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NEAR orTHE DANCE OF NATURE & NURTURE AND HOW THE BODY
KEEPS THE SCORE
Training sponsored by Prevention Works of Clallam County
March 26, 2018
Presenter: Marian Birch,DMH
• “Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well–being.” – Besser van der Kolk, M.D.
• “For an epidemic of influenza, a hurricane, an earthquake or a tornado, the worst is quickly over; treatment and recovery efforts can begin. In contrast, the chronic disaster that results from ACEs is insidious, constantly rolling out from generation to generation.” Robert Anda, M.D.
Components of NEAR Science
•Adverse Childhood Experiences
•Neuroscience
•Epigenetics
•Resilience
What do we mean by Adverse Childhood Experiences?
Abuse: 1. Physical2. Emotional3. Sexual4. Domestic
violence
Neglect1. Emotional2. Physical
Family Dysfunction1. Mentally ill parent2. Substance-abusing
parent3. Incarcerated
parent4. Separation/divorce
Some Additional proposed ACES1. Historical trauma2. Community violence3. Foster care4. Medical trauma
20%
59%
43%
69%41%
78%
45%
62%
Out of Work >1Year
No Satisfaction with
Neighborhood
Serious & Persistent
Mental Illness
15 of 30 Days Disturbed Work -
Emotional Problems
IV Drugs
Drunk Driving
VictimIntimate Partner Violence
Incarceration
ACEs
61%
Worker Injury
25% 15 of 30 Days Disturbed Work-
Ill Health
Law & Justice Workforc
e
Civic EngagementSafety
Controls: gender, age, income, education, race-
ethnicity
Foundation for Healthy Generations 2014
ACE Attributable Problems
Foundation for Healthy Generations 2014
DiseaseCardiovascular
Cancer
Asthma
Diabetes
Auto immune
COPD
Ischemic heart
disease
Liver diseaseHealth/Social ProblemsFair or poor health
Life dissatisfaction
Health-related limits to quality of life
Disability that impedes daily functioning
Don’t complete secondary education
Unemployment
History of adult homelessness
RisksSmoking
Heavy drinking
Obesity
Risk of AIDS
High on
painkillers
Obesity
Intergenerational TransmissionMental Illness
Drugs or Alcohol Problem
Multiple divorces, separations
Victim of family violence
Adult incarceration
Poor Mental HealthFrequent mental
distress
Sleep disturbances
Nervousness
MH problem requiring
medication
Emotional problems
restrict activities
Serious & persistent
mental illness
ACES Pyramid (thanks to Laura Porter)
ACE Categories (ACEs) are Interrelated
– 87% of people with 1 have >1
ACEs are Common
– Nearly 2/3 of adults have ≥1; 27% have ≥3; 5% have ≥6
Accumulation of ACEs Matters
– Higher # (ACE Score) = higher population risk
Graded Relationship: Disease, Disability,
Social, Productivity
Scores= Good Proxy Measure Childhood Toxic
Stress Dose
ACEs are the Most Powerful Known
Determinant of Health
– Mental, Physical, Behavioral, Productivity, Disability, &
Social Problems
Why are these experiencesADVERSE?
1.Disruption of Early Brain Development2.Disruption of Attachment
❖Toxic vs. tolerable stress
❖Familiar vs. stranger maltreatment
❖Absence/presence of sources of comfort, soothing
Components of Adversity
Neuroscience:Architecture of the Brain In the human brain,
•Connections between midbrain
and cortex develop after birth
•These connections are sculpted
by experience
•The most important kind of
experience is interaction with
caregivers
•Unrelieved distress alters brain
structure
•Growth is phenomenally rapid
until 18 months
•Between 18 months and 3 years,
brain connections are pruned
•Pruning is based on
•‘use it or lose it’
•‘fire together, wire together’
Neuroscience:The impact of chronic fear & anxiety
• The brains of human infants are ‘unfinished’
• They are ‘finished’ in the context of the caregiving environment
• Neurons that ‘fire together, wire together’
• The brain’s architecture is affected by chronic states of fearful arousal in infancy’
• ‘States’ become ‘traits’
The Brain Builds Itself
• Brain development takes more than just genes plus energy
• There is a time table for development of different neural systems guided by genes
• Neurons organize and stabilize themselves by processing information
Development of the Brain:Conception-20 years
Amygdala: online 3rd
trimester of pregnancy
Very rapid; all or nothing
activation of fight/flight/
freeze
In health: domesticated by attachment and representational
thinking
Anterior cingulate: online 2 months
Links attachment system to specific
attachment relationships
Internal working model is
template for all future
relationships
Right orbitofrontal cortex: online 10 months
Connects to, regulates amygdala, anterior
cingulate in 2nd year-adulthood
Slow, language-based, reflective
judgment of emotional
arousal
2-way feedback loops with amygdala, anterior cingulate
What is EPIGENETICS?Genes
encode
RNA builds
Proteins form
Organisms sense
Environments
influence
regul
Proteins, RNA
regulate
'Genes code for when the various components of the emotional
brain come on-line, but how each area develops depends on
the infant's epigenetically shaped emotional experiences with
his primary caregiver.'
