 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody today's presentation on complex trauma in children and adolescents. This presentation was requested by some of y'all. So I tried to put it together with some other stuff that happens to be favorite resources of mine and come up with something cohesive. It's based in part on a white paper from the National Child Traumatic Stress Network called complex trauma in children and adolescents. It was done in 2003. However, the majority of the research and information that is provided within that white paper is still really germane. It's not something that's going to be significantly changed by time. And to the best of our knowledge, there hasn't been any contradictory research presented. We also use child witness domestic violence and its adverse effects on brain development. Really good article. If you're interested in, you know, why some of the children who are exposed to trauma early in life have impulse control issues and have more emotional dysregulation. Really good article to look at. And by request, the Adverse Childhood Experiences Study, which was commissioned by the CDC, done in part with Kaiser. So we'll talk some about that as we get through. We're going to define complex trauma as opposed to simple trauma. Define and explore adverse childhood experiences. We'll highlight the cost of complex trauma. And we're not talking about just material cost, but also what effects does complex trauma have on the child, the physical brain, the development, and future ability to earn, to live a happy, healthy life, etc. And we'll examine the impact and diagnostic issues of complex trauma a little bit. So what is it? Complex trauma is exposure to traumatic events plus the short and long-term impact of exposure. So you may be exposed to a traumatic event, but if that significantly impacts the child and the child does not receive support, there are some longer term impacts because the child still doesn't feel safe. So it can result in emotion dysregulation, loss of safety, inability to detect or respond to danger cues. They may just kind of become oblivious to what's dangerous, what's not. I don't know. Inability to detect or respond to internal cues. And this is one that I see a lot in children that were or grownups who were children exposed to adverse childhood experiences or trauma of any sort. They just they don't notice what's going on inside them. And then all of a sudden it's just an explosion. So there's a lot more impulsivity, a lot more anger management issues that we tend to see. And there may be a generalization of cues and it can be over generalization of everybody's safe, but more likely it's a generalization of everybody is dangerous. A friend of mine works at a place with adolescents right now. And there is one youth there who is especially triggered by people of a specific racial or ethnic background who happen to be male or female. You know, so anybody who happens to be of that background who happens to be white, she is not happy with and she will proceed to pummel into next Tuesday if she gets an opportunity. So it encourages me to think about what would prompt that behavior? What happened in that child's life that she sees an entire race of people as threatening and hostile and she feels the need to act out in a violent way. Complex trauma is most likely to develop if the danger is unpredictable and uncontrollable. So yeah, occasionally trauma happens and it's predictable like a hurricane. But you know, a lot of times trauma is you're not just driving along and expect to get into a car wreck or you're not, you know, whatever happens, you didn't predict it. When you're in the situation, you couldn't control it. You couldn't get out of it. So you feel a sense of helplessness being out of control and unable to predict when or if it'll happen again. So you're always on edge. The greatest source of danger, unpredictability and uncontrollability is the absence of a caregiver who reliably and responsibly nurtures and protects the child. So let's think about that for a second. They're saying with smaller children, the greatest source of danger isn't necessarily a particular acute trauma, but the unpredictability and uncontrollability of a caregiver who is not there, a child who can't control their own situations. Think about a two or a three year old whose mom or dad may or may not be physically there or may or may not be emotionally present because they're on drugs in jail and they're not able to provide any sort of emotional comfort or nurturance. That little child is dealing with the world pretty much on his or her own as a two or three year old and how scary must that be? So they looked at, you know, okay, there's a lot of unpredictability but what is it that actually impacts children and causes developmental delays and further problems in life? And I will caveat that the ACE study looked at 17,000 people. So it was a really big sample size, no doubt. But the adverse childhood experiences they chose, they chose 10 experiences out of the myriad that were presented because these were the 10 that were most often reported. So we don't know if these were the ones that had the most significant impact. We just know that these were the ones that happened most often. So I want you to take this with an air of information because just because your clients did not experience multiple of these 10 adverse childhood experiences doesn't mean they're going to be scot-free. Any adverse childhood experiences that they witnessed, you know, a sibling beating up another sibling repeatedly to a pulp, witnessed, you know, any kind of traumatic thing you can think of, even if it's not on this list, consider that an adverse childhood experience. So when we start talking about the number of childhood experiences exponentially increasing the problems of depression and addiction and, you know, future victimization and all that kind of stuff, I don't want you to just get trapped thinking, well, they didn't have all of these 10. Any adverse childhood experience. These just happen to be the 10 that were mentioned most frequently. Additionally, in the study, they didn't narrow it down and say, is it more impactful or is it more detrimental if it happens in a particular age group? Now, they typically in other research have identified the ages of five to eight being really crucial growth periods. But the ASIC study just asked people, did you experience any of these anytime prior to your 18th birthday? So as clinicians, we assume, you know, hope that