Category Archives: Stress chemicals

Bruce Perry: Attachment and Developmental Trauma

BrousBlog9a Perry head shotDr. Bruce Perry, MD (left) documents the brain science of how attachment problems can cause developmental trauma to a fetus, infant, or child – just when the brain is developing.

And he’s taking his “attachment first” approach to Washington.  In “Trauma Impacts the Brain: Healing Happens in Relationships,” Perry leads a full-day Pre-conference University on Sunday May 4, to kick off  the National Council for Behavioral Health’s Annual Conference ’14 on May 5-7 (click here for details).

“Experiences profoundly influence the development of young children. Adverse Childhood Experiences (ACEs) shape the brain’s organization, which, in turn, influences the emotional, social, cognitive, and physiological activities,” the conference website notes.

“So often, trauma happens in relationships, but it is also in relationships that healing occurs. Explore the latest research and clinical treatment with trauma researcher, treatment visionary, and bestselling author of The Boy Who Was Raised as a Dog, and Born for Love:  Why Empathy is Essential and Endangered, Dr. Bruce Perry.”

Dr. Perry’s relationship and attachment theory healing model first assesses each child as an individual, using his  Neurosequential Model of Therapeutics (NMT).  He emphasizes that there is no one label for child trauma. Rather, “there are very individualized patterns of exposure to trauma (all with unique timing, nature, and patterns)… So we don’t call ‘it’ anything,” he wrote me recently. “We describe it — and try to ‘illustrate’ each individual’s trajectory separately” with the NMT’s individualized brain mapping technique. [FN1]

Dr. Perry recommends his books above as the best summaries of his work.  His latest research and key slides are online from his National Council webinar last fall, “Helping Children Recover from Trauma,” National Council LIVE, Sept. 5, 2013 (scroll down to Sept. 2013.)  I really recommend this – and it will only be online through August 2014.

Click here for an overview video:   [FN2]

Survival Brain Develops First

BrousBlog9c Perry Slide1 Brain 4 PartsDr. Perry says we’ve got to learn about the neuro-biological growth of the brain in order of time sequence from  conception to later development in infancy and childhood.

His “Four Part Brain” slide (above) shows the time sequence from the bottom up: first the brain stem develops (pink); then the diencephalon cerebellum (yellow); they make up our primitive reptilian “survival” brain.  Next develop the emotional limbic brain which only mammals have (green), and finally the thinking brain aka frontal cortex (blue).

The fetus’ “survival brain” develop first, because infants require breathing, heart beat, and other survival functions at birth, Dr. Perry told a March 2013 UCLA conference. The rest of the brain develops largely after birth and as an outgrowth of the brain stem. [FN3]

So injury during brain stem development in the first 45 months harms development of the entire brain, the neurons around the viscera, and most of the body.

Dr. Perry next details three key threats to an infant’s developing brain:  Trauma in utero (intra-uterine insult); post-birth attachment trauma; and other post-natal trauma – all before the thinking brain comes on line around age 3.

A fetus in utero is designed to develop in nurturing oxcytocin and other “reward” chemicals released by a mother supported by her family, all joyous a baby is coming. Intra-uterine insult occurs when the mother instead uses substances, or is under stress so that her stress hormones impact the fetus’ developing brain. This can be visible stress to the mother: domestic abuse, work stress, violence.

A fetus, however, can also be subject to stress chemicals with no visible external stress to the mother, as in mothers who are anxious, themselves victims of attachment disorder, don’t want a baby, etc.  Often these mothers have no steady pattern to their heart rate, and since a baby’s brain grows according to the mother’s heart rate rhythm, the baby’s brain develops dysregulated.

All these “causes a cascade of mental and physical problems in every part of the body and brain,” Perry says. “Every part of the whole brain these neurons enervate will be dysregulated.”

Birth: the Mother of All Stress

Attachment trauma occurs easily because birth is incredibly stressful to a baby: suddenly there’s lack of oxygen, blinding light, shocking cold, terrifying noise, and pain. This floods a baby with stress hormones — which is essential because now it’s not having needs met as in the womb; thus it’s got to protest so someone comes. “If animals in the wild didn’t feel the stress of hunger they’d just lie around and die of starvation,” Perry notes.

