tag:blogger.com,1999:blog-10694525297222619212024-02-19T04:30:39.917-08:00TeenShrinkTalkA Youth Psychiatrist wrestles with issues in mental health. Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.comBlogger12125tag:blogger.com,1999:blog-1069452529722261921.post-25546136054256625092013-09-02T14:07:00.000-07:002013-09-18T18:04:15.780-07:00Teen Shrink Talks Teens<br />
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<span style="font-size: large;"><span class="s3">M</span><span class="s3">any </span><span class="s3">of you </span><span class="s3">have asked</span><span class="s3">, “Hey Teenshrink, this is all well and</span><span class="s3"> good, but what about teens?” The question is understandable </span><span class="s3">given the name of this blog. But patience,</span><span class="s3"> </span><span class="s3">there is method to my madness. In order to make sense of teens, I felt the need to</span><span class="s3"> set the stage</span><span class="s3">. Adolescence only really makes sense if you understand the foundation it is built on.</span><span class="s3"> </span><span class="s3">Hopefully I have shed some light on this foundation so far.</span></span></div>
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<span style="color: #0b5394; font-size: large;">Teen transitions</span></h4>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Adolescents sit perched on the gateway between childhood and ad</span><span class="s3">ulthood</span><span class="s3"> and it is in these years that an astounding array of mental health difficulties have their origins.</span><span class="s3"> Roughly half of all lifetime mental disorders, in most studies, are found to start by the mid-teens and three quarters by the mid-20s. </span><span class="s3">The peak age of onset</span><span class="s3"> for all mental illnesses is 14</span><span class="s3"> (according to the National Comorbidity Survey)</span><span class="s3">.</span><span class="s3"> It may come as little surprise therefore that m</span><span class="s3">any parents are overcome by a strange pessimism at the mere thought of parenting their children through these ages.</span><span class="s3"> But with some insight into the brain and soul of the teenage years </span><span class="s3">it should be possible to reduce such</span><span class="s3"> pessimism.</span></span></span><br />
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Eric Ericson was one of the first theorists to extend the theory of development out of childhood. </span><span class="s3">This was u</span><span class="s3">nlike Freud and many of his early disciples who seemed to have difficulty looking beyond early childhood.</span><span class="s3"> According to Ericson’s</span><span class="s3"> theory</span><span class="s3">,</span><span class="s3"> basic interpersonal patterns of trust, cooperation, autonomy, mastery and sensitivity to shame and guilt </span><span class="s3">may </span><span class="s3">have been estab</span><span class="s3">lished by the</span><span class="s3"> time </span><span class="s3">of adolescence, </span><span class="s3">but the challenges of identity formation and integration into the broader community await the</span><span class="s3"> teenage years.</span></span></span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Adolescence has been defined as beginning with t</span><span class="s3">he onset of puberty and ending</span><span class="s3"> with the establishment of an independent role</span><span class="s3"> in society. H</span><span class="s3">owever that timespan seems to be expanding in our western culture. The average age of puberty has been decreasing</span><span class="s3"> (for reasons that have not been established)</span><span class="s3">,</span><span class="s3"> and the age of establishing an independent role in society has been getting later. With the age of social media upon us</span><span class="s3">,</span><span class="s3"> this time period has become e</span><span class="s3">ver more complex and tumultuous!</span><span class="s3"></span></span></span></div>
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<span style="color: #0b5394; font-size: large;">The Teenage Brain</span></h4>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">So what is going on in the brain during these years? Although the brain has achieved </span><span class="s3">90% of its size by the age of 6, the amount of white matter in the brain continues to increase into the thirties. White matter is the part of the brain that acts like highways. Meanwhile the houses in the city of the brain are </span><span class="s3">the gray matter. The gray matter begins to decline thr</span><span class="s3">ough middle adolescence. This has been referred to as</span><span class="s3"> synaptic pruning,</span><span class="s3"> but occurs inconsistently across various brain regions</span><span class="s3">. </span><span class="s3">The prefrontal cortex is one of the areas that fully matures through this time period. </span><span class="s3">With its</span><span class="s3"> increased differentiation and </span><span class="s3">interconnection</span><span class="s3"> the </span><span class="s3">teenager </span><span class="s3">becomes able to think</span><span class="s3"> </span><span class="s3">more </span><span class="s3">abstractly and experience greater </span><span class="s3">self-awareness</span><span class="s3"> than ever before</span><span class="s3">. This leads the adolescent to begin to ask him or herself the question “Who am I and where do I fit in?” in ways that younger children cannot yet do.</span><span class="s3"> The answer to this question for us, among the most social of mammals, has been incredibly important to our survival.</span></span></span></div>
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<span style="color: #0b5394; font-size: large;">The Social Brain</span></h3>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Perhaps for this reason</span><span class="s3"> the teenage</span><span class="s3"> brain appears to demonstrate a</span><span class="s3"> heightened sensitivity to social stimuli such as facial expressions</span><span class="s3">. The </span></span></span><span style="font-size: large;">medial frontal </span><span class="s3" style="font-size: large;">area of the prefrontal cortex used by adolescents to decode facial expressions is more actively linked to the emotional brain than the superior temporal area used by adults for similar tasks </span><span class="s3" style="font-size: large;">. </span><span class="s3" style="font-size: large;">Therefore, t</span><span class="s3" style="font-size: large;">he job of decoding facial expressions is much more tightly linked to the emotional brain in adolescence than it is in adulthood. For this </span><span class="s3" style="font-size: large;">reason</span><span class="s3" style="font-size: large;"> it seems that non-verbal signals are more likely to lead to powerful physical and emotional reactions in adolescence than at any other time of life.</span></div>
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<span class="s3" style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;">Male and female development, of course, take somewhat different trajectories. Male development in adolescence is associated with increases in the hormones testosterone and vasopressin, which act synergistically and result in increased intermale competition, while female development is associated with increased estrogen and oxytocin, which result in an increased tendency towards female relational bonding, which as we know can result in painful exclusion when it goes awry. (See Panksepp's "<i>Archeology of Mind"</i>)</span></span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Strangely as a culture it seems we </span><span class="s3">in the “western developed world” </span><span class="s3">have </span><span class="s3">gone down a rather strange road when it comes to how we approach</span><span class="s3"> this critical time of</span><span class="s3"> adolescence.</span><span class="s3"> In their book "<i>Escaping the Endless Adolescence"</i>, psychologists Joseph and Claudia Worrell Allen note that teenagers in the US spend just 16 hours per week interacting with adults and 60 hours with other adolescents. One century ago it was almost exactly the opposite, as it continues to be in more traditional societies. The implications of this may be very significant.</span></span></span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-size: large;"><span class="s3">Gordon Neufeld and Gabor Mate argue convincingly in their book, "<i>Hang Onto Your Kids</i>", that this environment, devoid of adult influence, increases the pressure on peer relationships and interferes with the parent child attachment bond that remains an important tether for the ongoing development for the adolescent. With weaker parent-youth bonds, youth are more likely to turn to their much more available same aged peers to meet their ongoing needs for nurturance and guidance. With the increased power of technology and social media this becomes seductively easier, and many parents unwittingly encourage this. Unfortunately, the results for the parent-teen relationship can be </span><span class="s3">devastating. Once teens have tuned out parent for their nurturance needs</span><span class="s3">,</span><span class="s3"> and tuned in their same aged peers, parents lose their natural parental authority and peers take over this powerful mantle of influence. </span></span></span><span style="font-size: large;">The guidance these teens tend to receive from other adolescents rarely encourages the long term goals and values that adult caregivers would be likely to encourage. </span><span style="font-size: large;">This shift in focus to same aged relationships is something that is almost taken for granted in our culture, but it inevitably leads to frustration among parents who find their offspring beyond their influence. Often parents either throw up their hands in defeat, or alternatively turn to harsh punishments which can result in further estrangement and resentment and breakdown of trust.</span></div>