a 16 or 17 year old is going to have better tools to deal with some of this stuff than maybe a two or three year old. So we also want to consider the weight or the impact of what the adverse childhood experience was and when it happened in this child cycle of development, you know, think about Erickson and Piaget and how children think and, you know, when they go from concrete operational to formal operational and being able to think about abstractions. I mean, young children, remember are very egocentric and dichotomous. So they're going to interpret things differently than a 14, 15, 16 year old. You know, so putting all that in there into the mix when we're determining whether or not something had an impact and obviously the child or adult, if you're working with an adult that was had a traumatic childhood is going to be able to tell us more about what at least right now in retrospect seemed like it was more detrimental or difficult to deal with. So what are the effects of adverse childhood experiences? Well, this one is kind of jargony, but I'll read it psychosocially induced biological alterations in the brain and HPA axis related to maladaptation, especially PTSD in the context of and this in particular with child witness domestic violence. So basically what they said is we realize that when children are exposed to trauma, this psychosocially induced condition or situation causes causes biological changes in the brain and the threat response system of these children. We see smaller hippocampal volume. We see a lot of other brain changes. We see potentially hypo cortisolism. We see a lot of things related to how this child perceives and responds to stress. Now, one of the things that we know with brain and HPA axis and hypocortisolism people who have hypocortisolism means they don't have enough cortisol normally, you know, their brain, their brains kind of holding on to that cortisol for when there's a really, a really true emergency. But when they do get stressed, they go from 0 to 250. I mean, it's just not even 0 to 100. It's 0 to 250. So the reaction is much more extreme. So you have a lot of emotional dysregulation with this particular group and you can speculate about a lot of reasons why that might happen. Ultimately, it happens and helping them figure out how to deal with that. And as they reduce their chronic stress, there's a chance that their cortisol levels will stabilize out. But if these problems happened in early childhood, if there actually has been a reduction in part volume of parts of the brain, they may not ever recover from that. The brain, the brain is really flexible though and it can develop all kinds of workarounds. So it's not a deaf sentence. It's not a, oh, you're just doomed to be depressed. But it's important for people to be aware that, you know what, compared to other people, I may react a lot more strongly to things and I need to be aware of that and take certain steps to take care of myself. Nearly 60% of women and 35% of men with four or more adverse childhood experiences reported chronic depression. Now I will say right now, I do not quiz you on any of these statistics. I just want you to kind of get the magnitude of what we're talking about. So when you looked at the charts or if you go online and you look at the charts, you'll see that there's a slightly increased risk with one, with two, with three. But once you hit four, it skyrockets. So with four or more, there's a greater risk of chronic depression. Again, it can be ACEs that were not asked about in a study. So don't limit yourself to just those 10. The risk of perpetrating violence increased dramatically when the ACE score was over five. And that doesn't mean they had to be a victim of violence. It could be a whole myriad of other ACEs. So we want to ask ourselves, what is it that makes that person so much more impulsive and reactive? And in reality, acting out and violence is often a way of protecting oneself because they feel threatened. You know, think about a cat in the corner. So we want to think to ourselves, what happened to this person? And if you have somebody who's acting out and seems to be really impulsively violent, we want to look back and say, what happened during your childhood and have there been brain changes? Have there been developmental changes? What coping skills do you know that will help you regulate emotions and deal with distress? And what is triggering these threats? Because a lot of times, you know, if you think of it from their perspective, they may be kind of going back to being that vulnerable three year old and trying to protect themselves. Those with at least four ACEs had nearly double the chance of being raped later in life. And just kind of let that sink in. So we might speculate that the more adverse childhood events there are, the lower the self-esteem or the more risk-taking behavior there is. And again, we want to say, what's the function of that? You can see where with some of those ACEs we talked about where it might hurt self-esteem. So there would be risk-taking behavior to get approval. You can see where there might be more drug use, which can make people more vulnerable. But we want to look and say, you know, if you have these ACEs and we're lucky enough to see you before something bad happens, you know, maybe somebody realized that they were depressed and they came to counseling. What can we do to help you feel safe and not be in a position where you could be vulnerable? 18% of people with at least four ACEs attempted suicide. So just let that sink in for a second. Nearly one in five of those people with at least four ACEs attempted suicide. So let's just kind of go back here for a second. Physical, sexual or emotional abuse. Okay, that one comes to mind right away. Physical or emotional neglect. Now think about the people that you've worked with. Think about the people that you know that you went to school with. How many of them experienced emotional neglect? And it didn't define whether it was ongoing, you know, for any period of time. Just said, did you experience it? Mother treated violently. Substance misuse, not even full-blown addiction, but substance misuse within the household. Household mental illness, parental separation or divorce or an incarcerated household member. So, you know, I'm looking through these and I'm thinking about the clients that I've worked with over the past, you know, 20 years and I'm thinking, yeah, they've got like nine out of 10. So when we're thinking about these experiences, I mean, it's really