Mom Smile Baby If all goes as designed, an attuned mother meets the baby’s needs, feeds it, swaddles it, turns down the lights, so the baby feels safe and is flooded with reward optiates like oxytocin. If animals didn’t feel opiate rewards when they get up and eat just what they need (not dirt, for example), they’d not get up.

Then they wouldn’t survive, so the stress hormones and the reward opiates are linked. “At the relief of hungry-thirsty-cold stress, we feel pleasure,” Dr. Perry says. An attuned mother “has a well-organized neurobiology to create a healthy organized neural network for the infant of attachment and regulation…

“And in the arms of that caregiver, that is that magic moment literally weaving together the neurobiology of all these different systems. The biology of attachment is that a baby learns by thousands of good experiences that this stress is tolerable because it leads to reward, and this pleasurable outcome is cathexsized to a person, Mom… Ultimately just seeing or hearing Mom makes you feel safe and pleasurable. Let a wounded soldier talk to his mom, he’ll need 45% less pain meds.”

Or not.

If mom instead is under too much stress herself to meet needs, has too many children and no support, or herself was raised by a mis-attuned mom, “she doesn’t get reward from responding to her baby’s distress,” Perry continues. “So the pull to respond isn’t there.”

Even if no stress to the mother is visible, “if she merely meets physical needs, without involving her own pleasure systems, then the weaving together of meeting needs and the reward/safety system is weak or absent. So her baby learns that stress can be life-threatening, that stress is terrifying,” Dr. Perry concludes. [FN3 op. cit.]

The “Or Not” baby’s brain learns: “that’s all she wrote.”

It develops in a state of perpetual stress in which the stress chemicals simply do not stop and the reward chemicals never or seldom come. In this state, fight/flight cortisol flood eventually leads to “freeze” dissociation, Judith Herman reported back in 1992. [FN4]

More Perry slides at: http://attachmentdisorderhealing.com/how-your-brain-works-101/

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1 Perry, B.D. and Hambrick, E. (2008), “The Neurosequential Model of Therapeutics (NMT),” in Reclaiming Children and Youth, 17 (3) 38-43;  and
Dobson, C. & Perry, B.D. (2010), “The role of healthy relational interactions in buffering the impact of childhood trauma in “Working with Children to Heal Interpersonal Trauma: The Power of Play,” (E. Gil, Ed.) The Guilford Press, New York, pp. 26-43
Both at: http://childtrauma.org/nmt-model/references/

FN2  Bruce Perry MD, Daniel Siegel MD, et.al, “Trauma, Brain & Relationship: Helping Children Heal,” www.youtube.com/watch?v=jYyEEMlMMb0 – introductory video on Attachment Disorder and development trauma. Copies at www.postinstitute.com/dvds.

FN3  Perry, Bruce D., MD,  “Born for Love: The Effects of Empathy on the Developing Brain,” Annual Interpersonal Neurobiology Conference “How People Change: Relationship & Neuroplasticity in Psychotherapy,” UCLA, Los Angeles, March 8, 2013 (unpublished).
Library of articles on interventions, trauma, brain development: https://childtrauma.org/cta-library/
Training in NMT Method and Somatosensory Regulation, Power of Rhythm — Individual and Site Training Certification Programs, DVD/streaming training, and online training: http://www.ctaproducts.org
Dr. Perry’s latest research and key slides: “Helping Children Recover from Trauma,” National Council LIVE, National Council on Behavioral Health, Sept. 5, 2013 at www.thenationalcouncil.org/events-and-training/webinars/webinar-archive/  (scroll down to Sept. 2013.)
Dr. Perry’s YouTube channel with educational videos in depth: https://www.youtube.com/channel/UCf4ZUgIXyxRcUNLuhimA5mA?feature=watch

FN4  Herman, Judith, “Trauma and Recovery,” Basic Books, New York, 1992

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The Hole in Half of Us

Brousblog1a Perry brains X-secThe Adult Attachment Interview (AAI) study since 1994 shows that  50% of Americans have some degree of failed attachment in childhood.  These are rigorous psychiatric studies of the general public which have nothing to do with “addicts.”  It’s not just about “them.”  [FN1]

It’s about “the hole in me” inside half of us.  Secure attachment is necessary for the neurons in a baby’s brain to develop. “The hole” is caused by any problematic bonding with the mother.  That means “parts of my brain are dark” — the neurons just don’t fire. (Above left: normal 3 year old. Right: major attachment disorder)

No coincidence, 50% of Americans also abuse not only alcohol and drugs (including prescriptions) but also tobacco, food, gambling, internet porn, sex…  Those of us who’d never “use” anything, often become work-aholics.  All these, abused, often cause premature death.

