Sunday, April 27, 2008

The Brain- Short Version

Brains are formed through interactions with others

The thinking part of the brain is formed through caretakers taking care of baby- organizing, meeting needs, creating a predictable life.

If these things aren’t done reliably, the thinking brain will be under developed, and the child will be more impulsive, less planful, and may have a learning disorder.

Through early attachment experiences the brain develops a template or pattern for how human relationships are going to be throughout life.

Events with a strong emotion attached are most strongly remembered.

The brain and body automatically respond to danger- alertness, focused attention, increased muscle tone, decreased ability to think.

If action is not possible body freezes, withdraws blood from limbs, releases opiods to prepare for injury.

Too much stress- the brain can get stuck in these modes.

When the brain is in survival mode, thinking interventions do not work. Thinking is shut down and not available.

Early positive attachment develops the ability to calm down, self sooth, and regulate response to danger. Inconsistent attachment leaves the person with less of these abilities. They are stuck in survival mode and their thinking brain is not kicking in to send safety messages or to realistically evaluate safety.

The brain can change and grow throughout life. It changes through use and attachments, especially through repetitive, rhythmic experiences.

What We Need to Know About the Brain

In order to offer the most complete healing possible to children with histories of trauma and attachment disruptions, we have to understand something about the brain, how it develops and how trauma effects that development.

Human beings develop through relationships. We have mirror cells in our brains that fire when OTHERS express emotions, creating similar emotions in us. This happens countless times between a mother and a baby. It is the basis of empathy. Human society is built on this interactivity, because relationships necessary for survival.

Infants are born dependent. Luckily, parenting is pleasureful. The infant associates touch with pleasure. She gets her needs met, gets relief from distress, which calms anxiety. Her brain develops a sensory pattern of human interaction associated with pleasure. A template is established. Thus our early experiences contribute the template: our definition of "normal".

Attachment and the Brain
Early attachment relationships sculpt the brain’s survival circuits and make them more or less able to regulate emotion when faced with stress. Secure attachment facilitates thoughtful processing, counters the survival-in-the-moment reactions to stress. We have evidence that loving relationships can help change the brain, regulate the amygdala and the survival-in-moment circuits. The nature of the child’s early attachment is etched in lower levels of the brain. Children respond from that place without awareness.
Although attachment is necessary for safety, humans are also our most dangerous predators. Therefore we are very sensitive to the moods, expressions, and gestures of others. Our stress responses very closely tied to systems that read and respond to social cues.

Principles of Neurodevelopment

The brain grows most rapidly from birth to age four. At 4, its 90 per cent of adult size.
Implication: The greatest opportunity to grow and influence the brain is with the developing child. This period also presents the greatest vulnerability to the destructive impact of threat, neglect, and trauma.

The brain develops from brainstem up to the more complex parts of brain. The primitive parts of brain are the most difficult to change (least plastic).
Implication: Change is possible, but is slow with early trauma. To change, we need repetition, repetition, repetition.

The brain neurons grow in a "use dependent" fashion. The brain sets down a "template" for how life is supposed to be and go. The brain and reacts particularly to any thing out side that template, anything new. To change a muscle through exercise, we must have moderate, repeated, patterned extra stress. Then the brain decides, oh, we are going to be doing this now, better develop some new muscle cells. It is the same with brain cells. The stress is a signal to the cortex- something new is going on here. Moderate stress is good for the brain and the body, it develops our ability to handle stress. However, imagine going to the gym for the first time and trying to lift 200 pounds. It would not build muscle or teach the body anything. You would hurt yourself. This is similar to the stress children receive from trauma.
Implication: Interventions need to be consistent, predictable, patterned, and FREQUENT. Kids with attachment problems need many, many positive nurturing interactions. The number of repetitions needed for change is so high that most adults become discouraged. We have unrealistic expectations about pace of change.

Trauma-related symptoms originate in brainstem and lower parts of the brain.
Implication: When brainstem-driven, the brain processes and functions differently (Perry, 2006). The child’s responses are mostly unconscious, old brain fear responses (not intentional). Cognitive, rational, highly verbal interventions generally don’t work. Conventional therapies will fail if the brainstem poorly regulated. Therapeutic interventions must influence the brainstem and lower parts of the brain.

