This Webinar was presented on Tuesday, February 15, 2011, as part of the free monthly series from Friends for Youth's Mentoring Institute with Special Presenter John Stirling, M.D. Clinicians caring for victims of early abuse or neglect are often puzzled at their inability to respond to a more consistent and caring environment, including mentoring. This presentation synthesizes concepts from developmental neurobiology, attachment theory, and family ecology to help participants understand the obstacles faced in leaving abuse behind, and to suggest paths to more effective therapy. Mentoring is an important component in treatment and there will be a special focus on understanding the Big Picture regarding early trauma, including the physiologic response to stresses, learned helplessness, and intrauterine drug exposure, to show how these children and youth react differently and need special handling.

1. Transforming lives through
the power of mentoring
Friends for Youth’s
Mentoring Institute
February 2011 Webinar

2. Webinar Logistics – Adding Comments
• All attendees muted for best sound
• “Raise your hand” to be unmuted – works best for telephone
or headset-to-computer connections; please monitor
background noise
• Type questions and comments in the question box;
responses will either be direct to you or possibly shared with
all attendees
Sarah Kremer, ATR-BC John Stirling, MD
Program Director Director
Center for Child Protection
Friends for Youth’s
Santa Clara Valley
Mentoring Institute Medical Center

3. Slides posted to
SlideShare
Link and brief survey
included in follow-up
email

4. John Stirling, MD
Center for Child Protection
Santa Clara Valley Medical Center
San Jose CA

5.  I have not yet found any corporate
sponsors
 I do not own any pharmaceutical stock
 I do have a deep personal and financial
interest in how well our children grow up.

6.  Lives w/ single mother since
parents separated 8yr ago
 Evaluated for sexual abuse at
age 5, recanted disclosure
 Runaway, cuts self, suicide
attempt

7.  Adopted at 5mo, “inadequate
caretaker”
 “Never met a stranger”
 Poor school performance
 Behavior issues: explosive,
violent

8.  Parents divorced when he was
2yo, lives with mother and
stepfather
 Academically accomplished,
but behaviors challenging
 Violence, “explosive”
 Meds: Concerta, Tenex,
Risperdal

9.  problems with interpersonal functioning
 cognitive functioning
 mental health disorders, including PTSD
 substance abuse disorders
 affective / conduct disorders
 anxiety disorders
 eating disorders
Briere, 1997; Nader, 1997; Saigh et al., 1999

10.  Abused and neglected kids
 Suffer a wide variety of insults including
 Prenatal exposures,
 Chronic activation of the threat response,
and
 Lack of parental support to provide
 Coping tools (self-regulation) that enable
 Cognitive and interpersonal learning

11.  What is abuse?
 What does it give children?
 What does it take away?
 Who’s at risk?
 What can we do?
 What’s with the title?

12.  Child traumatic stress refers to the physical
and emotional responses of a child to events
that threaten the life or physical integrity of
the child or of someone critically important
to the child (such as a parent or sibling).
 Traumatic events overwhelm a child’s capacity
to cope and elicit feelings of terror,
powerlessness, and out-of-control
physiological arousal.
12
12

13. • Acute trauma is a single traumatic event that is
limited in time. Examples include:
– Serious accidents
– Community violence
– Natural disasters (earthquakes, wildfires,
floods)
– Sudden or violent loss of a loved one
– Physical or sexual assault
13
13

14.  Chronic trauma refers to the experience of
multiple traumatic events.
 These may be multiple and varied events—such as
a child who is exposed to domestic violence, is
involved in a serious car accident, and then
becomes a victim of community violence—or
longstanding trauma such as physical abuse,
neglect, or war.
 The effects of chronic trauma are often
cumulative, as each event serves to remind the
child of prior trauma and reinforce its negative
impact.
14

15. Remember:
 The foster care system was conceived
to help children who had suffered
severe trauma.

16. Physical Abuse Sexual Abuse
~40%
Neglect

17. Domestic Child
20 –
Violence Abuse
40%
Family dysfunction?

19.  The brain is not mature at birth
 Experience determines its architecture
 Timing can be critical
 Relationships
are critical for social and
emotional development
 Effects of adversity

21. Stress
Hypothalamic / pituitary stimulation
Adrenal cortisol release

22. Studies show abuse victims have:
 Enhanced pituitary sensitivity
- Duval, 2004
 Cortisol spikes w/ trauma reminders
- Elzinga, 2003
 Higher cortisol levels, abnl variation
- Ciccetti, 2001
 Cortisol spikes, higher baseline
- Bugenthal, 2003
 Heightened inflammatory response
- Altemus, 2003