Until we treat the underlying childhood trauma, says Dr. Vincent J. Felitti, nothing will change and people will keep dying early. That’s the point of his 2003 “The Origins of Addiction: Evidence from the Adverse Childhood Experiences (ACE) Study,” published here last week:  click here.  [FN2]

“My point is that there is a Public Health Paradox,” Dr. Felitti wrote in transmitting his article, “wherein some of our most difficult public health problems are actually unconsciously attempted solutions, at the individual patient level, to problems that are unrecognized because they are lost in time and then protected by shame, by secrecy, and by major social taboos against exploring certain realms of human experience…

“Needless to say, vacuous cautionary advice doesn’t do much, coming from people who have no idea what has gone on.  Thus, ‘Obesity is bad for you,’ but it’s sexually protective; ‘Smoking is bad for you,’ but nicotine has been known for almost a century to have potent anti-anxiety, anti-depressant, appetite suppressant, and anger suppressant activity.  Moreover, those occur within 15-20 seconds of inhalation, whereas the risks, which are certainly real, occur in 15-20 years.”

“The current public health approach of repeated cautionary warnings has demonstrated its limitations,” as Dr. Felitti put it in his 2003 piece, “perhaps because the cautions do not respect the individual when they exhort change without understanding.”

Treat ACES  vs Early Death

BrousBlog7a ACE pyramidDr. Felitti is elegant and to the point: unless we treat Adverse Childhood Experiences per se, people will find something, somehow, anyhow, to numb the emotional pain of childhood trauma.  Details on the ACE pyramid. [FN3]

“People with attachment-based developmental trauma can start to feel so threatened that they get into a fight-flight alarm state, and the higher parts of the brain shut down first,” neuroscientist Dr. Bruce Perry, MD told a 2013 UCLA conference.

“First the stress chemicals shut down their cortex (thinking brain).  It’s instinct; they can’t control it.  Now they physically can not think. Ask them to think and you only make them more anxious.

“Next the more primitive emotional brain (limbic brain) goes. They have attachment trauma so people seem threatening; they don’t get reward from emotional or relational interaction. Their own emotions feel like a threat to them.

“Now the only part of the brain left functioning is the most primitive: the brain stem and diencephalon cerebellum (reptilian brain).  Here they can get rewards, but only from sweet/salty/fatty foods, drugs, sex — only the strongest sources of opiates can sooth these lower brain parts.

“They know cognitively it’s wrong to steal from Grandma, they may even love Grandma, but the brain is state-dependent.  At that moment, cognitive thinking or emotional-relational consequences, just can’t relieve their anxiety.  They are in such distress in the lower parts of the brain that they need the food, drugs, etc.  too badly.

“You can get to the point where you can’t even reach the lower part of the brain.  If you’re so ramped up and anxious, the only thing you want is to relieve the distress, and the only thing that can do it is to drink.  Alcohol will reduce anxiety, and make us more vulnerable to other unhealthy forms of reward pleasure.”

The problem is that the emotional pain from ACE is buried inaccessibly deep in our neural structures since our brains first developed, so we don’t even know it’s there.

“If you want a person to use relational reward, or cortical thought -– first the lowest parts of the brain have got to be regulated,” Perry concludes.  “We must regulate people, before we can possibly persuade them with a cognitive argument or compel them with an emotional affect.”

Perry has proven in thousands of clinical trials that the only way to do this is to treat the underlying childhood issues. [FN4]

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1  George, C., Kaplan, N., Main, Mary, “An Adult Attachment Interview,” Unpublished MS, University of California at Berkeley, 1994;  and Ainsworth, Mary D.S., Blehar, M.C., et al, “Patterns of attachment: A psychological study of the  Strange Situation,” Erlbaum, Hillsdale, NJ, 1978

FN2  Felitti, Vincent J. , MD, “The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study,” English version of the article published in Germany as:
Felitti VJ, “Ursprünge des Suchtverhaltens – Evidenzen aus einer Studie zu belastenden Kindheitserfahrungen,” Praxis der Kinderpsychologie und Kinderpsychiatrie, 2003; 52:547-559.

