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The Impact of Early Childhood Trauma on Brain, Behavior and Child Development OJDDA Conference September 28, 2010. David W. Willis, M.D., FAAP President, Oregon Pediatric Society Developmental-Behavioral Pediatrics Artz Center for Developmental Health Portland, Oregon .

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The Impact of Early Childhood Trauma on Brain, Behavior and Child DevelopmentOJDDA ConferenceSeptember 28, 2010

David W. Willis, M.D., FAAP

President, Oregon Pediatric Society

Developmental-Behavioral Pediatrics

Artz Center for Developmental Health

Portland, Oregon

eco biodevelopmental model
Eco-biodevelopmental Model

Biological Program

Childhood Experience





Genetics and



Physical, Social and


science of early brain and child development shonkoff 2002
Science of Early Brain and Child Development Shonkoff, 2002
  • Cognitive, emotional and social capacities are inextricably intertwined and learning, behavioral and physical and mental health are interrelated over the life coarse
  • Toxic stress in early years can damage developing brain architecture and lead to learning and behavioral problems and susceptibility to physical and mental illnesses
  • Brain plasticity and the ability to change behavior decrease over time
science of early brain and child development shonkoff 20026
Science of Early Brain and Child Development Shonkoff, 2002
  • Brain architecture is constructed by processes that begins before birth and continues into adulthood
  • Skill begets skill as brains are built in a hierarchical fashion – bottom up, increasing complex circuits and skills built on top of simple circuits and skills over time
  • The interaction of genes and experience shapes the circuitry of the developing brain
three legged stool for predicting developmental and health trajectories

“Three-legged stool” for “predicting” developmental and health trajectories

Genetic, Prenatal and Neurodevelop-mental Factors

Attachment and Relational Patterns

(ACE Scores)

Social-economic environment

neurodevelopmental processes
Neurodevelopmental Processes
  • Synaptogenesis
  • Mylenation
  • Synaptic pruning
  • Procedural and declarative memory
  • Neuronal networks coming “on-line”
  • Maturing inhibiting networks


Courtesy of Bruce Perry, MD, PhD


Synaptic Sculpting

Courtesy of Bruce Berry, MD, PhD



Courtesy of Bruce Perry, MD, PhD


Abstract thought


Concrete Thought



Sexual Behavior


Emotional Reactivity

Motor Regulation





Blood Pressure


Heart Rate

Body Temperature

principles of neurodevelopment
Principles of Neurodevelopment
  • The brain is underdeveloped at birth
  • The brain organizes from the “bottom” up - brainstem to cortex and from the inside out
  • Organization and functional capacity of neural systems is sequential
  • Experiences do not have equal influence throughout development (sensitive periods)
regulation of affect

Regulation of Affect

Right brain development by relational co-regulation

Early childhood sensitive period

Core skill for social and emotional well-being

the social brain dan siegel m d 2000
“The Social Brain” Dan Siegel, M.D. 2000
  • The brain is the organ of social


  • The mind exists between people
  • We have always had a psychology of the individual brain….but now we focus on the mind as developed “between” brains
  • Mindsight – “the ability to know the mind of others”
the developing mind fundamental principles
The Developing Mind Fundamental Principles
  • The mind emerges from the activity of the brain
  • The human mind involves the flow of energy and information within the brain and between brains
  • The mind emerges at the interface of neuropsychological processes and interpersonal experiences
  • Emerges as the genetically programmedmaturation of the brain responds to ongoing experience
attachment system j bowlby m ainsworth m main
Attachment SystemJ. Bowlby, M. Ainsworth, M. Main
  • An inborn system in the brain that influences and organizes motivational, emotional and memory processes with respect to significant care-giving figures
  • Involves seeking of proximity and protection from danger
  • Provides communication processes with others
  • Highly responsive to indications of danger
  • Serves to create a central foundation from which the mind develops
  • Genes have little to do with Attachment
  • Temperament and attachment are independent!
  • Attachment patterns are solely built by experience
  • L. Alan Sroufe, et al “The Development of the

Person,” 2005.

