What is neglect; a medical perspective and the neurobiological model

1. What is neglect; a medical perspective and the neurobiological model Jo Tully VFPMS April 2017

3. Neglect can be fatal

4. “when was the last time he said something to you?” “Last night. Something strange with him. He was saying “help, help” Could you pick me up please?” I turned him over to a comfy position and I helped him. I asked him what would you like? – ‘could you get me a glass of water’ – sad kind of talk”

5. Types of abuse substantiated across Australia 2014-15 Nursing Orientation 2016

6. Love Warmth Shelter & clothing Food Education Health & Wellbeing Protection/safety Play & social connection Medical treatment Emotional enrichment, moral/spiritual guidance/stability Appropriate stimulation

7. The sub-optimal professional response to neglect • Definitional difficulties – actual harm/likely harm…? • Threshold uncertainties • Repetitive, sub-threshold events • No clear critical event to trigger PS’s response • Chronicity results in greater harm • Often multiple reports involving many children • Lack of evidence about management • Lack of evaluation of intervention strategies

8. Neglect – WHO definition “The failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter and safe living conditions, in the context ofresources reasonably available to the family or caretakers, and causes or has a high probability of causing harm to the child’s health or physical, mental, spiritual, moral or social development. This includes the failure to properly supervise and protect children from harm as much as is feasible.” WHO Report of the consultations on Child Abuse Prevention. Geneva, Switzerland. March 1999 Consequences for child rather than parental behaviour….. Intention to harm not required

9. Over-riding definition neglect • Persistent, non-physical harmful interactions with the child by the caregiver, which include both commission and omission Glaser 2011

10. Concepts surrounding neglect

11. Ecological model of child neglect– the requirements Secure attachment to consistent caregiver Maternal physical & mental health Income Parenting style Parental health Parental education Crime Overcrowding Green spaces Policing Education Family supports Economics Population income Employment Immigration Cultural attitudes Racism Conflict

12. Ecological model of child neglect – the risk factors Age, prematurity Behaviour Disability/delay Planned/unplanned Chronic illness Mental health esp depression Stress Abuse history Substance abuse Domestic violence Young age, single parent Isolation, transience Low education Chronic poverty High unemployment Low education Limited green spaces High crime/drug rates Cultural attitudes Low income High unemployment Poor access to health Underfunded child welfare system Remember resilience-promoting and protective factors

13. Ways of thinking about neglect – ‘Tiers of Concern’ Tier 3 – child’s functioning of concern Tier 2 – harmful child-caregiver interaction Tier 1 – caregiver risk factors Tier 0 – social and environmental risk factors Glaser, D Child abuse and neglect 2011

14. The 3 Axis Types- classification Thresholds – degrees/severity – continuum of harm, chronicity, urgency of intervention, type of intervention Outcome – likelihood of harm, harm already present, defining the harm – the “arrow of time” Danya Glaser 2011

15. Types/categories of neglect

16. Thresholds Continuum of child/caregiver interaction Harmful Satisfactory (“good enough”) Undesirable  “the ill-treatment of the child and/or impairment of the child’s development which is attributable to the care given to the child or likely to be given to the child…not being what it would be reasonable to expect”

17. Outcomes No current or future harm likely – Undesirable behaviours/interactions… Child FIRST referral, supports in place, monitor • No current harm, future harm likely • Important group but no legal remit • Current harm but no future harm – single adverse act…might be catastrophic • Current and future harm • Clearly state harms and relate to caregiver-child interactions

18. Cumulative harm Cumulative harm is experienced by a child as a result of a series or pattern of harmful events and experiences that may be historical, or ongoing, with the strong possibility of the risk factors being multiple, inter-related and co-existing over critical developmental periods Cumulative Harm: A conceptual overview Vic Gov DHHS

20. Neglect and substance abuse “Parental drug use is one of the most serious issues confronting the child welfare sector in the past 20 years. The child welfare system, drug services arena, judicial system and the community at large are failing to cope with the increasing culture of illicit drug use in Australia and failing to address its impact on the children of parents who abuse drugs”. Neglect in all spheres plus abandonment – prison terms, death from OD (>1000 children from heroin OD death 2000) Involved in fatal neglect (Victorian Child Death Review Committee 2003) The child is often ignored (similar to FV?) The Child and Family Welfare Association of Australia 2002: 9

21. Noxious Neglect; the neurobiology of neglect and its effects on the developing brain Jo Tully August 2016

22. “Good mothering” • Knowledge over centuries that infants and young children need;’ • Love • Good nutrition • Stimulation • Responsive care • Critical period from conception to age 6 years, especially the 1st 3 years of life • Lasts a lifetime How does variation in parental care lead to (possibly) lifelong changes in neurobiology and behaviour?

