1. Babies Remember and Babies Can’t Wait: Translating Research Into Public Policy For Young Children and Families
Alicia F. Lieberman, PhD
Irving B. Harris Chair of Infant Mental Health
University of California San Francisco
© Alicia F. Lieberman, Ph.D.

2. An Ecological-Transactional Model of Development
“Development Lasts A Lifetime”
Protective & Risk Factors
“Allostatic load”
Macrosystem: Cultural practices
Exosystem: Neighborhood & community
Microsystem: Family inter-relationships
Ontogenetic development: The Individual
(Bronfenbrenner, 1979; Cicchetti & Lynch,1993; Sameroff, 1993; Rutter,2000)
Bronfenbrenner
Ortega y Gasset: "Yo soy yo y mi circunstancia"
Parents cannot protect their children unless they have access to the resources implicit in the social contract:
-- adequate housing
--safe neighbhorhoods
--schooling
--health care
© Alicia F. Lieberman, Ph.D.

3. What Is Mental Health? to love well and to work well” (Sigmund Freud)
“The capacity
to love well and to work well”
(Sigmund Freud)
© Alicia F. Lieberman, Ph.D.

4. What Is Infant Mental Health?
The capacity to grow well and to love well
Experience, express and regulate emotions & recover from dysregulation
Establish trusting relationships & repair conflict
Explore and learn
Within the society’s cultural values
(Lieberman; Zero to Three)
© Alicia F. Lieberman, Ph.D.

5. Normative, Developmentally Appropriate Stress
A Continuum
From Stress To Trauma And
Secondary Adversities
Normative, Developmentally Appropriate Stress
Emotionally Costly Stress
Traumatic Stress
Normative, developmentally appropriate stress:
The unavoidable challenges of coping with internal discomfort (hunger, cold, temporary illness) and external strains (birth of a sibling, mother returning to work, starting childcare). May promote psychological growth by stretching one's coping skills
Emotionally costly stress: Stresses that overtax age-appropriate coping resources and promote rigid self-protective patterns: chronic marital conflict, chronic parental rejection, a frightening single event that increases the threshold for generalized fear responses
Traumatic stress: Collapse of coping mechanisms
© Alicia F. Lieberman, Ph.D.

6. Defining Trauma (DC:0-3R, 2004; Freud, 1926; Pynoos et al., 1999)
A traumatic event overwhelms the
capacity to cope
Threatens physical or psychological integrity
Key features of trauma:
Unpredictability
Horror
Helplessness
(DC:0-3R, 2004; Freud, 1926; Pynoos et al., 1999)
© Alicia F. Lieberman, Ph.D.

7. Frequent Traumatic Stressors In Childhood
Exposure to violence
Child Abuse
Domestic Violence
Community Violence
Accidents
Car crashes
Near drownings
Dog bites
Burns
© Alicia F. Lieberman, Ph.D.

8. Violence As Paradigm of Childhood Trauma
More children die from abuse in their first year of life than
at any other time
Half of child abuse victims are under age 7
85% of abuse fatalities are under age 6
U. S. ranks THIRD among 27 industrialized countries in child maltreatment deaths
(Gentry, 2004; UNICEF, 2003; Children’s Bureau, 2003)
© Alicia F. Lieberman, Ph.D.

9. © Alicia F. Lieberman, Ph.D.

10. Sources of Violence Overlap
Children exposed to domestic violence
15 times more likely to be abused than the national average
30-70% overlap with child abuse
At serious risk of sexual abuse
Battered women
Twice more likely to abuse their children than comparison groups
(Osofsky, 2003; Edleson, 1999; Margolin & Gordis, 2000; McCloskey, 1995)
© Alicia F. Lieberman, Ph.D.

11. Adverse Childhood Experiences Last A Lifetime
Emotional, physical or sexual abuse
Domestic violence against the mother
Household member with mental illness
Household member with substance abuse
Household member ever imprisoned
Absence of one or both parents
Physical or emotional neglect
Predict the 10 leading causes of adult death/disability
(ACE Study, Felitti et al. 1998)
Kaiser-Permanente Study with a sample of about 18,000 participants:
Leading causes of death and disability:
heart disease
cancer
chronic lung disease
fractures
substance abuse
sexually reckless behavior
© Alicia F. Lieberman, Ph.D.

