applied neuropsychotherapy

Childhood Trauma and Neural Development Indicators for Interventions with Special Reference to Rural and Remote Environments

Pieter J Rossouw (MClin Psych; PhD; MAPS; MCClin) Unit for Neuropsychotherapy; School of , School of Social Work and Human Services, The University of Queensland

urrent Neurobiological research indicates that most men- tal illnesses begin earlier in life than was previously believed (Insel, Fenton 2005). An alarming epidemiological study of 10,000 adolescents in the USA indicates that one in every four to five youths meets the criteria of a mental disorder with se- Cvere impairment across the lifetime (Merikangas et. al. 2010). The study indicates the need for strategies that are based on prevention and early intervention. Studies indicate the need for enhancing neural develop- ment by decreasing exposure to unhelpful stressors that up regulate the HPA (-pituitary-adrenal) axis (Schonkoff 2011). Schonkoff and colleagues (2011) indicate that interventions that enhance execu- tive function and self-regulation and enhance the abilities of vulnerable mothers (beginning as early as pregnancy), offer promising markers to protect the developing of their children from detrimental neural development.

2 Neuropsychotherapist.com Dr Pieter Rossouw

Neural development & attachment significant resilience against the expres- sion of genetic risk. Animal studies by Shen The attachment relationship is central and Battersby clearly indicate protection in the development of early intervention against expressions of genetic risk through programs (Schore & Schore 2008). The neu- enriched environments (Shen & Battersby robiological basis of John Bowlby’s attach- 2000). Programs to enhance secure attach- ment theory (Bowlby 1969,1973,1980,1988) ments and the down regulation of re- points towards its biological nature – the sponses are highly indicated to reduce the structural connectivity of the right hemi- risk and onset of mental illness. sphere, limbic connectivity and neural fa- cilitation of the implicit self (Schore 2008). Whereas Bowlby focused on the behaviour- Childhood trauma & neural growth al and cognitive development in early child- Childhood trauma violates the basic hood, modern attachment theory focuses needs of attachment and control. Abuse on neural connectivity. Down regulation of (physical and/or emotional) up regulates the limbic alertness plays a vital role in the de- survival response and inhibits frontal corti- velopment of a safe, secure attachment re- cal sprouting. Early interventions to address lationship whereas unstable patterns (that is these needs are highly indicated. Effective unstable emotional or physical attachment) programs need to be based on two key prin- lead to insecure, ambivalent or disorganised ciples of neural anatomy and neural devel- attachment. opment: These attachment patterns tend to stabi- lise into long term patterns of functionality 1 The principle that the devel- or disfunctionality, depending on the initial ops from the bottom to the top: trajectory, with an alarming stability of sev- enty percent twenty years post initial as- o The first phase of neural develop- sessment (Waters et.al 2000). This study is ment involves the formation of the primi- in line with the trend projected by the study tive brain – the brain stem, pons and the of Merikongas 2010. cerebellum (the survival systems). Large Violations of the basic human needs numbers of precursor (stem) cells activate for attachment and control (Epstein 1993; the production of specific neurons in target- Grawe 2007), lead to the onset of up-regu- ed areas (up to 250,000 per minute). Violations of the basic human needs for attachment and control, lead to the onset of up-regulated limbic alertness, down regulation of cortical neural sprouting, and decreased right frontal cortical development

lated limbic alertness, down regulation of o The second phase of neural devel- cortical neural sprouting, and decreased opment involves the development of the right frontal cortical development – the paleomammallian brain - limbic structures key risk factors for the onset of mental ill- – , , hypothalamus, hip- ness. It is a well-established fact that the pocampus and basal ganglia (the stress and right frontal cortex is in a critical growth emotional response systems) period from the last trimester of pregnancy o The third phase of neural develop- to ten months post birth and in a second- ment is the development of the cortical re- ary growth period from ten months to thirty gions – the neocortex (the executive control six months (Schore 2012). Genetic factors systems). are expressed, through the interaction with the environment (experiences) and long 2 Second: the principle of neural de- term patterns of response to environmen- velopment and proliferation. The principle tal stimuli are facilitated during this time in of neural development indicates that the neural patterns. A secure attachment pro- brain is not fully developed at birth. vides an enriched environment to facilitate

