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Traumatically Disrupted Attachment: . How to recognize, diagnose, and treat toward optimal healing. Health Choices of Somerset and Bedford Counties, PA. Lark Eshleman, PhD November 3, 4, 2010. Day 1. 9 – 10:15            Brain-based research on attachment and trauma

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traumatically disrupted attachment

Traumatically Disrupted Attachment:

How to recognize, diagnose, and treat toward optimal healing

health choices of somerset and bedford counties pa
Health Choices of Somerset and Bedford Counties, PA

Lark Eshleman, PhD

November 3, 4, 2010

day 1
Day 1
  • 9 – 10:15            Brain-based research on attachment and trauma
  • 10:30 – 12:00     Brain research (continued)
day 14
Day 1
  • 1 – 2:15 Best Practice based on neurological understandings: sensory processing disorder and other “interrupted” developmental processes
  • 2:30 – 4:30  Best practice based on neurological understandings:  narrative, Theraplay®, EEG Biofeedback, EMDR
day 16
Day 1

Brain-based research on attachment and trauma

understanding our neuroanatomy
Understanding Our Neuroanatomy

Dr. Shore’s Central Assumption:

The social environment changes over the stages of infancy and induces the reorganization of brain structures

dr schore s central tenets
Dr. Schore’s Central Tenets
  • The growth of the brain occurs in critical periods and is influenced by the social environment.
  • The infant brain develops in stages and is hierarchically organized.
  • Genetic systems that program brain development are activated and influenced by the postnatal environment.
overview of critical brain structures
Overview of Critical Brain Structures


  • Heart Rate
  • Blood Pressure
  • Body Temperature
  • Respiration


overview of critical brain structures10
Overview of Critical Brain Structures

Part of brain stem that controls:

  • Arousal
  • Appetite
  • Satiety
  • Sleep
  • Motor Regulation


overview of critical brain structures11
Overview of Critical Brain Structures

Locus for:

  • Affiliation
  • Attachment
  • Sexual Behavior
  • Emotional Reactivity

Limbic System

cerebral cortex the cortical layers
Cerebral CortexThe Cortical Layers


  • Abstract Thinking
  • Concrete Thought
  • Cause & Effect Thinking
  • Reasoning
dopamine norepinephrine endorphins
Dopamine, Norepinephrine, & Endorphins
  • Regulate neuronal growth and the time frame of brain growth
  • The normal time frame for the onset of the critical period of orbitofrontal maturation is 10 to 12 months.
  • Decreased production of appropriate amounts of these substances can disrupt the onset of frontal lobe maturation.
starting in the first year of life
Starting in the first year of life:
  • A centralized set of neurons containing dopamine arises from the midbrain and helps promote activation of the right prefrontal cortex.
  • The activation leads to the engagement of the child with her environment and the stimulation of reward centers that produce endogenous endorphins.

Image of a Neuron

the effects of deprivation on the developing brain
The Effects of Deprivation on the Developing Brain
  • The right prefrontal cortex develops normally only if a child receives emotionally attuned interaction with primary caregivers.
  • The right prefrontal cortex is highly involved in creating social interaction and the recognition of attachment figures.

Schore A. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Develoment. Hillsdale, NJ, Lawrence Erlbaum Associates.

the effects of deprivation on the developing brain16
The Effects of Deprivation on the Developing Brain
  • Lack of emotionally

attuned interaction

leads to decreased growth and differentiation of this portion of the brain and impaired affect regulation.

Schore A. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Develoment. Hillsdale, NJ, Lawrence Erlbaum Associates.

problems in brain timing
Problems in Brain Timing
  • Ongoing research suggesting much of psychopathology could be attributed to problems in brain timing.
  • Dr. Rodolfo Llinas, of NYU Medical School, suggests that psychiatric and neurological conditions could be attributed to dysrhythmia between thalamus and cortex.
dysfunctional parenting and attachment can contribute to
Dysfunctional parenting and attachment can contribute to:
  • Hyper or hypo-activation of the sympathetic an/or parasympathetic nervous systems
  • The lack of Central Nervous System shift from sympathetic to parasympathetic predominance between 14-18 months of age
stress impairs prefrontal cortex pfc function
Stress Impairs Prefrontal Cortex (PFC) Function
  • This region of the brain is critical for the performance of “working memory”.
  • High levels of dopamine and norepinephrine (catecholamines) are released in the PFC during stress exposure, causing “working memory” deficits.
  • Humans with lesions of the PFC demonstrate “poor attention regulation, disorganized and impulsive behavior, and hyperactivity”.

