Toxic Stress in Early Childhood 31 st Annual Kansas Division for Early Childhood Conference February 28, 2013

1. Toxic Stress in Early Childhood • 31st Annual Kansas Division for Early Childhood Conference • February 28, 2013 • Kaela Byers, LMSW • University of Kansas • School of Social Welfare • Sharah Davis-Groves, LMSW • University of Kansas • School of Social Welfare • Northeast Kansas Infant-Toddler Services • Kathy Byrnes, MA, LMSW • University of Kansas • School of Social Welfare • Kristin Pedersen, MA, CCC-SLPUniversity of Kansas Schiefelbusch Speech-Language-Hearing ClinicNortheast Kansas Infant-Toddler Services

2. Agenda • Overview of Toxic Stress • What is it? • How does it impact children? • How do you recognize it? • New research on addressing Toxic Stress • How does Toxic Stress impact families and your work with families? • Strategies for coping with the effects of Toxic Stress in your work with families. • How can your program support you? • Challenges and opportunities in Early Intervention Services.

3. Toxic Stress: What is it? • In 2005 the National Scientific Council on the Developing Child proposed a scientifically grounded taxonomy of the stress experience to delineate between normative challenges that promote growth and development and challenges that may be threatening to child development. • Positive Stress • Tolerable Stress • Toxic Stress • Reference: National Scientific Council on the Developing Child. (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. Available at: http://www.developingchild.net.

4. Positive Stress • Positive stress is the reaction to typical daily experiences that provide opportunities for grown and learning.

5. Tolerable Stress • Tolerable Stress is the reaction to more serious stressors (community violence, natural disaster, frightening accident, illness, death of a loved one, etc.) and has the potential to damage the child’s brain structure if left unchecked. • These stressors subside over time or are • buffered by supportive caregiver relationships. • Caregiver support • Promotes feelings of safety • Facilitate acquisition of coping and • recovery skills • Protect against escalation of tolerable • stress to toxic stress.

6. Toxic Stress • Toxic stress is the reaction to strong, prolonged, uncontrollable, or chronic stressors activate the body’s stress • response system (e.g. abuse, neglect, parental substance abuse, maternal depression, etc.). • Toxic Stress occurs in the absence of a stable and responsive adult or caregiver to offer buffering protection to the child. • Ongoing activation of the body’s regulatory/stress response system over time results in changes to • the architecture of the brain. • Changes to the brain can promote • short-term effects on behavior and • learning as well as long-term impairments such as chronic and stress-related health and mental • health problems.

7. Ecobiodevelopmental Framework Reference: http://developingchild.harvard.edu/resources/multimedia/interactive_features/biodevelopmental-framework/

8. Toxic Stress: What Impact Does It Have On Children? • Toxic Stress may result in disruption of the child’s stress regulatory system. • This disruption increases vulnerability to: • Ability to detect and respond to emotionally stressful stimuli such as distress cues of others • Internalizing disorders (anxiety and depressive disorders) • Externalizing disorders (early onset aggression, oppositional defiant or conduct disorder, disruptive behavior disorder, antisocial behavior) • Chronic pain syndromes • Immune-related disorders • Cognitive deficits • Disorganized attachment • References: Gunnar & Donzella, 2002; Gunnar & Vazquez, 2001; Heim, Ehlert, & Hellhammer, 2000; Heim & Nemeroff, 2001; McBurnett, Lahey, Rathouz & Loeber, 2000; Pajer, Gardner, Rubin, Perel, & Neal, 2001

9. Toxic Stress: How can you recognize it in children? • No current validated screening tool • Key: Observation • Internalizing/Externalizing disorder symptoms • May not exhibit symptoms • Recognize constellations of • risk factors • Awareness of parenting • style and attachment • characteristics • Next steps in measurement/ • screening

