Infant mental health strategies in areas of conflict

The Power of Early Childhood Development Services in Conflict and Post-Conflict Environments Belfast, February 5, 2013 Joshua D Feder, MD Director of Research, Graduate School Interdisciplinary Council on Developmental and Learning Disorders jdfeder@mac.com

Thank You
• Early Years: Joanna, Siobahn • ICDL: Stuart Shanker • You

Outline
• Context: Settings, system levels, research and theory • Strategies: trauma focused therapy, a parentchild approach, and the DIR model • 2 Brief case vignettes • Discussion

A Shared Burden
• • • • We have all been impacted by trauma And we have learned to respect our diversity So we can learn from each other Because it is the way forward

Conflict and Post-Conflict Settings
• Stress reactions; Post-traumatic stress disorder; Chronic stress reactions: startle, avoidance, regression (tantrums), dissociation, etc. • Also depression, later substance problems, aggression, vulnerability to abuse, etc. • Body issues: injury, effects of chronic stress, sleep deprivation, etc. • Ongoing poverty, danger, hunger, disease • Effect of setting and symptoms on education, friendships, family

System Levels for Strategies
• Child – trauma treatment; building resilience, tolerance, assertiveness • Caregiver/Child - supporting caregivers (parents, teachers, others) to help children with stress and trauma and build resilience • Community – policies and institutions that build a resilient community that can secure better safety while hearing all voices

Epigenetic research on severe neurobehavioral effects of trauma on the developing child ‘Mice and Men’
• Epigenetic: how we nurture our offspring changes how their genetic plan unfolds, affecting their capacity for resilience. • Traumatic experiences cause methylation of genes and the long lasting high levels of adrenaline (vigilance) we find in these children, which makes them less able to think and adapt (Szyf, Bick 2013). • Prairie voles: licking in infancy increases oxytocin, and leads to better stress tolerance, and nurturing behavior in the next generation. Hugging and holding in humans increases oxytocin and social bonding behaviors.

Epigenetic Theories of severe neurobehavioral effects of trauma on the developing child ‘Men’

• Chronic stress and traumatic experience affects prefrontal cortex: child develops less of the necessary implicit sense of ‘me’, ‘you’, and ‘we’ required for resilience and problem solving (Dan Siegel). • Not enough ‘taking in’ of parent-child relationship that helps the child turn raw experiences into adaptive responses (Bion, Brown).

(Re)building resilience
• Child: Trauma focused therapies • Caregiver/ Child: Tronick and messy interactions • Child, Caregiver/Child, Community: multilevel regulation, engagement, and reciprocity with the DIR Model

Trauma Focused Therapies
• Relaxation and regulation strategies • Playing, drawing, talking – developing a trauma story • Sharing the trauma story with parents • Explaining why it happened in a way that leads to adaptive responses • Can be very helpful, but requires symbolic capacity – this is not always present

Tronick: messy interactions
• Starting in infancy there is a natural, ‘messy’ process of break and repair of communication • Happens in all communication between people. • There is a break, then there is repair, over and over • This helps create sense of self separate from parent • And builds confidence and faith in the ability to repair breaks in engagement, i.e., resilience • Resilience brings ability to manage stress, to work with diversity, and to be assertive vs. vulnerable, withdrawn, and / or reactively aggressive

The DIR Model :
Developmental – Individual Differences – Relationship based approach

Greenspan, Wieder, et. al.

• D: From co-regulation to engagement, creating a flow of back and forth interaction. • I: Taking into account the specific abilities and challenges of both child and caregiver • R: Supports caregivers, i.e., parents, teachers, and others, to build warm relationships with children that support effective relating, communicating, and problem solving.

The DIR Model and Trauma
• Developed in work with high risk families • Helps lessen problems of vigilance (including startle) startle, avoidance, regression (tantrums), and dissociation by supporting co-regulation and engagement • Builds internal (me) and shared (we) abilities to manage emotions and memories • Makes it possible to build new ideas for being in the world (symbolic ability), i.e., resilience, stress tolerance, social problem solving

Parallel Reflective Process
• From clinician to caregiver (parent, teacher) parent and from caregiver to child • Creates a safe, helping setting so that the parent/ teacher can help the child • Clinician does not tell caregiver what to do but helps the caregiver come up with ideas to try with the child. • Lots of tries and re-tries of ideas builds faith in the caregiver of her ability to help the child. • And then caregiver helps the child to come up with ideas, building the child’s ability and faith in his ability to solve problems (resilience).