The brain develops in sequential fashion from brainstem up to cortex. If a sensitive period in brain development is missed, may be hard or impossible to re-create later. For example, if a kitten’s eye is kept closed during a certain period of sight development, may never develop sight even if opened later. So traumas at different ages have differing effects depending on what the brain was working on at the time.
Implications: CBT, insight-oriented will fail if the brainstem is poorly regulated. Once the brainstem is regulated, the child can benefit from more traditional therapies. Just like healthy development, healing from trauma starts from the bottom up. The sequence of interventions matters. We must match interventions to child’s level of neurodevelopment. Examples of interventions to regulate brainstem are music and movement activities like dancing and drumming; EMDR; patterned massage; repetitive, consistent positive interpersonal interactions.

In order to develop, we need repetitive, patterned interactions. Rhythm is very important to human functioning. We need reliable internal cycles to sleep and wake, when to eat, heart rate, etc. The brain changes through repetitive, patterned activity. Rocking is a human comfort response, as exemplified by a person in crisis rocking back and forth or a chair.
Implications: Healing is facilitated by repetitive, rhythmic activities such as drumming, dance and music. Regular structured predictable schedules are also important.

Emotion is the central organizing mechanism of the brain. Humans are hard-wired to pay attention to sex and danger. Advertisers know this!

Although many things are learned through repetition, it is critical to our survival to learn quickly those things that led to negative experiences. We often must remember after ONE bad experience. We don’t have the luxury of taking many repetitions to learn that a snake can be poisonous. Intense negative emotions burn events in to memory.

Humans are programmed to identify danger. Some hard-wired danger cues are: darkness, sudden loud noises, and being alone

Humans are also programmed that comfort and protection is found in: closeness, rocking, and stroking. Note that many of these are found in sexual activity, hence the difficulty at times in differentiating comfort and sexuality.

Trauma sensitizes the nervous system. Extreme, repeated and intermittent stressors are the most likely to result in sensitization (although single stressors may also). When the nervous system is sensitized, relatively small triggers in the present cause extreme survival-in-moment responses. Children "make mountains out of molehills".

Extreme stress without control is the most harmful. This was shown in rat experiments- some rats were shocked when they pressed a lever (had control); some were shocked when the other rat pressed a lever (no control). The experiment found that animals who do have control developed strengths, those who did not developed ulcers, lose weight, had compromised immune systems, become more sensitized to shock, and couldn’t recover. Stress with control leads to habituation (developing new skills and coping mechanisms). Stress with lack of control leads to sensitization (disorganized intensifying response, immobility).

We now know a great deal about the functions of different parts of the brain.
Our brain has three tiers: the Cerebral Cortex (Human Brain); the Limbic System/Diencephalon (Mammalian Brain or Midbrain); and the Brain Stem and Cerebellum (Reptilian Brain). We can refer to them as the Old Brain vs. New Brain. The old brain is the lower order systems, which are responsible for survival. They develop first, and are located in the more primitive parts of brain like the brain stem. The new brain is the higher order systems. It develops last, and gives us our flexible adaptive capacities. It is located in the cerebral cortex.

The pre-frontal cortex is created by a caretaker doing cortex-functions (care taking, safety, meeting needs, figuring out problems). If no one is doing these things, the cortex will be under-developed. The cortex is responsible for complex thinking, analyzing, and using cognition to control emotional impulses.

The amygdala screens for threats, adds emotional valence to events, and activates the danger response when an event is a change from what is expected and appears threatening. It compares in-coming data with laid down patterns- asking one question- does this data suggest danger? It activates an immediate response while sending the information to the higher brain for further refinement. It makes the body become more alert and look for more information. It gets bigger when it is used more.

The hippocampus is involved with retrieval of verbal and emotional memory. It gets smaller as amygdala gets bigger.

The cerebellum is responsible for balance and rhythm.

Low Road vs. High Road of Emotional Processing (Le Doux, 1998, 2002)

"Traumatic stress is about "survival in the moment". The brain processes stimuli that are potentially life threatening and translates this perception into life sustaining responses." (Saxe 2006)

The brain receives sensory input into the sensory thalamus. The brain starts processing the stimulus in two ways, which we can refer to as the "ow road" and the "high road". The low road utilizes the more primitive, older brain; the high road uses the more complex newer brain.