Neuropsychotherapist.com 3 Childhood Trauma & Neural Development

The first area of the brain to fully devel- bic” structures (MacLean 1990) – the thala- op is the brainstem and then the lower part mus (chamber), the amygdala (almond) the of the midbrain. These areas control bod- hypothalamus (below-chamber) and the ily functions necessary for life – sometimes (sea horse). These structures referred to as the autonomic functions, At evolve on each side of the brain as it begins birth, these lower functions are fully devel- to development towards the two hemi- oped and functional facilitating basic sur- spheres in the cortical regions. vival responses: breathing, eating, sleeping, The limbic areas are fully developed at seeing, hearing, smelling, making noise, birth but do not function optimally (in com- By year three the young brain has up to three trillion neural connections

feeling sensations and recognising people. parison to the brain stem areas that are fully These are crucial functions – all needed operational at birth. These areas need en- for basic survival. Violation of any of these vironmental interaction to assist with the functions will compromise survival. This is activation process. During the first ten to the area that MacLean named the primitive twelve months of the newborn’s life most of / reptilian brain – a capability shared with the expressions of these functions occur. In- all living creatures. This neurological ability put from the environment shapes the limbic is crucial in the quest to understand mental structures. well-being and disorders. Recent findings in The infant brain comprises around one neuroscience indicated that synaptic con- hundred billion neurons. Each neuron has up nections (synaptic potentials) form the ba- to ten thousand synapses – resulting in a ca- sis of what constitutes “an individual” and pacity of one trillion connections. During the when neural connections change, the neu- first ten months post birth synaptogenesis ral networks change resulting in the indi- is facilitated at blistering pace. By year vidual “changing” – emotionally, cognitively three the young brain has up to three tril- and behaviourally. These changes facilitate lion neural connections. Then the process healthy development (given safe, enriched turns around – the neural connection re- environments) or pathology (in situations duces at an even more blistering pace – mil- where there are violations of basic needs). lions of connections stop connecting every The second region that develops in the minute – reducing the connections back to prenatal brain is the region that involves around one trillion within a few years. And the structures on top of the brain stem and whist this reduction is happening the brain lower midbrain – the areas in the upper mid- is still developing through the process of brain section. McLean coined the term “lim- neural pruning as the neural network be-

4 Neuropsychotherapist.com Dr Pieter Rossouw comes stronger. Effective pruning is vital for connections. These activities lead to chang- effective growth but it can only activate ef- es in cortical blood flow from the upper neu- fectively in a down regulated ral (cortical) regions to the deeper neural re- facilitated by a healthy, supportive and rich gions to ensure effective ability to maximise environment. the survival response. Over activation of this Violation of the safe environment (any survival mechanism leads to inhibition of threat to basic safety, or basic needs) also neural sprouting to the cortical areas. Ongo- leads to changes in the synaptic connec- ing activation of this pattern has an inverse tions. These changes result in closed neural relationship with long term neural sprouting systems of protection that are facilitated and proliferation (Rossouw 2012). In severe by the overproduction of stress hormones cases of violation, atrophy occurs in key lim- (adreno-corticotrophin hormone, adrenalin bic areas (especially the hippocampus), and and cortisol) which push the brain into con- cortical regions (anterior cingulate and sub- stant hyper alertness and closed neural fir- genual areas of the ), and ing – altering the networks of healthy neural hinders the ability of the individual to man- patterns. age even low intensity stress. Cognitive, and The third phase of neural development especially emotional, development is also involves the upper region of the neural sys- significantly inhibited (Van Der Kolk,- Bur tem - the cortex. This region is greatly un- bridge & Susiki 1997; Drevets 2001; Schore developed at birth, making it most suscepti- 2012; Rossouw 2012b). ble to signals from the environment during Without effective down regulation of lim- development. A good, supportive, healthy bic alertness (triggered by stress factors and and enriched environment (where the basic violations of basic needs), neural sprouting needs of secure attachment, control, devel- will be inhibited (Kandel 2006). opment of sense of self, and pleasure maxi- mization) is essential for the brain to devel- Implications for interventions: rural op connections and networks that support & remote areas well-being. Violation of any of these needs causes major disruption in the chemical The implications for service delivery are production, the neural connectivity, neural significant. Effective delivery of early inter- plasticity, and ultimately the neural net- ventions is required to assess, identify and works (Kandel et.al 2013). address violations of basic needs (especially The implications are significant in terms the needs for safety and control) are indi- of our understanding of the development of cated. Effective service delivery, to enhance wellbeing, the pathogenesis of mental dis- neural development has to be a collabora- orders and trauma, and even more impor- tive activity between mental health services tant in the consideration of strategies to ad- and attachment structures (parental sys- dress these issues (Van Eekelen et.al. 2011). tems). Many rural communities have collective Bottom up development sense of suffering due to current and his- torical traumas such as Aboriginal commu- The development of the brain from the nities affected by removal of children. These bottom to the top also indicates the neural painful are triggered by interven- pathway for the activation of distress sig- ing agencies attempting to assist in cases nals. Distress signals follow a particular pat- of need – especially when assistance is not tern in the excitation and inhibition of neural community based but linked to services that The implications for service delivery are significant. Effective delivery of early interventions is required to assess, identify and address violations of basic needs (especially the needs for safety & control) are indicated.

