1. Neurological Impact of Trauma and Attachment: Implications for Treating Sexual Behavior Problems Kevin Creeden, M.A. LMHC Whitney Academy East Freetown, MA kcreeden@whitneyacademy.org SASH Conference 2009 San Diego, CA

2. Experience of Trauma 1.Developmental stage 2.Temperament 3.Context 4.Response / Support

5. Neurodevelopment and trauma Teicher, et al (2002)  Increased limbic iritability  Decrease left hemisphere development  Decrease left/right hemisphere integration  Limited functioning of cerebellar vermis in self-regulation

6. Hypothalamus: controls appetite, hormones, and sexual behavior Amygdala: responsible for anxiety, fear and emotions Neocortex: Site of higher cognitive functions and sensory integration Cerebellum: seat of motor control and coordination Hippocampus: crucial to memory and learning facts Brain stem: responsible for sensory input and physiological responses

10. Brain StructureFunctionImpairment Amygdalafear conditioning; aggressive behavior; triggers fight/flight Increased arousal, impaired fear conditioning HippocampusRetrieval of verbal and emotional memory Memory impairment, especially verbal memory Left hemisphereRegulate analytical responses; mediate emotional responses; language processing Difficulties in accurate, effective reading of situation; language processing Corpus CollosumCommunication and integration between hemispheres Poor integration and modulation of responses to daily interactions Cerebellar VermisProduction and release of neuro-transmitters Problems regulating physical activity, attention, emotions Prefrontal cortexCenter for executive functionsPoor organization, rigid problem solving; increased impulsivity

11. Domains of Impairment: Complex Trauma I.Attachment  Distrust  Social isolation  Attunement difficulties  Boundary problems  Problems with perspective taking Cook, Spinnazzola, et al (2005)

12. Attachment Theory Assumption: maintenance of proximity to a secure and trusted figure is needed and sought by humans throughout the lifespan and particularly during periods of perceived danger or stress Behaviors related to attachment seek to both engage and maintain proximity Goal: safety and affiliation

13. Attachment and Neurobiology Emotion operates as a central organizing process within the brain (Seigel, 1999) Emotional responses to caregivers must play a crucial role in the regulation of early brain development (Trevarthen & Aitken 2001)

14. The development of the pre-frontal cortex depends upon relationship based experiences that become aggregated into the internal working model of attachment (Balbernie, 2001) The orbitofrontal cortex acts in the highest level of control of behavior, especially in relation to emotion.(Schore, 2003)

15. The pre-frontal cortex is a convergence area that receives multimodal visual, auditory, and tactile input from the external/social environment along with subcortical information from the internal environment (Schore, 2003) Persistent stressors in the first two years of life prune neural connections in the pre-frontal cortex and inhibit effective regulation of arousal

16. II.Biology  Sensorimotor problems  Somatization  Analgesia  Increased medical problems

17. III. Affect Regulation  Poor emotional self-regulation  Problems labeling and expressing emotions  Problems recognizing and describing internal states  Problems communicating wishes and needs

18. IV. Dissociation  Distinct alterations in states of consciousness  Amnesia  Depersonalization  Impaired memory for emotionally based events

19. V.Behavioral Control  Poor modulation of impulses  Self-destructive behavior  Aggression towards others  Pathological self-soothing  Sleep difficulties  Eating disorders  Substance abuse  Excessive compliance  Difficulty complying with rules  Reenactment of trauma behavior

20. VI. Cognition  Executive functioning problems  Lack of sustained curiosity  Problems processing novel information  Problems w/object constancy  Problems understanding responsibility  Problems w/ language development

21. VII. Self-Concept  Lack of continuous, predictable sense of self  Poor sense of separateness  Disturbances of body image  Low self – esteem  Shame and guilt

22. Resiliency Factors 1.Positive attachment to emotionally supportive and competent adults 2.Development of self-regulation and cognitive abilities 3.Positive self- concept 4.Motivation to act effectively

23. Informing Practice Assessment protocols should examine:  Current Trauma Symptoms: Trauma Symptom Checklist for Children (TSCC)  Executive functioning skills: Wisconsin Card Sort; Tower of London  Auditory Processing skills: SCAN:A

24. Assessment cont’d  Visual Organization and Processing: Bender- Gestalt Test; Rey Complex Figure Test  Memory: Weschler Memory Scales

25. Informing Practice  Availability of Occupational Therapy evaluations especially around sensory integration and self- regulation  Greater focus on multi-modal learning

26. Primary Treatment Issues 1.Establishing safety and predictabiltiy 2.Deconditioning and decreasing anxiety and arousal levels 3.Altering the way victims view themselves and their world (Van der Kolk, et al, 1996)

27. Maslow’s Hierarchy of Needs

28. Trauma Interventions Stabilization, deconditioning, relationships can be re-framed as “containment” attachment structure self-regulation WORKING ON TRAUMA thinking, feeling, and talking about trauma Allen, 2001

29. Treatment: Brain Based Different individuals have different styles of learning Certain brain processes will enhance or inhibit learning at different times Multi-modal (multiple pathway) learning will increase understanding and recall

30. Treatment: Brain Based Pre-exposure (education) increases learning and motivation You need the opportunity to practice what you learn in order to integrate Threat and stress (distress) minimize learning and creative thinking

31. Integration of affect and cognition a primary goal Interventions can help to re-create or alter attachment experiences Consideration given to stimulating particular neural pathways Persistent attention to monitoring arousal level and learning skills to regulate