Arnsten, A. (1998). Development of the Cerebral Cortex XIV. Stress Impairs Prefrontal Cortex Function. Journal of Am. Acad. Child Adol. Psychology, 37 (12): 1337-1339.

early abuse neglect create longstanding neuro physiological changes
Early abuse & neglect create longstanding neuro-physiological changes

Dr. Michael De Bellis, a Child Psychiatrist at WPIC, studied the excretion of catacholamines (ephinephrine, norepinephrine, and dopamine), and cortisol in prepubertal children who had experienced PTSD secondary to abuse

  • These children lived in stable home environments during the study
rachel yehuda research ptsd
Rachel Yehuda Research/ PTSD
  • Intergenerational transmission of altered DNA
  • Predisposes subsequent generations to PTSD and anxiety disorders
short term long term outcomes
Short-Term & Long-Term Outcomes
  • Dr. Schore defines psychopathology as:
    • A limitation of adaptive

stress-regulating capacities

    • This is more likely to occur if right prefrontal cortex, limbic system, and hypothalamic development is hampered by lack of appropriate interaction with attachment figures
    • Leads to impaired affect regulation
short term long term outcomes23
Short-Term & Long-Term Outcomes
  • Short-Term
    • Anxious, depressed, agitated, and excessively angry
  • Long-Term
    • Aggressive and oppositional
  • Some may develop a form of Attachment Disorder
to summarize
To Summarize
  • The attachment figure is the regulator of the infants’ endocrine and nervous systems.
  • Attuned caregivers of securely attached infants maintain the child’s arousal.
    • Within a moderate range that is high enough to maintain interaction
    • Without causing distress and avoidance through over-intensity
day 1 1 2 15 pm
Day 1, 1 – 2:15 PM
  • Neurological understandings: sensory processing disorder and other “interrupted” developmental processes
sensory integration neurology
Sensory Integration: Neurology
  • The brain’s “food” is sensory input. Attachment theory and its neurological underpinnings teaches that sensory input in early childhood determines later behavior and ability to cope. Deprived environments compromise achievement of developmental milestones, at least temporarily.
  • The nervous system “learns” movement and behaviors (“output”) by repetition of the sensory (afferent) input, coordination of motor (efferent) output and the resulting sensory feedback for further refinement.
what is sensory processing disorder
What is Sensory Processing Disorder?
  • SPD was formerly known as Dysfunction in Sensory Integration. It is currently being considered for inclusion in the DSM-V.
  • SPD occurs in 5-15% of the general population.
  • SPD causes a child or adult to interpret sensory information differently than the typical person. It can impact 1 or all of the sensory systems.
  • Research and treatment has been around since the 1960’s starting in OT with Dr. A. Jean Ayres, an OT and clinical psychologist.
why do we care about spd
Why do we care about SPD?
  • Check out behaviors from morning presentation.
  • How many are similar to following behaviors manifested in SPD?
  • What do current studies tell about impact of traumatic interruption in attachment and occurrence of SPD?
how does spd manifest
How does SPD manifest?
  • SPD can compel a person to behave “differently” than others. The world can be perceived as a potentially painful or offensive place and so anxiety or defensiveness can develop.
  • SPD can impact one or many life activities including self care, work, school, relationships, sleep, etc.
  • SPD often is comorbid with other

diagnoses such as learning disorders,

autism, & mental health diagnoses.