  • In every culture, healthy relationships are contingent on relational interactions
aai classifications and corresponding patterns in infant strange situation behavior m main
Adult state of mind with respect to attachment

Secure/autonomous (F)

Dismissing (D)

Preoccupied (E)

Unresolved/Disorganized (U)

Infant Strange Situation

Secure (B)

Avoidant (A)

Resistant or ambivalent C

Disorganized/disoriented (D)

AAI Classifications and Corresponding Patterns in Infant Strange Situation BehaviorM. Main
ghosts in the nursery selma fraiberg 1975

“Ghosts in the Nursery”Selma Fraiberg, 1975

“Angels in the Nursery”

Alicia Liberman, PhD 2005

dir model s greenspan and s weider developmental bio psychosocial model
“DIR” Model S. Greenspan and S. WeiderDevelopmental bio-psychosocial model


Individual differences

Relationship focused

functional emotional developmental levels s greenspan

2-3 mo. Shared attention

3-5 mo. Engagement

6-9 mo. Two-way intentional communication

12-18mo. Behavioral elaboration

Complex non-verbal gestural


24-36mo. Representational communication

Ideas and words

36-48mo. Emotional thinking

Linking ideas and thoughts

dir individual differences
DIR - Individual Differences
  • Sensory Processing systems
  • Cortical processing systems
    • Auditory processing
    • Visual-spatial processing
    • Intelligence
    • Memory systems
  • Motor output processes
dir relational context in early childhood parent child interactions
DIR - Relational Context in Early ChildhoodParent – Child Interactions
  • Attachment patterns
  • Cooperation patterns
  • Conflict-doing and conflict-resolution patterns
  • Regulation patterns of negative and positive affects
  • Intimacy communication patterns

Sibling and Peer Interactions

dir relational context in early childhood cultural patterns
DIR - Relational Context in Early ChildhoodCultural Patterns
  • Parenting styles reflect societal values
  • Early childcare variations (e.g. co-sleeping)
  • Social clans and multiple early relationships
  • Role of older children in child-rearing
  • Imitative roles
  • Toys and play

Adverse Childhood Experiences Are Common

Household dysfunction:

Substance abuse 27%

Parental sep/divorce 23%

Mental illness 17%

Battered mother 13%

Criminal behavior 6%


Psychological 11%

Physical 28%

Sexual 21%


Emotional 15%

Physical 10%


Adverse Childhood Experiences Score

Number of categories of adverse childhood experiences are summed …

ACE score Prevalence

0 48%

1 25%

2 13%

3 7%

4 or more 7%

  • More than half have at least one ACE
  • If one category of ACE is present, there is an 86% likelihood of additional categories being present.

Evidence from ACE Study indicates…Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs


Maternal MH, Substance Use and Domestic Violence in the Year after Delivery and Subsequent Behavioral Problems in Children at Age 3 YearsWhitaker, R, et al, 2006

health consequences of early life trauma vincent felitti m d
Health Consequences of Early Life TraumaVincent Felitti, M.D.,
  • Health in all domains is related to

childhood experience

  • Health risks:
    • Stroke
    • Heart disease
    • Depression and suicide
    • Substance abuse
    • Smoking
positive stress
Positive Stress
  • Moderate, short-lived physiological response
    • Increased heart rate, higher blood pressure
    • Mild elevation of stress hormone, cortisol , levels
  • Activated by:
    • Dealing with frustration, meeting new people

National Scientific Council on the Developing Brain, Harvard University 2006

tolerable stress
Tolerable Stress
  • Physiological responses large enough to disrupt brain architecture
  • Relieved by supportive relationships:
    • that facilitate coping,
    • restore heart rate and stress hormone levels
    • reduce child’s sense of being overwhelmed

Activated by:

    • Death of loved one, divorce, natural disasters

National Scientific Council on the Developing Brain, Harvard University 2006

toxic stress
Toxic Stress
  • Strong & prolonged activation of stress response systems in the absence of buffering protection of adult support
    • Recurrent abuse, neglect, severe maternal depression, substance abuse, family violence
    • Increased susceptibility to cardiovascular disease, hypertension, obesity, diabetes and mental health problems

