Toxic Stress, Trauma, and the Culture of Poverty Darcy Lowell, MD Founder and CEO, Child First, Inc. Associate Clinical Professor Yale University School.

Toxic Stress, Trauma, and the Culture of Poverty

Darcy Lowell, MDFounder and CEO, Child First, Inc.Associate Clinical ProfessorYale University School of Medicine

Melissa Mendez, LCSWPromising Starts Coordinator, Project LAUNCHChild First Clinical SupervisorNew Britain

Overview of SessionToxic stress, ACEs, and early brain developmentThe power of nurturing relationshipsThe culture of povertyEarly identification Effective social-emotional interventionsCT AIMH: Training and Endorsement

The Developing Brain *

Brain DevelopmentBy 8 months of age, brain synapses have increased from 50 to 1000 trillion: 700 synapses/secondThe childs early experiences actually build the architecture of the brain - EPIGENETICSBy 3 years, 80% of brain growth is complete.

But what happens in the face of ADVERSITY, when early experiences are threatening, unpredictable, neglectful, or abusive?

TOXIC STRESS!

Environmental RisksExtreme povertyDomestic and community violenceAbuse and neglectParental mental health issues, especially depressionSubstance abuseHomelessnessIncarcerationTeen and single parenthoodIsolation and lack of social supportsLack of education and illiteracyUnemployment Health and dental issuesPoor quality child careLack of basic needs: food, clothing, heat, furniture*

Adverse Childhood Experiences ACEsABUSEPhysicalEmotional SexualNEGLECTPhysicalEmotionalHOUSEHOLD DYSFUNCTIONMental illnessDomestic violenceSubstance abuseIncarcerationDivorce

Brain Research: Toxic Stress or ACEsBased on the most recent research about the young, developing brain:High stress destroys brain architecture. Leads to lifelong problems in: Mental health Development & learning Physical health

Biologic Effect of Profound NeglectThis 11 year old girl is the size of a 4 year old.

She has markedly reduced brain function and growth.

Incidence: 1 risk = 7% 8 + risks = 40%In Bridgeport: Of those children who were high risk, 70% screened positive for emotional concernsBehavioral Problems

And It Does Not Just Go Away!Emotional or behavioral problems at age 3 years 50% psychiatric diagnosis by kindergarten or 1st grade.

Social-Emotional Problems by Number of Risk Factors% Children with Social-Emotional Problems0 1 2 3 4 5 6+Risks

Power of Responsive Nurturing

Child SuccessNurturing RelationshipsSocial Emotional HealthLanguage & Cognitive DevelopmentPhysical Health

Who are the families we want to reach?

How do we effectively engage these families? We have to start by, and be in consistent practice of, reflecting on our values, beliefs and assumptions about ourselves and the families we serve

Values, Beliefs, and AssumptionsValues: How important something is.

Beliefs: The ideas we accept as true. Assumptions: Ideas based on our past experiences.

Values, Beliefs, and Assumptions"Your beliefs become your thoughts, Your thoughts become your words, Your words become your actions, Your actions become your habits, Your habits become your values, Your values become your destiny."

-Mahatma Ghandi

Families come to the work with their own values, beliefs, and assumptionsAssumptions based on past experiences that lead to current interactions: Can I trust you? Will you really help me? Could you hurt me? Do you get me? (you know how we are)

Mental Model of Poverty handout

Hidden Rules Among Class Groups

Poverty Middle Class Wealth MONEYTo be used, spent To be managed To be conserved, invested FOOD Quantity: Is there enough? Quality: Did we like it? Presentation: Was it presented well? TIME Present Future Traditions and history DESTINY Fate Choice Noblesse obligeMOTIVATIONSSurvival, relationships, entertainment Work, achievement Financial, political, social connections

Hidden Rules Video Clip http://www.youtube.com/watch?v=PYeWJlfu1ZA

Hidden rules about discipline Penance and forgiveness (pay a price/say youre sorry) Change (what did you learn?)

