CCPR: Dr. Fisher, you specialize in the treatment of trauma from a neurobiological perspective. Please tell us about that.
Dr. Fisher: i am part of the branch of the trauma treatment field that is looking to use neuroscience research as the jumpingoff point for decisions about treatment, with the idea that if we understand how the brain and body are perpetuating traumatic experiences then our treatment methods will be more successful.
CCPR: For those of us who work with kids and teenagers who have had traumatic experiences, what do you think the most important thing to remember is?
Dr. Fisher: probably the most important thing to remember is that the brain and body are designed to assume the worst. if achild has been neglected, abused, subjected to domestic violence, or developed an attachment disorder from parents who may not have been abusive but angry, critical, reactive, and in other ways frightening to the child, the child’s mind and body have, within a relatively short time, become adapted to those conditions. and what happens is that the child might want help, but his or her mind and body react to human beings as potential threats rather than potential sources of help.
CCPR: You talk about symptoms that people may see as “bad behavior” but that are really rather driven by neurobiological factors. Can you talk a little bit more about that?
Dr. Fisher: starting in infancy, in the face of danger or threat, a child’s body reacts with animal defense survival responses, which are patterns that we are all born with. These responses include the fight or flight response, the freeze response, and what is known as the “cry for help.” so typically what we see in kids as a manifestation of trauma is acting out behavior, which is related to fight/ flight and cry for help responses.
CCPR: And then there are also the children with the submissive responses.
Dr. Fisher: right. What is called “learned helplessness” and submission go hand in hand. Kids who are chronically depressed, apathetic, or “checked out” tend to be manifesting the submission response. They also come to attention of mental health professionals, but usually not with the same urgency as our fight/flight kids. Most children have the learned helplessness/submission response or the freeze and fear response until they reach adolescence and then the fight/flight response kicks in because the body actually becomes capable of effective fight or flight in teenagers. Five year olds can fight, but a grown-up can subdue a five year old. a teenager has the physical strength to fight and flee or even to live on the streets as some of our homeless teens do.
CCPR: The fight/flight kids often come to the attention of child psychiatrists because they are always getting into trouble, are in jail, or as you said, sometimes homeless.
Dr. Fisher: For reasons we don’t fully understand, some kids start fighting and fleeing in very early childhood and end up in either residential programs or incarcerated. The difficulty is that when this behavior, which is really an animal defense survival response, is treated as “bad” it actually intensifies the responses.
CCPR: How do you mean?
Dr. Fisher: if a teenager is feeling threatened and acts out in response and then everybody turns on him and says, “That was bad, that was inappropriate, you put yourself at risk, you put others at risk,” this is going to further increase his sense of danger and threat. Because not only has he been threatened, but now he is being punished for his response to that threat.
CCPR: That makes sense. People can get quite confrontational when presented with a raging teen.
Dr. Fisher: yes—but people need to recognize that fight/flight responses come from fear. When children kick, bite, and lash out, they are coming from a bodily sense of fear.
CCPR: So how do we best address this?
Dr. Fisher: There is a big problem in just being “nicer” to these kids, because for most children trauma is interpersonal andit occurs at the hands of those they are closest to. in fact, 90% of child abuse occurs at the hands of immediate family. so what happens then is that as children start to feel close to adults, whether those are residential counselors, teachers, or therapists, those adults start to feel threatening, because their experience is if you love someone you will either be neglected or abused or both.
CCPR: Now there is an argument that putting these kids in restraints is the only way to calm them down.
Dr. Fisher: The difficulty with restraints is that they are very effective in the short term, but when you put the child in restraints you induce the helplessness or submission response. so in the long term, what happens is a vicious circle because if you restrain a child, you induce the submission response, and right on the other side of that submission response is a heightened fight response. There is actually a small minority of children and adults who seek that; they act out until they get restrained, which induces that submission response. The safest time for a child is right after an act of abuse. so in some sense they induce the abuse, which is a known quantity, and then they can relax because there won’t be anything for a while. and many of our patients learn to submit in order to not be restrained, and their behavior improves and their functioning improves. however, there is a subset who get worse the more they are restrained. and even with those who benefit from restraints the dilemma is that they have benefited because they are now more checked out, more docile, but they haven’t actually done a piece of recovery.
CCPR: So what is a better approach?
Dr. Fisher: almost 20 years of neurobiological research shows that trauma-related feelings and body responses are so intense and overwhelming that they actually cause the frontal lobes to shut down. This is really important for people who work with kids to understand: when kids are threatened and their frontal lobes shut down, they have no way to access the contract they agreed to, the behavior plan they endorsed, and the skills that they practiced. all of that goes out the window because accessing those skills or those commitments is a frontal lobe cognitive act.
CCPR: So based on that, how can we stop the restraint cycle?
Dr. Fisher: The real challenge in treating traumatized children, teenagers, and adults is helping them to learn how to regulate their nervous systems so that they have reactions that are more appropriate for peacetime than for trauma and danger. We are talking about this as an inpatient restraint/seclusion problem, but this is equally true for parents of children who have been traumatized, perhaps adoptive parents or foster parents.
CCPR: So how can we help parents do this?
Dr. Fisher: We need to teach parents to regulate their nervous systems in response to the child. Because one of the things thatis so difficult is that if you have a child who is autonomically stimulated, then your heart starts pounding, you start pumping adrenaline, and the whole situation kind of amps up. so what happens to parents is that the child’s arousal level escalates, then the adult’s arousal level escalates, and things go from bad to worse. i try to tell parents, “anybody would be upset by how the child has acted, but the difficulty is that if your nervous system goes out of the optimal arousal zone—if you get worked up in response— your intervention will escalate the child rather than helping the situation.” We know from the research that in order for children to have mature nervous systems, those that care for them to have well regulated nervous systems.
CCPR: So we need to counsel our patients’ parents, and sometimes their therapists and other caregivers, to calm down. To lend the kids our frontal lobes, so to speak.
Dr. Fisher: exactly. as much as we would wish children to not be dependent on our nervous systems, the fact is that they are.
CCPR: You have some techniques to help kids when they recognize that they are going into these states of fight or flight. Could you give us a quick overview?
Dr. Fisher: a technique for decreasing anger and anxiety is for the child to put a hand over the heart. anger and anxiety are driven by a rapid heart rate fueled by adrenaline, and for some reason if you put a hand over the heart it slows the heart rate. This is a very simple technique that has been taught in attica state prison in New york to violent offenders as a way to help them learn how to regulate.
CCPR: Sounds pretty simple. Any other techniques?
Dr. Fisher: another technique that is being used by some of my child colleagues is drumming. This is especially useful for kids who have trouble verbalizing their feelings. We tell them to drum what they are feeling and then there is also the option of drumming what would make them feel better. a final technique that i am very fond of, which is really good for kids who are kindof checked out and in that learned helplessness state, but can also paradoxically work with kids who are more hyperdefensive and hypervigilant, is asking them to “get taller.” The adult language for this is “lengthen the spine” from the middle of the back.
CCPR: And how does this work?
Dr. Fisher: This counteracts learned helplessness. if you think about how aggressive behavior is fueled by fear, the “getting taller” approach actually helps with that because it is a way of reminding the body that it is powerful.
CCPR: Good advice. Anything else?
Dr. Fisher: Most parents and most staff members i have worked with have a tendency to get very serious and a little stern when kids act out, which, unfortunately, if you are a child of neglect and abuse, is actually going to be triggering. We will have more of an impact if we are lighter, if we are more playful, if we are more positive.
CCPR: Thank you, Dr. Fisher.
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