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<span style="color: #0b5394; font-size: large;">The Rising Tide</span></h3>
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<span style="font-size: large;">As adolescence proceeds, we see an increase in the incidence of depression, suicidal ideation, substance misuse, eating disorders and psychosis. Families and children face many pressures, such as illness, divorce, financial and personal upheaval which can accumulate and place strain on parent child bonds. With few alternate adults to turn to, youth often turn to their same age peers during these challenges, for a time often coming across as carefree and unaffected. However the world of peer relationships is unstable, many peers are struggling with their own problems, and hostility and rejection are everywhere to be found. As these pressures accumulate and as peers turn to one another, or turn inward, the chances of mental health issues reaching critical levels increases steadily. Drugs, self harm and disordered eating can serve as powerful ways to avoid pain and modify stress in the short term, but can quickly turn into compulsive patterns that are difficult to change, complicating long term social problems. Suicide looms as an ultimate "way out" that all too many youth consider. As parents find their influence on their troubled teens waning, their frustration and stress level naturally rise, and parents are themselves often under-supported in this world of ever decreasing social capital. (See Putnam <i>"Bowling Alone"</i>)</span><br />
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<span style="font-size: large;">Hopefully, with our greater understanding of neurobiology and of the developmental importance of the attachment relationship, we as a society may come to rethink our approaches to our vulnerable youth. Rethinking our approach to isolating youth in same age cohorts and instead integrating adolescents more successfully into integrated, age stratified, social contexts would certainly be worth considering. Perhaps by doing so we may see some reduction in the rates of adolescent mental health problems, violence, substance abuse and relationship problems that have come to dominate our news sources in recent years.</span></div>
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Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com5tag:blogger.com,1999:blog-1069452529722261921.post-64874034475849624702013-04-02T16:53:00.002-07:002013-09-11T06:04:51.084-07:00Trauma and Brain Body Interactions <h2 class="MsoNormal" style="margin: 0in 0in 0pt; text-align: center;">
<span style="color: #3d85c6;">Interpersonal Neurobiology Conference</span></h2>
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<span style="font-family: Calibri;"><span style="font-size: large;">I have returned from my conference in LA, which was truly inspiring. I followed this with a family vacation where I finished reading Robert Scaer’s book – <i style="mso-bidi-font-style: normal;">8 Keys to Brain-Body Balance</i>, which I highly recommend to any of you interested in the Brain-Body interface or developmental neuroscience in general. Robert Scaer has been himself deeply influenced by the work of Peter Levine, who presented at the conference, and whose work I found deeply moving and inspiring.<o:p></o:p></span></span></div>
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<span style="font-family: Calibri;"><span style="font-size: large;">In this post, <span style="mso-spacerun: yes;"> </span>I would like to cover some of the key points that have hit home for me over the course of this conference, focusing on some of the overlaps between presenters and, in particular, some of the key insights from the work of Peter Levine and Robert Scaer. (Scaer unfortunately did not present at the conference).</span></span><br />
<span style="font-family: Calibri;"><span style="font-size: large;"><br /></span></span><span style="font-family: Calibri;"><span style="font-size: large;">Here's a great interview with Robert Scaer by Dr. David Van Nuys. <a href="http://shrinkrapradio.com/321-the-brain-in-trauma-and-ptsd-with-robert-scaer-md/">click here</a></span></span></div>
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<o:p><span style="font-family: Calibri; font-size: large;"> </span></o:p><span style="font-family: Calibri;"><span style="font-size: large;">First, I would like to refer to a concept that was raised repeatedly at the conference. This is the concept of “windows of tolerance”. What this concept refers to is how we develop a range of emotional and physical responses over the course of development. In this process our nervous system and our physiological responses become integrated and we develop a changeable set-point (sort of like a thermostat). This occurs through a very complex interaction of our genetic make-up and our lived experiences. Many of the key points of this development I have referred to in my previous posts (Allan Schore's work). Through these repetitive and rhythmic interactions in the womb and in the first 2-3 years of life, our physiology and nervous system may develop a broad range of flexible arousal which allows us to adapt to many different situations in our environment (i.e. a wide window of tolerance – see figure 1). Alternatively we may find ourselves with a narrow window of tolerance, outside of which we experience disruptive reactivity or paralyzing immobility (see figure 2).</span></span></div>
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Figure 1</span></h2>
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<span style="font-family: Calibri;"><span style="font-size: large;">Healthy attachment and attunement, in the context of a stable environment and community, lead to wide and functional windows of tolerance. Alternatively expressed genetic factors and or environmental factors, that interfere with this development, lead to narrow windows of tolerance. A narrow window of tolerance may lead to strategies to avoid extremes, resulting in rigid patterns of behavior, or alternatively, a tendency to experience extremely chaotic emotional states.</span></span></div>
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<span style="color: #3d85c6; font-size: large;">Brain Body Interactions</span></h2>
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<span style="font-family: Calibri;"><span style="font-size: large;">Robert Scaer has proposed a robust theory of body-mind interactions that expands on the physical implications on this brain body balancing act. He explains the implications of being is a state of chronic high arousal. When the thermostat is set too high, into the chronic arousal state at the top of the graph, the body releases cortisol which over a long period of time can result in chronic health problems, such as high blood pressure, obesity, diabetes, stroke, and suppression of the immune system. High cortisol also results in damage to the hippocampus which I have explained in a previous post is responsible for memory and learning, therefore causing memory impairment and learning difficulties. In the extreme, these high arousal states can result in paranoia and psychosis. On the other hand when the thermostat is set too low, low arousal states can lead to problems with chronic fatigue, heart irregularities, irritable bowel, asthma and overactivity of the immune system. <o:p></o:p></span></span></div>
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<o:p><span style="color: #3d85c6; font-size: large;">When Trauma Strikes</span></o:p></h2>
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<span style="font-family: Calibri;"><span style="font-size: large;">A key factor that can lead to narrowing of our windows of tolerance is trauma. A traumatic experience is any experience that at the developmental stage of the individual (which varies accross development and with experience) pushes them completely out of their window of tolerance, with no expectation of safety. Scaer goes on to explain that when we have a traumatic experience we may enter a freeze state. The key brain area that assesses our environment and engages the freezing response is the amygdala. The amygdala is active from the third trimester of a fetus' development, and therefore, Scaer points out, we are susceptible to trauma even prior to being born. Traumatic memories are not encoded in the part of our brain that encodes ordinary memories. Those ordinary (explicit) memories are encoded by the hippocampus, which does not come online until the second to third year of life. In trauma, the hippocampus is disabled, as are the parts of our brain that control language. When this occurs the motor movements and sensations that we are engaged in just prior to this are stored in a form of memory called procedural memory. If this state of action and sensation is not “discharged”, which requires entering a state of calmness where we can return to emotional state prior to the trauma, these motor and sensory memories remain active and the traumatic state is stored in a sort of "perpetual present". (Scaer himself had a facial tic which was a remnant of traumatic incident he experienced at the age of 4.) Motor memories can lead to chronic changes in posture, tics or stutters. Sensory memories can lead to chronic pain conditions, an example of which is the phantom limb phenomenon.<o:p></o:p></span></span></div>
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<span style="font-family: Calibri;"><span style="font-size: large;">Peter Levine has developed a therapy which he has named <em>Somatic Experiencing</em> which engages the client in gradually accessing the stored motor and sensory memories of trauma, while deactivating the amygdala by careful attunement and providing resources to the patient that establish safety and empowerment.</span></span></div>