10. Toxic Stress: Next Steps • Early identification of families for early home-based services • Two-pronged approach to early childhood intervention • Compensatory mechanisms to temper the effect of toxic stress exposure in conjunction with elimination of risk factors • Ex. Promote nurturance, non-frightening parenting behaviors, following the child’s lead • Biobehavioral interventions to reverse negative changes, restore functioning, and build capacity to buffer against future stressors • Neurosequential Model of Therapeutics (NMT) • Attachment and Biobehavioral Catch-Up • Promotes healthy regulatory system development by enhancing attachment and responsive parenting • Promising evidence: more secure attachment, better behavioral and biological regulation, fewer reported behavioral problems, long-term efficacy • References: Dozier, Bick, & Bernard, 2011; Dozier, Lindhiem, Lewis, Bick, Bernard, & Peloso, 2009; Dozier, et al., 2006; Ferraro & Kelly-Moore, 2003; Lewis-Morrarty, Dozier, Bernard, Terracciano, & Moore, 2012; Perry, 2009

11. Toxic Stress: How Does It Impact Families and Your Work With Them? • Family engagement in services – Understanding how TS impacts the Dance or the partnership! • 1) Start where families are - listen to more than their words to understand the impact of TS. • What is the family’s understanding of their child’s special needs or environmental needs? • What TS symptoms do you see in caregivers & children? • How do these symptoms of TS impact your work with the family? • What do caregivers need to address the impact of the TS? • What can we do within our roles to link caregivers with resources to meet the needs? • References - Eggbeer, Shahmoon-Shanok, & Clark 2010;Gallager, Fialka, Rhodes, Arceneaux, 2002;Lippicott, Williams, & Wilkins, 2012; McCalister & Thomas, 2007; Virmani & Ontai, 2010

12. Toxic Stress: What Can You Do About It? • What do YOU need to deal with the impact of the TS families are experiencing? • Acknowledge the impact on you. • Assess how you feel when you leave? • What do you do with those feelings? • What is your strategy to unload/differentiate your life from the families you work with? What restores you? Where is your safe place to process? http://cehdvision2020.umn.edu/wp-content/uploads/2012/07/Reflective-Supervision.pdf • References: Baker, 2003; Dunn, Bell, & Bellah, 2012; Professional Self Care in Social Work, 2008;Watson & Gatti, 2012; McCalister & Thomas, 2007

13. Toxic Stress: What Can You Do About It? • What can YOU do to take care of yourself over time as you work with families experiencing TS? • Review strategies that promote personal and professional well-being. (handout) • Make a self care plan. http://www.e-psychologist.org/index.iml?mdl=exam/show_article.mdl&Material_ID=1

14. Toxic Stress: How Can Your Program Provide Support? • How do you use team meeting times? • To vent, share, coach, listen, refresh, rejuvenate • Is there a balance between business and fun? • What types of support and feedback are given? • How do you check in with each other? During the week • Calls, emails, face to face time between co-visits • Do you know your team members? What they need? • Who are the people on the team that are skilled at providing support? By discipline or personality • Making sure we take breaks in year-round service provision • vacation time, days off, covering for each other • Do you know your self? Do you know what you need and when? Do you know how to ask for help?

15. Toxic Stress: Challenges & Opportunities in Early Intervention Services • Taking time to deal with the impact of TS on families and workers. • Difficult to assess TS & determine change over time (no tools out there yet), and to articulate impact of TS on children’s social emotional development. • Being patient with self and families. • Staying focused on goals due to multiple needs in the environment. • Balance between meeting family needs and staying within the scope of our roles. • Collaboration across agencies to meet the family needs takes time and consistent effort.