Responding to Generational Poverty Emotional/Cognitive MindsetWhat is your tolerance level (1 (NO TOLERANCE) to 5 (HIGH TOLERANCE)) for a spouse/partner who: Repeatedly gives money to a relative who does not work?Left bills unpaid to give money to a relative? Quit job without having another because he/she didnt like the boss?Kept a low-paying position because he/she didnt want to separate from close co-workers?Allowed a relative or friend to stay move in for an undetermined amount of time?

Societal and Family Systems

Highly mobile, nuclear family Clan network (family all lives in same neighborhood/close proximity)Extended family that lives together and shares resources Friends sometimes take place of extended family Child may be used to high levels of activity in the home Child may have little contact with people outside of the family Children may have little contact with extended family Drop ins are the norm Child may be used to having responsibilities in the home/family Child experiences more routines and structure in their daily life Child may eat or sleep in more than one household Child may be used to sharing resources easily (seen as too passive)

Why is it important to consider these concepts? Enhances our working relationships with families Increases likelihood that families stay engaged 10-25% of families in low-income communities choose not to participate in early childhood home visiting 20-67% of families in low-income communities fail to fully complete early childhood home visiting servicesThe relationship between the parent and the provider is the most potent predictor for success of the intervention.

Historical Trauma for Families Living in Poverty Refers to cumulative of emotional and psychological damage, exceeding over an individual lifespan and across generations, caused by significant group traumatic experiences.

"Historical trauma is defined... as a constellation of characteristics associated with massive cumulative group trauma across generations.

Historical Trauma for Families Living in Poverty

Historical trauma differs fromother types of trauma in that the traumatic event is shared by a collective group of people who experience the consequences of the event, as well as the fact that the impact of the trauma is held personally and can be transmitted over generations."

Early Identification

Interaction between Brain Plasticity and Age

Screening and ReferralIdentify children and families as early as possibleFormal screening for risk and social-emotional concernsIdentification by concerned providers and caregivers

Early Childhood Mental Health Early Identification OpportunitiesPediatric Primary Care CenterObstetrics (depression and substance use)Early Care and Education / SchoolsDCFDSS Birth to ThreeHome visiting programsWICFamily Resource Centers

Pediatric Primary Care Center

Pediatric Primary Care Center at Bridgeport Hospital1300 children 47% + for emotional or behavioral concerns62% + for environmental risk

Screening MeasuresEmotional/Behavioral Development:Brief Infant-Toddler Social-Emotional Assessment (BITSEA): under age 4 yearsAges and Stages Social-Emotional: 3 months to 6 yearsDECA Infant/Toddler and PreschoolPediatric Symptom Checklist: over age 4 yearsPsychosocial Risk: Parent QuestionnaireACEs adult or child questionnaires (e.g., MIECHV DPH)

Parent Questionnaire: Scoring Example

1. I am worried about my childs development... YES NO He/she is not learning as fast as I expectedYES NO 2. I am worried about my childs behavior.YES NO I am worried that my child is not happy .YES NO

3. I am employed or in an education/training programYES NOMy childs other parent is employed or in an education/training program.YES NOI have completed high school or have a GEDYES NO

4. I feel very worried, stressed or sad a lot of timeYES NO Sometimes I feel that life is just too hard to continueYES NOAny Yes = 1 Any Yes = 13 Nos = 1Any Yes = 1*

Parent Questionnaire: Positive Screen3 or more pointsYes in any one of the red flag questions with a star - is an automatic positive:# 4 depression# 8 domestic violence# 10 substance abuseAny clinical concern, regardless of number of points

Mental Health Services

Ecological Approach within an Early Childhood System of Care

Child: Health & DevelopmentRelationshipsParental ChallengesCommunity

Two-Pronged Approach Decrease toxic psychosocial stress by connecting children and families to needed services and supports.Facilitate the development of a responsive, nurturing parent-child relationship that can protect the developing brain.12

Target Population: ChildrenPrenatal to 6 years Any problem that threatens healthy development:Emotional/behavioralDevelopmental/learning Abuse and neglectServe families with multiple children

Target Population: ParentsParents/caregivers (birth parents, foster parents, relatives) with multiple challenges:Depression and other mental health problemsSubstance useHomelessnessDomestic violenceChild protective service involvementPovertyFathers and caregiving partners included