devastating to recognize the impact that it has if people who've experienced four or more of those attempted suicide. So if I were looking at that data, I would want to go back and re-interview and figure out of those 18%, when did those ACEs occur? Did they occur in teenage years? Did they occur during a particular formative period? Can we identify is there a more dangerous time for people to experience adverse childhood experiences? My point is most people have experienced multiple ACEs, not just most clients, most people. So thinking about that and the fact that one in five attempts suicide, what can we as clinicians do in a prevention standpoint, from a prevention standpoint to help stop this? And, you know, there were other, there was other data about addiction and everything else, but there's a lot that can be done if we know that most people are experiencing this or a lot of people are experiencing this. Then what is it we can do in schools in prevention efforts to help counter the effects of this so people don't end up perpetrating violence, getting raped, having chronic depression? The National Incidence Study of Child Abuse and Neglect, and that was, that's in the white paper. And I'm not going to go through each one of these, but I do want you to recognize, I mean, we've got seven digit figures where in 1996, over a million and a half children were injured to the point where it met the harm standard of investigation. Endangerment standard was almost 3 million. In 2006, you know, it held about steady except for emotional abuse, more than doubled. So I'm wondering what is the impact on the youth that we're seeing today that were born in, you know, the late 1990s. So this exposure to trauma, this exposure to adverse childhood events or experiences comes out with seven domains of impairment attachment, biology, affect regulation, dissociation, behavioral regulation, cognition and self concept. So we're going to go through each one of those attachments. The big one, you know, we've got a lot of youth who are not securely attached. A securely attached person, whether it's a child or an adult can internalize regulation strategies. They can identify internal cues. They can self soothe. They can, you know, cope with life on life's terms pretty well. They can learn to use support systems in the face of overwhelming experience. They're able to reach out and establish relationships with other people to ask for help and to provide help in return. So there's secure attachment is healthy. They, it's a give and take. There's a balance. There's good boundaries. Everything we like hope our clients will be able to develop 80% of maltreated children. So there's 20% that still develop secure attachment. So that's good. But 80% of maltreated children develop insecure attachment. There are three types. Avoidant attachment means they reject caregiving. They don't want you to mess with them. They want you to leave them alone and they disregard and distrust not only other people, but also their own internal cues. So they don't know what they feel. They don't trust their own gut, but they certainly don't trust anybody else. Thank you very much. So just get the heck away. Put yourself in that person's mind for a minute. Imagine how scary it must be because their caregivers, they couldn't trust their caregivers to meet their needs. Their caregivers probably invalidated anything that they said they needed or indicated they needed. So now they don't know how to make themselves feel better and they don't know what they really want because they've been invalidated and neglected. Ambivalent attachment. Parents alternate between validation and invalidation. Detachment and enmeshment. So the parents are sometimes there and sometimes loving and sometimes not. And the child has no control over this. It's not like there's a cue that says, all right, it's Tuesday. Dad's going to be here. Mom's not. It's just they're left to guess whether somebody's going to be there to meet their needs. Sometimes the parents are really, really involved and what I've seen in addicted families is a lot of times this is when the parent is in a period of sobriety and they're acting out of guilt. So they're overly involved in the child's life. But then when they start to relapse or when they were in their addiction, they were very detached and when they would have periods of lucidity, not even sobriety, just not being high, you know, they might be there and apologize and swear they were going to, you know, be the best parent ever. And but the child didn't know how long that would last. So they were like, you know, I don't know if I should get really excited about this or not. I'm kind of ambivalent about the fact that you're saying you're going to be here because I can't count on you. Children become hypersensitive to cues and start to overgeneralize. You know, again, think about the addicted family where the or, you know, a family where there's persistent mental illness. Children become sensitive to cues of mom's, you know, stressed out, I bet she's going to come home and start drinking or mom's drinking. So I know it's going to go bad from here or I sense that dad's been sitting on the couch all day long. That means he's getting depressed and it's might as well not even bother him right now because he's not available. So children may disconnect to protect. Remember, young children are egocentric. So everything happens is about them. So if parents are unpredictable and parents are, they can't count on their parents. They're like, well, what am I doing wrong? I don't understand. And they don't want to get their hopes up because if they get their hopes up and then the parent disappears again, it is crushing. So they disconnect. They're just like, yeah, whatever. Good, you're here. Great, you know, we'll see if you actually stick around and disorganized. There's a lack of co-regulation in these families. There's erratic behavior in the young children. They may be clingy and then dismissive and then aggressive, you know, mommy, mommy, mommy, pick me up and then mommy picks them up and they're like, get away from me. Why are you always messing with me? They can be aggressive. They can act out. They don't know how they're feeling. There's no parents haven't helped them identify their internal cues or respond to them. So the child doesn't know how to identify their internal cues or respond to them. Adolescence behavior and this is important. Adolescence behavior can be extreme, rigid and somewhat themed. So in the past, if it has worked