12. Adverse Childhood Events And Adult Depression
Odds Ratio
Adverse Events
Chapman et al, 2004

13. Adverse Childhood Events And Adult Substance Abuse% %
Self-Report: Alcoholism Self-Report: Illicit Drug Use
Dube et al, Dube et al, 2005

14. Adverse Childhood Events And Adult Ischemic Heart Disease
Odds Ratio
Adverse Events
Dong et al, 2004

15. From acestudy.org

16. National Comorbidity Survey Replication
The National Comorbidity Survey Replication (NCS-R) sample was collected in (N= 5692, response rate = 70.9%)
Face-to-face structured diagnostic interview for 26 DSM Axis I disorders
The weighted sample is representative of U.S. population on census indicators (age, gender, race, education, marital status, region)
OhioCanDo4Kids.Org

17. Cumulative Risk Scores
The NCS-R inquired about adverse childhood antecedents occurring ≤18 years including: 1) sexual abuse, 2) physical abuse, 3) parental depression, 4) parental substance abuse, 5) being a crime victim, 6) loss of a parent and 7) exposure to domestic violence
For each subject, a Cumulative Risk Score (CRS) was calculated by adding the number of positive childhood antecedents that happened ‘most’ or ‘all’ of the time.
An “ACE-type” analysis was performed comparing the number of lifetime DSM diagnoses for CRS = 0, 1, 2, 3, and ≥ 4 or more childhood antecedents
OhioCanDo4Kids.Org

18. Childhood Adversity is Cumulative
Individuals with CRS ≥ 4 average 6.29 (± 0.3) DSM Axis I Diagnoses
Mean Number of DSM diagnoses by Cumulative Risk Score
252
0.3
6.29 4+
365
0.236
4.09 3
669
0.18
3.07 2
1598
0.09
1.92 1
2806
0.057
1.35 n se
mean
CR score
Overall Sample 4 5 6 7
Cell Mean Number of DSM Lifetime Diagnoses
NCS-R All Respondents
OhioCanDo4Kids.Org

19. Childhood Sexual Abuse Alone Significantly Increases Risk for a Range of Psychiatric Disorders in Males 1 2 3 4 5 6 7 8 9 10 11 12
PTSD
Panic Disorder
Nicotine Dependence
Mania
Major Depressive Episode
Dysthymia
Drug Abuse
Conduct Disorder
Agoraphobia
ADD
Odds Ratio
OhioCanDo4Kids.Org

20. Childhood Sexual Abuse Alone Significantly Increases Risk
for a Range of Psychiatric Disorders in Females 1 2 3 4 5 6 7 8 9 10 11 12 13 14
PTSD
Oppositional Defiant Disorder
Nicotine Dependence
Mania
Major Depressive Episode
Intermittent Explosive Disorder
Drug Abuse
Bipolar I
Alcohol Dependence
ADD
Odds Ratio
OhioCanDo4Kids.Org

21. Conclusions From NCSR Data
Increasing Childhood Risk Scores (CRS) are associated with an increased number of DSM diagnoses on structured interview in a nationally representative sample
Individuals with CRS ≥ 4 average more than 6 DSM diagnoses
Diagnoses in individuals with a high CRS cross multiple DSM diagnostic categories
OhioCanDo4Kids.Org

22. Infant Mental Health Disorders
Increasing awareness that young children
can have emotional problems
Two diagnostic classifications provide a basis for studies of construct validity
Research Diagnostic Criteria (2003)
DC: 0-3-Revised (2005)

23. Prevalence of Psychiatric Diagnosis In Toddlers and Preschoolers
2-5 year olds recruited from pediatric
public health clinic
(Egger, 2004)
Durham Pediatric Sample
n=307
Any emotional disorder
10.6%
Any behavioral disorder
11.3%
Any disorder
17.4%

24. Prevalence Of High Magnitude Events
Death of loved adult: 20.9%
Grandparent: 10.8%
Aunt/uncle: 3.7%
Other loved adult: 6.2%
Parent: 0.2%
Child hospitalized: 16.4%
Motor vehicle accident: 9.9%
Serious fall: 9.5%
Burned: 7.9%
(Egger, 2004)

25. Stressors Happen To Young Children
52.5% experienced at least one major stressor
No gender or race differences
Preschoolers more likely to experience a
major stressor, but 42% of 2-year olds had
experienced at least one such event
(Egger, 2004)

26. Cumulative Stressors And Psychiatric Disorders
Egger, 2004

27. Childhood Adversity And Minority Status
Minority children are more likely to be poor
Traumatic events cluster when there is poverty
The impact of traumatic events is cumulative
Minority children are more vulnerable to a traumatic event due to cumulative effect of adversities and less access to services
Childhood poverty and trauma disproportionately impact minority infants and toddlers, with repercussions on their readiness to learn and their long-term productivity.
(Oser & Cohen, 2003; Flores et al., 2002;
U.S. Surgeon General’s Report, 2001 )

28. When Systems Compound Adversity: Child Welfare and Foster Care
No race differences in abuse and neglect reports
Children of color are:
more often placed in out of home care
subjected to more placement changes
kept longer in foster care
less likely to be reunified with parents
(Casey Family Programs Child Welfare Fact Sheet, 2005)
In addition, when you take into account systems such as child welfare and foster care, you see an even greater impact on minority children.
African American children are 4xs more likely to be placed out of home. Alaskan natives and Native Americans are 3xs more likely and Latino children are twice as likely to be placed out of home as white children for comparable maltreatment reports.