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<span style="font-family: Calibri;"><span style="font-size: large;">In summary, the brain and body exist in a complex relationship with one another. Various life experiences can contribute to healthy and flexible brain-body interactions and others can lead to rigid or chaotic brain-body states. With a deeper understanding and appreciation of these patterns, we in the healing professions may be capable of profound healing. Without this understanding, we run the risk of perpetuating or even worsening these imbalances. In general, our health care system remains ignorant of these interconnections and we continue to treat the brain and body as strangely disconnected. Hopefully as the neuroscience and physiology of these interconnections becomes better understood, we will become better at improving the brain body balance in ourselves and in those we care for.</span></span></div>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com1tag:blogger.com,1999:blog-1069452529722261921.post-35341508843733376112013-03-01T11:16:00.001-08:002013-03-02T08:46:20.619-08:00Divided Brain, Divided Soul<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">This post has been inspired by Iain McGilchrist's book, “The Master and his Emissary”. This is a visionary work which explores the lateralization of the human brain. By lateralization I am referring to the fact that the human brain is divided into two hemispheres or halves. Specifically I have just finished listening to Dr. David Van Nuys' latest interview with Iain McGilchrist which I highly recommend. </span><a href="http://www.shrinkrapradio.com/2013/02/28/340-brain-lateralization-and-western-culture-with-iain-mcgilchrist-md/"><span style="font-size: large;">http://www.shrinkrapradio.com/2013/02/28/340-brain-lateralization-and-western-culture-with-iain-mcgilchrist-md/</span></a></span></span></div>
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<span lang="EN-CA"><span style="color: #3d85c6;">Left Brain, Right Brain</span></span></h2>
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<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">It has become a part of pop culture to refer to the right and left brain, ever since the “split brain” studies of the 60s and 70s. In these studies patients who had their brains surgically divided with a surgical procedure to control epilepsy were subjected to psychological tests to evaluate the differences between the hemispheres. This led to a popularized stereotype of the hemispheres that McGilchrist debunks in his very comprehensive survey of this topic, while bringing the most up to date neuroscience to the table. In this way McGilchrist synthesises a very new construct of the important differences between the two hemispheres of the human mind.</span></span></span></div>
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<span lang="EN-CA"><span style="color: #3d85c6;">2 Ways of Knowing<o:p></o:p></span></span></h2>
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<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">McGIlchrist takes an evolutionary look at how this specialization of the hemispheres developed, pointing out it’s origins in birds and mammals. McGilchrist posits that this lateralization evolved because of the adaptive advantage of having two kinds of attention that we can use at the same time. The left hemisphere attention system is narrowly focussed, predictive and exclusive, making it ideal for predatory, scavanging, or tool making and using tasks, while the right hemisphere attention system is wide ranging, inclusive, integrative and less predictive making it ideal for being on the look out for surprises, unexpected dangers or opportunities. By dividing itself in two, the mind can run both processes simultaneously which has massive and obvious survival implications. With social birds and mammals the hemispheres also specialized in their social functions. The right hemisphere taking on the role of holistic appraisals of the social world and it’s opportunites and dangers while the left using more practical strategies for manipulating social situations and presenting a social “persona” to the world.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">The main point here is that the left hemisphere tends to ignore context, which is both it’s great strength (separating relevant information from the whole, so as to manipulate it more effectively) and it’s weakness (losing sight of the forest for the trees). <o:p></o:p></span></span></span></div>
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<span lang="EN-CA"><o:p><span style="color: #3d85c6;">Birth of the Brains</span></o:p></span></h2>
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<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">Developmentally the right hemisphere is the earlier developing hemisphere. It stores the implicit learning of attachment experiences and it learns the implications of non-verbal information in our environment. It connects our social world to our physical world of stress responses, motivations and behaviours. This learning is chiefly organized by the subcortical brain structure known as the amygdala, which becomes active before birth. This right brain learning is implicit (unconscious) and enduring. The left hemisphere begins it’s growth spurt later (from 18 months or so), and it begins it’s process of naming and analyzing the world and developing more explicit (conscious) connections and strategies. The chief subcortical region that encodes this learning is the hippocampus, which comes online later and is more vulnerable to stress and injury.<o:p></o:p></span></span></span></div>
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<span lang="EN-CA"><o:p><span style="color: #3d85c6;">The Rise of the Left Brain</span></o:p></span></h2>
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<span lang="EN-CA"><o:p> </o:p></span><span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">McGilchrist’s thesis includes the argument that the western world has come to highly value left hemisphere knowing while undervaluing right hemisphere knowing. He argues that western culture tends to be reductionistic, glorifies factual knowledge and is dismissive of experience or context. I would agree that our modern approaches to society and child rearing have reflected and influenced this bias. We have tended to devalue communities, sacrificing them to the conveniences of parking lots and personal sanctuaries. We have also undervalued the developmental window of the right hemisphere, namely the first 18 months to 3 years of life with inadequate maternity leaves and insufficient support for at risk mothers, with the result that infants all too often are raised in crowded daycares or in front of screens watching “Baby Einstein”.</span></span></span></div>
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<span lang="EN-CA"><o:p><span style="color: #3d85c6;">Integration</span> </o:p></span></h2>
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<span lang="EN-CA"><span style="font-family: Arial;"><span style="font-size: large;">Hopefully, with the vision of new influences such as McGilchrist's this new era of neuroscience will bring a deeper commitment to the knowing of the right hemisphere. The right’s hemisphere’s inculsive nature is naturally empowering of the left. Mental health is not a contest between the hemispheres. The goal of all mental health work, ultimately, involves the healthy integration of both ways of knowing.<o:p></o:p></span></span></span></div>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com1tag:blogger.com,1999:blog-1069452529722261921.post-71444958121070219472013-02-26T12:45:00.001-08:002013-02-27T15:14:57.697-08:00Interpersonal Neurobiology and Shrink Rap<span style="font-size: large;">Yes, I know...</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">I have been away for the blog now for some time. :( </span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">However, I have been continuing my exploration of the world of Interpersonal Neurobiology and how it is shaping our view of human development and mental health.</span><br />
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<span style="font-size: large;">One fantastic source I have stumbled across is Dr. David Van Nuys podcast, Shrink Rap Radio. I have posted a link to his webpage at the bottom of the left sidebar and I recommend it to all, clinicians and non-clinicians alike. Dr. Dave, as he calls himself, is a psychologist who has taken it upon himself to interview thinkers and practicianers in the fields of psychology, psychotherapy, mental health, spirituality and neuroscience. I have been very impressed with his interviews and the selection of his guests. Thank you Dr Dave!</span><br />
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<span style="font-size: large;">I agree with David's recent musings that we are seeing a grand integration in mental health theory that is being lead by advances in neuroscience. This is very exciting. We may soon see a day where the various theoretical schools of psychology, social work, psychiatry and healers of all disciplines will be able to find scientifically supported common ground and find grand unifying mechanisms in the work of healing and recovery.</span><br />
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<span style="font-size: large;">I am looking forward the 2nd Annual Interpersonal Neurobiology conference I will be attending in LA. Let me recommend Dr. Dave's interview with Daniel Siegel that I just listened to. This conference is Dr. Siegel's brain child and his grand vision of the workings of the mind is one I certainly ascribe to. Let me quote his definition of the mind for you. <strong>"The mind is a relational and embodied process that regulates the flow of energy and information within an organism."</strong> It is in the concepts of "relational" and "embodied" that we are making the most headway in developing new understandings in neuroscience in the last decades. </span><br />
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<span style="font-size: large;">I see that we are entering a new paradigm where neuroscience is escaping the age old trap of reductionism. By understanding the mind and neurobiology as relational and embodied we can understand the transcendant aspects of mind and self. This is the key to great improvements in cooperation and wellbeing.</span><br />