for them to take on the helpless role, they may take on that role when it suits them. You know, so it's still sort of disorganized, but they're using this themed behavior in order to survive. You know, sometimes we think of it as manipulation, but if you take that nasty word out of it, it's kind of like resistance. I don't like manipulation and resistance. I like to look at it as what is the function of this behavior and how is it helping the youth survive? You know, why is this behavior necessary to help this youth survive right now? So, you know, the person can take on helplessness or coercive control. Either way, it's generally a primitive survival technique. You know, the small child is generally nurtured and taken care of. The helpless one is generally, you know, all poor thing. And then the ones that are doing okay on their own are generally overlooked. And then the big bully often gets attention too. So they may take on different roles. So again, ask yourself in current, in the current situation, contextually, how is whatever behavior you're seeing helping this child or adolescent survive and how during their traumatic period, whatever that was, might this have been functional because they learned this behavior and it was rewarded. How was it rewarded and why? It serves a function and it's up to us to help kind of try to figure that out. I don't expect a 15 year old to understand all that, but we can work together to try to figure out what's going on. Consequence is a poor attachment. So if you're not securely attached, you're not reaching out for help when you need it. You're not able to self soothe. You've got one or more of those other types of attachment styles. So you can't count on yourself. I mean, that's pretty much what we come down to in all three of those. They can't identify or respond to their own inner internal cues and they don't think they can count on anyone else to respond to them, which is a scary place to be. So there are lifelong risks for physical and psychosocial dysfunction. Increase susceptibility to stress. Well, yeah, if you are not able to be, I mean, we talk about mindfulness and checking in a lot of these youth who have been exposed to complex trauma don't have the vocabulary, let alone the ability to figure out how they feel. So they're probably they've probably got a lot of vulnerabilities to use a dbt term going on, which makes them more susceptible to stress. They're they're basically just barely holding on to survive. So when stress comes along, they don't have much left to give inability to regulate emotions. We learn these skills. You're not just born knowing how to self-regulate and calm down and identify your emotion and all that kind of stuff. This is stuff we learn. And so if they didn't learn those things, plus they've got some brain changes because of exposure to the trauma that make them more reactive than when they're exposed to stressful situations, their emotions may become even more dysregulated. You also have extremes and help seeking. Remember in the last one with the we were talking about people either being powerless, helpless, passive or somewhat the bully and extremes and help seeking is what we see is either people needing help because they don't feel like they can do anything for themselves. They feel completely disempowered or people who refuse to accept help because they are not going to trust anyone and they are not going to count on anyone because everybody in their life has let them down. So we hear all those extreme words backing up getting into that person's head. Where did they learn this from? Who did they learn this? I mean, things that you learn from your parents carry a pretty significant weight, you know more so than maybe something you saw between friends. So if your parents taught you that you can't trust anybody, imagine what is going on in their head. So these are the kinds of things that we see as clinicians. We can help them understand their reactivity to stress, understand vulnerabilities, learn about mindfulness, develop some emotion regulation and distress tolerance skills. But also those interpersonal effectiveness skills with help seeking and this one comes later, but being willing to ask for help, being willing to provide help and a lot of times there are baby steps here. So we need to go back over things that happened during the prior week and say, well, is there someone you could have asked to help you out with that? Why didn't you? And take a look at their reasoning as far as help seeking. Did they not want to be a bother or did they just not want to have to be indebted to someone or what was their reasoning? Symptoms and interventions, uncertainty about the reliability and predictability of the world and their own gut. So back to CPT again. I know you get tired of hearing this, but it is so useful using the challenging questions worksheet and you can Google cognitive processing therapy challenging questions worksheet. Have them evaluate when they have a belief about something. What is the evidence for and against it? What is the source of the information? Is it a reliable source? And is this information? Is my thought is my belief based on actual facts or just feelings? Those are the three big ones that I usually go through with them. We can help them use mindfulness to increase their self and other awareness. Self awareness, pretty obvious, but mindfulness can also increase other awareness to help them realize that other people are there and some people do have a good heart. Some people are there to help them and willing to help them. But also some people are going to take advantage. So increasing their ability to read other people and we can help them use mindfulness to improve their ability to communicate their wants and needs and ask for help. So mindfulness helps them identify what are their wants and needs? What am I needing right now? What am I feeling? And how do I communicate it in order to get help to get support to have my needs understood? And they may not need help or support, but helping others understand them is a big step in developing supportive relationships. We as clinicians, you know, we if we're the first line can create structure and stability. A lot of children remember the complex trauma was unpredictable and uncontrollable. So we want to take that element out. We want to be particular predictable and we want them to have a sense of control over their treatment. We want them to feel empowered and we want it to be, you know, we want them to understand or be