24.  Cerebral cortex
◦ EEG changes
◦ smaller callosum
 Limbic system
◦ neuronal changes
◦ decreased size
 Brainstem/
Cerebellum
◦ altered transmitters

25.  Cognitive (left brain)
◦ Vocabulary
◦ Logical reasoning
 Experiential (right brain)
◦ Emotional awareness
◦ Self-regulation

26. Criteria include:
 Intrusive memories
 Persistent arousal
 Avoidance of “trigger” events
…after an event that aroused fear, horror,
helplessness

32. “There is no such thing as a baby;
there is a baby and someone.”
- D.W. Winnicott

33.  Attachment
 Regulation
 Cognition

34.  Overview of attachment theory
 Styles of attachment
 Disorders of attachment
 Interventions

35. Bowlby’s definition of attachment:
 “Any form of behavior that results in a
person seeking proximity
 to some other differentiated and preferred
individual,
 usually conceived as stronger and/or wiser.”

36.  Evolutionary advantage:
A secure child can explore!

38.  Child forms EXPECTATIONS regarding relationship
with primary CAREGIVER.
 Child learns to BEHAVE (in predictable ways) based on
those expectations
 Child learns AFFECT REGULATION
◦ Caregiver interaction guides responses to emotionally
distressing situations.
◦ Governs how emotions are perceived.

39.  VIEW OF OTHERS
◦ Can I count on this person to be available?
◦ Can I predict interactions?
 VIEW OF SELF
◦ Am I desirable/worthy of support?
What can a person reasonably expect of others?

40.  Secure
◦ expectations rewarded, comfort available
 Avoidant
◦ rejects caregiver
 Anxious
◦ clings, fearful of separation
 Disordered
◦ approach/avoidance

41.  Secure (56-65%)
 Insecure
◦ Avoidant (20-25%)
◦ Ambivalent (10-20%)
◦ Disorganized (5-10%)

42. Child Parent
 Secure  Nurturing
 Avoidant  Dismissive
 Ambivalent  Preoccupied
 Disorganized  Disorganized

43. “Recovery” can depend on:
 Neuronal growth
 Behavioral compensation
 Minimizing secondary trauma
 … with a little help from your friends

44. Most conditions will get better
if you don’t make them worse!

45.  Persistent fear/alert state
 Poor differentiation of affect
 Dysregulation of affect
…and thus may be hard to parent!

46. One Positive Feedback Cycle
Parent Stress
child
maltreatment challenges
Attachment problems

47. A critical period for secure attachment?
There’s no data!

48.  Complex PTSD
 Attention-Deficit Hyperactivity Disorder
 Oppositional Defiant Disorder
 Major Depression or Bipolar Disorder
 Autism Spectrum Disorders
 “Reactive Attachment Disorder”

50. Traumatized children are a unique
group of kids:
 Trauma-altered physiology
 Often lack resilience; “empty toolbox”
 “Fish
out of water” – We (providers and
parents) can’t expect simple and quick
adaptation

51. Diagnosis
 Must take into account early stresses
 Looks for maladaptive adaptations

52. Therapy
 Remember that early trauma affects not only
perception, but ability to learn
 Should involve both hemispheres
 Cannot involve only the child!

53.  Meds control symptoms, don’t “cure”
 Many types
◦ Antidepressants
◦ Antianxiety agents
◦ Stimulants for attention
◦ Antipsychotics
 Usevaries widely
 None are approved for use in children!

54.  Abused and neglected kids
 Suffer a wide variety of insults including
 Prenatal exposures,
 Chronic activation of the threat response,
and
 Lack of parental support to provide
 Coping tools (self-regulation) that enable
 Cognitive and interpersonal learning

55. “God grant me the strength to change
those things I can, the grace to accept
those I cannot, and the wisdom to
know the difference.”
- Serenity Prayer

56. “It ain’t over ‘til it’s over.”
- Yogi Berra

57. NCTSNet.org
CAevidencebasedclearinghouse.org

59. Slides posted to
SlideShare
Link and brief survey
included in follow-up
email

60. www.mentoringinstitute.org
650-559-0200
• Products and resources
for mentoring programs
http://www.facebook.com/pages/Friends-for-Youth/105093182858863
• Trainings for program
staff, mentors, and mentees
http://twitter.com/friendsforyouth
• Individual consultations
Check out our Blog
http://www.friendsforyouth.blogspot.com/