Dr. Georgie Siggers
Consultant Community Paediatrician
Kent Community Health Trust
“ Despite the fact that an estimated 70% of all
psychiatric inpatients and 30% of outpatients have
histories of psychological trauma, the effects of
those histories often go unrecognized or
underestimated.”
Janina Fisher, Ph.D.
Instructor and Supervisor, The Trauma Center, Boston, Massachusetts
Dr. Georgie Siggers May 2014
Because of our work in Safeguarding and with
Children in Care we recognise these histories and
we have had to make ourselves aware of the
implications.
We are counselling prospective adopters on the
impact of these histories but …….
How much do we really know?
Dr. Georgie Siggers May 2014
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ATTACHMENT
Dr. Georgie Siggers
What is neglect?
The persistent failure to meet a child's basic needs (such as love,
safety, food, and warmth) in a way that seriously affects their
health , development or safety.
Or … the absence of critical organising experiences at key times
during development
Dr. Georgie Siggers
Dr. Georgie Siggers May 2014
TRAUMA:
any physical wound or injury; physical shock following this
DSM: "The person has been exposed to a traumatic event in which both
of the following were present:
the person experienced, witnessed, or was confronted with an event
or events that involved actual or threatened death or serious injury, or
a threat to the physical integrity of self or others
the person's response involved intense fear, helplessness, or horror.
Note: in children, this may be expressed instead by disorganized or
agitated behavior
Bowlby: any events that seriously threatened the attachment
relationship; which could include parental death, divorce, psychoses
etc.
Dr. Georgie Siggers May 2014
A collection of interconnected
brain nuclei that play a pivotal role
in the regulation of emotion and
memory.
The hippocampus is thought to be
important in the formation and
retrieval of both verbal and
emotional memories
The amygdala is concerned with
creating the emotional content of
memory e.g.. feelings relating to
fear conditioning and aggressive
responses.
Dr. Georgie Siggers May 2014
When we are threatened our limbic system is activated. Information
from senses is transmitted to the thalamus, our sensory information
center, where it is evaluated by both the amygdala and by the left orbital
prefrontal cortex (LeDoux, 2002) to determine if it is a true or false alarm.
If the stimulus is recognized as benign, the amygdala does not respond
If a true threat the amygdala signals the hypothalamus to “turn on” the
sympathetic nervous system. A cascade of neurochemicals from the
adrenal glands initiates the adrenaline stress response in preparation for
fight or flight.
This puts us in the “survival mode state”: increased HR, RR, O2 flow etc.
and ‘turning off’ other non-essential organ systems, including the frontal
cortex.
Dr. Georgie Siggers May 2014
Dr. Georgie Siggers May 2014
As we are mobilizing to flee or fight, the adrenal glands initiate
reciprocal activity in the parasympathetic nervous system, preparing
us for the cessation of danger and recovery from the event.
Production of cortisol increases; heart rate and respiration slow
down; and frontal lobe activity resumes but often hyperactively,
causing intrusive thoughts and
images of the event.
In case fighting or fleeing is not adaptive or possible, the
parasympathetic nervous system also offers two other survival
alternatives, freeze and
submission.
Dr. Georgie Siggers May 2014
Children, for example, are almost entirely dependent on freeze and
submission responses, as are battered wives, prisoners of war, and
hostages.
Following the event, after we have shaken and wept and trembled until
our bodies recalibrate (attachment), the hippocampus is responsible for
putting the experience into chronological order and perspective
preparatory to its transfer to verbal memory areas in the cortex during
sleep.
If the experience is a single event, and we have adequate support
afterward (attachment), and we have had little or no prior trauma, then
we will be left shaken, but the events will feel “behind” us now.
If traumatic events have been recurrent, and/or we are developmentally
vulnerable, and/or we have inadequate support (no attachment figure)
we can be left with a host of ‘implicit’ memories, intense responses and
symptoms that “tell the story” but without words and without the
knowledge that we are remembering (Siegel, 1999).