Neuropsychotherapist.com 5 Childhood Trauma & Neural Development

are provided outside of local areas. imise a sense of attachment and control to Unfortunately the history of service de- facilitate healing and empowerment. Chil- livery in rural and remote Australia (and dren living in rural and remote areas face more specifically our indigenous communi- significant challenges when they are in need ties) shows little understanding of the im- of interventions. All research clearly indi- plications of these neural principles. When cates the need for early intervention to min- provision of safety became a priority, with- imise the development of unhelpful neural out understanding the need for attach- patterns. But early diagnosis and/or inter- ment and control, children were removed vention is often lacking in rural and remote not only from the immediate area of risk areas. Localised services are often not avail- but also from the whole community. These able. This leads to interventions that may removals from community may have pro- compromise the basic needs of developing vided safety but could not effectively down children resulting in higher presentation of regulate the stress/fear/control response. uncontrollable incongruence. The net result Further, removal from a community disem- is the reduced opportunity to maximise neu- powers the community to provide care and ral sprouting, enhanced stress response ac- enhances community pathology. This does tivation, and long term frontal cortical defi- not only have historical relevance as there cits; resilience to HPA activation, effective are current cases under tribunal investiga- emotional and personality development, tion that involve removal of young children high level of cognitive integration and ap- from highly disenfranchised Aboriginal proach behavioural patterns. communities in far north Queensland. The Preventative programs to enhance pa- preliminary findings of research at the Uni- rental awareness of secure attachment, versity of Queensland coincides with the control maximization, neural development, study at Edith Cowen University and shows nutrition, limbic regulation, and frontal cor- that Aboriginal community responses have tical activation to enhance resilience needs been undermined as a result of colonialism to be facilitated. and the impact of western culture (Hovane Practical strategies to maximise neural 2012). Service delivery has mostly happened sprouting (such as sleep, hygiene, nutrition, outside the communities and not in close exercise, reduced substance abuse) need to collaboration with communities, resulting be provided in a safe, trusting environment in increased community disempowerment to reduce the risk of trans-generational pa- and enhancing the risk of pathology. thology and enhance genetic expressions Service delivery to maximise neural towards strong, safe, supportive and well growth needs to occur in the close proximity communities. of the social network (community) to max-