Alan Schore, 2015
The epigenetics of attachment
Dangerous
Safe
BRAIN
Prepares for
anticipated world
Survive
the worst
condition;
shortened
lives
CHARACTERISTICS
“Brawn over
Brains”
Focused: Fight,
Flight or
Freeze
‘Live fast, Die
youngTOXIC
STRESS
Survive in
good times;
vulnerable
in poor
conditions
CHARACTERISTICS
”Process over
Power”
Multi-focused:
Relational
Reflective
Hardwired for Anticipated World
Dissonance
between biological
adaptation & social
expectations fuels
problems
Adapted from the research of Martin Teicher, MD,
Ph.D
BIRTH
The 5 ‘A’s of Neurobiology
• Ancestry
• Evolutionary, genetic, & cultural heritage
• Architecture
• The unfolding structure of the human brain
• Attachment:
• Forming healthy expectations that relationships are nurturing, validating, and safe
• Affect Regulation:
• Shaping global arousal and withdrawal into a complex spectrum of familiar and manageable emotions that guide behavior
• Adverse Experiences
• Experiences of fear and danger characterized by unrelieved arousal
Ancestry
• Primates are social animals that have long infantile dependency and live in groups
• Human mothers are the ONLY primates who allow others to hold and care for their infants
• It has ALWAYS taken ‘a village’ to raise a human child
Insights from primate studies
•Monkey infants who grow up in social groups with competent mothers have
• larger brains,
• better coping abilities,
• better reasoning skills
• Than do isolated infants or infants with highly stressed mothers
• Protect me
• Comfort me
• Delight in me
• Organize my
feelings
Circle of SecurityParent Attending to the Child’s Needs
I need
you to
Support My
Exploration
Welcome
My Coming
To You
I need you
to
• Watch over me
• Help me
• Enjoy with me
I need
you to
I need you
to
© 2000 - Cooper, Hoffman, Marvin & Powell
Epigenetics
Functions of Attachment Relationship
• Safety & protection
• Prewired arousal and signaling to maintain contact with caregivers
• Affect regulation
• Protection from fearful, pained arousal
• Global infant arousal gradually becomes discrete emotions
• Affect attunement
• Working model of relationship
The unthought known
Attachment strategies, including their defensive and conflicted
components, are examples of the non-conscious, implicit, or
procedural representations that are developed in infancy
before the explicit memory system associated with
consciously recalled images or symbols is available.
These are encoded in the brain, particularly by the right
anterior cingulate and ‘domesticate’ the amygdala.
Epigenetics
Affect regulation
• Caregiving interactions,
• adverse experiences,
• and neglect all influence the child’s developing brain and nervous system and how competently s/he can manage stress
The Nature of Nurture
Experience affects how genes are turned on and off. Experience with caregivers sculpts our
‘default’ Responses to
• Danger
• Novelty
• People
• Both positive and negative emotions
Impact of ACES on attachment security
• Shattering of developmental expectation of protection from the attachment figure
• The protector becomes the source of danger
• “Unresolvable fear”: Nowhere to turn for help
• Contradictory feelings toward the parent• Need for protection
• Need for comfort, soothing & regulation
• Fear
12
How the body keeps score
• Brain architecture
• HPA axis dysregulation
• Altered metabolism of neurotransmitters & hormones like dopamine, oxytocin, cortisol, norepinephrine
• Shallow breathing
• Hyper- or hypo-active responses to ‘stressors’
• Constricted> explosive emotional expression
• Difficulties with intimacy
• Shortened life expectancy
If you drove your car with both the accelerator and the brake pedal fully depressed at all times, how long would that car run?
