trauma&and&development:& … · sensory%modulation • ability%to%grade ......
TRANSCRIPT
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Trauma and Development: An Integrated Best Practice
ApproachATTACH Conference-‐ September 27, 2015
Kathy Ryan, Ph.D., LCSWClinical Coordinator, Circle Preschool Program, GRSCAN, Richmond, VA
Denise Powers, M.Ed.
Early Childhood Specialist, Circle Preschool Program, GRSCAN
Shelly Lane, Ph.D., OTR, FAOTAFaculty of Health and Medicine Department of Occupational Therapy
Newcastle University, Callaghan, NSW, Australia
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Workshop Objectives
• Participants will explain the impact of developmental trauma on function within the relational, regulatory, and cognitive domains.
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• Participants will list 5 essential treatment techniques to support healing in a child who has experienced developmental trauma.
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• Participants will create a treatment plan for a young child who has experienced developmental trauma.
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And Who Are You?
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Circle Preschool ProgramGRSCAN (Stop Child Abuse Now)
Richmond, VA
• Therapeutic Classroom within a typical preschool setting• 3-‐5 year olds; trauma backgrounds + unsuccessful adaptation to typical settings• Provision of therapeutic, play-‐based , educational milieu, psychotherapy, occupational therapy • Family/ Caregiver therapy – group and individual • Goal-‐ To transition into typical setting and healing from trauma
• Length of stay-‐ dependent on need or age
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Typical Development
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Development is a neuro-‐biologic process…
vEpigenetics & Genetics…
vBrain says…Survival is key!
vOrganization & functional capacity of brain is hierarchical & sequential
v Use dependent development
v State based dependency
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Brain is Use Dependent
The brain changes in response to specific patterns of activation (experience )
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Sensation as Nourishment
• Essential for brain functioning• A starting place for the development of adaptive environmental interactions
• Critical for• Attachment and social relationships• Arousal regulation• Organization of action
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Emphasis: body centered sensory systems
Vestibular
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Sensory intake and processing
• Sensory intake: Receptors• Organization of sensation: brain structures• Brain hierarchy• Lays a foundation for regulation of alertness and emotions
• Results in production of an adaptive response
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Sensory Modulation• Ability to grade behavioral responses in relation to intensity, complexity, or novelty of sensation
•When modulation is working well, child can automatically• Filter out non-‐relevant stimuli• Notice relevant stimuli
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The “State” of the BRAIN
Function is STATE Dependent
• From calm to alert to alarm to fearful to terror….
• With increasing level of arousal, the primary area of neural activity shifts to lower levels within the brain
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Sensitive periods of Development
“Experience can change the mature brain, but experienceduring the critical periods of early childhood organizes brain systems.” Perry, 2006
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Trauma
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Trauma is…
• Experiences which are overwhelming, and over stimulating -‐-‐ more than a person can cope with at the time.
• Physical abuse, sexual abuse, emotional abuse (relational), domestic violence, chronic neglect
• Severe disasters, witnessing violence
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Healthy Development vs. Developmental Trauma
What Children Need:
• Dependent on predictable consistent nurturing attention
• Secure attachment patterns
• Fewer primary caregivers
• Co-‐regulation is needed àindependence
What children experience:• Primary caregivers abuse• Repeated abuse from adults• Highly aroused, negative environments• Domestic violence• Severe Neglect• Insufficient nurturing
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Abstract thought
Concrete Thought
Affiliation/reward
"Attachment"
Sexual Behavior
Emotional Reactivity
"Arousal"
Appetite/Satiety
Blood Pressure
Heart Rate
Body Temperature
Sleep
Motor Regulation
NEDA
ANS -‐ body
SER
All rights reserved © 2006-2012 Bruce D. Perry and The ChildTrauma Academy
Symptoms of Trauma
Trauma Core symptoms
Depressive and Affective symptoms
Relational difficulties
Guilt & Shame
Alcohol & substance abuse
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•Genetic vulnerabilities and gifts•Age at which trauma occurred
•Nature of the trauma•Pattern of the trauma•Style of adaptation•Relational supports
•Therapeutic experiences
Trauma:Will symptoms develop?
Bruce D Perry © 2010 www.ChildTrauma.org
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When Children Are: Caregivers tend to feel…
•Worried• Anxious• Aroused and Reactive• Alone & Helpless• Hopeless• RESULTING IMPACT ON CHILD?
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5 min.
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4 yr. old Michael
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M’s Functional Domains
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Trauma-‐informed Interventions: An Integrated Approach
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Treatment Goals & Interventions
Regulate
Relate
then
Reason Perry, 2010
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Respond to the developmental age
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Quality Relationships-‐ Essential, YET
•With Complex Trauma: people are perceived as dangerous, until PROVEN otherwise…..