The Low Road

Stimulus/Trigger sent to Sensory Thalamus then to Amygdala yields Response

The Advantages of the Low Road:
It prepares body for an emergency response, and very quickly gives the organism info about danger. It is reflexive, unconscious, and does not contain contextual info. It sacrifices details for speed

Disadvantages of the Low Road:
It responds rapidly to incomplete bits of information. There is no context to the information. It facilitates memory storage in an incomplete way. This memory may produce flashbacks, which are "flashes of emotionally-laden memory." It leads to misperception of triggers and to overreaction, making mountains out of mole hills.

The High Road

Stimulus/Trigger to Sensory Thalamus to Amygdala and to Prefrontal Cortex to the Medial Temporal Memory System (Hippocampus) to the Sensory Cortex leads to a Response

A "Cognitive Wedge" is inserted between stimulus and response

Advantages of the High Road:
This type of processing leads to the most adaptive response in the moment. The high road pathway can maintain the low road survival-in-moment response if needed. With the help of our cortex (higher brain), we respond at a level appropriate to the level of danger. Determining the level of safety or danger via high road is also often unconscious and rapid. The cortex adds a context to the information, and (if appropriate) sends safety signals to the amygdala. The cortex facilitates memory storage in continuous complete way.

Parts of Cerebral Cortex Used in High Road Processing:
The sensory cortex retrieves and engages information from long term memories that contain experiences with similar stimuli (accurate perception). The medial temporal memory system (which includes the hippocampus) places the stimulus in the proper time and context. The prefrontal cortex puts information into the individual’s direct awareness for considered action to occur. The person inserts a "wedge of cognition" between the stimulus and the response.

What the brain does in danger (hyper arousal):

  1. Focuses alertness
  2. Shuts down cortex chatter
  3. Becomes more vigilant and more concrete
  4. Heart rate increases- blood sent to limbs
  5. Focuses on social cues- is help available?
  6. Muscle tone increases
  7. Hunger/digestion disregarded

When unable to fight or flee, a person is left only with the option to freeze. If action does not seem possible, the brain sends a "freeze" response to the body. This response too is self-protective. This response is related to later dissociative responses. It is common in infants and young children. It is more common in females than males. It is driven by the most primitive parts of the old brain. In the freeze response, the brain prepares the body for injury. This response is also graded and occurs on a continuum. The person has a sense that time slows and what’s happening isn’t real.

In the freeze response (dissociation) the person:

  1. Curls up
  2. Makes her self as small as possible
  3. Prepares for injury
  4. Blood is shunted away from limbs
  5. Heart rate slows to reduce blood loss from wounds
  6. Body is flooded with opioids ("brain’s heroin") to protect against pain which produces a feeling of calm and a sense of distance from what is happening (Some times this can help with functioning, such as a soldier functioning without feeling)

Fight/Flight AND Freeze
In both responses, the person has their foot on the gas and the brake at the same time.

Some Clinical Implications
Fight/flight (hyperarousal) often looks like AD/HD, hyperactivity, oppositional defiant disorder. Freeze (dissociation) look like inattention, spaced out, defiance to adults because child literally cannot respond.
Both hyper arousal and dissociation help people survive trauma. Both can be harmful if prolonged and habituated.
Flash backs and re-enactments may be seen as an attempt to have small doses of trauma within one’s control to develop habituation or tolerance. However, if trauma is too much it cannot be mastered this way.

Our brains have two halves. The right hemisphere handles the gestalt, the big picture, and initial impressions. It is responsible for negative emotions such as anger and anxiety. The left hemisphere takes care of details and analysis. It holds positive emotions. Generally the left hemisphere is larger; in children with trauma histories the right is larger. The corpus collosum connects the two, and it is smaller in trauma victims. Therefore, they experience less integration and generalization in learning. For example, a child works on methods for not fighting with his room mate, but he doesn’t think to use these methods to avoid fighting with another person.
Humans are hard-wired to seek attachment, especially when danger is present. The primary goal of attachment for humans is safety. However, we cannot forget that one method of engagement is aggression and provocation.