Resilience, Recovery & Prevention
• ACEs cause irreversible changes in the brain, nervous system and endocrine system
•PREVENTION IS THE PRIMARY STRATEGY
!!!!!!!!!!!
Prevention strategies
• ‘It takes a village’• Policies and programs that ensure that children will be safe and cherished and
that parents have the support they need to be good parents• Housing• Food security• Employment opportunities and security• Spiritual and educational resources
• Programs that support parenting, for both ‘average’ and ‘high-risk’ families• New Family Services• Parents as Teachers• Nurse Family Partnership• P-CAP• Co-op nursery programs• Early Head Start
Baby.Link: A treatment and prevention programNurturing the Nurturers
• Weekly phone contact
• Transportation
• Child care
• Food
• Yoga & mindfulness
• Baby massage
• Instruction
• 117 moms & babies
• Age 15-42
• Average ACEs 6.7
• Attendance 77%
“Do unto others as you would have others do unto others”
Jeree Pawl
• EPDS* • Pre-(mean) • Standard
deviation
• Post (mean) • Standard
deviation
• All
mothers
• 15.31 • 4.90 • 9.51 • 4.50
• Pre
EPDS=>
10
(N=65)
• 16.23 • 4.05 • 9.80 • 4.27
• Pre
EPDS=>
13
• 17.56 • 3.52 • 10.40 • 4.12
Effectiveness of BabyLink Course
Pre & Post Edinburgh Postnatal
Depression Scale
Recovery
• All other strategies are only able to help people adapt to a disability. Some such strategies include
• Yoga therapy
• Meditation & DBT
• Family support programs (also preventive)
• ARC therapy (van der Kolk)
• BabyLink
CAPABILITIES ATTACHMENT & BELONGING
COMMUNITY, CULTURE,
SPIRITUALITY
Three Systems Promote Resilience
“Nurturing the healthy development of these
protective systems affords the most important
preparation or ‘inoculation’ for overcoming potential
threats and adversities in human development.
Similarly, damage or destruction of these systems has
dire consequences for the positive adaptive capacity of
individuals.”
Ann Masten, 2009
Resilience:“It’s not something you’re born with. It’s something that gets built over time.” Jack Shonkoff MD
• Family Protective Factors
• Nurturing parenting skills
• Stable family relationships
• Household rules and child monitoring
• Parental employment
• Adequate housing
• Access to health care and social services
• Community Protective Factors
• Communities that support parents and take responsibility for preventing abuse
• Churches, schools, afterschool programs, sports, bands and choruses, all offer protective skills and relationships to ACEs impacted individuals
• Caring adults outside the family who can serve as role models or mentors
PROTECTIVE FACTORS THAT BUILD RESILIENCE
NEAR@home Toolkit: a resource for
home visitors
• “Slowly, I have come to see that Asking, and Listening,
• and Accepting are a profound form of Doing” –
• Vincent J. Felitti, M.D.
PART 2: HOW TO TALK ABOUT NEAR
Leadership is knowledgeable about and committed to
bringing ACEs/NEAR into the program.
High quality, accurate education, coaching, and
support in ACEs/NEAR science provided for program
supervisors and home visitors so they can be safe and
effective in bringing ACEs/NEAR to families.
Home visitors are supported by reflective
supervision and agency policies on safety.
Community stakeholders and partners are
knowledgeable about and committed to supporting
ACEs/NEAR integration into programming.
CORE ELEMENTS OF A NEAR HOME VISIT
Preparing:Home visitors must have agency and community support:• Agency-wide ACEs, NEAR training• Reflective supervision• Healthy links to other services that also have NEAR
awareness like • law enforcement, • protective services, • medical services, • schools
CORE ELEMENTS OF A NEAR HOME VISIT
Preparing:The home visitor needs to feel calm and self-regulated, and able to be fully present with the client. If the home visitor is having a bad day, is not feeling well, or the home environment doesn’t feel safe, consider postponing the NEAR discussion. Consider balancing the day’s schedule so that some visits are likely to be lighter in content.