• Even then… by the nature of interventions…. you may be perceived as a threat
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Play-‐ The Language of children
• Child has an intrinsic motivation to play• Starts with child’s strengths and interests
• Aids in developing positive therapeutic alliance
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Co-‐Regulation with Sensory-‐Motor Materials
Bubbles in Jar Sand in Sensory Bin
Weighted Super Hero Vest
Basket of Weights to PullQuiet Space, Bean Bags, Balls
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Reduce sensory overload from the environment; provide a safe place
Lane, 2014
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The 1st Step …. RESPONSIVITY• Noah
VALIDATE
Soft Voice
Gentle Tone
Kind Face
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Healthy Attachment Responses + Regulation
Adult Helps Child to Regulate
Child Begins to Self-‐Regulate with
Adult’s Coaching
Child’s Trauma is Triggered
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Self-‐ Esteem in the beginning…..
YOU ARE…
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After a Positive Relational Climate….
I am …an artist
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Cognitive Development emerges when….
Relationships with Safe Adults
Co-Regulation
Successful Interactions and Experiences
Embedded Learning
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Michael – age 4
Strengths
• Vivacious greetings • Outgoing, highly social
• Gross motor skills; sports • Long term memory • Empathetic to other’s physical pain• Stable home
Challenges • Interactions shallow • Play skills • Hungry -‐ hoards food, normal wt.• Severe ADHD, anxiety• Changes à anxiety• Fear of being left out• Easily aroused -‐Hard to down regulate • Loud, aggressive verbally & physically
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Provide continual sensory motor opportunities
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TRAUMA TREATMENT-‐Setting a Positive Relational Climate
Following Interests to Represent the World Series and Concession Stand
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Interventions with MichaelIndividual
• Proprioceptive, vestibular, tactile: • Gum, Play Dough • Therapy ball• Rhythmic activity• Regulatory walks with staff
• Auditory:• Quiet, non-‐reactive voices (adults)• Rhythmic beats/music
• Predictable Change; Repetition
• Milieu and Play therapy
• Therapeutic holds with rocking and soothing
Family
• Parent psycho-‐educational • Impact of trauma • Sensory Integration & Regulation tools
• Family change is gradual process
• Ongoing need • strong relationship based interactions• appreciation for severity of illness
• Family acquired ‘new language’ and experienced a paradigm shift in caregiving
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Trauma informed Interdisciplinary Interventions
Mental Health
Occupational Therapy Education
1. Interest/ strength-‐based
2. Regulation 3. Relational safety4. Play-‐based5. Embedded
learning
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Questions and Your Case Examples
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Take Away Messages
Early trauma à neurodevelopmental impact àfunctional consequences (regulation, relationships, cognition)
HEALING from predictable, consistent, repeated, positive experiences
Safe relationally
Safe physically-‐Sensory-‐Motor interventions, Play-‐based, then Cognitive
Regulate Relate Reason
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STATE LEVEL and BRAIN FUNCTION
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Responsive Teachable Moments
DEFUSING THE FIGHTEveryone wants to be heard:
• LISTEN to the child • WAIT until the child LISTENS to YOU• LISTEN to EACH CHILD in the GROUP• BRIDGE the GROUP’S IDEAS• Go meet sensory needs and try again…
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Trauma informed-‐Therapeutic Interventions
Care-‐givers
School Community
Child
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CPP does make a difference… Even when healing continues.
• Of the 22 children who have attended Circle Preschool for over 3 months in the past 3 years.
• 17 have entered typical kindergarten rooms with some special supports• 2 have left precipitously• 3 have required special ed classroom• 20 have required ongoing support to caregivers / child therapy
• Overall-‐ caregivers give positive feedback-‐ especially in noting the increased play skills and regulation skills children are demonstrating.
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• Changes in resting heart rates• Chronic health problems, breathing issues, eating issues, sleep difficulties
• Arousal/ Dissociative Issues • Clumsiness, motor delays• Emotional reactivity, attachment difficulties
• Social skill issues… lack of empathy• Impulsivity, distractibility, • Cognitive delays…uneven cognitive picture• Limited play skills• perseveration • poor problem solving
Symptoms of Trauma
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Trauma-‐ informed Interdisciplinary Contributions
• Mental Health• Therapy with regulation & relational focus• Family therapy
• Occupational Therapy• Trauma sensitive-‐ relationships• Sensory Integration increasing regulation
• Education• Trauma sensitive relationships • Multiple regulation opportunities• Strength-‐based learning
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Relationships
Sensation as a Tool
Sensory integration
and processing
Trauma informed care
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Regulating arousal
• Deep pressure and proprioception• Vestibular • Rhythmic, repetitive inputs