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<span style="font-size: large;">I look forward to updating all of you on my experiences at the conference.</span>Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com2tag:blogger.com,1999:blog-1069452529722261921.post-52437646328497616342012-11-12T08:43:00.002-08:002013-02-26T08:27:13.385-08:00Against genetic and environmental determinism.<span style="font-size: large;">It has been a very busy week as tends to happen in November, as the hours of sunlight decline and the expectations at school increase.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">So I will not add another chapter this week to my vision of the dance between genetics and environment and the origins of mental illness.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">I hope I have engaged you in this dance, as it begins in the first years of life.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">I hope I have brought a slightly different perspective of the context of mood states and the relational nature of our selves as we emerge from potential selves to actual selves.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">My hope here is to break out of the dichotomy of genetic determinism and its opposite pole of environmental determinism. In breaking out of these two positions I hope to get away from the idea that mental illness needs to be blamed on individuals. Nuclear families (and sometimes single parents) have the burden of being the guardians of children's development on their shoulders in our modern world. Yet they cannot be expected to carry this burden alone. We must join them in taking responsibility for the environment of development as a society. Blaming parents for the ills of children is counterproductive and unfounded. Parents are usually doing their very best in difficult situations. I believe in shared responsibility, not blame. As mental health providers we can take our share of responsibility and empower others to take theirs, while facilitating access to the support that will make this possible.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">The idea of genetic determinism is tempting as an ideology which absolves others of responsibility, but it is untenable. Genetic determinism also disempowers the individual and the family suggesting that genetics is destiny and that only perhaps genetic interventions or alternatively palliative psychopharmacology are options. These are false conclusions.</span><br />
<span style="font-size: large;"><br /></span><span style="font-size: large;">I hope you have a good November week.</span><br />
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<br />Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com1tag:blogger.com,1999:blog-1069452529722261921.post-90511543278215699392012-11-04T09:02:00.000-08:002013-09-11T05:51:48.973-07:00Coming Detached<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: 'Calibri','sans-serif'; mso-fareast-font-family: 'Times New Roman';"><u1:p><span style="font-size: large;">Our modern world can pose enormous challenges for the relationships we rely on most. In this post I want to explore the attachment relationship and what we have learned about the instinctual reactions manifest by children and adults when they perceive these reactions as threatened. </span></u1:p></span></div>
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<span style="font-family: Calibri, sans-serif; font-size: large;">John Bowlby and his colleague James Robertson created a documentary in 1952 titled “A Two Year old goes to the Hospital”. This film depicted the series of stages a two year old underwent while hospitalized and separated from her parents. At the time it was hospital policy for children to be separated from parents while undergoing hospital treatments, with parents having as little as once a week contact with their hospitalized child. This was a practice that would change, in part due to this very documentary, as viewers of that time reacted with concern to the impact of such separations on very young children.</span></h2>
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<span style="font-family: Calibri, sans-serif; font-size: large;">In his seminal work, Bowlby explored attachment disruptions of various kinds and detailed children's emotional reactions to these disruptions. When attachments are threatened, children react at first with </span><strong style="font-family: Calibri, sans-serif; font-size: x-large;">anxiety</strong><span style="font-family: Calibri, sans-serif; font-size: large;">, a high energy state that promotes calling and clinging. When attachments are threatened further these reactions are often heighten into a stage he referred to as </span><b style="font-family: Calibri, sans-serif; font-size: x-large;">protest</b><span style="font-family: Calibri, sans-serif; font-size: large;">, which can include anger. Bowlby proposed that this high energy state might allow a child to overcome obstacles to reuniting with the attachment figure and communicate reproach in an effort to discourage the attachment figure from becoming unavailable in the future. If these efforts fail, the subsequent stage Bowlby described was the low energy state of</span><span class="apple-converted-space" style="font-family: Calibri, sans-serif; font-size: large;"> </span><b style="font-family: Calibri, sans-serif; font-size: x-large;">despair</b><span style="font-family: Calibri, sans-serif; font-size: large;">, characterized by sadness, listlessness and resignation. One can see how this would also be an adaptive survival behavior for a child, conserving energy and avoiding danger when separated from a parent. This stage was followed by a stage Bowlby referred to as</span><span class="apple-converted-space" style="font-family: Calibri, sans-serif; font-size: large;"> </span><b style="font-family: Calibri, sans-serif; font-size: x-large;">detachment.</b><span style="font-family: Calibri, sans-serif; font-size: large;"> In this stage the child mobilizes energy, but attachment emotions are downplayed. Bowlby hypothesized that this was a defensive reaction, inhibiting unhelpul emotions in order to go about the necessary activities of survival. In hospital, the youngster would start to allow care from the nurses and engage in day to day activities. However when parents would return, children would ignore or avoid them. This detached reaction could go on for some time before the child would begin to demonstrate attachment emotions (including anger and clinging) towards the parent once again. Bowlby's stages may sound familiar, as they are related to the stages of grief and loss that we continue to manifest throughout adult life as we respond to threats or losses to our ongoing attachment relationships.</span></h2>
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<span style="font-family: 'Calibri','sans-serif'; mso-fareast-font-family: 'Times New Roman';"><span style="font-size: large;">Here we see the full range of emotional reactions of fear, sadness, anger and numbness in the context of relational states. Very young children may manifest these emotional states in their efforts to reestablish or cope with threats to their key relationships. It is important here to understand that working models of attachment and their connections to emotional states are coded in implicit memory, in the early developing right hemisphere. Therefore the child, and later the adult, is often not aware of the reasons for their emotional reactions to these attachment cues. The older child, when asked why they are frightened or angry will often answer truthfully that they do not know why. At times they will attribute their fears to monsters rather than the loss of the attachment figure, or their anger may be directed at a target other than the attachment figure. <o:p></o:p></span></span><br />
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<span style="font-family: Calibri, sans-serif; font-size: large;">In our modern world we no longer separate children from their parents in hospitals. However our children do experience long periods of separation from parents. In overcrowded daycares and schools, often with both parents employed to meet the demands of modern expenses, very young children continue to experience threats to attachment. Parental isolation and depression can lead to parents being unavailable due to their own emotional states. Children frequently turn to other children for their attachment needs, a pattern that has become increasingly common as children can now contact one another easily with electronic devices. Although more common in adolescence, children can turn towards other children as their source of comfort and preferred source of positive attention. In this process they start to identify with peer values rather than adult values, much to their parents chagrin. Within these unstable relationships with peers, children can turn on one another or themselves in an effort to gain the acceptance and security that they crave. Parents can often feel helpless to reestablish these bonds once they have fractured despite their best intentions.</span></h2>
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<span style="font-family: 'Calibri','sans-serif'; mso-fareast-font-family: 'Times New Roman';"><span style="font-size: large;">As children react to perceived attachment threats with the range of emotional states that Bowlby first identified, these emotional reactions themselves can increase the challenges in these fragile relationships with parents. Fear and clinging can lead to parental frustration and resentment. Anger can result in defensive anger in parents. Sadness and withdrawal can be perceived as rejection by a sensitive parent or laziness. It is easy to see how emotional reactions can lead to cascading relationship breakdowns in fragile social situations. Unfortunately the remedies health care providers sometimes prescribe can contribute to the problem. These interventions can range from ill-advised exposure exercises in anxious children, to harsh time outs or punishments or cracking down with tough love on an unmotivated youngster. If we do not tune in to the need for restoring attachment relationships, these problems can often escalate. Healthy attachment relationships form the underpinnings of natural parental authority. In "Hold Onto Your Kids", Gordon Neufeld and Gabor Mate have argued persuasively for promoting parental attachment in a world where peer attachments can easily become all-consuming for young people. We should be careful to not inadvertently undermine our own role as parents by overdoing our promotion of peer activities and ourselves adding to the already existing pressure on youngster's to “fit in” with peers. It is time we developed a better understanding of the relational context of the mental health of our young people. Perhaps one day we will look back on the daycare and school environments we accept as ordinary today with as much disbelief as we do the hospital environments of 60 years ago.</span></span></div>