current nosology for spd
Current nosology for SPD

Miller et al; Am J Occ Ther Mar/Apr 2007 61:2

sensory modulation disorder
Sensory Modulation Disorder
  • Also called “sensory regulation.”
  • Child/adult has difficulty with incoming sensory information and responding to it in an appropriate manner.
  • Often seen in auditory sense but any sense or combination of senses can be involved.
  • Child cannot always identify what is wrong.
  • Behaviors can become entrenched.
  • Small amount of sensory input can be perceived as extreme or vice versa. Reactions are typically in response to the perceived sensory message.
sensory over responsivity
Sensory over-responsivity
  • The person responds with what is seen as a dramatically increased proportion to the sensory input
  • The neurological threshold is assumed to be very low; “hair trigger.”
  • Child may respond to this tendency by trying to avoid the stimulus input, controlling the environment so they can reduce the stimuli, or develop other skills to spare their nervous system from experiencing the sensory insults.
  • They often learn that their behavior is seen as “weird” or unusual and may try to hide their true response or avoid trying to explain it.
sensory under responsivity
Sensory under-responsivity
  • May respond to sensory input slowly or only after a lot of input to the sensory receptors (greater spatial or temporal summation).
  • May appear to be unresponsive to their name or have a high pain threshold.
  • They are more at risk for injury and exposure to dangerous situations. Parents need to be more vigilant with these kids to avoid danger.
  • Often accompanied by other behaviors that cause them to appear apathetic and assumptions may be made about their intellect.
sensory seeking craving
Sensory seeking/craving
  • Occupational Therapy assumes that people are driven to “normalize” their nervous system. Children with dysregulated systems often seek out sensory experiences to help move them into the normal range.
  • Movement, tastes, smells, textures, touch input, multisensory experiences can be compelling stimuli for this person.
  • A daily “sensory diet” helps provide the input this person needs. They may need help choosing the appropriate input. Ex: bike riding instead of kicking.
sensory based motor disorder
Sensory based motor disorder
  • May be seen as clumsy or uncoordinated.
  • May have low muscle tone.
  • May have handwriting issues.
  • May have right/left discrimination issues.
  • Motor output manifests poor processing in the brain.
  • May have poor posture.
  • May have gross and/or fine motor
  • un-coordination.
  • May have poor self-esteem from self perception of motor incompetence. May give up trying new skills.
how does spd manifest37
How does SPD manifest?
  • …can compel a person to behave “differently” than others. The world is seen as a potentially painful or offensive place; anxiety or defensiveness can develop.
  • …can impact many life activities including self care, work, school, relationships, sleep, etc.
  • …is comorbid with other

diagnoses such as learning disorders,

autism, & mental health diagnoses.

  • Thorough Evaluation, starting with Sensory Profile
  • Sensory Diet
  • EEG Biofeedback
  • Parent and Professional Education
  • Parent/Child Group Practice
  • Treating Sensory Processing Disorder increases chances of better healing of attachment and trauma difficulties.
  • Practice: With eyes covered, how frightening is it for someone you don’t know to tell you they’re going to touch you, but you can’t see it coming?
  • Ever feel “upset” and don’t know why? How about if it’s all the time?
the regulated brain
The Regulated Brain
  • Creates a fuss when unhappy, calms when needs are met
  • Plays and enjoys it!
  • Can change activity relatively easily (mastery)
  • Engages in reciprocal affection/attachment
  • If not (all of these things), something’s wrong
the regulated brain41
The Regulated Brain
  • How do we achieve this for our children?
    • Parents’ mental and physical health
    • Right brain to right brain “download” of healthy attachment
    • Attunement
    • Safe environment for learning regulation
the regulated brain42
The Regulated Brain
  • External regulation to teach and support internal regulation
  • Expectations must meet ability to develop positive self-esteem
  • Most predictive? Positive coherent narrative of parent and good parental attachment … 75 – 85%
dys regulated brain
Dysregulated Brain

Opposing Poles of Complexity

Rigidity ……………………. Chaos

considerations for diagnoses
Considerations for Diagnoses

These are for consideration only:

  • Overanxious Disorder of Childhood
  • Posttraumatic Stress Disorder
  • Acute Stress Disorder
  • Substance-Induced Anxiety Disorder?
  • Mood Disorders, including Depression, Dysthymic Disorder, Bipolar Disorder, Substance-Induced Mood Disorder?
  • Dissociative Disorders….
dys regulated brain46
Dysregulated Brain
  • By Circumstance: Examples:
  • Too many stressors
  • Not enough resources/support
  • Traumatic Event
  • Others?
dys regulated brain47
Dysregulated Brain

2. By Teratogens, or other injury, pre-birth or during critical brain development periods. While we still don’t know the totality of effects of teratogens, we are beginning to see “building block” damage on brain scans.