23. “The nature of love” Harlow’s monkeys and early attachment Critical periods Importance of ‘psychological’ parenting over ‘biological’ parenting Work in primates replicated since

24. Neurobiology -what do we mean? The interplay between nature and nurture How nutrition, care and nurturing directly affect wiring pathways of the brain in early life How parental nurturing in early years has a decisive and long-lasting impact on development, learning, behaviour, emotional regulation and health How negative experiences in early years, including neglect are likely to have sustained effects

25. What is the biological model of neglect? Biological explanations for emotional, behavioural and psychological effects observed Lasting and ‘transmissible’ effects of child neglect and emotional maltreatment Environmentalandgeneticinfluences - the “nature/nurture” debate HOW? Effects on structure and development of brain – - synapses and myelination Effect on the endocrine system - stress Epigenetics

26. Environmental influences • Factors in environment affect pre and post natal development of the brain • Prenatal • Maternal stress • Maternal drug/alcohol use • Postnatal • Poverty • Poor nutrition The “unique environment” • Healthcare availability • Educational opportunity • Stress, extreme deprivation and maladaptive experiences - abuse and neglect Abused and neglected children often have many/all these factors

27. What does abuse and neglect do to these systems? • Neglect = absence of critical organising experiences at key points in development • Child abuse harmful because • Critical period for brain development • Set points for activation of the stress axes are programmed • Cumulative damaging effect on neurodevelopment – not easy to ‘see’ • May be mediated by; • Age of child • Chronicity and type of abuse • Identity of abuser, presence of other stable adults

28. The brain, its structure and development and what happens to the neglected brain

29. Development of the brain Many capacities thought to be fixed are actually dependent on experiences Development occurs from ‘bottom up’ Regions regulating emotion, language and abstract thought develop rapidly in 1st 3 years of life

30. Brain cells present at birth, synapses poorly developed Brain development is process of creating, strengthening or discarding neuronal connections 2 million synapses per second in healthy toddler, 100 trillion by 2 years of age Neurotrophins act as mediators secreted in response to neuronal activity which in turn is regulated by environmental input 2 important process in brain development – myelination and synapse development

31. How the brain develops in early life • Brains are hard-wired to expect certain experiences’ eg speech, vision • Synaptic pruning; Create, strengthen and discard synapsis • Myelination changes • Pruning and myelination sensitive to environmental input • ‘Sensitive’ periods during which brain especially responsive to environmental input • Plasticity – ability to change in response to repeated stimulation • Stage of development • Brain system involved

32. Different types of brain development • Experience expectant • DEFICITS/FAILURE in stimuli ie. Neglect/attachment/vision • Failure of synapse development due to lack of environmental stimuli – “use it or lose it” (critical periods) • May be permanent problems • Experience dependent • Synapses form in response to positive or adverse stimuli “serve and return” • Neural plasticity • May adversely colour the child’s world • Abuse v neglect • Experience adaptive • How brain develops is adaptive to environment at time – maladaptive environment – maladaptive development • Not pathological but understandable adaptation

33. Negative pathways strengthened and developed Ability to respond to kindness and nurturing impaired

34. Effects of neglect on development of the brain Brain structure and function Effect on child Learning and memory, PTSD Inter-hemispheric communication Motor & executive function – correlation with IQ and brain size Behavioural, cognitive and emotional regulation Evaluates threat and triggers response, violent outbursts, increased social intelligence Poor learning, behaviour, executive functioning • Hippocampus volume reduced • Corpus callosum volume reduced • Cerebellar volume decreased • Smaller prefrontal cortex • Over-activity of amygdala (may be larger) and pre-frontal cortex • Decreased EEG activity, esp L frontal hemisphere • Decreased brain metabolism • Malnutrition impairs global brain development

35. The endocrine/neurohumeral system, what it does and what happens in the neglected or abused child

36. Stress • Stress = “stimulus or experience that produces a negative emotional reaction or affect including fear and a sense of loss of control” • Physiological coping mechanism • positive, tolerable,toxic • Abused/neglected children - “whole existence in danger” • Direct effect of violence - pain, fear • Effect of observing IPV – fear • Sexual abuse – fear, powerlessness, psychological and physical pain • Neglect – fear of abandonment, discomfort, hunger • Neglect is stressful but may not be traumatic • Excess stress leads to inappropriate responsiveness of stress system