FN3 ACE Study Pyramid, www.cdc.gov/ace/pyramid.htm; and “Adverse Childhood Experiences by Vince Felitti, MD,” 13 min video, Academy on Violence and Abuse, 2006: www.youtube.com/watch?v=GQwJCWPG478

FN4  Perry, Bruce D., MD, PhD, “Born for Love: The Effects of Empathy on the Developing Brain,” Annual Interpersonal Neurobiology Conference “How People Change,” UCLA, Los Angeles, March 8, 2013 (unpublished).  See also Perry, B.D. and Hambrick, E. (2008) The Neurosequential Model of Therapeutics. Reclaiming Children and Youth, 17 (3) 38-43, at: http://childtrauma.org/nmt-model/references/

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The Greatest Study Never Told

#1 in my news blog series; original post August 30, 2013

BrousBlog7a ACE pyramid I’d heard of the Adverse Childhood Experiences (ACE) Study — but never asked why does their logo pyramid top with “Early Death? [FN1]  Then last week I stumbled onto a highly-informative website, ACEsConnection.com, social media site for the ACE Study, which has the story and then some. [FN2]

In the ACE Study, 17,337 middle class adults at an average San Diego HMO were asked during 1995-97  if they’d had bad childhood experiences, physical or emotional.  Results were shocking.  Two-thirds (64-67%) had one or more types of child trauma, and 38-42% had two or more types.  In 2016, the same survey in inner city Nashville showed that 71% had four or more types and 51% had six or more.  I believe a true national average would show some 50% of Americans suffer childhood trauma. [FN3]  Check your ACE Score here.

The ACE Study then compared ACE scores to whether subjects developed serious bio-medical conditions as adults – and found a major correlation.  As the ACE Pyramid shows, Adverse Childhood Experiences lead to impaired thinking, unhealthy behavior, disease, disability, and early death.

“Adverse childhood exposures showed a graded relationship to … adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease,” study co-directors Dr. Vincent Felitti MD and Dr. Robert Anda MD reported in 1998. [FN4]

They also showed a “proportionate relationship between ACE score and the likelihood of developing autoimmune diseases decades later in adult life.”  Emotional disorders?  They found “depression, suicidality, chronic anxiety, amnesia, and hallucinations were directly proportionate” to ACE  trauma.

“It’s not about ‘them’ – it’s about us,” said Dr. Anda of these huge percentages and widespread lethal results.  ACEs are “the leading determinant of what happens to the health of a nation’s population,” says Dr. Felitti.

The ACE Study began in 1995 at Kaiser Permanente, the largest  HMO in California, jointly with the U.S. Centers for Disease Control (CDC).  But this rigorous research hasn’t woken up medicine and psychiatry, despite the fact that Felitti, Anda et. al. have published over 75 medical articles on it.  [FN5]

You’ve likely never heard of this, ‘tho we all should know about 20 years of official study on 17,337 citizens.  I never heard of it even as a Kaiser Permanente client in 2010-11.  So ACEsConnection is going to the grass roots, some states are doing ACE surveys, and social service agencies are training staff  in “Trauma-Informed Care.”

Dr. Felitti never dreamed of any of this.  He was an internist who fell into it all by accident. Kaiser had an obesity clinic, it was failing, and Dr. Felitti wanted to know why.  Suddenly, by interviewing people who quit, this data jumped into his lap.

Vincent Felitti

Now instead of retiring to the Bahamas after a long career, Dr. Felitti travels the world making speeches like “Why the Most Significant Factor Predicting Chronic Disease May Be Childhood Trauma” [FN6]

He insists that “contrary to conventional belief, time does not heal all wounds, since humans convert traumatic emotional experiences in childhood into organic disease later in life.” One does not “just get over” this, “not even 50 years later,” he says, without serious efforts and treatment.  [FN7]

Baby Casey: the Attachment Disorder ACE

This is not an academic issue.  Fifty percent of the American population has some degree of attachment disorder (see Blogs #1-4), and attachment disorder is a major component of many Adverse Childhood Experiences (ACE).