able to predict how we're going to react. We don't want to have big surprises. However, you know, there are times we're going to have to correct behaviors or there are significant others. If you know, maybe it's family counseling. We can correct behaviors and still love the child and that's something that takes them a while to get their head around to understand that they're good people. It's just this particular behavior, you know, beating somebody up or whatever. That's not okay. They're good people and we respect them for being human beings, which is something they probably didn't hear growing up or they didn't understand what was going on during this complex, whatever caused the complex trauma. So they were having all kinds of feelings and nobody was responding to their needs in a helpful way. So they felt felt like it was about them and anything they did to try to get attention to try to get somebody to help them was met with criticism. So they're going to be hypersensitive to criticism. So we need to make sure that we communicate our love and respect for them or, you know, compassion and respect, whatever you want to say. But the fact that, you know, sometimes you choose behaviors that aren't the best behaviors. People with complex trauma often have problems with boundaries. So we want to teach them about emotional boundaries just because I feel some way doesn't mean you have to feel somewhere. That's okay. Social boundaries, you know, just general what is too much information? What do we share with people? What's okay to share? How do you develop trust? And physical boundaries, you know, some trauma may have violated all physical boundaries. But even if they didn't have a violation of physical boundaries, sometimes youth with poor attachment will use physicality in order to get approval. So we want to talk about, you know, what are boundaries, emotional, social and physical? What are yours? And what a healthy relationships look like for you? We want to examine current relationships and are they healthy? Are they not? You know, most relationships have a kernel of health to them. So we can build on that if it's an important relationship to them. But we also want to talk about, you know, do they feel like their boundaries are being respected? And are they respecting their own boundaries? Because a lot of times in order to get the comfort in order to get what they needed as children after they were exposed to trauma, they were in invalidating environments. So they may have, you know, let their emotional boundaries go. And if you read some of Marshall Lenahan's work about the environments of people with emotional dysregulation, you'll learn more about these invalidating environments. And then we want to discuss motivations for maintaining poor boundaries if they are maintaining poor boundaries. So what's the benefit to you? Or what do you get out of that? How do you feel after you, you know, how did it feel after you forewent, foregone, gave up your emotional boundary? You know, you decided that you would cave. What did that feel like to you? Interpersonal difficulties with trust, communication and attachment. And as clinicians, we can model. We can model communication skills. We can model trust. We can model honesty, effective communication and genuine respect for that other person. We can educate them about interpersonal effectiveness skills. And we can help them with perspective taking, getting outside of that world in their own head and taking another's perspective who may not have lived through what they lived through and may not understand why they're reacting the way they are. So help them take that other person's perspective so they can better explain their position not to invalidate it, but so they can better explain their position and everybody can be on the same page. They may have difficulty interpreting nonverbal cues. So think about some of the adolescents you may have worked with where they were more sexually reactive interpreting everything as an invitation for sexuality. So we want to help them understand what is an appropriate interpretation of different nonverbal nonverbal cues. Another one is not just hyper sexuality, but also hostility. Some people can feel threatened by very innocuous looks or gestures or what are they calling them now micro micro expressions. Encouraging them to take a pause and think about is this what this person was intending. You can practice in group in vignettes with self report and you can use videos. You know, sitcoms whatever shows you want. Dr. Phil if you want I don't care to interpret nonverbal cues and you can play some of it and watch somebody you know sit back and cross their arms and you can pause it and go okay. Now what do you think is going on in that person's mind right there and help them learn to more effectively interpret what's a threat what's disinterest and etc. Difficulty in listing other people as allies. So we want to help them learn how to create a win-win. We want to help them learn how to create a situation where they say I need you to do whatever because it will help me feel less stressed or whatever create a situation where the other person has a positive benefit from doing what you want them to do. And obviously it's not always possible to do this. But becoming more effective with stating what they want and why it would be beneficial for both parties is huge in helping develop relationships but it's also helps the person helps our client see that yeah there is a benefit to both of us and start having a little bit more trust in kind of the way things work. We want to help them examine any fears preventing developing allies you know like I talked about before if they couldn't count on their parents who can they count on? So they might have concerns about abandonment and betrayal. A lot of times youth that were exposed to unhealthy relationships who didn't develop secure attachment in childhood will have bad relationship after bad relationship after bad relationship either trying to replay that family of origin and get it right this time or because they don't know any other way to act and it always ends up the same way with being betrayed or abandoned. So they feel like the world is always going to abandon them. So we want to look at what leads up to this? What is it in these past relationships that have maybe caused the other person to leave or you know what's going on? Sometimes they'll realize that they push the other person away. Other times they'll realize that they were attracted to people or got in