Dr. Georgie Siggers May 2014
Innate instinct to get close to the attachment figure
when frightened in the belief that the attachment
figure will provide protection
Activated by internal & external stressors
Requires a consistent, sensitive response
Process results in deactivation/ removing cause of
the attachment behaviour
Dr. Georgie Siggers May 2014
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D
REQUIRES
RESPONSE
AN
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/
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C A ESS
L
R
ST GOA
T
E
S
Proximity
Care giving
BOND ding
il ck
Bu blo
Dr. Georgie Siggers
Rocky foundation = unstable building
Dr. Georgie Siggers May 2014
Hippocampus
Slows down/
modulates
Amygdala off
Child feels secure,
loved, safe
Child able to learn
Stress
response
Calm
Child seeks
Attachment
Figure (AF)
Amygdala
activated
Fear
stimulus
Calm
Dr. Georgie Siggers
For children, these threats are 90% likely (van der Kolk, 1996) to emanate from the
immediate family. Thus, the very person to whom the child
would instinctively turn at the moment of danger is also the source of danger or the
source of non-protection from danger.
Attachment process activated but attachment figure doesn’t deactivate the process. Child
has no strategy
This dilemma lays the groundwork for“disorganized attachment,” : she or he turns or
moves toward the parent, but then stops, freezes, backs up or turns away, often with a
glazed or frightened look.
In the context of abusive or neglectful parenting, the attachment drive is intensified, but so
are the survival responses of freeze or flight.
Dr. Georgie Siggers May 2014
Hippocampus
Remains active
AF not
available
Stress
response
Constant stress
response leads to
physical effects on
brain
Amygdala on
Attachment behaviours
shown
Child unable
to learn
Child seeks
AF
Amygdala
activated
Stress
Fear
Prolonged &
overwhelming
Dr. Georgie Siggers
This leads to a hyper activated autonomic
nervous system and disorganized attachment
patterns which will have become wellentrenched, familiar, habitual responses.
Secure attachment buffers biological stress
response
Dr. Georgie Siggers May 2014
Effects on neurogenesis, synaptic overproduction and pruning, and
myelination during specific sensitive periods.
Major consequences include reduced size of the mid-portions of the
corpus callosum; attenuated development of the left neocortex,
hippocampus, and amygdala along with abnormal frontotemporal
electrical activity; and reduced functional activity of the cerebellar
vermis.
This negative impact on developing brain structures is associated with
changes in brain chemistry. Overwhelming stress early in life also alters
the production of both the stress-regulating hormone cortisol and key
neurotransmitters such as epinephrine, dopamine and serotonin, the
chemical messengers in the brain that affect mood and behavior.
These biochemical imbalances can have profound implications. For
example, abuse typically lowers serotonin levels, leading to depression
and impulsive aggression.
Dr. Georgie Siggers May 2014
Safety is destroyed and developmental patterns
become disorganised
Disturbed attachment patterns
Rapid shifts in emotional states
Aggressive behaviour against self and others
Anticipatory behaviour
Multiple somatic problems
Self endangering behaviours
Self hatred and self blame etc. etc. etc.
Dr. Georgie Siggers May 2014
The aftermath of childhood abuse can manifest itself at any
age in a variety of ways.
Internally it can appear as depression, anxiety, suicidal
thoughts or posttraumatic stress;
it can also be expressed outwardly as aggression,
impulsiveness, delinquency, hyperactivity or substance
abuse.
One of the more perplexing psychiatric conditions that is
strongly associated with early ill-treatment is borderline
personality disorder.
Dr. Georgie Siggers May 2014
Lives Across Times
132 infants 1964 – 1965
5/76 @30 yrs. NAI by father, all had current
psych diagnosis
All had shown symptoms at 7 yrs.
When Bowlby’s def. of trauma used, a child
who had 2 or more traumas had reduced
adult functioning
Dr. Georgie Siggers May 2014
Kaiser Health Plan
With increased ACE score, found increase in
rates of
Depression
Risk suicide
Prescription rate
Memory impairment
And effect on physical health
Dr. Georgie Siggers May 2014
Size affected by early
experience
Diminished size associated
with learning defects
Male monkeys in isolation
study
Reduced CC size most
prominent finding in
children with hx abuse &
PTSD
In boys, particularly
affected by neglect
Dr. Georgie Siggers May 2014
Vulnerable to ravages of stress
Reduced volume assoc with PTSD &
DID & BPD & hx childhood abuse
Reduced volume found in children
with hx PA or SA & depression cf
depression alone
Reduction only seen in adults
Could reduced volume be a risk
factor for PTSD or could it be
caused by alcohol?