<u1:p></u1:p><u1:p></u1:p><br />Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com1tag:blogger.com,1999:blog-1069452529722261921.post-54464121684782710012012-10-28T11:16:00.000-07:002013-09-11T05:43:06.374-07:00Getting Attached<br />
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<span style="font-size: large;">Under stress are you cool as a cucumber or hot headed? Do you trust others to be available, or doubt them? Do you tend to withdraw from your partner when stressed or cling to them? Do you challenge authority and feel more comfortable when you are in charge, or do you hate to rock the boat? The early stages of development have a lot to do with the “working models” we use to decide on how to include others or not include them in our lives.</span></div>
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<span style="font-size: large;">In the last two posts I discussed the process of attunement and sensory regulation that begins in the first nine months and the process of shame states and repair of the second nine months. When this process goes well it allows us to enjoy exploring our world and to respond appropriately to the needs of others. In this post I will discuss how we negotiate our needs with the caregivers in our world. <o:p></o:p></span></div>
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<span style="font-family: Calibri, sans-serif; font-size: large;">In this post, I want to discuss the concept of attachment, first identified by John Bowlby in the 1950s. Attachment is a relationship between an infant and its parent that evolves through the first year and a half of life. It is a process whereby an infant creates a “working model” to predict and direct the availability (that is the accessibility and responsiveness) of caregiving others in their world. In this process infants figure out in whose arms they will find comfort when it is needed and how to get it.</span></h2>
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<span style="font-size: large;">From the sixth week of life the infant can tell his caregivers apart and begins to respond unhappily when they are in the care of a stranger. Infants show preference for one caregiver who becomes the infants primary “attachment figure”. Human infants can allow (remember my earlier post "Mothers and Others") more than one attachment figure, but there remains a hierarchy of the most preferred attachment figure which the infant will select when available, and demand when most alarmed. Infants bond to their primary caregiver through the process of attunement, that is with a caregiver who is sensitive and responsive. The quality of this social engagement is more important than the amount of time spent with that caregiver.<o:p></o:p></span></div>
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<span style="font-family: Calibri, sans-serif; font-size: large;">The attachment system is a motivational system which leads the infant to seek out its caregiver for safety, security and protection when it is distressed. When the attachment system is aroused the infant is less able to calmly explore their surroundings. The infant will vocalize and call the caregiver and, when able, will move towards the caregiver. When they have safely been reunited with the caregiver, the distress resolves, the infant is comforted and they can resume exploration. The biological utility of this behaviour is clear. In the process of evolution, having a well-tuned attachment system maintains the safety and security of infants in an uncertain world. The neurobiology of this system is now well understood. A stressful situation activates the infants sympathetic nervous system (speeding up heart rate and mobilizing energy), the motivational system (involving the dopamine system) is now directed away from exploration and towards seeking out the caregiver When this is achieved the infant is soothed and comforted (a process involving oxytocin, serotonin and endorphins). When this behaviour pattern works, it is reinforced. If it is not successful, other patterns of behaviour emerge.</span></h2>
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<span style="font-family: Calibri, sans-serif; font-size: large;">Mary Ainsworth, a colleague of Bowlby, was a pioneer in studying toddlers’ attachment behaviour. She set up a series of laboratory scenarios that would mildly stress toddlers and observed how they responded. She identified three patterns of attachment. Further work by Margaret Main added a fourth pattern.</span></h2>
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<span style="font-size: large;">Ainsworth separated attachment styles into secure and insecure. The most famous observation scenario she created to rate children was called the “Strange Situation”. In this scenario the parent and the toddler are in a room, and are joined by a non-threatening stranger. At a prearranged point the parent leaves the room unannounced. After a few minutes, the parent returns.<o:p></o:p></span></div>
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<span style="font-size: large;">Securely attached toddlers were seen to protest (cry and call) when the parent left, but were able to calm quickly when the parent returned and comforted them. Ainsworth also identified two patterns that she referred to as insecure attachment.<o:p></o:p></span></div>
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<span style="font-size: large;">In the first, the child does not protest when the parent departs and when the parent returns the child ignores, avoids the parent, or approaches very hesitantly. Despite not protesting, the child’s exploration of the toys deteriorated and later studies revealed that these infants are showing stress reactions (elevated heart rates etc.) during the departure even though they are not protesting. This pattern was termed an avoidant attachment .<o:p></o:p></span></div>
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<span style="font-size: large;">In the second pattern, the child does protests, often in a dramatic fashion, sometimes clinging tightly to the departing parent. When the parent returns the infant continues to protest, even directing aggression toward the parent and does not settle for some time. This second “insecure” pattern was referred to as an ambivalent attachment.<o:p></o:p></span></div>
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<span style="font-size: large;">Mary Main demonstrated a fourth pattern, which she referred to as an insecure disorganized attachment. These infants appeared to be confused as to how to respond. The child might protest and then withdraw or appear frozen in indecision. This pattern has been demonstrated to occur in the most troubled of parent child situations and has been related to the worst outcomes. None of these patterns is in itself a “disorder”. They are merely relationship patterns. They have also been shown to have remarkable staying power although they can change as development progresses. These pattern have been shown to persist into adulthood in our relationships with significant others in our life.<o:p></o:p></span></div>
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<span style="font-family: Calibri, sans-serif; font-size: large;">Attachment patterns are strategies of communicating with a caregiver, and the ability to use that caregiver to become calm when faced with stress. Avoidant children have learned not to call their parent, as calls have not been attended to, or they have learned to inhibit their calls, having determined it is best not to burden their caregiver unless it is very necessary. Ambivalent children have learned to turn up the volume of their protests when distressed. They demand the presence of the caregiver loudly, and have determined that this is the best strategy for getting their needs met. In the end we have extremes of active versus passive strategies. Disorganized children may flip flop between these strategies, at times seizing control, and other times becoming passive. It is important to point out here that the child’s behavior is not related to the parents love for their child. Parents who very much love their children can be unavailable for many reasons or can be stressed by a multitude of factors. Also genetic or environmental (toxins/medical/trauma) factors may interfere with a parent's capacity to soothe a child despite their best efforts and availability. Any one of these strategies may be a functional strategy in such situations for a child.</span></h2>
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<span style="font-size: large;">In the last post we explored how children learn to accommodate their behaviour to the needs of others. In this post we have seen how children communicate responsibility to those others for their needs. These relationship patterns persist into adulthood and determine the patterns we engage in, in our most intimate relationships, when we are in need. These intimate relationships in turn are the relationships we rely on for support when we become the caregivers for the next generation. We, as a society, are charged with providing as supportive a community as possible to young parents, of all attachment styles, as they face the challenges of meeting the needs of their young ones. In this way we allow them the best opportunity to create sustaining relationships that will provide a strong foundation for the next generation.</span></div>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com0tag:blogger.com,1999:blog-1069452529722261921.post-15366443668836730942012-10-21T15:25:00.000-07:002013-09-11T05:34:14.247-07:00Putting on the Brakes<strong><span style="font-family: Calibri; font-size: large;"></span></strong><br />
