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Babies Remember and Babies Can’t Wait: Translating Research Into Public Policy For Young Children and Families Alicia F. Lieberman, PhD Irving B. Harris.

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Presentation on theme: "Babies Remember and Babies Can’t Wait: Translating Research Into Public Policy For Young Children and Families Alicia F. Lieberman, PhD Irving B. Harris."— Presentation transcript:

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

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)


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