Rats exposed to maternal isolation
stress- decreased H vol
Dr. Georgie Siggers May 2014
Impact on behavioural
control
Repeated abuse causes the
amygdala to signal danger
even when there is no
apparent threat.
Dr. Bruce Perry ''A
maladaptive amygdala
makes an abused child
recoil in fear at the drop of
a hat.''
Dr. Georgie Siggers May 2014
Early stress …precocious
maturation ….parentified
child
Arrested development and
reduced adult capacity
Evidence to suggest
trauma assoc with
alterations in symmetry,
grey matter volume,
neuronal integrity and EEG
coherence
Dr. Georgie Siggers May 2014
Dr. Georgie Siggers May 2014
Seen for Initial Statutory Health Assessment
Chronic neglect
Undernourished,
Transfer to
secondary school
Remanded into
secure
accommodation
Placement
changes
Adopted
ASD
Severe eczema
ADHD
Speech delay
Depression
Dr. Georgie Siggers
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LBW
Faltering growth
Drug & alcohol misuse
Hypotonia
Joint problems
Teenage pregnancy
Unemployment
Physical Signs
Offending
Complications
Bruising
Self Harm
Rashes
Poor parenting capacity
Repeated infections
SYNDROME
N
Dental decay
Difficulties with
relationships
Emotional
Global delay
Depression
Anxiety
Low self esteem
Social interaction ? ASD
Attachment problems
Neurodevelopmental
Eating disorder
Cognitive deficit
Aggression
Repetitive behaviour
Lack of empathy
Impulsive
?ADHD
Dr. Georgie Siggers
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Corpus
callosum
HIPPOCAMPUS
CEREBRAL
CORTEX
AMYGDALA
BRAIN GROWTH
EEG CHANGES
CHEMICAL CHANGES
Normal
Severe
Syndrome N
NEURAL
PRUNING
Dr. Georgie Siggers
Learning
difficulties
Mental health
problems
Lack of parenting
capacity
Abused as a
child
Drugs and alcohol
POVERTY
Dr. Georgie Siggers
During which different brain regions
maximally sensitive to effects of exposure to
childhood stress
? Different neuropsychiatric sequelae of
maltreatment may arise based on ages of
exposure
Resilience?
Dr. Georgie Siggers May 2014
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Frequency
Severity
Duration
Age
ATTACHMENT
Developmental status
Dr. Georgie Siggers
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Awareness
Educate ourselves &
others
Raise
awareness/Prevent
Intervention
Intervention
Awareness
Never lose sight of the
child
Lower our thresholds
Support
Consequences
Consequences
Support
Appreciate effect of early years on
current functioning
Acknowledge that it may take years
to undo the damage of neglect
Give these children the
on-going professional
support they require
Dr. Georgie Siggers May 2014
Early abuse increases the risk of
developing post-traumatic stress
disorder (PTSD), depression,
symptoms of attentiondeficit/hyperactivity, borderline
personality disorder, dissociative
identity disorder, and substance
abuse.
Animal studies showing that
new experiences can regenerate
brain cells
Promoting a secure attachment
is key to protection
Dr. Georgie Siggers May 2014
The impact of trauma & neglect can
be seen across all areas of child
development (Syndrome N)
It affects structure & function of brain
Trauma and neglect severely
damages attachment process
Promoting a secure attachment is key
to protection
Effects can last for generations
Dr. Georgie Siggers May 2014
“ Our brains are sculpted by our early
experiences. Maltreatment is a chisel that
shapes a brain to contend with strife but at
the cost of deep, enduring wounds.”
Teichner 2000
Dr. Georgie Siggers
[email protected]
Dr. Georgie Siggers
Dr. Georgie Siggers May 2014