, SA., Seng J. (2005). Violence exposure and traumatic stress symptoms as additional predictors of health problems in high-risk children. Journal of Pediatric, March,146(3):349-54
• Hamby, S, Finkelhor, D., Turner, H., & Ormrod, R. (2011). Children’s Exposure to Intimate Partner Violence and Other Family Violence, Juvenile Justice Bulletin – NCJ 232272. Washington, DC: U.S. Government Printing Office
• Howell, Graham-Bermann, Czyz, & Lilly 2010 Assessing resilience in preschool children exposed to intimate partner violence; Violence and victims25(2):150-64.
• Kiser, L. J., & Black, M. A. (2005). Family processes in the midst of urban poverty. Aggression and Violent Behavior, 10(6), 715-750.
• National Center for Children in Poverty, (2007). Strengthening Policies to Support Children, Youth, and Families Who Experience Trauma, July, working paper #2. protocols, and procedures 1-6, 315-360
• Excerpts from Bruce Perry, (1995) Childhood Trauma, the Neurobiology of Adaptation & Use-dependent Development of the Brain: How States become Traits, Infant Mental Health Journal, Vol 16.(4) Winter
72
Select References • Perry, B.D. Traumatized children: How childhood trauma influences brain
development. The Journal of the California Alliance for the Mentally Ill 11:1, 48-51, 2000 • Phillips, M. (2000) Finding the energy to heal: How EMDR, Hypnosis, TFT,
Imagery, and Body-Focused Therapy Can Help Restore Mindbody Health 240-248
• Sapolsky RM (1996). Why stress is bad for your brain. Science 273:749-750 • Shapiro, F. (2001) Eye movement desensitization and reprocessing : basic principles, • Sousa, Cindy, Herrenkohl, Todd, Moylan, Carrie, Tajima, Emiko, Klika, Bart
Herrenkohl, Roy and Russo, Jean (2011) Longitudinal Study on the Effects of Child Abuse and Children’s Exposure to Domestic Violence, Parent–Child Attachments, and Antisocial Behavior in Adolescence, Journal of Interpersonal Violence, 26(1) 111–136, published online May 10
• Van der Kolk, B.A., McFarlane, A.C. & Weisaeth, L., Eds. (1996). Traumatic stress: the effects of overwhelming experience on mind, body, and society. New York: Guilford Press.