6 Neuropsychotherapist.com Dr Pieter Rossouw

References neuropsychotherapist.com/childhood- trauma/. Rossouw, P.J. 2012b. Neuroscience, learn- Bowlby, J 1969. Attachment and Loss. Vol 1: ing and . From sea slugs to men- Attachment. New York, Basic Books. tal health. Neuropsychotherapy, 13. 2-6. Bowlby, J. 1973. Attachment and Loss. Vol March 2012. 2: Separation,. Anxiety and anger. New Shen, S., Battersby, S., et.al. 2000. Refined York, Basic Books. mapping of the human serotonin trans- Bowlby, J. 1980. Loss, sadness and depres- porter (SLC6A4) gene within 17q11 adja- sion. London, Hogarth. cent to the CPD and NF1 genes. Europe- Bowlby, J. 1988. A secure base: Parent-child an Journal of Human Genetics. 8: 75-78. attachment and healthy human develop- Schore, A.N. 2009. Attachment trauma ment. New York: Basic. and the developing right brain: origins Drevets, W.C. 2001. Neuroimaging and neu- of pathological dissociation. In P.F. Dell ropathological studies of depression: & J.A. O’Neil (Eds.) Dissociation and the Implications for the cognitive-emotion- dissociative disorders: DSM-V and be- al features of mood disorders. Current yond (pp. 141-153). New York: Routledge. Opinion in Neurobiology. 11: 249-249. Schore, A.N. 2012. The Science of the Art of Epstein, S. 1993. Implications of cognitive- psychotherapy. New York: W.W. Norton. experiential self-theory for personal- Schore, J.R. & Schore, A.N. 2008. Modern ity and developmental psychology. In attachment theory: The central role of Funder, D.C., Parke, R.D., Tomlinson- affect regulation in development and Keasey, C., Widaman, K. (eds). Studying treatment. Clinical Social Work Journal, lives through time: Personality and de- 36, 9-20. velopment. 399-438. Washington, APA. Shonkoff, J.P. 2011. Protecting brains, Grawe, K. 2007. Neuropsychotherapy. How not simply stimulating minds. Science, neurosciences inform effective psycho- 333,982-983. therapy. New York: Taylor & Francis. Van der Kolk, B.A., Burbridge, J.A., & Su- Hovane, V. 2012. Cultural insights provide zuki, J. 1997. The psychobiology of trau- guidance on Aboriginal child sexual matic memory. Clinical implications of abuse. InPsych. October, 30-31. neuroimaging studies. In R. Yehuda & Insel, T.R. & Fenton, W.S. 2005. Psychiatric A.C.McFarlane (eds.) Psychobiology of epidemiology. It’s not just about count- posttraumatic stress disorder. (99-113). ing anymore. Archives of General Psy- New York, Annals of the New York Acad- chiatry, 62, 590-592. emy of Sciences Kandel, E. 2006. In Search of Memory. The Van Eekelen, J.A.M. et al 2011. Identification Emergence of a new Science of Mind. and genetic determination of early life New York, W.W. Norton. risk disposition for depressive disorder: Kandel, E. 2013. Principles of Neuroscience. Atypical stress-related behaviour in early New York: McGraw Hill. childhood. Australian Journal of Psychol- MacLean, P.D. 1990. The Triune Brain in Evo- ogy. 63:6-17 lution: Role in Paleocerebral Functions. Waters, E. et.al. 2000. Attachment security New York, Plenum Press. in infancy and early adulthood: A twenty Merikangas, K.R. et.al. 2010. Lifetime year longitudinal study. Child Develop- prevalence of mental disorders in U.S. ment. 71: 684-689. adolescents: Results from the National Comorbidity Survey replication – adoles- cent supplement (NCS-A). Journal of the Dr Pieter Rossouw specialises in Neuropsychotherapy in Australia and is an expert American Academy of Child and Adoles- in anxiety and mood disorders. He has published five scientific cent Psychiatry, 49, 980-989. books and over twenty scientific articles. He has been involved Rossouw, P.J. 2012. Neurobiological in research in extensive clinical trials and presented research Markers of Childhood Trauma. The papers at thirty international conferences worldwide. He is on Neuropsychotherapist. Retrieved No- the Advisory Board of The Neuropsychotherapist. vember 7, 2012, from http://www.

Neuropsychotherapist.com 7 Go to www.mediros.com.au for information on Australian Neuropsychotherapy Workshops Pieter J. Rossouw MClin Psych; PhD; MAPS; CCLIN.

Pieter is the Director of the Master of Counselling Program at the School of Psychology and the School of So- cial Work and Human Services at The University of Queensland, Australia. His research and teaching focuses on Neuropsychotherapy. Pieter is also the Director of Mediros – a company that provides training in Neurobiology and Neuropsychotherapy.