If there are persistent stressors in the early years of life, neurons do not grow and connect in prefrontal cortex, less inhibition is available.

Less developed pre-frontal cortex leads to:

  1. Short attention span
  2. Memory problems
  3. Distractibility
  4. Impulse control difficulty
  5. Social and test anxiety
  6. Poor judgment
  7. Hyperactivity
  8. Lying
  9. Problems reading social cues
  10. Poor organization and time management

Terror early in life can shift person to a less thoughtful, more impulsive, more aggressive way of responding to the world. Thinking has been shut down too much just when it was time for it to develop.

The brain develops a template that danger is normal. This could also contribute to under-reaction to danger: since brain is particularly paying attention to what is new, what doesn’t fit the pattern, danger is not new to this brain.

Also, researchers have identified a kindling effect in which a trauma survivor over-screens for danger, over identifies threats. This interferes with reading social cues, distorts his perception of others.

People with "good enough" childhoods have arousal/relaxation cycles and know ways to calm down. Trauma survivors start at a higher base-line arousal, have rapid spikes, and rely on the external environment to help them calm down. This leads them to have to do something to draw in external control (i.e. cutting).

Trauma victims have 40% higher prevalence of learning disabilities especially language: auditory processing and expressive language (Receptive/expressive language disorder). This may be due to under-development of both the cortex and the corpus collosum.

Trauma Damages the Ability to See into the Future
The ability to calculate the potential risks and benefits of an action is a very important human function, and to children growing up in abusive households it is essential and life saving. However, due to the unpredictable nature of events, the over-exposure to danger, and the struggle to survive, this ability will be compromised. The child may both over and under estimate danger, and also may over and underestimate potential pleasure. They may not be able to see any future for themselves.

Healing From Trauma
Moving to high-road processing also depends on environmental interventions to help remove triggers (when possible) and reduce risk of continued exposure to trauma. In addition, the environment must provide the child many "signals of care", which work to counteract the "survival-in-the-moment" crisis mentality.

Selected Resources: Trauma and the Brain
Perry, B. and Szalavitz (2006). The Boy Who Was Raised As a Dog. New York: Basic Books.
Perry, B. (2006). “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children.” In Webb, N.B. Working With Traumatized Youth in Child Welfare. New York: Guilford.
Saxe, G.N., Ellis, H.B., and Kaplow, J.B. (2007). Collaborative Treatment of Traumatized Children and Teens. New York: Guilford.
Vanderkolk, B.A. (1996). “The Body Keeps the Score: Approaches to the Psychobiology of Posttraumatic Stress Disorder.” In Vanderkolk et. al. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society.

Thursday, April 24, 2008

How Will They Learn? What About Punishment?

Staff who are trying to work in this new way often raise this very legitimate question: if we don’t severely punish the kids for things they do wrong, how are they going to learn not to do them? They will be out in the world doing these horrid things and will end up in jail.

How are they going to learn?

Or, to put it another way, what are they going to learn? The idea of punishment is that a person will learn that when they do a certain behavior bad things happen, things they don’t want. So they stop doing that behavior to avoid those bad things.

Alan Kazden states that: "More than 50 years of good science tell us that punishment doesn't do much to improve behavior. Punishment doesn't teach what to do. It rarely succeeds even in teaching what not to do.
The misunderstanding and misuse of punishment go at the top of the list [of parenting misunderstandings]. For too many parents, trying to change behavior mostly means noticing what they don’t want and punishing it. Even if they don’t want to punish their child, they think it’s their duty to do so, but the research tells us that it’s not very effective. That’s because punishment doesn’t teach a child what to do, and it doesn’t reward the desired behavior, the only effective way to get the child to do it. Punishment also has bad side effects, such as increasing a child’s aggressiveness and tendency to avoid you, which can make it harder to improve his behavior. Research shows that even if punishment temporarily stops unwanted behavior, it will return at the same rate, or worse, in the hours or days to come. Your child’s resistance to punishment escalates as fast as the severity of the punishment does, or even faster, so you have to get harsher and harsher to achieve the same result.

