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?