Pieter has established a distinguished career as Clinical Psychologist, Lecturer, Clinical Consultant and Super- visor. He has been in Private Practice for the past 25 years. Pieter holds Honours Degrees in Philosophy and Psy- chology, a Master Degree in Clinical Psychology and a PhD. Pieter is a member of the Australian Psychological So- ciety and the APS College of Clinical Psychologists. He provides Mental Health training for GP’s and is accredited at the Royal Australian College of General Practitioners. In this role he developed and facilitated a Clinical Audit for General Practitioners (30 PD point activity) with over 600 GP's Nationwide involved in the training.

Before relocating to Australia, Pieter was a Professor in Clinical Psychology for 11 years. He was a guest lec- turer at Universities in Canada, Holland and South Africa where he also spearheaded a Psycho-Therapeutic Assis- tance Program to support people being exposed to trauma. In Sydney he worked as Senior Clinical Psychologist at the Northern Beaches Adolescent Service – Department of Health, he was the Clinical Director of the St John of God Psychiatric Hospitals – both Richmond and Burwood Hospitals as well as worked in Private Practice. He pro- vided clinical supervision to many Masters and PhD students as Clinical Associate of the Universities of Sydney, New South Wales, Western Sydney, Macquarie, Wollongong and Newcastle. Currently he is involved in full time research in the fields of neurobiology and neuropsychotherapy as well as clinical training for clinicians, psycholo- gists and general practitioners.

Pieter specialises in neuropsychotherapy and is an expert in anxiety and mood disorders. He has published 5 Scientific Books and 20 scientific articles. He has been involved in research in extensive clinical trials and pre- sented research papers at 30 International Conferences worldwide.

He is a member of the Global Association for Interpersonal Neurobiology Studies, the International Society for Traumatic Stress Studies, the International Association for Family Therapy and the Professional Association for Drug and Alcohol Workers. He also facilitates a Global Neuropsychotherapeutic Interest Group through its e-Journal (Neuropsychotherapy in Australia) and local specialist research and discussion groups. Currently it has over 2500 active members – comprising of clinicians and academics in the field of neuroscience.

Pieter developed three 2-day APS, specialist endorsed workshops – The Brain and Anxiety: Utilizing Neurobiological Information as Psychotherapeutic Tool; The Neuroscience of Depression: New Opportunities for Effective Treatment; and The Developing Brain and the Neuroscience of Memory and Trauma. He also runs neu- ropsychotherapy applied skills classes.

— Contact Pieter: [email protected] [email protected] The Developing Brain and the Neuroscience of Memory & Trauma Implications for effective skills based interventions

The psychological and neurobiological effects of trauma have signifi- cant implications for well being. Theoretical and treatment modalities for trauma have been the focus of study for many researchers. Recent discoveries in neurobiology have changed the landscape of theory and treatment of . These discoveries assisted with our understanding of neural processes, memory and neural communication. Clarity about these concepts assists clinicians towards more effective interventions with clients suffering from the aftermath of trauma.

The Brain and Anxiety Utilizing neurobiological information as a psychotherapeautic tool

Anxiety is a prevalent problem among Australians. Over one quarter of adults suffer from anxiety in any given year. The last decade of brain research made possible by fascinating advances in brain imaging and neurobiological data has moved the understanding of anxiety disorders into a new dimension. Although we can successfully treat clients without knowing the full implication of research, we can be more effective with more people in less time if we have a grasp of the neurobiology and why and how our treatment methods change brain function

The Neuroscience of Depression New opportunities for effective treatment

Depression is a common disorder without geographic, educational, socioeconomic, or racial boundaries. Recent advances in neuroscience provided new dimensions to the understanding and treatment of de- pression. Discoveries in the association of depression with neural plastic- ity and neurogenesis as well as insight in the role of talking therapies to change neural functioning as well as neural structure opened fascinating new perspectives and treatment options.

Neuropsychotherapy for Anxiety Neuropsychotherapy for Depression Applied strategies for treatment

These workshops look at recent advances and research into anxiety and depression and the implications for therapeutic interventions.