Meanwhile, your child is learning all sorts of bad lessons ... Hitting teaches hitting as the way to respond to life’s problems; yelling teaches yelling; becoming angry teaches anger, and so on. Modeling is a very strong way to teach behavior, stronger than punishment, which helps explain why the harm you do with harsh punishments can multiply and last a long time. And, of course, punishing a behavior is still a form of paying attention to it, and any kind of attention can encourage your child to do something again. And yet, in many cases, even the most loving and conscientious parents think that they have to punish and punish to change behavior.

The research shows that punishment can be a small, effective part of a program that also features lots of positive reinforcement of the behaviors you desire. This kind of punishment is mild, brief, and sparingly used, and, if possible, it occurs when the behavior first surfaces, so it can short-circuit an unwanted sequence of actions before that sequence can get fully underway. Sometimes all it takes is a well-timed look or word to stop misbehavior. Technically, that look or word is punishment, or the threat of it. But parents typically wait until the misbehavior has run its course, then punish severely, frequently, and often angrily, and that usually doesn’t work."

(Alan E. Kazdin is John M. Musser professor of psychology and child psychiatry at Yale University and director of Yale's Parenting Center and Child Conduct Clinic. He is also president of the American Psychological Association and author, most recently, of The Kazdin Method for Parenting the Defiant Child.)

Mac Bledsoe, author of Parenting with Dignity lists these reasons punishment doesn't work:
“Buck Minor, the cowboy on our ranch, used to always say, "If you teach an animal a lesson by meanness or cruelty, don't be surprised if the animal remembers the meanness and cruelty and forgets the lesson.
1. Punishment removes the focus of both the "punisher" and "punished" from the behavior in question. When a parent resorts to punishment both the parent and the child begin to pay attention to the punishment, its fairness and its enforcement. This allows the child to stop thinking about the decision process that brought about the negative consequences.
2. Punishment focuses anger on the "punisher." When we resort to punishment it gives children someone else to be mad at or someone else to blame, and when they are mad they do not have to face their own behavior and consequences. The resulting anger interrupts responsible thought for both the child and parent. A child sent to his/her room will seldom or never think about how to behave properly but rather will think about how unfair his/her parents are or some equally negative idea.
3. Punishment induced behavior "extinguishes" rapidly. In the absence of punishment, the negative behavior returns. Behavior that has been shaped by punishment will disappear soon after the punishment has disappeared. It becomes a game of not getting caught.
4. Punishment traps the "punisher" into maintaining the punishment schedule. "You made the rules, now you must enforce them."
5. Punishment does not teach accountability. The "punisher" (parent) is responsible to see that the child's behavior changes. If you use punishment, by your actions you have accepted responsibility for your child's behavior.
6. Most of all, punishment denies a child the right to experience the real consequence of their actions. The reward for good performance is... good performance. Seldom is it necessary for us to provide the reward, and the same is true for poor performance. The punishment for poor performance is poor performance.
7. If you use punishment as a tool it may work to stop a particular action. If you send a fighting kid to his room he may have stopped fighting for the immediate present. Sometimes that is necessary to do. The error comes when we think that the punishment has taught the child what to do in the next situation. It has taught the kid NOT to do something, but it has not taught them what to do!"

Surely our kids have had a lot of experience learning that their bad behavior brings negative consequences. In fact, they blame all the awful things that have happened to them on their own bad behavior. Because of what a terrible kid they are, their mother left them, their father beat them, they were molested, they ended up in residential.

If negative consequences could change them it surely would have happened by now.

Why are they doing these destructive things?

Because they are over whelmed with emotion, over-reactive, and often in the pit of despair. Because they feel lost, alone, and terrified. Because they don’t notice their emotions until they are in the midst of a hurricane. Because they see danger every where. Because they don’t trust others and can’t ask for or accept help. Because they feel worthless, have no hope and nothing to lose. Because they don’t believe any one cares, including themselves.

Does punishment help with all this? In fact it makes every aspect of it worse.

So what will help? What do they need to learn?

That they are safe. That people can be trustworthy. That they are worthwhile and can have a meaningful future. How to identify and manage emotions. Ways to sooth and take care of them selves. That when things go wrong between people, the rift can be mended. And most of all, that there is someone who likes them, sees good in them, and will stick with them as they struggle to heal.