37. Stress response involves: • Sympathetic nervous system (SAM) – immediate • Adrenaline and noradrenaline • Fight or flight • Hypothalamic-pituitary axis (HPA) • Cortisol • Neuro-endocrine system • Oxytocin • Neurotransmitter system • Immune system Dopamine Pre-frontal cortex • Early life experiences • mediate expression of • Behavioural • Emotional • Autonomic • Endocrine • responses to stress Noradrenaline/adrenalin Stressor Amygdala perceives stress Activates Hypothalamus Corticotrophin Releasing Hormone Anterior pituitary ACTH Adrenals Cortisol

38. Changes associated with abuse and neglect – stress systems –SAM and HPA • Stress-induced remodeling of structure/connectivity in • Hippocampus • Amygdala • Pre-frontal cortex (control of feelings, emotions, attention, impulses ie executive functioning) • Alters behaviour and physiological responses • Anxiety • Aggression • Mental inflexibility • Memory difficulties • Other cognitive processes affected • Maltreated children – cortisol abnormalities – reversed when placed in good foster care

39. Stress hyporesponsive period After early months the stress axis becomes hyporesponsive to protect developing brain from stress If early neglect/abuse this does not happen HPA axis continues to respond, cortisol produced, toxic effects to brain

40. The epigenetics story and the cycle of abuse

41. Genes determine POTENTIAL Environment determines HOW MUCH POTENTIAL IS REACHED -“nature v nurture” Abuse prevents children reaching their potential both through environmental deprivation and through environmentally induced epigenetic variation

42. Epigenetics • alterations to gene expression without structural changes to DNA sequence • molecular pathways regulating gene activity that have a critical role in brain development • largely due to; • methylation of DNA sequences • Post-translational histone modifications • Non-coding mRNA’s • Methylation changes increase or decrease gene expression or result in gene silencing • Epigenetic ‘signatures’ that can be inherited through mitosis

43. Epigenetic changes associated with abuse and neglect Early environment predicts later environment so development is adapted to that unique environment Quality of parent-child interaction induce epigenetic changes in developing brain Leads to variations in response to stress, cognition, sociability and reproductive behaviour Affects gene expression in brain cells, can be passed on Chemical changes initiated by life experiences Emotional/behavioural/psychological difficulties then become ‘inheritable’

44. Evidence? - look to the rats Rate natural tendency to lick/groom (LG) offspring varies Low LG’s – heightened stress-induced glucocorticoid levels, decreased memory/learning, reduced neural plasticity in offspring Low LG - decreased GR protein and mRNA in hippocampus as well as multiple other epigenetic changes in hippocampal tissue Can influence grooming patterns by manipulating environment

45. Transmissibility and the ‘cycle of abuse’ Maternal phenotypes transmitted to offspring who become low groomers Offspring of LG rats were LG’s Methylation changes in LG rats not present at birth – appeared in 1st week of life and persisted Transmissibility of behavioural phenotypes that can be altered by the environment later in life Evidence for impact of early life experiences adversity on offspring and grand-offspring Hope for early intervention strategies on cycle of abuse?

46. What about in human infants? • Difficulties in extrapolating • Post-mortem studies • Increased DNA methylation and decreased transcription of GR in hippocampus in abused suicide victims compared to non-abused suicide victims • Salivary samples • increased peripheral Nr3c1 (GR) DNA methylation in abused children (predicts stress reactivity) • Biomarker for early life adversity • Orphanage-reared children genome-wide hypermethylation

47. Cumulative harm – putting it all together

48. Extrapolating from biology to functioning – living with child abuse • Deprivation of experiences - neglect • Lack of empathy • Models of aggression • Exposure to fear and trauma • Pain • Emotional insults • Lack of affect regulation • Unpredictability • Persistent fear response • Hyper-arousal • Increased internalizing symptoms • Diminished executive functioning • Working memory • Inhibitory control • Cognitive flexibility • Delayed developmental milestones • Weakened response to negative feedback

49. Sophia’s story May 2016 - Presented to the VFPMS for assessment of a likely scald burn to her shoulder – no explanation for the injury Found to have fractured front incisors and multiple splinters in her feet Acknowledgment to Dr Chloe Smith, VFPMS

50. Development at 2 years and 9 months Not formally assessed due to poor cooperation BUT reported as; Social passivity – unsure about social interactions Poor eye contact, responds to her name only 20% of the time Cannot/does not follow instructions Limited imaginative play Deficits in non-verbal communication Poor integration of verbal and non-verbal communication Does not point, limited non-verbal gestures Stereotyped and repetitive motor movements – hand flapping, rocking, picking of skin Possible echolalia No ritualised or repetitive behaviours Hyper-reactive to loud noises but no sensory issues Poor language development Aggression – punching people and animal cruelty