dys regulated brain48
Dysregulated Brain

3. By genetic damage

New research by Rachel Yehuda,

Epigenetic research through several major research organizations

rachel yehuda and others
Rachel Yehuda and Others
  • Neuropsychopharmacology

“Twin studies suggest that genes play an important role in vulnerability to PTSD and other anxiety disorders, but not the entire role. The overall result of studies to date is that risk is the product of multiple genes and nongenetic factors working together.” (2010)

right brain over arousal
Right Brain Over-Arousal
  • Impulsive
  • Distractible
  • Hyperactive (driven-type)
  • Anxious (fear and physiological arousal)
  • Agitation/Agitated depression
  • Emotional reactivity to “small pain”
  • Shame (despair)
  • Non-verbal LD, poor visuaspatials
right brain over arousal52
Right Brain Over-Arousal
  • Manipulative
  • Holds a grudge
  • Lacks empathy
  • Poor comprehension and expression of emotions
  • Lack of body awareness
  • Poor balance/coordination
  • Nervous habits
right brain over arousal53
Right Brain Over-Arousal
  • Unmodulated voice
  • Poor eye contact
  • Poor social awareness
  • Lack of cause & effect thinking
  • Impatience
  • Aggressive
  • High pain tolerance
  • Lack of common sense
left brain under activation
Left Brain Under-Activation
  • Spaciness/daydreaming
  • Poor concentration
  • Lack of motivation
  • Slow, variable response time
  • Cognitive anxiety
  • Depression/helplessness/hopelessness
  • Perfectionist/low self-esteem
left brain under activation56
Left Brain Under-Activation
  • Poor receptive or expressive language
  • Poor sequential processing
  • Poor reading comprehension
  • Poor calculation
  • Poor logic
  • Immune deficiency
  • Low thyroid function
  • Hyperactivity following sugar (Hypoglycemia)
  • Hyperactivity with fatigue
  • Racing thoughts
  • Mood seings
  • Suicidal thoughts or actions
  • Panic attacks
  • Obsessive thoughts
  • Compulsive behaviors
  • Rages
  • Conduct disorder
  • Oppositional defiant behaviors
  • Encopresis
  • Posttraumatic stress symptoms
  • Anorexia/bulemia/compulsive overeating
  • Addictions (bipolar type)
  • Dissociative symptoms
  • Delusions
  • Pervasive developmental delays
  • Auditory processing deficits
  • Visual processing deficits
  • Scotopic sensitivity
  • Chemical sensitivities/autoimmune dx
  • Seizures
  • Vertigo
  • Tinnitus
  • Tremors
  • Motor or vocal tics
  • Spasticity
  • Headaches
  • Chronic nerve pain
  • Sciatica
  • Sleep walking
  • Nocturnal enuresis
  • Manic sleep behavior
  • Bruxism
  • Narcolepsy
3 examples of efficacious interventions
3 Examples of efficacious interventions
  • Theraplay® … play can go “under, around, over,” when we can’t get “through.”
  • EEG Biofeedback (Neurofeedback) … “bringing your brain to the gym,” to help the brain effortlessly repair itself
  • EMDR (Eye Movement Desensitization & Reprocessing) … open and secure pathways from pre-verbal, “locked” trauma to allow for safe processing
see theraplay org the theraplay institute chicago il
See (the Theraplay Institute, Chicago, IL)
  • Theraplay® Right-brained, pre-verbal, structured interactive play between parent and child to enhance attachment, process trauma, and teach regulation.
  • Structure, Nurture, Challenge & Engagement
  • Let’s play!
eeg biofeedback
EEG Biofeedback
  • Brain wants to heal itself
  • Children love to play novel games
  • Repetition of a healthy “brain state” creates a healthier processing brain
  • “Beeps and points” are their own reward, but feeling better is the ultimate reward!
  • Numbers of games/programs, but I like EAGER system of EEG Spectrum the best:


  • Eye Movement Desensitization and Reprocessing (EMDR)1 is a comprehensive, integrative psychotherapy approach. It contains elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2.
  • EMDR psychotherapy is an information processing therapy and uses an eight phase approach to address the experiential contributors of a wide range of pathologies. It attends to the past experiences that have set the groundwork for pathology, the current situations that trigger dysfunctional emotions, beliefs and sensations, and the positive experience needed to enhance future adaptive behaviors and mental health.