They will learn these things through relationships, not through punishments.

Sunday, April 20, 2008

RICH Relationships with Each Other

A central tenet of Risking Connection® trauma training is that trauma survivors are healed through relationships, and that the characteristics of a healing relationships is that it is RICH- containing Respect, Information, Connection and Hope. In my most recent training we began to discuss the idea (which I strongly believe) that we cannot have any better relationships with the children than we have with each other. So we began to consider- what can we do to establish RICH relationships among staff on our teams?

Respect involves (among many other things) treating each other politely, listening, assuming good intentions, not talking behind people’s backs, discussing concerns directly, and not undercutting each others’ decisions.

Information could include sharing events and happenings, communication across shifts and among disciplines, teaching each other, not keeping secrets, sharing schedules, and discussing clinical events and formulations.

Connection can be formed through social and fun events together, pot luck lunches, sharing stories about our lives, discussing common interests, sharing our emotional reaction to the work, and laughing together.

Hope can be created through pointing out small gains and changes, remembering other clients who have succeeded, sharing small victories, and pointing out each others’ strengths.

When we began doing this exercise in the training, we made two columns: one, what can you do to create these things with the clients; two, what can you do to create them within the team. But guess what- the column merged because they turned out to be the same things! What we want and need from each other is exactly what the kids and families want and need from us!

Kevin Creeden at MASOC

As I mentioned, I presented at the Massachusetts Adolescent Sex Offender Coalition Tenth Annual Joint Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents, and Adults in Marlborough, MA. (

I was lucky enough to attend a workshop by Kevin Creeden, M.A., LMHC, LMFT- Director of Assessment and Research at Whitney Academyan East Freetown, MA, an excellent speaker who I have seen several times.

Here are some of the points that Kevin made:

Important facts about the brain:

Children with trauma histories have fewer connections between their limbic system and their pre frontal cortex
The cortex is created by caretaker doing cortex-functions (care taking, safety, meeting needs, figuring out problems)

With psychological arousal the baseline heart rate goes up
There is constant scanning for threat

Cerebellum is responsible for balance, rhythm

Give infant rhythmic activities- rocking, structured activities, schedule
Rocking is a human comfort response (person rocking in crisis)

Amygdala adds emotional valence to events
Screens for threats

Kindling effect- trauma survivor over-screens, over identifies threats
Interferes with reading social cues, distorts

Humans hard-wired to pay attention to sex and danger
Hence use in advertising

Hard to extinguish

Hiking example- you are on a hike in the woods and you see something dark and curvy, it moves- a snake! All danger systems are activated. As you walk on and it slithers away, you see something else dark and curvy- you are on alert again! This time it is only a stick- but for the rest of the hike you over react to every stick.

Movie example- You are alone at home and you put on "Psycho" which you have seen many times before. Still, when he walks towards that shower curtain your heart races. After the movie is over, you have to go down to the basement and get the laundry. Even through you KNOW this was a movie, you put it in yourself, and you have seen it before, you are scared and on alert, and you run back upstairs and close the door. All night you are jittery and over-react to noises- and this after only two hours of something you had total control over and that you knew was not real. (Understanding does not lower arousal!)

Humans programmed to identify danger: darkness, sudden loud noises, being alone
PTSD produces constant danger signals- person may become immune; no longer differentiate real danger, under react (the body that cried wolf)

Humans programmed that comfort and protection is found in: closeness, rocking, stroking
Note similarities to sex
Can’t distinguish nurturing touch from sexual touch

Humans programmed to learn more quickly and more deeply, remember better, those things with strong affect, especially danger- you can’t afford many repetitions to learn that a snake is dangerous

"Normal" people have arousal/relaxation cycles and know ways to calm down-
Trauma survivors start higher, have rapid spikes, and rely on the external environment to help them calm down
Must do something to draw in external control (i.e. cutting)

In normal human relationships, attachment is the road to sexuality- we play monopoly, then we gradually become friends
In trauma survivors, sexuality is a desperate method for attachment- I don’t know how to start, form or maintain relationships so maybe if I have oral sex with you, you will play monopoly with me.