relationships with people who were in and of themselves just not healthy enough to have a proper relationship. So we want to look at changing it from an internal global thing of I'm not lovable or everyone out there. Nobody out there can be trusted and look at more specifics about you know what do you look for in an ally and how do we build trust? We will model helping them enlist other people as allies. We will have them ask us for help when they need help. You know, we're going to give them homework assignments or or whatever and we want them to ask for input. We want them to ask for help but we also want to model asking for their input getting them to tune into themselves and say you know what? This is what I need right now because I don't know what you need at every moment. I'm not in your head. Encouraging them to trust in their own gut. So we want to have them enlist themselves as an ally and be able to trust themselves as well as be able to enlist others. And we can also try role-playing. You know, if people are not comfortable asking for help you know, asking for help moving or writing a getting a letter of recommendation written or whatever it is they need. We can role play and have them state what they need why they need it and look at not only the verbals but also the nonverbals. Is it presented aggressively sheepishly or assertively? There's also problems with biology sensory motor developmental issues hypersensitivity to physical hypersensitivity to physical contact. So you have someone who may or may not be overly reactive if you touch them and they may not be able to integrate all of the sensory motor stuff coming in. They may have problems with coordination and balance. And there's some indication that some people have analgesia and a lot of that is people who experience some sort of physical physical trauma have learned to sort of dissociate so they don't feel but any of these add to the confusion of somebody who does is having a hard time reading their own internal cues. The world's coming in and all this sensory input can't be integrated real clearly. It's kind of like if you have if you're getting over the air TV and you don't have a good pair of rabbit ears and it's coming in but it's a little grainy kind of that way and that's frustrating after a while if you can't figure out exactly what's what you're seeing or what you're dealing with. A hypersensitive sensitivity to physical contact. I do want to highlight though because if somebody is hypersensitive to being touched then they may react really strongly to that. So if you're in a situation that seems very benign you're in the line at the cafeteria or you know people are waiting for meds med call or something and somebody touches them and they become extremely aggressive. Again, we want to back up. No after we get the situation under control but mentally we want to back up and say what prompted that? What were the vulnerabilities going into that? Is this person hypersensitive to physical contact? Why? And what can they do to learn how to work with that? They that may never go away but if they know that they're hypersensitive to physical contact then they can take steps to reduce their stress around that reduce the risk that they're going to be touched by a stranger not getting on a crowded elevator taking the stairs giving themselves plenty of space between other people. There are a lot of things that they can do but we have to know what's going on and what triggers them. Difficulty with emotional self-regulation describing feelings and internal experience and communicating wishes and desires. So affect regulation here. Well, if you don't know what's going on inside you you don't know what to do to fix it. So we need to start giving them words and if you're working even when you're working with adults sometimes if they never have gotten in touch with what's going on they've been either numb or just on autopilot all their lives. They may not know they may have words like I'm feeling or I'm feeling blah or I'm feeling really stressed out. Okay, that's a start. That tells me that we're on the negative end of the spectrum. Let's figure out exactly what you're feeling and why but we have to help them explore what's going on and become more self-aware and validate that that's okay. You feel how you feel and I'm not going to invalidate you and tell you you're overreacting or you shouldn't feel that way. I'm curious. I want to understand why you feel that way and then we can figure out how to improve the next moment but right now you feel how you feel and that's your brain's way of protecting you. Behavioral control impairments and this is what ends up landing a lot of the adolescents in our treatment centers. They're poor modulation of impulses. They want something they want it now which ends up in stealing aggressive actions towards someone else you know beating people up and it can also end up with using addictive substances. They hurt. They want the hurt to go away. They take something they're like oh that made the hurt go away. I'm going to do that again. They don't exactly maybe understand exactly why. Self-destructive behavior. Well if you've got poor impulse modulation then pretty much the first thing that comes to your mind is what you do. It's there's no filter like that's probably not a good idea. So many times when you have unpleasant feelings the knee jerk reaction is probably not the most helpful which ends up being self-destructive. So we want to help them see how their initial reaction to something may have been of pain or whatever it hurt. It was unpleasant and then their automatic reaction was to try to make that go away. Did that help them get closer to their goals or did that make them kind of spin in circles and make things worse. If it made things worse which it usually does then we want to say okay what other options might you have had if you would have practiced the pause. Aggressive impulses pathological self-soothing behaviors we can think of tritillomania. There's a lot of different behaviors binge eating drinking you name it if it helps somebody escape from the pain somehow it may be a self-soothing behavior self-injury that's another one. So we want to again look at what is the function this behavior is serving to help this person survive right now or why is it out there and remember that people who are exposed to complex trauma tend to respond more strongly. So take just understand that it was probably an overwhelming response to whatever it was. So it needed to stop difficulty