Institutionalization and Neglect of Young

Children Disrupts Their Body Chemistry


Percent of Childrenwith Abnormal Stress Hormone Levels







Middle Class US Toddlersin Birth Families

Neglected/Maltreated ToddlersArriving from Orphanages Overseas

Source: Gunnar & Fisher (2006)

types of trauma
Types of Trauma
  • Witnessing violence (domestic and other)
  • Natural disaster
  • Terrorism
  • Accidents
  • Abuse/Neglect
  • Loss of caregiver
types of trauma acute trauma
Types of Trauma: Acute Trauma
  • 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 (e.g., being shot or raped)
  • During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.
a cute r esponse to t rauma
Acute Response To Trauma



few supports


with supports


Vulnerable “with supports”







Traumatic Event

types of trauma chronic
Types of Trauma: Chronic
  • Chronic traumarefers 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.
m ultiple t raumatic e vents
Multiple Traumatic Events






Event #1

Event #3

Event #2

types of trauma complex
Types of Trauma: Complex
  • Complex traumadescribes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.
  • Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.
  • Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.
additional sources of stress
Additional Sources of Stress
  • Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include:
      • Poverty
      • Discrimination
      • Separations from parent/siblings
      • Frequent moves
      • School problems
      • Traumatic grief and loss
      • Refugee or immigrant experiences
the impact of a potentially traumatic event depends on several factors including
The impact of a potentially traumatic event depends on several factors, including:
  • The child’s age and developmental stage
  • The child’s perception of the danger faced
  • Whether the child was the victim or a witness
  • The child’s relationship to the victim or perpetrator
  • The child’s past experience with trauma
  • The adversities the child faces following the trauma
  • The presence/availability of adults who can offer help and protection
impact of trauma on child development

Impact of Trauma on Child Development

Physical and Neurodevelopment

Psychosocial and Relational Development


Hierarchy of Brain Function

Bruce Perry M.D., Ph.D. 1997


In the brain of someone who has experienced a variety of emotional,

behavioral and cognitive stimuli, a “top heavy” ratio develops.

In this ratio, the brain matures to moderate the more primitive instincts of the midbrain/brainstem.

Bruce Perry M.D., Ph.D. 1997


When key experiences (Which develop the cortical/limbic part of the brain)

are absent or minimal, the “higher” to “lower” brain ratio is impaired.

In this case, the ability of the brain to moderate impulsive, reactive responses and to work through frustration is diminished significantly.

Bruce Perry M.D., Ph.D. 1997


Children raised in environments characterized by domestic violence, physical abuse or other persistent trauma will develop an excessively active midbrain/brainstem. This results in an overly active and reactive stress response and a predisposition to aggression and impulsiveness.

Bruce Perry M.D., Ph.D. 1997


When the developing brain is both deprived of sensory stimuli and experiences traumatic stress, the brainstem/ midbrain to cortical/limbic ratio is profoundly altered.

Bruce Perry M.D., Ph.D. 1997

health status of foster children
Health Status of Foster Children
  • 85% Chronic medical conditions
  • 75% Developmental delays
  • 65% Behavioral/emotional problems
  • Congenital and Genetic susceptibilities
      • Prenatal exposures – stress, alcohol, drugs
      • ADHD
      • Learning disabilities
      • Mental health disorders
health and neurodevelopmental impacts of trauma
Health and Neurodevelopmental Impacts of Trauma
  • Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.
  • Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
health and neurodevelopmental impacts of trauma61
Health and Neurodevelopmental Impacts of Trauma
  • Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.
  • Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.
psychosocial and relational impact of trauma
Psychosocial and Relational Impact of Trauma
  • Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others.
  • Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.
psychosocial and relational impact of trauma63
Psychosocial and Relational Impact of Trauma
  • Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
  • Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.
impact of stress on young child
Impact of Stress on Young Child
  • Chronic Stressors
  • Acute Stressors
  • Resiliency of Child
  • Perception of the Child
  • Nature of their Ability to Process
  • Developmental Stage and/or Abilities
  • Structure, Quality, and Availability of a Support System
  • Examples: moving to a new caregiver, addition of a family member, loss of a family member, abuse, neglect, birth of a sibling










