1. Toxic Stress, Trauma, and the Culture of Poverty Darcy Lowell, MD Founder and CEO, Child First, Inc. Associate Clinical Professor Yale University School of Medicine Melissa Mendez, LCSW Promising Starts Coordinator, Project LAUNCH Child First Clinical Supervisor New Britain

2. Overview of Session Toxic stress, ACEs, and early brain development The power of nurturing relationships The culture of poverty Early identification Effective social-emotional interventions CT AIMH: Training and Endorsement

3. 3 The Developing Brain 3

4. 4 Brain Development By 8 months of age, brain synapses have increased from 50 to 1000 trillion: 700 synapses/second The child’s early experiences actually build the architecture of the brain - EPIGENETICS By 3 years, 80% of brain growth is complete.

5. 5 But what happens in the face of ADVERSITY, when early experiences are threatening, unpredictable, neglectful, or abusive?

6. 6 TOXIC STRESS!

7. 7 Environmental Risks Extreme poverty Domestic and community violence Abuse and neglect Parental mental health issues, especially depression Substance abuse Homelessness Incarceration Teen and single parenthood Isolation and lack of social supports Lack of education and illiteracy Unemployment Health and dental issues Poor quality child care Lack of basic needs: food, clothing, heat, furniture 7

8. Adverse Childhood Experiences ACEs ABUSE Physical Emotional Sexual NEGLECT Physical Emotional HOUSEHOLD DYSFUNCTION Mental illness Domestic violence Substance abuse Incarceration Divorce

9. 9 Brain Research: Toxic Stress or ACEs Based 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

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11. 11 Biologic Effect of Profound Neglect This 11 year old girl is the size of a 4 year old. She has markedly reduced brain function and growth.

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

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

15. 15 Social-Emotional Problems by Number of Risk Factors % Children with Social-Emotional Problems 0 1 2 3 4 5 6+ Risks

16. 16 Power of Responsive Nurturing

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19. 19 Child Success Nurturing Relationships Social – Emotional Health Language & Cognitive Development Physical Health

20. Who are the families we want to reach?

21. 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…

22. Values, Beliefs, and Assumptions Values: How important something is. Beliefs: The ideas we accept as true. Assumptions: Ideas based on our past experiences.

23. 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

24. Families come to the work with their own values, beliefs, and assumptions Assumptions 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

25. “Hidden Rules” Among Class Groups PovertyMiddle ClassWealth MONEYTo be used, spentTo be managedTo be conserved, invested FOODQuantity: Is there enough? Quality: Did we like it? Presentation: Was it presented well? TIMEPresentFutureTraditions and history DESTINYFateChoiceNoblesse oblige MOTIVATIONSSurvival, relationships, entertainment Work, achievement Financial, political, social connections

26. “Hidden Rules” Video Clip http://www.youtube.com/watch?v=PYeWJlfu1ZA Hidden rules about discipline … Penance and forgiveness (pay a price/say you’re sorry) Change (what did you learn?)

27. Responding to Generational Poverty Emotional/Cognitive Mindset What is your tolerance level (1 (NO TOLERANCE) to 5 (HIGH TOLERANCE) ) for a spouse/partner who: 1) Repeatedly gives money to a relative who does not work? 2) Left bills unpaid to give money to a relative? 3) Quit job without having another because he/she didn’t like the boss? 4) Kept a low-paying position because he/she didn’t want to separate from close co-workers? 5) Allowed a relative or friend to stay move in for an undetermined amount of time?

28. 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 normChild 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”)

29. 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 services The relationship between the parent and the provider is the most potent predictor for success of the intervention.

30. 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.”

31. Historical Trauma for Families Living in Poverty “Historical trauma differs from other 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."

32. Early Identification

33. 33 Interaction between Brain Plasticity and Age

34. 34 Screening and Referral Identify children and families as early as possible Formal screening for risk and social-emotional concerns Identification by concerned providers and caregivers

35. Early Childhood Mental Health Early Identification Opportunities Pediatric Primary Care Center Obstetrics (depression and substance use) Early Care and Education / Schools DCF DSS Birth to Three Home visiting programs WIC Family Resource Centers

36. Pediatric Primary Care Center Pediatric Primary Care Center at Bridgeport Hospital 1300 children 47% + for emotional or behavioral concerns 62% + for environmental risk

37. Screening Measures Emotional/Behavioral Development: Brief Infant-Toddler Social-Emotional Assessment (BITSEA): under age 4 years Ages and Stages – Social-Emotional: 3 months to 6 years DECA – Infant/Toddler and Preschool Pediatric Symptom Checklist: over age 4 years Psychosocial Risk: Parent Questionnaire ACEs adult or child questionnaires (e.g., MIECHV DPH)

38. Parent Questionnaire: Scoring Example 1. I am worried about my child’s development…………... YES NO He/she is not learning as fast as I expected……………YES NO 2. I am worried about my child’s behavior………………….YES NO I am worried that my child is not happy …….…………YES NO 3. I am employed or in an education/training programYES NO My child’s other parent is employed or in an education/training program………………………………….YES NO I have completed high school or have a GED…………YES NO 4. I feel very worried, stressed or sad a lot of time………YES NO Sometimes I feel that life is just too hard to continueYES NO Any Yes = 1 3 Nos = 1 Any Yes = 1 *

39. Parent Questionnaire: Positive Screen 3 or more points Yes in any one of the “red flag” questions – with a star - is an automatic positive: * # 4 – depression * # 8 – domestic violence * # 10 – substance abuse Any clinical concern, regardless of number of points

40. Mental Health Services

41. 41 Ecological Approach within an Early Childhood System of Care Child: Health & Development Relationships Parental Challenges Community

42. 42 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

44. 44 Target Population: Children Prenatal to 6 years Any problem that threatens healthy development: Emotional/behavioral Developmental/learning Abuse and neglect Serve families with multiple children

45. 45 Target Population: Parents Parents/caregivers (birth parents, foster parents, relatives) with multiple challenges: Depression and other mental health problems Substance use Homelessness Domestic violence Child protective service involvement Poverty Fathers and caregiving partners included

46. 46 Overview of Child First Intervention Screening and community referrals Home-based intervention Engagement Comprehensive assessment Child and Family Plan of Care Targeted parent guidance and Child-Parent Psychotherapy Mental health classroom consultation Connection to community-based services 46

47. 47 Parent-Child Intervention Intervention: Relationship-based, Trauma-informed Child-Parent Psychotherapy (CPP) Focus on the meaning of the child’s behavior Parent guidance Developmental lens Promote executive functioning 47

48. 48 Services and Supports Primary or specialty pediatric care Early care and education Birth to Three Special education Child mental health Parenting groups Family Resource Centers Parent mentors and aides Adult mental health Substance abuse treatment Adult health care Legal aide Domestic violence services Transportation Housing / shelters Job training Computer training Food stamps Food banks HUSKY GED Literacy ESL WIC TANF SSI CSHCN Clothing and furniture 48

49. 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.

50. Other CT Service Models Child-Parent Psychotherapy – agency-based Circle of Security parenting groups Family-Based Recovery Minding the Baby Early Childhood Consultation Partnership Triple P Parent-Child Interaction Therapy

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

52. 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®

53. 53 Thank you!

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