Overview of Child First Intervention Screening and community referralsHome-based interventionEngagement Comprehensive assessmentChild and Family Plan of CareTargeted parent guidance and Child-Parent PsychotherapyMental health classroom consultationConnection to community-based services*

Parent-Child InterventionIntervention:Relationship-based, Trauma-informed Child-Parent Psychotherapy (CPP)Focus on the meaning of the childs behaviorParent guidanceDevelopmental lensPromote executive functioning*

Services and SupportsPrimary or specialty pediatric careEarly care and educationBirth to ThreeSpecial educationChild mental healthParenting groupsFamily Resource CentersParent mentors and aidesAdult mental healthSubstance abuse treatmentAdult health careLegal aideDomestic violence servicesTransportationHousing / sheltersJob trainingComputer trainingFood stampsFood banksHUSKYGEDLiteracyESLWICTANFSSICSHCNClothing and furniture*

A Glimpse at How We Help? First, we help by holding and supporting caregivers in recognizing their ghosts, when it interferes with their nurturing their children.Second, we help by supporting families in identifying their angels, who have nurtured and held them in the past.

Other CT Service ModelsChild-Parent Psychotherapy agency-basedCircle of Security parenting groupsFamily-Based RecoveryMinding the BabyEarly Childhood Consultation PartnershipTriple PParent-Child Interaction Therapy

CT Association of Infant Mental HealthEndorsement for Culturally Sensitive, Relationship-focused Services to Infants, Toddlers, Parents, Other Caregivers and Families.

CT-AIMH Endorsement Endorsement for Culturally Sensitive, Relationship-focused Services to Infants, Toddlers, Parents, Other Caregivers and Families

http://www.ct-aimh.org/

CT-AIMH Endorsement Coordinator Tanika Simpson, LCSW, IMH-E

Thank you!

http://www.albertafamilywellness.org/resources/video/how-brains-are-built-core-story-brain-development

Need to begin with an understanding of early brain development.

These experiences positive or negative - lead to the production of hormones and chemicals which actually enter the cells and bind to the genetic material the DNA and are able to turn genes on and off. These genes direct development of the brain and other body systems.So it is not Nature versus Nurture as was the old controversy it is nature and nurture together!Prolonged repeated activation of the bodys stress response system damages the developing brainThese are the risks that we are seeing some are more important than others. Cumulative risk is criticalStress produces a rise in cortisol and other chemicals in the brain which actually destroy brain architecture.Mental health problems: Depression, anxiety, substance abuse, post traumatic stress disorderDevelopment and learning problems: Difficulties with self-regulation and executive functioning: specifically memory, attention, impulse control, problem solving, planning, monitoring, following directionsPhysical health problems: Heart disease, hypertension, cancer, diabetes, obesityACE S Adverse Childhood ExperienceFind very strong relationship between risk factors and behavioral problems: (Sameroff)1 risk = 7% incidence of behavioral problems8 or more risks = 40% incidence of behavioral problemsRutter very similar findings: When you compare a single risk factor to 4 risk factors, you see a ten fold increase in behavioral problems.Children experiencing two risk factors were four times as likely to have a psychiatric impairment compared to children not exposed to any risk factor or who were only exposed to one. Children with four risk factors were ten times as likely to have a psychiatric impairment as those with one or none. Risk factors included marital discord, low SES, large family size, parental criminality, maternal psychiatric disorder, and child welfare involvement. 419-420 Rutter, M. (1979). Protective factors in childrens responses to stress and disadvantage. Social competence in children (pp. 49-74). Hanover, NH: University of New England.Sameroff Doesnt matter what specific risks you are talking about. (Risk factors included marital discord, low SES, large family size, parental criminality, maternal psychiatric disorder, and child welfare involvement. )Findings in Bridgeport with young children:Of those children who were high risk, 70% screened positive for emotional concerns.Know from longitudinal work by Alice Carter and Margaret Briggs-Gowan that when emotional and behavioral problems are identified, they dont spontaneously resolve.If a child has a positive screen for emotional or behavioral problems at age 3 years, 50% will meet criteria for a psychiatric diagnosis by kindergarten or first grade.(This means that there is a 6 fold increase in the risk for a psychiatric diagnosis with a positive screen.)And there are not just mental health effects:Externalizing behaviors (like aggression and defiance) at age 5 predicted educational attainment at age 30

