Babies Remember and Babies Cant Wait Translating Research

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

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) © Alicia F. Lieberman, Ph. D.

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

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.

A Continuum From Stress To Trauma And Secondary Adversities Normative, Developmentally Emotionally Appropriate Costly Stress © Alicia F. Lieberman, Ph. D. Traumatic Stress

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

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.

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 © Alicia F. Lieberman, Ph. D. (Gentry, 2004; UNICEF, 2003; Children’s Bureau, 2003)

© Alicia F. Lieberman, Ph. D.

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; Mc. Closkey, 1995) © Alicia F. Lieberman, Ph. D.

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) © Alicia F. Lieberman, Ph. D.

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

Adverse Childhood Events And Adult Substance Abuse % % Self-Report: Alcoholism Dube et al, 2002 Self-Report: Illicit Drug Use Dube et al, 2005

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

From acestudy. org

National Comorbidity Survey Replication • The National Comorbidity Survey Replication (NCS-R) sample was collected in 2001 -2003 (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) Ohio. Can. Do 4 Kids. Org

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 Ohio. Can. Do 4 Kids. Org

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 NCS-R All Respondents Cell Mean Number of DSM Lifetime Diagnoses 7 6 Overall Sample 5 4 3 CR score mean se n 0 1. 35 0. 057 2806 1 1. 92 0. 09 1598 2 3. 07 0. 18 669 3 4. 09 0. 236 365 4+ 6. 29 0. 3 252 2 1 0 0 1 2 3 4+ Ohio. Can. Do 4 Kids. Org

Childhood Sexual Abuse Alone Significantly Increases Risk for a Range of Psychiatric Disorders in Males ADD Agoraphobia Conduct Disorder Drug Abuse Dysthymia Major Depressive Episode Mania Nicotine Dependence Panic Disorder PTSD 0 1 2 3 4 5 6 7 8 9 10 11 12 Odds Ratio Ohio. Can. Do 4 Kids. Org

Childhood Sexual Abuse Alone Significantly Increases Risk for a Range of Psychiatric Disorders in Females ADD Alcohol Dependence Bipolar I Drug Abuse Intermittent Explosive Disorder Major Depressive Episode Mania Nicotine Dependence Oppositional Defiant Disorder PTSD 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Odds Ratio Ohio. Can. Do 4 Kids. Org

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 Ohio. Can. Do 4 Kids. Org

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)

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%

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)

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)

Cumulative Stressors And Psychiatric Disorders Egger, 2004

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 (Oser & Cohen, 2003; Flores et al. , 2002; U. S. Surgeon General’s Report, 2001 )

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)

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)

The Body Remembers (As cited by Felitti & Anda, 2003; Source CDC)

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) © Alicia F. Lieberman, Ph. D.

Early Social Consequences Of Aggression • Gilliam (2005): Pre-K students expelled at a rate 3 x higher than K-12 peers (6. 67 v. 2. 09)

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

Cross-System Collaboration: Prevention, Intervention, Treatment

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

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)

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.

Parent As Protective Shield

Nurse Family Partnership National Outcomes Reductions in: • Child abuse & neglect 79% • Emergency room visits 56% • Maternal substance abuse 44% • Maternal arrests 69% • Subsequent pregnancies 32% Increase in work engagement: 83% Reductions in: • Child arrests • Child convictions 56% 81%

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

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.

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.

Child-Parent Psychotherapy Intervention Modalities 1. Promote development: Play, language, touch 2. Unstructured/reflective developmental guidance 3. Modeling protective behaviors 4. Interpretation: linking past and present 5. Emotional support 6. Concrete assistance, case management, crisis intervention © Alicia F. Lieberman, Ph. D.

Early Trauma Treatment • Participants: 75 3 -5 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)

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)

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

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

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)

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) © Alicia F. Lieberman, Ph. D.

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.

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)

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

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)