DIR and Global Interdependency: a developmental approach to conflict resolution
Shanker and Greenspan

Expands parallel reflective process to a global level: • Support safety – promotes better regulation • Recognize our shared humanity – promotes true engagement with each other • Presymbolic: Manage raw emotions, e.g., dependency, fear, assertive, aggression • Symbolic: Patiently persist in efforts to communicate and problem solve and in building reflective institutions like this conference • Leads us from polarized thinking toward interdependency.

Case Studies

• 1 - A Traumatized Mexican-American girl struggles to develop amidst chronic stress • 2 - From Community Conflict to Adaptive Collaboration in Early Intervention: The BRIDGE Collaborative

A Traumatized girl struggles to recover
• Conflict: Family escaping Mexican drug wars with kidnappings, mass killings, economic upheavals. Transit to the US is blocked by fences, drones, deserts, ‘coyotes’, etc. • Post-Conflict: Born shortly after parents’ come to US; attachment blocked by stress: new culture and language, little money to live on, dad distant and long working, mom impulsive, anxious and angry. • Child is bright, talented, but has signs of chronic stress, including startle, tantrums, social avoidance, depression

Treatment
• First another doctor tried lithium. She never had therapy. • I did individual therapy and parent coaching in a DIR model; able to see them up to three times per week – very important • Medication is helping, but not to replace therapy, including fluoxetine, topirimate, gabapentin, dextroamphetamine, aripiprazole • Medical / Sensory-OT found physical problems, led to trials of beta blockers

Outcome so far: regulation, engagement, then symbolic function
• Parents more able to support co-regulation, a little less angry with her. • Child more regulated and engaged with me in therapy, more able to control her self at home • For many months she was more social with me, with parents, and then with peers • Sadly, more social time with peers led to sexual assault by a peer and worse symptoms: upset, hopeless, helpless, depressed • But in therapy she can work with trauma (intersubjective to symbolic) and to some extent some with parents

Health System Case Study From Conflict to Collaboration in Early Intervention: The BRIDGE Collaborative
• Child with aggression, poor attachment and communication, danger, e.g., running off in parking lots. Neither tolerant, resilient nor assertive. • Dominant behaviorist culture discriminates against developmental, social-communication and other approaches, e.g., comparing them to electric shock, blocking research money, etc. • Anti- Evidence Based Practice: dictating treatment using narrow research, does not allow clinical judgment to guide informed consent by parents. • Did this cause failed treatments? Failure to protect? Deaths? Not hearing parents’ worries: case of parent killing child who was not getting better fast enough.

BRIDGE Strategies:
Bond, Regulate, Interact, Develop, Guide, Engage
• Goal: develop better Evidence Based Practice treatment for children at risk for these problems • Diverse group of clinicians, researchers, funding agencies, parents, mediators from the community • Regular reflective meetings, with food. • Long, close look at many treatment options. • Community presentations and focus groups. • Mediated pick of a ‘winner’. Process of acceptance. • Close group, able to build an approach that better fits what the community needs and wants.

BRIDGE Outcomes:
• Clinical: multiple clinics in pilot, now expanding to other clinics and regions • Research: Community Based Participatory Research (CBPR), grant funding • Training: writing treatment manual, expanding training, conference presentations • Continued reflective parallel process at many system levels supports commitment and sustainability.

The Fault in Our Stars
Green

• Cancer in teens with bad luck: genetically diversified to suffer and have a high death rate while young. • But they meet in a weekly group, build relationships, make music and poetry - truly engaged in life. • Maslow: ‘this can’t happen’ – stress from pain and fear cannot allow higher thought. • But reflective group brings regulation, engagement and supports thinking, relating, and living. • We can be reflective at this conference, joining together to build solutions that will help our children and our future.

Possible Discussion Topics
• Experiences in helping children • Supporting caregiver – child relationships • Addressing community conflict

My experience with Conflict and Post-Conflict Settings, Trauma, and Problem Solving:
• • • • Family history of loss in genocidal actions, Mielec, Poland 1941. Childhood head injury in sectarian attack in rural US 1968. Medical School: Boston City Hospital cases of abuse and neglect in racially troubled and poverty stricken area; US Navy: treating people with PTSD; developed training for supporting children of military members; therapy with high risk teen mothers with drug addiction and their babies; Family Advocacy service investigating abuse allegations in families; HQ child sexual abuse team Scholarly work: reviewer for Child Maltreatment San Diego: US/ Mexican border issues; abuse and trauma in context of general psychiatric and autism and other developmental disorders with forensic work specific to assessment of trauma in persons with developmental challenges. Familiarity with successful efforts at building cooperation: JITLI, Save A Child’s Heart, Medved’s VC efforts, Health Care outreach to PA with reduced infant mortality.

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