But there is some good news!Buffers the effects of exposure to toxic stress and protects the developing brain from damage.Serve and return or dance between parent and child which leads to secure attachment.Turns toxic stress into tolerable stress.1,116 vocabulary size at 36 months - college749 working class525 Welfare

Children talked to frequently have almost 300 more words by age 2 years. Hart and Risley did a study comparing two groups of children at age 3 years. Children of college educated parents had 1200 words, while those with parents on Welfare had only 300 words. By age four years, an average child in a professional family would have accumulated experience with almost 45 million words, an average child in a working-class family would have accumulated experience with 26 million words, and an average child in a welfare family would have accumulated experience with only 13 million words.

However, it is also the quality of the communication which is markedly different. The average child in a professional family would have accumulated 560,000 more instances of encouraging feedback than discouraging feedback, and an average child in a working-class family would have accumulated 100,000 more encouragements than discouragements. But an average child in a welfare family would have accumulated 125,000 more instances of prohibitions than encouragements. When children start this far behind, it is no wonder that there is such a profound achievement gap!So, remember all the damage that can be done by adversity problems in mental health, learning disability, and physical disease?Here, we have an opportunity to prevent that damage through the quality of the relationships between child and parent.What about this family? Is this what our families typically look like? What do you think about this family? What do you believe about this family based on this image? If this is not what our families typically look like, then what are some characteristics of the families that we see/serve in the work that we do in communities (participants can give some characteristics we will note on a chart). We are taught to judge based on our own set of hidden rules. Ruby Payne clip. Neural networks are wired from bottom up.Earlier connections serve as the scaffold or foundation for later connections.Whether the foundation will be strong and solid or weak and fragile is determined by the childs early experience.

Change in brain structure is easy early in development.As the child ages, the connections in the brain become hard-wired.Change in brain structure is increasing difficult as the child grows older.Later treatment is extremely costly!Later outcomes are poor!Screening in obstetrics prenatally, pediatrics, early care and education, WIC, family centers, etc.BITSEA and PQProviders see broad needs of family, instead of the one services that they provide new perspective, everyone winsAttention to maternal depressionAccording to CAPTA legislation, all children who are abused or neglected should be at least screened and referred to early intervention B-3DECA I/T will not identify problem behaviorsPediatric Primary Care Center at Bridgeport Hospital Have screened over 1300 children under age 6 years47% were positive for emotional or behavioral concerns62% reported elevated environmental risk70% of children with environmental risk had emotional/behavioral problemsFull time clinician who works with our Med-Peds or Yale peds residents to teach them to screen and provide consultation for families with significant environmental risks and children who are already having emotional, behavioral, or developmental problems.Ild like to encourage you to start screening in your own practices. Very easy.English and Spanish. One page, under 6th grade reading level. Takes under 5 minutes to complete.Covers 12 areas or domains.Scoring takes 1-2 minutes.Two-generation approach

Parental challenges both internal and external - External: unstable housing, food insecurity, lack of employment - Internal: depression, substance usage, self-regulation and executive functioning capacity

Work collaboratively:Home visiting: NFP, HFAEarly intervention (IDEA Part C)Early care and educationHealth: Pediatric primary care, ObstetricsFamily CentersChild protective servicesSheltersAdult mental health and substance abuseDV services and court systemDecrease toxic psychosocial stress by connecting children and families to needed services and supportsFacilitate the development of a responsive, nurturing parent-child relationship that can protect the brain. Intervention at any timeTwo generation approach (even three!)1) CPP- Two generation approach (even three!)- Creation of a protective, nurturing, caregiving relationship- Reflection on meaning of behaviorIntensive, reflective, clinical supervision Use of video Highly individualized

2) Parent guidance

3) Promote executive functioning