16. Questions

17. References Baker., E.K., (2003). Caring for Ourselves as Psychologists. Retrieved from http://www.e-psychologist.org/index.iml?mdl=exam/show_article.mdl&Exam_ID=1&Article_ID=1 on December 15, 2012. Dozier, M., Bick, J., & Bernard, K. (2011). Attachment-based treatment for young, vulnerable children. In J.D. Osofsky (Ed.) Clinical Work with Traumatized Young Children. New York: The Guilford Press, pp. 75-95. Dozier, M., Lindhiem, O., Lewis, E., Bick, J., Bernard, K., Peloso, E. (2009). Effects of a foster parent training program on young children’s attachment behaviors: Preliminary evidence from a randomized clinical trial. Child and Adolescent Social Work Journal, 26(4), 321-332. Dozier, M. Peloso, E., Lindhiem, O., Gordon, M.K., Manni, M., Sepulveda, S., Ackerman, J.., Benier, A., & Levine, S. (2006). Developing evidence-based interventions for foster children: An example of a randomized clinical trial with infants and toddlers. Journal of Social Issues, 62(4), 765-783. Dunn, T., Bell, L., & Bellah, L. (2002). Thinking about reflection. Retrieved from http://www.zerotothree.org/about-us/areas-of-expertise/reflective-practice-program-development/one-program-shares-its-experience.html on November 15, 2012. Eggbeer, L., Shahmoon-Shanok, R., & Clark, R. (2010). Reaching toward an evidence base for reflective supervision. Zero to Three, 31(2), 39-45. Ferraro, K.F., & Kelley-Moore, J.A. (2003). Cumulative disadvantage and health: Long-term consequences of obesity? American Sociological Review, 68(5), 707-729. Gallager, G.A., Fialka, J., Rhodes, C., Arceneaux, C., (2002). Working with Families: Rethinking Denial. Young Exceptional Children, 5(2), 11-17.

18. References Gunnar, M.R., & Donzella, B. (2002). Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology, 27, 199-220. Gunnar, M.R., & Vazquez, D.M. (2001). Low cortisol and a flattening of expected daytime rhythm: Potential indices of risk in human development. Development and Psychopathology, 13, 515-538. Heim C., & Nemeroff, C.B. (2001). The role of childhood trauma in the neurobiology of mood and anxiety disorders: Preclinical and clinical studies. Society of Biological Psychiatry, 49, 1023-1039. Heim, C., Ehlert, U., & Hellhammer, D.H. (2001). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1-35. Levine, S., Wiener, S.G., & Coe, C.L. (1993). Temporal and social factors influencing behavioral and hormonal responses to separation in mother and infant squirrel monkeys. Psychoneuroendocrinology, 18(4), 297-306. Lewis-Morrarty, E., Dozier, M., Bernard, K., Terracciano, S.M., & Moore, S. (2012). Cognitive flexibility and theory of mind outcomes among foster children: preschool follow-up results of a randomized clinical trial. Journal of Adolescent Health, 51, S17-S22. McBurnett, K., Lahey, B.B., Rathouz, P.J., & Loeber, R. (2000). Low salivary cortisol and persistent aggression in boys referred for disruptive behavior. Archives of General Psychiatry, 57, 38-43. McCalister , C.L., & Thomas, T., (2007). Infant Mental Health and Family Support: Contributions of Early Head Start to an Integrated Model for Community-Based Early Childhood Programs. Infant Mental Health Journal, 28(2), 192-215.

19. References National Association of Social Workers. (2008). Professional Self-Care and Social Work. Social Work Speaks. National Scientific Council on the Developing Child. (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. Available at: http://www.developingchild.net. Pajer, K., Gardner, W., Rubin, R.T., Perel, J., & Neal, S. (2001). Decreased cortisol levels in adolescent girls with conduct disorder. Archives of General Psychiatry, 58, 297-302. Perry, B.D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240-255. Rosenblum, L.A., & Andrews, M.W. (1994). Influences of environmental demand on maternal behavior and infant development. ActaPaediatrica, Supplement 397, 57-63. Rosenblum, L.A., Coplan, J.D., Friedman, S., Bassoff, T., Gorman, J.M., & Andrews. M.W. (1994). Adverse early experiences affect noradrenergic and serotonergic functioning in adult primates. Society of Biological Psychiatry, 35(4), 221-227. Virmani, E. A., & Ontai, L. L. (2010). Supervision and training in child care: does reflective supervision foster caregiver insightfulness? Infant Mental Health Journal, 31(1), 16-32. Watson, C., Gatti, S.N., (2012). Professional Development Through Reflective Consultation in Early Intervention. Infants and Young Children, 25, 2, 109-121.