Transcript Babies Remember and Babies Can’t Wait: Translating

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.
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
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:0-3R, 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; McCloskey, 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.
Adverse Childhood Events
And Adult Depression
5
Odds Ratio
4.5
4
3.5
0
1
2
3
4
5+
3
2.5
2
1.5
1
0.5
0
Adverse Events
Chapman et al, 2004
Adverse Childhood
Events And Adult
Substance Abuse
0
1
2
3
0
4+
2
3
4
5+
40
16
%
1
%
14
35
30
12
25
10
20
8
15
6
10
4
5
2
0
0
Self-Report: Alcoholism
Dube et al, 2002
Self-Report: Illicit Drug Use
Dube et al, 2005
Adverse Childhood Events
And Adult Ischemic Heart
Disease
3.5
Odds Ratio
3
0
1
2
3
4
5,6
7,8
2.5
2
1.5
1
0.5
0
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)
OhioCanDo4Kids.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
OhioCanDo4Kids.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
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
5
4
3
2
1
0
0
1
2
3
4+
OhioCanDo4Kids.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
DSM Lifetime Diagnoses
OR
95% CI
ADD
3.8
2.0-7.1
Agoraphobia
3.6
1.5-9.1
Conduct Disorder
2.7
1.4-5.0
Drug Abuse
3.3
1.8-6.0
Dysthymia
5.4
2.6-11.2
Major Depressive Episode
2.6
1.5-4.6
Mania
3.5
1.8-6.9
Nicotine Dependence
2.2
1.1-4.4
Panic Disorder
3.6
1.8-7.2
PTSD
4.3
2.0-9.5
12
Odds Ratio
OhioCanDo4Kids.Org
Childhood Sexual Abuse Alone Significantly Increases Risk
for a Range of Psychiatric Disorders in Females
ADD
Alcohol Dependence
Bipolar I
Drug Abuse
DSM Lifetime Diagnoses
OR
95% CI
ADD
2.5
1.7-3.9
Alcohol Dependence
4.7
3-7.3
Bipolar I
6.6
3.4-13
Drug Abuse
5.2
3.8-7.1
Intermittent Explosive Disorder
3.1
2.3-4
Major Depressive Episode
2.4
1.9-3
Mania
3.6
2.3-5.5
Nicotine Dependence
2.6
1.6-4.3
Oppositional Defiant Disorder
4.1
2.3-7.1
PTSD
4.8
3.4-6.8
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
OhioCanDo4Kids.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
OhioCanDo4Kids.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)
% with a DSM-IV disorder
Cumulative Stressors And
Psychiatric Disorders
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Low mag
High mag
1
2
3
4
5
6 or
more
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
30
25
20
Private
State
K-12
15
10
5
0
Expulsion
• Gilliam (2005): Pre-K students expelled
at a rate 3x 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
50
45
40
35
Child/Parent
Psychotherap
y
Comparison
30
25
20
15
10
5
0
Intake
Completion
(Lieberman, Van Horn & Ippen, 2005)
Percentage of Mothers
Diagnosed with PTSD
50
45
40
35
Child/Parent
Psychotherap
y
Comparison
30
25
20
15
10
5
0
Intake
Completion
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)