complying with rules if their needs were never met or rarely met or inconditionally met then it's important to understand that a lot of times their behavior while it appears oppositional may be self-protective they may be reacting as a mini parent. I mean think about whenever they had that trauma if nobody else was there to meet their needs they may have figured out how to survive on their own and so they're kind of setting their ways right now or they don't trust anybody so they may be oppositional because they're expecting something to be harmful or hurtful difficulty complying with the rules goes back to poor modulation of impulses. I want what I want and I wanted it yesterday. So it may not be that they're trying to be disrespectful to you as a rule setter they may not even think about it. They may just be like whatever I'm going to do what I want because they have difficulty modulating their impulses and maintaining or and exploring how their behavior affects other people they've never had to do that and they may reenact prior trauma in daily behaviors. One theory like I said earlier is people trying to redo the situation and master it this time. So we see people sometimes put themselves in more vulnerable situations. I've heard things like well lightning doesn't strike twice so you know whatever I do I'm never going to be victimized again so I can just do whatever I want or they might be trying to basically rewrite that chapter and be victorious this time problems with cognition in an attention regulation. Well if you're stressed out if the world's unpredictable if you don't know how you feel which means there's probably a lot of turmoil going on in here. You're going to have a hard time focusing. So I get that and part of our job as clinicians is to help you kind of sort through the noise in your head and in your heart so you can start focusing on OK. One step at a time what is the next thing I need to do. Lack of sustained curiosity kind of goes along with that if you're using all the energy you've got to try to control the chaos. When do you really have the energy to be curious. We need to help them kind of figure out how they're feeling what they're doing get an invalidate get into validating environments and reduce their stress levels. We need to help them process new information because you know somebody that's compassionate and consistent and there for me that doesn't compute. So we need to help them process this and what does it feel like when somebody's there for you might be scary or you know maybe it brings up great feelings of sadness because you wish you had had a loving parent. So help them process this new information and figure out what to do with it. Deficits an object constancy if that during that complex trauma period the caregiver was not. Reliably there then you know difficulty with object constancy I can't count on anything to be reliably there. Problems with orientation to time and space they may just not really even pay attention to what's going on. When that complex trauma happened they may have been too young to really have much care for time and space so they may not have developed time management skills and things. We can help them with that and problems understanding their own contribution to what happened to them. They're pointing out at everybody else blaming to fingers pointing out three fingers pointing back. So what was your part in whatever happened and helping them understand that they do have a part it may not have been a big part it may not have been a positive part but let's look at whatever it was that happened to you you got arrested. Okay. You got arrested what was your part in that. And you know maybe your friends made you do it and you know a whole lot of other blaming and excuses and stuff that went into it. We'll take that all into consideration when we're painting the big picture but I also want to make sure you understand what your part is because in the future you can change your part you can't change what your friends do you can't change this stuff over here. But you can decide whether you want to change your part. The good news. It's not all bad news stressors earlier later in life that are predictable escapable or controllable. Okay so and so early or later in life it doesn't have to be during that complex trauma period. But if the stressors predictable and controllable. Or in which a responsive caregiver contact is available. So even if it's unpredictable if there's a responsive caregiver there and there are safe opportunities for exploration and kind of getting your land legs again. The person will tend to show increased hippocampal and prefrontal cortex neuronal functioning. So remember I talked about the brain damage and the reduction in hippocampal volume and stuff. Well this can the functioning the neuronal firing can increase again we may not get more neurons back. But we can increase functioning and that plasticity is kicking in. And it can serve to behaviorally enhance curiosity working memory anxiety management and the ability to nurture self and others. So when stressors occur and you know sometimes we end up as clinicians in that caregiver role if you will. If we can provide safe opportunities for them to explore what happened and figure out what their strengths are and get their land legs back. They can start learning how to deal with stress. So they can there are workarounds complex trauma is not a you know something they can't work around restoration of secure caregiving after early life stressors has a protective effect reducing long term biological and behavioral impairment. So if they're early life stressors but then a secure caregiver whether it's a foster parent or you know maybe they're in long term treatment but there's somebody secure there. It can have a protective effect even if it's only visual and not tactile or symbolic with the original caregiver. So maybe they can see pictures of their mom or dad but they may not be able to touch hug or have that person in a parental role but they see pictures. The socio physical environment is severely impoverished. So even if they're not in the greatest environment it doesn't mean that they're they're doomed to dysregulation and the caregiver doesn't have to be the biological parent. So we know that as long as there's a secure caregiver somebody that is structure and is there and as you know they can count on. The person can learn how to self regulate the person can learn that there's a safe home base to go back to which can reduce the long term biological