Baby Casey fr video crop2On ACEsConnection.com, created by journalist Jane Stevens, the first thing I saw was a video of a baby in a Polish orphanage that turned me inside out (click here & scroll down page). [FN8]

This is what the physical pain of attachment failure looks like. Left alone for months in the Warsaw facility, Baby Casey did not get the “face time,” physical holding, emotional attunement, or any of the interactions required for an infant’s brain to grow. Humans from birth require a constant stream of “emotional, spiritual, psychological, and physical inputs” from another loving human, says trauma specialist Mary Jo Barrett — just as we require air, food, and liquid.” [FN9]

A child left without this input stream learns that its own hard-wired biological needs are terrifying.   “I learn that what I experienced internally and expressed externally with a cry, was met by a response that didn’t make any sense,” says neuroscientist Dr. Daniel Siegel. “I learned: it doesn’t matter what I’m feeling, because people don’t get what I need.  Ultimately, I’ll become disconnected, not only from other people, but even from my own internal bodily self. ”[FN10]

Babies are also hard-wired to be flooded with stress chemicals when those needs are not met, Dr. Bruce Perry explains. And the flood can go on for decades. [FN11]

The emotional pain and terror are so intense that the child will do anything to distract itself from those needs. “In states of distress I can only comfort myself in ways that are maladaptive – I bite myself, rock myself perpetually, so I’m distracting myself from my needs,” Siegel says.

The fight-or-flight stress chemicals flood the bloodstream at a level which feels so terrifying, that the baby would rather pass out — or even die — than to feel it. “The baby thinks it’s going to die,” as Dr. Nancy Verrier puts it. [FN12]  I saw this video and said, “That baby’s trying to knock herself out.”

Turning Gold into Lead

BrousBlog7c Gold into LeadLeft unhealed, all those stress chemicals and panic feelings begin to physically destroy  body parts.

“The ACE Study findings suggest certain adverse childhood experiences are major risk factors for the leading causes of illness and death in the US,” the CDC reports. “As the number of ACE increase, risk for the following health problems increases in a strong and graded fashion:

Ischemic heart disease
Cancer
Chronic lung disease
Liver disease
Skeletal fractures
Alcoholism and alcohol abuse
Depression
Fetal death
Early initiation of smoking
Illicit drug use
Multiple sexual partners
Risk for intimate partner violence
Sexually transmitted diseases (STDs)
Unintended pregnancies
Abortion
Suicide attempts…”

“The odds of having cancer before 50 among women increased twofold for those who had 2+ ACEs versus those with no ACEs,” confirmed a 2012 study of over 6,000 Britons born in 1958, “Childhood adversity as a risk for cancer: findings from the 1958 British birth cohort study,” published by the British Medical Council.

“This is the largest study of its type which has ever been done to examine the effect of ACE on physical health, over the course of a lifetime,” Dr. Felitti says. All 17,337 participants will be followed up for life.

“We’re asking, ‘How do you get from Here [slide above] to Here.’  From a newborn infant with total potential — to a man who is broken, bio-medically, psychologically and emotionally.

“We found that ACEs are remarkably common – what is uncommon is their recognition, or their acknowledgment. They are well-concealed by time, by shame, by secrecy, and by social taboo. They turn out to be strong predictors of what happens later in life in health risks, disease, and premature mortality. The combination of their high prevalence, and their great power, makes ACEs the leading determinant of what happens to the health of a nation’s population.”  [FN13]

“In no way could you dismiss this as a marginalized population,” Dr. Felitti says of his 17,337 patients. Most of them are white middle class; 47% had attended college; they all had jobs and health insurance; they were at Kaiser.

“ACE are the risk factors which underlie the 10 most common causes of death in the U.S. With an ACE score of zero, you have a very medically uninteresting population – no internist has a chance of making a living with that group,” he notes.

“Swiss psychoanalyst Alice Miller says: ‘The truth about our childhood is stored up in our bodies, and lives in the depths of our souls.  Our intellect can be deceived, our feelings can be numbed and manipulated, our perceptions can be shamed and confused, or our bodies tricked with medication. But our soul never forgets. And because we are one, one whole soul in one body, some day, our body will present its bill.’

“In this study, we are looking at it literally. The cost of this is truly enormous. Whoever would have thought that pediatrics is the breeding ground for internal medicine,” Dr. Felitti concludes.

Feel like you might have an ACE or two up your sleeve?

You can go to http://acestudy.org/faqs and take the ACE Survey, to see how many ACEs you might have. If you feel really awful, go to your family doctor, bring him this report, and tell him you want to see a specialist because you are a normal human responding to abnormal experiences. If you do not have health coverage, no matter what your age, you can contact the nearest children’s hospital or the National Children’s Advocacy Center’s local office and ask for help. At www.nationalcac.org/locator.html, I used my zip code and found four places right near my home, just so I could report to you that they probably have facilities to help near you.