The Limbic System






Trauma and Altered Neurodevelopment

Altered cardiovascular regulation

Behavioral impulsivity

Increased anxiety

Increased startle response

Sleep abnormalities

incidence and prognosis of ptsd in foster care population lubit r 2006
Incidence and Prognosis of PTSD in foster care population(Lubit, R 2006)
  • Incidence
    • Post sexual abuse 64%
    • Post physical abuse 42%
    • Exposure to violence 18%
  • Prognosis
    • 50% recover in 3 months
    • Type II trauma (chronic) poorest prognosis
    • Younger, worse prognosis
effects on relationship
Effects on Relationship
  • Difficulty forming positive relationships
  • Poor sense of self
  • Lowered self esteem
  • Expectation of being treated poorly
  • Loss of secure base
  • Loss of sense of trust
the power of relational experiences to heal
The Power of Relational Experiences to Heal
  • Mental health experiences
  • Developmental disabilities experiences
  • Co-regulation management for stress
  • Relational regulation of fear and pain
  • Premature nursery and stress monitoring
neurosequential model of therapeutics

Neurosequential Model of Therapeutics

Bruce Perry, MD

Child Trauma Academy

  • NMT utilizes multiple resources
    • NMT is not a specific therapy
    • NMT matches activities to brain regions
  • NMT Techniques Promote Neural
    • Organization
    • Regulation
    • Development
  • Techniques Rx: Based on Functional Development
  • Responses (interventions/interactions) must :
    • Stimulate development
    • Organize brain regions
    • Match the mediating brain region
    • Promoting more mature development
  • Hierarchical process (Mastery based).
  • Treatment is:
    • Often regressive
    • Always patterned
    • Always repetitive.
    • Requiring multiple rehearsals
ten nmt assumptions
Ten NMT Assumptions:
  • Regulation and Control: Begin with one’s own body.
  • Emotional and Relational Regulation: Begins after body control
  • Intellectual abilities: Develops after social and emotional competence.
ten nmt assumptions82
Ten NMT Assumptions:
  • Mastery and Integration: Lower brain to higher regions.
  • Sensory: Activities: Precede more structured activities.
  • Remedial Work: Begins at the lowest disregulated neurological level
ten nmt assumptions83
Ten NMT Assumptions:
  • Interventions: Interactive and reciprocal.
  • Models/Parallels: Natural developmental sequence between infant and caregiver.
  • Social Bond: Enhanced by mutual engagement and attention
  • Emotional Relationship: Crucial to success.
some things to remember greenspan 2001 perry 2006
Some Things to Remember:(Greenspan, 2001, Perry 2006)
  • All learning is experiential
  • Individual differences and development must be acknowledged account.
  • Priority is relationship.
  • Relational developmental progress moves from 1:1, to 1:1+1, to 1:1+3 and more.
some things to remember
Some Things to Remember:
  • Be flexible and adaptive to the child’s needs
  • Don’t coerce or force an activity (unless safety is at risk)
  • Avoid non-interactive time.
  • Avoid over stimulation, allow time to calm down and self-regulate.
structuring the environment
Structuring the Environment:
  • Structuring is proactive, positive action
    • To prevent problems
    • Insure success.
  • Traumatized children need:
    • A Trusted Adult to Protect Them
    • A Safe Environment
    • A Predictable Environment
    • A Patterned Environment
  • New development occurs only when the child

feels safe and secure.

  • Consistency=Predictability=Security (Landreth, 2002)

Circle of Security

Parent Attending to the Child’s Needs

© Cooper, Hoffman, Marvin, & Powell – 1998

the role of psychopharmacological interventions
The Role of Psychopharmacological Interventions
  • PTSD Clonidine
  • Regulatory Disorders Risperidone
  • ADHD Stimulants
  • Anxiety and OCD SSRI’s
predictors of recovery and healing
Predictors of Recovery and Healing
  • Stable intimate relationships
  • Safe community and family
  • Normal developmental capacities
  • Identification and monitoring of risk and resiliency factors
  • Intentional neuro-rehab and relational treatments
  • “Developmental home”
HOPE and


david w willis m d faap

David W. Willis, M.D,FAAP