Right hemisphere- gestalt, big picture
Initial impressions
Negative emotions, anger, anxiety
Left hemisphere- details, analysis
Positive emotions
Generally the left hemisphere is larger; in trauma kids the right is larger

Corpus collosum connects the two- smaller in trauma victims
Less integration

Less integration and generalization in learning- child works on methods for not fighting with his room mate, doesn’t think to use these methods to avoid fighting with another person

We must actively teach problem solving, considering alternatives and pros and cons

Amygdala involved with fear conditioning, aggressive behavior, triggers fighting
Gets bigger with increased use

Hippocampus involved with retrieval of verbal and emotional memory
Gets smaller as amygdala gets bigger

When dysregulated, children are helped by slow, rhythmic activities not high energy level activities- yoga, tai chi, brain gym, walking, swinging hands, crawling, rocking, exercise balls, metronomes

Trauma victims have 40% higher prevalence of learning disabilities especially language: auditory processing and expressive language. (Receptive/expressive language disorder)

Often crisis plans and relapse prevention plans are cognitive and language-based, and also are avoidance based- what I am trying NOT to do instead of what I am trying TO do.

Emotion is the central organizing mechanism of the brain

The pre-frontal cortex controls emotional behavior through cognition
If there are persistent stressors in the early years of life, neurons do not grow and connect in prefrontal cortex, less inhibition is available
Less developed pre-frontal cortex leads to:
Short attention span
Memory problems
Impulse control difficulty
Social and test anxiety
Poor judgment
Problems reading social cues
Poor organization and time management

The primary goal of attachment for humans is safety.
One method of engagement is aggression and provocation
(A new way of looking at that awareness we have that for these kids, negative attention is better than no attention)

Sexual offending behavior is about trying to get your needs met in a relationship- otherwise, why not sit home and look at pornography on the Internet?

Healing comes through persistent attention to the daily task of caring

Need whole brain learning, concrete examples, pay attention to generalizing
Understand cannot learn in emotional situations

Incorporate movement

Primary treatment goals:
Establish safety and predictability
Deconditioning and decreasing anxiety and arousal levels
Altering the way victims view themselves and the world
(Van der Kolk, 1996)

Attachment exercises: (do 5X a day, 3-5 minutes at a time)
Reading facial cues- use movies, sop, ask: what was he feeling now? What will he do next?
3 leg races
Jump rope
Reflective listening practice
Passing rhythms around
Taking own pulse, finger monitors
Boundaries- hula hoops

I would highly recommend Kevin Creeden as an excellent speaker and great thinker in our field.

Saturday, April 19, 2008

What’s Going on With Michael?

Michael is a fourteen year old boy who is living at a shelter home. He was brought there after his last foster placement, his fifth, disrupted. After nine months Michael had begun to think he might be able to stay with this family. But their bio son started playing with Michael’s game boy, they got into a fight, and somehow Michael found himself hitting the boy over and over. That was the end of that family. They say he can have another family if he learns to control his anger- fat chance that that will ever happen. So here he is at the shelter, and he has to admit it isn’t all that bad here. He has been starting to make a few friends at his new school. He had started to connect with Haley, a girl in his class, even thought they might get something going- how stupid of him. Yesterday she told him she wasn’t interested in him and he was a loser. So he came home in a lousy mood, and got into a fight with a staff member- that nice one, Alicia- over of all things cleaning up some soda he spilled. He refused to do it, it just all seemed too much. Then in home work hour he tried to drown out all of this with his music, but the dumb staff confiscated his radio. Finally he just crashed.

So now it is morning and here’s Alicia again waking him up in her cheery way. And he is still here in the shelter. And he is still himself. And she is reminding him that he has a restoration to clean up the kitchen before he goes to school. What can’t she leave him alone? He doesn’t really mean to start swearing at her.


We can talk abot how Alicia should talk to Michael, or about what his consequences should be, or about how she cannot let him speak to her this way, or how we have to be consistant and not let these kids get away with this sort of behavior.

But what will actually be healing to Michael?

Now- stop and think about your own life.