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<span style="font-size: large;">In my last post I reviewed the first nine months of human development. In this post I will review the next nine months. Both genetics and early relationships have something to do with how our moods change through our lifetime and these second nine months can be critical to how this goes.</span></div>
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<span style="font-size: large;">There is a profound change that occurs in the relationship between an infant and its mother in this next time period. This change has implications for shaping the person that we will become. The first nine months can involve a lot of warm and fuzzy interactions between mother and infant. Laughing and cooing and cuddling. During the first nine months the child’s capacity for tolerating the world of the senses and ideally the capacity to enjoy human contact and exploration develops. The next nine months take on a different dynamic between parent and infant, a change that happens in even the most successful relationships. As the child becomes more mobile the parent takes on the role of supervisor and parent directions towards the child skyrocket compared to the first period. “Don’t touch that.” “Don’t go there.” “Don’t put that in your mouth.” You get the picture. Infants don’t learn to say “no” at this time, that comes later, but parents start to say “No”, a lot.<o:p></o:p></span><br />
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<span style="font-size: large;">During these next nine months the growth burst in connections in the right brain continues. According to Allan Schore there is a new pathway being laid down during this period. During this time the infant may, or may not, develop the ability to put the brakes on their exploration of the world. As in the first period, the brain develops connections between the planning parts of the brain (frontal cortex) and the emotional brain that controls our physical state (limbic system). The connections that may develop now allow the child to stop certain socially undesirable or possibly unsafe behaviours. The infant is now mobile enough to move away from the parent but will pause from time to time to look to the parent for those flashing, approving eyes. But if, for example, they have drawn a masterpiece on the living room wall, they might receive a different look. Those eyes will reflect disapproval, maybe even anger.</span></div>
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<span style="font-size: large;">The “parasympathetic” reaction that follows will lead the child to become deflated. The eyes drop, the heart rate and motor output slows, and the child has had his first experience of shame. The infant of course, does not identify this emotion. Identifying emotions is a left brain task, which doesn’t develop until later (if it develops at all). This interaction, when it goes well, can have the happy result of the child learning that drawing on the wall is not acceptable. Shame, although much maligned, is part of normal healthy development. The key part of this interaction being adaptive, comes with the next part of the interaction. The stage that may hopefully follows, is the stage of repair. The child reconnects with the parent tentatively and gradually, and the positive relationship is re-initiated. When these two steps are successfully repeated over hundreds of interactions, a new type of regulation is achieved. The regulation of high energy, active, exploratory, mood states and low energy, quiescent, reflective mood states. The ability to tolerate frustration and even failure has its origins here, as does the ability to take responsibility when faced with expectations from others. These can be difficult waters to navigate. The infantile temper tantrum can emerge at this time, when children have difficulty making the transition from one mood state to the next. This, of course, has the potential to increase the stress level of the parent who will require considerable support, him or herself, to stay regulated in the face of flying food or cutlery.<o:p></o:p></span></div>
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<span style="font-size: large;">Interestingly, we can see the development of two patterns emerging in this second stage. As mentioned last time, infants can be identified at birth (even prenatally) as high sensitivity and low sensitivity infants, with an average group in between. Jerome Kagan famously followed groups of children through childhood and determined that high sensitivity infants were likely to become inhibited children and low sensitivity infants tended to become uninhibited children. Parental influences did make a difference as far as avoiding the extremes of recklessness for uninhibited children and high anxiety for inhibited children, but Kagan noted that high sensitivity children almost never became very daring and low sensitivity children almost never became highly cautious. <o:p></o:p></span></div>
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<span style="font-size: large;">By the time this second developmental period is over, children will have developed a consistent pattern of mood states which form their emerging character. Much like the characters from the children’s story Winnie the Pooh, some will bounce along in persistent high energy states, rather impervious to direction, much like Tigger. Others will spend much of their time in highly anxious mood states, sensitive to direction, much like Piglet. Still others will reside in chronic low energy, high shame, mood states like Eeyore. And still others will lurch dramatically between mood states, more like Jeckyl and Hyde. Ideally there will be smooth and flexible mood states. With flexibility, comes the ability to take responsibility for one’s actions and tolerate responsibility, frustration and even failure while not feeling crushed by these experiences. What is critical to understand is that the relationship is at the center of this development. It is in the relationship that the ability to regulate sensation (last post) develops and it is in the relationship that the ability to regulate mood states develops. Biological factors can make the difference between children who are likely to overreact, and those that are likely to underreact, but these patterns will develop in the relationship and, with support, relationships can lead the way to new abilities which may develop at any time in the lifespan.</span></h2>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com0tag:blogger.com,1999:blog-1069452529722261921.post-45997237437835346332012-10-14T11:16:00.000-07:002013-09-11T05:23:24.306-07:00Keeping it Regulated<span style="font-family: 'Lucida Grande'; font-size: large; letter-spacing: 0px;">In the next series of posts I want to walk you through the complex process of human development as we understand it.</span><br />
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<span style="font-family: 'Lucida Grande'; font-size: large; letter-spacing: 0px;">The debate whether we begin our lives as a “tabula rasa” (blank slate) verses having our development predestined, be it from God or from genetics is an ancient one. In addition to this, I want to explore the question of how much we can know about who we are. You may have heard of Renee Descartes, a philosopher who famously said "I think therefore I am", ushering in an era of human rationality known as the Enlightenment. Descartes was referring to the amazing ability we humans have for conscious reflection. Certainly this amazing ability is a powerful tool, but modern neuroscience increasingly reveals that, in fact, it represents only a relatively small proportion of who we are.</span></h2>
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<span style="font-size: large; letter-spacing: 0px;">Our study of human development has revealed that an amazing amount of neural development occurs in bursts over the first three years of human life (including prenatally), well before we are capable of conscious reflection. Here we may begin to explore the evolution of some of the layers of who we are, as they are laid down in a complex dance of inborn potential and environmental feedback.</span><br />
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<span style="font-size: large; letter-spacing: 0px;">Neural development, of course, involves all the major structures of the brain, however development appears to occur earlier for certain structures than others. Interestingly, it is the right hemisphere that appears to develop earliest. You may know that we humans have an interestingly divided neurology. We have a cerebral cortex, that highest level layer of our brain, that is divided in two, joined by a remarkably narrow strip of brain matter known as the corpus callosum. Each side of the brain is preferentially connected to the opposite side of the body, but these two hemispheres have also been shown to have very different ways of processing our lived world. A recent work by Iain McGilchrist (The Master and his Emissary) does a comprehensive job of illustrating the implications of this lateralization of human consciousness.</span></h2>
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<span style="font-size: large; letter-spacing: 0px;">This earlier developing right hemisphere certainly learns, and it certainly thinks, but it's learning and thinking happen implicitly. That is, learning happens through experience and is recalled automatically and unconsciously, leading to changes in our physical states including our emotional states. In human infants the learning and development that occurs first are various forms of bodily and sensory regulation. As you may know from experience, tiny infants cannot yet regulate almost anything about themselves. Unlike some creatures, who can be independent even at birth, humans have some of the most dependent infants in the animal kingdom. Human infants require the constant presence of the caregiver for regulation, and as studies of Romanian orphans have shown, the implications of having little physical contact with a caregiver, even in the presence of adequate food, water and shelter are profound and often devastating. Our emerging genetic potential requires the scaffolding of a human relationship to unfold from the very beginning.</span></div>