To read more, join ACEsConnection.com, the community of practice “private Facebook” network designed to prevent ACEs & further trauma and to increase resilience. Just sign up, fill out your profile, and go to “My Page” to start adding information about what you’re doing or thinking about these issues. If you’re looking for others doing what you want to do, join a group, or start a group and invite people to join. I joined, and I formed a Southern California ACEs group; here’s my SoCal ACEs page: http://www.acesconnection.com/profile/399727599840151624

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Excerpts from Kathy’s forthcoming book DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment DisorderHow I accidentally regressed myself back to infancy and healed it all  are posted here most Fridays, unless current events beg an interruption. Watch for the continuing series of excerpts from the rest of her book, in which she explores her journey of recovery and shares the people and tools that have helped her along the way.

Footnotes
FN1 CDC ACE Study pyramid: http://www.cdc.gov/ace/pyramid.htm

FN2 Centers for Disease Control (CDC), “ACE Study DVD Pre-View movie,” 3-minute version: http://www.acesconnection.com/blog/ace-study-co-founders-tell-story-on-dvd-here-s-an-intro

FN3  Dr. Felitti reports   67% of participants had one or more types of ACEs, and 42% had two or more types of ACEs. The CDC website states that 64% had one or more types of ACEs, and 38% had two or more types of ACEs; http://www.cdc.gov/violenceprevention/acestudy/prevalence.html    These percentages varied depending on when readings were taken as more subjects joined the study in the second “wave.”
Note: all these refer to “types” of ACEs. Thus, if 38-42% of the middle class Kaiser population had at two or more types of ACEs, each likely suffered multiple incidents of that type, be it abuse, neglect, or more.
In less privileged populations, far higher percentages suffer two or more types of ACEs as shown in Nashville, TN by The Family Center in 2016: http://www.familycentertn.org/our-impact

FN4  “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” by Vincent J Felitti MD, Robert F Anda MD, et al,  American Journal of Preventative Medicine, May 1998, Vol 14, Issue 4, p 245–258
http://www.ajpmonline.org/article/S0749-3797%2898%2900017-8/fulltext#back-BIB65

FN5  Felitti, Vincent, MD, “Adverse Childhood Experiences” www.youtube.com/watch?v=GQwJCWPG478

FN6  Felitti, Vincent, MD, official speaker biography at www.apbspeakers.com/speaker/vincent-felitti

FN7  Stevens, Jane, “The Adverse Childhood Experience Study” — the largest, most important public health study you never heard of — began in an obesity clinic”  also published by Huffington Post at http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html

FN8  Brooks, John, “Video of Baby Casey in the Orphanage,” Warsaw, Poland, 1991, from Brooks, John, “The Girl Behind the Door: An Adoptive Father’s Lessons Learned About Attachment Disorder,” at http://parentingandattachment.com/the-girl-behind-the-door/.  Baby Casey video at http://acestoohigh.com/2013/08/02/the-early-heartbreaking-rages-of-a-baby-with-attachment-disorder/. Original video at http://parentingandattachment.com/meet-my-casey/.

FN9  Barrett, Mary Jo, MSW, “How to Treat the Patient Without Further Trauma,” NICABM webinar June 29, 2011, NICABM.com.  She is a professor at the University of Chicago; founder and director of the Center for Contextual Change; co-author of “Systemic Treatment of Incest;” and co-editor of “Treating Incest: A Multiple Systems Perspective.”

FN10  Siegel, Daniel J., MD, “Early childhood and the developing brain,” “All in the Mind,” ABC Radio National, Australia.

FN11  Perry, Bruce, MD, PhD, “Born for Love: The Effects of Empathy on the Developing Brain,” speech at conference “How People Change: Relationship & Neuroplasticity in Psychotherapy,” UCLA Extension, Los Angeles, March 8, 2013. See also “Overview of Neuro-sequential Model of Therapeutics (NMT),” www.childtrauma.org, 2010

FN12 Verrier, Nancy, PhD, “Coming Home to Self: The Adopted Child Grows Up,” self-published, Lafayette, CA, 1993

FN13 Op Cit Footnote 3, Felitti 13 minute video at http://www.youtube.com/watch?v=GQwJCWPG478

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