Download Resilient outcome - Anna Freud Centre

Anna Freud National Centre for Children and Families
Latent
vulnerability
Child maltreatment
through the lens of
neuroscience
Eamon McCrory PhD DClinPsy
Director of Postgraduate Studies, Anna Freud
National Centre for Children and Families
Professor of Developmental Neuroscience &
Psychopathology, UCL
[email protected]
Friday 2nd December 2016
Mental Health Problems
•
•
•
•
May emerge many years later
More likely to be less responsive to traditional treatments
Problems more likely to be comorbid
Problems show greater severity
Adversity
Poor
outcome
Treatment
Resilient
outcome
Poor
outcome
Adversity
Resilient
outcome
1. Early Identification – how do we identify those most at risk?
Poor
outcome
Adversity
?
1. Early Identification – how do we identify those most at risk?
2. Pinpointing mechanisms – how does adversity get under the skin?
Resilient
outcome
Poor
outcome
Adversity
?
Resilient
outcome
1. Early Identification – how do we identify those most at risk?
2. Pinpointing mechanisms – how does adversity get under the skin?
3. Understanding resilience – what can we learn from resilient young people?
The concept of
Latent Vulnerability
McCrory & Viding
Development and Psychopathology, 2015
The theory of Latent Vulnerability is an
emerging framework for thinking about
how early adversity can embed long term
risk of mental health problems
High risk of disorder
Adverse
environment
•
•
•
Low protective factors
High stressors
Risk genotypes
•
•
•
High protective factors
Low stressors
Resilient genotypes
Response &
adaptation…
Low risk of disorder
Adolescence & Latent Vulnerability
• Growing up in an early adverse environment will lead to ‘adaptations’ at multiple
levels that may have a short term benefit but which may incur long term cots.
1. Alterations at the epigenetic level. How genes are regulated.
2. Alterations at the neurocognitive level in ‘representations’ (of self and other)
as well as in basic and higher order ‘processes’
• Both basic and higher order processes are altered in a range of disorders
associated with maltreatment (e.g. anxiety, depression and conduct problems).
Here I will focus on:
o Threat processing
o Autobiographical memory
• How might early adversity shape these domains in ways that may embed latent
vulnerability?
Genetic
/ Epigenetic
Cognitive
Behavioural
Maltreatment
Neurobiological
Genetic
/ Epigenetic
Cognitive
Behavioural
Maltreatment
Neurobiological
Adversity
?
?
?
?
What are the neurocognitive mechanisms
that embed latent
vulnerability following
childhood adversity?
i. Threat processing
ii. Autobiographical Memory
Psychiatric Vulnerability
1. Altered threat processing
Children exposed to physical maltreatment have been
shown to have altered processing of angry faces:
–
–
able to more accurately identify angry facial expressions using
sparse perceptual information than peers
devote more attentional resources to the processing of angry faces
- interpreted as increased hypervigilance to threat
Pollak & Sinha, 2002, Pollak et al., 2001
Pollak et al., 2009
Pollak et al., 2009: Cognition
% Image
1. Altered threat processing
Children exposed to physical maltreatment have been
shown to have altered processing of angry faces:
–
–
–
able to more accurately identify angry facial expressions using
sparse perceptual information than peers
devote more attentional resources to the processing of angry faces
- interpreted as increased hyper-vigilance to threat
In some contexts they show avoidance of threat cues – diverting
attention away from threat cues that may be processed as aversive
Pollak & Sinha, 2002, Pollak et al., 2001, Kelly et al., 2015
1. Altered threat processing
Kelly et al., 2015
Threat avoidance
Loser
Cabinet
Admired
Failure
Threat avoidance
•
Children exposed to maltreatment show significant hypo-activation of a network
potentially reflecting an avoidant response to social rejection cues
•
The greater the degree of hypo-activation the greater the level of dissociation
symptoms
Understanding the neural
basis of threat vigilance
Dec 2011
Dec 2011
Dec 2011
Increased right amygdala reactivity and
increased bilateral anterior insula
reactivity to angry vs. calm faces in
children exposed to family violence.
This may be a latent neural marker of
latent vulnerability – the same neural
signature is common in anxiety
disordered populations (Etkin & Wager,
2007).
Exposure to family violence may ‘recalibrate’
responsiveness of the anterior insula and
amygdala in processing potential threat.
But is this a conscious process? In other words, is
this hypervigilance to threat under higher order
regulatory influence?
McCrory et al., (2013) British Journal of Psychiatry, 202: 1-8
Cortex
“high road”
“low road”
LGN
Pulv
Amygdala
Thalamus
SC
emotional
stimulus
emotional
response
Amygdala
Is amygdala reactivity calibrated in
response to environmental adversity?