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<span style="font-size: large; letter-spacing: 0px;">Michael Meaney is a Canadian researcher who has done some fascinating work in the implications of infant mother interactions and the implications for this for gene expression. The word for environmental experiences that influence gene expression is “epigenetics”, and our understanding of this process is only just beginning. These very early interactions appear to be fundamental in the expression of certain genes that have major implications for behaviour and stress reactivity. In rats, the parental behaviour that triggers gene expression is anogenital licking. In humans it is a series of interactions that lay the groundwork for our ability to navigate the sensory and interpersonal world that we will be living in.</span></h2>
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<span style="font-size: large; letter-spacing: 0px;">Even prenatal development involves more than simple genetic unfolding. We know that stress during pregnancy increases the risk for premature birth and low birth weight, which are associated with various adverse health and developmental outcomes. Some recent studies have suggested increased rates of ADHD, anxiety and mood disorders, although this is a surprisingly under-researched area. Temperament may also be affected with infants whose mothers have been highly stressed showing temperaments at the extreme ends of the spectrum. It seems that genetics does contribute significantly to temperament at birth, determining how an infant may respond to stress, with either increased or decreased reactivity to stimulation. </span></h2>
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<span style="font-size: large;">The first nine months or so of human development involve an incredible surge of brain development. The senses of smell and touch are most important initially, when physical contact are paramount. Vision and hearing then play an increasing role. Here our preoccupation with the human face and voice begin. In particular, the eyes. Babies seek out the face of the mother and an incredible conversation begins. A conversation held with caresses, flashing eyes and playful vocalizations. In this interaction the baby develops an increasing ability and even enthusiasm for processing information. The mother is the guardian of stimulation. It is her job to optimize the amount of stimulation, much of it which will be coming from her. A "three bears" rule of not too little, not too much rule is something the baby manages on his end by seeking, calling and looking away. The mother intuitively responds to these cues from her end. The match between the mothers natural inclination to stimulate, her stress level, and the infants partially genetically determined optimal window of stimulation seems to be key here. This is what some researchers have referred to as “goodness of fit”. This window is a sensitive one and as we know from "Still face" experiments, a period of rupture from this dance of interaction can be very distressing for the infant, who as yet cannot navigate this world of stimulation.</span></h2>
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<span style="font-size: large; letter-spacing: 0px;">Some genetics appear to allow children to develop well enough in a wide range of environments while other genetics lead to high sensitivity which appears to lead to very good outcomes in well matched environments but very poor outcomes in other environments. Bruce Ellis, a family researcher at University of Arizona, coined the term “orchid children” to refer to these highly sensitive children with the more fragile genetic make-up. He referred to the hardier children as “dandelion children".</span></h2>
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<span style="font-size: large; letter-spacing: 0px;">In the first nine months of life the basic ability to regulate stimulation is beginning to develop. Allan Schore, in his series of texts, has compiled vast amounts of interdisciplinary research tracking the neural pathways in the right hemisphere that link our sensory brain to our planning brain and relay directly to our limbic system (emotional, physical control centres) that encode these mind-body interactions which we refer to as sensory-emotional regulation. Do you shy away from busy situations or do you seek them out? Do you detest quiet setting or do you thrive in them? This dance of genetic potential with environmental feedback in these nine months has a lot to do with it. Remember however that mother alone is not responsible for what happens here. Mothers themselves (as you might remember from my last post) are not islands. Their own stress levels are dependent on those around them. The support of fathers, extended family and the broader community has everything to do with the stress level under which any mother will be operating both during pregnancy and thereafter. Our society as a whole has responsibility for how stressful an environment these early years will be. </span></div>
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<span style="font-size: large; letter-spacing: 0px;">The amazing thing about development is that although there are important windows, the story if never fully determined. New developments can always emerge and neuroplasticity for change is much greater than we once believed. In the next few posts I will cover some of the next milestones the human infant will cross as we travel this complicated terrain of human development. </span></div>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com2tag:blogger.com,1999:blog-1069452529722261921.post-7660283071778362022012-10-07T14:14:00.001-07:002012-10-24T16:42:21.978-07:00Mothers and Others<br />
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<span style="font-size: large; letter-spacing: 0px;">In the next few posts I want to explore human development from a few different angles. In the current post I want to look at evolutionary and cultural factors. Relatively recent findings have helped us gain a greater understanding of how human development is influenced by its relational context. Laboratory studies bring us useful information about development, however human development does not occur in a Skinner box or a test tube. By the same principles any change we undergo at any point in our development will also occur in a relational context. </span></div>
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<span style="font-size: large;">I have borrowed the title for this post from the title of a groundbreaking book by Sarah Hrdy (2009) an accomplished anthropologist . In this book, Hrdy takes us on a journey across genetics, cultures and time to get to know our species and our unique way of raising offspring. Along the way we discover some fascinating truths about who we are. Due to our physical attributes (bipedal, big headedness), we humans give birth to our young at a very vulnerable stage Just as uniquely among primates, human mothers share the caregiving responsibilities for infants with other relatives. What you might not know, is that no other great apes or even monkeys do this (although some species of marmosets do). All other primates leave the care of the young entirely to the mother. Human mothers alone, among great apes, allow other females and even males to hold and even feed infants from the moment they are born. In hunter gatherer societies women expect the support of others in the clan, most importantly female relatives in the care of offspring. Humans throughout their evolutionary history have counted on "alloparents" for help in raising infants and this has allowed humans to have children more frequently than similar, slow developing primates. Humans tend to space children out by 2 years, whereas gorillas have offspring about 4 years apart and orangutans about 8 years apart. It is disturbing to learn that alloparenting marmosets as well as hunter gatherer humans are likely to commit infanticide when support from female relatives is unavailable. This behavior is extremely rare among other primates under similar conditions. It is not difficult to imagine the importance of determining whether an adult is a nurturing other or not for an immature member of the clan. This evolutionary situation may very well have selected for our highly developed ability to take one another’s perspective and the extension of this into language.</span> </div>
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<span style="font-size: large;">Hrdy's last chapter offers some further thought provoking analysis from her perspective as an anthropologist. Hunter gathers developed strong tendencies to nurture one another’s offspring in order to survive, and this strategy was so successful, that many cultures came to refer to the world with various terms that approximate "the giving place". Most hunter gatherer cultures developed powerful taboos against arrogance and individualism. Mothers tended to stay with their own mothers and female kin which promoted this "alloparenting" and cooperative care. With the advent of horticulture, animal husbandry and then agriculture, surpluses of grain and livestock, and the control of property and land, things changed (from about 10 000 years ago in central Asia to the past century in a few societies). There was now property and land to protect and thus to steal. Men began to rely on their fathers and brothers to protect these resources and mothers no longer stayed with their mothers, and often came to be seen as needing protection in a patrilineal, patriarchal social structure which eroded the nurturing matrilineal care human infants had relied on until then as well as many of the taboos mentioned above. "The giving place" was forever changed. Hrdy is not alone in hypothesizing that this shift marked a significant change in the history of childhood and childcare that has had tremendous repercussions. </span></div>