Imagine that last night you had a fight with someone you love. You awake today in a very angry and irritable mood. You stub your toe on the way to the bathroom and you can’t find your keys. The shirt you wanted to wear is in the laundry. Nothing is going right- and yet you have to go to work. And if you start swearing at people at work, your job won’t last long. What do you do to get yourself to a place where you can not only go to work, but treat the people there kindly?

Some people might pray, others meditatate. Some listen to music. Some deliberately compartmentalize ("I have to put this aside now; I can deal with it later.") Some talk about their difficulties with a friend before starting the day. Some remind themselves that all is not lost ("I’m sure Chris and I will be able to work this out, and the shirt I picked instead actually looks pretty good.")

What does Michael need in order to be able to survive his very real and serious difficulties with out making them worse?

He needs a sense that he is a worthwhile person who is having some problems, instead of his current certainty that he is a total mess with no redeeming qualities.

He needs to be able to recognize when he is upset, and to put words to it.

He needs some one he trusts with whom he can talk over his thoughts and feelings.

And he needs some strategies he can use to keep functioning when life is hard.

We can help him with this- we can notice the good in him, give him opportunities for competence, be delighted with his progress. We can name and normalize feelings. We can be that trustworthy person by acing in trustworthy ways. And we can deliberately teach him strategies, in part by modeling and naming our own.

So what should Alicia do in the moment of waking Michael? She should ignore his swearing, remain calm and gentle (not too cheery). She should note his mood and mention it gently: "I can see you are feeling a bit low this morning." She should provide any soothing strategy she can think of: "Maybe we can have some music on this morning as you get ready." She should not worry about needing to punish or correct or change him. She can instead concentrate on helping him feel better and calmer, and giving him some emotional supplies to bring to the day.

It is through these processes that Michael can heal and grow. The consequences for swearing are not our most powerful change strategy. Our most powerful change strategy is forming connected, calm relationships.

Tuesday, April 15, 2008

Thoughts from the MASOC Conference

Last week I presented at the Massachusetts Adolescent Sex Offender Coalition Tenth Annual Joint Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents, and Adults in Marlborough, MA. ( I highly recommend this annual conference to anyone with an interest in this subject. You know you are at a good conference when you can’t decide which of several interesting work shops to attend.

In this conference as in others I have attended I was struck by the convergence of thinking in our field. More and more treatment programs are learning about trauma and altering their approach to include that knowledge. There is increasing recognition of the bodily alterations caused by trauma, which can be summarized (and over simplified) by describing the trauma survivor as living in a hyper-aroused state. Programs are increasingly incorporating body-based interventions such as sensory integration, brain gym, bio-feedback and neuro-feedback. We understand we must actively teach the skills that the children have never learned: everything from establishing rhythms in life, to learning about personal space and touch, to self regulation, to social skills and working through relationship difficulties.

Programs are changing- adding body-based adjunct interventions, working more through art, music and drama, and providing skills training. I have come to see the Restorative Approach(tm) as a way of aligning our day-to-day operations with our current understanding of trauma. We understand more now about how trauma survivors live in a danger mode, and how when a person is in danger made they cannot think. Yet we run our programs based largely on cognitive interventions: discussing with the upset child the consequences of his actions; talking about safety plans and relapses prevention plans; explaining to the child how her life will go better if she stops hitting people.

The Restorative Approach(tm) utilizes our understanding of the brain through encouraging staff to simply help the upset child calm down, through listening, physical activity, distraction, sensory interventions, etc. Staff are asked to use their relationships with the kids to demonstrate coping skills, to use attachment to manage distress (as humans do) and to create new templates for the possibility of trustworthy help from adults. The child collaborates in developing a tool kit of strategies to manage their own symptoms. When something serious goes wrong, staff do not focus on punishment and thus increase shame. Instead they focus on the relationship effects and the possibility of redemption through making amends and working it through.

Our day-to-day interactions with the kids we treat provide our most powerful tool for healing. Let’s find more and creative ways to utilize what we are beginning to understand about trauma and the brain. Let our behavior management systems exemplify and make real our basic values. The system can recognize that the children are doing the best they can at any given time. We understand that they have been specifically wounded and have learned how to treat these wounds. Our children need healing through skillful training, interventions and love.