CORE ELEMENTS OF A NEAR HOME VISIT
Preparing:The home visitor’s state of mind is critical for a safe and respectful NEAR visit. People with a trauma history, whether ACEs or other trauma, will be very sensitive to a home visitor who is not fully present. As many home visitors themselves contend with significant ACEs history, they too are sensitive and may have unintentional emotional responses to the discussion if they are engaging in it while under personal stress.
CORE ELEMENTS OF A NEAR HOME VISIT
Preparing:The home visitor’s state of mind is critical for a safe and respectful NEAR visit. People with a trauma history, whether ACEs or other trauma, will be very sensitive to a home visitor who is not fully present. As many home visitors themselves contend with significant ACEs history, they too are sensitive and may have unintentional emotional responses to the discussion if they are engaging in it while under personal stress.
Home visitors build trust and model safety with
parents through the use of the ACEs/NEAR
framework :
• Educate about ACEs and associated health risks
• Offer the ACE questionnaire to all parents
• Focus on resilience while acknowledging trauma.
Home visitors communicate with respect and
curiosity:
“How have these childhood experiences affected you?”
”How have you done so well with safe discipline when
you have had such a difficult childhood?”
“How would you like your child’s life to be different?”
Ask, Listen, Affirm,
Remember
CORE ELEMENTS OF A NEAR HOME VISIT
Listening:Listening is the critical intervention! You honor his or her life story through your spacious listening.
Self-regulation and being fully present is vital at this moment. Home visitor responses such as chattering to fill the silence, flipping papers or changing the topic suggest a need for support and reflective supervision.
CORE ELEMENTS OF A NEAR HOME VISIT
Listening:
“Thank you for thinking about these difficult questions. I see you have had many of these difficult childhood experiences. How do you think these experiences have affected you?”
“Thank you for thinking about these difficult questions. Many of us who have had these experiences find we have to work harder at just about everything in life: staying healthy, quitting smoking, being a good mom.”
“As your baby grows we will keep talking about how brains work, how to manage stress. We will talk about things you can do to make sure your child has a lower ACE score”
Remembering:• WHAT:
• If during the NEAR home visit you didn’t respond to her in the way you wished you had, you can revisit it. It is better to repair than avoid talking about NEAR because you feel you don’t have the skills.
• WHY:
• Messing up presents a golden opportunity for repairing and strengthening the relationship. Acknowledge that everyone can mess up. This is an opportunity to model healthy relationships.
• CONSIDERATIONS:
• Even the most skilled, experienced home visitor will have an opportunity to practice repairing the interaction or relationship. Reflective supervision is a crucial support.
”In our last visit when we talked about your ACEs history, I wish I had given you more time to talk. I’m sorry I rushed you. Would you like to talk about it some more now?”
Parents have opportunity for a change moment: the experience
of feeling heard, understood, and accepted.
Parents know about the most powerful determinate of public
health.
Parents have a chance to talk about how ACEs have affected
their lives and to develop compassion for themselves in the
context of a safe and capable relationship.
Parents have the opportunity to identify and build on their
core gifts in terms of resilience – the ways they have managed to
navigate a life with ACE-related challenges.
Parents have Opportunity
Parents make decisions and are able to
take actions in their lives that protect
their children.
Parents engage with available
community and professional supports to
continue to develop parenting skills,
manage stress, and build health and
resilience.
Parents take steps to develop their
capacity to be more sensitive and
responsive to their child’s needs.
Children reach their full potential by
growing and developing in relationships that
are healthy and build resilience.
The next generation of children has lower
ACE scores than this parenting generation.
All ACE attributable problems are
concurrently reduced in the next generation.
Flourish
15 minute Role play
Groups of 3
1. Provider
2. Client
3. Observer
Provider: Adapt the Home Visitor model to your own professional setting
Client: Put yourself in the mindset of one of your more challenging clients
Observer: Notice what happens, what does and doesn’t work
After 10 minutes, discuss the role play within your 3-person group. Choose someone
to report briefly to whole audience
How brains develop
• Our brains become what our brains do when they are developing
• Organizing and stabilizing rich connections through exploring the world of objects and relationships
• Much of what a baby’s brain does is interface with the brains of caregivers
Wrapping up
How can you contribute to reducing the ‘hostile climate’ that makes
ACEs inevitable?