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</span><span style="font-size: large; letter-spacing: 0px;">These changes have only accelerated with industrialization and urbanization. Extended family units are increasingly scattered and even nuclear families have born up poorly under the stress of our modern world. Rates of mental illness are increasing in much of the western world and the onset of these problems are occurring at ever younger ages. To add a personal note, I myself was shocked at the challenges I faced as a parent, after moving across this country, prior to the arrival of our two children. I think we have a false notion that a mother should be able to parent infants in relative isolation for much of the day with minimal stress. The fact that this is not so often comes as a shock to mothers, whose rates of postpartum depression are high in the developed world. It can also come as a shock to spouses and to extended family alike. Perhaps if we had a better awareness that we are not, in fact, evolved to cope easily with such situations, we would as a society put greater stock in support for mothers and infants during these vulnerable years.</span><div style="font-family: 'Lucida Grande'; min-height: 13px;">
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<span style="font-size: large; letter-spacing: 0px;">An afterthought… I don't mean to come across as all “noble savage”. Hunter gatherer life was hard, and lifespans were short. The modern world has unleashed amazing creative potential in science, arts and medicine. I don't propose a retreat from modernity. What I propose is applying ourselves to understanding our modern ills holistically, so that we can find a way to apply this amazing creative potential to modern solutions. </span></div>
Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com0tag:blogger.com,1999:blog-1069452529722261921.post-56715496004614535372012-10-02T17:01:00.000-07:002012-10-22T09:04:29.323-07:00Collaboration vs Behaviour Modification<span style="font-size: large;">One of the earliest decisions we made on the Adolescent Psychiatric Unit was a decision on what approach we would take towards the behaviour of young people on our ward.</span><br />
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<span style="font-size: large;">As you may know psychiatry has gone through phases over its history. From the outset there have been two dominant schools of thought in terms of mental illness. A moral model which sees mental illness as a moral or spiritual problem and a medical model which sees mental illness as a disease of the brain. Both of these competing models still exist in various form today. (More on this in future posts.) The turn of the century saw the dawning of the psychoanalytic model which framed mental illness as "conflict" between conscious and unconscious processes, where unconscious drives overwhelmed the conscious mind leading to various symptoms of illness. As the century progressed a new paradigm took centre stage. Behaviourism arrived with the discipline of research based psychology. Behaviourism developed models of learning and behaviour that could be measured for research purposes, and dismissed motivational and emotional states that were more difficult to measure. Both of these models were fruitful in different ways but also led down sometimes unhelpful roads. Unhelpful interpretations of the psychoanalytic model such as the common understanding of Dr. Spock's advice came on the scene. This interpretation was that all we had to do was love children unconditionally and they would thrive. This unfortunately missed the fact that it is natural for us to have expectations of children and give them responsibility, which they often resist. From the behaviorists came recommendations to reward and punish and shape children's behaviour much as we would train circus animals. This misses the point that rewards and punishments only work in the context of a healthy relationship which they themselves do not help establish.</span><br />
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<span style="font-size: large;">Fortunately there have been new developments in the realms of developmental science upon which we may draw. In the 1950s John Bowlby and his student Mary Ainsworth introduced Attachment Theory to our theoretical repetoire. Borrowing from ethology, these clinicians used observational methods to establish that children develop patterns of behaviour in a relational context with their parents to establish a predictable pattern of establishing security which endure over time, generalize to relationships with significant others and romantic partners, and are often passed on from parent to child. New developments in behavioral neuroscience such as the establishment of the existence of mirror neurons and research on the process of parent child attunement have helped us gain an improved understanding of the developmental pathways for empathy and of theory of mind. These developments allow us to understand that learning occurs best in an attuned and secure relationship and at best involves more than simple conditioning.</span><br />
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<span style="font-size: large;">On the Adolescent Psychiatric Unit we have followed a model of "Collaborative Problem Solving" (with start up consultation from Ross Greene). What we have moved away from is the model of Behaviour Modification which still dominates on many, perhaps most, hospital wards. In the Behaviour Modification model rewards are given for desirable behaviour and consequences meted out for undesirable behaviour. The problem with the behaviour modification model is that those who can cope with it are rewarded while those who can't are punished. What you get in the end is extremes of behaviour. Studies have shown that these kinds of interventions increase the rates of seclusion and restraint. Collaboration involves having and discussing expectations while taking the time to listen to the concerns and expectations of the young person. It involves understanding that young people may not always be able to meet our expectations, but that there are many different reasons why they may not. Using this model we can learn what some of the barriers to meeting the expectations of others might be in this particular child, increasing our understanding, while improving communication skills and trust. In a relationship where kids feel safe and understood they usually come to accept the expectations of others. So far this model has worked well for us, although it can be challenging and requires more thoughtfulness and effort than a simple behavioral model would require. Overall the results have been rewarding and our restraint and seclusion rates have been near non-existant.</span>Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com5tag:blogger.com,1999:blog-1069452529722261921.post-56668006874741958292012-10-02T10:44:00.001-07:002012-10-22T09:05:41.222-07:00Introduction<span style="font-size: large;">I envision this blog as a way to reach out to other people working in the field of Youth Mental Health, or struggling with issues that relate to the mental health of young people.</span><br />
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<span style="font-size: large;">I am a Psychiatrist working on a specialized hospital unit for young people struggling with mental health issues in Kelowna, British Columbia, Canada. I also work on call at this hospital and am consulted to support young people in crisis in the Emergency Department and on the Paediatric Ward.</span><br />
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<span style="font-size: large;">As you can imagine this kind of work forces one to confront some challenging ethical questions as well as some important theoretical questions, such as:</span><br />
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<span style="font-size: large;">What exactly is mental illness?</span><br />
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<span style="font-size: large;">What aspects of treatment should young people decide for themselves, how does this change with development?</span><br />
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<span style="font-size: large;">What aspects of treatment should people with mental illness decide for themselves?</span><br />
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<span style="font-size: large;">What is the role of family in these decisions?</span><br />
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<span style="font-size: large;">How do we address the behaviours of young people, or mentally ill people in the hospital?</span><br />
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<span style="font-size: large;">How do families address the behaviours of young people, including those with mental illness at home and how is this the same or different?</span><br />
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<span style="font-size: large;">What is the role of medication in treating young people?</span><br />
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<span style="font-size: large;">What is the role of various other treatments in the hospital and after hospital in treating young people?</span><br />
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<span style="font-size: large;">I see this blog as being a forum for discussion on these topics. My team here on the Adolescent Psychitric Unit have wrestled and continue to wrestle with these questions and I will share some of our philosphical postitions on these matters in this blog as well as the role of various advances in the realm of developmental science and neuroscience that might inform these questions.</span>Anonymoushttp://www.blogger.com/profile/10574253468799505078noreply@blogger.com2