29. The Forgotten Mental Health Needs of Children in Child Welfare
About half of these children have a diagnosed mental health need
75% of diagnosed children did not receive mental health treatment within 12 months of a child abuse or neglect investigation
Children of color are disproportionally affected
(Pre-publication Copy: Improving the Quality of Health Care for Mental and Substance-Use Conditions, Institute of Medicine, 2006)

30. The Body Remembers (As cited by Felitti & Anda, 2003; Source CDC)
Stress and the Brain – PET Studies:
Constant stress affects early brain development
Studies of abused children show:
smaller brain volume,
larger fluid-filled cavities
smaller areas of connection
Severity of findings correlated with duration of trauma
These effects must be understood in context of brain plasticity and capacity to grow when there is a sense of protection and hope. There are no long-term longitudinal brain studies of traumatized children in a variety of life circumstances, so while we must be sobered by the impact of trauma on brain functioning we must also remember that we are in the infancy of our understanding of the long-term repercussions of trauma and that the findings should be an impetus to corrective action towards prevention and treatment rather than a pretext for despair
(As cited by Felitti & Anda, 2003; Source CDC)

31. Traumatic Stress In Infants And Young Children
Re-experiencing trauma (flashbacks, nightmares)
Numbing (social withdrawal, play constriction)
Increased arousal (attention problems, hypervigilance)
New Symptoms
Aggression
Sexualized behavior
New fears
Loss of developmental milestones
(Regression)
Trauma causes suffering and derails development in the present.
Example: 3.6 year old Jarred, who witnessed severe DV
-- woke up screaming "no, stop!"
-- aggressive with peers. In child care, when asked by th.
why he tensed his muscles when child passed by, said:
"He wants to hit me": Misattributions of aggression
-- separation anxiety: "you don't love me"
-- Hitting himself when he could not answer a question during test: "I don't like myself"
Finding by Walter Gilliam that 3-4 year olds have a much higher expulsion rate from preschool that ch. in K-12:
Hidden role of exposure to traumatic events?
© Alicia F. Lieberman, Ph.D.

32. Early Social Consequences Of Aggression
Gilliam (2005): Pre-K students expelled at a rate 3x higher than K-12 peers (6.67 v. 2.09)

33. A Continuum of Services
Normative Stress
Costly Stress
Traumatic Stress
Prevention
Intervention
Treatment
© Alicia F. Lieberman, Ph.D.

34. Cross-System Collaboration: Prevention, Intervention, Treatment

35. Quality Of Early Child Care
NICHD 10-site prospective, longitudinal study
N= 1364 newborns from infancy through school age
Impact of variations in early child care experiences
Smaller group sizes
Lower child-adult ratios
Skilled, warm, responsive caregivers
Safe, clean, stimulating physical environments
Fewer than 50% of centers met NAEYC standards
20% failed to meet any of the standards for infants
On average, 8% of centers are accredited across U.S.

36. Childcare Quality Matters
Quality of care was most important predictor of
-- Peer relations
-- Attention span
-- Memory skills
-- Vocabulary
Quality of parent-child relationship quality a better predictor than child care variables
(NICHD Study of Early Child Care)

37. Goal of Early Intervention: Creating Angels In The Nursery
Benevolent experiences also last a lifetime
Re-creating relationships, recreating the self
The intervenor as agent of hope
Life as “chiaroscuro”:
Interplay of light and darkness
© Alicia F. Lieberman, Ph.D.

38. Parent As Protective Shield

39. Nurse Family Partnership National Outcomes
Reductions in:
Child abuse & neglect %
Emergency room visits %
Maternal substance abuse 44%
Maternal arrests %
Subsequent pregnancies %
Increase in work engagement: 83%
Child arrests %
Child convictions %

40. Treatment Goals: Safety In The Relationship Safety In The Sense of Self

41. Therapeutic Objectives
Affect Regulation
Normalization of traumatic response
Trust in bodily sensations
Reciprocity in relationships
Differentiate remembering and reliving
Engagement in learning
© Alicia F. Lieberman, Ph.D.