Children
Soldiers
Amygdala
Anterior
insula
McCrory et al., (2011)
Wingen et al., (2011)
Amygdala activation
Duration of abuse associated with
amygdala response in children
r2= 0.57
Age of onset of neglect (years)
McCrory et al., 2013
Severity of abuse associated with
amygdala response in adults
Amygdala activation
r2= 0.37
Severity of abuse (CTQ score)
Dannlowski et al., 2013
Collectively, these findings suggest
that the responsiveness of the
amygdala is calibrated and adapts to
the degree of environmental threat
Do higher levels of amygdala reactivity to
threat predict future mental health
problems?
Change in PTSD Symptoms
Amygdala reactivity BEFORE stress predicts
future symptoms
Admon et al., 2009
Amygdala activation
before combat (T value)
Prior amygdala reactivity to threat cues predicts anxiety and
depression symptoms in a cohort of health adults (n=340) following
future life stressors over a 1 – 4 year period
Swartz, Knodt, Radtke & Hariri (2015), Neuron, 85(3):505-11
Is altered amygdala reactivity to threat
implicated in disorders associated with
maltreatment?
Yes - heightened amygdala reactivity has
been reliably associated with:
• Depression
• Anxiety
• PTSD
• Conduct Problems
Monk et al., 2008
• Therefore, increased threat-related amygdala reactivity
following maltreatment represents one promising candidate
mechanism characterizing latent vulnerability.
• It may signal adaptive vigilance within adverse early
environments. However, it may in the longer term be
maladaptive in more typical social and educational settings.
Adversity
•
Increasing likelihood of
interpersonal conflict with
peers
Altered Threat
Processing
• Reducing cognitive capacity available
for more normative developmental
tasks and social learning
Psychiatric Vulnerability
Social Environment
But there are other candidate neurocognitive systems that
will likely index Latent Vulnerability…
?
?
?
?
Increased Latent Vulnerability
1.
Threat processing
2.
Autobiographical memory
2. Autobiographical memory
• Autobiographical memory is concerned with the recollection
of personally experienced events and plays a central role in
scaffolding our sense of self.
• Our autobiographical memory provides the ‘data’ that helps
us simulate future events and negotiate them more
effectively.
• Children who have experienced maltreatment tend to show a
pattern of OVERGENERAL memory.
• Overgeneral memory is associated with increased risk of
depression and PTSD and may therefore represent another
latent vulnerability mechanism
Autobiographical Memory
These findings may reflect increased latent vulnerability to mental health
problems and social difficulties in two ways:
1. First, over-general memory may reduce the ability to draw on past
experiences to effectively negotiate future stressors. This may be
particular pertinent during adolescence as a young person needs to
navigate novel and challenging new contexts with reduced care-giver
support
2. Second, decreased specificity and salience of positive relative to negative
memories may increase the likelihood of a negative inferential style and a
ruminative response style.
Adversity
•
Over-general
Autobiographical
Memory
Poorer social problem
solving – greater peer
problems
• Increased negative ruminative style
• Poorer ability to conceptualize the
future self
Psychiatric Vulnerability
Social Environment
Unhealthy
•
•
•
Threat bias
Autobiographical memory
Emotion regulation
Clinical Threshold
Healthy
Outcome
Latent
Vulnerabilities
Maltreatment
Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood
Unhealthy
•
•
•
Threat bias
Autobiographical memory
Emotion regulation
Clinical Threshold
Healthy
Outcome
Latent
Vulnerabilities
Maltreatment
Life Stressors
AND
Developmental Challenge
Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood
Unhealthy
?
Healthy
Outcome
Clinical Threshold
Maltreatment
Infancy…..……..Childhood…..…..…Adolescence…..…..…Adulthood
Summary & Implications
•
According to the theory of latent vulnerability early adversity calibrates
epigenetic and neurocognitive systems in ways that may reflect adaptation to
early risk environments but carry long term costs for mental health.
•
We have seen that altered threat processing (both patterns of avoidance and
vigilance) as well as alterations in autobiographical memory processing may
have direct effects on psychiatric vulnerability as well as indirect effects, via the
environment.
•
We need to investigate whether changes in these systems represent markers of
latent vulnerability that can help us in the development of a clinical screening
tool that identifies those children at most high risk of later mental health
problems.
•
We also need to understand whether targeting these neurocognitive systems –
through social interventions – can help young people recalibrate these systems
in ways that ‘fit’ with their new environments. Understanding this process of
recalibration will be key to developing our understanding as to how best to
promote resilience through early prevention efforts.
Thank-you!