and behavioral impairment because basically they learn to start working through those Ericksonian stages. Common diagnoses ADD and conduct disorder. You see we talked about impulse control. We talked about hypocortisolism leading to extreme reactions. So you might have somebody who tends to be more stressed out and more nervous may tend to have more problems with impulse control and emotional dysregulation. I'm not going to go through each one of these because we don't have time but I want you to focus when we start making diagnoses of people who may have had complex childhood trauma. What is the function of their symptoms? How was that helpful or functional or what didn't they learn back during that time that would have helped them avoid these symptoms that we can address now. Oppositional defiant disorder you have somebody who's negative angry resentful defiant disobedient well if you were in an invalidating environment and learned that you couldn't trust anybody I can see where you might have a bad attitude. So looking again how did that protect them back there what didn't they learn and what can we help them learn now and generalized anxiety disorder just generally worrying not feeling empowered about anything. If the world that unpredictable trauma if that unpredictability of whether you are going to have a caregiver there or not was pervasive then yeah you could be stressed out and worried all the time because you don't know when somebody is going to be there to meet your needs or if you're going to be able to survive I mean a two year old can't go to Kroger and get groceries so they hope that mom or dad is eventually going to come home and change the diaper and feed them and reactive attachment disorder goes with those attachment issues that we talked about earlier. So looking at what is the function of these behaviors and how did it protect the child during the complex trauma. Millions of children in the U.S. are abused or neglected each year. This maltreatment often leads to negative emotional social and physical consequences that can but don't have to last a lifetime. People have the ability to develop the skills and tools to work even if they have permanent brain changes they can work around those and develop a happy healthy life. When put in context at the time the behaviors were learned the behavioral issues often make sense. You know if the person's acting like a three year old and their trauma was when they were three we want to look at what happened where they didn't develop further social skills as as they grew. Recovery requires learning to trust themselves. Develop a healthy support system and reexamine their prior learning experiences through a different lens because remember I said young children tend to be dichotomous and egocentric. So we want to help them explore possible other options about why might this have happened and their their view of themselves. You know are they overreacting are they troublesome are they drama queens are they whatever or you know in a in a different light where they children that we're just trying desperately to get their needs met and what can they do now that's going to help them succeed as teenagers or adults. All right that was a lot of material what questions do you have and I know some of you have got to go see clients so feel free to let me know you can email me. And I always get mucked up with private versus public there we go. You can email me if you have any questions if you've got to go that's totally cool if you've got questions or comments I would love to stick around and have a discussion about hormone interactions. Well I mean if you look strictly from the perspective of the HPA axis tending to reduce sex hormones which may seems to best that they can tell reduce availability of serotonin and GABA then people who are under chronic stress would tend to have higher levels of fight or flight higher levels of anxiety and anger then people who don't have chronic stress. You might also follow that with during pubescent years changes in hormones also affect changes in availability of the neurotransmitters so you know understanding the ebbs and flows and helping the children or youth understand the ebbs and flows based on and you know they hate it when I say it but it may just be a growth spurt or it may be a change in your hormone levels so think about what cycles that you have and you know then they can also talk with their primary care physician about whether there's anything that might help one thing that the research has shown at least in women of course is that artificial progesterone significantly increases depression so you know that's one thing that would make me nervous if for some reason the doctor wanted to look at that but obviously that's the doc's call and not mine. So as far as reading material that is tolerable you know I think the general public can understand it but it can be god awful boring sometimes if you're not like really into this stuff I don't know of any except for the ACEs study which is it's aceshigh.com I think it might be dot org let me see ACEs too high ACE here. Let me see in your course I also put a link to the white paper that was done by the national traumatic stress childhood traumatic stress center and I really recommend if you work with adolescents or adults who were exposed to unpredictable caregiving environments that you at least scan it over and take a look at it because I learned so much reading it. It's a little bit long so you know break it up over a few days but I found it to be a bunch of priceless information. As far as helping people break the cycle of complex trauma as far as breaking the cycle of the complex trauma it's really helping them learn to understand why they react and feel the way they do which I think we're already probably good at as clinicians but then also starting to help them develop the skills necessary to deal with whatever changes occurred you know because there's a whole range there's a whole page full of possible impacts of complex trauma. So we want to look at the individual and say okay what in what way did the complex trauma impact you what skills do you need in order to be able to live the happiest highest quality of life. And then and then work from there and a lot of it comes down to mindfulness emotion regulation and distress tolerance and the ability to develop healthy relationships and secure attachments. The first three are a lot easier to teach than the fourth one but it's possible. 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