42. Individualizing Treatment: Theoretical Integrations
Developmentally Informed
Attachment focus
Trauma-based
Psychoanalytic theory
Social Learning processes
Cognitive–Behavioral strategies
Culturally attuned
(Lieberman & Van Horn, 2005)
© Alicia F. Lieberman, Ph.D.

43. Child-Parent Psychotherapy Intervention Modalities
Promote development: Play, language, touch
Unstructured/reflective developmental guidance
Modeling protective behaviors
Interpretation: linking past and present
Emotional support
Concrete assistance, case management, crisis intervention
© Alicia F. Lieberman, Ph.D.

44. Early Trauma Treatment
Participants: year old children and their mothers
Location: San Francisco
Randomized controlled trial
Child Parent Psychotherapy
Weekly x 50 weeks (mean sessions = 32)
Case management and community treatment
73% of mothers and 55% of children received psychotherapy
(Lieberman, Van Horn & Ippen, 2005)

45. Early Trauma Treatment
Findings
Children
Reduced number of posttraumatic symptoms in CPP but not controls
Reduced number of behavior problems in CPP but not controls
Mothers
Reduced number of posttraumatic symptoms for CPP and controls
Reduced mothers’ distress for CPP but not controls
(Lieberman, Van Horn & Ippen, 2005)

46. Percentage of Children Diagnosed with PTSD
(Lieberman, Van Horn & Ippen, 2005)

47. Percentage of Mothers Diagnosed with PTSD
Lieberman, Van Horn & Ippen, 2005

48. Empirical Support For Relationship-Based Treatment
Five randomized studies with about 500 children and mothers
Infants, toddlers, preschoolers
Anxious attachment, child maltreatment,
maternal depression, domestic violence
Range of SES, multicultural samples
Consistent findings of CPP efficacy
Measures: Cognitive performance, quality of attachment, quality of child-mother relationship, mental representations, maternal and child diagnoses
(Lieberman et al., 1991; Cicchetti et al., 1999, 2000; Toth et al., 2002; Toth et al., 2006; Lieberman et al., 2005, 2006)

49. Treatment Is Not Enough: Ecology Matters
Protective & Risk Factors
“Allostatic load”
Macrosystem: cultural practices
Exosystem:neighborhood & community
Microsystem: family inter-relationships
Ontogenetic development: individual adaptation
(Bronfenbrenner, 1979; Cicchetti & Lynch,1993; Sameroff, 1993; Rutter,2000)
Bronfenbrenner
Ortega y Gasset: "Yo soy yo y mi circunstancia"
Parents cannot protect their children unless they have access to the resources implicit in the social contract:
-- adequate housing
--safe neighbhorhoods
--schooling
--health care
© Alicia F. Lieberman, Ph.D.

50. Trauma As A Supra-Clinical Phenomenon
“This ecological-transactional approach, although long recommended, is seldom implemented. …child trauma is seen only as a clinical phenomenon… This narrow focus must be super-ceded by the ubiquity of trauma as the frequent cause of physical and mental illness, school underachievement and failure, substance abuse, maltreatment, and criminal behavior… we are dealing with a supra-clinical problem that can only be resolved by going beyond the child’s individual clinical needs to enlist a range of coordinated services for the child and the family.”
(Harris, Lieberman & Marans, 2007)
© Alicia F. Lieberman, Ph.D.

51. A Compelling Conclusion
“The overarching question of whether we can intervene successfully in young children’s lives has been answered in the affirmative and should be put to rest.”
“However, interventions that work are rarely simple, inexpensive, or easy to implement”.
(From Neurons to Neighborhoods, 2000)

52. What Can We Do? Promote family-friendly policies
- child safety net, family leave, childcare
Early intervention: “Pre-K, starting at birth for those who need it”*
Promote inter-system coordination:
- early identification and referral
Fund training to build and preserve capacity
- primary care providers
- childcare providers
- infant mental health providers
- child protection workers
(*Sam Meisels, 2006)
Building bridges: Programs that take into account parents and children’s needs
Simultaneously – currently adults are treated in isolation from their children’s needs and their roles as parents
Evidence that CPP improves mothers’ mental health as well as children’s mental health
Examples of community-based treatment: Pynoos offers services in schools; AFL offers services in
childcare settings, the home, DV shelter, and Family Resource Centers
Safe Start as example of inter-system coordination and referral for children under 6 exposed to
Violence: childcare providers, mental health providers, Family Resource Centers, grassroots organizations, police, child welfare system,
the courts

53. Translating Research Into Public Policy
Three examples:
National Child Traumatic Stress Network
(NCTSN): Raising the standard of care
(SAMHSA)
Safe Start Initiative: Creating models of
community collaboration (OJJDP)
Court Team: Judicial system-Early Intervention partnership (OJJDP)